COPD exacerbation: Difference between revisions
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===Pseudomonas Risk Factors=== | ===Pseudomonas Risk Factors=== | ||
*Recent hospitalization (>2 days within previous 3 months) | |||
*Frequent abx tx (>4 courses w/in past year) | |||
*Severe underlying COPD (FEV1 < 50% predicted) | |||
*Previous isolation of pseudomonas | |||
==Clinical Presentation== | ==Clinical Presentation== | ||
| Line 45: | Line 45: | ||
==Treatment== | ==Treatment== | ||
===Oxygen=== | ===Oxygen=== | ||
*Maintain PaO<sub>2</sub> of 60-70 or SpO<sub>2</sub> 90-94% | |||
*If unable to correct hypoxemia with a low FiO2 consider alternative diagnosis | |||
*Adequate oxygenation is essential, even if it leads to hypercapnia | |||
*If hypercapnia leads to AMS, dysrhythmias, or acidemia consider [[Intubation]] | |||
===Albuterol/ipratropium=== | ===Albuterol/ipratropium=== | ||
*Improves airflow obstruction and treatment should involve rapid administration upon recognition of COPD exacerbation. <ref>Celli BR. Update on the management of COPD. Chest. Jun 2008;133(6):1451-62.</ref> | |||
===Steroids=== | ===Steroids=== | ||
Similar efficacy between oral and intravenous. Treatment options include: | Similar efficacy between oral and intravenous. Treatment options include: | ||
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**[[Levofloxacin]] 500 mg PO BID<ref>Anzueto A, Miravitlles M: Short-course fluoroquinolone therapy in exacerbations of chronic bronchitis and COPD. Respir Med 2010; 104:1396-1403</ref> | **[[Levofloxacin]] 500 mg PO BID<ref>Anzueto A, Miravitlles M: Short-course fluoroquinolone therapy in exacerbations of chronic bronchitis and COPD. Respir Med 2010; 104:1396-1403</ref> | ||
*Outpatient Healthy | |||
**[[Azithromycin]] OR [[Doxycycline]] OR [[TMP/SMX]] | |||
*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 | |||
===[[EBQ:NIPPV in COPD|Noninvasive ventilation]] (CPAP or BiPaP)=== | ===[[EBQ:NIPPV in COPD|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:'' | ''Contraindications:'' | ||
*Uncooperative or obtunded pt | |||
*Inability to clear secretions | |||
*Hemodynamic instability | |||
===Mechanical ventilation=== | ===Mechanical ventilation=== | ||
''Indications:'' | ''Indications:'' | ||
*Severe dyspnea w/ use of accessory muscles and paradoxical breathing | |||
*RR>35 bpm with anticipated clinical course for respiratory failure | |||
*PaO<sub>2</sub> <50 or PaO2/FiO2 <200 | |||
*pH <7.25 and PaCO2 >60 | |||
*Altered mental status | |||
*Cardiovascular complications (hypotension, shock, CHF) | |||
==Disposition== | ==Disposition== | ||
Consider hospitalization for: | 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== | ==See Also== | ||
[[EBQ:NIPPV in COPD]] | [[EBQ:NIPPV in COPD]] | ||
== | ==References== | ||
<references/> | <references/> | ||
[[Category:Pulm]] | [[Category:Pulm]] | ||
Revision as of 02:26, 5 May 2015
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
Precipitants
- Infection (75%)
- 50% viral, 50% bacterial
- Cold weather
- B-blockers
- Narcotics
- Sedative-hypnotic agents
- Pneumothorax
- PE
Pseudomonas Risk Factors
- Recent hospitalization (>2 days within previous 3 months)
- Frequent abx tx (>4 courses w/in past year)
- Severe underlying COPD (FEV1 < 50% predicted)
- Previous isolation of pseudomonas
Clinical Presentation
Differential Diagnosis
Acute dyspnea
Emergent
- Pulmonary
- Airway obstruction
- Anaphylaxis
- Angioedema
- Aspiration
- Asthma
- Cor pulmonale
- Inhalation exposure
- Noncardiogenic pulmonary edema
- Pneumonia
- Pneumocystis Pneumonia (PCP)
- Pulmonary embolism
- Pulmonary hypertension
- Tension pneumothorax
- Idiopathic pulmonary fibrosis acute exacerbation
- Cystic fibrosis exacerbation
- Cardiac
- Other Associated with Normal/↑ Respiratory Effort
- Other Associated with ↓ Respiratory Effort
Non-Emergent
- ALS
- Ascites
- Uncorrected ASD
- Congenital heart disease
- COPD exacerbation
- Fever
- Hyperventilation
- Interstitial lung disease
- Neoplasm
- Obesity
- Panic attack
- Pleural effusion
- Polymyositis
- Porphyria
- Pregnancy
- Rib fracture
- Spontaneous pneumothorax
- Thyroid Disease
- URI
Diagnosis
- VBG/ABG
- Perform if SpO2 <90% or concerned about symptomatic hypercapnia
- Peak flow
- <100 indicates severe exacerbation
- CXR
- Consider if concerned for PNA or CHF
- Sputum culture
- Usually not indicated except for pt w/ recent antibiotic failure
Treatment
Oxygen
- Maintain PaO2 of 60-70 or SpO2 90-94%
- If unable to correct hypoxemia with a low FiO2 consider alternative diagnosis
- Adequate oxygenation is essential, even if it leads to hypercapnia
- If hypercapnia leads to AMS, dysrhythmias, or acidemia consider Intubation
Albuterol/ipratropium
- Improves airflow obstruction and treatment should involve rapid administration upon recognition of COPD exacerbation. [1]
Steroids
Similar efficacy between oral and intravenous. Treatment options include:
- Methylprednisolone 1-2 mg/kg IV daily (usual adult dose 125mg)[2]
- Prednisone 40 mg PO daily
For outpatients a 5 day dose appears equally effective as longer doses and a taper is not required.[3]
Antibiotics
- GOLD collaborators recommend antibiotics for patients with purulent sputum or increased sputum production or those who required Non Invasive Positive Pressure Ventilation
- Antibiotics for COPD exacerbations have an NNT of 3 to prevent 1 conservative treatment failure and 8 to prevent 1 short-term mortality (NNTH of 20 to cause 1 case of diarrhea)[4]
- Antibiotics should be a 3-5 day course and options include:
- Azithromycin 500mg PO BID[5]
- Doxycycline 500 mg PO BID
- Levofloxacin 500 mg PO BID[6]
- Outpatient Healthy
- Azithromycin OR Doxycycline OR TMP/SMX
- 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
- If Pseudomonas risk factors the use:
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
References
- ↑ Celli BR. Update on the management of COPD. Chest. Jun 2008;133(6):1451-62.
- ↑ Eisner MD, et al: An official American Thoracic Society public policy statement: Novel risk factors and the global burden of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2010; 182:693-718
- ↑ Eisner MD, et al: An official American Thoracic Society public policy statement: Novel risk factors and the global burden of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2010; 182:693-718
- ↑ Ram FS, et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006.19(2).
- ↑ Rothberg MB, et al: Antibiotic therapy and treatment failure in patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. JAMA 2010; 303:2035-2042
- ↑ Anzueto A, Miravitlles M: Short-course fluoroquinolone therapy in exacerbations of chronic bronchitis and COPD. Respir Med 2010; 104:1396-1403