Recommendations for hobl. Clinical guidelines for the treatment of COPD complications

New guidelines for the treatment of chronic obstructive pulmonary disease (COPD) in outpatients recommend using oral corticosteroids and antibiotics to treat exacerbations. Also, the updated recommendations refer to the use of non-invasive mechanical ventilation in hospitalized patients with acute hypercapnic respiratory failure that occurred during an exacerbation of COPD.

The new paper was published in the March issue of the European Respiratory Journal and is based on a review of existing research by experts from the European Respiratory Society and the American Thoracic Society. These guidelines expand on the current GOLD guidelines published earlier this year.

In making these recommendations, the expert committee focused on 6 key issues related to the management of COPD: use of oral corticosteroids and antibiotics, use of oral or intravenous steroids, use of non-invasive mechanical ventilation, rehabilitation after hospital discharge, and application of programs home treatment patients.

1. Short course ( ⩽14 days) of oral corticosteroids is indicated for outpatients with exacerbations of COPD.
2. Antibiotics are indicated for outpatients with exacerbations of COPD.
3. In patients hospitalized for a COPD exacerbation, oral corticosteroids are preferred. intravenous administration drugs, if there is no violation of the gastrointestinal function.
4. Patients who have been in the emergency department or general ward should be told about the treatment they need to take at home.
5. Pulmonary rehabilitation should be started within 3 weeks after discharge from the hospital where patients were treated with an exacerbation of COJUL
6. or after the end of the adaptation period after discharge, but not during the stay in the hospital.

Discussion

• The Expert Committee notes that administration of corticosteroids for 9–14 days is associated with improved lung function and reduced hospitalizations. However, data on the effect on mortality have not been received.
• The choice of antibiotic should be based on local drug susceptibility. At the same time, antibiotic therapy is accompanied by an increase in the time between exacerbations of COPD, but at the same time an increase in the frequency of adverse events (primarily from the gastrointestinal tract).
• Pulmonary rehabilitation, including exercise, it is recommended to start between 3 and 8 weeks after discharge from the hospital. Although rehabilitation initiated during treatment improves exercise capacity, it was associated with increased mortality.

January 27, 2017 new report released working group Global Strategy for the Diagnosis, Treatment and Prevention of COPD (GOLD) 2017, a collaborative effort of 22 experts in the field of chronic obstructive pulmonary disease (COPD). This report is based on scientific publications on this issue that were published up to October 2016. It was simultaneously published online in the American Journal of Respiratory and Critical Care Medicine and hosted on the GOLD website. The updated recommendations consider last changes in the areas of diagnosis, strategies for de-escalation of therapy, non-pharmacological treatment options, and the role of comorbidities in the management of patients with COPD.

As before, the new report recommends testing for COPD in patients with a history of COPD risk factors and those with shortness of breath, chronic cough, or sputum production. In this case, as a diagnostic criterion, it is recommended to use the ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) after inhalation of a bronchodilator equal to< 0,70. Факторами риска развития ХОБЛ считаются отягощенный семейный анамнез, низкая масса тела при рождении, частые респираторные инфекции в детстве, а также воздействие табачного дыма, дыма от сгорания топлива, которое используется для обогрева или приготовления пищи, а также ряд профессиональных воздействий, например, пыли, паров, копоти и прочих химических факторов.

One of the key changes in the new document is the separation of symptom assessment from spirometry assessment. Although respiratory function testing remains essential for diagnosis, the main objectives of the examination are to assess symptoms, risk of exacerbations, and the degree of influence of the disease on general state patients' health. Based on these parameters, patients can then be classified into groups A, B, C and D, according to which treatment is prescribed. Thus, spirometry remains a diagnostic tool and a marker of the severity of obstruction, but it is no longer needed for pharmacotherapy decisions, with the exception of prescribing roflumilast. Thresholds determined by spirometry also remain relevant for non-pharmacological therapies, in particular lung volume reduction and lung transplantation.

Another change concerns the definition of aggravation, which is now formulated in a simpler and more practical way. The evidence base for the treatment of exacerbation prevention was also supplemented.

Another new aspect of the GOLD Report is a detailed discussion of treatment intensification and de-escalation strategies, while earlier reports have mainly focused on initial therapy recommendations. Along with the inclusion of treatment amplification and de-intensification algorithms, the experts modified the discussion of treatment options and removed the first line from alternatives therapy. The document now includes additional rationale for recommended initial therapy and possible alternatives for all patient categories (ABCD). The guidelines also place a lot of emphasis on the use of combined bronchodilators as the first line of treatment.

The updated guidance also provides a detailed analysis of non-pharmacological treatment options beyond influenza and pneumococcal vaccination to reduce the risk of lower respiratory tract infections. The most important aspect of any treatment plan remains smoking cessation, also in the highest degree a useful measure is pulmonary rehabilitation. The latter is understood as a complex intervention based on a thorough assessment of the patient's condition and adapted to his needs. It may include components such as physical training, education (including self-help), interventions aimed at achieving behavioral changes to improve physical and psychological well-being, as well as to increase adherence to treatment. Pulmonary rehabilitation has the potential to reduce the risk of readmissions and mortality in patients after a recent exacerbation, but there is evidence that its initiation before the patient's discharge may lead to an increase in mortality.

Oxygen inhalation may improve survival in patients with severe resting hypoxemia, but long-term oxygen therapy in individuals with stable COPD and moderate or exercise-only hypoxemia does not prolong life expectancy or reduce the risk of hospitalization. The usefulness of assisted ventilation remains unclear, although patients with proven obstructive sleep apnea should use continuous positive airway pressure machines to increase survival and reduce the risk of hospitalization.

As mentioned above, an important part of the new document is devoted to the diagnosis and treatment of comorbidities in patients with COPD. In addition to the importance of identifying and treating the obstructive sleep apnea discussed above, the GOLD Report highlights the importance of awareness of comorbid conditions. cardiovascular diseases, osteoporosis, anxiety and depression, gastroesophageal reflux, as well as their adequate treatment.

Compared to previous reports, surgical techniques that have proven effective, such as lung volume reduction surgery, bullectomy, lung transplantation, and some bronchoscopic interventions, are discussed in more detail. All should be considered in selected patients with appropriate indications.

The section on palliative care has also become more detailed. Discusses hospice care and other end-of-life issues, as well as optimal strategies for managing symptoms such as shortness of breath, pain, anxiety, depression, fatigue, and malnutrition.

In principle, new GOLD reports are published annually as needed, but the text undergoes significant changes only once every few years as a significant amount of new information accumulates, which must be taken into account in clinical practice. This update is the result of another scheduled major revision, and the authors hope that as a result of their work, the guidelines will be more practical and easier to use in a variety of clinical situations.

New guidelines for the treatment of chronic obstructive pulmonary disease (COPD) in outpatients recommend using oral corticosteroids and antibiotics to treat exacerbations. Also, the updated recommendations refer to the use of non-invasive mechanical ventilation in hospitalized patients with acute hypercapnic respiratory failure that occurred during an exacerbation of COPD.

The new paper was published in the March issue of the European Respiratory Journal and is based on a review of existing research by experts from the European Respiratory Society and the American Thoracic Society. These guidelines expand on the current GOLD guidelines published earlier this year.

In making these recommendations, the expert committee focused on 6 key issues related to the management of exacerbations of COPD: the use of oral corticosteroids and antibiotics, the use of oral or intravenous steroids, the use of non-invasive mechanical ventilation, rehabilitation after discharge from the hospital, and the use of home care programs for patients.

1. A short course (⩽14 days) of oral corticosteroids is indicated for outpatients with exacerbations of COPD.
2. Antibiotics are indicated for outpatients with exacerbations of COPD.
3. In patients hospitalized for an exacerbation of COPD, oral corticosteroids are preferred over intravenous agents unless gastrointestinal function is impaired.
4. Patients who have been in the emergency department or general ward should be told about the treatment they need to take at home.
5. Pulmonary rehabilitation should be started within 3 weeks after discharge from the hospital where patients were treated with exacerbation of COPD
6. or after the end of the adaptation period after discharge, but not during the stay in the hospital.

Discussion

• The Expert Committee notes that administration of corticosteroids for 9–14 days is associated with improved lung function and reduced hospitalizations. However, data on the effect on mortality have not been received.
• The choice of antibiotic should be based on local drug susceptibility. At the same time, antibiotic therapy is accompanied by an increase in the time between exacerbations of COPD, but at the same time an increase in the frequency of adverse events (primarily from the gastrointestinal tract).
• Pulmonary rehabilitation, including exercise, is recommended to begin between 3 and 8 weeks after discharge from the hospital. Although rehabilitation initiated during treatment improves exercise capacity, it was associated with increased mortality.

The main goal of treatment is to prevent the progression of the disease. Treatment goals are as follows (Table 12)

Table 12. Main goals of treatment

The main directions of treatment:

I. Non-pharmacological effects

• Reducing the influence of risk factors.
• · Educational programs.

II. Medical treatment

Non-pharmacological methods of exposure are presented in table 13.

Table 13. Non-pharmacological methods of exposure

In patients with severe disease (GOLD 2 - 4) as necessary action pulmonary rehabilitation should be applied.

II. Medical treatment

The choice of the amount of pharmacological therapy is based on the severity clinical symptoms, post-bronchodilatory FEV1, and exacerbation rates.

Table 14. Principles of drug therapy in stable COPD patients according to levels of evidence

Table 15. List of essential drugs registered in Russia and used for the basic therapy of patients with COPD

1DAI - metered-dose aerosol inhaler; 2DPI - metered-dose powder inhaler

Schemes of pharmacological therapy for patients with COPD, based on a comprehensive assessment of the severity of COPD (the frequency of exacerbations of the disease, the severity of clinical symptoms, the stage of COPD, determined by the degree of impaired bronchial patency) are given in Table 16.

Table 16. COPD pharmacological regimens (GOLD 2013)

*- KDAH - short-acting anticholinergics; SABA - short-acting β2-agonists; DDBA - long-acting β2-agonists; DDAH - long-acting anticholinergics; IGCS - inhaled glucocorticosteroids; PDE-4 - phosphodiesterase inhibitors - 4.

Other treatments: oxygen therapy, ventilation support and surgical treatment.

Oxygen therapy

Long-term administration of oxygen (>15 hours per day) has been found to increase survival in patients with chronic respiratory failure and severe hypoxemia at rest (B, 2++).

ventilation support

Non-invasive ventilation is widely used in patients with extremely severe and stable COPD.

The combination of NIV with long-term oxygen therapy may be effective in selected patients, especially those with overt daytime hypercapnia.

Surgery:

Lung volume reduction surgery (LVA) and lung transplantation.

The operation is performed by removing part of the lung to reduce hyperinflation and achieve more efficient pumping of the respiratory muscles. Its use is carried out in patients with upper lobe emphysema and low exercise tolerance.

Lung transplantation can improve quality of life and functional performance in carefully selected patients with very severe COPD. The selection criteria are FEV1<25% от должной величины, РаО2 <55 мм рт.ст., РаСО2 >50 mmHg when breathing room air and pulmonary hypertension (Pra > 40 mm Hg).