How to manage a case of acute exacerbation of COPD according to GOLD guidelines. Sincere thanks to Dr. Amardeep Toppo who has prepared most of this presentation.

1. T H O M A S K U R I A N
HOW TO MANAGE A CASE OF ACUTE
EXACERBATION OF COPD

2. CASE .........
• 74 yr/ M known case of COPD complains of increase
SOB , cough with expectoration from white to yellow
colour , increased weight , pedal oedema since 3 days
• What is your probable diagnosis ?
• AECOPD
• Definition- an acute event characterized by a worsening
of the patient’s respiratory symptoms that is beyond
normal day-to-day variations and leads to a change in
medication

3. WHAT ARE THE PRECIPITATING /
AGGRAVATING FACTORS ?
• Respiratory tract infections
• Exposure to air pollutants
• Pneumonia
• Pulmonary embolism
• Right heart failure
• Cardiac arrhythmia
• Pneumothorax
• Pleural effusion
• 1/3rd cases – cause???
Differential
diagnosis

4. EXACERBATIONS OF COPD ARE
IMPORTANT
• Negatively affect a patient’s quality of life
• Have effects on symptoms and lung function that take
several weeks to recover
• Accelerate the rate of decline of lung function.

5. • Are associated with significant mortality, particularly in
those requiring hospitalization
• Have high socioeconomic costs

6. GOALS OF TREATMENT
• Minimize the impact of the current exacerbation
• Prevent subsequent exacerbations

7. WHO IS A FREQUENT
EXACERBATOR?

8. ON PHYSICAL EXAMINATION
• Weight 70 kg , height 168 cm
• Respiratory distress
• Sitting in edge of bed leaning forward supporting his
weight with his palms ,breathing through pursed lip

9. WHAT IS THIS SIGN?

10. • Vitals – HR 124/min , bp – 150/ 90 , RR – 28 / min , temp
– 100.5 F Spo2 = 85% room air
• Neck – marked dilated neck vein , accessory muscles in
use

11. CYANOSIS

12. BARREL CHEST

13. • Chest – increase antero-posterior diameter , deep
suprasternal notch , paradoxical motion of abdomen ,
scattered expiratory wheezing, prolonged expiratory
phase .
• Heart – S1 S2 audible, no murmur
• CNS –conscious oriented
• Extremities – pitting edema was present

14. IS THE PATIENT'S CONDITION SEVERE
ENOUGH FOR ADMISSION??
• Yes..How to assess the severity of patient by clinical
examination ?
• Signs of severity are –
• Use of accessory respiratory muscles
• Paradoxical chest wall movements
• Worsening or new onset central cyanosis
• Development of peripheral edema
• Hemodynamic instability
• Deteriorated mental status

15. WHAT PERCENT OF EXACERBATION
CAN BE MANAGED IN OPD?
a) 10%
b) 20%
c) 30%
d) 80%

16. PATIENT IS ADMITTED TO EMERGENCY
ROOM
• What investigation will you like to order ?
• Chest x-ray
• ECG
• Complete blood count

17. • Serum electrolyte
• Co morbidities
• ABG analysis
• SpO2 < 92 % with clinical signs suggestive of respiratory
failure.

18. CHEST X RAY

19. LATERAL X RAY

20. ECG OF PATIENT

21. WHAT ARE OTHER FINDINGS IN ECG OF
COPD PATIENT??...
• Atrial premature beats
• Atrial flutter
• Atrial fibrillation
• Multi focal atrial tachycardia
• Right bundle branch block
• Right ventricular hypertrophy

22. ABG OF PATIENT
• pH – 7.32
• Pco2 – 50 mm of Hg
• Po2 – 44 mm of Hg
• HCO 3- =35 mm of Hg
• Spo2 = 85 %
• Patient was shifted to ICU

23. DOES PATIENT REALLY NEED ICU
ADMISSION
• If Yes … what is the indication for ICU admission?
• Severe dyspnea that responds inadequately to initial
emergency therapy
• Changes in mental status (confusion, lethargy, coma)
• Persistent or worsening hypoxemia (PaO2< 40 mmHg)
and/or severe/worsening respiratory acidosis (pH < 7.25)
despite supplemental oxygen and noninvasive ventilation

24. • Need for invasive mechanical ventilation
• Haemodynamical instability—need for vasopressors

25. WHAT WOULD YOU LIKE TO PRESCRIBE
?
• Supplemental oxygen therapy
• Bronchodilators
• Corticosteroids
• Antibiotics
• Diuretic , anticoagulants , nutritional support

26. • Monitor fluid balance and nutrition
• Low molecular weight heparin
• Treat associated conditions
• Monitor

27. WHICH BRONCHODILATOR ??...
• Short-acting inhaled beta2- agonists with or without
short-acting anticholinergics are usually the preferred
bronchodilators
• Route of delivery is MDIs and nebulizers for sicker
patients
• Intravenous methylxanthines (theophylline or
aminophylline) are second-line therapy

28. WHAT ARE THE INDICATION TO ADD
ANTIBIOTICS ?...
• Three cardinal symptoms – increase in dyspnea, sputum
volume, and sputum purulence
• Signs of pneumonia
• Mechanical ventilation
• Procalcitonin III

29. WHICH ARE MOST COMMON
ORGANISMS INVOLVED ???
• Hemophilus influenzae,
• Streptococcus pneumoniae
• Moraxella catarrhalis
• In GOLD 3 and GOLD 4 patients - Pseudomonas
aeruginosa

31. WHAT IS YOUR CHOICE ?
• Empirical treatment
• Frequent exacerbations, severe airflow limitation and/or
exacerbations requiring ventilation - cultures from sputum
should be sent and Gram negative coverage
• Duration - 10 days

32. RECOMMENDED CORTICOSTEROID ?
• 40 mg prednisone per day for 5 days
• Shorten recovery time, improve lung function (FEV1) and
arterial hypoxemia (PaO2) and reduce the risk of early
relapse, treatment failure and length of hospital stay.

33. Continued to deteriorate despite of
intervention
 Paradoxical abdominal motion
 Increase respiratory rate
 ABG-
pH – 7.30
Pco2 – 79mm of Hg
Po2 – 42mm of Hg
HCO 3- =35 mm of Hg
Spo2 = 90% on 26 % FiO2

34. Is NIV REQUIRED ????...
 If yes …. What is indication to put on NIV??
 Respiratory acidosis (arterial pH ≤ 7.35 and/or
> 45 PaCO2mm Hg)
 Severe dyspnea with clinical signs suggestive
of respiratory muscle fatigue, increased work of
breathing

35. What are the Pre requisites to put
patient on NIV ?..
 Normal or near normal bulbar function
 Ability to clear bronchial secretions
 Hemodynamic stability
 Functional GIT
 Ability to cooperate with treatment

36. Contraindication to put patient on
NIV ?...
Absolute contraindications
 Respiratory arrest
 Drowsiness , lethargy, Coma
 More than two organ failure
 Excessive facial trauma
 Upper airway obstruction

37. Contraindication to put patient on
NIV ?...
Relative contraindications
 Highly confused patient
 Unstable angina/ evolving myocardial
Infarction
 Recent oesophageal or gastric surgery
 Facial deformity

38. Patient was put on NIV
 MODE – S
IPAP – 15 cm of Hg
EPAP – 5 cm of Hg
O2 of 2 l/m

39.  Patient is not compliant with therapy
 Not tolerating bi pap
 Patient is getting drowsy
 ABG shows
pH – 7.25
PCO2 – 80
PO2 – 50
HCO3- -- 34
Spo2 – 85 %

40. Would you like to continue NIV
??
 NO
 What are the indications to put on invasive
ventilation ?..
 Unable to tolerate NIV or NIV failure
 Respiratory pauses with loss of consciousness
 Massive aspiration
 Persistent inability to remove respiratory secretions

41. Indications to put on invasive
ventilation
 Heart rate < 50 / min with loss of alertness
 Severe hemodynamic instability
 Severe ventricular arrhythmias
 Life-threatening hypoxemia

42. Decision to put on ventilation
 Mode CMV
Tidal Volume – 750 ml
FiO2 – 40 %
PEEP – 5 cm of H2O
I:E ratio – 1:4
After 24 hour patient improved

43. ABG
 pH – 7.36
pCO2 – 65
pO2 – 88
HCO3- -- 36
SpO2 -- 96 %

44. After 72 hours
Resolution of pneumonic patch
alert and co operative
ABG shows
pH- 7.39
pCO2 – 50
pO2 – 74
SpO2 – 94 %
HCO3- -- 34
Patient is planned for weaning

45. How to decide Weaning ???
 Ventilatory criteria
 Oxygenation criteria

46.  Patient has been put on SIMV mode followed
then put on spontaneous mode of CPAP
mode with pressure support of 5 cm of H2o
and FiO2 35 %
RR 18
Tidal volume 524 ml
RR/Vt 34 /min/L
 RR/Vt is <100 is sign of successful weaning

47. ABG shows
 pH – 7.38
pCO2 – 49
pO2 – 69
HCO3- - 34
SpO2 – 92 %
Patient is successfully extubated and kept at 2
l/m O2 via NP

48.  Then patient is shifted to medical general ward
 After two days discharge was planned

49. What should be the discharge criteria
?
 Able to use long acting bronchodilators
 Inhaled short-acting beta2-agonist therapy is
required no more frequently than every 4 hrs
 Able to walk across room

50. Discharge criteria
 Eat and sleep without frequent awakening by
dyspnea
 Clinically stable for 12-24 hrs
 ABG stable for 12-24 hrs
 Fully understands correct use of medications

51. Check list at time of discharge
 Reassessment of inhaler technique
 Education regarding role of maintenance
regimen
 Instruction regarding completion of steroid
therapy and antibiotics.

52. Check list at time of discharge
 Assess need for long-term oxygen therapy
 Assure follow-up visit in 4-6 weeks
 Provide a management plan for co-morbidities

53. Patient is to be discharged ....
 What prescription would you write ?
 Smoking cessation
 Pulmonary rehabilitation program.
 Advice for vaccination
 Bronchodilators
 Antibiotic
 Steroid
 Drugs for co morbidities

54. Importance of vaccination
 Vaccine has reduced the incidence of
community-acquired pneumonia in COPD
patients younger than age 65 with an FEV1 <
40% predicted
 Influenza vaccination can reduce serious
illness such as lower respiratory tract
infections requiring hospitalization and death
in COPD patient.

55. Importance of vaccination
 Pneumococcal polysaccharide vaccine is
recommended for age 65 years and older
 also in younger patients with significant co
morbid conditions such as cardiac disease.

56. PATIENT HAS COME FOR FOLLOW UP ?
• What to do now ????
• Measurement of FEV1
• Reassessment of inhaler technique
• Compliance
• Reassess need for long-term oxygen therapy and/or
home nebulizer

57. FOLLOW UP
• Capacity to do physical activity and activities of daily
living
• CAT score or mMRC
• Status of co morbidities

59. HOW TO ASSESS THE NEED OF LTOT ?
• PaO2 < 55 mmHg or SaO2 below 88% with or without
hyper capnia confirmed twice over a three week period
or
• PaO2 between 55 mmHg and 60 mmHg or SaO2 of
88%, if there is evidence of pulmonary hypertension,
peripheral edema suggesting congestive cardiac failure,
or hematocrit > 55%

60. • Patient PFT show post bronchodilator
FEV1 = 45 % of predicted
• Stop for breath after walking about 100 meters
• CAT score of 12
• Previous history of exacerbation is 2

61. WHICH RISK GROUP WILL PATIENT BE ?
• Patient risk Group D

62. C D
A B
Less symptom More symptom
mMrc 0 - 1 mMrc >=2
CAT <10 CAT >10
Highrisk
Lowrisk
Gold
4
3
2
1
Exacerbation
>=2
Or
>= 1 hospital
admission
0-1
Or
No hospital
admission

63. C
high risk
Less symptoms
D
high risk
More symptoms
A
low risk
Less symptoms
B
low risk
More symptoms
Less symptom More symptom
mMrc 0 - 1 mMrc >=2
CAT <10 CAT >10
Highrisk
Lowrisk
Gold
4
3
2
1
Exacerbation
>=2
Or
>= 1 hospital
admission
0-1
Or
No hospital
admission

64. 1ST RECOMMENDED CHOICE
BRONCHODILATOR WOULD BE ?
• ICS + LABA &/or LAMA

65. A
SABA or
SAMA
B
LAMA or
LABA
C
LAMA or
LABA + ICS
D
ICS + LABA
&/or LAMA
1 st recommended choice according to patient risk
groups

66. THANK YOU