Chronic obstructive pulmonary disease exacerbation resident survival guide: Difference between revisions

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==Definition==
==Definition==
* An exacerbation of COPD is an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication.<ref name="Vestbo-2013">{{Cite journal  | last1 = Vestbo | first1 = J. | last2 = Hurd | first2 = SS. | last3 = Agustí | first3 = AG. | last4 = Jones | first4 = PW. | last5 = Vogelmeier | first5 = C. | last6 = Anzueto | first6 = A. | last7 = Barnes | first7 = PJ. | last8 = Fabbri | first8 = LM. | last9 = Martinez | first9 = FJ. | title = Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. | journal = Am J Respir Crit Care Med | volume = 187 | issue = 4 | pages = 347-65 | month = Feb | year = 2013 | doi = 10.1164/rccm.201204-0596PP | PMID = 22878278 }}</ref>
* An exacerbation of COPD is an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication.<ref name="Burge-2003">{{Cite journal  | last1 = Burge | first1 = S. | last2 = Wedzicha | first2 = JA. | title = COPD exacerbations: definitions and classifications. | journal = Eur Respir J Suppl | volume = 41 | issue = | pages = 46s-53s | month = Jun | year = 2003 | doi = | PMID = 12795331 }}</ref><ref name="Celli-2007">{{Cite journal  | last1 = Celli | first1 = BR. | last2 = Barnes | first2 = PJ. | title = Exacerbations of chronic obstructive pulmonary disease. | journal = Eur Respir J | volume = 29 | issue = 6 | pages = 1224-38 | month = Jun | year = 2007 | doi = 10.1183/09031936.00109906 | PMID = 17540785 }}</ref><ref name="Rodriguez-Roisin-2000">{{Cite journal  | last1 = Rodriguez-Roisin | first1 = R. | title = Toward a consensus definition for COPD exacerbations. | journal = Chest | volume = 117 | issue = 5 Suppl 2 | pages = 398S-401S | month = May | year = 2000 | doi =  | PMID = 10843984 }}</ref>


* The diagnosis of an exacerbation relies exclusively on the clinical presentation of the patient complaining of an acute change of symptoms (baseline dyspnea, cough, and/or sputum production) that is beyond normal day-to-day variation.<ref name="Vestbo-2013">{{Cite journal  | last1 = Vestbo | first1 = J. | last2 = Hurd | first2 = SS. | last3 = Agustí | first3 = AG. | last4 = Jones | first4 = PW. | last5 = Vogelmeier | first5 = C. | last6 = Anzueto | first6 = A. | last7 = Barnes | first7 = PJ. | last8 = Fabbri | first8 = LM. | last9 = Martinez | first9 = FJ. | title = Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. | journal = Am J Respir Crit Care Med | volume = 187 | issue = 4 | pages = 347-65 | month = Feb | year = 2013 | doi = 10.1164/rccm.201204-0596PP | PMID = 22878278 }}</ref>


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==

Revision as of 23:25, 10 December 2013

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Abdurahman Khalil, M.D. [2]

Definition

  • An exacerbation of COPD is an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication.[1][2][3]
  • The diagnosis of an exacerbation relies exclusively on the clinical presentation of the patient complaining of an acute change of symptoms (baseline dyspnea, cough, and/or sputum production) that is beyond normal day-to-day variation.[4]


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

  • Air pollution

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


Management:
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

  1. ↑ Burge, S.; Wedzicha, JA. (2003). "COPD exacerbations: definitions and classifications". Eur Respir J Suppl. 41: 46s–53s. PMID 12795331. Unknown parameter |month= ignored (help)
  2. ↑ Celli, BR.; Barnes, PJ. (2007). "Exacerbations of chronic obstructive pulmonary disease". Eur Respir J. 29 (6): 1224–38. doi:10.1183/09031936.00109906. PMID 17540785. Unknown parameter |month= ignored (help)
  3. ↑ Rodriguez-Roisin, R. (2000). "Toward a consensus definition for COPD exacerbations". Chest. 117 (5 Suppl 2): 398S–401S. PMID 10843984. Unknown parameter |month= ignored (help)
  4. ↑ Vestbo, J.; Hurd, SS.; Agustí, AG.; Jones, PW.; Vogelmeier, C.; Anzueto, A.; Barnes, PJ.; Fabbri, LM.; Martinez, FJ. (2013). "Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary". Am J Respir Crit Care Med. 187 (4): 347–65. doi:10.1164/rccm.201204-0596PP. PMID 22878278. Unknown parameter |month= ignored (help)
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