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 
    • Breathing: focus on respiratory status 
    • Evaluate for severe respiratory insufficiency/impending respiratory arrest (inability to maintain respiratory effort, cyanosis, hemodynamic instability, and depressed mental status) 
    • Circulation: Assess for signs of hemodynamic instability 
  • 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 
  • Extremity Doppler US (Assess for DVT) 
  • CTA PE: 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 unless contraindication (vomiting, obtundation, facial trauma) 
    • 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 and treats w duonebs based on severity of the exacerbation 
    • If ordering bronchodilators individually: 
    • Albuterol 2.5 mg nebs or 4-8 puff via MDI, q4h or more 
    • Ipratropium 500 mcg nebs or 4-8 puffs via MDI q4h 
    • 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: no significant differences in treatment failure, mortality, hospital readmissions, or LOS 
    • Generally, PO prednisone 40mg x5d is appropriate 
    • IV methylprednisolone 125mg in ER when severe (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 
    • Otherwise, order Post-Hospital Follow Up for COPD clinic on discharge. They will be seen within 2 weeks
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