Acute Exacerbations Of COPD: A Practical Approach To Differential

Diagnosis And Management

Introduction
11:07p.m.:A55yearoldwomanisbroughtintotheEDwithdifficultybreathing;sheis
barelyabletospeakandhasthatfamiliarlookofterrorinhereyes.Themedicsthink
thatshehasahistoryofCHF,hypertension,andasthma,astheyfoundcontainersof
albuterol,lisinopril,andfurosemidescatteredonherkitchentable.
Barelyabletospeak,shegasps,"Cantbreathe."Herphysicalexamishardlymore
informative.Sheisdiaphoreticandherlungsdemonstratepoorairflow.Thereare
scatteredralesinallfields;herlegsshowsomemildedema.Themonitorshowsasinus
tachycardia,andaquickchestfilmdemonstratesaverticalheartwithquestionable
perihilarfullness.
Thenursesurgeyouon:"Howmuchoxygendoyouwant?ShouldwegivesomeLasix,
drawsomecardiacenzymes?Howaboutsomesteroids,albuterol,oranitroglycerin
drip?Doyouwanttheairwaycart?"
Decisiontime.

Critical Appraisal Of The Literature

"Statisticsarelikeabikini:whattheyrevealissuggestive,butwhattheyconcealis
vital."AaronLevenstein
Guidelines
Thereareseveralguidelinesthataddressthediagnosisandmanagementofchronic
obstructivepulmonarydisease(COPD).Influentialguidelinespublishedinthemid1990s
includethosebytheAmericanThoracicSociety, theEuropeanRespiratorySociety, and
theBritishThoracicSociety. MorerecentistheGlobalInitiativeforChronicObstructive
LungDisease(GOLD)WorkshopSummary(alsoavailableonlineat
http://www.goldcopd.com). ItrepresentsacombinedeffortoftheWorldHealth
OrganizationandtheNational,Heart,Lung,andBloodInstituteoftheNationalInstitutes
ofHealth.Thisguidelineismostlydirectedtowardtheprimarycareproviderandisless
gearedtowardemergencymanagement.
1

TheAmericanCollegeofPhysiciansAmericanSocietyofInternalMedicineandthe
AmericanCollegeofChestPhysicianshavepublisheda"competing"guideline.This
evidencebasedclinicalpracticeguidelineisentitled"Evidencebaseformanagementof
acuteexacerbationsofchronicobstructivepulmonarydisease. (Theserecommendations
arehereafterreferredtoasthe"JointGuidelines.")
5

TheFedshaveenteredthefraywithasponsoredguideline.Thisone,endorsedbythe
AgencyforHealthcareResearchandQuality,involvesanevidencebasedarticle
publishedbyresearchersfromDukeUniversityandMemorialSloanKetteringCancer
Center(hereafterreferredtoastheMcCroryguidelines). Inthisarticle,theauthorsrate
varioustherapeuticinterventions,diagnostictestsandriskstratificationbasedonthe
existingliterature.UnliketheCochraneCollaboration,thisgroupdidnotperformmeta
analysesofthepooleddata.ThiscomprehensivesummaryisavailableattheAgencyfor
HealthcareResearchandQualityWebsite
(http://www.ahcpr.gov/clinic/epcsums/copdsum.htm).
6

Definitions
TheMcCroryarticleandtheolderguidelinesseparateCOPDintochronicbronchitis,
emphysema,andasthma,whiletheGOLDguidelinesdonot.Thisdistinctionis
problematicbecauseemphysemaisdefinedanatomically,whilechronicbronchitisis
determinedbyclinicalcriteria.AccordingtotheAmericanThoracicSocietyGuidelines,
emphysemaisan"abnormalpermanentenlargementoftheairspacedistaltotheterminal
bronchioles,accompaniedbydestructionoftheirwallsandwithoutobviousfibrosis."
Chronicbronchitisisdefinedas"thepresenceofchronicproductivecoughforthree
monthsineachoftwosuccessiveyearsinapatientinwhomothercausesofchronic
coughhavebeenexcluded."However,McCroryetaladmitthat"infact,separatingthese
entitiesisdifficultbothwhenevaluatingclinicalstudiesandwhenpracticingclinical
medicine."
1

GOLDupdatesthedefinitionofCOPDas"adiseasestatecharacterizedbyairflow
limitationthatisnotfullyreversible."(SeeTable 1.)Theairflowlimitationisusually
bothprogressiveandassociatedwithaninflammatoryresponseofthelungstonoxious
particlesorgases.Whilethesevariousdefinitionsareanecessaryirritation,the
emergencyphysicianshouldconsiderCOPDinanypatientwithcough,sputum
production,ordyspnea.
Diagnostic Uncertainty
BeyondtheconfusionassociatedwiththeevolvingdefinitionofCOPD,thereisevidence
tosuggestthatphysiciansarenotverygoodatdiagnosingthisdiseaseevenwhenthe
presentationisrelativelystraightforward.Inonestudy,theauthorspresentedaclinical
scenarioto75primarycareprovidersinCanadaandaskedthemtoprovideadiagnosis.
Thecaseinvolveda52yearoldsmokerwithrecurrentrespiratoryinfectionsandwheeze.
Halfoftheprimarycarephysiciansweretoldthatthepatienthadhistoryofchronic
bronchitis,whiletheotherhalfwerenot.Thephysicianswhoweregivenahistoryof
chronicbronchitisdiagnosedCOPDtwiceasoftenasthosewhowerenottoldthisfact.A
morerecentstudypresentedasimilarscenariotoprimarycareprovidersintheU.S.and
Canada. Thistime,theyrandomizedprimarycarephysicianssothathalfreceivedthe
scenariowiththepatientasamale,whiletheotherhalfweregiventheidenticalscenario
7

withthepatientasafemale.Theyfoundthat65%ofthephysiciansdiagnosedCOPDin
themalepatient,whileonly49%diagnosedthewomanwithCOPD(P<0.05).
SystematicunderdiagnosingofwomenwithCOPDmayalsooccurintheED.
9

Epidemiology
In1990,theWorldHealthOrganizationreportedtheprevalenceofCOPDtobe
9.34/1000inmenand7.33/1000inwomen.TheexactprevalenceofCOPDintheU.S.is
unknown,butitisestimatedthatapproximately14millionAmericanssufferfromthis
condition. (Thisnumberislikelyanunderestimate,sinceCOPDremainsunder
diagnosedintheprimarycaresetting. )WhiledataonEDvisitsforCOPDaredifficultto
find,dataonCOPDdischargesareeasilyavailable. In1998,nearly700,000peoplewere
dischargedfromthehospitalwithadiagnosisofCOPD.Therateofwomendischarged
forCOPDexceededmenin1992,andtheratioofwomentomenhasbeenincreasing
yearlysincethen.ThereisclearevidencethattheprevalenceofCOPDhasdoubledinthe
pastfewdecadesinwomenwhileremainingrelativelystableinmen. Thismayreflecta
combinationofincreasedprevalenceofsmokingamongwomenaswellasthefactthat
womenmaybemoresusceptibletotheeffectsoftobaccosmoke.
10

11

12

13

14

COPDiscurrentlythefourthleadingcauseofdeathintheworld,andtheonlycauseof
deaththatisstillincreasing.Amongindustrializedcountries,theU.S.rankshighin
COPDmortality(sixthforwomenandninthformen). MorbidityofCOPDincreases
withageandisgreaterinmenthaninwomen.In2000,totalcosts(directandindirect)of
COPDintheU.S.reached$30.4billion. DirectcostsrelatedtoEDvisitsareestimatedat
$148million.
13

15

"YouandIbothknowthatTwinkiesdontkillpeople....Thedifferencebetweencigarettes
andTwinkies...isdeath.Thetobaccoindustryshouldknow:WhenitcomestoTwinkies,
Idratherfightthanquit."HenryWaxman(b.1939),U.S.Democraticcongressman
fromCalifornia.LosAngelesTimes,p.E2(June9,1994)