AECOPD
Michiel Thomeer
Jessica di Grazio
Overzicht AECOPD
• 5 vragen
Vraag 1
Wat is doodsoorzaak nr. 1 in Europa?
Vraag 1
Doodsoorzaak nr. 1 is
Tabak
COPD: the third biggest killer by 2020
1990
Ischemic heart disease
CVD disease
Lower respiratory infection
Diarrhoeal disease
Perinatal disorders
COPD
6th
Tuberculosis
Measles
Road traffic accident
Lung cancer
Murray & Lopez, Lancet 1997.
2020
3rd
Stomach cancer
HIV
Suicide
Vraag 2
• Hoe wordt de diagnose van COPD gesteld?
Longvolumes
Longcapaciteiten
Thoraxwand - Long
Dynamische compressie
van de luchtwegen
Vraag 3
• Wat bepaalt de prognose van COPD?
Exacerbations increase mortality
Probability of survival
1.0
0.8
No exacerbations
0.6
1-2 exacerbations
0.4
≥ 3 exacerbations
0.2
20
40
60 months
Soler-Cataluna et al. Thorax 2005
Eur Monograph, Vol 59, 2013
Invloed op ziekteverloop
• Obesitas
• Familiaal-economisch
Vraag 4
• Welke onderzoeken start ik op bij een
AECOPD?
AECOPD: Diagnostic testing
Evidence based data
• Chest-X-ray
– 16-21%: change in management
• Blood gas analysis
– assess severity of exacerbation
– requiring mechanical ventilation
– problem with interpretation?
• hypoventilation of pulmonary origin?
• hypoventilation <> shunt
• Spirometry
– of limited usefulness
– does not correlate with clinical status
Vraag 5
• Welke behandeling start ik op?
AECOPD: therapeutic interventions
Evidence based data
AECOPD: therapeutic interventions
Evidence based data
•
•
•
•
•
•
•
Oxygen
Bronchodilator agents
Steroids
Antibiotics
Mucolytic agents
Chest physiotherapy
NIPPV
Oxygen
Evidence based data
• Potential benefits
– Relief of pulmonary vasoconstriction
– Decrease on right heart pressure
– Decrease in myocardial ischemia (if present)
• Potential harm? Risk of hypercarbia?
– Sat O2% above 90% (or pO2 < 60mmHg)
Gomersall et al Crit Care Med 2002
Bronchodilator agents (1)
Evidence based data
• Efficacy
–
–
–
–
5 RCT’s, no placebo
Ipratropium, metaproterenol, albuterol
Improvement in FEV1
No info on LABA as first line therapy
• Benefit of 2nd bronchodilator
– No important evidence of additional benefit
• Adverse events
– Ipratropium: fewer and milder
• Tremors and dry mouth
– Albuterol
• Tremors, headache, vomiting, palpitations, cardiovascular effects
Bronchodilator agents (2)
Evidence based data
• Delivery devices (8 RCT’s)
– MDI vs nebulizer
• No difference
• Dose of MDI lower
• Small studies
– Parenteral
• methylxanthines, sympathomimetics
• Not better than inhaled SABA or anticholinergics
Steroids
Evidence based data
• 6 RCT’s
– short course of systemic corticosteroid therapy
– improvement FEV1
– decrease relapse rate
– in different RCT’s
• Variability in dose, duration of treatment
Oral Corticosteroids in AE
N = 271
SCCOPE
100
50
40
30
20
Placebo
Glucocorticoids, 2 wk
Glucocorticoids, 8 wk
10
FEV1 From Baseline (%)
Rate of Treatment Failure (%)
60
75
50
25
Active
Placebo
0
0
0
1
2
3
4
5
Time (months)
Niewoehner et al. NEJM 1999
6
Davies et al. Lancet 1999
Corticosteroids and Duration of Hospitalisation
Active
Placebo
% Patients remaining in hospital
100
80
60
40
20
0
0
2
4
6
8
10
12
14
Days of Admission
Davies et al, Lancet 1999: 354:456
16
18
20
22
Corticosteroids reduce subsequent relapse
Aaron et al NEJM 2003
Steroids (2)
Evidence based data
• Optimal dose
–?
– > 30 mg prednisone
• Inhaled steroids
– 1 RCT’s, n = 199
– Nebulised budesonide, oral prednisone, placebo
– By day 3, FEV1
• Significant diff steroids vs placebo (0.10 vs 0.16 l)
• No difference between steroid groups
– Limited data to give recommendation
Antibiotics
Evidence based data
• 80% of infectious etiology
• Role of antibiotics
– only effective in type I AECOPD
• with worsening dyspnea and cough also have increased
sputum volume and purulence
– the choice of agents
• should reflect local patterns of antibiotic sensitivity
among S. pneumoniae, H. influenzae, and M.
catarrhalis.
GOLD guidelines, 2003
Antibiotics
Evidence based data
• Most common pathogens
– Haemophilus species, Moraxella catarrhalis,
Streptococcus pneumoniae
• FEV1 < 50%
– Pseudomonas aeruginosa
– Atypeable Haemophilus influenza
• Active tobacco smoking
– H.influenza
Expectorants, Mucolytics and Mucokinetics
Evidence based data
• 5 RCT’s (McCrory et al Chest 2001)
– Do not shorten course of treatment
• No difference in FEV1
• May improve symptoms
• Domiodol, bromhexine, S-carboxymethylcysteine, potassium
iodide, chloramphenicol
• N-acetyl cysteine
– No RCT in AECOPD
– Reduction in number of AECOPD (Cochrane 2000)
Chest physiotherapy
Evidence based data
• 3 RCT’s
– Ineffective
• No improvement in ventilatory function
– 1 RCT (& 1 uncontrolled trial) with percussion
therapy
• Worsening of FEV1
Petersen et al Acta Med Scand 1967
Newton et al BMJ 1978
Wollmer et al Eur J Respir Dis 1985
The Passion, 2004 (M.Gibson)
NIPPV
Evidence based data
• NIV resulted in
– decreased mortality (RR 0.41; 95%CI 0.26-0.64)
– decreased need for ETI (RR 0.42; 95%CI 0.31-0.59)
• Greater improvements within 1 hour in
– pH (WMD 0.03; 95%CI 0.02-0.04)
– PaCO2 (WMD -0.40 kPa; 95%CI -0.78, -0.03)
– RR (WMD –3.08 bpm; 95%CI –4.26, -1.89)
• Reduction of
– Complications associated with treatment (RR 0.32; 95%CI 0.180.56)
– length of hospital stay (WMD -3.24 days; 95%CI -4.42, -2.06)
BMJ 2003