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.