Download presentation
Presentation is loading. Please wait.
Published byLaurel Warner Modified over 8 years ago
1
Management Of Exacerbations Of Chronic Obstructive Pulmonary Disease D.Anan Esmail Seminar Training Primary Care Asthma + COPD 03- 2015
2
defines an exacerbation of chronic obstructive pulmonary disease (COPD) as:
3
an acute event characterized by a worsening of the patient’s respiratory symptoms
4
Acute Exacerbations of COPD
6
Risk Factors For COPD Exacerbation
7
Advanced age
8
Productive cough
9
Chronic mucous Hypersecretion
10
Duration of COPD
11
History of antibiotic Therapy
12
COPD-related hospitalization within the previous year
13
Theophylline therapy
14
FEV1
15
Pulmonary Hypertension
16
Gastroesophageal reflux disease
17
Having one or more comorbidities: Ischemic heart disease Chronic heart failure Diabetes mellitus
18
Triggers
19
Respiratory infections Respiratory infections 70 % of COPD exacerbations Virus Virus Bacteria Bacteria Atypical ??? Atypical ???
20
30 % of COPD exacerbation 30 % of COPD exacerbation Environmental Pollution
21
30 % of COPD exacerbation 30 % of COPD exacerbation Pulmonary Embolism (25%)
22
30 % of COPD exacerbation 30 % of COPD exacerbation Unknown Etiology Heart disorders aspiration
23
clinical manifestations The clinical manifestations of exacerbations of COPD
29
Details about The past history of exacerbations
30
The past history of exacerbations should be ascertained NNNNumber of prior exacerbations CCCCourses of systemic Glucocorticoids EEEExacerbations requiring hospitalization or ventilatory support
31
Physical examination 31
32
Physical examination Physical examination Wheezing Tachypnea
33
Features of respiratory compromise Features of respiratory compromise Difficulty speaking due to respiratory effort Use of accessory respiratory muscles Paradoxical chest wall
34
Decreased mental status Decreased mental status Hypercapnia or Hypoxemia Asterixis Asterixis Increased Hypercapnia
35
physical findings that might suggest co-morbidity or alternate diagnosis
36
Fever Fever Hypotension Hypotension Bibasilar fine crackles Bibasilar fine crackles Peripheral edema Peripheral edema
37
Evaluation + Diagnosis Goals
38
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
39
Initial evaluation MMMMild exacerbation Clinical assessment Pulse oxygen saturation
40
Initial evaluation FFFFor patients who require emergency department care Pulse oxygen saturation A chest radiograph Laboratory studies Arterial blood gas analysis
41
Initial evaluation FFFFor patients who require emergency department care Electrocardiogram Cardiac Troponins Plasma brain natriuretic peptide (BNP) D-dimer
42
Sputum Gram stain and culture NNNNot useful MMMMay be helpful (Unsuccessful t tt treatment with Antibiotic)
43
Differential Diagnosis
44
Differential Diagnosis: Differential Diagnosis: Acute worsening of dyspnea heart failure pulmonary thromboembolism Pneumonia pneumothorax
45
Triage to Home or Hospital more than 80 percent of exacerbations of COPD can be managed on an outpatient
46
Criteria Criteria Management at Hospital 46
47
Inadequate response to outpatient or emergency department management Inadequate response to outpatient or emergency department management
48
Severe underlying COPD: Severe underlying COPD: FEV1 ≤50 FEV1 ≤50 percent of predicted
49
Insufficient Home support
50
History of frequent exacerbation
51
comorbidities High risk comorbidities including : Pneumonia Cardiac Arrhythmia Heart Failure Diabetes Mellitus Renal Failure Liver Failure
52
Dyspnea over baseline Dyspnea over baseline New onset resting dyspnea
53
Inability to eat or sleep due to symptoms Difficulty speaking due to respiratory effort
54
Use of accessory muscles Paradoxical chest wall
55
respiratory acidosis Acute or acute-on-chronic respiratory acidosis
56
New cyanosis or worsening hypoxemia
57
Changes in mental status Asterixis Asterixis
58
Intensive Home Care
59
Intensive Home Care Intensive Home Care Nurse visits Home oxygen Physical therapy
60
Intensive Home Care Intensive Home Care Cost savings Patient and family education Patient and family education
61
HOME MANAGEMENT OF COPD EXACERBATIONS
64
administered by a metered dose inhaler ( MDI ) with a spacer device
65
two inhalations by MDI every four to six hours
66
Patients who already have a nebulizer at home
67
administration of beta adrenergic agonists via nebulizer is helpful during COPD exacerbations
68
most studies have not supported a greater effect from nebulizer treatments over properly administered metered dose inhaler medication
69
may be combined with a short acting anticholinergic agent
70
combination therapy produces bronchodilation in excess of that achieved by either agent alone
73
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
78
The efficacy of inhaled glucocorticoids on the course of a COPD exacerbation has not been studied
79
should not be used as a substitute for systemic glucocorticoid therapy in COPD exacerbations
83
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
85
(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)
86
HOSPITAL MANAGEMENT OF COPD EXACERBATIONS
89
Beta adrenergic agonists MDI with spacer
90
Beta adrenergic agonists nebulization
91
Beta adrenergic agonists nebulization
92
Beta adrenergic agonists nebulization
93
Beta adrenergic agonists nebulization
94
Anticholinergic agents MDI with spacer
95
Anticholinergic agents nebulization
105
adverse effects hyperglycimia
106
upper gastrointestinal bleeding
107
psychiatric disorders
108
Antibiotic treatment of acute exacerbations of COPD (hospitalized)
109
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)
111
cigarette smoking cessation
112
nutritional support
113
continuation of ongoing supplemental oxygen therapy
114
administration of supplemental oxygen should target ppppulse oxygen saturation (SpO ) of 88 to 92 percent
115
administration of supplemental oxygen should target aaaarterial oxygen tension (PaO ) of approximately 60 to 70 mmHg
116
A high FiO is not required to correct the hypoxemia associated with most exacerbations of COPD
117
the risk of prompting worsened hypercapnia with excess supplemental oxygen
118
Hypercapnia is generally well tolerated in patients whose (PaCO ) is chronically elevated
121
Noninvasive ventilation ppppreferred method of ventilatory support iiiimproves numerous clinical outcomes
122
Invasive ventilation ppppatients fail NPPV ddddo not tolerate NPPV hhhhave contraindications to NPPV
129
Exacerbations of COPD are associated with increased mortality (3 to 9 %)
130
Factors Associated With Increased Mortality
133
smoking cessation
134
pulmonary rehabilitation
135
vaccination seasonal influenza and pneumococcus
136
proper use of medications (metered dose inhaler technique)
Similar presentations
© 2025 SlidePlayer.com. Inc.
All rights reserved.