Decreased duration of emergency department treatment of chronic obstructive pulmonary disease exacerbations with the addition of ipratropium bromide to beta-agonist therapy

Short-acting bronchodilators for the management of acute exacerbations of chronic obstructive pulmonary disease in the hospital setting: systematic review

BACKGROUND

Currently, there is a lack of guidelines for the use of short-acting bronchodilators (SABD) in people admitted to hospital for acute exacerbation of chronic obstructive pulmonary disease (AECOPD), despite routine use in practice and risk of cardiac adverse events.

AIM

To review the evidence that underpins use and optimal dose, in terms of risk versus benefit, of SABD for inpatient management of AECOPD and collate the results for future guidelines.

METHODS

Medline, Embase, the Cochrane Central Register of Controlled Trials, clinicaltrials.gov and International Clinical Trials Registry Platform were searched (inception to November 2017) for published and ongoing studies. Included studies were randomised controlled trials or controlled clinical trials investigating the effect of SABD (β2-agonist and/or ipratropium) on inpatients with a diagnosis of AECOPD. This review was undertaken in accordance with PRISMA guidelines and a pre-defined protocol. Due to heterogeneous methodologies, meta-analysis was not possible so the results were synthesised qualitatively.

RESULTS

Of 1378 studies identified, 10 met inclusion criteria. Narrative synthesis of 10 studies revealed no significant differences in most outcomes of interest relative to dose, delivery via inhaler or nebuliser, and type of β2-agonist used. However, some evidence demonstrated significantly increased cardiac side effects with increased dosage of β2-agonist (45% versus 24%), P<0.05).

CONCLUSION

This review identified a paucity of methodologically rigorous evidence evaluating use of SABD among AECOPD. The available evidence did not identify any additional benefits for participants receiving higher doses of short-acting β2-agonists compared to lower doses, or based on type of delivery method or β2-agonists used. However, there was a small increase in some adverse events for participants using higher doses of β2-agonists.

End-tidal arterial CO2 partial pressure gradient in patients with severe hypercapnia undergoing noninvasive ventilation

BACKGROUND

Patients with severe hypercapnia represent a particularly serious condition in an emergency department (ED), requiring immediate attention. Noninvasive ventilation (NIV) is an integral part of the treatment for acute respiratory failure. The present study aimed to validate the measurement of end-tidal CO2 (EtCO2) as a noninvasive technique to evaluate the effectiveness of NIV in acute hypercapnic respiratory failure.

METHODS

Twenty consecutive patients admitted to the ED with severe dyspnea were enrolled in the study. NIV by means of bilevel positive airway pressure, was applied to the patients simultaneously with standard medical therapy and continued for 12 hours; the arterial blood gases and side-stream nasal/oral EtCO2 were measured at subsequent times: T0 (admission to the ED), T1h (after 1 hour), T6h (after 6 hours), and T12h (after 12 hours) during NIV treatment.

RESULTS

The arterial CO2 partial pressure (PaCO2)-EtCO2 gradient decreased progressively, reaching at T6h and T12h values lower than baseline (P < 0.001), while arterial pH increased during the observation period (P < 0.001). A positive correlation was found between EtCO2 and PaCO2 values (r = 0.89, P < 0.001) at the end of the observation period.

CONCLUSION

In our hypercapnic patients, the effectiveness of the NIV was evidenced by the progressive reduction of the PaCO2-EtCO2 gradient. The measurement of the CO2 gradient could be a reliable method in monitoring the effectiveness of NIV in acute hypercapnic respiratory failure in the ED.

Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease in the Elderly

Chronic obstructive pulmonary disease (COPD) is a debilitating disease with rising worldwide prevalence. Exacerbations of COPD cause significant morbidity and become more common with advancing age. Healthcare providers caring for elderly patients should therefore be familiar with effective treatments for exacerbations of COPD. An extensive body of literature has identified several effective drug therapies for exacerbations. These drugs include inhaled bronchodilators, systemic corticosteroids and antibacterials. The two main classes of inhaled bronchodilators are beta-adrenoceptor agonists and anticholinergics. These drugs optimise lung function during exacerbations, with neither class demonstrating clear superiority over the other. Systemic corticosteroids are effective when used either for inpatient or outpatient treatment of exacerbations. They hasten recovery from exacerbations and reduce relapse rates. Antibacterials decrease morbidity from exacerbations and may decrease mortality in the more severe exacerbations. Other effective therapies for the treatment of acute exacerbations of COPD include oxygen and non-invasive ventilation. Oxygen can be safely administered in acute exacerbations associated with hypoxaemia, with titration of oxygen delivery to a goal oxygen saturation of 90%. Non-invasive ventilation reduces the morbidity and mortality associated with acute exacerbations complicated by hypercapnic respiratory failure. Strategies to prevent COPD exacerbations include smoking cessation, long-acting inhaled beta-adrenoceptor agonists, inhaled long-acting anticholinergics, inhaled corticosteroids and vaccination. Mucolytic agents, pulmonary rehabilitation, and case management programmes may also reduce exacerbation risk, but the current evidence supporting these interventions is weaker.

The efficacy of nebulized albuterol/ipratropium bromide versus albuterol alone in the prehospital treatment of suspected reactive airways disease

OBJECTIVE

Ipratropium bromide has demonstrated efficacy when added to albuterol for the treatment of reactive airways disease (RAD). Its prehospital use has not been explored.

METHODS

A before-and-after design was used. Prehospital and emergency department (ED) medical records were examined retrospectively six months before and six months after institution of a new protocol, which allowed the addition of ipratropium bromide to all nebulized treatments with albuterol. Primary outcome measures included: changes in vital signs (heart rate, respiratory rate, oxygen saturation), clinical improvement as assessed by paramedics, and admission rates.

RESULTS

A total of 371 patients were included (n = 192 albuterol alone, n = 179 ipratropium/albuterol). There was no statistically significant difference between groups with regard to the change in heart rate, respiratory rate, or oxygen saturation. In addition, there was no difference in the proportion of patients with clinical improvement or deterioration as assessed by paramedics. There was no statistically significant difference in the admission rate from the ED except in the subgroup of patients using a metered-dose inhaler at the time of illness. Of note, more than one-third (133/371) of the patients were ultimately determined to have a diagnosis other than RAD, the majority of whom were diagnosed as having cardiac disease.

CONCLUSIONS

The addition of ipratropium bromide to albuterol for the prehospital treatment of RAD does not appear to result in clinical outcome improvements. A substantial number of patients enrolled in the study were diagnosed as having cardiac disease.

Pharmacologic therapy for acute exacerbations of chronic obstructive pulmonary disease: a review

This article reviews available data on the drug therapy armamentarium for the acute exacerbation of chronic obstructive pulmonary disease (COPD). Summaries of studies and therapeutic issues for bronchodilators, antibiotic therapy, corticosteroid use, and a few miscellaneous agents are presented. Many controversies exist in the criteria defining the acute exacerbation, in defining appropriate outcome parameters for assessment, and, consequently, in developing specific consistent recommendations for drug therapy. Five published guidelines assist the clinician in therapeutic drug management of the acute exacerbation of COPD, and each differs in its recommendations for drug therapy prescription. The article includes synopses for drug therapy recommendations from the guidelines.

Acute exacerbations in chronic obstructive pulmonary disease: current strategies with pharmacological therapy

In acute exacerbation of chronic obstructive pulmonary disease (AECOPD), short-acting inhaled bronchodilators, such as salbutamol (albuterol) and ipratropium bromide, have proven useful. In patients who are refractory to these agents, intravenous aminophylline should be considered. Corticosteroids should also be used, either in the outpatient or inpatient setting. The duration of corticosteroids should probably not exceed 2 weeks and the optimum dosage is yet to be determined. Antibacterials, especially in patients with purulent or increased sputum, should be used, guided by the local antibiogram of the key microbes. Controlled oxygen therapy improves outcome in hypoxaemic patients and arterial blood gases should be performed to ensure hypercarbia is not becoming excessive. Should patients be in distress despite the above measures or if there is acidaemia or hypercarbia, noninvasive positive pressure ventilation could be used to improve outcomes without resorting to invasive mechanical ventilation. Mucous-clearing drugs and chest physiotherapy have no proven beneficial role in AECOPD.

Acute exacerbations of chronic obstructive pulmonary disease

This article discusses the definition, pathophysiology, cause, clinical presentation, laboratory work-up, and treatment of chronic obstructive pulmonary disease (COPD) exacerbation. The focus is on the presentation of acute exacerbations of COPD in the emergency department and the available evidence for testing and treatment.

A proposal for a practical treatment guideline designed for the initial two-hours of the management of patients with acute severe asthma and COPD using the principles of evidence-based medicine

We have proposed a clinical treatment guideline for the management of acute, severe asthma and chronic obstructive pulmonarydisease (COPD) using the principles of evidence-based medicine. The content is based upon practical clinical issues in need of consensus. A previous study has shown that this particular area is in serious need of quality control. Based on a strict 2 h time schedule with a unified treatment plan for both asthma and COPD, it is possible to secure for the patients a well-documented medical therapy promoting decision-making and clarification of the patient within this time limit. A summary of the statements is presented in a one-page, user-friendly format in order to cope with the clinician's need of having access to published evidence quickly and easily. A website (www.phanareth.dk or a website provided by Respiratory Medicine) has been established providing regular updates. A strategy for the implementation and the evaluation process has been planned after the publication of this paper. We believe this approach to be an important step towards an increase in the quality of guidelines and also a tool to make "guideline writers" aware of the responsibility of making their recommendations work.

Anti-cholinergic bronchodilators versus beta2-sympathomimetic agents for acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Inhaled bronchodilators form the mainstay of treatment for acute exacerbations of COPD. Two types of agent are used routinely, either singly or in combination: anticholinergic agents and beta2-sympathomimetic agonists.

OBJECTIVES

To assess the effect of anti-cholinergic agents on lung function and dyspnea in patients with acute exacerbations of COPD, compared with placebo or short-acting beta-2 agonists.

SEARCH STRATEGY

A comprehensive search of the literature was carried out on MEDLINE, EMBASE, CINAHL and the Cochrane COPD Trials Register, using the terms: bronchodilator* OR ipratropium OR oxitropium. References listed in each included trial were searched for additional trial reports.

SELECTION CRITERIA

Studies were included if the participants were adult patients with a known diagnosis of COPD and had symptoms consistent with criteria for acute exacerbation of COPD. All randomized controlled trials that compared inhaled ipratropium bromide or oxitropium bromide to appropriate controls were considered. Appropriate control treatments included placebo, other bronchodilating agents, or combination therapies. Studies of acute asthma or ventilated patients were excluded.

DATA COLLECTION AND ANALYSIS

All trials that appeared to be relevant were assessed by two reviewers who independently selected trials for inclusion. Differences were resolved by consensus.

MAIN RESULTS

Four trials compared the short-term effects of ipratropium bromide vs. a beta2-agonist. Short-term changes in FEV1 (up to 90 minutes) showed no significant difference between beta2-agonist and ipratropium bromide treated patients. The differences were similar among the studies and when combined: Weighted Mean Difference (WMD) 0.0 liters (95% Confidence Interval (95% CI) -0.19, 0.19). There was no significant additional increase in change in FEV1 on adding ipratropium to beta2-agonist: WMD 0.02 liter (95% CI -0.08, 0.12). Long-term effects (24 hours) of the ipratropium bromide and beta2-agonist treatment combination were similar: WMD 0.05 liters (95%CI -0.14, 0.05). Neither of two studies found significant changes in PaO2, either short- or long-term, with ipratropium vs. beta-agonist, although one showed an increase in PaO2 in subjects receiving ipratropium bromide at 60 minutes. Adverse drug reactions included dry mouth and tremor.

REVIEWER'S CONCLUSIONS

There was no evidence that the degree of bronchodilation achieved with ipratropium bromide was greater than that using a short-acting beta2-agonist. The combination of a beta2-agonist and ipratropium did not appear to increase the effect on FEV1 more than either used alone.

Management of acute exacerbations of COPD: a summary and appraisal of published evidence

STUDY OBJECTIVES

To critically review the available data on the diagnostic evaluation, risk stratification, and therapeutic management of patients with acute exacerbations of COPD.

DESIGN, SETTING, AND PARTICIPANTS

English-language articles were identified from the following databases: MEDLINE (from 1966 to week 5, 2000), EMBASE (from 1974 to week 18, 2000), HealthStar (from 1975 to June 2000), and the Cochrane Controlled Trials Register (2000, issue 1). The best available evidence on each subtopic then was selected for analysis. Randomized trials, sometimes buttressed by cohort studies, were used to evaluate therapeutic interventions. Cohort studies were used to evaluate diagnostic tests and risk stratification. Study design and results were summarized in evidence tables. Individual studies were rated as to their internal validity, external validity, and quality of study design. Statistical analyses of combined data were not performed.

MEASUREMENT AND RESULTS

Limited data exist regarding the utility of most diagnostic tests. However, chest radiography and arterial blood gas sampling appear to be useful, while short-term spirometry measurements do not. In terms of the risk of relapse and the risk of death after hospitalization for an acute exacerbation, there are identifiable clinical variables that are associated with these outcomes. Therapies for which there is evidence of efficacy include bronchodilators, corticosteroids, and noninvasive positive-pressure ventilation. There is also support for the use of antibiotics in patients with more severe exacerbations. Based on limited data, mucolytics and chest physiotherapy do not appear to be of benefit, and oxygen supplementation appears to increase the risk of respiratory failure in an identifiable subgroup of patients.

CONCLUSIONS

Although suggestions for appropriate management can be made based on available evidence, the supporting literature is spotty. Further high-quality research is needed and will require an improved, generally acceptable, and transportable definition of the syndrome "acute exacerbation of COPD" and improved methods for observing and measuring outcomes.

Inhaled short-acting beta2-agonists versus ipratropium for acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND

Inhaled short acting beta2 adrenergic agonists and ipratropium bromide are both used in the treatment of acute exacerbations of chronic obstructive pulmonary disease.

OBJECTIVES

In patients with acute exacerbations of COPD to: 1. To assess the efficacy of short-acting beta-2 agonists against placebo; 2. Compare the efficacy of short-acting beta-2 agonists and ipratropium.

SEARCH STRATEGY

A comprehensive search of the literature was carried out of EMBASE, MEDLINE, CINAHL and the Cochrane COPD trials register was carried out using the terms: bronchodilator* OR albuterol OR metaproterenol OR terbutaline OR isoetharine OR pirbuterol OR salbutamol OR beta-2 agonist.

SELECTION CRITERIA

All trials that appeared to be relevant were assessed by two reviewers who independently selected trials for inclusion. Differences were resolved by consensus.

DATA COLLECTION AND ANALYSIS

All trials that appeared to be relevant were assessed by two reviewers who independently selected trials for inclusion. Differences were resolved by consensus. References listed in each included trial were searched for additional trial reports. Trials were combined using Review Manager using a fixed effects model. The size of the treatment effects were tested for heterogeneity.

MAIN RESULTS

We identified no placebo-controlled comparisons of beta-2 agonists. Three studies permitted comparison of ipratropium to an inhaled beta-2 agonist. These studies included a total of 103 patients. The beta2-agonists used were: fenoterol and metaproterenol. One study was a parallel group trial of regular therapy for seven days. The other two were cross over studies of single dose treatments, with efficacy measured 90 min post dose. There was no washout period between treatments. Both treatments produced an improvement in forced expiratory volume (FEV1) after 90 min in the range 150-250 ml. The was no difference between treatments, mean difference in FEV1 10 ml; 95% CI -220, 230 ml. In one small crossover study (n=10) there was a significant improvement in arterial PaO2 after 30 minutes with ipratropium (+5.8 mm Hg +/- 3.0 (SEM)) compared to metaproterenol (-6.2 +/- 1.2 mm Hg), but this was not significant at 90 min. There were no data concerning respiratory symptoms. The crossover studies showed no evidence of an additive effect of the two treatments, although they were not designed specifically to test this.

REVIEWER'S CONCLUSIONS

There are few controlled trial data concerning the use of inhaled beta2-agonist agents in acute exacerbations of COPD and none that have compared these agents directly with placebo. None of the studies used the more modern beta2-agonists used most widely in this setting (salbutamol and terbutaline). Beta2-agonists and ipratropium both produce small improvements in FEV1, but beta2-agonists may worsen PaO2 for a period. We could not draw conclusions concerning possible additive effects.

The chronic obstructive pulmonary disease exacerbation

Chronic obstructive pulmonary disease is the only leading cause of death with a rising prevalence. The medical and economic costs arising from acute exacerbations of COPD are therefore expected to increase over the coming years. Although exacerbations may be initiated by multiple factors, the most common identifiable associations are with bacterial and viral infections. These are associated with approximately 50% to 70% and 20% to 30% of COPD exacerbations, respectively. In addition to smoking cessation, annual influenza vaccination is the most important method for preventing exacerbations. Controlled O2 is the most important intervention for patients with acute hypoxic respiratory failure. Evidence from randomized, controlled trials justifies the use of corticosteroids, bronchodilators (but not theophylline), noninvasive positive-pressure ventilation (in selected patients), and antibiotics, particularly for severe exacerbations. Antibiotics should be chosen according to the patient's risk for treatment failure and the potential for antibiotic resistance. In the acute setting, combined treatment with beta-agonist and anticholinergic bronchodilators is reasonable but not supported by randomized controlled studies. Physicians should identify and, when possible, correct malnutrition. Chest physiotherapy has no proven role in the management of acute exacerbations.

Does high dose ipratropium bromide added to salbutamol improve pulmonary function for patients with chronic obstructive airways disease in the emergency department?

BACKGROUND

To determine the effect of high dose ipratropium bromide, both alone or in combination with standard dose salbutamol, on pulmonary function in patients presenting to the Emergency Department (ED) with acute exacerbation of chronic obstructive airways disease (COAD).

METHOD

The trial was a prospective, randomised, double blind trial of adult patients with COAD. All patients received nebulised salbutamol 5 mg and 500 microg ipratropium and hydrocortisone 250 mg i.v. at time=0, then were randomised to receive further nebulisers at time=15 minutes and time=30 minutes of salbutamol 5 mg combined with ipratropium 500 microg or salbutamol 5 mg alone or ipratropium 500 microg alone. Pulmonary function tests were conducted at time=0 and time=90 minutes. The primary endpoints were absolute and percent change in FEV1.

RESULTS

The group randomised to receive 5 mg salbutamol and 500 microg ipratropium (n=18) showed a mean percentage change of FEV1 of 6.4% with a mean absolute change of 0.06 L (SD 0.18 L). Those who received 5 mg salbutamol (n=16) had a mean percentage change of 18.6% with a mean absolute change of 0.13 L (SD of 0.21 L). Those who received 500 microg ipratropium (n=16) had a mean percentage change of 4.8% with a mean absolute change of 0.023 L (SD of 0.07 L). There was no significant difference between the groups in FEV1 (p=0.56 for percentage change; p=0.36 for absolute change).

CONCLUSION

The addition of 500 microg ipratropium to 5 mg salbutamol in subsequent nebulisers adds no benefit to pulmonary function after the initial nebuliser of both bronchodilators in the treatment of COAD in the ED.

Can we justify ipratropium therapy as initial management of acute exacerbations of COPD?

Although inhaled ipratropium is commonly accepted as the drug of choice for long-term management of chronic bronchitis and emphysema, little evidence is available to promote its administration in conjunction with a beta2-agonist as part of initial management of exacerbations of chronic obstructive pulmonary disease (COPD) in the acute care setting. Reasons for its widespread acceptance for acutely ill patients may include its status as a first-line agent for long-term therapy, its relative safety, and attempts to provide optimal patient care. Since inhaled ipratropium is beneficial as immediate therapy for asthma in the emergency department, some practitioners attempted to extrapolate these findings to treatment of COPD. Review of available studies reveals wide variability in methodologies and results. Although some studies reported improvement in pulmonary function tests, no clinically significant differences in patient outcomes, including shorter hospitalization, were evident. In patients who fail traditional therapies, inhaled ipratropium is reasonable. Double-blind, randomized, placebo-controlled trials in patients receiving emergency department care and in hospitalized patients that reveal shorter length of stay or other improved outcomes, are necessary to establish routine addition of inhaled ipratropium to beta2-agonists in the initial management of acute COPD.

Effect of continuously nebulized ipratropium bromide plus albuterol on emergency department length of stay and hospital admission rates in patients with acute bronchospasm. A randomized, controlled trial

OBJECTIVE

To compare the outcome of patients with acute bronchospasm treated with continuously nebulized albuterol plus ipratropium bromide vs albuterol alone.

SETTING

The Emergency Department (ED) at the University of California San Francisco Medical Center.

PARTICIPANTS

Patients > or = 18 years old presenting to the ED with acute bronchospasm and a peak expiratory flow rate (PEFR) of < 70% predicted.

INTERVENTIONS

This was a prospective, randomized, double-blind, placebo-controlled trial. Subjects were treated with either a combination of albuterol (10 mg/h) plus ipratropium bromide (1.0 mg/h) or albuterol alone via continuous nebulization for a maximum of 3 h. Vital signs, Borg dyspnea score, and PEFR were recorded hourly. Primary outcome measures were improvement in PEFR, hospital admission rates, and length of stay in the ED.

MEASUREMENTS AND RESULTS

Data was analyzed for 67 subjects. The mean age (-/+ SD) was 47.5+/-18.8, and mean initial PEFR was 44.8+/-12.5% of predicted. The median length of stay for all subjects was 225 min, and 31% of all subjects were admitted. Patients given combination therapy averaged 6.3% greater improvement in PEFR compared with control subjects (95% confidence interval [CI], -15% to 27%. The odds ratio for admission with combination therapy was 0.88 (95% CI, 0.28 to 2.8). The median length of stay in the ED was 35 min shorter for those receiving combination treatment (210 vs 245 min; p = 0.03). However, when adjusted for initial PEFR, there was no statistically significant difference (p = 0.26).

CONCLUSION

Although the direction of all three outcome measures favored combination therapy, there was no statistically significant difference between ED patients with acute bronchospasm receiving continuous albuterol plus ipratropium bromide and those receiving albuterol alone.

Assessment and management of dyspnoea

The terms 'dyspnoea' or 'breathlessness' refer to an individual's subjective awareness of discomfort related to the act of breathing. Elevations in CO2 above normal levels have been shown to cause breathlessness although it is unlikely to be the sole cause of breathlessness in a clinical setting. Several studies suggest that supplemental O2 during exercise will diminish the sensation of breathlessness although not all work has confirmed this finding. Much about the role of gas exchange in dyspnogenesis remains controversial. Phrenic blockade can abolish dyspnoea in response to breath-holding, while work in quadriplegics suggests that the intercostal muscles are not involved. A separate and direct pathway from the respiratory centre to the sensory cortex has also be implicated. Threshold discrimination has established that patients with chronic airflow limitation (CAL) have a blunted response to the addition of resistive loads to breathing, while category scaling methods (e.g. the Borg scale) have added descriptive terms to these physiological measures. Questionnaires often appear limited by their subjectivity and lack of correlation with physiological changes, but remain a useful tool in the clinical setting. In regard to therapy of dyspnoea high fat diets have a theoretical advantage in the CAL group but are generally not well tolerated. Resistive training devices and exercise training in CAL have been widely researched but in general, measures of lung remain unaltered and many of the studies would suggest that they have little, if any, inpact on functional status. Beta-agonists have been widely shown to be useful in CAL patients, despite the fact that bronchodilatation is not always demonstrable. Anticholinergics have be shown to be effective bronchodilators, but whether there is an improvement in dyspnoea above that expected from improvement in lung function is unclear. Animal studies and work in normal individuals would suggest that methylxanthines have a theoretical role in CAL possibly by increasing diaphragmatic muscle strength and decaying fatigue, but toxicity and lack of clear benefit in this group suggest that they should not be used as monotherapy. There is little evidence to support the use of opioids in chronic CAL although their role in the acute dyspnoea of end-stage CAL remains defined. The use of benzodiazepines has also been disappointing. Bullectomy remains widely accepted in clinical practice. New techniques such as 'reduction surgery' for diffuse emphysema are showing promise, although still in need of further testing and validation.

Early corticosteroid use in acute exacerbations of chronic airflow obstruction

To determine the benefit of early steroid use in acute exacerbations of chronic airflow obstruction in the ED, 113 patients with an average age of 66 years, acute or chronic dyspnea, an FEV1 of < 60% and FEV1/FVC ratio of < 60% were included in a randomized, double-blinded, interventional clinical trial. All patients received the same bronchodilator treatment. At 6 hours the steroid- treated group showed a 21.71 L/min improvement in PEFR (P < .05) and 0.14 L improvement in FEV1 (P < .05), while the nonsteroid group showed insignificant improvements of 5.52 L/min and 0.02 L, respectively. Of those patients receiving steroids, 22 achieved > 40% improvements in PEFR by 6 hours and 17 achieved similar results in FEV1, whereas of those not receiving steroids, 13 and 8, respectively, achieved improvements. Within 24 hours of observation in the ED, 16 patients receiving steroids were discharged and none relapsed within 2 weeks. Of those not receiving steroids, only 10 were discharged and 3 returned with exacerbations. Although early response to steroids in chronic airflow obstruction is variable, the overall medical and cost benefits justify their early use in acute exacerbations.

Resuscitation of the geriatric patient

The elderly represent the fastest-growing segment of the population. As the country ages, the number of elderly patients who present in extremis will undoubtedly increase. Emergency physicians must be cognizant of the fact that age alone is a poor predictor of outcome in the critically ill elderly patient. Premorbid status, including previous level of functioning and pre-existing disease, is more important than chronologic age in predicting outcome, guiding assessment, and deciding on therapy. Knowledge and consideration of the geriatric ABCs includes a fundamental understanding that loss of protective airway reflexes, occult respiratory insufficiency, and clinically unrecognized shock are especially prevalent in the sickest geriatric patients. Early recognition and treatment can minimize morbidity and mortality rates in the ED.

Optimal pharmacologic treatment of the critically ill patient with obstructive airways disease

There are few experimental data evaluating the effect of inhaled bronchodilator treatment in the critically ill patient in the intensive care unit. Extrapolating from the data that are available in chronic and acute asthma and chronic obstructive pulmonary disease (COPD) studies, it appears that both agents may be beneficial. Beta-adrenergic receptor agonists are first-line agents in asthma. However, anticholinergics may be valuable as additive agents or as single agents if the patient is intolerant of beta-adrenergic side effects. This may be especially important in the critically ill patient with multiple organ failure in whom excessive tachycardia may reduce oxygen delivery. Anticholinergics and beta 2-adrenergic agonists both appear to be beneficial in smoking-related chronic bronchitis. Finally, because of the severity of illness in the critical care setting, both drugs should be titrated to maximal effect when possible, monitoring closely for adverse effects of the larger than normal doses that are used.

An international perspective on anticholinergic therapy

Since the introduction of inhaled quaternary anticholinergic bronchodilators, their clinical usefulness has been explored in a variety of settings. They have emerged as the inhaled bronchodilators of first choice in the management of chronic obstructive pulmonary disease (COPD). In other countries, they have also found an adjunctive role in the management of asthma. This may be best seen in the treatment of acute asthma where the combination of anticholinergic and adrenergic bronchodilators appear more effective than single-agent inhalation therapy. This finding appears consistently in large studies, whether in adult or pediatric populations. Such combination nebulizer therapy would appear to be cost effective, but further study is required.

Beta-agonists in the treatment of acute exacerbation of chronic obstructive pulmonary disease

OBJECTIVE

To critically evaluate the following issues regarding the use of beta-agonists in the treatment of acute exacerbations of chronic obstructive pulmonary disease (COPD): (1) optimal dose, (2) use of nebulizer (NEB) versus metered-dose inhaler-spacer devices (MDISs), (3) comparison with anticholinergic agents, and (4) use in mechanically ventilated patients. The patient populations addressed are limited primarily to emergency department (ED) and intensive care/acute care settings.

DATA SOURCES

English-language journal articles published between 1977 and 1993.

STUDY SELECTION

Nine studies were evaluated that included beta-agonists alone or in combination with other bronchodilators in the treatment of acute exacerbation of COPD. Many of the studies contained design flaws or were limited in size, making interpretation difficult. In studies containing both asthma and COPD patients, focus was restricted to analysis of COPD patients when possible.

DATA EXTRACTION

Performed subjectively by the authors. Studies were evaluated for methodologic strengths and weaknesses.

DATA SYNTHESIS

Dosing studies in patients with stable disease show a relationship between dose and the various pulmonary function tests (PFTs). Dose also correlates with duration of action and incidence of adverse effects. Four studies compared NEBs versus MDISs. Studies revealed significant improvement in PFTs for both treatments, with no significant difference between groups noted. Five studies compared various combinations of beta-agonists and ipratropium. Both ipratropium and beta-agonists caused statistically significant increases in PFTs from baseline. Combination therapy provided no further increase in spirometry compared with that of single-agent therapy. One study did report an early discharge from the ED with the addition of ipratropium. Most studies did not use large doses of beta-agonists or evaluate the effect of repeated doses. Many studies allowed concomitant therapy. Most did not include outcome measurements, such as ED length of stay, admission rates, hospital stay, or incidence of relapse.

CONCLUSIONS

Dose-response studies in patients with stable disease suggest that doses of albuterol powder up to 1 mg may be tolerated safely, although use of repeated larger doses has not been well studied. Beta-agonists given by MDIS or NEB are equally effective in this setting. There is no apparent advantage to combined use of beta-agonist and ipratropium in the acute setting. Future research in this area should evaluate the use of larger or repeated doses of beta-agonists in the acute setting. Optimizing concurrent therapy and evaluating various patient outcomes should receive special attention in further investigations.