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Clinical assessment and staging of COPD exacerbations Jørgen Vestbo Gentofte Hospital, Denmark.

Faculty disclosure I have received honoraria for consulting and presenting from Almirall AstraZeneca Boehringer-Ingelheim Chiesi GlaxoSmithKline Novartis Takeda

Aims of presentation To discuss assessment of exacerbations of COPD Important issues: Definition of exacerbations Differential diagnosis Assessment, what to measure and what not to Assessment of severity with main focus on acute respiratory failure Prognostic markers

Consequences of COPD exacerbations Negative impact on quality of life Impact on symptoms and lung function EXACERBATIONS Accelerated lung function decline Increased economic costs Increased Mortality

Consequences of COPD exacerbations Suissa S et al. Thorax 2012

Consequences of COPD exacerbations Suissa S et al. Thorax 2012

COPD Exacerbation: Definition An acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and may lead to a change in medication GOLD 2014 update

COPD Exacerbation: Definition An exacerbation of COPD is a clinical diagnosis of exclusion, made when a patient with COPD experiences an acute worsening in respiratory symptoms (typically cough, sputum quantity and purulence, and/or dypnoea), and in whom no alternative specific cause for that deterioration has been identified by clinical examination and/or corroborative testing. The worsening in respiratory symptoms may or may not warrant a change in underlying therapy and the symptoms will typically resolve over a period of days to weeks. ERS/ATS draft Position paper.

Heterogeneity of exacerbations Mrs Jones: 2-3 exacerbations per year, almost always precipitated by a cold, characterised by increasing breathlessness and wheeze, cough with minimal clear sputum and severely disturbed sleep. Mr Brown: 4-6 exacerbations per year, with gradual onset of increased sputum purulence and viscosity, fever and fatigue. More breathless on exertion, no wheeze.

COPD Exacerbation: Definition An acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and may lead to a change in medication GOLD 2014 update

COPD Exacerbation: Differential Diagnoses Clinical presentation Pneumonia Pneumothorax Pleural effusion Aspiration Lung cancer Heart failure Atrial fibrillation Pulmonary embolism Urosepsis Metabolic acidosis …

The “frequent exacerbator”

The “frequent exacerbator” ? Solér-Cataluna & Rodriguez-Roisin, J COPD 2010

Frequency and Severity of Exacerbations by GOLD stage Hurst et al. NEJM 2010.

Stability of the Exacerbator Phenotype 71% of Frequent Exacerbators in Year 1 and Year 2 were Frequent Exacerbators in Year 3 Hurst et al. NEJM 2010.

Stability of the Exacerbator Phenotype 74% of patients having no exacerbations in Years 1 and Year 2 had no exacerbations in Year 3

COPD Exacerbation: Differential Diagnoses Clinical presentation Pneumonia Pneumothorax Pleural effusion Aspiration Lung cancer Heart failure Atrial fibrillation Pulmonary embolism Urosepsis Metabolic acidosis …

Assessment GOLD 2014 update

Assessment GOLD 2014 update

Assessment GOLD 2014 update

Chest x-ray Leads to a change in therapy in 1:4, mostly due to new infiltrates – however, old studies !

Evaluation of sputum colour Sputum purulence correlates with presence of bacteria and favourable effect of antibiotics

Pulse oximetry and/or ABG Pulse oximetry should be used in everyone to ensure an initial saturation of 88-92% Arterial Blood Gases (ABGs) should be examined in everyone who is does not improve on initial treatment (within 30 minutes) If abnormal, ABGs should initially be repeated every 30-60 minutes to ensure improvement

Assessment GOLD 2014 update

Blood and Sputum Blood should be sampled for haematology, CRP, creatinine, urea and electrolytes Consider other tests (troponins, liver function, glucose, etc) depending on comorbidities Sputum should be sent for culture in patients to be started on antibiotics

Physical examination Chest examination But also: Evaluate alertness and confusion Signs of heart failure Exclude (the many) differential diagnoses Practice medicine !

Other tests ECG if irregular pulse or suspicion of myocardial ischaemia Echocardiography if heart failure or cor pulmonale is suspected Chest ultrasound if available, for screening for differential diagnoses

Exacerbation severity: Prognostic markers Older age Lower BMI Worse functional status 2 weeks before hospital admission Frequent prior admissions Worse APACHE III score Lower pH, higher PCO2 Lower PO2/fraction of inspired oxygen ratio History of congestive heart failure Lower serum albumin level Presence of cor pulmonale NOT PEF or FEV1

Exacerbation severity: Anthonisen Worsening dyspnoea, increase in sputum purulence, and increase in sputum volume. Type 1 exacerbations (severe): all three of the above symptoms. Type 2 exacerbations (moderate): two of the above symptoms. Type 3 exacerbations (mild): one of these symptoms, plus at least one of the following: an upper-respiratory-tract infection in the past 5 days, fever without other apparent cause, increased wheezing, increased cough, or increase in respiratory rate or heart rate by 20% above baseline.

Severity Grading Exacerbations Infectious Non-infectious Type 1 Anthonisen Type 2 Type 3

Severity Grading Exacerbations Infectious Non-infectious +/- Respiratory failure +/- Respiratory failure

CURB65 Confusion Urea > 7 mmol/l Respiratory Rate: ≥ 30 /minute Blood pressure: 90/60 mmHg 65 years

CURB65 & COPD exac Waikato Hospital, North Island, New Zealand Secondary/tertiary hospital (”teaching hospital”), uptake area 380,000. 1 year, 252 consecutive admissions Pneumonia excluded by chest x-ray Outcome: Inhospital mortality and mortality with 30 days of discharge Chang et al. Respirology 2011.

CURB65 & COPD exac Very severe COPD 37% Severe COPD 44% Moderate COPD 19% Died during admission 12/249 (4.8%) Died within 30 days of discharge 21/249 (8.4%) Chang et al. Respirology 2011.

CURB65 & COPD exac Adm. 30 days CURB65 0-1 1.0% 2.0% CURB65 score was predictive of 30 day mortality (crude OR 1.89, adjusted OR 1.71, p=0.013). Chang et al. Respirology 2011.

CURB65 & COPD exac pH (or PCO2) was also relatd to 30 days mortality while FEV1, BMI and PO2 had no impact on prognosis. Respiratory rate was the most predictive component of CURB65 ! Chang et al. Respirology 2011.

CURB65 Confusion Urea > 7 mmol/l Respiratory Rate: ≥ 30 /minute Blood pressure: 90/60 mmHg 65 years

Conclusions COPD exacerbations are currently poorly defined and very heterogeneous

Conclusions COPD exacerbations are currently poorly defined and very heterogeneous A significant number of differential diagnoses needs to be considered in the patient with COPD presenting with worsening of symptoms

Conclusions COPD exacerbations are currently poorly defined and very heterogeneous A significant number of differential diagnoses needs to be considered in the patient with COPD presenting with worsening of symptoms Proper evaluation of a COPD patient with an exacerbation should always include a chest x-ray, pulse oximetry and sputum culture if antibiotics are planned.

Conclusions COPD exacerbations are currently poorly defined and very heterogeneous A significant number of differential diagnoses needs to be considered in the patient with COPD presenting with worsening of symptoms Proper evaluation of a COPD patient with an exacerbation should always include a chest x-ray, pulse oximetry and sputum culture if antibiotics are planned. Arterial blood gases are key to evaluating respiratory failure

Conclusions COPD exacerbations are currently poorly defined and very heterogeneous A significant number of differential diagnoses needs to be considered in the patient with COPD presenting with worsening of symptoms Proper evaluation of a COPD patient with an exacerbation should always include a chest x-ray, pulse oximetry and sputum culture if antibiotics are planned. Arterial blood gases are key to evaluating respiratory failure Consider using CURB65