Treating an acute attack in COPD

Summarized by Robert W. Griffith, MD
October 11, 1999 (Reviewed: January 21, 2005)

The condition called chronic obstructive pulmonary disease (COPD) used to be known as chronic bronchitis and emphysema. It was extremely common in the United Kingdom before the introduction of regulations to control "smog" in the major cities. Nowadays it is primarily a disease of cigarette smokers. However, contributing factors include passive exposure to cigarette smoke, increasing age and a tendency to asthma or allergic rhinitis (hay fever). The main symptom is shortness of breath, which is often accompanied by wheezing and excessive production of sputum. The condition is diagnosed by physical examination, a chest x-ray and breathing tests.

From time to time a chest infection, starting as a cough or common cold, can bring on an acute attack, when the flow of air to the lungs is reduced due to secretions and sometimes constriction of the smaller airways. These attacks are quite serious, usually requiring hospitalization. Although 90% of patients recover from such an attack, as many as half of them may die within two years, and only a quarter of them will have a good quality of life six months later.

Acute attacks in patients with COPD are usually treated with antibiotics, drugs to dilate the small lung airways and to lessen secretions of sputum, and oxygen. The use of steroid hormone drugs was controversial until a few years ago. Recently, physicians are finding that steroid can be beneficial in both stable COPD and in acute attacks. A recent study carried out at Liverpool, UK, has examined the benefits of taking a steroid drug by mouth for an acute attack.

Sixty patients admitted to the emergency room with an acute worsening of their COPD were given standard treatment (as outlined above) and then assigned to receive, in addition, either 30 mg prednisone by mouth daily for 14 days, or identical dummy tablets. Their symptoms and breathing tests were recorded each day while in hospital, and then they were asked to return after six weeks for reassessment.

There were 34 men and 16 women who completed the study. Their average age was 67, and over half of them were current smokers. Five of the placebo patients withdrew before completing the study, compared with one steroid-treated patient. Two patients died before completing the 6-week follow-up period - one from the steroid group and one placebo.

The main measure of ability to breathe was the "forced expiratory volume-one" (FEV1), which is the volume of air that can be expelled from the lungs during one second. This measurement was made in all patients after they had received a dose of a bronchodilating drug to widen their small airways as much as possible.

The FEV1 increased significantly at a greater rate in the patients given the oral steroid drug. By day 5 after admission the steroid patients had reached almost the same level of FEV1 as they would have on hospital discharge. The symptoms of the attack decreased in both treatment groups, but to a greater extent in the steroid-treated patients. There were no serious signs of drug toxicity.

In addition, the average length of stay of patients taking the steroid drug was significantly less than that for the patients on the dummy treatment - 7 days instead of 9 days. At the 6-week follow-up visit, however, 9 of the steroid patients and 7 of the dummy tablets patients had required treatment for further acute attacks of COPD.

These findings, which are supported by those from other clinical studies, show that patients with acute worsening of their COPD can be helped by treatment with an oral steroid drug. Their shortness of breath improves more quickly, they have less symptoms, and their hospital stay is shorter. However, there are no persisting benefits from treatment with the steroid. It is possible, therefore, that an even shorter course of the steroid might produce the same benefits in an acute attack.

The most alarming figure coming out of this clinical trial is the fact that 52% of the patients were current cigarette smokers. Although they must have known about the effects of smoking on their disease, these patients were unable, or unwilling, to give it up. Obviously, all parties - physicians, caregivers, family and friends - must redouble their efforts to help COPD patients rid themselves of such a harmful habit.

Source

• Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomized controlled trial. L. Davies, RM. Angus, PMA. Calverley, Lancet, 1999, vol. 354, pp. 456--460

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