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exacerbations. These include receiving
both the influenza and pneumococcal
vaccinations and ceasing smoking.4
Once a patient has recovered from an
acute exacerbation, early enrolment in
pulmonary rehabilitation can improve
their exercise capacity and health status
within three months.4
Mr HK is receiving sub-optimal treatment
for his AECOPD. The COPD-X guidelines
advocate treating his AECOPD with
inhaled bronchodilators, prednis(ol)one
and antibiotic therapy.3 Mr HK has been
prescribed bronchodilators, a macrolide
antibiotic (roxithromycin) and is not
currently receiving oral prednis(ol)one.
As discussed above, the treatment of
AECOPD with macrolides is not currently
endorsed by the COPD-X guidelines.
Although roxithromycin is likely to cover a
sufficient spectrum to be of benefit, it may
not provide sufficient coverage against
Haemophilus influenzae.16 Furthermore,
anti-inflammatory effects of macrolides
are not likely to be significant with a
short course.16 It could also be argued
that non-judicious antibiotic use may
contribute to colonisation with resistant
organisms.16,19--21 For these reasons, it is
recommended that antibiotic guidelines
be adhered to and either amoxycillin
500 mg three times daily or doxycycline
100 mg twice daily be recommended. It
should be noted that doxycycline has the
propensity to worsen Mr HKs pre-existing
gastro-oesophageal reflux disease.
Mr HK has not been prescribed an oral
corticosteroid. There is strong evidence for
a short course of an oral glucocorticoid for
AECOPD to reduce severity and to shorten
the duration.8 The recommended duration
of corticosteroids is between 7--14 days.3,5
Mr HK had ceased his budesonide/
eformoterol turbuhaler before this
exacerbation, because he was advised
to rinse his mouth with salty water.
Fresh water is sufficient for rinsing after
an inhaled corticosteroid. It remains
unknown if salt water rinsing was
recommended by his pharmacist or if
he had misinterpreted the instructions.
In any case, this misunderstanding
resulted in non-adherence and may
have contributed to this exacerbation. It
would be reasonable for Mr HK to restart
the inhaled corticosteroid/long acting
beta-agonist combination and reassess its
effectiveness after six weeks compared with
his usual baseline.
Since dry powder inhalers require a
minimum threshold amount of inspiratory
effort, some very elderly patients and those
with advanced disease or who have an
AECOPD may not be able use the devices
effectively.23 To assess this devices are
available that generate a whistle if the
patient can generate sufficient inspiratory
force. Therefore, Mr HK may not be able to
use the budesonide/eformoterol turbuhaler
until he has at least partially recovered from
the AECOPD. Furthermore, his tiotropium
inhaler may also be ineffective.
Consideration could be given to using an
ipratropium MDI with a spacer if salbutamol
alone was not sufficient during this time.
There is good evidence that pulmonary
rehabilitation would be useful for MR HK to
help maintain lung function.4 This could be
facilitated through his GP.
Mr HK's GP was called as a matter of
urgency to discuss his AECOPD. It was
recommended that oral prednisolone be
started at a dose of 50 mg daily for 14 days.
Antibiotic treatment was also discussed and
it was recommended that roxithromycin
be replaced with amoxycillin 500 mg three
times daily. Bronchodilators were discussed,
highlighting that an ipratropium MDI with
spacer may be beneficial if salbutamol
alone was not effective during the AECOPD.
The following additional recommendations
were made to MR HK's GP:
Mr HK has not been adhering to his
budesonide/eformoterol inhaler as he
was under the false impression he needed
COPD treatment is multi-factorial and
includes treatment for optimising
function, preventing deterioration
and preventing and treating acute
exacerbations as outlined in the COPD-X
plan. The treatment of exacerbations
includes bronchodilators, appropriate
antibiotics and corticosteroids. Non-
guideline based antibiotic treatment
appears commonplace. However,
superior efficacy remains unclear and
may result in increased carriage of
to rinse his mouth with salty water. I have
advised him that rinsing his mouth with
fresh water will be adequate and to resume
his inhaler as soon as possible. Consider
reviewing the effectiveness after six weeks
and discontinue if there is no improvement
over his usual baseline.
Mr HK's inhaler technique was assessed and
optimised during the visit. Regular review
of technique is recommended. Mr HK may
also benefit from pulmonary rehabilitation to
optimise respiratory function.
Mr HK's use of corticosteroids and long term
use of omeprazole may predispose him to
osteoporosis. Consideration could be given
to measuring bone mineral density and
ensuring he receives adequate calcium,
vitamin D and load-bearing exercise.
1. AIHW 2010. Australia's health 2010. Australia's health no. 12. Cat.
no. AUS 122. Canberra: AIHW. At: www.aihw.gov.au/publication-
2. Australian Centre for Asthma Monitoring 2011. Asthma in
Australia 2011: with a focus chapter on chronic obstructive
pulmonary disease. Asthma series no. 4. Cat. no. ACM 22.
Canberra: AIHW. Viewed 29 Jun 2012 at: www.aihw.gov.au/
3. McKenzie DK, Abramson M, Crockett AJ, Glasgow N, Jenkins
S, McDonald C et al. The COPD-X Plan: Australian and New
Zealand Guidelines for the management of Chronic Obstructive
Pulmonary Disease. Queensland: The Australian Lung
Foundation; 2011 Aug.
4. Global initiative for the Chronic Obstructive Lung Disease. Global
strategy for the diagnosis, management, and prevention of
Chronic Obstructive Pulmonary Disease (Revised 2011). Spain:
Global Initiative for Chronic Obstructive Lung Disease Inc; 2011,
5. eTG complete [Internet]. Melbourne: Therapeutic Guidelines
Limited; 2010 Mar [updated 2010 Nov, cited 2012 Feb 28]. At:
6. Brown CD, McCrory DC, White J. Inhaled short-acting
beta2-agonists versus ipratropium for acute exacerbations of
chronic obstructive pulmonary disease. Cochrane Database
of Systematic Reviews 2001, Issue 1. Art. No.: CD002984. DOI:
7. Parameswaran GI, Murphy TF. Chronic obstructive pulmonary
disease role of bacteria and updated guide to antibacterial
selection in the older patient. Drugs Aging. 2009;26(12);985--95.
8. Walters JAE, Gibson PG, Wood-Baker R, Hannay M, Walters
EH. Systemic corticosteroids for acute exacerbations of
chronic obstructive pulmonary disease. Cochrane Database
of Systematic Reviews 2009, Issue 1. Art. No.: CD001288. DOI:
'...some very elderly
patients and those
disease or who have
an AECOPD may
not be able use the
devices effectively. '
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