COPD- Burden of Disease

Initial management of an acute

exacerbation

18/Oct/2005

Dr. David P. Breen

Definition
COPD is a disease state characterized by
airflow limitation that is not fully reversible.
The airflow limitation is usually both
progressive and associated with an
abnormal inflammatory response of the
lungs to noxious particles or gases.
Symptoms, functional abnormalities, and
complications of COPD can all be explained on the basis
on this underlying inflammation and the resulting pathology
www.goldcopd.com

18/Oct/2005

Dr. David P. Breen

18/Oct/2005

Dr. David P. Breen

Lung Function decline

18/Oct/2005

Dr. David P. Breen

Spirometry is the GOLD Standard for the

diagnosis of COPD

18/Oct/2005

Dr. David P. Breen

Exacerbations of COPD
Acute exacerbations of COPD present as a
worsening of a previously stable condition
Important symptoms include
Increased sputum purulence
Increased sputum volume
Increased dyspnoea
Increased wheeze
Chest tightness
Fluid retention
18/Oct/2005

Dr. David P. Breen

Exacerbation
A new respiratory event or complication
superimposed upon established disease
New events
Pneumonia
Pneumothorax
LVF/ Pulmonary Oedema
Lung Cancer
Upper airway Obstruction
18/Oct/2005

Dr. David P. Breen

Acute exacerbation of COPD

1.

Airflow Obstruction
a)
b)
c)

2.

Dyspnoea
Wheeze
Chest tightness

Respiratory Failure
a)

Hypoxia
i.

b)

Hypercapnia
i.

3.

Warm hands, dilated veins, tachycardia, bounding pulse, flapping

tremor, chemosis, papilloedema, confusion, agitation

Cor pulmonale
a)

4.

Dyspnoea, tachypnoea, cyanosis, confusion

Loud P2, RV (L Parasternal Heave), raised JVP, peripheral oedema

Infection
a)

Increased sputum volume/purulence, fever, raised WCC

18/Oct/2005

Dr. David P. Breen

Investigations
Full Blood Count
Renal Profile
Arterial Blood Gas
Chest X-Ray
Pneumonia
Bronchiectasis
Pneumothorax
LVF

Spirometry prior to discharge

18/Oct/2005

Dr. David P. Breen

TREATMENT
Airflow Obstruction
Bronchodilators- Salbutamol, ipratropium
Corticosteroids

Respiratory Failure
See later

Cor Pulmonale
Daily weight, accurate input/output chart
Diuretics
Monitor renal function carefully

Infection
Antibiotics
physiotherapy

18/Oct/2005

Dr. David P. Breen

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Acute Respiratory Failure

ABG Normal PO2

10.5-12.5 KPa

Normal PCO2 4.5- 6.0 KPa

Type 1 Failure PO2

PCO2 N or

Type 2 Failure PO2

PCO2

18/Oct/2005

Dr. David P. Breen

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Normally we breath mainly in response to

raised PCO2
In Type 1 failure, this response is
maintained
High O2 is safe
In COPD, there is usually chronic CO2
retention
The brain gets tired of responding to the
raised PCO2
The main stimulus to breathe is then a
decreased PO2
18/Oct/2005

Dr. David P. Breen

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So, How much O2 should we give?

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Dr. David P. Breen

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In Type 2 Respiratory Failure

PO2 Hypoxic Drive

SaO2

7.5maintained

90%

<7 maintained

<90%

5.0maintained

<70%

dangerously low

7.5maintained

90%

adequate/good

>8 decreasing

>90%

good

10 very poor

95%

good

18/Oct/2005

O2 Delivery

adequate/good
poor

Dr. David P. Breen

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Therefore
Look first at PO2
Maintain PO2 around 7.5-8.0 (SaO2 90-92%)
Do not be afraid to give enough O2 to achieve this
Do not push PO2 above this very little extra delivery
of O2 to all tissues and loss of hypoxic drive now
becomes a problem

Monitor PCO2 and clinical condition

If PCO2 elevated or clinical condition poor
Consider N.I.V
Start with 24-28% and titrate upwards
Monitor Sats and ABG
18/Oct/2005

Dr. David P. Breen

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But remember :
Cigarettes are the main
culprit!!
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Dr. David P. Breen

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Dr. David P. Breen

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Non-Invasive Ventilation:

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Dr. David P. Breen

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Selection Criteria
Respiratory distress
Moderate to severe dyspnoea
Accessory muscle use
Paradoxical movement of abdominal
muscles

pH<7.35 with PaCO2>6kPa

Respiratory rate >25breaths/min
At least two criteria should be present

18/Oct/2005

Dr. David P. Breen

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Exclusion Criteria (Absolute)

Respiratory Arrest situation
Cardiorespiratory instability
Hypotension
Arrhythmia
Myocardial infarction

Uncooperative patient
Recent facial, oesophageal or gastric
surgery
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Dr. David P. Breen

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Exclusion Criteria (Absolute)

Craniofacial trauma or burns
High aspiration risk
Absent gag reflex
Inability to manage secretions

Fixed anatomical abnormalities of

the nasopharynx
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Dr. David P. Breen

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Relative Contraindications
Extreme anxiety
Massive obesity
Copious secretions
Adult Respiratory distress
syndrome-ARDS
American Respiratory Care
18/Oct/2005 Foundation.
Dr. David P. Breen

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Complications
Local damage related to mask/strap pressure
Gastric distension
Eye irritation
Sinus pain
Nasal congestion
Barotrauma
Air leaks
Adverse Haemodynamic effects rare
Nosocomial pneumonia rare

18/Oct/2005

Dr. David P. Breen

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Predicting Poor Outcome

Higher APACHE II score (15 Vs 20)
Acute physiological and chronic health
evaluation

Lower pH in those who failed

7.22 Vs 7.28 Ambrosino et al

Lower FVC
Presence of pneumonia
Soo Hoo et al Crit Care Med 1994
18/Oct/2005

Dr. David P. Breen

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Suggested settings
NIPPY
Aim for IPAP of 20
Normal breathing= 1sec insp, 2sec exp,will
probably need to be shortened
Set trigger low eg. 0.5 = less effort required by
patient

BIPAP
Suggest starting with IPAP 10 or 12
May increase to 20 or higher
Suggest starting with EPAP of 4
Never use less than EPAP of 4 = CO2
rebreathing
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Dr. David
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May increase
EPAPP.toBreen
6, seldom require higher

Effectiveness

Significant decrease in mortality

(9% Vs 29%) Brochard et al NEJM 1995

18/Oct/2005

Dr. David P. Breen

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Effectiveness
Significant decrease in ICU length of stay
(13 Vs 32 days) Wysocki et al Chest 1995
Significant decrease in hospital length of
stay (23 Vs 35 days) Brochard et al NEJM
1995

18/Oct/2005

Dr. David P. Breen

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