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

defines an exacerbation of chronic obstructive pulmonary disease (COPD) as:

an acute event characterized by a worsening of the patient’s respiratory symptoms

Acute Exacerbations of COPD

Risk Factors For COPD Exacerbation

Advanced age

Productive cough

Chronic mucous Hypersecretion

Duration of COPD

History of antibiotic Therapy

COPD-related hospitalization within the previous year

Theophylline therapy

 FEV1

Pulmonary Hypertension

Gastroesophageal reflux disease

Having one or more comorbidities: Ischemic heart disease Chronic heart failure Diabetes mellitus

Triggers

Respiratory infections Respiratory infections  70 % of COPD exacerbations Virus Virus Bacteria Bacteria Atypical ??? Atypical ???

30 % of COPD exacerbation 30 % of COPD exacerbation   Environmental Pollution

30 % of COPD exacerbation 30 % of COPD exacerbation   Pulmonary Embolism (25%)

30 % of COPD exacerbation 30 % of COPD exacerbation   Unknown Etiology Heart disorders aspiration

clinical manifestations The clinical manifestations of exacerbations of COPD

Details about The past history of exacerbations

The past history of exacerbations should be ascertained NNNNumber of prior exacerbations CCCCourses of systemic Glucocorticoids EEEExacerbations requiring hospitalization or ventilatory support

Physical examination 31

Physical examination Physical examination  Wheezing  Tachypnea

Features of respiratory compromise Features of respiratory compromise   Difficulty speaking due to respiratory effort   Use of accessory respiratory muscles   Paradoxical chest wall

Decreased mental status Decreased mental status  Hypercapnia or Hypoxemia Asterixis Asterixis  Increased Hypercapnia

physical findings that might suggest co-morbidity or alternate diagnosis

Fever Fever Hypotension Hypotension Bibasilar fine crackles Bibasilar fine crackles Peripheral edema Peripheral edema

Evaluation + Diagnosis Goals

Confirm the diagnosis Confirm the diagnosis Identify the cause Identify the cause (when possible) Assess the severity Assess the severity Determine whether comorbidities are contributing Determine whether comorbidities are contributing

Initial evaluation MMMMild exacerbation Clinical assessment Pulse oxygen saturation

Initial evaluation FFFFor patients who require emergency department care Pulse oxygen saturation A chest radiograph Laboratory studies Arterial blood gas analysis

Initial evaluation FFFFor patients who require emergency department care Electrocardiogram Cardiac Troponins Plasma brain natriuretic peptide (BNP) D-dimer

Sputum Gram stain and culture NNNNot useful MMMMay be helpful (Unsuccessful t tt treatment with Antibiotic)

Differential Diagnosis

Differential Diagnosis: Differential Diagnosis:  Acute worsening of dyspnea heart failure pulmonary thromboembolism Pneumonia pneumothorax

Triage to Home or Hospital more than 80 percent of exacerbations of COPD can be managed on an outpatient

Criteria Criteria   Management at Hospital 46

Inadequate response to outpatient or emergency department management Inadequate response to outpatient or emergency department management

Severe underlying COPD: Severe underlying COPD:  FEV1 ≤50  FEV1 ≤50 percent of predicted

Insufficient Home support

History of frequent exacerbation

comorbidities High risk comorbidities including :   Pneumonia   Cardiac Arrhythmia   Heart Failure   Diabetes Mellitus   Renal Failure   Liver Failure

Dyspnea over baseline Dyspnea over baseline  New onset resting dyspnea

Inability to eat or sleep due to symptoms Difficulty speaking due to respiratory effort

Use of accessory muscles Paradoxical chest wall

respiratory acidosis Acute or acute-on-chronic respiratory acidosis

New cyanosis or worsening hypoxemia

Changes in mental status Asterixis Asterixis

Intensive Home Care

Intensive Home Care Intensive Home Care  Nurse visits  Home oxygen  Physical therapy

Intensive Home Care Intensive Home Care  Cost savings Patient and family education Patient and family education

HOME MANAGEMENT OF COPD EXACERBATIONS

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

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

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

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

(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

Beta adrenergic agonists MDI with spacer

Beta adrenergic agonists nebulization

Beta adrenergic agonists nebulization

Beta adrenergic agonists nebulization

Beta adrenergic agonists nebulization

Anticholinergic agents MDI with spacer

Anticholinergic agents nebulization

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)

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

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

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

Factors Associated With Increased Mortality

smoking cessation

pulmonary rehabilitation

vaccination seasonal influenza and pneumococcus

proper use of medications (metered dose inhaler technique)