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 increased V/Q mismatch, not expiratory airflow limitation
  • Although smoking is a major risk factor for developing COPD, only 15% of smokers actually develop COPD[1]
  • Antibiotics for COPD exacerbations have an NNT of[2]:
    • 3:1 to prevent conservative treatment failure
    • 8:1 to prevent short-term mortality
    • 20:1 to cause diarrhea
  • Relative hypoxia
    • Some COPD patients are accustomed to living with relative hypoxia, and high levels of oxygen may cause suppress respiratory drive. However, supplemental oxygen should not be withheld if the Sp02 is < 90.

Precipitants

Pseudomonas Risk Factors

  • Recent hospitalization (>2 days within previous 3 months)
  • Frequent antibiotic treatment (>4 courses within past year)
  • Severe underlying COPD (FEV1 < 50% predicted)
  • Previous isolation of pseudomonas

Clinical Features

Differential Diagnosis

Acute dyspnea

Emergent

Non-Emergent

Evaluation

  • VBG/ABG
    • Perform if SpO2 <90% or concerned about symptomatic hypercapnia
    • For every increase in PaC02 of 10 mmHg, the pH should change by 0.08
  • Peak flow
    • <100 indicates severe exacerbation
  • CXR
    • Consider if concerned for pneumonia or CHF
  • Sputum culture
    • Usually not indicated except for patient with recent antibiotic failure

Management

Oxygen

  • Maintain 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 altered mental status, dysrhythmias, or acidemia consider Intubation

Albuterol/ipratropium

  • Improves airflow obstruction and treatment should involve rapid administration upon recognition of COPD exacerbation. [3]

Steroids[4]

Similar efficacy between oral and intravenous. Treatment options include:

  • Hydrocortisone 100-125mg Q6H x 5 days
  • Methylprednisolone 1-2mg/kg IV daily (usual adult dose 125mg)[5]
  • Prednisone 60mg x 1, then 40mg PO daily x 5 days
    • For outpatients a 5 day dose appears equally effective as longer doses and a taper is not required.[6]

Magnesium

  • Mechanism: bronchial smooth muscle relaxation
  • Studies have found that while helpful in asthma, results are mixed for COPD[7]

Antibiotics

Indicated for patients with purulent sputum, increased sputum production, or requiring Non Invasive Positive Pressure Ventilation[8] (NNT = 3 to prevent treatment failure and 8 to prevent death)[9]

Outpatient Healthy

Outpatient Unhealthy

Inpatient

Noninvasive ventilation (CPAP or BiPaP)

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

Outcomes

  • Improves acidosis and ease respiratory distress

Contraindications:

  • Uncooperative or obtunded patient
  • Inability to clear secretions
  • Hemodynamic instability

Mechanical ventilation

Indications:

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

Disposition

Consider hospitalization for:

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

See Also

EBQ:NIPPV in COPD

References

  1. Bates C, et al. Chapter 73: Chronic Obstructive Pulmonary Disease. In: Tintinalli J. Tintinalli's Emergency Medicine. A comprehensive study guide. 7th ed. 2011: 511.
  2. Ram FS, et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006.19(2).
  3. Celli BR. Update on the management of COPD. Chest. Jun 2008;133(6):1451-62.
  4. Do systemic corticosteriods improve outcomes in COPD exacerbations? Feb 2016. Annals of EM. 67(2):258-259
  5. 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
  6. 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
  7. Shivanthan MC, Rajapakse S. Magnesium for acute exacerbation of chronic obstructive pulmonary disease: A systematic review of randomised trials. Ann Thorac Med. 2014 Apr;9(2):77-80.
  8. GOLD collaborators
  9. Ram FS, Rodriguez-Roisin R, Granados-Navarrete A, et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006; 19(2):CD004403.
  10. 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
  11. Anzueto A, Miravitlles M: Short-course fluoroquinolone therapy in exacerbations of chronic bronchitis and COPD. Respir Med 2010; 104:1396-1403