In episode 27, we examine the management of COPD Exacerbation and adjunctive treatments. We review the relatively good evidence for antibiotics and steroids in Exacerbations including the options in choice, dosing, and mode of administration. We briefly examination some of the other treatment options in chronic COPD with combination puffers, immunizations, theophyline, and home oxygen. We close by discussing the general use of methylxanthines (like chocolate) for overall well-being.

Show Notes

1) Vaccinations

“An annual influenza vaccination reduces morbidity and mortality from the disease by as much as 50% in the elderly and reduces the incidence of hospitalization by as much as 39% in patients with chronic respiratory conditions. The benefit of pneumococcal vaccine in COPD is less well established”

Can Respir J 2007;Vol 14 Suppl 5b-32b

Influenza vaccine

“It appears, from the limited number of studies performed, that inactivated vaccine reduces exacerbations in COPD patients”

Cochrane Library 2008

Pneumococcal vaccine

“There is no evidence from randomised controlled trials that injectable pneumococcal vaccination in persons with COPD has a significant impact on morbidity or mortality

Cochrane Library 2008

2) Work-up for Exacerbation

Can Respir J 2003;10 Suppl A:11A-65A Ann Intern Med. 2001;134:600-620.

3) Acute Exacerbation “Treatment of an exacerbation of COPD with oral or parenteral corticosteroids significantly reduces treatment failure and the need for additional medical treatment”

Cochrane Library 2008

“This review shows that in COPD exacerbations with increased cough and sputum purulence antibiotics, regardless of choice, reduce the risk of short-term mortality by 77%, decrease the risk of treatment failure by 53% and the risk of sputum purulence by 44%; with a small increase in the risk of diarrhoea”

Cochrane Library2008

Can Respir J 2007;Vol 14 Suppl 5b-32b

4) Home Oxygen

Ann Intern Med. 2007;147:633-638 Ann Intern Med. 2007;147:639-653.

5) Theophylline

“This systematic review shows that orally administered theophylline improves lung function and levels of oxygen and carbon dioxide in the blood. However, there is limited data on its effect on symptoms, exercise capacity or quality of life. Despite being associated with increased side effects, particularly nausea, subjects preferred theophylline over placebo.”

Cochrane Library 2008

In episode 26, we examine the initial management of COPD. We first discuss the diagnosis of COPD and if screening is recommended. We encourage an initial focus on smoking cessation and then episodic, symptom control. We then review long acting puffers and the large body of confusing research with underwhelming and at times conflicting results. Unfortunately, the data available for long acting puffers serves as a good example of how more information can exacerbate confusion.

Show Notes

1) Diagnosis data

JAMA 2000;283:1853-7

Ann Intern Med. 2007;147:633-638.

2) Lung decline and smoking

JAMA 2003;290:2301-2312.

3) Evidence only for symptomatic and FEV<60%

Ann Intern Med 2007;147:639-653

4) Outcomes for puffers in COPD

Overall

Ann Intern Med 2007;147:639-653

Tiotropium

JGIM 2006;21:1011-9

LABA/Steroid

NEJM 2007;356:775-89 LABA/steroid

5) Latest tiotropium data

JAMA 2008;300:1439-50 NEJM 2008;359:1543-54

6) Inhaled steroid adverse events

Chest. 2005;127:89-97 NEJM 2000;343:1902-9

Cochrane 2007;4: CD 006829

NEJM 2007;356:775-89

In episode 25, we finish (for now) the discussion of in-office infectious disease management. We first review a case of sinusitis including the challenges of diagnosis and the benefit of antibiotics and/or nasal steroids. We then discuss a case of bronchitis with the concerns of diagnosis and the benefits of antibiotics. We wrap up our discussion of upper respiratory tract infections with a summary and tangent that will leave most listeners questioning our role as educators.

Show Notes

1) Antibiotics for sinusitis

Cochrane Review

2) Steroids for sinusitis

Cochrane Review

3) Macrolides created resistance within 4 days and it lasted for at least 3 months

Lancet 2007; 369:482-90

4) Antibiotics for Bronchitis – Cochrane Library

5) Suppositories – where do they fit in?

Journal of Clinical Nursing 2006;16:98–103

In episode 24, we continue the discussion of in-office infectious disease management. We discuss a case of AOM in an 8 year old child including the signs/symptoms important in making the diagnosis, pain control and the utility of antibiotics. We then discuss a case of sore throat in a 17 year old woman including a validated scoring system for diagnosis, pain control, and the utility of antibiotics. We don’t complete all upper respiratory infections but make a mess of those we do discuss.

Show Notes

1) Diagnosis of AOM – does this child have acute otitis media

JAMA. 2003;290:1633-1640

2) Ibuprofen vs acetaminophen for pain control and fever

In musculoskeletal pain in children for every 10 children treated with ibuprofen instead of acetaminophen

1 more will have “adequate” pain relief

Pediatrics 2007;119:460-7

In children with migraine, acetaminophen and ibuprofen produced similar pain relief at all endpoints (6 major endpoints) except ibuprofen treated subjects had a 20% absolute increase in the number of children who were completely pain free at 2 hours

Neurology 1997;48:103-7

Ibuprofen faster (by 26 minutes) for time to fever clearance and a greater time (39 minutes) without fever in the first 4 hours (39 minutes) compared to acetaminophen. No difference in symptoms of discomfort.

BMJ 2008;337;a1302

Meta-analysis of ibuprofen versus acetaminophen for pain or fever. In children, single doses of ibuprofen and acetaminophen have similar efficacy for relieving moderate to severe pain, and similar safety as analgesics or antipyretics. Ibuprofen was a more effective antipyretic than acetaminophen at 2, 4, and 6 hours post-treatment.

Arch Pediatr Adolesc Med 2004;158:521-6

3) Compared “love” of parent vs television

Arch Dis Child 2006;91:1015-7

4) Antibiotic treatment of AOM – Cochrane Library

5) Scoring system for Strep Throat.

CMAJ. 1998;158:75-83

CMAJ. 2000; 163:811-815

6) Antibiotic treatment of Strep throat – Cochrane Library

7) Meta-analysis of short course antibiotic treatment for Group A Streptococcal tonsillopharyngitis

Pediatr Infect Dis J 2005;24:909–17

In episode 23, we begin the discussion of antibiotic prescribing in common respiratory tract infections with a focus on pneumonia. We talk about the limited evidence for the clinical exam in diagnosing pneumonia. We review the variability in antibiotics suggested in guidelines and evidence for coverage of atypical pneumonia. We also discuss the research on dosing and duration of antibiotics. We find out what antibiotic James and Mike would take (and some infections they have had)!

Show Notes

1) Contributions of symptoms, signs, and other things to the diagnosis of pneumonia.

Br J Gen Pract 2003;53:358–64

2) Do you cover for atypical organisms or not when you are treating pneumonia?

Community acquired

BMJ 2005;330:456-9

Hospitalized patients

Cochrane Review

3) Amoxicillin for community acquired pneumonia – use 500 to 1000 mg TID

Thorax 2001;56(Suppl 4):iv1-iv64

4) Shorter duration and treating until “feeling better” for 72hours “

Until further data are available, it seems reasonable to treat bacterial infections such as those caused by S. pneumoniae until a patient is afebrile for 72 h”

Lancet 2003;362:1991–2001

Three days of antibiotics for hospitalized patients with community acquired pneumonia

BMJ 2006;332:1355