management of acute exacerbations of copd...instructions for obtaining nursing, social work, and...

MiCMRC Educational Webinar

Management of Acute Exacerbations of COPD

August 22, 2018

MiCMRC Educational WebinarManagement of Acute Exacerbations of COPD

Expert Presenter:

Catherine A. Meldrum PhD RN MS CCRCUniversity of Michigan

Disclosures• There is no conflict of interest for anyone with the ability to

control content for this activity.• This webinar is available for CE credit until June 12, 2020 .• Participants who successfully view the entire live or recorded

webinar and complete the online CE process including required evaluation with email address will earn 1.0 contact hours.

• This continuing nursing education activity was approved by the Ohio Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. (OBN-001-91) ONA # 21571

Instructions for Obtaining Nursing, Social Work, and CCMC CE CreditTo receive Nursing, CCMC, or Social Work 1.0 continuing education contact hour for “Management of Acute Exacerbations of COPD” for Today’s Live Webinar 8/22/018 2:00 – 3:00 PM

• Attend the entire webinar

• Go to the Michigan Care Management Resource Center web site http://micmrc.org/webinars

• On the micmrc web site webinar page, locate the “Management of Acute Exacerbations of COPD” webinar information – Click the link titled To Request CE Credit Click Here– Complete the brief form, include your e-mail address, click submit

• This will generate an email message to you containing a link to complete the CE request and required evaluation form

• Follow instructions in the e-mail: Complete the evaluation and submit. This step generates an email to you containing the CE certificate

*Note: This webinar will be recorded. CE for viewing the recorded webinar will be available on http://micmrc.org/webinars soon.

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Management of Acute Exacerbations of COPD

Catherine A. Meldrum PhD RN MS CCRCUniversity of Michigan

August 22, 2018

Objectives

Definition of AECOPD

Risk factors and potential triggers for COPD exacerbations/hospital re-admissions.

Steps to evaluating and diagnosing an acute exacerbation of COPD.

Home/hospital management of a COPD exacerbation

Prevention measures for COPD exacerbations.

Chronic obstructive pulmonary disease (COPD), a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients.Global Initiative for Chronic Obstructive Lung Disease (GOLD) ;a project initiated by the NHLBI and WHO define COPD 2016

Defining COPD

Objectives






What is an Acute Exacerbation of COPD?

“A sustained worsening of the patient’s condition, from the 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”

Rodriguez-Roisin. Chest. 2000;117:398S-401S.

Impact of an exacerbation

Health status

Rates of hospitalization

Rates of hospital readmissions

Disease progression

Increased risk of MI and ischemic stroke post exacerbation

Rothnie KJ et al, Annals ATS 2018

Exacerbation Classifications

Mild– Treated with short acting bronchodilators only

Moderate – Treated with short acting bronchodilators plus

antibiotics and/or oral corticosteroids

Severe– Requires hospitalization or a visit to the

emergency room– May also be associated with acute respiratory

failure

Objectives






Risk Factors Age

Productive cough

Duration of COPD

History of antibiotic therapy

Chronic mucous hypersecretion

Theophylline

Peripheral blood eosinophil count >0.34 × 109 cells per liter

Comorbidities• Chronic heart failure, diabetes, ischemic heart disease

COPD-related hospitalization within the previous year

Risk Factors

Severity of previous exacerbation

Gastroesophageal reflux disease

Pulmonary Hypertension

Triggers

Respiratory viral infections•Human rhinovirus

Bacterial infections

Environmental factors•Air pollution•Air temperature

ExacerbationsAverage exacerbation length 7-10 days

20% of patients at 8 weeks have not fully recovered

Exacerbations contribute to disease progression

If exacerbations are slow, disease progression is more likely

One exacerbation predisposes a patient to having another exacerbation**

Seemungal et al AM.J Respi Crit Care Med 2000; 161 (5): 1608-13, Donaldson et al, AM.J Respi Crit Care Med 2015; 192(8):943-50, Hurst et al. N Engl J Med 2010; 363(12): 1128-38, Hurst AM.J Respi Crit Care Med 2000, al AM.J Respi Crit Care Med 2009; 179(5):369-74

Exacerbation frequency

Frequent exacerbator– Defined as 2 or more per year

Outcomes–Worse health status– Increased morbidity

Predictor–Number of exacerbations the previous

year

Exacerbation frequency risks

Increase in the ratio of the pulmonary artery to aorta

Percentage of emphysema

Percentage of airway wall thickness

Chronic Bronchitis

Well et al N Engl J Med 2012; 367(10): 913-21, Han et al Radiology 2011; 261(1): 274-82, Kim et al, Chest 2011; 140(3): 626-33, Burgelet al, Chest 2009; 135(4): 975-82.

Objectives




Home/Hospital management of a COPD exacerbation


Symptoms

Dyspnea

Cough

Sputum production

Onset may be over a few hours to days

Physical exam

AECOPD

Wheezing

Tachypnea

Difficulty speaking

Use of accessory muscles

Mental status changes

Differential diagnosis

Fever, chills, night sweats

Hypotension

Bibasilar fine crackles

Peripheral edema

Chest pain, chest pressure, peripheral edema

Risk factors for coronary disease or thromboembolic disease

Upper respiratory symptoms that may suggest a viral infection

Initial evaluation

Clinical assessment

Pulse oximetry

More than 80 % of exacerbations are managed on an outpatient basis

Hurst et al, N Engl J Med 2010; 363(12):1128-38, Celli et al, Eur Respir J 2007; 29(6):1224-38, Hoogendoorn et al Eur Respir J 2011; 37(3): 508-15

Triaging Patients Does the exacerbation appear life-threatening?

Are there indications for ventilator support?

New signs/symptoms

Increase in intensity of symptoms

Severe COPD disease severity

History of frequent exacerbations

Comorbidities

Frailty

Home support

Access to outpatient/ER

Advanced assessment

Pulse oximetry

Chest radiograph

Laboratory studies

Possible arterial blood gas

Management of severe but non life-threatening exacerbations

Bronchodilators–Beta adrenergic agonists

Anticholinergic agents

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of chronic obstructive pulmonary disease: 2018 Report. http://www.goldcopd.org (Accessed on April 27, 2018, Yawn et al Journal of COPD Foundation 2017: 4(3), 177-185


Consider oral glucocorticoid therapy

Antibiotics

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of chronic obstructive pulmonary disease: 2018 Report. http://www.goldcopd.org (Accessed on April 27, 2018).


Oxygen therapy if indicated

Consider noninvasive mechanical ventilation

Hospital management COPD exacerbations

Reverse air-flow limitation

Treat infection (if applicable)

Ensure adequate oxygenation

Prevent intubation and mechanical ventilation

Stoller, JK. 2017 UpToDate

Objectives






Prevention Measures

Smoking Cessation

Pulmonary Rehabilitation

Increased physical activity

Proper use of medications

Vaccinations

Medications

Katajistco er al. Respir Med 2015: 147.894, Au et al, J Gen Intern Med 2009: 24.457, Criner et al Chest 2015: 147.894.

Preventing Frequent Exacerbations

Albert RK. NEJM 2011;365: 689

Roflumilast in frequent exacerbation*

0

0.5

1

1.5

2

2.5

All patients Infrequent exacerbators Frequent exacerbators

Mea

n ra

te o

f mod

erat

e or

sev

ere

exac

erba

tions

per

yea

r

Placebo Roflumilast

Δ = –16.9%Rate ratio 0.831

(95% CI 0.75, 0.92)p=0.0003

n=1537

*FREQUENT EXACERBATORS (≥2 MODERATE OR SEVERE EXACERBATIONS IN PREVIOUS YEAR)INFREQUENT EXACERBATORS (<2 MODERATE OR SEVERE EXACERBATIONS IN PREVIOUS YEAR)

n=1554 n=1137 n=1124 n=417 n=413

Δ = –16.5%Rate ratio 0.835

(95% CI 0.73, 0.95)p=0.0062

Δ = –22.3%Rate ratio 0.777

(95% CI 0.66, 0.91)p=0.0017

a POST-HOC ANALYSESBateman ED et al Eur Respir J 2011; 38:553-560

Roflumilast in CB phenotype

Rennard SI et al; Respir Res 2011; 12: 1

Practical Implication of Chronic Bronchitis Phenotype

Roflumilast: specific therapy for a COPD phenotype– Chronic Bronchitis with frequent exacerbation– Can be initiated in the in-patient or out-patient

setting– Consider roflumilast for exacerbation prevention

Novel risk factors for re-admissions Fibrosis of lung or other chronic lung disordersDepression Anxiety Sleep apneaCardiorespiratory failureMetastatic cancer Vertebral fractureRespiratory failure Fluid/electrolyte disorders

Glaser et al Ann of ATS 2015 12.9

Resources for COPD Informationwww.copdfoundation.org

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