COPD exacerbation: Difference between revisions
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==Treatment==
==Treatment==
#O2
===Oxygen===
##Maintain PaO2 of 60-70 or SpO2 90-94%
#Maintain PaO<sub>2</sub> of 60-70 or SpO<sub>2</sub> 90-94%
##If unable to correct hypoxemia with a low FiO2 consider alternative diagnosis
#If unable to correct hypoxemia with a low FiO2 consider alternative diagnosis
##Adequate oxygenation is essential, even if it leads to hypercapnia
#Adequate oxygenation is essential, even if it leads to hypercapnia
##If hypercapnia leads to AMS, dysrhythmias, or acidemia consider mechanical ventilation
#If hypercapnia leads to AMS, dysrhythmias, or acidemia consider [[Intubation]]
#Albuterol/ipratropium
===Albuterol/ipratropium===
#Steroids ("low-dose," oral preferred)
#Improves airflow obstruction and treatment should involve rapid administration upon recognition of COPD exacerbation. <ref>Celli BR. Update on the management of COPD. Chest. Jun 2008;133(6):1451-62.</ref>
##Duration = 7-10d (no tapering required)  
===Steroids===
##Oral: Prednisone 40-60mg daily
Similar efficacy between oral and intravenous. Treatment options include:
##IV: Methylprednisolone 60-125mg BID-QID
*Methylprednisolone 1-2 mg/kg IV daily (usual adult dose 125mg)<ref>Eisner MD, et al: An official American Thoracic Society public policy statement: Novel risk factors and the global burden of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2010; 182:693-718</ref>
#Antibiotics
*[[Prednisone]] 40 mg PO daily
##Indicated for:
 
###Increased sputum volume or change in color
For outpatients a 5 day dose appears equally effective as longer doses and a taper is not required.<ref>Eisner MD, et al: An official American Thoracic Society public policy statement: Novel risk factors and the global burden of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2010; 182:693-718</ref>
###Fever
 
###Suspicion of infectious etiology of exacerbation
===Antibiotics===
##Options:
GOLD collaborators recommend antibiotics for patients with purulent sputum or increased sputum production or those who required [[EBQ:NIPPV_in_COPD|Non Invasive Positive Pressure Ventilation]]
###Outpatient Healthy
 
####Azithromycin OR doxycline OR TMP/SMX  
Antibiotics should be a 3-5 day course and options include:
###Outpatient Unhealthy
*[[Azithromycin]] 500mg PO BID<ref>Rothberg MB, et al: Antibiotic therapy and treatment failure in patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. JAMA 2010; 303:2035-2042</ref>
####Age >65, cardiac disease, >3 exacerbations/pyr
*[[Doxycycline]] 500 mg PO BID
######Levofloxacin/moxifloxacin OR amox/clavulanate 
*[[Levofloxacin]] 500 mg PO BID<ref>Anzueto A, Miravitlles M: Short-course fluoroquinolone therapy in exacerbations of chronic bronchitis and COPD. Respir Med 2010; 104:1396-1403</ref>
##Inpatient  
 
###Pseudomonas risk factors:
#Outpatient Healthy
####Levofloxacin PO or IV OR cefepime IV OR Ceftazadine IV OR pip-tazo IV
#*[[Azithromycin]] OR [[Doxycycline]] OR [[TMP/SMX]]
###No pseudomonas risk factors:
#Outpatient Unhealthy
####Levo/moxifloxacin PO or IV OR [[ceftriaxone]] IV OR cefotaxime IV  
#*Age >65, cardiac disease, >3 exacerbations/per year
#*[[Levofloxacin]]/[Moxifloxacin]] OR [[Amoxicillin/Clavulanate]]
#Inpatient  
##If Pseudomonas risk factors the use:
##*[[Levofloxacin]] PO or IV OR [[Cefepime]] IV OR [[Ceftazidime]] IV OR [[Piperacillin/Tazobactam]] IV
##No pseudomonas risk factors:
##*[[Levofloxacin]] or [[Moxifloxacin]] PO or IV OR [[Ceftriaxone]] IV OR [[Cefotaxime]] IV  
###Consider oseltamivir during influenza season  
###Consider oseltamivir during influenza season  
#[[EBQ:NIPPV in COPD|Noninvasive ventilation]] (CPAP or BiPaP)
 
##CPAP: start at low level and titrate up to max 15
===[[EBQ:NIPPV in COPD|Noninvasive ventilation]] (CPAP or BiPaP)===
##BiPAP: Start IPAP 8 (max 20), EPAP 4 (max 15)
#CPAP: start at low level and titrate up to max 15
##Contraindications:
#BiPAP: Start IPAP 8 (max 20), EPAP 4 (max 15)
###Uncooperative or obtunded pt
 
###Inability to clear secretions
 
###Hemodynamic instability
''Contraindications:''
#Mechanical ventilation
#Uncooperative or obtunded pt
##Indications
#Inability to clear secretions
###Severe dyspnea w/ use of accessory muscles and paradoxical breathing
#Hemodynamic instability
###RR>35 bpm
 
###PaO2 <50 or PaO2/FiO2 <200
===Mechanical ventilation===
###pH <7.25 and PaCO2 >60
''Indications:''
###Altered mental status
#Severe dyspnea w/ use of accessory muscles and paradoxical breathing
###Cardiovascular complications (hypotension, shock, CHF)
#RR>35 bpm with anticipated clinical course for respiratory failure
#PaO<sub>2</sub> <50 or PaO2/FiO2 <200
#pH <7.25 and PaCO2 >60
#Altered mental status  
#Cardiovascular complications (hypotension, shock, CHF)


==Disposition==
==Disposition==

Revision as of 15:04, 29 December 2014

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
  1. ↑ Celli BR. Update on the management of COPD. Chest. Jun 2008;133(6):1451-62.
  2. ↑ Eisner MD, et al: An official American Thoracic Society public policy statement: Novel risk factors and the global burden of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2010; 182:693-718
  3. ↑ Eisner MD, et al: An official American Thoracic Society public policy statement: Novel risk factors and the global burden of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2010; 182:693-718
  4. ↑ Rothberg MB, et al: Antibiotic therapy and treatment failure in patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. JAMA 2010; 303:2035-2042
  5. ↑ Anzueto A, Miravitlles M: Short-course fluoroquinolone therapy in exacerbations of chronic bronchitis and COPD. Respir Med 2010; 104:1396-1403
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