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

• 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.

• 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

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

• Respiratory tract infections (50%)
• Unknown (~⅓)
• Air pollutants

Differential Diagnosis

• Asthma
• CHF
• PE
• ACS
• Pneumothorax
• Pneumonia
• Lobar atelectasis

Management

COPD Exacerbation ❑ Cough↑ ❑ Dyspnea↑ ❑ Sputum↑

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).

Don'ts

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