MiCMRC Educational Webinar Management of Acute Exacerbations of COPD August 22, 2018
MiCMRC Educational Webinar Management of Acute Exacerbations of COPD Expert Presenter: Catherine A. Meldrum PhD RN MS CCRC University of Michigan
Disclosures There is no conflict of interest for anyone with the ability to control content for this activity. This webinar is available for CE credit until June 12, 2020. Participants who successfully view the entire live or recorded webinar and complete the online CE process including required evaluation with email address will earn 1.0 contact hours. This continuing nursing education activity was approved by the Ohio Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. (OBN-001-91) ONA # 21571
Instructions for Obtaining Nursing, Social Work, and CCMC CE Credit To receive Nursing, CCMC, or Social Work 1.0 continuing education contact hour for Management of Acute Exacerbations of COPD for Today s Live Webinar 8/22/018 2:00 3:00 PM Attend the entire webinar Go to the Michigan Care Management Resource Center web site http://micmrc.org/webinars On the micmrc web site webinar page, locate the Management of Acute Exacerbations of COPD webinar information Click the link titled To Request CE Credit Click Here Complete the brief form, include your e-mail address, click submit This will generate an email message to you containing a link to complete the CE request and required evaluation form Follow instructions in the e-mail: Complete the evaluation and submit. This step generates an email to you containing the CE certificate *Note: This webinar will be recorded. CE for viewing the recorded webinar will be available on http://micmrc.org/webinars soon. For technical assistance please e-mail: micmrc-requests@med.umich.edu
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Management of Acute Exacerbations of COPD Catherine A. Meldrum PhD RN MS CCRC University of Michigan August 22, 2018
Objectives Definition of AECOPD Risk factors and potential triggers for COPD exacerbations/hospital re-admissions. Steps to evaluating and diagnosing an acute exacerbation of COPD. Home/hospital management of a COPD exacerbation Prevention measures for COPD exacerbations.
Defining COPD Chronic obstructive pulmonary disease (COPD), a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients. Global Initiative for Chronic Obstructive Lung Disease (GOLD) ;a project initiated by the NHLBI and WHO define COPD 2016
Objectives Definition of AECOPD Risk factors and potential triggers for COPD exacerbations/hospital re-admissions. Steps to evaluating and diagnosing an acute exacerbation of COPD. Home/hospital management of a COPD exacerbation Prevention measures for COPD exacerbations.
What is an Acute Exacerbation of COPD? A sustained worsening of the patient s condition, from the stable state and beyond normal day-to-day variations, that is acute in onset and necessitates a change in regular medication in a patient with underlying COPD Rodriguez-Roisin. Chest. 2000;117:398S-401S.
Impact of an exacerbation Health status Rates of hospitalization Rates of hospital readmissions Disease progression Increased risk of MI and ischemic stroke post exacerbation Rothnie KJ et al, Annals ATS 2018
Exacerbation Classifications Mild Treated with short acting bronchodilators only Moderate Treated with short acting bronchodilators plus antibiotics and/or oral corticosteroids Severe Requires hospitalization or a visit to the emergency room May also be associated with acute respiratory failure
Objectives Definition of AECOPD Risk factors and potential triggers for COPD exacerbations/hospital re-admissions. Steps to evaluating and diagnosing an acute exacerbation of COPD. Home/hospital management of a COPD exacerbation Prevention measures for COPD exacerbations.
Risk Factors Age Productive cough Duration of COPD History of antibiotic therapy Chronic mucous hypersecretion Theophylline Peripheral blood eosinophil count >0.34 109 cells per liter Comorbidities Chronic heart failure, diabetes, ischemic heart disease COPD-related hospitalization within the previous year
Risk Factors Severity of previous exacerbation Gastroesophageal reflux disease Pulmonary Hypertension
Triggers Respiratory viral infections Human rhinovirus Bacterial infections Environmental factors Air pollution Air temperature
Exacerbations Average exacerbation length 7-10 days 20% of patients at 8 weeks have not fully recovered Exacerbations contribute to disease progression If exacerbations are slow, disease progression is more likely One exacerbation predisposes a patient to having another exacerbation** Seemungal et al AM.J Respi Crit Care Med 2000; 161 (5): 1608-13, Donaldson et al, AM.J Respi Crit Care Med 2015; 192(8):943-50, Hurst et al. N Engl J Med 2010; 363(12): 1128-38, Hurst AM.J Respi Crit Care Med 2000, al AM.J Respi Crit Care Med 2009; 179(5):369-74
Exacerbation frequency Frequent exacerbator Defined as 2 or more per year Outcomes Worse health status Increased morbidity Predictor Number of exacerbations the previous year
Exacerbation frequency risks Increase in the ratio of the pulmonary artery to aorta Percentage of emphysema Percentage of airway wall thickness Chronic Bronchitis Well et al N Engl J Med 2012; 367(10): 913-21, Han et al Radiology 2011; 261(1): 274-82, Kim et al, Chest 2011; 140(3): 626-33, Burgel et al, Chest 2009; 135(4): 975-82.
Objectives Definition of AECOPD Risk factors and potential triggers for COPD exacerbations/hospital re-admissions. Steps to evaluating and diagnosing an acute exacerbation of COPD. Home/Hospital management of a COPD exacerbation Prevention measures for COPD exacerbations.
Symptoms Dyspnea Cough Sputum production Onset may be over a few hours to days
Physical exam AECOPD Wheezing Tachypnea Difficulty speaking Use of accessory muscles Mental status changes
Differential diagnosis Fever, chills, night sweats Hypotension Bibasilar fine crackles Peripheral edema Chest pain, chest pressure, peripheral edema Risk factors for coronary disease or thromboembolic disease Upper respiratory symptoms that may suggest a viral infection
Initial evaluation Clinical assessment Pulse oximetry More than 80 % of exacerbations are managed on an outpatient basis Hurst et al, N Engl J Med 2010; 363(12):1128-38, Celli et al, Eur Respir J 2007; 29(6):1224-38, Hoogendoorn et al Eur Respir J 2011; 37(3): 508-15
Triaging Patients Does the exacerbation appear life-threatening? Are there indications for ventilator support? New signs/symptoms Increase in intensity of symptoms Severe COPD disease severity History of frequent exacerbations Comorbidities Frailty Home support Access to outpatient/er
Advanced assessment Pulse oximetry Chest radiograph Laboratory studies Possible arterial blood gas
Management of severe but non lifethreatening exacerbations Bronchodilators Beta adrenergic agonists Anticholinergic agents Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of chronic obstructive pulmonary disease: 2018 Report. http://www.goldcopd.org (Accessed on April 27, 2018, Yawn et al Journal of COPD Foundation 2017: 4(3), 177-185
Management of severe but non lifethreatening exacerbations Consider oral glucocorticoid therapy Antibiotics Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of chronic obstructive pulmonary disease: 2018 Report. http://www.goldcopd.org (Accessed on April 27, 2018).
Management of severe but non lifethreatening exacerbations Oxygen therapy if indicated Consider noninvasive mechanical ventilation
Hospital management COPD exacerbations Reverse air-flow limitation Treat infection (if applicable) Ensure adequate oxygenation Prevent intubation and mechanical ventilation Stoller, JK. 2017 UpToDate
Objectives Definition of AECOPD Risk factors and potential triggers for COPD exacerbations/hospital re-admissions. Steps to evaluating and diagnosing an acute exacerbation of COPD. Home/hospital management of a COPD exacerbation Prevention measures for COPD exacerbations.
Prevention Measures Smoking Cessation Pulmonary Rehabilitation Increased physical activity Proper use of medications Vaccinations Medications Katajistco er al. Respir Med 2015: 147.894, Au et al, J Gen Intern Med 2009: 24.457, Criner et al Chest 2015: 147.894.
Preventing Frequent Exacerbations Albert RK. NEJM 2011;365: 689
Roflumilast in frequent exacerbation * Mean rate of moderate or severe exacerbations per year 2.5 2 1.5 1 0.5 0 Δ = 16.9% Rate ratio 0.831 (95% CI 0.75, 0.92) p=0.0003 Δ = 16.5% Rate ratio 0.835 (95% CI 0.73, 0.95) p=0.0062 Δ = 22.3% Rate ratio 0.777 (95% CI 0.66, 0.91) p=0.0017 n=1554 n=1537 n=1137 n=1124 n=417 n=413 All patients Infrequent exacerbators Frequent exacerbators Placebo Roflumilast *FREQUENT EXACERBATORS ( 2 MODERATE OR SEVERE EXACERBATIONS IN PREVIOUS YEAR) INFREQUENT EXACERBATORS (<2 MODERATE OR SEVERE EXACERBATIONS IN PREVIOUS YEAR) a POST-HOC ANALYSES Bateman ED et al Eur Respir J 2011; 38:553-560
Roflumilast in CB phenotype Rennard SI et al; Respir Res 2011; 12: 1
Practical Implication of Chronic Bronchitis Phenotype Roflumilast: specific therapy for a COPD phenotype Chronic Bronchitis with frequent exacerbation Can be initiated in the in-patient or out-patient setting Consider roflumilast for exacerbation prevention
Novel risk factors for re-admissions Fibrosis of lung or other chronic lung disorders Depression Anxiety Sleep apnea Cardiorespiratory failure Metastatic cancer Vertebral fracture Respiratory failure Fluid/electrolyte disorders Glaser et al Ann of ATS 2015 12.9
Resources for COPD Information www.copdfoundation.org
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