COPD Exacerbation

Summary

Paul Sarmiento, MD

Prior Diagnosis of COPD?

Dyspnea: Progressive? Worse with exercise? Persistent? Air Hunger?

Chronic cough: intermittent? May be unproductive

Chronic sputum production: any pattern of chronic sputum may indicate COPD

History of exposure to risk factors: Tobacco? Occupational dusts/chemicals? Smoke from home cooking and heating fuel?

Chronic medications? Home oxygen therapy? Exacerbation frequency? Last steroid dose?

Prior Spirometric classification of COPD Severity based on Post-Bronchodilator FEV1

Is this a COPD exacerbation?

Increased breathlessness? With Wheezing? Chest tightness? Increase in baseline cough frequency? Dyspnea? Change in Sputum – color? Texture? Acute in onset?

Most common cause of an exacerbation are infection of the traceobroncial tree and air pollution, but the cause of ~1/3 of severe exacerbations cannot be identified.

Any clinical signs of airway infection?

Increased sputum? Increased sputum purulence? Fever?

Recent investigations have shown that at least 40% of patients have bacteria in high concentrations in their lower airways during exacerbations. Most common pathogens include Streptococcus pneumonia, Hemophilus influenzae, Moraxella catarrhalis

Other Findings?

Tachycardia? Tachypnea? Malaise? Insomnia? Sleepiness? Fatigue? Depression? Confusion? Any mental status change?

Assessing severity:

Assess past medical history before exacerbation, preexisting comorbidities, severity of symptoms. What is the frequency/severity of prior exacerbations?

Check: Blood gas, CXR, ECG, Pulse Ox, CBC, Electrolytes, Glucose, Acid-base disorder

Spirometry, PFTs are not accurate during an acute exacerbation and routine use is not recommended.

ABG Indications of Respiratory Failure:

PaO2 < 60 mm Hg on RA

SaO2 < 90% with or without  PaCO2 > 50 on RA

Acidosis pH < 7.36 + Hypercapnia PaCO2 > 45-60 with respiratory failure is an indication for mechanical ventilation

Always consider PE in your differential.

Especially if PaO2 does not increase despite high-flow oxygen

Differential includes pneumonia, CHF, PTX, pleural effusion, cardiac arrhythmias,

Management:

Risk of dying is proportional to respiratory acidosis, significant comorbidities, ventilatory support.  Patients without these factors are not at high risk for dying.

Level of Care Considerations:

Indications for Hospital assessment or admission

• Marked increase in intensity of symptoms, acute development or resting dyspnea, change in vital signs
• Severe underlying COPD
• New physical signs such as cyanosis, peripheral edema
• Failure of exacerbation to respond to initial management
• Significant comorbidities
• Frequent Exacerbations
• Newly occurring arrhythmias
• Diagnostic uncertainty
• Older age
• Insufficient Home support

Indications for ICU admisstion

• Severe dyspnea that responds inadequately to initial emergency therapy
• Mental status change (confusion, lethargy, coma)
• Persistent or worsening hypoxemia (PaO2 < 40mm Hg)
• Severe or worsening hypercapnia (PaCO2 > 60 mmHg)
• Severe or worsening acidosis (pH < 7.25) despite oxygen and non-invasive ventilation
• Hemodynamic instability

First Actions:

Oxygen Therapy; Goal SaO2 > 90%, PaO2 > 60;

Venturi masks (high-flow) deliver oxygen better than nasal prongs but are less tolerable.

Determine if exacerbation is life threatening; consider ICU admission if appropriate

Next Steps:

Once oxygen started, check ABG in 30-60 min.

Check: Blood gas, CXR, ECG, Pulse Ox, CBC, Electrolytes, Glucose, Acid-base disorder

BRONCHODILATOR THERAPY:

Short acting inhaled B-agonists (evidence A)

Albuterol MDI 100-200 mcg QID

Albuterol Nebulizer 0.5-2.0 mg QID

Albuterol Pill PO 4 mg BID

ANTICHOLINERGICS:

Ipratropium Bromide MDI 18-36 ug QID

Ipratropium Bromide Nebulizer 0.5 mg QID

GLUCOCORTICOSTEROID: 

Consider the following regimen for inpatient exacerbations**:

Methylprednisone 125 mg IV Q6H x 3 days

Methylprednisone 60 mg PO QD x 4 days

Methylprednisone 40 mg PO QD x 4 days

Methylprednisone 20 mg PO QD x 4 days

Consider for outpatient management or mild inpatient exacerbation**:

Prednisone 40mg PO QD x 2 days

Prednisone 30mg PO QD x 2 days

Prednisone 20mg PO QD x 2 days

Prednisone 10mg PO QD x 2 days

LIMITED SPECTRUM ANTIBIOTICS

TMP-SMX 160/800 mg BID x 5-10 days

Amoxicillin 250 mg PO QID x 5-10 days

Doxycycline 100 mg PO, 2 tablets day 1, 1 tablet/day for 5-10 days

(some authors suggest all should be 10-day course)

Other options:

Methyxanthines such as aminophylline, theophylline

Studies suggest that two-week systemic glucocorticoid regimens that begin with either high-dose or low-dose initial therapy can improve clinical outcomes in hospitalized patients. The optimal initial dose remains to be determined, since the two studies used somewhat different methodologies, and high versus lower-dose regimens have not been directly compared. The outcomes of the two studies show that early FEV1 improvements were greater in the study which used an initial regimen of IV methylprednisolone 125 mg every six hours [3]; however, an initial regimen of 30 mg per day of oral prednisolone achieved a similar reduction in hospital length of stay [4].

Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group. Niewoehner DE. N Engl J Med 1999 Jun 24;340(25):1941-7.

Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial. Davies L. Lancet 1999 Aug 7;354(9177):456-60.

** Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Stoller JK.  N Engl J Med 346:988, March 28, 2002

VENTILATORY SUPPORT

Non-invasive BIPAP, CPAP

Invasive

Indications and Relative Contraindications for NI Intermittent Ventilation

• Moderate/Severe dyspnea with use of accessory muscles, paradoxical abdominal motion
• Moderate to severe acidose (pH < 7.35 and/or hypercapnea (PaCO2 > 45)
• RR > 25 b/min
• Exclusion critieria
  • Respiratory arrest
  • CV instability
  • Change in mental status; uncooperative
  • High aspiration risk
  • Viscous or copious secretions
  • Recent facial or gastroesophageal surgery
  • Craniofacial trauma
  • Fixed nasopharyngeal abnormalities
  • Burns
  • Extreme Obesity

Indications for Invasive Mechanical Ventilation

• Unable to tolerate NIV or NIV failure
• Severe dyspnea with use of accessory muscles, paradoxical abdominal motion
• RR > 35 b/min
• Life threatening hypoxemia
• Severe acidosis (pH < 7.25) and/or hypercapnia (PaCO2 > 60)
• Respiratory arrest
• Worsening mental status
• Cardiovascular complications (hypotension, shock)
• Other complications (metabolic, sepsis, pneumonia, PE, barotrauma, massive pleural effusion)

Discharge Criteria

• Inhaled b2-agonist therapy is required no more frequently than every 4H
• Patient, if previously ambulatory, is able to walk across the room
• Patient is able to eat and sleep without frequent awakening by dyspnea
• Clinical stable for 12-24H
• ABG have been stable for 12-24H
• Patient fully understands the correct use of medications
• Follow up and home care arrangements have been made (visiting nurse, oxygen delivery, meal provisions)
• Patient, family, and physician are confident patient can manage successfully at home

Further thoughts

Prognosis?

The impact of exacerbations is significant and a patient’s symptoms and lung function may both take several weeks to recover to baseline values.