Evidence Base for Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Snow, Vincenza; Lascher, Steven; Mottur‐Pilson, Christel

doi:10.7326/0003-4819-134-7-200104030-00015

Cited by 153 publications

(71 citation statements)

References 1 publication

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“…In fact, currently there are no reliable methods of risk stratification for COPD patients who present to the ED with exacerbation, based on studies of relapse or inpatient mortality. 32 Composite measures or scoring systems, with more weights on the practical predictors identified in our study, may need to be constructed for COPD exacerbation to better risk-stratify these patients and support physician decision making in the ED.…”

Section: Discussionmentioning

confidence: 99%

Factors Associated with Hospital Admission among Emergency Department Patients with Chronic Obstructive Pulmonary Disease Exacerbation

Tsai

Clark

Cydulka

et al. 2007

Academic Emergency Medicine

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Objectives: To determine the patient factors associated with hospital admission among adults who present to the emergency department (ED) with acute exacerbations of chronic obstructive pulmonary disease (COPD) and to determine whether admissions were concordant with recommendations in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Methods:The authors performed a prospective multicenter cohort study involving 29 EDs in the United States and Canada. By using a standard protocol, consecutive ED patients with COPD exacerbation were interviewed, and their charts were reviewed. Predictors of admission were determined by multivariate logistic regression.Results: Of 384 patients, 233 (61%; 95% confidence interval = 56% to 66%) were admitted. Multivariate analysis showed that a higher likelihood of admission was associated with older age, female gender, more pack-years of smoking, recent use of inhaled corticosteroid, self-reported activity limitation in the past 24 hours, higher respiratory rate at ED presentation, and a concomitant diagnosis of pneumonia. Patients who reported the ED as their usual site for problem COPD care, or who had mixed COPD and asthma, were less likely to be admitted. The authors confirmed five of the seven testable indications for hospital admission in the GOLD guidelines.Conclusions: Several patient factors were independently associated with hospital admission among ED patients with COPD exacerbations. Overall, concordance with admission recommendations in the GOLD guidelines was high. The authors also identified a few novel predictors of admission (female gender, ED as the usual site for problem COPD care, mixed diagnosis of COPD and asthma, recent use of inhaled corticosteroid) that require replication in future studies. ACADEMIC EMERGENCY MEDICINE 2007; 14:6-15 ª 2007 by the Society for Academic Emergency MedicineKeywords: chronic obstructive pulmonary disease, exacerbation, admission, emergency department C hronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. COPD is the third most common cause of hospitalization in the United States, with an estimated 726,000 hospitalizations in 2000. 1 Chronic obstructive pulmonary disease exacerbation also accounts for approximately 1.5 million emergency department (ED) visits per year. 1 Despite the tremendous burden of hospital admissions and ED visits caused by COPD exacerbations, little is known regarding factors associated with hospital admission from the ED. Previous studies focused on risk factors for admission in stable COPD patients, 2,3 external factors (e.g., air pollution) and admission, 4 or prognostic factors for in-hospital mortality. [5][6][7] However, these studies did not address the decision making for admission among patients presenting to the ED

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Section: Discussionmentioning

confidence: 99%

Factors Associated with Hospital Admission among Emergency Department Patients with Chronic Obstructive Pulmonary Disease Exacerbation

Tsai

Clark

Cydulka

et al. 2007

Academic Emergency Medicine

View full text Add to dashboard Cite

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“…18,19 We also identified pharmacy or diagnostic charges for interventions that were recommended in current guidelines (beta-adrenergic and anticholinergic bronchodilators, steroids, and noninvasive positive-pressure ventilation); those that were not recommended or were of uncertain benefit (methylxanthine bronchodilators, spirometry/pulmonary function testing, mucolytic medications, chest physiotherapy, and sputum testing); and drugs that might be associated with severe exacerbations or end-stage COPD (loop diuretics, morphine, and nutritional supplements). 1,[6][7][8][9] Hospitals were categorized by region (Northeast, South, Midwest, or West), bed size, setting (urban vs. rural), ownership, and teaching status.…”

Section: Data Elementsmentioning

confidence: 99%

“…1,[6][7][8][9] These recommendations are based on a number of small randomized trials, most of which were conducted more than 20 years ago using narrow spectrum antibiotics that are no longer commonly used. 10 Only 4 studies, totaling 321 subjects, included hospitalized patients, and most studies excluded patients who required steroids.…”

mentioning

confidence: 99%

Comparative effectiveness of macrolides and quinolones for patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease (AECOPD)

Rothberg

Pekow

Lahti

et al. 2010

Journal of Hospital Medicine

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BACKGROUND: Meta‐analyses of randomized trials have found that antibiotics are effective in acute exacerbations of chronic obstructive pulmonary disease (AECOPD), but there is insufficient evidence to guide antibiotic selection. Current guidelines offer conflicting recommendations. OBJECTIVE: To compare the effectiveness of macrolides and quinolones for AECOPD DESIGN: Retrospective cohort study using logistic regression, propensity score–matching, and grouped treatment models. SETTING: A total of 375 acute care hospitals throughout the United States. PATIENTS: Age ≥40 years and hospitalized for AECOPD. INTERVENTION: Macrolide or quinolone antibiotic begun in the first 2 hospital days. MEASUREMENTS: Treatment failure (defined as the initiation of mechanical ventilation after hospital day 2, inpatient mortality, or readmission for AECOPD within 30 days), length of stay, and hospital costs. RESULTS: Of the 19,608 patients who met the inclusion criteria, 6139 (31%) were treated initially with a macrolide and 13,469 (69%) with a quinolone. Compared to patients treated initially with a quinolone, those who received macrolides had a lower risk of treatment failure (6.8% vs. 8.1%; P < 0.01), a finding that was attenuated after multivariable adjustment (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.78–1.01), and disappeared in a grouped‐treatment analysis (OR, 1.01; 95% CI, 0.75–1.35). There were no differences in adjusted length of stay (ratio, 0.98; 95% CI, 0.97–1.00) or adjusted cost (ratio, 1.00; 95% CI, 0.99–1.02). After propensity score–matching, antibiotic‐associated diarrhea was more common with quinolones (1.2% vs. 0.6%; P < 0.001). CONCLUSIONS: Macrolide and quinolone antibiotics are associated with similar rates of treatment failure in AECOPD; however, macrolides are less frequently associated with diarrhea. Journal of Hospital Medicine 2010;5:267–267. © 2010 Society of Hospital Medicine.

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“…On the basis of recommendations contained in the COPD guidelines, [12][13][14]24 we categorized the following diagnostic evaluations and treatments as beneficial quality indicators: chest radiography, pulse oximetry, inhaled bronchodilators, systemic corticosteroids, and antibiotics. The use of bronchodilator and systemic corticosteroids was recently included as quality measures in pharmacotherapy for AECOPD in the Health Care Effectiveness Data and Information Sets in 2008.…”

Section: Study Setting and Populationmentioning

confidence: 99%

“…Although several COPD practice guidelines have been published, little is known about the actual ED management of AECOPD in the United States. The main guidelines for the treatment of AECOPD over the past two decades include the first American Thoracic Society (ATS) guidelines published in 1995, 9 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines published in 2001 10 and updated annually, 11 the ATS and European Respiratory Society joint guidelines published in 2004, 12 and the 2001 American College of Physicians guidelines 13,14 with a recent update. 15, 16 We previously showed that adherence of ED management of AECOPD to current treatment guidelines was low at 29 academic EDs in North America.…”

mentioning

confidence: 99%

National Study of Emergency Department Visits for Acute Exacerbation of Chronic Obstructive Pulmonary Disease, 1993–2005

Tsai

Sobrino

Camargo

2008

Academic Emergency Medicine

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Objectives: Little is known about recent trends in U.S. emergency department (ED) visits for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) or about ED management of AECOPD. This study aimed to describe the epidemiology of ED visits for AECOPD and to evaluate concordance with guideline-recommended care.Methods: Data were obtained from National Hospital Ambulatory Medical Care Survey (NHAMCS). ED visits for AECOPD, during 1993 to 2005, were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Concordance with guideline recommendations was evaluated using process measures.Results: Over the 13-year study period, there was an average annual 0.6 million ED visits for AECOPD, and the visit rates for AECOPD were consistently high (3.2 per 1,000 U.S. population; P trend = 0.13). The trends in the use of chest radiograph, pulse oximetry, or bronchodilator remained stable (all P trend > 0.5). By contrast, the use of systemic corticosteroids increased from 29% in 1993-1994 to 60% in 2005, antibiotics increased from 14% to 42%, and methylxanthines decreased from 15% to <1% (all P trend < 0.001). Multivariable analysis showed patients in the South (vs. the Northeast) were less likely to receive systemic corticosteroids (odds ratio [OR] = 0.6; 95% confidence interval [CI] = 0.4 to 0.9). Conclusions:The high burden of ED visits for AECOPD persisted. Overall concordance with guidelinerecommended care for AECOPD was moderate, and some emergency treatments had improved over time.

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Evidence Base for Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Cited by 153 publications

References 1 publication

Factors Associated with Hospital Admission among Emergency Department Patients with Chronic Obstructive Pulmonary Disease Exacerbation

Factors Associated with Hospital Admission among Emergency Department Patients with Chronic Obstructive Pulmonary Disease Exacerbation

Comparative effectiveness of macrolides and quinolones for patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease (AECOPD)

National Study of Emergency Department Visits for Acute Exacerbation of Chronic Obstructive Pulmonary Disease, 1993–2005

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