Pulmonary Embolism Prevalence in Acute COPD Exacerbations

The prevalence of pulmonary embolism (PE) during an acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) varies from 3% in an emergency department (ED) to 29% in an inpatient setting, according to a literature review published in the Journal of Emergency Medicine.

COPD is an independent risk factor for the development of venous thromboembolism, which suggests that the prevalence of PE in COPD may be relatively high. The symptoms of an AE-COPD are acute dyspnea, often accompanied by a productive cough and bronchospasm. A number of conditions present with similar symptoms, including congestive heart failure, cardiac dysrhythmia, asthma exacerbation, pneumonia, and PE. Because PE and AE-COPD both cause dyspnea, tachypnea, tachycardia, and cough, it may be difficult to differentiate between the 2 conditions in patients with COPD. Subjecting every patient presenting with AE-COPD to the ED to a computed tomography pulmonary angiography is not only expensive but also carries with it significant radiation exposure, which may increase cancer risk.

Ali Pourmand, MD, MPH, RDMS, from the Emergency Medicine Department at the George Washington University School of Medicine and Health Sciences in Washington, DC, and colleagues conducted a systematic literature review of PubMed and MEDLINE databases from 1990 to 2017 to determine the prevalence of PE in patients admitted to hospital with a clinical diagnosis of AE-COPD.

A total of 5 articles were included in the analysis with a range of PE in patients with a clinical diagnosis of AE-COPD from 3.3% to 29.1%. The population size in these studies varied from 49 to 197 patients, and the settings included both EDs and inpatient settings, including intensive care units. The researchers noted that obesity and immobility were factors associated with PE in AE-COPD.

The review is limited by the dissimilarities of the studies included, small sample size, and that not all patients were seen in the ED only. Some studies used ultrasound of lower limbs rather than computed tomography pulmonary angiography to identify PE, which could have falsely elevated the prevalence of PE. Publication bias also could have affected the findings.

The researchers urged ED providers to be aware of the association between PE and AE-COPD to help prevent delayed diagnosis of PE. Furthermore, they advised providers to use clinical gestalt and validated screening tools when establishing the risk for PE in patients with AE-COPD because clinical decision tools fail to take into account COPD as a risk factor despite the increased risk for venous thromboembolism associated with COPD.

Reference

Pourmand A, Robinson H, Mazer-Amirshahi M, Pines JM. Pulmonary embolism among patients with acute exacerbation of chronic obstructive pulmonary disease: implications for emergency medicine [published June 23, 2018]. J Emerg Med. doi:10.1016/jemermed.2018.05.026