1. Management Of Exacerbations Of Chronic Obstructive Pulmonary Disease D.Anan Esmail Seminar Training Primary Care Asthma + COPD 03- 2015

2. defines an exacerbation of chronic obstructive pulmonary disease (COPD) as:

3. an acute event characterized by a worsening of the patient’s respiratory symptoms

4. Acute Exacerbations of COPD

6. Risk Factors For COPD Exacerbation

7. Advanced age

8. Productive cough

9. Chronic mucous Hypersecretion

10. Duration of COPD

11. History of antibiotic Therapy

12. COPD-related hospitalization within the previous year

13. Theophylline therapy

14.  FEV1

15. Pulmonary Hypertension

16. Gastroesophageal reflux disease

17. Having one or more comorbidities: Ischemic heart disease Chronic heart failure Diabetes mellitus

18. Triggers

19. Respiratory infections Respiratory infections  70 % of COPD exacerbations Virus Virus Bacteria Bacteria Atypical ??? Atypical ???

20. 30 % of COPD exacerbation 30 % of COPD exacerbation   Environmental Pollution

21. 30 % of COPD exacerbation 30 % of COPD exacerbation   Pulmonary Embolism (25%)

22. 30 % of COPD exacerbation 30 % of COPD exacerbation   Unknown Etiology Heart disorders aspiration

23. clinical manifestations The clinical manifestations of exacerbations of COPD

29. Details about The past history of exacerbations

30. The past history of exacerbations should be ascertained NNNNumber of prior exacerbations CCCCourses of systemic Glucocorticoids EEEExacerbations requiring hospitalization or ventilatory support

31. Physical examination 31

32. Physical examination Physical examination  Wheezing  Tachypnea

33. Features of respiratory compromise Features of respiratory compromise   Difficulty speaking due to respiratory effort   Use of accessory respiratory muscles   Paradoxical chest wall

34. Decreased mental status Decreased mental status  Hypercapnia or Hypoxemia Asterixis Asterixis  Increased Hypercapnia

35. physical findings that might suggest co-morbidity or alternate diagnosis

36. Fever Fever Hypotension Hypotension Bibasilar fine crackles Bibasilar fine crackles Peripheral edema Peripheral edema

37. Evaluation + Diagnosis Goals

38. Confirm the diagnosis Confirm the diagnosis Identify the cause Identify the cause (when possible) Assess the severity Assess the severity Determine whether comorbidities are contributing Determine whether comorbidities are contributing

39. Initial evaluation MMMMild exacerbation Clinical assessment Pulse oxygen saturation

40. Initial evaluation FFFFor patients who require emergency department care Pulse oxygen saturation A chest radiograph Laboratory studies Arterial blood gas analysis

41. Initial evaluation FFFFor patients who require emergency department care Electrocardiogram Cardiac Troponins Plasma brain natriuretic peptide (BNP) D-dimer

42. Sputum Gram stain and culture NNNNot useful MMMMay be helpful (Unsuccessful t tt treatment with Antibiotic)

43. Differential Diagnosis

44. Differential Diagnosis: Differential Diagnosis:  Acute worsening of dyspnea heart failure pulmonary thromboembolism Pneumonia pneumothorax

45. Triage to Home or Hospital more than 80 percent of exacerbations of COPD can be managed on an outpatient

46. Criteria Criteria   Management at Hospital 46

47. Inadequate response to outpatient or emergency department management Inadequate response to outpatient or emergency department management

48. Severe underlying COPD: Severe underlying COPD:  FEV1 ≤50  FEV1 ≤50 percent of predicted

49. Insufficient Home support

50. History of frequent exacerbation

51. comorbidities High risk comorbidities including :   Pneumonia   Cardiac Arrhythmia   Heart Failure   Diabetes Mellitus   Renal Failure   Liver Failure

52. Dyspnea over baseline Dyspnea over baseline  New onset resting dyspnea

53. Inability to eat or sleep due to symptoms Difficulty speaking due to respiratory effort

54. Use of accessory muscles Paradoxical chest wall

55. respiratory acidosis Acute or acute-on-chronic respiratory acidosis

56. New cyanosis or worsening hypoxemia

57. Changes in mental status Asterixis Asterixis

58. Intensive Home Care

59. Intensive Home Care Intensive Home Care  Nurse visits  Home oxygen  Physical therapy

60. Intensive Home Care Intensive Home Care  Cost savings Patient and family education Patient and family education

61. HOME MANAGEMENT OF COPD EXACERBATIONS

64. administered by a metered dose inhaler ( MDI ) with a spacer device

65. two inhalations by MDI every four to six hours

66. Patients who already have a nebulizer at home

67. administration of beta adrenergic agonists via nebulizer is helpful during COPD exacerbations

68. most studies have not supported a greater effect from nebulizer treatments over properly administered metered dose inhaler medication

69. may be combined with a short acting anticholinergic agent

70. combination therapy produces bronchodilation in excess of that achieved by either agent alone

73. For patients who have a history of benign prostatic hypertrophy or prior urinary retention, the addition of ipratropium to a long-acting anticholinergic agent (eg, tiotropium) may increase the risk of acute urinary retention, although data are conflicting For patients who have a history of benign prostatic hypertrophy or prior urinary retention, the addition of ipratropium to a long-acting anticholinergic agent (eg, tiotropium) may increase the risk of acute urinary retention, although data are conflicting

78. The efficacy of inhaled glucocorticoids on the course of a COPD exacerbation has not been studied

79. should not be used as a substitute for systemic glucocorticoid therapy in COPD exacerbations

83. We do not initiate antibiotic therapy in patients whose exacerbation is mild, which we define as having only one of these three symptoms and not requiring hospitalization We do not initiate antibiotic therapy in patients whose exacerbation is mild, which we define as having only one of these three symptoms and not requiring hospitalization

85. (Grade 2B) Pseudomonas risk factors:  Frequent administration of antibiotics (4 or more courses over the past year)  Recent hospitalization (2 or more days' duration in the past 90 days)  Isolation of Pseudomonas during a previous hospitalization  Severe underlying COPD (FEV1 <50 percent predicted) Pseudomonas risk factors:  Frequent administration of antibiotics (4 or more courses over the past year)  Recent hospitalization (2 or more days' duration in the past 90 days)  Isolation of Pseudomonas during a previous hospitalization  Severe underlying COPD (FEV1 <50 percent predicted)

86. HOSPITAL MANAGEMENT OF COPD EXACERBATIONS

89. Beta adrenergic agonists MDI with spacer

90. Beta adrenergic agonists nebulization

91. Beta adrenergic agonists nebulization

92. Beta adrenergic agonists nebulization

93. Beta adrenergic agonists nebulization

94. Anticholinergic agents MDI with spacer

95. Anticholinergic agents nebulization

105. adverse effects hyperglycimia

106. upper gastrointestinal bleeding

107. psychiatric disorders

108. Antibiotic treatment of acute exacerbations of COPD (hospitalized)

109. Pseudomonas risk factors:  Frequent administration of antibiotics (4 or more courses over the past year)  Recent hospitalization (2 or more days' duration in the past 90 days)  Isolation of Pseudomonas during a previous hospitalization  Severe underlying COPD (FEV1 <50 percent predicted) Pseudomonas risk factors:  Frequent administration of antibiotics (4 or more courses over the past year)  Recent hospitalization (2 or more days' duration in the past 90 days)  Isolation of Pseudomonas during a previous hospitalization  Severe underlying COPD (FEV1 <50 percent predicted)

111. cigarette smoking cessation

112. nutritional support

113. continuation of ongoing supplemental oxygen therapy

114. administration of supplemental oxygen should target ppppulse oxygen saturation (SpO ) of 88 to 92 percent

115. administration of supplemental oxygen should target aaaarterial oxygen tension (PaO ) of approximately 60 to 70 mmHg

116. A high FiO is not required to correct the hypoxemia associated with most exacerbations of COPD

117. the risk of prompting worsened hypercapnia with excess supplemental oxygen

118. Hypercapnia is generally well tolerated in patients whose (PaCO ) is chronically elevated

121. Noninvasive ventilation ppppreferred method of ventilatory support iiiimproves numerous clinical outcomes

122. Invasive ventilation ppppatients fail NPPV ddddo not tolerate NPPV hhhhave contraindications to NPPV

129. Exacerbations of COPD are associated with increased mortality (3 to 9 %)

130. Factors Associated With Increased Mortality

133. smoking cessation

134. pulmonary rehabilitation

135. vaccination seasonal influenza and pneumococcus

136. proper use of medications (metered dose inhaler technique)