Nonantibiotic Pharmacological Treatment of Severe Chronic Obstructive Pulmonary Disease Exacerbations

Abstract

Severe, acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a rapid deterioration of the respiratory symptoms of patients with COPD, requiring hospital admission and escalation of pharmacological and nonpharmacological care including the more severe cases of respiratory failure and admission to an intensive care unit (ICU). These events severely impact patients' quality of life and prognosis. This review will describe the nonantibiotic, pharmacological treatment options available for critically ill patients with AECOPD. The aim of treatment is to alleviate symptoms, improve patient's functional and respiratory status, reduce mortality, reduce the risk or the duration of invasive mechanical ventilation, and prevent reexacerbations. Inhaled bronchodilators (i.e., short-acting β2-agonists and anticholinergics) and systemic corticosteroids are the main drugs used in the treatment of AECOPD. These drugs are also used in the treatment of stable COPD and in the treatment of AECOPD patients in the non-ICU or community setting. Other drugs are essentially only used in the ICU setting such as inhaled anesthetic agents, ketamine, intravenous methylxanthines, and magnesium. Finally, recently developed drugs, such as the specific phosphodiesterase-4 inhibitors, may play a role in the prevention of relapsing AECOPD following a critical event than the treatment of the exacerbation itself. Although they significantly improve the survival of critically ill patients with AECOPD, none of available drugs, alone or combined, is able to significantly modify the prognosis of patients with COPD. This remains an open challenge for the current and future generations of researchers and clinicians.

Association Between Systemic Corticosteroid Therapy and Mortality in Critically Ill Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Retrospective Cohort Study

“…Biologically, glucocorticoids can relieve airways in ammation and in return reduce the airways resistance to improve the dyspnea and the work of breathing [17]. The use of systemic glucocorticoids has been recommended during COPD exacerbations by GOLD 2021 (https://goldcopd.org/2021-gold-reports/).…”

Chronic Obstructive Pulmonary Disease Treatment and Pharmacist-Led Medication Management

“…Inhaled bronchodilators (ie, LABAs and LAMAs) are the main drugs in reducing lung hyperinflation secondary to reduced airway resistance and in turn relieving dyspnoea during AECOPD. 8,20 These drugs are also used in the treatment of stable COPD and AECOPD in the non-ICU or community setting. Recently developed drugs such as roflumilast, specific PDE-4 inhibitors, play a role in the prevention of exacerbations and hospitalizations in the real-world population with severe COPD.…”

“…AECOPD often follow increased airway inflammation, mainly due to infection, and lead to decreased airflow and increased lung hyperinflation relative to stable COPD. 8 The role of bacterial infection in AECOPD is mainly manifested by the primary bacterial infection in lower airway, secondary bacterial infection along with viral infection, followed by bacterial antigeninduced hyperresponsiveness of airway, and eosinophil inflammation. 31 Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Enterobacter, and Pseudomonas aeruginosa, are prevailing bacteria classes in COPD patients.…”

“…6,7 AECOPD is a rapid deterioration of respiratory symptoms requiring hospital admission and escalation of pharmacological and non-pharmacological care including more severe cases of respiratory failure and admission to an intensive care unit (ICU). 8 Some COPD patients experience frequent exacerbations (≥2 per year) independently of disease severity, but are associated with impaired health-related quality of life, reduced physical activity and poor disease prognosis. 8 The cornerstone of pharmacotherapy for stable COPD is long-acting bronchodilators or combined with inhaled corticosteroids (ICS), while the treatment for AECOPD also includes antiinfective drugs.…”

“…8 Some COPD patients experience frequent exacerbations (≥2 per year) independently of disease severity, but are associated with impaired health-related quality of life, reduced physical activity and poor disease prognosis. 8 The cornerstone of pharmacotherapy for stable COPD is long-acting bronchodilators or combined with inhaled corticosteroids (ICS), while the treatment for AECOPD also includes antiinfective drugs. 9 The treatment strategies will be more complicated especially for patients with complex complications.…”