Example Conference EBM format Noon Conference Example Conference EBM format Set B1 – Title Slide

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 Set A1 – Content Slide

No fevers, chill, or night sweats Never had SOB like this in the past No chest pain No fevers, chill, or night sweats Never had SOB like this in the past Set A1 – Content Slide

PMH/PSH COPD Gold Stage III HTN Hyperlipidemia DM diet controlled FEV1 45% predicted HTN Hyperlipidemia DM diet controlled Appendectomy in 1978 Set A1 – Content Slide

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 Set A1 – Content Slide

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 Set A1 – Content Slide

FMH CAD Father had MI at age 72 DM Set A1 – Content Slide

ROS Negative except for HPI Set A1 – Content Slide

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 Set A1 – Content Slide

Imaging Set A1 – Content Slide

Labs WBC 12.1 Hb 15.6 Chemistries wnl Set A1 – Content Slide

EKG Set A1 – Content Slide

Diagnosis Acute exacerbation COPD Set A1 – Content Slide

Clinical Question Question Population/problem: Intervention: 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? Set A1 – Content Slide

The Search Type of question Database Search terms Therapy Pubmed Systemic corticosteroids and acute exacerbation COPD Set A1 – Content Slide

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. Set A1 – Content Slide

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 Set A1 – Content Slide

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 Set A1 – Content Slide

Summary of the Evidence Set A1 – Content Slide

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 Set A1 – Content Slide

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 Set A1 – Content Slide

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. Set A1 – Content Slide

Closing Slide