Exacerbations of COPD Dr J Cullen
Definition An AECOPD is a sustained worsening of the patient s clinical condition from their stable state that is beyond their usual day-to-day variation is acute in onset and usually warrants additional treatment
Definition An AECOPD is an event in the natural course of the illness characterised by a change in the patient s baseline dyspnoea, cough and/or sputum beyond usual day-to-day variability and sufficiently severe to warrant a change in management
Levels Level 1: treated at home Level 2: requires hospitalisation Level 3: respiratory failure
Characteristics Increase in dyspnoea Increase in sputum purulence/colour Increase in sputum volume (any one of three heralds an exacerbation)
Causes Infection (50-60%) Air pollution Changes in temperature 1/3 no cause found
Epidemiology In the U.S. annual cost associated with AECOPD is $ 32 billion $ 14 billion is lost to work absence alone
Epidemiology In the EU, AECOPS accounts for 17,300 consultations pre 100,000 10.3 billion euro in healthcare cost annually
Further drain on resources After aggressive treatment of AECOPD in A&E 1/3 have symptoms again within 14 days 14% relapse and require hospitalisation
Risk of relapse Incidence 21-40% Increased risk with: Low pre-treatment FEV1 Need to bronchodilator/steroid use Previous exacerbations (>3 in past year) Prior antibiotic therapy Presence of serious co-morbid conditions
Risk of exacerbation Risk of having more than 1 exacerbation per year increases with: Advancing age Chronic mucus hypersecretion Co-morbidities Low FEV1 Gastro-oesophageal reflux
Presentation Increased dyspnoea is main symptom. May be accompanied by Change in sputum colour/tenacity Change in sputum volume Chest tightness Wheeze Ankle swelling
Presentation Also may have General malaise Dysphoria Insomnia Fatigue
Differential diagnosis Pulmonary embolus Heart failure Pneumonia Dysrhythmia pneumothorax
Assessment of severity Duration of symptoms How severe is breathlessness: limitations on patient s activities Sputum colour and volume Previous exacerbations Previous hospitalisation Previous intubation
Assessment of severity Change in mental function is sign of severe exacerbation: such patients should be admitted to hospital Previous ABGs and PFTs can be helpful to gauge severity
Spirometry Can be difficult for breathless patients to perform. Generally: FEV1 < 1L or PEFR < 100 L/min - Indicates a severe exacerbation
PaO2 < 8 kpa Arterial blood gases PaCO2 > 6.7 kpa if patient has AECOPD and PaCO2 > 6.7 kpa, then 14% will be dead at 3 months, 33% at 6 months and 43% at 1 year. ph < 7.30
CXR Always perform Pneumonia Pneumothorax Heart failure
high-risk patients Likely to relapse after A&E visit: Previous high relapse rate Previous A&E visit within 7 days Serious comorbid conditions Poor response to steroids/antibiotics Patient on LTOT Bronchodilator use
Indications for hospitalisation Presence of high-risk comorbid conditions Very marked in dyspnoea Inability to eat or sleep Worsening hypoxaemia Worsening hypercapnia Change in mental status Lack of home/social support Uncertain diagnosis
Treatment Controlled oxygen therapy Venturi mask Aim for SaO2 > 85% optimal: 88-90%
Treatment Inhaled bronchodilator inhaled nebulised Salbutamol 2.5-5mg 1-6 hourly Ipratropium 0.5mg 2-6 hourly Synergism
Treatment Inhaled bronchodilator inhaled nebulised Salbutamol 2.5-5mg 1-6 hourly Ipratropium 0.5mg 2-6 hourly Synergism grade 1b recommendation
Treatment Corticosteroids 2 weeks of corticosteroids: Decreased: -30 day treatment failure rate, -90 day treatment failure rate and -hospital stay. Also improved lung function. grade 1a recommendation
Treatment antibiotics. If increase in sputum volume and/or purulence Met-analysis of 11 studies: decrease in mortality, treatment failure and sputum purulence grade 1a recommendation
Treatment No role for mucokinetics: can actually worsen bronchospasm Theophyllines: toxic, overall dubious benefit NIV definite role in AECOPD
Prevention of exacerbations Stop smoking Long-acting beta agonist (LABA) eg. Formoterol Inhaled corticosteroid (ICS) e.g. Budesonide Combination therapy (E.G. Symbicort)
Prevention of exacerbations Tiotropium LABA + ICS + Tiotropium Pulmonary rehabilitation Vaccination PDE4 inhibitors
Stage ALL Recommended treatment - Avoidance of risk factor(s) - Influenza vaccination I: Mild COPD - Short-acting bronchodilator when needed II: Moderate COPD - Short-acting bronchodilator when needed - Regular treatment with one or more long-acting bronchodilators - Rehabilitation III: Severe COPD - Short-acting bronchodilator when needed - Regular treatment with one or more long-acting bronchodilators - Rehabilitation - Inhaled glucorticosteroids if significant symptoms, lung function response, or if repeated exacerbations IV: Very severe COPD - Short-acting bronchodilator when needed - Regular treatment with one or more long-acting bronchodilators - Inhaled glucocorticosteroids if significant symptoms, lung function response, or if repeated exacerbations - Treatment of complications - Rehabilitation - Long-term oxygen therapy if chronic respiratory failure - Consider surgical treatments