Updated: 2/5/2020

COPD Exacerbation

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Snapshot
  • A 68-year-old man with a history of hypertension, heart failure, and emphysema presents to the emergency department with worsening shortness of breath and purulent sputum production. His symptoms began approximately 4 days ago, where he has had difficulty cleaning around the house and walking 1 block. Prior to this event, he was able to walk 7-10 blocks without much difficulty and did not experience dyspnea at rest. He has a 45-pack-year smoking history. He has not received the influenza vaccine. He has been hospitalized 5 times within the past year for similar symptoms. He is febrile and his oxygen saturation is 85% on room air. On physical exam, the patient appears uncomfortable and is having trouble completing his sentences.  Chest radiography demonstrates hyperinflated lungs. A sputum culture is obtained and an arterial blood gas is significant for hypercarbia, hypoxemia, and acidemia. He is started on supplemental oxygen, inhaled ipratropium, albuterol, intravenous methylprednisolone, and levofloxacin.
Introduction
  • Definition
    • an acute worsening of a patient's respiratory symptoms leading to a change in treatment
    • cardinal symptoms of an acute change include an increased
      • frequency and severity of a cough
      • sputum volume or character change
      • dyspnea
  • Epidemiology
    • risk factors
      • advanced age
      • duration of COPD
      • history of antibiotic therapy
      • worsened FEV1
      • a productive cough
      • peripheral eosinophilia
  • Etiology
    • respiratory infections
      • most commonly H. influenzae, M. catarrhalis, and S. pneumoniae
      • patients are at increased risk for P. aeruginosa infection when they
        • have multiple hospitalizations in the past
        • advanced COPD
        • previous isolation of Pseudomonas from sputum
        • concomitant bronchiectasis
        • frequent antibiotic treatment
        • systemic glucocorticoid use
    • congestive heart failure
    • pulmonary embolism
  • Prevention
    • influenza vaccine
    • 23-valent pneumococcal polysaccharide vaccine (PPSV23)
    • 13-valent pneumococcal conjugate vaccine (PCV13) for all patients ≥ 65 years of age
  • Prognosis
    • associated with an increased mortality
Presentation
  • Symptoms
    • worsening dyspnea and cough
    • increased sputum production or change in sputum character
  • Physical exam
    • wheezing
    • tachypnea
    • patients may have difficulty speaking due to respiratory effort
    • accessory respiratory muscle use
    • asynchrony between chest and abdominal motion with respiration
    • confusion (secondary to hypercarbia and hypoxemia)
Imaging
  • Chest radiography
    • indication
      • initial imaging modality of choice
      • used to determine etiology for the COPD exacerbation, such as
        • pneumonia
        • congestive heart failure
Studies
  • Arterial blood gas
    • findings
      • hypercarbia, hypoxemia, and acidosis
  • Pulse oximetry
Treatment
  • Conservative
    • O2 supplementation
      • indication
        • used to improve oxygen saturation to 88-92% or a PaO2 of approximately 60 to 70 mmHg
      • comments
        • the only treatment to improve mortality in patients with COPD
  • Medical
    • ipratropium and albuterol
      • indication
        • typically used in combination for patients with a COPD exacerbation
    • Magnesium
      • relaxes smooth muscle
    • systemic corticosteroids
      • indication
        • typically used in patients with a COPD exacerbation
      • medications
        • prednisolone (oral)
        • methylprednisolone (intravenous)
          • use in patients who cannot tolerate oral medications
      • comments
        • decreases treatment failure and hospital stay
    • antibiotics
      • high P. aeruginosa risk
        • levofloxacin
        • piperacillin-tazobactam
        • cefipime
        • ceftazidime
      • low P. aeruginosa risk
        •  moxifloxacin
        • ceftriaxone
        • cefotaxime

 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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