Acute exacerbation of COPD

Presented by Ralph Bou Deleh

Under the direction of :
DR Mirna el Ali
DR Alissar Saleh
NOTRE DAME DE SECOURS
CENTRE HOSPITALIER
UNIVERSITAIRE
Plan
 Patient presentation
 Chief complaint
 Medical and medication history
 Physical exam
 Impression and plan
 Laboratory results
 Final diagnosis
 Treatment at the hospital
 Evaluation of the therapy
 Discharge sheet
 Advices
 References
Patient presentation
Female

SMOKER
74 Y.O
>30Y

Patient

BMI=25.59
Weight:68kg
kg/m2

Height: 163
Cm
Chief complaint
Expectoration
Dyspnea
from 1 week

Desaturation
Cough
to 40 %
Medical & medication history
• Symbicort 320/9 mcg B.I.D
COPD • Spiriva Handihaler 18mcg O.D
• BIPAP at home

Diabetes mellitus • Glucophage 850 mg 1 tab O.D

type 2 • Amaryl 1 mg 1 tabO.D

• Concor 2.5 mg 1 tab O.D

Hypertension • Fludex LP 2.5 mg 1 tab O.D

TAVI for aortic • Plavix 75 mg 1 tab O.D

stenosis • NU-SEALS 75 mg (aspirin) 1 TAB O.D

GERD • Esomeprazole 40 mg 1 cp O.D

P/E
 Decreased breath sounds
 Crackles
 Normal heart sounds
 No fever
Impression and plan
Impression

• Acute COPD exacerbation

Tests ordered
• Arterial blood gases , CBC , Electrolytes , CRP ,
troponin, chest x ray , creatinine .
Laboratory Results
Respiratory
Acidosis+ o2
ABG desaturation

N ER Icu d 1 Icu d 3 d7 d13

PH 7.35-7.45 7.2 7.3 7.45 7.44 7.4
Pco2 35-45 102 103 69 62 60
P02 75-100 83 52 80 70 81
Hco3 22-26 42 45 36 33 25
Sat o2 >95 % 40 99 98 91 95
Chemistry N 23 24 25 28/4 1/5
Troponin <0.4 o.o19
Hb 12-15 12.8 12.5 11.8 14 12.6

HCT 37-48 42 41 39 44 41
RBC 4.2-5.8 5.4 5.3 5.05 5.9 5.3

MCV 80-100 79 79 78 75 76
WBC 4,3-10(103) 9.8 6.0 6.48 8.9 7.9

Platelets 150-450(103) 243 189 179 224 107

BUN 2.5-7.1 22 33 22 44 22
Creatinin 0.7-1.1 1.38 1.08 1.13 0.96 1.59

k 3.5-5.1 4.3 4.7 4.12 3.82 4

NA 135-145 141 142 142 143 140

C-reactive <3 10.9 8.2 6.6 5.3 5

protein
Final diagnosis
Blood
gases Signs and
Chest x
symptoms
ray

COPD
EXACERBATION
COPD EXACERBATION
 Exacerbations are episodes of increased dyspnea and
cough and change in the amount and character of
sputum.
 Triggered mainly by respiratory viral infections .
COPD EXACERBATION
KEY POINTS FOR THE MANAGEMENT OF ALL
EXACERBATIONS (GOLD 2018):
•Bronchodilators: SABA with or without short-acting
anticholinergics are the preferred bronchodilators
•Systemic corticosteroids: shorten recovery time and hospitalisation
duration, improve lung function (FEV₁) and arterial hypoxaemia (PaO₂);
duration of therapy should be 5−7 days
•Antibiotics: when indicated, can shorten recovery time, reduce the risk
of an early relapse, treatment failure, and hospitalisation duration;
duration of therapy should be 5−7 days
•Methylxanthines: not recommended
•Non-invasive mechanical ventilation: should be the first mode of
ventilation used in COPD patients with acute respiratory failure
COPD EXACERBATION

TREATMENT AT
THE HOSPITAL
D 1 2 3 4 5 6 7 8 9 10 11 12 13
S.M 0.45% 500 900 1000 1500 1000 1000 1000 1000 1000 1000 1000 1000 1000

SOLUMEDROL 40 MG 40 MG 40 MG 40 MG 40 MG 40 MG 40 40 40 40 20 MG 20 MG 20 MG
OD TID TID TID TID TID TID BID BID BID BID BID BID BID

MAXIPIME 1G BID 1G BID 1G BID 1G BID 1G BID 1G BID 1G 1G 1G 1G 1G 1G

BID BID BID BID BID BID

LOVENOX 40 MG 40 MG 40 MG 40 MG 40 MG 40 MG 40 40 OD 40 OD 40 OD 40 OD 40 OD 40 OD
OD OD OD OD OD OD OD

MUCOSOLVANT 75 MG 75 MG 75 MG 75 MG 75 MG 75 MG 75 75 MG 75 MG 75 MG 75 MG 75 MG 75 MG
OD OD OD OD OD OD MG OD OD OD OD OD OD
OD

COMBIVENT NEB 3 ML 3 ML 3 ML 3 ML 3 ML 3 ML 3 ML 3 ML 3 ML 3ML 3ML 3ML 3ML

TID TID TID TID TID TID TID TID TID SOS SOS SOS SOS

SYMBICORT 1 INH 2 INH 2 INH 2 INH 2 INH 2 INH 2 INH 2 INH 2 INH 2 INH 2 INH 2 INH 2 INH
BID BID BID BID BID BID BID BID BID BID BID bid

CONCOR 1 CP 1 OD 1 OD 1 OD 1 OD 1OD 1 OD 1 OD 1 OD 1 OD 1 OD 1 OD 1 OD

SPIRIVA - 18 OD 18 OD 18 OD 18 OD 18 OD 18 OD 18 OD 18 OD 18 OD 18 OD 18 OD 18 OD

FLUDEX 1 TB OD 1 TB OD 1 TB OD 1 TB 1 TB 1 TB 1 TB 1 TB 1 TB 1 TB 1 TB 1 TB 1 TB
OD OD OD OD OD OD OD OD OD OD

PLAVIX 1 TB OD 1 TB OD 1 TB OD 1 TB 1 TB 1 TB 1 TB 1 TB 1 TB 1 TB 1 TB 1 TB 1 TB
OD OD OD OD OD OD OD OD OD OD

Nu-Seals 75 mg 1 tab od 1 tab od 1 tab od 1 tab od 1 tb od 1 tb od 1 tb 1 tb od 1 tb od 1 tb od 1 tb od 1 tb od 1 tb od

(aspirin) od

NEXIUM 40 OD 40 OD 40 OD 40 OD 40 OD 40 40 OD 40 OD 40 OD 40 OD 40 OD 40 OD
OD

ACTRAPID HGT HGT HGT HGT HGT HGT HGT HGT HGT HGT HGT HGT

BIPAP
Evaluation of the treatment
 Oxygen therapy
 Administration of supplemental oxygen should target
a pulse oxygen saturation (SpO2) of 88 to 92 percent or
an arterial oxygen tension (PaO2) of approximately 60
to 70 mmHg .
Evaluation of the therapy
Recommended in
A/E:Bitter taste, tachycardia,
exacerbations, Improve
palpitations, muscle
symptoms, rapid onset of
tremor,hypokalemia
action.

Combivent
Ipratropium/salbutamol
SAMA +SABA

Monitor:blood pressure, heart

Dose : 1 vial (3 mL) q 6 hrs via rate;serum glucose, serum
nebuliser potassium; signs/symptoms of
glaucoma; urinary retention.
Evaluation of the therapy
Recommended in exacerbations,
A/E: hyperglycemia ,hypertension ,
improve symptoms and lung
fluid retention ,hypokalemia,
function, and decrease the length of
hyperlipidemia, ,myopathy.
hospital stay.

Solumedrol
Methylprednisolone

Monitor: Blood pressure, blood

Dose : variable , for 5 to 14 days
glucose, electrolytes; weight.
Evaluation of the therapy
Antibiotherapy
Pseudomonas risk
factors:
• Advanced COPD
• Previous isolation
of Pseudomonas
from sputum
• Concomitant
bronchiectasis
• Frequent
administration of
antibiotics
• Frequent hospital
admissions
• Systemic
glucocorticoid use
Evaluation of the therapy
Recommended in exacerbations, shorten
recovery time, reduce the risk of an early A/E: diarrhea , Superinfection, elevated
relapse, treatment failure, and INR, Neurotoxicity,seizure.
hospitalisation duration

Maxipime
Cefepime
4rd g cephslosporin

Dose : 1-2 g iv q 8-12h Monitor:Monitor renal function. Observe

for signs and symptoms of anaphylaxis
during first dose.
Evaluation of the therapy
A/E: dizziness and blurred vision, glaucoma
Not Recommended in exacerbations,
, Prostatic hyperplasia, Xerostomia.

SPIRIVA
Tiotropium
LAMA

Monitor: anticholinergic adverse reactions ;

Dose : 1 capsule (18 mcg) inhaled once daily
signs and symptoms of narrow angle
using HandiHaler
glaucoma and urinary retention
Evaluation of the therapy
A/E: Nasopharyngitis , oral
Not Recommended with iv
candidiasis, pulmonary
glucocorticoid
infection .

Symbicort
Budesonide/formoterol

Monitorbone mineral density;

Dose : 2 inhalations twice blood pressure, heart rate;
daily CNS stimulation; serum
glucose, serum potassium
Evaluation of the therapy
 Mucoactive agents (MUCOSOLVANT)
 There is little evidence supporting the use of
mucoactive agents in exacerbations of COPD
Drug interactions

Increase
Spiriva Combivent anticholinergic
effect

Combiven Pharmacological
t concor antagonism
Drug interactions

Actrapi
d
Concor Hypoglycemia
Drug interactions
Actrapid

Hypokalemia

Solumedrol Fludex
Drug interactions
Nu Seals

Increased
bleeding
risk

Lovenox Plavix
DISCHARGE SHEET
• SUYMBICORT 320/9 MCG BID
• SPIRIVA HANDIHALER 18 MCG 1 INH OD
• GLUCOPHAGE 850 MG OD
• AMARYL 1MG OD
• FLUDEX 1.5 MG LP I TB OD
• CONCOR 2.5 MG 1 TB OD
• PLAVIX 75 MG OD
• ESOMEPRASOLE 40 MG OD
• NU SEALS 75 MG OD
ADVICES
Smoking cessation Vaccinations Proper use of inhaler

• Nicotine • Influenza vaccine • Inhaler technique

replacement • Pneumococcal needs to be
therapy vaccine(PCV13 and assessed regularly
• Pharmacothraypy: PPSV23)
 varenicline

 Bupropion

 nortriptyline
Inhalational devices
Nebulizers
Advantages:
• Capacity to generate aerosols
using a variety of water-soluble
medications
• lack of requirement for a
proper ‘press and breathe’

Disadvantages:
• Heavy, bulky, and noisy
• Requiring electricity .
• Limited portability
• Require 5–20 minutes
inhalation
• Requirement for scrupulous
cleaning
Inhalational devices
Pressurized metered-dose inhalers

Advantages:
• compact size, portability, low
cost, ubiquitous availability
• repeated consistent drug doses
and short treatment time

Disadvantages:
• Drug suspended will settle
out of the suspension over
time
• Dose-to-dose variability in
drug content
• Advised to shake
• Coordination of actuation
with inhalation
Inhalational devices
Dry powder inhalers

Advantages:
• No need for coordination
• Highly stable, dry, drug powder
formulation.

Disadvantages:
• Relying on patient
inspiratory effort
• lower than optimal flows can
result in substantial
reductions of inhaled dose.
Inhalational devices
Soft Mist inhaler

Advantages:
• Doubled pulmonary drug
deposition relative to a pMDI
• Patients with advanced COPD
who have low peak inspiratory
flow.
Disadvantages:
• Need for coordination
between actuation and
breathing
• Long spray time
References
 Uptodate
 GOLD GUIDELINES 2018