TREATMENT OF COPD EXACERBATIONS. Prof.Dr.Hakan GÜNEN İnönü Üniversitesi Tıp Fakültesi Göğüs Hastalıkları Ana Bilim Dalı MALATYA. Objective.
İnönü Üniversitesi Tıp Fakültesi
Göğüs Hastalıkları Ana Bilim Dalı
(outpatients, hospital, intensive care unit)
a)Antonisen’s definition (1987): This definition is based upon the hypothesis that exacerbations are are caused by bacterial infections.
“defined as worsening of at least one of the cardinal COPD symptoms, dyspnea, ,increased sputum volume or sputum purulence; Type 1, Type 2, Type 3”
“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”
“an exacerbation of COPD is an event in the natural course of the disease characterised by a change in the patient’s baseline dyspnoea, cough and/or sputum beyond day-to-day variability sufficient to warrant a change in management”
d) Definition of GOLD: GOLD avoided making a specific definition until 2006. Their definition resembels ATS-ERS definition.
Definition of GOLD 2007;
“An exacerbation of COPD is defined as an event
in the natural course of the disease characterized
by a change in the patientes baseline dyspnea,
cough, and/or sputum that is beyond normal
day-to-day variations, is acute in onset, and may
warrant a change in regular medication in a
patient with underlying COPD.”
-Primary causes: Infections, inhalation of environmental irritants, cold air, uncompliance with the treatment
-Sekondary causes: Pneumoniae, pulmonary emboli, pneumothorax, cardiac failures
S. Pneumoniae, H. İnfluenza, M. Catarrhalis, (less frequently, Mycoplasma P. , Chylamidia P., P. aeuroginosa).
Rhinoviruses, RSV, (less frequently Influenza A-B, Parainfluenza, Coronavirus, Adenovirus).
TORCH: 1 exacerbation/year
MISTRAL: 1,5 exacerbation/year
GLAXO world data: 1exacerbation/year
ISOLDE: 1,5 exacerbation/year
According to the results of all studies
1) COPD patients do not report at least half of their exacerbations when asked.
2) One of every 2 exacerbation ends with hospitalization
(8 times more exacerbation and hospitalization rates than asthma)
-home, hospital, intensive care unit
-non-invasive, invasive mechanical ventilation
-additional treatments (diuretics, cardiac support destek)
(Seemungal ve ark. AJRCCM 2000)
(Burge et al. ERJ 2003)
“Assessment of the severity of an exacerbation is based
on the patientes medical history before the exacerbation,
preexisting comorbidities, symptoms, physical examination,
arterial blood gas measurements, and other laboratory
tests. Specific information is required on
the frequency and severity of attacks of breathlessness
and cough, sputum volume and color, and limitation of
daily activities. When available, prior arterial blood gas
measurements are extremely useful for comparison with
those made during the acute episode, as an acute change
in these tests is more important than their absolute values“.
- Spirometry and PEF measurements
- Arterial blood gas analysis (PaO2<60 mmHg, PaCO2>50 mmHg, pH<7.35)
- Chest films and ECG
- Blood tests (leucocyte, hemoglobin, electrolytes, blood glucose)
- Sputum Gram staining and culture antibiogram
There is no strict criteria about which patients should be treated at home. However there are some criteria which patients should not be treated at home
Respiratory rate higher than 25/min
Pulse rate higher than110/min
PaO2 less than 60 mm Hg
Abnormal chest radiograph
Serious concomitant disease
Altered mental state
- If the patient can use, inhalers or spacers should be preferred. There is no additional efficacy administrating the drugs by nebulizers except indicated.
- Short acting Beta-2 mimetics should be preferred. Initial doses can be given more frequently. The total dose should not exceed 12 times a day by inhaled or nebulized routes.
- Side effects??
- If the expected result from frequent initial bronchodilator treatment can not be obtained specifically in patients with FEV1<%50; 7-10 days perdnisolone 30-40 mgr/gün (GOLD 2007)
- Oral route should be preferred
- It is assumed to shorten the recovery period and accelarates the normalization of FEV1 and PaO2 ??
- SIDE EFFECTS???
- High dose nebulized budesonide may be an alternative (GOLD 2007 ref.419)
development of resting dyspnea
– Increase doses and/or frequency
– Combine 2-agonists and anticholinergics
– Use spacers or air-driven nebulizers
– Consider adding intravenous mehylxanthines, if needed
– Monitor fluid balance and nutrition
– Consider subcutaneous heparin
– Identify and treat associated conditions (e.g., heart failure, arrhythmias)
– Closely monitor condition of the patient
(PaCO2>60 mmHg), and/or severe/worsening
respiratory acidosis (pH<7.25) despite supplemental
oxygen and noninvasive ventilation
These patients should be transferred to the intensive care unit
Hospitalized patients are Grup B and C any more
Not recommenden in general termsç.
Only doxapram may be tried in cases where noninvasive ventilation is indicared but can not be available
2. Ventilatory support:
Noninvasive and invasive mechanical ventilation
pulmonary embolism, barotrauma, massive pleural effusion)
-ability to cope in usual environment
-measurement of FEV1, arterial blood gases if necessary
-reassessment of inhaler technique, medication, smoking,
-understanding of recommended treatment regimen
should be evaluated
There after follow-up visits to be repeated every 4-6 weeks