A Brief Synopsis of: AFP's "Management of COPD Exacerbations"

A brief synopsis of: Management of COPD Exacerbations
ANN E. EVENSEN, MD, University of Wisconsin School of Medicine and Public Health, Verona, Wisconsin
Am Fam Physician. 2010 Mar 1;81(5):607-613
http://www.aafp.org/afp/2010/0301/p607.pdf

     Proper management of COPD can really help the quality of life in a suffering patient.  Exacerbations can be caused by infection, tobacco smoke. occupational exposure or ozone. There are many times when the  cause cannot be identified. Symptoms of an exacerbation are most commonly cough, dyspnea, and  increased sputum production. Other symptoms such as tachycardia, confusion, wheezing, fatigue and fever are just a few.  COPD exacerbations can be classified into three stages of severity. Mild exacerbations can be controlled by increasing the dosage of medication. Moderate exacerbations require treatment with antibiotics or systemic steroids. Severe exacerbations require hospitalizations, or a least a trip to the ER.
     When evaluating a patient for an exacerbation, taking a proper history, previous chest x rays, ABGs and spirometry will help to determine baseline function. All patients should have a pulse oximetry, ABG, chest x ray, BNP, and cardiac enzymes ordered when they arrive to the ED. A CBC, echo, and BMP can be considered depending on the severity.  If the patient is in, or at risk of, respiratory distress, hospitalization should be considered.
     The patient should have an oxygen saturation over 90%. If oxygen supplementation through cannula or high flow mask is not adequate, NIPPV can be used. If the pH is less than 7.36 and the CO2 is greater than 45 mmHg  on ABG, the patient needs to be intubated. 
   The medications used for a COPD exacerbation are beta agonists (long acting) and anticholinergics. The medication most commonly used are albuterol and ipratropium. Combivent is a "combo" of both of these medications. Short courses of corticosteroids can help by shortening hospital stay, improving hypoxemia, increasing FEV1, and decreasing rate of treatment failure. There is no benefit of using corticosteroids for longer than two weeks compared to eight weeks, and treatment is the same regardless if the medication is oral or parenteral.
     Antibiotics can be used if the patient is not getting better with the above therapy and the exacerbations are of moderate or severe intensity. Broad spectrum antibiotics that correlate with local resistance patterns should be chosen. The length of time the antibiotic should be give is unclear, but long term prophylaxis has not been shown to be effective. Commonly used antibiotics are cephalosporins, quinolones and macrolides.
     The patient may be considered for discharge if they do not need albuterol more frequently than every 4 hours, their oxygen partial pressure on the ABG is above 60 mmHg for 12 hours, and they are clinically y stable. Patient education, at home support (oxygen, nebulizers), and close follow up should be in place upon discharge.