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COPD Exacerbation

Taylor Coston

Background

  • Presentation: increased dyspnea, cough, and sputum production or purulence, diffuse wheezing, distant breath sounds, tachypnea, tachycardia

  • Severe respiratory insufficiency: accessory muscle use, fragmented speech, inability to lie supine, profound diaphoresis, agitation, asynchrony between chest and abdominal wall with respiration, failure to improve with initial emergency treatment

  • Impending respiratory arrest: Inability to maintain respiratory effort, cyanosis, hemodynamic instability, and depressed mental status

  • Remember that patients with COPD can have other causes of respiratory distress including acute coronary syndrome, decompensated heart failure, PE, PNA, PTX, sepsis, acidosis

Evaluation

  • Initial Assessment: ABCs

    • Airway/Breathing: Ensure patient is protecting airway

      • If obtunded or in severe respiratory distress intubation

      • BiPAP typically appropriate for severe COPD exacerbation unless contraindication (vomiting, obtundation, facial trauma)

        • BiPAP is ordered as IPAP and EPAP, 12/5 is often a good start

    • Circulation

      • For hemodynamic instability immediate rapid sequence intubation. Pt’s can be hypotensive for a host of reasons (pneumothorax, sepsis, circulatory collapse from hypoxia and bradycardia, etc)

  • Subsequent Workup:

    • Continuous pulse oximetry, ABG/VBG, EKG, CXR, CBC, BMP, troponin, BNP, sputum cx, RPP, blood cultures if hemodynamically unstable

    • Lung ultrasound to differentiate COPD from pulmonary edema when a pt presents with wheezing and respiratory failure (pulmonary edema will have B lines)

    • Consider trigger: viral infection (70%), PNA, PE (have a high index of suspicion for PE)

Management

  • Bronchodilators

    • Order “Respiratory Care Therapy Management Protocol” at VUMC

      • RT evaluates the pt and based on physical exam will give a duoneb. Continues to assess the pt and treats based on severity of the exacerbation

    • If ordering bronchodilators individually:

      • Albuterol 2.5 mg diluted to 3 mL via nebulizer or 4 to 8 inhalations from MDI every 4 hours while awake (RT) or more frequently if needed

      • Ipratropium 500 mcg via nebulizer, or 4-8 inhalations from MDI q4 hrs while awake

      • Can additionally order Duoneb (albuterol and ipratroprium) q4-6 hours at VUMC

      • There is no respiratory order protocol at the VA, order individually as above

  • Steroids

    • For severe exacerbation give methylprednisolone 125 mg IV BID (or 60mg IV q6h)

    • For moderate to mild COPD exacerbations give prednisone 40mg PO daily for 5 days (including the initial IV dose if pt received one in the ER)

  • Antibiotics

    • For moderate to severe exacerbations

    • Azithromycin (500mg x 1 then 250mg daily x 4 or 500mg daily x 3) or doxycycline 100mg BID if concern for QT prolongation. Can consider respiratory fluroquinolone in certain high-risk patients but typically too broad

    • Refer to Pneumonia in Infection Disease chapter if treating concomitant pneumonia

  • Discharge Planning:

    • Controller medications/inhalers (see COPD in Outpatient chapter)

      • Make sure any new inhalers are covered by insurance prior to discharge

      • Provide inhaler education and consider use of a spacer

    • Vaccinations (influenza, COVID, pneumococcal)