COPD:A Management Plan for Acute Exacerbations of This Chronic Illness George L. Higgins III, M.D., F.A.C.E.P. Professor of Emergency Medicine Maine Medical Center Tufts University School of Medicine
Case Study:HPIA 70 year old man in transported to your small, rural ED by EMS personnel with a chief complaint of shortness of breath.He has several chronic illnesses, including COPD, CAD with stable angina, and symptomatic peripheral vascular disease.
Case Study:HPIHe has become increasingly SOB over the past three days, and has noted a moderate increase in sputum production. He denies fever/chills, chest pain, and hemoptysis.Today, his SOB has dramatically worsened.
Case Study:Focused PMHOver the past year he has presented to your ED twice for COPD exacerbations: admitted once and more recently discharged from the ED with a course of antibiotics.He has never required mechanical ventilation.
Case Study:Social HistoryHe’s a widower and lives alone, but enjoys woodworking.He has smoked two packs of cigarettes a day for nearly fifty years and continues to do so.He drinks 2-3 beers daily.
Case Study:COPD MedicationsLong-acting inhaled anticholenergic(tiotropium)Long-acting inhaled beta-agonist (salmeterol)Inhaled corticosteroid(fluticasone)He insists he’s compliant
Case Study:Pertinent PE FindingsBP 160/90, RR 30, P 110, T 37.5O2 saturation 82% on mask O2Obviously fatiguedChachetic in appearanceSitting uprightAcutely dyspneicDiaphoreticUsing accessory muscles of respirationDecreased breath sounds bilaterally
Beware! Large Alveolar Blebs Can Mimic Pneumothorax
Case Study:Additional InformationWith significant effort, he hands you an index card provided to him by his physician, documenting his recent baseline lung function: FEV1 60% of predicted FEV1/FVC 25% of predicted.He also tells you he never wants to be kept alive on a breathing machine.
This Patient Allows Us to Explore Practical and Pertinent Issues • The GOLD classification of COPD • Risk factors for COPD exacerbations • Risk factors for ED discharge relapse • Admission criteria • Effective and ineffective therapies • Indications for the initiation of antibiotics • Targets for oxygen therapy • Options for ventilatory support
COPD Defined • “Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. Although COPD affects the lungs, it also produces significant systemic consequences.” Eur Respir J 2004; 23: 932–946
Socio-economic Impact of COPD • In the United States…. • 1.5+ million emergency department visits • Nearly 800,000 hospitalizations • Over 120,000 deaths • Healthcare costs exceed $32 billion annually • $14 billion lost annually due to work absence • 6-month mortality rate = 33%, 12-month = 43%
COPD Mortality Increasing JAMA.2005;294:1255-1259.
Percent Change in Age-Adjusted Death Rates, U.S., 1965-1998 Proportion of 1965 Rate 3.0 Coronary Heart Disease Stroke Other CVD COPD All Other Causes 2.5 2.0 1.5 1.0 0.5 –59% –64% –35% +163% –7% 0 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 1965 - 1998 Source: NHLBI/NIH/DHHS
COPD Mortality:Perverse Gender Equality MMWR 2005
Risk Factors for COPD Nutrition Infections Socio-economic status Aging Populations
Oxidative Stress and Inflammation Barnes, PJ. Chronic obstructive pulmonary disease. NEJM 2000.
Interesting Trivia • In non-smokers with normal lungs, the natural aging process from age 25 to age 75 results in… • 20% reduction in vital capacity • 25% decrease in FEV1 (30ml/year) • Elastin fiber degradation with less elastic recoil • In some smokers, the FEV1 can decrease by 150ml/year!
Interesting Trivia • A single, average cigar, as compared to a single, average cigarette, has… • 20 times the amount of tobacco • 7 times the tar • 11 times the carbon monoxide • 4 times the nicotine • Cigar smoke is more alkaline, which facilitates absorption through the oral vasculature
Impact of Smoking on FEV1 BMJ 1977; 1: 1645–1648 91
GOLD Classification of COPD (Global initiative for chronic Obstructive Lung Disease) Stage I: Mild FEV1/FVC < 0.70 FEV1> 80% predicted Stage II: Moderate FEV1/FVC < 0.70 50% > FEV1 < 80% predicted Stage III: Severe FEV1/FVC < 0.70 30% > FEV1 < 50% predicted Stage IV: Very Severe FEV1/FVC < 0.70 FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure
Causes of Death in COPD NEJM 356:851-854
Goals of COPD Management • Relieve symptoms • Prevent disease progression • • Improve exercise tolerance • • Improve health status • • Prevent and treat complications • •Prevent and treat exacerbations • •Reduce mortality
Active Reduction of Risk Factors Influenza and Pneumonia Vaccination Add Short-acting Bronchodilator When Needed I: Mild II: Moderate III: Severe IV: Very Severe Add Regular Treatment with One or More Long-acting Bronchodilators When Needed Add Rehabilitation Add Inhaled Glucocorticoids for Repeated Exacerbations Add Long Term Oxygen for Respiratory Failure Consider Surgical Treatments End of life Discussions
Estimated Direct Costs of COPD Care The Obvious Goal: Prevent Acute Exacerbations
Risk Factors for aCOPD Exasperation • Advanced age • Chronic mucous hypersecretion with productive cough • Longer duration of COPD • Antibiotic therapy within the past year • Hospitalization within the past year • Co-morbidities • e.g. CAD, CHF, DM
Mortality from a COPD Exacerbation with Hypercapnia • 10% in-hospital mortality • 20% 60-day mortality • 30% 180-day mortality • 40% 1-year mortality • 50% 2-year mortality
Challenging Differential Diagnosis COPD ASTHMA • Onset in mid-life • Symptoms slowly progressive • Long smoking history • Dyspnea during exercise • Largely irreversible airflow • limitation • Onset early in life • Symptoms vary from day to day • Symptoms at night/early morning • Allergy, rhinitis, and/or eczema • Family history of asthma • Largely reversible airflow limitation
Challenging Differential Diagnosis ASTHMA COPD • Hypoxia and hypercarbia common • CarboxyHb common • Polycythemia common • Purulent sputum typical • Compensated metabolic acidosis common • Hypoxia and hypercarbia uncommon (except in extremis) • CarboxyHb normal • Polycythemia rare • Purulent sputum uncommon • Compensated metabolic acidosis rare
The List of Therapeutic Options is Short but Sweet • Oxygen • Bronchodilators • Beta-agonists • Anticholenergics • Systemic glucocorticoids • Antibiotics • Non-invasive mechanical ventilation • Conventional mechanical ventilation
Oxygen Therapy • Hypoxia is a defining feature of acute exacerbations of COPD • Supplemental oxygen is essential • Target PaO2 60-65mm Hg • Target O2 saturation 90% • If hypoxia cannot be corrected, think of other causes (e.g. pulmonary embolus, pneumonia) • Permissive hypercapnia is acceptable • Ventilatory support may be required
Home Oxygen Therapy • Benefits of long-term oxygen in COPD • Improved tolerance of exercise and other ambulatory activities • Decreased pulmonary hypertension • Improved neuropsychiatric function • Decreased erythrocytosis and polycythemia • Reduced morbidity and mortality
Bronchodilators: Beta-agonists • Sort-acting: albuterol, levalbuterol • Rapid bronchodilation • Rescue medication • Long-acting: salmeterol, formoterol, arformoterol • Improve dyspnea • Increase FEV1 • No role in acute exacerbations • Adverse effects • Palpitations, tremor, tachycardia, hypokalemia, worsening V/Q mismatch
Bronchodilators: Beta-agonists • Albuterol is the “Go To” agent at this time • Nebulized dose: 2.5-5mg every 1-2 hours • MDI with spacer: 180mcg (2 puffs) every 1-2 hours • The breathing mechanics in the acutely dyspneic patient make this route less effective • Continuous nebulization has not been proven to add bennefit in COPD • Subcutaneous or intravenous beta-agonist administration is rarely required
Bronchodilator Therapy: Anticholinergics • Anticholinergics (ipratropium, tiotropium) are effective bronchodilators in COPD • Vagal cholinergic tone often is the only reversible cause of airway obstruction in COPD • Block the muscarinic receptors on airway smooth muscle causing relaxation of the muscle and decreased bronchoconstriction • May also reduce airway mucus secretions and improve secretion clearance
Bronchodilator Therapy: Anticholinergics • Ipratropium is the “Go To” agent at this time • Nebulized dose: 500mcg every 2-4 hours • MDI with spacer: 36mcg (2 puffs) every 2-4 hours • The breathing mechanics in the acutely dyspneic patient make this route less effective • There is no role for the long-acting anticholinergic agents (e.g. tiotropium) in acute phase management
Systemic Corticosteroids • Corticosteroids in acute exacerbations… • Reduce the 30-day and 90-day treatment failure rates • Shorten hospital length of stay • Improve lung function • N Engl J Med 1999; 340(25):1941-7 • Typical agents and doses include… • Methylprednisolone 60-125mg IV BID to QID • Prednisone 60mg PO in the less severely ill patient • Inhaled corticosteroids have not been shown to benefit patients in the acute phase of care
Non-invasive Positive Pressure Ventilation • Have a low threshold for instituting NPPV • Benefits of NPPV include… • Fewer intubations • Decreased mortality • Shortened ICU length of stay • Move to conventional mechanical ventilation if… • Patient fails an NPPV trial • Patient benefits but will not tolerate NPPV • Patient has contraindications to NPPV
Contraindications to NPPV • Immediate intubation required • Hemodynamic instability • Encephalopathy or inability to cooperate • Facial deformity, surgery or trauma • Upper airway obstruction • Inability to protect airway or clear secretions • High risk for aspiration
Indications for Antibiotics in COPD Exacerbations • The general recommendation is to provide antibiotic therapy if the COPD patient presents with at least two of the following: • Increased dyspnea • Increased sputum production • Increased purulence of sputum • Nearly 100% of the patients I manage will meet these criteria
Antibiotics • Selection depends on severity of illness • Out-patient • Admission • Obtain sputum culture to evaluate for resistant organisms • Antibiotics in COPD exacerbations appear to… • Reduce the risk of short-term mortality by 77% • Decrease the risk of treatment failure by 53%
Antibiotics • Proven choices • Amoxicillin 500-875mg TID • Doxycycline 100mg BID • Azithromycin 500mg, then 250mg QD for 4 doses • Trimethoprim-Sulfa 1 DS tablet BID • Duration 10-14 days • For more severely ill patients, treat like hospital acquired pneumonia • E.g. levofloxacin or ceftriaxone