Management Of Exacerbations Of Chronic
Obstructive Pulmonary Disease
Seminar Training
Primary Care Asthma + COPD
03- 2015
D.Anan Esmail
Acute Exacerbations of COPD
Cough increases in frequency and
severity
Sputum production increases in
volume and/or changes character
Dyspnea increases
These episodes vary in severity from:
Mild exacerbations
• only one of the three cardinal symptoms
moderate to severe exacerbations
• at least two of the three cardinal
symptoms
HOME MANAGEMENT OF COPD
EXACERBATIONS
glucocorticoids
bronchodilator
Antibiotics
management of
COPD
EXACERBATIONS
mainstay of therapy of acute
exacerbation COPD
rapid onset of action
efficacy in producing
bronchodilation
administered by a metered dose inhaler
(MDI) with a spacer device
two inhalations by MDI every four to
six hours
Patients who already have a nebulizer
at home
administration of beta adrenergic agonists
via nebulizer is helpful during COPD
exacerbations
most studies have not supported a
greater effect from nebulizer treatments over
properly administered metered dose inhaler
medication
may be combined with a short acting
anticholinergic agent
combination therapy produces
bronchodilation in excess of that
achieved by either agent alone
Ipratropium bromide
an effective bronchodilator
for exacerbations of COPD
used in combination with
inhaled short-acting beta
adrenergic agonists
Ipratropium bromide
usual dose: two inhalations by
metered dose inhaler (MDI)
every four to six hours
glucocorticoids
bronchodilator
Antibiotics
management of
COPD
EXACERBATIONS
prednisone 40
mg per day
five days
the severity of
the
exacerbation
response to
prior courses of
glucocorticoids
higher dose
Longer course
The efficacy of inhaled glucocorticoids on
the course of a COPD exacerbation has
not been studied
should not be used as a substitute for
systemic glucocorticoid therapy in COPD
exacerbations
glucocorticoids
bronchodilator
Antibiotics
management of
COPD
EXACERBATIONS
guidelines recommend antibiotic therapy only
for:
patients have bacterial infection
guidelines recommend antibiotic therapy only
for:
moderate or severe
exacerbation of COPD
The initial antibiotic regimen should target
likely bacterial pathogens
Haemophilus
influenzae
Moraxella
catarrhalis
Streptococcus
pneumoniae
Pseudomonas risk factors:
- Frequent administration of antibiotics (4 or more
courses over the past year)
- Recent hospitalization (2 or more days' duration in
(Grade 2B)
the past 90 days)
- Isolation of Pseudomonas during a previous
hospitalization
- Severe underlying COPD (FEV1 <50 percent
predicted)
HOSPITAL MANAGEMENT OF
COPD EXACERBATIONS
glucocorticoids
bronchodilator
Antibiotics
management of
COPD
EXACERBATIONS
nebulizer
metered dose inhaler (MDI) with a spacer
device
• We favor nebulized therapy because
many patients with COPD have difficulty
using proper MDI technique in the setting of
an exacerbation
Beta adrenergic agonists
four to eight puffs
(90 mcg per puff)
every one to four
hours as needed
MDI with spacer
Beta adrenergic agonists
albuterol 2.5 mg
every one to four
hours as needed
nebulization
Beta adrenergic agonists
Increasing dose of
albuterol to 5 mg
does not have a
significant impact
on spirometry or
clinical outcomes
nebulization
Beta adrenergic agonists
continuously
nebulized beta
agonists have not
been shown to
confer an advantage
in COPD
nebulization
Beta adrenergic agonists
using air, rather
than oxygen-driven
bronchodilator
nebulization
nebulization
Anticholinergic agents
two to four puffs
(18 mcg per puff)
every four hours
as needed
MDI with spacer
Anticholinergic agents
Ipratropium 500
mcg every four
hours as needed
nebulization
improve symptoms and lung function
reduced treatment failure
decrease the length of hospital stay
Oral glucocorticoids
rapidly absorbed (peak serum levels
achieved at one hour after ingestion)
appear equally efficacious to
intravenous glucocorticoids
intravenous glucocorticoids
severe exacerbation
respond poorly to oral glucocorticoids
unable to take oral medication
impaired absorption (patients in
shock)
Dose
prednisone 40 mg once
daily
Dose
methylprednisolone 60
to 125 mg
two to four times daily
evidence favors using a moderate
rather than high dose of glucocorticoids
for most patients with an exacerbation of
COPD
higher dose: methylprednisolone >240
mg/day
•not associated with a mortality benefit
• shorter hospital and ICU lengths of
stay
The optimal duration of systemic
glucocorticoid therapy depends on the
severity of the exacerbation and the
observed response to therapy
(5 to 14 days(
longer duration
No additional benefit
more glucocorticoidrelated side effects
adverse effects
hyperglycimia
adverse effects
upper gastrointestinal bleeding
adverse effects
psychiatric disorders
Antibiotic treatment of acute
exacerbations of COPD (hospitalized)
Pseudomonas risk factors:
- Frequent administration of antibiotics (4 or more
courses over the past year)
- Recent hospitalization (2 or more days' duration in
the past 90 days)
- Isolation of Pseudomonas during a previous
hospitalization
- Severe underlying COPD (FEV1 <50 percent
predicted)
Thromboprophylaxis
• Hospitalization for exacerbations of COPD
increases the risk for deep venous
thrombosis and pulmonary embolism
cigar ette smoking cessa tion
nutritional suppor t
continuation of ongoing
supplemental oxygen therapy
• administration of supplemental
oxygen should target
 pulse oxygen sa tura tion ( SpO ) of
88 to 92 percent
• administration of supplemental
oxygen should target
 arterial oxygen tension ( PaO ) of
approxima tely 60 to 70 mmHg
A high FiO is not required to correct the
hypoxemia associated with most
exacerbations of COPD
the risk of prompting worsened
hypercapnia with excess
supplemental oxygen
Hypercapnia is generally well tolerated
in patients whose ( PaCO ) is
c hronically elevated
Adequate oxygenation to achieve an oxygen
saturation of 88 to 92 percent must be
assured, even if it leads to acute hypercapnia
mechanical ventilation may be required if
hypercapnia is associated with
• depressed mental status
• profound acidemia
• cardiac dysrhythmias
• Noninvasive ventila tion
 preferred method of ventila tor y
suppor t
 impr oves numer ous clinical outcomes
• Invasive ventila tion
 pa tients f ail NPPV
 do not toler a te NPPV
 ha ve contr aindica tions to NPPV
Contraindications for NPPV include the
following:
• respiratory arrest
• cardiovascular instability
• impaired mental status causing an inability to
cooperate
• copious and/or viscous secretions with high aspiration
risk
• recent facial or gastroesophageal surgery
• craniofacial trauma
• fixed nasopharyngeal abnormality
• Burns
• extreme obesity
not been shown to confer benefit for
patients with a COPD exacerbation
Mucoactive agents
mechanical techniques to augment sputum
clearance
Methylxanthines
• aminophylline and theophylline, are
considered second-line therapy for
exacerbations of COPD
• nausea and vomiting, tremor, palpitations,
arrhythmias
Nebulized magnesium
• no effect on FEV when added to nebulized
salbutamol (albuterol) in patients with
exacerbations of COPD
Subcutaneous injection of short-acting beta
adrenergic agonists (eg, terbutaline,
epinephrine) almost never used for COPD
exacerbations
(Arrhythmias , myocardial ischemia)
Exacerba tions of COPD ar e
associa ted with incr eased
mor tality (3 to 9 %)
Factors Associated With Increased
Mortality
Increased age - male gender
Severity of airway obstruction (FEV1)
prior hospitalization for COPD
Hypercapnia
urea >8 mmol/L
presence of Pseudomonas aeruginosa in the
patient’s sputum
• smoking cessa tion
• pulmonar y
r ehabilita tion
• vaccina tion
seasonal influenza
and pneumococcus
• proper use of
medica tions
(meter ed dose
inhaler technique)
use of an action plan
earlier recognition of an exacerbation
by the patient
earlier initiation of antibiotics
earlier initiation of glucocorticoids
Prophylactic antibiotics
• we suggest not administering antibiotic
prophylaxis For most patients with COPD