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There are two widely used definitions of exacerbation. The Anthonisen definition is based on the presence of one or more of three cardinal symptoms, including. La enfermedad pulmonar obstructiva crónica (EPOC) es una entidad que causa una gran 9. eisner md, Anthonisen n, coultas d, et al. 38 | Proceso asistencial integrado del paciente con EPOC exacerbado. Anthonisen NR, Manfreda J, Warren CP, Hershfield ES, Harding GK, Nelson NA.

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To draw an analogy, confining our goal in the treatment of COPD exacerbations to short term resolution of symptoms would be the equivalent of treating acute myocardial infarction with the only aim being resolution of chest pain.

Optimizing antibiotic selection in treating COPD exacerbations

Whether antibiotics are of benefit in the treatment of exacerbations when a short course of systemic corticosteroids are co-administered has still not been studied in a large well designed trial. In addition to the risk factors described above, experience in other respiratory infections tells us that recent antibiotic use, within the past 3 months, places the patient in a high risk group for harboring antibiotic resistant pathogens and therefore having a poor outcome.

Exposure to antibiotic is not confined to those prescribed for respiratory infections, but includes antibiotics prescribed for any indication. Acute bronchodilator use could be related to the severity of underlying COPD or reflect the wheezy phenotype of exacerbation that may be less responsive to antibiotic treatment.

The list of potential pathogens in COPD exacerbations includes typical respiratory bacterial pathogens, respiratory viruses and atypical bacteria Table 2. The increase in symptoms should be of at least 24 hours duration and should be of greater intensity than their normal day to day variability. Evolution of nocturnal oxyhemoglobin desaturation in patients with chronic obstructive pulmonary disease and daytime PaO2 above 60 mmHg.

Br Med J,pp.

Archo Bronconeumol, 41pp. It is likely that acquisition of these pathogens in a patient with COPD, because of compromised lung defense, allows establishment of infection in the lower respiratory tract, with or without overt clinical manifestations.

EPOC y apneas del sueño | Archivos de Bronconeumología

Factors associated with relapse after ambulatory treatment of anthonnisen exacerbations of chronic bronchitis. It is evident that we need a better definition and objective measures of severity of exacerbations.

Epof of treatment of exacerbations Traditionally, the aims of treatment of an exacerbation are the recovery to baseline clinical status and the prevention of complications.

The paucity of well-designed, large randomized controlled trials in this field upon which to spoc solid recommendations has undoubtedly contributed to the state of affairs Sethi b. This trial had several unique design features which relate to observations made in this study.


This determination of severity is relatively simple and does correlate with benefit with antibiotics, with such benefit seen only in Type 1 and 2 exacerbations. Another suggested measure of severity of exacerbations is the intensity of treatment recommended, with treatment with bronchodilators only indicating mild exacerbations, while treatment with antibiotics and steroids in addition to bronchodilators regarded annthonisen indicating moderate or severe exacerbations.

Effects of non-invasive positive pressure ventilation on gas exchange and sleep in COPD patients. Sleep and sleep disordered breathing in adults with predominatly mild obstructive airway disease. The emerging concept that an increase in airway inflammation from the baseline level characteristic of COPD is central to the pathogenesis of acute exacerbations is supported by several recent studies White et al ; Sethi a.

Attiya Siddiqi and Sanjay Sethi. Although episodes aanthonisen nocturnal saturation can reasonably be supposed to increase morbidity and anthonnisen in these patients, the diagnostic importance of these desaturations has not been demonstrated.

Contribution of hipoventilation to sleep oxygen desaturation in chronic obstructive pulmonary disease. Any stimulus that acutely increases airway inflammation could lead to increased bronchial tone, edema in the bronchial wall and mucus production.

Chest, 85pp. Any 1 of the above 3 cardinal symptoms and 1 or more of the following minor symptoms or signs. A common cause of exacerbations, the rhinovirus, demonstrates considerable antigenic variation among its more than serotypes, allowing for recurrent infections. Antibiotics anfhonisen associated with lower relapse rates in outpatients with acute exacerbations of COPD. N Eng J Med,pp.

The subsequent discussion will focus on the role of antibiotics in the treatment of acute exacerbation. In an already diseased lung, these processes could worsen ventilation-perfusion mismatch and expiratory flow limitation. Thorax, 47pp.

Chest, eopcpp. Furthermore, it needs to tested in outpatients with exacerbations, where the majority of exacerbations are treated, patients are not as closely supervised and other supportive care is less rigorous.

Eur Respir J, 17pp.

Two meta-analyses of placebo-controlled trials in exacerbations have been published. Basophil-bound IgE and serum IgE directed against Epkc influenzae and Streptococcus pneumoniae in patients with chronic bronchitis during acute exacerbations.

Chronic obstructive pulmonary disease and sleep apneas. However, though a large number of such trials have been conducted, in the vast majority, antibiotic choice does not appear to affect the clinical outcome.

Non-apneic mechanisms of arterial oxygen desaturation during rapid-eye aanthonisen sleep. However, because of antigenic variability among strains of these bacterial species, the antibodies that develop to the infecting strain are usually strain-specific, and do not provide protection to the host from other antigenically eopc strains of the same species. However, there are limitations to the Anthonisen severity classification. Oxygen saturation during breath-holding and during apneas in sleep.


Other definitions have required symptoms to be of at least 48 hrs and even 72 hrs in duration. This is contrary to expectations that antibiotics with better in vitro and in vivo antimicrobial efficacy and better rpoc and pharmacokinetic characteristics should show superiority in clinical outcomes. If the 26 week follow up period had not been instituted, significant differences in clinically relevant outcomes of recurrence of exacerbations and respiratory related hospitalization would have been missed.

Cli Sci, 84pp. Among the therapeutic options for the treatment of acute exacerbations are antibiotics. In the first such analysis published inonly nine trials met quality criteria and a small but significant beneficial effect of antibiotics over placebo in acute exacerbation was demonstrated Saint et al Microbial pathogens in COPD exacerbations The list of potential pathogens in COPD exacerbations includes typical respiratory bacterial pathogens, respiratory viruses and anrhonisen bacteria Table 2.

Based on the discussion above, we use the Wnthonisen criteria of anthknisen cardinal symptom exacerbations defined as mild, while the presence of 2 or all 3 of the cardinal symptoms defines moderate and severe exacerbations.

The role and choice anthnoisen antibiotics in the treatment of exacerbations has been a matter of controversy. Persistence of systemic inflammation predicts early relapse.

Patients who had a successful clinical outcome at 28 days were then offered enrollment in a follow up period for a total anthonisfn 26 weeks of observation.

Goals Comments Clinical Clinical resolution to baseline Needs baseline assessment prior to exacerbation onset for comparison Prevention of relapse Relapse within 30 days is quite frequent Increasing exacerbation-free interval Needs long epkc follow up after treatment Faster resolution of symptoms Needs validated symptom assessment tools Preservation of health-related quality of life Sustained decrements seen after exacerbations Biological Bacterial eradication Often presumed in usual antibiotic comparison studies Resolution of airway inflammation Shown to be incomplete if bacteria persist Resolution of systemic inflammation Persistence of systemic inflammation predicts early relapse Restoration of lung function to baseline Incomplete recovery is seen in significant proportion Preservation of lung function Needs long term studies.

In the setting of COPD, with diminished respiratory reserve, this acute bronchitis has more profound manifestations and serious clinical consequences.