COPD exacerbation

Background

• Increase in cough, sputum, or dyspnea
• Precipitants
  • Infection: 50%
  • Unknown: 30%
  • MI, PE, CHF, aspiration
  • Environment: 10%

Differential Diagnosis

1. CHF
2. PE
3. PNA

Work-up

1. Consider CXR
   1. For sick patients or those with fever
2. Consider VBG/ABG
   1. Assesses severity of exacerbation and baseline from which to judge improvement
3. Consider sputum culture
   1. For for patients with:
      1. Strong clinical suspicion for bacterial infection yet unresponsive to abx
      2. Risk factors for pseudomonas infection
      3. Recent hospitalization (>2 days within previous 3 months)
      4. Frequent abx tx (>4 courses w/in past year)
      5. Severe underlying COPD (FEV1 < 50% predicted)
   2. Previous isolation of pseudomonas

Treatment

1. O2
   1. Target 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, acidemia then consider mechanical ventilation
2. Albuterol/atrovent
3. Steroids (no difference in efficacy between PO and IV)
   1. Duration = 7-10 days (no tapering required)
   2. Oral: Prednisone 40-60mg daily
   3. IV: Methylprednisolone 60-125mg BID-QID
4. Antibiotics
   1. Indicated for moderate to severe exacerbations
5. Noninvasive ventilation (e.g. CPAP, BiPaP) if needed

Outpatient

1. Risk factors (Age >65, cardiac disease, >3 exacerbations per year)
   1. Levofloxacin/moxifloxacin OR amox/clavulanate
2. No risk factors
   1. Azithromycin OR doxycline OR TMP/SMX
3. Pseudomonas risk factors (see above)
   1. Ciprofloxacin

Maintenance

1. B-agonist
   1. Short: albuterol 90µg/inh 1-2 q4-6h prn; neb 2.5mg q4-6h prn
   2. Long: Salmeterol 50µg/inh 1 bid
      1. Formoterol MDI 12µg/INH 1 bid; neb 20µg bid
      2. Arfomoterol neb 15µg bid
2. Anticholinergic
   1. Short: ipratriopium 17µg/INH 2xINH 4x/d up to 12; neb 0.5mg q6-8h
   2. Long: tiotropium 18µg/INH 1xINH qam
3. Steroids (inhaled)
   1. Fluticasone (dry powder) 250µg/INH 1-2 bid; (aerosol) 220µg 1-2INH bid
   2. Budesonide 160µk 2 inh bid
   3. Beclomethasone 80µg/inh 2INH bid
   4. Mometasone 220µg/INH 1-2INH bid
4. Combination
   1. Albuterol-Ipratropium 90/18 2INH 4xd up to 12
   2. Advair Diskus = Fluticasone-salmeterol (dry powder): 250/50 1INH bid
   3. Budesonide-Formoterol: 160/4.5 2INH bid
5. Home O2
   1. Indicated if PaO2 < 55mmHg or O2 Sat < 88% RA
   2. Goal is 18h/day including sleep with flow rate that maintain sat > 90%

Inpatient

Duration = 3-5 days

1. Pseudomonas risk factors
   1. Levofloxacin PO or IV OR cefepime IV OR Ceftazadine IV OR pip-tazo IV
2. No pseudomonas risk factors
   1. Levo/moxifloxacin PO or IV OR CTX IV OR cefotaxime IV
3. Consider oseltamivir during influenza season

Disposition

Consider hospitalization for the following:

1. Inadequate response of symptoms to outpatient management
2. Inability to eat or sleep due to symptoms
3. Changes in mental status
4. Uncertain diagnosis
5. High risk comorbidities (e.g. PNA, CHF, renal failure)

Source

DONALDSON 1/06, NEJM 4/10, UpToDate