KI 2011
COPD ER
Definitions:
Chronic bronchitis: sputum production on most days in 3 months of the yr in 2 consecutive yrs
Emphysema: permanent enlargement and destruction of distal to terminal bronchiole
Abnormal tests of expiratory flow that is not really reversible
COPD exacerbation: Sustained worsening of patient’s condition, from the stable state and beyond
normal day-to-day variation, that is acute in onset and necessitates a change in regular medications in
a patient with underlying COPD (Aspen Lung Conference, 1999). Need one or more of the
following: increased sputum purulence, increase in sputum volume, or worsening of dyspnea
Common Infectious Etiologies of AECOPD Common Precipitants of AECOPD
1. H. influenzae 1. Pneumonia
2. M. catarrhalis 2. PE
3. S. pneumoniae 3. CHF
4. P. aeruginosa 4. Non-pulmonary infection
5. Atypical bacteria (Chlamydia, Mycoplasma, 5. Pneumothorax
Legionella) 6. Air pollutants
6. Respiratory viruses 7. Non-Compliance
Initial Assessment:
ABCs (watch for CO2 retention)
Signs of respiratory distress
Initial Tests: CBC, lytes, BUN/Cr, Ca/Mg/PO4, Albumin, CK, Troponin, ABG, CXR portable
History:
Quantify current dyspnea
ROS, R/O other etiologies for dyspnea
Get COPD hx:
o When diagnosed
o Baseline symptoms
o Prior PFTs
o Known CO2 retainer
o Home O2 need
o Previous episodes/exacerbations/hospitalizations/intubations
o Hx of pulm HTN, right heart failure
Triggers:
o Pneumonia/Infection
o PE
o CHF
o Pneumothorax
o Air pollutants
o Med non-compliance
KI 2011
PMHx, Meds, Allergies, SHx (Smoking, Alcohol, Drugs, Occupation), Vaccinations, FMHx
** JAMA RCE:
o COPD exacerbation: SOBOE (LR 2-3), cough (LR 1.8), sputum > ¼ cup (LR 4)
o COPD: Smoking > 70 pack years (LR 8); Smoking ever (LR 1.8)
o Smoking > 40 py; Laryngeal height < 4cm; Age > 45; self reported COPD
All 4 elements: LR 220
None of 4 elements: LR 0.13
Physical:
Vitals: fever, tachypnea, pulsus during acute exacerbation (> 15 has LR 3.7)
Mental status
Resp:
o signs of respiratory distress (cyanosis, nasal flaring, accessory muscle use, paradoxical
breathing)
o barrel chest, decreased cardiac dullness, decreased breath sounds, wheezing.
** JAMA RCE
o Reported Wheezing (LR 3.8) or Objective Wheezing (LR 36)
o Barrel chest (LR 10)
o Decreased cardiac dullness (LR 10)
o Match test (LR 7.1) – “I would NOT do this test as it is impractical and unsafe”
o Ronchi (LR 5.9)
o Hyperresonance (LR 4.8)
o Forced exp wheeze > 9sec @ trachea (LR 4.8), 6-9 sec (LR 2.7)
o Subxiphoid cardiac impulse (LR 4.6)
o Decreased breath sounds (LR 3.7)
o Pulsus (LR 3.7)
Labs:
CBC, lytes, BUN, creatinine
ABG especially in CO2 retainers
o Drive to breath due to hypoxia; remove hypoxia = no drive to breathe
o By displacing Nitrogen in alveoli with increasing FiO2, unable to blow off as much CO2
with each breath
o Look at HCO3 – determine acute vs chronic hypercapnia. If acute may need NIPPV
CXR – rule out infection, comment on hyperinflation. Routine use recommended.
No Role for PFT in acute setting; obtain when stable
CT Chest – 25% of AECOPD found to have sub-segmental PE (clinical implication unclear).
Consensus is if not responding to treatment or atypical features consider PE
CK, trop, ECG – look for MAT, other arrhythmias, ischemia
Acute Management:
KI 2011
Ventolin 2.5-5mg and Atrovent 0.25-0.5mg Nebs initially Q15min then Q4H with Q1H PRN
Prednisone 25-50mg OD or Methylpred 60-125mg Q8H for 10-14 days, no need to taper if < 14 days.
o Reduces LOS and treatment failure; no mortality benefit (Multiple RCT)
o Inhaled corticosteroids no role in AECOPD
Antibiotics if 2 of 3: increased sputum, increased sputum purulence, increased dyspnea
o 3 Gen cephalosporin, Macrolide, Fluorquinolone, Clavulin
o Decrease recurrence and symptom duration (Multiple RCT’s)
Oxygen (target 88-92% if CO2 retainer) – do not let hypercarbia deter from using O2. Venturi mask
safer than NP (allows for greater control of FiO2 delivered). Check ABG half hour after O2 started.
NIPPV (BiPAP) to avoid intubation
o Decreases LOS, Mortality and Intubation need – RCT’s and Cochrane meta-analysis
No role for mucolytics, chest physio, methylxanthines in acute exacerbation
Pulmonary rehab post exacerbation (improves QOL)
Indications for hospital admission: (Global Initiative for COPD):
Marked increase symptom severity
Severe COPD at baseline
Bronchodilators in AECOPD
New physical signs (cyanosis, edema)
Failure to respond to ER mgmt Short-acting 2-agonist and
anticholinergic agents give similar
New arrhythmias
improvements in FEV1 (but
Dx uncertain anticholinergic agents have less
Older age side-effects)
Insufficent home support Use of parenteral bronchodilators
or methylxanthines is not
Risk of relapse with (if d/c home from ER): supported by evidence
Delivery via MDI with
Prior ER visit < 1 wk
Higher doses of MDI
Home O2
Prior relapse
Steroids/abx at time of dc from ER
Indications for BIPAP (Reduces intubation) Contraindications for BIPAP
Mod-Sev Dyspnea Resp or Cardiac Instability
Respiratory Acidosis (pH < 7.35) High risk aspiration or copious secreations
Hypercapnea (PaCO2 > 45mmHg) Diminshed LOC or Uncooperative
RR > 25 Facial surgery, trauma, burns or obesity
Discharge Issues:
B2-agonist max frequency q 4h, Exercise tolerance back to baseline
Med optimization:
o long acting anticholinergic (tiotropium), LABA (salmeterol)
o inhaled corticosteroids – Decreases frequency of exacerbation in mod/severe disease.
(rinse mouth after use, same side effects as oral steroids if using high dose inhaled)
Education (‘written plan of action’), puffer use, trigger avoidance
FU arranged
Vaccination
KI 2011
Smoking cessation (Mortality Benefit)
Home O2 (Mortality Benefit): SaO2 < 88%, PaO2 <=55 mmHg or PaO2<= 59 mmHg with cor
pulmonale, clinical right heart failure or hematocrit > 56%
