COPD exacerbation

Background

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

Differential Diagnosis

• CHF
• PE
• PNA

Work-up

• CXR
• Often normal
• VBG/ABG
• Assesses severity of exacerbation and baseline from which to judge improvement
• O2
• Target PaO2 of 60-70, or SpO2 90-94%
• If unable to correct hypoxemia with a low FiO2 consider alternative diagnosis
• Adequate oxygenation is essential, even if it leads to hypercapnia
• If hypercapnia leads to AMS, dysrhythmias, acidemia then consider mechanical ventilation
• Sputum culture
• Consider for for patients with:
• Strong clinical suspicion for bacterial infection yet unresponsive to abx
• Risk factors for pseudomonas infection
• Recent hospitalization (>2 days within previous 3 months)
• Frequent abx tx (>4 courses w/in past year)
• Severe underlying COPD (FEV1 < 50% predicted)
• Previous isolation of pseudomonas

Treatment

• Albuterol/atrovent
• Steroids (no difference in efficacy between PO and IV)
• Duration = 7-10 days (no tapering required)
• Oral: Prednisone 40-60mg daily
• IV: Methylprednisolone 60-125mg BID-QID
• Antibiotics
• Indicated for moderate to severe exacerbations
• Outpatient
• Risk factors (Age >65, cardiac disease, >3 exacerbations per year)
• Levofloxacin/moxifloxacin OR amox/clavulanate
• No risk factors
• Azithromycin OR doxycline OR TMP/SMX
• Pseudomonas risk factors (see above)
• Ciprofloxacin
• Inpatient
• Pseudomonas risk factors
• Levofloxacin PO or IV OR cefepime IV OR Ceftazadine IV OR pip-tazo IV
• No pseudomonas risk factors
• Levo/moxifloxacin PO or IV OR CTX IV OR cefotaxime IV
• Duration
• 3-5 days
• Consider oseltamivir during influenza season
• Noninvasive ventilation (e.g. CPAP, BiPaP) if needed

Disposition

• Consider hospitalization for the following:
• Inadequate response of symptoms to outpatient management
• Inability to eat or sleep due to symptoms
• Changes in mental status
• Uncertain diagnosis
• High risk comorbidities (e.g. PNA, CHF, renal failure)

Maintenance

1. B-agonist

    Short: albuterol 90µg/inh 1-2 q4-6h prn; neb 2.5mg q4-6h prn

    Long:  Salmeterol 50µg/inh 1 bid

              Formoterol MDI 12µg/INH 1 bid; neb 20µg bid

              Arfomoterol neb 15µg bid

2. Anticholinergic

    Short: ipratriopium 17µg/INH 2xINH 4x/d up to 12; neb 0.5mg q6-8h

    Long: tiotropium 18µg/INH 1xINH qam

3. Steroids (inhaled)

    Fluticasone (dry powder) 250µg/INH 1-2 bid; (aerosol) 220µg 1-2INH bid

    Budesonide 160µk 2 inh bid

    Beclomethasone 80µg/inh 2INH bid

    Mometasone 220µg/INH 1-2INH bid

4. Combination

    Albuterol-Ipratropium 90/18 2INH 4xd up to 12

    Advair Diskus = Fluticasone-salmeterol (dry powder): 250/50 1INH bid

    Budesonide-Formoterol: 160/4.5 2INH bid

5. Home O2

Indicated if PaO2 < 55mmHg or O2 Sat < 88% RA

Goal is 18h/day including sleep with flow rate that maintain sat > 90%

Source

DONALDSON 1/06, NEJM 4/10, UpToDate