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Information ⬇

Author: Eui-Sik Suh

  • Among hospitalized patients with an exacerbation of COPD, 90-day mortality is 14%, and one-third of patients are readmitted over this period.
  • Exacerbations of COPD are associated with a decline in lung function and quality of life, and therefore impose a significant burden on patients and their carers.
  • Left ventricular failure and pulmonary embolism may be misdiagnosed as, or be associated with, an acute exacerbation of COPD.
  • COPD may be associated with coronary disease. Angina or myocardial infarction may complicate an acute exacerbation of COPD.

Priorities ⬆ ⬇

The working diagnosis is made in a patient with chronic obstructive pulmonary disease (COPD) by an acute change in dyspnoea, cough and/or sputum production, beyond normal day-to-day variation.

Consider pneumonia (Chapter 62), heart failure (Chapter 48) and pulmonary embolism (Chapter 57) in the differential diagnoses; these may coexist with an exacerbation of COPD.

Oxygen

  • Give 28% via a Venturi mask.
  • Aim initially for arterial oxygen saturation (SaO2) 88–92% until an arterial blood gas (ABG) sample is obtained.
  • If PaCO2 is normal, aim for SaO2 94–98% unless there is a history of previous hypercapnic (type 2) respiratory failure requiring ventilatory support, but repeat ABG in 1 hour.
  • Monitor closely for decreases in respiratory rate and conscious level, as this may indicate oxygen-induced hypercapnic encephalopathy. Repeat ABG if this occurs.
  • If the patient is hypercapnic and PaO2 >8 kPa, consider reducing FiO2 and repeat ABG.
  • If PaO2<8 kPa and the patient has a respiratory acidosis, consider NIV (Figure 61.1 and Chapter 113).

Bronchodilators

  • Give nebulized salbutamol 2.5–5 mg 4 hourly, although continuous (‘back-to-back’) salbutamol nebulization may be required in severely breathless patients.
  • Ipratropium 0.5 mg up to 4-hourly. Stop long-acting anti-muscarinic agents (e.g. tiotropium) for the duration of ipratropium therapy.

Corticosteroid

  • Give prednisolone 30 mg daily for 7–10 days.
  • Hydrocortisone (100–200 mg IV 6-hourly) may be given if the patient is unable to swallow tablets.
  • In the presence of radiographic consolidation, patient should be treated as having pneumonia; while a substantial proportion of COPD patients with community-acquired pneumonia will be commenced on steroid therapy, there are currently no strong data to support the use of steroids in the routine treatment of severe pneumonia.

Antibiotic therapy

  • Indicated if there is a history of increased sputum purulence or radiographic evidence of pneumonia.
  • Amoxicillin, doxycycline or macrolides may be appropriate according to local policy.
  • Intravenous therapy may be indicated in severely unwell patients.
  • Adjust antibiotic therapy when sputum or blood cultures become available.

Aminophylline

  • Consider giving under expert guidance when conventional bronchodilator therapy has failed.
  • There is a narrow therapeutic index and a risk of arrhythmia.
  • Cardiac monitoring.
  • 250–500 mg (5 mg/kg) IV over 20 minutes unless the patient is already on a theophylline.
  • Then 0.5 mg/kg/hour IV infusion.
  • Check aminophylline levels within 24 hours of commencing, then as clinically indicated.

Non-invasive ventilation

  • In acute hypercapnic respiratory failure complicating an exacerbation of COPD, NIV improves survival, reduces intubation rates and reduces length of ICU stay.
  • The use of NIV is summarized in Figure 61.1 and detailed in Chapter 113.

Establishing the ceiling of care

  • Predicting survival in COPD patients who require admission to the ICU is difficult: clinicians' estimates of mortality are variable, inaccurate and generally pessimistic.
  • Any decision to limit the escalation of care should be made by a senior physician, taking into account the patient's wishes expressed during or before hospital admission. A ruling by the Court of Appeal in England and Wales in 2014 now places a legal obligation on physicians to consult with patients before making do-not-attempt-resuscitation (DNAR) orders.
  • Age, arterial blood pH and reduced conscious level are predictive of mortality. Functional status, body mass index, requirement for supplemental oxygen when stable, comorbidities and previous admissions to the ICU should also be considered when assessing whether invasive mechanical ventilation is appropriate.

Further Management ⬆ ⬇

Outline

Supportive Care!!navigator!!

  • Ensure a fluid intake of 2–3 L/day.
  • Check electrolytes the day after admission. Salbutamol and steroids may result in significant hypokalaemia. Give potassium supplement if the plasma level is <3.5 mmol/L.
  • Physiotherapy is of little value unless sputum is copious (>25 mL/day) or there is mucus plugging with lobar atelectasis.
  • DVT prophylaxis with stockings/LMW heparin. Assess/treat comorbidities, for example atrial fibrillation, congestive heart failure.

If the Patient is Not Improving, Consider:!!navigator!!

  • Wrong diagnosis: reconsider pneumonia, heart failure and pulmonary embolism. Other causes of respiratory failure with raised PaCO2 are given in Table 23.4. Echocardiography is indicated to exclude left ventricular dysfunction.
  • Missed pneumothorax.
  • Inadequately treated infection. Consider changing to cefuroxime or cefotaxime IV and adding a macrolide.
  • Inadequate bronchodilator therapy. Check that nebulizers are being run at the correct flow rate. Nebulized salbutamol and ipratropium can be given 2-hourly if necessary, or salbutamol can be given by IV infusion 5–30 mg/min (see xxx).
  • Cor pulmonale. Fluid retention with peripheral oedema may occur in patients with COPD complicated by acute or chronic respiratory failure even without right ventricular dysfunction. The diagnosis of cor pulmonale is made from a raised JVP, enlarged cardiac silhouette on the chest X-ray, and ECG evidence of right ventricular hypertrophy (not an invariable feature). Obtain an echocardiogram to confirm right ventricular dysfunction, estimate pulmonary artery pressures and exclude left ventricular or aortic/mitral valve disease. Treat fluid retention with a diuretic. There is no definite evidence for the use of digoxin (unless indicated for rate control in atrial fibrillation) or ACE inhibitors in cor pulmonale. Resistant cor pulmonale raises the suspicion of obstructive sleep apnoea.

Arrhythmias!!navigator!!

  • Supraventricular arrhythmias are common in acute exacerbations of COPD. Check plasma potassium: salbutamol and steroids may result in significant hypokalaemia. Give potassium replacement if plasma potassium is <3.5 mmol/L.
  • Treat atrial fibrillation/flutter with digoxin, combined if needed with verapamil or diltiazem. Treat multifocal atrial tachycardia with verapamil if the ventricular rate is >110/min. DC cardioversion is ineffective.

Chest Pain!!navigator!!

  • Chest pain from coronary disease occurs in acute exacerbations of COPD and may be caused by hypoxia, sepsis or tachycardia. A rise and fall in troponin T may also occur without chest pain or acute ECG changes
  • Ask for advice from a cardiologist. There is evidence that a beta blocker, aspirin and a statin improve outcome.
  • Further cardiac investigation with a functional test may be indicated in individual cases.

Enuring Safe Discharge!!navigator!!

  • Patients should be off intravenous therapy for >24 hours before discharge and established on discharge medication.
  • Refer for early post-exacerbation pulmonary rehabilitation, and arrange supported discharge package or social support as appropriate.
  • Check functional status in the context of the patients' home circumstances.
  • Check inhaler technique.
  • Prescribe a rescue pack of oral corticosteroids and antibiotics for patients with frequent exacerbations and educate them on recognizing an exacerbation.
  • Record spirometry at discharge.
  • Give smoking cessation counselling if required.
  • Arrange primary care review within 1 week and chest clinic review within 4–6 weeks.

Further Reading ⬆

Aleva FE, Voets LWLM, Simons SO, et al. (2016) Prevalence and localization of pulmonary embolism in unexplained acute exacerbations of COPD: A systematic review and meta-analysis. Chest 151, 544–554.

Davidson AC, Banham S, Elliott M, et al. (2016) British Thoracic Society/Intensive Care Society Acute Hypercapnic Respiratory Failure Guideline Development Group. BTS/ICS Guidelines for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax 71, ii1–ii35. https://www.brit-thoracic.org.uk/document-library/clinical-information/acute-hypercapnic-respiratory-failure/bts-guidelines-for-ventilatory-management-of-ahrf/. Global Initiative for Chronic Obstructive Lung Disease website: http://goldcopd.org/

MacDonald MI, Shafuddin E, King PT, Chang CL, Bardin PG, Hancox R.J. (2016) Cardiac dysfunction during exacerbations of chronic obstructive pulmonary disease. Lancet Respir Med 4, 138–148.

Vanfleteren LEGW, Spruit MA, Wouters EFM, Franssen F.M.E. (2016) Management of chronic obstructive pulmonary disease beyond the lungs. Lancet Respir Med 4, 911–924.