Acute exacerbation of COPD

Anum haider
House officer medical unit IV
CHK
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 Productive cough
parenchyma >3 months/yr x > 2 yrs

Pathophysiology Tissue destruction Small airways affected

Matched V/Q defects V/Q mismatch
Mild hypoxemia Severe hypoxemia,
Hypercapnia
PHT, Cor Pulmonale
Clinical Manifestation Severe constant dyspnea Intermittent dyspnea
Mild cough Copious sputum
production
Physical Examination “Pink Puffers” ‘Blue Bloaters”
Tachypneic, Cyanotic, obese,
Non-cyanotic, thin Edematous
Diminished breath Rhonchi & wheezes
sounds
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 AECOPD
Agent Dose Comments

Ipratropium MDI 4 – 8 puffs q 1 – 2 h 1st line therapy

Nebulizer 0.5mg q 1 -2 h

Albuterol MDI 4 – 8 puffs q 1 – 2 h Benefit if component

Nebulizer 2.5 - 5mg q 1 -2 h of reversible
bronchoconstriction
Agent Dose
Corticosteroids No consensus for optimal dose
and duration
(Cochrane 2009: CD001288)
Methylprednisolone 125mg IV q
6 h x 72 hrs
Then Prednisolone 60 mg PO qd
with 20mg taper q 3 -4 days
(NEJM 1999: 340:1941)
Prednisolone 40 mg x 10days
Or Prednisolone 30mg qd x 2
wks if pH > 7.26
(Lancet 1999: 354:456)
Comments
1. Treatment Failure
2. Hospital Stay
3. OPD Rx after ED
visit
4. Relapse
(NEJM 2003:348:2618)
1. FEV1
2. Complications
(Cochrane 2009: CD001288)
Agent Dose Comments

Antobiotics • Amoxicillin, TMP-SMX • H. flu, M. catarrhalis, S.pneumo

Doxycycline, are the most frequent precipitants
clarithrimycin,
Antipneumococcal FQ • Increased Dyspnea, sputum
etc, all reasonable production, purulence suggest
Bacterial Infection …therefore Abx
• No single ABx proven may improve outcome
(Annals 1987)
superior
• Incrreased PEF & chance of clinical
• Consider local flora resolution ( JAMA 1995)
•Avoid repeat courses of • Decreased subsequent
same Abx. exacerbation ( Thorax 2008)

• < 5 days course likely enough for

mild –moderate exacerbation
(Thorax 2008 ; JAMA 2010)
Agent Dose Comments

Oxygenation FiO2 to achieve PaO2 Watch for CO2

>55-60 or retention(due to V/Q
SaO2 90-93% 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 Ventilation
Non Invasive Positive Initiate “early” if:
Pressure Ventilation 1.Moderate/ severe dyspnea
2.Decreased pH
3.Increased PaCO2
4.RR > 25
Advantages of NIV ( Non Invasive Ventialtion):
1. 58% decrease in intubation
2. Decrease Length of Stay in Hospital by 3.2 days
3. 59% decrease in Mortality

Contra Indications for NIV ( Non Invasive Ventialtion):

1.Change mental status
2.Inability to cooperate or clear secretions
3.Upper GI Bleed
4.Heamodynamic instability
(NEJM 1995 ; 333:817 ; Annals 2003 ; 138:861 ; Cochrane 2004 ; CD004)
 Invasive ventilation
Endotracheal Intubation Consider if:

1. PaO2 <55-60
2.Increasing PaCO2
3.Decreasing pH
4.Increasing RR
5.Respiratory fatigue
6.Change in mental status,
7.Haemodynamic instability
Thank you