Acute exacerbation of COPD

By Mohd Rafiuddin Hamidon

Introduction
Chronic Obstructive Pulmonary Disease has been

defined by GOLD (Global Initiative for Chronic Obtructive Lung Disease) as a disease state characterised by increased airflow resistance that is not fully reversible. Emphysema abnormal, permanent enlargement of the distal air spaces distal to the terminal bronchiole, accompanie by destruction of their walls Bronchitis cough with sputum production at least for 3months in a year, for two or more consecutive years. Acute Exacerbation of COPD
Defined as episodes of increased dyspnoea,

cough and change in the amount and character of the sputum with other signs of infection-

Precipitating factor
Infection
Most commonly encountered organisms: Streptococcus pneumoniae Hemophilus influenzae Moraxella catarrhalis Pseudomonas aeruginosa Viruses 1/3 of the cases

Allergen - air pollution, dust, pollen, cold Smoking - active or passive Occupation coal miners, exposure to fumes Low socio economic status Genetic Alpha 1 antitrypsin deficiency (early onset of emphysema)

Pathophysiology
Airflow obstruction air-trapping

voluminous lungs, hyperinflation inadequate gas exhange hypoxaemia and hypercapnia

Persistent reduction in expiratory flow rates

increase residual volume increase the ratio of residual volume to total lung capacity

Ventilation-perfusion missmatch (A defect

which occurs in the lungs whereby ventilation (the exchange of air between the lungs and the environment) and perfusion (the passage of blood through the lungs) are not evenly matched)

Pathophysiology contd
Hyperthrophy of mucous producing glands

Goblet cell hyperplasia

Ciliary cells reduced with sluggish movements Mucosal edema Hyperthrophy of smooth muscles of bronchus Reduced caliber of air space

Clinical features
Symptoms of COPD
Cough with sputum and exertional dyspnoe (more

than 2 years)
Symptoms of acute exacerbation
Fever, tachycardia, tachypnoea, difficulty in speech,

appearance of cyanosis Giddiness, headache,vertigo

Physical signs
Barrel shaped chest Decreased movements of the chest Indrawing of the ribs during inspiration Hoovers

sign Vesicular breath sound with prolonged expiration Expiratory crackles

Investigation
CBC leucocytosis

Sputum microscopy and culture if purulent

Pulmonary function test
Reduction in FEV1/FVC ratio FEV1 reduced (reversibility is <15%) Increase Total lung capacity, Residual volume and

functional residual capacity

ABG
Hypoxaemia
Hypercapnia

Investigation contd
Radiology
Chest X-ray Hypertranslucent (Black) Lungs Tubular (Narrow) heart Pushed down diaphragm Widely placed horizontal ribs Pulmonary arteries prominent CT scan

Management
Aims
To assess the severity of illness To identify the precipitant and plan strategies to

reduces frequency of exacerbations To institute appropriate therapy

Assessment of the patient

History Physical examination

GOLD criteria for the severity of COPD

Stage 0 I II Severity At risk Mild Moderate Pulmonary function test Normal FEV1/FVC < 0.7 FEV1 >80% FEV1/FVC < 0.7 FEV1 50-80%

III
IV

Severe
Very severe

FEV1/FVC < 0.7 FEV1 30-50%

FEV1/FVC < 0.7 FEV1 <30%

*Stage IV , associated with respiratory failure or RHF

History
Symptoms- fever, change of characters of sputum, Ill contact; associates symptoms- nausea, vomitting,

diarrhea, myalgias, and chills Functional capacity when well using the MRC dyspnoea scale: Grade 1: Not troubled by breathlessness except on strenuous exercise. Grade 2: Short of breath when hurrying or walking up a slight hill. Grade 3: Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace. Grade 4: Stops for breath after walking about 100m or after a few minutes on level ground. Grade 5: Too breathless to leave the house, or breathless when dressing or undressing. *MRC- Medical Research Council

History contd
Frequency and severity of prior exacerbations.

Previous admissions with COPD.

Previous episodes of ventilation (both NIV and

intubation). Usual treatment including oxygen (specifying whether short burst, portable, long term i.e. 16 hours per day or a combination of oxygen treatments). Concurrent illnesses (co-morbidities are common in these patients). Check for previous blood gas and lung function results.

Physical Examination

Respiratory rate (Tachycardia) Degree of distress Sign of perioral or peripheral cyanosis Ability to speak full sentences Patients mental status Use of accessory muscles or paradoxical chest wall movements. Oxygen saturation and FIO2 Signs of hypercapnoea (warm peripheries, bounding pulse, flap, confusion). Cor pulmonale (peripheral oedema). Heart rate and rhythm. Chest examination- presence/absence focal finding, degree of air movement, presence/absent of wheezing, asymetry in the chest

Identification of the precipitant

Infection bacteria or virus

Smoking
Allergen

Indications for hospitalisation of patients with a COPD exacerbation

Presence of high-risk co-morbid conditions, including

pneumonia, cardiac arrhythmia, congestive heart failure, diabetes mellitus, renal or liver failure Inadequate response of symptoms to outpatient management Marked increase in dyspnoea Inability to eat or sleep due to symptoms Worsening hypoxaemia Worsening hypercapnia Changes in mental status Inability of the patient to care for her/himself Uncertain diagnosis Inadequate home care

Treatment
Hospitalisation Oxygen therapy Controlled oxygen at 24%-28% to maintain a PaO2>8

kPa(60mmhg) or saturation at 80% High oxygen conc. respiratory depression and worsening acidosis
Inhaled bronchodilators Nebulised short-acting B-agonist combined with Anticholinergic

agent -Salbutamol 2.5mg (diluted to a total of 3mL) every hour -Ipratropium 500mcg every 3 hours - Levosalbutamol sulphate 1.25mg and Ipratropium Bromide 500mcg (Duolin respules)
IV infusion theophylline Add theophylline or aminophylline in the drip
250 500 mg in 20ml 25% dextrose over 20 minutes (severe) Infusion 500mg in 500ml 5% dextrose over 24 hours

Antibiotic Quinolones (Levofloxacin) of Co amoxiclav (Augmentin ) Corticosteroid Oral prednisolone 30-40mg x 10-14days IV Hydrocortisone 200mg

 Non-invasive ventilation (non invasive positive pressure ventilation) RR>25/minute Mild to moderate respiratory acidosis (pH <7.35) Hypercarbia (Paco2>45mmHg) If the patient remains tachypnoeic and acidotic Ventilatory support by nasal or fullmask, BiPAP Mechanical ventilation support indications: Severe respiratory failure Respiratory rate>35/minute Hypercarbia (Paco2>60mmHg) Acidosis (pH<7.25) Respiratory arrest Altered mental status Hypotension, cardiac failure, shock NIPPV failure Additional therapy Exacerbation may be accompanied by peripheral edema give

diuretic Respiratory stimulant - doxapram

 BiPAP

Discharge Criteria for Patients With Exacerbations of COPD

Inhaled 2-agonist therapy is required no more

frequently than every 4 hrs. Patient is able to walk across room, eat and sleep without frequent awakening by dyspnea. Patient has been clinically stable for 12-24 hrs. Arterial blood gases have been stable for 12-24 hrs. Patient (or home caregiver) fully understands correct use of medications. Follow-up and home care arrangements have been completed (e.g., visiting nurse, oxygen delivery, meal provisions). Patient, family, and physician are confident patient can manage successfully.

Classification of Severity of Acute Exacerbation of COPD

The Operational Classification of Severity is as

follows: Level I: ambulatory (outpatient), Level II: requiring hospitalisation, and Level III: acute respiratory failure.

The Operational Classification of Severity of COPD exacerbation

Level I
Clinical history
Co-morbid conditions History of frequent exacerbations Severity of COPD + + Mild/moderate +++ +++ Moderate/severe +++ +++ Severe

Level II

Level III

Physical findings
Haemodynamic evaluation Use accessory respiratory muscles, tachypnoea Persistent symptoms after initial therapy Stable Not present No Stable ++ ++ Stable/unstable +++ +++

Diagnostic procedures
Oxygen saturation Arterial blood gases Chest radiograph Blood tests Serum drug concentrations Sputum gram stain and culture Electrocardiogram Yes No No No If applicable No No Yes Yes Yes Yes If applicable Yes Yes Yes Yes Yes Yes If applicable Yes Yes

Level I: outpatient treatment

Patient education
Check inhalation technique Consider use of spacer devices

Bronchodilators
Short-acting 2-agonist and/or ipratropium MDI with spacer or hand-held nebulizer as needed Consider adding long-acting bronchodilator if patient is not already using it.

Corticosteroids (the actual dose may vary)

Prednisone 3040 mg per os q day for 10 days Consider using an inhaled corticosteroid

Antibiotics
May be initiated in patients with altered sputum characteristics Choice should be based on local bacteria resistance patterns - Amoxicillin/ampicillin, cephalosporins - Doxycycline - Macrolides If the patient has failed prior antibiotic therapy consider: - Amoxicillin/clavulanate - Respiratory fluoroquinolones

Level II: treatment for hospitalised patient

Bronchodilators
-Short acting 2-agonist (albuterol, salbutamol) and/or -Ipratropium MDI with spacer or hand-held nebuliser as needed

Supplemental oxygen (if saturation <90% )

Low flow oxygen supplementation to avoid supression of hypoxic drive.

Corticosteroids
-If patient tolerates, prednisone 3040 mg per os q day for 10 days -If patient can not tolerate oral intake, equivalent dose i.v. for up to 14 days -Consider use inhaled corticosteroids by MDI or hand-held nebulizer

Antibiotics (based on local bacterial resistance patterns)

-May be initiated in patients who have a change in their sputum characteristics (purulence and/or volume) -Choice should be based on local bacterial resistance patterns - Amoxicillin/clavulanate - Respiratory fluoroquinolones (moxifloxacin, levofloxacin, gatifloxacin) -If Pseudomonas spp. and/or other Enterobactereaces spp. are suspected, consider combination therapy

Level III: treatment in patients requiring special or intensive care unit

Supplemental oxygen Ventilatory support

Bronchodilators
-Short-acting 2-agonist (albuterol, salbutamol) and ipratropium MDI with spacer, two puffs every 24 h, or Tiotropium bromide DPI once daily. -If the patient is on the ventilator, consider MDI administration, consider long-acting -agonist

Corticosteroids
-If patient tolerates oral medications, prednisone 3040 mg per os q day for 10 days. -If patient can not tolerate, give the equivalent dose i.v. for up to 14 days. -Consider use inhaled corticosteroids by MDI or hand-held nebulizer.

Antibiotics (based on local bacterial resistance patterns)

-Choice should be based on local bacterial resistance patterns - Amoxicillin/clavulanate - Respiratory fluoroquinolones (gatifloxacin, levofloxacin, moxifloxacin) -If Pseudomonas spp. and or other Enterobactereaces spp. are suspected, consider combination therapy

Indications for ICU Admission

Severe dyspnea that responds inadequately to initial

emergency therapy. Confusion, lethargy, coma. Persistent or worsening hypoxemia (PaO2 < 5.3 kPa, 40 mm Hg), and/or severe/worsening hypercapnia (PaCO2 > 8.0 kPa, 60 mm Hg), and/or severe/worsening respiratory acidosis (pH < 7.25) despite supplemental oxygen and NIPPV.