Management Of Chronic Obstructive Pulmonary Disease Exacerbations Research Articles

Virtual reality for COPD exacerbation: A randomized controlled trial

BackgroundPulmonary rehabilitation (PR) is an effective treatment method for chronic obstructive pulmonary disease (COPD). However, individuals with chronic diseases that require lifelong treatment and experience exacerbations need motivational methods. ObjectivesThe aim of this study was to examine the effects of virtual reality on symptoms, daily living activity, functional capacity, anxiety and depression levels in COPD exacerbation. MethodsFifty patients hospitalized for COPD exacerbation were included in the study. They were randomly assigned to two groups. Twenty-five patients participated in a traditional PR (once-daily until discharge), including pedaling exercises. The second/25 patients followed the same protocol but experienced cycling simulation in the forest via virtual reality (VR + PR). All patients were evaluated using 1-minute/Sit-to-Stand test (STST), modified-Medical Research Council (mMRC) scale, COPD Assessment test (CAT), Hospital Anxiety and Depression Scale (HADS), and London Chest Activities of Daily Living (LCADL) before and after the treatment. ResultsThe STST showed an increase in both groups post-treatment, notably higher in the VR + PR (p = 0.037). Dyspnea levels and CAT scores decreased in all patients, but the decrease was greater in the PR + VR group for both parameters (p = 0.062, p = 0.003; respectively). Both groups experienced a reduction in the HADS scores compared to the pre-treatment, with a more significant decrease in depression and the total score in the VR + PR (p < 0.05). LCADL's sub-parameters and total score, excluding household, decreased in both groups after treatment (p < 0.05). The improvement was more substantial in the VR + PR. ConclusionsVirtual reality provides benefits in the management of COPD exacerbations and can be used safely. Clinical trial registirationRegistered at clinicaltrials.gov, registration ID: NCT05687396, URL: www.clinicaltrials.gov.

Evaluation of the quality of emergency department management for patients with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is associated with exacerbations and high risk of serious outcomes. Our goal was to determine the appropriateness of the emergency department (ED) management of COPD exacerbations. This observational cohort study incorporated a health records review and included COPD exacerbation cases seen at two large academic EDs. We included all patients with the primary diagnosis of COPD exacerbation. From the electronic medical record, demographic and clinical data were abstracted, and the Ottawa COPD Risk Score (OCRS) was calculated for each. Short-term serious outcomes included intensive care unit admission, intubation, myocardial infarction, noninvasive positive pressure ventilation (NIV), and death at 30 days. Cases were judged for appropriateness of treatment according to explicit indications and standards developed a priori. We enrolled 500 cases with mean age of 71.9 years, 51.2% female patients, 50.2% admitted, and 4.4% death. The calculated OCRS score was >2 for 70.8% of patients. The treatments provided were inhaled β-agonists (82.6%), inhaled anticholinergics (76.6%), corticosteroids (75.2%), antibiotics (71.0%), oxygen (63.8%), NIV (8.8%), and intubation (0.6%). Overall, 50.0% of cases were judged to have had inadequate management due to missing treatments. Specifically, the proportion of missing treatments were inhaled β-agonist (17.0%), inhaled anticholinergic (22.6%), corticosteroids (24.4%), antibiotics (12.8%), and NIV (2.0%). Adequate treatment of COPD exacerbation was lacking in 50.0% of patients in these two large academic EDs. Concerning were the number of patients not receiving corticosteroids or antibiotics. Implementation of explicit treatment standards should lead to improved patient care of this common and serious condition.

Mapping the Common Barriers to Optimal COPD Care in High and Middle-Income Countries: Qualitative Perspectives from Clinicians.

Chronic obstructive pulmonary disease (COPD) poses a significant global health burden despite being largely preventable and treatable. Despite the availability of guidelines, COPD care remains suboptimal in many settings, including high-income countries (HICs) and upper-middle-income countries (UMICs), with varied approaches to diagnosis and management. This study aimed to identify common and unique barriers to COPD care across six countries (Australia, Spain, Taiwan, Argentina, Mexico, and Russia) to inform global policy initiatives for improved care. COPD care pathways were mapped for each country and supplemented with epidemiological, health-economic, and clinical data from a targeted literature review. Semi-structured interviews with 17 respiratory care clinicians were used to further validate the pathways and identify key barriers. Thematic content analysis was used to generate the themes. Six themes were common in most HICs and UMICs: "Challenges in COPD diagnosis", "Strengthening the role of primary care", "Fragmented healthcare systems and coordination challenges", "Inadequate management of COPD exacerbations", "Limited access to specialized care" and, "Impact of underfinanced and overloaded healthcare systems". One theme, "Insurance coverage and reimbursement challenges", was more relevant for UMICs. HICs and UMICs differ in patient and healthcare provider awareness, primary care involvement, spirometry access, and availability of specialized care. Both face issues with healthcare fragmentation, guideline adherence, and COPD exacerbation management. In addition, UMICs also grapple with resource limitations and healthcare infrastructure challenges. Many challenges to COPD care are the same in both HICs and UMICs, underscoring the pervasive nature of these issues. While country-specific issues require customized solutions, there are untapped possibilities for implementing global respiratory strategies that support countries to manage COPD effectively. In addition to healthcare system-level initiatives, there is a crucial need for political prioritization of COPD to allocate the essential resources it requires.

Management of Chronic Obstructive Pulmonary Disease (COPD) Exacerbations in Hospitalized Patients From Admission to Discharge: A Comprehensive Review of Therapeutic Interventions.

Chronic obstructive pulmonary disease (COPD) is a common and debilitating condition that often necessitates hospitalization for exacerbations. Since COPD exacerbations can cause significant morbidity and mortality, managing them is crucial for patient care. Effective management of COPD exacerbations is essential to prevent complications, as COPD exacerbations are associated with increased healthcare costs and decreased quality of life. This review aims to comprehensively discuss the management of COPD exacerbations, covering various pharmacologic and non-pharmacologic strategies. These include inhaled bronchodilators, systemic steroids, antibiotics, invasive and non-invasive ventilation, oxygen therapy, smoking cessation, immunization with pneumococcal vaccine, inhalers at discharge, pulmonary rehabilitation, long-term oxygen therapy (LTOT), ambulatory oxygen therapy, short-burst oxygen therapy, extracorporeal membrane oxygenation (ECMO), lung volume reduction surgery (LVRS), endobronchial procedures, and lung transplant. It is drawn upon various sources, including clinical studies, systemic reviews, and observational studies, to provide a comprehensive overview of current practices and identify areas for future research and innovation in managing COPD exacerbations. Addressing these areas of interest can improve patient outcomes and quality of life.

Outcomes of a Pharmacy-Driven Inpatient Chronic Obstructive Pulmonary Disease (COPD) Transitions of Care (TOC) Management Process

Background: Current data shows 30% of patients hospitalized for Chronic Obstructive Pulmonary Disease (COPD) exacerbation are readmitted within 30 days. Medication management during transitions of care (TOC) has shown impact on clinical outcomes, however there is insufficient data to suggest how pharmacy TOC services might benefit this patient population. Objective: Evaluate the effects of pharmacy-driven COPD TOC services on hospital re-presentation rates. Methods: A single-center retrospective chart review conducted of patients hospitalized for a COPD exacerbation. A comprehensive admission-to-discharge TOC service was provided by early immersion pharmacy students, advanced immersion pharmacy students, and an attending pharmacist in a layered learning model. The primary outcome was 30-day re-presentation rate. Secondary outcomes were 90-day re-presentation rate, volume of interventions made and description of the service. Results: From 1/1/2019 to 12/31/2019, there were 2422 patients admitted for COPD exacerbation management and 756 patients received at least one intervention from the COPD TOC service. 30% needed a change to inhaler therapy. The provider accepted 57.8% of the recommended changes, and 36% and 33% of eligible patients received an inhaler technique education and bedside delivery of the new inhaler, respectively. Outcomes in the 30-day re-presentation and 90-day censored re-presentation rates for the intervention and control group were 28.5% vs 25.5% (P = .12) and 46.7% vs 42.9%, respectively. Conclusion: This study did not find a significant change in 30-day re-presentation rate with a pharmacy-driven COPD TOC service. It did find that a significant number of patients admitted with COPD exacerbation may need an inhaler change, and demonstrates the utility of this kind of TOC service for identifying and correcting medication-related problems unique to this disease state. There were opportunities for improvement in percent of patients receiving the full intended intervention.

Mucolytics for acute exacerbations of chronic obstructive pulmonary disease: a meta-analysis.

This meta-analysis explored the safety and effectiveness of mucolytics as an add-on treatment for chronic obstructive pulmonary disease (COPD) exacerbations. Based on a pre-registered protocol and following Cochrane methods, we systematically searched for relevant randomised or quasi-randomised controlled trials (RCTs). We used the Risk of Bias v2 tool for appraising the studies and performed random-effect meta-analyses when appropriate. We assessed certainty of evidence using GRADE. This meta-analysis included 24 RCTs involving 2192 patients with COPD exacerbations, entailing at least some concerns of methodological bias. We demonstrated with moderate certainty that mucolytics increase the rate of treatment success (relative risk 1.37, 95% CI 1.08-1.73, n=383), while they also exert benefits on overall symptom scores (standardised mean difference 0.86, 95% CI 0.63-1.09, n=316), presence of cough at follow-up (relative risk 1.93, 95% CI 1.15-3.23) and ease of expectoration (relative risk 2.94, 95% CI 1.68-5.12). Furthermore, low or very low certainty evidence suggests mucolytics may also reduce future risk of exacerbations and improve health-related quality of life, but do not impact on breathlessness, length of hospital stay, indication for higher level of care or serious adverse events. Overall, mucolytics could be considered for COPD exacerbation management. These findings should be validated in further, rigorous RCTs.

Chronic Obstructive Pulmonary Disease and Telehealth: Remote Monitoring and Patient Outcomes

The integration of telehealth interventions into the management of Chronic Obstructive Pulmonary Disease (COPD) represents a transformative approach to improving patient outcomes and reducing the burden on healthcare systems. With the global prevalence of COPD on the rise, innovative care models, including remote monitoring and teleconsultation, have emerged as essential tools in the early detection and management of COPD exacerbations. These interventions not only lead to a significant reduction in exacerbation frequency and severity but also enhance patients' quality of life by empowering them to take an active role in their healthcare. Improved pulmonary function, medication adherence, and cost-effectiveness further underscore the value of telehealth in COPD care. The high levels of patient satisfaction and the potential for reduced mortality rates emphasize the promising future of telehealth in COPD management. As we continue to advance in technology and healthcare delivery, the comprehensive and personalized care offered by telehealth is poised to make a lasting impact on the lives of COPD patients worldwide.

Management of COPD exacerbations in the community.

British Journal of Community NursingVol. 27, No. 8 ProfessionalManagement of COPD exacerbations in the communitySarah Jane PalmerSarah Jane PalmerE-mail Address: [email protected]Registered nurse and freelance writer, based at the Department of Work and Pensions as a disability analystSearch for more papers by this authorSarah Jane PalmerPublished Online:4 Aug 2022https://doi.org/10.12968/bjcn.2022.27.8.398AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Adibi A, Sin DD, Safari A, Johnson KM, Aaron SD, FitzGerald JM, Sadatsafavi M. The Acute COPD Exacerbation Prediction Tool (ACCEPT): a modelling study. Lancet Respir Med. 2020;8(10):1013-1021. http://doi.org/10.1016/S2213-2600(19)30397-2 Google ScholarBMJ. Acute exacerbation of chronic obstructive pulmonary disease. 2022. https://bestpractice.bmj.com/topics/en-gb/3000086 (accessed 20 July 2022) Google ScholarBritish Lung Foundation. Chronic obstructive pulmonary disease (COPD) statistics. https://statistics.blf.org.uk/copd (accessed 20 July 2022) Google ScholarDepartment of Health. An outcomes strategy for people with chronic obstructive pulmonary disease (COPD) and asthma in England. 2011. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/216139/dh_128428.pdf (accessed 20 July 2022) Google ScholarEchevarria C, Steer J, Wason J, Bourke S. Oxygen therapy and inpatient mortality in COPD exacerbation. Emergency Medicine Journal. 2021;38(3):170-177. http://dx.doi.org/10.1136/emermed-2019-209257 Google ScholarNational Institute for Health and Care Excellence. Quality standard chronic obstructive pulmonary disease in adults. 2016. https://tinyurl.com/yckuwbxf (accessed 20 July 2022) Google ScholarNational Institute for Health and Care Excellence. Scenario: acute exacerbation of chronic obstructive pulmonary disease. 2021. https://cks.nice.org.uk/topics/chronic-obstructive-pulmonary-disease/management/acute-exacerbation/ (accessed 20 July 2022) Google Scholar FiguresReferencesRelatedDetails 2 August 2022Volume 27Issue 8ISSN (print): 1462-4753ISSN (online): 2052-2215 Metrics History Published online 4 August 2022 Published in print 2 August 2022 Information© MA Healthcare LimitedPDF download

Factors Related with Hospital Attendance and Mortality in Patients with COPD: A Case-Control Study in a Real-Life Setting.

IntroductionThe rising trend in hospital admissions among patients with chronic obstructive pulmonary disease (COPD) is worrying, not only because of the increasing costs, but also because of the worsening quality of life. We aimed to identify the predictive factors of hospital admission, re-admission and mortality of COPD patients through using information exclusively registered in electronic clinical records.MethodsWe conducted a population-based case–control study. All data were sourced from the different information systems comprising the Galician Health Service electronic record database. We included in the study patients diagnosed with COPD (code R95 in the medical record), ≥35 years old and with at least one spirometry performed ≤3 years prior inclusion. We fitted three logistic regression models, each one to ascertain the factors that influence the probability of admission, re-admission, and mortality, and calculated odds ratios (OR) with their 95% confidence intervals (95% CI).ResultsCOPD patients were admitted due to respiratory causes a mean of 1.51 times across the period December 2016–December 2017, with 55% requiring re-admission in the next 90 days. The factor most closely associated with the re-admission profile was home oxygen therapy (OR 3.06 95% CI 2.42–3.87), followed by male gender (OR 2.01 95% CI 1.48–2.72), a CHA2D-VASc scale score >2 (OR 1.28 95% CI 1.16–1.42), and severity by clinical risk group stratification (OR 1.14 95% CI 1.04–1.26). Male sex (OR 1.47 CI 95% 1.04–2.09), having been readmitted ≥2 times (OR 1.34 CI 95% 1.11–1.61) and being ≥70 years old (OR 1.05 CI 95% 1.03–1.08) increase the probability of dying from COPD during the study period.ConclusionThese results confirm the complexity of management of COPD exacerbations, and indicate the need to establish strategies that would ensure continuity of care after hospital admission, with the aim of preventing re-admissions and death.

Effectiveness of Indacaterol-Glycopyrronium in preventing COPD exacerbations in comparison to Salmeterol-Fluticasone

COPD exacerbations are complex events usually associated with increased airway inflammation, increased mucus production and marked gas trapping. These changes contribute to increased dyspnoea that is the key symptom of an exacerbation. Inhaled long acting bronchodilators not only control symptoms but also prevent exacerbations of chronic obstructive pulmonary disease (COPD). The purpose of the study was to compare the efficacy between Indacaterol-Glycopyrronium and salmeterol fluticasone (SFC) in preventing COPD exacerbations during 24 weeks of treatment. This randomised active-controlled trial was conducted at Department of Respiratory Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka involving 200 patients with COPD exacerbations. Patients were randomly divided into two groups; &amp; treated with Indacaterol- Glycopyrronium 110/50 ug o.d. &amp; Salmeterol-Fluticasone (50/500 ug b.i.d.) (SFC) respectively; &amp; follow-up was done after 12 and 24 weeks. The FEV1 was significantly higher at 12 and 24 weeks in the Indacateol- Glycopyrronium group compared with SFC. Statistically significant improvements in peak FVC was observed in Indacaterol- Glycopyrronium when compared to SFC at week 12 and week 24. Our study result showed that Indacaterol-Glycopyrronium was superior to Salmeterol-Fluticasone in terms of prevention and optimal management of COPD exacerbation. BSMMU J 2021; 14(3): 43-49

COVID-19 Pandemic: What Considerations Should Be Taken during the Assessment and Management of COPD Exacerbation?

The on-going coronavirus disease 2019 (COVID-19) pandemic could contribute to higher mortality in population with underlying respiratory diseases, including chronic obstructive pulmonary disease (COPD). The aim of this review was to inform readers pertaining to the correlation of COPD exacerbation and severe acute respiratory syndrome-2 (SARS-CoV-2) infection along with considerations that could be taken in the clinical diagnosis and management. The literature search was conducted on Google Scholar, Scopus, and PubMed databases using related terms (such as, but not limited to, “COVID-19,” “SARS-CoV-2,” “COPD management,” “N-acetylcysteine,” and “corticosteroids”) on November 1–9, 2021. Recent studies suggest that COVID-19 and COPD are correlated through three pathways, namely, angiotensin-converting enzyme 2 expression, dysregulation of biological parameters, and occurrence of pneumonia. Early detection of COVID-19 in patients with underlying COPD is difficult because they share similar symptoms, attributed to advanced progression of the infection and subsequently deteriorates lung function. During COPD management, clinicians are expected to take consideration on the effect of systemic corticosteroids if patients develop COVID-19. In conclusion, COVID-19 and COPD and its management are potentially correlated, contributing to the worsening of the disease. There is a need of immediate research to reveal the true correlation between COVID-19 and COPD to improve the management.

2021 Guideline for the Management of COPD Exacerbations: Emergency Medicine Association of Turkey (EMAT) / Turkish Thoracic Society (TTS) Clinical Practice Guideline Task Force.

Chronic obstructive pulmonary disease (COPD) is an important public health problem that manifests with exacerbations and causes serious mortality and morbidity in both developed and developing countries. COPD exacerbations usually present to emergency departments, where these patients are diagnosed and treated. Therefore, the Emergency Medicine Association of Turkey and the Turkish Thoracic Society jointly wanted to implement a guideline that evaluates the management of COPD exacerbations according to the current literature and provides evidence-based recommendations. In the management of COPD exacerbations, we aim to support the decision-making process of clinicians dealing with these patients in the emergency setting.

Validation of COPDPredict™: Unique Combination of Remote Monitoring and Exacerbation Prediction to Support Preventative Management of COPD Exacerbations.

BackgroundCOPDPredict™ is a novel digital application dedicated to providing early warning of imminent COPD (chronic obstructive pulmonary disease) exacerbations for prompt intervention. Exacerbation prediction algorithms are based on a decision tree model constructed from percentage thresholds for disease state changes in patient-reported wellbeing, forced expiratory volume in one second (FEV1) and C-reactive protein (CRP) levels. Our study determined the validity of COPDPredict™ to identify exacerbations and provide timely notifications to patients and clinicians compared to clinician-defined episodes.MethodsIn a 6-month prospective observational study, 90 patients with COPD and frequent exacerbations registered wellbeing self-assessments daily using COPDPredict™ App and measured FEV1 using connected spirometers. CRP was measured using finger-prick testing.ResultsWellbeing self-assessment submissions showed 98% compliance. Ten patients did not experience exacerbations and treatment was unchanged. A total of 112 clinician-defined exacerbations were identified in the remaining 80 patients: 52 experienced 1 exacerbation; 28 had 2.2±0.4 episodes. Sixty-two patients self-managed using prescribed rescue medication. In 14 patients, exacerbations were more severe but responded to timely escalated treatment at home. Four patients attended the emergency room; with 2 hospitalised for <72 hours. Compared to the 6 months pre-COPDPredict™, hospitalisations were reduced by 98% (90 vs 2, p<0.001). COPDPredict™ identified COPD-related exacerbations at 7, 3 days (median, IQR) prior to clinician-defined episodes, sending appropriate alerts to patients and clinicians. Cross-tabulation demonstrated sensitivity of 97.9% (95% CI 95.7–99.2), specificity of 84.0% (95% CI 82.6–85.3), positive and negative predictive value of 38.4% (95% CI 36.4–40.4) and 99.8% (95% CI 99.5–99.9), respectively.ConclusionHigh sensitivity indicates that if there is an exacerbation, COPDPredict™ informs patients and clinicians accurately. The high negative predictive value implies that when an exacerbation is not indicated by COPDPredict™, risk of an exacerbation is low. Thus, COPDPredict™ provides safe, personalised, preventative care for patients with COPD.

Management of acute COPD exacerbations in France: A qualitative survey in a private practice setting

BackgroundThe current prevalence of chronic obstructive pulmonary disease (COPD) in France is estimated to be 2.6 million and is predicted to increase to 2.8 million by 2025. Presently, there is a lack of data on COPD management within the private healthcare setting. The aim of this study was to investigate the management of COPD exacerbations by pulmonologists within private practices in France.MethodsA prospective, online, qualitative survey was distributed to private practice pulmonologists in France. The survey covered all aspects of COPD management from diagnosis and therapeutic management, to secondary prevention and organization of care. Survey responses were collected between 27 January 2018 and 18 June 2018 and all data were summarized descriptively.ResultsThe survey had a response rate of 20.6%, with 116 out of 563 pulmonologists providing responses. Overall, 87.4% of respondents stated that the management of COPD represented over 15% of their total clinical activity. Most respondents indicated that they work closely with general practitioners and a large multidisciplinary team to manage patients with numerous comorbidities. Following a COPD exacerbation, the majority of respondents (78.4%) were in favor of using respiratory-connected devices (class 2a-connected medical device according to the French HAS classification and available on medical prescription) to assist with patient follow-up at home.ConclusionsCOPD management forms part of the core clinical activity for pulmonologists within the private practice setting in France. Patients with COPD generally have multiple comorbidities and are managed by a multidisciplinary team in line with French guidelines. The use of respiratory-connected devices was highlighted as an important new strategy for improving patient care following a COPD exacerbation.

Approach to: Chronic obstructive pulmonary disease (COPD)

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the world, affecting developing and developed countries alike. Recent advancements in medical and interventional therapies have led to decreasing overall mortality rates in the last decade. Despite these improvements, COPD continues to cause significant morbidity and lost productivity. This review summarizes the pathophysiology of COPD and the work-up of a patient with suspected COPD, emphasizing pulmonary function testing, an approach to treatment, and the management of COPD exacerbations.

Efficacy and safety of Jia Wei Bushen Yiqi formulas as an adjunct therapy to systemic glucocorticoids on acute exacerbation of COPD: study protocol for a randomized, double-blinded, multi-center, placebo-controlled clinical trial

BackgroundSystemic glucocorticoids are effective for the management of chronic obstructive pulmonary disease (COPD) exacerbation but have serious adverse effects. Traditional Chinese medicine (TCM) can bring additional benefits to these patients but has few adverse effects. The present study aims to evaluate the efficacy and safety of Jia Wei Bushen Yiqi (JWBY) formulas in patients who suffer from COPD exacerbations and to investigate whether the short-term (5-days) systemic glucocorticoid therapy is non-inferior to the long-term (9-day) regime.MethodsIn this multi-center, randomized, double-blinded trial, eligible inpatients with COPD exacerbation are randomly assigned to four groups (A, B, C, and D). Group A will receive placebo plus 5-day prednisone, group B will receive placebo plus 9-day prednisone, group C will receive JWBY formulas plus 5-day prednisone, and group D will receive JWBY formulas plus 9-day prednisone. The primary outcomes are the time interval to the patient’s next exacerbation during a 180-day following up and the COPD assessment test (CAT) during treatment. Secondary outcomes include lung function, TCM syndrome assessment, laboratory tests, and safety. The changes of the hypothalamic pituitary adrenaline axis (HPA axis) and inflammatory cytokine will be measured as well.DiscussionBy demonstrating the advantages of utilizing TCM and an appropriate duration of systemic glucocorticoids, this effectiveness comparison trial will provide new references to physicians on how to improve the management of COPD exacerbation. The results of HPA axis and inflammation cytokine measurements will shed light on the molecular mechanisms and entail further mechanism studies.Trial registrationwww.chictr.org.cn ChiCTR1900023364. Registered on 24 May 2019.

Proton pump inhibitors for chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a common and progressive disease characterised by chronic cough, airflow limitation and recurrent exacerbations. Since COPD exacerbations are linked to rising mortality and reduced quality of life, the condition poses a substantial burden on individuals, society and the healthcare system. Effective management of COPD exacerbations that includes treatment of related conditions in people with COPD is thus recognised as a relevant clinical question and an important research topic. Gastroesophageal reflux disease (GERD) is a known comorbidity of COPD, and pulmonary microaspiration of gastric acid is thought to be a possible cause of COPD exacerbations. Therefore, reducing gastric acid secretion may lead to a reduction in COPD exacerbations. Proton pump inhibitors (PPIs) are one of the most commonly prescribed medications and are recommended as first-line therapy for people with GERD because of their inhibitory effects on gastric acid secretion. Treatment with PPIs may present a viable treatment option for people with COPD. To evaluate the efficacy and safety of PPI administration for people with COPD, focusing on COPD-specific outcomes. We searched the Cochrane Airways Register of Trials and conventional clinical trial registers from inception to 22 May 2020. We also screened bibliographies of relevant studies. Parallel-group and cluster-randomised controlled trials (RCTs) that compared oral PPIs versus placebo, usual care or low-dose PPIs in adults with COPD were eligible for inclusion. We excluded cross-over RCTs, as well as studies with a duration of less than two months. Two independent review authors screened search results, selected studies for inclusion, extracted study characteristics and outcome data, and assessed risk of bias according to standard Cochrane methodology. We resolved discrepancies by involving a third review author. Primary outcomes of interest were COPD exacerbations, pneumonia and other serious adverse events. Secondary outcomes were quality of life, lung function test indices, acute respiratory infections and disease-specific adverse events. We extracted data on these outcome measures and entered into them into Review Manager software for analysis. The search identified 99 records, and we included one multicentre RCT that randomised 103 adults with COPD. The 12-month RCT compared an oral PPI (lansoprazole) and usual care versus usual care alone. It was conducted at one tertiary care hospital and three secondary care hospitals in Japan. This study recruited participants with a mean age of 75 years, and excluded people with symptoms or history of GERD. No placebo was used in the usual care arm. Among the primary and secondary outcomes of this review, the study only reported data on COPD exacerbations and acute respiratory infections (the common cold). As we only included one study, we could not conduct a meta-analysis. The included study reported that 12 of the 50 people on lansoprazole had at least one exacerbation over a year, compared to 26 out of 50 on usual care (risk ratio 0.46, 95% CI 0.26 to 0.81). The frequency of COPD exacerbations per person in a year was also lower in the PPI plus usual care group than in the usual care alone group（0.34 ± 0.72 vs 1.18 ± 1.40; P < 0.001). The number of people with at least one cold over the year was similar in both groups: 26 people on lansoprazole and 27 people in the usual care group. We judged the evidence to be of low to very low certainty, according to GRADE criteria. The study reported no data on pneumonia and other serious adverse events, quality of life, lung function test indices or disease-specific adverse events. The risk of bias was largely low or unclear for the majority of domains, though the performance bias was a high risk, as the study was not blinded. Evidence identified by this review is insufficient to determine whether treatment with PPIs is a potential option for COPD. The sample size of the included trial is small, and the evidence is low to very low-certainty. The efficacy and safety profile of PPIs for people with COPD remains uncertain. Future large-scale, high-quality studies are warranted, which investigate major clinical outcomes such as COPD exacerbation rate, serious adverse events and quality of life.

Management of COPD exacerbations: pharmacotherapeutics of medications

Chronic obstructive pulmonary disease (COPD) is widely established as a health challenge, with predictions that it will be the third leading cause of global mortality and reduced health status within the next 10 years. Exacerbations of COPD are now the second largest cause of emergency hospitalisation in the UK. The respiratory clinical nurse specialist has an active role in the acute management of COPD exacerbations in the hospital setting, and it is essential that prescribing decisions are made based on the best available evidence. This article critically evaluates the pharmacotherapeutics and evidence base for the use of two medications, salbutamol and amoxicillin, in treating unstable COPD, and discusses implications for clinical practice.

Management of COPD exacerbations: pharmacotherapeutics of medications.

Chronic obstructive pulmonary disease (COPD) is widely established as a health challenge, with predictions that it will be the third leading cause of global mortality and reduced health status within the next 10 years. Exacerbations of COPD are now the second largest cause of emergency hospitalisation in the UK. The respiratory clinical nurse specialist has an active role in the acute management of COPD exacerbations in the hospital setting, and it is essential that prescribing decisions are made based on the best available evidence. This article critically evaluates the pharmacotherapeutics and evidence base for the use of two medications, salbutamol and amoxicillin, in treating unstable COPD, and discusses implications for clinical practice.

Hospitalised exacerbations of chronic obstructive pulmonary disease: adherence to guideline recommendations in an Australian teaching hospital.

Optimal management of exacerbations of chronic obstructive pulmonary disease (COPD) reduces patient morbidity and healthcare system burden. COPD guidelines, including the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and the COPD-X Plan, provide evidence-based recommendations, but adherence in hospital practice is variable. To examine current practice in management of COPD exacerbations at an Australian teaching hospital and to compare with COPD-X Plan recommendations. Data were collected retrospectively from electronic medical records for admissions occurring during 1 May to 31 August 2016, and compared with recommendations from the COPD-X Plan. A total of 134 patients (n = 68 females) was admitted for a COPD exacerbation during the study period. Mean age was 75.4 ± 10.2 years and 33.6% were current smokers. Airflow obstruction on spirometry was confirmed in 67.2% (mean forced expiratory volume in 1 s was 53 ± 22% predicted (1.2 ± 0.5 L)). Excellent adherence to the COPD-X Plan was demonstrated in the ordering of chest radiographs (97%) and electrocardiograms (94%). Supplemental oxygen was appropriately provided to all patients with oxygen saturation of <88%. All patients with confirmed hypercapnic respiratory failure were managed with non-invasive ventilation. Corticosteroids and bronchodilators were prescribed for the majority of patients. Areas of suboptimal practice included inadequate usage of arterial blood gases, excess supplemental oxygen in the absence of hypoxaemia, over-prescription of intravenous antimicrobials, low referral rates to pulmonary rehabilitation and insufficient smoking cessation counselling. Level of adherence to guideline recommendations in the management of COPD exacerbations is inadequate and further strategies are required to elevate standards of practice.