COPD exacerbation

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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