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Acute Exacerbation of Chronic Obstructive Pulmonary Disease

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									Acute Exacerbation of Chronic
   Obstructive Pulmonary
          Disease.


        Prof. Ashraf M. Hatem, MD, FCCP
Definition of Acute exacerbation:
• The definition of COPD exacerbation is an
  acute change in a patient’s baseline
  dyspnoea, cough and/or sputum beyond
  day-to-day variability sufficient to warrant a
  change in therapy.
• Causes of exacerbation can be both
  infectious and non-infectious e.g. air
  pollution.
• Most commonly encountered organisms:

 -Streptococcus pneumoniae

 -Hemophilus influenzae

 -Moraxella catarrhalis

• The cause in one third of exacerbations
  remains unidentified
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          Level II         Level III
Clinical history
     Co-morbid conditions                              +              +++               +++
     History of frequent exacerbations                 +              +++               +++
     Severity of COPD                            Mild/moderate   Moderate/severe       Severe

Physical findings
     Haemodynamic evaluation                        Stable            Stable       Stable/unstable
     Use accessory respiratory muscles,           Not present           ++               +++
     tachypnoea                                       No                ++               +++
     Persistent symptoms after initial therapy
Diagnostic procedures
     Oxygen saturation                                Yes               Yes              Yes
     Arterial blood gases                             No                Yes              Yes
     Chest radiograph                                 No                Yes              Yes
     Blood tests                                      No                Yes              Yes
     Serum drug concentrations                   If applicable     If applicable    If applicable
     Sputum gram stain and culture                    No                Yes              Yes
     Electrocardiogram                                No                Yes              Yes
• 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
    Level I: outpatient treatment
Patient education
   Check inhalation technique
   Consider use of spacer devices

Bronchodilators
   Short-acting β2-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 30–40 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 β2-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 30–40 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 β2-agonist (albuterol, salbutamol) and ipratropium MDI with spacer, two puffs every
     2–4 h, or Tiotropium bromide DPI once daily.
    -If the patient is on the ventilator, consider MDI administration, consider long-acting β-agonist


Corticosteroids
    -If patient tolerates oral medications, prednisone 30–40 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
    In-patient Oxygen Therapy
• The goal is to prevent tissue hypoxia by
  maintaining arterial oxygen saturation (Sa,O2)
  at >90%.

• Main delivery devices include nasal cannula and
  venturi mask.

• Alternative delivery devices include
  nonrebreather mask, reservoir cannula, nasal
  cannula or transtracheal catheter.
• Arterial blood gases should be monitored
  for arterial oxygen tension (Pa,O2), arterial
  carbon dioxide tension (Pa,CO2) and pH.

• Arterial oxygen saturation as measured by
  pulse oximetry (Sp,O2) should be
  monitored for trending and adjusting
  oxygen settings.
• Prevention of tissue hypoxia supersedes
  CO2 retention concerns.

• If CO2 retention occurs, monitor for
  acidosis.

• If acidaemia occurs, consider mechanical
  ventilation.
 MEASURES TO MOBILIZE AIRWAY SECRETIONS
   IN HOSPITALIZED PATIENTS WITH COPD

• Directed coughing, “huff coughing.” Benefit
  extrapolated from experience in cystic fibrosis
• Chest physiotherapy: manual or mechanical chest
  percussion     and     postural   drainage.     Benefit
  extrapolated from experience in cystic fibrosis. Can
  cause transient fall in FEVI. Assumed role limited to
  patients with > 25 ml sputum per day or lobar
  atelectasis from mucus plugging
• Intermittent positive pressure breathing (IPPB). Not
  indicated; no proven benefit In COPD
• Positive expiratory pressure (PEP). Benefit
  extrapolated from experience in cystic fibrosis. No
  reported experience in acute exacerbations of COPD.
• Bland aerosol therapy. No demonstrated benefit
  in COPD unless artificial airway is in place. May
  cause bronchospasm in nonintubated patients.
• Systemic hydration. No demonstrated benefit
  beyond repletion of intravascular volume to
  euvolemia.
• Nasotracheal suctioning. Limited benefit;
  tolerated only for short periods
• Mini-tracheotomy. Possible temporary benefit in
  patients with persistent airway secretions
  causing respiratory deterioration.
  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.
Assisted ventilation
• Noninvasive positive pressure ventilation
  (NPPV) should be offered to patients with
  exacerbations when, after optimal medical
  therapy and oxygenation, respiratory
  acidosis (pH <7.36) and or excessive
  breathlessness persist. All patients
  considered for mechanical ventilation
  should have arterial blood gases
  measured.
• If pH <7.30, NPPV should be delivered
  under controlled environments such as
  intermediate intensive care units (ICUs)
  and/or high-dependency units.

• If pH <7.30, NPPV should be delivered
  under controlled environments such as
  intermediate intensive care units (ICUs)
  and/or high-dependency units.
• If pH <7.25, NPPV should be administered in the
  ICU and intubation should be readily available.
• The combination of some continuous positive
  airway pressure (CPAP) (e.g. 4–8 cmH2O) and
  pressure support ventilation (PSV) (e.g. 10–15
  cmH2O) provides the most effective mode of
  NPPV.
• Patients meeting exclusion criteria should be
  considered for immediate intubation and ICU
  admission.
• Exclusion criteria include:
   – respiratory arrest,
   – cardiovascular instability,
   – impaired mental status,
   – somnolence,
   – inability to cooperate,
   – copious and/or viscous secretions with high aspiration risk,
   – recent facial or gastro-oesophageal surgery; craniofacial trauma
     and/or fixed naso-pharyngeal abnormality,
   – burns,
   – extreme obesity.

• In the first hours, NPPV requires the same level of
  assistance as conventional mechanical ventilation.
Non-rebreather Oxygen Mask
     Indications for Mechanical
              Ventilation
• Severe dyspnea with use of accessory
  muscles an paradoxical abdominal motion.
• Respiratory frequency > 35 breaths per
  minute.
• Life-threatening hypoxemia (PaO2 < 5.3
  kPa, 40 mm Hg or PaO2/FiO2 < 200 mm
  Hg).
• Severe acidosis (pH < 7.25) and
  hypercapnia (PaCO2 > 8.0 kPa, 60 mm
  Hg).
• Respiratory arrest.
• Somnolence, impaired mental status.
• Cardiovascular complications
  (hypotension, shock, heart failure).
• Other complications (metabolic
  abnormalities, sepsis, pneumonia,
  pulmonary embolism, barotrauma,
  massive pleural effusion).
• NIPPV failure (or contraindication to
  NIPPV).
       Mechanical Ventilation
• Assisted ventilation should be considered for
  patients with acute exacerbations of COPD
  when pharmacologic and other nonventilatory
  treatments fail to reverse clinically significant
  respiratory failure.
• The clinician must aim to avoid complications
  associated with mechanical ventilation and
  should initiate weaning and discontinuation of
  mechanical ventilation as soon as possible.
• The main goals of assisted positive
  pressure ventilation in acute respiratory
  failure complicating COPD are:
      - Resting of ventilatory muscles, and
      - Restoration of gas exchange to a
        stable baseline.
• Allow for permissive hypercapnea (except
  in cerebral edema, myocardial ischemia,
  LVF….)
• There are three specific pitfalls in ventilating
  patients with COPD:
     i- Overventilation, resulting in acute respiratory
          alkalemia,
     ii- Initiation of complex pulmonary and
                 cardiovascular interactions that may
  result in      systemic ypotension.
     iii- Creation of intrinsic positive end-expiratory
          pressure (PEEP), or “auto-PEEP,” especially if
          expiratory time is inadequate or if dynamic
          airflow obstruction exists
• The three ventilatory modes most widely used for
  managing patients with COPD are:
      - Assist-control ventilation (ACV),
      - Intermittent mandatory ventilation (IMV), and
      - Pressure support ventilation (PSV).
• PSV provides increased patient comfort,
  promotes patient synchrony with the ventilator,
  and facilitate weaning from mechanical ventilation
  in the patient who maintains adequate ventilatory
  drive.
                 GOLD Guidelines:
                 Treatment of COPD
Stage   0: At   I: Mild       II:            III: Severe IV: Very Severe
        Risk                  Moderate
                          Avoidance of risk factor(s); influenza vaccination

                            Add short-acting bronchodilator when needed
                                    Add regular treatment with one or
                                    more long-acting bronchodilators
                                    Add rehabilitation
                                             Add inhaled glucocorticids
                                              if repeated exacerbations
                                                          Add long-term
                                                       oxygen if chronic
                                                       respiratory failure
                                                       Consider surgical
                                                       treatments
Discharge Criteria for Patients With
     Exacerbations of COPD
• Inhaled ß2-agonist therapy is required no
  more frequently than every 4 hrs.
• Patient, if previously ambulatory, is able to
  walk across room.
• Patient is able to 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.
     Strategies to Help the Patient
     Willing to Quit Smoking (5 As)
• ASK: Systematically identify all tobacco users at every visit.
  Implement an office-wide system that ensures that, for EVERY
  patient at EVERY clinic visit, tobacco-use status is queried and
  documented.
• ADVISE: Strongly urge all tobacco users to quit. In a clear, strong,
  and personalized manner, urge every tobacco user to quit.
• ASSESS: Determine willingness to make a quit attempt. Ask every
  tobacco user if he or she is willing to make a quit attempt at this time
  (e.g., within the next 30 days).
• ASSIST: Aid the patient in quitting. Help the patient with a quit plan;
  provide practical counseling; provide intra-treatment social support;
  help the patient obtain extra-treatment social support; recommend
  use of approved pharmacotherapy except in special circumstances;
  provide supplementary materials.
• ARRANGE: Schedule follow-up contact. Schedule follow-up
  contact, either in person or via telephone.
  Long Term Oxygen Therapy
• Oxygen administration >15 hours/day.
• Indications:
     - PaO2 < 55 mmHg or SaO2 < 88%
     - PaO2 55-60 mmHg or SaO2 > 89%
       if there is evidence of Pulmonary
       hypertension, CHF, or Polythycemia
       (Hematocrit > 55%)
     Pulmonary Rehabilitation
• Goals:
  - Reduce symptoms
  - Improve QOL
  - Promote physical and emotional
    participation in every day life
• Program should be at least 2 months.
• Aim is to strengthen inspiratory muscles
  and increase endurance.
        Surgical Treatment
• Bullectomy
• LVRS and Bronchoscopic volume
  reduction
• Lung transplantation
    Assessment 4-6 Weeks After
      Discharge from Hospital
• Ability to cope in usual environment.
• Measurement of FEV1.
• Reassessment of inhaler technique.
• Understanding of recommended treatment
  regimen.
• Need for long-term oxygen therapy and/or
  home
• Nebulizer (for patients with very severe
  COPD).
THANK YOU

								
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