Original Title: Protocoles médicaux nationaux et ordonnances associées: exacerbation aiguë de la maladie pulmonaire obstructive chronique

Authors' objectives: Chronic obstructive pulmonary disease (COPD) is a disorder that interferes with the normal passage of air into and out of the lungs. It is caused mainly by tobacco smoke. According to the World Health Organization (WHO), more than 3 million people died from COPD in 2015. In Canada, in 2013, chronic lower airway diseases were the fourth leading cause of death. As for acute exacerbation of COPD (AECOPD), it is defined as an acute, sustained worsening of respiratory symptoms beyond the normal day-to-day variations associated with underlying COPD. Despite advances in the overall understanding, diagnosis and treatment of COPD and AECOPDs, in COPD patients with frequent exacerbations, lung function deteriorates faster, which is associated with a poor prognosis. Consequently, the major challenge for all COPD patients is to keep the occurrence of exacerbations to a minimum. Therefore, in addition to information on the diagnosis and treatment of AECOPDs, most clinical practice guidelines (CPGs) provide considerable information on preventing them and reducing their frequency. It was against this background that the Institut national d’excellence en santé et en services sociaux (INESSS) undertook an update of its optimal usage guide (OUG) on AECOPDs, which dated from 2009. The objective of this report is to present all the data gathered in connection with INESSS’s work on this update as well as the recommendations that were developed.

Authors' results and conclusions: RESULTS: While treating an AECOPD with antibiotics is entirely appropriate in the presence of purulent sputa together with increased dyspnea or an increased quantity of sputum, nonbacterial factors, such as viruses or environmental factors, can cause an AECOPD as well. Therefore, it was highlighted in the OUG that the clinician should be vigilant when considering prescribing a patient an antibiotic, this to reduce the number of inappropriate prescriptions. Furthermore, the sections on treatment principles and complementary therapies (bronchodilators and corticosteroids) were enriched, and changes were made concerning second-line antibiotic therapies for patients with a complex AECOPD. In fact, before initiating second-line therapy in such patients, it is important to reassess their condition and to identify the culprit pathogen and adjust the treatment accordingly. But the main change made to the OUG is the addition of a section on measures for preventing future exacerbations. It is fundamental to try to prevent them because they have a negative impact on the quality of life of COPD patients, are slow to resolve, accelerate the deterioration in lung function and are associated with increased mortality and socioeconomic burden. Smoking cessation should therefore be continually encouraged in COPD patients in order to improve their lung function. Similarly, vaccination is important for preventing infections that can lead to an exacerbation. There are, at different health-care facilities, a number of effective programs (pulmonary rehabilitation, COPD clinic, and self-management program) for COPD patients aimed at guiding them toward a healthier lifestyle that is less conducive to exacerbations or at helping them recognize the warning signs of an AECOPD so that they can try to prevent it. These measures have therefore been proposed in this new version of the OUG. CONCLUSION: In conclusion, the improvement of the sections entitled “Diagnosis” and “Treatment principles” is intended to increase the clinician’s vigilance in order to improve drug use. The addition of the new section on measures for reducing the number of exacerbations is aimed at helping COPD patients reduce their number of exacerbations, at slowing the deterioration of their lung function and at preserving or improving their quality of life.

Authors' methods: The update is based on the best scientific data available evaluated by the authors of CPGs and other guidelines, and on recent systematic reviews (SRs) concerning AECOPDs. These data were enriched with organizational and legislative contextual elements specific to Québec, prevalence and resistance data on the various bacterial strains, and the experiential knowledge possessed by different Québec clinicians and experts who contributed to this work. A systematic search was conducted in the MEDLINE, EBM Review and Embase databases for CPGs and other guidelines, consensus conference reports and SRs. The literature search was limited to CPGs from G7 member countries published between 2009 and 2016 and in French or English only. In addition, a grey literature search was conducted, by a librarian, by consulting the websites of the Guidelines International Network (GIN) and the National Guideline Clearinghouse (NGC). The official product monographs of Health Canada-approved antibiotics were consulted as well.

Project Status: Completed

URL for protocol: https://www.inesss.qc.ca/thematiques/medicaments/protocoles-medicaux-nationaux-et-ordonnances-associees/eampoc.html

Year Published: 2019

URL for published report: https://www.inesss.qc.ca/thematiques/medicaments/protocoles-medicaux-nationaux-et-ordonnances-associees/eampoc.html

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en santé et en services sociaux (INESSS)