Therapeutic algorithm for chronic obstructive pulmonary disease

Maintenance therapy for obstructive lung disease

Preview In all cases of obstructive lung disease, smoking cessation, proper use of metered-dose inhalers, up-to-date immunizations, adequate nutrition, and general physical conditioning are important components of treatment. Dr Jacobs summarizes these components as well as stepwise pharmacologic approaches to controlling the inflammation of asthma, the bronchospasm of chronic bronchitis and emphysema, and the symptoms of secondary or coexisting conditions.

Injectable vaccines for preventing pneumococcal infection in patients with chronic obstructive pulmonary disease

BACKGROUND

As chronic obstructive pulmonary disease (COPD) progresses, exacerbations can occur with increasing frequency. One goal of therapy is to prevent these exacerbations, thereby reducing morbidity and associated healthcare costs. Pneumococcal vaccinations are one strategy for reducing the risk of infective exacerbations.

OBJECTIVES

To determine the safety and efficacy of pneumococcal vaccination in COPD. The primary outcomes assessed were episodes of pneumonia and acute exacerbations. Secondary outcomes of interest included hospital admissions, adverse events related to treatment, disability, change in lung function, mortality, and cost effectiveness.

SEARCH STRATEGY

We searched the Cochrane Airways Group COPD trials register and the databases CENTRAL, MEDLINE and EMBASE using pre-specified terms. The latest searches were performed in March 2010.

SELECTION CRITERIA

Randomised controlled trials assessing the effects of injectable pneumococcal vaccine in people with COPD were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and three review authors independently assessed trial quality.

MAIN RESULTS

Seven studies were identified that met the inclusion criteria for this review and were included in the 2010 review update. Two older trials used a 14-valent vaccine and five more recent trials used a 23-valent injectable vaccine.In six studies involving 1372 people, the reduction in likelihood of developing pneumonia with pneumococcal vaccination compared to control did not achieve statistical significance, the odds ratio (OR) was 0.72 (95% confidence interval (CI) 0.51 to 1.01), with moderate heterogeneity present between studies. The reduction in likelihood of acute exacerbations of COPD from two studies involving 216 people was not statistically significant (Peto OR 0.58; 95% CI 0.30 to 1.13).Of the secondary outcomes for which data were available there was no statistically significant effect for reduction in hospital admissions (two studies) or emergency department visits (one study). There was no significant reduction in pooled results from three studies involving 888 people for odds of all-cause mortality for periods up to 48 months post-vaccination (OR 0.94; 95% CI 0.67 to 1.33), or for death from cardiorespiratory causes (OR 1.07; 95% CI 0.69 to 1.66).

AUTHORS' CONCLUSIONS

The limited evidence from randomised controlled trials (RCTs) included in this review suggests that, while it is possible that injectable polyvalent pneumococcal vaccines may provide some protection against morbidity in persons with COPD, no significant effect on any of the outcomes was shown. Further large RCTs in this population would be needed to confirm effectiveness of the vaccine suggested by results from longitudinal studies.

The development of anticholinergics in the management of COPD

Anticholinergics have been used to treat obstructive respiratory disease for many years from historical preparations of the deadly nightshade genus, to the more recent developments ofipratropium, oxitropium, and tiotropium. The medical treatment of airways obstruction has focused on achieving maximal airway function through bronchodilators. Of the two main bronchodilators, beta2-agonists are often the first treatment choice although there is evidence of equivalence and some suggestions of the superiority of anticholinergics in chronic obstructive pulmonary disease (COPD). The following review looks at the background of anticholinergics, their pharmacological properties, and the evidence for use with suggestions for their place in the treatment of COPD.

Injectable vaccines for preventing pneumococcal infection in patients with chronic obstructive pulmonary disease

BACKGROUND

As chronic obstructive pulmonary disease (COPD) progresses, exacerbations can occur with increasing frequency. One goal of therapy in COPD is to try and prevent these exacerbations, thereby reducing disease morbidity and associated healthcare costs. Pneumococcal vaccinations are considered to be one strategy for reducing the risk of infective exacerbations.

OBJECTIVES

To determine the safety and efficacy of pneumococcal vaccination in COPD. The primary outcome assessed was acute exacerbations. Secondary outcomes of interest included episodes of pneumonia, hospital admissions, adverse events related to treatment, disability, change in lung function, mortality, and cost effectiveness.

SEARCH STRATEGY

We searched the Cochrane Airways Group COPD trials register using pre-specified terms. We also conducted additional handsearches of conference abstracts. The last round of searches were performed in April 2006.

SELECTION CRITERIA

Only randomised controlled trials assessing the effects of injectable pneumococcal vaccine in people with COPD were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and three review authors independently assessed trial quality.

MAIN RESULTS

Although 10 studies cited in 11 publications were identified that met the inclusion criteria for this review, only four of these provided data on participants with COPD. The studies which did provide data for this review consisted of two trials using a 14-valent vaccine, and two using a 23-valent injectable vaccine. Data for the primary outcome, acute exacerbation of COPD, was available from only one of the four studies. The odds ratio of 1.43 (95% confidence interval (CI) 0.31 to 6.69) between interventions was not statistically significant. Of the secondary outcomes for which data were available and could be extracted, none reached statistical significance. Three studies provided dichotomous data for persons who developed pneumonia (OR 0.89, 95% CI 0.58 to 1.37, n = 748). Rates of hospital admissions and emergency department visits came from a single study. There was no significant reduction in the odds of all-cause mortality 1 to 48 months post-vaccination (Peto odds ratio 0.94, 95% CI 0.67 to 1.33, n = 888), or for death from cardiorespiratory causes (OR 1.07, 95% CI 0.69 to 1.66).

AUTHORS' CONCLUSIONS

There is no evidence from randomised controlled trials that injectable pneumococcal vaccination in persons with COPD has a significant impact on morbidity or mortality. Further large randomised controlled trials would be needed to ascertain if the small benefits suggested by individual studies are real.

Direct medical costs of chronic obstructive pulmonary disease: chronic bronchitis and emphysema

In this study we aimed to estimate direct medical costs of Chronic Obstructive Pulmonary Disease (COPD) by disease type; chronic bronchitis and emphysema. This study estimates direct costs in 1996 dollars using a prevalence approach and both aggregate and microcosting. A societal perspective is taken using prevalence, and multiple national, state and local data sources are used to estimate health-care utilization and costs. Chronic bronchitis and emphysema together account for $14.5 billion in annual direct costs. Inpatient costs are greater than outpatient and emergency costs ($8.3 vs. $7.8 billion) and hospital and medication costs account for most resources spent. The high prevalence of chronic bronchitis accounts for its larger total costs ($11.7 billion) compared with emphysema ($2.8 billion). Emphysema, which is more severe, has higher costs per prevalent case ($1341 vs. $816). Hospital stays account for the highest costs, $6.0 billion for chronic bronchitis and $1.9 billion for emphysema. The hospitalization rate, length of stay and average cost per prevalent case are higher for emphysema than for chronic bronchitis. Medication costs are the second highest cost category ($4.4 billion for chronic bronchitis, $0.693 billion for emphysema). The high hospitalization and low home care costs (0.2% of total) suggest underuse of home care and room to shift from acute to preventive care. More attention to healthcare management of chronic bronchitis and emphysema is suggested, and improving inhaler and anti-smoking compliance might be important targets.

Pharmacoeconomic evaluation of a combination of ipratropium plus albuterol compared with ipratropium alone and albuterol alone in COPD

STUDY OBJECTIVE

To conduct a post hoc pharmacoeconomic evaluation of two double-blind, randomized, prospective, parallel group studies comparing the long-term efficacy and safety of ipratropium combined with albuterol in a single inhalational canister against either bronchodilator agent alone in patients with COPD.

PATIENTS

One thousand sixty-seven patients with COPD.

METHODS

The dose of each bronchodilator was two puffs four times a day (42 microg of ipratropium bromide, 240 microg of albuterol sulfate). Pulmonary function testing was performed on days 1, 29, 57, and 85 of treatment. Outcomes, health-care resource consumption, and costs were compared for the three treatment groups over the 85-day study period. A total of 1,067 patients were randomized in the two studies (albuterol alone, n = 347; ipratropium alone, n = 362; albuterol plus ipratropium, n = 358).

RESULTS

Improvement in FEV1 and area under the FEV1 response-time curve from time 0 to 4 h (FEV1AUC0-4) was significantly greater for the combination of albuterol plus ipratropium than either agent alone on all test days. Compared with albuterol, patients receiving ipratropium and ipratropium plus albuterol experienced significantly fewer COPD exacerbations and patient-days of exacerbation. In addition, the increased frequency of exacerbations observed in the albuterol group was associated with a significant increase in the number of patient hospital days and antibiotic and corticosteroid use. As a result, the total cost of treatment over the study period was significantly less for ipratropium ($156 per patient) and ipratropium plus albuterol ($197 per patient) than for albuterol ($269 per patient). Increased cost-effectiveness, defined as total estimated treatment cost per mean change in FEV1AUC0-4, was observed in both treatment arms containing ipratropium.

CONCLUSIONS

The inclusion of ipratropium in a pharmacologic treatment regimen is associated with a lower rate of exacerbations in COPD. The result is lower total treatment costs and improved cost-effectiveness.

Efficacy, tolerability, and effects on quality of life of inhaled salmeterol and oral theophylline in patients with mild-to-moderate chronic obstructive pulmonary disease. SLMT02 Italian Study Group

The aims of management in mild-to-moderate stable chronic obstructive pulmonary disease (COPD) are to improve symptoms and quality of life (QOL), reduce decline in lung function, prevent and treat complications, increase survival while maintaining QOL, and minimize the adverse effects of treatment. Bronchodilator therapy is the keystone of improving COPD symptoms and functional capacity. The primary objective of this open-label study was to compare the efficacy and tolerability of salmeterol 50 microg BID administered by metered-dose inhaler versus oral, titrated, sustained-release theophylline BID, both given for 3 months to patients with a clinical history of chronic bronchitis. The secondary objectives of the study were to evaluate the safety profile of the two drugs for an additional 9-month period and to assess changes in QOL both within and between treatment groups, using the 36-Item Short Form (SF-36) Health Survey. One hundred seventy-eight outpatients (122 men, 56 women; mean age, 56 +/- 12.9 years; mean body weight, 76.1 +/- 11.8 kg) were randomized to the two treatment groups. Patients receiving salmeterol showed significant improvement in mean morning peak expiratory flow rate (16.56 L/min) over the 3-month period compared with patients receiving theophylline (P = 0.02). Salmeterol also significantly increased the percentage of symptom-free days and nights with no additional salbutamol requirement (P < 0.01). A significant difference was found between increases in forced expiratory volume in 1 second compared with baseline for salmeterol compared with theophylline throughout the initial 3-month period (0.13, 0.16, and 0.16 L at months 1, 2, and 3, respectively) and during the additional 9 months. The incidence of adverse events was similar in the two groups (salmeterol, 49.5%; theophylline, 49.4%), with a lower percentage of pharmacologically predictable adverse events in patients receiving salmeterol (4%) compared with those receiving theophylline (14.8%). Both drugs improved QOL, as measured by effects on the eight aspects of life experience analyzed by the SF-36 questionnaire. Salmeterol therapy was effective in more aspects, and the improvements seen in each were numerically greater than those seen with theophylline therapy. Statistically different changes between the two treatment groups were reported for physical functioning, changes in health perception, and social functioning (P = 0.02, P = 0.03, and P = 0.004, respectively). These data suggest that inhaled salmeterol 50 microg BID was more effective and better tolerated than oral, titrated theophylline and allowed better long-term control of airways obstruction and symptoms with improved lung function in patients with COPD.

Standards for the optimal management of COPD: a summary

Tobacco smoking is the main cause of COPD, and encouragement and support in smoking cessation is the best way to help the patient with COPD. The three major goals of COPD management are to lessen airflow limitation, to prevent and treat secondary medical complications, and to decrease respiratory symptoms and improve quality of life. Outpatient pharmacotherapy should be organized in a stepwise manner according the severity of disease, the aims being to induce bronchodilation, reduce inflammation, and facilitate expectoration, although the role of anti-inflammatory and mucolytic treatment of COPD has not been clearly established. Patients whose conditions are not well controlled with optimal pharmacotherapy are candidates for enrollment in a pulmonary rehabilitation program. Correction or prevention of hypoxemia is a priority, and long-term oxygen therapy supplementation prolongs survival in hypoxemic patients. With only limited data on criteria for hospital admission and the objectives of hospitalization, the published standards on the management of COPD include an expert consensus statement on these aspects of hospital care. Surgery, special considerations such as sleep, nutrition, and air travel, and ethical issues are discussed.

Bronchodilator therapy for chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a heterogeneous group of diseases characterized by cough, sputum production, dyspnoea, airflow limitation and bronchial hyperreactivity. The airflow limitation declines progressively and is irreversible or partially reversible. Bronchodilator therapy is prescribed to relieve the symptoms, reverse airway obstruction and hopefully slow the rate of disease progression and decelerate the decline in pulmonary function. During acute exacerbation, inhalation of beta2-agonists remain the therapy of choice. The usefulness of anticholinergic inhalation in acute attacks is investigated in order to determine if a higher dose and more frequent administration have same benefit as beta2-agonists inhalation. Theophylline is usually given orally as a sustained release formulation for chronic maintenance therapy. Some patients may benefit from theophylline infusion during an acute phase when appropriately used; however, sympathomimetic agents fail to produce adequate bronchodilation. During interim periods of stability, inhalation of ipratropium bromide has increased in popularity as a regular long-term bronchodilator therapy. Although ipratropium and beta2-agonists are equally efficacious when the dosage is adequate enough, a combination of both provides a rapid onset of action of the adrenergic agents and a prolonged action of the anticholinergic. Furthermore, this combination can be given in a reduced dose, thereby avoiding side-effects. Inhalation techniques can influence the efficacy of bronchodilator therapy. For severe dyspnoeic patients or patients with poor technique of co-ordination with metered-dose inhaler (MDI), attachment of a spacer to the MDI or using a nebulizer will overcome these difficulties. Bronchodilator therapy can not prevent the development of COPD or slow down the decline of pulmonary function, other interventions should be included in a comprehensive management programme.

Influence of inspired oxygen concentration on deadspace, respiratory drive, and PaCO2 in intubated patients with chronic obstructive pulmonary disease

OBJECTIVES

To investigate the response of CO2-retaining chronic obstructive pulmonary disease (COPD) patients to an increase in FIO2 following a period of mechanical ventilation with PaO2 in the normal range. The administration of a high FIO2 to chronic obstructive pulmonary disease (COPD) patients may result in hypercapnia. Recent evidence indicates that the hypercapnia may be due to reversal of preexisting regional hypoxic pulmonary vasoconstriction resulting in a greater deadspace. This effect would be more pronounced in patients whose initial PaO2 was < 60 torr (< 7.9 kPa).

DESIGN

Single blinded, prospective study.

SETTING

A medical surgical intensive care until in a tertiary care, teaching hospital.

PATIENTS

COPD CO2-retaining patients.

INTERVENTIONS

FIO2 increased to 0.7.

MEASUREMENTS AND MAIN RESULTS

Twelve intubated COPD patients weaned from mechanical ventilation were studied both at their baseline FIO2 (0.3 to 0.4), and following a 20-min period of exposure to an FIO2 of 0.7. Mean baseline values were: PaO2 of 85 torr (11.3 kPa), PCO2 of 56 torr (7.5 kPa), deadspace of 73%, and respiratory drive normal, as measured by P0.1. Statistical analysis using the paired Student's t-test showed that the PaO2 increased significantly when the FIO2 was increased to 0.7, but there was no significant change in PaCO2, deadspace, or respiratory drive.

CONCLUSION

These results show that following a period of mechanical ventilation with an FIO2 sufficient to maintain a normal PaO2, a further increase in FIO2 does not result in an increased PaCO2 in this group of CO2-retaining COPD patients.

A comparison of breath-actuated and conventional metered-dose inhaler inhalation techniques in elderly subjects

BACKGROUND

Poor coordination of canister actuation and inspiration often prevents adequate metered-dose inhaler (MDI) usage by patients, perhaps especially so among the elderly. Breath-actuated inhalers (BAI) have been developed to prevent this problem.

METHODS

We compared the adequacy of inhaler technique and patient preferences between MDI and BAI in a group of elderly subjects (mean age, 70.8 +/- 5.4 years). Half of the subjects were regular MDI users; half had never before used one. Two trained observers assessed the adequacy of MDI and BAI usage subjectively while performance was monitored objectively using a light source and infrared system to detect canister actuation and a spirometer to measure the inspiratory volume. If canister actuation was not followed by at least a 50 percent vital capacity, inhaler use was deemed unsuccessful. A brief teaching session preceded inhaler usage.

RESULTS

By subjective assessment, BAI was used successfully more often than MDI (79 vs 60 percent, p < 0.05). By objective assessment, BAI was used successfully more often than MDI (64 vs 36 percent, p < 0.0005), although the percentage of inhalations scored adequate was lower than when assessment was subjective. Neither device was used correctly as often by those unfamiliar with MDIs as by those who were regular users. A significantly higher percentage of patients preferred BAI to MDI (71 vs 19 percent, p < 0.005), similar preferences being reported by MDI familiar and MDI unfamiliar groups.

CONCLUSIONS

We conclude that (1) elderly subjects frequently handle inhalers poorly, (2) mishandling is better detected by objective than subjective monitoring, and (3) BAI is used correctly and preferred by patients more often than conventional MDIs.