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June 2006





Results
Case study 42:
Managing COPD
exacerbations

NPSCS0348
The information contained in this material is derived from a critical analysis of a wide range of authoritative evidence.
Any treatment decision based on this information should be made in the context of the clinical circumstances of each patient.

2
Inside
Case study 42: Managing COPD exacerbations
Scenario and questions page 3
Summary of results page 5
Results in detail page 6
Commentaries
Dr Julia Walters page 14
Associate Professor Christine McDonald page 16
Appendix page 18
References page 19
3
Case study 42
Managing COPD exacerbations
Scenario
Cedric, a 50-year-old man, was diagnosed with COPD 5 years ago. He presents with worsening
dyspnoea, cough and increasing purulent sputum production over the past 3 days. On examination,
BP is 130/84 mmHg, pulse 102, respiratory rate 18 and temperature 37.8 C. Auscultation of the
chest reveals widespread expiratory wheeze and inspiratory coarse crackles in the left lung base.
He is dyspnoeic but able to speak in whole sentences. No cyanosis is present.
Last spirometry results (8 months ago, after his last COPD exacerbation) were: post-bronchodilator
FEV
1
55% predicted and FEV
1
/FVC ratio 65%. Cedric previously smoked 25 cigarettes per day
(for 30 years) but cut down to 10 cigarettes per day after his first COPD exacerbation 2 years ago.
He has attempted to quit smoking on several occasions without any success.
Cedrics regular medications for COPD are tiotropium (Spiriva) 18 micrograms once daily and
salbutamol (Airomir, Asmol, Ventolin) metered-dose inhaler 200 micrograms every 46 hours when
required. He is also taking indapamide (Dapa-Tabs, Natrilix) 2.5 mg and atorvastatin (Lipitor) 10 mg
(both in the morning) for hypertension and hypercholesterolaemia, respectively. He has no other
medical conditions, and has no known allergies.

1. What drug therapy would you use for the exacerbation?
tiotropium Cease
Continue without change
Change to: o Dose o o Route o o Frequency o
__________________________________________________________________________
salbutamol Cease
Continue without change
Change to: o Dose o o Route o o Frequency o
________________________________________________________________________
any other medications for this exacerbation: (please specify)
ooooooDrugoooooo o Dose o o Route o o Frequency o o Duration o
i. _________________________________________________________________________________
ii. _________________________________________________________________________________
iii. _________________________________________________________________________________
iv. _________________________________________________________________________________
Please give reasons why you did OR did not prescribe an antibiotic:
___________________________________________________________________________________
___________________________________________________________________________________
4
2. What would you prescribe for stable COPD management after this exacerbation?
ooooooDrugoooooo o Dose o o Route o o Frequency o o Duration o
i. __________________________________________________________________________________
ii. __________________________________________________________________________________
iii. _________________________________________________________________________________
iv. _________________________________________________________________________________
3. What else (if anything) would you include in the management plan?
During this exacerbation: ______________________________________________________________
In stable disease: _____________________________________________________________________
4. What strategies would you implement to help him quit smoking?
i. __________________________________________________________________________________
ii. __________________________________________________________________________________
iii. _________________________________________________________________________________
5
Summary of results
At the time of publication, 1219 responses had been received from doctors and other health
professionals. Responses from 200* general practitioners have been compiled for feedback.
Case synopsis
A patient with COPD presents with worsening dyspnoea, cough and increasing purulent sputum
production over the past 3 days. His current medications for COPD are tiotropium and salbutamol.
(See page 3 for more details.)

Drug therapy
Acute exacerbation
98.5% of participants would continue tiotropium.
98.5% would continue salbutamol but 71.5% would change the method of delivery from metered-
dose inhaler (MDI) to MDI with spacer or nebuliser, and/or increase the dosage.
80% would prescribe an oral steroid, most commonly prednisolone or prednisone 50 mg daily for 12
weeks.
98% would prescribe one or more antibiotics, mostly amoxycillin (69.9%) or doxycyline (14.8%), and
usually for 12 weeks.
Stable disease (n = 121)
98.3% and 70.2% would continue prescribing tiotropium and salbutamol, respectively.
46.3% would add a long-acting beta
2
agonist, either as a single product (15.7%) or in combination
with an inhaled corticosteroid (30.6%). When prescribed as a single-ingredient product, about half
would review the medication after 48 weeks, but when prescribed as a combination product, most
would continue it indefinitely.
50.4% added an inhaled corticosteroid, either as a single product (19.8%) or in combination with a
long-acting beta
2
agonist (30.6%). When prescribed as a single-ingredient product, most would review
the medication after 48 weeks, but when prescribed as a combination product, most would continue
it indefinitely.
Other aspects in management of COPD
Acute exacerbation
Other management included advice to stop smoking (49.7%), physiotherapy (18.8%), return for
follow-up (14.4%) and considering other drug therapy (14.3%).
Stable disease
Other management included advice and assistance with smoking cessation (61.1%), reassessing lung
function (16.7%), reviewing and optimising therapy (14.4%), respiratory rehabilitation (13.3%) and
ensuring currency of vaccinations (12.8%).
Strategies for smoking cessation
Non-pharmacological strategies include brief counselling and/or encouragement (56.8%); referral to
Quitline (44.7%); and support, follow-up and/or review (30.7%).
Pharmacological strategies included consideration of nicotine replacement therapy (52.3%) and/or
bupropion (34.1%), or a general discussion about available therapies (24.1%).
* Unless otherwise specified, all percentages cited in this report are based on n = 200.
6
Results in detail
Drug therapy for COPD exacerbation
Bronchodilator
98.5% of participants would continue tiotropium.
2% would also prescribe ipratropium in one case, instead of tiotropium.
98.5% would continue salbutamol but 71.5% would change the method of delivery (originally MDI)
and/or increase the dosage (originally 200 micrograms every 46 hours when required):
34% recommended using the MDI via a spacer, 9% with a nebuliser, and 3.5% with either
28.5% increased the dose (up to 400 micrograms without a spacer, 1200 micrograms with a
spacer, or 5 mg through a nebuliser) and 69.5% increased the frequency (up to every 12 hours)
2% would also prescribe salmeterol (in addition to salbutamol).
Oral steroid
80% would prescribe an oral steroid (prednisolone or prednisone in all cases except one).
The most commonly prescribed dose was 50 mg daily (range 1075 mg) mainly for 12 weeks
(range 3 days unspecified); 16.5% advocated a dosage reduction schedule.
Inhaled corticosteroid
4.5% would prescribe an inhaled corticosteroid (1.5% in conjunction with an oral steroid).
6.5% would prescribe combined inhaled corticosteroid plus a long-acting beta
2
agonist
(3.5% in conjunction with an oral steroid).
Antibiotic
98% would prescribe one or more antibiotics, mainly for about 12 weeks (Table 1).
Most respondents based their decision to prescribe an antibiotic on the presence of one or more of the
following signs and symptoms: fever (62.5%), increased sputum purulence (59.5%), local lung signs
(39%), increased dyspnoea (20%), increased sputum volume (13%), increased cough (7%),
tachycardia (6.5%), increased respiratory rate (1.0%), and tachypnoea (1.0%).
As recommended in the COPD-X guidelines,
1
26% of respondents listed increased sputum purulence
plus increased sputum volume and/or increased dyspnoea as the reason for prescribing an antibiotic.
Other reasons for prescribing an antibiotic included a presentation consistent with acute infective
exacerbation of COPD, suspected pneumonia, and to prevent hospitalisation.
Other medications
Other medications prescribed during the exacerbation included senega and ammonia mixture APF (1%)
and theophylline (0.5%).
7
Table 1.
Antibiotic therapy during exacerbation
% of
respondents
(n = 196)
Amoxycillin
500 mg every 8 hours
1000 mg every 12 hours
Other (e.g. 250 mg every 8 hours, 500 mg every 6 hours)
Doxycycline
100 mg once daily (in some cases 200 mg on the first day)
100 mg twice daily
50 mg once daily
Amoxycillin / clavulanic acid
875/125 mg twice daily
Other (500/125 mg twice daily or not specified)
Amoxycillin and roxithromycin
Roxithromycin (150 mg twice daily or 300 mg once daily)
Cephalexin (250 mg every 6 hours or 500 mg every 8 hours)
Procaine penicillin and amoxycillin
Procaine penicillin, amoxycillin and roxithromycin
69.9
55.1
10.2
4.6
14.8
13.3
1.0
0.5
8.7
6.1
2.6
2.6
2.0
1.0
0.5
0.5
Practice points
During acute exacerbations of COPD, increase the use of short-acting bronchodilators.
An MDI with a spacer is as effective as a nebuliser if an adequate dose is taken, and is cheaper and
more portable.
1, 2
Nebulisers should be reserved for patients who are unable to use MDIs (with or
without spacer).
2
The dose via a spacer that is considered equivalent to a 5 mg salbutamol nebule
varies from 815 puffs of a 100 microgram salbutamol MDI.
1,3

Consider oral prednisolone 3050 mg daily for 714 days (short courses less than 14 days do not
usually require tapering).
1,2,4

Consider antibiotic therapy if increased sputum purulence is present with increased sputum volume and/or
dyspnoea.
1
The goal of therapy is to reduce volume and purulence of sputum; elimination of colonising
organisms is not required.
2
The presence of fever is not necessarily indicative of a bacterial infection.
2

Amoxycillin (500 mg every 8 hours for 5 days) or doxycycline (100 mg twice daily for 5 days) is
recommended as first-line therapy;
2
other antibiotics have not been shown to be superior and are not
recommended unless patients do not respond, or resistant organisms are suspected.
1,2

Amoxycillin 1000 mg twice daily is currently not recommended by Therapeutic Guidelines for
acute exacerbations of COPD.
2

In a study of 395 patients with acute exacerbation of chronic bronchitis, amoxycillin 1000 mg
twice daily offered no additional benefits (in efficacy or safety) compared with amoxycillin 500 mg
every 8 hours.
5
When compared with the current guidelines for antibiotic therapy in COPD
exacerbations, the study also used a longer duration of therapy and placed less emphasis on
increased sputum purulence as one of the criteria for antibiotic therapy.
If pneumonia is suspected, investigate and treat as for community-acquired pneumonia:
assessment should include history and examination, chest X-ray, measurement of arterial blood
oxygen saturation, investigations for the causal pathogen, and Pneumonia Severity Index class.
2



8
Drug therapy for stable COPD
Table 2 summarises the medication regimens that respondents would use for stable COPD management.
Table 2.
Drug therapy for stable COPD management
% of
respondents
(n = 121*)
Tiotropium and salbutamol (existing treatment)
Tiotropium, salbutamol, long-acting beta
2
agonist and inhaled corticosteroid
Tiotropium, salbutamol and inhaled corticosteroid
Tiotropium, long-acting beta
2
agonist and inhaled corticosteroid
Tiotropium only
Tiotropium, salbutamol and long-acting beta
2
agonist
Tiotropium and long-acting beta
2
agonist
Tiotropium and inhaled corticosteroid
Miscellaneous
28.1
22.3
12.4
11.6
7.4
5.8
5.8
3.3
3.3
* Only responses that were clear about whether or not tiotropium and salbutamol were to be continued have been included in the
analysis.
Bronchodilator (n = 121)
98.3% and 70.2% of respondents stated that they would continue tiotropium and salbutamol,
respectively.
32.2% and 14.1% would add salmeterol and eformoterol, respectively. Long-acting beta
2
agonists
were prescribed either on their own (15.7%) or in a combination product (30.6%). When prescribed as
a single-ingredient product, about half would review the medication after 48 weeks, but when
prescribed as a combination product, most would continue it indefinitely.
Other bronchodilators that were prescribed were ipratropium (1.7%) and terbutaline (0.8%).
Inhaled corticosteroid (n = 121)
2.5%, 11.6% and 35.5% prescribed beclomethasone, budesonide and fluticasone, respectively.
Inhaled corticosteroids were prescribed either on their own (19.8%) or in a combination product
(30.6%). When prescribed as a single-ingredient product, most would review the medication after
48 weeks, but when prescribed as a combination product, most would continue it indefinitely.

9
Practice points
To date, the use of long-acting beta
2
agonists in conjunction with tiotropium has not been investigated
in clinical trials.
2
However, these drugs work by different mechanisms, and several guidelines advocate
combined bronchodilator therapy for patients who remain symptomatic on monotherapy.
1,4,6

Long-acting beta
2
agonists should be stopped and reassessed if there are no changes in
symptoms, ability to perform daily activities or exercise capacity after 4 weeks.
2,6

Inhaled corticosteroid should be considered in patients who have documented evidence of
responsiveness to inhaled corticosteroids, or who have moderate or severe COPD (FEV1 50%
predicted) and have 2 or more exacerbations requiring treatment with antibiotics or oral corticosteroids
in a 12-month period.
1,2,6

Recommended trial periods for inhaled corticosteroids vary from 6 weeks up to 6 months
(depending on the guideline).
1,2,7
However, a longer trial may be necessary to assess an impact on
exacerbation rates.
There are conflicting findings regarding the efficacy of combined inhaled corticosteroid plus long-
acting beta
2
agonist in a single inhaler, compared with inhaled corticosteroid or long-acting beta
2

agonist alone in COPD.
8

The option of using either long-acting beta
2
agonist or inhaled corticosteroid alone should be
considered first before considering adding both medications to the existing regimen.
While combination products may be more convenient for the patient, when indicated, an initial
trial of inhaled corticosteroid and long-acting beta
2
agonist in separate inhalers may allow better
assessment of the benefits offered by each medication.

10
Other aspects of COPD management
During COPD exacerbation
In addition to the drug therapy already listed on page 6, 181 respondents (90.5%) would include in
their management plan for COPD exacerbation the measures listed in Table 3.
Table 3.
Other measures to manage COPD exacerbation
% of
respondents*
(n = 181)
Advise to stop smoking
Recommend physiotherapy/ chest physiotherapy
Follow-up
In 24 hours
In 48 hours
Not specified
Consider other drug therapy
Consider oral steroid (if condition worsens)
Consider other medications (e.g. paracetamol, oral theophylline, mucolytics, long-acting beta
2

agonist)
Consider hospital admission if deteriorating/ no improvement
Review inhalation device
Order chest X-ray
Check inhaler technique
Consider use of spacer and/or nebuliser
Assess lung function (using spirometry)
Miscellaneous (e.g. consider oxygen therapy, action plan, regular peak flow measurements)
49.7
18.8
14.4
8.8
1.7
3.9
14.3
6.6
7.7

9.9
7.7
6.1
4.4
3.3
3.3
20.4
* Respondents may have more than one response
During stable COPD
In addition to the drug therapy already listed on page 8, 180 respondents (90%) would include in their
management plan for stable COPD the measures listed in Table 4.
11
Table 4.
Other measures in stable COPD management
% of
respondents*
(n = 180)
Advise/ assist with smoking cessation
Reassess lung function (via spirometry)
Review/ optimise drug therapy
Recommend respiratory rehabilitation
Ensure currency of influenza and/or pneumococcal vaccination
Recommend exercise
Check inhaler technique
Prepare an action plan
Assess compliance
Miscellaneous (e.g. advise the patient to use a peak flow meter, conduct regular reviews,
consider referral to a respiratory physician)
61.1
16.7
14.4
13.3
12.8
8.9
7.2
6.7
3.3
16.7
* Respondents may have more than one response
Practice points
Pulmonary rehabilitation is considered one of the most effective interventions in COPD and has been
shown to improve symptoms and functioning of patients with COPD.
1
It should be offered to patients
with moderate to severe COPD who are sufficiently motivated and do not have severe co-morbidities
which preclude active participation in the program.
2
Comprehensive programs encompassing exercise
training, patient education and psychosocial support have been shown to have the greatest benefit.
1

Annual influenza vaccination is recommended to reduce the incidence of acute exacerbations of
COPD.
1,6

Pneumococcal vaccination is also recommended.
1,2
The current schedule for pneumococcal vaccination
is as follows:
9

non-Indigenous adults 65 years, or Aboriginal and Torres Strait Islander adults 50 years: one
dose followed by a single revaccination 5 years later
non-Indigenous adults < 65 years with risk factors (includes pulmonary disease): one dose
followed by a single revaccination at 65 years of age or 10 years after the first dose, whichever
is later
Aboriginal and Torres Strait Islander adults 1549 years of age with risk factors (includes
pulmonary disease): revaccination 5 years after the first dose, then again at 50 years of age or
10 years after the first revaccination, whichever comes later.
Demonstration and repetition are essential for achieving optimal patient inhaler technique.
2
Inhaler
technique should be checked regularly to ensure that patients are using their inhalers correctly
1,2
and
compliance should be assessed.
Patients should be encouraged to take appropriate responsibility in managing their own condition.
1

A COPD action plan may be helpful and is recommended.
1,2
It may include medications for stable
and acute management, and instructions on how to identify and respond to an acute
exacerbation. You can download a template from the Australian Lung Foundation at
www.lungnet.com.au/copd/copd_action_plan.html.
Patients at risk of COPD exacerbations should keep a course of antibiotic and corticosteroid tablets
at home for use as part of self-management.
2

12
Strategies to assist with smoking cessation
Table 5.
Strategies
% of respondents*
(n = 199)
Non-pharmacological strategies
Brief counselling and/or encouragement
Refer to Quitline or other resources by the national tobacco campaign
Support, follow-up and/or review (at consultations or by telephone)
Discuss benefits of smoking cessation and/or risks of continuing to smoke
Assess readiness to change
Provide education or written material
Behavioural therapy
Intensive counseling
Use 5As (Ask, Advise, Assess, Assist, Arrange) strategy
Discuss previous attempts (e.g. what was tried, what did not work)
Refer to a smoking-cessation specialist
Miscellaneous (e.g. hypnotherapy, exercise program, local smoking-cessation program, referral
to a psychologist, setting a quit date)

56.8
44.7
30.7
12.1
5.5
5.5
4.5
4.0
4.0
2.5
2.5
19.1
Pharmacological therapies
Discuss and advise about available drug therapy options
Nicotine replacement therapy (NRT)
Bupropion
Bupropion (and intensive counselling)


Bupropion if NRT unsuccessful

24.1
52.3

27.6
6.5
* Respondents may have more than one response

Some respondents listed both NRT and bupropion


Practice points
Smoking cessation is the single most important intervention to prevent or slow the progression of
COPD.
1,4,10

Brief counselling (35 minutes) by a health professional has been shown to be effective
4,11
and every
smoker should be offered at least this intervention at every visit.
1,4
When aware of patients previous
attempts, it may be helpful to first discuss what worked or did not work in previous attempts.
Bupropion (in conjunction with counselling and support) or nicotine replacement therapy (NRT) doubles
the rate of smoking cessation compared with placebo.
11,12
There are insufficient data to recommend
bupropion in preference to NRT, and vice versa.
1,13

The effectiveness of bupropion has only been studied in conjunction with intensive counselling and
support program. Examples of such programs from randomised controlled trials with bupropion include
a combination of:
14,15

brief intervention by a trained health professional
weekly assessment (15 minutes individual counseling session looking at motivation, identification
of triggers, coping responses, weight management and use of medications)
follow-up assessments and relapse prevention strategies
supported telephone call (e.g. 8 telephone calls of approximately 10 minutes duration for
5 months).
13
The different forms of NRT have similar effectiveness,
11,12
and choice should be based on patient
preference, need and tolerance.
1

Other interventions that have been shown to work include:
11

intensive (> 10 minutes) counselling by a health professional
telephone counselling services
group behavioural therapy
follow-up visits to a GP
repeated telephone support by nurses after initial intervention.

14

Commentary 1
Dr Julia Walters
Research Fellow, Discipline of Medicine
University of Tasmania
Hobart, Tasmania



Key points
The only factor known to be effective in
preventing progression of COPD is smoking
cessation. Intensive assistance, using quit
methods with the highest success rates, should
be given when COPD is diagnosed in a smoker.
Two or more exacerbations of COPD in one
year are associated with more rapid lung
function decline.
Acute exacerbation of COPD
Diagnosis
This man (at age 50 relatively young compared
with most general practice COPD patients) is
known by his GP to have COPD. This is in itself
relatively unusual, as most people (6080%) in
community surveys who are found to have
COPD do not have a previous diagnosis of
COPD.
16-18
However, Cedric had spirometry
recently (8 months ago) and this demonstrated
obstruction, with an FEV
1
/FVC ratio of 65%.
With an FEV
1
of 55% of the value predicted for
his age, Cedric would be classified with
moderate COPD by the COPD-X guidelines
1
, i.e.
his FEV
1
lies in the range 4059%.
The clinical symptoms Cedric displays are typical
of an exacerbation of COPD, defined as a
sustained worsening of symptoms from the
usual stable state, being acute in onset with
worsening dyspnoea, cough, increased sputum
production and change in sputum colour.
6

Treating in the community
The need for immediate treatment was
recognised by at least 98% of respondents. This
is an important point, as lung function may not
recover fully after an exacerbation, and rapid
institution of therapy is required. A study of
community-managed exacerbations found that
in 25% of patients recovery to baseline was not
complete after five weeks.
19
There is also a
significantly increased risk of mortality
associated with exacerbations in severe COPD.
20

This case study assumes that the GP will manage
the exacerbation at home and this is accepted as
appropriate for all but the most severe
exacerbations. The presence of cyanosis,
peripheral oedema, acute confusion and severe
tachypnoea (in addition to impaired physical
functioning and inability to cope at home)
probably indicate the need for hospital
admission.
6

Management of acute exacerbation
Cedrics symptoms of breathlessness were
addressed effectively by most respondents, who
indicated use of bronchodilators, continuing his
inhaled tiotropium (98.5%) and salbutamol
(98.5%). However, only 28.5% increased the
dose of short-acting beta
2
agonist although
69.5% increased the frequency. These agents
should be used at a dose high enough to relieve
breathlessness; 8 puffs 23-hourly may be
required. More effective delivery can be ensured
from an MDI by using a spacer. They have been
shown to be as effective as nebulisers and are
more convenient and readily available.
A recently published Cochrane systematic
review
21
concluded that antibiotic therapy,
regardless of antibiotic choice, significantly
reduced mortality (relative risk [RR] 0.23,
95% confidence interval [CI] 0.10 to 0.52; with
number needed to treat [NNT] of 8, 95% CI 6 to 17)
and treatment failure (RR 0.47, 95% CI 0.36 to 0.62;
with NNT of 3, 95% CI 3 to 5) in exacerbations
in patients who are moderately or severely ill.
An appropriate antibiotic was indicated by 85%
of respondents. Only 2% would prescribe
roxithromycin, and 3.1% chose to give this in
addition to amoxycillin an unnecessary
combination in COPD exacerbation without
pneumonia that increases the possibility of side
effects such as diarrhoea. For 59.5% of
respondents the decision to treat with an
antibiotic was based on increased sputum
purulence. This agrees with the evidence-based
recommendations. Fever was cited by 62.5% of
respondents although this is an uncommon
feature in exacerbations
6
and, if found, further
investigations would be merited. The presence
of focal crackles might indicate you are dealing
with pneumonia or lung cancer, and a chest
X-ray is indicated.
15
Guidelines recommend considering using oral
steroids for managing an exacerbation in the
community unless there are significant
contraindications. A Cochrane systematic
review
22
found that there were significantly
fewer treatment failures in patients given
corticosteroid treatment (odds ratio [OR] 0.48,
95% CI 0.34 to 0.68; with NNT of 9 patients,
95% CI 6 to 14). Most respondents chose to use
a conventional-length course (714 days) of oral
prednisolone or prednisone. Only 16.5%
tapered the dose; for a course less than 14 days
this is not required.
Smoking cessation
Advice to stop smoking was the most frequent
additional management activity undertaken
during the exacerbation (49.7% of
respondents). This is important because Cedric
still smokes even 5 years after having the
diagnosis of COPD, but it was an opportunity
missed by more than half the respondents. Even
brief advice to stop smoking is valuable and
effective
23
and is emphasised in all guidelines.
Only 61.1% included smoking cessation in
measures to manage Cedrics COPD when he
was stable. This should be the highest priority
for treatment, as stopping smoking is the most
effective intervention to slow progression.
Cedric has made previous efforts so far
unsuccessful in achieving sustained
abstinence and is likely to need pharmacological
therapy in addition to the counselling and
encouragement offered by 56.8% of
respondents, as this increases his chances of
success. Both bupropion and nicotine-
replacement therapy double the rates of
cessation compared with placebo; 51.3%
proposed using nicotine-replacement therapy
and 24.6% bupropion to assist Cedric.
Management of stable COPD
When reviewing Cedric at follow-up, the
principles of COPD-X (optimising function,
preventing deterioration, developing self-
management strategies) should be followed.
1

Spirometry
In assessing the longer-term need for therapy
after Cedric is stable, only 16.7% would use
spirometry to reassess lung function. Spirometry
would give the GP an objective measure to
assess Cedrics severity and his response to
additional treatment, which most respondents
instituted, and it could help to reinforce his
efforts to quit smoking.
Medication
Cedric has now had two exacerbations within
one year and is at higher risk of more rapid
decline in lung function. He should be given a
trial of therapy with inhaled corticosteroids. His
response can be assessed by symptoms and
FEV
1
, although for assessment on exacerbation
rate the length of treatment needs to be
prolonged. Inhaled corticosteroids were given by
50.4% of respondents, with most reviewing
efficacy after 48 weeks. Combination products
with long-acting beta
2
agonists were used by
30.6%. Use of these products in stable COPD
has preceded full consideration of their efficacy.
A Cochrane systematic review
8
concluded that,
although they led to clinically meaningful
differences in quality of life, symptoms and rate
of exacerbations compared with placebo, there
were conflicting results when the different
combination therapies were compared with
either inhaled corticosteroids alone or long-
acting beta
2
agonists alone. More data are
necessary to draw firmer conclusions about the
effects of combination therapy in a single
inhaler, and their use is not currently
recommended by guidelines.
Preventing deterioration
Ensuring that influenza and pneumococcal
vaccination were up to date was noted by
12.8% of respondents. Measures to develop a
support network and self-management plan
were addressed by some respondents:
recommending respiratory rehabilitation
(13.3%), recommending exercise (8.9%) and
preparing an action plan (6.7%). As well as
enhancing physical fitness and quality of life,
respiratory rehabilitation aims to foster self-
management and emotional coping skills.
Completing respiratory rehabilitation and/or
having an action plan leads to better recognition
of deterioration and more appropriate treatment
of exacerbations
24,25
but many patients with
COPD who would benefit do not have the
opportunity, through lack of referral or
availability.
26
Access will hopefully be improved
with the launch of a toolkit this year by the
Australian Lung Foundation and Australian
Physiotherapy Association to assist health
professionals in developing programs more
widely throughout Australia.
27

16

Commentary 2
Associate Professor Christine McDonald
Deputy Director, Department of Respiratory and Sleep Medicine
Director, Institute for Breathing and Sleep Medicine
Austin Hospital
Melbourne, Victoria



Key points
Spirometry is the gold standard for
diagnosing and monitoring COPD.
Smoking cessation and oxygen therapy in
patients with COPD who are hypoxaemic
are the only treatments known to impact
survival in COPD.
Recurrent exacerbations of COPD are
associated with a more rapid decline in
both lung function and quality of life and
may be managed by a range of long-term
treatments, including long-acting
bronchodilators, corticosteroids and
combinations of both.
Management tools for COPD
COPD is defined as a disease state characterised
by airflow limitation that is not fully reversible.
4

Spirometry is the gold standard for diagnosing
COPD and it is pleasing to note that Cedric has
undergone spirometric testing, which has
demonstrated that he has moderate COPD
(by COPD-X criteria
1
). Repeat spirometry may
be appropriate to monitor progressive decline
in lung function, which is faster in patients with
COPD who continue to smoke.
It is unclear whether knowledge about the
presence of COPD impacts on patients success
with quitting smoking. One study of patients
offered smoking-cessation advice after screening
spirometry found that those identified as having
moderate to severe COPD were more likely to
have successfully quit at 12 months after the
intervention than those with normal lung
function or only mild airflow obstruction.
28

There are several sets of mostly complementary
guidelines to assist in managing a patient with
COPD, and these have been drawn on in the
practice points and this commentary.
1,2,4,6

The Australian COPD-X Guidelines are updated
regularly and are available online through the
Australian Lung Foundation website at
www.lungnet.com.au.
Management of the acute
exacerbation
Up to 50% of patients with moderate to
severe COPD suffer recurrent exacerbations.
Early diagnosis and prompt treatment of
such exacerbations may prevent functional
deterioration and also reduce hospital
admissions. Cedric is clearly unwell but
should respond to standard therapy.
An acute exacerbation requires stepped-up
therapy with more frequent and higher-dose
bronchodilators, systemic corticosteroids
and possibly antibiotics.
1
Consistent with this,
71.5% of respondents stated they would
change the method of delivery of salbutamol
and/or increase the dosage. Metered-dose
inhaler plus spacer is as effective as nebuliser
as long as the dosage is equivalent, and this
may require up to 810 or more puffs of
100-microgram salbutamol or equivalent
short-acting bronchodilator.
Eighty per cent of respondents would
prescribe oral corticosteroids, most commonly
prednisolone 50 mg once daily for 12 weeks.
This should not require tapering and is
associated with more rapid resolution of the
exacerbation and a reduced likelihood of
relapse.
1

It is important that Cedric stops smoking during
the acute attack; indeed, the occurrence of this
acute attack is a perfect opportunity to intensify
discussion about smoking cessation. About half
of the respondents identified advice and other
assistance in stopping smoking as being of
importance during an acute exacerbation.
Although many acute exacerbations are
triggered by viral infections or have no clear
infective trigger, bacterial infection may have
a primary or secondary role in about 50% of
exacerbations. Many patients with COPD are
colonised with organisms such as Haemophilus
influenzae, Streptococcus pneumoniae or
Moraxella catarrhalis.
17
In patients who are at least moderately ill, with
clinical signs of infection such as increased
volume and purulence of sputum, a Cochrane
review confirmed that antibiotics reduce
mortality risk and risk of treatment failure.
21

Australian Therapeutic Guidelines
2
recommend
oral amoxycillin or doxycycline for treatment
of such an acute exacerbation, unless there is
known colonisation with a resistant organism,
or the presence of pneumonia.
The finding of crackles at the left lung base does
raise the question of possible pneumonia, as
recognised by some respondents. This could be
confirmed by chest radiograph, if clinically
indicated. Confirmation of pneumonia would
prompt treatment for community-acquired
pneumonia with standard combination
antibiotic therapy.
Management of stable COPD
Both during and after the acute attack, attention
to smoking-cessation strategies is paramount.
Smoking cessation has been shown to reduce
the accelerated decline in lung function seen in
COPD.
1
The COPD-X Checklist (available from
www.lungnet.com.au) contains the well-known
modified Fletcher and Peto graph of decline
in FEV
1
over time and the positive impact of
smoking cessation on this decline. Discussing the
graph with patients may be a useful adjunct in
addressing this issue.
The type of smoking-cessation program should
be tailored to the patient and may include
assessing the degree of nicotine addiction using
the Fagerstrom questionnaire (available in
Smoking Cessation Guidelines for Australian
General Practice
29
). Unless contraindicated,
nicotine replacement therapy and/or bupropion
in addition to ongoing support and counselling
should be used to optimise quit rates for
patients with COPD.
6

In patients with moderate to severe COPD and
recurrent exacerbations, inhaled corticosteroids
have been demonstrated both to reduce
exacerbation rate and improve quality of life.
Long-acting bronchodilator therapy with either
inhaled anticholinergics or long-acting beta
2

agonists may also have a role in improving
quality of life in COPD.
The place of combination therapy with inhaled
corticosteroid and long-acting beta
2
agonist
either used separately or in one inhaler remains
unclear, and a recent Cochrane systematic
review
8
concluded that more data are necessary
before firm recommendations can be made.
Useful further data should soon be available
through publication of the results of the TORCH
study.
30
This large, randomised controlled study
examined combination therapy with fluticasone
and salmeterol versus placebo, versus each
component alone, with the primary endpoint
of mortality and secondary endpoints including
exacerbation rate and quality of life.
The rate of referral for pulmonary rehabilitation
seems rather low at 13.3% of respondents.
This could be because of Cedrics relatively
young age and the potential impact a 6-week
program may have on his working life. However,
it is important to recognise that pulmonary
rehabilitation is one of the most effective
interventions available in managing COPD,
improving both exercise capacity and quality of
life as well as impacting on the anxiety and
depression commonly associated with the
condition.
1
If not available locally, the recently
released Pulmonary Rehabilitation Toolkit
(www.lungnet.com.au) provides practical
information about how to set up such a program.

18

Inhaled medications used in COPD
Generic name Device Brand names
Strength
(in micrograms, unless
otherwise indicated)
Bronchodilators
Short-acting beta
2
agonists
Salbutamol



Terbutaline
Autohaler
MDI
Nebuliser
Rotahaler
Nebuliser
Turbuhaler
Airomir Autohaler
Airomir, Asmol CFC-free, Epaq, Ventolin CFC-free
Asmol Uni-dose, Butamol, Ventolin Nebules
Ventolin Rotacaps
Bricanyl Respules
Bricanyl Turbuhaler
100
100
2.5mg/2.5mL, 5mg/2.5mL
200
5mg/2mL
500
Long-acting beta
2
agonists*
Eformoterol

Salmeterol
Aeroliser
Turbuhaler
Accuhaler
MDI
Foradile
Oxis Turbuhaler
Serevent Accuhaler
Serevent
12
6, 12
50
25
Anticholinergic bronchodilators
Ipratropium


Tiotropium
MDI
Nebuliser

Handihaler
Atrovent CFC-Free
Aeron, Apoven, Atrovent preparations, Ipratrin,
Ipravent
Spiriva
21
250/mL, 500/mL

18
Combination bronchodilator


Salbutamol/ipratropium MDI Combivent 100/20
Corticosteroids


Beclomethasone

Budesonide

Ciclesonide
Fluticasone
Autohaler
MDI
Nebuliser
Turbuhaler
MDI
Accuhaler
MDI
Qvar Autohaler
Qvar
Pulmicort Respules
Pulmicort Turbuhaler
Alvesco
Flixotide Accuhaler
Flixotide
50, 100
50, 100
500/2mL,1000/2mL
100, 200, 400
80, 160
100, 250, 500
50, 125, 250
Combination corticosteroid / long-acting beta
2
agonists


Budesonide/eformoterol
Fluticasone/salmeterol
Turbuhaler
Accuhaler
MDI
Symbicort Turbuhaler
Seretide Accuhaler
Seretide
100/6, 200/6, 400/12
100/50, 250/50, 500/50
50/25, 125/25, 250/25
* Long-acting beta
2
agonists are approved by the Therapeutic Goods Administration for COPD (except for Oxis Turbuhaler) but are not
subsidised on the PBS for COPD

Combination bronchodilator is only subsidised for COPD under the Repatriation PBS

Inhaled corticosteroids and combination corticosteroid / long-acting beta


2
agonists are not approved by the Therapeutic Goods
Administration for COPD (except for Seretide) and are not subsidised on the PBS for COPD
MDI = metered-dose inhaler
Appendix
19
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