COPD Exacerbation Management

COPD Exacerbation – Taylor Coston

Background

  • Diffuse wheezing, distant breath sounds, barrel-shaped chest, tachypnea, tachycardia, smoking >20 pack years
  • Features of severe respiratory insufficiency: accessory muscle use; fragmented speech; inability to lie supine; profound diaphoresis; agitation; asynchrony between chest and abdominal motion with respiration; failure to improve with initial emergency treatment
  • Features of impending respiratory arrest: Inability to maintain respiratory effort, cyanosis, hemodynamic instability, and depressed mental status
  • Remember: Patients with COPD can have other causes of respiratory distress including acute coronary syndrome, decompensated heart failure, PE, PNA, PTX, sepsis, acidosis

 

Evaluation

  • Initial Assessment: ABCs
    • Airway/Breathing
      • Ensure patient is protecting airway. If obtunded or in severe respiratory distress (see above) call anesthesia early for consideration of endotracheal intubation. (If in the MICU during the day, just call the MICU fellow)
        • Noninvasive ventilation (NIV), particularly BiPAP: Appropriate for most patients with severe COPD exacerbation unless immediate intubation is needed or other contraindication (vomiting, too obtunded to take off mask if necessary, facial trauma). Necessitates MICU admission
        • Remember: BiPAP is ordered as IPAP and EPAP. I.e. if the pt is on 12/5 the mask will deliver a pressure of 12 when breathing in and 5 when breathing out.
        • 12/5 is a good start, in comments write “auto-titrate” and the RT will have some leeway to change settings
      • Immediate pharmacotherapy, in tandem with diagnostics and airway mgmt
    • Circulation
      • For hemodynamic instability, HR < 50, call anesthesia for immediate rapid sequence intubation (RSI). Pt’s can be hypotensive for a host of reasons including pneumothorax, sepsis, circulatory collapse from hypoxia and bradycardia, etc.
  • Subsequent Workup:
    • Continuous pulse oximetry, ABG/VBG, EKG, CXR, CBC, BMP, troponin, BNP (if considering HF dx), Sputum cx, consider blood cx if concern for sepsis, rapid flu.
    • Lung Ultrasound to differentiate COPD from pulmonary edema when a pt presents with wheezing and respiratory failure (pulmonary edema will have Kerley B lines)
    • During evaluation, consider triggers for COPD exacerbation: viral infection (70%), PNA, PE. Have a high index of suspicion for PE in these pts.

 

Management

  • Manage airway as above - many pts will need BiPAP if severe respiratory distress or hypercapnia are present
  • Bronchodilators
    • Order “Respiratory Care Therapy Management Protocol” at VUMC
    • When ordered, an RT evaluates the pt and based on physical exam will give a duoneb
    • The RT will then continue to assess the pt based on severity of the exacerbation
    • If ordering bronchodilators individually (this is discouraged) order:
      • 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 q 4 hrs while awake
      • Can additionally order "duoneb" at VUMC
      • There is no respiratory order protocol at the VA, order individually as above. RT is available to assess if needed
  • Steroids
    • For severe exacerbation give methylprednisolone 125 mg IV BID (or 60mg IV q6h)
    • For moderate to mild COPD exacerbations give prednisone 40mg PO daily for 5 days (including the initial IV dose if pt received one in the ER)
  • Antibiotics
    • Benefit less clear in mild to moderate exacerbations
    • Azithromycin 500mg x 1 then 250mg daily for 4 days or doxycycline 200 mg BID if concern for QT prolongation. Can also consider Levaquin 750mg PO daily for 5 days, however this is often too broad for a standard COPD exacerbation.
    • Refer to “Pneumonia” if treating a separate PNA in addition to COPD
  • Discharge Planning:
    • Teaching on medication compliance and appropriate use. Ensure pt has a spacer
    • Pulmonary Rehab
    • Vaccinations (see outpatient management COPD in handbook)
    • Controller medications/inhalers (see outpatient management COPD in handbook)
    • Exacerbation Action plans: No consensus as to what the components should be, but instead a patient-specific plan can be made should the pt’s symptoms recur