Contemporary Management of Acute Exacerbations of COPD: A Systematic Review and Meta-Analysis

This review and meta-analysis identified randomized controlled trials published in English from January 1968 to November 2006 that examined evidence for use of systemic corticosteroids, antibiotics, and non-invasive positive pressure ventilation (NPPV) in patients with acute chronic obstructive pulmonary disease (COPD) exacerbations. Ten studies with a total of 959 patients were identified examining the role of systemic corticosteroids in acute COPD exacerbations, 11 studies with a total of 1020 patients examined the role of antibiotics, and 14 studies with a total of 979 patients examined the role of NPPV. Two independent authors examined the studies and extracted the data. When possible, results were pooled to produce summary effects. Relative risks and confidence intervals were calculated when results were dichotomous. Systemic corticosteroids reduced treatment failure by 46% compared with placebo (relative risk [RR] 0.54; 95% CI 0.41–0.71; p = 0.27) and reduced hospital length of stay (LOS) by a mean of 1.42 days (95% CI 0.65–2.18; p = 0.40). Hyperglycemia was the only reported adverse event. Antibiotic use decreased treatment failures when given to hospitalized patients (RR 0.34; 95% CI 0.20–0.56; p = 0.48) but not in the outpatient setting. In-hospital mortality was reduced by 78% in three studies with the use of antibiotics (RR 0.22; 95% CI 0.08–0.62; p = 0.92). NPPV reduced intubation rates by 65% (RR 0.35; 95% CI 0.26–0.47; p = 0.82), in-hospital mortality by 55% (RR 0.45; 95% CI 0.30–0.66; p = 0.99), and LOS by a mean of 1.94 days (95% CI 0.01–3.81). The authors concluded from this study that corticosteroids in acute COPD exacerbation were beneficial in both in- and outpatient settings, antibiotics were beneficial only in hospitalized patients (although data and studies were largely heterogeneous), and NPPV was beneficial particularly in patients with respiratory acidosis (pH < 7.35).