Chronic obstructive pulmonary disease exacerbation resident survival guide: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{CMG}}; {{AE}} {{AK}} | {{CMG}};{{AE}}{{AK}} | ||
==Definition== | |||
==Definition== | COPD exacerbation commonly caused by infections, should be recognized when any of the following symptoms is noticed in a chronic COPD patient:worsening cough, increasing dyspnea, increasing in sputum production more than the baseline for chronic COPD patients.<ref name="pmid17507545">{{cite journal| author=Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P et al.| title=Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. | journal=Am J Respir Crit Care Med | year= 2007 | volume= 176 |issue= 6 | pages= 532-55 | pmid=17507545 | doi=10.1164/rccm.200703-456SO | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17507545 }} </ref> | ||
==Causes== | ==Causes== | ||
===Life | ===Life Threatening Causes=== | ||
Include conditions which may result death or permanent disability within 24 hours if left untreated, and some of them may mimic and/or aggravate exacerbations: | |||
* [[ | *[[Pneumonia]] | ||
* [[ | *[[PE]] | ||
* [[ | *[[Pneumothorax]] | ||
* [[ | *[[Pleural effusion]] | ||
* [[ | *[[CHF]] | ||
* [[ | *[[Cardiac arrhythmias]] | ||
===Common Causes=== | ===Common Causes=== | ||
* | *Respiratory tract infections 50%(bacterial or viral). | ||
* Unknown ( | *Exposure to pollutants. | ||
*Unknown (⅓ of cases ). | |||
== | ==Differential Diagnosis== | ||
* [[Asthma]] | |||
* [[CHF]] | |||
* [[PE]] | |||
* [[ACS]] | |||
* [[Pneumothorax]] | |||
* [[Pneumonia]] | |||
* [[Atelectasis|Lobar atelectasis]] | |||
==Management== | ==Management== | ||
{{Family tree/start}} | {{Family tree/start}} | ||
{{Family tree | | | | A01 | | | |A01= '''COPD Exacerbation'''<br>↑[[cough]], ↑[[dyspnea]], ↑[[sputum]], <br> ↑[[wheezing]], [[fever]] or chest tightness}} | {{Family tree | | | | A01 | | | |A01= '''COPD Exacerbation'''<br>↑[[cough]], ↑[[dyspnea]], ↑[[sputum]], <br> ↑[[wheezing]], [[fever]] or chest tightness}} | ||
| Line 54: | Line 36: | ||
{{Family tree | | | | C01 |~| C02 | |C01='''Assessment''' :<br>1-O2 sat+ ABG <br>2-[[CXR]] <br>3-[[EKG]] <br>4-[[CBC]] | {{Family tree | | | | C01 |~| C02 | |C01='''Assessment''' :<br>1-O2 sat+ ABG <br>2-[[CXR]] <br>3-[[EKG]] <br>4-[[CBC]] | ||
<br> | <br> | ||
'''Management:''' <br>1-Inhaled bronchodilators <br>2-Systemic corticosteroids <br>3-Empirical antibiotics <br>4-O2 (target Sat >90%)|C02='''Corticosteroids(Solumedrol)'''<br>Methylprednisolone 125 mg×1 dose <br> followed with 60-80 mg Q8-12based on severity <br> IV Solumedrol to PO Prednisone taper 4--60 mg Q 8-12<br> 2-5 days taper depending on severity<br> '''Antibiotics'''<br>'''Group A'''*<br>Doxycycline Cap '''Vibramycin''' PO 100 mg Q12H<br>(if unable to tolerate choose Cefpodoxime Tab '''Vantin''' PO 200 mg Q12H)<br>'''Group B'''*<br>Ceftriaxone Inj '''Rocephin''' 1GM D5W50 ml Q24H 200 ml/Hr<br>(If Beta-Lactam allergy choose Levofloxacin Tab '''Levaquin''' PO 500 mg daily )<br> '''Group C'''*<br>Ciprofloxacin Tab '''Cipro'''PO 250 Daily<br>or Ciprofloxacin Inj Cipro 400 mg premixed at 400 mg /200 ml Q12H 200 ml/Hr. | '''Management:''' <br>1-Inhaled bronchodilators <br>2-Systemic corticosteroids <br>3-Empirical antibiotics <br>4-O2 (target Sat >90%)| C02='''Corticosteroids(Solumedrol)'''<br>Methylprednisolone 125 mg×1 dose <br> followed with 60-80 mg Q8-12based on severity <br> IV Solumedrol to PO Prednisone taper 4--60 mg Q 8-12<br> 2-5 days taper depending on severity<br> '''Antibiotics'''<br>'''Group A'''*<br>Doxycycline Cap '''Vibramycin''' PO 100 mg Q12H<br>(if unable to tolerate choose Cefpodoxime Tab '''Vantin''' PO 200 mg Q12H)<br>'''Group B'''*<br>Ceftriaxone Inj '''Rocephin''' 1GM D5W50 ml Q24H 200 ml/Hr<br>(If Beta-Lactam allergy choose Levofloxacin Tab '''Levaquin''' PO 500 mg daily )<br> '''Group C'''*<br>Ciprofloxacin Tab '''Cipro'''PO 250 Daily <br>or Ciprofloxacin Inj Cipro 400 mg premixed at 400 mg /200 ml Q12H 200 ml/Hr. | ||
}} | }} | ||
{{Family tree | | | | |!| | | | |}} | {{Family tree | | | | |!| | | | |}} | ||
{{Family tree | | | | D01 | | | |D01=Respiratory acidosis? OR <br> PH≤35? OR<br> PaCo2≥45? OR<br> Severe signs of dyspnea? OR <br>Accessory muscles use,<br>paradoxical motion of abdomen,<br> retraction of intercostal space}} | {{Family tree | | | | D01 | | | |D01=Respiratory acidosis? OR <br> PH≤35? OR<br> PaCo2≥45? OR<br> Severe signs of dyspnea? OR <br>Accessory muscles use, <br>paradoxical motion of abdomen,<br> retraction of intercostal space}} | ||
{{Family tree | | |,|-|^|-|.| | }} | {{Family tree | | |,|-|^|-|.| | }} | ||
{{Family tree | E01 | | | E02 |E01=No | E02= Yes}} | {{Family tree | E01 | | | E02 |E01=No | E02= Yes}} | ||
{{Family tree | |!| | | | |!| |}} | {{Family tree | |!| | | | |!| |}} | ||
{{Family tree | F01 | | | F02|F01=Continue the same management |F02='''ICU Admission''' | {{Family tree | F01 | | | F02|F01=Continue the same management |F02='''ICU Admission''' <br>'''NIV''' }} | ||
{{Family tree | | | | | | |!| |}} | |||
{{Family tree | | | | | | |! | |||
{{Family tree | | | | | | G01 |G01= Unable to tolerate NIV?<br> Severe hemodynamic instability?<br>Resp/cardiac arrest ? }} | {{Family tree | | | | | | G01 |G01= Unable to tolerate NIV?<br> Severe hemodynamic instability?<br>Resp/cardiac arrest ? }} | ||
{{Family tree | | | | | | |!| | |}} | {{Family tree | | | | | | |!| | |}} | ||
{{Family tree | | | | | | H01 | |H01=Invasive mechanical ventilation}} | {{Family tree | | | | | | H01 | |H01=Invasive mechanical ventilation}} | ||
{{Family tree/end}} | {{Family tree/end}} | ||
'''*Group A''':mild exacerbation, no risk factors, 2>symptoms present | |||
'''Group B''':Mod Exacerbation w/risk factors for poor outcomes:comorbid disease, severe COPD, Frequent exacerbation>3, Antimicrobial use within the last 3 months | |||
'''Group C''':Severe exacerbation w/risk factors for P.aeruginosa infection. | |||
==Do's== | ==Do's== | ||
| Line 75: | Line 59: | ||
*Consider subcutaneous heparin or low molecular weight heparin. | *Consider subcutaneous heparin or low molecular weight heparin. | ||
*Treat associated conditions if exist(e.g., heart failure,arrhythmias). | *Treat associated conditions if exist(e.g., heart failure,arrhythmias). | ||
==References== | ==References== | ||
{{ | {{reflist|2}} | ||
Latest revision as of 00:59, 17 December 2013
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Abdurahman Khalil, M.D. [2]
Definition
COPD exacerbation commonly caused by infections, should be recognized when any of the following symptoms is noticed in a chronic COPD patient:worsening cough, increasing dyspnea, increasing in sputum production more than the baseline for chronic COPD patients.[1]
Causes
Life Threatening Causes
Include conditions which may result death or permanent disability within 24 hours if left untreated, and some of them may mimic and/or aggravate exacerbations:
Common Causes
- Respiratory tract infections 50%(bacterial or viral).
- Exposure to pollutants.
- Unknown (⅓ of cases ).
Differential Diagnosis
Management
| COPD Exacerbation ↑cough, ↑dyspnea, ↑sputum, ↑wheezing, fever or chest tightness | |||||||||||||||||||||
| Admission | |||||||||||||||||||||
| Assessment : 1-O2 sat+ ABG 2-CXR 3-EKG 4-CBC
1-Inhaled bronchodilators 2-Systemic corticosteroids 3-Empirical antibiotics 4-O2 (target Sat >90%) | Corticosteroids(Solumedrol) Methylprednisolone 125 mg×1 dose followed with 60-80 mg Q8-12based on severity IV Solumedrol to PO Prednisone taper 4--60 mg Q 8-12 2-5 days taper depending on severity Antibiotics Group A* Doxycycline Cap Vibramycin PO 100 mg Q12H (if unable to tolerate choose Cefpodoxime Tab Vantin PO 200 mg Q12H) Group B* Ceftriaxone Inj Rocephin 1GM D5W50 ml Q24H 200 ml/Hr (If Beta-Lactam allergy choose Levofloxacin Tab Levaquin PO 500 mg daily ) Group C* Ciprofloxacin Tab CiproPO 250 Daily or Ciprofloxacin Inj Cipro 400 mg premixed at 400 mg /200 ml Q12H 200 ml/Hr. | ||||||||||||||||||||
| Respiratory acidosis? OR PH≤35? OR PaCo2≥45? OR Severe signs of dyspnea? OR Accessory muscles use, paradoxical motion of abdomen, retraction of intercostal space | |||||||||||||||||||||
| No | Yes | ||||||||||||||||||||
| Continue the same management | ICU Admission NIV | ||||||||||||||||||||
| Unable to tolerate NIV? Severe hemodynamic instability? Resp/cardiac arrest ? | |||||||||||||||||||||
| Invasive mechanical ventilation | |||||||||||||||||||||
*Group A:mild exacerbation, no risk factors, 2>symptoms present
Group B:Mod Exacerbation w/risk factors for poor outcomes:comorbid disease, severe COPD, Frequent exacerbation>3, Antimicrobial use within the last 3 months
Group C:Severe exacerbation w/risk factors for P.aeruginosa infection.
Do's
- Monitor fluid balance,nutrition and patient condition closely.
- Consider subcutaneous heparin or low molecular weight heparin.
- Treat associated conditions if exist(e.g., heart failure,arrhythmias).
References
- ↑ Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P; et al. (2007). "Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary". Am J Respir Crit Care Med. 176 (6): 532–55. doi:10.1164/rccm.200703-456SO. PMID 17507545.