Question of the Week

For August 5, 2014

Your answer is correct.

AzithromycinA long-acting bronchodilatorVancomycin and piperacillin–tazobactamIntravenous heparinNoninvasive positive-pressure ventilation

Key Learning Point View Case Presentation

A patient hospitalized with an exacerbation of chronic obstructive pulmonary disease and no evidence of hypercapnic respiratory failure or pneumonia should be treated with bronchodilator therapy, systemic glucocorticoids, and doxycycline, a fluoroquinolone or a macrolide antibiotic.

Detailed Feedback

In patients hospitalized for an exacerbation of chronic obstructive pulmonary disease (COPD), glucocorticoids and bronchodilators are the mainstays of treatment because they reduce symptoms and often shorten hospital stays. Antibiotics, particularly in the setting of purulent sputum, have been shown to significantly improve outcomes, lower the risk for treatment failure, increase time between exacerbations, and reduce the risk for death in cases of acute exacerbation. About 50% of acute exacerbations are caused by bacterial infection. Currently, fluoroquinolones, doxycycline, or macrolide antibiotics (such as azithromycin) are recommended to treat COPD exacerbations.

Vancomycin and piperacillin–tazobactam are not indicated if the patient has not been hospitalized within the past 90 days.

Long-acting bronchodilators are not indicated for acute exacerbations of COPD. It would be appropriate, however, to consider adding a long-acting bronchodilator to the patient’s outpatient regimen on discharge.

A patient with an unexplained exacerbation may have a pulmonary embolism requiring heparin treatment, but the presence of purulent sputum points to infection rather than pulmonary embolism, and diagnosis should be pursued before treatment.

Noninvasive positive-pressure ventilation has been shown to improve outcomes in patients with COPD exacerbations, but its use is limited to patients with hypercapnia (partial pressure of carbon dioxide >45 mm Hg), persistent hypoxemia, or increased work of breathing.

Last reviewed Nov 2017. Last modified Jun 2017.

Citations

Stoller JK. Clinical practice. Acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 2002 Mar 29; 346:988. > View Abstract

Sethi S and Murphy TF. Infection in the pathogenesis and course of chronic obstructive pulmonary disease. N Engl J Med 2008 Nov 29; 359:2355. > View Abstract

Ram FS et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2006 Apr 21.   > View Abstract

Vogelmeier CF et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report. GOLD executive summary. Am J Respir Crit Care Med 2017 Mar 1; 195:557.   > View Abstract

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