II. Risk Factors: Severe COPD exacerbation

  1. Altered Level of Consciousness
  2. Three or more exacerbations in the last year
  3. Severe COPD with FEV1/FVC ratio <0.70 or FEV1 < 50% of predicted
  4. Body Mass Index 20 kg/m2 or less
  5. Marked increase in symptoms or change in Vital Signs
  6. Sedentary
  7. Poor social support
  8. Non-compliance Home oxygen use
  9. Medical comorbidity
    1. Congestive Heart Failure
    2. Coronary Artery Disease
    3. Pneumonia
    4. Diabetes Mellitus
    5. Renal Failure
    6. Hepatic Failure

III. Symptoms: Cardiopulmonary

  1. Increased Sputum production or Purulent Sputum
  2. Cough
  3. Dyspnea
  4. Tachypnea
  5. Wheezing
  6. Decreased Exercise tolerance
  7. Chest tightness
  8. Tachycardia

IV. Symptoms: General

  1. Fatigue
  2. Fever
  3. Malaise
  4. Confusion
  5. Insomnia

V. Evaluation: Severity

  1. Mild Exacerbation
    1. COPD controlled with an increase in regular medications
  2. Moderate Exacerbation
    1. COPD controlled with Systemic Corticosteroids or antibiotics
  3. Severe Exacerbation
    1. COPD controlled with emergency department evaluation or hospitalization

VI. Evaluation

  1. Pulse Oximetry in all patients
  2. Chest XRay in moderate to severe exacerbations
  3. Severe Exacerbations (emergency department or hospital admission evaluation)
    1. Arterial Blood Gas
    2. Complete Blood Count
    3. Basic chemistry panel
    4. Electrocardiogram
  4. Additional cardiac labs to consider (part of Dyspnea differential diagnosis)
    1. Troponin
    2. Brain Natriuretic Peptide (BNP or ntBNP)

VII. Management: General Measures

  1. See COPD Management for Bronchodilator and other COPD specific interventions
  2. Low Flow Oxygen to keep Arterial PaO2 > 60mmHg (O2 Sat 90% or greater)
    1. High Flow Oxygen is associated with worse outcomes
    2. Austin (2010) BMJ 341: c5462
  3. Systemic Corticosteroids (oral or intravenous)
    1. Indicated in all moderate to severe COPD exacerbations
    2. Prednisone 30-60 mg/day orally tapered over 2 weeks or
    3. Methylprednisolone (Solumedrol) 60-125 mg IV every 6 hours

VIII. Indications: Antibiotic indications if 3 criteria met

  1. Increased Dyspnea
  2. Increased Sputum
  3. Purulent Sputum

IX. Management: Uncomplicated Chronic Bronchitis

  1. Criteria
    1. Under age 65 years old
    2. FEV1 > 50% of predicted
    3. Under 4 acute exacerbations per year
    4. No significant comorbid disease
  2. Coverage
    1. HaemophilusInfluenzae
    2. Streptococcus Pneumoniae
    3. Moraxella catarrhalis
    4. Chlamydia pneumoniae
    5. Mycoplasma pneumoniae
  3. Antibiotics (5 day course)
    1. First-Line
      1. Bactrim DS one tablet PO bid
      2. Doxycycline 100 mg PO bid
      3. Amoxicillin 500 mg PO tid
        1. Equivalent to Moxifloxacin in clinical outcome
        2. Wilson (2004) Chest 125:953-64
    2. Alternative Antibiotics
      1. Augmentin 875 mg PO bid
      2. Second generation Macrolide
        1. Clarithromycin 500 mg PO bid
        2. Azithromycin 500 mg day 1, then 250 mg PO x4 days
          1. Also available as 3 day preparation
          2. Similar outcomes to Levofloxacin for 7 days
          3. Amsden (2003) Chest 123:772-7

X. Management: Complicated Chronic Bronchitis

  1. Criteria
    1. Uncomplicated criteria not met (see above)
  2. Coverage
    1. Uncomplicated Chronic Bronchitis bacteria (see above)
    2. Gram Negative Rods (e.g. Pseudomonas)
  3. Dosing for 5 day course
    1. Augmentin 875 mg PO bid
    2. Fluoroquinolone
      1. Levofloxacin (Levaquin) 250 mg po qd
      2. Moxifloxacin (Avelox) 400 mg PO qd

XI. Management: Severe Exacerbation requiring hospitalization

  1. Co-administer Corticosteroids
    1. Initially use intravenous Corticosteroids
      1. Methylprednisolone (Solumedrol) 60 mg IV every 6 hours
      2. Avoid high doses (e.g. 125 mg) as they offer no added benefit
    2. Transition to oral Corticosteroids as soon as prudent
      1. Prednisone 30-40 mg orally daily
      2. Taper off over 2 weeks (no benefit to previously used longer taper over 8 weeks)
  2. Protocol: Two parenteral drug combination
    1. Drug 1: Cephalosporin or Antipseudomonal Penicillin
    2. Drug 2: Fluoroquinolone or Aminoglycoside
  3. Cephalosporins
    1. Ceftriaxone (Rocephin) 1 to 2 grams IV q24 hours
    2. Cefotaxime (Claforan) 1 gram IV q8-12 hours
    3. Ceftazidime (Fortaz) 1-2 grams IV q8-12 hours
  4. Antipseudomonal Penicillins
    1. Piperacillin-Tazobactam (Zosyn) 3.375 g IV q6 hours
    2. Ticarcillin-Clavulanate (Timentin) 3.1 g IV q4-6 hour
  5. Fluoroquinolones
    1. Levofloxacin (Levaquin) 500 mg IV q24 hours
    2. Gatifloxacin (Tequin) 400 mg IV q24 hours
  6. Aminoglycoside
    1. Tobramycin (Tobrex)
      1. Split dosing: 1 mg/kg IV q8-12 hours
      2. Once daily: 5 mg/kg IV q24 hours

XII. Management: Severe Exacerbations refractory to above measures

  1. Oxygen supplementation
    1. High Flow Oxygen (e.g. oximizer)
    2. Non-Invasive Positive Pressure Ventilation or NIPPV (e.g. BIPAP)
      1. Consider weaning bipap when ABG or VBG pH 7.32 or higher
  2. Intubation Indications
    1. Arterial Blood Gas with arterial pH <7.36 and pCO2 >45 mmHg
    2. Respiratory distress and intolerance to NIPPV (see oxygen supplementation above)
    3. Severe, unstable comorbidity (e.g. Sepsis, Coronary Artery Disease)

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