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 clinical signs suggestive of respiratory muscle fatigue ❑ Increased work of breathing 2b. Indications for Invasive Mechanical Ventilation ❑ Unable to tolerate NIV or NIV failure ❑ Respiratory or cardiac arrest ❑ Respiratory pauses with loss of consciousness or gasping for air ❑ Diminished consciousness, psychomotor agitation inadequately controlled by sedation ❑ Massive aspiration ❑ Persistent inability to remove respiratory secretions ❑ Heart rate <50/min with loss of alertness ❑ Severe hemodynamic instability without response to fluids and vasoactive drugs ❑ Severe ventricular arrhythmias ❑ Life-threatening hypoxemia in patients unable to tolerate NIV
		3. Indications for Hospitalization ❑ Marked increase in intensity of symptoms (eg, sudden development of resting dyspnea) ❑ Severe underlying COPD (GOLD 3—4 categories) ❑ Onset of new physical signs (eg, cyanosis, peripheral edema) ❑ Failure of an exacerbation to respond to initial medical management ❑ Presence of serious comorbidities (eg, heart failure or newly occurring arrhythmias) ❑ Frequent exacerbations (≥2 events per year) ❑ Older age (>65 years) ❑ Insufficient home support 4. Assessment of Severity of Exacerbation ❑ Chest radiograph (exclude alternative diagnoses) ❑ ECG (identify coexisting cardiac problems) ❑ Whole-blood count (identify polycythemia, anemia, or leukocytosis) ❑ Electrolytes and glucose (identify electrolyte disturbances or hyperglycemia) ❑ Sputum purulence (if ⊕ → give empiric antibiotics)

^†Pa_O2 <60 mm Hg with or without Pa_CO2 >50 mm Hg in ambient air

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

Non-invasive ventilation

Unable to tolerate NIV? Severe hemodynamic instability? Resp/cardiac arrest ?

Invasive mechanical ventilation

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.