1. Management Of Exacerbations Of Chronic Obstructive Pulmonary Disease D.Anan Esmail Seminar Training Primary Care Asthma + COPD 03- 2015

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

3. 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

4. HOME MANAGEMENT OF COPD EXACERBATIONS

5. management of COPD EXACERBATIONS bronchodilatorglucocorticoidsAntibiotics

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

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

8. two inhalations by MDI every four to six hours

9. Patients who already have a nebulizer at home

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

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

12. may be combined with a short acting anticholinergic agent

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

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

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

16. 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

17. management of COPD EXACERBATIONS bronchodilatorglucocorticoidsAntibiotics

18. small but beneficial Effect in outpatients exacerbations of COPD

19. prednisone 40 mg per day five days

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

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

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

23. management of COPD EXACERBATIONS bronchodilatorglucocorticoidsAntibiotics

24. guidelines recommend antibiotic therapy only for: patients have bacterial infection

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

26. 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

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

28. (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)

29. HOSPITAL MANAGEMENT OF COPD EXACERBATIONS

30. 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

31. 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

32. management of COPD EXACERBATIONS bronchodilatorglucocorticoidsAntibiotics

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

34. 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

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

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

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

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

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

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

41. Anticholinergic agents Ipratropium 500 mcg every four hours as needed nebulization

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

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

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

45. Dose prednisone 40 mg once daily

46. Dose methylprednisolone 60 to 125 mg two to four times daily

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

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

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

50. longer durationNo additional benefit more glucocorticoid- related side effects

51. adverse effects hyperglycimia

52. upper gastrointestinal bleeding

53. psychiatric disorders

54. Antibiotic treatment of acute exacerbations of COPD (hospitalized)

55. 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)

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

57. cigarette smoking cessation

58. nutritional support

59. continuation of ongoing supplemental oxygen therapy

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

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

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

63. the risk of prompting worsened hypercapnia with excess supplemental oxygen

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

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

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

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

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

69. 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:

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

71. Mucoactive agents mechanical techniques to augment sputum clearance

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

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

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

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

76. Factors Associated With Increased Mortality

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

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

79. smoking cessation

80. pulmonary rehabilitation

81. vaccination seasonal influenza and pneumococcus

82. proper use of medications (metered dose inhaler technique)

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

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