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Acute exacerbation of COPDAnum haiderHouse officer medical unit IVCHK
COPD Definition
• Progressive airflow limitation caused by airway and parenchymal inflammation
•It includes chronic bronchitis and emphyesema
Emphysema Vs Chronic Bronchitis
Emphysema Chronic bronchitis
Definition Dilation/destruction of parenchyma
Productive cough >3 months/yr x > 2 yrs
Pathophysiology Tissue destruction Matched V/Q defectsMild hypoxemia
Small airways affectedV/Q mismatchSevere hypoxemia, HypercapniaPHT, Cor Pulmonale
Clinical Manifestation Severe constant dyspneaMild cough
Intermittent dyspneaCopious sputum production
Physical Examination “Pink Puffers”Tachypneic, Non-cyanotic, thinDiminished breath sounds
‘Blue Bloaters”Cyanotic, obese, EdematousRhonchi & wheezes
Exacerbation
• An exacerbation of COPD should be defined as: “a sustained worsening of the patient’s condition,
from stable state and beyond normal day to-day variations, that
is acute in onset and necessitates a change in regular medication in a patient with underlying COPD”
• Subsequently, the definition was amended to include exacerbations that did not necessitate a change in treatment
Rodriguez-Roisin R. Toward a consensus definition for COPD exacerbations. Chest 2000; 117(5 Suppl 2):398S-401S
Evaluation of the patients with AECOPD• PMH: COPD severity, exacerbations, co-morbidities
• Physical exam: VS, hemodynamic status, mental
status, accessory muscles
• Tests: Spirometry, O2 saturation, CXR,
blood tests, ECG and sputum culture
Principles of Management of AECOPD•Treat Infections/ Avoid Triggers
▫Antibiotics
•Optimize Gas Exchange▫Optimize bronchodilation▫Steroid therapy▫Oxygen as required▫Consider Non Invasive / Invasive
ventilation
Treatment of AECOPDAgent Dose Comments
Ipratropium MDI 4 – 8 puffs q 1 – 2 hNebulizer 0.5mg q 1 -2 h
1st line therapy
Albuterol MDI 4 – 8 puffs q 1 – 2 hNebulizer 2.5 - 5mg q 1 -2 h
Benefit if component of reversible bronchoconstriction
Agent Dose CommentsCorticosteroids
No consensus for optimal dose and duration(Cochrane 2009: CD001288)
Methylprednisolone 125mg IV q 6 h x 72 hrsThen Prednisolone 60 mg PO qd with 20mg taper q 3 -4 days (NEJM 1999: 340:1941)
Prednisolone 40 mg x 10daysOr Prednisolone 30mg qd x 2 wks if pH > 7.26 (Lancet 1999: 354:456)
1. Treatment Failure
2. Hospital Stay3. OPD Rx after ED
visit4. Relapse
(NEJM 2003:348:2618)
1. FEV12. Complications
(Cochrane 2009: CD001288)
Agent Dose Comments
Antobiotics • Amoxicillin, TMP-SMXDoxycycline, clarithrimycin, Antipneumococcal FQ etc, all reasonable
• No single ABx proven superior
• Consider local flora
•Avoid repeat courses of same Abx.
• H. flu, M. catarrhalis, S.pneumoare the most frequent precipitants
• Increased Dyspnea, sputum production, purulence suggest Bacterial Infection …therefore Abx may improve outcome(Annals 1987)
• Incrreased PEF & chance of clinical resolution ( JAMA 1995)
• Decreased subsequent exacerbation ( Thorax 2008)
• < 5 days course likely enough for mild –moderate exacerbation(Thorax 2008 ; JAMA 2010)
Agent Dose Comments
Oxygenation FiO2 to achieve PaO2 >55-60 orSaO2 90-93%
Watch for CO2 retention(due to V/Q mismatch, loss of hypoxeamic resp drive, haldane effect) but must maintain oxygenation
Other Measures Mucolytics not supported by data(Chest 2001 : 119: 1190)
Non Invasive VentilationNon Invasive Positive Pressure Ventilation
Initiate “early” if:1.Moderate/ severe dyspnea2.Decreased pH3.Increased PaCO24.RR > 25
Advantages of NIV ( Non Invasive Ventialtion):1. 58% decrease in intubation2. Decrease Length of Stay in Hospital by 3.2 days3. 59% decrease in Mortality
Contra Indications for NIV ( Non Invasive Ventialtion):1.Change mental status2.Inability to cooperate or clear secretions3.Upper GI Bleed4.Heamodynamic instability(NEJM 1995 ; 333:817 ; Annals 2003 ; 138:861 ; Cochrane 2004 ; CD004)
Invasive ventilation
Endotracheal Intubation
Consider if:
1. PaO2 <55-602.Increasing PaCO23.Decreasing pH4.Increasing RR5.Respiratory fatigue6.Change in mental status, 7.Haemodynamic instability
Thank you