#378 Acute Exacerbations of COPD (AECOPD)

January 23, 2023 | By Cyrus Askin

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Pro Tips & Practical Insights from Dr. Jim O’Brien

Are acute COPD exacerbations taking the wind out of YOUR sails? Join us as we navigate the stormy waters that can be AECOPD with our guest expert,  Dr. Jim O’Brien from National Jewish Health Center.

Show Segments

• Intro, disclaimer, guest bio
• What is a COPD 
• Case from Kashlak – Natalie Harrison
• Knee jerk reaction: Determining level of illness & disposition
• Initial work-up considerations
• What’s in your differential?
• The second-order assessment – shuffling the differential, honing in on the patient
• AECOPD: Triggers & Pathophysiology
• Treatment Pearls I: Steroids
• Treatment Pearls II: Antibiotics
• Treatment Pearls III: Bronchodilators
• Treatment Pearls IV: Oxygen Therapy
• Preparing for discharge
• Take home points
• Lightning Round! Getting to know Dr. O’Brien &  Picks of the Week*
• Outro

AECOPD Pearls

1. An ounce of prevention is worth a pound of cure! Preventing AECOPD is the first step to managing acute exacerbations! Talk to your patients about smoking cessation, appropriate use of inhalers and make sure you have a good idea as to their disease trajectory.
   1. Don’t forget vaccines, specifically for COVID, influenza and pneumonia
2. When approaching a patient with a possible AECOPD, don’t forget about the presence of PE as being a complicating/triggering factor!
3. Consider broad spectrum antibiotics – informed by prior culture data when available – when first admitting a COPD patient. Keep in mind covering for those at risk for or with a history of P. aeruginosa and MRSA 
4. Steroids are recommended in AECOPD – how much, we don’t really know! GOLD recommends 40mg daily for 5 days, while Dr. O’Brien recommends consideration for a higher dose perhaps in sicker patients
5. Oxygen therapy comes in many flavors – heated, humidified high-flow nasal cannula, CPAP and bi-level non-invasive ventilation can all be good options in the right patient. They all can decrease work-of-breathing!
6. Non-invasive ventilation, for home use, has been shown to reduce recurrent exacerbations and decrease mortality in patients with COPD and persistent hypercapnia
7. Discharge planning is critical! Ensure close follow up and intermediate follow up, review medications, consider adjuncts (azithromycin, roflumilast) and pulmonary rehabilitation

AECOPD – Notes

Basics of AECOPD & the Initial Assessment

• What is a COPD exacerbation?
  • Dr. O’Brien tells patients they are having an AECOPD if they have a change in the three “cardinal symptoms” of COPD: Cough, dyspnea, or volume/character of sputum (specifically increased purulence).
    • Often driven pathophysiologically by airway edema at the small-airway level
  • Need for hospitalization = more severe exacerbation
  • What precipitates exacerbations?
    • More than half of patients admitted with AECOPD are found to have an underlying suspected infectious (viral or bacterial) cause
    • Airborne pollutants have been thought to be a possible trigger for AECOPD
    • Gastro-esophageal reflux disease that is left uncontrolled, may also be a trigger
• Initial history & other basic info  is important!
  • Common symptoms include cough, dyspnea, and increased sputum production. 
  • History of smoking, being undomiciled or having a lower socioeconomic status can raise your pre-test probability for AECOPD.
  • Vitals are vital! Does the patient need oxygen?
  • Exam:
    • Wheezing?
    • Accessory muscle use?
    • Paradoxical breathing (chest / abdominal discordance)
    • Dependent edema?
    • Cyanosis?
    • Ask: Is the patient getting tired? 
    • POCUS: Evidence of RV dysfunction/dilation? Evidence of LV dysfunction/failure? Pericardial effusion? Pneumothorax? B-lines (evidence of pulmonary edema)? 
  • Initial Workup:
    • BMP (to assess anion gap, bicarbonate – compared to prior if possible)
    • CBC (anemia?, leukocytosis?)
    • Blood gas (ABG or VBG – primarily to assess carbon dioxide levels) 
    • Chest X-ray (to assess for presence of pneumonia, effusions, etc.)
• BMI matters! The phenotypes colloquially referred to as the “Pink Puffer” and “Blue Bloater” can help frame the illness.
  • The “Pink Puffer” is characterized as having a maintained brain-stem response to hypoxemia & hypercapnia, thus resulting in their body working to maintain normal levels of oxygen and carbon dioxide  which, over the long term, results in cachexia. Hypoxemia and hypercapnia in these patients may be related to an acute decompensation that must be addressed promptly.
  • The “Blue Bloater” usually is overweight or obese, with concomitant sleep apnea, and as a result, has a blunted response to hypoxemia and hypercapnia. When these patients are seen in the ED, their elevated carbon dioxide and hypoxemia are often acute-on-chronic processes indicative of greater physiologic reserve.
• Consider other diagnoses / complicating factors
  • Heart failure
  • Endocarditis / valvular disease
  • Pneumonia
  • Pulmonary Embolism (in some studies 25-30% of AECOPD patients were found to have PE!)
  • Pleural effusions
  • Pneumothorax
  • Iron deficiency anemia vs anemia of chronic disease
  • Hyponatremia (often seen in chronic heart failure and/or SIADH related to lung disease)

Treatment and Management Pearls

• Steroids
  • Benefits: reduce time to next exacerbation, contribute to more swift recovery and limit treatment failures
  • Oral and IV options depending on the patient
  • Can consider inhaled budesonide in those that cannot take systemic steroids
    • 4-8mg, nebulized (very high-dose)
  • Otherwise, Dr. O’Brien explains the literature is very limited regarding approach to steroid use/dose
    • One large study in 2010 demonstrated PO is equivalent to high-dose IV but that study had some limitations based upon data collection
  • Dr. O’Brien will often use methylprednisolone (IV), dosing 60 mg two or three times daily
  • The COPD GOLD guidelines cite 40mg prednisone, oral, for five days but do not elaborate further nor does the guidelines differentiate between different exacerbating patients
  • Do you taper? Dr. O’Brien cites the literature which, generally does not “support” tapering, or longer courses of steroids but also reminds us of the challenges of such studies and the importance of tailoring therapy based upon the patient in front of you
• Antibiotics
  • Not as straightforward as you might think!
  • Dr. O’Brien generally agrees with GOLD, which suggests a benefit for antibiotics in those with worsening of all three “cardinal symptoms” of COPD, worsening of two of these symptoms if one is worsening/more purulent sputum, or those requiring any mechanical respiratory support
  • Dr. O’Brien considers the presence of other forms of lung disease, such as bronchiectasis, when it comes to determining the utility of antibiotics
  • He also strongly recommends reviewing prior culture results to help inform the choice of antibiotic, as well as prior history of antibiotic exposure (specific concerns are for potential P. aeruginosa or MRSA infection)
    • Dr. O’Brien’s risk factors regarding P. aeruginosa: bronchiectasis, history of broad-spectrum antibiotic use, recent hospitalization, chronic steroid use, history of very severe COPD
    • Dr. O’Brien’s risk factors regarding MRSA: history of nasal colonization, recent systemic antibiotic exposure, recent hospitalization, chronic steroid use
  • What to use? If you are treating empirically, Dr. O’Brien recommends consideration of a 3rd generation cephalosporin, or a respiratory fluoroquinolone such as levofloxacin or moxifloxacin, often with azithromycin – likely due to its immunomodulatory effect
  • Don’t hang your hat on a negative sputum culture! Dr. O’Brien suggests that ~50% of cases of pneumonia won’t generate a positive sputum culture, although some studies suggest the yield may be even worse [Musher 2004, Shariatzadeh 2009, Naidus 2018]!
  • Dr. O’Brien recommends tailoring therapy to be broad enough to cover likely pathogens based on patient risk factors, but not unnecessarily broad if such risk factors (known prior resistant respiratory pathogens, repeated hospitalizations, antibiotic exposures, significant structural lung disease, etc.) do not exist
  • Be on the look out for influenza as these patients may be co-infected with MRSA and could benefit from the use of oseltamivir if they present within five days of initial symptoms
• Bronchodilators
  • No great, high-quality data for short-acting bronchodilators in AECOPD, however, they are used by convention
  • Home inhalers: Dr. O’Brien states that continuing long acting medications is often reasonable as it can keep patients in a rhythm with their medication regimen
    • Be on the lookout of excessive antimuscarinic activity that can contribute to issues such as urinary retention
• Oxygen Therapy
  • You do, indeed, need oxygen to live!
  • Nasal cannula, oxymask and non-rebreather provide supplemental oxygen without physiologic assistance – can be used when work-of-breathing is of less concern
  • Consider targeting 88-94% to provide adequate oxygenation while mitigating the Haldane Effect (The greater the oxygen tension in the the blood, the greater hemoglobin’s affinity is for oxygen, and the lower it’s affinity is for carbon dioxide, contributing to carbon dioxide retention)
  • High-flow nasal cannula and non-invasive positive pressure ventilation provide both supplemental oxygen & physiologic support
    • Dr. O’Brien is a big fan of heated, humidified, high-flow nasal cannula which when appropriately used can decrease work of breathing
    • In those patients that are “sicker” there is good-quality data regarding non-invasive positive-pressure ventilation in AECOPD as a means to treat respiratory failure
      • Dr. O’Brien states that positive pressure support does not have to be bi-level – CPAP can also decrease work of breathing, but may not be optimal for hypercapnic respiratory failure
  • Dr. O’Brien recommends the following for monitoring patients on non-invasive
    • Watch the patient closely, check in with them frequently: Are they tiring out?
    • Is the patient’s blood gas improving or have they gotten worse / stagnated? 
    • Consider moving a patient to the ICU if they are holding their own, but not improving, on bi-level, where nursing/respiratory therapy ratios may be more advantageous for a patient “on-the-fence”
• Discharge Planning
  • Providing noninvasive positive pressure ventilation upon hospital discharge, in those with persistent hypercapnia has been shown to reduce time to readmission or death
    • Hospital systems and patient demographics can admittedly make this challenging
  • Dr. O’Brien reminds us that the goal with home non-invasive support is to normalize the carbon dioxide and reverse the compensatory metabolic alkalosis
  • Hospital follow up, per GOLD, should occur within 1-4 weeks of discharge and again between 12-16 weeks post-discharge
  • Pulmonary rehabilitation (PR) should be consider upon discharge and has been shown to be safe following AECOPD
    • There is also a signal for reductions in mortality and readmissions when PR is used following AECOPD
  • Consider adjunct therapy with roflumilast as a means to improve lung function and reduce exacerbations – especially in those with chronic bronchitis
    • Caution: Diarrhea, nausea, loss of appetite, abdominal pain, and headache
  • Consider adjunct therapy with azithromycin following AECOPD as a means to improve quality of life and reduce exacerbation frequency
    • Caution: QT prolongation, hearing-loss
    • Do not use in patients with NTM (azithromycin monotherapy breeds resistant NTM organisms)
    • Dr. O’Brien recommends caution with azithromycin in patients with non-tuberculosis mycobacterium infections as this can breed significant resistance

Links

1. Officer “Big-B” and the Fort Worth, TX Police Recruitment Video (link)
2. High Noon Hard Seltzers (beverage)

Scar Tissue by Anthony Kedis (book)

Goal

Listeners will develop a multi-faceted, logical approach to managing acute exacerbations of COPD in the in-patient setting.

Learning objectives

After listening to this episode listeners will… 

1. Develop an approach to evaluating a patient with possible AECOPD
2. Recognize risk factors for AECOPD, specifically socioeconomic risk factors that may not be focused upon traditionally
3. Appreciate the triggers, complicating factors associated with AECOPD
4. Develop a coherent work up when admitting a patient with suspected AECOPD
5. Survey the various categories of treatment for AECOPD – understanding indications, contraindications and the supporting evidence
6. Review the importance of hospital discharge and close follow up

Disclosures

Dr. O’Brien reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Askin CA, O’Brien J, Amin A, Trubitt, M. “#378 Acute Exacerbations of COPD (AECOPD)”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list January 23rd, 2023.