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2014 by the author

2. Clinical assessment and staging of COPD exacerbations
Jørgen Vestbo
Gentofte Hospital, Denmark.

3. Faculty disclosure
I have received honoraria for consulting and presenting from
Almirall
AstraZeneca
Boehringer-Ingelheim
Chiesi
GlaxoSmithKline
Novartis
Takeda

4. Aims of presentation To discuss assessment of exacerbations of COPD
Important issues:
Definition of exacerbations
Differential diagnosis
Assessment, what to measure and what not to
Assessment of severity with main focus on acute respiratory failure
Prognostic markers

5. Consequences of COPD exacerbations
Negative
impact on
quality of life
Impact on
symptoms
and lung
function
EXACERBATIONS
Accelerated
lung function
decline
Increased
economic
costs
Increased
Mortality

6. Consequences of COPD exacerbations
Suissa S et al. Thorax 2012

7. Consequences of COPD exacerbations
Suissa S et al. Thorax 2012

8. COPD Exacerbation: Definition
An acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and may lead to a change in medication
GOLD 2014 update

9. COPD Exacerbation: Definition
An exacerbation of COPD is a clinical diagnosis of exclusion, made when a patient with COPD experiences an acute worsening in respiratory symptoms (typically cough, sputum quantity and purulence, and/or dypnoea), and in whom no alternative specific cause for that deterioration has been identified by clinical examination and/or corroborative testing.
The worsening in respiratory symptoms may or may not warrant a change in underlying therapy and the symptoms will typically resolve over a period of days to weeks.
ERS/ATS draft Position paper.

10. Heterogeneity of exacerbations
Mrs Jones: 2-3 exacerbations per year, almost always precipitated by a cold, characterised by increasing breathlessness and wheeze, cough with minimal clear sputum and severely disturbed sleep.
Mr Brown: 4-6 exacerbations per year, with gradual onset of increased sputum purulence and viscosity, fever and fatigue. More breathless on exertion, no wheeze.

11. COPD Exacerbation: Definition
An acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and may lead to a change in medication
GOLD 2014 update

12. COPD Exacerbation: Differential Diagnoses
Clinical presentation
Pneumonia
Pneumothorax
Pleural effusion
Aspiration
Lung cancer
Heart failure
Atrial fibrillation
Pulmonary embolism
Urosepsis
Metabolic acidosis …

13. The “frequent exacerbator”

14. The “frequent exacerbator” ?
Solér-Cataluna & Rodriguez-Roisin, J COPD 2010

15. Frequency and Severity of Exacerbations by GOLD stage
Hurst et al. NEJM 2010.

16. Stability of the Exacerbator Phenotype
71% of Frequent Exacerbators in Year 1 and Year 2 were Frequent Exacerbators in Year 3
Hurst et al. NEJM 2010.

17. Stability of the Exacerbator Phenotype
74% of patients having no exacerbations in Years 1 and Year 2 had no exacerbations in Year 3

19. COPD Exacerbation: Differential Diagnoses
Clinical presentation
Pneumonia
Pneumothorax
Pleural effusion
Aspiration
Lung cancer
Heart failure
Atrial fibrillation
Pulmonary embolism
Urosepsis
Metabolic acidosis …

20. Assessment
GOLD 2014 update

21. Assessment
GOLD 2014 update

22. Assessment
GOLD 2014 update

23. Chest x-ray
Leads to a change in therapy in 1:4, mostly due to new infiltrates – however, old studies !

24. Evaluation of sputum colour
Sputum purulence correlates with presence of bacteria and favourable effect of antibiotics

25. Pulse oximetry and/or ABG
Pulse oximetry should be used in everyone to ensure an initial saturation of 88-92%
Arterial Blood Gases (ABGs) should be examined in everyone who is does not improve on initial treatment (within 30 minutes)
If abnormal, ABGs should initially be repeated every minutes to ensure improvement

26. Assessment
GOLD 2014 update

27. Blood and Sputum
Blood should be sampled for haematology, CRP, creatinine, urea and electrolytes
Consider other tests (troponins, liver function, glucose, etc) depending on comorbidities
Sputum should be sent for culture in patients to be started on antibiotics

28. Physical examination Chest examination But also:
Evaluate alertness and confusion
Signs of heart failure
Exclude (the many) differential diagnoses
Practice medicine !

29. Other tests
ECG if irregular pulse or suspicion of myocardial ischaemia
Echocardiography if heart failure or cor pulmonale is suspected
Chest ultrasound if available, for screening for differential diagnoses

30. Exacerbation severity: Prognostic markers
Older age
Lower BMI
Worse functional status 2 weeks before hospital admission
Frequent prior admissions
Worse APACHE III score
Lower pH, higher PCO2
Lower PO2/fraction of inspired oxygen ratio
History of congestive heart failure
Lower serum albumin level
Presence of cor pulmonale
NOT
PEF or FEV1

31. Exacerbation severity: Anthonisen
Worsening dyspnoea, increase in sputum purulence, and increase in sputum volume.
Type 1 exacerbations (severe): all three of the above symptoms.
Type 2 exacerbations (moderate): two of the above symptoms.
Type 3 exacerbations (mild): one of these symptoms, plus at least one of the following: an upper-respiratory-tract infection in the past 5 days, fever without other apparent cause, increased wheezing, increased cough, or increase in respiratory rate or heart rate by 20% above baseline.

32. Severity Grading Exacerbations Infectious Non-infectious Type 1
Anthonisen Type 2
Type 3

33. Severity Grading Exacerbations Infectious Non-infectious
+/- Respiratory failure
+/- Respiratory failure

34. CURB65 Confusion Urea > 7 mmol/l Respiratory Rate: ≥ 30 /minute
Blood pressure: 90/60 mmHg
65 years

35. CURB65 & COPD exac Waikato Hospital, North Island, New Zealand
Secondary/tertiary hospital (”teaching hospital”), uptake area 380,000.
1 year, 252 consecutive admissions
Pneumonia excluded by chest x-ray
Outcome: Inhospital mortality and mortality with 30 days of discharge
Chang et al. Respirology 2011.

36. CURB65 & COPD exac Very severe COPD 37% Severe COPD 44%
Moderate COPD 19%
Died during admission /249 (4.8%)
Died within 30 days of discharge 21/249 (8.4%)
Chang et al. Respirology 2011.

37. CURB65 & COPD exac Adm. 30 days CURB65 0-1 1.0% 2.0%
CURB65 score was predictive of 30 day mortality (crude OR 1.89, adjusted OR 1.71, p=0.013).
Chang et al. Respirology 2011.

38. CURB65 & COPD exac
pH (or PCO2) was also relatd to 30 days mortality while FEV1, BMI and PO2 had no impact on prognosis.
Respiratory rate was the most predictive component of CURB65 !
Chang et al. Respirology 2011.

39. CURB65 Confusion Urea > 7 mmol/l Respiratory Rate: ≥ 30 /minute
Blood pressure: 90/60 mmHg
65 years

40. Conclusions
COPD exacerbations are currently poorly defined and very heterogeneous

41. Conclusions
COPD exacerbations are currently poorly defined and very heterogeneous
A significant number of differential diagnoses needs to be considered in the patient with COPD presenting with worsening of symptoms

42. Conclusions
COPD exacerbations are currently poorly defined and very heterogeneous
A significant number of differential diagnoses needs to be considered in the patient with COPD presenting with worsening of symptoms
Proper evaluation of a COPD patient with an exacerbation should always include a chest x-ray, pulse oximetry and sputum culture if antibiotics are planned.

43. Conclusions
COPD exacerbations are currently poorly defined and very heterogeneous
A significant number of differential diagnoses needs to be considered in the patient with COPD presenting with worsening of symptoms
Proper evaluation of a COPD patient with an exacerbation should always include a chest x-ray, pulse oximetry and sputum culture if antibiotics are planned.
Arterial blood gases are key to evaluating respiratory failure

44. Conclusions
COPD exacerbations are currently poorly defined and very heterogeneous
A significant number of differential diagnoses needs to be considered in the patient with COPD presenting with worsening of symptoms
Proper evaluation of a COPD patient with an exacerbation should always include a chest x-ray, pulse oximetry and sputum culture if antibiotics are planned.
Arterial blood gases are key to evaluating respiratory failure
Consider using CURB65