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Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Summary and Appraisal of Published Evidence

Peter B. Bach, MD, MAPP; Cynthia Brown, MD; Sarah E. Gelfand, BA; and Douglas C. McCrory, MD, MHSc
[+] Article and Author Information

From Memorial Sloan-Kettering Cancer Center, New York, New York; and the Center for Clinical Health Policy Research, Duke Evidence-Based Practice Center, and Duke University Medical Center, Durham, North Carolina.


This paper will also appear in Chest (2001; volume 119).

Annals of Internal Medicine encourages readers to copy and distribute this paper, providing such distribution is not for profit. Commercial distribution is not permitted without the express permission of the publisher.

Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services.

Grant Support: By the American College of Physicians–American Society of Internal Medicine, American College of Chest Physicians, and the Agency for Healthcare Research and Quality (contract no. 290-97-0014).

Acknowledgments: This article is based on research conducted by investigators at Memorial Sloan-Kettering Cancer Center, New York, New York, under contract with the American College of Physicians–American Society of Internal Medicine (ACP–ASIM) and the American College of Chest Physicians (ACCP), and by investigators at Duke University, Durham, North Carolina, under contract with the Agency for Healthcare Research and Quality (contract no. 290-97-0014). The authors thank the combined ACP–ASIM/ACCP Expert Panel; the Evidence-Based Center peer review and technical advisory panels; Ruth E. Goslin, MAT; and Rebecca N. Gray, DPhil.

Requests for Single Reprints: Peter B. Bach, MD, MAPP, Health Outcomes Research Group, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, Box 221, New York, NY 10021.

Current Author Addresses: Dr. Bach and Ms. Gelfand: Health Outcomes Research Group, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, Box 221, New York, NY 10021.

Dr. Brown: 350 Bell Building, Box 3221, Duke University Medical Center, Durham, NC 27710.

Dr. McCrory: 2200 West Main Street, Suite 230, Duke University Medical Center, Durham, NC 27705.


Ann Intern Med. 2001;134(7):600-620. doi:10.7326/0003-4819-134-7-200104030-00016
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Purpose: To review critically the available data on diagnostic evaluation, risk stratification, and therapeutic management of patients with acute exacerbations of chronic obstructive pulmonary disease (COPD).

Data Sources: English-language articles were identified by searching MEDLINE (1966 to 2000, week 5), EMBASE (1974 to 2000, week 18), HealthStar (1975 to June 2000), and the Cochrane Controlled Trials Register (2000, Issue 1).

Study Selection: The best available evidence on each subtopic was selected for analysis. Randomized trials, sometimes buttressed by cohort studies, were used to evaluate therapeutic interventions. Cohort studies were used to evaluate diagnostic tests and risk stratification.

Data Extraction: Study design and results were summarized in evidence tables. Individual studies were rated by internal validity, external validity, and quality of design. Statistical analyses of combined data were not performed.

Data Synthesis: Data on the utility of most diagnostic tests are limited. However, chest radiography and arterial blood gas sampling seem useful while acute spirometry does not. Identifiable clinical variables are associated with risk for relapse and risk for death after hospitalization for an acute exacerbation. Evidence of efficacy was found for bronchodilators, corticosteroids, and noninvasive positive-pressure ventilation. There is also support for the use of antibiotics in patients with more severe exacerbations. On the basis of limited data, mucolytics and chest physiotherapy do not seem to be of benefit, and oxygen supplementation seems to increase the risk for respiratory failure only in an identifiable subgroup of patients.

Conclusions: Although suggestions for appropriate management can be made on the basis of available evidence, the supporting literature is scarce and further high-quality research is necessary. Such research will require an improved, generally acceptable, and transportable definition of acute exacerbation of COPD, as well as improved methods for observing and measuring outcomes.

Figures

Grahic Jump Location
Figure.
Relationship among arterial pH, PaO 2 , and risk for respiratory failure.O22O2O2squarescircles(98)

The discriminant function pH = 7.66 − 0.00919 × (Pa ) helps identify patients at risk for CO retention after the administration of supplemental oxygen. When the patient's observed Pa is entered into the equation, the pH calculated can be compared with the measured pH to distinguish between high- and low-risk patients. If a patient is at high risk, the value calculated will be greater than that observed in the arterial blood gas. The symbols in the figure represent Pa and pH values on admission of patients who were eventually intubated ( ) or not intubated ( ) in a study evaluating this predictive model. The diagonal line reflects values of the discriminant function and separates high- and low-risk patients. Adapted with permission from Bone et al. .

Grahic Jump Location

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