Inpatient / Pulmonology and Critical Care
COPD Exacerbation
# COPD Exacerbation
Checklist
-- ABCs: evidence of respiratory failure or AMS requiring intubation? does ABG/VBG suggest worsening hypercarbia?
-- Chart Check: home regimen, prior exacerbations, intubations
-- Admission Criteria: dyspnea, worsening hypoxia or hypercarbia, or need for IV medications
-- HPI Intake: home meds and adherence, inhaler use and nighttime awakenings, symptoms, prior exacerbations and intubations, red flags
-- Can't Miss: hypercarbic respiratory failure, PE
-- Admission Orders: continuous pulse ox, tele, EKG, CBC, BMP, VBG, VitD, CXR, consider RVP, procal, trop, BNP, CT chest; clarify intubation preferences
-- Initial Treatment to Consider: duonebs, steroids, abx
Intake
-- Home Meds and Adherence: *** issues with cost/access
-- Severity: *** rescue inhaler use, nighttime awakenings,
-- Symptoms: *** dyspnea, sputum, cough, URI sxs, CHF sxs
-- Prior Exacerbations: ***
-- Prior Intubations: ***
-- Red Flags: *** AMS, retraction, nasal flaring, difficulty speaking
Assessment:
-- History: *** home regimen, smoking, prior exacerbations, intubations, sick contacts
-- Clinical: *** dyspnea, sputum, cough; URI sxs (sneezing, rhinorrhea, headache), CHF sxs,
-- Exam: *** increased WOB (nasal flaring, retraction, tripoding, pursed lips, difficulty speaking), cyanosis, tachypnea, wheezing, AMS, cachexia, volume exam, e/o PNA (rhonchi, sputum), c/f DVT (asymmetric legs, erythema, pain)
-- Data: *** WBC, RVP, procal, VBG, CXR
-- Etiology/DDx: *** infection, missed home medications, weather, smoke; rule out CHF, PNA, PTX, PE
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
Plan:
Workup
-- CBC with Diff, BMP, ABG/VBG, Vitamin D
-- consider RVP if high suspicion as etiology of exacerbation and procalcitonin if on the fence about antibiotics
-- EKG, troponin, NT-proBNP if suspicious for cardiac involvement
-- CXR, CT Chest is c/f other underlying lung disease
Treatment
-- Bronchodilators: Duonebs q4 w/ albuterol q2 PRN; space as able; consider inhalers over nebs if able to inspire well
-- Oxygen: currently ***; monitor with ***, titrate to goal 88-92%
-- Steroids: *** PO or IV prednisone 40mg for 5 days; IV methylpred 60-125mg q6-12 for 3 days if severe exacerbation
-- Antibiotics: *** azithromycin 500mg PO once, 250mg daily for 4 days; if c/f CAP, ass ceftriaxone 1g IV vs. Levofloxacin 750mg IV; if risk of PsA - pip-tazo 4.5g IV vs. Cefepime 1-2g IV
-- Home Meds: continue ***
-- Monitoring: *** tele, daily CBC, BMP
-- NIPPV if resp acidosis, dyspnea, increased WOB; Mechanical ventilation if pH <7.26 and PaCO2 is rising despite NIV
-- discharge with Vitamin D as needed
If You Remember Nothing Else
AECOPD is a clinical diagnosis with worsening dyspnea, cough, and sputum. You need to rule out CHF, PNA, PTX and PE as other common causes of hypoxia and resp distress. The most common cause of an exacerbation is a viral illness. Treat with duonebs, steroids and antibiotics if needed. Watch for worsening hypercarbia, and trial non-invasive positive pressure ventilation, but do not wait to intubate if needed.
Clinical Pearls
- AECOPD is a clinical diagnosis - symptoms include dyspnea, increased frequency and severity of cough, and increased volume/ purulence of sputum
- 40% of AECOPD thought to be related to viral illness like rhinovirus
- Since AECOPD is a clinical diagnosis, you need to think about and rule out CHF, PNA, PTX, PE
- Hyperoxia leads to decreased ventilation via the Haldane effect and hypoxic vasoconstriction, leads to V/Q mismatch and increased mortality (maybe not true, but this is the classical teaching)
- Home O2 if SpO2 <88% and quitting smoking are the only things that increase mortality in the outpatient setting (oxygen improves mortality in COPD with PaO2 <55, otherwise improves functionality); inhalers only reduce symptoms
- Quitting smoking is still the best way to prevent or slow the progression of COPD
- Antibiotics reduce mortality and treatment failure - Chest Meta-Analysis 2008; however, Cochrane Analysis suggests it helps in ICU, but on floor and in the outpatient setting its less clear who will benefit
- Azithro 250mg daily decreases hospializations in patient with COPD who have 2+ exacerbations per year; roflumilast (PDE4i) can also reduce exacerbations and can lead to weight loss
- EKG: Look for sinus tachycardia, RVH, P pulmonale, RBBB
- If emphysema in young, non-smoker, check alpha-1-antitrypsin deficiency - an autosomal dominant deficiency of a protein protease inhibitor, without it there is uninhibited neutrophil elastase activity leading to panacinar emphysema vs. centrilobular emphysema with smoking; tell will also be liver disease, will have PAS-positive inclusion bodies in hepatocytes on biopsy - should avoid smoking
- In those with severe COPD, lung volume reduction surgery can remove apical lobes which leads to improved quality of life; endobronchial valves can also close off part of lung if the patient is not a candidate for surgery
Trials and Literature
- PO and IV Prednisolone are the Same in AECOPD; 60mg PO was not inferior to 60mg IV - followed for 90 days; No difference in LOS, or early (within 2 weeks) or later treatment failure (Chest, 2007)
- REDUCE Trial - in AECOPD - 5 days steroid non-inferior to 14 days steroid for 6-month readmissions (JAMA, 2013)
- Cochrane Analysis of Nebulizers vs. Inhalers for Exacerbation - somewhat favors nebulizers over inhalers, but pretty close; In general, can start with nebs and quickly switch to inhalers (since inhalers likely deliver a more potent dose); Inhalers also tend to be cheaper than nebs, less aerosolizing, and more portable (Cochrane, 2016)
- Titrated Oxygen in COPD Improves Mortality, Hyperoxia Makes Worse - (BMJ ,2010)
- Procalcitonin and COPD for the floor (overall low quality evidence, but may lead to less antibiotics with similar outcomes in AECOPD) and for the ICU - guidance for general use
- Vitamin D Supplementation to Reduce Exacerbations - Vitamin D supplementation safely and substantially reduced the rate of moderate/severe COPD exacerbations in patients with baseline 25-hydroxyvitamin D levels <25 nmol/L but not in those with higher levels (Thorax, 2019)
- Pulse Oximeters have ~3x frequency of occult hypoxemia not detected on pulse ox in people of color when comparted to white patients (NEJM commentary), hidden hypoxia is associated with worse outcomes (in-hospital death, but not LOS) regardless of race (hidden hypoxemia: 4.9% White, 6.9% Black, 6.0% Hispanic, 4.9% Asian) (JAMA, 2020)
Other Resources
- The Curbsiders - #86 COPD: Diagnosis, treatment, PFTs
- Core IM/EM - Steroids in COPD and Abx in COPD
- Run the List - Episode 70: COPD
- Make sure patients know how to use their inhalers appropriately
- Tweet of a Graphic of COPD Physiology - Eric Wong
- Tweet of Educational Crib Sheet for COPD - @drokane
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