Updated: 3/19/2021

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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