• More common in winter months
• Cold, damp climates
• Air pollution
• Cigarette smoke
• Most commonly caused by respiratory viruses
• Secondary bacterial infections

• M. pneumoniae
• C. pneumoniae
• B. pertussis

Other Possible Pathogens

• Streptococcus
• Staphylococcus
• Haemophilus
  

• Infection of trachea and bronchi
• Edematous mucus membranes
• Increased bronchial secretions
• Destruction of respiratory epithelium
• Impaired mucociliary activity

• Cough persisting > 5 days to weeks
• Coryza
• Sore throat
• Malaise
• Headache
• Fever rarely > 39 C

• Rhonchi or coarse, moist, bilateral rales
• Purulent sputum in ~50% of patients
• Chest X-Ray -- Normal

1.  Mild Analgesic/Anti-Pyretic Therapy

• Acetaminophen
• Ibuprofen

2.  Dextromethorphan

• For persistent, mild cough that is bothersome
• In general, avoid OTC products as they can dehydrate bronchial secretions and aggravate/prolong recovery

3.  Codeine

• Antitussive for severe coughs
• Avoid codeine in productive coughs

4.  Antibiotics

• Empiric therapy against suspected bacterial pathogens
• Avoid routine use

5.  Antivirals

• In case of viral epidemics, consider amantadine, rimantadine, zanamavir, or oseltamivir

• Increased neutrophils and eosinophils in sputum
• Poor gas exchange
• Increased muscle fatigue

• Bacterial/Viral Infection
• Indoor/Outdoor Air Pollution
• Smoking

• S. pneumoniae
• H. influenzae
• M. catarrhalis
  

3 Cardinal Symptoms

• INCREASED SOB
• INCREASED SPUTUM VOLUME
• INCREASED SPUTUM PURULENCE

• Wheezing and chest tightness
• Increased cough
• Fever
• Changes in mental status
• Decreased exercise tolerance
• Increased use of rapid-acting bronchodilators
• Nasal flaring
• Use of accessory muscles for respiration

Nonspecific:

• Tachycardia, tachypnea, fatigue, insomnia

Decrease PaO2 of 10-15 mmHg

+

SaO2 < 90%

+

PaO2 < 60 mmHg

AND

Increased PaCO2 that decreases serum pH < 7.3

Chest Radiography

• New infiltrates
• Limited value
• Useful for finding alternative diagnosis

Sputum Cultures

• Gram stain
• Cells (Neutrophils > 25, Epithelial < 10)
• Speciation and sensitivities
• Colonization?

• Pneumonia
• CHF
• AMI
• PE
• Pneumothorax
• Pleural Effusion
• Cardiac Arrhythmia

Mild

1 cardinal symptoms plus one of the following:

URTI within 5 days

Fever

Increased Wheezing

Cough

Tachypnea or Tachycardia

Moderate

2 Cardinal Symptoms

Severe

3 Cardinal Symptoms

Bronchodilator Therapy

Increase dose/frequency of home Beta agonists and/or anticholinergics

Glucocorticoids

Systemic, NOT inhaled

Prednisone 30-40 mg PO QD x 7-10 days

• CORNERSTONE of therapy

Goal Parameters:

SaO2 > 90%

+

PaO2 > 60 mmHg

SABA

• Albuterol = 1st line agent
• Albuterol 0.5% Sol'n Nebulizer, Albuterol MDI

Anticholinergic Agent

• Ipratropium
• Used concurrently or alternating with SABA
• Ipratropium 0.02% Sol'n Nebulizer, Ipratropium MDI

Combination SABA/Anticholinergic

• Albuterol/Ipratropium Nebulizer or MDI

COPD Exacerbation In-Hospital Management: Glucocorticoid Therapy

• For moderate to severe exacerbations
• Especially advantageous in patients who are wheezing
• Oral or IV --> as addition to other therapies
• Inhaled corticosteroids should NOT be used for treatment of acute exacerbation
• Methylprednisolone, Prednisone

Used in the following situations:

• 3 cardinal symptoms present
• 2 of 3 cardinal symptoms if increased purulence of sputum is one of the 2 symptoms
• Mechanical ventilation is needed

Should be empiric based therapy

Duration usually 7-10 days

If concerned for other respiratory pathogens (MRSA), cover those pathogens (Vanco, Linezolid)

De-escalation of therapy if pathogen identified

TMP/SMX, amoxicillin, 1st Gen Ceph, and Erythromycin should not be used due to resistance

COPD Exacerbation In-Hospital Antibiotic Management: Uncomplicated Exacerbations

Patient characteristics, Likely Pathogens, and Treatment

Patient Characteristics

• < 4 exacerbations/yr
• No comorbid illnesses
• FEV1 > 50% predicted

Likely Pathogens

• S. pneumoniae
• H. influenzae
• M. catarrhalis
• H. parainfluenza

Treatment

• Macrolide
• 2nd or 3rd Gen Ceph
• Beta Lactam/Beta-Lactamase Inhibitor

COPD Exacerbation In-Hospital Antibiotic Management: Complicated Exacerbations

Patient characteristics, Likely Pathogens, and Treatment

Patient Characteristics

• Age > 65 yr
• > 4 exacerbations/yr
• FEV1 < 50% but > 35% predicted

Likely Pathogens

• S. pneumoniae
• H. influenzae
• M. catarrhalis
• H. parainfluenza
• Drug resistant Pneumococci
• Beta-Lactamase producing H. influenzae, M. catarrhalis
• Some enteric G-

Treatment

• 2nd or 3rd Gen Ceph
• Beta Lactam/Beta-Lactamase Inhibitor
• Respiratory Fluoroquinolone

COPD Exacerbation In-Hospital Antibiotic Management: Complicated Exacerbations w/ Risk of Pseudomonas

Patient characteristics, Likely Pathogens, and Treatment

Patient Characteristics

• > 4 exacerbations/yr
• Chronic bronchial sepsis
• Chronic corticosteroid therapy
• Nursing home resident
• FEV < 35% predicted

Likely Pathogens

• S. pneumoniae
• H. influenzae
• M. catarrhalis
• H. parainfluenza
• Drug resistant Pneumococci
• Beta-Lactamase producing H. influenzae, M. catarrhalis
• Some enteric G-
• Pseudomonas

Treatment

• 3rd or 4th Gen Ceph w/ Pseudomonas activity
• Beta Lactam/Beta-Lactamase Inhibitor
• Fluoroquinolone

COPD Exacerbation: Non-Invasive Ventilatory Support

Indications, Relative Contraindications

• Positive pressure ventilation provided via face mask or nasal mask
• Common types -- BiPAP and CPAP
• FIRST LINE therapy -- improves resp. acidosis and decreases resp. rate, severity of breathlessness, length of hospital stay, and intubation rate

Indications for NIV:

• Moderate to severe dyspnea w/ use of accessory muscles and/or paradoxical abdominal motion
• Moderate to severe acidosis (pH < 7.35)
• Moderate to severe hypercapnea (PaCO2 > 45 mmHg)
• Resp. rate > 25 breaths/min

Relative CI:

• Respiratory arrest
• Cardiovascular instability
• Changes in mental status
• High aspiration risk
• Craniofacial trauma or recent craniofacial surgery

COPD Exacerbation: Invasive Ventilatory Support

Indications, Complications

Indications:

• Unable to tolerate NIV or NIV failure
• Severe dyspnea w/ use of accessory muscles and paradoxical abdominal motion
• Resp. rate > 35 breaths/min
• Life-threatening hypoxemia
• Severe acidosis (pH < 7.25) and/or hypercapnea (PaCO2 > 60 mmHg)
• Respiratory arrest
• Worsening mental status despite optimal therapy
• Cardiovascular complications (hypotension, shock)

Complications:

• Ventilator-Associated Pneumonia
• Barotrauma
• Failure to extubate from invasive ventilation

• Smoking Cessation
• Current vaccinations -- influenza and pneumococcal
• Patient education on current therapies
• Proper inhalation/nebulizer technique
• Education on recognizing symptoms of exacerbation

• Clinically stable for 12-24 hrs
• Arterial blood gas stable for 12-24 hrs
• Inhaled SABA needed < q 4 hrs
• Patient able to walk across room if ambulatory pre-hospitalization
• Patient able to eat and sleep w/o frequent interruption by dyspnea
• Patient/caregiver understands proper use of medications
• Follow-up and home care arrangements completed

• Assessment at 4-6 week F/U
• FEV1 measurements
• Reassessment of inhaler technique
• Understanding of current treatment regimens
• Need for long-term oxygen therapy and/or home nebulizer

• Baseline Dyspnea
• Lower BMI
• Older age
• CHF
• Development of extra-pulmonary organ failures
• Serum albumin levels
• Cor pulmonale
• Ventilation > 72 hrs