ICEM 2014

ICEM 2014

Tintinalli Headlines & Holliman Assumes Presidency

On June 11, EPM Editor-in- Chief and renowned educator Judith Tintinalli took to the stage in Hong Kong to address…

The Medical Malpractice Rundown: A State-by-State Report Card

The Medical Malpractice Rundown: A State-by-State Report Card

When it comes to medical liability laws and culture, where you live matters.

Find out how your state stacks up against the other 49.

CT – Lowering Cost and Radiation

CT – Lowering Cost and Radiation

Medicare pays only about 20% of typical charges and radiation can be reduced by 90%.

The cost of a CT is actually quite nominal – the charge, however, is an entirely different matter. 

 Aftermath: The Night Shift Season 1 Finale Review

Aftermath: The Night Shift Season 1 Finale Review

At Loose Ends

It’s strange calling this a season finale, because it’s only been an 8-episode summer run, and nearly every episode has…

Doximity’s Next Trick: Connectivity at the Point of Care

Doximity’s Next Trick: Connectivity at the Point of Care

You’ve raised $81 million in investments and your physician membership now exceeds that of the AMA. What’s next?

If you're Doximity, it's time to dream big. 

Subcutaneous Insulin in DKA: Safe — But Not Better

Subcutaneous Insulin in DKA: Safe — But Not Better

Newer Isn't Always Better

Studies show that the benefits of subcutaneous insulin over old fashioned IV insulin are marginal at best.

A Return to (Lousy) Form: Episode 7 of The Night Shift

A Return to (Lousy) Form: Episode 7 of The Night Shift

Forks! Strippers! Guns!

Once again, our characters are responding to the (frankly unbelievable) events unfolding around them, rather than driving the action.

Oxygen is a Drug— Act Accordingly

Oxygen is a Drug— Act Accordingly

Understanding the dangers of indiscriminate oxygenation in the ED setting

As with many things in medicine, dogma seems to overpower the evidence in this arena. 

Oh Henry: A Sucker is Born Every Minute

Oh Henry: A Sucker is Born Every Minute

Pharmaceutical Ads, Government, and the Physician-Patient Relationship

Though it pains me to say it, this is one time where caveat emptor doesn’t apply. 


A Ray of Hope

A Ray of Hope

The Night Shift, episode 6

This was the first episode where it felt like the characters were driving the plot.

The Downside of the Upswing

The Downside of the Upswing

You should have cashed in big-time. 
But did you?

The last several years of returns have been among the best ever.

5 Things Your Patients Might Think After Watching ‘Code Black’

5 Things Your Patients Might Think After Watching ‘Code Black’

An inside view of the ED

Code Black provides a harrowing and enlightening window into the front lines of healthcare. 

Talking Points

Talking Points

Link your vision to action

As an ED leader, you must not only have a vision and plan, but you must communicate that vision effectively…

Toxic Liquid Nicotine

Toxic Liquid Nicotine

New FDA regulations proposed for E-cigs

Highly unregulated, the sale of toxic nicotine concoctions for e-cigarette refills pose a serious threat to children.

All Choked Up

All Choked Up

Best Practices for Battery Ingestion

A two-year-old presents at a clinic with persistent cough and neck discomfort and winds up in the ED.

Gag Order

Gag Order

New ruling prohibits would-be ACEP leaders from answering questions from non-ACEP publications.

Greg Henry seldom fails to deliver on a promise. But this time, it looks like it’s out of his control.

Lock the Gates!

Lock the Gates!

Board certification is vital in EM

Last month, Rick Bukata suggested that ACEP open its gates to non-boarded EPs. 
This would be an insult to EM…

AMA Meeting Highlights

AMA Meeting Highlights

Association Gives Nod to First EP President-elect

This June’s AMA Annual Meeting proved as eventful as ever, with one exciting twist that has the potential to impact…

The Storm Episode!

The Storm Episode!

Episode 5 of NBC's "The Night Shift"

It’s time for the passion that’s been building up between the two lead ED doctors for … the past few…

Frontpage Slideshow | Copyright © 2006-2014 JoomlaWorks Ltd.
Home
Print
E-mail
Reprint
Educational Objectives:
After evaluating this article participants will be able to:
-Discuss the current, evidence-based treatment recommendations for patients with acute exacerbations of COPD (AECOPD)
-Incorporate corticosteroids into clinical practice, based on evidence-based standards
-Rationally prescribe antibiotics, based on their benefits and limitations
-Employ non-invasive positive pressure ventilation in appropriate cases

 
The Setup:
You are working in a busy ED when a 58-year-old male presents with worsening dyspnea over a few days, with increasing cough and purulent sputum production. He is well known to your ED as a lifelong smoker with moderate to severe COPD with increasing exacerbations. Your clinical assessment reveals a patient with moderate respiratory distress, audible wheezing and oxygen saturation of 90% (room air), but who is otherwise speaking normally and mentating well with normal vital signs. You initiate short-acting bronchodilators (beta-agonists, anticholinergics), while pondering your other treatment options…

Your Choices:
You have determined that your patient is having a AECOPD. Based on his past history of stable, moderate COPD and recent worsening symptoms, he will need to be admitted. In addition to bronchodilator therapy, you consider the following questions:
(1) Does this patient need steroids? If so, in what form and by what route?
(2) Does this patient need antibiotics (Abx)? If so, which one(s)?
(3) Can this patient use non-invasive positive pressure ventilation (NIPPV), or should we just intubate him if he deteriorates?

The Evidence:
Quon, BS, Gan, WQ, Sin, DD. Chest 2008; 133: 756-766. Contemporary Management of Acute Exacerbations of COPD: A Systematic Review and Metaanalysis.


Study Design: This article was a systematic review and meta-analysis of all relevant randomized trials aimed at treatment interventions for AECOPD. The authors examined all trials relevant to the use of steroids, antibiotics and NIPPV for AECOPD.

Population: Adult patients (age 50+ years in reported studies), with AECOPD. Patients met the Global Initiative for Chronic Obstructive Lung Disease (GOLD) definition of COPD: a change in baseline dyspnea, cough, and/or sputum beyond day-to-day variation that might mandate medication change. Mixed patient settings.

Interventions: Systemic corticosteroids (IV, PO dosing; 6 studies methylprednisolone, 2 each prednisone or hydrocortisone), antibiotics (in and out patient settings; beta-lactams 43%, tetracyclines 29%), NIPPV

Comparator: Standard therapy (placebo for corticosteroid (CS) trials and Abx trials; doxapram for NIPPV trials)

Outcomes: Risk of treatment failures, hospital length-of-stay (LOS), intubation rates, in-hospital mortality. Treatment failure defined as either clinical deterioration, study withdrawal due to unsatisfactory clinical improvement, or relapse of exacerbation symptoms during follow-up period.

Appraisal of Evidence: This meta-analysis was comprehensive in its search strategy and rating of quality of evidence. There was no significant heterogeneity amongst the trials examining steroids and NIPPV in treating AECOPD, but there was among the antibiotics trials (based on difference between inpatient vs. outpatient treatment settings). Heterogeneity is defined as study-to-study variability beyond that expected by chance alone suggesting that the design may be measuring different populations, interventions, or outcomes and ought not be combined into a meta-analysis.
 
The Results: The results of the meta-analysis are summarized in the table.

click on chart to view pdf
alt

Subgroups
•Trend to increased benefit of NIPPV to avoid intubation with lower initial pH values.
•No significant benefits for Abx on short-term lung FEV measures, blood gases or hospital LOS.
•No significant differences noted between Abx classes studied.

How do I apply this information to my patients?

1) Systemic corticosteroids reduce treatment failures by 46% in combined in- and out-patient AECOPD exacerbations, and there is no difference in efficacy between parenteral or orally administered corticosteroids.

2) Antibiotics reduced treatment failure by 46% and improved survival in hospitalized patients. There were no benefits noted in outpatients (2 studies). These results must be interpreted with caution in light of significant heterogeneity amongst compared Abx trials. Only 3 studies examining Abx benefits on AECOPD outcomes have been conducted since 1987, likely reflecting the accepted practice of using Abx for AECOPD.

3) Antibiotics and NIPPV were both found to reduce in-hospital mortality, with moret robust trials in the NIPPV groups. It is hypothesized that the Abx benefits were most realized in those patients with nosocomial infections and intubated patients at risk of venilator-associated pneumonia.

4) NIPPV significantly reduced intubation and hospital LOS, as well as in-hospital mortality. Greater benefits to reduce intubation were noted with lower initial pH measures (reflecting more severe respiratory acidosis). This finding is in keeping with GOLD recommendations to apply NIPPV to AECOPD patients with pH <7.35.
While there may be other indications for the use of NIPPV for AECOPD, they extend beyond the conclusions supported by this article.

Case Resolution:
Based on your assessment of this patient having a severe AECOPD presentation needing admission, you decide to treat this patient with systemic steroids, antibiotics (based on local practices), and NIPPV. The patient steadily improves in the ED, and is transferred to an inpatient ward…

Commentary:
In a disease with increasing incidence and high burden of hospitalization (avg. cost $660/day), admission to ICU (25%) and in-hospital mortality (10%), it is important to identify those interventions that will reduce important patient and system outcomes (treatment failure, hospital LOS, intubation rates, mortality). This study identifies interventions that will reduce a number of these negative outcomes in hospitalized patients.

Although systemic steroids and antibiotics seem to still be the standard of care, it is not as clear from this study which patients can benefit from various interventions in the ambulatory setting,

Suneel Upadhye, MD, MSc, is an Assistant Clinical Professor/Undergraduate Coordinator, Division of Emergency Medicine, McMaster University



     

    Popular Authors

    • Greg Henry
    • Rick Bukata
    • Mark Plaster
    • Kevin Klauer
    • Jesse Pines
    • David Newman
    • Rich Levitan
    • Ghazala Sharieff
    • Nicholas Genes
    • Jeannette Wolfe
    • William Sullivan
    • Michael Silverman

    Earn CME Credit