The document presents a detailed case study of a 55-year-old male patient with COPD, highlighting his medical history, current medications, and presenting symptoms. It discusses the management of COPD exacerbation based on established GOLD guidelines and outlines various treatment options, including medications, lifestyle changes, and the importance of exercise therapy. Key points include the need for personalized treatment plans and the role of systemic corticosteroids and bronchodilators in managing exacerbations.

1. COPD Case Presentation
Farah Al Souheil, PharmD, RPh
Lebanese International University, Faculty of Pharmacy

2. Patient
presentation
Gold Guideline
Summary
COPD
Exacerbation
Care Plan
Smoking
Cessation
Newly
approved drugs
for COPD
References

3. CC:
• SOB and cough and subjective fever for 2 days
HPI:
• AG is a 55 yo male presenting to the ER clinic with
cough and SOB. No chest pain, NV, chills. Patient was
hospitalized 7 days prior to admission to R/O ACS

4. PMH:
• DMII for 2 years
• Metformin
• HTN
• Lisinopril (possible dry cough), Metoprolol
(possible bronchoconstriction)
• Dyslipidemia
• Pravastatin (possible anti-inflammatory
benefit in COPD)
• COPD
• ICS: fluticasone and LABA: salmeterol and
SABA: Albuterol
• HCV (not targeted)
• Seizure (last was 2 weeks ago)
• CVA 2 years ago
• Aspirin
• CHD (MI)
• Aspirin, Metoprolol, Pravastatin
Current medications:
• Metformin 500mg PO BID
• Lisinopril 5mg PO BID
• Aspirin 81mg QD
• Pravachol 40mg qHS
• Metoprolol 12.5 PO daily
• Advair 250/50 mg one puff BID (fluticasone
and salmeterol)
• Tamiflu 75mg PO BID for 1 day
• Albuterol HFA 2 puffs q 4-6 hr prn

5. SH:
• Tobacco 2-3 packs per day for 30 yrs (60-90 pack year)
• Etoh 2-4 beers for 3-4d/week
• Heroin and cocaine for 30 years (DC 5 years ago)

6. General: fatigue & fever
Skin: no rash, sores, itching, dryness
HEENT: pain around rt eye ( no recent injury), dizzy, blurred vision/ no hearing changes, tinnitus,
no dry mouth, hoarseness, congestion
Neck: no lumps or swollen glands or pain or stiffness
Respiratory: SOB and dry cough. Expiratory wheezes present in R&L upper & middle lobes
Cardiac: no chest pain, no palpitations, edema
GI: no trouble swallowing, heart burn, abd pain, jaundice, normal bowel sounds
Urinary: no polyuria or nocturia
Genital: no testicular pain or mass
Extremities: no varicose veins or leg cramps
Muscoloskeletal: limited in motion during inspiration
Psychiatric: no changes in mood or anxiety
Neurologic: seizure

7. Vitals:
• pulse 80-85, RR:17-20 BP: 95-129/ 58-73
General:
• Overweight (include in the plan)
HEENT:
• Visual acuity 20/20 in both eyes
• Poor dentition
• No tonsillar erythema or exudate
• No JVD

8. CXR: (done)
• RLL infiltrate
• No acute pulmonary pleuritic dx
• Left Hemi-diaphragm elevated
Echocardiogram: (not done)
• Aids in the differential diagnosis
• R/O right-heart hypertrophy, arrhythmias, and ischemic
episodes

9. Hgb: 14.4
Hct: 41.6
Plt: 157
Rbc: 4.4
Na: 137
K: 4.3
Cl: 102
Ca: 10 ( corrected Ca= 10+
0.8 (4-alb) =10.72) inc
Albumin: 3.1 dec
Scr: 0.8
Alk phosph 47
MISSED:
HBA1C
FBG
CBC-d
CRP
Spirometry measurements are
not accurate during an acute
exacerbation
ABG
• pH 7.41 pco2 42 po2 47 hco3 26
• Check for resp acidosis
Systemic inflammation
• Susceptibility to exacerbations is attributed to a genetic variance in the CCL1 gene(
encodes for chemotactic factors)
• CRP level, in the presence of a major exacerbation symptom, has been the most
effective biomarker for differentiating exacerbations from day-to-day symptom
variations, but it is not helpful in predicting severity
• Elevated fibrinogen levels(>400), is predictive for the occurrence of moderate-to-
severe exacerbations)

10. Azithromycin
500mg PO daily
(choice of Abx
and dosing?)
Atrovent
albuterol HFA
q4hrs
Advair 250/50
bid
Prednisone 60mg
PO qd
Lisinopril
5mg PO
BID
Metoprolol
25mg PO
qd
(selective)
Low
sodium diet
Metformin
500mg PO
BID
SSI
2200 kcal
ADA diet
Enoxaparin
40mg SQ
daily
(COPD inc
the risk of
DVT)
Famotidine
20mg po
BID
Phenytoin LD
then 400 mg
PO daily
+vit D
(prevent
osteoporesis)
Seizure
precautions
(smoking
cessation
medi-cations)
Pravastatin
40 mg PO
qd
Low fat
diet
Nicotine
transdermal
patch
21/24hr qd
(right
choce?)
Famotidine
20 mg po
bid
Alpha
fetoprotein
HCV viral
load
pending

11. Case
discussion

12. COPD
• Onset in
mid life
• Hx of
tobacco
use
Asthma
• Onset
early in
life
• Sx vary
on a day-
day basis
• Sx worse
at
night/earl
y morning
• Presence
of
allery/rhin
itis/eczem
a
• Obesity
• Family hx
CHF
• Dilated
heart on
CXR
• Volume
restriction
not
airflow
limitation
by PFTs
Bronchiect-
asis
• Purulent
sputum
• Associate
d with
bacterial
infections
• CXR:
brochial
dilation or
thickening
of the
wall
TB
• CXR:
lung
infiltrates
• Confirme
d by
microbiol
ogy
Obliterative
bronchiolitis
• Hx of RA
• Post Bone
marrow
transplant
Diffuse
panbronchiolitis
• Chronic
sinusitis
• CXR:
small
nodular
opacities
and
hyperinfla
tion

13.  Definition:
• Change in the patient's baseline dyspnea, cough, and/or sputum
• The most important sign of a severe exacerbation is a change in the
mental status of the patient
 Risks for severe COPD Exacerbation
• Altered mental status
• ≥ 3 exacerbations in the last year
• BMI≤20
• Comorbidities
 MI, heart failure, DM, pneumonia, renal or hepatic failure
• Poor performance status
• Marked change in VS
• Severe baseline COPD (FEV1<50%)
• Use of home oxygen therapy
• Other pertinent laboratory tests

14. Haemophilus influenzae
Streptococcus pneumoniae
Moraxella catarrhalis
Pseudomonas aeruginosa
• Isolated from patients with severe disease (who require
mechanical ventilation, have extremely low forced
expiratory volume in one second (FEV1), and have used
systemic steroids and/or antibiotics within the
preceding months)

15. Indications:
• Comorbidities
• Respiratory acidosis
• Older age
• Severe COPD
• Marked increase in
sputum
• Need for ventilation
• Onset of new
signs(edema,cyanosis)
ICU admission:
• Severe non responsive
dyspnea
• Altered mental status
• Need for invasive
ventilation
• Hemodynamic
instability
• Respiratory acidosis,
hypoxemia,
hypercapnia not
responsive to NIV
Actions:
• Monitor for dyspnea
and hypoxemia
• Confirm the relief of
bronchospasm
(improvement in
expiratory flow rate
and volume)
• Chest physiotherapy
with
• Postural drainage,
intermittent positive
pressure breathing,
increased fluid
intake, aerosol mist
(normal saline)

16.  GOLD guidelines recommend 30-40mg prednisolone
qd for 10-14 days in COPD exacerbation
 Increase in FEV1 and shorter hospital stay
 PO vs IV
• Less incidence of hyperglycemia and insomnia with PO
• PO non inferior in efficacy
 Systemic versus ICS (budesonide)
• No difference in efficacy
• Fewer side effects
 For this patient:
• At risk for corticosteroids and IV access related complications
• Initiate 30mg PO prednisone qd
5-7days

17.  Trimethoprim-sulfamethoxazole should not be
used due to increasing pneumococcal resistance
 Amoxicillin and first-generation cephalosporins
are not recommended due to beta-lactamase
susceptibility
 Erythromycin is not recommended due to
insufficient activity against H influenzae
 Decrease the risk of relapse or treatment failure
 Indicated if 2 of the following:
• Increased dyspnea
• Increased sputum volume/ viscosity
• Increased sputum purulence

18. 5-7days
<2 per year
>2 per year
FEV1<30% predicted
Broad spectrum Ab in last 3 months
Bronchioctasis on CT scan
>2 per year
Cefuroxime,cefdinir,
cefpodoxime

19.  In hospital: improve survival in people with chronic
hypoxaemia
 Out-patient: recommended for patients with very severe
COPD (PaO2<55 mmHg or spO2<88%) and the goal of
therapy is to preserve the function of vital organs by
increasing the PaO2 to ≥60 mmHg and spO2 to ≥90%
 Increase survival in severe resting chronic hypoxemia
 No effect on survival in moderate resting chronic
hypoxemia and exercise induced hypoxemia
 Low dose long acting PO & IV opiods may be indicated
to treat dyspnea caused by severe COPD

20. Indications:
• Respiratory arrest
• Cardiovascular instability
• High aspiration risk
• Extreme obesity
• Impaired mental status
• Not responding to NIV

21. Post short acting bronchodilator
FEV1/FVC <0.7 -> COPD
Assessment of airflow limitation
FEV1≥80 mild
50≤FEV1<80 moderate
30≤FEV1<50 severe
FEV1<30 very severe
Assessment of symptoms and risk of
exacerbation
0/1 exacerbation not leading to
hospitalization -> A/B
•mMRC 0-1 or CAT<10 A
•Otherwise B
≥2 or 1 exacerbation leading to
hospitalization -> C/D
• mMRC 0-1 or CAT<10 C
•Otherwise D
GOLD classification based on assessment of symptoms and
future risk of exacerbations

23.  SABA:
• Fenoterol, Albuterol, levalbuterol( longer acting), terbutaline
• Preferred brochodilator (q4hrs)
• MDI & DPI are as effective as nebulization therapy and
favored due to reasons of cost and convenience, even in the
hospital setting
 If not effective, add SAMA q6hr
• Ipratropium/ oxitropium (longer acting)
 SABA/SAMA:
• Ipratropium +
 Fenoterol
 Albuterol

24.  Decreases the number of exacerbations
 Slows the decline of QOL scores in patients with severe COPD
 Never taken alone
 Side effects: oral candidiasis, hoarseness and pneumonia
especially in smokers, age>55, hx of pneumonia, BMI<25,
severe airflow limitation

25. Formoterol has a faster onset of action and a greater peak bronchodilatory effect than
salmeterol. This may be a result of formoterol’s higher selectivity for the beta2 receptor
and lower lipophilicity
Formeterol + (budesonide/
beclomethasone/
momtasone)

26. ipratropium is not recommended for use with tiotropium, whereas SABAs and LABAs
may be used concomitantly

27. LABA Vilanterol QD
LAMA Revefenacin QD

28. Beta 2 agonists increase CAMP production in the lungs and decrease
calcium concentration (smooth muscle relaxation)
• Side efffects: sweating, hypokalemia, somatic tremor and sinus tachycardia
LAMAs are associated with a lower rate of exacerbations compared with
LABAs and better side effect profile
• Occasional uriary retention, no CV side effects,
The inhaler technique needs to be checked and a suitable device selected
If the patient doesn’t respond to optimizing inhaled medication and
continues to have 2-3 exacerbations/year
• Add additional options: pulmonary rehabilitation, a macrolide, theophylline,
phosphodieseterase (PDE4) inhibitor or N-acetylocysteine/carbocysteine

29. + Formeterol 2 puff bid / cough
LABA inc asthma deaths, UTI
+ tiotropium qd/ cough
Nasopharyngitis, backpain
+ indacaterol 1 tab bid /
nasopharangitis, HTN

30. Fluticasone,
umiclidinium,
vilanterol
Beclo-
methasone,
formeterol,
glyco-
perronium
DPI q24hrMDI q12hrs

31. After exacerbation step up to one of the
ICS/LABA/LAMA

32. Best choice of regular medication may be a
combination of inhaled corticosteroid and a
LABA
Guidelines suggest that
• Asthma component in asthma COPD overlap syndrome
should be the initial treatment target
• LABA alone should be avoided
• A trial of a LAMA is used if ICS is refused
• Both drugs reduce exacerbation rates

33. Non
pharmacologic
treatment

34.  Medical evaluation & disease management
(medication and proper use)
 Lifestyle (smoking cessation, physical activities
and exercise
 Co-morbid diseases
 Self-care and functional abilities & Frailty
• Dynamic state associated with decline of physiologic
reserves in multiple systems and inability to respond to
stressful insults
• Frailty assessment tools, such as the seven-point Clinical
Frailty Index

35. Reduces further decline in lung function will
Decreases the severity of exacerbations
Reduces cough & phlegm
Doesn’t inhibit exacerbations
Bupropion and COPD
Bupropion, varenicline and seizure

36. Varenicline
Bupropion SR
Nicotine gum, inhaler, nasal spray, lozenges,
patch
Highest rates of abstinence reported with
combination nicotine therapy (patch 21/24 hr +
gum 2mg q1-2hrs for 14 weeks

37. Exacerbations of
COPD are mainly
triggered by viral
URTI
Annual flu
immunization
reduces
exacerbations and
hospitalization when
flu is circulating
Pneumococcal
immunization:
Evidence for
reducing
exacerbations is
weak
PCV13 decrease
bacteremia in pts>65
PPSV23 decrease the
incidence of CAP in
COPD pts<65 and
FEV1< 40% or with
comorbidities

38.  Exercise training, education and behaviour change
 Improves symptoms, quality of life and reduces
hospital admission
 Moderate-to-very-severe COPD
 Most efficacious in patients who are symptomatic
(MRC dyspnoea scale 3 and above)
 Most effective in reducing exacerbations when
delivered early after an exacerbation (within 4
weeks)

39. Other
long term
options

40.  Theophyllines (pill) or aminophylline (solution)
 Given QD
 Limited data on supplemental effectiveness in COPD
and chronic bronchitis
 Prevent acute exacerbations
 Used with caution in this frail elderly man
 Potential side effects such as diarrhoea, nausea,
headache and weight loss
 Side effects tend to diminish over time
 Increase intracellular cAMP levels
 Second-line intravenous therapy for insufficient
response to inhaled short-acting bronchodilators
 Not recommended in exacerbation

41.  Roflumilast
 Orally QD
 No direct bronchodilator effects but anti-
inflammatory
 Decrease mod-severe exacerbations in patients
• Treated with systemic steroids
• Severe/very severe COPD
• Hx of exacerbations
 Side effects: diarrhea, wt loss, decreased appetite,
abd pain, sleep disturbance and headache

42.  Azithromycin (250mg qd or 500mg tiw) OR
erythromycin (500mg bid)
 Studied in COPD patients already treated with
inhaled therapies
 Decrease exacerbation over one year
 Potential for harm, such as QT prolongation ,
hearing loss and bacterial resistance
 Duration (beyond 1 year) and exact dosage of
macrolide therapy (for example, once daily versus
three times per week) are unknown
 Prevent acute exacerbations
 Used with caution in this frail elderly man

43. Erdosteine/ carbocysteine/ N-acetylcysteine
Orally BID
Prevent acute exacerbations
Used with caution in this frail elderly man
THERE’S NO EVIDENCE ABOUT THE
ROLE OF ANTITUSSIVES

44. No longer than 30 days after exacerbation
Improve FEV1 and oxygenation
Decrease hospital stay
Max for 5-7 days

45. Not recommended
Simvastatin doesn’t prevent COPD
exacerbations
If used for other indication can have positive
outcomes on COPD

46. Used as add-on therapy for patients with severe asthma
and blood eosinophil counts ≥300 cells/microL
In two parallel RCT
Over 3900 patients with moderate to very severe COPD
and frequent exacerbations, benralizumab did not reduce
the annualized rate of exacerbations relative to placebo,
(even if eosinophil counts ≥220 cells/microL)
In a post hoc analysis,
patients with (≥3 exacerbations in the previous year,
using triple inhaler therapy, and blood eosinophilia)
experienced a 30 % reduction in exacerbations with
benralizumab at the highest dose compared with placebo
IL-5 receptor Mab
May 28, 2019

47. Goldcopd.org
Up-to-date
Medscape