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Am Fam Physician. 2004;69(3):707

Chronic obstructive pulmonary disease (COPD) accounts for approximately 1 million emergency department visits per year. Given the high rates of hospitalization and the cost of caring for patients with COPD, Cydulka and colleagues conducted a study to determine whether emergency department treatment of COPD was in accordance with published guidelines.

The study combined data from two prospective cohort studies that were part of the Multicenter Airway Research Collaboration, involving 29 emergency departments in the United States and Canada. Patients with COPD and relevant characteristics, including information on outcomes, were identified through chart review and follow-up telephone interviews. Adherence to five published COPD guidelines on evaluation and treatment was assessed. Evaluation components included use of spirometry, arterial blood gas measurement, sputum testing, and chest radiography. Treatment components included use of inhaled beta agonists, anticholinergic agents, methylxanthines, systemic corticosteroids, and antibiotics.

Analysis was performed on 397 mixed COPD-asthma and COPD-only patients. Most patients had severe disease and eventually required hospitalization. Peak expiratory flow was obtained in 32 percent of the patients, and only 10 percent of values measured forced expiratory volume in one second. Adherence to evaluative aspects of the five guidelines was low. Objective measurement of pulmonary function, recommended by all five guidelines, was obtained in 43 percent of patients with mixed disease and in 21 percent of COPD-only patients. One half of patients received recommended blood gas evaluation. Sputum testing was 6 and 7 percent, respectively. Chest radiography was performed in 87 percent of the patients.

Patients were given only a median of one short-acting beta-agonist treatment in the first hour of emergency care. While patients with mixed disease received an anticholinergic aerosol during the first hour of care, no COPD-only patients received this medication. Only one patient received a methylxanthine. Overall, 62 percent were treated in the emergency department with a systemic corticosteroid, 28 percent received antibiotics in the emergency department, and 24 percent of nonadmitted patients received them at discharge. Adherence to the five guidelines regarding treatment was low. Finally, 43 percent of patients reported a relapse event or ongoing exacerbation at the two-week follow-up. More patients with mixed disease experienced relapse than COPD-only patients, and both groups experienced ongoing exacerbation equally.

The authors found low adherence to published guidelines, with considerable potential for improved emergency department care. It is likely that these findings reflect inconsistency among guidelines, resulting in confusion about proper management. The role and use of spirometry, in particular, remain controversial. Agreement among guidelines is much greater regarding treatment—currently supporting the use of inhaled anticholinergics and antibiotics for initial treatment—but adherence in emergency departments was low in this area as well. Emphasis on adaptable guidelines and improved guideline adherence may lead to improved clinical outcomes.

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