Pulmonology Book

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Acute Exacerbation of Chronic Bronchitis

Aka: Acute Exacerbation of Chronic Bronchitis, Antibiotic Use in COPD Exacerbation
  1. See Also
    1. COPD
    2. COPD Management
    3. COPD Exacerbation Prevention
    4. COPD Action Plan
  2. 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
  3. 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
  4. Symptoms: General
    1. Fatigue
    2. Fever
    3. Malaise
    4. Confusion
    5. Insomnia
  5. Evaluation: Severity
    1. Do not define exacerbation severity by Spirometry
    2. Mild Exacerbation
      1. COPD controlled with an increase in regular medications
    3. Moderate Exacerbation
      1. COPD controlled with Systemic Corticosteroids or antibiotics
    4. Severe Exacerbation
      1. COPD controlled with emergency department evaluation or hospitalization
  6. Evaluation
    1. Pulse Oximetry in all patients
    2. Chest XRay
      1. Indicated 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)
  7. Management: First line management
    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
        1. Austin (2010) BMJ 341: c5462 [PubMed]
      2. However, do not limit FIO2 in severe Hypoxemia in CO2 retainers
        1. See Below
        2. Set O2 Sat goal of 88-91%
        3. Anticipate CO2 rise of 12 points
        4. Consider BiPap for pH < 7.25
    3. Systemic Corticosteroids (oral or intravenous)
      1. Indicated in all moderate to severe COPD exacerbations
      2. Prednisone 40 mg orally daily (5 day course is typical)
        1. Five day course of 40 mg daily is sufficient for most COPD exacerbations
          1. Leuppi (2013) JAMA 309(21):2223-31 [PubMed]
        2. Ten day course reduces relapse rate after COPD evaluation in ER
          1. Aaron (2003) N Engl J Med 348:2618-25 [PubMed]
      3. Prednisone 30-60 mg/day orally tapered over 2 weeks or
      4. Methylprednisolone (Solumedrol) 60-125 mg IV every 6 hours
    4. Avoid low efficacy therapies
      1. Mucolytic medications are not shown helpful
      2. Chest physiotherapy is not efficacious
      3. Theophylline not helpful in exacerbations
  8. Management: Second-line management
    1. Increased oxygen supplementation
      1. Titrate to High Flow Oxygen (e.g. oximizer)
        1. Set O2 Sat goal of 88-91%
      2. Do not limit FIO2 in severe Hypoxemia in CO2 retainers
        1. Anticipate CO2 rise of 12 points
    2. Non-Invasive Positive Pressure Ventilation or NIPPV (e.g. BIPAP)
      1. Mechanism
        1. Supplies the threshold pressures needed to expand collapsed and inflamed airways
      2. Starting
        1. Start early, before the onset of significant respiratory Fatigue
        2. Consider starting BiPap for pH < 7.25 to 7.30
      3. Weaning
        1. Consider weaning bipap when ABG or VBG pH 7.32 or higher
      4. Refractory cases
        1. Consider intubation for pH <7.20
      5. Efficacy
        1. Reduces the need for intubation, ICU admission, mortality
        2. Berg (2012) Intern Emerg Med 7(6): 539-45 [PubMed]
    3. 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)
  9. Indications: Antibiotic indications if 3 criteria met
    1. Increased Dyspnea
    2. Increased Sputum
    3. Purulent Sputum
  10. Management: Antibiotics for 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 [PubMed]
      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 [PubMed]
  11. Management: Antibiotics for Complicated Chronic Bronchitis
    1. Criteria
      1. Uncomplicated criteria not met (see above)
    2. Coverage
      1. Uncomplicated Chronic BronchitisBacteria (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
  12. Management: Antibiotics for 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
  13. References
    1. Decramer (2008) Respir Med 102(suppl 1): S3-S15 [PubMed]
    2. Evensen (2010) Am Fam Physician 81(5): 607-13 [PubMed]
    3. Fein (2000) Curr Opin Pulm Med 6:122-6 [PubMed]
    4. Gentry (2017) Am Fam Physician 95(7): 433-41 [PubMed]
    5. Quon (2008) Chest 133(3): 756-66 [PubMed]
    6. Saint (1995) JAMA 273:957-60 [PubMed]
    7. Sethi (2000) Chest 117(5 suppl 2):S380-5 [PubMed]

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