Management of severe acute exacerbations of COPD: an updated narrative review

Abstract

BackgroundPatients with chronic obstructive pulmonary disease (COPD) may experience an acute worsening of respiratory symptoms that results in additional therapy; this event is defined as a COPD exacerbation (AECOPD). Hospitalization for AECOPD is accompanied by a rapid decline in health status with a high risk of mortality or other negative outcomes such as need for endotracheal intubation or intensive care unit (ICU) admission. Treatments for AECOPD aim to minimize the negative impact of the current exacerbation and to prevent subsequent events, such as relapse or readmission to hospital.Main bodyIn this narrative review, we update the scientific evidence about the in-hospital pharmacological and non-pharmacological treatments used in the management of a severe AECOPD. We review inhaled bronchodilators, steroids, and antibiotics for the pharmacological approach, and oxygen, high flow nasal cannulae (HFNC) oxygen therapy, non-invasive mechanical ventilation (NIMV) and pulmonary rehabilitation (PR) as non-pharmacological treatments. We also review some studies of non-conventional drugs that have been proposed for severe AECOPD.ConclusionSeveral treatments exist for severe AECOPD patients requiring hospitalization. Some treatments such as steroids and NIMV (in patients admitted with a hypercapnic acute respiratory failure and respiratory acidosis) are supported by strong evidence of their efficacy. HFNC oxygen therapy needs further prospective studies. Although antibiotics are preferred in ICU patients, there is a lack of evidence regarding the preferred drugs and optimal duration of treatment for non-ICU patients. Early rehabilitation, if associated with standard treatment of patients, is recommended due to its feasibility and safety. There are currently few promising new drugs or new applications of existing drugs.

Targeting Vitamin D Deficiency to Limit Exacerbations in Respiratory Diseases: Utopia or Strategy With Potential?

“…Interestingly, polymorphisms in the vitamin D binding protein gene might also be related to higher exacerbation frequencies (Ishii 2014), suggesting a relationship between vitamin D and the occurrence of exacerbations. Current strategy to treat exacerbations in COPD includes long-acting bronchodilators and longterm use of inhaled corticosteroids or macrolide antibiotics but they are all modestly effective and evidence on the preferred drug and optimal treatment duration are lacking [82]. An attractive alternative target for intervention studies in COPD is the vitamin D pathway.…”

Effect of high-flow nasal therapy during early pulmonary rehabilitation in patients with severe AECOPD: a randomized controlled study

“…Acute exacerbation (AE) of COPD (AECOPD) is defined as episodes of acute worsening of respiratory symptoms (such as dyspnea, coughing, and sputum production) that require additional therapy [3,4]. Treatments for AECOPD aim to minimize the negative impacts of the current exacerbation and prevent subsequent events, such as relapse or readmission to the hospital [5]. AECOPD requiring hospitalization is associated with poor outcomes, including accelerated declines in muscle strength [6] and lung function [7], a reduced health status and quality of life (QOL) [8], accelerated disease progression [9], a significant risk of recurrent exacerbations, and an increased risk of mortality [10,11].…”

“…In this way, treatment goals for patients with AECOPD are to minimize the negative impacts of these events and prevent their recurrence [13]. The management of severe AECOPD is divided into pharmacological (inhaled bronchodilators, steroids, and antibiotics) and nonpharmacological treatments (oxygen therapy, high-flow nasal therapy (HFNT), non-invasive mechanical ventilation (NIMV), and pulmonary rehabilitation (PR)) [5].…”

Interventions at presentation and discharge for patients with acute exacerbation of chronic obstructive pulmonary disease to reduce unnecessary admissions and readmissions: A scoping review protocol

“…The primary aim of AECOPD treatment was to minimize the clinical impact of the current exacerbation and to prevent subsequent deterioration events that may include readmission (Crisafulli, Barbeta, Ielpo, & Torres, ). Published AECOPD treatment guidelines exist (GOLD, ; NICE, ) although adherence has been found to be challenging (Lodewijck et al, ) with clinician‐reported barriers including poor familiarity with recommendations, low self‐efficacy and time constraints (Perez, Wisniveskya, Lurslurchachai, Kleinman, & Kronish, ).…”