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Christian Medical College and Hospital
Ludhiana, India
To the Editor:
I read with interest the review by Dr. Antonio Anzueto and colleagues (1), wherein the authors have beautifully discussed the etiology, mechanisms, and management 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); however, the role of theophylline and supportive management is not mentioned; all of these have implications in the management of the disease.
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 (2). However, the withdrawal of methylxanthines in patients already receiving them can worsen lung function, clinical status, exercise performance, and ratings of dyspnea (3). 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 nebulized short-acting bronchodilators (4). Appropriate fluid balance (with special attention to the administration of diuretics), nutrition, anticoagulants, and cardiovascular agents are standard complementary measures. Manual or mechanical chest percussion and postural drainage may be beneficial in patients producing more than 25 ml sputum per day or with lobar atelectasis.
The standard package for the treatment in an acute exacerbation of COPD should include nebulized bronchodilators (usually a β2-agonist and anticholinergic in combination), antibiotics, systemic steroids, methylxanthines, appropriate fluid balance, nutritional supplementation, deep venous thrombosis prophylaxis, stress ulcer prophylaxis, controlled oxygen therapy, and ventilatory support. The timely institution of the above measures is important in preventing the mortality and morbidity associated with acute exacerbation of COPD.
Besides active immunizations and chronic maintenance pharmacotherapy for the prevention of COPD exacerbation, reduction of total personal exposure to tobacco smoke, occupational dusts and chemicals, and indoor and outdoor air pollutants, including smoke from cooking over biomass-fueled fires, is an important goal to prevent the onset and progression of COPD.
FOOTNOTES
Conflict of Interest Statement: A.S. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript.
REFERENCES
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