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COPD

Date Last Search Run: Feb 01, 2022
Table last updated: Sep 29, 2022
Data last added: Sep 10, 2022

Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)  
2 (fair evidence exists)  
3 (weak evidence exists)  


Interventions

Anticholinergic
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Hospital admission Patient ED-MD Nouira S., Bouida W., Grissa MH., et al. Magnesium sulfate versus ipratropium bromide in chronic obstructive pulmonary disease exacerbation: A randomized trial. Am J Ther 2014; 21(3):152-8. Medline
I Neutral (Yellow) FEV1 Patient ED-MD Koutsogiannis Z., Kelly AM. Does high dose ipratropium bromide added to salbutamol improve pulmonary function for patients with chronic obstructive airways disease in the emergency department? Aust N Z J Med 2000; 30(1):38-40. Medline
I Neutral (Yellow) Peak flow rateĀ  Patient ED-MD O'Driscoll BR., Taylor RJ., Horsley MG., et al. Nebulized salbutamol with and without ipratropium bromide in acute airflow obstruction. Lancet 1989; 1:1418-20. Medline
I Neutral (Yellow) Forced expiratory volume Patient ED-MD Rebuck AS., Chapman KR., Abboud R., et al. Nebulized anticholinergic and sympathomimetic treatment of asthma and chronic obstructive airway disease in the emergency room. AM J Med 1987; 82:59-64. Medline

Beta Agonist-MDI
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) PEFR, Respiratory Rate Process PH-Paramedic Campbell IA., Colman SB., Mao JH., et al. An open, prospective comparison of B2 agonists given via nebuliser, nebuhaler, or pressurised inhaler by ambulance crew as emergency treatment. Thorax 1995; 50:79-80. Medline
II Supportive (Green) Improvement in pulmonary function Patient ED-MD Kuhl DA., Agiri OA., Mauro LS. Beta-agonists in the treatment of acute exacerbation of chronic obstructive pulmonary disease. Ann Pharmacother 1994; 28(12):1379-88. Medline

Beta Agonist-Nebulized
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Paramedic Score, PEFR Process PH-Paramedic Zehner WJ., Scott JM., Iannolo PM., et al. Terbutaline vs albuterol for out-of-hospital respiratory distress: Randomized double-blind trial. Acad Emerg Med 1995; 2(8):686-691. Medline
II Supportive (Green) PEFR, Respiratory Rate Process PH-Paramedic Campbell IA., Colman SB., Mao JH., et al. An open, prospective comparison of B2 agonists given via nebuliser, nebuhaler, or pressurised inhaler by ambulance crew as emergency treatment. Thorax 1995; 50:79-80. Medline
II Supportive (Green) Improvement in pulmonary function Patient ED-MD Kuhl DA., Agiri OA., Mauro LS. Beta-agonists in the treatment of acute exacerbation of chronic obstructive pulmonary disease. Ann Pharmacother 1994; 28(12):1379-88. Medline
II Supportive (Green) Mortality Patient PH-Paramedic Stiell IG., et al. Advanced Life Support for Out-of-Hospital Respiratory Distress. NEJM 2007; 356:2156-64. Medline
II Neutral (Yellow) Partial carbon dioxide pressure in arterial blood, respiratory rate and the need for post-ED hospitalization. Patient Gueho F., Beaune S., Devillier P., Urien S., Faisy C. Modeling the effectiveness of nebulized terbutaline for decompensated chronic obstructive pulmonary disease patients in the emergency department. Medicine (Baltimore) 2016; 95(32):e4553. Medline
III Supportive (Green) Clinical improvement Patient PH-Paramedic Markenson D., Foltin G., Tunik M., Cooper A., Treiber M., Caravaglia K. Albuterol Sulfate Administration by EMT-Basics: Results of a Demonstration Project. PEC 2004; 8(1):34-40. Medline

Beta Agonist-Parenteral
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Paramedic Score, PEFR Process PH-Paramedic Zehner WJ., Scott JM., Iannolo PM., et al. Terbutaline vs albuterol for out-of-hospital respiratory distress: Randomized double-blind trial. Acad Emerg Med 1995; 2(8):686-691. Medline

High flow nasal canula
Level Direction Primary Outcome Patient/Process Setting Reference
III Neutral (Yellow) Need for mechanical ventilation in the ED Patient Jones PG., Kamona S., Doran O., Sawtell F., Wilsher M. Randomized Controlled Trial of Humidified High-Flow Nasal Oxygen for Acute Respiratory Distress in the Emergency Department: The HOT-ER Study. Respir Care 2016; 61(3):291-9. Medline

Humidified oxygen
Level Direction Primary Outcome Patient/Process Setting Reference
III Neutral (Yellow) Need for mechanical ventilation in the ED Patient Jones PG., Kamona S., Doran O., Sawtell F., Wilsher M. Randomized Controlled Trial of Humidified High-Flow Nasal Oxygen for Acute Respiratory Distress in the Emergency Department: The HOT-ER Study. Respir Care 2016; 61(3):291-9. Medline

Intubation
Level Direction Primary Outcome Patient/Process Setting Reference
II Neutral (Yellow) Mortality Patient PH-Paramedic Stiell IG., et al. Advanced Life Support for Out-of-Hospital Respiratory Distress. NEJM 2007; 356:2156-64. Medline

Magnesium
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Resolution of exacerbation Patient Other Dobler CC, Morrow AS, Beuschel B, Farah MH, Majzoub AM, Wilson ME, Hasan B, Seisa MO, Daraz L, Prokop LJ, Murad MH, Wang Z. Pharmacologic Therapies in Patients With Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review With Meta-analysis. Ann Intern Med. 2020 Mar 17;172(6):413-422. doi: 10.7326/M19-3007. Epub 2020 Feb 25. PMID: 32092762. Medline
I Neutral (Yellow) FEV1 Patient ED-MD Jahanian F, Khatir IG, Ahidashti HA, Amirifard S. The Effect of Intravenous Magnesium Sulphate as an Adjuvant in the Treatment of Acute Exacerbations of COPD in the Emergency Department: A Double-Blind Randomized Clinical Trial. Ethiop J Health Sci. 2021 Mar;31(2):267-274. doi: 10.4314/ejhs.v31i2.9. PMID: 34158778; PMCID: PMC8188071. Medline
II Supportive (Green) Efficacy Patient ED-MD Skorodin MS, Tenholder MF, Yetter B, Owen KA, Waller RF, Khandelwahl S, Maki K, Rohail T, D'Alfonso N. Magnesium sulfate in exacerbations of chronic obstructive pulmonary disease. Arch Intern Med. 1995 Mar 13;155(5):496-500. PMID: 7864705. Medline
II Supportive (Green) Change in Peak Expiratory Flow Rate Patient ED-MD Vafadar Moradi E, Pishbin E, Habibzadeh SR, Talebi Doluee M, Soltanifar A. The Adjunctive Effect of Intravenous Magnesium Sulfate in Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Randomized Controlled Clinical Trial. Acad Emerg Med. 2021 Mar;28(3):359-362. doi: 10.1111/acem.14050. Epub 2020 Jul 7. PMID: 32542879. Medline
II Opposes (Red) FEV1 Patient ED-MD Edwards L, Shirtcliffe P, Wadsworth K, Healy B, Jefferies S, Weatherall M, Beasley R; Magnesium COPD Study Team. Use of nebulised magnesium sulphate as an adjuvant in the treatment of acute exacerbations of COPD in adults: a randomised double-blind placebo-controlled trial. Thorax. 2013 Apr;68(4):338-43. doi: 10.1136/thoraxjnl-2012-202225. Epub 2013 Jan 7. PMID: 23299960. Medline
II Opposes (Red) Improvement Patient Other Shivanthan MC, Rajapakse S. Magnesium for acute exacerbation of chronic obstructive pulmonary disease: A systematic review of randomised trials. Ann Thorac Med. 2014 Apr;9(2):77-80. doi: 10.4103/1817-1737.128844. PMID: 24791169; PMCID: PMC4005165. Medline
III Supportive (Green) Percentage change in FEV1 and FVC Process ED-MD Mukerji S, Shahpuri B, Clayton-Smith B, Smith N, Armstrong P, Hardy M, Marchant G, Marsh E. Intravenous magnesium sulphate as an adjuvant therapy in acute exacerbations of chronic obstructive pulmonary disease: a single centre, randomised, double-blinded, parallel group, placebo-controlled trial: a pilot study. N Z Med J. 2015 Nov 20;128(1425):34-42. PMID: 26905985. Medline

NiPPV
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Changes in dyspnea score and respiratory rate Patient PH-Paramedic Finn JC, Brink D, Mckenzie N, Garcia A, Tohira H, Perkins GD, et al. Prehospital continuous positive airway pressure (CPAP) for acute respiratory distress: A randomised controlled trial. Emerg Med J 2021. Medline
I Supportive (Green) Mortality Patient ED-MD Ram FSG., Picot J., Lightowler J., Weszicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2004; (3). Medline
I Supportive (Green) Need for tracheal intubation Patient PH-Paramedic Thompson J., Petrie DA., Ackroyd-Stolarz S., Bardua DJ. Out-of-hospital continuous positive pressure ventilation vs usual care in acute respiratory failure: a RCT. Ann Emerg Med 2008; 52(3):232-41. Medline
I Supportive (Green) need for intubation Patient ED-MD Thys F., Roeseler J., Reynaert M., Liistro G., Rodenstein DO. Noninvasive ventilation for acute respiratory failure: A prospective randomised placebo-controlled trial. Eur Respir J 2002; 20(3):545-555. Medline
II Supportive (Green) Management, treatment indicator Patient PH-Paramedic & MD Dunand A, Beysard N, Maudet L, Carron PN, Dami F, Piquilloud L, et al. Management of respiratory distress following prehospital implementation of noninvasive ventilation in a physician-staffed emergency medical service: a single-center retrospective study. Scand J Trauma Resusc Emerg Med 2021; 29(1):85. Medline
II Supportive (Green) Mortality, Time to intubation Patient ED-MD Wood KA., Lewis L., Von Harz B., Kollef MH. The use of noninvasive positive pressure ventilation in the emergency department: results of a randomized clinical trial. Chest 1998; 113(5):1339-1346. Medline
II Neutral (Yellow) Intubation rate Process PH-Paramedic Cheskes S., Turner L., Thomson S., Aljerian N. The Impact of Prehospital Continuous Positive Airway Pressure on the Rate of Intubation and Mortality from Acute Out-of-hospital Respiratory Emergencies. Prehosp Emerg Care 2013; 17(4):435-41. Medline
II Neutral (Yellow) Patient selection Process PH-MD & CCT Pinczon J, Terzi N, Usseglio-Polatera P, Gheno G, Savary D, Debaty G, et al. Outcomes of Patients Treated with Prehospital Noninvasive Ventilation: Observational Retrospective Multicenter Study in the Northern French Alps. J Clin Med 2021; 10(7). Medline
III Supportive (Green) Respiratory Rate and SpO2 Patient PH-Paramedic Bledsoe BE., Anderson E., Hodnick R., Johnson L., Johnson S., Dievendorf E. Low-fractional oxygen concentration continuous positive airway pressure is effective in the prehospital setting. Prehosp Emerg Care 2012; 16(2):217-21. Medline
III Supportive (Green) Practicability and efficacy of prehospital NIV Patient PH-Paramedic Schmidbauer W., Ahlers O., Spies C., Dreyer A., Mager G., Kerner T. Early prehospital use of non-invasive ventilation improves acute respiratory failure in acute exacerbation of chronic obstructive pulmonary disease. Emerg Med J 2011; 28(7):626-7. Medline

Oxygen-high flow
Level Direction Primary Outcome Patient/Process Setting Reference
I Opposes (Red) Mortality Patient PH-Paramedic Austin MA., Wills KE., Blizzard L., Walters EH., Wood-Baker R. Effect of high flow oxygen on mortality in COPD a Prehospital RCT. BMJ 2010; 341:c5462. Medline
II Opposes (Red) Association between PaO2 and adverse outcomes Process ED-MD Cameron L., Pilcher J., Weatherall M., Beasley R., Perrin K. The risk of serious adverse outcomes associated with hypoxaemia and hyperoxaemia in acute exacerbations of COPD. Postgrad Med J 2012; 88(1046):684-9. Medline
II Opposes (Red) Targeted SpO2 Process Chow JW., Khullar K., Katechia K., Klim S., Kelly AM. Controlled oxygen therapy at emergency department presentation increases the likelihood of achieving target oxygen saturations in patients with exacerbations of chronic obstructive pulmonary disease. Emerg Med Australas 2016; 28(1):44-7. Medline
III Neutral (Yellow) PaO2 Process ED-MD Ford DJ., Rothwell RP. Safe oxygen in acute asthma: Prospective trial using 35% ventimask prior to admission. Resp Med 1989; 83:189-94. Medline
III Opposes (Red) Risk of hypercapnea Patient PH-Paramedic Durrington HJ., Flubacher M., Ramsay CF., Howard LS., Harrison BD. Initial oxygen management in patients with an exacerbation of chronic obstructive pulmonary disease. QJM 2005; 98(7):499-504. Medline

Oxygen-titrated
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Mortality Patient PH-Paramedic Austin MA., Wills KE., Blizzard L., Walters EH., Wood-Baker R. Effect of high flow oxygen on mortality in COPD a Prehospital RCT. BMJ 2010; 341:c5462. Medline
II Supportive (Green) Association between PaO2 and adverse outcomes Process ED-MD Cameron L., Pilcher J., Weatherall M., Beasley R., Perrin K. The risk of serious adverse outcomes associated with hypoxaemia and hyperoxaemia in acute exacerbations of COPD. Postgrad Med J 2012; 88(1046):684-9. Medline
II Supportive (Green) Targeted SpO2 Process Chow JW., Khullar K., Katechia K., Klim S., Kelly AM. Controlled oxygen therapy at emergency department presentation increases the likelihood of achieving target oxygen saturations in patients with exacerbations of chronic obstructive pulmonary disease. Emerg Med Australas 2016; 28(1):44-7. Medline
III Supportive (Green) Risk of hypercapnea Patient PH-Paramedic Durrington HJ., Flubacher M., Ramsay CF., Howard LS., Harrison BD. Initial oxygen management in patients with an exacerbation of chronic obstructive pulmonary disease. QJM 2005; 98(7):499-504. Medline
III Neutral (Yellow) Recovery times Process ED-MD Ford DJ., Rothwell RP. Safe oxygen in acute asthma: Prospective trial using 35% ventimask prior to admission. Resp Med 1989; 83:189-94. Medline

Oxymetry Monitoring
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Detection of hypoxemia Patient PH-Paramedic Bota GW., Rowe BH. Continuous monitoring of oxygen saturation in prehospital patients with severe illness: the problem of unrecognized hypoxemia. J Emerg Med 1995; 13:305-11. Medline


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