Annual World CRITER Conference Acute Severe COPD Management: Is there anything more than NIV? Brian H. Rowe, MD, MSc, CCFP(EM), FCCP Tier I CRC in Evidence-based Emergency Medicine Professor and Research Director Department of Emergency Medicine University of Alberta Definition • AECOPD: – A sustained worsening of dyspnea, cough or sputum production, for at least 2 days; – Leading to an increase in the maintenance medications and/or supplementation with additional medications. • Exacerbations are more common as severity of COPD worsens. • Recovery always incomplete, so prevention is the key. Diagnosis • Confirm diagnosis with history, physical and objective lung function measurements. • Differential (other co-morbidities/causes): – – – – – – HF: CXR, BNP/NT-proBNP; PE: PTP (Wells’), D-dimer, advanced imaging; CAP: CXR, advanced imaging; ACS: ECG, biomarkers, provocative testing; Pneumothorax: CXR, U/S, advanced imaging; Others Differentiating COPD from Asthma Spirometry-2 FEV1/FVC > 0.7 FEV1/FVC < 0.7 O‘Donnell DE, et al. CRJ 2008;15:1A-8A Question 1: Bronchodilator choices • Not as clear cut as asthma. • Both salbutamol and IB are effective. • Synergy: – Not demonstrated to date. • Side effects: – More pronounced with salbutamol. • Delivery: – MDI + spacer vs nebs. Question 2: Efficacy of corticosteroids in exacerbations of COPD? All evidence • Systemic corticosteroids vs placebo: – Cochrane Review: high quality; – Involving 11 trials and >1080 adult patients; • Outcomes: – Fewer treatment failures within 30 days (OR = 0.50; 95% CI: 0.36 to 0.69) – NNT = 10. – LOS (Hosp): -1.2 days (95% CI: -2.3 to -0.2); • Caveat: – S/Es (OR = 2.3; 95% CI: 1.6 to 3.4). Walters JAE, et al. CDSR. 2009; 1:CD001288. Outcome: treatment failure Walters JAE, et al. CDSR. 2009; 1:CD001288. Outcome: Mortality Walters JAE, et al. CDSR. 2009; 1:CD001288. Following discharge? • Canadian study involving Pulmonary and Emergency Medicine with low RofB: – Concealed allocation; – RCT; – Multiple levels of blinding. • AECOPD patients: – Not on corticosteroids prior to presentation; – Treated by ED physicians and improved to the point where discharge was considered safe. Aaron S, et al NEJM 2003; 348:2618-24. Corticosteroids after discharge Emergency Department discharge Prednisone 40 mg po OD X 10 days Emergency Department Treatment Combivent® 2 puffs QID + antibiotics R Placebo prednisone Combivent® 2 puffs QID + antibiotics Visit: Week: 1 0 PC1 10-14 days Aaron S, et al NEJM 2003; 348:2618-24. 2 4 weeks Prednisone for Out-Patient Acute Exacerbation of COPD Summary • Systemic corticosteroids are effective in the early treatment of acute severe COPD to reduce failures and ↓ LOS. • Systemic corticosteroids are effective in the out-patient treatment of COPD to prevent relapse (NNT: 7). • S/E’s are impressive, so selection must be appropriate. • Duration: 5 = 10 days (new evidence). Walters JAE, et al. CDSR. 2012: CD006897. Question 3: Efficacy or antibiotics in exacerbations of COPD? Who needs them and which ones do you use? Infectious etiology • AECOPD can be associated with both viral and bacterial infections. • Bacteria growth related to severity: – Mild: • Usually associated with S. pneumonia. – Severely ↓ FEV1/frequent exacerbations: • Often associated with H. influenzae / M. catarrhalis. – Frequent Abx/recent hospitalization/culture +ve: • May be associated with P. aurigenosa. Effectiveness of Antibiotics in COPD % Success Placebo Antibiotic 80 70 60 50 40 30 20 10 0 Type 1 Type 2 Type 3 Anthonisen NR, et al. Ann Intern Med 1987; 106:196-204. All evidence • Systemic antibiotics vs placebo (Type II/I): – SR: high quality; – Involving 11 trials and >900 adult patients; • Outcomes: – Lower mortality (RR = 0.23; 95% CI: 0.1 to 0.5) – NNT = 10. – Fewer treatment failures (RR = 0.47; 95% CI: 0.4 to 0.6) – NNT = 3. • NB: not influenced by the antibiotic choice. Ram F, et al Cochrane Database Syst Rev. 2006; 2:CD004403 Proposed Therapies for AECOPD According to Patient Subsets Simple, uncomplicated AECOPD Complicated AECOPD Complicated AECOPD at risk for P aeruginosa Any age >64 years < 4 exacerbations/yr >4 exacerbations/yr No comorbid illness Serious comorbid illness Need for chronic corticosteroid therapy FEV1 <50% and frequent (>4/yr) courses of antimicrobials FEV1 >50% Patients with chronic bronchial sepsis FEV1 <35% Macrolide (azithromycin, clarithromycin) or new cephalosporin (cefpodoxime, cefuroxime, cefdinir), doxycycline Newer respiratory fluoroquinolone or amoxicillin/clavulanate Fluoroquinolone with antipseudomonal activity (eg, ciprofloxacin) FEV1 = Forced expiratory volume in 1 second. O’Donnell et al. Can Respir J. 2003;10(Suppl A):11A. Canadian Guidelines O'Donnell D, et al. CRJ 2007; 14:5B-32B Question 4: Efficacy of NIV in exacerbations of COPD? Who needs it? NIV The evidence • • • • • Design: 10 RCTs (> 750 patients). Population: Acute severe COPD. Interventions: NIV + standard care. Control: standard care. Outcomes: – Death, intubation, LOS • High quality methods for SRs Ram FSF, et al. CDSR. 2004, Issue 3. NIV – treatment failures Ram FSF, et al. CDSR. 2004, Issue 3. NIV – Mortality outcome Ram FSF, et al. CDSR. 2004, Issue 3. NIV – Intubation outcome Ram FSF, et al. CDSR. 2004, Issue 3. Utilization data (others exist) Chandra D, et al. Am J Respir Crit Care Med. 2012; 185:152–159. Other issues • Misuse is a concern in the ED. • Tran et al poster at ICEM 2012: – 912 eligible AECOPD patients in Calgary receiving systemic CSs (severe); – 67.4% had BG determination; – 19.2% met criteria for respiratory failure and treatment with NIV; – Only 59.3% of these received treatment; however, 44% of those who received NIV did not meet criteria. Question 5: In those who receive antibiotics, what other issues should we be considering? Most recent antibiotics? Percent resistant (or non-susceptible) Effect of Prior Antibiotic on S pneumoniae Resistance 35 No (or no known) antibiotic use Any prior antibiotic 30 Prior use same class 40 25 20 15 10 5 0 Penicillin Cefotaxime Erythromycin Tmp/Smx Quinolones Vanderkooi OG, CID 2005;40: 1288-97 Question 6: In those who receive antibiotics, what other issues should we be considering? Duration of treatment? 5 = 10 days Evidence Summary • Systematic review (21 studies; 10,698 pts). • A short course of antibiotics (5 days) seems to be just as effective in achieving clinical and bacteriological cure rates as a longer course (7-10 days). • Given the side effects of antibiotics and the elderly nature of COPD patients, it seems reasonable to reduce the duration of antibiotics in this patient population. Short (< 5 days) vs long (>7 days) Moussaoui RE, et al. Thorax 2008; 63: 415-422 Real data (others exist) Tsai et al. Acad Emerg Med. 2008; 15: 1275 Question 7: In patients with AECOPD, is there evidence to assist in admission decisions? Canadian data. Admission • CAEP-RC (Academ Emerg Med; 2009) – Of 501 study pts across 20 Canadian sites, 247 (49%; 95% CI: 45 to 54) admitted; – Admission was associated with: • ≥ 2 COPD admissions in the past two years (OR=2.10; 95% CI: 1.24 to 3.56); • Receiving oral CS for COPD (OR=1.72; 95% CI: 1.08 to 2.74); • CTAS 1-2 score (OR=2.04; 95% CI: 1.33 to 3.12); • Receiving adjunct ED treatments (OR=3.95; 95% CI: 2.45 to 6.35). • Use of EDs for usual COPD care was associated with a reduced risk of admission (OR=0.43; 95% CI: 0.28 to 0.66). Other considerations • Gaps exist in what is known and what patients need/are receiving: – Follow-up: after ED visits; – Medications: • Appropriate chronic pharmacological management; • Spacer devices. – Counselling: smoking cessation; – Immunization: influenza and pneumococcal; – Prevention: Action plans and education. Follow-up • Evidence suggests that the majority of patients with COPD have primary care providers (PCP). • Delays in follow-up may decrease the chance to prevent the next deterioration: – AB: median follow-up occurred at 13 days and only 40% in the first 7 days following D/C. • Needed: evidence of effective interventions after discharge to enhance follow-up. Prevention strategies • Pulmonary rehabilitation better than most pharmacological interventions. • Problem: – Limited availability; – Rarely prescribed (<25% in recent study). • Consider educational strategies for COPD: – COPD education; – Smoking cessation; – Referral to specialist. Future directions • Decision rules for COPD – Ottawa decision rule. • Implementation of guidelines. • Personalized/metabolomic medicine: – Diagnostics (e.g., PCT, CRP, others); – Treatments. • New drug classes (biologics): – Anti-ILx monoclonal antibodies and other immune modulators. Summary • Systemic corticosteroids reduce failures: – Consider in most admitted patients; – Consider 5 days at discharge for Anthonisen type I and II cases. • Antibiotics improve outcomes: – AECOPD classified as simple and complex; – Ask about recent antibiotic use and sensitivity; – Treat for 5 days, unless otherwise indicated. • NIV: – Consider in patents with extreme symptoms prior to “IN2B8N”. • Admissions: – Predictable. Annual World CRITER Conference Thanks for Listening! Questions?