Weekly Blog - COPD

Today we discussed COPD in rounds.  Some "take home" points:

1) Antibiotics may have value in purulent exacerbations (2 of 3 of increased dyspnea, sputum, or change in sputum color) in patients who are hospitalized.  There is evidence in support of amoxicillin–clavulanic acid, trimethoprim/sulphamethoxazole, doxycycline, and penicillin in the recent meta-analysis.  

http://annals.org/article.aspx?articleid=1676474

Due to the association with C. difficile, we locally suggest to reserve the fluoroquinolones to those who have anaphalactic allergy to all of the above, known or highly suspected to be infected with Pseudomonas, or recent treatment failure with a macrolide (with penicillin severe allergy)

Some narrower agents have been shown to be non-inferior:
http/www.ncbi.nlm.nih.gov/pubmed/20536364

Duration should probably be limited to five days in most cases
http://www.ncbi.nlm.nih.gov/pubmed/18234905

2) Dose/Duration of oral steroids should be limited to 40mg of prednisone for 5 days in most patients.

http://www.ncbi.nlm.nih.gov/pubmed/23695200

3) Inhaled steroids should be more carefully administered to balance the improvement in exacerbations with the risk of bacterial pneumonia.  Number needed to treat for three years to prevent one exacerbation is 44 with number needed to harm to cause pneumonia is 16.  I usually review the indication for the steroid in patients hospitalized with pneumonia and discuss with them the risk:benefit of stopping (which in most cases leads to stopping)

thorax.bmj.com/content/68/6/540.full

FINALLY -- with thanks to KS for bringing up the point --

When admitting a patient with "COPD" the best practice is to properly understand the diagnosis and document it in the admission history
* Is this actually objectively COPD?  Not everything that wheezes is COPD -- does the spriometry suggest it?
* If they have known COPD part of the history is to know that is their FEV1; are they on home oxygen; do they have pulmonary hypertension; how often to they have exacerbations?

Many times patients are admitted with a diagnosis of COPD without documenting these things...  Sometimes they don't even have COPD on previous pulmonary function tests!