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