Early COPD Exacerbation Treatment with Combination of ICS and LABA for Patients Presenting with Mild-to-Moderate Worsening of Dyspnea

The efficacy and safety of antibiotics and glucocorticoids in the treatment of elderly patients with chronic obstructive emphysema: systematic review and meta-analysis

Background

To systematically evaluate the efficacy and safety of inhaled corticosteroids (ICS) combined with antibiotics in the treatment of elderly chronic obstructive pulmonary disease (COPD) patients, and to provide some reference for the optimization of clinical treatment regimen for elderly COPD patients.

Methods

Combination of perfect search and keywords from the Chinese and foreign language databases, and the Cochrane Collaboration Center provided Review Manger 5.2 software [Cochrane Information Management System (IMS)] for statistical analysis, and the risk ratio (RR) of dichotic variables was adopted. RR and 95% confidence interval (95% CI) were used as efficacy and side effects analysis statistics in metaanalysis.

Results

After independent screening by two researchers, 18 studies were included into the meta-analysis. After data analysis and statistics, the results of meta-analysis showed that the observation group (glucocorticoid combined with antibiotic treatment) and the control group (glucocorticoid therapy) first second forced expiratory volume (FEV1%) expected value (OR =1.21; 95% CI: 0.11–2.32; P=0.03), and 6-min walking distances (6-MWDs) (OR =12.92; 95% CI: 4.61–21.22; P=0.002), the COPD Assessment Test (CAT) score (OR =3.08; 95% CI: 2.58−3.57; P<0.00001) the improvement was statistically significant; incidence of adverse reactions (OR =1.24; 95% CI: 0.58–2.67; P=0.58), the incidence of acute exacerbation (OR =0.65; 95% CI: 0.39–1.08; P=0.10), FEV1 (OR =0.07; 95% CI: 0.01–0.15; P=0.09). There was no statistical difference.

Discussion

The combination of glucocorticoids and antibiotics in elderly patients with stable COPD can significantly improve their lung function and exercise ability with minimal adverse reactions.

Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Primer for Emergency Physicians

BACKGROUND

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) impose a significant burden on patients and the emergency health care system. Patients with COPD who present to the emergency department (ED) often have comorbidities that can complicate their management.

OBJECTIVE

To discuss strategies for the management of acute exacerbations in the ED, from initial assessment through disposition, to enable effective patient care and minimize the risk of treatment failure and prevent hospital readmissions.

DISCUSSION

Establishing a correct diagnosis early on is critical; therefore, initial evaluations should be aimed at differentiating COPD exacerbations from other life-threatening conditions. Disposition decisions are based on the intensity of symptoms, presence of comorbidities, severity of the disease, and response to therapy. Patients who are appropriate for discharge from the ED should be prescribed evidence-based treatments and smoking cessation to prevent disease progression. A patient-centric discharge care plan should include medication reconciliation; bedside "teach-back," wherein patients demonstrate proper inhaler usage; and prompt follow-up.

CONCLUSIONS

An effective assessment, accurate diagnosis, and appropriate discharge plan for patients with AECOPD could improve treatment outcomes, reduce hospitalization, and decrease unplanned repeat visits to the ED.

Pharmacologic Therapies in Patients With Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review With Meta-analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterized by frequent exacerbations.

PURPOSE

To evaluate the comparative effectiveness and adverse events (AEs) of pharmacologic interventions for adults with exacerbation of COPD.

DATA SOURCES

English-language searches of several bibliographic sources from database inception to 2 January 2019.

STUDY SELECTION

68 randomized controlled trials that enrolled adults with exacerbation of COPD treated in out- or inpatient settings other than intensive care and compared pharmacologic therapies with placebo, "usual care," or other pharmacologic interventions.

DATA EXTRACTION

Two reviewers independently extracted data and rated study quality and strength of evidence (SOE).

DATA SYNTHESIS

Compared with placebo or management without antibiotics, antibiotics given for 3 to 14 days were associated with increased exacerbation resolution at the end of the intervention (odds ratio [OR], 2.03 [95% CI, 1.47 to 2.80]; moderate SOE) and less treatment failure at the end of the intervention (OR, 0.54 [CI, 0.34 to 0.86]; moderate SOE), independent of severity of exacerbations in out- and inpatients. Compared with placebo in out- and inpatients, systemic corticosteroids given for 9 to 56 days were associated with less treatment failure at the end of the intervention (OR, 0.01 [CI, 0.00 to 0.13]; low SOE) but also with a higher number of total and endocrine-related AEs. Compared with placebo or usual care in inpatients, other pharmacologic interventions (aminophyllines, magnesium sulfate, anti-inflammatory agents, inhaled corticosteroids, and short-acting bronchodilators) had insufficient evidence, showing either no or inconclusive effects (with the exception of the mucolytic erdosteine) or improvement only in lung function.

LIMITATION

Scant evidence for many interventions; several studies had unclear or high risk of bias and inadequate reporting of AEs.

CONCLUSION

Antibiotics and systemic corticosteroids reduce treatment failure in adults with mild to severe exacerbation of COPD.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (PROSPERO: CRD42018111609).

Clinical Outcomes Of Using Nebulized Budesonide As The Initial Treatment For Acute Exacerbations Of Chronic Obstructive Pulmonary Disease: A Post-Hoc Analysis

Purpose

The current guidelines recommend the use of systemic corticosteroids (SCS) as the optimal treatment for acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The aim of this real-world study was to evaluate whether nebulized budesonide (NBS) could also be used as an initial treatment for AECOPD.

Patients and methods

AECOPD patients initially treated with NBS or SCS (oral/intravenous) were enrolled. A large-scale, long-term multicenter cohort study of AECOPD patients was performed to analyze outcomes for each treatment (NCT02051166).

Results

Initial NBS and SCS treatment resulted in similar outcomes in terms of improvements in FEV₁, PaO₂, SaO₂, and PaCO₂. Disease severity affected outcome similarly in both groups. When the groups were stratified according to whether the initial treatment was subsequently intensified or reduced, more intubation was seen in the groups in which initial treatment was intensified. NBS escalation and SCS reduction groups spent more days in the hospital. The NBS escalation group was associated with the highest medical expenditure and a relatively higher rate of new-onset pneumonia. The NBS maintenance/reduction group showed the lowest mortality rate between groups. Stratification according to initial PaCO₂ level showed more intubation in the groups with high initial PaCO₂ concentrations.

Conclusion

These results indicate that NBS may be used as an initial treatment in certain AECOPD patients, and further studies are needed to better define those most likely to benefit.

Intensified Therapy with Inhaled Corticosteroids and Long-Acting β2-Agonists at the Onset of Upper Respiratory Tract Infection to Prevent Chronic Obstructive Pulmonary Disease Exacerbations. A Multicenter, Randomized, Double-Blind, Placebo-controlled Trial

RATIONALE

The efficacy of intensified combination therapy with inhaled corticosteroids (ICS) and long-acting β₂-agonists (LABA) at the onset of upper respiratory tract infection (URTI) symptoms in chronic obstructive pulmonary disease (COPD) is unknown.

OBJECTIVES

To evaluate whether intensified combination therapy with ICS/LABA, at the onset of URTI symptoms, decreases the incidence of COPD exacerbation occurring within 21 days of the URTI.

METHODS

A total of 450 patients with stable, moderate to very severe COPD, were included in this investigator-initiated and -driven, double-blind, randomized, placebo-controlled study. At inclusion, patients were assigned to open-labeled low-maintenance dose ICS/LABA. Each patient was randomized either to intensified-dose ICS/LABA or placebo and instructed to start using this medication only in case of a URTI, at the onset of symptoms, twice daily, for 10 days.

MEASUREMENTS AND MAIN RESULTS

The incidence of any exacerbation following a URTI was not significantly decreased in the ICS/LABA group, as compared with placebo (14.6% vs. 16.2%; hazard ratio, 0.77; 95% confidence interval, 0.46-1.33; P = 0.321) but the risk of severe exacerbation was decreased by 72% (hazard ratio, 0.28; 95% confidence interval, 0.11-0.74%; P = 0.010). In the stratified analysis, effect size was modified by disease severity, fractional exhaled nitric oxide, and the body mass index-airflow obstruction-dyspnea, and exercise score. Compared with the stable period, evidence of at least one virus was significantly more common at URTI, 10 days after URTI, and at exacerbation.

CONCLUSIONS

Intensified combination therapy with ICS/LABA for 10 days at URTI onset did not decrease the incidence of any COPD exacerbation but prevented severe exacerbation. Patients with more severe disease had a significant risk reduction for any exacerbation. Clinical trial registered with www.isrctn.com (ISRCTN45572998).

Management of severe acute exacerbations of COPD: an updated narrative review

Background

Patients with chronic obstructive pulmonary disease (COPD) may experience an acute worsening of respiratory symptoms that results in additional therapy; this event is defined as a COPD exacerbation (AECOPD). Hospitalization for AECOPD is accompanied by a rapid decline in health status with a high risk of mortality or other negative outcomes such as need for endotracheal intubation or intensive care unit (ICU) admission. Treatments for AECOPD aim to minimize the negative impact of the current exacerbation and to prevent subsequent events, such as relapse or readmission to hospital.

Main body

In this narrative review, we update the scientific evidence about the in-hospital pharmacological and non-pharmacological treatments used in the management of a severe AECOPD. We review inhaled bronchodilators, steroids, and antibiotics for the pharmacological approach, and oxygen, high flow nasal cannulae (HFNC) oxygen therapy, non-invasive mechanical ventilation (NIMV) and pulmonary rehabilitation (PR) as non-pharmacological treatments. We also review some studies of non-conventional drugs that have been proposed for severe AECOPD.

Conclusion

Several treatments exist for severe AECOPD patients requiring hospitalization. Some treatments such as steroids and NIMV (in patients admitted with a hypercapnic acute respiratory failure and respiratory acidosis) are supported by strong evidence of their efficacy. HFNC oxygen therapy needs further prospective studies. Although antibiotics are preferred in ICU patients, there is a lack of evidence regarding the preferred drugs and optimal duration of treatment for non-ICU patients. Early rehabilitation, if associated with standard treatment of patients, is recommended due to its feasibility and safety. There are currently few promising new drugs or new applications of existing drugs.

Metabolomics in COPD Acute Respiratory Failure Requiring Noninvasive Positive Pressure Ventilation

We aimed to investigate whether metabolomic analysis can discriminate acute respiratory failure due to COPD exacerbation from respiratory failure due to heart failure and pneumonia. Since COPD exacerbation is often overdiagnosed, we focused on those COPD exacerbations that were severe enough to require noninvasive mechanical ventilation. We enrolled stable COPD subjects and patients with acute respiratory failure requiring noninvasive mechanical ventilation due to COPD, heart failure, and pneumonia. We excluded subjects with history of both COPD and heart failure and patients with obstructive sleep apnea and obstructive lung disease other than COPD. We performed metabolomics analysis using NMR. We constructed partial least squares discriminant analysis (PLS-DA) models to distinguish metabolic profiles. Serum (p=0.001, R² = 0.397, Q² = 0.058) and urine metabolic profiles (p < 0.001, R² = 0.419, Q² = 0.142) were significantly different between the four diagnosis groups by PLS-DA. After excluding stable COPD patients, the metabolomes of the various respiratory failure groups did not cluster separately in serum (p=0.2, R² = 0.631, Q² = 0.246) or urine (p=0.065, R² = 0.602, Q² = −0.134). However, several metabolites in the serum were reduced in patients with COPD exacerbation and pneumonia. We did not find a metabolic profile unique to COPD exacerbation, but we were able to clearly and reliably distinguish stable COPD patients from patients with respiratory failure in both serum and urine.