Pulmonology Book

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COPD ManagementAka: COPD Exacerbation Management

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  1. See Also
    1. COPD
    2. Antibiotic Use in COPD Exacerbation
  2. Prevention
    1. See Pulmonary Rehabilitation Exercises
    2. Immunizations
      1. Annual Influenza Vaccine
        1. Wongsurakiat (2004) Chest 125:2011
      2. Pneumococcal Vaccine (consider every 5-10 years)
    3. Tobacco Cessation
      1. Coughing stops in 77% of those quitting smoking
      2. Cough improves in 17%
      3. Cough may stop within 4 weeks of quitting (54%)
      4. Quitting decreases all cause mortality >15 years
      5. Quitting smoking alters the decline in lung function
    4. Body habitus
      1. Overweight "Blue boater": Attempt weight loss
      2. Thin "Pink Puffer": Nutritional supplementation
  3. Monitoring
    1. Pulse oximetry
    2. Timed walking of specific distances
    3. Spirometry
      1. Serial FEV1 Measurements are most significant value
      2. FEV1 <1 Liter indicates severe disease
      3. Poor prognosis if FEV1 <750 cc (<50% predicted)
  4. Management: Stepped care of Dyspnea
    1. At risk: Stage 0 (Normal Pulmonary Function Tests)
      1. Chronic intermittent symptoms
      2. Eliminate exposures (e.g. Tobacco)
    2. Mild: Stage I (FEV1/FVC <70%, FEV1>80%)
      1. Short-acting Beta Agonist 2 puffs as needed up to qid
        1. Used for intermittent symptoms
      2. Consider Ipratropium Bromide or Tiotropium
        1. Donohue (2002) Chest 122:47
    3. Moderate: Stage II (FEV1/FVC <70%, FEV1 50-80%)
      1. Short-acting Beta Agonist 2 puffs qid
      2. Ipratropium Bromide or Tiotropium
      3. Long-acting beta-agonist (e.g. Salmeterol)
        1. Patients benefit most during daytime active hours
          1. Consider dosing only in morning to save cost
          2. However, sleep is improved
        2. Consider Fluticasone and Salmeterol (Advair Diskus)
          1. Better symptom relief than Salmeterol alone
          2. See Inhaled Corticosteroids below
      4. Fluticasone with Salmeterol (Advair Diskus)
        1. More effective than Salmeterol alone
        2. See efficacy data below
      5. Low-flow oxygen at night and with exertion
    4. Severe: Stage III (FEV1/FVC <70%, FEV1 30-50%)
      1. Beta agonist
      2. Ipratropium Bromide or Tiotropium
      3. Fluticasone with Salmeterol (Advair Diskus) or
        1. Long-acting beta-agonist (e.g. Salmeterol)
        2. High dose Inhaled Corticosteroid (e.g. Fluticasone)
      4. Low-flow oxygen at night and with exertion
      5. Pulmonary rehabilitation
      6. Systemic Bronchodilator
        1. Leukotriene Receptor Antagonist (e.g. Accolate)
        2. Theophylline (see efficacy below)
    5. Very severe: Stage IV (FEV1/FVC <70%, FEV1 <30%)
      1. Offer severe persistent symptom management as above
      2. Consider less efficacious methods for Dyspnea
        1. Buspirone as Anxiolytic agent
        2. Sustained release oral Morphine 20 mg daily
          1. Use with caution, studies are preliminary
          2. Abernethy (2003) BMJ 327:523
    6. Crisis
      1. Beta agonist up to 6 to 8 puffs q1-2 hours
      2. Ipratropium Bromide up to 6 to 8 puffs q3-4 hours
      3. Systemic Corticosteroids for 2 weeks (see below)
      4. Theophylline (see efficacy below)
      5. BiPAP
      6. Oxygen therapy
        1. Do not limit FIO2 in CO2 retainers
          1. Set O2 Sat goal of 88-91%
          2. Anticipate CO2 rise of 12 points
          3. Consider BiPap for pH < 7.25
  5. Management: Protocols
    1. Exacerbation Guidelines
      1. See Stepped Management as above
      2. See Antibiotic Use in COPD Exacerbation
      3. Do not define exacerbation severity by Spirometry
      4. Consider Chest XRay in hospitalized patients
      5. Prednisone 40 mg PO qd for 10 days
        1. Reduces relapse rate after COPD evaluation in ER
        2. Aaron (2003) N Engl J Med 348:2618
      6. Avoid low efficacy therapies
        1. Mucolytic medications are not shown helpful
        2. Chest physiotherapy is not efficacious
        3. Theophylline not helpful in exacerbations
      7. References
        1. Snow (2001) Chest 119:1185
    2. Maintenance Guidelines
      1. Before Intervention
        1. Test Spirometry
        2. Review Patient's symptoms
      2. Initiate Trial of Intervention
      3. After Intervention
        1. Recheck Spirometry
        2. Were Patient's symptoms improved?
  6. Agents: Inhaled Bronchodilators
    1. Efficacy
      1. Spirometry improved 15% significant
      2. Symptom improvement also suggests benefit
      3. Use with spacer always due to lack of lung excursion
      4. Give prn unless jittery (precedes cardiotoxicity)
    2. Safety
      1. Low risk of precipitating major cardiovascular event
        1. Salpeter (2004) Chest 125:2309
    3. Agents
      1. Long-acting Beta Agonist for maintenance (Serevent)
        1. Effective and safe (no increased vascular events)
        2. Ferguson (2003) Chest 123:1817
      2. Short-acting Beta Agonist for rescue (Albuterol)
        1. In crisis, may be used up to 6-8 puffs q1-2 hours
  7. Agents: Inhaled anticholinergics (Ipratropium Bromide)
    1. Efficacy
      1. Greater bronchodilation than Beta agonists in COPD
      2. Combined with beta agonist may offer additive effect
      3. No tachyphylaxis
      4. Decreases bronchoconstriction by inhibiting cGMP
    2. Preparations
      1. Ipratropium Bromide (Atrovent) 2-3 puffs qid
        1. In crisis may be used up to 6 to 8 puffs q3-4 hours
      2. Ipratropium Bromide 500 ug vial nebulized qid
      3. Combivent (Ipratropium with Albuterol)
        1. Significant cost savings when combined
        2. Benayoun (2001) Chest 119:85
  8. Agents: Systemic Corticosteroids
    1. Short course Corticosteroids in severe exacerbation
      1. Increases FEV1 and shortens hospital stay
      2. Avoid use longer than 2 weeks
      3. Protocol (total of 10 day course at full strength)
        1. Solu-Medrol 1-2 mg/kg q6-12 hours IV for 3 days
        2. Prednisone 60 mg qd for 7 days
        3. Prednisone tapered off over additional 2 weeks
    2. Long-term Systemic Corticosteroids not often helpful
      1. Long-term Corticosteroid use is rarely indicated
      2. Beneficial effects seen in only 10-20% COPD patients
      3. Test to see if COPD patient Corticosteroid responsive
        1. Prednisone 40 mg PO for 10 days
        2. Alternative: Theophylline challenge
        3. Test PFTs before and after course
      4. Attempt to slowly discontinue Corticosteroids
        1. Decrease Corticosteroid dose by 5 mg per week
      5. Most patients tolerate taper without rebound
        1. No change in Spirometry
        2. No change in symptoms (e.g. Dyspnea)
      6. Stopping steroids often alleviates adverse effects
        1. Anticipate resolution of prior weight gain
      7. Risk of Osteoporosis with long-term steroid use
        1. See Corticosteroid Associated Osteoporosis
        2. Dubois (2002) Chest 121:1456
      8. References
        1. Rice (2000) Am J Respir Crit Care Med 162:174
  9. Agents: Inhaled Corticosteroids
    1. Fluticasone with Salmeterol (Advair Diskus)
      1. Significant benefit compared with either agent alone
      2. Resulted in symptom control and sustained for >1 year
      3. No significant adverse effects seen in studies
      4. Calverly (2003) Lancet 361:449
      5. Hanania (2003) Chest 124:834
    2. Possible impact on exacerbations and quality of life
      1. Consider in patients with FEV1 < 1.5 Liters (<50%)
      2. Consider if frequent exacerbations
      3. Consider trial for 6-18 weeks
        1. Check PFTs before and after course
    3. Pulmonary Function Tests do not reflect benefit
      1. Minimal impact on lung function
      2. No impact on rate of lung function decline
    4. Adverse effects may outweigh benefits
      1. Mild effects: bruising, Dysphonia, Candidiasis
      2. Serious effects: Osteoporosis, Cataracts
      3. Agents are expensive (many are over $100 per month)
  10. Agents: Systemic Bronchodilators
    1. Leukotriene Receptor Antagonist (e.g. Accolate)
      1. Effective in combination with inhaled Bronchodilator
    2. Theophylline 10-15 mg/kg to drug level 10-12 ug/ml
      1. Recent guidelines do not recommend in exacerbation
      2. Several serious drug interactions (e.g. Quinolones)
        1. Review interactions at every medication change
      3. Efficacy in stable COPD
        1. Weak Bronchodilator
          1. Weaker than Beta agonists (e.g. Albuterol)
          2. Weaker than anticholinergics (e.g. Atrovent)
        2. Improves respiratory muscle strength and endurance
        3. Improves mucociliary clearance
        4. Increases central respiratory drive
        5. May lead to symptomatic improvement
        6. Associated with reduced hospitalization rate
        7. Appears synergistic with long-acting Bronchodilator
          1. ZuWallack (2001) Chest 119:1661
  11. Agents: Home Oxygen
    1. Indications
      1. Stable clinical Status
      2. No end-organ dysfunction: PaO2 < 55 mmHg or O2 < 88%
      3. End Organ changes: PaO2 < 59 mmHg or O2 < 90%
        1. Cor Pulmonale or right Heart Failure
        2. P-pulmonale on EKG
        3. Polycythemia present (Hematocrit >55%)
    2. Documentation
      1. O2 Sat measured at rest or
      2. O2 Sat after 6 minute ambulation
        1. Document with and without oxygen
    3. Benefits
      1. Home Oxygen use only beneficial if >18 hours/day
      2. Increases life span in COPD by 6-7 years
      3. Goal to keep Oxygen Saturation >90%
    4. Adjuncts
      1. Consider Continuous Positive Airway Pressure (CPAP)
  12. Agents: Surgical Interventions
    1. Lung transplantation
    2. Lung Volume reduction surgery
  13. Agents: Other Interventions
    1. Influenza Vaccine yearly
    2. Intranasal Steroid (Helps reduce airway phlegm)
    3. Regularly scheduled mucolytics (e.g. Guaifenesin)
      1. Reduces days of illness per month by 1/2 day
      2. Doubles chance of being free of exacerbations
      3. Poole (2001) BMJ 322:1
  14. Resources
    1. Global Initiative for Chronic Obstructive Lung Disease
      1. http://www.goldcopd.com
    2. ATS/ERS COPD Guidelines
      1. http://www.thoracic.org/COPD
  15. References
    1. (1995) Am J Respir Crit Care Med 152(5 pt 2):S77
    2. Celli (1998) Postgrad Med 103(4):159
    3. Cooper (1997) Ann Thorac Surg 63:312
    4. Fein (2000) Curr Opin Pulm Med 6:122
    5. Hunter (2001) Am Fam Physician 64(4):603
    6. Obrien (1998) Postgrad Med 103(4):179
    7. Runo (2001) West J Med 175:197
    8. Sayiner (2001) Chest 119:726
    9. Voelkel (2000) Chest 117(5 suppl 2):S376
    10. Weg (1998) Postgrad Med 103(4):143

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