COPD exacerbation resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Definition

  • Exacerbation of COPD is an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication.[1][2][3]
  • The diagnosis of an exacerbation relies exclusively on the clinical presentation of the patient complaining of an acute change of symptoms (baseline dyspnea, cough, and/or sputum production) that is beyond normal day-to-day variation.[4]

Causes

Life-Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Treatment Setting

COPD Exacerbation
❑ Cough ↑
❑ Dyspnea ↑
❑ Sputum ↑
 
 
 
 
1. Oxygen Supplement
❑ Pulse oximetry (maintain SaO2 ≥88—92%)[5]
❑ Arterial blood gas (if acute or acute-on-chronic respiratory failure is suspected)
 
 
 
 
 
2. Indications for ICU Admission
❑ Hemodynamic instability
❑ Changes in mental status (confusion, lethargy, coma)
❑ Severe dyspnea that responds inadequately to initial emergency therapy
❑ Worsening hypoxemia (PaO2 <40 mm Hg) and/or respiratory acidosis (pH <7.25)
 
 
 
 
 
 
 
 
 
 
2a. Indications for Noninvasive Mechanical Ventilation
❑ Respiratory acidosis (arterial pH < 7.35 or PaCO2 >45 mm Hg)
❑ Severe dyspnea with sings of respiratory muscle fatigue
❑ Increased work of breathing
2b. Indications for Invasive Mechanical Ventilation
❑ Diminished consciousness, psychomotor agitation inadequately controlled by sedation
❑ Severe hemodynamic instability without response to fluids and vasoactive drugs
❑ Respiratory pauses with loss of consciousness or gasping for air
❑ Life-threatening hypoxemia in patients unable to tolerate NIV
❑ Persistent inability to remove respiratory secretions
❑ Heart rate <50/min with loss of alertness
❑ Severe ventricular arrhythmias
❑ Respiratory or cardiac arrest
❑ Failure of initial trial of NIV
❑ Massive aspiration
 
 
 
 

3. Indications for Hospitalization
❑ Marked increase in intensity of symptoms (eg, sudden development of resting dyspnea)
❑ Presence of serious comorbidities (eg, heart failure or newly occurring arrhythmias)
❑ Failure of an exacerbation to respond to initial medical management
❑ Onset of new physical signs (eg, cyanosis, peripheral edema)
❑ Severe underlying COPD (GOLD 3—4 categories)
❑ Frequent exacerbations (≥2 events per year)
❑ Insufficient home support
❑ Older age (>65 years)


4. Assessment of Exacerbation
❑ Cardinal symptoms (↑ dyspnea, ↑ sputum volume, and ↑ sputum purulence)
❑ ECG (identify coexisting cardiac problems)
❑ Chest radiograph (exclude alternative diagnoses)
❑ Whole-blood count (identify polycythemia, anemia, or leukocytosis)
❑ Electrolytes and glucose (identify electrolyte disturbances or hyperglycemia)
 
 
 
 
 
 
 
 
 

Severe Exacerbation (⊕ 3 cardinal symptoms)
❑ Consider inpatient management
❑ Assess symptoms, ABG, and CXR
❑ Monitor fluid balance and nutrition
❑ Identify and treat associated conditions
❑ Consider subcutaneous heparin or LMWH
❑ Controlled oxygen therapy (consider NIV if indicated)
❑ Antibiotics (if ↑ sputum purulence or ⊕ bacterial infection)
❑ Corticosteroids
❑ Bronchodilators
▸ Increase doses/frequency of short-acting bronchodilators
▸ Combine short-acting β2-agonists and anticholinergics
▸ Use spacers or air-driven nebulizers


Moderate Exacerbation (⊕ 2 cardinal symptoms)
❑ Consider outpatient management
❑ Require a short course of antibiotics and/or oral corticosteroids


Mild Exacerbation (⊕ 1 cardinal symptom)
❑ Consider outpatient management
❑ Require change of inhaled treatment by the patient

Pharmacologic Treatment

Indications for Antibiotics
❑ Mechanical ventilation required
❑ Severe exacerbation (⊕ 3 cardinal symptoms)
❑ Moderate exacerbation with ↑ sputum purulence

Complicated COPD (⊕ Risk Factors)
❑ Age ≥65 years
❑ FEV1 ≤50% predicted
❑ ≥3 exacerbations per year
❑ Cardiac disease
▸ Moxifloxacin
▸ Gemifloxacin
▸ Levofloxacin
▸ Amoxicillin–Clavulanate
▸ Ciprofloxacin with sputum culture (if at risk for Pseudomonas)


Uncomplicated COPD (⌀ Risk Factors)
▸ Azithromycin
▸ Clarithromycin
▸ Cefuroxime
▸ Cefpodoxime
▸ Cefdinir
▸ Doxycycline
▸ Trimethoprim–Sulfamethoxazole


Treatment Notes
❑ Antibiotic choice should reflect local resistance pattern ❑ Use alternative class if antibiotic exposure within 3 months
❑ Re-evaluate and consider sputum culture if failed to respond in 72 hours

Checklist at Time of Discharge From Hospital

Action Items at Discharge
❑ Reinforce smoking cessation measures
❑ Assure effective home maintenance of pharmacotherapy regimen
❑ Reassess inhaler technique
❑ Educate about maintenance regimen
❑ Give instruction regarding completion of steroid therapy and antibiotics
❑ Assess need for long-term oxygen therapy
❑ Assure follow-up visit in 4—6 weeks
❑ Provide a management plan for comorbidities and their follow-up

Checklist at Follow-Up Visit 4—6 Weeks After Discharge

Action Items at Follow-Up Visit
❑ Smoking cessation measures
❑ Ability to cope in usual environment
❑ Reassess inhaler technique
❑ Measurement of FEV1
❑ Inhaler technique
❑ Understanding of recommended treatment regimen
❑ Need for long-term oxygen therapy and/or home nebulizer
❑ Capacity to do physical activity and activities of daily living
❑ Chronic Obstructive Pulmonary Disease Assessment Test (CAT)
❑ Modified British Medical Research Council questionnaire on breathlessness (mMRC)
❑ Status of comorbidities

Do's

Assessment

  • The presence of purulent sputum during an exacerbation can be sufficient indication for starting empirical antibiotic treatment.[6]

Treatment

Treatment Setting
  • When a patient comes to the ED, the first actions are to provide controlled oxygen therapy and to determine whether the exacerbation is life-threatening. If so, the patient should be admitted to the ICU immediately.[4]
Short-Acting Bronchodilators
  • A systematic review found no significant differences in FEV1 between MDI and nebulizers,[8]although the latter can be more convenient for sicker or frail patients.
Corticosteroids
  • Consensus on optimal corticosteroids dose and duration for COPD exacerbations has not been reached.[19]
Antibiotics
Adjunct Therapies
  • Healthcare providers should strongly enforce stringent measures against active cigarette smoking.[4]
Respiratory Support

Hospital Discharge and Follow-up

Prevention of COPD Exacerbations

  • Early outpatient pulmonary rehabilitation after hospitalization for an exacerbation is safe and results in clinically significant improvements in exercise capacity and health status at 3 months.[32]

Don'ts

Assessment

  • Spirometry is not recommended during an exacerbation because it can be difficult to perform and measurements are not accurate enough.[4]

Treatment

Adjunct Therapies
Respiratory Support
  • NIPPV is not considered in the following conditions:
Contraindications for NIPPV[34]
❑ Inability to cooperate/protect the airway
❑ Inability to clear respiratory secretions
❑ Facial surgery, trauma, or deformity
❑ Upper airway obstruction
❑ High risk for aspiration
❑ Cardiac or respiratory arrest
❑ Nonrespiratory organ failure
▸ Severe encephalopathy (e.g., GCS <10)
▸ Severe upper gastrointestinal bleeding
▸ Hemodynamic instability or unstable cardiac arrhythmia

References

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  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Vestbo, J.; Hurd, SS.; Agustí, AG.; Jones, PW.; Vogelmeier, C.; Anzueto, A.; Barnes, PJ.; Fabbri, LM.; Martinez, FJ. (2013). "Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary". Am J Respir Crit Care Med. 187 (4): 347–65. doi:10.1164/rccm.201204-0596PP. PMID 22878278. Unknown parameter |month= ignored (help)
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