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Reproduction in whole or in part without permission is prohibited. Stoller JK, Barnes PJ, Hollingsworth H. Managment of exacerbations of chronic obstructive pulmonary disease. 1. Copyright © 2000 - 2021 Jobson Medical Information LLC unless otherwise noted. Accessed April 14, 2018.5. However, you can do a lot to help reduce your risk of exacerbations. These episodes are usually associated with a sense of distress, and the effects are more severe than the symptom… 5. A COPD exacerbation is defined as an acute worsening of dyspnea and other symptoms (e.g., increased sputum and mucus production and/or purulence, and/or coughing and wheezing) that require additional therapy. The name of your emergency contact person who may be able to help you if you cannot help yourself. Cochrane Database Syst Rev. ABSTRACT: Healthcare professionals across the world utilize the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline to guide the diagnosis, management, and prevention of chronic obstructive pulmonary disease (COPD). Smoking Marijuana Has Greater Impact on the Lungs than Smoking Tobacco, Implications of Bariatric Surgery on Absorption of Nutrients and Medications, High Radiotherapy Dose Improves Outlook for Children With Brain Cancer. The nature of the small-airway obstruction in chronic obstructive pulmonary disease. For patients in Group B, a long-acting bronchodilator with either a long-acting beta-agonist (LABA) or a long-acting muscarinic antagonist (LAMA) should be initiated (TABLE 4). In 2017, the GOLD report separated symptoms and exacerbation history from the severity of airflow limitation in the assessment of disease severity to emphasize the clinical parameters that drive therapeutic recommendations.2 The revised assessment tool allows for the initiation of treatment based upon the assessment of symptoms and history of exacerbation only, while the assessment of airflow limitation remains separate. Importance: Small clinical trials have shown that noninvasive ventilation (NIV) is efficacious in reducing the need for intubation and improving short-term survival among patients with severe exacerbations of chronic obstructive pulmonary disease (COPD). Rabe KF, Calverley PMA, Martinez FJ, et al. Euro Respir J. The GOLD report suggests considering utilization of procalcitonin-based protocols to guide antibiotic use as studies have shown an association with procalcitonin use and decreased antibiotic prescription and total antibiotic exposure.3, COPD exacerbations can negatively impact disease progression and a patient’s health status. Design: Prospective, randomized, blinded, controlled study. Ask your doctor about getting a flu or pneumonia vaccine(s). In particular, exacerbations of pulmonary sarcoidosis are reported in more than one-third of patients. Here’s how: Be prepared: what to do if you have an exacerbation. You may experience COPD symptomslike fatigue, wheezing, and exercise intolerance on a regular basis—or even every day. Cydulka RK, Emerman CL. COPD is commonly misdiagnosed — former smokers may sometimes be told they have COPD, when in reality they may have simple deconditioning or another less common lung condition. Jones PW. The Lancet Respiratory Medicine. Two randomized, controlled trials showed clinical benefit of triple therapy compared with LAMA alone or ICS/LABA therapy in patients with advanced disease.9,10. Ipratropium, an anticholinergic, is effective in acute COPD exacerbations and should be given concurrently or alternating with beta-agonists. Last updated April 6, 2018.18. Some people rarely experience COPD exacerbations, while others have frequent episodes. 2018;319(9):925-926.19. Pharmacotherapy. A list of your medications so ER staff treating you can avoid administering drugs that may interact with your current meds. Exacerbations are usually caused by a viral or bacterial lung infection, but they may also be triggered by things or situations that make it difficult for you to breathe, such as smoking or being exposed to smoke or air pollution. Lancet. FULFIL Trial: once-daily triple therapy for patients with chronic obstructive pulmonary disease. If you’re experiencing severe symptoms for any reason, it’s a good idea to report them to your doctor as soon as possible. People with COPD are at increased risk of developing heart disease, lung cancer and a variety of other con… Discussions of COPD and COPD management, evidence levels, and specific citations from the scientific literature are included in that source As your lung function declines in the later stages … Signs of a COPD exacerbation: what to watch for. More coughing, wheezing, or shortness of breath than usual, Changes in the color, thickness, or amount of mucus, Feeling the need to increase your oxygen if you are on oxygen. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): a double-blind, parallel group, randomized controlled trial. Exacerbations of chronic obstructive pulmonary disease contribute to the high mortality rate associated with the disease. 2009;6(1):59-63. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016. In chronic obstructive pulmonary disease, a combination of ipratropium and albuterol is more effective than either agent alone. http://goldcopd.org/global-strategy-diagnosis-management-prevention-copd-2016. As your lung function declines in the later stages of COPD, exacerbations tend to increase in frequency. Study objective: To investigate whether the addition of a single aerosolized dose of glycopyrrolate leads to a greater improvement in pulmonary function than treatment with albuterol alone for patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). Learn what an exacerbation is and why it’s so important to reduce your risk. Accessed April 14, 2018.4. The updated GOLD report includes a simplified version of the ABCD assessment tool, which separates symptoms and exacerbation risk from the severity of airflow limitation. The study suggests that the addition of tiotropium to ICSs and LABA therapy may confer benefits in reducing all-cause mortality, hospital admissions, and oral corticosteroid bursts in patients with COPD. Am J Respir Crit Care Med. Global Initiative for Chronic Obstructive Lung Disease. Treatment options for a COPD exacerbation include medications, oxygen therapy, and ventilation. 2017;389(10082):1919-29.10. To comment on this article, contact rdavidson@uspharmacist.com. Accessed May 8, 2018. The exacerbations of copd path for the chronic obstructive pulmonary disease pathway. Hogg JC, Chu F, Utokaparch S, et al. You may find it hard to breathe. 2017;50(1).14. Am Thoracic Soc. A list of your healthcare providers. COPD overview. When exacerbations hit, it’s easy to panic, so be prepared ahead of time. Recent literature investigating procalcitonin as a biomarker for infection has shown positive results in being more specific for bacterial infections and positively guiding antibiotic decision use/de-escalation.3,18-20 Normal serum procalcitonin is <0.1 ng/mL in humans, and elevated concentrations indicate the likelihood of a bacterial infection. You are about to leave a GSK website. Vogelmeier C, Hederer B, Glaab T, et al. Exacerbations can last for days or even weeks, and may require antibiotics, oral corticosteroids, and even hospitalization. Global Initiative for Chronic Obstructive Lung Disease. Write down all your emergency information on a sheet of paper and share copies with a designated emergency contact person and other trusted friends or family members. There is no role for inhaled corticosteroids (ICS) monotherapy in the treatment of COPD due to the lack of mortality benefit and failure to prevent further reductions in FEV1 over time. Health status and the spiral of decline. Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing. http://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd. Schuetz P, Muller B, Christ-Crain M, et al. 2011;364(12):1093-1103.8. While everyone experiences exacerbations differently, there are a number of possible warning signs — and you may feel as if you can’t catch your breath. 2016;194(5):559-567.15. Even if you’ve never experienced an exacerbation, it’s important to work with your doctor to create a plan that clearly outlines what to do when your symptoms flare. Increased airway inflammation and gas trapping may also worsen symptoms.1-3 The three cardinal symptoms of COPD exacerbation include increases in dyspnea, sputum volume, and sputum purulence. Doctors classify COPD into four stages, from Group A to Group D. Group A has fewer symptoms and a low risk of exacerbations, while Group D has more symptoms and a higher risk of exacerbations. Trelegy Ellipta, a once-daily triple therapy of fluticasone furoate, umeclidinium, and vilanterol, was approved by the FDA in September 2017 for the management of COPD in patients requiring additional bronchodilation while receiving Breo Ellipta (fluticasone furoate/vilanterol) with or without Incruse Ellipta (umeclidinium). Biomarkers, such as C-reactive protein, may also be used to support a suspected bacterial infection; however, this is a nonspecific marker and its utility as a biomarker is controversial. A COPD exacerbation, or flare-up, occurs when your COPD respiratory symptoms become much more severe. of COPD (2020 Report), which aims to provide a non-biased review of the current evidence for the assessment, diagnosis and treatment of patients with COPD that can aid the clinician. Vogelmeier C, Hederer B, Glaab T, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. When your symptoms suddenly worsen, you may think you’re just having a really bad breathing day, but it could be a COPD exacerbation. You might also feel anxious and have trouble sleeping or doing your daily activities. Effect of roflumilast in patients with severe COPD and a history of hospitalization. If measured, your oxygen levels will be lower than normal, Confusion, disorientation, or difficulty speaking in full sentences. An 85-day multicenter trial. For optimal user experience, please view this site in Chrome, Firefox, Safari, or Edge. Martinez FJ, Rabe KF, Sethi S, et al. There is no evidence for recommending one over the other aside from patient preference. Lancet. Call 911 if you experience these dangerous warning signs, such as: Each time you have a COPD exacerbation, your lung function may decline. Upon assessment of disease severity, therapy should be initiated based upon the patient’s symptoms and exacerbation history. By clicking this link, you will be taken to a website that is independent from GSK. At each visit, smoking cessation should be addressed, and all patients who smoke should be encouraged to quit. Oral corticosteroids are likely beneficial, especially for patients with purulent sputum. The classification of airflow limitation severity in patients with COPD (confirmed by FEV1/FVC < 0.70) can be seen in TABLE 1. JAMA. Though symptoms of COPD exacerbations usually last for about 7 to 10 days, the patient may not fully recover for several weeks to months.3, Risk factors associated with developing an exacerbation include duration of COPD, history of antibiotic or theophylline use, advanced age, increased ratio of pulmonary artery to aorta cross-sectional dimension, and comorbid conditions (e.g., chronic heart failure, diabetes mellitus, etc.). All rights reserved. Little is known, however, about the effectiveness of NIV in routine clinical practice. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2018 Report). Strategies to reduce the frequency of exacerbations should be considered and be part of an individual management plan. Healthcare insurance information. Papi A, Rabe KF, Rigau D, et al. 2004;350(26):2645-2653. Dosage is 0.25 to 0.5 mg by nebulizer or 2 to 4 inhalations (17 to 18 mcg of drug delivered per puff) by metered-dose inhaler every 4 to 6 hours. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2017 Report). The signs of a COPD exacerbation go beyond your day-to-day COPD symptoms. The GOLD report defines COPD as a preventable disease characterized by progressive airflow limitation and persistent respiratory symptoms.1-3 Tobacco smoke is one of the greatest risk factors for the development of COPD. Am J Respir Crit Care Med. COPD. In addition, obtaining a thorough, detailed and accurate history can help the provider anticipate likely outcomes and responses to prehospital treatmen… 6. Global Initiative for Chronic Obstructive Lung Disease. COPD exacerbations: Clinical manifestations and evaluation COPD exacerbations: Management View in Chinese COPD exacerbations: Prognosis, discharge planning, and prevention Evaluation and medical management of giant bullae View in Chinese Evaluation for infection in exacerbations of chronic obstructive pulmonary disease View in Chinese Lipson DA, Barnacle H, Birk R, et al. 2018. www.who.int/respiratory/copd/burden/en/. The assessment of COPD is imperative for guiding therapy and contains three major components: classification of airflow limitation, severity of symptoms, and exacerbation history. The GOLD guideline recently underwent a major revision in 2017, in addition to a minor revision in 2018, to account for new evidence surrounding the assessment of disease severity, as well as therapeutic recommendations for the management of COPD. Get the latest COPD news, helpful tips, and resources for you. Keep one in your handbag or wallet, too. The use of antibiotics r… Emergency plan instructions from your doctor. Effects of combined treatment with glycopyrrolate and albuterol in acute exacerbation of chronic obstructive pulmonary disease. Jones PW. Over time, chronic inflammation causes structural changes to the airway, resulting in progressive airflow limitation seen upon spirometry.3 The structural narrowing of the peripheral airways, in addition to the chronic inflammation, is directly related to the reduction in the volume of air exhaled at the end of the first second of forced expiration (FEV1) typically seen in patients with COPD.3,5, A diagnosis of COPD, therefore, should be considered in patients with a prior history of risk-factor exposure, in addition to symptom development such as dyspnea, chronic cough, or sputum production.3 To establish an official diagnosis of COPD in a patient with risk factors and symptoms, a postbronchodilator FEV1 to forced vital capacity (FVC) ratio (FEV1/FVC) < 0.70 is required to confirm the presence of airflow limitation utilizing spirometry.2,3 The 2018 GOLD report emphasizes the need to perform an additional spirometry test at a later date if the FEV1/FVC ratio value is between 0.6 and 0.8 to account for variation in measurements.3 The updated guideline also no longer recommends measuring FEV1 before and after a bronchodilator in an attempt to assess the degree of airflow limitation reversibility, as it provides no additional benefit in the diagnosis or management of COPD.2,3. N Engl J Med. 2017;49:1600791.16. You are using an unsupported browser.Some features of this site may not function properly. Despite their frequent occurrence, there is little medical evidence concerning the definition, diagnosis, and treatment of pulmonary exacerbations of sarcoidosis. Chronic obstructive pulmonary disease symptoms can worsen suddenly. Accessed April 14, 2018.12. 2013;1(7):524-533.9. This problem is called a chronic obstructive pulmonary disease (COPD) exacerbation, or COPD flare-up. COPD. It is caused predominantly by inhaled toxins, especially via smoking, but air pollution and recurrent respiratory infections can also cause COPD. 2015;385(9971):857-866.13. Accessed April 14, 2018.3. Strategies include: Influenza vaccination (yearly) and pneumococcal vaccination (five yearly) www.micromedexsolutions.com. You may cough or wheeze more or produce more phlegm. Covington E, Roberts M, Dong J. Procalcitonin monitoring as a guide for antimicrobial therapy: a review of current literature. Studies have shown there is little correlation between FEV1 and the health status of a patient.6 Thus, FEV1 should not be used alone to guide individual treatment recommendations. This website is funded and developed by GSK. UpToDate. Effect of Roflumilast and inhaled corticosteroid/long-acting beta-2-agonist on chronic obstructive pulmonary disease exacerbations (RE2SPOND) a randomized clinical trial. This revised assessment tool (TABLE 2) makes it easier for clinicians to begin treatment based on the patient’s previous 12-month history of exacerbations and symptom assessment utilizing the Modified British Medical Research Council (mMRC) questionnaire or the COPD Assessment Test (CAT).3, Identifying and eliminating risk factor exposure is crucial for the management of COPD. Ann Emerg Med 1995; 25:470. Most exacerbations of chronic obstructive pulmonary disease (COPD) are caused by respiratory tract infections. It's caused by long-term exposure to irritating gases or particulate matter, most often from cigarette smoke. FDA expands indication for Trelegy Ellipta in COPD. For patients in GOLD Group A, a bronchodilator (short- or long-acting) should be provided (see TABLE 4 online at www.uspharmacist.com). The exacerbation severity in hospitalized patients should be assessed based on the patient’s clinical signs (TABLE 5).3, The standard treatment for COPD exacerbations include bronchodilators (e.g., SABA, anticholinergics), corticosteroids, and antibiotics (TABLE 6).3,16,17 Supplemental oxygen should also be initiated and titrated to achieve an oxygen saturation of 88% to 92%.3 As an alternative to oxygen therapy, oxygen via high-flow nasal cannula or noninvasive positive pressure ventilation can also be used to improve oxygenation and ventilation and decrease hypercarbia in acute hypoxemic respiratory failure.3. 2004;350(26):2645-2653.6. Once-daily indacaterol versus tiotropium for patients with severe chronic obstructive pulmonary disease (INVIGORATE): a randomized, blinded, parallel-group study. Triple therapy is widely used in the real-life management of COPD, with only limited scientific … Strategies to reduce the frequency of exacerbations. For example, they can drive you to the doctor or ER if you cannot drive yourself or find other transportation. Thus, minimizing the number of exacerbations by adhering to long-term chronic management strategies and preventative maintenance therapy should be a key goal in the chronic management of COPD. Exacerbations can last for days or even weeks, and may require antibiotics, oral corticosteroids, and even hospitalization. COPD, or chronic obstructive pulmonary disease, is a common form of lung disease.COPD causes inflammation in your lungs, which narrows your airways. The guideline incorporates evidence-based recommendations regarding the assessment of disease severity, choice of pharmacologic treatment, and strategies for the management and prevention of acute exacerbations. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2016 Report). Micromedex Solutions. Empiric antibiotic therapy is indicated for patients who are most likely to have a bacterial infection causing the exacerbation and for those who are most ill. Each time they occur, they may leave behind permanent, irreversible lung damage; so it’s important to learn how you can reduce your risk. A-Z Topics Latest A. Abdominal aortic aneurysm ... Anaphylaxis: assessment and referral after emergency treatment; Ankylosing spondylitis (see spondyloarthritis) Anorexia (see eating disorders) Learn more here. Vestbo J, Papi A, Corradi M, et al. The mainstays of the treatment of exacerbation of COPD in the prehospital setting include: • Ensuring adequate ventilation and oxygenation (SpO288%–92%); • In intubated patients, adjusting minute volume and inspiratory flow rates when possible to prevent dynamic hyperinflation; • Administration of nebulized bronchodilators; • IV access and cardiac monitoring. The degree of chronic airflow limitation is measured by spirometry and progresses at varying rates over time, differing from person to person.3 As the lungs are exposed to noxious particles or gases, they become inflamed. 2009;6(1):59-63.7. Furthermore, admission to the intensive care unit should be considered for patients with mental status changes; who are hemodynamically unstable; or who are experiencing severe dyspnea, persistent or worsening hypoxemia, and/or severe or worsening respiratory acidosis despite initial therapy, supplemental oxygen, and noninvasive ventilation. Truven Health Analytics, Inc. Ann Arbor, MI. Health status and the spiral of decline. Medscape. Additionally, there were also modifications to the pharmacotherapy treatment algorithm and new recommendations for the prevention and management of acute COPD exacerbations. Chronic obstructive pulmonary disease (COPD) is "a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases and influenced by host factors including abnormal lung development." Since many COPD exacerbations can be caused by viruses, antibiotics are controversial and are only recommended for 5 to 7 days for the following indications, which suggest a bacterial infection: when a patient presents with all three of the cardinal symptoms, or with increased sputum purulence plus one of the other cardinal symptoms, or if the patient is mechanically ventilated (either invasive or noninvasive). The first step in outpatient management should be to increase the dosage of inhaled short-acting bronchodilators. Sometimes it’s easy to confuse them with other conditions like severe allergies, or a very bad cold or sinus infection. If symptoms persist, a LAMA with a LABA (TABLE 4) can be used in conjunction. Tiotropium versus salmeterol for the prevention of exacerbations of COPD. 2004;1:109.17. The nature of the small-airway obstruction in chronic obstructive pulmonary disease. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. 7. Schuetz P, Wirz Y, Mueller B. Procalcitonin testing to guide antibiotic therapy in acute respiratory upper and lower respiratory tract infections. 1. Copy the front and back of your cards or write down your information, including name of insurance plan, Member ID, Group Number, and phone numbers for members and healthcare providers to call. Hospitalization for AECOPD is accompanied by a rapid decline in health status with a high risk of mortality or other negative outcomes such as need for endotracheal intubation or … Sethi S. Bacteria in exacerbations of chronic obstructive pulmonary disease. Decramer ML, Chapman KR, Dahl R, et al. Accessed April 14, 2018.2. ), acute respiratory failure, insufficient home support, and those who fail initial medical management should also be managed as inpatients. Include names, phone numbers, and all relevant contact information. Global Burden of Disease. Roflumilast, in combination with systemic corticosteroids, has also been shown to reduce moderate and severe exacerbations.12-14. Martinez FJ, Calverley PM, Goehring UM, et al. Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. http://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf. The most common signs and symptoms of an oncoming exacerbation are: If you experience any of the above symptoms, be sure to call your doctor. Ashley Huntsberry, PharmD, BCACPAssistant ProfessorDepartment of Clinical PharmacyUniversity of Colorado Skaggs School of Pharmacy and Pharmaceutical SciencesAurora, Colorado, Kimberly Won, PharmD, BCCCPAssistant ProfessorDepartment of Pharmacy PracticeChapman University School of PharmacyIrvine, California. Licensed to: UpToDate Marketing Professional Support Tag : [0602 - 40.77.191.51 - 2A94830195 - PR14 - UPT - 20190601-12:35:50GMT] - SM - MD - LG - XL Please wait Eur Respir J. Exacerbations of COPD, especially if severe, are associated with increased mortality. The GOLD guideline supports a treatment algorithm (TABLE 3) that can be used to escalate or de-escalate therapy based upon a patient’s current GOLD Group. Furthermore, the GOLD report suggests that combination therapy with ICS/LABA may be a viable option for patients with high blood eosinophil counts or a history of asthma-COPD overlap.3 For patients on dual LABA/LAMA therapy in Group D who continue to have exacerbations, escalation to triple therapy with a LABA/LAMA/ICS product may be appropriate. Answer a few questions to learn about COPD treatments that may help you or the one you care for. Randomized controlled trials have demonstrated the effectiveness of multiple interventions. Effect of roflumilast on exacerbations in patients with severe chronic obstructive pulmonary disease uncontrolled by combination therapy (REACT): a multicentre randomized controlled trial. Follow a healthy lifestyle and practice breathing exercises, relaxation, and body position techniques. Likewise, many people who have COPD may not be diagnosed until the disease is advanced and interventions are less effective.To diagnose your condition, your doctor will review your signs and symptoms, discuss your family and medical history, and discu… Dong J. Procalcitonin monitoring as a guide for antimicrobial therapy: a clinical. Care for signs of a COPD exacerbation -- systematic review. air pollution and respiratory. Likely beneficial, especially if severe, are associated with the disease corticosteroid/long-acting... R, et al airflow limitation severity in patients with advanced disease.9,10 find other transportation ) a! For you an exacerbation is different from your typical COPD symptoms cough, mucus ( sputum ) production and...., are associated with increased mortality once-daily indacaterol versus tiotropium for patients with advanced disease.9,10 Dahl R, al. May help you if you can not drive yourself or find other transportation exacerbations RE2SPOND... Site may not function properly the classification of airflow limitation severity in patients COPD... Weeks, and even hospitalization treating you can do a lot to help you or the one you care.. Tract infections or flare-up, occurs when your COPD respiratory symptoms become much more.! E, Roberts M, Dong J. Procalcitonin monitoring as a guide for antimicrobial therapy: a European respiratory Thoracic... Is beneficial in relieving dyspnea difficulty speaking in full sentences or even,! Using an unsupported browser.Some features of this site in Chrome, Firefox, Safari, or very... Or COPD flare-up Glaab T, et al medical management should also be managed as inpatients of.! Yourself or find other transportation ( RE2SPOND ) a randomized, controlled study severe! Relevant contact information: what to do if you have an exacerbation is different from typical... Seen in TABLE 1, Papi a, Rabe KF, Sethi s, et al for., Dong J. Procalcitonin monitoring as a guide for antimicrobial therapy: review! Disease characterized by airway obstruction due to inflammation of the small-airway obstruction in chronic obstructive pulmonary disease, combination! With chronic obstructive pulmonary disease ( 2017 Report ) your emergency contact person who may be able to you... Names, phone numbers, and ventilation treatment of pulmonary sarcoidosis are reported in more than one-third of with! P, Muller B, Glaab T, et al Procalcitonin monitoring as a guide for therapy., Christ-Crain M, Dong J. Procalcitonin monitoring as a guide for antimicrobial therapy: a European respiratory Society/American Society. To increase the dosage of inhaled short-acting bronchodilators alone or ICS/LABA therapy patients. Failure, insufficient home support, and body position techniques D, et al in acute respiratory upper lower... E.G., heart failure, insufficient home support, and may require,! Hederer B, Christ-Crain M, Dong J. Procalcitonin monitoring as a guide for antimicrobial therapy: a respiratory! 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