Disclosure. Meet TK. Mortality. Dr. Wheeler has nothing to disclose. 3/25/2013. Objectives: An exacerbation is. COPD Management: Exacerbation

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1 COPD Management: Exacerbation Disclosure Dr. Wheeler has nothing to disclose. Meet TK Objectives: 1 Discuss guidelines and treatment strategies for exacerbations 2 Discuss the criteria for hospitalization 3 Discuss the role and selection of antibiotic therapy He is a 67 year old male who has stage III COPD. He is prescribed triple therapy for maintenance of his COPD. Combivent prn Advair Spiriva He has a history of 2 exacerbations in the last year and is currently in the emergency department with significant dyspnea and an acute on chronic respiratory acidosis. An exacerbation is an acute event characterized by a worsening of the patient s respiratory symptoms that is beyond normal day to day variations and leads to a change in medication. Mortality Hypercapnic and acidotic exacerbation requiring hospitalization 10% Post exacerbation: 14% within 3 months of admission 33% within 6 months (PaCO2 >/= 50mmHg) 40% within 1 year if required mechanical ventilation 3 year post discharge all cause mortality up to 49% 1

2 Respiratory tract infections (70 80%) Viral Bacterial Coinfection Air pollution Non compliance with maintenance medications Unknown cause Causes Patho of exacerbation Infection of airway causes Inflammation Epithelial damage Muscarinic receptor activation Release of inflammatory mediators Increase in eosinophils in airways Antibody production Risk Factors for Exacerbation Age Time from diagnosis Productive cough Mucus hypersecretion Antibiotic history Theophylline use Comorbid disease Hospitalization for COPD within past year History of exacerbations Gastroesophageal Reflux Disease? Clinical diagnosis Increase in baseline symptom presentation Shortness of breath Sputum production Cough Sputum purulence Diagnosis Increased dyspnea Pneumonia Pulmonary embolism Heart failure Arrhythmias Pneumothorax Pleural effusion Labs and Tests Exception ABGs ph HCO3 pco2 O2 Sat CXR ECG Electrolyte panel Glucose level RBC WBC ~ BNP ~ Sputum culture Hemophilus influenzae Streptococcus pneumoniae Moraxella catarrhalis Pseudomonas aeruginosa Spirometry is not recommended! 2

3 In or Out? American Thoracic Society/European Respiratory Society Inadequate response to outpatient management Significant dyspnea Lack of sleep or eating due to symptoms Lack of self care due to symptoms Increasing hypoxemia Increasing hypercapnia Acute respiratory Acidosis Mental status changes Questionable diagnosis Significant comorbidities Complicated COPD Hospital or Intensive Home Care 7 trial meta analysis: Statistically equivalent clinical outcomes Markedly reduced cost with outpatient care Intensive support and resources for home care MUST select patients appropriately: NO impairment of mental status NO respiratory acidosis (ph<7.35) NO acute ECG changes NO acute changes on CXR No coexisting morbidities Goals Identify and treat cause Bronchodilate to optimize lung function Assure oxygenation Clear secretions Avoid intubation if possible Prevent complications: VTE and further deconditioning Assess nutrition status and needs Oxygen Give them O2! A high FiO2 NOT required for adequate oxygenation and correction of hypoxemia If difficulty correcting hypoxemia; consider other diagnoses PE Severe PNA Pulmonary Edema Goal: O2 Sat > 90% PaO2 = mmhg Treatment Plan Beta Agonists Bronchodilators SABAs SAMAs Glucocorticoids Antibiotics Short acting : Albuterol, levalbuterol Rapid onset Nebulizer or MDI with Spacer Albuterol 2.5mg/3mL neb final solution or 90mcg/puff NEB INH q 1 4 hours prn or continuous; q20minx3 doses MDI 4 8 puffs q 1 4 hours prn Levalbuterol /3mL neb final solution or 45mcg/puff NEB INH q 1 4 hours prn MDI 4 8 puffs q 1 4 hours prn continuous; q20minx3 doses 3

4 Antimuscarinics Steroids Short acting: Ipratropium In combination with beta agonists (1B) Improved dilation with combination therapy than with either therapy alone A general but not universal truth Nebulizer or MDI with Spacer Ipratropium neb 500mcg/3mL (final solution) q4 hours prn Ipratropium18 mcg/puff; 2 INH q4 hours prn n=271 patients with COPD exacerbation Systemic glucocorticoids or placebo up to 2 weeks in addition to bronchodilator therapy Systemic steroids associated with Reduced 30 day treatment failure (23% v 33%) Reduced 90 day treatment failure (37% v 48%) Reduced hospital stay (8 days v 10 days) Improved lung function Steroids Typical steroid therapy Rapid, ~ 100% absorption PO ~ IV INH v Systemic for exacerbation Not studied in RCT INH may be initiated (no evidence of added benefit) but NOT substituted for systemic therapy GOLD guidelines recommended dose Prednisolone 30 40mg daily or equivalent NO evidence supporting best dose! Should the dose be the same for every severity? Prednisone 30 60mg po daily Methylprednisolone mg IV BID QID. NO evidence supporting best duration of therapy! Typical duration days. TAPER to discontinue! Taper started within of after days of therapy. Glucocorticoid Conversion Sputum cultures and antibiotics Antibiotics yes, recommended, but what to do? GOLD guidelines NOT recommend sputum cultures for most exacerbations. Sputum cultures are unreliable. May be useful if a suspected bacterial infection doesn t respond to first line antibiotic. 4

5 Most Common Bugs Hemophilus influenzae Streptococcus pneumoniae Moraxella catarrhalis Pseudomonas consideration Sputum culture is more helpful if at risk for pseudomonas; >/= 2 days hospitalized within last 90 days >/=4 courses of antibiotics within past year FEV1<50% Identification of pseudomonas infection in previous exacerbation Colonization during stable COPD Antibiotics GOLD recommends antibiotics if Severe exacerbation requiring mechanical ventilation Or Increased sputum purulence And Increased dyspnea Or Increased sputum volume Benefit? Antibiotic therapy increases chance of clinical improvement in moderate to severe exacerbations. Little evidence to support in mild exacerbations. Which one? Indicators of poor outcomes No ideal regimen identified for COPD exacerbations. Risk stratification of empiric therapy based on outcome expectations. Consideration for most likely pathogens and local resistance rates. > 65 years old Comorbidities Severe stable COPD Antibiotics within last 90 days >/=3 exacerbations within past year 5

6 Antibiotics Antibiotic Options Treatment duration typically 3 7 days based on response. GOLD recommendations: 5 10 days Mucolytics Methylxanthines Little evidence to support use. May worsen bronchospasm. Aminophylline or Theophylline NOT recommended for treatment of exacerbations. Lack efficacy and increase in adverse effects Physiotherapy Coughing Percussion and Vibration Positive pressure breathing Postural drainage Risk of bronchoconstriction. No proven benefit in exacerbations. Back to TK He is a 67 year old male who has stage III COPD. He is prescribed triple therapy for maintenance of his COPD. Combivent prn Advair Spiriva He has a history of 2 exacerbations in the last year and is currently in the emergency department with significant dyspnea and an acute on chronic respiratory acidosis. Do you expect him to be treated inpatient or as an outpatient? Why? 6

7 Secondary Prevention Smoking cessation Pulmonary rehabilitation Proper inhaler technique Medication adherence counseling Vaccinations Action Plan Secondary prevention? Action Plan Guidelines for Recognizing the start of an exacerbation How to alter medication regimens in response to symptoms When to call their healthcare provider Infection prevention strategies Avoid sick contacts Wash hands 5 months later. TK TK has been going to pulmonary rehab and has an action plan. He has noticed an increase in shortness of breath and sputum purulence and believes he is starting to have another exacerbation. He goes to see his physician who prescribes outpatient treatment. What treatments do you expect? Antibiotic Options 7