Exacerbation of COPD

Tamsil Syafiuddin
2005
AECB
Outline of discussion
Diagosis of COPD
Diagnosis acute exacerbation of COPD
Impact of acute exacerbation COPD
Treatment of acute exaerbation COPD
Definition of Chronic Obstructive
Pulmonary Disease (COPD)

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.
R. A. Pauwels et al. AJCCM 2001; 163:1256-76
NHLBI/WHO Global Initiative (GOLD)
DIAGNOSIS OF COPD

A diagnosis of COPD should be considered
in any patient who has symptoms of cough,
sputum production, or dyspnea, and/or a
history of exposure to risk factors for the
disease.
The diagnosis is confirmed by spirometrie
R. A. Pauwels et al. AJCCM 2001; 163:1256-76
NHLBI/WHO Global Initiative (GOLD)
How to Diagnosis/
How to thing
Data:
Analysis
Planning
Lung/COPD ?
Heart/LVF?


Cough ?
Dyspnoe ?
Wheezing ?
Age?

Risk factors?
Radiologic examinations?
Spirometri
PEFR
Data

Pathogenic bacteria are found in 50 - 80%
of patients experiencing AECB.
AECB
R. A. Pauwels et al. AJCCM 2001; 163:1256-76
NHLBI/WHO Global Initiative (GOLD)
Importance of Exacerbations
1
Burrows. NEJM 1969; 280:397-404
2
Miravitlles. Respir Med 1999; 93:173-179

Exacerbations are the most common
observable cause of death in
prospective studies1
COPD patients suffered mean of 2
AE/year, with a high drug use; 10%
required admission2
Causative Pathogens in LRTI I
H. influenzae
S. pneumoniae
Branhamella catarrhalis
Mycoplasma/Chlamydia?

Purulent Bronchitis
Advanced Clinical Disease
Klebsiella spp.
Proteus spp.
Enterobacter spp.
P. aeruginosa

Infective Exacerbations
of Chronic Bronchitis
Relation between
Bacteriologic Etiology
and Lung Function
Jrg Eller, MD; Anja Ede, MD; Tom Schaberg, PhD;
Michael S. Niedermann, MD, FCCP; Harald Mauch, MD; and Hartmut Lode, MD
Chest 1998;113:1542-1548

Study objective: Possible relationship between
functional respirat. impairment
(FEV1) and pathogens in AECB

Setting: 6 pneumology units in Spain

Patients: 91 with AECB


Interventions: Quantitative sputum cultures
(106 pathogens, <10 squ. cells,
>25 granuloc.)

Relationship Between Bacterial Flora in Sputum
and Functional Impairment in Patients With
Acute Exacerbations of COPD
Miravitlles M et al. Chest 1999;116:40
Results: FEV1 <50%, was associated with a high risk
of P. aeruginosa or H. influenzae isolation
(OR; 6.62)



Conclusions: Pat. with the greatest degree of functional
impairment presented a higher probability
of P. aeruginosa or H. influenzae

Relationship Between Bacterial Flora in
Sputum and Functional Impairment in
Patients With Acute Exacerbations of
COPD
Miravitlles M et al. Chest 1999;116:40
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Changes in Bronchial
Inflammation during acute
exacerbations of chronic
bronchitis


S. Gompertz, C. OBrien, D.L. Bayley, S.L.
Hill R.A. Stockley

Europ Respir J 2001; 17:1112-1119
Inflammatory mediators at
presentation
Mucoid Purulent
bronchitics bronchitics

MPO units x mL-1 0.48 (0.37-0.69) 0.62 (0.42-1.50)+
NE nM 0.0 (0.0-0.0) 7.6 (0.8-13.8)***
IL8 nM 2.4 (07-4.7) 5.5 (2.8-12.6)***
LTB4 nM 3.4 (1.1-11.3) 7.1 (4.6-15.2)+
Albumin ratio % 0.4 (0.3-0.9) 1.4 (0.7)-3.1)***


Data are presented as median (interquartile range). MPO:
myeloperoxidase; NE: neutrophil elastase; IL-8 interleukin-8; LTB4:
leukotriene B4; +: p < 0.025;***: p < 0.001

The Vicious Circle of Respiratory Decline in Chronic Bronchitis
Breathing in COPD
Normal Alveolar Emptying
Alveolar Emptying in COPD
In COPD, airflow is limited because alveoli lose their elasticity,
supportive structures are lost, and small airways are narrowed
Breathing in COPD
Air Trapping
Occurs in patients with COPD
Results in an increase in the work of breathing
Places respiratory muscles at a mechanical disadvantage
Contributes to the sensation of breathlessness (dyspnea)
Normal Hyperinflation
Images courtesy of Denis ODonnell, Queens University, Kingston, Canada
Chronic Obstructive Pulmonary Disease (COPD)

Treatment
The 3 major goals of the comprehensive
treatment of COPD :

Lessen airflow limitation


Prevent and treat secondary medical complications
(eg, hypoxemia, infection)


Decrease respiratory symptoms and improve QoL
The goal of the treatment of COPD
to improve daily living and quality of life by

preventing symptoms and exacerbations
optimal lung function
Smoking cessation is the most important thing
to improve COPD symptoms
preventing symptoms and exacerbations
Acute exacerbation of COPD is one of the
major reasons for hospital admission in the
United States.
Bronchodilators
Inhaled beta2 agonists are the treatment of choice for
acute exacerbations of COPD
Usually delivered via a nebulizer
Adding Xanthin to the combination of
bronchodilators can be beneficial
Inhaled anticholinergic agent is also usually added.

Corticosteroids are used if do not improve sufficiently after
trying other drugs or who develop an exacerbation.
Sharma S, Graham L, Pulmonary and Critical Care Medicine, University of Manitoba, Lung and Airway, 2004

Hospitalized :

develop severe respiratory dysfunction
serious respiratory diseases (eg, pneumonia, acute
bronchitis)



The purpose of hospitalization is to treat symptoms and
to prevent further deterioration/lung functions.
This therapy is most beneficial for people
whose exacerbations are characterized by at
least 2 of the following (ie, Winnipeg criteria):

increased shortness of breath,
increased sputum production,
and increased sputum purulence.
Antibiotics
American Thoracic Society
Proposed Classification of
AECBs
Type Core organisms Features

Uncomplicated H. influenzae, S. pneumoniae <4 exacerbations per year
M. catarrhalis, H. parainfluenzae No comorbidity

Complicated Increased risk of drug-resistant <64 years old
S. pneumoniae and Gram- <4 exacerbations per year
negative bacilli Comorbidity
Cost of failure greater

Suppurative Risk of P. aeruginosa Chronic steroid use
FEV1 <35% of predicted


American Thoracic Society. Am J Respir Crit Care Med 2001,
Winnipeg criteria for AECB
Typ I Typ II Typ III*
Dyspnoe

Sputum purulent

Sputum volume

Anthonisen et al. Ann Intern Med 1987
American Thoracic Society
Proposed Treatment
Guidelines for AECBs
Type Agent

Uncomplicated New macrolide (azithromycin,
clarithromycin), cephalosporin
(cefuroxime, cefpodoxime,
cefprozil) doxycycline

Complicated Fluoroquinolone,
amoxicillin/claculanic

Suppurative Ciprofloxacin


American Thoracic Society. Am J Respir Crit Care Med 2001,
General guidelines that are used in determining the ideal
time to begin ventilatory support are as follows:

progressive worsening of respiratory acidosis and/or an
altered mental state.

significant hypoxemia despite supplemental oxygen.
Assisted ventilation/ICU
Admitted to the intensive care unit (ICU)
if require the following symptoms:

Confusion

Lethargy

Respiratory muscle fatigue

Worsening hypoxemia (not enough oxygen in the
blood)

Respiratory acidosis (retention of carbon dioxide in
the blood)
How to Diagnosis/
How to thing
Data:
Analysis
Planning
Lung/COPD ?
Heart/LVF?


Cough ?
Dyspnoe ?
Wheezing ?
Age?

Risk factors?
Radiologic examinations?
Spirometri
PEFR
Data
Missed diagnosis COPD