Noon Conference

Example Conference

EBM format

Case

• 65 year old white male• Presents to ED via EMS with chief c/o SOB• Symptoms worsening over last 4 days• Productive cough• Wheezing• Using albuterol nebs 6-8 times per day with

limited relief

• No chest pain

• No fevers, chill, or night sweats

• Never had SOB like this in the past

PMH/PSH

• COPD Gold Stage III – FEV1 45% predicted

• HTN

• Hyperlipidemia

• DM diet controlled

• Appendectomy in 1978

Medications

• Advair 250/50 one inhalation BID

• Spireva 18 mcg one inhalation QD

• ProAir HFA 2 puffs every 4 hrs as needed

• Albuterol Nebs every 4 hrs as needed

• HCTZ 25mg/day

Social

• 55 pack year tobacco history; quit in 1998

• Previous heavy Etoh use; sober since 1998

• No IVDA

• No occupational or TB exposures

• No recent travel

FMH

• CAD

• Father had MI at age 72

• DM

ROS

• Negative except for HPI

Physical Exam

• T 100.5 P 105 R 22 BP 105/68 SpO2 90%• HEENT wnl• CV tachy but regular• Lungs wheezing throughout• Abdomen benign• Ext no edema• Neuro intact

Imaging

Labs

• WBC 12.1

• Hb 15.6

• Chemistries wnl

EKG

Diagnosis

• Acute exacerbation COPD

Clinical Question• Population/problem:

– 65 year old male with an acute exacerbation of COPD 

• Intervention:– Systemic corticosteroids + bronchodilators

• Comparison:– Bronchodilators alone

• Outcome:– Treatment Failure

• Question– In patients with acute exacerbations of COPD, do systemic

steroids improve rate of treatment success when compared to bronchodilators alone?

The Search

• Type of question– Therapy

• Database– Pubmed

• Search terms– Systemic corticosteroids and acute

exacerbation COPD

Citation

• BS, Gan WQ, Sin DD. Contemporary management of acute exacerbations of COPD: a systematic review and meta-analysis. Chest. 2008 Mar;133(3):756-66. Review.

Summary of the Evidence

• Metaanalysis of contemporary management of AECOPD

• 10 studies involving 959 patients reviewed– 6 of the ten studies (742 patients) specifically

looking at treatment failures• Failure defined as clinical deterioration, study

withdrawal, relapse

Summary of the Evidence• Overall treatment

failure reduced by 46%

• RR 0.54 (95% CI 0.41-0.71)

• NNT is approximately 6

• Hyperglycemia RR 5.88– Will be seen in 1 in every

10 pt treated with steroids

Summary of the Evidence

Summary of the Evidence

• Doses in studies range from 60 mg qd to 100 mg q4h from 8-15 days– Ideal dose not identified– Extended length therapy (> 2wks) does

improve benefit

• All studies in which risk of treatment failure was reported (6 of 10) there was a decrease in failures

Do these apply to my patient?

• Yes this study applies to this patient– Similar characteristics as patients enrolled in

included studies– Has an identified COPD exacerbation– Concern for hyperglycemia needs to be

considered in this patient

Bottom Line

• Patients who have an acute exacerbation of COPD and who are treated with steroids have a lower risk of treatment failures.

• Hyperglycemia occurs frequently in patients with AECOPD who receive steroids.