Exacerbation of COPD

Definition of Exacerbation

You'd have thought that defining an exacerbation would be easy...but everywhere seems to have different exacerbation:

- worsening of the patient's symptoms from stable state that is beyond normal day-to-day variations, and is acute in onset.

- Anthonisen criteria - increased dyspnea, increased sputum volume, and increased sputum purulence 

Investigations

- CXR in all patients coming into hospital 

- ABGs

- ECG

- FBC, U+E

Antibiotics?

- Purulent sputum is often used, but limited accuracy. 

- Bloods - markers of infection are hypothetically useful. 

- GP notebook advises antibiotics if increased in purulent sputum or suspected pneumonia. 

Medical Management

Maximum medical treatment includes:

Controlled oxygen therapy to maintain SaO2 88-92%

Nebulised salbutamol 2.5-5 mg

Nebulised Ipratropium 500 micrograms

Prednisolone 30 mg for 7 to 14 days

Antibiotic agent when indicated

Conflicting evidence about the role of IV magnesium

NIV

NIV should be considered within 60 minutes of arrival to hospital in all patients with an exacerbation of COPD and a persistent respiratory acidosis (pH <7.35 and PaCO2 >6 kPa) in whom medical treatment unsuccessful. 

Patients should improve within four hours - if they don't, consider intubation. 

Exclusion criteria

Life-threatening hypoxaemia

Severe co-morbidity

Confusion/agitation/severe cognitive impairment

Facial burns/trauma/recent facial or upper airway surgery, vomiting, upper airway obstuction, secretions, inability to protect the airway

Haemodynamically unstable requiring

inotropes/pressors (unless in a critical care unit)

Patient moribund

Bowel obstruction

May be used in heart failure or pneumonia

NIV Technique

- Full face mask for 24hours

- Start with an IPAP of 10cm H20, EPAP of 4-5cmH20

- IPAP should be increased by 2–5 cm increments at a rate of approximately 5 cm H2O every 10 minutes

- Bronchodilators, although preferably administered off NIV, should as necessary be entrained between the expiration port and face mask. 

Repeat ABGs:

– after 1 hour of NIV therapy and 1 hour after every subsequent change in settings

– after 4 hours, or earlier in patients who are not improving clinically

Invasive Intubation 

NIV failure or inability to tolerate NIV

Respiratory or cardiac arrest

Respiratory pauses with loss of consciousness or gasping for air

Reduced consciousness or uncontrolled agitation

Massive aspiration

Persistent inability to remove respiratory secretions

Heart rate < 50 with loss of alertness

Haemodynamic instability unresponsive to fluid and vasopressors

Life threatening hypoxaemia

Home or Hospital?

Mortality 

DECAF score

- If intubated and ventilated have an in- hospital mortality of 25%. Two thirds will be dead within a year.  Patients do better than people think. 

References

http://www.doctors.net.uk/ecme/wfrmNewIntro.aspx?moduleid=1609

http://www.enlightenme.org/the-curriculum-zone/node/12303

http://www.enlightenme.org/knowledge-bank/cempaedia/chronic-obstructive-pulmonary-disease-copd

http://www.enlightenme.org/learning-zone/resus-lottery

http://learning.bmj.com/learning/module-intro/copd-diagnosis-management-primary-care.html?moduleId=10020707&searchTerm=%E2%80%9CCOPD%E2%80%9D&page=1&locale=en_GB

http://learning.bmj.com/learning/module-intro/chronic-obstructive-pulmonary-disease-diagnosis-severity.html?moduleId=10032711&searchTerm=%E2%80%9CCOPD%E2%80%9D&page=1&locale=en_GB

http://learning.bmj.com/learning/module-intro/.html?locale=en_GB&moduleId=10035815&

http://www.atsjournals.org/doi/pdf/10.1513/pats.201201-014ST

http://pulmccm.org/2013/cardiovascular-disease-review/continuing-beta-blockers-safe-during-acute-copd-exacerbations-thorax/

http://ebn.bmj.com/content/8/2/61.full

http://journal.publications.chestnet.org/article.aspx?articleid=1216510

http://pulmccm.org/2012/critical-care-review/how-dangerous-is-this-patients-copd-exacerbation-decaf-score-may-help-predict-thorax/

http://www.atsjournals.org/doi/full/10.1164/ajrccm.182.9.1207#.VK7toiusXng

http://radiopaedia.org/articles/chronic-obstructive-pulmonary-disease-1

http://www.scancrit.com/2014/06/11/copd-icu-mortality/

http://embasic.org/oxygen-in-copd-followup/

http://pulmccm.org/main/2014/copd-review/vitamin-d-relationship-copd-exacerbations-chest/

http://emrespodcast.org/blog/2014/8/31/episode-20-copd-part-2

http://embasic.org/wp-content/uploads/2013/12/copd-sob-shownotes.pdf

http://www.geripal.org/2012/06/role-for-acupuncture-in-copd-management.html

http://www.atsjournals.org/doi/full/10.1164/ajrccm.182.9.1207#.VK7toiusXng

http://radiopaedia.org/articles/chronic-obstructive-pulmonary-disease-1

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528209/

http://www.ncbi.nlm.nih.gov/pubmed/3492164

http://www.atsjournals.org/doi/full/10.1164/ajrccm.182.9.1207a#.VLVZWyusXsY

http://www.gpnotebook.co.uk/simplepage.cfm?ID=724893768

http://www.thoracicmedicine.org/article.asp?issn=1817-1737;year=2014;volume=9;issue=2;spage=77;epage=80;aulast=Shivanthan 

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