Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline

Abstract

This document provides clinical recommendations for treatment of chronic obstructive pulmonary disease (COPD) exacerbations.Comprehensive evidence syntheses, including meta-analyses, were performed to summarise all available evidence relevant to the Task Force's questions. The evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluation approach and the results were summarised in evidence profiles. The evidence syntheses were discussed and recommendations formulated by a multidisciplinary Task Force of COPD experts.After considering the balance of desirable and undesirable consequences, quality of evidence, feasibility, and acceptability of various interventions, the Task Force made: 1) a strong recommendation for noninvasive mechanical ventilation of patients with acute or acute-on-chronic respiratory failure; 2) conditional recommendations for oral corticosteroids in outpatients, oral rather than intravenous corticosteroids in hospitalised patients, antibiotic therapy, home-based management, and the initiation of pulmonary rehabilitation within 3 weeks after hospital discharge; and 3) a conditional recommendation against the initiation of pulmonary rehabilitation during hospitalisation.The Task Force provided recommendations related to corticosteroid therapy, antibiotic therapy, noninvasive mechanical ventilation, home-based management, and early pulmonary rehabilitation in patients having a COPD exacerbation. These recommendations should be reconsidered as new evidence becomes available.

Three-Year Hospitalization and Mortality in Elderly Smokers with Chronic Obstructive Pulmonary Disease or Chronic Heart Failure

“…A history of at least one hospital admission in the previous 12 months was strongly associated with mortality in CHF, but not with mortality or hospitalization in COPD. This finding is in conflict with the previously reported result that a history of moderate to severe exacerbations of COPD is a strong risk factor for mortality and future exacerbations in patients with COPD [31][32][33]. By contrast, we confirmed that previous 12-month hospitalizations are predictors of mortality in patients with CHF [34] and extended this finding to patients with a milder disease (NYHA I and II).…”

Treatment of COPD Exacerbation in Switzerland: Results and Recommendations of the European COPD Audit

“…It is especially striking that although a blood gas analysis is recommended in the GOLD guidelines [1] , this examination was performed on only 85.6% of the patients fulfilling the criteria for severe exacerbation and thus requiring hospitalization. NIV reduces the mortality rate and the length of ICU and hospital stay [16] ; yet only 66.7% of the patients fulfilling the ABG criteria for NIV received this therapy, and only 30.0% of those requiring IMV were treated accordingly. In the other European countries, NIV was administered to only 51.3% of the patients fulfilling the ABG criteria, and IMV to only 15.2% of the patients.…”

Treatment burden should be included in clinical practice guidelines

“…The evidence to decision (EtD) framework developed by the GRADE Working Group acknowledges the importance of patients’ values and preferences 10. Following this framework, the 2017 guidelines on prevention of COPD exacerbations published by the European Respiratory Society and the American Thoracic Society added a paragraph on “values and preferences” to every treatment recommendation 11. For example, the statement accompanying the conditional recommendation to use oral mucolytic agents to prevent future COPD exacerbations reads: “This recommendation places a high value on avoiding hospitalisations and a lower value on the cost and burden of taking daily medication.”…”

“…The 2017 guidelines on prevention of COPD exacerbations make a conditional recommendation for initiation of pulmonary rehabilitation within three weeks after hospital discharge 11. The current “values and preferences” section states: “This recommendation places a high value on improving clinical outcomes and a lower value on the burden and cost of pulmonary rehabilitation.”…”