S.L. In Portugal, hospitalizations due to COPD between 2009 and 2016 decreased by 8%, but they still represented 8049 hospitalized patients in 2016. Symptoms, correct use of inhaled therapy and adequate management of comorbidities should be re-assessed. Executive summary: prevention of acute exacerbation of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline. In mild exacerbations there is a worsening of symptoms which can be managed at home, with an increase in dosage of regular medications.1,6,17 Moderate exacerbations do not respond to an increased dosage of bronchodilators and therefore require treatment with systemic corticosteroids and/or antibiotics.1,6,17,18 Severe exacerbations require hospitalization or evaluation in the ER1,6,17,18 and have a severe impact on physical activity. H. Qureshi, A. Sharafkhaneh, N.A. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Several factors that can lead to a worsening of symptoms have been identified, and in 70% to 80% of COPD exacerbation cases, the precipitant factor is a respiratory tract infection,4 either viral4,9,14,15 or bacterial,4,9,15 but in about a-third of severe exacerbations of COPD a cause cannot be identified.1. The journal publishes 6 issues per year, mainly about respiratory system diseases in adults and clinical research. NLM 848-854. He was experiencing dyspnea on exertion. Does eosinophilic COPD exacerbation have a better patient outcome than non-eosinophilic in the intensive care unit?. 39-49. Hanania. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. J. Ferreira, M. Drummond, N. Pires, G. Reis, C. Alves, C. Robalo-Cordeiro. NIH While there are studies that aid in evaluation, an acute COPD exacerbation is a clinical diagnosis that is characterized by symptoms which are more severe than the patient’s baseline. Discharge Instructions: COPD. COVID-19 is an emerging, rapidly evolving situation. With COPD, you are also more likely to get lung infections. Respiratory infectious phenotypes in acute exacerbation of COPD: an aid to length of stay and COPD Assessment Test. “Non-invasive mechanical ventilation should be the first mode of ventilation used in COPD … An exacerbation can cause more lung damage. Tsui, S.L. You can change the settings or obtain more information by clicking, http://dx.doi.org/10.1186/s12931-015-0313-4, Predictors of intubation in COVID-19 patients treated with out-of-ICU continuous positive airway pressure. AR declares having received speaking fees from AstraZeneca, Boehringer Ingelheim, Novartis, Bial, Medinfar, Mundipharma, Menarini, Grifols, Mylan, Tecnifar, Teva and cslbehring. These data suggest that the individualized care undertaken in this study can impact COPD morbidity and mortality after an acute exacerbation.40 All patients who have had a severe exacerbation should be re-assessed 4–6 weeks after discharge from hospital,1 given an anti-pneumococcal vaccination prescription, and a smoking cessation and respiratory rehabilitation plan should be prepared – Fig. F. Rivas-Ruiz, M. Redondo, N. Gonzalez, S. Vidal, S. Garcia, I. Lafuente. Chronic Obstructive Pulmonary Disease (COPD) is a serious pulmonary condition. Epub 2010 May 21. You may experience COPD symptomslike fatigue, wheezing, and exercise intolerance on a regular basis—or even every day. Thus the discharge plan for a COPD patient should cover all elements related to the respiratory illness itself, as well as any comorbid conditions, and address issues such as anxiety and depression. Sundh J, Österlund Efraimsson E, Janson C, Montgomery S, Ställberg B, Lisspers K. Prim Care Respir J. Efficacy of a self-management plan in exacerbations for patients with advanced COPD. Combination therapy with OCS and a bronchodilator has been shown to … Huang, K.C. Leung, A.P. The management of exacerbations in primary care should include maximization of bronchodilator therapy and systemic corticosteroids if not contraindicated (30mg prednisolone) for 7 days.1,7,8 Therapy with oral prednisolone is equally as effective as intravenous administration.1 The GOLD 2018 document recommends a dose of 40mg prednisone per day for 5 days1 whilst NICE 2016 recommends a dose of 30mg for 7–14 days, and further recommends that a course of corticosteroid treatment should not be longer than 14 days as there is no advantage in prolonged therapy.8 The use of systemic corticosteroids in COPD exacerbations have been shown to shorten recovery time, improve lung function, improve oxygenation, decrease the risk of early relapse and treatment failure, and decrease the length of hospitalization.1, A meta-analysis confirmed that the rate of treatment success increased with systemic corticosteroids in comparison to usual care of COPD exacerbations. -Spirometry and PFTs outpatient when the patient is stable, not recommended during an exacerbation. N. Roche, K.R. Ohar. Cordoba, E.L. Strandberg. G.J. Detailed A/P I have for COPD Exacerbation treatment that also has doses of medications, etc. Very severe <30% Quality of life significantly impaired; exacerbations may be life-threatening. 12-Day Steroid Taper. 785-797. Acute exacerbations of chronic obstructive pulmonary disease: identification of biologic clusters and their biomarkers. —-///—-Pearls. A new two-step algorithm for the treatment of COPD. Diekemper, D.R. Conclusions Comorbidities, previous exacerbations and hospitalisation, and increased length of stay were significant risk factors for 30- and 90-day all-cause readmission after an index hospitalisation with an exacerbation of COPD. C. Llor, L. Bjerrum, A. Munck, M.P. Pharmacological strategies to reduce exacerbation risk in COPD: a narrative review. Cohen, M.C. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease (2017 report). About a third of patients are readmitted within 90 days of discharge.2 Significant … The diagnosis of chronic obstructive pulmonary disease (COPD) is dependent upon spirometric testing. Patients who have had an episode of respiratory failure should have satisfactory oximetry or arterial blood gas results before discharge.  |  Ther Adv Chronic Dis, 5 (2014), pp. Exacerbations of COPD may be classified as mild, moderate, severe6 and very severe. There are several diagnostic tools that can be used to assess an exacerbation and its severity, which will in turn guide treatment, and prognostic scores should be used to predict the risk of future exacerbations. The definition of exacerbation in the 2016 GOLD update,12 “an acute event characterized by a worsening of the patient's respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication”, was simplified in the GOLD 2017 document13 to “an acute worsening of respiratory symptoms that results in additional therapy”. 662-671. Chang, K.C. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Three prognostic scores have been proposed based on biological and clinical characteristics of exacerbations: the BAP-65 score,9 the DeCOPD score9 and the score proposed by Roche et al.10,11. Read our disclaimer for details. Those who have had a successful treatment with simple aspiration or intercostal drain with underwater seal (ie, resolution of symptoms and/or a rim of air <2 cm). Predictive model of hospital admission for COPD exacerbation. Patient preference and satisfaction in hospital-at-home and usual hospital care for COPD exacerbations: results of a randomised controlled trial Int J Nurs Stud. While COPD is a mainly chronic disease, a substantial number of patients suffer from exacerbations. “cardinal symptoms”, or Anthonisen criteria, which include an increase in dyspnea, sputum purulence and/or sputum volume. A evolução da Doença Pulmonar Obstrutiva Crónica no internamento hospitalar entre 2005–2014. 48-55. Very severe exacerbations require admission to the ICU, with invasive ventilation, and are outside the scope of this paper. More than 3 million people died of COPD in 2012 accounting for 6% of all deaths globally. My COPD … COPD is most often caused by … The lack of confirmatory spirometric testing leads to diagnostic uncertainty in patients hospitalized for an acute exacerbation of COPD (AECOPD). 1. Objectives To determine the effectiveness of early assisted discharge for chronic obstructive pulmonary disease (COPD) exacerbations, with home care provided by generic community nurses, compared with usual hospital care. Chapman, C.F. C.H. Identification of the underlying cause of COPD exacerbations and assessment of their severity is fundamental to guiding treatment. Puhan. Donohue, J.A. When there is any doubt about the patient's capacity to manage his/her therapy, a formal activities of daily living assessment may be helpful. Management of COPD exacerbations in primary care: a clinical cohort study. Infectious exacerbations are characterized by increases in volume and purulence of the sputum associated with aggravated dyspnea and should be treated with antibiotics.1,8, The assessment of an exacerbation and its severity is based on the patient's medical history,1,6 e.g., airflow limitation, duration of worsening of symptoms and number of previous episodes (total/hospitalizations). Vogelmeier, F.J. Herth, C. Thach, R. Fogel. Discharge Criteria for Patients Hospitalized with Heart Failure Recommended for all adult patients with heart failure: Precipitating and exacerbating factors addressed Transition from intravenous to oral diuretic successfully Near optimal/ optimal volume status achieved Near optimal/ optimal pharmacologic therapy for heart failure Stable renal function and electrolytes … Copyright © 2018. N. Roche, M. Zureik, D. Soussan, F. Neukirch, D. Perrotin. Readmission for acute exacerbation within 30 days of discharge is associated with a subsequent progressive increase in mortality risk in COPD patients: a long-term observational study. If the patient remains hypoxemic, long-term supplemental oxygen therapy may be required.1 Also, patients should be given clear instructions about when and how to stop their corticosteroid treatment.1,8 Concerning the need for individualized care, a Canadian study in which the patients were offered a post discharge phone call, a home visit and continued care concluded that although there was no reduction in 30- and 90-day readmission rates, a decrease in 90-day total mortality was seen. Global Strategy for the Diagnosis, Management, Eighty-three patients with an acute exacerbation of COPD were studied; 45 percent were admitted to the hospital while 17 percent of the patients who were discharged suffered a relapse. Rehabilitative practice in Europe: Roles and competencies of physiotherapists. SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field. Analysis of chronic obstructive pulmonary disease exacerbations with the dual bronchodilator QVA149 compared with glycopyrronium and tiotropium (SPARK): a randomised, double-blind, parallel-group study. Daniels, M. Schoorl, D. Snijders, D.L. This includes, among other symptoms, worsening dyspnea, increased cough and sputum … Are we learning something new from COVID-19 pandemic? Preventing hospitalization for COPD exacerbations. The dosage of maintenance bronchodilators should be increased6,17 and the patient been given an oral corticosteroid6,17,18 for 5 days.1,38,39 If the exacerbation is infectious4,8,31 an antibiotic should be given.1,7. Fabbri, H. Magnussen, E.F. Wouters. J.S. Funding was used to access all necessary scientific bibliography and cover meeting expenses. C. Salturk, Z. Karakurt, N. Adiguzel, F. Kargin, R. Sari, M.E. COPD includes chronic bronchitis and emphysema. M. Miravitlles, A. D’Urzo, D. Singh, V. Koblizek. 2016 Aug 17;11:1939-47. doi: 10.2147/COPD.S104728. Moreover, the recent FLAME study,28 the first prospective study evaluating blood eosinophilia as a biomarker of therapeutic response, showed that indacaterol/glycopyrronium demonstrated a significant improvement in lung function compared with salmeterol/fluticasone for all the cutoffs analyzed.29 A recent post hoc analysis of the WISDOM study identified a subgroup of patients – patients with ≥2 exacerbations and ≥400cells/μL – that seem to be at increased risk of exacerbation when discontinued from ICS.30 In fact, and according to the most recent version of the GOLD document,1 symptomatic patients in the stable phase of COPD and a history of ≥2 moderate exacerbations, or 1 with hospital admission, in the past year, may benefit from an ICS on top of LABA/LAMA. 15002. The patient should not require albuterol more often than every four hours. USA.gov. 767-774. 61-71, © Copyright 2021. Impact of individualized care on readmissions after a hospitalization for acute exacerbation of COPD. You have been diagnosed with chronic obstructive pulmonary disease (COPD). Appropriate management of COPD exacerbations presents a clinical challenge and, in order to guide therapy, it is important to identify the underlying cause; however, this is not possible in about a third of severe COPD exacerbations. A proper discharge plan will decrease symptom burden, contribute to a faster recovery, increase the patient's quality of life, and prevent or delay future exacerbations. Miles, J.F. On discharge from a moderate exacerbation, bronchodilation should be optimized, anti-pneumococcal vaccination should be prescribed, and a smoking cessation and respiratory rehabilitation plan should be prepared. 2. Keywords: Referral to a Pulmonology Consultation if the patient is not already attending one is of the utmost importance. In this paper, we will focus on the pharmacological strategies for the management of COPD exacerbations, risk stratification and a hospital discharge plan proposal. Heterogeneity of chronic obstructive pulmonary disease exacerbations: a two-axes classification proposal. The authors propose that the patient should be prescribed an anti-pneumoccocal vaccine 10 to 20 days after discharge from the ER or Hospital. B. Planquette, J. Peron, E. Dubuisson, A. Roujansky, V. Laurent, A. For all patients, the choice of antibiotic should be guided by the local bacterial resistance pattern,1,8 the microbiology story of the patient and his/her risk factors. Sánchez-Nieto JM, Andújar-Espinosa R, Bernabeu-Mora R, Hu C, Gálvez-Martínez B, Carrillo-Alcaraz A, Álvarez-Miranda CF, Meca-Birlanga O, Abad-Corpa E. Int J Chron Obstruct Pulmon Dis. Curran, S. Parmar, K.G. This review summarises the current knowledge on the different aspects of COPD exacerbations. Int J Chron Obstruct Pulmon Dis, 11 (2016), pp. A COPD exacerbation means your symptoms suddenly get worse. Ther Adv Respir Dis, 7 (2013), pp. Spirometric testing is generally performed in the outpatient setting, because of concern over spurious results in hospitalized patients who are not at their baseline. Vollenweider, H. Jarrett, C.A. Prevention and treatment information (HHS). The GOLD 2018 document1 does not recommend that CRP be used routinely but state that several studies have suggested that procalcitonin-guided antibiotic treatment reduces antibiotic exposure and side effects with the same clinical efficacy. Am J Respir Crit Care Med, 184 (2011), pp. C-reactive protein level and microbial aetiology in patients hospitalised with acute exacerbation of COPD. F. Abroug, I. Ouanes, S. Abroug, F. Dachraoui, S.B. 2013 Nov;50(11):1537 … A clinical in-hospital prognostic score for acute exacerbations of COPD. Chief symptoms: Progressive shortness of breath, cough, and wheezing for 4 days History: A 67-year-old man with a history of chronic obstructive pulmonary disease (COPD), hypertension, and dyslipidemia was brought into the ED by his daughter with 4-day history of worsening shortness of breath, wheezing, and increased productive cough with change in color of sputum from clear tan to greenish. Usually initial empirical treatment encompasses aminopenicillin with clavulanic acid, a macrolide, or a tetracycline.1,8 However, the long-term use of macrolides may be associated with important side-effects and the risk of developing bacterial resistance.36 Sputum should be sent for culture (in the case of patients with frequent exacerbations, severe airflow limitation, and/or exacerbations requiring mechanical ventilation1), as gram-negative bacteria (e.g., Pseudomonas species) or resistant pathogens that are not sensitive to the above-mentioned antibiotics may be present.1. As with the lack of definition of an exacerbation, there is no consensual classification system to assess the exacerbation severity, although some have been proposed.16 Some of these scores will be discussed further. In terms of pharmacological treatment and place of treatment, if exacerbations are mild and non-infectious,1,4,7,8,31 they may be treated at home with an increase in the dosage of maintenance bronchodilators.6,17 If the exacerbation is infectious4,8,31 an antibiotic should be given.1,7, Moderate exacerbations should be treated in the ER and the patient then discharged as these exacerbations do not require hospitalization, unless the hospitalization occurs for socioeconomic reasons. P.M. Calverley, K. Tetzlaff, C. Vogelmeier, L.M. Criteria for discharge from hospital. There are several diagnostic tools to assess an exacerbation and its severity, which will help in decisions like whether patient can be managed at home or in a primary care setting or if he/she should be referred to an ER and eventually hospitalized.1,5–7 The severity of an exacerbation will inform its treatment,1,7,8 and prognostic scores should be used to predict the risk of a future exacerbation. In Portugal, hospitalizations due to COPD between 2009 and 2016 decreased by 8%, but they still represented 8049 hospitalized patients in 2016. CA declares having received speaking fees from AstraZeneca, Pfizer, Novartis and Mundipharma. Would you like email updates of new search results? Discharge and Mortality . After an exacerbation is appropriately managed, a suitable discharge plan should be prepared. This observation is corroborated by a Cochrane review demonstrating that procalcitonin can guide antibiotic therapy.32 In contrast, other authors reported that CRP might be a more valuable marker,34 and a real-life primary care study concluded that performing CRP rapid tests led general practitioners to prescribe fewer antibiotics than those who did not.35. 2019 Jun 25;6:79. doi: 10.3389/fcvm.2019.00079. 167-176. Globally, the COPD burden is projected to increase in coming decades because of continued exposure to COPD risk factors and aging of the population. In the case of a patient who has had a severe exacerbation, requiring hospitalization, the patient should be reclassified as a frequent exacerbator. Moderate 50-79% Patients typically seek medical attention at this stage due to respiratory symptoms or an exacerbation. Read more. Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide.
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