UptoDate: COPD Exacerbation

Definition: exacerbation of COPD defined as acute increase in one or more of the following symptoms: Cough increases in severity and frequency Sputum production increases in volume and or changes character Dyspnea increases Precipitants 70-80% of COPD exacerbations are due to respiratory infections (most common: H. influenza, M. catarrhalis, S. pneumo, P. aeruginosa) Risk factors for exacerbation: DDx CHF exacerbation Pulmonary thromboembolism PNA Advanced age Productive cough Duration of COPD Hx of antibiotic therapy COPD-related hospitalization within previous year Comorbidities (eg ischemic heart dz, CHF, DM)

O2 Tx: target PaO2 of 60 70 mmHg, with saturation of 90-94%. Adequate oxygenation must be assured, even if it leads to hypercapnia, which is well tolerated by patients whose PaCO2 is chronically elevated. However, mech ventilation may be required if hypercapnia is associated with depressed mental status, profound academia, or cardiac dysrhythmias. Pharmacologic Tx: Beta adrenergic agonists Inhaled short-acting beta adrenergic agonists (eg, albuterol) are the mainstay of therapy because of their rapid onset of action and efficacy in producing bronchodilation. These may be administered via a nebulizer or a metered dose inhaler (MDI) with a spacer device. o Albuterol 2.5 mg (diluted to a total of 3 mL) by nebulizer q1-4 hours prn, or four to eight puffs (90 mcg per puff) by MDI (metered dose inhaler) with a spacer q1-4 hours prn. Anticholinergic agents Inhaled short-acting anticholinergic agents (eg, ipratropium bromide) are used with inhaled short-acting beta adrenergic agonists. Combination therapy produces bronchodilation in excess of that achieved by either agent alone. o Atrovent 500 mcg by nebulizer q4 hours prn. Alternatively, two puffs (18 mcg per puff) by MDI with a spacer q4 hrs Systemic glucocorticoids- when added to the bronchodilator therapy, improve symptoms and lung function, and decrease the length of hospital stay. Oral glucocorticoids appear equally effective as IV glucocorticoids. o Prednisone 30 to 40 mg daily or methylprednisolone 60 to 125 mg, two to four times daily for 10 to 14 days. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines advise using equivalents of prednisone 30 to 40 mg qday Antibiotics Antibiotics are indicated for many patients having a COPD exacerbation. See table flow chart Mucoactive agents little evidence supports the use of mucoactive agents (eg, N-acetylcysteine) in acute exacerbations of COPD. Methylxanthines Aminophylline and theophylline are NOT recommended for the treatment of COPD exacerbations.

Prognosis It is estimated that 14% of patients admitted for an exacerbation of COPD will die within three months of admission. Prevention - Measures should be taken to prevent future exacerbations, including smoking cessation, pulmonary rehabilitation, proper use of medications (including metered dose inhaler technique), and vaccination

UptoDate: COPD Exacerbation

Managing patients with both COPD with CAD Coronary artery disease (CAD) and chronic obstructive pulmonary disease (COPD) share tobacco abuse as a risk factor, therefore these two disorders commonly exist. 50% of patients over 50 years old with COPD also had CAD, HTN, or heart failure. Exacerbation of COPD may strain an already diseased heart, through hypoxemia and increased work of breathing, while an exacerbation of ischemic heart disease can further impair gas exchange by incrementally raising airway resistance or reducing the oxygen saturation. Because its hard to distinguish which organ is causing the symptoms, empiric treatment of both conditions is warranted. Treatment of either condition has the potential to worsen the other. Inhaled beta-2 agonists are of special concern because, even though they are relatively selective for beta-2 adrenergic receptors, they may have the following deleterious effects that could be a problem in patients with CAD: o The possible induction of arrhythmias by stimulation of cardiac beta-adrenoreceptors o Reflex activation of adrenergic mechanisms by causing peripheral vasodilation o Downregulation of myocardial beta-2-receptors, worsening heart failure associated with left ventricular systolic dysfunction o Provocation of hypokalemia and hypoxemia through worsened matching of ventilation and perfusion Recommendation consider first prescribing alternative, potentially safer drug like inhaled glucocorticoid or tiotropium. Beta blockers Beta blockers, which are useful in managing ischemic heart disease, may induce bronchospasm in those with COPD, in particular, nonselective beta blockers. The dosage required for this effect might be as low as that found in topical eye preparations such as timolol. o Beta-1 selective beta blockers (eg, atenolol or metoprolol) appear to be safe in patients with COPD, even when there is a bronchospastic component. Recommendation Many patients with emphysema and chronic bronchitis have been successfully treated with beta blocker therapy, with few adverse events. A cardioselective beta blocker, such as atenolol or metoprolol, or a combined beta and alpha blocker, such as carvedilol, can be cautiously prescribed. Salmeterol plus fluticasone It is assumed that the cardiovascular effects of this combination are directly related to the long acting betaagonist component. This combination was evaluated in the TORCH trial. The incidence of cardiovascular events was not increased in this group, compared to placebo Recommendation While the data is not yet conclusive, when a long-acting bronchodilator is indicated, we suggest initiating a long-acting anticholinergic agent first. However, the combination of an inhaled glucocorticoid plus a long-acting beta-2 agonist can be added safely if the anticholinergic alone is insufficient.