Question special

In ProACT, acute exacerbations of COPD (AECOPDs) represented 31.9% of patients. In this subset, adherence to guidelines was lower than average (49.2%), with most of the patients presenting with low procalcitonin (91.1% in tiers I and II) and AECOPD being amongst the most common reasons reported for non-adherence (33.9% of total). We usually make treatment decisions in AECOPD within an entirely different framework (increase in dyspnea/sputum/change of characteristics of the latter), that is subjective and very similar to patient inclusion criteria. Do AECOPDs pose specific research challenges? Should they be studied separately?

On a similar note, a recent French trial (Daubin C et al. Intensive Care Med 2018) reported a failed attempt to demonstrate non-inferiority of a 5-day PCT algorithm vs. usual care in a homogenous ICU population (sick COPD patients requiring non-invasive or invasive ventilation). What is most striking is that the initiation of antibiotics improved 3-month survival regardless of the PCT. This contrast drastically with Stoltz et al. (Chest 2007), as they showed a NNT of 3 for reducing antibiotic use within 6 months in ED COPD patients with a PCT-based protocol. AECOPDs seem to be a heterogeneous group all on its own. Any thoughts?