Original Title: Guides et normes: Exacerbation aigüe de la maladie pulmonaire obstructive chronique - démarche diagnostique, usage optimal des traitements et suivi

Authors' objectives: Chronic obstructive pulmonary disease (COPD) is characterized by expiratory airflow limitation, which causes persistent and progressive respiratory symptoms. The prevalence of COPD has been relatively stable in Québec over the past decade and is around 10%. Despite advances in the overall understanding, the diagnosis and the treatment of COPD, some people still experience frequent exacerbations and a more rapid deterioration in their pulmonary function, which is associated with a poor prognosis. Considering the recent publication of tools on the management of COPD [INESSS, 2022], the Institut national d'excellence en santé et en services sociaux (INESSS) wanted to revise, concurrently, its recommendations regarding the diagnostic approach and the pharmacological treatments for an acute exacerbation of COPD (AECOPD) published about five years ago – a guide to the optimal use of antibiotics and a national medical protocol on the initiation of first-line treatment, together with a collective prescription model. These updates are in keeping with the Institute's commitment to provide up-todate recommendations that are consistent with the latest scientific data and best practice trends, particularly in antibiotic stewardship. The proposed tools are specifically designed to support settings and facilitate interprofessional work within, for example, family medicine groups, nursing clinics and primary care access points.

Authors' results and conclusions: RESULTS (#1 RESPIRATORY SYMPTOMS BEYOND THE USUAL VARIATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE AS AN INDICATION OF ACUTE EXACERBATION): A sustained change over time in respiratory and inflammatory symptoms beyond the daily variations associated with underlying COPD (48 hrs or more and less than 14 days) generally suggests an AECOPD. The severity of an acute exacerbation is generally determined on the basis of the nature and degree of the clinical manifestations, and on the frequency of the exacerbations. In the past, exacerbations were divided into two categories: simple and complex. Now, according to the current state of knowledge, the severity of AECOD can be subdivided into three categories: 1. Mild, which is defined as dyspnea that is slightly worse than usual, with a slight increase in the respiratory rate (< 24 breaths/minute) and heart rate (< 95 bpm), 2. Moderate, which is characterized by dyspnea that is moderately to significantly worse than usual, with an acceleration of the respiratory rate (≥ 24 breaths/minute) and heart rate (≥ 95 bpm), 3. Severe, which is defined as an increase in dyspnea, the respiratory and the heart rate, and a decrease in saturation like those defined for a moderately severe exacerbation AND – Hypercapnia (PaCO2 > 45 mm Hg) with acidosis (pH < 7.35) OR – A condition requiring hospitalization. (#2 A CLINICAL DIAGNOSIS SUPPORTED BY ETIOLOGICAL MARKERS): The diagnosis of AECOPD is based on an assessment of the symptoms and signs; information gathered during the history, including any exposure to irritants; an assessment of the patient’s adherence to maintenance treatments, a verification of their inhalation device technique; and the ruling out of other medical conditions. Identifying the presumed etiology of the AECOPD is crucial for choosing the optimal treatment and limiting inappropriate antibiotic prescribing. AECOPD are often of infectious (50-70%) and sometimes environmental (10%) origin or are of undetermined cause (30%). An AECOPD is presumed to be bacterial if there is a change in the sputum (purulence) accompanied by an increased dyspnea or an increase in the quantity of sputum. A bacterial sputum culture is useful if there are recurrent acute exacerbations or when an antibiotic-resistant bacterium is suspected because of a non-response to first-line treatment. Since the symptomatology does not usually enable one to clearly distinguish a bacterial etiology from a viral one, tests for respiratory viruses lodged in the airways may help if the patient is hospitalized, depending on the current epidemiological context. Other paraclinical examinations can also help distinguish an AECOPD from another medical condition with similar clinical manifestations. (#3 TIMELY OPTIMAL TREATMENT FOR REDUCING SYMPTOMS AND THE RISK OF COMPLICATIONS): The choice of optimal treatment is based on the severity of the acute exacerbation and the presumed etiology, and on the risk-benefit trade-off for the patient. Treatment is aimed first and foremost at providing relief to the patient and at taking a preventive approach by helping to optimize their COPD maintenance therapy. Optimizing the dose or the dosing frequency of a short-acting bronchodilator with or without an anticholinergic is fundamental to the management of an AECOPD, regardless of its etiology or severity. By its anti-inflammatory action, the addition of prednisone is also helpful during a moderate or severe AECOPD in reducing airway inflammation. In line with the latest clinical practice guidelines published by learned societies specializing in COPD, the duration and dosage of corticosteroid therapy have been changed from the previous recommendations in order to limit the adverse effects associated with this medication. The guideline is now to administer corticosteroids for as short a time as possible so as not to cause any major metabolic disturbances, and to prescribe a smaller dose, especially to multi-medicated elderly patients, frail or underweight individuals, and those with uncontrolled diabetes or a coexisting psychiatric illness. (#4 MONITORING THE PATIENT’S COURSE AND AIMING FOR SELF-MANAGEMENT): The symptoms of an exacerbation can generally last from 7 to 10 days, and sometimes longer. The effect of treatment is usually observed within the first three days. Worsening symptoms are cause for a medical reassessment and sometimes even hospitalization. It is not uncommon for an AECOPD episode to be the first manifestation of undiagnosed COPD. In such case, a diagnostic approach should be planned during a period of clinical stability. AECOPD episodes aside, there are key measures for limiting symptoms and preventing acute exacerbations, such as smoking cessation, reducing or eliminating exposure to irritants (e.g., pollution, smoke and biomass), vaccination against respiratory infections, adhering to treatment and adopting healthy life habits. Health professionals other than a physician or a specialized nurse practitioner, such as a pharmacist, nurse or respiratory therapist, can support the patient in the optimal management of their disease. To facilitate self-management, having a "written" action plan is an essential tool for guiding the patient so that they recognize changes in their symptoms and, if applicable, take appropriate steps prior to an AECOPD episode. Yet, our work has shown that the practice of providing such an action plan is not uniform across the province, even though its use has been shown to be effective in COPD self-management. CONCLUSION: Moderate and severe AECOPD have a considerable impact on resource utilization, with repeated family medicine group and emergency department visits, or hospital and even intensive care stays. Self-management education for preventing exacerbations is therefore vital. In addition, knowledge of the most appropriate treatments based on the etiology and severity of the AECOPD and according to the risk of therapeutic failure or complications is a decisive factor in participating in antibiotic stewardship efforts, preserving the use of antibiotics for when they are truly needed, and reducing the negative effects associated with the use of certain antibiotics. While not replacing clinical judgment, the updated recommendations should support a clinical evaluation, promote optimal treatment choices and improve patients’ experience. Practice enhancement and harmonization will, however, depend on: • The dissemination of the updated clinical tools; • The adherence to these changes and the uptake of the recommendations by the health professionals concerned; • The commitment of family medicine group managers, nursing directors and councils of physicians, dentists and pharmacists to adopt or adapt the INESSS collective prescription template accompanying the national medical protocol; • The application of winning conditions to interprofessional work in the different care – especially front-line care − settings. To support the efforts to improve COPD management in Québec, INESSS is currently piloting a large-scale project focusing on reflective practice within front-line clinical teams. Workshops are being offered in which data on their patient base’s profile and their results on certain quality-of-care indicators are presented. These teams also have access to a clinical toolkit, which includes the clinical tools published by INESSS on COPD and AECOPD, and support in identifying desired areas for improvement and in drawing up an action plan.

Authors' recommendations: RESULTS (#1 RESPIRATORY SYMPTOMS BEYOND THE USUAL VARIATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE AS AN INDICATION OF ACUTE EXACERBATION): A sustained change over time in respiratory and inflammatory symptoms beyond the daily variations associated with underlying COPD (48 hrs or more and less than 14 days) generally suggests an AECOPD. The severity of an acute exacerbation is generally determined on the basis of the nature and degree of the clinical manifestations, and on the frequency of the exacerbations. In the past, exacerbations were divided into two categories: simple and complex. Now, according to the current state of knowledge, the severity of AECOD can be subdivided into three categories: 1. Mild, which is defined as dyspnea that is slightly worse than usual, with a slight increase in the respiratory rate (< 24 breaths/minute) and heart rate (< 95 bpm), 2. Moderate, which is characterized by dyspnea that is moderately to significantly worse than usual, with an acceleration of the respiratory rate (≥ 24 breaths/minute) and heart rate (≥ 95 bpm), 3. Severe, which is defined as an increase in dyspnea, the respiratory and the heart rate, and a decrease in saturation like those defined for a moderately severe exacerbation AND – Hypercapnia (PaCO2 > 45 mm Hg) with acidosis (pH < 7.35) OR – A condition requiring hospitalization. (#2 A CLINICAL DIAGNOSIS SUPPORTED BY ETIOLOGICAL MARKERS): The diagnosis of AECOPD is based on an assessment of the symptoms and signs; information gathered during the history, including any exposure to irritants; an assessment of the patient’s adherence to maintenance treatments, a verification of their inhalation device technique; and the ruling out of other medical conditions. Identifying the presumed etiology of the AECOPD is crucial for choosing the optimal treatment and limiting inappropriate antibiotic prescribing. AECOPD are often of infectious (50-70%) and sometimes environmental (10%) origin or are of undetermined cause (30%). An AECOPD is presumed to be bacterial if there is a change in the sputum (purulence) accompanied by an increased dyspnea or an increase in the quantity of sputum. A bacterial sputum culture is useful if there are recurrent acute exacerbations or when an antibiotic-resistant bacterium is suspected because of a non-response to first-line treatment. Since the symptomatology does not usually enable one to clearly distinguish a bacterial etiology from a viral one, tests for respiratory viruses lodged in the airways may help if the patient is hospitalized, depending on the current epidemiological context. Other paraclinical examinations can also help distinguish an AECOPD from another medical condition with similar clinical manifestations. (#3 TIMELY OPTIMAL TREATMENT FOR REDUCING SYMPTOMS AND THE RISK OF COMPLICATIONS): The choice of optimal treatment is based on the severity of the acute exacerbation and the presumed etiology, and on the risk-benefit trade-off for the patient. Treatment is aimed first and foremost at providing relief to the patient and at taking a preventive approach by helping to optimize their COPD maintenance therapy. Optimizing the dose or the dosing frequency of a short-acting bronchodilator with or without an anticholinergic is fundamental to the management of an AECOPD, regardless of its etiology or severity. By its anti-inflammatory action, the addition of prednisone is also helpful during a moderate or severe AECOPD in reducing airway inflammation. In line with the latest clinical practice guidelines published by learned societies specializing in COPD, the duration and dosage of corticosteroid therapy have been changed from the previous recommendations in order to limit the adverse effects associated with this medication. The guideline is now to administer corticosteroids for as short a time as possible so as not to cause any major metabolic disturbances, and to prescribe a smaller dose, especially to multi-medicated elderly patients, frail or underweight individuals, and those with uncontrolled diabetes or a coexisting psychiatric illness. (#4 MONITORING THE PATIENT’S COURSE AND AIMING FOR SELF-MANAGEMENT): The symptoms of an exacerbation can generally last from 7 to 10 days, and sometimes longer. The effect of treatment is usually observed within the first three days. Worsening symptoms are cause for a medical reassessment and sometimes even hospitalization. It is not uncommon for an AECOPD episode to be the first manifestation of undiagnosed COPD. In such case, a diagnostic approach should be planned during a period of clinical stability. AECOPD episodes aside, there are key measures for limiting symptoms and preventing acute exacerbations, such as smoking cessation, reducing or eliminating exposure to irritants (e.g., pollution, smoke and biomass), vaccination against respiratory infections, adhering to treatment and adopting healthy life habits. Health professionals other than a physician or a specialized nurse practitioner, such as a pharmacist, nurse or respiratory therapist, can support the patient in the optimal management of their disease. To facilitate self-management, having a "written" action plan is an essential tool for guiding the patient so that they recognize changes in their symptoms and, if applicable, take appropriate steps prior to an AECOPD episode. Yet, our work has shown that the practice of providing such an action plan is not uniform across the province, even though its use has been shown to be effective in COPD self-management. CONCLUSION: Moderate and severe AECOPD have a considerable impact on resource utilization, with repeated family medicine group and emergency department visits, or hospital and even intensive care stays. Self-management education for preventing exacerbations is therefore vital. In addition, knowledge of the most appropriate treatments based on the etiology and severity of the AECOPD and according to the risk of therapeutic failure or complications is a decisive factor in participating in antibiotic stewardship efforts, preserving the use of antibiotics for when they are truly needed, and reducing the negative effects associated with the use of certain antibiotics. While not replacing clinical judgment, the updated recommendations should support a clinical evaluation, promote optimal treatment choices and improve patients’ experience. Practice enhancement and harmonization will, however, depend on: • The dissemination of the updated clinical tools; • The adherence to these changes and the uptake of the recommendations by the health professionals concerned; • The commitment of family medicine group managers, nursing directors and councils of physicians, dentists and pharmacists to adopt or adapt the INESSS collective prescription template accompanying the national medical protocol; • The application of winning conditions to interprofessional work in the different care – especially front-line care − settings. To support the efforts to improve COPD management in Québec, INESSS is currently piloting a large-scale project focusing on reflective practice within front-line clinical teams. Workshops are being offered in which data on their patient base’s profile and their results on certain quality-of-care indicators are presented. These teams also have access to a clinical toolkit, which includes the clinical tools published by INESSS on COPD and AECOPD, and support in identifying desired areas for improvement and in drawing up an action plan.

Authors' methods: A systematic search of the scientific literature published between 2018 and 2021 was carried out, in collaboration with a scientific information consultant (librarian), in the PubMed, Embase, EBM Reviews (Cochrane Database of Systematic Reviews) and CINAHL databases. A targeted manual search of the grey literature published between July 2018 and January 2023 was carried out as well by consulting, among others, the websites of learned societies specializing in the field related to the topic of this report. Items were selected, data and recommendations were extracted, and methodological quality was assessed independently by two scientific professionals. In addition, a manual literature search was performed by consulting the websites of regulatory agencies, health technology assessment agencies, government bodies, and Québec professional associations and healthcare facilities. The official product monographs for Health Canada-approved antibiotics were examined as well, as were tertiary references in pharmacotherapy. The analysis and synthesis of the contextual elements gathered were performed by one professional and then validated by a second. An advisory committee consisting of clinicians from different specialties and areas of expertise, and a follow-up committee consisting of representatives from various Québec orders, federations and associations were set up to gather the stakeholders’ perspectives. The populational, clinical, organizational and economic dimensions were examined when assessing all of the evidence. The key clinical benchmarks were identified and the recommendations were drawn up in collaboration with the advisory committee’s members. Lastly, the overall quality of this report, its acceptability and applicability were assessed, on the one hand, with the representatives of the monitoring committee and, on the other, with external reviewers who are specialists in the field of interest, as well as with future users who were not involved in this work.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/maladie-pulmonaire-obstructive-chronique.html

Year Published: 2023

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/maladie-pulmonaire-obstructive-chronique.html

English language abstract: An English language summary is available

Publication Type: Other

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 sante et en services sociaux (INESSS)