This will depend on the severity of the exacerbation, but should generally include reclassification of the patient according to the GOLD criteria,1 optimization of pharmacological therapy,1,4,8 management of comorbidities, patient (or home caregiver) education on the correct use of medications,1,8 referral to a Pulmonology Consultation if they are not already attending one, and a smoking cessation and pulmonary rehabilitation program. Impact of individualized care on readmissions after a hospitalization for acute exacerbation of COPD. Donaldson GC, Wedzicha JA. NLM While there are studies that aid in evaluation, an acute COPD exacerbation is a clinical diagnosis that is characterized by symptoms which are more severe than the patient’s baseline. Cheung. Eighty-three patients with an acute exacerbation of COPD were studied; 45 percent were admitted to the hospital while 17 percent of the patients who were discharged suffered a relapse. This makes it harder to breathe. About a third of patients are readmitted within 90 days of discharge.2 Significant … Daniels, M. Schoorl, D. Snijders, D.L. This is a name given to a group of diseases that limit the flow of air in and out of your lungs. The definition of exacerbation in the 2016 GOLD update,12 “an acute event characterized by a worsening of the patient's respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication”, was simplified in the GOLD 2017 document13 to “an acute worsening of respiratory symptoms that results in additional therapy”. 48-55. Chronic Obstructive Pulmonary Disease (COPD) is a serious pulmonary condition. The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Chest 2007; 131:696. Pulmonology (previously Revista Portuguesa de Pneumologia) is the official journal of the Portuguese Society of Pulmonology (Sociedade Portuguesa de Pneumologia/SPP). Those who have had a successful treatment with simple aspiration or intercostal drain with underwater seal (ie, resolution of symptoms and/or a rim of air <2 cm). After an exacerbation is appropriately managed, a suitable discharge plan should be prepared. Ouellette, D. Goodridge, P. Hernandez. Setting Five hospitals and three home care … B. Planquette, J. Peron, E. Dubuisson, A. Roujansky, V. Laurent, A. Le Monnier, Int J Chron Obstruct Pulmon Dis, 10 (2015), pp. N. Roche, J.M. Appropriate management of COPD exacerbations presents a clinical challenge and, in order to guide therapy, it is important to identify the underlying cause; however, this is not possible in about a third of severe COPD exacerbations. COPD is involved in up to 20% of hospitalizations for adults in the U.S. —-///—-Pearls. COPD cannot be cured, but you can take action to feel better and prevent exacerbations: Do not … Are you a health professional able to prescribe or dispense drugs? Taylor. AR declares having received speaking fees from AstraZeneca, Boehringer Ingelheim, Novartis, Bial, Medinfar, Mundipharma, Menarini, Grifols, Mylan, Tecnifar, Teva and cslbehring. A Respiratory Therapist Disease Management Program for Subjects Hospitalized With COPD. Ther Adv Respir Dis, 7 (2013), pp. Severe 30-49% Dyspnea, reduced exercise capacity, and repeated exacerbations impact quality of life. You can change the settings or obtain more information by clicking, http://dx.doi.org/10.1186/s12931-015-0313-4, Predictors of intubation in COVID-19 patients treated with out-of-ICU continuous positive airway pressure. Identification of the underlying cause of COPD exacerbations and assessment of their severity is fundamental to guiding treatment. 2019 Jun 25;6:79. doi: 10.3389/fcvm.2019.00079. For SP, the underlying condition should also have returned to a stable state (see criteria for asthma and COPD). 2010 Jun;31(3):313-20. doi: 10.1055/s-0030-1254071. The diagnosis of chronic obstructive pulmonary disease (COPD) is dependent upon spirometric testing. Clinical audit indicators of outcome following admission to hospital with acute exacerbation of chronic obstructive pulmonary disease. J Eval Clin Pract, 21 (2015), pp. COPD includes chronic bronchitis and emphysema. COPD; Discharge; Exacerbation; Hospitalization; Management. When using theophylline, it is necessary to monitor blood levels, side effects and potential drug interactions.8,31. Science Citation Index Expanded, Journal of Citation Reports; Index Medicus/MEDLINE; Scopus; EMBASE/Excerpta Medica, The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two receding years.© Clarivate Analytics, Journal Citation Reports 2020, CiteScore measures average citations received per document published. While everyone experiences exacerbations differently, there are a number of possible warning signs — and you may feel as if you can’t catch your breath.. Exacerbations can last for days or even weeks, and may require antibiotics, oral corticosteroids, and even … As previously mentioned, exacerbations of COPD are very heterogeneous making it particularly relevant to determine their etiology, pathology, severity and risk as all of these factors will have implications in the prognosis, pharmacological treatment and place of treatment. Rehabilitative practice in Europe: Roles and competencies of physiotherapists. Am J Health Syst Pharm. While COPD is a mainly chronic disease, a substantial number of patients suffer from exacerbations. If the patient remains hypoxemic, long-term supplemental oxygen therapy may be required.1 Also, patients should be given clear instructions about when and how to stop their corticosteroid treatment.1,8 Concerning the need for individualized care, a Canadian study in which the patients were offered a post discharge phone call, a home visit and continued care concluded that although there was no reduction in 30- and 90-day readmission rates, a decrease in 90-day total mortality was seen. This site needs JavaScript to work properly. 61-71, © Copyright 2021. Sánchez-Nieto JM, Andújar-Espinosa R, Bernabeu-Mora R, Hu C, Gálvez-Martínez B, Carrillo-Alcaraz A, Álvarez-Miranda CF, Meca-Birlanga O, Abad-Corpa E. Int J Chron Obstruct Pulmon Dis. H. Qureshi, A. Sharafkhaneh, N.A. Chan, W.S. Miles, J.F. 2257-2263. CD010257. Management of chronic obstructive pulmonary disease: A review focusing on exacerbations. Some of these factors were studied in patients following hospital discharge with a COPD exacerbation 48. In the case of a patient who has had a severe exacerbation, requiring hospitalization, the patient should be reclassified as a frequent exacerbator. This should generally include reclassification of the patient according to GOLD criteria, optimization of pharmacological therapy, management of comorbidities, patient (or caregiver) education on the correct use of medications, referral to a Pulmonology Outpatient Clinic, if they are not already attending one, and a smoking cessation and respiratory rehabilitation program. J.A. Eosinophilia, frequent exacerbations, and steroid response in chronic obstructive pulmonary disease. In this paper, we will focus on the pharmacological strategies for the management of COPD exacerbations, risk stratification and a hospital discharge plan proposal. In addition, it should list other healthcare providers (especially the family doctor) relevant to the patient and specify clearly how they can contact members of the healthcare … This includes, among other symptoms, worsening dyspnea, increased cough and sputum … Continuing navigation will be considered as acceptance of this use. Global Initiative for Chronic Obstructive Lung Disease. Clipboard, Search History, and several other advanced features are temporarily unavailable. There are several diagnostic tools that can be used to assess an exacerbation and its severity, which will in turn guide treatment, and prognostic scores should be used to predict the risk of future exacerbations. International Journal of Chronic Obstructive Pulmonary Disease: "Risk factors of hospitalization and readmission of patients with COPD exacerbation -- systematic review." Many patients experience exacerbations and some require Emergency Room visits and hospitalization. COVID-19 is an emerging, rapidly evolving situation. Design Prospective, randomised controlled and multicentre trial with 3-month follow-up. Sociedade Portuguesa de Pneumologia, , on behalf of the GI DPOC-Grupo de Interesse na Doença Pulmonar Obstrutiva Crónica, Pulmonology Department, Hospital São Teotónio, Viseu, Portugal, Pulmonology Department, Hospital de Nossa Senhora do Rosário, Barreiro, Portugal, Pulmonology Department, Hospital Beatriz Ângelo, Loures, Portugal, Pulmonology Department, Unidade Local de Saúde de Matosinhos, Portugal, Pulmonology Department, Centro Hospitalar de São João, Porto, Portugal, Porto Medical School, Porto University, Portugal, Pulmonology Department, University Hospital, Coimbra, Portugal, Coimbra Medical School, Coimbra University, Portugal, Antibiotics, corticosteroids and xanthines, To improve our services and products, we use cookies (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. C-reactive protein level and microbial aetiology in patients hospitalised with acute exacerbation of COPD. In Portugal, hospitalizations due to COPD between 2009 and 2016 decreased by 8%, but they still represented 8049 hospitalized patients in 2016. Am J Respir Crit Care Med, 184 (2011), pp. S.L. CRC declares speaking fees from Boehringer Ingelheim, Roche, Novartis, AstraZeneca, Pfizer vaccines, Teva, Menarini, Medinfar and Tecnifar, and participating in advisory boards of Boehringer Ingelheim, Roche, Novartis, GSK, AstraZeneca and Pfizer vaccines. This Pocket Guide has been developed from the . The addition of short-term OCS therapy to bronchodilator therapy during COPD exacerbations should also be considered for patients with an FEV 1 <50%, although some physicians prescribe OCS if they feel the exacerbation is severe enough to warrant their use, regardless of FEV 1. Chronic obstructive pulmonary disease exacerbations: latest evidence and clinical implications. Core Measure Documentation at Discharge for COPD . Many patients experience COPD exacerbations and some of these require Emergency Room (ER) visits and hospitalizations. D.J. Vogelmeier, F.J. Herth, C. Thach, R. Fogel. MD declares having received fees for talks from AstraZeneca, Boehringher Ingelheim, Bial, GSK, Menarini and Novartis and for participation in advisory boards of Bial, GSK and Novartis. 2020 Feb 7;77(4):259-268. doi: 10.1093/ajhp/zxz306. Roberts CM, Lowe D, Bucknall CE, et al. Chang, K.C. This review summarises the current knowledge on the different aspects of COPD exacerbations. Appropriateness of diagnostic effort in hospital emergency room attention for episodes of COPD exacerbation. On discharge from a moderate exacerbation, bronchodilation should be optimized, anti-pneumococcal vaccination should be prescribed, and a smoking cessation and respiratory rehabilitation plan should be prepared. Front Cardiovasc Med. Silver PC, Kollef MH, Clinkscale D, Watts P, Kidder R, Eads B, Bennett D, Lora C, Quartaro M. Respir Care. Knol, R. Lutter, H.M. Jansen. With COPD, you are also more likely to get lung infections. Chapman, C.F. Exacerbations of COPD may be classified as mild, moderate, severe6 and very severe. Usually initial empirical treatment encompasses aminopenicillin with clavulanic acid, a macrolide, or a tetracycline.1,8 However, the long-term use of macrolides may be associated with important side-effects and the risk of developing bacterial resistance.36 Sputum should be sent for culture (in the case of patients with frequent exacerbations, severe airflow limitation, and/or exacerbations requiring mechanical ventilation1), as gram-negative bacteria (e.g., Pseudomonas species) or resistant pathogens that are not sensitive to the above-mentioned antibiotics may be present.1. 2017 Jan;62(1):1-9. doi: 10.4187/respcare.05030. 12-Day Steroid Taper. Patients (or home caregivers) should be given appropriate information to enable them to fully understand the correct use of medications, including inhalers and oxygen, and, if necessary, arrangements for follow-up and home care (such as visiting nurse, oxygen delivery, referral for other support) should be made. More than 3 million people died of COPD in 2012 accounting for 6% of all deaths globally. Cordoba, E.L. Strandberg. Analysis of chronic obstructive pulmonary disease exacerbations with the dual bronchodilator QVA149 compared with glycopyrronium and tiotropium (SPARK): a randomised, double-blind, parallel-group study. Indacaterol-glycopyrronium versus salmeterol-fluticasone for COPD. M. Miravitlles, A. D’Urzo, D. Singh, V. Koblizek. After an exacerbation is appropriately managed, a suitable discharge plan should be prepared. Infectious exacerbations are characterized by increases in volume and purulence of the sputum associated with aggravated dyspnea and should be treated with antibiotics.1,8, The assessment of an exacerbation and its severity is based on the patient's medical history,1,6 e.g., airflow limitation, duration of worsening of symptoms and number of previous episodes (total/hospitalizations). Leuppi, P. Schuetz, R. Bingisser, M. Bodmer, M. Briel, T. Drescher. 2020. After an exacerbation is appropriately managed, a suitable discharge plan that will depend on its severity should be prepared. NPJ Prim Care Respir Med, 25 (2015), pp. The lack of confirmatory spirometric testing leads to diagnostic uncertainty in patients hospitalized for an acute exacerbation of COPD (AECOPD). If the patient is admitted to the ICU, besides the tests recommended in severe exacerbations, the Glasgow Coma Scale5 should be used, respiratory tract infections investigated25 and a hemoculture performed.24 According to the GOLD 2018 document only patients requiring non-invasive ventilation (NIV) or invasive ventilation (IV) should be hospitalized.1, Short-acting inhaled β2 agonists (SABAs) and short-acting muscarinic antagonists (SAMAs) remain the mainstay in the treatment of symptoms and airflow obstruction during COPD exacerbations.1,4,6 Although at the time of publication of the GOLD 2018 document there were no clinical studies evaluating the usefulness of long-acting β2 agonists (LABA) or long-acting muscarinic antagonists (LAMA) in exacerbations, the recommendation is to continue this medication during the exacerbation or to start it as soon as possible before hospital discharge.1 The LABA+LAMA combination does have a documented benefit in the reduction of exacerbations when prescribed to patients in the stable phase of COPD,26 particularly the indacaterol/glycopyrronium combination as demonstrated in the SPARK27 and FLAME28 studies. 2013 Nov;50(11):1537 … Niewoehner, T. Sandstrom, A.F. Moderate 50-79% Patients typically seek medical attention at this stage due to respiratory symptoms or an exacerbation. Does eosinophilic COPD exacerbation have a better patient outcome than non-eosinophilic in the intensive care unit?. COPD exacerbations .1: Epidemiology. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease (updated 2016). In Portugal, hospitalizations due to COPD between 2009 and 2016 decreased by 8%, but they still represented 8049 hospitalized patients in 2016. Corticosteroids seem to be beneficial to the whole population in terms of treatment success rate.37, Some studies suggest that corticosteroids may be less efficacious in treating acute COPD exacerbations in patients with lower levels of blood eosinophils.15,38, As for methylxanthines in the management of COPD exacerbations, current evidence does not support their use, given that the possible beneficial effects in lung function and clinical endpoints are modest and inconsistent, whilst adverse events are significant.1,4,6,31 Intravenous methylxanthines (theophylline or aminophylline) may be considered second-line therapy and used as an add-on when there is insufficient response. During the follow-up consultation (three months for moderate exacerbations and 4–6 weeks for severe exacerbations), spirometry and arterial blood gases should be measured. Combination therapy with OCS and a bronchodilator has been shown to … Procalcitonin vs C-reactive protein as predictive markers of response to antibiotic therapy in acute exacerbations of COPD. 379-388. Pharmacological treatment should be optimized. For all patients, the choice of antibiotic should be guided by the local bacterial resistance pattern,1,8 the microbiology story of the patient and his/her risk factors. Efficacy of a self-management plan in exacerbations for patients with advanced COPD. Replicate hospital discharge studies were initiated to examine efficacy and safety of once-daily tiotropium HandiHaler® versus placebo, in addition to usual care, in patients discharged from the hospital after an AECOPD. Rev Port Pneumol (2006), 22 (2016), pp. After an exacerbation is appropriately managed, a suitable discharge plan should be prepared. 39-49. Many patients experience exacerbations and some require Emergency Room visits and hospitalization. Some biomarkers have been suggested as useful for optimizing antibiotic treatment. Pharmacological strategies to reduce exacerbation risk in COPD: a narrative review. This makes it hard to breathe and get enough oxygen. In mild exacerbations there is a worsening of symptoms which can be managed at home, with an increase in dosage of regular medications.1,6,17 Moderate exacerbations do not respond to an increased dosage of bronchodilators and therefore require treatment with systemic corticosteroids and/or antibiotics.1,6,17,18 Severe exacerbations require hospitalization or evaluation in the ER1,6,17,18 and have a severe impact on physical activity. You may experience COPD symptomslike fatigue, wheezing, and exercise intolerance on a regular basis—or even every day. –Home meds and discharge recommendations. 2016 Aug 17;11:1939-47. doi: 10.2147/COPD.S104728. Hospitalization for an AECOPD is an important medic…