A few key
points on patients presenting with Acute Exacerbation of COPD
Diagnosis of COPD:
1) Presence
of symptoms compatible with COPD (i.e. SOB at rest and SOBOE, cough +/- sputum,
progressive limitation of activity)
2) Spirometry:
Obstructive pattern/airflow limitation, with FEV1/FVC <0.70 PLUS FEV1
<80% predicted with incomplete response to SABA
3) Absence
of alternative explanation for symptoms and airflow limitation
Think about COPD in smokers, patients with symptoms
of chronic bronchitis, a history of wheezing, recurrent CAP, and a reduction in
exercise tolerance. Also, consider
screening for alpha-1 anti-trypsin deficiency if:
· The
patient is <45 years of age
· The
patients has a predominance of basilar emphysema
· There
is a minimal or absent smoking history
· There
is a family history of “early onset COPD”
· There
is a known family history of alpha-1 anti-trypsin disease or associated liver
disease
AECOPD:
Winnipeg Criteria- An acute increase in 1 or more
of the following cardinal symptoms:
•
Cough increases in frequency and severity; Sputum
production increases in volume and/or changes character; Dyspnea increases
Clinical
History Pearls
JAMA: >70 pack yearà 95% SP, 40% SN, LR+ 8 for airflow
limitation
o
Sputum: >1/4 cup per dayà 95%
SP, 20% SN LR+4
o
Occupational history
o
Cough, Sputum (amt, most in AM, usually mucoid,
appearance, hemoptysis), Exercise Tolerance, Dyspnea, Ischemia Heart Disease,
HTN, OSA/OHS, previous VTE disease, FHx lung disease or cirrhosis, cognitive
change, fatigue (hypercarbia!)
o
Symptoms & pattern of onset: dyspnea, chronic
cough, sputum
o
Earliest: exertional dyspnea
o
Other: wheezing, chest tightness, cough syncope
(vagal)
o
Constitutional symptoms: NS, weight loss (>10%
in 6mn), diffuse arthralgia and myalgia
AECOPD:
infectious symptoms, medication compliance, lifestyle/environmental (dust,
pollutants, cold air), PE, CHF/pulmonary edema, progression of disease, ACS,
pneumothorax, post-op
Physical Exam
Early on:
normal +/- prolonged expiration or wheezes on forced exhalation
With increased severity of obstruction: hyperinflation signs
·
Increased resonance on
percussion (hyper-resonance): SN 32%, SP 94%, LR+ 4.8
·
Barrel Chest (increased
AP diameter): SN 10%, SP 99%, LR+ 10
·
Decreased Cardiac
Dullness on Percussion: SN 13%, SP 99%, LR+10
·
Match Test: requires
patients to extinguish a lighted match held 10 cm from the open mouth. Failure
to accomplish this is associated with a higher likelihood of airflow
limitation. SN 61%, SP 91%, LR + 7.1
·
Sub-xiphoid cardiac
impulse: SN 8%, SP 98%, LR+4.6
·
Pulsus Paradoxus (>15
mm Hg): SN 45%, SP 88%, LR+ 3.7
·
FEV1>9 seconds LR+ 4.8
·
Maximum laryngeal height
<4cm; the distance measured between the top of the thyroid cartilage to the
suprasternal notch at end of expiration: LR+ 2.8
End-Stage: may adopt positions to
relieve dyspnea
o
Lean forward with arms
outstretched and weight supported on palms or elbows
o
Accessory respiratory
muscles (anterior scalene, SCM)
o
Expiration through pursed
lips
o
Paradoxical retraction of
lower interspaces during inspiration (Hoover’s sign)
o
Cyanosis;
o
Asterixis (course, non-intentional,
4-6 beats/minute) due to hypercapnia
o
Cor pulmonale (elevated
JVP, tender enlarged liver)—increased intra-thoracic pressure
o
Clubbing-NOT TYPICAL! (it
is associated with ILD, Lung CA, bronchiectasis)
ACUTE MANAGEMENT OF AECOPD
Consider
DDx: CHF,
PE, Pneumoia, Aspiration, Metabolic, etc
Optimize
lung function
1.OXYGEN
& IV Access: supplemental O2 (target SpO2 88-92%); reduce pulm
artery vasoconstriction, improve cardiac output
-Venture mask: preferred, to permit precise
delivery of FiO2; can use nasal prong delivery for feeds
-Inability to correct hypoxemia with low dose
FiO2: consider PE, CHF, ARDS, pulmonary edema, Acute Interstitial Pneumonia
(AIP), severe CAP
-Re-assess frequently
2.
GOALS of CARE: Discuss, as you may need NIPPV or Intubation/ICU
management
3.
MEDICAL MANAGEMENT:
o
INH
SA BRONCHODILATORS (Beta-agonists & anti-cholinergics)
o
Ventolin: 2.5 mg NEB INH q1-4h PRN OR 4-8 puff by
MDI with spacer q1-4h (while awake) prn
o
Atrovent: 500 mcg NEB q4h prn; 2 puff (18
mcg/puff MDI) with spacer q4h (while awake) prn
o
MDI vs NEB: during AECOPD, NEB may be easier to
use
NOTE:
in RCTs, NEBs are no more effective than MDI (when used properly!)
o
STEROIDS:
decrease Length of Stay (0.5-2 days) & reduce treatment failure
o
Oral: rapid absorption, complete bioavailability,
equally efficacious to IV
o
GOLD: 30-40 mg PO daily x 5 days
o
REDUCE TRIAL: compared 40 mg PO daily x 5 days vs
14 days—extending treatment duration did NOT reduce risk of recurrent
exacerbation
o
ANTIBIOTICS: indicated
(i.e. Cefuroxime, Azithromycin, Levofloxaxin); some meta-analysis data suggest
that Abx reduce treatment failure among inpatients, shorten LOS, and reduce
mortality
o
MUCOACTIVE
AGENTS: little evidence to support N-acetylcysteine
4.
NON PHARMACOLOGICAL
o
Chest Physiotherapy: many techniques have NOT
been shown to be beneficial…
5. MECHANICAL
VENTILATION (NIPPV)
-Trial may be needed in patients with AECOPD
-Indications: pH<7.3, RR>25, use of
accessory muscles, hypoxemic *(must be alert, no facial trauma, no
UBIG/Aspiration risk/copious secretions, HD instability, etc)
-R/A frequently and if no improvement in 30 min-1
h, move to intubation if goals of care allow
6.
DVT Prophylaxis!
7.
CONTINUE LONG ACTING AGENTS (i.e. Spiriva) IF ABLE!!! MAY CHANGE INTERFACE IF EASIER
(i.e. diskus to MDI)
8. LT
MANAGEMENT & FOLLOW UP
o
Education: Symptoms of AECOPD
o
Smoking cessation
o
Vaccinations: pneumovax, annual influenza vaccine
o
Exercise tolerance/rehabilitation
o
Review of puffer technique
o
Review of triggers
o
Treat other contributing illnesses or conditions
(dysphagia, aspiration-SLP, GERD, etc)
o
Screen: Follow up with PFTs, 6 minute walk test,
monitor BMI* (better outcome with less in patient admissions with overweight or
normal weight)
o
LA agents: i.e. LA anti-cholinergic (Spiriva),
LABA + ICS (Symbicort-budesonide & formoterol; 2 puff BID), SABA prn
o
Home O2 assessment with specific delivery of O2
o
PaO2< 55 mg Hg, or <60 mm Hg with cor
pulmonale or Hct>56%
Some useful papers & links:
