COPD exacerbation resident survival guide

# Overview
COPD exacerbation is an acute event characterized by a worsening of the patients respiratory symptoms (baseline dyspnea, cough, and/or sputum production) that is beyond normal day-to-day variations and leads to a change in medication.

# Causes

## Life-Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
- Arrhythmia
- Congestive heart failure
- Pleural effusion
- Pneumonia
- Pneumothorax
- Pulmonary embolism

## Common Causes
- Respiratory tract infections (~12)
- Unknown (~13)
- Air pollutants

# Management

# Pharmacologic Treatment

# Checklist at Time of Discharge From Hospital

# Checklist at Follow-Up Visit 46 Weeks After Discharge

# Do's

## Assessment
- The presence of purulent sputum during an exacerbation can be sufficient indication for starting empirical antibiotic treatment.

## Treatment
- When a patient comes to the ED, the first actions are to provide controlled oxygen therapy and to determine whether the exacerbation is life-threatening. If so, the patient should be admitted to the ICU immediately.
- Short-acting inhaled 2-agonists with or without short-acting anticholinergics are usually the preferred bronchodilators for treatment of an exacerbation.
- A systematic review found no significant differences in FEV1 between MDI and nebulizers, although the latter can be more convenient for sicker or frail patients.
- Intravenous methylxanthines (theophylline or aminophylline) are only to be used in selected cases when there is insufficient response to short-acting bronchodilators.
- Systemic corticosteroids in COPD exacerbations shorten recovery time, improve FEV1 and PaO2, and reduce the risk of early relapse, treatment failure, and length of hospital stay.
- Consensus on optimal corticosteroids dose and duration for COPD exacerbations has not been reached.
- Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis are the most common bacterial pathogens involved in an exacerbation. However, the choice of the antibiotic should be based on the local bacterial resistance pattern.
- Empirical coverage of Pseudomonas aeruginosa in GOLD 3 and GOLD 4 patients is important.
- Procalcitonin may be of value in the decision to use antibiotics.
- An appropriate fluid balance with special attention to the administration of diuretics, anticoagulants, treatment of comorbidities, and nutritional aspects should be considered.
- Healthcare providers should strongly enforce stringent measures against active cigarette smoking.
- Once oxygen is started, arterial blood gases should be checked 30 to 60 minutes later to ensure satisfactory oxygenation without carbon dioxide retention or acidosis.
- Venturi masks offer more accurate and controlled delivery of oxygen than do nasal prongs but are less likely to be tolerated by the patient.
- Noninvasive mechanical ventilation improves respiratory acidosis and decreases respiratory rate, severity of breathlessness, complications such as ventilator-associated pneumonia, length of hospital stay, mortality, and intubation rates.

## Hospital Discharge and Follow-up
- In the hospital prior to discharge, patients should start long-acting bronchodilators, either anticholinergics and/or 2-agonists with or without inhaled corticosteroids.
- For patients who are hypoxemic during an exacerbation, arterial blood gases and/or pulse oximetry should be evaluated prior to hospital discharge and in the following 3 months. If the patient remains hypoxemic, long-term supplemental oxygen therapy may be required.

## Prevention of COPD Exacerbations
- Smoking cessation, influenza and pneumococcal vaccines, knowledge of current therapy including inhaler technique, and treatment with long-acting inhaled bronchodilators, with or without inhaled corticosteroids, and phosphodiesterase-4 inhibitors are all therapies that reduce the number of exacerbations and hospitalizations.
- Early outpatient pulmonary rehabilitation after hospitalization for an exacerbation is safe and results in clinically significant improvements in exercise capacity and health status at 3 months.

# Don'ts

## Assessment
- Spirometry is not recommended during an exacerbation because it can be difficult to perform and measurements are not accurate enough.

## Treatment
- The use of mucolytics is not well-supported by evidence.
- NIPPV is not considered in the following conditions: