Version May 2024
| Clinical features |
| Features of COPD exacerbation: Diffuse wheezing, distant breath sounds, barrel-shaped chest, tachypnea, tachycardia, smoking >20 pack years. |
| Features of severe respiratory insufficiency: Use of accessory muscles; brief, fragmented speech; inability to lie supine; profound diaphoresis; agitation; asynchrony between chest and abdominal motion with respiration; failure to improve with initial emergency treatment. |
| Features of impending respiratory arrest: Inability to maintain respiratory effort, cyanosis, hemodynamic instability, and depressed mental status |
| Features of cor pulmonale: Jugular venous distension, prominent left parasternal heave, peripheral edema. |
| COPD exacerbations are most often precipitated by infection (viral or bacterial). |
| Severe respiratory distress in a patient with known or presumed COPD can be due to an exacerbation of COPD or a comorbid process, such as acute coronary syndrome, decompensated heart failure, pulmonary embolism, pneumonia, pneumothorax, sepsis. |
| Management |
| Assess patient's airway, breathing, and circulation; secure as necessary. |
| Provide supplemental oxygen to target a pulse oxygen saturation of 88 to 92% or PaO2 of 60 to 70 mmHg (7.98 to 9.31 kPa); Venturi mask can be useful for titrating FiO2; high FiO2 usually not needed and can contribute to hypercapnia (high FiO2 requirement should prompt consideration of alternative diagnosis [eg, PE]). |
| Determine patient preferences regarding intubation based on direct questioning or advance directive whenever possible. |
| Provide combination of aggressive bronchodilator therapy and ventilatory support (NIV or invasive ventilation). |
| Noninvasive ventilation (NIV): Appropriate for the majority of patients with severe exacerbations of COPD unless immediate intubation is needed or NIV is otherwise contraindicated |
| Contraindications to NIV include: Severely impaired consciousness, inability to clear secretions or protect airway, high aspiration risk. |
| Initial settings for bilevel NIV: 8 cm H2O inspiratory pressure (may increase up to 15 cm H2O if needed to aid ventilation); 3 cm H2O expiratory pressure. |
| Administer bronchodilators via nebulizer or MDI: Nebulizer usually requires interruption of NIV; MDIs can be delivered in line using adaptor (refer to dosing below). |
| Obtain ABG after two hours of NIV and compare with baseline: Worsening or unimproved gas exchange and pH <7.25 are indications for invasive ventilation. |
| Tracheal intubation and mechanical ventilation: Indicated for patients with acute respiratory failure, hemodynamic instability (eg, heart rate <50/minute, uncontrolled arrhythmia) and those in whom NIV is contraindicated or who fail to improve with NIV and aggressive pharmacotherapy |
| Rapid sequence induction (eg, etomidate, ketamine, or propofol). |
| Intubate with #8 endotracheal tube (8 mm internal diameter) or larger, if possible. |
| Initial ventilator settings aim to maintain adequate oxygenation and ventilation while minimizing elevated airway pressures: SIMV, tidal volume 6 to 8 mL/kg, respiratory rate 10 to 12/minute, inspiratory flow rate 60 to 80 L/min (increase if needed to enable longer expiratory phase), PEEP 5 cm H2O. May need to tolerate elevated PaCO2 to avoid barotrauma (ie, permissive hypercapnia). In patients with chronic hypercapnia, aim for PaCO2 close to baseline. |
| Administer inhaled bronchodilator therapy: Usually via MDI with in-line adaptor (refer to dosing below). |
| Diagnostic testing |
| Assess oxygen saturation with continuous pulse oximetry. |
| Obtain ABG in all patients with severe COPD exacerbation. |
| ETCO2 monitoring (capnography) has only moderate correlation with arterial PaCO2 in COPD exacerbations. |
| Do not assess peak expiratory flow or spirometry in acute severe COPD exacerbations as results are not accurate. |
| Obtain portable chest radiograph: Look for signs of pneumonia, acute heart failure, pneumothorax. |
| When evidence of acute infection (eg, purulent phlegm, pneumonia) is absent and chest radiograph is unrevealing, obtain CT pulmonary angiogram for possible pulmonary embolism. |
| Obtain complete blood count, electrolytes (Na+, K+, Cl–, HCO3–), BUN, and creatinine; also obtain cardiac troponin, BNP, or NT-proBNP, if diagnosis is uncertain. |
| Test for influenza infection during influenza season.* |
| Obtain ECG: Look for arrhythmia, ischemia, cor pulmonale. |
| Pharmacotherapy |
| Inhaled beta agonist: Albuterol 2.5 mg diluted to 3 mL via nebulizer or 2 to 4 inhalations from MDI every hour for 2 or 3 doses; up to 8 inhalations may be used for intubated patients, if needed. |
| Short-acting muscarinic antagonist (anticholinergic agent): Ipratropium 500 micrograms (can be combined with albuterol) in 3 mL via nebulizer or 2 to 4 inhalations from MDI every hour for 2 to 3 doses. |
| Intravenous glucocorticoid (eg, methylprednisolone 60 mg to 125 mg IV, repeat every 6 to 12 hours). |
| Antibiotic therapy*: Appropriate for majority of severe COPD exacerbations; select antibiotic based on likelihood of particular pathogens (eg, Pseudomonas risk factors¶, prior sputum cultures, local patterns of resistance). |
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| Antiviral therapy (influenza suspected)*: Oseltamivir 75 mg orally every 12 hours or peramivir 600 mg IV once (for patients unable to take oral medication). |
| Monitoring |
| Perform continual monitoring of oxygen saturation, blood pressure, heart rate, respiratory rate. |
| Close monitoring of respiratory status. |
| Continuous ECG monitoring. |
| Monitor blood glucose. |
| Disposition |
| Criteria for ICU admission include: |
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COPD: chronic obstructive pulmonary disease; PaO2: arterial tension of oxygen; FiO2: fraction of inspired oxygen; PE: pulmonary embolism; NIV: noninvasive ventilation; MDI: metered dose inhaler; ABG: arterial blood gas; SIMV: synchronized intermittent mechanical ventilation; PEEP: positive end-expiratory pressure; PaCO2: arterial tension of carbon dioxide; ETCO2: end-tidal carbon dioxide; BUN: blood urea nitrogen; BNP: brain natriuretic peptide; NT-ProBNP: N-terminal pro-BNP; ECG: electrocardiogram; IV: intravenous; ICU: intensive care unit.
* When influenza is suspected, therapy should not be delayed while awaiting results of testing. Doses shown are for patients with normal renal function. Some agents require dose adjustment for renal impairment; refer to separate UpToDate algorithms of antibiotic treatment of exacerbations of COPD.
¶ Pseudomonas infection risk factors: Broad spectrum antibiotic use in the past 3 months; chronic colonization or previous isolation of Pseudomonas aeruginosa from sputum (particularly in past 12 months); very severe underlying COPD (FEV1 <30% predicted); chronic systemic glucocorticoid use.آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
