COPD Exacerbation (1) C.L.I.P.S. Definition Acute worsening of respiratory symptoms (typically cough, dyspnea, and/or sputum production) beyond normal daily variations that result in additional therapy. A clinical diagnosis -> Differential Cardiac (CHF, ACS, arrhythmia), PE, PNA, PTX, pleural effusion May be overlapping (e.g. PE may be present in 25% of patients hospitalized for COPD exacerbation) Triggers Viral or bacterial respiratory infection most likely. Other cardiopulmonary comorbidities. Environmental factors like air pollution may trigger or amplify. Risk factors for frequent exacerbations # of exacerbations in past year, baseline FEV1, GERD Who to admit? severe symptoms or signs (MICU if AMS or worsening respiratory status with hypoxemia, hypercapnia, resp acidosis) serious comorbidities inadequate home support What proportion of patients with a COPD exacerbation can be managed on an outpatient basis? More than 80% Updated 1/18 Stromberg

COPD Exacerbation (2) C.L.I.P.S. Inpatient Floor Treatment Oxygen titrated to SpO2 88-92%. Albuterol 2.5mg neb q4h prn, +/- ipratropium 500mcg neb q4h prn (RT can’t do more frequently than q4h on floor) prednisone 40 mg/day PO (or equivalent) x5 days (max 7 days) Antibiotics. No optimal regimen. Typically 5-7d. Consider procalcitonin levels to reduce antibiotic use. Risk stratify patients at risk for resistant organisms (UpToDate algorithm) ABX reduce treatment failure and mortality in severe COPD. DVT/PE prophylaxis Some suggested discharge criteria (GOLD 2016) Can eat and sleep without frequent disruptions due to dyspnea Can walk across room (if previously ambulatory) Able to use long-acting bronchodilators +/- ICS (start as soon as possible prior to discharge) Prevention Smoking cessation, home O2 and med adherence including proper inhaler use, pneumococcal and flu immunizations Inhaler treatment regimen appropriate for COPD Stage (GOLD Guidelines), prefer tiotropium where LAMA indicated What is all- cause mortality at 5 years after hospitalization for COPD exacerbation? About 50%