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COPD Exacerbation:Practical Evidence-based
Strategies
Daniel D. Dressler, MD, MScDirector of Education
Section of Hospital MedicineIM Associate Residency DirectorAssistant Professor of Medicine
Emory University School of [email protected]
Society of Hospital Medicine Annual MeetingSan 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 severityWeight lossNutritional abnormalitiesSkeletal muscle dysfunction
Classification of COPD Severity
by SpirometryStage 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: DefinitionAcute 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
• VS: BP 150/90, HR 110 (reg), RR 28, T 38.1
• Mild to Mod increased WOB, RR 28, alert.
• Lungs: significant bilat inspiratory and expiratory wheezes
• Ext: 1+ to 2+ edema bilat
Studies
• CXR: Chronic changes, hyperinflation
• ABG:
– 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 ExacerbationBRONCHODILATOR 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 ExacerbationBRONCHODILATOR 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 ExacerbationBRONCHODILATOR THERAPIES
Methylxanthine Bronchodilators: Efficacy
ED Return Visits within 1 wk Symptom Scores
Barr RG, et al. BMJ 2003. 327: 643-48.
The Evidence: Pharmacologic Therapies for COPD ExacerbationBRONCHODILATOR 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 ExacerbationSYSTEMIC 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 onA. FEV1 after BD, and B. LOS
A. FEV1 after BD (p<0.0001)
B. LOS (p = 0.039)
RCT data, 56 patients
Davies L, et al. Lancet 1999; 354: 456-60.
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.
Reduces mean number of exacerbations per subject per month (weighted mean difference, and 95% confidence intervals)*No effect on lung functionPoole, P. et al. BMJ 2001;322:1271
Mucolytic Agents in Chronic COPD:Effect on Exacerbations
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 = 8Ram 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 = 3Ram 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 EvidenceProcalcitonin Levels
• 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.
Decision Support for Antibiotic Use in COPD Exacerbation
New EvidenceProcalcitonin 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!
• Inhaled Bronchodilators
– Duh! (Evidence A)
• Oxygen
– Duh! (No Evidence)
• Systemic Steroids (Evidence A)
– Improves BD response
– Reduces Hospital LOS
– Improves time to next exacerbation or rx failure
• Antibiotics
NO!
• Methylxanthine
– Unless you like that ‘speed’ feeling and arrhythmias
• Mucolytic Agents
– Little valuable evidence for exacerbations
– Some evidence in chronic COPD for decreasing exacerbations
• 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
• COPD exacerbations
• Hypoxemic or ventilatory Respiratory Failure
• CHF
• Extubation Management
Contraindications
• Cardiac/Respiratory arrest
• Malignant arrhythmias
• Refractory hypoxemia
• Hemodynamic instability
• 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
• Outcomes
– Mortality (n = 622)
– Treatment Failure (n = 541)
– Intubation (n = 758)
– LOS (n = 546)
– Other Surrogate Outcomes (RR, pCO2, pH)
Averages for Studies
Age: 63-76
Adm pH: 7.26-7.34
FEV1: 0.68-1.03
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
ICU Summary
Ward Summary
Ram FS, et al. Cochrane Database of Systematic Reviews.
(3):CD004104, 2004.
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?
• Hospital Mortality
• Intubations
Systematic Review, Annals of IM
“Non-Severe Exacerbations”: pH>7.30
)
Keenan SP, et al. Ann Intern Med. 2003.
NPPV for pH > 7.35?
• RCT 2007
– NPPV + Usual Care vs.
– Usual Care
• Hospital Admissions for COPD Exacerbation
• pH>7.35 in all patients
• Results
– No mortality or intubation reduction
– 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.
*
** LOS
*pCO2
Bottom Line: NPPV inCOPD 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 10Evidence Level A
Bottom Line: NPPV inCOPD 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: 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 longer-term 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
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
0 1 2 3 4 5 6 7 8 9 10 11
Sustained quitters
Intermittent quitters
Continuoussmokers
Anthonisen NR et al. Am J Respir Crit Care Med 2002:166:675-9. Calverley PMA and Walker P. Lancet 2003;362:1053-1061.
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.
*Large Retrospective Cohort
Jackson LA, et al. N Engl J Med. 2003; 348: 1747-55.
**Multiple studies
Summary: Seymann GB. J of Hosp Med. 2006; 1: 344-53.
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 low-molecular-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
YES!!
• Tiotropium (p<0.001)
• LABA (p<0.001)
• Corticosteroids (p=0.01)
• Combined LABA and corticosteroid (p=0.06)
No!!
• Ipratropium
RR = 0.84, NNT = 15
RR = 0.76, NNT = 13
RR = 0.87, NNT = 22
RR = 0.83, NNT = 16
Outpatient Inhaled Therapies that Reduce Exacerbations vs. Placebo (statistically significant)
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
• PaO2 < 55 or SaO2 < 88%
– At Rest
– During Sleep
• OR ↓ PaO2 > 10mmHg or ↓ SaO2 5% associated with symptoms or signs of hypoxemia*
– During Activity
Group II Coverage
• PaO2 56-59mmHg or SaO2 89% +
• Any of the following*:
– Dependent Edema
– Pulmonary HTN or Cor Pulmonale
– Erythrocythemia
• Hct > 56%
• Requires re-testing between 61 and 90 days
Final Summary
Final Summary
• Pharmacologic Therapies
Bronchodilators
Inhaled—YES!
o Oral/IV—No!
Steroids—YES!
Antibiotics—YES!!!
Procalcitonin levels to decide?
• Other Therapies
Oxygen—YES!
NPPV—ABSOLUTELY YES!!!
Mucolytics—Maybe!
o Chest PT—NO!!
• Prevention (Inpatient)
Smoking Cessation Counseling—YES!!
Vaccines
Pneumovax—YES!
Influenza Vaccine—YES!
VTE Prophylaxis—YES!!
• Prevention (Home Regimen)
Augmentation with combined LABA/steroid inhaled—YES!!
Mortality Reduction!!
Most others for exacerbation and symptom reduction
• Home O2: Medicare Criteria
COPD Exacerbation:Practical Evidence-based
Strategies
Daniel D. Dressler, MD, MScDirector of Education
Section of Hospital MedicineIM Associate Residency DirectorAssistant Professor of Medicine
Emory University School of [email protected]
Society of Hospital Medicine Annual MeetingSan Diego, California
April 4, 2008