European, American Societies Provide Guidelines for Managing COPD Exacerbations

The European Respiratory Society and the American Thoracic Society have conducted a comprehensive review of evidence on managing exacerbations of chronic obstructive pulmonary disease (COPD) in order to create a guideline of clinical recommendations. The guideline was published in the European Respiratory Journal.

The Task Force appraised evidence from clinical trials that was relevant to the 6 questions it wanted to develop treatment recommendations for.

“These guidelines provide the basis for rational decisions in the treatment of COPD exacerbations,” the authors wrote.

1. Should oral corticosteroids be used to treat ambulatory patients who are having COPD exacerbation?

Recommendation: A short course of 14 days or fewer of oral corticosteroids for ambulatory patients with an exacerbation of COPD.

The Task Force identified 3 clinical trials in this area that had enrolled a total of 204 patients. A review of the trials found that oral corticosteroids for 9 to 14 days in outpatients experiencing COPD exacerbations results in improved lung function and reduces hospitalizations.

2. Should antibiotics be used to treat ambulatory patients who are having a COPD exacerbation?

Recommendation: Ambulatory patients with a COPD exacerbation should receive antibiotics, but selection of antibiotics should be based on local sensitivity patterns.

A total of 2 trials with 483 enrolled participants were analyzed. While antibiotic therapy reduced the risk of treatment failure and increased the time between exacerbations, patients had a trend toward more adverse events.

3. Should intravenous or oral corticosteroids be used to treat patients who are hospitalized with a COPD exacerbation?

Recommendation: Patients hospitalized because of a COPD exacerbation should receive oral rather than intravenous corticosteroids if gastrointestinal access and function are intact.

The Task Force identified 2 trials with a total of 250 patients hospitalized with a COPD exacerbation. They found that there was not an observable difference in treatment failure, hospital readmission, or length of hospital stay between oral or intravenous corticosteroids. However, intravenous corticosteroids might increase the risk of adverse events.

4. Should noninvasive mechanical ventilation be used in patients who are hospitalized with a COPD exacerbation associated with acute or acute-on-chronic respiratory failure?

Recommendation: Patients with acute or acute-on-chronic respiratory failure due to COPD who are hospitalized should be given noninvasive mechanical ventilation.

A total of 21 trials were used to inform the Task Force’s judgement. Noninvasive mechanical ventilation reduced the need for intubation and decreased mortality, complications of therapy, and length of both hospital stay and intensive care unit stay for patients who were hospitalized due to a COPD exacerbation.

5. Should a home-based management program be implemented in patients with COPD exacerbations?

Recommendations: A home-based management program can be used for patients with a COPD exacerbation who present to the emergency department or hospital.

The Task Force analyzed 9 trials comparing home-based management to usual care in patients with COPD exacerbations. The researchers found that the home-based management model reduced the number of readmissions and they identified a slight trend toward lower mortality. No adverse events were reported.

6. Should pulmonary rehabilitation be implemented in patients hospitalized with a COPD exacerbation?

Recommendations: Pulmonary rehabilitation should be initiated within 3 weeks of being discharged for patients who were hospitalized with a COPD exacerbation. The Task Force does not recommend initiating rehabilitation while patients are still hospitalized.

A total of 13 trials implementing pulmonary rehabilitation were analyzed. The Task Force members found that pulmonary rehabilitation initiated during hospitalization increased exercise capacity, while rehabilitation initiated within 3 weeks of discharge reduced readmissions and quality of life. Rehabilitation initiated within 8 weeks of discharge increased exercise capacity.

The recommendation regarding noninvasive mechanical ventilation was the only one to receive a strong recommendation, while conditional recommendations were made for oral corticosteroids in outpatients, oral rather than intravenous corticosteroids in hospitalized patients, antibiotic therapy, home-based management, and initiation of pulmonary rehabilitation within 3 weeks of hospital discharge.

However, it is important to note that there was sparse evidence in several areas.

“These recommendations should be reconsidered as new evidence becomes available,” the authors wrote.