Management Of Exacerbations Of Chronic Obstructive Pulmonary Disease D.Anan Esmail Seminar Training Primary Care Asthma + COPD

Acute Exacerbations of COPD Cough increases in frequency and severity Sputum production increases in volume and/or changes character Dyspnea increases

These episodes vary in severity from: Mild exacerbations only one of the three cardinal symptoms moderate to severe exacerbations at least two of the three cardinal symptoms

HOME MANAGEMENT OF COPD EXACERBATIONS

management of COPD EXACERBATIONS bronchodilatorglucocorticoidsAntibiotics

mainstay of therapy of acute exacerbation COPD rapid onset of action efficacy in producing bronchodilation

administered by a metered dose inhaler ( MDI ) with a spacer device

two inhalations by MDI every four to six hours

Patients who already have a nebulizer at home

administration of beta adrenergic agonists via nebulizer is helpful during COPD exacerbations

most studies have not supported a greater effect from nebulizer treatments over properly administered metered dose inhaler medication

may be combined with a short acting anticholinergic agent

combination therapy produces bronchodilation in excess of that achieved by either agent alone

Ipratropium bromide an effective bronchodilator for exacerbations of COPD used in combination with inhaled short-acting beta adrenergic agonists

Ipratropium bromide usual dose: two inhalations by metered dose inhaler (MDI) every four to six hours

For patients who have a history of benign prostatic hypertrophy or prior urinary retention, the addition of ipratropium to a long-acting anticholinergic agent (eg, tiotropium) may increase the risk of acute urinary retention, although data are conflicting For patients who have a history of benign prostatic hypertrophy or prior urinary retention, the addition of ipratropium to a long-acting anticholinergic agent (eg, tiotropium) may increase the risk of acute urinary retention, although data are conflicting

management of COPD EXACERBATIONS bronchodilatorglucocorticoidsAntibiotics

small but beneficial Effect in outpatients exacerbations of COPD

prednisone 40 mg per day five days

higher dose Longer course the severity of the exacerbation response to prior courses of glucocorticoids

The efficacy of inhaled glucocorticoids on the course of a COPD exacerbation has not been studied

should not be used as a substitute for systemic glucocorticoid therapy in COPD exacerbations

management of COPD EXACERBATIONS bronchodilatorglucocorticoidsAntibiotics

guidelines recommend antibiotic therapy only for: patients have bacterial infection

guidelines recommend antibiotic therapy only for: moderate or severe exacerbation of COPD

We do not initiate antibiotic therapy in patients whose exacerbation is mild, which we define as having only one of these three symptoms and not requiring hospitalization We do not initiate antibiotic therapy in patients whose exacerbation is mild, which we define as having only one of these three symptoms and not requiring hospitalization

The initial antibiotic regimen should target likely bacterial pathogens Haemophilus influenzae Moraxella catarrhalis Streptococcus pneumoniae

(Grade 2B) Pseudomonas risk factors: - Frequent administration of antibiotics (4 or more courses over the past year) - Recent hospitalization (2 or more days' duration in the past 90 days) - Isolation of Pseudomonas during a previous hospitalization - Severe underlying COPD (FEV1 <50 percent predicted) Pseudomonas risk factors: - Frequent administration of antibiotics (4 or more courses over the past year) - Recent hospitalization (2 or more days' duration in the past 90 days) - Isolation of Pseudomonas during a previous hospitalization - Severe underlying COPD (FEV1 <50 percent predicted)

HOSPITAL MANAGEMENT OF COPD EXACERBATIONS

Inadequate response to outpatient or emergency department management Marked increase in dyspnea over baseline (eg, new onset resting dyspnea) Severe underlying COPD (FEV1 ≤50 % of predicted) Inability to eat or sleep due to symptomsNew cyanosis or worsening hypoxemia

Acute or acute-on-chronic respiratory acidosisChanges in mental statusInsufficient home supportHistory of frequent exacerbations comorbidities: pneumonia, cardiac arrhythmia, heart failure, diabetes mellitus, renal failure, or liver failure

management of COPD EXACERBATIONS bronchodilatorglucocorticoidsAntibiotics

reversing airflow limitation with inhaled short- acting bronchodilators and systemic glucocorticoids treating infectionaverting intubation and mechanical ventilation

nebulizer metered dose inhaler (MDI) with a spacer device We favor nebulized therapy because many patients with COPD have difficulty using proper MDI technique in the setting of an exacerbation

Beta adrenergic agonists four to eight puffs (90 mcg per puff) every one to four hours as needed MDI with spacer

Beta adrenergic agonists albuterol 2.5 mg every one to four hours as needed nebulization

Beta adrenergic agonists Increasing dose of albuterol to 5 mg does not have a significant impact on spirometry or clinical outcomes nebulization

Beta adrenergic agonists continuously nebulized beta agonists have not been shown to confer an advantage in COPD nebulization

Beta adrenergic agonists using air, rather than oxygen-driven bronchodilator nebulization nebulization

Anticholinergic agents two to four puffs (18 mcg per puff) every four hours as needed MDI with spacer

Anticholinergic agents Ipratropium 500 mcg every four hours as needed nebulization

improve symptoms and lung functionreduced treatment failuredecrease the length of hospital stay

Oral glucocorticoids rapidly absorbed (peak serum levels achieved at one hour after ingestion) appear equally efficacious to intravenous glucocorticoids

intravenous glucocorticoids severe exacerbationrespond poorly to oral glucocorticoidsunable to take oral medication impaired absorption (patients in shock)

Dose prednisone 40 mg once daily

Dose methylprednisolone 60 to 125 mg two to four times daily

evidence favors using a moderate rather than high dose of glucocorticoids for most patients with an exacerbation of COPD

higher dose : methylprednisolone >240 mg/day not associated with a mortality benefit shorter hospital and ICU lengths of stay

The optimal duration of systemic glucocorticoid therapy depends on the severity of the exacerbation and the observed response to therapy (5 to 14 days(

longer durationNo additional benefit more glucocorticoid- related side effects

adverse effects hyperglycimia

upper gastrointestinal bleeding

psychiatric disorders

Antibiotic treatment of acute exacerbations of COPD (hospitalized)

Pseudomonas risk factors: - Frequent administration of antibiotics (4 or more courses over the past year) - Recent hospitalization (2 or more days' duration in the past 90 days) - Isolation of Pseudomonas during a previous hospitalization - Severe underlying COPD (FEV1 <50 percent predicted) Pseudomonas risk factors: - Frequent administration of antibiotics (4 or more courses over the past year) - Recent hospitalization (2 or more days' duration in the past 90 days) - Isolation of Pseudomonas during a previous hospitalization - Severe underlying COPD (FEV1 <50 percent predicted)

Thromboprophylaxis Hospitalization for exacerbations of COPD increases the risk for deep venous thrombosis and pulmonary embolism

cigarette smoking cessation

nutritional support

continuation of ongoing supplemental oxygen therapy

administration of supplemental oxygen should target ppppulse oxygen saturation (SpO ) of 88 to 92 percent

administration of supplemental oxygen should target aaaarterial oxygen tension (PaO ) of approximately 60 to 70 mmHg

A high FiO is not required to correct the hypoxemia associated with most exacerbations of COPD

the risk of prompting worsened hypercapnia with excess supplemental oxygen

Hypercapnia is generally well tolerated in patients whose (PaCO ) is chronically elevated

Adequate oxygenation to achieve an oxygen saturation of 88 to 92 percent must be assured, even if it leads to acute hypercapnia

mechanical ventilation may be required if hypercapnia is associated with depressed mental status profound acidemia cardiac dysrhythmias

Noninvasive ventilation ppppreferred method of ventilatory support iiiimproves numerous clinical outcomes

Invasive ventilation ppppatients fail NPPV ddddo not tolerate NPPV hhhhave contraindications to NPPV

respiratory arrest cardiovascular instability impaired mental status causing an inability to cooperate copious and/or viscous secretions with high aspiration risk recent facial or gastroesophageal surgery craniofacial trauma fixed nasopharyngeal abnormality Burns extreme obesity Contraindications for NPPV include the following:

not been shown to confer benefit for patients with a COPD exacerbation

Mucoactive agents mechanical techniques to augment sputum clearance

Methylxanthines aminophylline and theophylline, are considered second-line therapy for exacerbations of COPD nausea and vomiting, tremor, palpitations, arrhythmias

Nebulized magnesium no effect on FEV when added to nebulized salbutamol (albuterol) in patients with exacerbations of COPD

Subcutaneous injection of short-acting beta adrenergic agonists (eg, terbutaline, epinephrine) almost never used for COPD exacerbations (Arrhythmias, myocardial ischemia)

Exacerbations of COPD are associated with increased mortality (3 to 9 %)

Factors Associated With Increased Mortality

Increased age - male genderSeverity of airway obstruction (FEV1)prior hospitalization for COPD

Hypercapniaurea >8 mmol/L presence of Pseudomonas aeruginosa in the patient’s sputum

smoking cessation

pulmonary rehabilitation

vaccination seasonal influenza and pneumococcus

proper use of medications (metered dose inhaler technique)

use of an action plan earlier recognition of an exacerbation by the patient earlier initiation of antibioticsearlier initiation of glucocorticoids

Prophylactic antibiotics we suggest not administering antibiotic prophylaxis For most patients with COPD