5. 5
Definition of Acute COPD Exacerbation
An exacerbation of chronic obstructive pulmonary disease
(COPD) is an acute increase in symptoms beyond normal
day-to-day variation.
This generally includes an acute increase in one or more of
the following cardinal symptoms:
1. Cough increases in frequency and severity
2. Sputum production increases in volume and/or
changes character (more purulent)
3. Dyspnea increases
8. Impact of COPD exacerbation
Increased symptoms
Reduced lung function
Accelerate lung function
decline
Deteriorate quality of life
Increased economic cost
Increased mortality
Impact of
acute
exacerabations in
COPD
“an acute event characterized by worsening
of respiratory symptoms that is beyond
normal day-to-day variations and leads to a
change in medication.”
GOLD Strategy Document 2014 (http://www.goldcopd.org/)
9. 1. Donaldson et al. Thorax 2002;57:847-52.
2 Donaldson et al. Eur Respir J 2003;22:931-6.
3. Seemungal et al. Am J Respir Crit Care Med 1998;157:1418-22.
4. Groenewegen et al. Chest 2003;124:459-67.
5. Soler-Cataluna et al. Thorax 2005;60:925-31.
Exacerbations Drive Morbidity and Mortality
COPD exacerbations lead to:
Increased symptoms
(breathlessness)2
Increased risk
of hospitalization4
Increased risk of mortality
4,5
Decline in lung function1
Worsening health status3
12. 12
7
18
33
22
33
47
0
10
20
30
40
50
GOLD II
(N=945)
GOLD III
(N=900)
GOLD IV
(N=293)
%ofpatients
Hospitalised for exacerbation in yr 1 Frequent exacerbations (2 or more)
The ‘frequent exacerbator phenotype’:
Frequency/severity by GOLD Category ECLIPSE 1 year data
Frequent exacerbators (those reporting 2 or more exacerbations per year)
is more common in the very severe GOLD Category
18. 18
Most Common Infectious Causes of
COPD Exacerbations
Mild to moderate exacerbations
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Chlamydia pneumoniae
Mycoplasma pneumoniae
Viruses
Severe exacerbations
Pseudomonas species
Other gram-negative enteric
bacilli
19. 19
While the severity of exacerbation is increasing,
infecting microorganism profile shifts from
S.pneumoniae to Gram (-) enteric bacilli &
P.aeruginosa .
In patients with GOLD 3 and 4 severity, Pseudomonas
aeruginosa infection becomes an important pathogen .
21. 21
Diagnosis of COPD exacerbations relies exclusively on
the clinical presentation of the patient complaining of
an acute change of symptoms that is beyond normal
day-to-day variation.
27. 27
More than 80% of exacerbations can be
managed on an outpatient basis with
pharmacologic therapies including:
Bronchodilators
Corticosteroids
Antibiotics.
28. 28
At Home Treatment Plan
• ABC plan
-Antibiotic
-Bronchodilators
-Corticosteroid
32. 32
• The presence of purulent sputum during an
exacerbation can be sufficient indication for starting
empirical antibiotic treatment.
• The recommended length of antibiotic therapy is
usually 5-10 days .
• The choice of the antibiotic should be based on the
local bacterial resistance pattern.
33. 33
o Usual initial antibiotics for uncomplicated
COPD include :
Azithromycin
Clarithromycin,
Doxycycline,
Trimethoprim/sulfamethoxazole
Amoxicillin, with or without clavulanate.
34. 34
o In complicated COPD with risk factors:
Amoxicillin/clavulanate
Levofloxacin
Moxifloxacin
o Risk factors:
- Comorbid diseases
- Severe COPD (FEV1 less than 50% of
predicted) - More than 3
exacerbations/year -
Antibiotic use in past 3 months
35. 35
o If at risk of Pseudomonas infection :
High-dose levofloxacin (750 mg) or ciprofloxacin;
obtain sputum culture.
Risk factors:
- Four or more courses of antibiotics in past year
- Severe COPD (FEV1 less than 50% of
predicted) - Recent hospitalization (past 90
days) - isolation of
Pseudomonas during past hospitalization
36. 36
Optimal antibiotic therapy has not been determined
but should be based on local resistance patterns.
If Recent (less than 3 months) antibiotics, use
alternative class.
If exacerbation does not respond to initial antibiotic,
sputum culture and sensitivity should be performed.
40. 40
Inhaled bronchodilators (inhaled SABAs with or
without short-acting anticholinergics) are the
preferred treatment of COPD exacerbations.
a. Usual doses of albuterol are 2.5 mg via nebulizer every
1–4 hours as needed or 4–8 puffs by MDI with holding
chamber every 1–4 hours as needed.
b. Short-acting anticholinergics (ipratropium) are generally
added for acute exacerbation.
43. 43
In patients with a COPD exacerbation presenting
to the hospital, a shorter course of systemic
corticosteroids (5 days) was noninferior to a
longer (14 days) course with respect to re-
exacerbation within 6 months
46. Children’s Healthcare of Atlanta
Management of Exacerbations
Associated With COPD
The Global Initiative for Chronic Obstructive Lung Disease. GOLD Report—Global Strategy for the Diagnosis, Management,
and Prevention of Chronic Obstructive Pulmonary Disease. Updated 2009.
Slide ID: 24209
Steroids: acute exacerbation of COPD favorable results and substantial benefits
Improvement in wheezing, air flow
Improvement in abnormal mucus
Reduces treatment failure risk by 30%
Trial for 2-3 weeks if considering long term
Demonstrate 20-30% improvement FEV1
Response to oral steroids poor predictor respond to inhaled steroids
Treatments for exacerbations associated with COPD are chosen in part based on severity1
In mild to moderate COPD exacerbations, bronchodilator doses are increased or optimized when possible and patients are prescribed antibiotics and steroids (IV or PO)
As symptoms become more severe, patients are often hospitalized and may require ICU-assisted ventilation
Severity can be staged by level of healthcare utilization2
Mild=patient has an increased need for medication, which he or she can manage in his or her own normal environment
Moderate=patient has an increased need for medication and feels the need to seek additional medical assistance
Severe=patient/caregiver recognizes obvious and/or rapid deterioration, requiring hospitalization
References
The Global Initiative for Chronic Obstructive Lung Disease. GOLD Report—Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Updated 2009.
Rodriguez-Roisin R. Toward a consensus definition for COPD exacerbations. Chest. 2000;117(5 suppl 2):398S-401S.
