Management of acute exacerbations of chronic obstructive pulmonary disease (COPD). Guidelines from the Société de pneumologie de langue française (summary)

Risk factors and effect of dyspnea inappropriate treatment in adults' emergency department: a retrospective cohort study

Dyspnea is a frequent symptom in adults' emergency departments (EDs). Misdiagnosis at initial clinical examination is common, leading to early inappropriate treatment and increased in-hospital mortality. Risk factors of inappropriate treatment assessable at early examination remain undescribed herein. The objective of this study was to identify clinical risk factors of dyspnea and inappropriate treatment in patients admitted to ED. This is an observational retrospective cohort study. Patients over the age of 15 who were admitted to adult EDs of the University Hospital of Toulouse (France) with dyspnea were included from 1 July to 31 December 2019. The primary end-point was dyspnea and inappropriate treatment was initiated at ED. Inappropriate treatment was defined by looking at the final diagnosis of dyspnea at hospital discharge and early treatment provided. Afterward, this early treatment at ED was compared to the recommended treatment defined by the International Guidelines for Acute Heart Failure, bacterial pneumonia, chronic obstructive pulmonary disease, asthma or pulmonary embolism. A total of 2123 patients were analyzed. Of these, 809 (38%) had inappropriate treatment in ED. Independent risk factors of inappropriate treatment were: age over 75 years (OR, 1.46; 95% CI, 1.18-1.81), history of heart disease (OR, 1.32; 95% CI, 1.07-1.62) and lung disease (OR, 1.47; 95% CI, 1.21-1.78), SpO2 <90% (OR, 1.64; 95% CI, 1.37-2.02), bilateral rale (OR, 1.25; 95% CI, 1.01-1.66), focal cracklings (OR, 1.32; 95% CI, 1.05-1.66) and wheezing (OR, 1.62; 95% CI, 1.31-2.03). In multivariate analysis, under-treatment significantly increased in-hospital mortality (OR, 2.13; 95% CI, 1.29-3.52) compared to appropriate treatment. Over-treatment nonsignificantly increased in-hospital mortality (OR, 1.43; 95% CI, 0.99-2.06). Inappropriate treatment is frequent in patients admitted to ED for dyspnea. Patients older than 75 years, with comorbidities (heart or lung disease), hypoxemia (SpO2 <90%) or abnormal pulmonary auscultation (especially wheezing) are at risk of inappropriate treatment.

Diagnostic yield of viral multiplex PCR during acute exacerbation of COPD admitted to the intensive care unit: a pilot study

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is one of the leading causes of admission to the intensive care unit, often triggered by a respiratory tract infection of bacterial or viral aetiology. Managing antibiotic therapy in this context remains a challenge. Respiratory panel molecular tests allow identifying viral aetiologies of AECOPD. We hypothesized that the systematic use of a respiratory multiplex PCR (mPCR) would help antibiotics saving in severe AECOPD. Our objectives were to describe the spectrum of infectious aetiologies of severe AECOPD, using a diagnostic approach combining conventional diagnostic tests and mPCR, and to measure antibiotics exposure. The study was bicentric, prospective, observational, and included 105 critically ill patients with a severe AECOPD of presumed infectious aetiology, in whom a respiratory mPCR with a viral panel was performed in addition to conventional microbiological tests. Altogether, the microbiological documentation rate was 50%, including bacteria alone (19%), respiratory viruses alone (16%), and mixed viruses and bacterial species (16%). The duration of antibiotic therapy was shorter in patients without documented bacterial infection (5.6 vs. 9 days; P = 0.0006). This pilot study suggests that molecular tests may help for the proper use of anti-infective treatments in critically ill patients with severe AECOPD.

Efficacy and safety of oral corticosteroids to treat outpatients with acute exacerbations of COPD in primary care: a multicentre pragmatic randomised controlled study

Aim

To compare prednisone and placebo for the treatment of outpatients treated for acute exacerbations of chronic obstructive pulmonary disease (COPD) in a primary care setting.

Methods

A multicentre, parallel, double-blind, pragmatic randomised controlled trial was performed in France. A total of 66 general practitioners included patients aged ≥40 years with cumulative smoking of ≥10 pack-years and a diagnosis of certain or likely acute exacerbation of COPD. Oral prednisone (40 mg) or placebo were administered daily for 5 days. The main outcome was treatment failure at 8 weeks, defined as a composite criterion based on the occurrence of at least one of the following: unplanned visit to an emergency department or to a practitioner in the ambulatory setting, hospital admission or death. The planned sample size was 202 patients per group.

Results

175 patients were included from February 2015 to May 2017 (43% of the planned sample). All-cause 8-week treatment failure rate was 42.0% in the prednisone group and 34.5% in the placebo group (relative risk 1.22, 95% CI 0.87-1.69, p=0.25). Respiratory-related 8-week treatment failure rate was 27.6% in the prednisone group and 13.6% in the placebo group (relative risk 2.00, 95% CI 1.15-3.57, p=0.015).

Conclusion

Although the planned sample size was not achieved, the study does not suggest that oral corticosteroids are more effective than placebo for the treatment of an acute exacerbation of COPD in a primary care setting.

Use and persistence of single and multiple inhaler triple therapy prescribed for patients with COPD in France: a retrospective study on THIN database (OPTI study)

INTRODUCTION

From 2018 single inhaler triple therapy (SITT) became available in France to treat moderate-to-severe chronic obstructive pulmonary disease (COPD). Given its simplified inhaler use compared with multiple inhaler triple therapy (MITT), this therapeutic option has the potential to offer benefit in terms of improved persistence and adherence. Given the lack of real-world evidence of the effectiveness of triple therapy, this study was designed to evaluate the use of MITT and SITT in France and compare persistence.

METHODS

A retrospective cohort study was performed. Patients with COPD who initiated triple therapy between 1 July 2017 and 31 December 2019 were included from The Health Improvement Network, a large electronic medical database in France, which includes pharmacy data. A 60-day treatment gap defined discontinuation and thereby persistence.

RESULTS

A total of 3134 patients initiated triple therapy for COPD in the study period, among them 485 with SITT. In 2019, the rate of use of SITT was 28.2%. The mean age (67.3 years) and sex (44.2% female) of patients initiating triple therapy was similar between MITT and SITT, and most patients had escalated from dual therapy (84.1%). However, SITT was more frequently initiated by a pulmonologist (59.8%) and a higher prevalence of comorbid asthma was observed for SITT (47.0% vs 37.9%). Persistence was assessed among patients who did not discontinue after a single dispensation of triple therapy (n=1674). Median persistence was 181 days for SITT and 135 days for MITT, and the covariate-adjusted HR for persistence was 1.47 (p<0.001) and the estimated persistence at 1 year was 33% for SITT compared with 18% for MITT.

DISCUSSION

This study suggests that persistence was higher for the patients treated with SITT compared with MITT in France. Moreover, most patients initiated with triple therapy were previously treated with dual therapy and had exacerbations in the previous year.

Antibiotic stewardship in the ICU: time to shift into overdrive

Antibiotic resistance is a major health problem and will be probably one of the leading causes of deaths in the coming years. One of the most effective ways to fight against resistance is to decrease antibiotic consumption. Intensive care units (ICUs) are places where antibiotics are widely prescribed, and where multidrug-resistant pathogens are frequently encountered. However, ICU physicians may have opportunities to decrease antibiotics consumption and to apply antimicrobial stewardship programs. The main measures that may be implemented include refraining from immediate prescription of antibiotics when infection is suspected (except in patients with shock, where immediate administration of antibiotics is essential); limiting empiric broad-spectrum antibiotics (including anti-MRSA antibiotics) in patients without risk factors for multidrug-resistant pathogens; switching to monotherapy instead of combination therapy and narrowing spectrum when culture and susceptibility tests results are available; limiting the use of carbapenems to extended-spectrum beta-lactamase-producing Enterobacteriaceae, and new beta-lactams to difficult-to-treat pathogen (when these news beta-lactams are the only available option); and shortening the duration of antimicrobial treatment, the use of procalcitonin being one tool to attain this goal. Antimicrobial stewardship programs should combine these measures rather than applying a single one. ICUs and ICU physicians should be at the frontline for developing antimicrobial stewardship programs.

Impact of corticosteroids on the duration of ventilatory support during severe acute exacerbations of chronic obstructive pulmonary disease in patients in the intensive care unit: a study protocol for a multicentre, randomized, placebo-controlled, double-blind trial

BACKGROUND

Patients who are admitted to the intensive care unit (ICU) for severe acute exacerbations of chronic obstructive pulmonary disease (COPD) have poor outcomes. Although international clinical practice guidelines cautiously recommend the routine use of systemic corticosteroids for COPD exacerbations, data are scarce and inconclusive regarding their benefit for most severe patients who require mechanical ventilation in the ICU. Furthermore, corticosteroids may be associated with an increased risk of infection, ICU-acquired limb weakness, and metabolic disorders.

METHODS AND ANALYSIS

This study is an investigator-initiated, multicentre, randomized, placebo-controlled, double-blind trial comparing systemic corticosteroids to placebo during severe acute exacerbations of COPD in patients who require mechanical ventilation in French ICUs. A total of 440 patients will be randomized 1:1 to methylprednisolone (1 mg/kg) or placebo for 5 days, and stratified according to initial mechanical ventilation (non-invasive or invasive), pneumonia as triggering factor, and recent use of systemic corticosteroids (< 48 h). The primary outcome is the number of ventilator-free days at day 28, defined as the number of days alive and without mechanical invasive and/or non-invasive ventilation between randomization and day 28. Secondary outcomes include non-invasive ventilation (NIV) failure rate, duration of mechanical ventilation (invasive and/or NIV), circulatory support (vasopressor), outcomes related to corticosteroid adverse events (severe hyperglycaemia, gastrointestinal bleeding, uncontrolled arterial hypertension, ICU-acquired weakness, ICU-acquired infections, and delirium), lengths of ICU and hospital stay, ICU and hospital mortality, day 28 and day 90 mortality, number of new exacerbation(s)/hospitalization(s) between hospital discharge and day 90, and dyspnoea and comfort at randomization, ICU discharge, and day 90. Subgroup analyses for the primary outcome are planned according to stratification criteria at randomization.

Pulmonary Embolism and Respiratory Deterioration in Chronic Cardiopulmonary Disease: A Narrative Review

Patients with chronic cardiopulmonary pathologies have an increased risk of developing venous thromboembolic events. The worsening of dyspnoea is a frequent occurrence and often leads patients to consult the emergency department. Pulmonary embolism can then be an exacerbation factor, a differential diagnosis or even a secondary diagnosis. The prevalence of pulmonary embolism in these patients is unknown, especially in cases of chronic heart failure. The challenge lies in needing to carry out a systematic or targeted diagnostic strategy for pulmonary embolism. The occurrence of a pulmonary embolism in patients with chronic cardiopulmonary disease clearly worsens their prognosis. In this narrative review, we study pulmonary embolism and chronic obstructive pulmonary disease, after which we turn to pulmonary embolism and chronic heart failure.

Early antibiotic therapy is associated with a lower probability of successful liberation from mechanical ventilation in patients with severe acute exacerbation of chronic obstructive pulmonary disease

Background

While antibiotic therapy is advocated to improve outcomes in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) whenever mechanical ventilation is required, the evidence relies on small studies carried out before the era of widespread antibiotic resistance. Furthermore, the impact of systematic antibiotic therapy on successful weaning from mechanical ventilation was never investigated accounting for the competitive risk of death. The aim of the study was to assess whether early antibiotic therapy (eABT) increases successful mechanical ventilation weaning probability as compared to no eABT, in patients with AECOPD without pneumoniae, using multivariate competitive risk regression.

Methods

Retrospective analysis of patients admitted in 2 intensive care units (ICU) from 2012 to 2020 for AECOPD without pneumonia and requiring mechanical ventilation. eABT was defined as any anti-bacterial chemotherapy introduced during the first 24 h after ICU admission. The primary outcomes were the adjusted subdistribution hazard ratio (SHR) of the probability of being successfully weaned from mechanical ventilation (i.e. non-invasive and invasive ventilation) according to eABT status and accounting for the competitive risk of death.

Results

Three hundred and ninety-one patients were included, of whom 66% received eABT. eABT was associated with a lower probability of successful liberation from mechanical ventilation when accounting for the competing risk of death in multivariate analyses (SHR 0.71 [95% confidence interval, 0.57–0.89], p < 0.01), after adjustment with covariates of disease severity. This association was present in all subgroups except in patients under invasive mechanical ventilation on ICU day-1, in patients with ICU day-1 worst PaCO₂ > 74 torr (median value) and in patients with a documented bacterial bronchitis at ICU admission. Ventilator-free days at day 28, ICU-free days at day 28 and invasive mechanical ventilation-free days at day 28, were significantly lower in the eABT group, while there was no significant difference in mortality at day 28 between patients who received eABT and those who did not.

Conclusions

eABT was independently associated with a lower probability of being successfully weaned from mechanical ventilation, suggesting that the clinician decision to overrule systematic administration of eABT was not associated with a detectable harm in AECOPD ICU patients without pneumonia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01060-2.

Management of acute COPD exacerbations in France: A qualitative survey in a private practice setting

Background

The current prevalence of chronic obstructive pulmonary disease (COPD) in France is estimated to be 2.6 million and is predicted to increase to 2.8 million by 2025. Presently, there is a lack of data on COPD management within the private healthcare setting. The aim of this study was to investigate the management of COPD exacerbations by pulmonologists within private practices in France.

Methods

A prospective, online, qualitative survey was distributed to private practice pulmonologists in France. The survey covered all aspects of COPD management from diagnosis and therapeutic management, to secondary prevention and organization of care. Survey responses were collected between 27 January 2018 and 18 June 2018 and all data were summarized descriptively.

Results

The survey had a response rate of 20.6%, with 116 out of 563 pulmonologists providing responses. Overall, 87.4% of respondents stated that the management of COPD represented over 15% of their total clinical activity. Most respondents indicated that they work closely with general practitioners and a large multidisciplinary team to manage patients with numerous comorbidities. Following a COPD exacerbation, the majority of respondents (78.4%) were in favor of using respiratory-connected devices (class 2a-connected medical device according to the French HAS classification and available on medical prescription) to assist with patient follow-up at home.

Conclusions

COPD management forms part of the core clinical activity for pulmonologists within the private practice setting in France. Patients with COPD generally have multiple comorbidities and are managed by a multidisciplinary team in line with French guidelines. The use of respiratory-connected devices was highlighted as an important new strategy for improving patient care following a COPD exacerbation.

Telemedicine for Pre-Employment Medical Examinations and Follow-Up Visits on Board Ships: A Narrative Review on the Feasibility

BACKGROUND

Telemedicine has already been applied to various medical specialties for diagnosis, treatment, and follow-up visits for the general population. Telemedicine has also proven effective by providing advice, diagnosis, and treatment to seafarers during emergency medical events onboard ships. However, it has not yet been applied for pre-employment medical examinations and follow-up visits on board ships.

OBJECTIVE

This review aimed to assess the possibility of using telemedicine during periodic visits between one pre-employment medical examination and others on board ships, and to recommend necessary medical examination tests with screening intervals for seafarers.

METHODS

Various databases including PubMed, EMBASE, Scopus, CINAHL, and Cochrane Library were explored using different keywords, titles, and abstracts. Studies published between 1999 and 2019, in English, in peer-reviewed journal articles, and that are conference proceedings were considered. Finally, the studies included in this review were chosen on the basis of the eligibility criteria.

RESULTS

Out of a total of 168 studies, 85 studies were kept for further analysis after removing the duplicates. A further independent screening based on the inclusion and exclusion criteria resulted in the withdrawal of 51 studies that were not further considered for our analysis. Finally, 32 studies were left, which were critically reviewed. Out of 32 accepted studies, 10 studies demonstrated the effectiveness of the electrocardiogram (ECG) in monitoring and managing remote patients with heart failure, early diagnosis, and postoperative screening. In 15 studies, telespirometry was found to be effective in diagnosing and ruling out diseases, detecting lung abnormalities, and managing patients with chronic obstructive pulmonary disease (COPD) and asthma. Seven studies reported that telenephrology was effective, precise, accurate, and usable by non-medical personnel and that it reduced sample analysis times and procedures in laboratories.

CONCLUSION

using new technologies such as high-speed internet, video conferencing, and digital examination, personnel are able to make the necessary tests and perform virtual medical examination on board ships with necessary training.

Prioritising outcomes for evaluating eosinophil-guided corticosteroid therapy among patients with acute COPD exacerbations requiring hospitalisation: a Delphi consensus study

OBJECTIVES

Presently, those outcomes that should be prioritised for chronic obstructive pulmonary disease (COPD) exacerbation studies remain unclear. In order to coordinate multicentre studies on eosinophilia-driven corticosteroid therapy for patients hospitalised for acute exacerbation of COPD (AECOPD), we aimed to find consensus among experts in the domain regarding the prioritisation of outcomes.

DESIGN

A modified Delphi study was proposed to recognised COPD experts. Two brainstorming questionnaires were used to collect potential outcomes. Four subsequent rounds of questionnaires were used to rank items according to a six-point Likert scale for their importance in the protocol, as well as for being the primary outcome. Priority outcome criteria were predefined as those for which ≥70% of experts indicated that the outcome was essential for interpreting study results.

SETTING

COPD exacerbation management in France.

PARTICIPANTS

34 experts recommended by the French Language Pulmonology Society were invited to participate. Of the latter, 21 experts participated in brainstorming, and 19 participated in all four ranking rounds.

RESULTS

105 outcomes were ranked. Two achieved consensus as candidate primary outcomes: (1) treatment failure defined as death from any cause or the need for intubation and mechanical ventilation, readmission because of COPD or intensification of pharmacologic therapy, and (2) the time required to meet predefined discharge criteria. The 10 secondary priority outcomes included survival, time with no sign of improvement, episodes of hospitalisation, exacerbation, pneumonia, mechanical or non-invasive ventilation and oxygen use, as well as comorbidities during the initial hospitalisation.

CONCLUSIONS

This Delphi consensus project generated and prioritised a great many outcomes, documenting current expert views concerning a diversity of COPD endpoints. Among the latter, 12 reached consensus as priority outcomes for evaluating the efficacy of eosinophil-driven corticosteroid therapy in AECOPD inpatients.

STUDY REGISTRATION

The eo-Delphi project/protocol was registered on 23 January 2018 at https://osf.io/4ahqw/.

Spanish clinical practice consensus in internal medicine on chronic obstructive pulmonary disease patients with comorbidities (miEPOC)

Background: Chronic obstructive pulmonary disease (COPD) is one of the diseases that leads to a higher number of hospitalizations in internal medicine departments. These patients are usually older and have greater multimorbidity than COPD patients hospitalized in other departments, which hinders the implementation of clinical guidelines necessarily focused on the management of a single disease.Aims: To ascertain the opinion of Spanish internists on the management of COPD in scenarios in which the available evidence is sparse and to produce a consensus document designed to assist in decision-making in COPD patients with comorbidities treated in internal medicine services.Methods: After identifying the clinical areas of greatest uncertainty by consensus, a survey was designed with 89 questions on the epidemiology and diagnosis of COPD, its management both in stable phase and during decompensation, and the treatment of the associated comorbidities in outpatients and inpatients. The consensus process was carried out using the Delphi method in an anonymized two-round process.Results: The survey was completed by 67 internists experienced in the clinical management of COPD. Of all the questions posed, a consensus was reached for 51 (57.3%) in the first round and for 67 (75.3%) in the second round. The result of the process is a series of 67 suggestions that may assist in the care of these patients.Conclusions: Our study allows us to ascertain the views of a large number of internists experienced in the management of COPD and to learn how the recommendations for guidelines are applied in clinical practice.

Quels médicaments dans nos services mobiles d’urgence et de réanimation ?

Introduction : La dotation médicamenteuse nécessaire lors d’une intervention médicale préhospitalière n’est pas référencée, ce qui laisse chaque structure libre de constituer sa propre pharmacie. L’objectif principal de notre étude était de faire un état des lieux des dotations médicamenteuses des services mobiles d’urgence et de réanimation (Smur).

Méthode : Il s’agit d’une étude observationnelle déclarative, réalisée entre novembre 2017 et avril 2018 auprès de l’ensemble des Smur adultes de France.

Résultats : Sur 402 services sollicités, 191 (48 %) ont répondu et 177 (44 %) inclus. Un Smur disposait en moyenne de 74 ± 9 médicaments. Au total, 231 molécules ont été répertoriées. Parmi elles, 73 (32%) étaient disponibles dans plus de 50%des structures et 94 (41%) dans moins de 5%. Il existait des disparités des dotations médicamenteuses dans l’ensemble des spécialités, plus ou moins importantes selon la classe thérapeutique.

Discussion : La majorité des services dispose des médicaments nécessaires à la prise en charge des urgences les plus graves. Cependant, quelques recommandations ne sont pas toujours respectées. À la vue de nos résultats et des recommandations en vigueur, nous proposons une liste de molécules qui nous semblent être indispensables dans l’arsenal thérapeutique des Smur.

Nebulized Terbutaline and Ipratropium Bromide Versus Terbutaline Alone in Acute Exacerbation of Chronic Obstructive Pulmonary Disease Requiring Noninvasive Ventilation: A Randomized Double-blind Controlled Trial

BACKGROUND

Short-acting β₂ -agonists are the mainstay of treatment of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in the emergency department (ED). It is still unclear whether the addition of short-acting anticholinergics is clinically more effective care compared to treatment with β₂ -agonists alone in patients with hypercapnic AECOPD.

OBJECTIVE

The objective was to evaluate whether combining ipratropium bromide (IB) to terbutaline reduces hospital and intensive care unit (ICU) admission rates compared to terbutaline alone in AECOPD hypercapnic patients.

METHODS

In this double-blind controlled trial, patients who were admitted to the ED for AECOPD requiring noninvasive ventilation (NIV) were randomized to receive either 5 mg of nebulized terbutaline combined to 0.5 mg of IB (terbutaline/IB group, n = 115) or 5 mg of terbutaline sulfate (terbutaline group, n = 117). Nebulization was repeated every 20 minutes for the first hour and every 4 hours within the first day. Primary outcomes were the rate of hospital admission and need for endotracheal intubation within the first 24 hours of the start of the experimental treatment. Secondary outcomes included changes from baseline of dyspnea, physiologic variables, length of hospital stay, ICU admission rate, and 7-day mortality.

RESULTS

The two groups were similar regarding baseline demographic and clinical characteristics. Hospital admission was observed in 70 patients (59.8%) in the terbutaline/IB group and in 75 patients (65.2%) in the terbutaline group (respiratory rate [RR] = 1.09, 95% confidence interval [CI] = 0.93 to 1.27, p = 0.39). ICU admission was required in 37 (32.2%) patients in the terbutaline/IB group and 30 patients (25.6%) in terbutaline group (RR = 1.25, 95% CI = 1.02 to 1.54, p = 0.27). There were no significant differences in dyspnea score, blood gas parameters changes, vital signs improvement, and 7-day death rate between both groups.

CONCLUSION

In patients admitted to the ED for AECOPD requiring NIV, combination of nebulized IB and terbutaline did not reduce hospital admission and need to ICU care.

[From acute cough to chronic cough in adults: Overview on a common reason for consultation]

Cough is divided into two categories: acute cough lasting less than 3 weeks, and chronic cough lasting more than 8 weeks. Acute cough is usually triggered by a viral infection of the upper airways. Evidence of treatment effectiveness is low and management of acute cough is complex in clinical practice. Chronic cough is a common reason for consultation in medicine. The most frequent causes are upper airway diseases, gastroesophageal reflux disease, asthma, eosinophilic bronchitis, and drugs. Before investigation, smoking cessation and drug withdrawal must be achieved for 4 to 6 weeks. Once this step is completed, simple investigations have to be performed in order to find common causes of chronic cough (questioning, physical examination, spirometry, chest X-ray). If no causes have been identified or cough remains despite optimal treatment, exhaustive exploration has to be performed to rule out rare causes. A chronic cough hypersensitivity syndrome is suggested if any causes have been found despite exhaustive assessment or if cough remains with optimal treatments. This syndrome is characterized by an increase in the sensitivity of cough peripheral receptors and is not sensitive to usual therapies. The therapeutic options are limited but innovative treatments such as P2X3 receptor antagonists are in development.