Action plans for COPD: strategies to manage exacerbations and improve outcomes

Figures & data

Table 1 Summary of studies evaluating effectiveness of COPD action plan

Study	Bourbeau et al^Citation11	Sridhar et al^Citation13	Sedeno et al^Citation32	Effing et al^Citation14	Rice et al^Citation12	Fan et al^Citation15
Study design	RCT	RCT	Retrospective analysis of multicenter RCT	Prospective 2×2 factorial trial	Single-blinded RCT	RCT
Patients, n	96 (I) and 95 (C)	61 (I) and 61 (C)	85 (I) and 81(C)	70 (I) and 72 (C)	372 (I) and 371 (C)	209 (I) and 217 (C)
Exclusion of comorbidities	No	Yes	No	Yes	No	No
Severe exacerbation (>1 hospitalization/year)	Yes	No	Yes	No	No	Yes
Action-plan coordinator	Nurses, RT, and physiotherapist	RN	Case manager	RN	RT	Case managers
Education format and follow-up	Flip-chart modules: 1 hour/week at home for 7–8 weeks Weekly telephone calls for 8 weeks, then monthly for 1 year	Nurse phone calls every month and home visits every 3 months	Home teaching: 1 hour/week for 7–8 weeks Weekly telephone calls for 8 weeks, then monthly for 1 year	Four small-group 2-hour self-management sessions Telephone calls at 4, 13, and 26 weeks	Single 1- to 1.5-hour group-education session Monthly phone calls	Four individual 90-minute weekly sessions Phone calls: once a month for 3 months, then every 3 months
Action plan
Initial steroid	No	Yes	No	Yes	Yes	Yes
Initial steroid + Abx	Yes	No	Yes	No	No	No
Conditional Abx addition	No	Yes	No	Yes	Yes	Yes
Follow-up period	1 year	2 years	1 year	1 year	I year	1 year
Definition of exacerbation/AP triggers	Change in respiratory symptoms lasting for minimum 24 hours and respiratory status to return to baseline for at least 72 hours	Unscheduled need for health care, need for steroid tablets, or antibiotics for worsening of their COPD	Change in one of three respiratory symptoms lasting >24 hours	A clear negative change in two major symptoms or one major and one minor symptom from baseline for at least 2 consecutive days	GOLD criteria	Increase in or new onset of one or more respiratory symptoms for at least 2 days
Decrease in AECOPD	No	No	No	No, but fewer exacerbation days in I group	Yes	No
Decrease in ER visits and hospital admissions	Yes	No	Yes	No (trend)	Yes	No
Reduced urgent physician visits	Yes	Yes	Yes	Yes	Not assessed	Not assessed
Mortality	Not assessed	Mortality benefit in intervention group	Not assessed	Not assessed	No benefit	Increased mortality in the intervention group
Cost-effective?	Not assessed	Yes	Not assessed	Yes	Not assessed	Not assessed

Abbreviations: RCT, randomized controlled trial; ER, emergency room; AECOPD, acute exacerbation of COPD; I, intervention; C, control; resp, respiratory; Abx, antibiotic; AP, action plan; RT, respiratory therapist; RN, registered nurse; GOLD, Global Initiative for Chronic Obstructive Lung Disease.

Table 2 Summary of studies investigating role of antibiotics in COPD exacerbation

Study	Anthonisen et al^Citation21	Stockley et al^Citation23	Allegra et al^Citation24	Roede et al^Citation28	Llor et al^Citation26	Miravitlles et al^Citation27
Study design	Double-blind RCT	Prospective cohort	Prospective cohort	Retrospective data analysis	Multicenter double-blind placebo-controlled RCT	Data analysis of placebo arm of RCT
Patients	182 (I) and 180 (C) outpatients with AECOPD	121 Outpatients with AECOPD	315 Outpatients with AECOPD	842 Outpatients with AECOPD	156 (I) and 152 (C) outpatients with AECOPD	152 Outpatients with AECOPD
Disease severity	Any COPD	Any COPD	Moderate-to-severe COPD	Any COPD	Mild-to-moderate COPD	Mild-to-moderate COPD
Methods	Patients who developed AECOPD treated with Abx vs placebo	Patients with AECOPD assessed with sputum analysis + Abx prescription to patients with green purulent sputum	Qualitative and quantitative sputum analysis of patients that developed AECOPD	Comparison of long-term risk of subsequent exacerbation after treatment with steroid alone vs combination steroid and Abx	Patients were randomized to receive amoxicillin/clavulanate 125/500 mg TID vs placebo TID for 8 days during AECOPD	Assessment of failure rate in patients with AECOPD that did not receive Abx therapy
Results	Increased success rate with Abx (68%) vs placebo (55%) Reduced failure rate with deterioration: Abx (10%) vs placebo (19%) Faster rate of peak-flow recovery in Abx group	Positive bacterial culture if purulence (84%) vs mucoid (38%) Purulent sputum 94.4% sensitive and 77% specific for yield of high bacterial load	Absence of bacterial growth in mucoid (22%) vs purulent (5%) sputum samples Gram-negative and P. aeruginosa/Enterobacteriaceae isolated more frequently in sputum when FEV1 <35%	Treatment of AECOPD with steroid and Abx combination increased the median time from second to third AECOPD (199 vs 258 days)	74.1% (I) versus 59.9% (C) achieved end of therapy cure Median time to next exacerbation 233 days versus 160 days CRP >40 mg/L predicted failure with placebo	Increased clinical failure without Abx (19.9%) vs with Abx (9.5) Only factor associated with risk of treatment failure was sputum purulence and CRP >40 mg/L
Adverse effects (antibiotic group)	No	Not assessed	NA	Not assessed	Yes (mainly GI-related)	NA
Major findings/conclusions	Abx treatment during AECOPD associated with earlier resolution of symptoms	Patients with purulent sputum likely to benefit from Abx therapy High CRP seen in patients with sputum purulence	Purulent sputum associated with bacterial growth in AECOPD Deepening sputum color associated with increased yield of Gram-negative bacteria	Abx addition to oral CS associated with reduced risk of subsequent exacerbations and decreased risk of all-cause mortality	Abx use associated with increase in median time to next exacerbation CRP a useful marker for treatment response	Among Anthonisen criteria, only sputum purulence predicts failure without Abx

Abbreviations: RCT, randomized controlled trial; AECOPD, acute exacerbation of COPD; I, intervention; C, control; CRP, C-reactive protein; Abx, antibiotic; FEV₁, forced expiratory volume in 1 second; P. aeruginosa, Pseudomonas aeruginosa; TID, ter in die (thrice daily); GI, gastrointestinal; NA, not applicable; CS, corticosteroid.

Figure 1 COPD action plans: limitations and barriers.

Abbreviations: ACOS, asthma–COPD overlap syndrome; CPFE, combined pulmonary fibrosis and emphysema.

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