Acute exacerbation of COPDAnum haiderHouse officer medical unit IVCHK

COPD Definition

• Progressive airflow limitation caused by airway and parenchymal inflammation

•It includes chronic bronchitis and emphyesema

Emphysema Vs Chronic Bronchitis

Emphysema Chronic bronchitis

Definition Dilation/destruction of parenchyma

Productive cough >3 months/yr x > 2 yrs

Pathophysiology Tissue destruction Matched V/Q defectsMild hypoxemia

Small airways affectedV/Q mismatchSevere hypoxemia, HypercapniaPHT, Cor Pulmonale

Clinical Manifestation Severe constant dyspneaMild cough

Intermittent dyspneaCopious sputum production

Physical Examination “Pink Puffers”Tachypneic, Non-cyanotic, thinDiminished breath sounds

‘Blue Bloaters”Cyanotic, obese, EdematousRhonchi & wheezes

Exacerbation

• An exacerbation of COPD should be defined as: “a sustained worsening of the patient’s condition,

from stable state and beyond normal day to-day variations, that

is acute in onset and necessitates a change in regular medication in a patient with underlying COPD”

• Subsequently, the definition was amended to include exacerbations that did not necessitate a change in treatment

Rodriguez-Roisin R. Toward a consensus definition for COPD exacerbations. Chest 2000; 117(5 Suppl 2):398S-401S

Evaluation of the patients with AECOPD• PMH: COPD severity, exacerbations, co-morbidities

• Physical exam: VS, hemodynamic status, mental

status, accessory muscles

• Tests: Spirometry, O2 saturation, CXR,

blood tests, ECG and sputum culture

Principles of Management of AECOPD•Treat Infections/ Avoid Triggers

▫Antibiotics

•Optimize Gas Exchange▫Optimize bronchodilation▫Steroid therapy▫Oxygen as required▫Consider Non Invasive / Invasive

ventilation

Treatment of AECOPDAgent Dose Comments

Ipratropium MDI 4 – 8 puffs q 1 – 2 hNebulizer 0.5mg q 1 -2 h

1st line therapy

Albuterol MDI 4 – 8 puffs q 1 – 2 hNebulizer 2.5 - 5mg q 1 -2 h

Benefit if component of reversible bronchoconstriction

Agent Dose CommentsCorticosteroids

No consensus for optimal dose and duration(Cochrane 2009: CD001288)

Methylprednisolone 125mg IV q 6 h x 72 hrsThen Prednisolone 60 mg PO qd with 20mg taper q 3 -4 days (NEJM 1999: 340:1941)

Prednisolone 40 mg x 10daysOr Prednisolone 30mg qd x 2 wks if pH > 7.26 (Lancet 1999: 354:456)

1. Treatment Failure

2. Hospital Stay3. OPD Rx after ED

visit4. Relapse

(NEJM 2003:348:2618)

1. FEV12. Complications

(Cochrane 2009: CD001288)

Agent Dose Comments

Antobiotics • Amoxicillin, TMP-SMXDoxycycline, clarithrimycin, Antipneumococcal FQ etc, all reasonable

• No single ABx proven superior

• Consider local flora

•Avoid repeat courses of same Abx.

• H. flu, M. catarrhalis, S.pneumoare the most frequent precipitants

• Increased Dyspnea, sputum production, purulence suggest Bacterial Infection …therefore Abx may improve outcome(Annals 1987)

• Incrreased PEF & chance of clinical resolution ( JAMA 1995)

• Decreased subsequent exacerbation ( Thorax 2008)

• < 5 days course likely enough for mild –moderate exacerbation(Thorax 2008 ; JAMA 2010)

Agent Dose Comments

Oxygenation FiO2 to achieve PaO2 >55-60 orSaO2 90-93%

Watch for CO2 retention(due to V/Q mismatch, loss of hypoxeamic resp drive, haldane effect) but must maintain oxygenation

Other Measures Mucolytics not supported by data(Chest 2001 : 119: 1190)

Non Invasive VentilationNon Invasive Positive Pressure Ventilation

Initiate “early” if:1.Moderate/ severe dyspnea2.Decreased pH3.Increased PaCO24.RR > 25

Advantages of NIV ( Non Invasive Ventialtion):1. 58% decrease in intubation2. Decrease Length of Stay in Hospital by 3.2 days3. 59% decrease in Mortality

Contra Indications for NIV ( Non Invasive Ventialtion):1.Change mental status2.Inability to cooperate or clear secretions3.Upper GI Bleed4.Heamodynamic instability(NEJM 1995 ; 333:817 ; Annals 2003 ; 138:861 ; Cochrane 2004 ; CD004)

Invasive ventilation

Endotracheal Intubation

Consider if:

1. PaO2 <55-602.Increasing PaCO23.Decreasing pH4.Increasing RR5.Respiratory fatigue6.Change in mental status, 7.Haemodynamic instability

Thank you