Chronic obstructive pulmonary disease exacerbation resident survival guide: Difference between revisions
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* 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> | * 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> | * 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> | ||
==Causes== | ==Causes== | ||
Revision as of 23:29, 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
- Respiratory tract infections (50%)
- Unknown (~⅓)
- 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
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).
Don'ts
- Spirometry is not recommended during an exacerbation because it can be difficult to perform and measurements are not accurate enough.
References
- ↑ Burge, S.; Wedzicha, JA. (2003). "COPD exacerbations: definitions and classifications". Eur Respir J Suppl. 41: 46s–53s. PMID 12795331. Unknown parameter
|month=ignored (help) - ↑ 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) - ↑ 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) - ↑ 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)