chronic obstructive pulmonary disease
DISEASE INTERVENTION COMPARISON RESULTS
N Engl J Med. 2018 Apr 18. doi: 10.1056/NEJMoa1713901. [Epub ahead of print] Randomized Controlled Trial, Multicenter Study
IN chronic obstructive pulmonary disease, stable The Use of
triple inhaled therapy (glucocorticoid - fluticasone, long-acting muscarinic antagonist (LAMA) - umeclidinium, and a long-acting β2-agonist (LABA) - vilanterol)
As Treatment, Chronic
Is better Than
any dual therapy combination
To reduce the annual rate of moderate or severe exacerbations: 0.9 triple tt VS. 1.1 dual tt. Higher risk of pneumonia in dual or triple Tt taking glucocorticoids.
Fam Pract. 2009 Aug;26(4):260-8 Systematic Review
IN chronic obstructive pulmonary disease The Use of
clinical items: >45 years, dyspnoea, wheezing, current smoking and extensive smoking (>40 pack years), previous consult for wheezing, self-reported history of COPD, auscultatory wheezing, forced expiratory time, laryngeal height, prolonged expiration
As Diagnostic Tool
Is useful Than
spirometry as gold standard
To diagnose chronic obstructive pulmonary disease
N Engl J Med. 2004 Jun 24;350(26):2645-53 Descriptive
IN chronic obstructive pulmonary disease The Use of
pathology of small airways
As Prognostic Item
Is useful Than
-
To understand the natural history: progression of COPD is associated with the accumulation of inflammatory mucous exudates in the lumen, inflammatory infiltration of the wall and a remodeling process that thickens the walls of small airways
Cochrane Database Syst Rev. 2014;3:CD010844 Systematic Review, Cochrane Review
IN chronic obstructive pulmonary disease The Use of
double inhaled therapy, combining long-acting beta-agonist and inhaled corticosteroids
As Treatment, Chronic
Is better Than
any single inhaled therapy: long-acting anticholinergic, long-acting beta-agonist or inhaled corticosteroids
To increase, at 1 year, FEV1 (+100 mL combined LABA+ICS) and a respiratory clinical score. LAA and LABA were roughly equivalent, ICS were more effective than placebo but less than the other long-term threatments
Cochrane Database Syst Rev. 2014;3():CD010115 Systematic Review, Cochrane Review
IN chronic obstructive pulmonary disease The Use of
inhaled corticosteroids, fluticasone, budesonide
As Treatment, Chronic
Is worse Than
Comparison to be defined
To carry an increased risk of severe pneumonia (causing hospitalization or death) : OR 1.8 for fluticasone, 1.6 with budesonide. The risk of any pneumonia event (i.e. less serious cases) was higher with fluticasone than with budesonide (OR 1.86
Thorax. 2013 Nov;68(11):1029-36 Cohorts
IN chronic obstructive pulmonary disease The Use of
inhaled corticosteroids, specially fluticasone, less budesonide
As Treatment, Chronic
Is worse Than
no inhaled corticosterois
To carry an increased risk of severe pneumonia (causing hospitalization or death) : RR 2.0 for fluticasone, 1.2 with budesonide
Canadian Agency for Drugs and Technologies in Health (CADTH). 2010 May;127:1-131 Systematic Review
IN chronic obstructive pulmonary disease The Use of
triple inhaled therapy combining long-acting anticholinergic, long-acting beta-agonist and inhaled corticosteroids
As Treatment, Chronic
Is better Than
dual combination therapy or monotherapy
To reduce the number of severe exacerbations leading to hospitalization and increase quality of life (compared to monotherapy), with a possible increase in the risk of pneumonia
N Engl J Med. 2003 May 22;348(21):2059-73 Randomized Controlled Trial
IN chronic obstructive pulmonary disease, emphysema The Use of
lung-volume-reduction surgery
As Treatment, Chronic
Is equal Than
medical therapy only
To reduce mortality (overall 11% per year in both treatment groups) and improve exercise capacity (15% in intv. VS 3% in ctrl.). Mortality was reduced in patients with predominantly upper-lobe emphysema and low exercise capacity, but increased in the rest.
Chest. 2005 Nov;128(5):3489-99 Randomized Controlled Trial, Multicenter Study
IN chronic obstructive pulmonary disease, emphysema The Use of
lung-volume-reduction surgery
As Treatment, Chronic
Is worse Than
physical training alone
To perioperative and at 1 year mortality risk: 7/53 patients death in the surgery group VS 1/53 patients in control (p non significant). Health status and FEV1 were improved after surgery at 1 year.
N Engl J Med. 2011 Aug 25;365(8):689-98 Randomized Controlled Trial, Multicenter Study
IN chronic obstructive pulmonary disease, exacerbations The Use of
long-term antibiotics, azithromycin 250 mg daily for 1 year
As Prevention, Secondary
Is better Than
placebo
To reduce (but only marginally) nuber of exacerbations (1.5 par year azytro VS 1.8 per year placebo. Hearing impairment was higher: 25% patients azytro VS 20% placebo
Ann Intern Med. 2001 Apr 3;134(7):600-620 Randomized Controlled Trial
IN chronic obstructive pulmonary disease, exacerbations The Use of
bronchodilators, corticosteroids, antibiotics, and non-invasive positive-pressure ventilation
As Treatment, Acute
Is better Than
placebo or treatment not using it
To reduce death, need for intubation or reduce lenght of hospital stay.
BMJ. 2011 Jun 14;342:d3215. doi: 10.1136/bmj.d3215 Systematic Review
IN chronic obstructive pulmonary disease, exacerbations The Use of
inhaled anticholinergics, long acting, tiotropium, using mist inhaler
As Treatment, Acute
Is worse Than
placebo
To mortality: increased with tiotropium (2.4%) VS placebo (1.7%). NNH = 124
Thorax. 2001 Sep;56(9):708-712 Randomized Controlled Trial, Multicenter Study
IN chronic obstructive pulmonary disease, exacerbations The Use of
non-invasive ventilation
As Treatment, Acute
Is better Than
standard treatment without ventilatory support
To reduce mortality: median length of survival was 17 months in those treated with ventilation VS 13 months without
Lancet. 2000 Jun 3;355(9219):1931-1935 Randomized Controlled Trial, Multicenter Study
IN chronic obstructive pulmonary disease, exacerbations The Use of
non-invasive ventilation
As Treatment, Acute
Is better Than
standard treatment without ventilatory support
To reduce need for intubation (15% with ventilation VS 27% without) and reduce mortality (10% with ventilation VS 20% without)
Thorax. 2008 May;63(5):415-22 Meta-Analysis
IN chronic obstructive pulmonary disease, exacerbations The Use of
short-course antibiotic treatment (5 days or less)
As Treatment, Acute
Is equal Than
longer duration of antibiotic course
To achieve clinical and bacteriological cure (OR 1.0 and 1.05 respectively)
Chest. 2005 Jul;128(1):48-54 Randomized Controlled Trial
IN chronic obstructive pulmonary disease, exacerbations The Use of
smaller doses of short-acting inhaled beta2 agonists (albuterol, 2.5mg/4h)
As Treatment, Acute
Is equal Than
greater doses of the same drug (albuterol, 5mg/4h)
To increase FEV1 and peak expiratory flow rate, increase recovery rate, reduce hospital stay (trend to lower stay with higher doses: 6 vs 9 days, but not significant) or reduce side effects.
Lancet. 1999 Aug 7;354(9177):456-60 Randomized Controlled Trial
IN chronic obstructive pulmonary disease, exacerbations The Use of
systemic corticosteroids
As Treatment, Acute
Is better Than
placebo
To improve faster FEV1 and reduce lenght of hospital stay
Cochrane Database Syst Rev. 2005;(1):CD001288 Systematic Review, Cochrane Review
IN chronic obstructive pulmonary disease, exacerbations The Use of
systemic corticosteroids
As Treatment, Acute
Is better Than
placebo
To reduce, at 1 month, treatment failure (NNT 9) and improve respiratory failure and breathlessness, but increased adverse effects (OR 2.3)
N Engl J Med. 1999 Jun 24;340(25):1941-7 Randomized Controlled Trial, Multicenter Study
IN chronic obstructive pulmonary disease, exacerbations The Use of
systemic corticosteroids
As Treatment, Acute
Is better Than
placebo
To reduce treatment failure (death or mechanical ventilation or need to intensificate treatment): 23% with corticoids VS 33% without. Also, reduce lenght of hospital stay.
Chest. 2008 Mar;133(3):756-66 Systematic Review
IN chronic obstructive pulmonary disease, exacerbations The Use of
systemic corticosteroids, antibiotics, and noninvasive positive pressure ventilation
As Treatment, Acute
Is better Than
placebo or no use of that treatment
To reduce in-hospital mortality (antibiotics and ventilation) and reduce treatment failure (all, corticosteroids)
BMJ. 2003 Sep 20;327(7416):643 Meta-Analysis
IN chronic obstructive pulmonary disease, exacerbations The Use of
theophylline, methylxanthines
As Treatment, Acute
Is worse Than
placebo
To it did not reduce admissions to hospital, length of stay and relapses at one week. But it caused more adverse effects: vomiting, tremor, arrhythmias
Cochrane Database Syst Rev. 2018 Oct 30;10:CD009764 Systematic Review, Cochrane Review
IN chronic obstructive pulmonary disease, exacerbations The Use of
long-term antibiotics, macrolides, for 3 to 12 months
As Treatment, Chronic
Is better Than
placebo
To reduce patients with exacerbations at 1 year (47% antibiotics VS 61% controls). No effect in hospital admissions, change in FEV1, serious adverse events or all-cause mortality.
Chest. 2007 Jan;131(1):9-19 Randomized Controlled Trial
IN chronic obstructive pulmonary disease, exacerbations, respiratory infection, lower airways The Use of
procalcitonin, treating with antibiotics according to serum procalcitonin levels
As Diagnostic Tool
Is better Than
systematic treatment with antibiotics
To identify patients with active respiratory infection and guide antibiotic use: it reduced antibiotic use (40% vs 72%) obtaining same clinical outcome at 14 days and rehospitalzation rate (21% vs 24%)
Chest. 2001 Jun;119(6):1840-1849 Descriptive
IN chronic obstructive pulmonary disease, exacerbations, severe, requiring invasive mechanical ventilation The Use of
presence of comorbidities, APACHE, need for ventilation for > 72h or extubation failure
As Prognostic Item
Is useful Than
-
To predict higher in-hospital mortality
Chest. 2010 Sep 30;epub(epub):epub Cohorts
IN chronic obstructive pulmonary disease, in non-smokers The Use of
non-smokers, never smokers patients
As Etiologic risk factor
Is useful Than
no comparison
To though never smokers have much less risk of developing CPOD, they comprise 20-23% of all individuals with COPD. Asthma, age, lower education occupational exposure, childhood respiratory diseases and BMI alterations predicted COPD
Cochrane Database Syst Rev. 2005 Oct 19;(4):CD003566 Systematic Review, Cochrane Review
IN chronic obstructive pulmonary disease, stable The Use of
cardioselective beta-blockers
As Treatment, Chronic
Is equal Than
placebo
To modify respiratory function: no significant difference, at 3 months, in FEV1 or respiratory symptoms
BMJ. 2011 May 10;342:d2549. doi: 10.1136/bmj.d2549 Cohorts
IN chronic obstructive pulmonary disease, stable The Use of
cardioselective beta-blockers, given in addition to inhaled corticosteroid and long acting β agonist, with or without long acting antimuscarinic
As Treatment, Chronic
Is better Than
no beta-blockers use
To reduce all-cause mortality (22% relative reduction) and reduce hospital admissions due to respiratory disease.
Chest. 2007 Mar;131(3):682-9 Meta-Analysis
IN chronic obstructive pulmonary disease, stable The Use of
corticosteroids, inhaled
As Treatment, Chronic
Is better Than
placebo
To increase, at 6 months, FEV1 (mean of 42 mL in men and 29 mL in women compared with placebo) and keep this difference afterwards
Cochrane Database Syst Rev. 2007;(2):CD002991 Systematic Review, Cochrane Review
IN chronic obstructive pulmonary disease, stable The Use of
corticosteroids, inhaled
As Treatment, Chronic
Is better Than
placebo
To temporarily (first 6 months) reduce the decline of FEV1 and reduce at long term rate of exacerbations (-0.26 /patient/year)
Lancet. 1998 Mar 14;351(9105):773-80 Randomized Controlled Trial
IN chronic obstructive pulmonary disease, stable The Use of
corticosteroids, inhaled
As Treatment, Chronic
Is better Than
placebo
To reduce excerbation rate at 6 months (32% in intv. VS 37% in ctrl.) and increase FEV1, symptoms and 6 min walking distance
Lancet. 1999 May 29;353(9167):1819-23 Randomized Controlled Trial
IN chronic obstructive pulmonary disease, stable The Use of
corticosteroids, inhaled
As Treatment, Chronic
Is equal Than
placebo
To reduce the rate of decline in FEV1, reduce exacerbations or improve symptoms at 3 years.
BMJ. 2000 13 May;320(7245):1297-1303 Randomized Controlled Trial
IN chronic obstructive pulmonary disease, stable The Use of
corticosteroids, inhaled
As Treatment, Chronic
Is better Than
placebo
To reduce excerbation rate (0,99/year in intv. VS 1,32/year in ctrl.) and produce a small increase in FEV1. But it did not affect the rate of decline in FEV1
JAMA. 2008 Nov 26;300(20):2407-16 Meta-Analysis
IN chronic obstructive pulmonary disease, stable The Use of
corticosteroids, inhaled
As Treatment, Chronic
Is equal Than
placebo
To reduce overall mortality at 1 year (RR 0.86). Inhaled corticoids increased pneumonia rate (RR 1.34).
N Engl J Med. 2000 Dec 28;343(26):1902-1909 Randomized Controlled Trial, Multicenter Study
IN chronic obstructive pulmonary disease, stable The Use of
corticosteroids, inhaled
As Treatment, Chronic
Is equal Than
placebo
To reduce the rate of decline of post-bronchodilator FEV1 at 3 years. It reduced the visits to a physician because of a respiratory illness (1.2% /year in intv. VS 2.1% /year in ctrl.) and reduced symptoms.
Chest. 2010 Feb;137(2):318-25 Meta-Analysis
IN chronic obstructive pulmonary disease, stable The Use of
corticosteroids, inhaled
As Treatment, Chronic
Is better Than
placebo
To modestly reduce exacerbations rate (RR 0.82) across all levels of severity.
Thorax. 2003 Nov;58(11):937-41 Meta-Analysis
IN chronic obstructive pulmonary disease, stable The Use of
corticosteroids, inhaled
As Treatment, Chronic
Is better Than
placebo
To reduce the rate of FEV1 decline (mean reduction 7.7 ml/year, and with high dose regimens 9.9 ml/year)
N Engl J Med. 1999 Jun 24;340(25):1948-53 Randomized Controlled Trial, Multicenter Study
IN chronic obstructive pulmonary disease, stable The Use of
corticosteroids, inhaled
As Treatment, Chronic
Is better Than
placebo
To reduce the rate of decline of post-bronchodilator FEV1 in the first 6 monts of treatment but but does not appreciably affect the long-term progressive decline.
Am J Respir Crit Care Med. 2009 Oct 15;180(8):741-50 Randomized Controlled Trial, Multicenter Study
IN chronic obstructive pulmonary disease, stable The Use of
corticosteroids, inhaled (budesonide), combined with inhaled long-acting beta2 agonists (formoterol), added to inhaled long-acting anticholinergics (tiotropium)
As Treatment, Chronic
Is better Than
placebo plus tiotropium
To improve, at 3 months, VEMS (1.14 cortics/beta2 VS 1.08 placebo), improve respiratory symptoms and reduce exacerbations (8% cortics/beta2 VS 18% placebo)
N Engl J Med. 2007 Feb 22;356(8):775-89 Randomized Controlled Trial, Multicenter Study
IN chronic obstructive pulmonary disease, stable The Use of
corticosteroids, inhaled (fluticasone), alone or combined with inhaled long-acting beta2 agonists
As Treatment, Chronic
Is equal Than
placebo
To modify survival 3 years. There was a trend to better survival with combined inhaled corticosteroids plus lon-acting beta2 agonists but it did not reach sisnificance
J Gen Intern Med. 2006 Oct;21(10):1011-9 Meta-Analysis
IN chronic obstructive pulmonary disease, stable The Use of
inhaled anticholinergics
As Treatment, Chronic
Is better Than
long acting beta2-agonists
To reduced severe exacerbations (RR 0.67, compared to placebo) and respiratory deaths (RR 0.27, compared to placebo) while beta2-agonists associated increased risk for respiratory deaths
Cochrane Database Syst Rev. 2006 Jul 19;3:CD006101 Systematic Review, Cochrane Review
IN chronic obstructive pulmonary disease, stable The Use of
inhaled anticholinergics, ipratropium bromide
As Treatment, Chronic
Is equal Than
long acting beta2-agonists
To to improve COPD symptoms and exercise tolerance, although beta2-agonists improved better morning PEF and FEV1. combination therapy was a little better than beta-2 agonists alone for symptoms.
Thorax. 2006 Oct;61(10):854-62. Epub 2006 Jul 14 Meta-Analysis
IN chronic obstructive pulmonary disease, stable The Use of
inhaled anticholinergics, long acting, tiotropium
As Treatment, Chronic
Is better Than
placebo, ipratropium bromide, or long acting beta2-agonists
To reduce exacerbations (OR 0.73) and related hospitalisation (OR 0.68), but not to reduce mortality, all-cause or specific
Ann Intern Med. 2007 Nov 6;147(9):639-53 Systematic Review
IN chronic obstructive pulmonary disease, stable The Use of
long-acting beta2 agonists plus corticosteroids, inhaled and oxygen ; pulmonary rehabilitation
As Treatment, Chronic
Is better Than
placebo or inhaled corticosteroids alone and no oxygen
To reduce mortality (8.6% long-acting beta2 plus cortics VS 11% controls) (oxygen in resting hypoxemic patients RR 0.61). All lon-acting bronchodilators (B2 or tiatropium) reduced exacerbations and rehabilitation improved health status.
Lancet. 2008 Jun 14;371(9629):2013-8 Randomized Controlled Trial, Multicenter Study
IN chronic obstructive pulmonary disease, stable The Use of
mucolytics, carbocisteine
As Treatment, Chronic
Is better Than
placebo
To reduce exacerbation rate: 1.01 per patient per year with carbocisteine VS 1.35 placebo.
Lancet. 2005 Apr 30;365(9470):1552-60 Randomized Controlled Trial, Multicenter Study
IN chronic obstructive pulmonary disease, stable The Use of
mucolytics, N-acetylcysteine
As Treatment, Chronic
Is equal Than
placebo
To reduce yearly reduction in pulmonary function (FEV1 reduction 54ml VS 47ml/y) and the number of exacerbations per year (1.5 VS 1.29)
Chest. 2001 Jun;119(6):1661-70 Randomized Controlled Trial
IN chronic obstructive pulmonary disease, stable The Use of
theophylline, added to inhaled beta2-agonists
As Treatment, Chronic
Is better Than
inhaled beta2-agonists alone
To reduce - at 3 months - symptoms and dyspnea (53% in Theo+B2 VS 40% in B2 alone) and improve FEV1. Number of exacerbations was not significantly different and theophylline increased adverse effects.
N Engl J Med. 2017 Sep 07;377(10):923-935 Randomized Controlled Trial, Multicenter Study
IN chronic obstructive pulmonary disease, stable, early stage The Use of
inhaled anticholinergics, long acting, tiotropium
As Treatment, Chronic
Is better Than
placebo
To slightly improve at 2 years the FEV1 (mean difference 71 to 133 ml after bronchodilator use) and slightly reduce the decline of FEV1 after bronchodilator use (29 ml/year tiotrop VS 51 ml/year placebo)
N Engl J Med. 2011 Mar 24;364(12):1093-103 Randomized Controlled Trial, Multicenter Study
IN chronic obstructive pulmonary disease, stable, moderate to severe The Use of
inhaled anticholinergics, long acting, tiotropium
As Treatment, Chronic
Is better Than
long acting beta2-agonists, salmeterol
To reduce number of moderate or seve exarcerbations at 1 year: 0.64 tiotropium VS 0.72 salmeterol. the incidence of serious adverse events was similar.
Lancet. 2010 Sep 4;376(9743):784-93 Randomized Controlled Trial, Multicenter Study
IN palliative care, dyspnea, advanced cancer, advanced chronic obstructive pulmonary disease The Use of
oxygen, via a concentrator, nasal cannula, at 2 L per min
As Treatment, Acute
Is equal Than
room air, via a concentrator, nasal cannula
To relieve subjective breathlessness, measured in a 0-10 numerical rating scale: it changed about -0.5 points in both groups.
Cochrane Database Syst Rev. 2010;(1):CD007354 Systematic Review, Cochrane Review
IN palliative care, dyspnea, advanced cancer, advanced chronic obstructive pulmonary disease The Use of
benzodiazepines
As Treatment, Chronic
Is equal Than
placebo
To relief breathlessness