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BauernOpfer
Bearbeiter
Hindemith
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Untersuchte Arbeit:
Seite: 44, Zeilen: 3-30
Quelle: Sethi 2008
Seite(n): 2, Zeilen: l.col: 11ff
On the other hand, Sachs et al (Sachs APE et al, 1995) included patients of younger age, mild underlying disease and asthma. Not surprisingly, only 11% of their exacerbations were associated with a positive bacterial culture, rather than the usual 40% to 50%. Not surprisingly, antibiotics were of no benefit in this study and, in their placebo arm, there was a 93% resolution rate compared with 55% in the Anthonisen study (Anthonisen NR et al, 1987).

Severity of exacerbations

These systematic reviews considered non-severe exacerbations based on the site of treatment, that is, outpatient treatment. This classification is clearly very broad as the site of care will vary among countries and healthcare systems as well as with patient and physician preferences. Furthermore, over time, changes in healthcare delivery and results of outcome studies can change the site of care for the same severity of exacerbation. As Sethi states (Sethi S, 2008) a 40-year-old smoker without underlying airway obstruction, infrequent exacerbations and free of comorbid conditions would have been included as a mild-to-moderate exacerbation. On the other hand, a patient with severe COPD, frequent exacerbations and comorbid conditions who does not require hospitalization would also be classified as a mild-to-moderate exacerbation. In the former patient, it is possible that host immunity can adequately deal with the infection and the exacerbation will spontaneously resolve. In the latter patient, such resolution is less likely and complications are more frequent. Grouping these patients together can lead to confusing and contradictory results.

The severity of an exacerbation is a complicated concept, constituted by at least two factors, the severity of the underlying COPD and the acute change induced by the exacerbation itself. Therefore, a patient with severe underlying COPD will have significant clinical consequences from a relatively small change from the baseline state, while a patient with mild COPD will tolerate a much larger change in symptoms and lung function. It is evident that we need more objective measures of severity of exacerbations.

Severity of exacerbations

Puhan et al have grouped together mild and moderate exacerbations based on the site of treatment, that is, outpatient treatment. This classification is clearly very broad as the site of care will vary among countries and healthcare systems as well as with patient and physician preferences. Furthermore, over time, changes in healthcare delivery and results of outcome studies can change the site of care for the same severity of exacerbation. A 40-year-old smoker without underlying airway obstruction, infrequent exacerbations and free of comorbid conditions would have been included as a 'mild to moderate' exacerbation. On the other hand, a patient with severe COPD, frequent exacerbations and comorbid conditions who does not require hospitalization would also be classified as a 'mild to moderate exacerbation'. In the former patient, it is possible that host immunity can adequately deal with the infection and the exacerbation will spontaneously resolve. In the latter patient, such resolution is less likely and complications are more frequent. Grouping these patients together can lead to confusing and contradictory results.

The severity of an exacerbation is a complicated concept, constituted by at least two factors, the severity of the underlying COPD and the acute change induced by the exacerbation itself. Therefore, a patient with severe underlying COPD will have significant clinical consequences from a relatively small change from the baseline state, while a patient with mild COPD will tolerate a much larger change in symptoms and lung function. It is evident that we need more objective measures of severity of exacerbations. [...]

[...]

[...] As is evident from this comparison, Sachs et al [5] included patients of younger age, mild underlying disease and asthma. Not surprisingly, only 11% of their exacerbations were associated with a positive bacterial culture, rather than the usual 40% to 50%. Not surprisingly, antibiotics were of no benefit in this study and, in their placebo arm, there was a 93% resolution rate compared with 55% in the Anthonisen study [4].


4. Anthonisen NR, Manfreda J, Warren CPW, Hershfield ES, Harding GKM, Nelson NA: Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med 1987, 106:196-204.

5. Sachs APE, Koeter GH, Groenier KH, Waaij D van der, Schiphuis J, Jong BMd: Changes in symptoms, peak expiratory flow, and sputum flora during treatment with antibiotics of exacerbations in patients with chronic obstructive pulmonary disease in general practice. Thorax 1995, 50:758-763.

Anmerkungen

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