Management of chronic obstructive pulmonary disease

Editor—The editorial by Babu and Chauhan on the management of acute exacerbations of chronic obstructive pulmonary disease contains a serious error of fact. The Cochrane review by Barr et al is quoted to support their proposal that standard treatment for exacerbations of chronic obstructive pulmonary disease should include theophyllines.1 This review said no such thing. The reviewers' conclusions were that there is no evidence to support the routine use of methyl-xanthines for exacerbations of chronic obstructive pulmonary disease. Methyl-xanthines do not appreciably improve forced expiratory volume in one second (FEV1) during exacerbations, and cause adverse effects; evidence of their effect on admissions is limited.2 Although theophyllines were used by previous generations of doctors for managing acute exacerbations of asthma and chronic obstructive pulmonary disease, this use was not evidence based, and these agents have been shown to be associated with increased adverse effects (but no proved clinical benefit) for both groups of diseases.2,3 I have occasionally had to deal with severe adverse effects (including cardiac arrest) when intravenous aminophylline had been given to patients with acute airflow obstruction by admitting medical teams, especially when strict safety precautions were not followed. This misleading statement in a BMJ editorial could lead a new generation of doctors on call to restart the use of these toxic drugs, which are of unproved clinical benefit when given in addition to more modern treatment. This error of fact will require a prominent notice of correction in the journal.