COPD Exacerbations

Question 1

COPD Exacerbations

Answer 1

Often lead to temporary change in meds, may be permanent
Each exacerbation worsens overall COPD
Most are managed outpatient, can be hospitalized if: bad response, bad signs like cyanosis, serious comorbidities, frailty
Typically includes an acute change in one or more of the cardinal s/s: cough worsens, sputum increase, dyspnea increase

Question 2

Home management of COPD Exacerbations

Answer 2

Access to a SABA (bronchodilator)
Short term titration up from 2 puffs every 4-6 hours to 2 puffs every 1-2 hours. May need nebulizer instead.
Combination therapy favored
Continue use of LAMA/LABA/ICS
Consider oral steroids for exacerbations. Prednisone 40mg daily for 1-2 weeks
Antibiotics: Only for those with s/s of bacterial infection (increased cough and sputum) AZITHROMYCIN
Antivirals: COVID antivirals

Question 3

Prednisone

Answer 3

Oral glucocorticoid
Anti-inflammatory or immunosuppressant. Suppresses migration of leukocytes
CONTRA: If administering live vaccines or if they have a systemic fungal infection (only a/w long term use)
ADR: Agitation, aggression, hunger, insomnia, energy boost with short term. More ADRs in long term use
Other common Glucocorticoids: Methylprednisolone, Prednisolone, and Dexamethasone

Question 4

Azithromycin

Answer 4

For acute COPD exacerbation
Covers G+/-, Atypicals, NO MRSA or Pseudomonas
Inhibits protein synthesis of bacterial proteins and also reduces inflammatory cytokine production
CONTRA: Hx of jaundice/hepatic dysfunction from prior azithromycin use
ADR: QT prolongation

Question 5

Oseltamavir

Answer 5

Tamiflu
Prophylaxis and treatment of influenza A or B. Dosing must start no later than 2 days after symptom onset
Inhibits Viral neuraminidase, stopping viral replication
ADR: GI
Renal adjustment needed

Question 6

ED/Hospital Management COPD E

Answer 6

Reverse airflow limitation with short acting bronchodilators, NEBULIZED.
Usually it’s continuous albuterol (10mg/hr followed by 1 nebulizer (2.5mg) every 2-4 hours as needed). Can also use combination SABA/SAMA, continue using LABA/LAMA/ICS
Systemic Glucocorticoids: Methylprednisolone IV for 1-2 weeks
Treat underlying infections. Pneumonia antibiotics and anti-COVID meds
Nicotine replacement, usually a patch
VTE Prophylaxis: Enoxaparin 40mg daily, 30 if kidney dysfucntion, or Heparin 5000 units subQ every 8-12h. (7500 in fats)

Question 7

Expectorants

Answer 7

Drug that renders a more productive cough by stimulating the flow of respiratory tract secretions
Guaifensin: Only one that has clinical efficacy
Increases hydration of respiratory tract, reducing viscosity of mucus. Pt must be adequately hydrated and drug must be taken with full glass of water

Question 8

Acetylcysteine

Answer 8

Mucolytic or acetaminophen overdose
Lowers mucus viscosity = more productive cough
Must be sure we use nebulized for mucolytic, oral/IV for acetaminophen OD
ADR: Bronchospasm

Question 9

Hypertonic Saline

Answer 9

Mucolytic
Restores moisture to Pulmonary system = more productive cough
Nebulized
ADR: Bronchospasm

Question 10

Codeine

Answer 10

Cough suppressant
BOX: A LOT. Ultra rapid metabolism can cause life threatening respiratory depression. P450 3A4 inhibitors can cause plasma concentrations
Direct action in medulla
CONTRA: peds, recent tonsillectomy or adenoidectomy, MAOIs
Renal adjustment needed

Question 11

Dextromethorphan

Answer 11

Cough suppressant
Depress medullary cough center
CONTRA: MAOI
ADR: Euphoria, Drowsiness, dizzy, restless

Question 12

Benzonatate

Answer 12

Cough suppressant
Topical that reduces the lungs “feeling the need to cough”
ADR: sedation, constipation, OD, bronchospasm

Question 13

Antihistamines

Answer 13

Diphenhydramine, Promethazine, Doxylamine
Cough suppressants
Histamine-1 antagonist
ADR: anti-cholinergic effects (dry mouth, urine retention), drowsiness, sedation