Acute exacerbation of COPD Flashcards
What are exacerbations of COPD
- Exacerbations of chronic obstructive pulmonary disease are defined as a sustained worsening of the patient’s symptoms from his or her usual stable state
What are some commonly reported symptoms of COPD
- Worsening breathlessness
- Cough
- Increased sputum production
- Change in sputum colour
This change usually requires a change in medication
What is the trigger of most cases of acute exacerbations of copd
- Viral infections
- Other causes are bacterial infections, air pollutants and ambient tempeature
Viral causes of exacerbations of COPD
- Rhinoviruses
- Influenza
- Parainfluenza
- Coronavirus, adenovirus and respiratory syncytial virus
Bacterial causes of exacerbations of COPD
Bacterial community-acquired infections are often due to
- Streptococcus pneumoniae
- Haemophilus influenzae
- Less commonly moraxella catarrhalis, staphylococcus aureus and pseudomonas aeruginosa may calso cause exacerbations of copd
Common pollutants that cause exacerbations of copd
- Nitrogen dioxide
- Particulates
- Sulfur dioxide
- Ozone
Acute exacerbation of copd associated symptoms
• Increased dyspnoea.
• Increased cough; increased sputum purulence and increased sputum volume.
• Upper airway symptoms (eg, colds and sore throats).
• Increased wheeze and chest tightness.
• Malaise.
• Reduced exercise tolerance.
• Fluid retention.
• Increased fatigue.
• Marked respiratory distress with dyspnoea and tachypnoea, acute confusion, increased cyanosis, peripheral oedema.
Respiratory failure - may develop and may require non-invasive ventilation (NIV)
COPD differential diagnosis -
- Pneumonia
- Pneumothorax
- Congestive heart failure
- Pulmonary embolus
- Lung cancer
- Upper airway obstruction
- Pleural effusion
- Recurrent apsiration
- Rib fracture
- Bronchiectasis
COPD investigations
Lung function tests are not reliable during an exacerbation and so are not recommended as a routine investigation. In primary care, sending a sputum sample is not recommended. Assessment is clinical and involves taking a history, examining the chest and checking temperature and peripheral oxygen saturation.
In hospital:
• CXR.
• Arterial blood gases.
• FBC, renal function tests and electrolytes.
• Electrocardiogram (ECG): for comorbidities and differential diagnoses.
• Sputum cultures.
• Blood culture if there is pyrexia
• Theophylline level if the person is on theophylline treatment.
Assessing the need for hospital treatment - copd
Following features suggest the person may need hospital treamtnet:
- Marked dyspnoea
- Tachypnoea
- Pursed-lip breathing
- Use of accessory muscles(sternomastoid and abdominal) at rest
- Acute confusion or impaired level of consciousness
- New-onset cyanosis
- Worsening peripheral oedema
- Rapid rate of onset
- Marked reduction in ADLs
- Inability to cope at home
• Poor or deteriorating general condition.
• Already receiving home oxygen therapy.
• Oxygen saturation levels <90%.
Intermediate care: Hospital-at-Home schemes, provided by community respiratory teams, may be available in some areas and are an alternative to hospital admission.
• Hospital-at-Home and assisted-discharge schemes are safe and effective and should be used as an alternative way of managing patients with exacerbations of COPD who would otherwise need to be admitted or remain in hospital.
Management in general practice - steroids
- Increase the dose or frequency ofshort-acting bronchodilators(inhalers used with a spacer device are as effective as nebulisers).
- Oral steroids:
- Prednisolone 30 mg daily for 7-14 days (for all patients with a significant increase in breathlessness unless contra-indicated).
- There is no advantage in more prolonged corticosteroid therapy.
- Osteoporosis prophylaxis should be considered in patients requiring frequent courses of oral corticosteroids.
Antibiotics in copd
• The value of antibiotics in this situation is uncertain and studies show conflicting results[6].
• Many exacerbations are triggered by viral infection and will not respond to antibiotics.
• Consider antibiotic treatment if the sputum is purulent or there are signs of consolidation. Also take into account symptom severity, history of previous exacerbations and need for hospital admission, previous sputum culture results and the risk of developing resistance with repeated courses of antibiotics.
• When sputum has been sent for culture, the appropriateness of antibiotic treatment should be checked against laboratory culture and sensitivities when they become available.
• If antibiotics are not given, advise about seeking help urgently if the nature of the sputum changes or if symptoms worsen.
First-line options in primary care are amoxicillin (500 mg tds for five days), doxycycline (200 mg then 100 mg od for a further four days) or clarithromycin (500 mg bd for five days)
O2 therapy in copd
This is indicated only where oxygen saturation levels are below the individual’s target levels
- Establish on optimal therapy.
- Arrange multidisciplinary assessment if necessary. Consider involving professionals such as a community matron, specialist respiratory nurses and physiotherapists.
Self-management
- Encourage people at risk of having an exacerbation to respond quickly to the symptoms of an exacerbation by:
- Starting oral corticosteroid therapy (unless contra-indicated) if increased breathlessness interferes with activities of daily living.
- Starting antibiotic therapy if their sputum is purulent.
- Adjusting bronchodilator therapy to control symptoms.
- Give people at risk of exacerbations a course of antibiotic and corticosteroid tablets to keep at home. Monitor the use of these drugs and advise people to contact a healthcare professional if their symptoms do not improve. Educate with regard to the risks and benefits of medication and how and when to take them correctly.
Hospital management in COPD
- Either handheld inhalers or nebulisers can be used to deliver bronchodilator therapy. If using the latter, change back to inhalers as soon as possible in order to facilitate earlier hospital discharge. If a person with COPD is hypercapnic or acidotic, the nebuliser should be driven by compressed air rather than oxygen (to avoid worsening hypercapnia).
- If necessary, oxygen should be given to keep the SaO2within the individualised target range. Monitor arterial blood gases regularly.
- Use systemic corticosteroids and antibiotics as above. In addition, give antibiotics if CXR shows consolidation. If an antibiotic is indicated, use oral treatment where possible. If intravenous therapy is required, review this after 48 hours and step down where possible[5].
- Consider intravenous theophyllines, with appropriate monitoring, if response to nebulised bronchodilators is poor.
- Assess need for non-invasive ventilation (NIV):
- Consider NIV for patients who are slow to wean from invasive ventilation.
- Use NIV for persistent hypercapnic ventilatory failure despite optimal medical therapy.
- NIV should be delivered in a dedicated setting by trained, experienced staff who are aware of its limitations.
- Consider doxapram only if NIV is not available.
- Assess the need for intubation using age, forced expiratory volume in one second (FEV1), functional status, body mass index (BMI), requirement for oxygen when stable, comorbidities, and previous admissions to intensive care units.
- Consider physiotherapy using positive expiratory pressure devices for selected people with exacerbations of COPD, to help with clearing sputum
