Acute exacerbation of chronic obstructive pulmonary disease

注意

The Cochrane Clinical Answer (CCA) noted that the number of participants included in the meta-analyses for the primary outcomes of treatment failure and relapse may be too small (450 and 478 participants) to detect differences between treatment groups.

The Cochrane review which underpins the CCA noted that one large study carried most of the weight in the meta-analysis, and was therefore responsible for the confidence in the conclusion that shorter courses of oral corticosteroids (for five days) can be used as treatment for COPD exacerbation as they seem to be equally effective as longer courses.

The Cochrane review which underpins this CCA noted that the reviewed studies did not include people with mild or moderate COPD and future studies are required in this patient group.

The Cochrane review also reported two outcomes not included in the CCA (mortality: no statistically significant difference between treatment groups, moderate GRADE rating; lung function (end of treatment; FEV1; 10–14 days]: no statistically significant difference between treatment groups, very low GRADE rating).

ᵃ Other adverse effects included gastrointestinal tract bleeding, symptomatic gastrointestinal reflux, symptoms of congestive heart failure or ischemic heart disease, sleep disturbance, fractures, and depression.

Эта таблица с доказательными данными относится к следующему разделу (разделам):

• Алгоритм лечения
• Рекомендации по ведению пациентов

Примечание

This systematic review reported that in the study population as a whole, vitamin D did not influence the rate of moderate or severe COPD exacerbations when compared with placebo.

However, subgroup analyses showed that vitamin D supplementation decreased moderate or severe COPD exacerbations in patients with baseline 25-hydroxyvitamin D levels <25 nmol/l but not in those with baseline levels ≥25 nmol/.

Эта таблица с доказательными данными относится к следующему разделу (разделам):

• Вторичная профилактика

Nota

This systematic review reported that procalcitonin-guided protocols have limited value in determining the use of antibiotics in acute exacerbations of COPD, and that procalcitonin should not be used in the intensive care unit (ICU) setting to guide antibacterial prescribing in these patients.

The systematic review also reported results from observational studies, in which effectiveness was the same as the RCTs and GRADE was reported as very low, except for length of hospital stay, for which GRADE was reported as low.

ᵃ Results showed that procalcitonin-guided protocols reduced the overall duration of antibiotic treatment by two days. However, a sensitivity analysis excluding studies with ≥1 high risk-of-bias item (except blinding for outcome assessment), or those with converted outcome value, found no significant difference between treatment groups.

ᵇ Subgroup analysis of patients in an ICU setting found a significantly longer length of hospital stay in the procalcitonin group compared with the standard therapy group (MD = 4.03 days [95% CI 0.74 to 7.32 days], p = 0.02).

ᶜ The reviewers reported that for the two studies conducted in an ICU setting, the mortality rates in the procalcitonin group were higher than the standard therapy group, although this difference was not statistically significant.

Esta tabla de evidencias está relacionada con la/s sección/es siguiente/s:

• Recomendaciones de diagnóstico
• Pruebas diagnósticas

Las recomendaciones que figuran en la directriz fuente

The AAFP recommends that clinicians prescribe systemic antibiotics for adults with acute exacerbation of COPD to improve clinical cure and reduce clinical failure (weak recommendation; moderate quality of evidence). Choice of antibiotic should be based on local resistance patterns, affordability, and patient history and preferences because there is insufficient evidence to support a preferential recommendation.

Nota

The guideline group noted that there were no statistically significant differences in other outcomes of interest, including mortality and quality of life. Outcomes of interest were defined as patient-oriented clinical outcomes. However, it is unclear which other outcomes of interest were reported in the included studies.

The guideline group also noted that, although they found studies of one antibiotic versus another and different dosages of antibiotics, there was “insufficient evidence to estimate an effect on most of the outcomes of interest”. No studies were identified for routes of administration of antibiotics in this population.

ᵃ Clinical cure was defined as the complete improvement of clinical signs and symptoms following treatment. Three RCTs (633 participants) were included in the clinical cure analysis. One study randomized 223 patients to doxycycline or placebo for seven days in addition to corticosteroids. A second study randomized 100 patients to receive a fluoroquinolone or amoxicillin compared with placebo for 10 days. The third study randomized 310 patients to receive amoxicillin or placebo.

ᵇ Clinical failure, the main outcome of interest, was defined as “the lack of a significant improvement of clinical signs and symptoms and/or the requirement for additional or alternate treatment for an acute exacerbation event”.

Esta tabla de evidencias está relacionada con la/s sección/es siguiente/s:

• Algoritmo de tratamiento
• Recomendaciones de manejo

Nota

ᵃ 30% of people in the NIV plus usual care group had complications specifically related to NIV (not experienced in the usual care alone groups). See Cochrane Clinical Answer (CCA) for more details.

Esta tabela de evidências está relacionada às seguintes seções:

• Algoritmo de tratamento
• Recomendações de tratamento

Примечание

ᵃ Accompanied by a single short educational component along with ongoing support directed at use of the action plan, but without a comprehensive self‐management program.

Эта таблица с доказательными данными относится к следующему разделу (разделам):

• Вторичная профилактика

Рекомендации, изложенные в исходном руководстве

The AAFP recommends that clinicians prescribe corticosteroids for adults with acute exacerbation of COPD to reduce clinical failure (weak recommendation; low quality of evidence). There is insufficient evidence to guide the dose, route of administration, or duration of treatment.

Примечание

The guideline group noted that there were no statistically significant differences in other outcomes of interest, including mortality and rehospitalization. It is unclear which other outcomes of interest were reported in the included studies.

The evidence to inform the route of administration (oral; inhaled; intravenous) of corticosteroids in adults with acute exacerbation of COPD was insufficient. No significant difference in outcomes was observed in three studies which evaluated different durations of systemic corticosteroids (3 days vs. 10 days; 5 days vs. 14 days; and 2 weeks vs. 8 weeks) in the inpatient setting. The guideline group also noted that a large observational study published subsequent to the guideline search also found that shorter courses of corticosteroid were noninferior to longer courses, and longer courses were associated with a small increase in pneumonia-associated hospitalization and mortality.

ᵃ Clinical failure, the main outcome of interest, was defined as “the lack of a significant improvement of clinical signs and symptoms and/or the requirement for additional or alternate treatment for an acute exacerbation event”.

Эта таблица с доказательными данными относится к следующему разделу (разделам):

• Алгоритм лечения
• Рекомендации по ведению пациентов

Примечание

The Cochrane review which the CCA is based upon also noted continued uncertainty around the treatment effectiveness of antibiotics for treatment failure, mortality, re-exacerbations, or health-related quality of life in those people with acute exacerbation of COPD, since results are heterogenous and associated with some risk of bias.

It also stated that factors such as patient preferences, resistance of bacteria to antibiotics, and cost are important when making recommendations or treatment decisions. There is also a need for research into clinical signs and biomarkers which can help identify patients who would benefit the most from antibiotic treatment.

ᵃ Included studies ranging from 5 to 14 days duration of antibiotic/placebo treatment.

ᵇ The CCA noted that when reviewers focused on currently prescribed drugs in their analysis, there was no statistical significance between treatment groups for inpatients with severe exacerbations who were not admitted to ICU.

ᶜ Evidence for ICU patients was limited to one trial of 93 patients.

Эта таблица с доказательными данными относится к следующему разделу (разделам):

• Рекомендации по ведению пациентов

Note

The Cochrane Clinical Answer (CCA) noted that patient characteristics varied across reviewed studies in terms of lung function and reasons for trial exclusion, affecting the generalizability of results. It also noted that the co-interventions given to participants varied across studies.

The Cochrane review which underpins this CCA noted that while the review showed that treatment with a hospital-at-home scheme is safe, acceptable, and as effective as inpatient care, the majority of patients will still continue to require hospital care for their exacerbation. They also highlighted that more studies are required to evaluate the cost-effectiveness of hospital-at-home schemes.

ᵃ The CCA noted that trials reported variable respiratory exclusion criteria (e.g., respiratory failure, pneumonia, pneumothorax, lung cancer, chest X‐ray changes, pulmonary embolism, hypoxia) and also that patients with acute/unstable co‐morbidities, reduced level of consciousness, and/or confusion were excluded by some trials.

ᵇ Results reported narratively. Three RCTs (332 participants) reported quality of life using the St George’s Respiratory Questionnaire. Results could not be combined since one study reported percentage improvement while the other two reported standard deviations. The latter showed no statistically significant difference between treatment groups.

This evidence table is related to the following section/s:

• Treatment algorithm