Pulmonary Disorders II

ii.

Data remain inconclusive regarding treatment failure, mortality, and repeated exacerbations

for patients who are hospitalized outside the ICU with severe COPD and for outpatients.

iii.

The findings within this systematic review are further limited by the inconsistency among

studies in the description of COPD severity at baseline.

populations:

Patients with all three cardinal symptoms: increase in dyspnea, increased sputum, and sputum

purulence

Patients with two cardinal symptoms if purulent sputum is one of the two symptoms

Patients requiring invasive or noninvasive MV for their respiratory insufficiency or failure as the

result of an ECOPD

Choice of antimicrobial should be based on local resistance patterns.

Initial therapy with amoxicillin/clavulanate, macrolide, tetracycline, or quinolone is suggested by

the guidelines. Considerations for antimicrobial selection should be guided by local resistance

patterns.

For patients with frequent exacerbations, severe airflow obstruction, and/or exacerbations requiring

MV, broader-spectrum antimicrobials should be considered because of the possible presence of P.

aeruginosa.

De-escalation

Antimicrobial therapy should be de-escalated as appropriate according to culture results, if

available.

Use of procalcitonin in critically ill patients with ECOPD is controversial. A study of ECOPD

in ICU patients found that using a procalcitonin-based algorithm for initiating or discontinuing

antibiotics was associated with a higher mortality rate compared with patients receiving standard

Vitamin D

Mechanism of effect: Vitamin D metabolites attenuate inflammation and support immune system

responses to pathogens.

in patients hospitalized with ECOPD with vitamin D concentrations less than 10 ng/mL.

A systematic review and meta-analysis of three randomized controlled trials (469 patients with data

available) showed that supplementation of vitamin D did not affect the rate of moderate/severe ECOPD

Prespecified subgroup analysis of 87 patients identified that vitamin D supplementation

reduced the rate of moderate to severe ECOPD in patients whose concentrations were deficient

(25-hydroxyvitamin D concentrations less than 10 ng/mL) at baseline.

No effect on exacerbations for patients whose concentrations were not deficient at baseline

In a more recent randomized controlled trial of patients with COPD investigating the effects of vitamin

D supplementation on exacerbations, a prespecified subgroup analysis of patients with vitamin D

concentrations of 6–10 ng/mL compared with placebo found no difference in time to first exacerbation,