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Nebulized corticosteroids in the management of acute exacerbation of COPD
Gaude G,Nadagouda S
Lung India , 2010,
Abstract: Acute exacerbations in chronic onstructive pulmonary disease (COPD) are common and systemic steroids play an important role in the management of these cases along with the bronchodilators. Nebulized budesonide is being used in the acute attacks of bronchial asthma either in children or in adults. But the role of nebulized steroids in acute exacerbation of COPD is not much studied in the literature. In this clinical review we have evaluated the role of nebulized corticosteroids in the management of acute exacerbation of COPD (AECOPD). Through Medline, Pubmed and Embase we analyzed the various studies that has been done to study the role of nebulized corticosteroids in the management of acute exacerbation of COPD. The key words used for the search criteria were: acute exacerbation, COPD, nebulized corticosteroids, budesonide, fluticasone. Only eight studies were found which had evaluated the role of nebulized corticosteroids in acute exacerbations of COPD. All these studies had used nebulized budesonide in AECOPD in different dosages, and had been compared with both either parental or oral steroids, and standard bronchodilator therapy. All the studies had found the clinical efficacy of nebulized budesonide to be of similar extent to that of either parental or oral steroids in AECOPD. Side effects profile of nebulized budesonide was minimal and acceptable as compared to systemic steroids. Nebulized budesonide may be an alternative to parental/oral prednisolone in the treatment of acute exacerbations of COPD but further studies should be done to evaluate its long-term impact on clinical outcomes after an initial episode of COPD exacerbation.
Sputum Inflammatory Cell-Based Classification of Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease  [PDF]
Peng Gao, Jie Zhang, Xiaoyan He, Yuqiu Hao, Ke Wang, Peter G. Gibson
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0057678
Abstract: Background Patients with chronic obstructive pulmonary disease (COPD) commonly suffer from acute exacerbations (AECOPD) and display varying disease severity. However, there is no available biomarker for the classification of AECOPD. This study is aimed at investigating the sputum cellular profiles to classify patients with AECOPD. Methods A total of 83 patients with AECOPD and 26 healthy controls were recruited. Their demographic and clinical characteristics were recorded, and their lung function was examined. The phenotypes of sputum inflammatory cells were characterised, and the concentrations of sputum and serum amyloid-A (SAA), C-reactive protein (CRP), interleukin-6 (IL-6), and matrix metalloproteinase-9 (MMP-9) were measured. Based on the sputum inflammatory cell profiles, individual patients were categorized into one of the four subgroups with inflammatory eosinophilic, neutrophilic, paucigranulocytic, and mixed granulocytic AECOPD. Most AECOPD patients were reevaluated within 12–14 months after discharge. Results There were 10 (12%) eosinophilic, 36 (43%) neutrophilic, 5 (6%) mixed granulocytic, and 32 (39%) paucigranulocytic AECOPD patients. The patients with mixed granulocytic or neutrophilic AECOPD had a higher BODE score, more sputum inflammatory cells, lower lung function, and longer hospital stay, accompanied by higher concentrations of sputum MMP-9, IL-6 and CRP, and serum SAA, IL-6 and CRP. Notably, 83% of patients with neutrophilic AECOPD displayed evidence of bacterial infection and many of them responded poorly to standard therapies. In addition, patients with mixed granulocytic or neutrophilic stable COPD remained at lower lung functions and higher levels of inflammation. Conclusion Patients with AECOPD display heterogeneous inflammation, and the profiles of sputum inflammatory cells may be used as valuable biomarkers for the classification of AECOPD patients.
Study of Factors Determining Outcomes in the Hospitalized Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD)  [PDF]
MJ Sijapati,N Bhatta,B Khanal,M Lamsal,S Chaudhary
Journal of Universal College of Medical Sciences , 2014, DOI: 10.3126/jucms.v2i2.11171
Abstract: BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is a major cause of mortality and morbidity across the world. Information related to the factors associated with COPD exacerbation and factors determining outcome in hospitalized patient with acute exacerbation of COPD are very important for effective long-term management of this disease. Within this background we attempted to study the factors determining outcome in hospitalized patients with acute exacerbation of COPD.
MMP-9, TIMP-1 and inflammatory cells in sputum from COPD patients during exacerbation
PF Mercer, JK Shute, A Bhowmik, GC Donaldson, JA Wedzicha, JA Warner
Respiratory Research , 2005, DOI: 10.1186/1465-9921-6-151
Abstract: This study has prospectively examined changes in sputum levels of inflammatory cells, MMP-9 and TIMP-1 during exacerbations comparing with paired samples taken prior to exacerbation.Nineteen COPD patients ((median, [IQR]) age 69 [63 to 74], forced expiratory volume in one second (FEV1) 1.0 [0.9 to1.2], FEV1% predicted 37.6 [27.3 to 46.2]) provided sputa at exacerbation. Of these, 12 were paired with a samples collected when the patient was stable, a median 4 months [2 to 8 months] beforehand.MMP-9 levels increased from 10.5 μg/g [1.2 to 21.1] prior to exacerbation to 17.1 μg/g [9.3 to 48.7] during exacerbation (P < 0.01). TIMP-1 levels decreased from 3.5 μg/g [0.6 to 7.8] to 1.5 μg/g [0.3 to 4.9] (P = 0.16). MMP-9/TIMP-1 Molar ratio significantly increased from 0.6 [0.2 to 1.1] to 3.6 [2.0 to 25.3] (P < 0.05). Neutrophil, eosinophil and lymphocyte counts all showed significant increase during exacerbation compared to before (P < 0.05). Macrophage numbers remained level. MMP-9 levels during exacerbation showed highly significant correlation with both neutrophil and lymphocyte counts (Rho = 0.7, P < 0.01).During exacerbation, increased inflammatory burden coincides with an imbalance of the proteinase MMP-9 and its cognate inhibitor TIMP-1. This may suggest a pathway connecting frequent exacerbations with lung function decline.Chronic obstructive pulmonary disease (COPD) is a classic disease of airway damage and remodelling, characterised by slowly progressive airflow obstruction, resulting in increasing dyspnoea and exercise limitation. It is a widely accepted theory that an important causative factor is extracellular matrix (ECM) remodelling, resulting from aberrant inflammation and disruption of the proteinase – antiproteinase balance; reviewed [1]. The identity of candidate proteinases has been a subject of much debate, however the balance between matrix metalloproteinases (MMPs) and their inhibitors; the tissue inhibitors of metalloproteinase (TIMPs), is thought t
Microbiological study of patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) and the usefulness of analytical and clinical parameters in its identification (VIRAE study)  [cached]
Boixeda R,Rabella N,Sauca G,Delgado M
International Journal of COPD , 2012,
Abstract: Ramon Boixeda,1,5 Nuria Rabella,2 Goretti Sauca,3 Maria Delgado,1 Xavier Martinez-Costa1, Montserrat Mauri,1 Vanessa Vicente,1 Elisabet Palomera,4 Mateu Serra-Prat,4 Josep Antón Capdevila11Department of Internal Medicine, Hospital of Mataró, Barcelona, Spain; 2Department of Microbiology, Hospital of Santa Creu and Sant Pau, Barcelona, Spain; 3Department of Microbiology, Hospital of Mataró, Barcelona, Spain; 4Department of Research, Hospital of Mataró, Barcelona, Spain; 5Department of Medicine, Autonomous University of Barcelona, Barcelona, SpainPurpose: Respiratory infection is the most common cause for acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). The aim of this work was to study the etiology of the respiratory infection in order to assess the usefulness of the clinical and analytical parameters used for COPD identification.Patients and methods: We included 132 patients over a period of 2 years. The etiology of the respiratory infection was studied by conventional sputum, paired serology tests for atypical bacteria, and viral diagnostic techniques (immunochromatography, immunofluorescence, cell culture, and molecular biology techniques). We grouped the patients into four groups based on the pathogens isolated (bacterial versus. viral, known etiology versus unknown etiology) and compared the groups.Results: A pathogen was identified in 48 patients. The pathogen was identified through sputum culture in 34 patients, seroconversion in three patients, and a positive result from viral techniques in 14 patients. No significant differences in identifying etiology were observed in the clinical and analytical parameters within the different groups. The most cost-effective tests were the sputum test and the polymerase chain reaction.Conclusion: Based on our experience, clinical and analytical parameters are not useful for the etiological identification of COPD exacerbations. Diagnosing COPD exacerbation is difficult, with the conventional sputum test for bacterial etiology and molecular biology techniques for viral etiology providing the most profitability. Further studies are necessary to identify respiratory syndromes or analytical parameters that can be used to identify the etiology of new AE-COPD cases without the laborious diagnostic techniques.Keywords: respiratory viruses, chronic obstructive pulmonary disease, exacerbation, diagnostic tests, hospitalization
Spirometry for patients in hospital and one month after admission with an acute exacerbation of COPD
Rea H, Kenealy T, Adair J, Robinson E, Sheridan N
International Journal of Chronic Obstructive Pulmonary Disease , 2011, DOI: http://dx.doi.org/10.2147/COPD.S24133
Abstract: ometry for patients in hospital and one month after admission with an acute exacerbation of COPD Original Research (3494) Total Article Views Authors: Rea H, Kenealy T, Adair J, Robinson E, Sheridan N Published Date October 2011 Volume 2011:6 Pages 527 - 532 DOI: http://dx.doi.org/10.2147/COPD.S24133 Harry Rea1, Timothy Kenealy1, Jacqui Adair1, Elizabeth Robinson2, Nicolette Sheridan3 1Section of Integrated Care, South Auckland Clinical School, University of Auckland, 2Biostatistics and Epidemiology, School of Population Health, University of Auckland, 3Section of Integrated Care, South Auckland Clinical School and School of Nursing, University of Auckland, Auckland, New Zealand Aim: To assess whether spirometry done in hospital during an admission for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is clinically useful for long-term management. Methods: Patients admitted to hospital with a clinical diagnosis of AECOPD had spirometry post-bronchodilator at discharge and approximately 4 weeks later. Results: Spirometry was achieved in less than half of those considered to have AECOPD. Of 49 patients who had spirometry on both occasions, 41 met the GOLD criteria for COPD at discharge and 39 of these met the criteria at 1 month. For the 41, spirometry was not statistically different between discharge and 1 month but often crossed arbitrary boundaries for classification of severity based on FEV1. The eight who did not meet GOLD criteria at discharge were either misclassified due to comorbidities that reduce FVC, or they did not have COPD as a cause of their hospital admission. Conclusion: Spirometry done in hospital at the time of AECOP is useful in patients with a high pre-test probability of moderate-to-severe COPD. Small changes in spirometry at 1 month could place them up or down one grade of severity. Spirometry at discharge may be useful to detect those who warrant further investigation.
Spirometry for patients in hospital and one month after admission with an acute exacerbation of COPD  [cached]
Rea H,Kenealy T,Adair J,Robinson E
International Journal of COPD , 2011,
Abstract: Harry Rea1, Timothy Kenealy1, Jacqui Adair1, Elizabeth Robinson2, Nicolette Sheridan31Section of Integrated Care, South Auckland Clinical School, University of Auckland, 2Biostatistics and Epidemiology, School of Population Health, University of Auckland, 3Section of Integrated Care, South Auckland Clinical School and School of Nursing, University of Auckland, Auckland, New ZealandAim: To assess whether spirometry done in hospital during an admission for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is clinically useful for long-term management.Methods: Patients admitted to hospital with a clinical diagnosis of AECOPD had spirometry post-bronchodilator at discharge and approximately 4 weeks later.Results: Spirometry was achieved in less than half of those considered to have AECOPD. Of 49 patients who had spirometry on both occasions, 41 met the GOLD criteria for COPD at discharge and 39 of these met the criteria at 1 month. For the 41, spirometry was not statistically different between discharge and 1 month but often crossed arbitrary boundaries for classification of severity based on FEV1. The eight who did not meet GOLD criteria at discharge were either misclassified due to comorbidities that reduce FVC, or they did not have COPD as a cause of their hospital admission.Conclusion: Spirometry done in hospital at the time of AECOP is useful in patients with a high pre-test probability of moderate-to-severe COPD. Small changes in spirometry at 1 month could place them up or down one grade of severity. Spirometry at discharge may be useful to detect those who warrant further investigation.Keywords: classification of COPD, spirometry, acute exacerbation of COPD, primary care, cohort study
Microbiological study of patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) and the usefulness of analytical and clinical parameters in its identification (VIRAE study)
Boixeda R, Rabella N, Sauca G, Delgado M, Martínez-Costa X, Mauri M, Vicente V, Palomera E, Serra-Prat M, Capdevila JA
International Journal of Chronic Obstructive Pulmonary Disease , 2012, DOI: http://dx.doi.org/10.2147/COPD.S30568
Abstract: robiological study of patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) and the usefulness of analytical and clinical parameters in its identification (VIRAE study) Original Research (2514) Total Article Views Authors: Boixeda R, Rabella N, Sauca G, Delgado M, Martínez-Costa X, Mauri M, Vicente V, Palomera E, Serra-Prat M, Capdevila JA Published Date May 2012 Volume 2012:7 Pages 327 - 335 DOI: http://dx.doi.org/10.2147/COPD.S30568 Received: 05 February 2012 Accepted: 04 March 2012 Published: 29 May 2012 Ramon Boixeda,1,5 Nuria Rabella,2 Goretti Sauca,3 Maria Delgado,1 Xavier Martinez-Costa1, Montserrat Mauri,1 Vanessa Vicente,1 Elisabet Palomera,4 Mateu Serra-Prat,4 Josep Antón Capdevila1 1Department of Internal Medicine, Hospital of Mataró, Barcelona, Spain; 2Department of Microbiology, Hospital of Santa Creu and Sant Pau, Barcelona, Spain; 3Department of Microbiology, Hospital of Mataró, Barcelona, Spain; 4Department of Research, Hospital of Mataró, Barcelona, Spain; 5Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain Purpose: Respiratory infection is the most common cause for acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). The aim of this work was to study the etiology of the respiratory infection in order to assess the usefulness of the clinical and analytical parameters used for COPD identification. Patients and methods: We included 132 patients over a period of 2 years. The etiology of the respiratory infection was studied by conventional sputum, paired serology tests for atypical bacteria, and viral diagnostic techniques (immunochromatography, immunofluorescence, cell culture, and molecular biology techniques). We grouped the patients into four groups based on the pathogens isolated (bacterial versus. viral, known etiology versus unknown etiology) and compared the groups. Results: A pathogen was identified in 48 patients. The pathogen was identified through sputum culture in 34 patients, seroconversion in three patients, and a positive result from viral techniques in 14 patients. No significant differences in identifying etiology were observed in the clinical and analytical parameters within the different groups. The most cost-effective tests were the sputum test and the polymerase chain reaction. Conclusion: Based on our experience, clinical and analytical parameters are not useful for the etiological identification of COPD exacerbations. Diagnosing COPD exacerbation is difficult, with the conventional sputum test for bacterial etiology and molecular biology techniques for viral etiology providing the most profitability. Further studies are necessary to identify respiratory syndromes or analytical parameters that can be used to identify the etiology of new AE-COPD cases without the laborious diagnostic techniques.
Role of BiPAP applied through endotracheal tube in unconscious patients suffering from acute exacerbation of COPD: a pilot study
Rawat J, Sindhwani G, Biswas D, Dua R
International Journal of Chronic Obstructive Pulmonary Disease , 2012, DOI: http://dx.doi.org/10.2147/COPD.S30126
Abstract: le of BiPAP applied through endotracheal tube in unconscious patients suffering from acute exacerbation of COPD: a pilot study Original Research (2435) Total Article Views Authors: Rawat J, Sindhwani G, Biswas D, Dua R Published Date May 2012 Volume 2012:7 Pages 321 - 325 DOI: http://dx.doi.org/10.2147/COPD.S30126 Received: 22 January 2012 Accepted: 28 March 2012 Published: 11 May 2012 Jagdish Rawat,1 Girish Sindhwani,1 Debasis Biswas,2 Ruchi Dua1 1Department of Pulmonary Medicine, 2Department of Microbiology, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Jolly Grant, Dehradun, Uttarakhand, India Background and objectives: Mechanical ventilation is the recommended treatment in unconscious patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) and hypercapenic respiratory failure. But, in resource-poor countries, many of these patients are not able to afford this treatment due to financial constraints. The main aim of this study was to evaluate the usefulness, safety and cost-effectiveness of bilevel positive airway pressure (BiPAP) applied via endotracheal tube in such patients. Methods: Twenty patients with acute exacerbation of COPD and altered sensorium, who were unable to afford ventilatory support, were intubated and BiPAP therapy was provided to these patients through the endotracheal tube. The outcome of these patients was studied. Results: The BiPAP success rate and hospital mortality were 85% (17/20) and 15% (3/20) respectively. BiPAP failure was associated with high sequential organ failure assessment (SOFA) score at the time of admission (P = 0.002). Improvement in Glasgow coma scale (GCS) score (P < 0.001), pH (P = 0.001), PaCO2 (partial pressure of carbon dioxide) (P < 0.001), respiratory rate (P < 0.001), and SOFA score (P = 0.001) was observed among the responders following 2 hours of therapy. Only one of the responders developed aspiration pneumonitis, as a complication. The daily cost of BiPAP therapy was 8.75 times lower than the average cost of mechanical ventilation. Conclusion: This pilot study reveals that this treatment modality could be a safe, cost-effective and efficacious method of treatment in unconscious patients with acute exacerbation of COPD.
COPD Exacerbations: Clinical Management Options
Unnati Desai, Dipti Gothi and Jyotsna M. Joshi
Indian Journal of Clinical Medicine , 2012, DOI: 10.4137/IJCM.S5476
Abstract: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a sudden and sustained worsening in cough, dyspnoea and/or sputum production in patients with COPD. AECOPD is an infrequent occurrence in mild COPD, but is a common feature of moderate to severe COPD. It is essential to treat AECOPD early to prevent morbidity and mortality related to the disease. The treatment can be administered at home or in hospital depending on the facility and patient condition. The pharmacological and non pharmacological therapies are essential component of management and complimentary to each other. Prevention of further exacerbation after its optimum treatment is as important as the treatment, as these episodes lead to progressive decline in lung function. Evidence based management; newer advances and direction for future research are included in this review.
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