Noninvasive Ventilation Is a Must For Most Inpatients With COPD

SAN DIEGO — Noninvasive positive pressure ventilation should “absolutely” be used for nearly every patient hospitalized for an acute exacerbation of chronic obstructive pulmonary disease, said Dr. Daniel D. Dressler, director of education for the section of hospital medicine at Emory University, Atlanta.

“Learn how to use this therapy,” Dr. Dressler advised at the annual meeting of the Society of Hospital Medicine. Although contraindicated in COPD patients who have malignant arrhythmias, refractory hypoxemia, cardiac or respiratory arrest, or hemodynamic instability, adding noninvasive positive pressure ventilation (NPPV) to usual care has been shown in a Cochrane meta-analysis of 14 clinical trials to save one life for every 10 COPD inpatients treated and to avoid intubation for 1 of every 4 patients treated, compared with usual care alone. Further, NPPV has been shown to lower the average length of stay by 3.2 days.

Dr. Dressler advised starting NPPV in the emergency department if possible, since “early intervention likely improves outcomes.” Monitor these patients closely with arterial blood gases at 30–60 minutes after initiating or changing NPPV settings. Don't wait 2 hours before taking these measures.

The usual starting pressure level is 10/5 cm of water pressure, and the settings are titrated upward to tolerance with the assistance of the respiratory therapist, he said.

Based on the Cochrane review, those who respond best to NPPV are patients with pH values less than 7.3. But that finding largely may reflect the level of care at individual hospitals rather than the likelihood that the therapy was poorly tolerated by individual patients. In a recent study of COPD patients with pH values of 7.35 and higher, NPPV did not reduce the risk of death or intubation, but it did speed up reduction in the partial pressure of carbon dioxide (pCO₂) and reduced average length of stay from 10.2 days to 5.5 days (Eur. J. Intern. Med. 2007;18:524–30).

Antibiotic treatment for nearly all hospitalized patients with COPD exacerbations also reduces length of stay and is strongly supported by evidence, according to Cochrane analysis. On average, treating eight patients will prevent one death, and treating three patients will prevent one treatment failure.

The evidence for the choice of antibiotic is not great, however, and not all hospitalized patients with COPD exacerbations are likely to need antibiotic therapy. Among the tests investigators are examining, as tools to guide antibiotic prescribing, are measures of procalcitonin levels, with values less than 0.1 ng/mL discouraging the use of antibiotics and values exceeding 0.25 ng/mL encouraging the use of antibiotics. When compared with patients treated empirically by their physicians, outcomes did not differ for those treated based on procalcitonin levels, but using the test did have the desired result of reducing antibiotic use. One had to test four patients in order to avoid prescribing antibiotics for one patient. The procalcitonin test is not broadly available and is estimated to cost about $250, but Dr. Dressler predicted more use of this test in the next 2–4 years.

The evidence is similarly strong for prescribing systemic steroids and inhaled bronchodilators for these patients. Oxygen obviously is prescribed as well, despite a lack of studies showing it to be appropriate for COPD exacerbations among inpatients.

During hospitalization and at discharge of COPD patients, Dr. Dressler advised tobacco cessation counseling and, if not previously administered, a pneumonia vaccine and an annual influenza vaccine. Prophylaxis for venous thromboembolism is standard during the hospital stay.

Patients' home medication regimens should be augmented with a long-acting β-agonist and corticosteroid inhaler. Single agents have been shown to reduce the risk of exacerbations, but they have not been shown to reduce mortality. Combination therapy has been shown to reduce exacerbations and avoids one death for every 53 patients treated.

SAN DIEGO — Noninvasive positive pressure ventilation should “absolutely” be used for nearly every patient hospitalized for an acute exacerbation of chronic obstructive pulmonary disease, said Dr. Daniel D. Dressler, director of education for the section of hospital medicine at Emory University, Atlanta.

“Learn how to use this therapy,” Dr. Dressler advised at the annual meeting of the Society of Hospital Medicine. Although contraindicated in COPD patients who have malignant arrhythmias, refractory hypoxemia, cardiac or respiratory arrest, or hemodynamic instability, adding noninvasive positive pressure ventilation (NPPV) to usual care has been shown in a Cochrane meta-analysis of 14 clinical trials to save one life for every 10 COPD inpatients treated and to avoid intubation for 1 of every 4 patients treated, compared with usual care alone. Further, NPPV has been shown to lower the average length of stay by 3.2 days.

Dr. Dressler advised starting NPPV in the emergency department if possible, since “early intervention likely improves outcomes.” Monitor these patients closely with arterial blood gases at 30–60 minutes after initiating or changing NPPV settings. Don't wait 2 hours before taking these measures.

The usual starting pressure level is 10/5 cm of water pressure, and the settings are titrated upward to tolerance with the assistance of the respiratory therapist, he said.

Based on the Cochrane review, those who respond best to NPPV are patients with pH values less than 7.3. But that finding largely may reflect the level of care at individual hospitals rather than the likelihood that the therapy was poorly tolerated by individual patients. In a recent study of COPD patients with pH values of 7.35 and higher, NPPV did not reduce the risk of death or intubation, but it did speed up reduction in the partial pressure of carbon dioxide (pCO₂) and reduced average length of stay from 10.2 days to 5.5 days (Eur. J. Intern. Med. 2007;18:524–30).

Antibiotic treatment for nearly all hospitalized patients with COPD exacerbations also reduces length of stay and is strongly supported by evidence, according to Cochrane analysis. On average, treating eight patients will prevent one death, and treating three patients will prevent one treatment failure.

The evidence for the choice of antibiotic is not great, however, and not all hospitalized patients with COPD exacerbations are likely to need antibiotic therapy. Among the tests investigators are examining, as tools to guide antibiotic prescribing, are measures of procalcitonin levels, with values less than 0.1 ng/mL discouraging the use of antibiotics and values exceeding 0.25 ng/mL encouraging the use of antibiotics. When compared with patients treated empirically by their physicians, outcomes did not differ for those treated based on procalcitonin levels, but using the test did have the desired result of reducing antibiotic use. One had to test four patients in order to avoid prescribing antibiotics for one patient. The procalcitonin test is not broadly available and is estimated to cost about $250, but Dr. Dressler predicted more use of this test in the next 2–4 years.

The evidence is similarly strong for prescribing systemic steroids and inhaled bronchodilators for these patients. Oxygen obviously is prescribed as well, despite a lack of studies showing it to be appropriate for COPD exacerbations among inpatients.

During hospitalization and at discharge of COPD patients, Dr. Dressler advised tobacco cessation counseling and, if not previously administered, a pneumonia vaccine and an annual influenza vaccine. Prophylaxis for venous thromboembolism is standard during the hospital stay.

Patients' home medication regimens should be augmented with a long-acting β-agonist and corticosteroid inhaler. Single agents have been shown to reduce the risk of exacerbations, but they have not been shown to reduce mortality. Combination therapy has been shown to reduce exacerbations and avoids one death for every 53 patients treated.

SAN DIEGO — Noninvasive positive pressure ventilation should “absolutely” be used for nearly every patient hospitalized for an acute exacerbation of chronic obstructive pulmonary disease, said Dr. Daniel D. Dressler, director of education for the section of hospital medicine at Emory University, Atlanta.

“Learn how to use this therapy,” Dr. Dressler advised at the annual meeting of the Society of Hospital Medicine. Although contraindicated in COPD patients who have malignant arrhythmias, refractory hypoxemia, cardiac or respiratory arrest, or hemodynamic instability, adding noninvasive positive pressure ventilation (NPPV) to usual care has been shown in a Cochrane meta-analysis of 14 clinical trials to save one life for every 10 COPD inpatients treated and to avoid intubation for 1 of every 4 patients treated, compared with usual care alone. Further, NPPV has been shown to lower the average length of stay by 3.2 days.

Dr. Dressler advised starting NPPV in the emergency department if possible, since “early intervention likely improves outcomes.” Monitor these patients closely with arterial blood gases at 30–60 minutes after initiating or changing NPPV settings. Don't wait 2 hours before taking these measures.

The usual starting pressure level is 10/5 cm of water pressure, and the settings are titrated upward to tolerance with the assistance of the respiratory therapist, he said.

Based on the Cochrane review, those who respond best to NPPV are patients with pH values less than 7.3. But that finding largely may reflect the level of care at individual hospitals rather than the likelihood that the therapy was poorly tolerated by individual patients. In a recent study of COPD patients with pH values of 7.35 and higher, NPPV did not reduce the risk of death or intubation, but it did speed up reduction in the partial pressure of carbon dioxide (pCO₂) and reduced average length of stay from 10.2 days to 5.5 days (Eur. J. Intern. Med. 2007;18:524–30).

Antibiotic treatment for nearly all hospitalized patients with COPD exacerbations also reduces length of stay and is strongly supported by evidence, according to Cochrane analysis. On average, treating eight patients will prevent one death, and treating three patients will prevent one treatment failure.

The evidence for the choice of antibiotic is not great, however, and not all hospitalized patients with COPD exacerbations are likely to need antibiotic therapy. Among the tests investigators are examining, as tools to guide antibiotic prescribing, are measures of procalcitonin levels, with values less than 0.1 ng/mL discouraging the use of antibiotics and values exceeding 0.25 ng/mL encouraging the use of antibiotics. When compared with patients treated empirically by their physicians, outcomes did not differ for those treated based on procalcitonin levels, but using the test did have the desired result of reducing antibiotic use. One had to test four patients in order to avoid prescribing antibiotics for one patient. The procalcitonin test is not broadly available and is estimated to cost about $250, but Dr. Dressler predicted more use of this test in the next 2–4 years.

The evidence is similarly strong for prescribing systemic steroids and inhaled bronchodilators for these patients. Oxygen obviously is prescribed as well, despite a lack of studies showing it to be appropriate for COPD exacerbations among inpatients.

During hospitalization and at discharge of COPD patients, Dr. Dressler advised tobacco cessation counseling and, if not previously administered, a pneumonia vaccine and an annual influenza vaccine. Prophylaxis for venous thromboembolism is standard during the hospital stay.

Patients' home medication regimens should be augmented with a long-acting β-agonist and corticosteroid inhaler. Single agents have been shown to reduce the risk of exacerbations, but they have not been shown to reduce mortality. Combination therapy has been shown to reduce exacerbations and avoids one death for every 53 patients treated.