Page 163 - Hospital Authority Convention 2018

Masterclasses

M10.1 Advances in Chronic Obstructive Pulmonary Disease 09:00 Room 423 & 424
Management

Prevention of Chronic Obstructive Pulmonary Disease Exacerbations – International Guidelines and Local
Applicability
Ko FWS HOSPITAL AUTHORITY CONVENTION 2018
Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong

Chronic obstructive pulmonary disease (COPD) is a common disease worldwide with significant morbidity and mortality, and
incurs an intensive expenditure of healthcare resources. Acute exacerbations of COPD (AECOPD) are defined by the Global
Obstructive Lung Disease (GOLD) guideline as an acute worsening of respiratory symptoms that result in additional therapy.1
The GOLD guideline has provided a good resource for management and prevention of exacerbations. Infection and air
pollution are some of the important causes of AECOPD.2, 3 According to the Hospital Authority statistical report 2015-2016,
a total of 26,329 inpatient COPD-related discharges and deaths were recorded with 1,373 deaths.
While smoking cessation is the most important and effective intervention, other non-pharmacological interventions including
disease-specific self-management, pulmonary rehabilitation, early medical follow-up, home visits by respiratory health
workers, integrated programmes and telehealth-assisted hospital at home have been studied during hospitalisation and
shortly after discharge in patients who have had a recent AECOPD.4 A local study on pulmonary rehabilitation programme
for eight weeks for patients shortly after an exacerbation were able to lead to improvement in quality of life up to six months,
but did not reduce health-care utilisation at one year.5 A randomised controlled trial in Hong Kong comparing comprehensive
COPD programme versus usual care found that comprehensive COPD programme could reduce hospital readmissions for
COPD and length of stay, in addition to improving symptoms and quality of life of patients.6

Pharmacological approaches to reduce the risk of future exacerbations include long-acting bronchodilators, inhaled steroids,
mucolytics, vaccinations and long-term macrolides. Early treatment of long-acting anti-cholinergic agents for mild COPD may
also help to decrease exacerbations.7,8

Further studies are needed to assess the cost-effectiveness of these interventions in preventing AECOPD.

M10.2 Advances in Chronic Obstructive Pulmonary Disease 09:00 Room 423 & 424
Management

Update on the Use of Non-invasive Ventilation in Chronic Obstructive Pulmonary Disease
Chu CM
Department of Medicine and Geriatrics, United Christian Hospital, Hong Kong

Acute non-invasive ventilation (NIV) has been shown by multiple randomised controlled trials (RCTs) to improve arterial
blood gases, reduce the length of hospital stay, Intensive Care Unit (ICU) stay, intubation and mortality in patients suffering
from acute acidotic exacerbation of chronic obstructive pulmonary disease (COPD)1. NIV should be considered the firstline
treatment in the majority of COPD patients presenting with acidotic exacerbation.

Other potential uses of NIV for COPD are as follows: Tuesday, 8 May 2018
In intubated and mechanically ventilated COPD patients, NIV facilitates early weaning from mechanical ventilation, shorter
ICU stay, reduced incidence of ventilator associated pneumonia and lower 60-day mortality2.
NIV may be used as the ceiling of treatment in COPD patients with acute respiratory failure who refused intubation, if the
patients accept that they will have high rates of subsequent mortality and recurrent respiratory failure3. However, there is
inadequate data to support its routine use for palliative intent at present.
Home continuous positive airway pressure reduces hospitalisation and mortality in the COPD/obstructive sleep apnea
syndrome overlapped syndrome4.
NIV improves dyspnea and exercise tolerance when applied during exercise training5,6 by prolonging the duration of
exercise-induced lactataemia7, and maybe a useful adjunct in pulmonary rehabilitation.
COPD patients who survive an episode of AHcRF due to COPD after treatment by acute NIV are characterised by high rates
of readmission and life-threatening events8. There is conflicting evidence whether continuation of home NIV in this selected
group of patients may reduce recurrent acidotic exacerbation9,10.
In severe COPD patients with persistent hypercapnia during stable phase (as an outpatient or after surviving an episode of
acidotic respiration failure > two weeks), home NIV improves quality of life and survival when compared to medical treatment
and oxygen11,12.

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