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Slide 2 COPD Exacerbation UNM Best Practice Meeting Josh Young 8/27/10 Slide 3 Why do we need to worry about this? Growing number of hospitalizations in the U.S. 463,0020 in 1990 726,000 in 2000 10% mortality in hospitalized patients ~25% mortality in ICU admissions $32 billion in the U.S. in 2002 ($18 billion related to in-hospital care) 2 Best Practice Meeting - COPD Exacerbation Slide 4 Definition The Global Initiative for Chronic Obstructive Lung Disease (GOLD) defines an exacerbation as: an event in the natural course of the disease characterized by a change in the patients baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD. Best Practice Meeting - COPD Exacerbation 3 Slide 5 Goals Understand the pathophysiology of exacerbations Learn more about the current guidelines for treatment of COPD exacerbation and why? Discuss the current practices at UNM? Develop our own best practices Smoking cessation 4 Best Practice Meeting - COPD Exacerbation Slide 6 Pathophysiology (Brief Overview) Characterized by 2 separate processes Chronic Bronchitis: Excessive mucus production with airway obstruction mostly affecting the smaller airways with hyperplasia of mucus producing glands and damage to the endothelium that impairs the clearance of bacteria and mucus. Emphysema: Gradual destruction of alveolar septae and the pulmonary capillary bed 5 Best Practice Meeting - COPD Exacerbation Slide 7 Pathophysiology (Exacerbations) Exacerbations are heterogeneous in severity and presentation They are usually contributed to bacterial or viral infection and pollutants such as tobacco smoke A significant amount (~30%) do not have a clear etiology Severe exacerbations are thought to be due to increased inflammation leading to worsening expiratory flow limitation and dynamic hyperinflation and increased air trapping This increased air trapping causes your tidal breathing to shift closer to total lung capacity, where you have a less favorable relationship between volume and pressure 6 Best Practice Meeting - COPD Exacerbation Slide 8 Goals Understand the pathophysiology of exacerbations Learn more about the current guidelines for treatment of COPD exacerbation and why? Discuss the current practices at UNM? 7 Best Practice Meeting - COPD Exacerbation Slide 9 Global Initiative for Chronic Obstructive Lung Disease (GOLD) Global organization initiated in 1998 Goal to produce recommendations for management of COPD based on the best scientific information available First guidelines were released in 2001 with a complete revision in 2006 Last update in 2009 including articles up to June 30, 2009 www.goldcopd.org Best Practice Meeting - COPD Exacerbation 8 Slide 10 Department of Veteran Affairs/ Department of Defense VA/DoD clinical practice guideline for management of outpatient chronic obstructive pulmonary disease. Updated in 2007 Focus mostly on outpatient management and target patients of VA/DoD system Best Practice Meeting - COPD Exacerbation 9 Slide 11 Prevention Smoking cessation is still the most effective intervention in reducing risk of developing COPD and decreasing its progression Recommendations are to counsel smokers to quit at every opportunity Apply affective counseling techniques Consider pharmacotherapy in situations where counseling isnt enough Influenza vaccines can reduce serious illness and death in COPD patients by 50% Pneumococcal vaccine is recommended in COPD patients over 65 years old and in patients with FEV1 < 40% Best Practice Meeting - COPD Exacerbation 10 Slide 12 Evaluation Careful history and physical exam General recommendations do not support spirometry upon acute evaluation Pulse oximetry Arterial blood gases Best Practice Meeting - COPD Exacerbation 11 Slide 13 Evaluation and Triage Chest X-ray ECG CBC, BMP Differential Diagnosis: Pulmonary embolism should be considered with any patient being hospitalized with a pretest probability of intermediate to high Pneumonia, CHF, pneumothorax, pleural effusion, and cardiac arrhythmia Best Practice Meeting - COPD Exacerbation 12 Slide 14 Prevalence of Pulmonary Embolism in Acute Exacerbations of COPD : A Systematic Review and Metaanalysis. Rizkallah et al. Chest. 2009. Clinical question: What is the prevalence of PE in acute exacerbations of COPD in patients who did and did not require hospitalization. Methods: Only cross-sectional or prospective studies that used CT scanning or pulmonary angiography for PE diagnosis were included. 2,407 articles were identified, 5 met the inclusion criteria including 550 patients Overall prevalence of PE was 19.9% (95% confidence interval [CI], 6.7 to 33.0%; p 0.014). Hospitalized patients 24.7% (95% CI, 17.9 to 31.4%; p 0.001) Best Practice Meeting - COPD Exacerbation 13 Slide 15 Triage Hospitalization: Marked increase in intensity of symptoms (resting dyspnea) Severe underlying COPD Onset of new physical symptoms Failure of initial medical management Significant comorbidities Frequent exacerbations Newly occurring arrhythmias Diagnostic uncertainty Older age Insufficient home support Best Practice Meeting - COPD Exacerbation 14 Slide 16 Triage MICU: Severe dyspnea that does not respond adequately to initial therapy Changes in mental status Persistent or worsening hypoxemia (PaO2 60 mm Hg or pH < 7.25 despite O2 and NIV Need for invasive mechanical ventilation Need for vasopressors Best Practice Meeting - COPD Exacerbation 15 Slide 17 Oxygen Therapy Both guidelines state that oxygen supplementation should be used to keep PaO2 > 60 mm Hg or SaO2 > 90% GOLD notes that CO2 retention can occur insidiously with little change in symptoms and recommend rechecking an ABG 30-60 minutes after oxygen therapy started Appropriate to start before complete evaluation Best Practice Meeting - COPD Exacerbation 16 Slide 18 Bronchodilators 3 classes of medications: B2 agonists (albuterol) Anticholinergics (ipratropium) Methylxanthines (theophylline) Guidelines vary with respect to use and no studies appear to clearly demonstrate superiority Agree that initiation of therapy can be started prior to full ED evaluation There does not appear to be a difference in MDI or nebulizer therapy 17 Best Practice Meeting - COPD Exacerbation Slide 19 Bronchodilators GOLD recommends stepwise approach to use by starting with short-acting B2-agonist If no prompt response to treatment occurs, consider adding anticholinergic All agree that methylxanthines should not be used routinely because of adverse effects and lack of efficacy Although, GOLD notes that they are considered second-line IV therapy 18 Best Practice Meeting - COPD Exacerbation Slide 20 Glucocorticosteroids Both guidelines agree that oral corticosteroids should be used for acute exacerbations 30 40 mg of oral prednisolone daily GOLD: 7-10 days VA/DoD: up to 14 days Best Practice Meeting - COPD Exacerbation 19 Slide 21 EFFECT OF SYSTEMIC GLUCOCORTICOIDS ON EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Niewoehner et al. N Engl J Med. 1999 Double blind randomized trial Clinical Question: Determine rates of treatment failure between systemic glucocorticoids and placebo. Secondary goal to determine the optimal duration of therapy. Methods: All patients admitted to participating VAs for COPD exacerbation who met inclusion criteria: Clinical diagnosis of COPD exacerbation Age > 50 years 30 pack year smoking history FEV1 of 1.5L or less or inability to complete testing Best Practice Meeting - COPD Exacerbation 20 Slide 22 EFFECT OF SYSTEMIC GLUCOCORTICOIDS ON EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Niewoehner et al. N Engl J Med. 1999 Exclusion criteria included: Diagnosis of asthma Systemic glucocorticoids in last 30 days Comorbidities making survival of 1 year unlikely Inability to give consent Patients hospitalized for at least 3 days and given IV Solu-Medrol followed by either 2 or 8 week taper starting at 60 mg of Prednisone Best Practice Meeting - COPD Exacerbation 21 Slide 23 EFFECT OF SYSTEMIC GLUCOCORTICOIDS ON EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Niewoehner et al. N Engl J Med. 1999 Best Practice Meeting - COPD Exacerbation 22 Slide 24 EFFECT OF SYSTEMIC GLUCOCORTICOIDS ON EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Niewoehner et al. N Engl J Med. 1999 Best Practice Meeting - COPD Exacerbation 23 No significant difference in outcomes between 2 and 8 week courses Did show complications with treatment arms including hyperglycemia and trend toward more hospitalizations for infection Slide 25 Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial. Davies et al. The Lancet. August 7, 1999 Clinical question: Does oral prednisolone 30-40 mg modify rate of improvement of lung function or course of hospital stay? Design: RCT, double blind study of 60 pts Included patients with COPD exacerbation, Age 40-80 years, 20 pack year history, FEV1 < 70%, and FEV1/FVC < 75% Best Practice Meeting - COPD Exacerbation 24 Slide 26 Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial. Davies et al. The Lancet. August 7, 1999 Excluded if personal or family history of asthma/atopy, uncontrolled LVF, clinical/radiological PNA, oral steroids in last month, or arterial pH < 7.26 Patients randomized to prednisolone 30 mg for 14 days or placebo Patients followed to discharge with 6 week follow up Best Practice Meeting - COPD Exacerbation 25 Slide 27 Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial. Davies et al. The Lancet. August 7, 1999 Study showed FEV1 after bronchodilation increased more rapidly in the prednisolone group although no significant difference was found at 6 weeks Hospital length of stay was decreased from 9 to 7 days in treatment group Best Practice Meeting - COPD Exacerbation 26 Slide 28 Oral or IV Prednisolone in the Treatment of COPD Exacerbations* A Randomized, Controlled, Double-blind Study. De Jong et al. Chest. 2007 Randomized control trial comparing 60 mg of IV versus PO prednisolone Study results did not show any significant difference in short or long term outcomes. Best Practice Meeting - COPD Exacerbation 27 Slide 29 Antibiotics Antibiotic therapy should be considered when patients have 2 of the 3 following symptoms: Increased dyspnea Increased sputum volume Increased sputum purulence And if the patient has a severe exacerbation requiring mechanical ventilation Best Practice Meeting - COPD Exacerbation 28 Slide 30 Antibiotics Common pathogens recovered from lower airways of patients with COPD exacerbation are S. pneumoniae, H. influenzae, and M. catarrhalis Most studies were done in chronic bronchitis and recommend 3-7 days of treatment Best Practice Meeting - COPD Exacerbation 29 Slide 31 Antibiotics Type of antibiotic is divided by severity of exacerbation and risk factors for poor outcome: Comorbid conditions Severe COPD > 3 exacerbations/year Antimicrobial use in the last 3 months Best Practice Meeting - COPD Exacerbation 30 Slide 32 Antibiotics Mild with no risk factors: B-lactam, tetracycline, bactrim Alternative of augmentin, macrolide, 2-3 generation cephalosporin Moderate with risk factors: B-lactam/B-lactamase inhibitor or fluoroquinolone Severe with risk for P. aeruginosa: Fluoroquinolone or B-lactam with pseudomonas activity Best Practice Meeting - COPD Exacerbation 31 Slide 33 Noninvasive Intermittent Ventilation (NIV) Improves respiratory acidosis, increases pH, reduces PaCO2 Decreases need for endotrachial intubation Reduces respiratory rate and dyspnea Decreases length of hospital stay and mortality Best Practice Meeting - COPD Exacerbation 32 Slide 34 Noninvasive Intermittent Ventilation (NIV) Indications: Moderate Severe dyspnea with use of accessory muscles and paradoxical abdominal motion Moderate Severe acidosis pH 45 mm Hg Respiratory rate > 25 breaths/minute Best Practice Meeting - COPD Exacerbation 33 Slide 35 Noninvasive Intermittent Ventilation (NIV) Relative contraindications: Respiratory arrest Cardiovascular instability Mental status changes preventing cooperability High aspiration risk Thick/copious secretions Recent facial or gasteroesophageal surgery Craniofacial trauma Fixed nasopharyngeal abnormalities Burns Extreme obesity Best Practice Meeting - COPD Exacerbation 34 Slide 36 Noninvasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and metaanalysis. Lightowler et al. BMJ. January 25, 2003. Best Practice Meeting - COPD Exacerbation 35 Slide 37 Noninvasive Intermittent Ventilation (NIV) Best Practice Meeting - COPD Exacerbation 36 Slide 38 Discharge and Follow Up Discharge criteria: Inhaled B2- agonist therapy is required no more that q4 hrs Patient, if previously ambulatory, is able to walk across the room Patient is able to eat and sleep Patient has been clinically stable for 12-24 hrs ABGs have been stable for 12-24 hrs Patient (Caregiver) understands correct use of medications Follow up and home care is arranged Patient, family, and physician are confident patient can manage successfully Best Practice Meeting - COPD Exacerbation 37 Slide 39 Follow up items Ability to cope in usual environment FEV1 Inhaler technique Understanding of recommended treatment regimen Need for long term oxygen therapy or nebulizer therapy 38 Best Practice Meeting - COPD Exacerbation Slide 40 Goals Understand the pathophysiology of exacerbations Learn more about the current guidelines for treatment of COPD exacerbation and why? Discuss the current practices at UNM? 39 Best Practice Meeting - COPD Exacerbation Slide 41 Do our current practices coincide with the current guidelines? 40 Best Practice Meeting - COPD Exacerbation Slide 42 Resources Brochard L, Mancebo J, Wysocki M, Lofaso F, Conti G, Rauss A, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 1995;333(13):817-22. Davies L, Angus RM, Calverly PM. Oral corticosteroids of chronic obstructive pulmonary disease: a prospective randomised controlled trial. Lancet 1999;354(9177):456-60. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Executive Summary, 2009. Holguin F, Folch E, Redd SC, Mannino DM. Comorbidity and mortality in COPD-related hospitalizations in the United States, 1979 to 2001. Chest 2005;128(4):2005-11. de Jong YP, Uil SM, Grotjohan HP, Postma DS, Kerstjens HA, van den Berg JW. Oral or IV prednisone in the treatment of COPD exacerbations: a randomized, controlled, double-blind study. Chest. 2007 Dec;132(6):1741-7. Epub 2007 Jul 23. Lightowler JV, Wedzicha JA, Elliot MW, Ram FS. Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis. BMJ 2003;326(7382):185. Maltais F, Ostinelli J, Bourbeau J, Tonnel AB, Jacquemet N, Haddon J, et al. Comparison of nebulized budesonide and oral prednisone with placebo in the treatment of acute exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. Am J Respir Crit Care Med 2002;165(5):698-703. Niewoehner DE, Erbland ML, Deupree RH, Collins D, Gross NJ, Light RW, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group. N Engl J Med 1999;340(25):1941-7. Quon BS, Gan WQ, Sin DD. Contemporary Management of Acute Exacerbations of COPD: A Systematic Review and Metaanalysis. Chest. 2008:133;756-766. Reilly JJ, Silverman EK, Shapiro SD. Ch. 254: Chronic Obstructive Pulmonary Disease. Harrisons Principals of Internal Medicine, 17th ed. (1635-1643). McGraw Hill, 2008. Rizkallah J, Man SF, Sin DD. Prevalence of pulmonary embolism in acute exacerbations of COPD: a systematic review and metaanalysis. Chest. 2009 Mar;135(3):786-93. Epub 2008 Sep 23. Stallberg B, Selroos O, Vogelmeier C, Andersson E, Ekstrom T, Larsson K. Budesonide/formoterol as effective as prednisone plus formoterol in acute exacerbations of COPD. A double-blind, randomised non-inferiority, parallel-group, multicentre study. Respir Res. 2009 Feb 19; 10:11. Stoller, JK. Management of acute exacerbations of chronic obstructive pulmonary disease. Up to Date, www.uptodate.com. June 2010. www.uptodate.com 41 Best Practice Meeting - COPD Exacerbation Slide 43 Thanks 42 Best Practice Meeting - COPD Exacerbation Slide 44 Comments/Questions 43 Best Practice Meeting - COPD Exacerbation