COPD Exacerbation

Brian Haimerl

Etiology: infection (~70%; viral more often than bacterial), allergens, pollution, seasonal variations (colder temperatures) PE Presentation: acute increase/worsening (≤ 14d) in 1 or more "cardinal symptom" (cough, sputum production/purulence, dyspnea) 

  • Often associated with tachypnea, tachycardia, and diffuse wheezing
  • Confounders/contributors: Pts with COPD can have other causes of respiratory distress including ACS, decompensated heart failure, PE, PNA, PTX, sepsis, acidosis

Evaluation 

  • Initial Assessment: ABCs
    • Airway: Ensure pt is protecting airway
  • CO2 narcosis can impair consciousness
    • Breathing: focus on respiratory status
      • Evaluate for wheezes, rales, rhonchi, stridor, air movement, and work of breathing
      • Severe respiratory insufficiency: accessory muscle use, fragmented speech, inability to lie supine, diaphoresis, agitation, asynchrony between chest and abdominal wall with respiration, failure to improve with initial emergency treatment
      • Impending respiratory arrest: Inability to maintain respiratory effort, cyanosis, hemodynamic instability, and depressed mental status
    • Circulation
      • Assess for signs of hemodynamic instability (hypotension, severe tachycardia or tachypnea, cold vs warm extremities, capillary refill, mental status)
  • Subsequent Workup:
    • Labs: ABG/VBG, CBC, CMP, troponin, BNP, sputum cx, RPP, blood cultures
    • Imaging: CXR, POCUS (assess for lung slide, B-lines),
    • Consider:
      • Lactate, procalcitonin, urine Legionella, fungal workup in select pts
      • Extremity Doppler US (Assess for DVT)
      • CTA PE: Not recommended for every pt admitted for COPD exacerbation; use clinical judgement and scoring tools (Well's Criteria) to make clinical decision; studies show up to 25% of patients admitted for AECOPD have concurrent PE

Management 

  • Supplemental O2: target saturation 88-92% for everyone
    • BiPAP typically appropriate for severe COPD exacerbation unless contraindication (vomiting, obtundation, facial trauma)
      • BiPAP is ordered as IPAP and EPAP, 12/5 is often a good start
    • If obtunded, in severe respiratory distress, hemodynamic instability →intubation
  • Bronchodilators/Inhalers
    • Order “Respiratory Care Therapy Management Protocol” at VUMC
      • RT evaluates the pt and based on physical exam will give a duoneb. Continues to assess the pt and treats based on severity of the exacerbation
    • If ordering bronchodilators individually:
      • Albuterol 2.5 mg diluted to 3 mL via nebulizer or 4 to 8 inhalations from MDI every 4 hours while awake (RT) or more frequently if needed
      • Ipratropium 500 mcg via nebulizer, or 4-8 inhalations from MDI q4 hrs while awake
      • Preferred is Duoneb (albuterol and ipratropium) q4-6 hours at VUMC
      • There is no respiratory order protocol at the VA, order individually as above
    • Home Inhalers: Usually continue home long-acting bronchodilators (LABA/LAMA) w/ or w/o ICS during exacerbations unless receiving frequent scheduled nebs (per GOLD 2023)
  • Steroids: Indicated for moderate to severe exacerbations (almost anyone being admitted)
    • IV vs. PO: studies have shown no significant differences in treatment failure, mortality, hospital readmissions, or LOS between IV or PO
    • Generally, PO prednisone 40mg x5d is appropriate
    • In severe exacerbations, may receive IV methylprednisolone 125mg in ER (this will count as day 1 when converting to PO prednisone)
    • Consider steroid taper if pt has not substantially recovered, has frequent exacerbations,
  • Antibiotics: Recommended by GOLD guidelines if all 3 cardinal symptoms or 2 if one is purulent sputum
    • Azithromycin (500mg x 1 then 250mg daily x 4 or 500mg daily x 3) or doxycycline 100 mg BID if concern for QT prolongation. Can consider respiratory fluroquinolone in certain high-risk pts
      • Pseudomonal coverage if: chronic colonization or infection past 12mo, FEV1 <30% predicted, bronchiectasis, BSA use w/in past 3mo, chronic systemic glucocorticoid use
    • Refer to Pneumonia in Infection Disease chapter if treating concomitant pneumonia
  • Other Inpatient Therapies
    • Magnesium: Often used In the ED (2g IV mag sulfate), though not great data. Has bronchodilator activity and reduced hospitalizations when used in stable COPD pts
      • Reasonable to give as low risk (consider renal insufficiency or myasthenia patients)
    • Pulmonary Hygiene: consider guaifenesin / other airway clearance therapy
  • Discharge Planning:
    • Controller medications/inhalers (see COPD in Outpt chapter)
      • Make sure any new inhalers are covered by insurance prior to discharge
      • Provide inhaler education and consider use of a spacer
    • Vaccinations (influenza, COVID, pneumococcal, RSV)
    • Early follow-up w/ COPD provider (w/in 1mo) -- Increased 90d mortality for those who do not attend early f/u
      • Fellows will often arrange early outpatient follow up if on a pulmonary service
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