Treatment and Protocol of Acute Exacerbation of COPD

CME/Internal Medicine
Dpt, FPRRH

By Dr. Dalton K.M., Specialist in Internal Medicine & Lecturer

Date: 25/06/2024
Definitions
• Event characterized by dyspnea and/or cough and sputum that worsen
over < 14 days.
• Exacerbations of COPD are often associated with increased local and
systemic inflammation caused by airway infection, pollution, or other
insults to the lungs.
One or more of the following cardinal symptoms:
●Cough increases in frequency and severity
●Sputum production increases in volume and/or changes character
●Dyspnea increases
Definitions
• Chest tightness and discomfort,
• sleep disturbance,
• anxiety, and fatigue during exacerbations.
• Constitutional symptoms, a decrease in pulmonary function, and
tachypnea are variably present during an exacerbation
• In the presence of severe underlying airflow obstruction, an
exacerbation can cause respiratory failure and death.
Epidemiology in Uganda
Pathophysiology
• The final common pathway for an exacerbation, regardless of the
initial stimulus,= an inflammatory response characterized by airway
inflammation, mucus hypersecretion, and airway smooth muscle
constriction that combine to produce the classic triad of dyspnea,
cough, and sputum.
• Viral or bacterial pathogens can be implicated in 75 to 80% of acute
exacerbations of COPD.
Pathophysiology/risk factors
• Implicated viruses are rhinovirus, influenza , parainfluenza, respiratory
syncytial virus,coronaviruses, and adenovirus.
• Many patients with chronic bronchitis are chronically colonized with
bacterial species that have also been implicated in exacerbations, notably
• Streptococcus pneumoniae,
• Haemophilus influenza,
• Moraxella catarrhalis
• and, to a lesser extent, Pseudomonas aeruginosa.
• Other environmental exposures:particularly in the 20 to 25% for which no
pathogen or infectious exposure is identified.
Clinical manifestations and diagnosis
• Because acute exacerbations of COPD are often accompanied by fever
or occur after contact with other sick individuals,
• the symptoms are generally similar to those of acute bronchitis .
• The patient should be questioned about acute symptoms, prior history
of exacerbations, presence of comorbidities such as heart disease, any
infectious exposures, baseline functional status, past response to
therapy (if any), and the presence of somnolence or confusion that
may suggest hypercarbia.
CM & DX
• The physical examination : assessment of vital signs, signs of
respiratory distress (i.e., use of accessory muscles, intercostal
retractions, tachypnea, and the inability to speak in complete
sentences).
• The cardiac examination should assess the presence of tachycardia,
irregular rhythm, and signs of left or right heart failure, including
bibasilar rales, an elevated jugular venous pressure, hepatic
congestion, peripheral edema, and an S3 gallop.
• Abnormal mental status should raise concerns for hypercarbia.
…
• CBC
• ABG
• Oxymetry
• BNP
• CXR
• Non Contrast chest CT
• Contrast-enhanced chest CT
• Sputum culture,…
Classification
• Currently, exacerbations are classified after the event has occurred as:
►Mild (treated with short acting bronchodilators only, SABDs)
►Moderate (treated with SABDs and oral corticosteroids ± antibiotics)
or
►Severe (patient requires hospitalization or visits the emergency
room).
Severe exacerbations may also be associated with acute respiratory
failure.
Treatment
• The goals of treatment for COPD exacerbations : to minimize the
negative impact of the current exacerbation and prevent the
development of subsequent events.
• Depending on the severity of an exacerbation and/or the severity of the
underlying disease, an exacerbation can be managed in either the
outpatient or inpatient setting.
• More than 80% of exacerbations are managed on an outpatient basis
with pharmacological therapies including oxygen supplementation ,
bronchodilators, corticosteroids,antibiotics and sometimes ventilator
assistance with noninvasive ventilation or intubation and ventilation.
RX
• Hospitalized patients
• the severity of the exacerbation should be based on the patient’s
clinical signs and recommend the following classification
• No respiratory failure: Respiratory rate: ≤ 24 breaths per minute;
heart rate < 95 beats per minute, no use of accessory respiratory
muscles; no changes in mental status; hypoxemia improved with
supplemental oxygen given via Venturi mask 24-35% inspired oxygen
(FiO2); no increase in PaCO2.
RX
• Acute respiratory failure – non-life-threatening: Respiratory rate: >
24 breaths per minute; using accessory respiratory muscles; no change
in mental status; hypoxemia improved with supplemental oxygen via
Venturi mask > 35% FiO2; hypercarbia i.e., PaCO2 increased
compared with baseline or elevated 50-60 mmHg.
RX
• Acute respiratory failure – life-threatening: Respiratory rate: > 24
breaths per minute; using accessory respiratory muscles; acute
changes in mental status; hypoxemia not improved with supplemental
oxygen via Venturi mask or requiring FiO2 > 40%; hypercarbia i.e.,
PaCO2 increased compared with baseline or elevated > 60 mmHg or
the presence of acidosis (pH ≤ 7.25).
Pharmacotherapy

Inhaled beta agonist: Albuterol 2.5 mg diluted to 3 mL via nebulizer or 4 to 8 inhalations from MDI every hour

Inhaled anticholinergic agent: Ipratropium 500 micrograms via nebulizer or 4 to 8 inhalations from MDI every four hours

Intravenous glucocorticoid (eg, methylprednisolone 60 mg to 125 mg IV, repeat every 6 to 12 hours)

Antibiotic therapy*: Appropriate for majority of severe COPD exacerbations; select antibiotic based on likelihood of particular pathogens
(eg, Pseudomonas risk factors¶, prior sputum cultures, local patterns of resistance)

•No Pseudomonas risk factor(s)¶: Ceftriaxone 1 to 2 grams IV, OR levofloxacin 750 mg IV or orally, OR moxifloxacin 400 mg IV or orally

•Pseudomonas risk factor(s)¶: Levofloxacin 750 mg IV or orally, OR piperacillin-tazobactam 4.5 grams IV, OR cefepime 1 to 2 grams
IV, OR ceftazidime 1 to 2 grams IV

Antiviral therapy (influenza suspected)*: Oseltamivir 75 mg orally every 12 hours OR peramivir 600 mg IV once (for patients unable to
take oral medication)
Monitoring

Perform continual monitoring of oxygen saturation, blood pressure, heart rate, respiratory rate

Close monitoring of respiratory status

Continuous ECG monitoring
Monitor blood glucose
Disposition
Criteria for ICU admission include:

•Patients with high-risk comorbidities (pneumonia, cardiac arrhythmia, heart failure, diabetes mellitus, renal failure, liver
failure)

•Continued need for NPPV or invasive ventilation

•Hemodynamic instability

•Need for frequent nebulizer treatments or monitoring

Prognosis
• Exacerbations are independent determinants of health-related quality
of life and are associated with an increase in short-term mortality
(about 10% for patients hospitalized with an exacerbation) and longer-
term mortality (43% at 1 year, 49% at 2 years).
• Resting hypoxemia, weight loss, a low body mass index, more severe
dyspnea, and low exercise tolerance are independent predictors of
mortality in patients with COPD.
• A diagnosis of COPD is also a risk factor for lung cancer.
• Given that most patients with COPD have a significant smoking
history, the prevalence of cardiovascular disease is also increased
References
• GOLD,2023
• LEE GOLDMAN CECIL,26TH EDITION,2020
• MEDSCAP,2022