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

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
  • 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)

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