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)
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
- 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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