Chronic obstructive pulmonary disease exacerbation resident survival guide

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

Definition

• 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.

• 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.

Causes

Life-Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Arrhythmia
• Congestive heart failure
• Pleural effusion
• Pneumonia
• Pneumothorax
• Pulmonary embolism

Common Causes

• Respiratory tract infections (~½)
• Unknown (~⅓)
• Air pollutants

Treatment Setting and Severity

COPD Exacerbation ❑ Cough ↑ ❑ Dyspnea ↑ ❑ Sputum ↑
		1. Oxygen Supplement ❑ Pulse oximetry (maintain SaO2 ≥88—92%) ❑ Arterial blood gas (if acute or acute-on-chronic respiratory failure is suspected)
		2. Indications for ICU Admission ❑ Hemodynamic instability ❑ Changes in mental status (confusion, lethargy, coma) ❑ Severe dyspnea that responds inadequately to initial emergency therapy ❑ Worsening hypoxemia (PaO2 <40 mm Hg) and/or respiratory acidosis (pH <7.25)
				2a. Indications for Noninvasive Mechanical Ventilation ❑ Respiratory acidosis (arterial pH < 7.35 or PaCO2 >45 mm Hg) ❑ Severe dyspnea with sings of respiratory muscle fatigue ❑ Increased work of breathing 2b. Indications for Invasive Mechanical Ventilation ❑ Diminished consciousness, psychomotor agitation inadequately controlled by sedation ❑ Severe hemodynamic instability without response to fluids and vasoactive drugs ❑ Respiratory pauses with loss of consciousness or gasping for air ❑ Life-threatening hypoxemia in patients unable to tolerate NIV ❑ Persistent inability to remove respiratory secretions ❑ Heart rate <50/min with loss of alertness ❑ Unable to tolerate NIV or NIV failure ❑ Severe ventricular arrhythmias ❑ Respiratory or cardiac arrest ❑ Massive aspiration
		3. Indications for Hospitalization ❑ Marked increase in intensity of symptoms (eg, sudden development of resting dyspnea) ❑ Presence of serious comorbidities (eg, heart failure or newly occurring arrhythmias) ❑ Failure of an exacerbation to respond to initial medical management ❑ Onset of new physical signs (eg, cyanosis, peripheral edema) ❑ Severe underlying COPD (GOLD 3—4 categories) ❑ Frequent exacerbations (≥2 events per year) ❑ Insufficient home support ❑ Older age (>65 years) 4. Assessment of Severity of Exacerbation ❑ Sputum purulence ❑ ECG (identify coexisting cardiac problems) ❑ Chest radiograph (exclude alternative diagnoses) ❑ Whole-blood count (identify polycythemia, anemia, or leukocytosis) ❑ Electrolytes and glucose (identify electrolyte disturbances or hyperglycemia)
						Severe Exacerbation ❑ Consider inpatient management ❑ Assess symptoms, ABG, and CXR ❑ Monitor fluid balance and nutrition ❑ Identify and treat associated conditions ❑ Consider subcutaneous heparin or LMWH ❑ Controlled oxygen therapy (use NIV if indicated) ❑ Antibiotics (if ↑ sputum purulence or ⊕ bacterial infection) ❑ Corticosteroids ❑ Bronchodilators ▸ Increase doses/frequency of short-acting bronchodilators ▸ Combine short-acting β2-agonists and anticholinergics ▸ Use spacers or air-driven nebulizers Moderate Exacerbation ❑ Consider outpatient management ❑ Require a short course of antibiotics or oral corticosteroids Mild Exacerbation ❑ Consider outpatient management ❑ Require change of inhaled treatment by the patient

Do's

Assessment

• The presence of purulent sputum during an exacerbation can be sufficient indication for starting empirical antibiotic treatment.
• Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis are the most common bacterial pathogens involved in an exacerbation.

• Coverage of Pseudomonas aeruginosa in GOLD 3 and GOLD 4 patients is important.

Bronchodilators

• Short-acting inhaled β2-agonists with or without short-acting anticholinergics are usually the preferred bronchodilators for treatment of an exacerbation.

Don'ts

• Spirometry is not recommended during an exacerbation because it can be difficult to perform and measurements are not accurate enough.