COPD Guideline Addresses Care of Ambulatory Patients

Diana Phillips

March 23, 2017

A new guideline for managing exacerbations of chronic obstructive pulmonary disease (COPD) supports the use of oral corticosteroids and antibiotic therapy in ambulatory patients having an exacerbation. It also recommends noninvasive mechanical ventilation (NIV) for hospitalized patients with acute or acute-on-chronic hypercapnic respiratory failure resulting from a COPD exacerbation.

Unlike most existing COPD guidelines, which rely primarily on evidence from hospitalized patients with severe exacerbations, the new document also addresses the needs of outpatients, said Marc Miravitlles, MD, from University Hospital Vall d'Hebron in Barcelona, Spain, coauthor of the guideline.

The new document, published in the March 16 issue of the European Respiratory Journal, is based on a comprehensive review of the available evidence by a multidisciplinary task force convened jointly by the European Respiratory Society and the American Thoracic Society. The guidelines extend and update existing evidence-based clinical practice guidelines, including the Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) 2017 Report, which was published online earlier this year.

Some of the recommendations in the new guideline "confirm the current approach to management, and others provide more solid evidence for treatment," Dr Miravitlles told Medscape Medical News in an interview. The task force developed the document "using the GRADE [Grading of Recommendations Assessment, Development and Evaluation] methodology, which allows a nonbiased evaluation of the scientific evidence," he explained.

The recommendations for outpatient management should be of particular interest to primary care providers, because they are the providers "treating a large proportion of patients with exacerbated COPD," Dr Miravitlles said. "The report summarizes the evidence for the most important ambulatory treatment of exacerbations: the ambulatory use of antibiotics and the use of systemic corticosteroids, explaining when antibiotics should be used and when and how oral corticosteroids should be given."

Six Questions Addressed

To develop the guidelines, the task force identified six questions regarding the treatment of COPD exacerbations not answered by existing guidance documents, including use of oral corticosteroids and antibiotics to treat ambulatory patients, use of oral or intravenous corticosteroids for inpatient care, use of noninvasive mechanical ventilation (NIV), rehabilitation after hospital discharge, and use of a home-based management program.

According to the data review, the task force developed a strong recommendation for the use of NIV in patients with COPD with acute or acute-on-chronic respiratory failure. The data show NIV reduces the need for intubation, mortality, complications of therapy, and length of both hospital stay and intensive care unit stay in these patients, with no reports of adverse consequences, the authors report.

Although the task force rated the quality of the NIV evidence as low because of bias risks, inconsistent effects across studies, small sample sizes, or incomplete data, the strong recommendation "reflects the panel's consensus opinion that the overwhelming majority of patients would want NIV given the possibility of one or more important clinical benefits with minimal risk of harm," the authors write.

The remaining six recommendations were deemed conditional because of uncertainty among task force members of the relative risk–benefit balance.

"Reasons for uncertainty included low or very low quality of evidence, the desirable and undesirable consequences being finely balanced, or the underlying values and preferences playing an important role," the authors write. "A conditional recommendation indicates that well-informed patients may make different choices regarding whether to have or not have the intervention."

The conditional recommendations include

  • a short course (⩽14 days) of oral corticosteroids for ambulatory patients with an exacerbation of COPD;

  • the administration of antibiotics for ambulatory patients with an exacerbation of COPD;

  • for patients hospitalized for a COPD exacerbation, oral corticosteroids are preferred over intravenous ones if gastrointestinal access and function are intact;

  • a home-based management program for patients with a COPD exacerbation who present to the emergency department or hospital;

  • the initiation of pulmonary rehabilitation within 3 weeks after hospital discharge for patients who are hospitalized with a COPD exacerbation; and

  • waiting until postdischarge rather than during hospitalization to initiate pulmonary rehabilitation.

With respect to the outpatient corticosteroid recommendation, the task force determined that a 9- to 14-day course "improves lung function and causes a trend toward fewer hospitalisations," with no demonstrated effect on treatment failure, mortality, or adverse effects, "although there were too few events in the trials to definitively confirm or exclude an effect on any of these outcomes."

The conditional recommendation for outpatient antibiotic therapy was based on evidence indicating that such therapy, with antibiotic selection based on local sensitivity patterns, reduces the risk for treatment failure and increases the time between COPD exacerbations, despite a trend toward an increase in adverse events, primarily mild gastrointestinal adverse effects.

The small sample sizes and variability of the studies addressing the value of home-based management options, also called "hospital-at-home" models that offer an alternative to hospitalization, contributed to the conditional recommendation; however, the available data suggest that such programs reduce hospital admissions, "making it a safe and effective way of discharging patients with additional home-based support" in certain cases, the authors write.

The pulmonary rehabilitation recommendations reflect the task force's assessment of evidence for early rehabilitation programs comprising physical exercise and education implemented during hospitalization, within 3 weeks postdischarge, and within 8 weeks postdischarge.

Although pulmonary rehabilitation initiated during hospitalization increased exercise capacity, it also increased mortality, whereas programs initiated within 3 weeks of discharge reduced hospital admissions and improved quality of life. Programs initiated within 8 weeks of discharge also increased exercise capacity, the authors report.

The variability of pulmonary rehabilitation programs, timing, and outcomes indicate that "[r]esearch is needed to identify the interventions that provide the greatest benefits," the authors write.

Because the new guidelines are based on the most recent clinical evidence available, and the quality of much of the evidence is not robust, "recommendations should be reconsidered as new evidence becomes available," the authors write.

Eur Respir J. 2017;49:1600791. Full text

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