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