COPD -
Exacerbation
Associate Professor Mark Hurwitz
Director
Respiratory and Sleep Medicine
The Canberra Hospital
COPD - Exacerbation
Exacerbation
Event characterised by a worsening of the patients
respiratory symptoms that is beyond normal day to
day variations and leads to a change in medication.
Generally includes the following symptoms
• increased cough frequency and severity
• increased sputum volume and/or change in
character
• increased dyspnoea
Risk Factors
Candidates with:
Increasing age
Productive cough
Antibiotic therapy
Recent hospitalisation (12 months)
Chronic sputum production
COPD - Exacerbation
COPD - Exacerbation
Risk Factors cont’d...
Candidates with:
Eosinophilia
Co-morbidities
- OCAD
- Cardiac failure
- Diabetes
Progression of the disease
COPD - Exacerbation
Exacerbation Risk
Severity of COPD
History of exacerbations
Hospitalisation for exacerbations
Number of exacerbations
0-1 = Low Risk
>2 = High Risk
Mild to moderate COPD – Low Risk
Severe or very severe – High Risk
COPD - Exacerbation
Oesophageal Reflux
Additional risk for exacerbation
Increased exacerbations = increased reflux
? Benefit from proton pump inhibitor – open mind
Pulmonary Hypertension
Increased risk of exacerbation.
COPD - Exacerbation
Triggers
Respiratory infections 70% of exacerbations
Viral and bacterial infection
Pollution; pulmonary embolism or idiopathic 30%
Idiopathic -
- Coronary Artery Disease
- Cardiac Failure
- Aspiration
- Pulmonary Embolism
COPD - Exacerbation
Clinical Manifestations
Dyspnoea
Productive cough/sputum
Respiratory Failure
Hypoxia
COPD - Exacerbation
Clinical Manifestations
History – increased and worsening of respiratory
symptoms
Time course
Comparison to baseline
Compromise
Sputum characterisation
Hospitalisation
Number of exacerbations
Corticosteroids
COPD - Exacerbation
Clinical Finding
Shortness of breath
Wheeze/Ronchi
Increased respiratory rate
Difficulty speaking
Work of breathing
Reduced mental status
Flap
Alternative diagnosis
COPD - Exacerbation
Evaluation and Diagnosis
Confirm
Cause
Severity
Co-Morbidity
COPD - Exacerbation
Evaluation and Diagnosis
Initial evaluation
Mild:
- Clinical assessment
- Oximetry
COPD - Exacerbation
Evaluation and Diagnosis
Oximetry
CXR
Laboratory studies
Arterial Blood Gas
Additional Tests
ECG
Sputum
Viral Swabs
COPD - Exacerbation
Differential Diagnosis
Heart Failure
Pulmonary Embolism
Pneumonia
Pneumothorax
Chronic sputum production
Chest Xray
Home or Hospital
COPD - Exacerbation
Hospital
Not responded as outpatient
New Signs
Increasing severity
Severity
Frequency
Co-morbidities
Frailty
No support
COPD - Exacerbation
Bronchodilators
Beta Adrenergic Agonists
Anti Cholinergic Agents
Corticosteroids
Antibiotics
Oxygen
COPD - Exacerbation
Supportive Care
Smoking Cessation
Thromboprophylaxis
Mucolytics
COPD - Exacerbation
Management
Methylxanthine (Theophylline)
Antibiotics
Physiotherapy – Bubble PEP
Ventilation – Non invasive
Prognosis
Increased morbidity
Increased mortality
COPD - Exacerbation
Prevention
Smoking Cessation
Pulmonary Rehabilitation
Increased Activity
Vaccination
Combined bronchodilators
Antibiotics
Management Plan
COPD - Exacerbation
Additional Thoughts
Pollution
Medication -
Bronchodilators
Antibiotics
Beta Blockers
COPD - Exacerbation
New Thoughts
Corticosteroids
Beta Blockers
Co-morbidity
Pollution
Fatigue
COPD - Exacerbation
Non Pharmacological Management
Vaccination
Influenza
Pneumococcus
Smoking Cessation
Rehabilitation
Oxygen
COPD - Exacerbation
Pharmalogical
Symptom evaluation not only Spirometry
Combined therapy as first line and the role of
Inhaled Corticosteroids.
COPD - Exacerbation
Co-morbidities
Cardiovascular
Osteoporosis
Gastro oesophageal reflux
Anxiety & Depression
Sleep Apnoea
Palliative Care