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Updated: Aug 19 2022

COPD Exacerbation

  • 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
    • Prevention
      • influenza vaccine
      • 23-valent pneumococcal polysaccharide vaccine (PPSV23)
      • 13-valent pneumococcal conjugate vaccine (PCV13) for all patients ≥ 65 years of age
  • 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
  • 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
    • Associated with an increased mortality
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