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Acute COPD exacerbations: an evidenced-based approach.

The treatment of patients with acute exacerbations of their COPD is a critical topic for those who work in the acute setting. It is (or should be) also of deep concern to those who work in the rehabilitation and homecare of these patients since a good, formal rehabilitation program and/or excellence in care, including patient education in the home, may prevent some acute exacerbations. The importance of using the evidence-based (EB) or evidence-based medicine (EBM) approaches to patient care for any health care professional, besides providing the best evidence possible for valid treatment, may not be obvious. In the practice of respiratory therapy care, for instance, most if not all respiratory therapists should advocate for use of an EB(M) approach to their practice. Why? The entire answer would be another article. Succinctly, the EB(M) approach expresses what we know about respiratory therapy based on scientific evidence and outcomes data to assist in making better and more informed clinical decisions. EBM should logically provide a better way to develop critical pathways, respiratory care protocols, and clinical practice guidelines (CPGs), (note that the AARC is converting all CPGs to EBGs (evidence-based guidelines). With EBM as a basis, respiratory therapists can be valuable consultants and members of the team in the evaluation and treatment of individual patients. Aren't you sick AND tired of taking orders, or getting orders generated from those who may not have correct or up-to-date information, that make no sense and have no scientific basis? Try the EB approach. Staying consistent, any respiratory therapist worth their salt has wondered at some time in their career whether a particular treatment or was doing any good. In fact, the therapist might have sometimes wondered if he/she was actually doing harm. The medical literature has always been important to respiratory therapists in supporting or disputing the diagnosis and treatment of patients. You may have said or heard this stated: "Well, it's the standard treatment" (we've always done if this way) or "It's a published guideline" (it's probably outdated). Well, was it valid? Was it realiable? Did anyone ever sit down to analyze "the literature?" There should be an EBM part of the library. Search the major library databases and see for yourself (see the "Cochrane Database"). One caveat though: EBM and the EB approach is general. Good patient care is individual. The blending of the two is where the art and science of respiratory therapy come together and therein lies the magic.

COPD Exacerbation Treatment As Example: What is the evidence? It's never been a secret that COPD has a huge impact on not only our patients but also the U.S. health care system. COPD is the fourth leading cause of death in the U.S. and accounts for 500,000 hospitalizations each year. COPD patients typically present with acute decompensation of their disease 1 to 3 times per year with 3%-16% of these requiring hospital admission. Hospital mortality of these patients is 3% -10% in severe COPD and much higher for those patients requiring ICU admission. Up to 80% of the ICU admissions is from infections. Other conditions that can mimic an acute exacerbation or act as a "trigger" to exacerbation may include: air pollutants, heart failure, pulmonary embolism, nonpulmonary infections, and pneumothorax. A wonderful article to reference for EBM for acute COPD is: "Evidence-based approach to acute exacerbations of COPD" by Francisco J. Soto, MD and Basil Varkey, MD, FRCP, FCCP (Current Opinion in Pulmonary Medicine. 9(2):117-124, 2003 March).

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Infectious causes of COPD exacerbation: Bacterial Non-typeable haemophilus influenzae, Moraxella catarrhalis, Streptococcus pneumoniae, Pseudomonas aeruginosa, nerobacteriaceae, Haemophilius parainfiuenzae. Viral Rhi-novirus (common cold), Influenza, Parainfluenza, Coronavirus, Adendovirus, Respiratory syncytial virus. Atypical bacteria Chlamydia pneumoniae, Mycoplasma pneumoniae (rare) and Legionella.

Diagnostic testing: Both Chest X-ray and ABG analysis is recommended. PF testing (spirometry and peak flow) is not recommended.

Therapeutic Interventions: Oxygen is recommended for keeping the Sp02 or Sa02 just above 90% or the Pa02 above 60 torr. Oxygen via venturi mask may be safer and more effective than through nasal prongs. Chest physiotherapy has no role in the acute period.

Pharmacologic Intervention

Bronchodilating agents and delivery systems: Either an anticholinergic or a short-active beta 2 agonist is the preferred bronchodilator agent. The choice between the two lies largely on potential undesirable die effects and the patient's coexisting conditions. Adding a second bronchodilator to the first doesn't seem to be beneficial. Metered dose inhalers (MDIs) and nebulizers offer similar benefits. If MDIs are used then spacers are recommended.

Steroids: Improve several outcomes. A 10-14 day course is appropriate.

Antibiotics: Antibiotics can be beneficial, particularly with patients with severe exacerbation. Changes in bacteria strains have been documented so newer generation antibiotics may improve response rate.

Mucolytics: Mucolytics have no role in the acute period. Noninvasive positive pressure ventilation (NIPPV): NIPPV may benefit a group of patients with rapid deterioration in respiratory function and gas exchange. It may potentially decrease the need for intubation and invasive mechanical ventilation and possibly decrease in-hospital mortality. Heliox: For now, it should not be part of the EB approach to treatment of acute COPD exacerbation.

Let's do our own analysis of Dr. Soto and Dr. Varkey's EBM review of this very important topic. Does this EBM review seem complete to you? Well, it doesn't to me! Why? Well, it didn't seem complete in many ways and categories. For instance, why didn't they mention the use of EKG, sputum sampling and subsequent culture and sensitivity or CBC in the "diagnostic testing" category? I don't know. Maybe there's no specific evidence there since no one has studied those categories. It's a good question and worth investigating more. The article by Soto and Varkey contained 67 references with commentary on how or why these references might be useful. Is it a useful article? In my opinion it is. Should it represent the last word on this topic? No, Is there more evidence or guidance on this topic? Yes. This site is the Veterans Health Administration Clinical Practice Guideline For The Management of COPD or Asthma-lnpatient Management of COPD: Emergency Department Management (Module B1) and is part of a series of modules published on the net which contain a wealth of information on COPD management and are designed to assist respiratory therapists, nurses, physicians and others in this segment of care. References to the literature, along with a "Table of Evidence" providing the specific intervention, the article or articles that were used, the "grade of evidence" and "strength of evidence" (both quality indicators for the EB approach) are listed. This would be an excellent starting point for any respiratory therapy department wishing to "stop the madness" with regard to unnecessary, useless or even harmful respiratory therapy.

Are you interested in seeing what the government has to say about this topic? Go to: http://www.ahcpr.gov/clinic/epcquick.htm to see what the Agency for Healthcare Research and Quality (AHRQ) has to offer in terms of this and other topics. Public Law 106-129 of 1999 law authorizes AHRQ (a part of the U.S. Dept. of Health and Human Services) to "continue its research on the cost, quality, and outcomes of health care and expands its role to improve patient safety and address medical errors". This document, entitled Management of Acute Exacerbations of Chronic Obstructive Pulmonary Disease may be used as the basis for development of clinical practice guidelines and other quality enhancement tools, or a basis for reimbursement and coverage policies.

Conclusion

The EB approach, EBM or whatever other labels are to come, that use the literature as the basis for treating our patients in the best ways possible including therapeutically, economically, psychosocial!^ humanely, etc., is here to stay. As a respiratory therapist these many years, it is my observation that many of us (at least in my generation, the tail end of the infamous "baby boomers") entered the profession of Respiratory Therapy to help others and to make a true difference (along with making a decent living and making a great life). The EB approach to patient care is unquestionably the answer to the madness of diagnostics and therapeutics without scientific basis. Shouldn't everyone (including the bean counters) be happy when we follow "what works and what doesn't"? The EB approach within our profession is one of the major keys to our professional growth and development. We need to embrace it and use it to our advantage if we are to survive, develop and grow.

Joe Sorbello, MS, Ed., RRT
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Title Annotation:CLINICAL RESPIRATORY CARE
Author:Sorbello, Joe
Publication:FOCUS: Journal for Respiratory Care & Sleep Medicine
Date:Sep 22, 2011
Words:1419
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