Transcript COPD Exacerbation

COPD Exacerbation
UNM Best Practice Meeting
Josh Young
8/27/10
Why do we need to worry about
this?
• Growing number of hospitalizations in the
U.S.
– 463,0020 in 1990
– 726,000 in 2000
• 10% mortality in hospitalized patients
• ~25% mortality in ICU admissions
• $32 billion in the U.S. in 2002 ($18 billion
related to in-hospital care)
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Definition
• The Global Initiative for Chronic
Obstructive Lung Disease (GOLD) defines
an exacerbation as:
– “an event in the natural course of the disease
characterized by a change in the patient’s
baseline dyspnea, cough, and/or sputum that
is beyond normal day-to-day variations, is
acute in onset, and may warrant a change in
regular medication in a patient with
underlying COPD.”
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Goals
• Understand the pathophysiology of
exacerbations
• Learn more about the current guidelines
for treatment of COPD exacerbation and
why?
• Discuss the current practices at UNM?
• Develop our own best practices
• Smoking cessation
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Pathophysiology
(Brief Overview)
• Characterized by 2 separate processes
• Chronic Bronchitis:
– Excessive mucus production with airway
obstruction mostly affecting the smaller
airways with hyperplasia of mucus producing
glands and damage to the endothelium that
impairs the clearance of bacteria and mucus.
• Emphysema:
– Gradual destruction of alveolar septae and the
pulmonary capillary bed
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Pathophysiology
(Exacerbations)
• Exacerbations are heterogeneous in severity and
presentation
• They are usually contributed to bacterial or viral
infection and pollutants such as tobacco smoke
• A significant amount (~30%) do not have a clear etiology
• Severe exacerbations are thought to be due to increased
inflammation leading to worsening expiratory flow
limitation and dynamic hyperinflation and increased air
trapping
• This increased air trapping causes your tidal breathing to
shift closer to total lung capacity, where you have a less
favorable relationship between volume and pressure
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Goals
• Understand the pathophysiology of
exacerbations
• Learn more about the current guidelines
for treatment of COPD exacerbation and
why?
• Discuss the current practices at UNM?
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Global Initiative for Chronic
Obstructive Lung Disease (GOLD)
• Global organization initiated in 1998
• Goal to produce recommendations for
management of COPD based on the best
scientific information available
• First guidelines were released in 2001 with
a complete revision in 2006
• Last update in 2009 including articles up
to June 30, 2009
• www.goldcopd.org
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Department of Veteran Affairs/
Department of Defense
• VA/DoD clinical practice guideline for
management of outpatient chronic
obstructive pulmonary disease.
• Updated in 2007
• Focus mostly on outpatient management
and target patients of VA/DoD system
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Prevention
• Smoking cessation is still the most effective
intervention in reducing risk of developing COPD and
decreasing its progression
• Recommendations are to counsel smokers to quit at
every opportunity
• Apply affective counseling techniques
• Consider pharmacotherapy in situations where
counseling isn’t enough
• Influenza vaccines can reduce serious illness and death
in COPD patients by 50%
• Pneumococcal vaccine is recommended in COPD
patients over 65 years old and in patients with FEV1 <
40%
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Evaluation
• Careful history and physical exam
• General recommendations do not support
spirometry upon acute evaluation
• Pulse oximetry
• Arterial blood gases
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Evaluation and Triage
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Chest X-ray
ECG
CBC, BMP
Differential Diagnosis:
– Pulmonary embolism should be considered
with any patient being hospitalized with a
pretest probability of intermediate to high
– Pneumonia, CHF, pneumothorax, pleural
effusion, and cardiac arrhythmia
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Prevalence of Pulmonary Embolism in Acute
Exacerbations of COPD : A Systematic Review and
Metaanalysis. Rizkallah et al. Chest. 2009.
• Clinical question: What is the prevalence of PE in
acute exacerbations of COPD in patients who did
and did not require hospitalization.
• Methods: Only cross-sectional or prospective
studies that used CT scanning or pulmonary
angiography for PE diagnosis were included.
• 2,407 articles were identified, 5 met the inclusion
criteria including 550 patients
• Overall prevalence of PE was 19.9% (95%
confidence interval [CI], 6.7 to 33.0%; p 0.014).
• Hospitalized patients 24.7% (95% CI, 17.9 to
31.4%; p 0.001)
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Triage
• Hospitalization:
– Marked increase in intensity of symptoms (resting
dyspnea)
– Severe underlying COPD
– Onset of new physical symptoms
– Failure of initial medical management
– Significant comorbidities
– Frequent exacerbations
– Newly occurring arrhythmias
– Diagnostic uncertainty
– Older age
– Insufficient home support
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Triage
• MICU:
– Severe dyspnea that does not respond
adequately to initial therapy
– Changes in mental status
– Persistent or worsening hypoxemia (PaO2 <
40 mm Hg or hypercapnia PaCO2 > 60 mm
Hg or pH < 7.25 despite O2 and NIV
– Need for invasive mechanical ventilation
– Need for vasopressors
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Oxygen Therapy
• Both guidelines state that oxygen
supplementation should be used to keep
PaO2 > 60 mm Hg or SaO2 > 90%
• GOLD notes that CO2 retention can occur
insidiously with little change in symptoms
and recommend rechecking an ABG 30-60
minutes after oxygen therapy started
• Appropriate to start before complete
evaluation
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Bronchodilators
• 3 classes of medications:
– B2 agonists (albuterol)
– Anticholinergics (ipratropium)
– Methylxanthines (theophylline)
• Guidelines vary with respect to use and no
studies appear to clearly demonstrate
superiority
• Agree that initiation of therapy can be started
prior to full ED evaluation
• There does not appear to be a difference in
MDI or nebulizer therapy
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Bronchodilators
• GOLD recommends stepwise approach to use
by starting with short-acting B2-agonist
• If no prompt response to treatment occurs,
consider adding anticholinergic
• All agree that methylxanthines should not be
used routinely because of adverse effects and
lack of efficacy
• Although, GOLD notes that they are
considered second-line IV therapy
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Glucocorticosteroids
• Both guidelines agree that oral
corticosteroids should be used for acute
exacerbations
• 30 – 40 mg of oral prednisolone daily
• GOLD: 7-10 days
• VA/DoD: up to 14 days
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EFFECT OF SYSTEMIC GLUCOCORTICOIDS ON
EXACERBATIONS OF CHRONIC OBSTRUCTIVE
PULMONARY DISEASE. Niewoehner et al. N Engl J Med. 1999
• Double blind randomized trial
• Clinical Question: Determine rates of treatment
failure between systemic glucocorticoids and
placebo. Secondary goal to determine the optimal
duration of therapy.
• Methods: All patients admitted to participating
VA’s for COPD exacerbation who met inclusion
criteria:
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Clinical diagnosis of COPD exacerbation
Age > 50 years
30 pack year smoking history
FEV1 of 1.5L or less or inability to complete testing
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EFFECT OF SYSTEMIC GLUCOCORTICOIDS ON
EXACERBATIONS OF CHRONIC OBSTRUCTIVE
PULMONARY DISEASE. Niewoehner et al. N Engl J Med. 1999
• Exclusion criteria included:
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Diagnosis of asthma
Systemic glucocorticoids in last 30 days
Comorbidities making survival of 1 year unlikely
Inability to give consent
• Patients hospitalized for at least 3 days and
given IV Solu-Medrol followed by either 2 or
8 week taper starting at 60 mg of Prednisone
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EFFECT OF SYSTEMIC GLUCOCORTICOIDS ON
EXACERBATIONS OF CHRONIC OBSTRUCTIVE
PULMONARY DISEASE. Niewoehner et al. N Engl J Med. 1999
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EFFECT OF SYSTEMIC GLUCOCORTICOIDS ON
EXACERBATIONS OF CHRONIC OBSTRUCTIVE
PULMONARY DISEASE. Niewoehner et al. N Engl J Med. 1999
• No significant difference in outcomes
between 2 and 8 week courses
• Did show complications with treatment
arms including hyperglycemia and trend
toward more hospitalizations for infection
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Oral corticosteroids in patients admitted to hospital with
exacerbations of chronic obstructive pulmonary disease:
a prospective randomised controlled trial. Davies et al. The Lancet.
August 7, 1999
• Clinical question: Does oral prednisolone
30-40 mg modify rate of improvement of
lung function or course of hospital stay?
• Design: RCT, double blind study of 60 pts
• Included patients with COPD
exacerbation, Age 40-80 years, 20 pack
year history, FEV1 < 70%, and FEV1/FVC
< 75%
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Oral corticosteroids in patients admitted to hospital with
exacerbations of chronic obstructive pulmonary disease:
a prospective randomised controlled trial. Davies et al. The Lancet.
August 7, 1999
• Excluded if personal or family history of
asthma/atopy, uncontrolled LVF,
clinical/radiological PNA, oral steroids in
last month, or arterial pH < 7.26
• Patients randomized to prednisolone 30
mg for 14 days or placebo
• Patients followed to discharge with 6 week
follow up
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Oral corticosteroids in patients admitted to hospital with
exacerbations of chronic obstructive pulmonary disease:
a prospective randomised controlled trial. Davies et al. The Lancet.
August 7, 1999
• Study showed FEV1 after bronchodilation
increased more rapidly in the
prednisolone group although no
significant difference was found at 6 weeks
• Hospital length of stay was decreased from
9 to 7 days in treatment group
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Oral or IV Prednisolone in the
Treatment of COPD Exacerbations*
A Randomized, Controlled, Double-blind Study.
De
Jong et al. Chest. 2007
• Randomized control trial comparing 60
mg of IV versus PO prednisolone
• Study results did not show any significant
difference in short or long term outcomes.
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Antibiotics
• Antibiotic therapy should be considered
when patients have 2 of the 3 following
symptoms:
– Increased dyspnea
– Increased sputum volume
– Increased sputum purulence
• And if the patient has a severe
exacerbation requiring mechanical
ventilation
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Antibiotics
• Common pathogens recovered from lower
airways of patients with COPD
exacerbation are S. pneumoniae, H.
influenzae, and M. catarrhalis
• Most studies were done in chronic
bronchitis and recommend 3-7 days of
treatment
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Antibiotics
• Type of antibiotic is divided by severity of
exacerbation and risk factors for poor
outcome:
– Comorbid conditions
– Severe COPD
– > 3 exacerbations/year
– Antimicrobial use in the last 3 months
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Antibiotics
• Mild with no risk factors:
– B-lactam, tetracycline, bactrim
– Alternative of augmentin, macrolide, 2-3
generation cephalosporin
• Moderate with risk factors:
– B-lactam/B-lactamase inhibitor or
fluoroquinolone
• Severe with risk for P. aeruginosa:
– Fluoroquinolone or B-lactam with pseudomonas
activity
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Noninvasive Intermittent
Ventilation (NIV)
• Improves respiratory acidosis, increases
pH, reduces PaCO2
• Decreases need for endotrachial
intubation
• Reduces respiratory rate and dyspnea
• Decreases length of hospital stay and
mortality
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Noninvasive Intermittent
Ventilation (NIV)
• Indications:
– Moderate – Severe dyspnea with use of
accessory muscles and paradoxical abdominal
motion
– Moderate – Severe acidosis pH < 7.35 and/or
PaCO2 > 45 mm Hg
– Respiratory rate > 25 breaths/minute
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Noninvasive Intermittent
Ventilation (NIV)
• Relative contraindications:
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Respiratory arrest
Cardiovascular instability
Mental status changes preventing cooperability
High aspiration risk
Thick/copious secretions
Recent facial or gasteroesophageal surgery
Craniofacial trauma
Fixed nasopharyngeal abnormalities
Burns
Extreme obesity
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Noninvasive positive pressure ventilation to treat respiratory failure
resulting from exacerbations of chronic obstructive pulmonary disease:
Cochrane systematic review and metaanalysis. Lightowler et al. BMJ.
January 25, 2003.
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Noninvasive Intermittent
Ventilation (NIV)
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Discharge and Follow Up
• Discharge criteria:
– Inhaled B2- agonist therapy is required no more that
q4 hrs
– Patient, if previously ambulatory, is able to walk
across the room
– Patient is able to eat and sleep
– Patient has been clinically stable for 12-24 hrs
– ABG’s have been stable for 12-24 hrs
– Patient (Caregiver) understands correct use of
medications
– Follow up and home care is arranged
– Patient, family, and physician are confident patient
can manage successfully
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Follow up items
Ability to cope in usual environment
FEV1
Inhaler technique
Understanding of recommended
treatment regimen
• Need for long term oxygen therapy or
nebulizer therapy
•
•
•
•
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Goals
• Understand the pathophysiology of
exacerbations
• Learn more about the current guidelines
for treatment of COPD exacerbation and
why?
• Discuss the current practices at UNM?
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• Do our current practices coincide with the
current guidelines?
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Resources
•
Brochard L, Mancebo J, Wysocki M, Lofaso F, Conti G, Rauss A, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J
Med 1995;333(13):817-22.
•
Davies L, Angus RM, Calverly PM. Oral corticosteroids of chronic obstructive pulmonary disease: a prospective randomised controlled trial. Lancet 1999;354(9177):456-60.
•
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.
Executive Summary, 2009.
•
Holguin F, Folch E, Redd SC, Mannino DM. Comorbidity and mortality in COPD-related hospitalizations in the United States, 1979 to 2001. Chest 2005;128(4):2005-11.
•
de Jong YP, Uil SM, Grotjohan HP, Postma DS, Kerstjens HA, van den Berg JW. Oral or IV prednisone in the treatment of COPD exacerbations: a randomized, controlled,
double-blind study. Chest. 2007 Dec;132(6):1741-7. Epub 2007 Jul 23.
•
Lightowler JV, Wedzicha JA, Elliot MW, Ram FS. Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive
pulmonary disease: Cochrane systematic review and meta-analysis. BMJ 2003;326(7382):185.
•
Maltais F, Ostinelli J, Bourbeau J, Tonnel AB, Jacquemet N, Haddon J, et al. Comparison of nebulized budesonide and oral prednisone with placebo in the treatment of
acute exacerbations of chronic obstructive pulmonary disease: a randomized controlled trial. Am J Respir Crit Care Med 2002;165(5):698-703.
•
Niewoehner DE, Erbland ML, Deupree RH, Collins D, Gross NJ, Light RW, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary
disease. Department of Veterans Affairs Cooperative Study Group. N Engl J Med 1999;340(25):1941-7.
•
Quon BS, Gan WQ, Sin DD. Contemporary Management of Acute Exacerbations of COPD: A Systematic Review and Metaanalysis. Chest. 2008:133;756-766.
•
Reilly JJ, Silverman EK, Shapiro SD. Ch. 254: Chronic Obstructive Pulmonary Disease. Harrison’s Principals of Internal Medicine, 17th ed. (1635-1643). McGraw Hill,
2008.
•
Rizkallah J, Man SF, Sin DD. Prevalence of pulmonary embolism in acute exacerbations of COPD: a systematic review and metaanalysis. Chest. 2009 Mar;135(3):786-93.
Epub 2008 Sep 23.
•
Stallberg B, Selroos O, Vogelmeier C, Andersson E, Ekstrom T, Larsson K. Budesonide/formoterol as effective as prednisone plus formoterol in acute exacerbations of
COPD. A double-blind, randomised non-inferiority, parallel-group, multicentre study. Respir Res. 2009 Feb 19; 10:11.
•
Stoller, JK. Management of acute exacerbations of chronic obstructive pulmonary disease. Up to Date, www.uptodate.com. June 2010.
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Thanks
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Comments/Questions
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