Treatment Of Chronic Obstructive Pulmonary Disease Exacerbations Research Articles

Assessing the use of initial oxygen therapy in chronic obstructive pulmonary disease patients: a retrospective audit of pre-hospital and hospital emergency management.

Carbon dioxide retention in chronic obstructive pulmonary disease (COPD) exacerbations can be a complication of oxygen therapy. Current recommendations suggest an inspired oxygen level (FiO2 ) < 0.28, aiming for saturation (SpO2 ) of 88-92% until arterial blood gas analysis is available. This study aims to assess the use of O2 therapy and FiO2 in the emergency management of patients with a known diagnosis of COPD. Retrospective audit of 150 COPD patients admitted over 18 months, data being extracted from the hospital records. Of the records reviewed, 57% were male, mean age 75 years. COPD was recognised in 53%. SpO2 recorded in 124 patients, with SpO2 < 88% seen in 40 patients. Oxygen was administered in 123 patients in ambulances; high flow in 111 patients, and only 12 patients received O2 therapy in line with the recommended FiO2 < 0.28. In the emergency department (ED), 112 patients received O2 supplementation; high flow given in 68 patients. Hypercapnia was seen in 71 patients; FiO2 > 0.28 given in 54 patients in ambulances and in 35 patients in ED. Non-invasive ventilation was required in 53 patients; FiO2 > 0.28 given in 29 patients in the ED. Seven patients were admitted to intensive care unit, and 10 patients died. High-flow oxygen is used for the initial treatment of COPD exacerbations, but only 53% are recognised as having COPD. A FiO2 > 0.28 is often initiated before admission and continued in the ED. A larger study would be required to assess any possible harm of this approach, but education of those involved in the care of COPD patients may reduce the risk of complications of hypercapnia.

Impact of antibiotics on acute exacerbations of COPD

BackgroundMost patients with an exacerbation of chronic obstructive pulmonary disease (COPD) are treated with antibiotics. However the value of their use remains uncertain. Some controlled trials of antibiotics have shown benefit while others have not. This study was conducted in order to help resolve the issues surrounding the value of antibiotic therapy for exacerbations of COPD. Patients and methodsOne hundred subjects were recruited from patients with type 1 exacerbation of COPD referred to the outpatient clinics of Assiut and Al-Azhar University hospitals for treatment of COPD exacerbation from April 2013 to October 2014. Patients were divided into two groups, placebo and antibiotic group. Each group contain 50 patients, the placebo group received (bronchodilators, corticosteroids), the treatment group received bronchodilators, corticosteroids, and 10day course of antibiotics. ResultsThe frequency of individual symptoms was significantly different before and after treatment in antibiotic and placebo-treated groups. Lung function studies showed no significant difference in both antibiotic-treated and placebo groups. Peak flow data increased in antibiotic treated group and in placebo treated group without statistical significance (p=0.205, paired t-test). However, this increase in PEFR occurs significantly more rapid and in shorter duration in antibiotic-treated group than placebo group (15±3days versus 18±5days) p=0.001. The success rate was higher in antibiotic-treated exacerbations while failure with deterioration was higher in placebo-treated group. When exacerbations without deterioration were considered, antibiotic-treated exacerbations showed more rapid improvement in symptoms than those with placebo treated group (13±7days versus 16±6days) p=0.02. ConclusionsIn conclusion, this study has clearly shown that in type 1 exacerbations of COPD, antibiotic therapy, significantly results in decrease in duration of treatment, success rate and more rapid improvement in peak flow.

Steroids for Treatment of COPD Exacerbations

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) is a common, progressive lung condition, characterized by cough and dyspnea and punctuated by episodes of acute exacerbations or “lung attacks” during which these symptoms significantly increase. These lung attacks can induce severe symptoms, causing patients to seek urgent medical care and can result in respiratory failure and death. In the United States, COPD exacerbations are responsible for more than 800 000 hospital admissions each year and 143 000 deaths annually, making it the third leading cause of mortality. Furthermore, acute exacerbations accelerate decline in lung function, reduce patients’ quality of life, and increase health care use (with exacerbation management accounting for up to 70% of the total direct costs of COPD management). Acute exacerbations are common among patients with COPD, with nearly 1 in 2 patients experiencing at least 1 exacerbation annually. Although the pathophysiology of exacerbations is poorly understood, in most cases, it is thought to be provoked by an acute respiratory tract infection (by either a virus or bacteria), which suborns a hyperinflammatory state in the airways, causing patients to experience paroxysms of cough, sputum production, and shortness of breath. Accordingly, these episodes are usually treated with systemic corticosteroids in varying doses and duration. Over the past 30 years, randomized trials have demonstrated the benefits of systemic (usually oral) corticosteroids in providing symptom relief, accelerating lung function recovery, and preventing respiratory failure and treatment relapses in patients experiencing exacerbations. However, prior clinical trials have used different dosing regimens, leading to significant practice variation across physicians, hospitals, and countries. Some trials have used high doses of systemic corticosteroids and tapered the dose over several weeks to months, and others have used fixed (short duration) therapy without any tapering. Currently, there is no firm consensus on the dose or duration of therapy but most national and international guidelines recommend a 10to 14-day course of oral prednisone (approximately40 mg/d). However, even using this conservative regimen, patients frequently experience adverse effects of corticosteroids including hyperglycemia, weight gain, and insomnia. Moreover, because approximately 10% of patients experience frequent exacerbations (defined as 2 or more exacerbations annually), cumulative exposure to oral corticosteroids may be substantial in some patients, leading to serious long-term steroid toxicity, including weight gain, diabetes, osteoporosis, fractures, adrenal suppression, and ocular complications. Because steroid toxicity is dose and duration dependent, ascertainment of a minimal effective dose to treat acute exacerbations is of critical clinical importance for millions of patients with COPD who experience frequent exacerbations. This important but unresolved question is addressed by Leuppi and colleagues in this issue of JAMA. In this rigorous, high-quality, randomized noninferiority clinical trial involving 314 patients with acute exacerbations of COPD, a 5-day course of oral prednisone (at 40 mg daily) was compared with the conventional 14-day course of prednisone as recommended by most guidelines. The study found no significant differences in the primary outcome of treatment relapse (ie, reexacerbation) rate within 180 days (37.2% in the 5-day treatment group vs 38.4% in the 14-day treatment group). There were also no significant differences in lung function or in any of the subjective outcomes such as dyspnea or quality of life between the 2 groups. Thus, the 5-day treatment was noninferior to the 14-day treatment despite a 65% reduction in the cumulative steroid exposure over 6 months in the short-term treatment group (560 mg in the conventional group vs 200 mg median prednisone exposure in the short-term group). While the risk of acute steroid toxicity, including hyperglycemia, was similar between the 2 groups, there were fewer occurrences of hypertension in the short-term treatment group, but this difference was not statistically significant. In addition, patients in the short-term treatment group had significantly shorter hospital stays than those in the con-

The influence of various regimens of treatment on the level of proinflammatory cytokine TNF-alpha in induced sputum in case of an exacerbation of chronic obstructive pulmonary disease (copd) in persons, who suffered from pulmonary tuberculosis

The influence of various regimens of treatment of the regional (in induced sputum) level of proinflammatory cytokine TNF-α in patients with chronic obstructive pulmonary disease (COPD), who have suffered from pulmonary tuberculosis (PT), has been studied. An advantage of using a combined treatment of COPD exacerbation by means of β2agonist and an anticholinergic preparation (berodual), and also doxofillin (aerofillin) for the purpose of correcting regional (endobronchial) imbalance of cytokine homeostasis is proved.

Early Identification of Exacerbations in Patients With Chronic Obstructive Pulmonary Disease

Frequent exacerbations of chronic obstructive pulmonary disease (COPD) place a considerable burden on the health care system and are a major cause of decreased health-related quality of life, accelerated pulmonary decline, and mortality in individual patients. Primary care physicians are usually the first point of contact for patients experiencing an exacerbation and are therefore best placed to prevent, identify, and treat these events in a timely manner. This review addresses the triggers and risk factors for COPD exacerbations, including the exacerbation-prone phenotype. The prevention, prompt diagnosis, and early appropriate pharmacological/nonpharmacological treatment of COPD exacerbations is important, as early recognition of symptoms (as supported by tools for measuring the illness/wellness experience of COPD patients in primary care) and treatment lead to optimal recovery in these patients. The review also highlights the importance of the urgency in identifying exacerbations and the important role played by primary care physicians in the prevention and postexacerbation management of patients with COPD.

Syndrome of inappropriate antidiuretic hormone associated with moxifloxacin

A possible case of moxifloxacin-induced syndrome of inappropriate antidiuretic hormone (SIADH) is reported. A 66-year-old Caucasian woman with stage II chronic obstructive pulmonary disease (COPD) arrived at the emergency department from an outpatient clinic complaining of worsening shortness of breath, headache, body aches, and dizziness. Five days before her arrival at the hospital, the patient was seen in an outpatient clinic with symptoms of COPD exacerbation and was given a corticosteroid taper of prednisone 40 mg daily and moxifloxacin 400 mg daily. The patient was hospitalized, and her serum sodium concentration was 110 meq/L. Moxifloxacin was continued on admission, and the patient was admitted to the intensive care unit for frequent neurologic examination, serial serum sodium measurements, and fluid restriction. Her laboratory test results were consistent with SIADH. Fluid restriction at 1 L/day initially corrected her serum sodium concentration to 119 meq/L, but increases in serum sodium plateaued by day 2 of admission (119-122 meq/L). Moxifloxacin was discontinued on hospital day 3. At discharge, on hospital day 5, her serum sodium concentration had increased to 131 meq/L. She was restarted on her home medications and followed up in an outpatient clinic one week later. After multiple etiologies were ruled out, drug-induced SIADH associated with moxifloxacin was the most likely diagnosis for this patient. Clinicians should be aware of this potential adverse drug effect when assessing patients with hyponatremia or SIADH. A 66-year-old woman developed severe hyponatremia after receiving moxifloxacin for five days for treatment of COPD exacerbation.

An Evaluation of Inhaled Bronchodilator Therapy in Patients Hospitalized for Non-Life-Threatening COPD Exacerbations

Chronic obstructive pulmonary disease (COPD) increasingly is a cause of morbidity and mortality in and economic burden on the US healthcare system, and COPD exacerbations continue to be among the top 10 causes of hospitalization in adults. The objective of this study was to evaluate the incidence and potential implications of missed scheduled nebulized bronchodilator therapy in the setting of acute, non-life-threatening COPD exacerbations. This study was a retrospective chart review of all of the patients with a primary diagnosis of severe, non-life-threatening COPD exacerbations admitted from January 2007 to June 2008 at a university-affiliated hospital. Each patient's inhaled bronchodilator treatment regimen, including potential for nebulization to metered-dose inhaler (MDI) with valved holding chamber (VHC) conversion, was assessed. A total of 259 patients met inclusion criteria: 235 (90.7%) patients received inhaled bronchodilators by nebulization alone in the treatment of COPD exacerbations; 81.1% of these patients could have used MDI with VHC. Patients missed 24.3% of their scheduled, nebulized bronchodilator doses. Patient care can be improved through the initiation of MDI with VHC, especially considering the number of missed nebulizations that these patients experienced. Development of an inhaled bronchodilator treatment algorithm for COPD exacerbations should be considered to ensure an evidence-bassed medicine approach to these patients.

IL-5 release of CD4 + non-effector lymphocytes is increased in COPD — modulating effects of moxifloxacin and dexamethasone

T-lymphocytes are crucial in chronic obstructive pulmonary disease (COPD) pathogenesis. Especially T H1-lymphocytes are involved in local and systemic inflammation in COPD, yet the role of T H2-mediated immune-responses in COPD pathogenesis is poorly understood. The objective of this study was to examine IL-5 expression in T H2-lymphocytes in smokers with and without COPD ex vivo compared with non-smokers and to evaluate the effects of bacterial endotoxin (lipopolysaccharide, LPS) as well as two drugs often used for treatment of COPD exacerbation, corticosteroids and moxifloxacin. CD4 + lymphocytes were isolated from the peripheral blood of non-smokers (NS; n = 11), current smokers without airflow limitation (S; n = 11) and smokers with COPD (n = 11). Baseline IL-5 release of CD4 + T-lymphocytes was significantly increased in COPD compared to S and NS. After T-cell activation and differentiation into T H2-lymphocytes, IL-5 release increased without differences between the cohorts. LPS reduced IL-5 release of ex vivo generated T H2-lymphocytes without differences in all cohorts. Moxifloxacin and dexamethasone significantly reduced IL-5 release in T H2-lymphocytes in the absence and presence of LPS without differences between groups. In summary, our data indicate that IL-5 might contribute to systemic inflammation in smokers with COPD and that T H2-based immune responses might be suppressed in response to gram-negative bacterial infections independent from smoking and disease status. Dexamethasone and moxifloxacin both have T H2-immunmodulating effects.

Factors affecting revisit of COPD exacerbated patients presenting to emergency department

The primary purpose of this prospective cohort study was to characterize the use of the Emergency Department (ED) in patients with chronic obstructive pulmonary disease (COPD) exacerbations and determine the factors affecting the revisit of COPD patients. This is a prospective cohort study on ambulatory patients with exacerbated chronic bronchitis in an ED setting. Patients included in the study were above 18 years of age, had a previous diagnosis of COPD, and presented to the ED for the treatment of COPD exacerbation. All the information relevant to the study was collected during the patient's visit to the ED. Revisit was defined as an unscheduled visit to an ED or primary physician within 2 weeks of initial ED visit for worsening COPD symptoms. Telephone follow-up was done on all patients at the end of 2 weeks. Variables of 26 revisit cases versus 78 nonrevisit cases were compared. Home oxygen therapy, intensive care admission, previous intubation, increased cough, and the number of ED visits in the previous year were associated with increased risk of revisit in the univariate analysis. Increased cough (odds ratio: 0.232; 95% confidence interval: 0.063-0.853) and the number of ED visits in the previous year (odds ratio: 1.166; 95% confidence interval: 1.005-1.353) were still significant after multivariate analysis. In conclusion, the number of ED visits previous year and increased cough can predict the revisit of a COPD exacerbated patient within 14 days of an ED visit.

Systemic corticosteroids in the treatment of acute exacerbations of chronic obstructive pulmonary disease

The literature was reviewed to determine whether data support current treatment guideline recommendations regarding the use of systemic corticosteroids in the treatment of chronic obstructive pulmonary disease (COPD) exacerbations. Exacerbations of COPD are common and can be detrimental to both patient health and health care costs. Corticosteroids are recommended by consensus guidelines for patients during exacerbations of COPD. Although guidelines make very specific recommendations, clinical data are conflicting and inconsistent. A search of the English-language medical literature was performed, and all randomized, double-blind, placebo-controlled trials or meta-analyses that examined the use of systemic corticosteroids in COPD exacerbations were included. Trials that included nebulized corticosteroids were also included as long as they were compared to a systemic corticosteroid and a placebo. Recommendations regarding the use of systemic corticosteroids are not optimal or completely supported. Data support recommendations if patients are treated on an outpatient basis. However, hospitalized patients might also benefit from higher doses of systemic steroids initially, followed by an oral taper dose. In the treatment of COPD exacerbations, systemic corticosteroids improve airflow limitations, decrease treatment failure rates, decrease the risk of relapse, and may improve symptoms and decrease the length of hospital stay. Because of the risks of adverse effects, the lowest dose and shortest duration of corticosteroid therapy that will provide therapeutic benefit should be chosen. The literature suggests that hospitalized patients should benefit from a higher initial dosage of systemic corticosteroids than the 30-40 mg of i.v. or oral prednisolone for 7-10 days recommended in current guidelines.

Acting on Comparative Effectiveness Research in COPD

COMPARATIVE EFFECTIVENESS RESEARCH (CER) HAS been defined by a report by the Federal Coordinating Council for Comparative Effectiveness as “the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat, and monitor health conditions in ‘real world’ settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision makers, responding to their expressed needs about which interventions are most effective for which patients under specific circumstances.” Comparative effectiveness research uses observational and clinical trial methods to compare different care strategies providedbytypicalhealthcareclinicians,addressingpossibleharms and benefits for heterogeneous patient populations in heterogenous health care settings. In contrast, traditional efficacy research compares treatment alternatives (including no treatmentorplacebo)incarefullyselectedpatientpopulationstreated inidealsettings.Thus,efficacyresearchanswersquestionssuch as“can this interventionwork?”whereasCERposesquestions morebroadly: “which interventionswhentranslated intopracticeimprovecareandincreasethelikelihoodofhealthbenefits?” The study reported by Lindenauer and colleagues in this issue of JAMA comparing the benefits and harms of lowdose oral corticosteroids and high-dose intravenous corticosteroids for patients hospitalized for exacerbations of chronic obstructive pulmonary disease (COPD), as well as an earlier publication from the same group examining the use of antibiotics, provide 2 examples of well-designed observational CER studies. Hospitalizations for COPD exacerbations are common complications associated with high morbidity and cost. Chronic obstructive pulmonary disease affects about 12 million to 24 million persons in the United States alone, leads to more than 500 000 hospitalizations each year, and results in $32 billion in health care expenditures. Further mortality from COPD is increasing, with COPD predicted to become the third leading cause of death in this decade. The efficacy of systemic corticosteroids (vs placebo) for the treatment of COPD exacerbations is well established. A metaanalysisofrandomizedcontrolledtrialsincludingapproximately 1000patientswithCOPDexacerbations (includingabout700 hospitalizedforCOPDexacerbations) foundthatsystemiccorticosteroids are associated with substantial benefit, including a reduction of approximately 50% in the combined end point of treatment failures, suchas treatment intensification, rehospitalization, and death. However, use of systemic corticosteroids was associated with a 2-fold increase in the risk of drug-relatedadverseeffectscomparedwithplacebo, including hyperglycemia, increasedappetite,weightgain, and insomnia. Multiple treatment guidelines recommend systemic corticosteroids for the treatment of COPD exacerbations. Although these guidelines acknowledge that data are insufficient to define the optimal dose or route of systemic corticosteroids, treatment recommendations suggest the use of oral corticosteroids at prednisone equivalent doses of 30 to 40 mg/d rather than higher intravenous doses. Oral corticosteroids are simpler to administer, are highly bioavailable, and therefore are likely to be as effective, and higher doses are more likely to result in adverse events. In this context, the study by Lindenauer et al provides new evidence. The investigators conducted an observational comparative effectiveness study using a registry linking administrative and billing data sets from about 80 000 hospitalizations for COPD exacerbations in more than 400 US hospitals. Hospitalized patients initially admitted to intensive care units were excluded. Illustrating the utility of linked registries, investigators found that clinicians in these real-world settings were much more likely to administer high-dose intravenous systemic corticosteroids (average 600 mg/d of prednisone equivalent) than administer low-dose oral corticosteroids (average60mg/dprednisoneequivalent) as initial therapy(92% and 8%, respectively). Thus, the real-world practice was largely inconsistent with current guideline recommendations to use lower doses of corticosteroids administered orally. Basedonanalysesusingsophisticatedmodeling techniques to control for possible confounding and selection bias, the in-

The appropriateness of the South African Thoracic Society’s guidelines for antibiotic treatment of patients with chronic obstructive pulmonary disease exacerbation in the Universitas Academic Hospital, Bloemfontein

Chronic obstructive pulmonary disease (COPD) is a progressive disease predominantly associated with smoking. Exacerbation of COPD frequently results from respiratory infections. The South African Thoracic Society (SATS) recommends treatment with amoxicillin/ clavulanate, cefuroxime or a fluoroquinolone. The study aimed to determine the appropriateness of these guidelines regarding organisms isolated from sputum of patients with COPD exacerbation at Universitas Academic Hospital, Bloemfontein. A descriptive study was performed. Seventeen hospitalised patients diagnosed with COPD exacerbation from July - October 2007, not treated with antibiotics or corticosteroids or having a respiratory infection four weeks prior to admission, were included. Demographic information (age, gender, area of residence, smoking history) was obtained from patients' files, as well as FEV 1 values, FEV 1 /FVC ratio, infection markers, microorganisms isolated from sputum and their antibiotic susceptibility profiles. Nine patients were male and eight female, with a median age of 72 years (range 53 - 82 years). Twelve (70.6%) patients resided in the Bloemfontein urban area. Three patients (18.8%) never smoked, 25% smoked previously and 56.3% were active smokers (median pack years 45 years, range 17 - 70 years). Eight patients had culture-positive sputum specimens. Haemophilus influenzae, H. parainfluenzae, Streptococcus pneumoniae, Staphylococcus aureus, Pseudomonas aeruginosa, Serratia marcescens and Escherichia coli were isolated from sputa. With the exception of S. aureus, all isolates were susceptible to at least one antibiotic recommended by SATS. The guidelines proposed by SATS for treatment of COPD exacerbation were appropriate and would be effective in the management of these patients in the Free State region.

COPD guidelines in relation to infections: a critical analysis

Educational aims 1. To define the importance of exacerbations in COPD and chronic bronchitis. 2. To assess current guidelines for the treatment of COPD exacerbations. 3. To outline current antibiotic treatments and treatment periods for exacerbations. Summary Chronic obstructive pulmonary disease (COPD) exacerbations have been associated with an increased risk of mortality and currently available therapies for exacerbations show only limited beneficial effects. Bacterial infections caused by pathogens are the predominant cause of acute exacerbations in COPD and chronic bronchitis. Current guidelines suggest a correlation between forced expiratory volume in 1 s (FEV1) and the type of infecting pathogen and that purulence of sputum is one of the most important factors associated with the presence of a bacterial infection. Antibiotics are recommended for patients with exacerbations and sputum purulence. However, resistance to antibiotics is increasing, especially in southern Europe. To reduce the risk of resistance, shorter treatment periods can be implemented for patients with mild-to-moderate exacerbations.

Airways inflammation and treatment during acute exacerbations of COPD

Inflammation is a core feature of acute chronic obstructive pulmonary disease (COPD) exacerbations. It is important to focus on inflammation since it gives insight into the pathological changes causing an exacerbation, thereby possibly providing directions for future therapies which modify inflammation. To provide a cell-by-cell overview of the inflammatory processes during COPD exacerbations. To evaluate cell activation, and cytokine production, cellular interactions, damaging effects of inflammatory mediators to tissue, and the relation to symptoms at the onset of COPD exacerbations. To speculate on future therapeutic options to modify inflammation during COPD exacerbations. During COPD exacerbations, there is increased airway wall inflammation, with pathophysiological influx of eosinophils, neutrophils, and lymphocytes. Although links have been suggested between the increase in eosinophils and lymphocytes and a viral etiology of the exacerbation, and between the increase in neutrophils and a bacterial aetiology, these increases in both inflammatory cell types are not limited to the respective aetiologies and the underlying mechanisms remain elusive. Further research is required to fully understand the inflammatory mechanisms in the onset and development of COPD exacerbations. This might make inflammatory pathway-specific intervention possible, resulting in a more effective treatment of COPD exacerbations with fewer side effects.

Short course of antibiotic treatment in acute exacerbations of COPD

Antibiotics are commonly prescribed empirically for lower respiratory infections. Infections of the airway mucosa are much more common than pneumonia and the illness they cause is less severe because the...

Inspiratory capacity and forced expiratory volume in the first second in exacerbation of chronic obstructive pulmonary disease

Periodic exacerbations of symptoms are the major cause of morbidity, mortality and health care costs in patients with chronic obstructive pulmonary disease (COPD). Dyspnea is the major factor affecting the comfort of patients in the exacerbation of COPD. In this study, we aimed to compare the value of forced expiratory volume in the first second (FEV(1)) and inspiratory capacity (IC) measured before and after treatment in exacerbations and in the improvement in dyspnea. Eighty-seven patients (male/female, 80/7; mean age, 63 +/- 7) with COPD exacerbation were included in this study. All subjects underwent spirometric tests on the first day and at the end of treatment. The subjects were asked to quantify the sensation of dyspnea that was described to them as a nonspecific discomfort associated with the act of breathing. The patients quantified dyspnea by pointing to a score on a large Borg scale from 0 to 10 arbitrary units. In the beginning and at the end of treatment, forced vital capacity (FVC), FEV(1), forced expiratory flow rate between 25% and 75% of FVC (FEF25-75), peak expiratory flow rate (PEF), IC and Borg score (BS) values were compared. After treatment of COPD exacerbations, FEV(1), FEF25-75, PEF and IC significantly increased, and the BS significantly decreased compared to the initial values. The increase in IC was more significantly correlated with the improvement in BS compared with FEV(1). Admission and discharge day BS was negatively correlated with FEV(1), FEF25-75 and IC. We have shown a more dramatic improvement in IC compared with FEV(1) in patients treated as a result of acute exacerbation of COPD. These data suggest that IC may be more useful than FEV(1) during acute exacerbation of COPD. Moreover, IC better reflects the severity of dyspnea in these patients.

Clinical and economic analysis of antimicrobial therapy of chronic obstructive pulmonary disease exacerbations

The aim of the study was to analyse the clinical and economic indicators of the treatment of acute exacerbations of chronic obstructive pulmonary disease (COPD). The study focused specifically on antimicrobial therapy and the use of fluoroquinolones in the management of exacerbations. Data on the consumption of antibiotics to treat exacerbations in ambulatory care were derived from IMS Health. Also, an observational, retrospective analysis was carried out of patients who entered the clinical pathway for COPD exacerbations in University Hospitals Leuven. IMS Health data showed that there is a trend towards the increasing use of broad-spectrum penicillins and fluoroquinolones, and decreasing use of tetracyclines in the treatment of COPD exacerbations in ambulatory care in Belgium in the first half of the 2000s. The observational analysis enrolled 267 patients who were hospitalised between October 2000 and October 2005 to manage 359 exacerbations according to the clinical pathway. Median length of stay per exacerbation amounted to 10 days. Mean quality of life associated with an exacerbation was 74 using the Chronic Respiratory Disease Questionnaire. Median costs of hospital treatment amounted to euro5514 (third-party payer reimbursement and patient co-payment) per exacerbation. Treatment costs were driven by hospital stay (75% of total costs), diagnostic and laboratory tests (20%) and medication (5%). Antibiotics played a role in the hospital management of 75% of exacerbations. Fluoroquinolones were used to treat more severe exacerbations. Treatment of acute exacerbations of COPD imposes a significant clinical and economic burden on patients, the healthcare system and the society.

Relationship between respiratory symptoms and medical treatment in exacerbations of COPD

Exacerbations of chronic obstructive pulmonary disease (COPD) can be defined symptomatically or by healthcare contacts, yet the relationship between these events is unknown. Data were collected during a 1-yr study of the budesonide/formoterol combination in COPD patients, where exacerbations, defined by increases in treatment, were compared with daily records of respiratory symptoms, rescue medication use and peak expiratory flow (PEF). The relationship between changes in these variables and the medical event was examined using different modelling approaches. Data from the first exacerbation treated with oral corticosteroids and/or antibiotics and/or hospitalisation (event based) were available in 468 patients. Patients exacerbating were significantly more breathless and more likely to report cough than healthy patients, but did not differ in baseline spirometry. Exacerbations defined by changes in individual symptoms were only weakly related to event-based exacerbations; however, defined with 63% of such events being predicted from symptom changes. Changes in rescue medication use or PEF were poor predictors of event-based exacerbations. The mean peak change in symptoms was closely related to the onset of therapy. In conclusion, event-based exacerbations are a valid way of identifying acute symptom change in a chronic obstructive pulmonary disease population. However, daily symptom monitoring is too variable using the current diary cards to make individual management decisions.

Management of Atrial Fibrillation in Patients With Chronic Obstructive Pulmonary Disease

Atrial fibrillation is the cardiac arrhythmia encountered most often in clinical practice. It is triggered by many conditions such as thyroid dysfunction, cardiac disease, alcohol, and pulmonary disease. Patients with chronic obstructive pulmonary disease (COPD) are susceptible to many insults that can lead to an acute deterioration superimposed on chronic disease. Changes in blood gases, abnormalities in pulmonary functions, and hemodynamic changes resulting from pulmonary hypertension can lead to the development of atrial fibrillation. Atrial fibrillation and COPD frequently coexist and complicate treatment of both conditions. The treatment of COPD exacerbation may include beta-adrenergic agonist and theophylline, which can precipitate atrial fibrillation with rapid ventricular response. Pharmacologic and electrical cardioversion may be ineffective in the management of atrial fibrillation in patients with COPD until respiratory decompensation has been corrected. This article focuses on the management of atrial fibrillation in patients with COPD.

Treatment of COPD exacerbations

PREVIEWAcute exacerbations of chronic obstructive pulmonary disease (COPD) pose a continuing threat to quality and length of life in affected patients. As the prevalence of the disease increases, early diagnosis and appropriate interventions become even more crucial. In this article, Dr Blanchard provides a concise overview of risk factors for exacerbations of COPD, current pharmacologic options, and more advanced treatment measures for patients with acute respiratory failure.