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Beyond the "ABC approach"

Pulmonary and Critical Care Medicine, Christian Medical College and Hospital, Ludhiana, India.

To the Editors:

I read with interest the recent review by Celli and Barnes 1, wherein the authors have beautifully discussed the aetiology, cellular and molecular mechanisms, management and new definition of exacerbations of chronic obstructive pulmonary disease (COPD).

In the management of acute exacerbations of COPD they have discussed the role of three classes of drugs (antibiotics, bronchodilators and corticosteroids, i.e. an "ABC approach"); however, the role of oxygen therapy, theophylline and supportive management is not mentioned. All of these have implications for the management of the disease.

Hypoxia at exacerbation of COPD is quite common and may be life threatening. The importance of controlled oxygen therapy during the management of acute exacerbation cannot be overlooked 2.

Theophylline is widely used in the management of stable patients with COPD. A recent meta-analysis evaluating the role of intravenous aminophylline in cases of acute exacerbation of COPD did not find any beneficial effect in terms of improvement of pulmonary function or symptoms 3. However, the withdrawal of methylxanthines in patients already receiving them can worsen lung function, clinical status, exercise performance and ratings of dyspnoea 4. Therefore, patients already receiving oral preparations of methylxanthines for stable disease should continue on such treatments at the time of exacerbation. The current Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines even suggest adding aminophylline to standard therapy for patients with moderate-to-severe exacerbations or those not responding to nebulised short-acting bronchodilators 5.

Appropriate fluid balance (with special attention to the administration of diuretics), nutritional aspects, anticoagulants, and cardiovascular agents are the most complementary standard measures. Manual or mechanical chest percussion and postural drainage may be beneficial in patients producing >25 mL sputum per day or with lobar atelectasis.

REFERENCES

1. Celli BR, Barnes PJ. Exacerbations of chronic obstructive pulmonary disease. Eur Respir J 2007;29:1224–1238.[Abstract/Free Full Text]
2. Aubier M, Murciano D, Milic-Emili J, et al. Effects of the administration of O₂ on ventilation and blood gases in patients with chronic obstructive pulmonary disease during acute respiratory failure. Am Rev Respir Dis 1980;122:747–754.[Web of Science][Medline] [Order article via Infotrieve]
3. Barr RG, Rowe BH, Camargo CA Jr. Methylxanthines for exacerbations of chronic obstructive pulmonary disease: meta-analysis of randomised trials. BMJ 2003;327:643[Abstract/Free Full Text]
4. Kirsten DK, Wegner RE, Jörres RA, Magnussen H. Effects of theophylline withdrawal in severe chronic obstructive pulmonary disease. Chest 1993;104:1101–1107.[Web of Science][Medline] [Order article via Infotrieve]
5. Rabe KF, Hurd S, Anzueto A, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease–2006 Update. Am J Respir Crit Care Med 2007; [Epub ahead of print PMID: 17507545]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Permissions Request Permissions Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Singh, A. Search for Related Content PubMed PubMed Citation Articles by Singh, A.