1. COPD Exacerbations UCI Internal Medicine Mini-Lecture
Slideset updated 12/03/2012 by Michael Rochon-Duck

2. A Tale from the ED
“I have an easy admission for you. 70-year-old active smoker with severe COPD, progressively short of breath for three days. Frequent flyer, was here last month with the same complaints. He’s afebrile and tachypneic, with wheezes and poor air movement on both sides. His chest film shows bilateral pneumonia, so I started ceftriaxone and azithromycin. I gave him Solumedrol and nebs, and he looks a little better.”
Read the case to the audience. Ask them to think to themselves if there are any questions they’d like to ask the ED, tests to order, or management changes to make. We will return to the case at the end of the presentation.

3. Objectives
Formulate a differential and workup for an acutely dyspneic patient with COPD
Choose appropriate initial therapy and anticipate complications
Plan for discharge to reduce readmissions

4. Differential
“Not all that wheezes is asthma.” Or COPD. There are many disorders in the differential when you are called for a patient with “COPD exacerbation”.
(Image: source unknown)

5. Precipitants of Exacerbation
Acute bronchitis caused by:
Viruses
H. influenzae
Moraxella catarrhalis
Strep. pneumoniae
P. aeruginosa
Three other potentially fatal precipitants:
Heart failure
Pneumonia
Pulmonary embolism
After establishing COPD as the working diagnosis, it is important to consider what is causing the patient to decompensate.
A recent Serbian autopsy series (Chest 2009;136(2):  doi: /chest ) of patients admitted with COPD exacerbation identified heart failure (37%), pneumonia (28%), and pulmonary embolism (21%) as the most frequent causes of death within 24 hours of admission.

6. CXR #1: COPD Suddenly Got Worse
Say: “this patient with known COPD presents to the ED with dyspnea and is admitted with a diagnosis of COPD exacerbation. Looking at the CXR, what do you think is causing his symptoms.”
Arrow points to right-sided wedge infarct from pulmonary embolism. Source:

7. CXR #2: COPD Exacerbation & Edema
Say: “another patient with known COPD, admitted from the ED with COPD exacerbation and bilateral pneumonia. What do you think?”
CXR shows vascular congestion and bilateral pleural effusions from heart failure. Source:

8. Initial Interventions
Bronchodilators: Duoneb q4h scheduled around-the-clock.
Steroids: oral prednisone (after first dose IV Solumedrol in ED) if the patient can swallow. Check fingerstick blood sugars.
Oxygen: caution! Titrate to SaO % in advanced COPD to avoid hypercapneic respiratory failure
Antibiotics …
Read the slide

9. Choosing Antibiotics
Say: “Antibiotics are indicated for moderate or severe exacerbation” and run through the criteria in the left-hand box.
Next say: “the most important aspect of choosing antibiotics is to assess the patient’s risk for Pseudomonal infection” and discuss the right-hand box.
(Source: UpToDate: “Management of infections in acute exacerbations of chronic obstructive pulmonary disease”, topic updated 03/27/2012)

10. Consider Ventilation For …
Intractable dyspnea
Worsening hypercapnea
Refractory hypoxia
Read the slide. Say: “hypercapneic respiratory failure can be difficult to catch early because the patient gets sleepy and will not show the tachypnea and accessory muscle use that would alarm nurses.”
(Source:

11. Discharge Planning Optimize the patient’s inhaler regimen
Assess eligibility for home oxygen and pulmonary rehabilitation
Smoking cessation
Followup with PCP in days
Read slide. Can discuss different steroid tapers.

12. A Tale from the ED, Revisited
“I have an easy admission for you. 70-year-old active smoker with severe COPD, progressively short of breath for three days. Frequent flyer, was here last month with the same complaints. He’s afebrile and tachypneic, with wheezes and poor air movement on both sides. His chest film shows bilateral pneumonia, so I started ceftriaxone and azithromycin. I gave him Solumedrol and nebs, and he looks a little better.”
Questions for discussion:
Is this COPD?
If so, what caused the exacerbation?
Does the patient need antibiotics?
What initial treatments and studies do you want?

13. Summary
Think of heart failure, pneumonia, and pulmonary embolism in the differential of all cases of COPD exacerbation (although viral respiratory infections are more common)
Treat with bronchodilators, systemic glucocorticoids, oxygen, and antibiotics
Reevaluate diagnosis and consider ventilation for declining respiratory status
Read slide