COPD / Exacerbation

COPD Stages: 
  • GOLD Stage1: Mild: FEV1 > 80 %
  • GOLD Stage 2: Moderate: FEV1 50 - 80 %
  • GOLD Stage 3 Severe: FEV1 30 - 50 %
  • GOLD Stage 4: Very Severe: FEV1 < 30 %
GOLD Risk Classification: Stage A/B/C/D

COPD  ACUTE EXACERBATION



  • With / Without Respiratory Failure 
  • Mild/Moderate/Severe
    • Complicated or Uncomplicated (If moderate to severe. See Abx selection chart below)
  •  2/2 URTI/CHF etc 
Infection in the Pathogenesis and Course of Chronic Obstructive Pulmonary Disease NEJM 2008
  • Management:
    • Outpatient / ER Treatment of Acute Exacerbation
      • Maintain Oxygenation: Titrate to maintain oxygen 9-94%
        • Venturi mask is preferred over NC
      • Obtain Serial Blood Gases (if appropriate) 
      • Bronchodilation
        • SABA (increase dose and frequency)
        • SABA with anticholigerics
        • Use of space driven breathing treatment
      • Oral or IV steroids
        • REDUCE Study (ER Based Study) JAMA 2013
          • 5 day vs 14 day prednisone (similar in VA hospital)
          • 40 mg of prednisone for 5 days
          • For frequent exacerbation, it is reasonable to do prolonged therapy
      • Antibiotics selection  
        • Abx 40 % reduction in readmission
        • Also caused decreased mortality
        • Doxycyclin: No different at 30 days; but symptomatic improvement at day 10
Infection in the Pathogenesis and Course of Chronic Obstructive Pulmonary Disease NEJM 2008
      • DVT prophylaxis 
      • Treat associated condition
      • Use of Inhalors
        • SABA and an anticholinergics bronchodilator
        • Especially in elderly
        • Hand-held MDI and Dry Powder Inhalor .... are often used with wrong technique
        • 80 % of patient at the time of discharge from hospital may not know how to use it properly
          • With good education, it can be brought down to 40%. Such teaching can take unto 45 min.
          • Dry Powder Inhalor is not useful if patient do not have good inspiratory effort 
            • Because of these two reasons, Nebulizer use if recommended
            • Following drugs have nebulizer formulary that can be used at home 
              • Inhaled Sterods
                • Budesonide 
              • LABA 
                • Formoterol 20 ug BID
                • Aformoteroal tartarte 15 mug BID 
    • When to consider hospital admission
      • Stage of COPD (Stage 3 or 4 are at greater risk)
      • Use of accessary muscles 
      • Response to initial therapy 
      • Adequate support at homes
      • Previous exacerbation
    • ICU admission risk factors
      • Use of respiratory accessary muscles
      • Paradoxical motion of the abdomen
      • Retration of the intercostal spaces (HOOVER SIGN; Lower Ribcages move in - due to diaphragm contraction pulling ribcages in)
    • Consider NIPPV for patients with increased work of breathing and respiratory acidosis (ph < 7.35)
  • Discharge Planning 
    • Nebulizers should not be used more frequently than 4 hrs
    • Able to walk across the room
    • Use of LABA 
    • Stable for about a day
      • Eat and Sleep without difficulty 
    • Understand the correct use of medication
    • Confidence that they can be managed safely at home
    • Smoking Cessation
    • Follow up plan should be clear
      • Going for follow-up has shown to decrease readmission 
    • Steroid Taper Instruction and monitoring 
    • Oxygen instruction
    • Medication Errors and drug affordability 
      • Roughly 50 % of patient with COPD were not prescribed maintenance brochodilator
      • 30 % of patients even did not have short acting rescue inhalers
  • Preventing Exacerbation
    • LABA : Decreases exacer
    • LAMA (long acting anti-muscarinic) : additional 18 - 20 % reduction of readmission
    • Triple Therapy (LAMA, LABA, Inhaled Steroids): Around 50 % reduction in exacerbation
    • Azithromycin (250 mg daily): Decreases COPD exacerbation by 30 % (NEJM 2011; Not yet adopted by Guideline due to drug-drug interaction; modest QT prolongation effect; risk for drug resistance) 
    • Roflumilast (PD4 Inhibitor): In a patient with Chronic Bronchitis, it decreases number of exacerbation
      • SE: Weight loss and anorexia
        • Useful for overweight, OSA, and COPD patient 

Management and prevention of exacerbations of COPD BMJ 2014
  • Mechanism of Acute Exacerbation 

Summary from Grand Rounds:
  • 2nd leading cause of disability; 3rd leading cause of 30-day readmission; 3rd leading cause of death (2nd of CV disease and cancer)
  • Exacerbation is a marker of poor prognosis
    • 27% 2nd re-exacerbation in 8 weeks
    • 34 % readmission in 3 months (UK); 22 % readmission in 30 days in US
    • 1-2 Exacerbation : <50 % survival in 5 years 
    • 3-4 Exacerbation: 25 % survival in 5 years
  • SGRQ Total score for COPD Exacerbation
    • Repeated exacerbation changes their baseline to newer level
  • GOLD stages can predict
    • Exacerbation
    • Hospitalization / yr
    • 3 - yr Mortality 
Role of Alpha-1-antitrypsin deficiency in COPD 
  • Emphysema is a main pulmonary manifestation
  • Liver Biopsy is not needed
  • Even cirrhotic patient do okay without transplant. 
  • Whom should be tested
    • All COPD and unexplained bronchiectasis regardless of smoking history
    • Nectrozing panniculitis
    • Unexplained Chronic Liver Disease
    • C-ANCA-Positive Vasculitis
    • Severe Asthma 
  • Is an acute phase reactant. So, do not test during acute illness


Additional Reference:  
Infection in the Pathogenesis and Course of Chronic Obstructive Pulmonary Disease NEJM 2008 
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