Management of AE COPD

1. Management of Acute Exacerbations of
COPD

2. COPD Exacerbation
 Defined as an event characterised by increased dyspnoea and/or cough and sputum
that worsens in <14 days and may be accompanied by tachypnoea and/or tachycardia.
An acute exacerbation of COPD is often associated with increased local and systemic
inflammation caused by infections, pollution, or other insult to the airway.
 An acute worsening of respiratory symptoms that results in additional therapy.
 Usually associated with: Increased airway inflammation, Increased mucus production, Marked
gas trapping. Symptoms : Increased dyspnea (key symptom) , increased sputum purulence and
volume, together with increased cough and wheeze.
 Exacerbations negatively impact health status, increase rates of hospitalization and readmission
and enhance disease progression.
 Goals in exacerbation management:
 Minimize the negative impact of the current exacerbation
 Prevent subsequent events
 Respiratory Tract Infection is most common precipitating cause for exacerbation.

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Exacerbation
symptoms are not
specific to COPD, and
hence relevant
differential diagnosis
should be considered.

4. Exacerbation Severity Assessment
 Exacerbations severity can be graded as mild/moderate/severe according to objectively
measured variables as below :
o Dyspnea Visual Analogue Scale (VAS) <5 or ≥ 5
o Oxygen Saturation. Resting SaO2 ≥ 92% OR <92% breathing ambient air / patient's usual oxygen
prescription and/or change in saturation >3 % from baseline
o Respiratory Rate (RR) <24 or ≥24 breaths per minute
o Heart Rate (HR) <95 or ≥ 95 beats per minute
o Serum C-reactive protein (CRP) <10 mg/L Or ≥10 mg/L
o Arteria Blood Gases (ABG) in few cases. Hypercapnia and acidosis on ABG (PaCO2 >45 mmHg
and pH <7.35)
o Mild: Exacerbation meeting any of the above criteria
o Moderate: Three out of above first five criteria fulfilled
o Severe: Meets Moderate criteria + ABG finding indicating hypercapnia & acidosis

5. COPD Exacerbations: Management Simplified
 Classified as:
 Mild : Treated with short acting bronchodilators only (SABDs)
 Moderate : Treated with SABDs + antibiotics and/or oral corticosteroids
 Severe : Patient requires hospitalization or visits the emergency room. Severe
exacerbations may also be associated with respiratory failure
 COPD patients should be educated on understanding exacerbation symptoms
and importance of reporting same and seek HCP advice.
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6. Management of Exacerbations: Treatment Options:
 > 80% of exacerbations are managed on outpatient basis with pharmacological
therapies including bronchodilators, corticosteroids and antibiotics
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7. Hospitalized COPD Patients with exacerbation:
Severity of exacerbation should be based on patient’s clinical signs.
 No respiratory failure:
 RR 20-30 breaths per minute, No use of accessory respiratory muscles
 No changes in mental status
 Hypoxemia improved with supplemental O2 given via Venturi mask 24-35% inspired oxygen (FiO2)
 No increase in PaCO2
 Acute respiratory failure-Non life threatening:
 RR > 30 breaths per minute, using accessory respiratory muscles
 No change in mental status
 Hypoxemia improved with supplemental O2 given via Venturi mask > 35% FiO2
 Hypercarbia i.e. PaCO2 increased compared with baseline or elevated 50-60 mmHg
 Acute respiratory failure – life threatening
 RR > 30 breaths per minute using accessory respiratory muscles
 Acute change in mental status
 Hypoxemia not improved with supplemental O2 given via Venturi mask or requiring FiO2 > 40%
 Hypercarbia i.e. PaCO2 increased compared with baseline or elevated > 60 mmHg or the presence of acidosis
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10. Pharmacological Treatment
 Three main classes of drugs used. Bronchodilators, Glucocorticoids, Antibiotics
Bronchodilators:
 Short acting inhaled beta2 agonists, with or without short-acting anticholinergics are preferred initial
bronchodilators
 No significant difference in FEV1 between MDI or nebulizer. Nebulizer may be preferred for sicker patients
 Patients should continue to use inhaled Long-acting bronchodilators with or without ICS during an
exacerbation or should start as soon as possible before hospital discharge.
 Patients should not use continuous nebulization. MDI inhaler one or two puffs every one hour for two to
three doses and then every 2-4 hours based on patient response should be used.
 IV methylxanthines are not recommended.
 Air driven bronchodilator nebulization is preferable to oxygen –driven to avoid potential risk of increasing
the PaCO2 associated with oxygen-driven bronchodilator administration.

11. Pharmacological Treatment
Glucocorticoids:
 Systemic glucocorticoids shorten recovery time and improve Lung Function (FEV1).
 Improves oxygenation, reduces risk of early relapse, treatment failure and length of hospitalization
 40 mg Prednisone OD for 5 days is recommended.
 Limitations: Increased risk of pneumonia and mortality
 Recent studies suggest less prominent role of glucocorticoids in treating acute COPD exacerbation in
patients with low levels of blood eosinophils.
Antibiotics:
 Should be given to patients with exacerbations of COPD who have three cardinal symptoms : Increase in
dyspnea, sputum volume and sputum purulence OR have two of the cardional symptoms, if increased
purulence is one of the two symptoms OR if patients require mechanical ventilation
 Recommended length of therapy : 5-7 days

12. Respiratory Support
 O2 Therapy:
 Key component of hospital treatment of an exacerbation.
 Target saturation of 88-92%
 Check blood gases frequently to ensure satisfactory oxygenation, without CO2 retention and/or worsening acidosis
 Venturi masks offer more accuracy and controlled oxygen delivery of oxygen than nasal prongs.
 High-flow nasal therapy (HFNT):
 Delivers heated and humidified air-oxygen blend via special devices at rates upto 8L/min in infants and up to 60
L/min in adults.
 HFNT has been associated with decreased RR and effort, decreased work of breathing, improved gas exchange,
improved lung volume and dynamic compliance, transpulmonary pressures and homogeneity.
 HFNT has been reported to improve Oxygenation and Ventilation, decrease hypercabia and improve HRQOL in
patients with hypercapnia during an acute exacerbation, and also in select patients with stable hypercapnic COPD.
 Well designed prospective RCTs are required to study and confirm the effects of HFNT .
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 Preferred as initial mode of ventilation
 Success rate of 80-85%
 Improves Oxygenation and Acute Respiratory Acidosis i.e. increases pH and decreases PaCO2
 Decreases RR, work of breathing and severity of breathlessness
 Decreases complication such as VAP and length of hospital stay
 Reduces Mortality and Intubation Rates
 No Weaning required: Once patient improves and tolerates at least 4 hrs of unassisted breathing,
NIV can be directly discontinued.
Non Invasive Ventilation (NIV) :

15. Invasive Mechanical Ventilation :
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 Use of invasive ventilation in patients with very severe COPD is influenced by the likely reversibility
of the precipitating event, patient’s wishes, and the availability of intensive care facilities
 Major hazards: Risk of VAP, barotrauma and volumotrauma, risk of tracheostomy and
consequential prolonged ventilation.

16. Hospital Discharge and Follow Up
 Follow up within One (1) month:
 Allows careful review of discharge therapy and opportunity to make any needed changes.
 Has been related to less exacerbation related readmissions
 Patients not attending early follow-up have increased 90-day mortality.
 Several Patient issues might be associated i.e. patient non compliance, limited access to medical care,
poor social support, and/or the presence of more severe disease
 Additional Follow up Three (3) months:
 Ensure return to a stable clinical state
 Review patient’s symptoms, lung function (by spirometry)
 Asses the prognosis using scoring systems (i.e. BODE)
 Determine need of long-term O2 therapy based on arterial O2 saturation and blood gas assessment
 Patients with Recurrent Exacerbations/ and or hospitalizations: CT assessment should be done to
determine presence of Bronchiectasis and Emphysema.

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18. Prevention of Exacerbations:
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19. Thank You !