COPD Exacerbations

UCI Internal Medicine Mini-Lecture

Slideset updated 12/03/2012 by

Michael Rochon-Duck
 A Tale from the ED
“I have an easy admission for you. 70-year-old
active smoker with severe COPD, progressively
short of breath for three days. Frequent flyer, was
here last month with the same complaints.
He’s afebrile and tachypneic, with wheezes
and poor air movement on both sides.
His chest film shows bilateral pneumonia, so I
started ceftriaxone and azithromycin. I gave him
Solumedrol and nebs, and he looks a little better.”
 Objectives
1. Formulate a differential and workup for an
acutely dyspneic patient with COPD

2. Choose appropriate initial therapy and

anticipate complications

3. Plan for discharge to reduce readmissions

Differential
 Precipitants of Exacerbation
Acute bronchitis caused Three other potentially
by: fatal precipitants:
1. Viruses
2. H. influenzae 1. Heart failure
3. Moraxella catarrhalis 2. Pneumonia
4. Strep. pneumoniae 3. Pulmonary embolism
5. P. aeruginosa
CXR #1: COPD Suddenly Got Worse
CXR #2: COPD Exacerbation & Edema
 Initial Interventions
1. Bronchodilators: Duoneb q4h scheduled around-the-
clock.

2. Steroids: oral prednisone (after first dose IV

Solumedrol in ED) if the patient can swallow. Check
fingerstick blood sugars.

3. Oxygen: caution! Titrate to SaO2 90-93% in advanced

COPD to avoid hypercapneic respiratory failure

4. Antibiotics …
Choosing Antibiotics
Consider Ventilation For …

• Intractable dyspnea

• Worsening hypercapnea

• Refractory hypoxia
 Discharge Planning
1. Optimize the patient’s inhaler regimen

2. Assess eligibility for home oxygen and

pulmonary rehabilitation

3. Smoking cessation

4. Followup with PCP in 10-14 days

 A Tale from the ED, Revisited
“I have an easy admission for you. 70-year-old
active smoker with severe COPD, progressively
short of breath for three days. Frequent flyer, was
here last month with the same complaints.
He’s afebrile and tachypneic, with wheezes
and poor air movement on both sides.
His chest film shows bilateral pneumonia, so I
started ceftriaxone and azithromycin. I gave him
Solumedrol and nebs, and he looks a little better.”
 Summary
1. Think of heart failure, pneumonia, and
pulmonary embolism in the differential of all
cases of COPD exacerbation (although viral
respiratory infections are more common)

2. Treat with bronchodilators, systemic

glucocorticoids, oxygen, and antibiotics

3. Reevaluate diagnosis and consider ventilation

for declining respiratory status