Transcript Asthma_COPD

Updates in
Treatment Options for
Asthma and C.O.P.D.
Patients
Asthma and C.O.P.D.
Lecture Objectives
ƒ Know presenting signs & symptoms
ƒ Be able to assess case severity
ƒ Know medication and other treatment
options
ƒ Be able to formulate appropriate plans
of care
ƒ Know indications for admission
Asthma : Definition &
General Demographics
ƒ Is a chronic inflammatory disorder of the airways, with
airflow obstruction & airway inflammation, & recurring
wheezing, dyspnea, & cough
ƒ Prevalence, morbidity, & mortality has increased since
1980's
ƒ Age - adjusted death rate for ages 5 to 34 increased 40
% from 1982 to 1992
ƒ About 5000 deaths per year in U.S.
ƒ However Rowe and Camargo’s editorial in 2006 notes
improved control and decreasing mortality in some
countries
ƒ About 2 million E.D. visits in U.S. per year
This prevalence trend is still true
Morbidity and mortality aspects of asthma
Triggers of asthma
Additional triggers of asthma
Markers of a Potentially Fatal
Asthma Attack
ƒ Historical factors :
–Hyperacute
exacerbation
–Lack of steroid use
–Non-compliance
–Psychiatric illness
–> 3 hospital
admissions
–Prior intubation or
barotrauma
ƒ Physical findings :
–Altered mental status
–Diaphoresis
–Inability to speak
–PEFR < 100 L / min.
Diagnostic Assessments to
Consider for Asthma
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Peak Expiratory Flow Rate (PEFR)
Pulse oximetry
Arterial blood gas (ABG)
Hematology & chemistry studies
Chest X-ray (CXR)
PEFR Considerations for
Asthma
ƒ Probably the single most useful assessment test
ƒ Can stratify patients into severity groups :
– < 25 % : Severe (impending resp. failure)
– 25 to 50 % : moderate to severe
– 50 to 70 % : mild to moderate
– > 70 % : mild (can be discharged if at this value)
ƒ Initial value not highly correlated with admission
rate but higher risk if < 100 or improves < 60 with
Rx
ƒ Should usually not discharge if < 250 L / min.
Pulse Oximetry Considerations for
Asthma
ƒ Trend toward lower initial values correlating
with higher chance of admission, but not very
sensitive
ƒ Especially helpful in patients unable to
perform PEFR and in kids
ƒ Can be at normal levels in some with severe
bronchospasm
ABG Considerations for
Asthma
ƒ Initial ABG is poor predictor of outcome
and rarely influences therapy
ƒ NOT recommended routinely
ƒ Indications :
–Suspected respiratory failure
–Altered mental status (need to know pCO2)
–Pulse oximeter unable to track, & hypoxia is
suspected
–Worsening despite therapy
Hematology and Chemistry
Studies for Asthma
ƒ Generally are NOT needed for most cases
ƒ WBC count NOT reflective of severity or
associated infection
ƒ Most patients are not dehydrated, and do
not have electrolyte abnormalities (except
pseudohypokalemia from beta agonists)
ƒ Only useful test might be theophylline level
if the patient is taking a methylxanthine
CXR Considerations for
Asthma
ƒ NOT routinely needed for "typical"
exacerbations
ƒ May be needed for :
–New onset asthma (especially in kids)
–Unclear Dx (e.g., R / O CHF, foreign body, etc.)
–Asthma refractory to treatment
–Respiratory failure
–ETT placement
–Strong clinical suspicion for infection
–Chest pain (R / O pneumo - thorax or - mediastinum)
26 year old male with asthma and chest pain
Same patient with arrows denoting pneumomediastinum
General E.D. Management
Scheme for Asthma
ƒ Triage
ƒ Primary treatments :
–Beta agonists
–Corticosteroids
ƒ Secondary (or "refractory") treatments :
–Anticholinergics
–Magnesium, leukotriene inhibitors, Heliox,
antibiotics, ketamine, mucolytics
ƒ Disposition
Triage Considerations for
Asthma
ƒ All patients with acute asthma should be
quickly taken to a monitored treatment area
ƒ Initial nursing interventions :
–Pulse oximetry
–Oxygen by nasal prongs (or blow-by mask for kids)
–Cardiac monitor (if moderate to severe)
–PEFR
–IV line if severe
–Notify physician
Main Therapy for Acute Asthma
Exacerbations :
Inhaled Beta Agonists
ƒ MDI-spacer delivery may be equivalent to
traditional nebulizer
–The patient may think MDI Rx in E.D. will be
ineffective since has already tried it at home
ƒ Continuous nebulization may be more
effective in severe cases, but no difference
for moderate cases (although takes less
E.D. personnel time)
–Albuterol doses are 10 to 30 mg / hr for adults, 5
to 7.5 mg / hr for kids
Choices for Short Acting Beta
Agonists (SABA’s)
• Albuterol (Ventolin, Proventil)
– PO 0.1 to 0.2 mg/kg/dose up to 12 mg/day
– MDI one to two puffs q 20 minutes X 3 or :
– 2.5 mg of 0.5 % solution via nebulizer q 20 minutes X 3
• Levalbuterol (Xopenex)
– R isomer of albuterol
– MDI 1 to 2 puffs q 4 h
– Not shown superior to racemic albuterol (but is more
expensive)
• Metaproterenol (Alupent)
– Same doses for MDI and nebulizer as albuterol
– No big comparative studies versus albuterol
Considerations for Parenteral
Use of Beta Agonists
ƒ Subcutaneous may be useful for rare
patient not able to receive aerosol
–Terbutaline probably safest (0.01 mg/kg, max.
0.3 mg)
–Epinephrine (same dose; causes more HBP)
ƒ For "crashing" patient, give IV
–0.1 mg diluted and via SLOW IV push
–then 0.4 mcg/kg/min IV drip
ƒ Prior to discharge, can give Susphrine (epi tannate in oil)
SQ at 0.005 mg/kg (more useful for allergic reactions)
although availability of this med has decreased
Long Acting Beta Agonists
(LABA’s)
ƒ Salmeterol (Serevent) MDI 50 mcg bid
ƒ Onset in 10 to 20 minutes & duration 12 hours
ƒ Twice as expensive as albuterol
ƒ Useful for nocturnal asthma
ƒ May be useful prior to E.D. discharge to help
prevent early relapse
ƒ Formoterol (Oxis, Foradil) MDI 12 to 25 mcg bid
ƒ Note FDA black box warning for these
Clinical Use Guidelines for the LABA’s
ƒ NOT to be used as monotherapy for long term
control of asthma
ƒ Recommended in combination with Inhaled
Corticosteroids (ICS) for long term control in
moderate and severe persistent asthma
ƒ NOT to be used frequently or chronically before
exercise because this may mask poorly
controlled asthma
Other Medications for Acute Asthma
ƒ "Primary" Meds
–Corticosteroids
–Anticholinergics
–Magnesium
ƒ "Secondary" Meds
–Methylxanthines
–Ketamine
–Heliox
–Halothane
–Leukotriene inhibitors
Use of Systemic Steroids in
Asthma
ƒ Clearly shown to decrease admission & relapse
rates
ƒ Oral route is fine for most
–40 to 60 mg prednisone / day for adults
–2 mg / kg per day for kids
–5 day duration best (typical length of attack)
–taper usually not needed
ƒ IV only for severe dyspnea, emesis, altered
mental status, or intubated (IV versus PO shows
same acute effects)
ƒ Methylprednisolone, hydrocortisone, dexamethasone
Use of Inhaled Steroids for
Asthma
ƒ Regular use decreases need for beta
agonists & relapse rates
ƒ Use during an acute attack may just
increase cough
ƒ Use of spacer and post-Rx mouth
rinse decrease side effects
(dysphonia, oral Candidiasis)
Choices of Inhaled Steroids for
Asthma (via MDI’s)
ƒ Fluticasone (Flovent) 250 to 500 mcg bid
ƒ Budesonide (Pulmicort, Rhinocort) 200 to 800
mcg bid
ƒ Triamcinolone (Azmacort) 2 to 4 puffs bid to qid
ƒ Beclomethasone (Vanceril, Beclovent) 84 to 840
mcg per day
ƒ Virtually all patients should be on one of these
after discharge
Use of Anticholinergics for Acute
Asthma
ƒ Inhaled (via MDI or nebulizer) these decrease
bronchospasm by reducing vagal tone
–Atropine (0.2 to 0.5 mg)
–Glycopyrrolate (Robinul) 0.2 to 0.4 mg
–Ipratropium (Atrovent) 250 to 500 mcg
ƒ Several studies show mild added benefit when
added to first three beta agonist nebulizations
in E.D. (not helpful after this)
ƒ Ipratropium has low rate of side effects
ƒ May help undefined subsets of patients
Use of Magnesium for Acute
Asthma
ƒ Acts as smooth muscle relaxer &
suppresses neutrophil burst response
ƒ Conflicting results of efficacy in different
studies ( ? inadequate dosing in some)
ƒ Clearly safe & few side effects
ƒ 2.0 to 5.0 gm IV dose reasonable to try for :
–Severe symptoms
–Respiratory failure
–Non-response to standard Rx
Use of Methylxanthines for
Asthma
ƒ Problems with aminophylline :
–weak bronchodilator
–high rate adverse side effects
–narrow toxic / therapeutic window
–requires monitoring of serum levels (goal 5 to 15 mcg/ml)
–many medication interactions
ƒ Clearly shown to add no benefit to acute Rx with beta agonists
& steroids
–However, slow release forms (Slo-Bid, Theo-Dur, Uniphyl)
may be useful in some patients for chronic maintenance
–5 to 8 mg/kg/day
Use of Ketamine for Acute
Asthma
ƒ Dissociative anesthetic
ƒ Relaxes bronchial smooth muscle
ƒ Excellent agent for RSI for critically ill asthmatic
–2 mg / kg IV or 4 mg / kg IM
–Continued infusion 1 to 2.5 mg / kg / hr
ƒ May cause :
–Laryngospasm
–Hypertension
–Hallucinations
Use of Heliox for Acute
Asthma
ƒ Is premixed air 20 % and helium 80 %
ƒ Gas density is lower than air so flow
resistance is less
ƒ Somewhat limited usefulness for asthma
because as more O2 is blended in, the
gas density re-increases (max. O2 is 40
%)
ƒ Expensive if used for extended period
ƒ No major extended benefits in controlled
studies
Use of Leukotriene Receptor
Antagonists (LTRA’s) for Asthma
ƒ Leukotrienes are released from mast cells,
eosinophils, and basophils and mediate :
–bronchoconstriction
–mucus secretion
–airway mucosal edema
ƒ The LTRA’s are useful for :
–Treatment of stable, mild, persistent asthma, and
prophylaxis of exercise induced asthma
–decrease airway response to cold & allergens
–Role in acute asthma not yet clear (IV montelukast
is in phase 3 research trials)
Choices of LTRA’s for Asthma
ƒ Montelukast (Singulair)
ƒ 10 mg PO hs or two hours before exercise
ƒ Systemic eosinophilia and vasculitis
consistent with Churg-Strauss Syndrome
rarely reported
ƒ Zafirlukast (Accolate)
ƒ 20 mg PO bid
ƒ Rarely has caused liver failure
Another Category of Meds : 5Lipoxygenase Inhibitors
ƒ Zileuton (Zyflo, Zyflo CR)
ƒ Inhibits leukotriene formation
ƒ Dose 600 mg pc and hs for Zyflo
ƒ Dose 1200 mg bid for Zyflo CR
ƒ Can cause liver failure
ƒ Not studied for acute use
Still Another Category of Meds :
Mast Cell Degranulation Inhibitor
• Cromolyn (Intal)
– Inhibits degranulation of sensitized mast cells
– Attenuates bronchospasm caused by exercise,
cold air, aspirin, and environmental pollutants
– MDI dose 2 puffs qid or two puffs 15 to 60
minutes prior to exercise
– Rarely has caused liver impairment
And the Final Category of Asthma
Medication : Omalizumab (Xolair)
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Recombinant DNA-derived immunoglobulin G
monoclonal antibody which binds selectively
to human immunoglobulin E on the surface of
mast cells and basophils and then reduces
mediator release
Used when Sx are not controlled by inhaled
steroids
Dose 150 to 375 mg SQ q 2 to 4 weeks
Annual cost $12,000 to $15,000
Can cause anaphylaxis
Combination Medications Available
for Asthma
ƒ Ipratropium and albuterol (Combivent)
ƒ Nebulizer 3 ml q 20 min X 3 doses
ƒ MDI 4 to 8 puffs q 20 min X 3
ƒ Salmeterol and Fluticasone (Advair Diskus)
ƒ 3 dosage forms ;
ƒ 100, 250, or 500 mcg fluticasone with 50
mcg salmeterol
ƒ One inhalation bid
Expert Panel 3 (2007) List of
Ineffective Treatments for Asthma
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Methotrexate
Cyclosporin
Colchicine
Acupuncture
Chiropractic
Homeopathy
Breathing techniques
Yoga
Airway Management in
Asthma
ƒ Endotracheal intubation should be required in <
5% of admitted pts.
ƒ Indications for ETT :
–Altered mental status due to hypercarbia or hypoxia
–Progressive resp. failure or resp. acidosis despite
maximal Rx
–Base decision on clinical situation (not a particular
value of pCO2 or pO2 or pH)
ƒ Always preoxygenate & ETT attempt should be
made by most experienced operator
Considerations About Nasotracheal
Intubation of the Asthmatic Patient
ƒ Advantages :
–Can leave pt. sitting up ( resp. distress may worsen if
forced supine)
–Pt.'s resp. effort often makes the procedure easy
–Tube may be more comfortable for pt.
–Tube less likely to be dislodged
ƒ Disadvantages :
–May cause epistaxis
–Requires smaller tube diameter than oral (so more airflow
resistance)
–May predispose pt. to sinusitis later
Considerations About Orotracheal
Intubation of the Asthmatic Patient
ƒ Advantages :
–Method of choice if pt. apneic or markedly bradypneic
–No predisposition to epistaxis or sinusitis
–Larger diameter tube can be used (may permit later
bronchoscopy)
ƒ Disadvantages :
–Generally requires "full" Rapid Sequence Intubation
(RSI) technique & supine position
–May be less comfortable for pt. & more likely to
dislodge
Options for RSI Meds for the
Asthmatic Patient
ƒ For nasal ETT may only need etomidate or
benzodiazepine IV (after topical anesthesia in
nose)
ƒ Usual oral ETT sequence :
–Preoxygenate
–Lidocaine 1.0 to 1.5 mg/kg IV
–Ketamine 1.0 to 2.0 mg/kg IV
–+/- benzodiazepine 1 to 5 mg IV
–Succinylcholine 1.0 to 1.5 mg/kg IV
–Perform intubation
General Considerations for Mechanical
Ventilation of the Asthmatic Patient
ƒ Mortality of ventilated pts. prior to
1984 reported as 20 to 40 %
ƒ Current mortality < 10 % using
"permissive hypercapnia"
–uses smaller tidal volumes
–goal is to limit barotrauma
–does not require normalization of pCO2 or
pH
Specific Guidelines for Mechanical
Ventilation of the Asthmatic Patient
ƒ 1. Volume control (A/C or SIMV) preferred
over pressure control to avoid
overventilation
ƒ 2. Tidal volume set at 5 to 8 ml/kg
ƒ 3. Initial rate set at 6 to 10 breaths per min.
–allows increased time for exhalation & avoids
dynamic hyperinflation ("breath stacking")
Specific Guidelines for Mechanical
Ventilation of the Asthmatic Patient (cont.)
ƒ 4. Set FIO2 to keep arterial pO2 > 60 mm Hg
–Should be < 50% to avoid O2 toxicity if ventilation
prolonged
ƒ 5. Set PEEP adjusted to 75 to 80 % of measured
auto-PEEP level
–Make sure endogenous (auto) PEEP does not
exceed the amount dialed on the ventilator
ƒ 6. Set Peak Insp. Flow Rate 70 to 90 L/min
–Produces rapid inspiration allowing time for exhalation
–End-inspiratory plateau pressures should be < 35 mm Hg
Specific Guidelines for Mechanical
Ventilation of the Asthmatic Patient (cont.)
ƒ 7. Sedation to prevent tachypnea & allow pt. to
rest
ƒ 8. Aerosolized beta agonists should be given via
ventilation circuit (continuous Rx can be done)
ƒ 9. As wheezing improves, may increase TV & rate
ƒ 10. Monitor for barotrauma (risk greater if endinsp. plateau pressure > 35 mm Hg)
ƒ 11. Monitor for clinical improvement allowing
extubation
Complications of Mechanical
Ventilation of the Asthmatic Patient
ƒ Barotrauma due to alveolar rupture
–Pneumomediastinum, pneumothorax, or SQ emphysema
–Should usually treat with chest tube
–May need to reset ventilation parameters to decrease
end-inspiratory plateau pressure
ƒ Prolonged muscle weakness
–Can be due to prolonged effect of paralytic agent used for
intubation (esp. if renal insufficiency)
–May be partly due to steroid Rx
–Can be a myopathic syndrome with increased muscle enzymes &
require ventilation for several weeks
Education of the Asthmatic Patient to
be Discharged from the E.D.
ƒ Consider pt. education regarding the following items
prior to D/C :
–MDI / spacer use training
–Review of medications
–Self use of short course oral steroids
–Home use of PEFR
ƒ Identify PEFR #'s for which pt. should come to E.D.
–Arrange F/U with primary care doctor
–Asthma diary
–Identify avoidable triggers (shoot any cats in the
house)
Other Considerations for Education of
the Asthmatic Patient
ƒ Make sure family members are also
educated re meds & severity assessment
ƒ Emphasize planning & early response to
minimize time lost from school or work
ƒ Remember it is a chronic recurrent
disease, so limit diagnostic tests unless
there are atypical features or severity of an
attack
Asthma
Lecture Summary
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Assess severity at presentation
Start multiple simultaneous Rx if severe
Decide if diagnostic studies needed
Monitor for response to Rx
Consider second line Rx's & intubation &
ventilation for refractory cases
ƒ Provide careful education & post - E.D.
planning for discharged pts.
Chronic Obstructive
Pulmonary Disease (COPD)
ƒ Refers to triad of disease processes :
–Asthma (airway reactivity)
–Bronchitis (airway inflammation)
–Emphysema (airway collapse)
–All 3 coexist to some degree in same pt.
ƒ Definitions :
–Chronic bronchitis = chronic cough with sputum
production for at least 3 months / yr. for at least 2 yrs.
–Emphysema = enlargement of distal air passages due to
alveolar septal destruction (& obliteration of pulm. capillary
bed)
COPD Epidemiology
ƒ 4th leading cause of death in U.S.
ƒ Leading cause of death in smokers > age
55
ƒ 12.5 million in U.S. have chronic bronchitis
ƒ 14 million in U.S. have emphysema
ƒ 2nd most common cause of permanent
disability
ƒ Huge economic impact
Risk Factors to Develop COPD
ƒ Major factor is cigarette smoking
ƒ Less common factors :
–Inhalation of "second hand" smoke
–Occupational exposure
–Cystic fibrosis
–Alpha 1 antitrypsin deficiency
–Intravenous drug abuse
Pathophysiologic Features of
COPD
ƒ airflow
ƒ lung volumes, hyperinflation
ƒ V/Q mismatch
ƒ Arterial hypoxemia & hypercarbia
ƒ Often intrinsic airway inflammation
ƒ Note typical inflammatory cells in
COPD are usually neutrophils,
whereas they are usually
eosinophils in asthma
Sequence of Pathophysiologic
Events with COPD
ƒ Parenchymal destruction continues
ƒ Distal air spaces enlarge
ƒ Loss of elastic recoil
–Increases lung volumes when resp. rate
–Expiratory time then
–Hyperinflation results
Pathophysiologic Results of
Dynamic Hyperinflation in COPD
ƒ Inspiratory muscle dysfunction
–Acts at stiffer portion of its volume pressure relationship
–Muscle fibers forced from vertical to
horizontal position
–Increased reliance on accessory muscle
fibers
ƒ Causes increased work of breathing &
increased dyspnea
Goals of the E.D. Evaluation of
the COPD Patient
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Rapidly stabilize the pt. in resp. failure
Identify precipitating causes
Treat complications
Rule out or treat concurrent
conditions
Clinical Presentation of Patients
with Exacerbations of COPD
ƒ Dyspnea ; most common ; may be severe
ƒ Other Sx may or may not be present
–Chest pain ; may be :
ƒ Diffuse or vague
ƒ Pleuritic
ƒ Chest wall (from cough injury)
–Cough
–Fever
–Altered mental status
–Apprehension
Signs Associated with COPD
Exacerbations
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Dyspnea
Tachypnea
Tachycardia
Ashen skin color or cyanosis
Diaphoresis
Accessory muscle use
Intercostal retractions
Rales / rhonchi / wheezes / decreased BS
Apprehension
Signs of Severe or Critical Airflow
Obstruction in a COPD Exacerbation
ƒ Altered mental status
ƒ Inability to speak
ƒ "Silent chest" (no or limited audible
BS)
ƒ Combativeness / seizures
Differential Dx of COPD
Exacerbation
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CHF
Acute myocardial ischemia
Airway obstruction
Pneumonia
Pneumothorax
Pulmonary embolus
Pleural effusion
Acute aortic dissection
Allergic reaction
Caveats About Differential Dx
of COPD Exacerbation
ƒ COPD exacerbation may coexist or be
concurrent with any of Dx's on previous
slide
ƒ Particularly CHF may cause COPD
exacerbation & vice versa
–PEFR > 150 L/min suggestive of Dx of CHF
ƒ Pulm. embolus particularly difficult to Dx
in COPD pt.
Spirometry Use for COPD
Exacerbation
ƒ Should be performed on all pts.
–Determine initial severity
–Determine response to Rx
ƒ Clinical eval. alone is unreliable at estimating
airflow obstruction
ƒ Many pts. with post-Rx FEV1 > 40% can be
safely discharged
ƒ Another discharge criterion is PEFR > 250
(assuming pt.'s baseline PEFR is > 300 ; need to know pt.'s
prior PFT's to determine this)
Use of ABG's in COPD
Exacerbation
ƒ Some recommend on all pts.
ƒ I favor using only in pts. who :
–Appear critical at presentation
–Do not respond well to Rx
–Have altered mental status
ƒ ALL pts. should have continuous pulse
oximetry
ƒ Pt. can have hypoxemia even when pulm.
function approaches 50% of normal
Use of CXR in COPD
Exacerbation
ƒ CXR should be obtained on all pts.
ƒ At least 15 % of CXR's show a directly
treatable finding :
–Pneumonia
–Pleural effusion
–Pneumothorax
–Atelectasis
–Aortic dissection
ƒ Also allows R/O CHF
E.D. Management of COPD
Exacerbations
ƒ For ALL Pts. :
–Oxygen
–Beta agonist aerosol
ƒ Consider SQ terbutaline if unable to take aerosol
–Anticholinergic aerosols
ƒ For some pts. :
–Corticosteroids
–Antibiotics
–Diuretics
–CPAP / BiPAP / Intubation / Ventilation
Considerations for O2 Therapy for
COPD Exacerbations
ƒ Risk of eliminating hypoxic drive (&
causing further resp. acidosis / failure) is
overstated
–Only applies to < 5% of COPD
population
ƒ Venturi mask can be used to give precise
regulated O2 concentrations
ƒ Pts. that develop resp. acidosis with O2
Rx usually need to be intubated &
ventilated anyway
Anticholinergic Med Choices &
Doses for COPD Exacerbations
Medication
Dose
Ipratropium
0.5 mg
Atropine
1 to 2 mg (0.025 mg/kg)
Glycopyrrolate
0.2 to 1.0 mg
Ipratropium preferred because of less side
effects such as tachycardia
Considerations in Use of Corticosteroids for
Rx of COPD Exacerbation
ƒ Not of benefit to all pts. with COPD
ƒ Should be considered if :
–Pt. on chronic steroid Rx
–Wheezing component is prominent
–Allergic trigger
–Prior response to steroids
–IV versus PO is equivalent
Considerations in Use of Antibiotics
for COPD Exacerbation
ƒ Not indicated for all pts.
ƒ Usually indicated for COPD exacerbation with :
–Fever / chills
–Increased sputum production
–Change in color of sputum
–Persistent increased cough
–Atelectasis or infiltrate on CXR
ƒ Most common pathogens :
–Strep pneumoniae (with increasing rates of PCN resistance)
–Hemophilus influenzae
–Moraxella (Branhamella) catarrhalis
Antibiotic Choices for COPD
Exacerbation
ƒ Best first line agents :
–Azithromycin
–Cefuroxime
–Trimethoprim - sulfa
–? levofloxacin
ƒ Problems with other choices :
–Doxycycline, amoxicillin : resistance
–Erythromycin : no H. flu coverage
–Amoxil / clavulanate : cost, side effects
–Clarithromycin : cost, drug interactions, taste
Ventilatory Assistance Considerations
for COPD Exacerbation
ƒ 3% of COPD pts. require ETT & ventilation
for resp. failure
ƒ Indications & complications same as for
asthma
ƒ Need to be careful to avoid barotrauma
ƒ Intubated COPD pts. have higher mortality
& longer time on ventilator than asthma
pts.
ƒ CPAP or BiPAP can be tried prior to ETT
Disposition Considerations for
COPD Exacerbation
ƒ Indications for hospital admission :
–Persistent hypoxemia (O2 sat. < 90%)
–Persistent hypercarbia / resp. acidosis
–Persistent dyspnea
–Overt resp. failure
–Altered mental status
–Usually if associated pneumonia
–Pneumothorax
ƒ "Borderline " admission candidate may
be considered for observation unit first
Suggested E.D. Management
of COPD Exacerbation
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Immediate O2 & beta 2 aerosol
Rapid CXR to R/O CHF or pneumothorax
Evaluate for cardiac ischemia (EKG)
Consider other Dx tests
Early PEFR & repeat after each Rx
Continued Rx (aerosols, +/- steroids, +/antibiotics, etc.)
ƒ Monitor for response :
–ETT / ventilation if worsening
–Admission if not improving satisfactorily
Adjunctive Treatments to Consider for
COPD Exacerbations
ƒ Phosphodiesterase-4 Inhibitors
ƒ Reduce inflammation via macrophages and
lymphocytes
ƒ Cilomilast 15 mg PO bid
ƒ Mucolytic agents
ƒ N-acetycysteine
ƒ Efficacy debatable
ƒ Referral for surgical bullectomy, lung volume
reduction surgery, or lung transplantation
Web Sites with Useful Clinical
Guidelines for Asthma and COPD
ƒ Expert Panel Report 3 Summary Report 2007
ƒ 440 pages ; summary is 74 pages
ƒ http://www.nhlbi.nih.gov/guidelines/asthma/asthgdl
n.htm
ƒ http://www.medscape.com/viewarticle/564670 , and
564654
ƒ emedicine.com has 4 nice articles under both
“emergency medicine” and “pulmonology” :
ƒ http://www.emedicine.com/med/topic177.htm , & 373
ƒ http://www.emedicine.com/emerg/topic43.htm , & 99