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AHRQ Assesses Evidence for Best Management of COPD Exacerbations

Cheryl A. Thompson

The summary of an evidence report issued by the Agency for Healthcare Research and Quality (AHRQ) offers a preview of a soon-to-be-published clinical practice guideline on the management of acute exacerbations of chronic obstructive pulmonary disease (COPD).

According to the summary, based on a report developed by the Duke University Evidence-based Practice Center under contract to AHRQ, currently used therapies benefit some, but not all, adults having an acute exacerbation of COPD. AHRQ said that the report served as the basis for an upcoming clinical practice guideline developed by the American College of Physicians–American Society of Internal Medicine and the American College of Chest Physicians.

The evidence shows that antimicrobial treatment of acute exacerbations improves pulmonary function, but patients with more evidence of bacterial infection—purulent sputum—and more severe illness—a worsened peak expiratory flow rate---tend to reap greater benefit than other patients.

Inhaled ipratropium bromide and beta2-agonists have similar bronchodilating effects but do not conclusively outperform placebo or no treatment. Although ipratroprium generally produces fewer adverse effects than beta2-agonists do, the anticholinergic agent must be used cautiously in patients with urinary retention. Because patients having an acute exacerbation of COPD may be unable to hold their breath, nebulizers may be necessary to deliver bronchodilator therapy. The anticholinergic agent glycopyrrolate may act synergistically with a beta2-agonist to improve bronchodilation. Injectable aminophylline, compared with placebo, does not improve forced expiratory volume in one second or hospitalization or relapse rates.

There is strong evidence that patients hospitalized because of an acute exacerbation of COPD benefit from a course of systemic corticosteroids, but the optimal dosage and duration are not clear. Dosages as low as prednisone 30 mg/day and durations as short as three days have been effective; two- and eight-week courses of systemic corticosteroids have been similarly effective. Among patients with acute exacerbation of COPD the most common adverse effect of systemic corticosteroids is hyperglycemia. Inhaled corticosteroids have not been adequately tested in this patient population.

Potassium iodide, a mucolytic agent, does not improve ventilatory function in patients with acute exacerbation of COPD.

AHRQ expects the clinical practice guideline to be published this winter in Annals of Internal Medicine and Chest.