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 GOLD 2017 COPD GOLD 2017 COPD GOLD 2017 COPD GOLD 2017 COPD  ACUTE EXACERBATION:  With / Without Respiratory Failure  Mild/Moderate/Severe Complicated or Uncomplicated (If moderate to severe. See Abx selection chart below) Severity of Acute COPD Exacerbation (MKSAP 16 PCCM Table 18)  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) Management and prevention of exacerbations of COPD BMJ 2014 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  Management and prevention of exacerbations of COPD BMJ 2014 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 Prevention of Acute Exacerbations of COPD American College of Chest Physicians and Canadian Thoracic Society Guideline Chest 2015 Additional Reference:   COPD GOLD 2017 Infection in the Pathogenesis and Course of Chronic Obstructive Pulmonary Disease NEJM 2008  Hypercapnia in COPD Up-to-Date Management and prevention of exacerbations of COPD BMJ 2014 COPD Management GOLD 2014 GOLD pocket guide for COPD management 2014 Immunologic Aspects of Chronic Obstructive Pulmonary Disease Diagnosis and Management of Stable COPD: ACP/ACCP/ATS/ERS  Guideline Annals 2011 COPD Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive Pulmonary Disease (REDUCE Trial) JAMA 2013 SCCOPE Trial Control Clin Trials 1998  Continuous prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD) reduces Exacerbation and HLQoL CDSR 2013