Evidence base for management of acute exacerbations of chronic obstructive
pulmonary disease.
SOURCE(S):
Ann Intern Med 2001 Apr 3;134(7):595-9 [3 references]
Chest 2001 Apr;119(4):1185-9
MAJOR RECOMMENDATIONS:
Recommendation 1. An admission chest radiography may be useful since it has
been shown that up to 23% of patients admitted had changes in management
related to findings on chest radiography. Chest radiography in patients
visiting the emergency department may also useful. To date, there is no
evidence for or against the utility of chest radiography in the office
setting.
Recommendation 2. For patients hospitalized with an acute exacerbation of
chronic obstructive pulmonary disease, acute spirometry should not be used
to diagnose an exacerbation or to assess its severity.
Recommendation 3. Inhaled anticholinergic bronchodilators or inhaled
short-acting beta2-agonists are beneficial in the treatment of patients
presenting to the hospital with acute exacerbation of chronic obstructive
pulmonary disease. Since the inhaled anticholinergic bronchodilators have
fewer and more benign side effects, consider these agents first. Only after
the initial bronchodilator is at maximum dose is the addition of a second
inhaled bronchodilator beneficial.
Recommendation 4. In the treatment of patients presenting to the hospital
with moderate or severe acute exacerbation of chronic obstructive pulmonary
disease, the following therapeutic options are beneficial: (a) systemic
corticosteroids given for up to 2 weeks in patients who are not receiving
long-term therapy with oral steroids, (b) noninvasive positive-pressure
ventilation administered under the supervision of a trained physician, and
(c) oxygen, with caution, in hypoxemic patients.
Recommendation 5. In patients with severe exacerbations of chronic
obstructive pulmonary disease, initial narrow-spectrum antibiotics are
reasonable first-line agents. The superiority of newer, more broad-spectrum
antibiotics has not been established.
Randomized, placebo-controlled trials favored amoxicillin,
trimethoprim-sulfamethoxazole, and tetracycline. Most of these studies were
done before the emergence of multidrug-resistant organisms, particularly
Streptococcus pneumoniae. To date, however, no randomized,
placebo-controlled trials have proved the superiority of newer
broad-spectrum antibiotics in acute exacerbations of chronic obstructive
pulmonary disease. The trials also did not include nursing home residents or
recently hospitalized patients.
Recommendation 6. In the treatment of patients with acute exacerbation of
chronic obstructive pulmonary disease, the following therapeutic options are
not beneficial: mucolytic medications, chest physiotherapy, and
methylxanthine bronchodilators. The latter two options may be harmful.
Recommendation 7. Currently, there are no reliable methods of risk
stratification for relapse or inpatient mortality.
DEVELOPER(S):
American College of Physicians-American Society of Internal Medicine -
Medical Specialty Society
American College of Chest Physicians - Medical Specialty Society
COMMITTEE:
Joint Expert Panel on Chronic Obstructive Pulmonary Disease of the American
College of Chest Physicians (ACCP) and the American College of
Physicians-American Society of Internal Medicine (ACP-ASIM)
GROUP COMPOSITION:
Authors: Vincenza Snow, MD, Steven Lascher, DVM, MPH, and Christel
Mottur-Pilson, PhD
Joint Expert Panel on Chronic Obstructive Pulmonary Disease of the American
College of Chest Physicians (ACCP) and the American College of
Physicians-American Society of Internal Medicine (ACP-ASIM): Peter Almenoff,
MD; Paul G. Auwaerter, MD; Sidney Braman, MD; Bart Celli, MD; Alan Fein, MD
(Co-Chair); Stan Fiel, MD; David Hudgel, MD; Stephanie Levine, MD; Michael
Mandel, MD; Sean Tunis, MD, MSc (Co-Chair); Peter Bach, MD; and Steven
Lascher, DVM, MPH.
ACP-ASIM Clinical Efficacy Assessment Subcommittee: David Dale, MD (Chair);
Patricia Barry, MD, MPH; William Golden, MD; Robert McCartney, MD; Keith
Michl, MD; Stephen Pauker, MD; Allan Ronald, MD; Sean Tunis, MD, MSC; Kevin
Weiss, MD; Preston Winters, MD; and John Whyte, MD, MPH.
ACCP Health and Science Policy Committee: Gene Colice, MD (Chair); Russel
Acevedo, MD; Robert Baughman, MD; Michael Bauman, MD; Joann Blessing-Moore,
MD; Richard Dart, MD; James Fink, MD; Susan Harding, MD; Alan Lisbon, MD;
George Mallory, MD; Peter McKeown, MD; Edward Oppenheimer, MD; David
Schroeder, MD; Gerard Silvestri, MD; and Dorsett Smith, MD.
ENDORSER(S):
American College of Physicians-American Society of Internal Medicine Board
of Regents - Medical Specialty Society
American College of Chest Physicians Board of Directors - Medical Specialty
Society
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the American College of
Physicians-American Society of Internal Medicine (ACP-ASIM) Web site
<http://www.annals.org/issues/v134n7/full/200104030-00015.html> .
Print copies: Available from the American College of Physicians-American
Society of Internal Medicine (ACP-ASIM), 190 N. Independence Mall West,
Philadelphia, PA 19106-1572.
COMPANION DOCUMENTS:
The statements made by the American College of Physicians-American Society
of Internal Medicine (ACP-ASIM) and the American College of Chest Physicians
in the guideline document are developed using the information provided in
the following background papers:
*         *Bach PB, Brown C, Gelfand SE, McCrory DC. Management of acute
exacerbations of chronic obstructive pulmonary disease: a summary and
appraisal of published evidence*. Ann Intern Med 2001 Apr 3;134(7):600-20
[129 references]. Electronic copies available from the ACP-ASIM Web site
<http://www.annals.org/issues/v134n7/full/200104030-00016.html> .
*         Management of acute exacerbations of chronic obstructive pulmonary
disease. Rockville, MD: Agency for Healthcare Research and Quality.
(Evidence Report/Technology Assessment; no. 19). Electronic copies and
further information regarding the availability of print copies is available
from the Agency for Healthcare Research and Quality (AHRQ) Web site
<http://www.ahrq.gov/clinic/copdsum.htm> .
Information contained in these background papers is represented in the
methodology fields of the NGC Summary (i.e., Methods to Collect Evidence;
Methods to Analyze the Evidence; Cost Analysis).
* Also available as:
*         McCrory DC, Brown C, Gelfand SE, Bach PB. Management of acute
exacerbations of COPD: a summary and appraisal of published evidence. Chest
2001 Apr;119(4):1190-209. Electronic copies available to registered users
only from the American College of Chest Physicians (ACCP) at the Chest
journal Web site <http://www.chestjournal.org/cgi/content/full/119/4/1190> .


Edward E. Rylander, M.D.
Diplomat American Board of Family Practice.
Diplomat American Board of Palliative Medicine.