Transcript COPD Exacerbation 2008

COPD Exacerbation:
Practical Evidence-based
Strategies
Daniel D. Dressler, MD, MSc
Director of Education
Section of Hospital Medicine
IM Associate Residency Director
Assistant Professor of Medicine
Emory University School of Medicine
[email protected]
Society of Hospital Medicine Annual Meeting
San Diego, California
April 4, 2008
What will NOT be discussed during
this session…
•
Knock-out mice
• Pathophysiology
• Disease Burden
• Precipitants
• Differential
• Adm criteria
Objectives
• By the end of this session, participants
will be able to:
• Locate, Evaluate and Interpret the highest
level of medical evidence for management
of COPD Exacerbations
 Summary of RCT data
 RCT data
 Observational Data
Definition of COPD




Progressive Pulmonary airflow limitation that is not
completely reversible
Abnormal inflammatory response of the lung to
noxious particles or gases
Preventable and Treatable
Extrapulmonary effects may contribute to
disease severity
Weight loss
Nutritional abnormalities
Skeletal muscle dysfunction

Classification of COPD Severity
by Spirometry
Stage I: Mild
FEV1/FVC < 0.70
FEV1 > 80% predicted
Stage II: Moderate
FEV1/FVC < 0.70
50% < FEV1 < 80% predicted
Stage III: Severe
FEV1/FVC < 0.70
30% < FEV1 < 50% predicted
Stage IV: Very Severe
FEV1/FVC < 0.70
FEV1 < 30% predicted or
FEV1 < 50% predicted plus
chronic respiratory failure
Exacerbation of COPD: Definition
 Acute change in baseline dyspnea, cough,
and/or sputum beyond normal day-to-day
variations
 May warrant a change in regular
medication(s)
Exacerbations: Mortality
• Hospitalized
– Inpatient mortality (non-ICU): 2.5%* (1 in 40)
– 3-month mortality after hospitalization for exacerbation: 14%
(1 in 7)
– If pCO2>50:
• 6 month mortality = 33%
• 12 month mortality = 43%
• ICU
– 17% in-hospital (1 in 6)
– 26% in-hospital if intubated* (1 in 4)
– 45% 1-year mortality (1 in 2)
*Patil SP, et al. Arch Intern Med. 2003.
DIAGNOSIS
• Exacerbations: CLINICAL Diagnosis
• Spirometry (PFTs and/or Peak Flows)
– No demonstrated value in setting of COPD exacerbation
– Useful only in the outpatient diagnosis of stable COPD
– DIFFERENT for Asthma patients, where spirometry is
useful in the setting of stable asthma and asthma
exacerbation
• Assess Severity!!
Case: Mr. BH
• Mr. BH is a 63 year old
portly Southern
Gentleman with h/o
severe COPD (i.e.
baseline FEV1 30 to 50%
predicted) admitted from
the ED with 3 days of
SOB, increased cough
and clear sputum
production. + exposure
to grandkids with ‘colds’
Case: Mr. BH
• PMH:
1. COPD
• PFTs: FEV1 32% predicted (FEV1/FVC 60%)
• baseline pCO2 55
2. CASHD, s/p MI 12/2007
• Preserved cardiac function (EF 60%)
3. HTN
4. Secondary Pulmonary HTN (mild)
Case: Mr. BH
• Medications on admission:
– ASA
– Albuterol MDI prn
– Carvedilol CR 20mg daily
– Lisinopril 10mg daily
– prn SL NTG
• SH: former town mayor, 60 pack-year Tob
use, quit 10 years ago, enjoys working on
his white convertible cadilac
Case: Mr. BH
Physical Exam
Studies
• VS: BP 150/90, HR 110
(reg), RR 28, T 38.1
• CXR: Chronic changes,
hyperinflation
• Mild to Mod increased
WOB, RR 28, alert.
• ABG:
• Lungs: significant bilat
inspiratory and
expiratory wheezes
• Ext: 1+ to 2+ edema
bilat
– pH 7.36
– pCO2 58
– pO2 64 on 2L O2 NC
• Other labs: Cr 1.4,
Troponin-I: 0.09
Question #1
Pharmacologic Therapies
Question #1: Pharmacologic
Therapies in COPD Exacerbation
•
Which pharmacologic therapies are
supported by high-level studies (RCTs)
demonstrating their benefit in COPD
exacerbation to improve outcomes
(select all that apply)?
A. Inhaled Bronchodilators
B. Methylxanthine Bronchodilators
C. Oxygen
D. Systemic Steroids
E. Acupuncture, Aromatherapy, Massage*
*According to healingdeva.com !!
The Evidence: Pharmacologic
Therapies for COPD Exacerbation
BRONCHODILATOR THERAPIES
Inhaled Bronchodilators
•
Short-acting inhaled ß2 agonist BDs recommended by guidelines
(Evidence A)*
– Outcomes: Main benefit on symptoms and FEV1
•
5 RCTs suggest ß2 agonists similar efficacy to anticholinergic BDs on
FEV1**
– Fewer side effects with anticholinergics agents alone
•
Some patients benefit from adding a 2nd bronchodilator after
maximum dose** of the initial bronchodilator has been reached
•
Oral and injected bronchodilators NOT as effective**
•
No clinical studies of long-acting inhaled BDs during exacerbation
*American Thoracic Society (ATS), European Respiratory Society (ERS), National Institute for Clinical
Excellence (NICE/Thorax), GOLD (Global Initiative for Chronic Obstructive Lung Disease)
** Bach PB, et al. Ann Intern Med 2001. 134: 600-620.
The Evidence: Pharmacologic
Therapies for COPD Exacerbation
BRONCHODILATOR THERAPIES
Methylxanthine Systemic Bronchodilators
• Meta-analysis summary
• 4 RCTs, 169 total patients
• Evaluation in patients treated in EDs or
inpatient for exacerbations of COPD
• Relevant Outcomes:
– Return to ED, Symptoms, Arrhythmias
The Evidence: Pharmacologic
Therapies for COPD Exacerbation
BRONCHODILATOR THERAPIES
Methylxanthine Bronchodilators: Efficacy
ED Return Visits within 1 wk
Barr RG, et al. BMJ 2003. 327: 643-48.
Symptom Scores
The Evidence: Pharmacologic
Therapies for COPD Exacerbation
BRONCHODILATOR THERAPIES
Methylxanthine Bronchodilators: Adverse Effects
Arrhythmias/Palpitations
Barr RG, et al. BMJ 2003. 327: 643-48.
The Evidence: Pharmacologic
Therapies for COPD Exacerbation
OXYGEN
• “Controlled oxygen therapy” recommended by
GOLD Guidelines (no evidence level provided)
– Flow-controlled systems (e.g. Venturi mask) preferred
• Indicated for hypoxemic patients (PaO2 < 60)
– Give just enough to relieve hypoxemia
• Monitor closely for signs of hypercarbia and
respiratory failure (i.e. ABG 30 – 60 min after
initiation of new O2 rx)
What about Steroids…
The Evidence: Pharmacologic
Therapies for COPD Exacerbation
SYSTEMIC CORTICOSTEROIDS
• Oral or IV glucocorticosteroids recommended in
hospital management of COPD exacerbations
(Evidence A)*
– Improve symptoms and FEV1* (based on 6 RCTs**)
• 30-40 mg prednisolone daily x 7-10 days is
effective and safe (Evidence C)*
– No more than 2 weeks of systemic rx necessary***
• No role for inhaled corticosteroids in acute
exacerbation of COPD (no studies to date*)
*Global Initiative for Chronic Obstructive Lung Disease (“GOLD”). NIH/NHLBI; April 2001,
updated May 2007. NIH Publication 2701. Available at: www.goldcopd.com
** Bach PB, et al. Ann Intern Med 2001. 134: 600-620.
***Niewoehner DE, et al. N Engl J Med 1999. 340: 1941-47.
COPD: Systemic Steroids on Rx Failure
Figure: Kaplan-Meier Estimates of the Rate of First Treatment Failure at Six Months,
According to Treatment Group (271 patients)
Niewoehner DE, et al. N Engl J Med 1999. 340: 1941-47.
ACP Journal Club 2000. 132(1): 14.
COPD Exac: Systemic Steroids effects on
A. FEV1 after BD, and B. LOS
A. FEV1 after BD
(p<0.0001)
RCT data, 56 patients
Davies L, et al. Lancet 1999; 354: 456-60.
B. LOS (p = 0.039)
Question #2
(enough with the easy stuff…)
Case (continued)
Question #2
•
Admission orders written…
•
…medical student presentation…reports that
she witnessed significant purulent sputum
production while interviewing the patient for 90
minutes.
•
Question: Are there other medical therapies we
should add to Mr. BH’s regimen (supported by
high-level evidence)?
A. Mucolytics
B. Chest Physiotherapy
C. Antibiotics
D. Sildinafil/Viagra for pulmonary HTN
(…oops, contraindicated with his nitrate therapy)
The Evidence for Mucolytics…
The Evidence: Pharmacologic
Therapies for COPD Exacerbation
MUCOLYTIC AGENTS
• 5 RCTs of Mucolytic/Mucokinetic agents in
the setting of COPD Exacerbations did
NOT demonstrate shortening of disease
course, but may improve symptoms*
• However, outpatient use of mucolytics in
COPD patients may reduce number of
exacerbations…
*Bach PB, et al. Ann Intern Med 2001. 134: 600-620.
Mucolytic Agents in Chronic COPD:
Effect on Exacerbations
Reduces mean number of exacerbations per subject per month (weighted mean
difference, and 95% confidence intervals)
*No effect on lung function
Poole, P. et al. BMJ 2001;322:1271
What about Pulmonary Toilet?
The Evidence: Therapies for COPD
Exacerbation
CHEST PHYSIOTHERAPY
• Mechanical percussion of the chest by
PTs or RTs is ineffective (or detrimental)
• No change or decrease in FEV1
• Therefore: NO Pulmonary Toilet!
*Based on 3 RCTs and 1 observational study
*Bach PB, et al. Ann Intern Med 2001. 134: 600-620.
The Evidence: Pharmacologic
Therapies for COPD Exacerbation
ANTIBIOTICS
• Antibiotics indicated for exacerbation…
– COPD Exacerbation with 3/3 ‘cardinal
symptoms’: increased dyspnea, increased
sputum volume, increased sputum purulence
(Evidence B)*
– COPD Exacerbation with 2/3 ‘cardinal
symptoms’ that includes increased sputum
purulence (Evidence C)*
• Antibiotics indicated for hospitalized
exacerbation…?
*GOLD Initiative Guidelines
The Evidence: Antibiotic vs Placebo—
Outcome: Mortality
RR = 0.23 (0.10, 0.52), NNT = 8
Ram FSF, et al. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004403. DOI:
10.1002/14651858.DC004403.pub2.
The Evidence: Antibiotic vs Placebo—
Outcome: Treatment Failure
(limiting to hospitalized patients only)
RR = 0.47, NNT = 3
Ram FSF, et al. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004403. DOI:
10.1002/14651858.DC004403.pub2.
Antibiotic vs Placebo—
Outcome: Length of Stay
Ram FSF, et al. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004403. DOI:
10.1002/14651858.DC004403.pub2.
New Evidence
Procalcitonin Levels
Decision Support for Antibiotic Use in COPD Exacerbation
•
Background
– Serum procalcitonin may be useful for detecting bacterial
infections
•
Design
– RCT, blinded, COPD exacerbation presenting to ED
•
Randomized to:
– Rx guided by Procalcitonin level
•
<0.1  abx discouraged
•
>0.25  abx recommended
– Control
•
Clinician abx rx based on guidelines (attending discretion)
Stolz D, et al. Chest 2007; 131: 9-19.
New Evidence
Procalcitonin Levels
•
Results
– No difference b/w groups with respect to mortality, symptoms,
re-exacerbation rate, LOS, ICU LOS, FEV1
– +Reduction in ABX use
•
•
RR = 0.64 in procalcitonin-guided group
•
NNT = 4
Availability
– Not currently broadly available
•
Cost
– Lab Charge: approximately $170
Which Antibiotic?...not great evidence
Martinez FJ, et al. Expert
Rev Anti Infect Ther. 2006;
4: 101-124.
Bottom Line: Pharmacologic Therapies for
Hospitalized with COPD Exacerbation
YES!
NO!
•
•
Inhaled Bronchodilators
– Duh! (Evidence A)
•
•
– Unless you like that
‘speed’ feeling and
arrhythmias
Oxygen
– Duh! (No Evidence)
•
Systemic Steroids (Evidence A)
– Some evidence in
chronic COPD for
decreasing exacerbations
– Reduces Hospital LOS
•
Antibiotics
Mucolytic Agents
– Little valuable evidence
for exacerbations
– Improves BD response
– Improves time to next
exacerbation or rx failure
Methylxanthine
•
Chest PT
•
Heliox
Question #3
(enough of the drugs, lets move
onto electronics gadgets…)
Question #3: NPPV for COPD
Exacerbation
•
Will Mr. BH benefit from non-invasive positive
pressure ventilation (NPPV)?
•
Reminder—ABG on 2L O2 NC:
–
•
pH 7.36, pCO2 58, pO2 64
Which patients attain benefit from this therapy?
A. pH 7.10 – 7.30
B. pH 7.25 – 7.35
C. pH > 7.25
D. pH > 7.35
NPPV
Indications
Contraindications
•
COPD exacerbations
•
Cardiac/Respiratory arrest
•
Hypoxemic or ventilatory
Respiratory Failure
•
Malignant arrhythmias
•
Refractory hypoxemia
•
CHF
•
Hemodynamic instability
•
Extubation Management
•
Severe encephalopathy
•
Unable to tolerate mask
•
High risk of aspiration
•
Anatomic abnormalities
NPPV vs Usual Care
• Meta-Analysis of RCTs (14)
– Concealed allocation, unblinded
• Patients
– COPD with Respiratory Failure
– Total of 758 patients studied
Averages for Studies
Age: 63-76
Adm pH: 7.26-7.34
FEV1: 0.68-1.03
• Outcomes
– Mortality (n = 622)
– Treatment Failure (n = 541)
– Intubation (n = 758)
– LOS (n = 546)
– Other Surrogate Outcomes (RR, pCO2, pH)
NPPV vs Usual Care—
Outcome: Mortality
RR = 0.52 (95%CI: 0.35, 0.76), NNT = 10
Ram FS, et al. Non-invasive positive pressure ventilation for treatment of respiratory failure due to
exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews.
(3):CD004104, 2004.
NPPV vs Usual Care—
Outcome: Mortality
pH 7.3-7.35
Summary
pH < 7.3
Summary
Ram FS, et al.
Cochrane Database
of Systematic
Reviews.(3):CD00410
4, 2004.
ICU
Summary
Ward
Summary
NPPV vs Usual Care—
Outcome: Treatment Failure
RR 0.48 (95%CI: 0.37, 0.63), NNT = 5
Ram FS, et al. Cochrane Database of Systematic Reviews. (3):CD004104, 2004.
NPPV vs Usual Care—
Outcome: Intubation
RR 0.41 (95%CI: 0.33, 0.53), NNT = 4
Ram FS, et al. Cochrane Database of Systematic Reviews. (3):CD004104, 2004.
NPPV vs Usual Care—
Outcome: LOS
LOS Reduction 3.2 days (95%CI: 2.1 - 4.4 days)
Ram FS, et al. Cochrane Database of Systematic Reviews. (3):CD004104, 2004.
What about less severe exacerbations?
NPPV for pH > 7.30?
Systematic Review, Annals of IM
“Non-Severe Exacerbations”: pH>7.30
)
•
Hospital
Mortality
•
Intubations
Keenan SP, et al. Ann Intern Med. 2003.
NPPV for pH > 7.35?
•
RCT 2007
*pCO2
– NPPV + Usual Care vs.
– Usual Care
•
Hospital Admissions for COPD
Exacerbation
•
pH>7.35 in all patients
•
Results
– No mortality or intubation
reduction
*
**
LOS
– More rapid reduction in pCO2*
– +LOS Reduction (5.5 vs. 10.2
days, p = 0.0004)**
Pastaka C, et al. Eur J Intern Med 2007; 18: 524-530.
Bottom Line: NPPV in
COPD Exacerbation
• Improves respiratory status
– Rapidly improved physiologic variables (pH, PCO2, RR,
breathlessness)
• Reduces Hospital LOS
– >3 days on average!
– Even for less severe exacerbations (pH>7.35)
• Reduced Intubation Rate
– NNT 4
• Reduced complications (e.g. VAP)
• Improves mortality!!
– NNT 10
Evidence Level A
Bottom Line: NPPV in
COPD Exacerbation
• Maintain a low threshold to utilize!
• Apply in the ED!!
– Early intervention likely improves outcomes
• Monitor closely with ABGs (30-60 min after
initiation or change in NPPV settings)
• Adjust with assistance from RT
– Mask type, pressure levels (usual start 10/5)
• Recommendations/Guidelines: pH 7.25-7.35
– But likely benefit in COPD exacerbation with
• pH < 7.25 (use cautiously, monitor closely)
• pH > 7.35 (LOS benefit)
Question #4
Comorbid Conditions
Question #4: ß-block in COPD
Exacerbation
•
Mr. BH has had a recent MI, and now has
a mildly elevated troponin during this
admission.
•
Should Mr. BH continue his ß-block
therapy in this setting of acute
exacerbation?
A. Yes
B. No
C. Who knows?—no data in exacerbations
The Evidence and Bottom Line:
ß-block in COPD Exacerbation
• NO Studies in inpatient or outpatient
exacerbations!
• Outpatient studies summarized in 2007
Meta-Analysis (Cochrane Collaboration)
– 20 RCTS in patients with COPD, including
severe COPD
– No significant effects of single dose or longerterm treatment with ß-block on outcomes of
symptoms or FEV1
Salpeter S, et al. Cardioselective beta-blockers for chronic obstructive pulmonary disease. Cochrane Database
of Systematic Reviews 2005, Issue 4. Art. No.: CD003566. DOI: 10.1002/14651858.CD003566pub2.
Case (continued)
• Mr. BH was placed on NPPV in the ED,
started on q2 hour albuterol nebulizer
therapy, IV methylprednisolone 30mg bid,
doxycycline 100mg bid, and continued on
his cardioselective beta-blocker.
• His symptoms improved quickly, and he
was able to rapidly wean off of NPPV and
repeat ABG on Day 2 revealed pH 7.42,
pCO2 38, pO2 69 on 1L NC.
Question #5
Prevention During
Hospitalization
and At Discharge
Question #5: Prevention During
Hospitalization and @ Discharge
•
What interventions should be instituted by
hospitalists (prior to or at discharge), as
supported by outcomes in COPD patients?
A. Tobacco Cessation Counseling
B. Pneumonia Vaccine (if not previously received)
and Influenza Vaccine (if not received this
season)
C. VTE Prophylaxis
D. Augment Home Medication Regimen (if so, which
ones?)
Prevention for COPD:
Smoking Cessation Counseling
 Smoking Cessation Counseling
 Single counseling event, tob cessation 1 yr
 Meta-analysis RCTs*
 ARR 2% (NNT 50)
 P<0.001
 Pneumonia Outcomes Research Team
(PORT)**
 15% of counseled quit
 93% of those who quit did so at the time they
developed PNA
*Law M, Tang JL. Arch Intern Med. 1995; 155: 1933-41.
**Rhew DC. Ann Intern Med. 2001; 135: 736-43.
Smoking Cessation Slows Lung
Function Decline in Mild COPD:
The Lung Health Study at 11 Years
2.9
2.8
2.7
2.6
2.5
2.4
Sustained quitters
2.3
Intermittent quitters
2.2
Continuous
smokers
2.1
2
0
1
2
3
4
5
6
7
Anthonisen NR et al. Am J Respir Crit Care Med 2002:166:675-9.
Calverley PMA and Walker P. Lancet 2003;362:1053-1061.
8
9
10
11
Prevention for COPD:
Vaccination
 Pneumococcal
Vaccination*
 Chronic Lung
Disease
 Reduced Mortality
 RRR 30%
 Reduced Pneumonia
 RRR 43%
 Influenza Vaccination in
Chronic Lung Disease**
 Reduced mortality
 RRR >50%
 Reduced hospitalization
 RRR 20-30%
 Reduced PNA
 Cost-effective
 Annual Revaccination
necessary
*Nichol KL, et al. Arch Intern Med. 1999; 159: 2437-42.
**Multiple studies
*Large Retrospective Cohort
Summary: Seymann GB. J of Hosp Med. 2006; 1: 344-53.
Jackson LA, et al. N Engl J Med. 2003; 348: 1747-55.
Prevention for COPD:
VTE Prophylaxis
• Prevalence of VTE in COPD Exacerbation
– Up to 30% based on Autopsy Studies*
– Approx 10% based on retrospective assessments*
– Risk of VTE in COPD: Adjusted HR 1.33 (1.17-1.51)**
• >92,000 patients inpatient COPD
• Comparison HRs
– ICU Adm: HR 1.35
– Paralysis/paresis: HR 1.35
*Ambrosetti M, et al. Prevalence and prevention of venous thromboembolism in patients with acute
exacerbations of COPD. Thrombosis Research 2003. 112: 203-207. [systematic review]
**Edelsberg J, et al. Risk of venous thromboembolism among hospitalized medically ill patients. Am J
Health-Syst Pharm 2006. 63 (S6): S16-S22.
Prevention for COPD:
VTE Prophylaxis
• Pharmacologic prophylaxis*
– Reduces risk of VTE with use of pharmacologic
prophylaxis (LMWH or UFH) in medical patients
• RRR 55%
• ACCP Guidelines for VTE Prophylaxis (Grade 1A,
RCT):
– “Acutely ill medical patients admitted...with severe
respiratory disease…” should receive pharmacologic
VTE prophylaxis
*Mismetti P, et al. Prevention of venous thromboembolism in internal medicine with unfractionated or lowmolecular-weight heparins: a meta analysis of randomised clinical trials. Thromb Haemost 2000; 83: 14-19.
Geerts WH, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and
Thrombolytic Therapy. Chest 2004. 126(3 Suppl):338S-400S.
Prevention:
Augmentation of Home Medication
Regimen—Newest Evidence
• Systematic Review of RCTs and Meta-Analyses
• Published November 2007
• Outcomes:
 Mortality Reduction
 Exacerbation Reduction
Prevention:
Augmentation of Home Medication Regimen—
OUTCOME: Mortality
• Outpatient Interventions that Reduce Mortality
(statistically significant…and clinically relevant!)
• Severity @ baseline: Mod to Very Severe
 Combined LABA and Corticosteroid therapy vs.
Placebo*
 >4600 patients
 Mortality reduction: RR = 0.83, NNT = 53
 Combined LABA and corticosteroid therapy vs.
Corticosteroid therapy alone*
 Mortality reduction: RR = 0.79, NNT = 44
 Combined LABA and corticosteroid vs. Tiotropium**
 Mortality reduction: RR = 0.56, NNT = 55 (p = 0.032)
*Wilt TJ, et al. Ann Intern Med 2007; 147: 639-653.
**Wedzicha JA, et al. Am J Respir Crit Care Med 2008; 177: 19-26.
Prevention:
Augmentation of Home Medication Regimen—
OUTCOME: Mortality
Inhaled Combined LABA and Corticosteroid therapy
vs. Placebo
 RR = 0.83, NNT = 53
Wilt TJ, et al. Ann Intern Med 2007; 147: 639-653.
Prevention:
Augmentation of Home Medication Regimen—
OUTCOME: Mortality
• No Mortality Reduction with the following
inhaled therapies (vs. placebo):
– Short-Acting Anticholinergic (Ipratropium)
– Long-Acting Anticholinergic (Tiotropium)
– LABA alone
– Corticosteroids alone
– D2/ß2-Agonist (Sibenadet)
Wilt TJ, et al. Ann Intern Med 2007; 147: 639-653.
Prevention:
Augmentation of Home Medication Regimen—
OUTCOME: Exacerbations
Outpatient Inhaled Therapies that Reduce Exacerbations vs.
Placebo (statistically significant)
YES!!
• Tiotropium (p<0.001)
RR = 0.84, NNT = 15
• LABA (p<0.001)
RR = 0.76, NNT = 13
• Corticosteroids (p=0.01)
RR = 0.87, NNT = 22
• Combined LABA and
corticosteroid (p=0.06)
RR = 0.83, NNT = 16
No!!
• Ipratropium
Wilt TJ, et al. Ann Intern Med 2007; 147: 639-653.
Bottom Line: Hospitalist Prevention
Efforts for COPD Exacerbation
•
Tobacco Cessation
Counseling
•
Pneumonia Vaccine
and Influenza Vaccine
•
VTE Prophylaxis during
hospital stay
•
Augment Home
Medication Regimen

LABA + Corticosteroid
inhalers
Case
• Mr. BH recovers from his exacerbation,
but his resting O2 Sat is 89%.
• Repeat ABG at resolution of exacerbation
reveals pO2 57.
• Q: Will Mr. BH benefit from and qualify for
home oxygen therapy?
Question #6
Home O2
Who Benefits from and qualifies
for Home Oxygen Therapy?
•
Evidence for Benefit
– Supplemental O2 for >15 hours/day to
maintain pO2 > 60*
– Reduced death** in patients with
•
•
Mean FEV1 < 30% &
•
PaO2 < 55
Medicare Criteria
*Report of the Medical Research Council Working Party. Lancet 1981; 1: 681-686.
**Gorecka D, et al. Thorax 1997; 52: 674-679.
Medicare Coverage Criteria:
Home Oxygen Therapy
Group I Coverage
Group II Coverage
•
•
PaO2 56-59mmHg or SaO2
89% +
•
Any of the following*:
PaO2 < 55 or SaO2 < 88%
– At Rest
– During Sleep
•
– Dependent Edema
OR ↓ PaO2 > 10mmHg or ↓
SaO2 5% associated with
symptoms or signs of
hypoxemia*
– Pulmonary HTN or Cor
Pulmonale
– Erythrocythemia
– During Activity
•
•
Hct > 56%
Requires re-testing between
61 and 90 days
Final Summary
Final Summary
•
Pharmacologic Therapies
•
 Bronchodilators
 Smoking Cessation Counseling—
YES!!
 Inhaled—YES!
o
 Vaccines
Oral/IV—No!
 Pneumovax—YES!
 Steroids—YES!
 Influenza Vaccine—YES!
 Antibiotics—YES!!!
 VTE Prophylaxis—YES!!
 Procalcitonin levels to decide?
•
Other Therapies
•
Prevention (Home Regimen)
 Augmentation with combined
LABA/steroid inhaled—YES!!
 Oxygen—YES!
 NPPV—ABSOLUTELY YES!!!
 Mortality Reduction!!
 Mucolytics—Maybe!
o
Prevention (Inpatient)
 Most others for exacerbation and
symptom reduction
Chest PT—NO!!
•
Home O2: Medicare Criteria
COPD Exacerbation:
Practical Evidence-based
Strategies
Daniel D. Dressler, MD, MSc
Director of Education
Section of Hospital Medicine
IM Associate Residency Director
Assistant Professor of Medicine
Emory University School of Medicine
[email protected]
Society of Hospital Medicine Annual Meeting
San Diego, California
April 4, 2008