COPD exacerbation

Background

• Airflow limitation (FEV1:FVC < 0.70) that is not fully reversible
  • Encompasses chronic bronchitis (85%) and emphysema (15%)
• Acute exacerbations due to incr V/Q mismatch, not expiratory airflow limitation
• Although smoking is a major risk factor for developing COPD, only 15% of smokers actually develop COPD.

Steroids

Similar efficacy between oral and intravenous. Treatment options include:

• Methylprednisolone 1-2 mg/kg IV daily (usual adult dose 125mg)
• Prednisone 40 mg PO daily

For outpatients a 5 day dose appears equally effective as longer doses and a taper is not required.

Antibiotics

Indicated for patients with purulent sputum, increased sputum production, or requiring Non Invasive Positive Pressure Ventilation

Outpatient Healthy

• Antibiotics should be a 3-5 day course and options include:
  • Azithromycin 500mg PO BID
  • Doxycycline 500 mg PO BID
  • Levofloxacin 500 mg PO BID

Outpatient Unhealthy

• Age >65, cardiac disease, >3 exacerbations/per year
• Levofloxacin/Moxifloxacin OR Amoxicillin/Clavulanate

Inpatient

• If Pseudomonas risk factors the use:
  • Levofloxacin PO or IV OR Cefepime IV OR Ceftazidime IV OR Piperacillin/Tazobactam IV
• No pseudomonas risk factors:
  • Levofloxacin or Moxifloxacin PO or IV OR Ceftriaxone IV OR Cefotaxime IV
  • Consider oseltamivir during influenza season

Evidence

Antibiotics for COPD exacerbations have an NNT of:

• 3:1 to prevent conservative treatment failure
• 8:1 to prevent short-term mortality
• 20:1 to cause diarrhea

Noninvasive ventilation (CPAP or BiPaP)

• CPAP: start at low level and titrate up to max 15
• BiPAP: Start IPAP 8 (max 20), EPAP 4 (max 15)

Contraindications:

• Uncooperative or obtunded pt
• Inability to clear secretions
• Hemodynamic instability

Mechanical ventilation

Indications:

• Severe dyspnea w/ use of accessory muscles and paradoxical breathing
• RR>35 bpm with anticipated clinical course for respiratory failure
• PaO₂ <50 or PaO2/FiO2 <200
• pH <7.25 and PaCO2 >60
• Altered mental status
• Cardiovascular complications (hypotension, shock, CHF)

Disposition

Consider hospitalization for:

• Marked increase in intensity of symptoms (e.g. sudden development of resting dyspnea)
• Background of severe COPD
• Onset of new physical signs (e.g., cyanosis, peripheral edema)
• Failure of exacerbation to respond to initial medical management
• Significant comorbidities
• Newly occurring arrhythmias
• Diagnostic uncertainty
• Older age
• Insufficient home support

See Also

EBQ:NIPPV in COPD