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COPD Exacerbation

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Background

  • Airflow limitation (FEV1:FVC < 0.70) that is not fully reversible
    • Encompasses chronic bronchitis (85%) and emphysema (15%)
  • Acute exacerbations due to incr V/Q mismatch, not expiratory airflow limitation

Precipitants

  1. Infection (75%)
    1. 50% viral, 50% bacterial
  2. Cold weather
  3. B-blockers
  4. Narcotics
  5. Sedative-hypnotic agents
  6. PTX
  7. PE

Diagnosis

  • Increase in cough, sputum, or dyspnea
  • Hypoxemia
  • Tachypnea
  • Tachycardia
  • HTN
  • Cyanosis
  • AMS
  • Hypercapnia

DDX

  1. Asthma
    1. More likely in younger pt (<50yo)
  2. PNA
    1. Frequently coexists w/ COPD exacerbation
  3. CHF
    1. Can coexist w/ COPD
    2. Orthopnea, interstitial edema more c/w CHF
    3. BNP >500 very likely to be CHF
  4. PE
    1. 20% of pts w/ severe COPD exacerbation of unclear trigger have a PE
  5. ACS
  6. PTX
    1. COPD is major risk factor for PTX

Work-up

  1. VBG/ABG
    1. Perform if SpO2 <90% or concerned about symptomatic hypercapnia
  2. Peak flow
    1. <100 indicates severe exacerbation
  3. CXR
    1. Consider if concerned for PNA or CHF
  4. Sputum culture
    1. Usually not indicated except for pt w/ recent antibiotic failure

Pseudomonas Risk Factors

  1. Recent hospitalization (>2 days within previous 3 months)
  2. Frequent abx tx (>4 courses w/in past year)
  3. Severe underlying COPD (FEV1 < 50% predicted)
  4. Previous isolation of pseudomonas

Treatment

Oxygen

  1. Maintain PaO2 of 60-70 or SpO2 90-94%
  2. If unable to correct hypoxemia with a low FiO2 consider alternative diagnosis
  3. Adequate oxygenation is essential, even if it leads to hypercapnia
  4. If hypercapnia leads to AMS, dysrhythmias, or acidemia consider Intubation

Albuterol/ipratropium

  1. Improves airflow obstruction and treatment should involve rapid administration upon recognition of COPD exacerbation. [1]

Steroids

Similar efficacy between oral and intravenous. Treatment options include:

  • Methylprednisolone 1-2 mg/kg IV daily (usual adult dose 125mg)[2]
  • Prednisone 40 mg PO daily

For outpatients a 5 day dose appears equally effective as longer doses and a taper is not required.[3]

Antibiotics

GOLD collaborators recommend antibiotics for patients with purulent sputum or increased sputum production or those who required Non Invasive Positive Pressure Ventilation

Antibiotics should be a 3-5 day course and options include:

  1. Outpatient Healthy
  2. Outpatient Unhealthy
  3. Inpatient
    1. If Pseudomonas risk factors the use:
    2. No pseudomonas risk factors:
      1. Consider oseltamivir during influenza season

Noninvasive ventilation (CPAP or BiPaP)

  1. CPAP: start at low level and titrate up to max 15
  2. BiPAP: Start IPAP 8 (max 20), EPAP 4 (max 15)


Contraindications:

  1. Uncooperative or obtunded pt
  2. Inability to clear secretions
  3. Hemodynamic instability

Mechanical ventilation

Indications:

  1. Severe dyspnea w/ use of accessory muscles and paradoxical breathing
  2. RR>35 bpm with anticipated clinical course for respiratory failure
  3. PaO2 <50 or PaO2/FiO2 <200
  4. pH <7.25 and PaCO2 >60
  5. Altered mental status
  6. Cardiovascular complications (hypotension, shock, CHF)

Disposition

Consider hospitalization for:

  1. Marked increase in intensity of symptoms (e.g. sudden development of resting dyspnea)
  2. Background of severe COPD
  3. Onset of new physical signs (e.g., cyanosis, peripheral edema)
  4. Failure of exacerbation to respond to initial medical management
  5. Significant comorbidities
  6. Newly occurring arrhythmias
  7. Diagnostic uncertainty
  8. Older age
  9. Insufficient home support

See Also

EBQ:NIPPV in COPD

Source

  • NEJM 4/10
  • UpToDate
  • Tintinalli


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