Acute Exacerbation of COPD: Some Key Points

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:

Assessment of COPD (Dr. A. McIvor, et al)

Short-term vs Conventional Glucocorticoid Therapy in Acute Exacerbations of Chronic Obstructive Pulmonary Disease The REDUCE Randomized Clinical Trial

How to Properly use MDI inhaler with a Spacer- Great Link for Patients!