COPD EXACERBATIONS IN OLDER PERSONS Carlos Fragoso, MD Yale University School of Medicine VA Connecticut Healthcare System No Conflicts of Interest
True or False Re. COPD exacerbations Age is a predisposing factor Sputum analysis should be performed routinely Respiratory failure is the most common cause of death
Outline Epidemiology Risk Factors Pathophysiology Management Follow-Up ATS/ERS Guidelines: http://www.thoracic.org/clinical/copd-guidelines/index.php GOLD Guidelines: Am J Respir Crit Care Med 2007;176:532-555. The 2009 report is available online at http://www.goldcopd.com CTS COPD guidelines: Can Respir J 2007;14 (Suppl B):5B-32B.
Epidemiology Definition A COPD exacerbation refers to acute worsening of respiratory symptoms,* requiring a change in management * Up to 50% may go unreported Cardinal symptoms: dyspnea, sputum purulence/volume Mild exacerbation: one cardinal symptom Moderate exacerbation: 2 of 3 cardinal symptoms Severe exacerbation: 3 cardinal symptoms Plus one or more of the following: URI, fever, wheezing or coughing, or RR or HR.
Epidemiology Outcomes COPD accounts for over 500,000 hospitalizations (USA) High relapse rates: 1/3 rd of patients discharged from the ED have recurrent symptoms within 2-weeks, requiring hospitalization in 17% Of those hospitalized in hypercapneic respiratory failure, about 50% will be readmitted within 6 months High morbidity and mortality: For those requiring an ICU admission, there are progressive decrements in functional status and quality of life, with mortality rates of 30-50%
Outline Epidemiology Risk Factors Pathophysiology Management Follow-Up
Predisposing Factors Age Multimorbidity Low physical activity Low SES Chronic bronchitis Low FEV1 Chronic respiratory failure Escalating use of bronchodilators or corticosteroids Prior exacerbation (ED, hospitalization)
Aging as a predisposing factor AJRCCM 2008;177:253-60. Associated with airflow limitation and air trapping
Aging as a predisposing factor Two-thirds of older persons have 2 or more chronic conditions www.cdc.gov/aging
www.cdc.gov/aging Aging as a predisposing factor
MMWR 2008; 57(45):1229-32. Aging as a predisposing factor
Precipitating Factors Infection: ~ 60% Bacteria: S pneumoniae, H influenzae, M catarrhalis, Enterobactericae, P aeruginosa Viruses: Rhinovirus, Influenza, Parainfluenza, RSV, Coronavirus Pollutants: ~ 10% Ozone, sulphur dioxide, nitrogen dioxide, particulate matter, biomass fuels Unknown: ~ 30%
Precipitating Factors Prevalence of chronic bronchitis relative to active smoking Eur Respir Mono 2006;38:41-70.
Precipitating Factors AJRCCM 2001;164:358-64 Physician visits in the continuous smoking group
AJRCCM 2002;166;675-679. Precipitating Factors
Thorax 2006;61;164-168. Precipitating Factors
Perpetuating Factors Depression and anxiety adds to disability caused by physical illness reduces adherence to medications risk factor for cognitive decline prolongs COPD exacerbations increases frequency of hospital admissions Int J Geriatr Psychiatry 2000; 15: 1090-1096 Int J Geriatr Psychiatry 1997; 12: 817-824
Outline Epidemiology Risk Factors Pathophysiology Management Follow-Up
Pathophysiology Baseline Small airways and alveolar destruction, with pulmonary vascular remodeling Sarcopenia and reduced central respiratory drive
Pathophysiology Exacerbation airway inflammation, mucous hypersecretion, and bronchoconstriction, resulting in impaired gas exchange and respiratory muscle fatigue
Pathophysiology Comorbidities In one autopsy-based study, of 43 decedents hospitalized with a COPD exacerbation (median age 70), the cause of death was heart failure in 16 (37%), pneumonia in 12 (28%), thromboembolism in 9 (21%), but respiratory failure in only 6 (16%). Of the decedents, 33 (77%) had 1 or more comorbidities, with the most common being chronic heart failure (25; 58%). Chest 2009;136:376-80.
Outline Epidemiology Risk Factors Pathophysiology Management Follow-Up
Management Admission Criteria Marked increase in dyspnea, associated with changes in vital signs, cyanosis, or peripheral edema Severe COPD: FEV1<50%Pred, chronic respiratory failure, prior exacerbations Arrhythmias Comorbidities Older age Inadequate home support
Management ICU Criteria Severe dyspnea refractory to initial emergency therapy Change in mental status (delirium) Severe respiratory failure: PaCO2 >60 torr, ph <7.25 Hemodynamic instability
Management Evaluation CBC, CHEM7, theophylline level (if on medication) ABG if no prompt improvement in response to initial Rx ECG CXR Blood cultures if febrile Sputum gram stain and culture if poor response to empiric antibiotics or pseudomonas is suspected does not distinguish pathogens versus colonizing flora
Management Bronchodilators A short-acting beta-2 agonist is effective (Evidence A) with or without an anticholinergic (Evidence B) Albuterol: 2.5 mg by nebulizer every one to four hours, or 4 to 8 puffs (90 mcg/puff) by MDI with a spacer every one to four hours. Ipratropium: 500 mcg by nebulizer every four hours, or 2 puffs (18 mcg/puff) by MDI with a spacer every four hours. Methylxanthines: controversial Limited efficacy in COPD exacerbations, side effects
Management Steroids Effective treatment for exacerbations; recovery time, FEV1, PaO2 (Evidence A) Prednisone 40-60 mg po per day for 7-14 days. Methylprednisolone 60-125mg IV Q6H (3 days), followed by prednisone (60, 40, and 20-mg po QD, each for 4-days) NEJM 1999;340:1941-1947
Management Antibiotics Antibiotics may be useful, if the exacerbation is associated with dyspnea and sputum purulence or volume (moderateto-severe), or requires mechanical ventilation (Evidence B) H influenza, S pneumoniae, M catarrhalis, C pneumoniae Beta-lactamase resistant species Enterobacteriaceae P aeruginosa Antibiotics based on local resistance patterns No role for mucolytics or chest PT
Management Antibiotics If <65 years, FEV1 >50% Pred, no prior Abx, no comorbidity Advanced macrolide (azithromycin), or doxycycline, or cephalosporin (cefuroxime), or trimethoprin/sulfamethoxazole. If >65 years, FEV1 <50% Pred, prior Abx, comorbidity Respiratory fluoroquinolone (gatifloxacin, levofloxacin, moxifloxacin) or amoxicillin/clavulanate. Consider sputum analysis, if worsening clinical status or inadequate response in 72-hrs.
Management Antibiotics Suspect P aeruginosa: prior isolation, recent Abx use or hospitalization, FEV1 <50%Pred, and/or systemic steroid use order sputum gram stain and culture consider dual antibiotic therapy: levofloxacin, ciprofloxacin, piperacillin-tazobactam, cefepime, and/or ceftazidine.
Management Oxygen Adequate oxygenation (PaO2 60-70 torr, SpO2 90-94%) Prevention of hypoxia trumps CO2 retention concerns Venturi mask: delivers a precise FiO2 of 24, 28, 31, 35, 40, 50, or 60%; FiO2 gradually monitor PaO2 & PaCO2.
Management Oxygen Nasal cannula can provide up to 40% FiO2 (6 L/min) Variations in ventilation and entrainment of RA affect FiO2 Simple facemask can provide up to 55% FiO2 (6-10 L/min) Variations in ventilation and entrainment of RA affect FiO2 Non-rebreathing masks with a reservoir, one-way valves, and tight seal can deliver up to 90% FiO2. suspect comorbidity if high FiO2 required (HF, PNA, PE)
Management Noninvasive Ventilation Improves respiratory acidosis and dyspnea, and decreases intubation rates, length of hospitalization, and mortality (Evidence A) Selection criteria: Moderate to severe dyspnea (use of accessory muscles, paradoxical abdominal motion, >25 breaths/min) Hypercapneic respiratory failure: ph <7.35, PaCO2 >45 torr Settings: CPAP (4 8 cmh2o) and PSV (10 15 cmh2o) provides the most effective mode of NIV
Management Noninvasive Ventilation Exclusion Criteria: Respiratory arrest Cardiovascular instability (hypotension, arrhythmias, ACS) Delirium (uncooperative) Secretions (viscous, copious) High aspiration risk Craniofacial trauma Nasopharyngeal abnormalities Burns Extreme obesity
Management Comorbidities Monitor fluid balance and nutrition DVT prophylaxis Identify and manage associated conditions heart failure, arrhythmias, pneumonia, pulmonary embolism
Management Hospital Discharge ABG stable for 24-hours Clinically stable for 24-hours Able to eat and sleep w/o frequent disruption by dyspnea If previously ambulatory, able to walk across room Beta-2 agonist no more frequent than every 4-hours Home follow-up Patient/caregiver understand treatment plan Referrals completed (VNA, O2, nebulizer, meals, etc)
Home-Based Management Ram et al. HOSPITAL AT HOME FOR PATIENTS WITH ACUTE EXACERBATIONS OF COPD: systematic review of evidence. BMJ 2004; 329: 315-320. 7 studies: randomized to hospital-at-home or inpatient No difference in readmission or mortality rates; less costly. Exclusion criteria for hospital-at-home : Impaired consciousness Acute changes on radiography or ECG Arterial ph < 7.35 Comorbidities Social problems
Outline Epidemiology Risk Factors Pathophysiology Management Follow-Up
Follow-up Respiratory At 4-6 weeks post discharge Revisit smoking status Review vaccination status Spirometry Reinforce inhaler technique Tiotropium and combined [beta-2 agonist and CS] Assess need for home oxygen and nebulizer Evaluate understanding of treatment regimen review written action plan for exacerbations
Follow-up Comprehensive
Follow-up Pulmonary Rehab Benefits include (Evidence A) Improves dyspnea and exercise capacity Improves health-related quality of life Reduces number and duration of hospitalizations
Geriatrics-based providers are uniquely qualified to coordinate the care of older persons with COPD, given their expertise in multimorbidity and geriatric syndromes. Pulmonary consultation should be sought in the setting of escalating respiratory symptoms and/or respiratory failure
Re. COPD exacerbations Age is a predisposing factor TRUE Sputum analysis should be performed routinely FALSE Respiratory failure is the most common cause of death FALSE