Reprints are not available from the author. Stephens MB, Donaldson GC, Fourgaut G, Angus RM, Walters JA, Hanania NA, Chacko E, Short-course antibiotic treatment in acute exacerbations of chronic bronchitis and COPD: a meta-analysis of double-blind studies. Evans N, Management of acute exacerbations of COPD in 2020 Mona Bafadhel MBChB, PhD, FRCP ... •Long term outcomes 3. Steroids help resolve COPD exacerbations, and probably save lives. Chapman KR. Prins JM, 2. Loke YK. 20. 10. Inhaled corticosteroids in patients with stable chronic obstructive pulmonary disease: a systematic review and meta-analysis [published correction appears in JAMA. 1987;91(6):804–807. Accessed January 11, 2010. CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease. Standards for the Diagnosis and Management of Patients with COPD. Decramer M, Donaldson GC, Kerstjens HA, Oral prednisolone is equivalent to intravenous prednisolone in decreasing the risk of treatment failure in patients with COPD. 3. Nici L, Singh S, Sethi S, Celli B, Appropriate management of these exacerbations can have a significant impact on the patient’s morbidity and mortality; therefore, it is important that evidence-based regimens are utilized in these patients. Gibson PG, corrected] An RCT comparing oral and intravenous prednisolone in equivalent dosages (60 mg daily) showed no difference in lengths of hospitalization and rates of early treatment failure.22, Because oral corticosteroids are bioavailable, inexpensive, and convenient, parenteral corticosteroids should be reserved for patients with poor intestinal absorption or comorbid conditions that prevent safe oral intake (e.g., decreased mental status, vomiting).5,6 Inhaled corticosteroids have no role in the management of an acute exacerbation.8, One half of patients with COPD exacerbations have high concentrations of bacteria in their lower airways.6,23 Cultures often show multiple infectious agents, including Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Mycoplasma pneumoniae, and viruses.6,23, The use of antibiotics in moderately or severely ill patients with COPD exacerbations reduces the risk of treatment failure and death.24 Antibiotics may also benefit patients with mild exacerbations and purulent sputum.5 The optimal choice of antibiotic and length of use are unclear. of COPD (2020 Report), which aims to provide a non-biased review of the current evidence for the assessment, diagnosis and treatment of patients with COPD that can aid the clinician. for the American Thoracic Society, European Respiratory Society Task Force on Outcomes of COPD. Invasive mechanical ventilation is needed if the patient cannot tolerate NIPPV; has worsening hypoxemia, acidosis, confusion, or hypercapnia despite NIPPV; or has severe comorbid conditions, such as myocardial infarction or sepsis.6 Worsening hypercarbia and acidosis herald respiratory failure. Anzueto A, Inpatient mortality for COPD exacerbations is 3 to 4 percent.9 Patients admitted to the intensive care unit have a 43 to 46 percent risk of death within one year after hospitalization.9. Wood-Baker R. 16. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. 2008;359(15):1543–1554. Ward E, de Jong YP, The NHS protocol for management of COPD exacerbations in primary care states that bronchodilators and corticosteroids are the mainstay of exacerbation treatment. 2007;146(8):545–555. Donohue JF, Contemporary management of acute exacerbations of COPD: a systematic review and metaanalysis. Although several studies have shown that both parenteral and oral steroids are effective and GOLD guideline recommends use of oral steroids at a dose of 30–40 mg/day, very little data exists as to whether any route of admininstration (parenteral vs oral) or any dose is more effective and/or safer. Camargo CA. Comparison of domiciliary nebulized salbutamol and salbutamol from a metered-dose inhaler in stable chronic airflow limitation. of COPD exacerbations with oral prednisone reported improvements in FEV 1 at day 3, with further improve-ments at day 10. On hospitalization, corticosteroids are generally administered IV. Several therapies lack adequate evidence for routine use in the treatment of COPD exacerbations, including mucolytics (e.g., acetylcysteine [formerly Mucomyst]), nitric oxide, chest physiotherapy, antitussives, morphine, nedocromil, leukotriene modifiers, phosphodiesterase IV inhibitors (drug class not available in the United States), and immunomodulators (e.g., OM-85 BV, AM3 [neither drug available in the United States]).6,7  Table 5 summarizes the treatment options for acute COPD exacerbations.5,6,8,9,18,25, Antibiotic, broad spectrum (e.g., amoxicillin/clavulanate [Augmentin], macrolides, second- or third-generation cephalosporins, quinolones), Consider if sputum is purulent or after treatment failure, Use if local microbial patterns show resistance to narrow-spectrum agents, Decreases risk of treatment failure and mortality compared with narrow-spectrum agents, Antibiotic resistance, diarrhea, yeast vaginitis; side effects specific to the antibiotic prescribed, Amoxicillin/clavulanate: 875 mg orally twice daily or 500 mg orally three times daily for 5 days, Levofloxacin (Levaquin): 500 mg daily for 5 days, Antibiotic, narrow spectrum (e.g., amoxicillin, ampicillin, trimethoprim/sulfamethoxazole [Bactrim, Septra], doxycycline, tetracycline), Use if local microbial patterns show minimal resistance to these agents and if patient has not taken antibiotics recently, Believed to decrease mortality risk, but has not been tested in placebo-controlled trials, Amoxicillin: 500 mg orally three times daily for 3 to 14 days Doxycycline: 100 mg orally twice daily for 3 to 14 days, Anticholinergic, short acting (e.g., ipratropium [Atrovent]), May add to beta agonist; if patient is already taking an anticholinergic, increase dosage, Ipratropium: 500 mcg by nebulizer every 4 hours as needed; alternatively, 2 puffs (18 mcg per puff) by MDI every 4 hours as needed*, Beta agonist, short acting (e.g., albuterol, levalbuterol [Xopenex]), Headache, nausea, palpitations, tremor, vomiting, Albuterol: 2.5 mg by nebulizer every 1 to 4 hours as needed, or 4 to 8 puffs (90 mcg per puff) by MDI every 1 to 4 hours as needed*, Consider using oral corticosteroids in moderately ill patients, especially those with purulent sputum, Use oral corticosteroids if patient can tolerate; if not suitable for oral therapy, administer intravenously, Decreases risk of subsequent exacerbation, rate of treatment failures, and length of hospital stay Improves FEV1 and hypoxemia, Gastrointestinal bleeding, heartburn, hyperglycemia, infection, psychomotor disturbance, steroid myopathy, Oral prednisone: 30 to 60 mg once daily Intravenous methylprednisolone (Solu-Medrol): 60 to 125 mg 2 to 4 times daily, Use if patient cannot tolerate NIPPV; has worsening hypoxemia, acidosis, confusion, or hypercapnia despite NIPPV; or has comorbid conditions such as myocardial infarction or sepsis, Decreases short-term mortality risk in severely ill patients, Aspiration, cardiovascular complications, need for sedation, pneumonia, Titrate to correct hypercarbia and hypoxemia, Use in patients with worsening respiratory acidosis and hypoxemia when oxygenation via high-flow mask is inadequate, Improves respiratory acidosis and decreases respiratory rate, breathlessness, need for intubation, mortality, and length of hospital stay, Expensive, poorly tolerated by some patients, Use in patients with hypoxemia (PaO2 less than 60 mm Hg), Titrate to PaO2 > 60 mm Hg or oxygen saturation ≥ 90 percent. et al., Donaldson GC, Manta KG, Heaton RW, Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. If multiple recent courses of high dose oral steroids (e.g. Non steroid responsive. Influenza vaccine for patients with chronic obstructive pulmonary disease. Moxham J. Yew KS. Clin Ther. Chacko E, exacerbations of COPD, says there is insufficient ev-idence to show that rescue packs in themselves are safe and cost effective at reducing hospital admis-sions. COPD Exacerbation. 28. Postma DS, 17. Treatment of acute exacerbations of COPD with a shorter course of systemic corticosteroids (seven or fewer days) is likely to be as effective and safe as … 2008;102(suppl 1):S3–S15. Hospitalization for AECOPD is accompanied by a rapid decline in health status with a high risk of mortality or other negative outcomes such as need for endotracheal intubation or … Grotjohan HP, The exacerbations of copd path for the chronic obstructive pulmonary disease pathway. Since the median lengthof hospitalization for an exacerbation of COPD is 7 to 9days. Anevidence-based approach to treating COPD exacerbations would suggestthat the appropriate duration of therapy is in the range of 5 days to 2weeks. Søyseth V. Ram FS, Version 1.2. The choice of antibiotic should be guided by local resistance patterns and the patient's recent history of antibiotic use. But steroids cause hyperglycemia, which can certainly be harmful, and regular (long-term) use of corticosteroids is linked to higher mortality in people with COPD. Identify which patients with an acute exacerbation of COPD should receive antibiotics. Chien JW, Davies L, Brown C, 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. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Wood-Baker RW, Chest radiography is appropriate in hospitalized patients and can guide treatment by revealing comorbid conditions such as congestive heart failure, pneumonia, and pleural effusion. Wedzicha JA. Walters EH. Use of B-type natriuretic peptide in the management of acute dyspnea in patients with pulmonary disease. Wood-Baker RW, Jeffries DJ, Rowe BH, Copyright © 2020 American Academy of Family Physicians. Trends in the leading causes of death in the United States, 1970–2002. et al. In this study, 210 hospitalized adults older than 40 years with COPD and at least 24 hours of exacerbation were randomized to receive 5 days of oral or IV prednisolone (60 mg daily) followed by a tapering oral dose. Snow V, 5(March 1, 2010) The exacerbations of copd path for the chronic obstructive pulmonary disease pathway. In particular, this recommendation is made for patients with COPD who have a history of at least 1 exacerbation in the past year that required antibiotics, oral steroids, or hospitalization. 23. Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial. Weitzenblum E. Suissa S. McCrory DC, Systemic corticosteroids are a critical therapy for COPD exacerbations, ... who require assisted ventilation.” 6 This knowledge gap has occurred because the majority of large studies evaluating steroid dosing during COPD exacerbations have specifically avoided studying patients requiring assisted ventilation (e.g., those needing invasive or noninvasive mechanical ventilation). Poole PJ, Timmer W, Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide. Management of acute exacerbations of COPD: a summary and appraisal of published evidence. Uil SM, Correspondence to: Roger S. Goldstein, MB, ChB, FCCP, Division of Respiratory Medicine, West Park Hospital, 82 Buttonwood Ave, Toronto, Ontario M6M 2J5, Canada; It is now 20 years since Richard Albert and colleagues. Anevidence-based approach to treating COPD exacerbations would suggestthat the appropriate duration of therapy is in the range of 5 days to 2weeks. Laule-Kilian K, Contact Treatments •What the guidelines say •What the evidence shows 4. N Engl J Med. 2005;294(10):1255–1259. 19. 1. The necessary length of hospital stay for chronic obstructive pulmonary disease. 2008;300(12):1439–1450. Fourgaut G, Targeting the COPD exacerbation. 31. 8. Yew KS. Steroid responsive (Overlaps with asthma) – suspect if has eosinophilia on work up FBC (<0.1 non steroid responsive, 0.1 or higher rx as steroid responsive) OR evidence of reversibility on spiro (>400mls) or proven diurnal variation. Time course and recovery of exacerbations in patients with chronic obstructive pulmonary disease. Importance: International guidelines advocate a 7- to 14-day course of systemic glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease (COPD). Speelman P, Maintenance use of oral corticosteroid therapy in … 3. Ernst P, Inhaled corticosteroid use in chronic obstructive pulmonary disease and the risk of hospitalization for pneumonia. afpserv@aafp.org for copyright questions and/or permission requests. 2008;63(5):415–422. 11. Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Korbila IP, 7. Barnes NC. Explain recent evidence supporting a shorter duration of steroid treatment for acute exacerbations of COPD. New strains of bacteria and exacerbations of chronic obstructive pulmonary disease. Dasenbrook EC, Palda VA, Methylxanthines for exacerbations of chronic obstructive pulmonary disease. X2.2.2 Systemic corticosteroids for treatment of exacerbations Systemic corticosteroids reduce the severity of and shorten recovery from exacerbations (Walters 2014) [evidence level I, strong recommendation]. We are moving towards a clearer understanding of the dose, duration, and effectiveness of systemic steroids for managingacute exacerbations of COPD. Recommendations. Siempos II, Thorax. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.xml. Inhaled anticholinergics and risk of major adverse cardiovascular events in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Faller M, / Chronic Obstructive Pulmonary Disease (COPD) is currently the fourth leading cause of death in the world1 but is projected to be the 3rd leading cause of death by 2020. This contradicted the prevailing GOLD guidelines at the time, which suggested 10 days of steroids for COPD exacerbations. Get Permissions, Access the latest issue of American Family Physician. The NHS protocol for management of COPD exacerbations in primary care states that bronchodilators and corticosteroids are the mainstay of exacerbation treatment. Postma DS, Methylxanthines, once considered essential to treatment of acute COPD exacerbations, are no longer used; toxicities exceed benefits. Chest. Murphy TF. 2008;31(2):416–469. 13. Loke YK. A 4-year trial of tiotropium in chronic obstructive pulmonary disease. Eur Respir J. Increasing microbial resistance has prompted some physicians to treat exacerbations with broad-spectrum agents, such as second- or third-generation cephalosporins, macrolides, or quinolones. 1. El Moussaoui R, Remember steroid helping in an exacerbation is not proof of long term steroid responsive copd. The following is a reasonable approach: (#1) Start with 125 mg IV methylprednisolone in the emergency department. Management: Protocols. New official guidelines have been published by the American Thoracic Society (ATS) for the treatment of chronic obstructive pulmonary disease (COPD).. Furberg CD. 35. Turnock AC, Monsó E, Suissa S. Kessler R, Gan WQ, Hurd S, Walters JA, Short-course antibiotic treatment in acute exacerbations of chronic bronchitis and COPD: a meta-analysis of double-blind studies. Randomized controlled trials have demonstrated the effectiveness of multiple interventions. Antibiotics should be used in patients with moderate or severe COPD exacerbations, especially if there is increased sputum purulence or the need for hospitalization. 2009;(1):CD001288. for the Canadian Thoracic Society/Canadian Respiratory Clinical Research Consortium. 24. Enthusiasm for using steroids in the management of COPD exacerbationshas persisted, notwith standing that the evidence for efficacy waslimited to an improvement in spirometry. for the Global Initiative for Chronic Obstructive Lung Disease. Patients with chronic obstructive pulmonary disease (COPD) may experience an acute worsening of respiratory symptoms that results in additional therapy; this event is defined as a COPD exacerbation (AECOPD). for the EFRAM Investigators. By continuing you agree to the. Respir Med. Jenkins SC, Am J Respir Crit Care Med. 2009;24(4):457–463. 2009;169(3):219–229. Severe exacerbations are related to a significantly worse survival outcome. 2008;78(1):87–92. The most widely used drug is albuterol 2.5 mg by nebulizer or 2 to 4 puffs (100 mcg/puff) by metered-dose inhaler every 2 to 6 hours. for the UPLIFT Study Investigators. / Journals Good response to initial therapy (β-agonists, iaprotropium, steroids). Drs. All of the published studies have excluded patients who receivedsystemic steroids with in the preceding month. Omland T, Chest. people with COPD should be given a self-manage-ment plan that encourages them to respond promptly to the symptoms of an exacerbation. Bryson CL, ANN E. EVENSEN, MD, University of Wisconsin School of Medicine and Public Health, Verona, Wisconsin. Calverley PM. Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. Quon BS, Short courses of oral corticosteroids are commonly used for acute exacerbations of chronic obstructive pulmonary disease (COPD). Uil SM, Rodriguez-Roisin R, Fan E. Donaldson GC, Drummond MB, Comparison of first-line with second-line antibiotics for acute exacerbations of chronic bronchitis: a metaanalysis of randomized controlled trials. 2008;30(spec no):989–1002. Respir Med. et al., Cazzola M, Rabe KF, Snow V, Hanania NA, Monsó E, Moxham J. If the patient is stable and can use a metered dose inhaler, there is no benefit to using nebulized bronchodilators.28 Patient education may improve the response to future exacerbations29; suggested topics include a general overview of COPD, available medical treatments, nutrition, advance directives, and advice about when to seek medical help. Walters JA, Oral or IV prednisolone in the treatment of COPD exacerbations: a randomized, controlled, double-blind study. Noninvasive positive pressure ventilation (NIPPV) is indicated if adequate oxygenation or ventilation cannot be achieved using a high-flow mask.15 Patients requiring NIPPV should be monitored continuously for decompensation. Cochrane Database Syst Rev. Use: For the treatment of acute exacerbations of multiple sclerosis. COPD Exacerbation This accelerated treatment protocol requires frequent reassessment . Department of Veterans Affairs Cooperative Study Group. Stanbrook and Goldstein are from the Division of Respiratory Medicine, University of Toronto, Toronto, Ontario, Canada. Rowe BH, Jenkins SC, Mottur-Pilson C, Oral corticosteroids are likely beneficial, especially for patients with purulent sputum. 38. Vandemheen KL, Change in volume, color, or tenacity of sputum, At least three exacerbations in the previous 12 months, Marked increase in symptoms or change in vital signs, Medical comorbidities (especially cardiac ischemia, congestive heart failure, pneumonia, diabetes mellitus, or renal or hepatic failure), Severe baseline COPD (FEV1/FVC ratio less than 0.70 and FEV1 less than 50 percent of predicted). Søyseth V. 15. A multicenterrandomized trial by the Veterans Affairs Cooperative StudyGroup. Ernst P, Good response to initial therapy (β-agonists, iaprotropium, steroids). Recommended diagnostic evaluation of an exacerbation depends on its severity (Table 4).5,8,9,12,13 Pulse oximetry should be performed in all patients. for the EFRAM Investigators. The evidence base for management of acute exacerbations of COPD: clinical practice guideline, part 1. Poole PJ, 2007;176(2):162–166. 1999;354(9177):456–460. for the Global Initiative for Chronic Obstructive Lung Disease. Au DH, et al. Palda VA, Cochrane Database Syst Rev. US Pharm. for the UPLIFT Study Investigators. Exacerbation Guidelines. JAMA. Usual Adult Dose for Asthma - Acute. Diagnosis of chronic obstructive pulmonary disease. Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial. Davies et al3 did measure FEV 1 daily from the start of steroid treatment and noted that the improvement in FEV 1 reached a plateau after 5 days, with little further change at discharge or at 6 weeks. Lascher S, Randomized controlled trials have demonstrated the effectiveness of multiple interventions. Sin DD. Singh S, Hospitalization for AECOPD is accompanied by a rapid decline in health status with a high risk of mortality or other negative outcomes such as need for endotracheal intubation or … Sin DD. Cochrane Database Syst Rev. 2007;176(6):532–555. Steroid inhalers are commonly prescribed, but there is uncertainty over how beneficial they are to all patients living with COPD, and steroid inhalers are expensive and have been associated with a range of adverse effects including an increased risk of pneumonia. et al., If the patient cannot be adequately oxygenated, complications, such as pulmonary embolism or edema, should be considered.6 Carbon dioxide retention is possible in moderately and severely ill patients; therefore, ABG should be measured 30 to 60 minutes after initiating oxygen supplementation. 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