COPD Exacerbation:Practical Evidence-based

Strategies

Daniel D. Dressler, MD, MScDirector of Education

Section of Hospital MedicineIM Associate Residency DirectorAssistant Professor of Medicine

Emory University School of MedicineDaniel.Dressler@emory.edu

Society of Hospital Medicine Annual MeetingSan Diego, California

April 4, 2008

What will NOT be discussed during this session…

• Knock-out mice • Pathophysiology

• Disease Burden

• Precipitants

• Differential

• Adm criteria

Objectives

• By the end of this session, participants will be able to:

• Locate, Evaluate and Interpret the highest level of medical evidence for management of COPD Exacerbations

Summary of RCT data

RCT data

Observational Data

Definition of COPD

Progressive Pulmonary airflow limitation that is not completely reversible

Abnormal inflammatory response of the lung to noxious particles or gases

Preventable and Treatable Extrapulmonary effects may contribute to

disease severityWeight lossNutritional abnormalitiesSkeletal muscle dysfunction

Classification of COPD Severity

by SpirometryStage I: Mild FEV1/FVC < 0.70

FEV1 > 80% predicted

Stage II: Moderate FEV1/FVC < 0.70 50% < FEV1 < 80% predicted

Stage III: Severe FEV1/FVC < 0.70 30% < FEV1 < 50% predicted

Stage IV: Very Severe FEV1/FVC < 0.70 FEV1 < 30% predicted or

FEV1 < 50% predicted plus chronic respiratory failure

Exacerbation of COPD: DefinitionAcute change in baseline dyspnea, cough, and/or sputum beyond normal day-to-day variations

May warrant a change in regular medication(s)

Exacerbations: Mortality

• Hospitalized

– Inpatient mortality (non-ICU): 2.5%* (1 in 40)

– 3-month mortality after hospitalization for exacerbation: 14% (1 in 7)

– If pCO2>50:

• 6 month mortality = 33%

• 12 month mortality = 43%

• ICU

– 17% in-hospital (1 in 6)

– 26% in-hospital if intubated* (1 in 4)

– 45% 1-year mortality (1 in 2)

*Patil SP, et al. Arch Intern Med. 2003.

DIAGNOSIS

• Exacerbations: CLINICAL Diagnosis

• Spirometry (PFTs and/or Peak Flows)

– No demonstrated value in setting of COPD exacerbation

– Useful only in the outpatient diagnosis of stable COPD

– DIFFERENT for Asthma patients, where spirometry is useful in the setting of stable asthma and asthma exacerbation

• Assess Severity!!

Case: Mr. BH

• Mr. BH is a 63 year old portly Southern Gentleman with h/o severe COPD (i.e. baseline FEV1 30 to 50% predicted) admitted from the ED with 3 days of SOB, increased cough and clear sputum production. + exposure to grandkids with ‘colds’

Case: Mr. BH

• PMH:

1.COPD

• PFTs: FEV1 32% predicted (FEV1/FVC 60%)

• baseline pCO2 55

2.CASHD, s/p MI 12/2007

• Preserved cardiac function (EF 60%)

3.HTN

4.Secondary Pulmonary HTN (mild)

Case: Mr. BH

• Medications on admission:

– ASA

– Albuterol MDI prn

– Carvedilol CR 20mg daily

– Lisinopril 10mg daily

– prn SL NTG

• SH: former town mayor, 60 pack-year Tob use, quit 10 years ago, enjoys working on his white convertible cadilac

Case: Mr. BH

Physical Exam

• VS: BP 150/90, HR 110 (reg), RR 28, T 38.1

• Mild to Mod increased WOB, RR 28, alert.

• Lungs: significant bilat inspiratory and expiratory wheezes

• Ext: 1+ to 2+ edema bilat

Studies

• CXR: Chronic changes, hyperinflation

• ABG:

– pH 7.36

– pCO2 58

– pO2 64 on 2L O2 NC

• Other labs: Cr 1.4, Troponin-I: 0.09

Question #1

Pharmacologic Therapies

Question #1: Pharmacologic Therapies in COPD Exacerbation

• Which pharmacologic therapies are supported by high-level studies (RCTs) demonstrating their benefit in COPD exacerbation to improve outcomes (select all that apply)?

A. Inhaled Bronchodilators

B. Methylxanthine Bronchodilators

C. Oxygen

D. Systemic Steroids

E. Acupuncture, Aromatherapy, Massage*

*According to healingdeva.com !!

The Evidence: Pharmacologic Therapies for COPD ExacerbationBRONCHODILATOR THERAPIES

Inhaled Bronchodilators

• Short-acting inhaled ß2 agonist BDs recommended by guidelines (Evidence A)*

– Outcomes: Main benefit on symptoms and FEV1

• 5 RCTs suggest ß2 agonists similar efficacy to anticholinergic BDs on FEV1**

– Fewer side effects with anticholinergics agents alone

• Some patients benefit from adding a 2nd bronchodilator after maximum dose** of the initial bronchodilator has been reached

• Oral and injected bronchodilators NOT as effective**

• No clinical studies of long-acting inhaled BDs during exacerbation

*American Thoracic Society (ATS), European Respiratory Society (ERS), National Institute for Clinical Excellence (NICE/Thorax), GOLD (Global Initiative for Chronic Obstructive Lung Disease)

** Bach PB, et al. Ann Intern Med 2001. 134: 600-620.

The Evidence: Pharmacologic Therapies for COPD ExacerbationBRONCHODILATOR THERAPIES

Methylxanthine Systemic Bronchodilators

• Meta-analysis summary

• 4 RCTs, 169 total patients

• Evaluation in patients treated in EDs or inpatient for exacerbations of COPD

• Relevant Outcomes:

– Return to ED, Symptoms, Arrhythmias

The Evidence: Pharmacologic Therapies for COPD ExacerbationBRONCHODILATOR THERAPIES

Methylxanthine Bronchodilators: Efficacy

ED Return Visits within 1 wk Symptom Scores

Barr RG, et al. BMJ 2003. 327: 643-48.

The Evidence: Pharmacologic Therapies for COPD ExacerbationBRONCHODILATOR THERAPIES

Methylxanthine Bronchodilators: Adverse Effects

Arrhythmias/Palpitations

Barr RG, et al. BMJ 2003. 327: 643-48.

The Evidence: Pharmacologic Therapies for COPD Exacerbation

OXYGEN

• “Controlled oxygen therapy” recommended by GOLD Guidelines (no evidence level provided)

– Flow-controlled systems (e.g. Venturi mask) preferred

• Indicated for hypoxemic patients (PaO2 < 60)

– Give just enough to relieve hypoxemia

• Monitor closely for signs of hypercarbia and respiratory failure (i.e. ABG 30 – 60 min after initiation of new O2 rx)

What about Steroids…

The Evidence: Pharmacologic Therapies for COPD ExacerbationSYSTEMIC CORTICOSTEROIDS

• Oral or IV glucocorticosteroids recommended in hospital management of COPD exacerbations (Evidence A)*

– Improve symptoms and FEV1* (based on 6 RCTs**)

• 30-40 mg prednisolone daily x 7-10 days is effective and safe (Evidence C)*

– No more than 2 weeks of systemic rx necessary***

• No role for inhaled corticosteroids in acute exacerbation of COPD (no studies to date*)

*Global Initiative for Chronic Obstructive Lung Disease (“GOLD”). NIH/NHLBI; April 2001, updated May 2007. NIH Publication 2701. Available at: www.goldcopd.com

** Bach PB, et al. Ann Intern Med 2001. 134: 600-620.***Niewoehner DE, et al. N Engl J Med 1999. 340: 1941-47.

COPD: Systemic Steroids on Rx Failure

Figure: Kaplan-Meier Estimates of the Rate of First Treatment Failure at Six Months, According to Treatment Group (271 patients)

Niewoehner DE, et al. N Engl J Med 1999. 340: 1941-47. ACP Journal Club 2000. 132(1): 14.

COPD Exac: Systemic Steroids effects onA. FEV1 after BD, and B. LOS

A. FEV1 after BD (p<0.0001)

B. LOS (p = 0.039)

RCT data, 56 patients

Davies L, et al. Lancet 1999; 354: 456-60.

Question #2

(enough with the easy stuff…)

Case (continued)Question #2

• Admission orders written…

• …medical student presentation…reports that she witnessed significant purulent sputum production while interviewing the patient for 90 minutes.

• Question: Are there other medical therapies we should add to Mr. BH’s regimen (supported by high-level evidence)?

A. Mucolytics

B. Chest Physiotherapy

C. Antibiotics

D. Sildinafil/Viagra for pulmonary HTN

(…oops, contraindicated with his nitrate therapy)

The Evidence for Mucolytics…

The Evidence: Pharmacologic Therapies for COPD Exacerbation

MUCOLYTIC AGENTS

• 5 RCTs of Mucolytic/Mucokinetic agents in the setting of COPD Exacerbations did NOT demonstrate shortening of disease course, but may improve symptoms*

• However, outpatient use of mucolytics in COPD patients may reduce number of exacerbations…

*Bach PB, et al. Ann Intern Med 2001. 134: 600-620.

Reduces mean number of exacerbations per subject per month (weighted mean difference, and 95% confidence intervals)*No effect on lung functionPoole, P. et al. BMJ 2001;322:1271

Mucolytic Agents in Chronic COPD:Effect on Exacerbations

What about Pulmonary Toilet?

The Evidence: Therapies for COPD Exacerbation

CHEST PHYSIOTHERAPY

• Mechanical percussion of the chest by PTs or RTs is ineffective (or detrimental)

• No change or decrease in FEV1

• Therefore: NO Pulmonary Toilet!

*Based on 3 RCTs and 1 observational study

*Bach PB, et al. Ann Intern Med 2001. 134: 600-620.

The Evidence: Pharmacologic Therapies for COPD Exacerbation

ANTIBIOTICS• Antibiotics indicated for exacerbation…

– COPD Exacerbation with 3/3 ‘cardinal symptoms’: increased dyspnea, increased sputum volume, increased sputum purulence (Evidence B)*

– COPD Exacerbation with 2/3 ‘cardinal symptoms’ that includes increased sputum purulence (Evidence C)*

• Antibiotics indicated for hospitalized exacerbation…?

*GOLD Initiative Guidelines

The Evidence: Antibiotic vs Placebo—Outcome: Mortality

RR = 0.23 (0.10, 0.52), NNT = 8Ram FSF, et al. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004403. DOI: 10.1002/14651858.DC004403.pub2.

The Evidence: Antibiotic vs Placebo—Outcome: Treatment Failure

(limiting to hospitalized patients only)

RR = 0.47, NNT = 3Ram FSF, et al. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004403. DOI: 10.1002/14651858.DC004403.pub2.

Antibiotic vs Placebo—Outcome: Length of Stay

Ram FSF, et al. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004403. DOI: 10.1002/14651858.DC004403.pub2.

New EvidenceProcalcitonin Levels

• Background

– Serum procalcitonin may be useful for detecting bacterial infections

• Design

– RCT, blinded, COPD exacerbation presenting to ED

• Randomized to:

– Rx guided by Procalcitonin level

• <0.1 abx discouraged

• >0.25 abx recommended

– Control

• Clinician abx rx based on guidelines (attending discretion)

Stolz D, et al. Chest 2007; 131: 9-19.

Decision Support for Antibiotic Use in COPD Exacerbation

New EvidenceProcalcitonin Levels

• Results

– No difference b/w groups with respect to mortality, symptoms, re-exacerbation rate, LOS, ICU LOS, FEV1

– +Reduction in ABX use

• RR = 0.64 in procalcitonin-guided group

• NNT = 4

• Availability

– Not currently broadly available

• Cost

– Lab Charge: approximately $170

Which Antibiotic?...not great evidence

Martinez FJ, et al. Expert Rev Anti Infect Ther. 2006; 4: 101-124.

Bottom Line: Pharmacologic Therapies for Hospitalized with COPD Exacerbation

YES!

• Inhaled Bronchodilators

– Duh! (Evidence A)

• Oxygen

– Duh! (No Evidence)

• Systemic Steroids (Evidence A)

– Improves BD response

– Reduces Hospital LOS

– Improves time to next exacerbation or rx failure

• Antibiotics

NO!

• Methylxanthine

– Unless you like that ‘speed’ feeling and arrhythmias

• Mucolytic Agents

– Little valuable evidence for exacerbations

– Some evidence in chronic COPD for decreasing exacerbations

• Chest PT

• Heliox

Question #3

(enough of the drugs, lets move onto electronics gadgets…)

Question #3: NPPV for COPD Exacerbation

• Will Mr. BH benefit from non-invasive positive pressure ventilation (NPPV)?

• Reminder—ABG on 2L O2 NC:

– pH 7.36, pCO2 58, pO2 64

• Which patients attain benefit from this therapy?

A. pH 7.10 – 7.30

B. pH 7.25 – 7.35

C. pH > 7.25

D. pH > 7.35

NPPV

Indications

• COPD exacerbations

• Hypoxemic or ventilatory Respiratory Failure

• CHF

• Extubation Management

Contraindications

• Cardiac/Respiratory arrest

• Malignant arrhythmias

• Refractory hypoxemia

• Hemodynamic instability

• Severe encephalopathy

• Unable to tolerate mask

• High risk of aspiration

• Anatomic abnormalities

NPPV vs Usual Care

• Meta-Analysis of RCTs (14)

– Concealed allocation, unblinded

• Patients

– COPD with Respiratory Failure

– Total of 758 patients studied

• Outcomes

– Mortality (n = 622)

– Treatment Failure (n = 541)

– Intubation (n = 758)

– LOS (n = 546)

– Other Surrogate Outcomes (RR, pCO2, pH)

Averages for Studies

Age: 63-76

Adm pH: 7.26-7.34

FEV1: 0.68-1.03

NPPV vs Usual Care—Outcome: Mortality

RR = 0.52 (95%CI: 0.35, 0.76), NNT = 10 Ram FS, et al. Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. (3):CD004104, 2004.

NPPV vs Usual Care—Outcome: Mortality

pH 7.3-7.35 Summary

pH < 7.3 Summary

ICU Summary

Ward Summary

Ram FS, et al. Cochrane Database of Systematic Reviews.

(3):CD004104, 2004.

NPPV vs Usual Care—Outcome: Treatment Failure

RR 0.48 (95%CI: 0.37, 0.63), NNT = 5

Ram FS, et al. Cochrane Database of Systematic Reviews. (3):CD004104, 2004.

NPPV vs Usual Care—Outcome: Intubation

RR 0.41 (95%CI: 0.33, 0.53), NNT = 4

Ram FS, et al. Cochrane Database of Systematic Reviews. (3):CD004104, 2004.

NPPV vs Usual Care—Outcome: LOS

LOS Reduction 3.2 days (95%CI: 2.1 - 4.4 days)

Ram FS, et al. Cochrane Database of Systematic Reviews. (3):CD004104, 2004.

What about less severe exacerbations?

NPPV for pH > 7.30?

• Hospital Mortality

• Intubations

Systematic Review, Annals of IM

“Non-Severe Exacerbations”: pH>7.30

)

Keenan SP, et al. Ann Intern Med. 2003.

NPPV for pH > 7.35?

• RCT 2007

– NPPV + Usual Care vs.

– Usual Care

• Hospital Admissions for COPD Exacerbation

• pH>7.35 in all patients

• Results

– No mortality or intubation reduction

– More rapid reduction in pCO2*

– +LOS Reduction (5.5 vs. 10.2 days, p = 0.0004)**

Pastaka C, et al. Eur J Intern Med 2007; 18: 524-530.

*

** LOS

*pCO2

Bottom Line: NPPV inCOPD Exacerbation

• Improves respiratory status

– Rapidly improved physiologic variables (pH, PCO2, RR, breathlessness)

• Reduces Hospital LOS

– >3 days on average!

– Even for less severe exacerbations (pH>7.35)

• Reduced Intubation Rate

– NNT 4

• Reduced complications (e.g. VAP)

• Improves mortality!!

– NNT 10Evidence Level A

Bottom Line: NPPV inCOPD Exacerbation

• Maintain a low threshold to utilize!

• Apply in the ED!!

– Early intervention likely improves outcomes

• Monitor closely with ABGs (30-60 min after initiation or change in NPPV settings)

• Adjust with assistance from RT

– Mask type, pressure levels (usual start 10/5)

• Recommendations/Guidelines: pH 7.25-7.35

– But likely benefit in COPD exacerbation with

• pH < 7.25 (use cautiously, monitor closely)

• pH > 7.35 (LOS benefit)

Question #4

Comorbid Conditions

Question #4: ß-block in COPD Exacerbation

• Mr. BH has had a recent MI, and now has a mildly elevated troponin during this admission.

• Should Mr. BH continue his ß-block therapy in this setting of acute exacerbation?

A. Yes

B. No

C. Who knows?—no data in exacerbations

The Evidence and Bottom Line:ß-block in COPD Exacerbation

• NO Studies in inpatient or outpatient exacerbations!

• Outpatient studies summarized in 2007 Meta-Analysis (Cochrane Collaboration)

– 20 RCTS in patients with COPD, including severe COPD

– No significant effects of single dose or longer-term treatment with ß-block on outcomes of symptoms or FEV1

Salpeter S, et al. Cardioselective beta-blockers for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003566. DOI: 10.1002/14651858.CD003566pub2.

Case (continued)

• Mr. BH was placed on NPPV in the ED, started on q2 hour albuterol nebulizer therapy, IV methylprednisolone 30mg bid, doxycycline 100mg bid, and continued on his cardioselective beta-blocker.

• His symptoms improved quickly, and he was able to rapidly wean off of NPPV and repeat ABG on Day 2 revealed pH 7.42, pCO2 38, pO2 69 on 1L NC.

Question #5

Prevention During Hospitalization

and At Discharge

Question #5: Prevention During Hospitalization and @ Discharge

• What interventions should be instituted by hospitalists (prior to or at discharge), as supported by outcomes in COPD patients?

A. Tobacco Cessation Counseling

B. Pneumonia Vaccine (if not previously received) and Influenza Vaccine (if not received this season)

C. VTE Prophylaxis

D. Augment Home Medication Regimen (if so, which ones?)

Prevention for COPD:Smoking Cessation Counseling

Smoking Cessation Counseling

Single counseling event, tob cessation 1 yr

Meta-analysis RCTs*

ARR 2% (NNT 50)

P<0.001

Pneumonia Outcomes Research Team (PORT)**

15% of counseled quit

93% of those who quit did so at the time they developed PNA

*Law M, Tang JL. Arch Intern Med. 1995; 155: 1933-41.

**Rhew DC. Ann Intern Med. 2001; 135: 736-43.

Smoking Cessation Slows Lung Function Decline in Mild COPD:

The Lung Health Study at 11 Years

2

2.1

2.2

2.3

2.4

2.5

2.6

2.7

2.8

2.9

0 1 2 3 4 5 6 7 8 9 10 11

Sustained quitters

Intermittent quitters

Continuoussmokers

Anthonisen NR et al. Am J Respir Crit Care Med 2002:166:675-9. Calverley PMA and Walker P. Lancet 2003;362:1053-1061.

Prevention for COPD:Vaccination

Pneumococcal Vaccination*

Chronic Lung Disease

Reduced Mortality RRR 30%

Reduced Pneumonia RRR 43%

Influenza Vaccination in Chronic Lung Disease**

Reduced mortality

RRR >50%

Reduced hospitalization

RRR 20-30%

Reduced PNA

Cost-effective

Annual Revaccination necessary

*Nichol KL, et al. Arch Intern Med. 1999; 159: 2437-42.

*Large Retrospective Cohort

Jackson LA, et al. N Engl J Med. 2003; 348: 1747-55.

**Multiple studies

Summary: Seymann GB. J of Hosp Med. 2006; 1: 344-53.

Prevention for COPD:VTE Prophylaxis

• Prevalence of VTE in COPD Exacerbation

– Up to 30% based on Autopsy Studies*

– Approx 10% based on retrospective assessments*

– Risk of VTE in COPD: Adjusted HR 1.33 (1.17-1.51)**

• >92,000 patients inpatient COPD

• Comparison HRs

– ICU Adm: HR 1.35– Paralysis/paresis: HR 1.35

*Ambrosetti M, et al. Prevalence and prevention of venous thromboembolism in patients with acute exacerbations of COPD. Thrombosis Research 2003. 112: 203-207. [systematic review]

**Edelsberg J, et al. Risk of venous thromboembolism among hospitalized medically ill patients. Am J Health-Syst Pharm 2006. 63 (S6): S16-S22.

Prevention for COPD:VTE Prophylaxis

• Pharmacologic prophylaxis*

– Reduces risk of VTE with use of pharmacologic prophylaxis (LMWH or UFH) in medical patients

• RRR 55%

• ACCP Guidelines for VTE Prophylaxis (Grade 1A, RCT):

– “Acutely ill medical patients admitted...with severe respiratory disease…” should receive pharmacologic VTE prophylaxis

*Mismetti P, et al. Prevention of venous thromboembolism in internal medicine with unfractionated or low-molecular-weight heparins: a meta analysis of randomised clinical trials. Thromb Haemost 2000; 83: 14-19.

Geerts WH, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004. 126(3 Suppl):338S-400S.

Prevention:Augmentation of Home Medication

Regimen—Newest Evidence

• Systematic Review of RCTs and Meta-Analyses

• Published November 2007

• Outcomes:

Mortality Reduction

Exacerbation Reduction

Prevention:Augmentation of Home Medication Regimen—

OUTCOME: Mortality• Outpatient Interventions that Reduce Mortality

(statistically significant…and clinically relevant!)

• Severity @ baseline: Mod to Very Severe

Combined LABA and Corticosteroid therapy vs. Placebo*

>4600 patients

Mortality reduction: RR = 0.83, NNT = 53

Combined LABA and corticosteroid therapy vs. Corticosteroid therapy alone*

Mortality reduction: RR = 0.79, NNT = 44

Combined LABA and corticosteroid vs. Tiotropium**

Mortality reduction: RR = 0.56, NNT = 55 (p = 0.032)*Wilt TJ, et al. Ann Intern Med 2007; 147: 639-653.

**Wedzicha JA, et al. Am J Respir Crit Care Med 2008; 177: 19-26.

Prevention:Augmentation of Home Medication Regimen—

OUTCOME: Mortality

Inhaled Combined LABA and Corticosteroid therapy vs. Placebo

RR = 0.83, NNT = 53

Wilt TJ, et al. Ann Intern Med 2007; 147: 639-653.

Prevention:Augmentation of Home Medication Regimen—

OUTCOME: Mortality

• No Mortality Reduction with the following inhaled therapies (vs. placebo):

– Short-Acting Anticholinergic (Ipratropium)

– Long-Acting Anticholinergic (Tiotropium)

– LABA alone

– Corticosteroids alone

– D2/ß2-Agonist (Sibenadet)

Wilt TJ, et al. Ann Intern Med 2007; 147: 639-653.

Prevention:Augmentation of Home Medication Regimen—

OUTCOME: Exacerbations

YES!!

• Tiotropium (p<0.001)

• LABA (p<0.001)

• Corticosteroids (p=0.01)

• Combined LABA and corticosteroid (p=0.06)

No!!

• Ipratropium

RR = 0.84, NNT = 15

RR = 0.76, NNT = 13

RR = 0.87, NNT = 22

RR = 0.83, NNT = 16

Outpatient Inhaled Therapies that Reduce Exacerbations vs. Placebo (statistically significant)

Wilt TJ, et al. Ann Intern Med 2007; 147: 639-653.

Bottom Line: Hospitalist Prevention Efforts for COPD Exacerbation

• Tobacco Cessation Counseling

• Pneumonia Vaccine and Influenza Vaccine

• VTE Prophylaxis during hospital stay

• Augment Home Medication Regimen

LABA + Corticosteroid inhalers

Case

• Mr. BH recovers from his exacerbation, but his resting O2 Sat is 89%.

• Repeat ABG at resolution of exacerbation reveals pO2 57.

• Q: Will Mr. BH benefit from and qualify for home oxygen therapy?

Question #6

Home O2

Who Benefits from and qualifies for Home Oxygen Therapy?

• Evidence for Benefit

– Supplemental O2 for >15 hours/day to maintain pO2 > 60*

– Reduced death** in patients with

• Mean FEV1 < 30% &

• PaO2 < 55

• Medicare Criteria

*Report of the Medical Research Council Working Party. Lancet 1981; 1: 681-686.

**Gorecka D, et al. Thorax 1997; 52: 674-679.

Medicare Coverage Criteria:Home Oxygen Therapy

Group I Coverage

• PaO2 < 55 or SaO2 < 88%

– At Rest

– During Sleep

• OR ↓ PaO2 > 10mmHg or ↓ SaO2 5% associated with symptoms or signs of hypoxemia*

– During Activity

Group II Coverage

• PaO2 56-59mmHg or SaO2 89% +

• Any of the following*:

– Dependent Edema

– Pulmonary HTN or Cor Pulmonale

– Erythrocythemia

• Hct > 56%

• Requires re-testing between 61 and 90 days

Final Summary

Final Summary

• Pharmacologic Therapies

Bronchodilators

Inhaled—YES!

o Oral/IV—No!

Steroids—YES!

Antibiotics—YES!!!

Procalcitonin levels to decide?

• Other Therapies

Oxygen—YES!

NPPV—ABSOLUTELY YES!!!

Mucolytics—Maybe!

o Chest PT—NO!!

• Prevention (Inpatient)

Smoking Cessation Counseling—YES!!

Vaccines

Pneumovax—YES!

Influenza Vaccine—YES!

VTE Prophylaxis—YES!!

• Prevention (Home Regimen)

Augmentation with combined LABA/steroid inhaled—YES!!

Mortality Reduction!!

Most others for exacerbation and symptom reduction

• Home O2: Medicare Criteria

COPD Exacerbation:Practical Evidence-based

Strategies

Daniel D. Dressler, MD, MScDirector of Education

Section of Hospital MedicineIM Associate Residency DirectorAssistant Professor of Medicine

Emory University School of MedicineDaniel.Dressler@emory.edu

Society of Hospital Medicine Annual MeetingSan Diego, California

April 4, 2008