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UNM Best Practice Meeting Josh Young 8/27/10

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1 UNM Best Practice Meeting Josh Young 8/27/10
COPD Exacerbation UNM Best Practice Meeting Josh Young 8/27/10

2 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) Best Practice Meeting - COPD Exacerbation

3 Best Practice Meeting - COPD Exacerbation
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 patient’s 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

4 Best Practice Meeting - COPD Exacerbation
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 Best Practice Meeting - COPD Exacerbation

5 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 Best Practice Meeting - COPD Exacerbation

6 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 Best Practice Meeting - COPD Exacerbation

7 Best Practice Meeting - COPD Exacerbation
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? Best Practice Meeting - COPD Exacerbation

8 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 Best Practice Meeting - COPD Exacerbation

9 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

10 Best Practice Meeting - COPD Exacerbation
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 isn’t 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% 1. Pneumococcal shown to decrease incidence Best Practice Meeting - COPD Exacerbation

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Evaluation Careful history and physical exam General recommendations do not support spirometry upon acute evaluation Pulse oximetry Arterial blood gases S/sx of severity: FEV1 Duration of worsening or new sxs Number of previous episodes Comorbidities Present treatment regimen Use of accessory muscles, paradoxical chest wall movements, central cyanosis, peripheral edema, hemodynamic instability, right heart CHF, mental status changes VA/DoD note that spirometry can be considered in patient’s able to perform the test and have baseline studies to compare to. Both agree in ABG important to evaluate severity with PaO2 < 60 mm Hg and/or SaO2 < 90% with or without PaCO2 > 50 mm Hg on RA indicates respiratory failure ABG with acidosis pH < 7.36 plus PaCO2 > mm Hg is an indication for mechanical ventilation Best Practice Meeting - COPD Exacerbation

12 Best Practice Meeting - COPD Exacerbation
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 ECG to evaluate right heart hypertrophy, arrhythmias, ischemia Low SBP and inability to increase PaO2 > 60 mm Hg should suggest PE Best Practice Meeting - COPD Exacerbation

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Prevalence of Pulmonary Embolism in Acute Exacerbations of COPD : A Systematic Review and Metaanalysis. Rizkallah et al. Chest 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 ). Hospitalized patients 24.7% (95% CI, 17.9 to 31.4%; p ) Only 1 study calculated pretest probability use Geneva score and found prevalence of ~9% Note limitations of heterogeneity and small sample size Best Practice Meeting - COPD Exacerbation

14 Best Practice Meeting - COPD Exacerbation
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

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Triage MICU: Severe dyspnea that does not respond adequately to initial therapy Changes in mental status Persistent or worsening hypoxemia (PaO2 < 40 mm Hg or hypercapnia PaCO2 > 60 mm Hg or pH < 7.25 despite O2 and NIV Need for invasive mechanical ventilation Need for vasopressors Best Practice Meeting - COPD Exacerbation

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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 minutes after oxygen therapy started Appropriate to start before complete evaluation 1. No clear evidence to support this practice and there are no recommendations as what further treatment steps should be taken Best Practice Meeting - COPD Exacerbation

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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 Best Practice Meeting - COPD Exacerbation

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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 Guidelines appear to be made without any significant evidence Multiple studies show no improvement with addition of anticholinergic Theophylline side effects: nausea/vomiting, tremor, palpitations, and arrhythmias Best Practice Meeting - COPD Exacerbation

19 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

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EFFECT OF SYSTEMIC GLUCOCORTICOIDS ON EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Niewoehner et al. N Engl J Med 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 VA’s 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 Treatment failure consists of: Death from any cause Need for intubation Readmission for COPD Intensification of therapy Best Practice Meeting - COPD Exacerbation

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EFFECT OF SYSTEMIC GLUCOCORTICOIDS ON EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Niewoehner et al. N Engl J Med 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

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EFFECT OF SYSTEMIC GLUCOCORTICOIDS ON EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Niewoehner et al. N Engl J Med Best Practice Meeting - COPD Exacerbation

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EFFECT OF SYSTEMIC GLUCOCORTICOIDS ON EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Niewoehner et al. N Engl J Med 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 Best Practice Meeting - COPD Exacerbation

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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 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 years, 20 pack year history, FEV1 < 70%, and FEV1/FVC < 75% Best Practice Meeting - COPD Exacerbation

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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

26 Best Practice Meeting - COPD Exacerbation
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

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Oral or IV Prednisolone in the Treatment of COPD Exacerbations* A Randomized, Controlled, Double-blind Study. De Jong et al. Chest 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

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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

29 Best Practice Meeting - COPD Exacerbation
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

30 Best Practice Meeting - COPD Exacerbation
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

31 Best Practice Meeting - COPD Exacerbation
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

32 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

33 Noninvasive Intermittent Ventilation (NIV)
Indications: Moderate – Severe dyspnea with use of accessory muscles and paradoxical abdominal motion Moderate – Severe acidosis pH < 7.35 and/or PaCO2 > 45 mm Hg Respiratory rate > 25 breaths/minute Best Practice Meeting - COPD Exacerbation

34 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

35 Best Practice Meeting - COPD Exacerbation
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. 1. We defined treatment failure as the combination of mortality, need for intubation, and intolerance to the allocated treatment. Data from seven of the studies showed that NPPV resulted in a significantly lower risk of treatment failure (relative risk 0.51), compared with usual medical care, with a number needed to treat for NPPV to have a benefit of five (figure 2, table 1) – NPPV significantly reduced the risk of mortality (relative risk 0.41), with a number needed to treat of eight (figure 3, table 1). The risk of endotracheal intubation was more than halved with NPPV, and for every five patients treated with NPPV one patient would avoid intubation (figure 4, table 1). NPPV also reduced complications of treatment and length of stay in hospital (tables 1 and 2). NPPV significantly improved pH, PaCO2, and respiratory rate within one hour of initiation Best Practice Meeting - COPD Exacerbation

36 Noninvasive Intermittent Ventilation (NIV)
Best Practice Meeting - COPD Exacerbation

37 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 hrs ABG’s have been stable for 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

38 Best Practice Meeting - COPD Exacerbation
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 Best Practice Meeting - COPD Exacerbation

39 Best Practice Meeting - COPD Exacerbation
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? Best Practice Meeting - COPD Exacerbation

40 Best Practice Meeting - COPD Exacerbation
Do our current practices coincide with the current guidelines? Best Practice Meeting - COPD Exacerbation

41 Best Practice Meeting - COPD Exacerbation
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): Davies L, Angus RM, Calverly PM. Oral corticosteroids of chronic obstructive pulmonary disease: a prospective randomised controlled trial. Lancet 1999;354(9177): 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 Chest 2005;128(4): 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 Dec;132(6): 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): 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): Quon BS, Gan WQ, Sin DD. Contemporary Management of Acute Exacerbations of COPD: A Systematic Review and Metaanalysis. Chest. 2008:133;   Reilly JJ, Silverman EK, Shapiro SD. Ch. 254: Chronic Obstructive Pulmonary Disease. Harrison’s Principals of Internal Medicine, 17th ed. ( ). McGraw Hill, 2008. Rizkallah J, Man SF, Sin DD. Prevalence of pulmonary embolism in acute exacerbations of COPD: a systematic review and metaanalysis. Chest Mar;135(3): 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 Feb 19; 10:11. Stoller, JK. Management of acute exacerbations of chronic obstructive pulmonary disease. Up to Date, June 2010.  Best Practice Meeting - COPD Exacerbation

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Thanks Best Practice Meeting - COPD Exacerbation

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