COPD exacerbations

Question 1

symptoms

Answer 1

increased dyspnoea
reduced exercise tolerance
tachypnoea
increased cough frequency
increased sputum volume or purulence
fever
right heart failure, manifesting s ankle oedema

Question 2

treatment

Answer 2

inhaled bronchodilators
may be started by the patient at home in accordence with their COPD action plan
salbutamol, terbutaline and ipratropium (SAMA) work equally well to relieve symptoms of COPD exacerbation, however, ipratropium has a slower effect and is contraindicated in patients taking a LAMA

Question 3

dministration of bronchodilator

Answer 3

delivery via a pMDI with spacer is as effective as nebuliser for patients with FEV1 more than 30% predicted

Question 4

using a nebuliser

Answer 4

used compressed air rather than oxygen to avoid excessve and potentially fatal hyperoxygenation
use salbutamol or ipratropium (except in patients using a LAMA)

Question 5

if one drug does not control symptoms adequately

Answer 5

combine salbutamol and ipratropium (except patients taking LAMA)
may provide added benefits without compounding adverse effects

Question 6

adverse effects with repeated doses of SABA

Answer 6

hypokalaemia and hypomagnesaemia are likely with repeated high doses of salbutamol or terbutaline
anticipate and manage early
cardiovascular effects (eg. MI, prolonged QT) can also occur

Question 7

when to use systemic corticosteroids

Answer 7

a 5 day course is recommended for exacerbations that dont respondd sufficiently to inhaled bronchodilators

Question 8

which systemic corticosteroids to use

Answer 8

if oral = prednisolone
if orl is not tolerated = hydrocortisone

Question 9

oxygen therapy

Answer 9

administer oxygen to maintain sats at 88-92%
patients with COPD are at risk of hypercapnic respiratory failure during an exacerbation, and excessive supplimental oxygen is associated with mortality

Question 10

ventilatory support

Answer 10

use non-invasive ventilation for COPD exacerbations associated with hypercapnic respiratory failure and acidosis, despite optimal oxygenn therapy
BPAP usually preferred

Question 11

when to consider hypercapnia

Answer 11

consider hypercapnia if a patient on acute oxygen therapy develops a reduced level of consciousness (eg. drowsiness, confusion)
or other signs of hypercapnia (eg. bounding pulse, flushed skin

Question 12

arterial blood gas analysis

Answer 12

perform arterial blood gas analysis in patieents at risk of hypercapnia recieving oxygen Therapy
venous carbon dioxide values do not correlate directly with arterial carbon dioxide values
their use to exclude carbon dioxide retention is controversial

Question 13

how to identify bacterial cause

Answer 13

consider nose and throat swabs for for respirtory virus pael PCR
bacterial infection is more likely in the patient with increased sputum volume, sputum purulence or a change in putum colour
sputum culture is not recommended

Question 14

why is sputum culture not recommended

Answer 14

pateints with COPD are peristantly colonised withh haemophilus influenzae, moraxella catarhalis or strep pneumoniae, and a positive sputum culture result is not necessarily indicative of infection

Question 15

antibiotics for patients in the community with less severe excerbations

Answer 15

treatment with antibiotics does not consistently improve outcomes
antibiotics can be safetly withheld in most cases

Question 16

antibiotics if a bacterial cause is likley

Answer 16

antibiotics have limited benefit for patients outside of the intensive care setting
if antibiotics are indicated, use oral antibiotic therapy of amoxycillin or doxycycline

Question 17

why do you use amoxycillin or doxycycline if antbiotic therapy is indicated

Answer 17

in exacerbations of COPD, antibitoic therapy aims to hasten recovery rather than eradicate the colonising organism because most patients have persistant airway colonisation
therefore, lower dose amoxycillin or doxycycline are used to void exposing the patient to unecessary broader spectrum treatment
avoid aoxycillin + clavulanate