What Other Teaching Needs Would You Review With Db While He Is Hospitalized?
Management of COPD Exacerbations
Am Fam Physician. 2010 Mar 1;81(5):607-613.
Patient information: See related handout on COPD exacerbations, written by the author of this commodity.
Commodity Sections
- Abstract
- Definition and Classification
- Etiology
- Initial Evaluation
- Indications for Hospitalization
- Oxygenation and Ventilation
- Therapeutic Options
- Preparation for Hospital Belch
- Preventing Future Exacerbations
- References
Exacerbations of chronic obstructive pulmonary disease contribute to the high mortality rate associated with the disease. Randomized controlled trials take demonstrated the effectiveness of multiple interventions. The offset step in outpatient management should be to increase the dosage of inhaled short-acting bronchodilators. Combining ipratropium and albuterol is benign in relieving dyspnea. Oral corticosteroids are likely benign, especially for patients with purulent sputum. The employ of antibiotics reduces the risk of handling failure and mortality in moderately or severely ill patients. Physicians should consider antibiotics for patients with purulent sputum and for patients who have inadequate symptom relief with bronchodilators and corticosteroids. The choice of antibiotic should be guided by local resistance patterns and the patient's recent history of antibiotic use. Hospitalized patients with exacerbations should receive regular doses of curt-acting bronchodilators, continuous supplemental oxygen, antibiotics, and systemic corticosteroids. Noninvasive positive force per unit area ventilation or invasive mechanical ventilation is indicated in patients with worsening acidosis or hypoxemia.
In patients with known chronic obstructive pulmonary disease (COPD), exacerbations occur an average of 1.iii times per year.1 Exacerbations range in severity from transient declines in functional status to fatal events. In the United states, exacerbations accept contributed to a 102 percent increase in COPD-related mortality from 1970 to 2002 (21.4 to 43.three deaths per 100,000 persons).2 Effective management of a COPD exacerbation combines relieving acute symptoms and lowering the risk of subsequent exacerbations.
SORT: KEY RECOMMENDATIONS FOR Practice
| Clinical recommendation | Evidence rating | References | Comments |
|---|---|---|---|
| Noninvasive positive pressure ventilation improves respiratory acidosis and decreases respiratory rate, breathlessness, need for intubation, mortality, and length of hospital stay. | A | 6, nine, 15, xviii | — |
| Inhaled bronchodilators (beta agonists, with or without anticholinergics) relieve dyspnea and improve practise tolerance in patients with COPD. | A | 6, nine | — |
| Short courses of systemic corticosteroids in patients with COPD increase the time to subsequent exacerbation, decrease the rate of treatment failure, shorten hospital stays, and improve FEV1 and hypoxemia. | A | 1, 6, vii, 9, 17–20 | — |
| Low-dosage corticosteroid regimens are not inferior to high-dosage regimens in decreasing the chance of treatment failure in patients with COPD. | B | 17, 19 | — |
| Oral prednisolone is equivalent to intravenous prednisolone in decreasing the risk of handling failure in patients with COPD. | B | 22 | Because they are bioavailable, inexpensive, and convenient, oral corticosteroids are recommended in patients who can safely consume and absorb them. |
| Antibiotics should be used in patients with moderate or astringent COPD exacerbations, particularly if there is increased sputum purulence or the need for hospitalization. | B | 6, 9, 18, 24 | — |
| The option of antibody in patients with COPD should be guided by symptoms (east.grand., presence of purulent sputum), recent antibiotic use, and local microbial resistance patterns. | C | xviii, 23, 25 | At that place is limited evidence that wide-spectrum antibiotics are more constructive than narrow-spectrum antibiotics. |
| Smoking abeyance reduces mortality and future exacerbations in patients with COPD. | A | 6, 7, 30 | — |
| Long-term oxygen therapy decreases the hazard of hospitalization and shortens hospital stays in severely ill patients with COPD. | B | vii, 32 | — |
Definition and Classification
- Abstract
- Definition and Classification
- Etiology
- Initial Evaluation
- Indications for Hospitalization
- Oxygenation and Ventilation
- Therapeutic Options
- Preparation for Hospital Discharge
- Preventing Future Exacerbations
- References
Criteria for the diagnosis of COPD have been established.three Still, at that place is no validated diagnostic test or biomarker of COPD exacerbations.four The American Thoracic Society (ATS) and European Respiratory Social club (ERS) ascertain an exacerbation as an acute change in a patient'south baseline dyspnea, cough, or sputum that is beyond normal variability, and that is sufficient to warrant a change in therapy.5 The ATS and ERS classify COPD exacerbations as mild, moderate, or severe, based on the intensity of the medical intervention required to control the patient's symptoms (Table 1).iv,v In improver to the hallmark symptoms of a COPD exacerbation (cough, dyspnea, and increased sputum), systemic inflammation also causes extrapulmonary symptoms (Table 2).6–8 Factors that increase the risk of a astringent exacerbation are listed in Table three.5–7,ix–11
Table 1.
Classification of COPD Exacerbations by Severity
| Severity of exacerbation | Description |
|---|---|
| Mild | Can be controlled with an increment in dosage of regular medications |
| Moderate | Requires treatment with systemic corticosteroids or antibiotics |
| Severe | Requires hospitalization or evaluation in the emergency section |
Table 2.
Symptoms of COPD Exacerbation
| Body system | Symptoms |
|---|---|
| Cardiac | Chest tightness |
| Tachycardia | |
| Musculoskeletal | Decreased exercise tolerance |
| Psychiatric | Defoliation |
| Depression | |
| Insomnia | |
| Sleepiness | |
| Pulmonary | Modify in volume, color, or tenacity of sputum |
| Cough | |
| Dyspnea | |
| Tachypnea | |
| Wheezing | |
| Systemic | Fatigue |
| Fever | |
| Angst |
Table 3.
Factors that Increment Risk of Severe COPD Exacerbations
| Altered mental condition |
| At least iii exacerbations in the previous 12 months |
| Body mass index of 20 kg per m2 or less |
| Marked increase in symptoms or change in vital signs |
| Medical comorbidities (peculiarly cardiac ischemia, congestive heart failure, pneumonia, diabetes mellitus, or renal or hepatic failure) |
| Poor concrete activity levels |
| Poor social support |
| Severe baseline COPD (FEVane/FVC ratio less than 0.70 and FEV1 less than 50 percentage of predicted) |
| Underutilization of abode oxygen therapy |
Etiology
- Abstruse
- Definition and Nomenclature
- Etiology
- Initial Evaluation
- Indications for Hospitalization
- Oxygenation and Ventilation
- Therapeutic Options
- Preparation for Infirmary Discharge
- Preventing Future Exacerbations
- References
Infection of the tracheobronchial tree and air pollution (e.chiliad., tobacco smoke, occupational exposures, ozone) are the most mutual identifiable causes of COPD exacerbations. 1 third of exacerbations have no identifiable cause.vi Other medical problems, such equally congestive heart failure, nonpulmonary infections, pulmonary embolism, and pneumothorax, tin also prompt a COPD exacerbation.nine
Initial Evaluation
- Abstract
- Definition and Classification
- Etiology
- Initial Evaluation
- Indications for Hospitalization
- Oxygenation and Ventilation
- Therapeutic Options
- Preparation for Infirmary Discharge
- Preventing Time to come Exacerbations
- References
The initial evaluation of patients with a suspected COPD exacerbation should include a history of baseline and current symptoms, such as limitations in activities of daily living. If available, previous chest radiographs, arterial blood gas measurements, and spirometry results can help found the baseline lung office and illustrate a typical exacerbation. Because increasing confusion is a hallmark of respiratory compromise, the physical examination should include a mental status evaluation, likewise as heart and lung examinations.
Recommended diagnostic evaluation of an exacerbation depends on its severity (Table 4).5,8,ix,12,13 Pulse oximetry should be performed in all patients. Chest radiography is appropriate in hospitalized patients and can guide handling by revealing comorbid weather such every bit congestive centre failure, pneumonia, and pleural effusion. A room air arterial claret gas (ABG) measurement should be obtained at the time of hospital admission to quantify hypercarbia and hypoxemia. Measurement of encephalon natriuretic peptide and serial cardiac enzyme levels should exist considered in hospitalized patients, because cardiac ischemia and congestive heart failure are common comorbidities in patients with COPD.5,12,13
Table 4.
Diagnostic Evaluation of Patients with Suspected COPD Exacerbation
| Examination | Potential diagnosis |
|---|---|
| Perform routinely | |
| Pulse oximetry | Hypoxemia |
| Perform if hospitalized | |
| Arterial blood gas measurement | Hypercarbia |
| Hypoxemia | |
| Respiratory acidosis | |
| Chest radiography | Alternating sources of dyspnea |
| Consummate blood count | Anemia |
| Leukocytosis | |
| Polycythemia | |
| Electrocardiography | Cardiac arrhythmias |
| Cardiac ischemia | |
| Metabolic console | Electrolyte disturbances |
| Hypo- or hyperglycemia | |
| Metabolic acid-base changes | |
| Consider performing, especially if patient is not responding to conventional exacerbation treatment | |
| Brain natriuretic peptide measurement | CHF (ane third of dyspnea in chronic lung disease may be owing to CHF) |
| Cardiac enzyme measurement | Cardiac ischemia (myocardial infarction is underdiagnosed in patients with COPD) |
Other physical examination maneuvers, laboratory tests, and assessments of cardiac function take non been proven beneficial in the treatment of COPD exacerbations.ix
Indications for Hospitalization
- Abstract
- Definition and Nomenclature
- Etiology
- Initial Evaluation
- Indications for Hospitalization
- Oxygenation and Ventilation
- Therapeutic Options
- Training for Hospital Discharge
- Preventing Time to come Exacerbations
- References
Almost 50 percentage of COPD exacerbations are not reported to physicians, suggesting that many exacerbations are mild.14 The hazard of decease from an exacerbation increases with the development of respiratory acidosis, the presence of meaning comorbidities, and the need for ventilatory support.five Patients with symptoms of respiratory distress and those at take a chance of distress should be admitted to the hospital to provide access to critical care personnel and mechanical ventilation. Inpatient mortality for COPD exacerbations is 3 to 4 percent.9 Patients admitted to the intensive care unit accept a 43 to 46 percent risk of death within one year after hospitalization.ix
Nonambulatory patients should receive routine pro-phylaxis for deep venous thrombosis. Because COPD is a progressive and often fatal disease, physicians should consider discussing and documenting the patient'southward wishes apropos cease-of-life care.
Oxygenation and Ventilation
- Abstract
- Definition and Classification
- Etiology
- Initial Evaluation
- Indications for Hospitalization
- Oxygenation and Ventilation
- Therapeutic Options
- Training for Infirmary Belch
- Preventing Future Exacerbations
- References
Oxygen supplementation should exist titrated to an oxygen saturation level of at least xc percent. High-flow oxygen devices deliver oxygen more reliably than nasal prongs, but nasal prongs may exist better tolerated. Noninvasive positive pressure ventilation (NIPPV) is indicated if adequate oxygenation or ventilation cannot be achieved using a high-flow mask.15 Patients requiring NIPPV should be monitored continuously for decompensation.
If the patient cannot exist fairly oxygenated, complications, such every bit pulmonary embolism or edema, should be considered.6 Carbon dioxide retention is possible in moderately and severely sick patients; therefore, ABG should be measured 30 to 60 minutes after initiating oxygen supplementation.
Invasive mechanical ventilation is needed if the patient cannot tolerate NIPPV; has worsening hypoxemia, acidosis, confusion, or hypercapnia despite NIPPV; or has severe comorbid conditions, such equally myocardial infarction or sepsis.half-dozen Worsening hypercarbia and acidosis herald respiratory failure. A pH of less than vii.36 and an arterial partial pressure of carbon dioxide of more than than 45 mm Hg indicate the demand for mechanical ventilation.
Therapeutic Options
- Abstract
- Definition and Classification
- Etiology
- Initial Evaluation
- Indications for Hospitalization
- Oxygenation and Ventilation
- Therapeutic Options
- Preparation for Hospital Discharge
- Preventing Future Exacerbations
- References
SHORT-Acting BRONCHODILATORS
Inhaled short-interim bronchodilators include beta agonists (e.k., albuterol, levalbuterol [Xopenex]) and anti-cholinergics (e.g., ipratropium [Atrovent]). These agents improve dyspnea and exercise tolerance.vi,ix The starting time step in treating a COPD exacerbation is increasing the dosage of albuterol delivered via metered dose inhaler or nebulizer.9 Levalbuterol is more expensive than albuterol but has similar benefits and adverse effects.sixteen If the patient is not already taking ipratropium, it tin can exist added to the treatment regimen.5 Fixed-dose albuterol/ipratropium (Combivent) is available.
CORTICOSTEROIDS
Short courses of systemic corticosteroids increase the time to subsequent exacerbation, decrease the charge per unit of handling failure, shorten hospital stays, and improve hypoxemia and forced expiratory book in one second (FEVone).1,six,7,9,17–20 Administration of oral corticosteroids early in an exacerbation decreases the demand for hospitalization.21 A randomized controlled trial (RCT) of patients with COPD compared viii weeks of corticosteroids, two weeks of corticosteroids, and placebo; participants in the treatment groups had fewer handling failures than those in the control grouping.17 Treatment failure rates were the same for long and short courses of corticosteroids.
Loftier-dosage corticosteroid regimens (methylprednisolone [Solu-Medrol], 125 mg intravenously every six hours) and low-dosage regimens (prednisolone, 30 mg orally daily) decrease the length of hospitalization and meliorate FEVone compared with placebo.17,19 [ corrected] An RCT comparing oral and intravenous prednisolone in equivalent dosages (60 mg daily) showed no divergence in lengths of hospitalization and rates of early treatment failure.22
Considering oral corticosteroids are bioavailable, inexpensive, and convenient, parenteral corticosteroids should be reserved for patients with poor intestinal absorption or comorbid conditions that forestall safe oral intake (e.g., decreased mental status, vomiting).v,6 Inhaled corticosteroids accept no role in the management of an acute exacerbation.8
ANTIBIOTICS
One half of patients with COPD exacerbations have high concentrations of leaner in their lower airways.6,23 Cultures oftentimes show multiple infectious agents, including Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Mycoplasma pneumoniae, and viruses.six,23
The apply of antibiotics in moderately or severely ill patients with COPD exacerbations reduces the risk of handling failure and death.24 Antibiotics may also benefit patients with mild exacerbations and purulent sputum.5 The optimal pick of antibiotic and length of use are unclear. Increasing microbial resistance has prompted some physicians to treat exacerbations with broad-spectrum agents, such as second- or 3rd-generation cephalosporins, macrolides, or quinolones. I meta-analysis showed a lower adventure of handling failure with broad-spectrum antibiotics compared with narrow-spectrum antibiotics (odds ratio = 0.51; 95% confidence interval, 0.34 to 0.75), simply no change in mortality rates.25 Some other meta-analysis showed no difference in clinical cure rates when broad-spectrum antibiotics were administered for at least v days versus less than v days.26 At that place is no comparable study of narrow-spectrum antibiotics. The determination to use antibiotics and the choice of antibiotic should exist guided past the patient's symptoms (east.g., presence of purulent sputum), recent antibiotic use, and local microbial resistance patterns.18,23,25 Safe, continuous utilize of antibiotics does non ameliorate outcomes in patients with COPD.6
OTHER Handling OPTIONS
Parenteral methylxanthines, such every bit theophylline, are non routinely recommended for the treatment of COPD exacerbations.27 These agents are less effective and have more potentially adverse effects than inhaled bronchodilators.
Several therapies lack acceptable evidence for routine use in the treatment of COPD exacerbations, including mucolytics (eastward.g., acetylcysteine [formerly Mucomyst]), nitric oxide, chest physiotherapy, antitussives, morphine, nedocromil, leukotriene modifiers, phosphodiesterase Iv inhibitors (drug grade not available in the U.s.), and immunomodulators (east.g., OM-85 BV, AM3 [neither drug available in the United States]).6,7 Table 5 summarizes the handling options for acute COPD exacerbations.5,half dozen,8,ix,18,25
Tabular array v.
Treatment Options for Acute COPD Exacerbations
| Therapy | Outpatient management | Inpatient direction | Benefits | Disadvantages/common adverse furnishings | Typical dosage |
|---|---|---|---|---|---|
| Antibiotic, wide spectrum (e.g., amoxicillin/clavulanate [Augmentin], macrolides, second- or third-generation cephalosporins, quinolones) | Consider if sputum is purulent or after treatment failure | Use if local microbial patterns testify resistance to narrow-spectrum agents | Decreases risk of handling failure and mortality compared with narrow-spectrum agents | Antibody resistance, diarrhea, yeast vaginitis; side furnishings specific to the antibiotic prescribed | Amoxicillin/clavulanate: 875 mg orally twice daily or 500 mg orally three times daily for 5 days |
| Use if local microbial patterns testify resistance to narrow-spectrum agents | |||||
| Levofloxacin (Levaquin): 500 mg daily for v days | |||||
| Antibiotic, narrow spectrum (e.g., amoxicillin, ampicillin, trimethoprim/sulfamethoxazole [Bactrim, Septra], doxycycline, tetracycline) | Consider if sputum is purulent or subsequently treatment failure | Employ if local microbial patterns bear witness minimal resistance to these agents and if patient has not taken antibiotics recently | Believed to decrease mortality gamble, but has not been tested in placebo-controlled trials | Antibiotic resistance, diarrhea, yeast vaginitis; side effects specific to the antibiotic prescribed | Amoxicillin: 500 mg orally three times daily for iii to 14 days Doxycycline: 100 mg orally twice daily for 3 to fourteen days |
| Use if local microbial patterns testify minimal resistance to these agents and if patient has non taken antibiotics recently | |||||
| Anticholinergic, short acting (eastward.one thousand., ipratropium [Atrovent]) | May add to beta agonist; if patient is already taking an anticholinergic, increment dosage | May add together to beta agonist; if patient is already taking an anticholinergic, increase dosage | Improves dyspnea and exercise tolerance | Dry oral fissure, tremor, urinary retentivity | Ipratropium: 500 mcg by nebulizer every 4 hours every bit needed; alternatively, 2 puffs (eighteen mcg per puff) past MDI every 4 hours as needed* |
| Beta agonist, curt acting (e.thou., albuterol, levalbuterol [Xopenex]) | Increase dosage | Increase dosage | Improves dyspnea and do tolerance | Headache, nausea, palpitations, tremor, vomiting | Albuterol: 2.5 mg by nebulizer every one to four hours every bit needed, or 4 to eight puffs (90 mcg per puff) by MDI every 1 to iv hours as needed* |
| Corticosteroid | Consider using oral corticosteroids in moderately sick patients, especially those with purulent sputum | Use oral corticosteroids if patient can tolerate; if not suitable for oral therapy, administer intravenously | Decreases risk of subsequent exacerbation, rate of handling failures, and length of hospital stay Improves FEVone and hypoxemia | Gastrointestinal bleeding, heartburn, hyperglycemia, infection, psychomotor disturbance, steroid myopathy | Oral prednisone: 30 to sixty mg once daily Intravenous methylprednisolone (Solu-Medrol): 60 to 125 mg 2 to 4 times daily |
| Mechanical ventilation | NA | Use if patient cannot tolerate NIPPV; has worsening hypoxemia, acidosis, confusion, or hypercapnia despite NIPPV; or has comorbid conditions such as myocardial infarction or sepsis | Decreases brusque-term mortality hazard in severely ill patients | Aspiration, cardiovascular complications, need for sedation, pneumonia | Titrate to correct hypercarbia and hypoxemia |
| NIPPV | NA | Employ in patients with worsening respiratory acidosis and hypoxemia when oxygenation via loftier-menstruation mask is inadequate | Improves respiratory acidosis and decreases respiratory rate, breathlessness, need for intubation, mortality, and length of hospital stay | Expensive, poorly tolerated by some patients | Titrate to correct hypercarbia and hypoxemia |
| Oxygen supplementation | NA | Employ in patients with hypoxemia (PaO2 less than 60 mm Hg) | Decreases mortality adventure | Hypercarbia | Titrate to PaOii > lx mm Hg or oxygen saturation ≥ 90 percent |
Preparation for Hospital Discharge
- Abstract
- Definition and Nomenclature
- Etiology
- Initial Evaluation
- Indications for Hospitalization
- Oxygenation and Ventilation
- Therapeutic Options
- Preparation for Hospital Discharge
- Preventing Future Exacerbations
- References
To qualify for discharge, a patient should have stable clinical symptoms and a stable or improving arterial partial pressure of oxygen of more than 60 mm Hg for at to the lowest degree 12 hours. The patient should not crave albuterol more than oft than every four hours. If the patient is stable and can employ a metered dose inhaler, there is no benefit to using nebulized bronchodilators.28 Patient education may meliorate the response to future exacerbations29; suggested topics include a general overview of COPD, available medical treatments, nutrition, advance directives, and advice almost when to seek medical help. In-home support, such every bit an oxygen concentrator, nebulizer, and home health nurse services, should be arranged before discharge.
Preventing Future Exacerbations
- Abstract
- Definition and Classification
- Etiology
- Initial Evaluation
- Indications for Hospitalization
- Oxygenation and Ventilation
- Therapeutic Options
- Preparation for Hospital Discharge
- Preventing Futurity Exacerbations
- References
Smoking cessation, immunization confronting flu and pneumonia, and pulmonary rehabilitation have been shown to improve function and reduce subsequent COPD exacerbations.6,7,30 Long-term oxygen therapy decreases the risk of hospitalization and shortens infirmary stays in severely ill patients with COPD.7,31,32 The indications for long-acting inhaled bronchodilators and inhaled corticosteroids to improve symptoms and reduce the risk of exacerbations in patients with stable COPD are reviewed elsewhere.5,7,33–38
To encounter the full article, log in or purchase admission.
REFERENCES
bear witness all references
ane. Singh JM, Palda VA, Stanbrook MB, Chapman KR. Corticosteroid therapy for patients with acute exacerbations of chronic obstructive pulmonary disease: a systematic review. Arch Intern Med. 2002;162(22):2527–2536. ...
2. Jemal A, Ward E, Hao Y, Thun G. Trends in the leading causes of death in the United States, 1970–2002. JAMA. 2005;294(10):1255–1259.
iii. Stephens MB, Yew KS. Diagnosis of chronic obstructive pulmonary disease. Am Fam Physician. 2008;78(1):87–92.
4. Cazzola Grand, MacNee W, Martinez FJ, et al., for the American Thoracic Club, European Respiratory Club Job Force on Outcomes of COPD. Outcomes for COPD pharmacological trials: from lung function to bio-markers. Eur Respir J. 2008;31(ii):416–469.
5. American Thoracic Social club, European Respiratory Gild Task Force. Standards for the Diagnosis and Management of Patients with COPD. Version 1.2. New York, NY: American Thoracic Society; 2004. http://www.thoracic.org/go/copd. Accessed Jan 11, 2010.
half dozen. Rabe KF, Hurd S, Anzueto A, et al., for the Global Initiative for Chronic Obstructive Lung Affliction. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary illness: Gold executive summary. Am J Respir Crit Care Med. 2007;176(6):532–555.
7. Decramer One thousand, Nici Fifty, Nardini Southward, et al. Targeting the COPD exacerbation. Respir Med. 2008;102(suppl i):S3–S15.
viii. Snowfall 5, Lascher S, Mottur-Pilson C, for the Articulation Expert Panel on COPD of the American Higher of Breast Physicians and the American College of Physicians/American Society of Internal Medicine. The testify base of operations for direction of astute exacerbations of COPD: clinical practice guideline, office 1. Chest. 2001;119(4):1185–1189.
ix. McCrory DC, Chocolate-brown C, Gelfand SE, Bach PB. Management of acute exacerbations of COPD: a summary and appraisal of published evidence. Chest. 2001;119(iv):1190–1209.
ten. Kessler R, Faller M, Fourgaut Thousand, Mennecier B, Weitzenblum East. Predictive factors of hospitalization for acute exacerbation in a series of 64 patients with chronic obstructive pulmonary illness. Am J Respir Crit Care Med. 1999;159(ane):158–164.
11. Garcia-Aymerich J, Monsó East, Marrades RM, et al., for the EFRAM Investigators. Risk factors for hospitalization for a chronic obstructive pulmonary disease exacerbation. Am J Respir Crit Care Med. 2001;164(half-dozen):1002–1007.
12. Mueller C, Laule-Kilian 1000, Frana B, et al. Use of B-type natriuretic peptide in the management of acute dyspnea in patients with pulmonary disease. Am Heart J. 2006;151(2):471–477.
13. Brekke PH, Omland T, Smith P, Søyseth V. Underdiagnosis of myocardial infarction in COPD—Cardiac Infarction Injury Score (CIIS) in patients hospitalised for COPD exacerbation. Respir Med. 2008;102(nine):1243–1247.
14. Seemungal TA, Donaldson GC, Bhowmik A, Jeffries DJ, Wedzi-cha JA. Fourth dimension course and recovery of exacerbations in patients with chronic obstructive pulmonary illness. Am J Respir Crit Intendance Med. 2000;161(v):1608–1613.
xv. Ram FS, Picot J, Lightowler J, Wedzicha JA. Not-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary illness. Cochrane Database Syst Rev. 2004;(3):CD004104.
16. Donohue JF, Hanania NA, Ciubotaru RL, et al. Comparison of levalbuterol and racemic albuterol in hospitalized patients with acute asthma or COPD: a 2-week, multicenter, randomized, open-label study. Clin Ther. 2008;30(spec no):989–1002.
17. Niewoehner DE, Erbland ML, Deupree RH, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Written report Group. Northward Engl J Med. 1999;340(25):1941–1947.
eighteen. Quon BS, Gan WQ, Sin DD. Contemporary management of acute exacerbations of COPD: a systematic review and metaanalysis. Chest. 2008;133(3):756–766.
xix. Davies L, Angus RM, Calverley PM. Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary illness: a prospective randomised controlled trial. Lancet. 1999;354(9177):456–460.
20. Walters JA, Gibson PG, Wood-Baker R, Hannay M, Walters EH. Systemic corticosteroids for astute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2009;(1):CD001288.
21. Wilkinson TM, Donaldson GC, Hurst JR, Seemungal TA, Wedzicha JA. Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2004;169(12):1298–1303.
22. de Jong YP, Uil SM, Grotjohan HP, Postma DS, Kerstjens HA, van den Berg JW. Oral or IV prednisolone in the handling of COPD exacerbations: a randomized, controlled, double-bullheaded study. Chest. 2007;132(six):1741–1747.
23. Sethi South, Evans N, Grant BJ, White potato TF. New strains of bacteria and exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 2002;347(vii):465–471.
24. Ram FS, Rodriguez-Roisin R, Granados-Navarrete A, Garcia-Aymerich J, Barnes NC. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;(2):CD004403.
25. Dimopoulos G, Siempos Ii, Korbila IP, Manta KG, Falagas ME. Comparison of offset-line with 2nd-line antibiotics for acute exacerbations of chronic bronchitis: a metaanalysis of randomized controlled trials. Breast. 2007;132(2):447–455.
26. El Moussaoui R, Roede BM, Speelman P, Bresser P, Prins JM, Bossuyt PM. Short-course antibody handling in acute exacerbations of chronic bronchitis and COPD: a meta-assay of double-blind studies. Thorax. 2008;63(5):415–422.
27. Barr RG, Rowe BH, Camargo CA. Methylxanthines for exacerbations of chronic obstructive pulmonary affliction. Cochrane Database Syst Rev. . 2003;(2):CD002168.
28. Jenkins SC, Heaton RW, Fulton TJ, Moxham J. Comparison of domiciliary nebulized salbutamol and salbutamol from a metered-dose inhaler in stable chronic airflow limitation. Chest. 1987;91(6):804–807.
29. Turnock AC, Walters EH, Walters JA, Wood-Bakery R. Action plans for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005;(4):CD005074.
30. Au DH, Bryson CL, Chien JW, et al. The effects of smoking abeyance on the risk of chronic obstructive pulmonary disease exacerbations. J Gen Intern Med. 2009;24(4):457–463.
31. Poole PJ, Chacko E, Wood-Bakery RW, Cates CJ. Influenza vaccine for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;(i):CD002733.
32. Drummond MB, Dasenbrook EC, Pitz MW, Murphy DJ, Fan East. Inhaled corticosteroids in patients with stable chronic obstructive pulmonary disease: a systematic review and meta-assay [published correction appears in JAMA. 2009;301(10):1024]. JAMA. 2008;300(xx):2407–2416.
33. Singh S, Amin AV, Loke YK. Long-term use of inhaled corticosteroids and the risk of pneumonia in chronic obstructive pulmonary affliction: a meta-assay. Arch Intern Med. 2009;169(3):219–229.
34. Ernst P, Gonzalez AV, Brassard P, Suissa S. Inhaled corticosteroid use in chronic obstructive pulmonary disease and the take chances of hospitalization for pneumonia. Am J Respir Crit Care Med. 2007;176(2):162–166.
35. Tashkin DP, Celli B, Senn S, et al., for the UPLIFT Study Investigators. A four-twelvemonth trial of tiotropium in chronic obstructive pulmonary disease. Due north Engl J Med. 2008;359(15):1543–1554.
36. Singh Due south, Loke YK, Furberg CD. Inhaled anticholinergics and risk of major adverse cardiovascular events in patients with chronic obstructive pulmonary affliction: a systematic review and meta-analysis. JAMA. 2008;300(12):1439–1450.
37. Rabe KF, Timmer West, Sagkriotis A, Viel K. Comparison of a combination of tiotropium plus formoterol to salmeterol plus fluticasone in moderate COPD. Chest. 2008;134(ii):255–262.
38. Aaron SD, Vandemheen KL, Fergusson D, et al., for the Canadian Thoracic Society/Canadian Respiratory Clinical Research Consortium. Tiotropium in combination with placebo, salmeterol, or fluticasonesalmeterol for treatment of chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2007;146(8):545–555.
Copyright © 2010 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or after invented, except equally authorized in writing past the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.
MOST RECENT ISSUE
April 2022
Access the latest result of American Family Md
Read the Issue
Email Alerts
Don't miss a single issue. Sign up for the free AFP electronic mail tabular array of contents.
Sign Upward Now
Source: https://www.aafp.org/afp/2010/0301/p607.html
0 Response to "What Other Teaching Needs Would You Review With Db While He Is Hospitalized?"
Post a Comment