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COPD Exacerbation (PowerPoint)

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					  COPD Exacerbation:
Practical Evidence-based
       Strategies

Daniel D. Dressler, MD, MSc
          Director of Education
      Section of Hospital Medicine
    IM Associate Residency Director
     Assistant Professor of Medicine
   Emory University School of Medicine
      Daniel.Dressler@emory.edu

Society of Hospital Medicine Annual Meeting
            San Diego, California
                April 4, 2008
     What will NOT be discussed during
                this session…


•   Knock-out mice      • Pathophysiology
                        • Disease Burden
                        • Precipitants
                        • Differential
                        • Adm criteria
                   Objectives
• By the end of this session, participants
  will be able to:
• Locate, Evaluate and Interpret the highest
  level of medical evidence for management
  of COPD Exacerbations
   Summary of RCT data
   RCT data
   Observational Data
             Definition of COPD
   Progressive Pulmonary airflow limitation that is not
    completely reversible
   Abnormal inflammatory response of the lung to
    noxious particles or gases
   Preventable and Treatable
   Extrapulmonary effects may contribute to
    disease severity
     Weight loss
     Nutritional abnormalities

     Skeletal muscle dysfunction
       Classification of COPD Severity
                 by Spirometry
Stage I: Mild           FEV1/FVC < 0.70
                        FEV1 > 80% predicted

Stage II: Moderate      FEV1/FVC < 0.70
                        50% < FEV1 < 80% predicted

Stage III: Severe       FEV1/FVC < 0.70
                        30% < FEV1 < 50% predicted

Stage IV: Very Severe   FEV1/FVC < 0.70
                        FEV1 < 30% predicted or
                          FEV1 < 50% predicted plus
                          chronic respiratory failure
 Exacerbation of COPD: Definition
 Acute change in baseline dyspnea, cough,
  and/or sputum beyond normal day-to-day
  variations
 May warrant a change in regular
  medication(s)
          Exacerbations: Mortality
• Hospitalized
   – Inpatient mortality (non-ICU): 2.5%* (1 in 40)
   – 3-month mortality after hospitalization for exacerbation: 14%
     (1 in 7)
   – If pCO2>50:
        • 6 month mortality = 33%
        • 12 month mortality = 43%

• ICU
   – 17% in-hospital (1 in 6)
   – 26% in-hospital if intubated* (1 in 4)
   – 45% 1-year mortality (1 in 2)

                                         *Patil SP, et al. Arch Intern Med. 2003.
                   DIAGNOSIS
• Exacerbations: CLINICAL Diagnosis


• Spirometry (PFTs and/or Peak Flows)
   – No demonstrated value in setting of COPD exacerbation
   – Useful only in the outpatient diagnosis of stable COPD
   – DIFFERENT for Asthma patients, where spirometry is
     useful in the setting of stable asthma and asthma
     exacerbation


• Assess Severity!!
                   Case: Mr. BH

• Mr. BH is a 63 year old
  portly Southern
  Gentleman with h/o
  severe COPD (i.e.
  baseline FEV1 30 to 50%
  predicted) admitted from
  the ED with 3 days of
  SOB, increased cough
  and clear sputum
  production. + exposure
  to grandkids with ‗colds‘
                Case: Mr. BH

• PMH:
  1. COPD
      • PFTs: FEV1 32% predicted (FEV1/FVC 60%)
      • baseline pCO2 55

  2. CASHD, s/p MI 12/2007
      • Preserved cardiac function (EF 60%)

  3. HTN
  4. Secondary Pulmonary HTN (mild)
               Case: Mr. BH

• Medications on admission:
  – ASA
  – Albuterol MDI prn
  – Carvedilol CR 20mg daily
  – Lisinopril 10mg daily
  – prn SL NTG

• SH: former town mayor, 60 pack-year Tob
  use, quit 10 years ago, enjoys working on
  his white convertible cadilac
                  Case: Mr. BH

Physical Exam                Studies
• VS: BP 150/90, HR 110      • CXR: Chronic changes,
  (reg), RR 28, T 38.1         hyperinflation
• Mild to Mod increased      • ABG:
  WOB, RR 28, alert.            – pH 7.36
• Lungs: significant bilat      – pCO2 58
  inspiratory and
                                – pO2 64 on 2L O2 NC
  expiratory wheezes
                             • Other labs: Cr 1.4,
• Ext: 1+ to 2+ edema          Troponin-I: 0.09
  bilat
     Question #1

Pharmacologic Therapies
         Question #1: Pharmacologic
       Therapies in COPD Exacerbation
  •   Which pharmacologic therapies are
      supported by high-level studies (RCTs)
      demonstrating their benefit in COPD
      exacerbation to improve outcomes
      (select all that apply)?
      A. Inhaled Bronchodilators
      B. Methylxanthine Bronchodilators
      C. Oxygen
      D. Systemic Steroids
      E. Acupuncture, Aromatherapy, Massage*
*According to healingdeva.com !!
              The Evidence: Pharmacologic
             Therapies for COPD Exacerbation
             BRONCHODILATOR THERAPIES
Inhaled Bronchodilators
•    Short-acting inhaled ß2 agonist BDs recommended by guidelines
     (Evidence A)*
       – Outcomes: Main benefit on symptoms and FEV1
•    5 RCTs suggest ß2 agonists similar efficacy to anticholinergic BDs on
     FEV1**
       – Fewer side effects with anticholinergics agents alone
•    Some patients benefit from adding a 2nd bronchodilator after
     maximum dose** of the initial bronchodilator has been reached
•    Oral and injected bronchodilators NOT as effective**
•    No clinical studies of long-acting inhaled BDs during exacerbation


*American Thoracic Society (ATS), European Respiratory Society (ERS), National Institute for Clinical
Excellence (NICE/Thorax), GOLD (Global Initiative for Chronic Obstructive Lung Disease)
** Bach PB, et al. Ann Intern Med 2001. 134: 600-620.
    The Evidence: Pharmacologic
   Therapies for COPD Exacerbation
   BRONCHODILATOR THERAPIES

Methylxanthine Systemic Bronchodilators
• Meta-analysis summary
• 4 RCTs, 169 total patients
• Evaluation in patients treated in EDs or
  inpatient for exacerbations of COPD
• Relevant Outcomes:
  – Return to ED, Symptoms, Arrhythmias
       The Evidence: Pharmacologic
      Therapies for COPD Exacerbation
      BRONCHODILATOR THERAPIES
Methylxanthine Bronchodilators: Efficacy

ED Return Visits within 1 wk               Symptom Scores




  Barr RG, et al. BMJ 2003. 327: 643-48.
           The Evidence: Pharmacologic
          Therapies for COPD Exacerbation
          BRONCHODILATOR THERAPIES
 Methylxanthine Bronchodilators: Adverse Effects

              Arrhythmias/Palpitations




Barr RG, et al. BMJ 2003. 327: 643-48.
    The Evidence: Pharmacologic
   Therapies for COPD Exacerbation
               OXYGEN
• ―Controlled oxygen therapy‖ recommended by
  GOLD Guidelines (no evidence level provided)
   – Flow-controlled systems (e.g. Venturi mask) preferred

• Indicated for hypoxemic patients (PaO2 < 60)
   – Give just enough to relieve hypoxemia

• Monitor closely for signs of hypercarbia and
  respiratory failure (i.e. ABG 30 – 60 min after
  initiation of new O2 rx)
What about Steroids…
          The Evidence: Pharmacologic
         Therapies for COPD Exacerbation
          SYSTEMIC CORTICOSTEROIDS
  • Oral or IV glucocorticosteroids recommended in
    hospital management of COPD exacerbations
    (Evidence A)*
         – Improve symptoms and FEV1* (based on 6 RCTs**)

  • 30-40 mg prednisolone daily x 7-10 days is
    effective and safe (Evidence C)*
         – No more than 2 weeks of systemic rx necessary***

  • No role for inhaled corticosteroids in acute
    exacerbation of COPD (no studies to date*)
*Global Initiative for Chronic Obstructive Lung Disease (“GOLD”). NIH/NHLBI; April 2001,
updated May 2007. NIH Publication 2701. Available at: www.goldcopd.com
** Bach PB, et al. Ann Intern Med 2001. 134: 600-620.
***Niewoehner DE, et al. N Engl J Med 1999. 340: 1941-47.
COPD: Systemic Steroids on Rx Failure




Figure: Kaplan-Meier Estimates of the Rate of First Treatment Failure at Six Months,
According to Treatment Group (271 patients)

Niewoehner DE, et al. N Engl J Med 1999. 340: 1941-47.
ACP Journal Club 2000. 132(1): 14.
 COPD Exac: Systemic Steroids effects on
     A. FEV1 after BD, and B. LOS
A. FEV1 after BD
                                             B. LOS (p = 0.039)
(p<0.0001)




RCT data, 56 patients
Davies L, et al. Lancet 1999; 354: 456-60.
       Question #2

(enough with the easy stuff…)
                 Case (continued)
                   Question #2
•   Admission orders written…
•   …medical student presentation…reports that
    she witnessed significant purulent sputum
    production while interviewing the patient for 90
    minutes.
•   Question: Are there other medical therapies we
    should add to Mr. BH‘s regimen (supported by
    high-level evidence)?
    A. Mucolytics
    B. Chest Physiotherapy
    C. Antibiotics
    D. Sildinafil/Viagra for pulmonary HTN
        (…oops, contraindicated with his nitrate therapy)
The Evidence for Mucolytics…
          The Evidence: Pharmacologic
         Therapies for COPD Exacerbation
              MUCOLYTIC AGENTS

  • 5 RCTs of Mucolytic/Mucokinetic agents
    in the setting of COPD Exacerbations did
    NOT demonstrate shortening of disease
    course, but may improve symptoms*


  • However, outpatient use of mucolytics in
    COPD patients may reduce number of
    exacerbations…

*Bach PB, et al. Ann Intern Med 2001. 134: 600-620.
                    Mucolytic Agents in Chronic COPD:
                         Effect on Exacerbations




Reduces mean number of exacerbations per subject per month (weighted mean
difference, and 95% confidence intervals)
*No effect on lung function
Poole, P. et al. BMJ 2001;322:1271
What about Pulmonary Toilet?
  The Evidence: Therapies for COPD
            Exacerbation
      CHEST PHYSIOTHERAPY

• Mechanical percussion of the chest by
  PTs or RTs is ineffective (or detrimental)
• No change or decrease in FEV1
• Therefore: NO Pulmonary Toilet!




  *Based on 3 RCTs and 1 observational study
  *Bach PB, et al. Ann Intern Med 2001. 134: 600-620.
          The Evidence: Pharmacologic
         Therapies for COPD Exacerbation
                  ANTIBIOTICS
   • Antibiotics indicated for exacerbation…
        – COPD Exacerbation with 3/3 ‗cardinal
          symptoms‘: increased dyspnea, increased
          sputum volume, increased sputum purulence
          (Evidence B)*
        – COPD Exacerbation with 2/3 ‗cardinal
          symptoms‘ that includes increased sputum
          purulence (Evidence C)*

   • Antibiotics indicated for hospitalized
     exacerbation…?
*GOLD Initiative Guidelines
        The Evidence: Antibiotic vs Placebo—
                 Outcome: Mortality




RR = 0.23 (0.10, 0.52), NNT = 8
Ram FSF, et al. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004403. DOI:
10.1002/14651858.DC004403.pub2.
        The Evidence: Antibiotic vs Placebo—
             Outcome: Treatment Failure
        (limiting to hospitalized patients only)




RR = 0.47, NNT = 3
Ram FSF, et al. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004403. DOI:
10.1002/14651858.DC004403.pub2.
                       Antibiotic vs Placebo—
                      Outcome: Length of Stay




Ram FSF, et al. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004403. DOI:
10.1002/14651858.DC004403.pub2.
                             New Evidence
                          Procalcitonin Levels
Decision Support for Antibiotic Use in COPD Exacerbation
   •   Background
         – Serum procalcitonin may be useful for detecting bacterial
           infections
   •   Design
         – RCT, blinded, COPD exacerbation presenting to ED
   •   Randomized to:
         – Rx guided by Procalcitonin level
                 •   <0.1  abx discouraged
                 •   >0.25  abx recommended
         – Control
                 •   Clinician abx rx based on guidelines (attending discretion)

   Stolz D, et al. Chest 2007; 131: 9-19.
                      New Evidence
                   Procalcitonin Levels
•   Results
    – No difference b/w groups with respect to mortality,
      symptoms, re-exacerbation rate, LOS, ICU LOS, FEV1
    – +Reduction in ABX use
           •   RR = 0.64 in procalcitonin-guided group
           •   NNT = 4

•   Availability
    – Not currently broadly available
•   Cost
    – Lab Charge: approximately $170
Which Antibiotic?...not great evidence




                                Martinez FJ, et al. Expert
                                Rev Anti Infect Ther. 2006;
                                4: 101-124.
      Bottom Line: Pharmacologic Therapies for
        Hospitalized with COPD Exacerbation

YES!                                 NO!
•   Inhaled Bronchodilators          •   Methylxanthine
    – Duh! (Evidence A)                  – Unless you like that
                                           ‗speed‘ feeling and
•   Oxygen                                 arrhythmias
    – Duh! (No Evidence)             •   Mucolytic Agents
•   Systemic Steroids (Evidence A)       – Little valuable evidence
                                           for exacerbations
    – Improves BD response
                                         – Some evidence in
    – Reduces Hospital LOS                 chronic COPD for
    – Improves time to next                decreasing exacerbations
      exacerbation or rx failure     •   Chest PT
•   Antibiotics                      •   Heliox
         Question #3
(enough of the drugs, lets move
  onto electronics gadgets…)
        Question #3: NPPV for COPD
               Exacerbation
•   Will Mr. BH benefit from non-invasive positive
    pressure ventilation (NPPV)?
•   Reminder—ABG on 2L O2 NC:
    –   pH 7.36, pCO2 58, pO2 64

•   Which patients attain benefit from this therapy?
    A. pH 7.10 – 7.30
    B. pH 7.25 – 7.35
    C. pH > 7.25
    D. pH > 7.35
                          NPPV

Indications                    Contraindications
•   COPD exacerbations         •   Cardiac/Respiratory arrest

•   Hypoxemic or ventilatory   •   Malignant arrhythmias
    Respiratory Failure
                               •   Refractory hypoxemia
•   CHF
                               •   Hemodynamic instability
•   Extubation Management
                               •   Severe encephalopathy
                               •   Unable to tolerate mask
                               •   High risk of aspiration
                               •   Anatomic abnormalities
              NPPV vs Usual Care
• Meta-Analysis of RCTs (14)           Averages for Studies
   – Concealed allocation, unblinded   Age: 63-76
• Patients                             Adm pH: 7.26-7.34
   – COPD with Respiratory Failure
                                       FEV1: 0.68-1.03
   – Total of 758 patients studied

• Outcomes
   – Mortality (n = 622)
   – Treatment Failure (n = 541)
   – Intubation (n = 758)
   – LOS (n = 546)
   – Other Surrogate Outcomes (RR, pCO2, pH)
                             NPPV vs Usual Care—
                              Outcome: Mortality




RR = 0.52 (95%CI: 0.35, 0.76), NNT = 10
Ram FS, et al. Non-invasive positive pressure ventilation for treatment of respiratory failure due to
exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews.
(3):CD004104, 2004.
                      NPPV vs Usual Care—
                       Outcome: Mortality

                                            pH 7.3-7.35
                                            Summary
                                            pH < 7.3
                                            Summary



                                            ICU
                                            Summary
Ram FS, et al.
Cochrane Database
of Systematic
Reviews.(3):CD00410
                                            Ward
4, 2004.                                    Summary
                    NPPV vs Usual Care—
                  Outcome: Treatment Failure




RR 0.48 (95%CI: 0.37, 0.63), NNT = 5
Ram FS, et al. Cochrane Database of Systematic Reviews. (3):CD004104, 2004.
                         NPPV vs Usual Care—
                         Outcome: Intubation




RR 0.41 (95%CI: 0.33, 0.53), NNT = 4
Ram FS, et al. Cochrane Database of Systematic Reviews. (3):CD004104, 2004.
                          NPPV vs Usual Care—
                            Outcome: LOS




LOS Reduction 3.2 days (95%CI: 2.1 - 4.4 days)
Ram FS, et al. Cochrane Database of Systematic Reviews. (3):CD004104, 2004.
What about less severe exacerbations?
                  NPPV for pH > 7.30?
                     Systematic Review, Annals of IM
                     “Non-Severe Exacerbations”: pH>7.30
                     )
•   Hospital
    Mortality




•   Intubations




                                     Keenan SP, et al. Ann Intern Med. 2003.
                      NPPV for pH > 7.35?
•   RCT 2007                                                      *pCO2
    – NPPV + Usual Care vs.
    – Usual Care
•   Hospital Admissions for COPD      *
    Exacerbation
•   pH>7.35 in all patients
•   Results                                                   **
    – No mortality or intubation
                                                              LOS
      reduction
    – More rapid reduction in pCO2*
    – +LOS Reduction (5.5 vs. 10.2
      days, p = 0.0004)**


                                      Pastaka C, et al. Eur J Intern Med 2007; 18: 524-530.
             Bottom Line: NPPV in
              COPD Exacerbation
• Improves respiratory status
   – Rapidly improved physiologic variables (pH, PCO2, RR,
     breathlessness)
• Reduces Hospital LOS
   – >3 days on average!
   – Even for less severe exacerbations (pH>7.35)
• Reduced Intubation Rate
   – NNT 4
• Reduced complications (e.g. VAP)
• Improves mortality!!
   – NNT 10
                                       Evidence Level A
             Bottom Line: NPPV in
              COPD Exacerbation
• Maintain a low threshold to utilize!
• Apply in the ED!!
   – Early intervention likely improves outcomes
• Monitor closely with ABGs (30-60 min after
  initiation or change in NPPV settings)
• Adjust with assistance from RT
   – Mask type, pressure levels (usual start 10/5)
• Recommendations/Guidelines: pH 7.25-7.35
   – But likely benefit in COPD exacerbation with
        • pH < 7.25 (use cautiously, monitor closely)
        • pH > 7.35 (LOS benefit)
   Question #4

Comorbid Conditions
      Question #4: ß-block in COPD
              Exacerbation
•   Mr. BH has had a recent MI, and now has
    a mildly elevated troponin during this
    admission.
•   Should Mr. BH continue his ß-block
    therapy in this setting of acute
    exacerbation?
    A. Yes
    B. No
    C. Who knows?—no data in exacerbations
                  The Evidence and Bottom Line:
                  ß-block in COPD Exacerbation
        • NO Studies in inpatient or outpatient
          exacerbations!
        • Outpatient studies summarized in 2007
          Meta-Analysis (Cochrane Collaboration)
              – 20 RCTS in patients with COPD, including
                severe COPD
              – No significant effects of single dose or longer-
                term treatment with ß-block on outcomes of
                symptoms or FEV1


Salpeter S, et al. Cardioselective beta-blockers for chronic obstructive pulmonary disease. Cochrane Database
of Systematic Reviews 2005, Issue 4. Art. No.: CD003566. DOI: 10.1002/14651858.CD003566pub2.
            Case (continued)

• Mr. BH was placed on NPPV in the ED,
  started on q2 hour albuterol nebulizer
  therapy, IV methylprednisolone 30mg bid,
  doxycycline 100mg bid, and continued on
  his cardioselective beta-blocker.
• His symptoms improved quickly, and he
  was able to rapidly wean off of NPPV and
  repeat ABG on Day 2 revealed pH 7.42,
  pCO2 38, pO2 69 on 1L NC.
             Question #5




Prevention During
 Hospitalization
and At Discharge
      Question #5: Prevention During
      Hospitalization and @ Discharge
•   What interventions should be instituted by
    hospitalists (prior to or at discharge), as
    supported by outcomes in COPD patients?
    A. Tobacco Cessation Counseling
    B. Pneumonia Vaccine (if not previously received)
       and Influenza Vaccine (if not received this
       season)
    C. VTE Prophylaxis
    D. Augment Home Medication Regimen (if so, which
       ones?)
      Prevention for COPD:
   Smoking Cessation Counseling
 Smoking Cessation Counseling
      Single counseling event, tob cessation 1 yr
             Meta-analysis RCTs*
             ARR 2% (NNT 50)
             P<0.001

      Pneumonia Outcomes Research Team
       (PORT)**
             15% of counseled quit
             93% of those who quit did so at the time they
              developed PNA
*Law M, Tang JL. Arch Intern Med. 1995; 155: 1933-41.
**Rhew DC. Ann Intern Med. 2001; 135: 736-43.
        Smoking Cessation Slows Lung
        Function Decline in Mild COPD:
                    The Lung Health Study at 11 Years
     2.9
     2.8
     2.7
     2.6
     2.5
     2.4            Sustained quitters

     2.3            Intermittent quitters
     2.2
     2.1            Continuous
                    smokers
       2
              0     1      2      3      4     5      6      7   8   9   10   11


Anthonisen NR et al. Am J Respir Crit Care Med 2002:166:675-9.
Calverley PMA and Walker P. Lancet 2003;362:1053-1061.
                          Prevention for COPD:
                              Vaccination
 Pneumococcal                                             Influenza Vaccination in
  Vaccination*                                              Chronic Lung Disease**
        Chronic Lung                                          Reduced mortality
         Disease                                                         RRR >50%
                 Reduced Mortality                            Reduced hospitalization
                         RRR 30%                                        RRR 20-30%
                 Reduced Pneumonia
                                                               Reduced PNA
                         RRR 43%
                                                               Cost-effective
                                                               Annual Revaccination
                                                                necessary


*Nichol KL, et al. Arch Intern Med. 1999; 159: 2437-42.     **Multiple studies
*Large Retrospective Cohort                                 Summary: Seymann GB. J of Hosp Med. 2006; 1: 344-53.
Jackson LA, et al. N Engl J Med. 2003; 348: 1747-55.
                              Prevention for COPD:
                                VTE Prophylaxis
     • Prevalence of VTE in COPD Exacerbation
            – Up to 30% based on Autopsy Studies*
            – Approx 10% based on retrospective assessments*
            – Risk of VTE in COPD: Adjusted HR 1.33 (1.17-1.51)**
                     • >92,000 patients inpatient COPD
                     • Comparison HRs
                              – ICU Adm: HR 1.35
                              – Paralysis/paresis: HR 1.35


*Ambrosetti M, et al. Prevalence and prevention of venous thromboembolism in patients with acute
exacerbations of COPD. Thrombosis Research 2003. 112: 203-207. [systematic review]
**Edelsberg J, et al. Risk of venous thromboembolism among hospitalized medically ill patients. Am J
Health-Syst Pharm 2006. 63 (S6): S16-S22.
                       Prevention for COPD:
                         VTE Prophylaxis
• Pharmacologic prophylaxis*
     – Reduces risk of VTE with use of pharmacologic
       prophylaxis (LMWH or UFH) in medical patients
              • RRR 55%

• ACCP Guidelines for VTE Prophylaxis (Grade 1A,
  RCT):
     – ―Acutely ill medical patients admitted...with severe
       respiratory disease…‖ should receive pharmacologic
       VTE prophylaxis


*Mismetti P, et al. Prevention of venous thromboembolism in internal medicine with unfractionated or low-
molecular-weight heparins: a meta analysis of randomised clinical trials. Thromb Haemost 2000; 83: 14-19.
Geerts WH, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and
Thrombolytic Therapy. Chest 2004. 126(3 Suppl):338S-400S.
            Prevention:
  Augmentation of Home Medication
    Regimen—Newest Evidence




• Systematic Review of RCTs and Meta-Analyses
• Published November 2007
• Outcomes:
    Mortality Reduction
    Exacerbation Reduction
                Prevention:
Augmentation of Home Medication Regimen—
           OUTCOME: Mortality
     • Outpatient Interventions that Reduce Mortality
       (statistically significant…and clinically relevant!)
     • Severity @ baseline: Mod to Very Severe
             Combined LABA and Corticosteroid therapy vs.
              Placebo*
                    >4600 patients
                    Mortality reduction: RR = 0.83, NNT = 53
             Combined LABA and corticosteroid therapy vs.
              Corticosteroid therapy alone*
                    Mortality reduction: RR = 0.79, NNT = 44
             Combined LABA and corticosteroid vs. Tiotropium**
                    Mortality reduction: RR = 0.56, NNT = 55 (p = 0.032)
 *Wilt TJ, et al. Ann Intern Med 2007; 147: 639-653.
 **Wedzicha JA, et al. Am J Respir Crit Care Med 2008; 177: 19-26.
                Prevention:
Augmentation of Home Medication Regimen—
           OUTCOME: Mortality




     Inhaled Combined LABA and Corticosteroid therapy
        vs. Placebo
      RR = 0.83, NNT = 53

 Wilt TJ, et al. Ann Intern Med 2007; 147: 639-653.
                Prevention:
Augmentation of Home Medication Regimen—
           OUTCOME: Mortality

   • No Mortality Reduction with the following
     inhaled therapies (vs. placebo):
          – Short-Acting Anticholinergic (Ipratropium)
          – Long-Acting Anticholinergic (Tiotropium)
          – LABA alone
          – Corticosteroids alone
          – D2/ß2-Agonist (Sibenadet)

 Wilt TJ, et al. Ann Intern Med 2007; 147: 639-653.
                Prevention:
Augmentation of Home Medication Regimen—
       OUTCOME: Exacerbations
 Outpatient Inhaled Therapies that Reduce Exacerbations vs.
               Placebo (statistically significant)
 YES!!
 • Tiotropium (p<0.001)                                RR = 0.84, NNT = 15
 • LABA (p<0.001)                                      RR = 0.76, NNT = 13
 • Corticosteroids (p=0.01)                            RR = 0.87, NNT = 22
 • Combined LABA and                                   RR = 0.83, NNT = 16
   corticosteroid (p=0.06)
 No!!
 • Ipratropium
  Wilt TJ, et al. Ann Intern Med 2007; 147: 639-653.
        Bottom Line: Hospitalist Prevention
          Efforts for COPD Exacerbation
•   Tobacco Cessation
    Counseling
•   Pneumonia Vaccine
    and Influenza Vaccine
•   VTE Prophylaxis during
    hospital stay
•   Augment Home
    Medication Regimen
        LABA + Corticosteroid
         inhalers
                   Case


• Mr. BH recovers from his exacerbation,
  but his resting O2 Sat is 89%.
• Repeat ABG at resolution of exacerbation
  reveals pO2 57.
• Q: Will Mr. BH benefit from and qualify for
  home oxygen therapy?
Question #6

 Home O2
         Who Benefits from and qualifies
          for Home Oxygen Therapy?

   •      Evidence for Benefit
         – Supplemental O2 for >15 hours/day to
           maintain pO2 > 60*
         – Reduced death** in patients with
                 •    Mean FEV1 < 30% &
                 •    PaO2 < 55

   •      Medicare Criteria

*Report of the Medical Research Council Working Party. Lancet 1981; 1: 681-686.
**Gorecka D, et al. Thorax 1997; 52: 674-679.
             Medicare Coverage Criteria:
               Home Oxygen Therapy
Group I Coverage                       Group II Coverage
•   PaO2 < 55 or SaO2 < 88%            •   PaO2 56-59mmHg or SaO2
                                           89% +
    – At Rest
    – During Sleep                     •   Any of the following*:
         •   OR ↓ PaO2 > 10mmHg or ↓       – Dependent Edema
             SaO2 5% associated with
             symptoms or signs of          – Pulmonary HTN or Cor
             hypoxemia*                      Pulmonale

    – During Activity                      – Erythrocythemia
                                                 •   Hct > 56%

                                       •   Requires re-testing between
                                           61 and 90 days
Final Summary
                              Final Summary
•   Pharmacologic Therapies                   •   Prevention (Inpatient)
     Bronchodilators                               Smoking Cessation Counseling—
                                                     YES!!
           Inhaled—YES!
          o   Oral/IV—No!                           Vaccines

     Steroids—YES!                                      Pneumovax—YES!
                                                         Influenza Vaccine—YES!
     Antibiotics—YES!!!
                                                    VTE Prophylaxis—YES!!
           Procalcitonin levels to decide?

•   Other Therapies                           •   Prevention (Home Regimen)

     Oxygen—YES!                                   Augmentation with combined
                                                     LABA/steroid inhaled—YES!!
     NPPV—ABSOLUTELY YES!!!                             Mortality Reduction!!
     Mucolytics—Maybe!                             Most others for exacerbation and
    o   Chest PT—NO!!                                symptom reduction
                                              •   Home O2: Medicare Criteria
  COPD Exacerbation:
Practical Evidence-based
       Strategies

Daniel D. Dressler, MD, MSc
          Director of Education
      Section of Hospital Medicine
    IM Associate Residency Director
     Assistant Professor of Medicine
   Emory University School of Medicine
      Daniel.Dressler@emory.edu

Society of Hospital Medicine Annual Meeting
            San Diego, California
                April 4, 2008

				
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