Antibiotics for exacerbations of chronic obstructive pulmonary disease

Vollenweider, Daniela; Frei, Anja; Steurer-Stey, Claudia; Garcia‐Aymerich, Judith; Puhan, Milo A.

doi:10.1002/14651858.cd010257.pub2

Cited by 94 publications

(118 citation statements)

References 92 publications

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“…Despite the widespread use of antibiotics for AECOPD in clinical practice, a Cochrane systematic review of 16 trials (2068 participants) of antibiotics versus placebo for AECOPD found inconsistent benefit for the use of antibiotics, depending on the clinical setting and severity of the exacerbation . For hospitalized patients, the pooled results showed that antibiotics reduced the risk of treatment failure (relative risk of 0.77).…”

Section: Management Of Acute Exacerbations Of Copdmentioning

confidence: 99%

Acute exacerbation of COPD

et al. 2016

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The literature of acute exacerbation of chronic obstructive pulmonary disease (COPD) is fast expanding. This review focuses on several aspects of acute exacerbation of COPD (AECOPD) including epidemiology, diagnosis and management. COPD poses a major health and economic burden in the Asia-Pacific region, as it does worldwide. Triggering factors of AECOPD include infectious (bacteria and viruses) and environmental (air pollution and meteorological effect) factors. Disruption in the dynamic balance between the 'pathogens' (viral and bacterial) and the normal bacterial communities that constitute the lung microbiome likely contributes to the risk of exacerbations. The diagnostic approach to AECOPD varies based on the clinical setting and severity of the exacerbation. After history and examination, a number of investigations may be useful, including oximetry, sputum culture, chest X-ray and blood tests for inflammatory markers. Arterial blood gases should be considered in severe exacerbations, to characterize respiratory failure. Depending on the severity, the acute management of AECOPD involves use of bronchodilators, steroids, antibiotics, oxygen and noninvasive ventilation. Hospitalization may be required, for severe exacerbations. Nonpharmacological interventions including disease-specific self-management, pulmonary rehabilitation, early medical follow-up, home visits by respiratory health workers, integrated programmes and telehealth-assisted hospital at home have been studied during hospitalization and shortly after discharge in patients who have had a recent AECOPD. Pharmacological approaches to reducing risk of future exacerbations include long-acting bronchodilators, inhaled steroids, mucolytics, vaccinations and long-term macrolides. Further studies are needed to assess the cost-effectiveness of these interventions in preventing COPD exacerbations.

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Section: Management Of Acute Exacerbations Of Copdmentioning

confidence: 99%

Acute exacerbation of COPD

et al. 2016

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“…Antimicrobial use must be judicious as non‐infective and non‐bacterial exacerbations are not uncommon . A Cochrane review concluded that antibiotics afforded only a mortality benefit following intensive care admissions for severe exacerbations, though the review was limited by inconsistent definitions, highlighting the inconclusive nature of current evidence . Continued collaboration with initiatives including Choosing Wisely and antimicrobial stewardship is required, particularly when inappropriate prescribing in COPD was identified at 38% in a national antimicrobial stewardship report …”

Section: Discussionmentioning

confidence: 99%

Hospitalised exacerbations of chronic obstructive pulmonary disease: adherence to guideline recommendations in an Australian teaching hospital

Sha

Worsnop

Leaver

et al. 2020

Internal Medicine Journal

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Background: Optimal management of exacerbations of chronic obstructive pulmonary disease (COPD) reduces patient morbidity and healthcare system burden. COPD guidelines, including the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and the COPD-X Plan, provide evidence-based recommendations, but adherence in hospital practice is variable.Aims: To examine current practice in management of COPD exacerbations at an Australian teaching hospital and to compare with COPD-X Plan recommendations.Methods: Data were collected retrospectively from electronic medical records for admissions occurring during 1 May to 31 August 2016, and compared with recommendations from the COPD-X Plan.Results: A total of 134 patients (n = 68 females) was admitted for a COPD exacerbation during the study period. Mean age was 75.4 AE 10.2 years and 33.6% were current smokers. Airflow obstruction on spirometry was confirmed in 67.2% (mean forced expiratory volume in 1 s was 53 AE 22% predicted (1.2 AE 0.5 L)). Excellent adherence to the COPD-X Plan was demonstrated in the ordering of chest radiographs (97%) and electrocardiograms (94%). Supplemental oxygen was appropriately provided to all patients with oxygen saturation of <88%. All patients with confirmed hypercapnic respiratory failure were managed with non-invasive ventilation. Corticosteroids and bronchodilators were prescribed for the majority of patients. Areas of suboptimal practice included inadequate usage of arterial blood gases, excess supplemental oxygen in the absence of hypoxaemia, over-prescription of intravenous antimicrobials, low referral rates to pulmonary rehabilitation and insufficient smoking cessation counselling.Conclusions: Level of adherence to guideline recommendations in the management of COPD exacerbations is inadequate and further strategies are required to elevate standards of practice.

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“…Although not all COPD exacerbations are due to bacterial pathogens, antibiotics are recommended for all patients with moderate to severe exacerbations, including all patients requiring hospitalization [7]. Antibiotics have been shown to reduce treatment failure in severe exacerbations [31].…”

Section: Antibioticsmentioning

confidence: 99%

Acute Exacerbation of COPD

Lief

2020

Evidence-Based Critical Care

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A 73 year-old man, current smoker of 50 pack-years, a history of chronic obstructive pulmonary disease (COPD) on home oxygen, and an ischemic cardiomyopathy presented to the emergency department (ED) with shortness of breath. He noted 1 week of progressive dyspnea on exertion and increasing cough with purulent sputum. He denied fever, chills, hemoptysis, orthopnea, paroxysmal nocturnal dyspnea and leg edema. He has been using inhaled bronchodilators several times daily and had increased the flow rate of his supplemental oxygen to 4 liters per minute without notable improvement. On the morning of admission, he had dyspnea, even at rest, and called EMS. On presentation, he was afebrile, tachycardic to 110 beats per minute and hypertensive to 178/90 mmHg; he had a respiratory rate of 36 breaths per minute and an oxygen saturation of 85% on 4 liters per minute of supplemental oxygen via nasal cannula. An ABG drawn while on oxygen revealed: pH 7.24, pCO 2 60 mmHg, PO 2 55 mmHg. On exam, he was awake, in mild distress, using accessory muscles of inspiration and exhalation. The remainder of his exam was notable for tachycardia, diffuse end-expiratory wheezes bilaterally, and an absence of rales. Chest radiograph demonstrated hyperinflation without focal opacity. QuestionWhat is the immediate approach to this patient with acute hypercarbic respiratory failure?Answer Non-invasive positive pressure ventilation Non-invasive positive-pressure ventilation (NIPPV) is the preferred method of ventilatory support in patients with acute respiratory failure secondary to an acute exacerbation of COPD (AECOPD). This patient was placed on bilevel NIPPV with an inspiratory pressure of 12 cm of water and an expiratory pressure of 5 cm of water with an inspired fraction of oxygen of 0.5 via an oronasal mask interface. His oxygen saturation was maintained between 88 and 92%. He was given 500 mg of intravenous azithromycin and 60 mg of intravenous methylprednisolone. Within hours, his respiratory rate had decreased to 22 and he appeared comfortable with improvement in his arterial blood gas.The natural history of COPD is punctuated by periods of acute exacerbation, during which patients experience increased symptoms and utilize more healthcare resources. Common symptoms of AECOPD include increased sputum production, cough and dyspnea as a result of increased airway inflammation, mucous plugging and gas trapping [1,2]. Exacerbations of COPD are associated with a mortality of 10% in the hospital, 43% at 1 year and 50% in the subsequent 5 years [3][4][5]. Exacerbations themselves are associated with a step-wise decline in lung function and deteriorating quality of life [6]. The most commonly identified triggers for AECOPD are respiratory viruses, particularly rhinovirus, as well as bacterial pathogens and environmental exposures. NIPPVNIPPV is indicated in the setting of acute respiratory failure secondary to COPD exacerbation [7,8]. The goal of NIPPV in this setting is to reduce work of breathing, improve ventilation, correct hypercapnia and...

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Antibiotics for exacerbations of chronic obstructive pulmonary disease

Cited by 94 publications

References 92 publications

Acute exacerbation of COPD

Acute exacerbation of COPD

Hospitalised exacerbations of chronic obstructive pulmonary disease: adherence to guideline recommendations in an Australian teaching hospital

Acute Exacerbation of COPD

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