Preventing exacerbations in chronic obstructive pulmonary disease
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.c7207 (Published 24 January 2011) Cite this as: BMJ 2011;342:c7207All rapid responses
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To the Editor
We have some concerns with the clinical review (1) on preventing
exacerbation in chronic obstruction pulmonary disease (COPD).
First, to
evaluate carefully COPD patients in terms of when to refer and when to admit to
hospital (Table 1).
Second, where more than physiological functional tests
were measured (especially FEV1 response), a meta-analysis of the studies
available showed five biomarkers: Pa02, sputum neutrophils, IL-8,
systematic TNF Alfa and C-reactive protein.
Third, the application in the management
of severe exacerbation in COPD of non-invasive ventilation (NIV). In
fact severe exacerbation leads to acute hypercapnia respiratory failure and
NIV commenced early should be the first line ventilator support for these
patients. NIV could avoid: i) a severe acidosis, ii) the need for
endotracheal intubation and is very effective in reducing mortality
with an improved survival. NIV should be provided in the Respiratory Unit and
not in ICU, such as in our hospital for less severe cases with pH values
>7.30.
Finally, although there are no robust respiratory tract
infections data to support the chronic use of NIV in stable COPD patients,
it should be considered in a minority of cases.
References
1. Preventing exacerbations in chronic obstructive pulmonary disease.
BMJ 2011; 342:c7207.
Table 1
Competing interests: No competing interests
With reference to your DTB article "Preventing exacerbations in COPD"
BMJ 2011;342:c7207
I would like to point out an error; the assessment used for severity
of airflow obstruction is according to the old NICE (2004) recommendation,
also previously recommended by the British Thoracic Society (BTS). This
has also been incorrectly referenced as from the new NICE guidelines in
the article.
The Global initiative for chronic obstructive lung disease (GOLD) 2008
criteria defines a post-bronchodilator FEV1 percent predicted of not less
than 80% as mild (Stage 1), between 50 to 79% as moderate (Stage 2),
between 30 to 49% as severe (Stage 3) and less than 30% as very severe
(Stage 4). This GOLD criteria has now been adopted by the NICE clinical
guideline 101 (2010) as well. Thus GOLD, NICE as well the American
Thoracic Society (ATS) and European Respiratory Society (ERS) now all use
the same uniform definitions/assessments for COPD.
Dr Burhan Khan
Consultant Physician Respiratory Medicine
Darent Valley Hospital,
Dartford Kent DA2 8DA
burhan.khan@dvh.nhs.uk
Competing interests:
None declared
Table 1: Assessing severity of airflow obstruction using reduction in FEV1 (NICE clinical guideline 101; 2010)
Competing interests: No competing interests
I enjoyed both the review on preventing COPD exacerbations (from the
DTB) and the management of Generalised Anxiety Disorder in adults (summary
of NICE guidance), in this weeks BMJ, but thought their juxtaposition
missed a trick.
Whilst, the DTB article, stated "patients with frequent exacerbations
have high levels of anxiety and depression...", there was no mention of
how the reverse could also be true e.g. high levels of anxiety and
depression result in patients attending with frequent exacerbations.
Whilst this may appear a circular argument, this is a common finding in
many an Emergency Department and Medical Admissions Unit across the UK.
There was also no mention, of how treating such anxiety and
depression could reduce such exarcebations, or at least hospital
admission. Being breathless is frightening, many of these patients are
breathless chronically and thus it is no surprise that many of them
develop anxiety but objectively when assessed such patients are often no
(physiologically) worse than normal (for them).
Certainly, medical teams can offer a bed, reassurance and regular
medical and nursing assessment but very often these patients are
discharged only to be re-admitted the following, or indeed the same day.
Is there a longer term psychological crook we can offer?
Unless it is me who is missing a trick.
Competing interests: No competing interests
In response to your article I note that you have defined mild COPD as
an FEV1 of 50-79% predicted, moderate as 30-49%, and severe as below 30%
based on NICE clinical guideline 101 (2010). However, I note that the
figures above actually refer to NICE guideline 12 (2004). The new
definition, as per clinical guideline 101, states that mild COPD is
defined as a post-bronchodilator FEV1 of more than or equal to 80%
predicted, moderate as 50-79%, severe as 30-49%, and very severe as
<30%. I would be most grateful if you could clarify this and explain
which guideline we should be using in practice.
Competing interests: No competing interests
Correction for DTB review: Preventing exacerbations in COPD
I would like to draw readers' attention to the following correction
for the Drug and Therapeutics Bulletin (DTB) Clinical Review entitled
Preventing exacerbations in COPD (reprinted as BMJ 2011; 342: c7207,
doi:10.1136/bmj.c7207), to be published on bmj.com:
"Several readers have pointed out that this Clinical Review article
contained some outdated definitions on the grades of severity of airflow
obstruction (BMJ 2011; 342: c7207, doi:10.1136/bmj.c7207). This article
was first published in Drug and Therapeutics Bulletin (DTB) in July 2010
(http://dtb.bmj.com/content/48/7/74.abstract) and reprinted in the BMJ in
January 2011. The definitions given in the article were cited as being
from the 2010 guideline from the National Institute for Health and
Clinical Excellence (NICE) on chronic obstructive pulmonary disease.
However, the updated (2010) NICE guideline was published during the final
stage of the production of the DTB article, and although the article text
was amended to reflect the revised NICE recommendations on management of
exacerbations, NICE's revised definitions of severity of airflow
obstruction were mistakenly not included in the DTB article or in the
subsequent reprinted version in the BMJ. The article therefore defined
mild chronic obstructive pulmonary disease as an FEV1 of 50-79% predicted,
moderate as 30-49%, and severe as below 30%, whereas the NICE 2010
guideline defines mild airflow obstruction in chronic obstructive
pulmonary disease as a post-bronchodilator FEV1 of at least 80% predicted,
moderate as 50-79%, severe as 30-49%, and very severe as <30%. This
error does not affect any of the DTB article's own recommendations."
Competing interests: No competing interests