Management of Acute

Exacerbation of COPD &

Asthma
Dr. Shirshendu Dhar
M.D Emergency Medicine
AGMC & GBPH
 Status Asthmaticus
• Reversible airflow obstruction

• Triggers:- Viral infections / environmental triggers / NsAIDs / Beta

blockers / Emotional stress / Menstruation

• Mild :- PEF >70% predicted

• Moderate:- PEF 40 -69% predicted
• Severe:- PEF< 40% predicted
• Life Threatening:- PEF <25% Predicted
 Acute exacerbation of COPD
• H/o previous OAD/ COPD is essential, 1st time exacerbation attending in
emergency in age > 60 yrs are rare & to suspect other D/ds.

• Triggers:- GERD / Hypoxia / Cold Weather / Beta Blockers / Opioids /

Sedative –hypnotic agents

• Final pathway is to release of inflammatory mediators resulting in

bronchoconstriction , pulmonary vasoconstriction & mucous
hypersecretion

• Primarily a ventilation-perfusion mismatch whereas Asthma is due to

expiratory airflow limitation.
 Clinical features
• Hypoxemia:- abnormally low arterial oxygen tension

• Hypoxia:- Insufficient alveolar oxygen content or insufficient oxygen

delivery to the tissues

• Signs – Tachypnoea / Tachycardia / HTN / Cyanosis / Change in mental

status / Wheeze or crepitation / Silent Chest

• Alveolar hypoventilation creates arterial CO2 retention & respiratory

acidosis

• Pursed lip exhalation / Accessory muscle use / Pulsus Paradoxus

 Triggers
• Pneumonia
• Pneumothorax
• Pulmonary Embolism
• Acute Abdomen
• CCF
• Tuberculosis
• Metabolic Disturbances
Differential Diagnosis
 Investigations
• Pulse oximetry
• CBC / Electrolytes /Troponin
• Arterial Blood Gas Analysis – Look for pCO2 > 40 & pH<7.35
• ECG
• X-Ray Chest
• BNP /Nt-PRO BNP
• d-Dimer
• HRCT Thorax
Treatment
 Oxygen Therapy
• Keep the saturation between 88 – 92%

• May take 20 -30 mins from administration of oxygen to improvement

• Oxygen can cause Hypercapnia – V/Q mismatch can occur

• Avoid NRBM as much as possible

 Beta Adrenergic Agonist
• Short acting Beta 2 agonist are 1st line therapy eg; Salbutamol
• Nebulized aerosol every 20 mins may result in more improvement of
FEV1, 3 doses can be given
• Cardiac monitoring is required for patients with pre-existing arrythmia
• S/Es:- Tremor / Tachyarryhthmia / Anxiety / palpitation

• Anti-cholinergics:- Can be best combined with beta 2 agonist

• Ipratropium Bromide 0.5 mg
• S/Es :- Dry Mouth / Metallic Taste
 Corticosteroids
• Short course of 5-7 days of systemic steroids improve lung function
and hypoxemia and shortens recovery time.

• Dose :- Methylprednisolone – 2mg/kg loading f/b 0.5 – 1mg/kg/dose

every 6h
• Or Dexamethasone – 0.6 mg/kg/dose
NIV

BiPAP
Intubation
 Other Agents
• Inj. Magnesium Sulphate :- Act as a bronchodilator by inhibiting
smooth muscle contraction

• Dose:- 25 – 75 mg/kg/dose (Max 2 gms.), once

• Inj. Ketamine :- Sympathomimetic causes bronchodilatation

• Dose:- 1-2 mg/kg/dose, once

• Methylxanthines:- Theophylline & Aminophylline have been replaced

by much safer and more effective beta 2 agonists
• Dose:- 3-5 mg/kg IV over 30 mins (Aminophylline)
 Antibiotics
• Agents directed towards Strep. Pneumoniae , H. influenzae & M.
catarrhalis

• Provide pseudomonas coverage in patients with risk factors :-

Admission or antibiotic use in prior 3 months / Concomitant
Bronchiectasis / Prior culture

• Can be as short course as 3 days