Exacerbation of COPD

Question 1

How could you define a COPD exacerbation?

Answer 1

An acute worsening of a COPD patients respiratory symptoms that is beyond normal day-day variations and leads to a change in medication.

Question 2

What are the most common triggers for COPD exacerbations?

Answer 2

Respiratory tract infection- either bacterial or viral

Most common bacterial causes is haemophilus influenzae

Question 3

What are some causes of COPD exacerbation?

Answer 3

Infection- Bacterial or viral
Air pollution
Interruption of maintenance therapy
Idiopathic

Question 4

What are some mimics for COPD exacerbation, which must be considered?

Answer 4

Pneumonia- Radiological evidence
PE
Pneumothorax
Heart failure
ARDS
Pulmonary oedema
Arrhythmia 
Pulmonary effusion

Question 5

What are some differentials for breathlessness?

Answer 5

Pneumonia
LRTI
Asthma exacerbation
Pneumothorax
Pleural effusion
Pulmonary embolism
ARDS
Cardiac failure
Arrhythmia 
Foreign body in airway 
Malignancy

Question 6

When should patients with an COPD exacerbation be admitted to hospital? What features should indicate admission is needed?

Answer 6

Tachypnea
Pursed lip breathing
Accessory muscle usage
Very low oxygen saturations
Confusion
New onset of worsening cyanosis 
Haemodynamic instability

Question 7

How might patients present with COPD?

Answer 7

On a background of COPD:
Worsened breathlessness
Worsened cough
Change in sputum colour or volume
Confusion, Fatigue, Lethargy
Wheeze
Chest tightness

Question 8

What investigations should be done when exacerbation of COPD is considered?

Answer 8

PEFR-
Sputum Culture and sensitivity
Oxygen saturations

Bloods-
FBC, ESR, CRP
ABG- Asses for features of respiratory failure
Blood culture is risk of sepsis

CXR
ECG

Question 9

What test is done to diagnose COPD?

Answer 9

Spirometry

Question 10

What is the treatment for a COPD exacerbation?

Answer 10

Oxygen therapy
- Use venturi mask 28% at 4L initially targeting 88-92%/. Requires continuous monitoring and reassess with ABG after 20-30 minutes if CO2 raised consider ventilation

Bronchodilators

• Nebulised Salbutamol (2.5-5mg QDS) and Ipratropium Bromide (500mg QDS)
• Drive using oxygen or air if hyerpcapnic

Steroids
- Prednisolone 40mg OD for 5 days PO

Antibiotics-

• Check local guidelines, more effective in severe exacerbation, use in patients with more sputum or more purulent sputum than usual, consolidation on CXR,
• Following results of sputum culture adjust
• Check past treatments and possible resistant causes

2nd Line: Theophylline IV

• If no response to maximal therapy above, only given by sensior
• Side effects include tachycardia and seizures
• Monitor levels

Question 11

Summarise the initial management for COPD exacerbation

Answer 11

Oxygen
Bronchodilators- Salbutamol (2.5-5mg QDS) + Ipratropium bromide (500mg QDS)
Steroids- Prednisolone 40mg OD 5 days
Antibiotics- according to local guidelines

Question 12

When are antibiotics indicated for a COPD exacerbation?

Answer 12

Severe exacerbation
Increased sputum production
Purulent sputum production
Other signs of infection
Consolidation on CXR- Follow pneumonia guidelines

Note- Follow local guidelines and once culture results return adjust accordingly

Question 13

When might theophylline be given?

Answer 13

After failure of initial therapy (oxygen, salbutamol, ipratropium bromide, steroids, antibiotics)

It is an anticholinesterase inhibitor and should only be given by a senior physician

Question 14

What are some side effects of theophyline

Answer 14

Tachycardia
Cardiac arrhythmia
Seizure

Question 15

When should ventilation be considered for patients with COPD exacerbation?

Answer 15

Failure to respond to initial therapies

Type 2 respiratory failure with increasing PCO2 on oxygen therapy

Question 16

What type of ventilation should be considered?

Answer 16

Bilevel Non-invasive ventilation (NIV)- mainstay in COPD ventilation

This includes IPAP and EPAP and cycles between the two

IPAP- Increases tidal volume and decreases the work of breathing

EPAP- Prevents collapse of small airways, increases tidal volume

Question 17

What are the criteria for initiation bi-level non-invasive ventilation in COPD exacerbations?

Answer 17

Type 2 respiratory failure with rising carbon dioxide partial pressures
Poor response to conventional medical therapy and controlled oxygen
If pH<7.26- start NIV in HDU/ITU with low threshold for intubation

Question 18

What’re some CIs to NIV?

Answer 18

Patient doesn't consent
Facial trauma
Recent facial or airway surgery
Vomiting
Undrained pneumothorax
Inability to maintain a patent airway
Bowel obstruction

Question 19

What are some reasons why invasive ventilation- intubation- may be considered?

Answer 19

Inability to maintain a patent airway
Vomiting or bowel obstruction
Large amounts of secretions
Bleeding
Suitable for low GCS patients- can't maintain their own airway

Also provides better control of ventilation , but requires ITU care.