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Acute Exacerbation of COPD

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General Information

Description

  • acute worsening of COPD characterized by change in baseline symptoms (cough, dyspnea, and/or sputum) beyond normal daily variations that requires change in therapy1,2

Definitions

  • COPD is characterized by chronic airflow obstruction that is not fully reversible and usually progressive1
  • COPD exacerbations classified as1
    • mild - treated with short-acting bronchodilators only
    • moderate - treated with short-acting bronchodilators and/or oral corticosteroids
    • severe - requires hospitalization or visit to emergency room; may also be associated with acute respiratory failure
  • Global Initiative for Chronic Obstructive Lung Disease (GOLD) severity classification of airflow limitation in COPD1
    • diagnosis of COPD applied to patients with airflow limitation, defined as forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio < 0.7
    • based on postbronchodilator FEV1
      Table 1. GOLD Classification for Severity of Airflow Limitation
      Severity FEV1
      GOLD 1 (Mild)≥ 80% predicted
      GOLD 2 (Moderate)50%-79% predicted
      GOLD 3 (Severe)30%-49% predicted
      GOLD 4 (Very severe)< 30% predicted

      Abbreviations: FEV1, forced
                                          expiratory volume in 1 second; GOLD, Global Initiative for
                                          Chronic Obstructive Lung Disease.

  • symptom severity assessments include1
    • modified British Medical Research Council (mMRC) questionnaire - evaluates breathlessness based on scale of 0 (breathless with strenuous exercise) to 4 (too breathless to leave the house or breathless when dressing or undressing)
    • COPD Assessment Test (CAT) - is an 8-item questionnaire worth 5 points each (overall score range 0-40) that may aid in determining disease-specific, health-related quality of life (see CAT websiteOpenInNew for questionnaire and user guide)
  • Global Initiative for Chronic Obstructive Lung Disease (GOLD) severity assessment based on symptom burden and risk of exacerbation1
    • Grade A
      • 0 exacerbations or 1 exacerbation not leading to hospital admission
      • mMRC score 0-1
      • CAT score < 10
    • Grade B
      • 0 exacerbations or 1 exacerbation not leading to hospital admission
      • mMRC score ≥ 2
      • CAT score ≥ 10
    • Grade C
      • ≥ 2 exacerbations or ≥ 1 exacerbation leading to hospital admission
      • mMRC score 0-1
      • CAT score < 10
    • Grade D
      • ≥ 2 exacerbations or ≥ 1 exacerbation leading to hospital admission
      • mMRC score ≥ 2
      • CAT score ≥ 10

References

General references used

  1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD. GOLD 2019OpenInNew
  2. Evensen AE. Management of COPD exacerbations. Am Fam Physician. 2010 Mar 1;81(5):607-13OpenInNewfull-textOpenInNew, correction can be found in Am Fam Physician 2010 Aug 1;82(3):230

Recommendation grading systems used

  • American College of Physicians (ACP) guideline grading system
    • strength of recommendation
      • Strong - benefits clearly outweigh risks and burden, or risks and burden clearly outweigh benefits
      • Weak - benefits closely balanced with risks and burden or uncertainty in estimates of benefits, risks, and burdens
      • Insufficient - balance of benefits and risks cannot be determined
    • quality of evidence
      • High - randomized trials without important limitations, or overwhelming evidence from observational studies
      • Moderate - randomized trials with important limitations (inconsistent results, methodologic flaws, indirect, or imprecise), or exceptionally strong evidence from observational studies
      • Low - observational studies or case series
      • Insufficient - evidence is conflicting, poor quality, or lacking
    • Reference - ACP methods for development of clinical practice guidelines and guidance statements (20679562Ann Intern Med 2010 Aug 3;153(3):194OpenInNew)
  • British Thoracic Society/Intensive Care Society (BTS/ICS) uses Scottish Intercollegiate Guidelines Network (SIGN) grading system
    • grades of recommendations
      • Grade A
        • at least 1 meta-analysis, systematic review, or randomized controlled trial (RCT) rated as 1++ and directly applicable to the target population, or
        • body of evidence consisting principally of studies rated as 1+, directly applicable to target population and demonstrating overall consistency of results
      • Grade B
        • body of evidence including studies rated as 2++, directly applicable to target population and demonstrating overall consistency of results, or
        • extrapolated evidence from studies rated as 1++ or 1+
      • Grade C
        • body of evidence including studies rated as 2+, directly applicable to target population and demonstrating overall consistency of results, or
        • extrapolated evidence from studies rated as 2++
      • Grade D
        • evidence level 3 or 4, or
        • extrapolated evidence from studies rated as 2+
      • Good Practice Point (GPP) - recommended best practice based on clinical experience of guideline development group
    • levels of evidence
      • 1++ - high-quality meta-analyses, systematic reviews of RCTs, or RCTs with very low risk of bias
      • 1+ - well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with low risk of bias
      • 1- - meta-analyses, systematic reviews of RCTs, or RCTs with high risk of bias
      • 2++
        • high-quality systematic reviews of case-control or cohort studies
        • high-quality case-control or cohort studies with very low risk of confounding or bias and high probability that relationship is causal
      • 2+ - well-conducted case-control or cohort studies with low risk of confounding or bias and moderate probability that relationship is causal
      • 2- - case-control or cohort studies with high risk of confounding or bias and significant risk that relationship is not causal
      • 3 - nonanalytical studies (for example, case reports, case series)
      • 4 - expert opinion
  • Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades of recommendation
    • Evidence A - based on randomized controlled trials with rich body of high-quality evidence without any significant limitation or bias
    • Evidence B - based on randomized controlled trials with important limitations or limited body of evidence
    • Evidence C - based on nonrandomized trials or observational studies
    • Evidence D - based on panel consensus judgement
    • Reference - GOLD strategy for diagnosis, management, and prevention of COPD (GOLD 2019OpenInNew)
  • European Respiratory Society/American Thoracic Society (ERS/ATS) uses Grades of Recommendation, Assessment, Development, and Evaluation (GRADE)
    • strength of recommendations
      • Strong recommendation - certainty about balance of desirable and undesirable consequences of an intervention
      • Conditional recommendation - less certainty, or balance of desirable and undesirable consequences was finely balanced
    • quality of evidence determination
      • High - randomized trial without limitation in study quality, indirectness, important inconsistency, sparse or imprecise data, or high probability of publication bias
      • Moderate - downgraded randomized trial or upgraded observational study
      • Low - well done observational study with control groups
      • Very low - any other evidence (for example, case reports, case series)

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • The American College of Physicians (Marjorie Lazoff, MD, FACP; ACP Deputy Editor, Clinical Decision Resource) provided review in a collaborative effort to ensure DynaMed provides the most valid and clinically relevant information in internal medicine.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T116563, Acute Exacerbation of COPD; [updated 2018 Dec 04, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T116563. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

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      Management

      • Site of care

      • Medications

      • Additional treatment measures

  • Related Summaries

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    Hospitalist Focused Content

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      Admission Checklists

      • General Admission Checklist

      • Admission Checklist for Patients With Acute Exacerbation of COPD

    • Treatment Setting

    • Consultation and Referral

    • Discharge Planning

    • Discharge Checklist

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    General Information

    • Description

    • Definitions

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    Epidemiology

    • Incidence/Prevalence

    • Possible risk factors

    • Associated conditions

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • KeyboardArrowRight

      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Medication history

      • Past medical history (PMH)

      • Social history (SH)

    • KeyboardArrowRight

      Physical

      • General physical

      • Skin

      • Lungs

      • Extremities

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • Clinical prediction rules

    • Blood tests

    • Imaging studies

    • Other diagnostic testing

  • KeyboardArrowRight

    Management

    • Management overview

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      Treatment setting

      • Hospital admission

      • Discharge criteria for patients with COPD exacerbation

      • Home care

    • KeyboardArrowRight

      Activity

      • Pulmonary rehabilitation

      • Other activities

    • KeyboardArrowRight

      Medications

      • Bronchodilators

      • KeyboardArrowRight

        Steroids

        • Recommendations

        • Efficacy

        • Comparative efficacy of steroid treatments

      • KeyboardArrowRight

        Antibiotics

        • Recommendations

        • Decision to initiate

        • Efficacy

        • Antibiotic duration

        • Comparative efficacy

      • Oxygen

      • Other medications

    • KeyboardArrowRight

      Other management

      • Noninvasive ventilation

      • Airway clearance

      • Mechanical ventilation

      • Stem cell transplant

      • Alternative treatments

      • Eosinophil-guided corticosteroids therapy

    • Follow-up

  • KeyboardArrowRight

    Complications and Prognosis

    • Complications

    • KeyboardArrowRight

      Prognosis

      • In-hospital mortality

      • Mortality after hospital discharge

      • Factors associated with increased mortality

      • Duration of hospitalization

      • Depression associated with poorer prognosis

  • KeyboardArrowRight

    Prevention and Screening

    • KeyboardArrowRight

      Prevention

      • General information

      • Oral mucolytics

      • KeyboardArrowRight

        Bronchodilators for preventing exacerbations

        • Overview

        • Long-acting muscarinic antagonists (LAMAs)

        • Combination inhalers

      • Roflumilast

      • Influenza vaccine

      • Prophylactic antibiotics

      • Other medications

      • Targeted lung denervation

    • Screening

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • International guidelines

      • United States guidelines

      • United Kingdom guidelines

      • European guidelines

      • Asian guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Linda Nici MD
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Affiliations

Site Director, Pulmonary and Critical Care Fellowship Program, and Clinical Professor of Medicine, Brown University Alpert Medical School; Rhode Island, United States

Conflicts of Interest

Dr. Nici declares no relevant financial conflicts of interest.

Recommendations Editor
Zbys Fedorowicz MSc, DPH, BDS, LDSRCS
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Affiliations

Director of Bahrain Branch of the United Kingdom Cochrane Center, The Cochrane Collaboration; Awali, Bahrain

Conflicts of Interest

Dr. Fedorowicz declares no relevant financial conflicts of interest.

Deputy Editor
Terence K. Trow MD, FACP, FCCP
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Affiliations

Deputy Editor of Pulmonary, Critical Care, and Sleep Medicine; Connecticut, United States; Ex-Director of the Yale Pulmonary Vascular Disease Program, Associate Clinical Professor of Medicine, Yale University School of Medicine; Connecticut, United States

Conflicts of Interest

Dr. Trow declares no relevant financial conflicts of interest.

Produced in collaboration with American College of Physicians

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