Inpatient, Outpatient, ICU Management Options For COPD Exacerbations

The treatment and management of an acute exacerbation of chronic obstructive pulmonary disease (COPD) first require that the diagnosis of the flare-up be firmly established. It makes it easier for the physician if the patient has already been diagnosed as a COPD case.

There are a host of treatment options and the list of medicines are mostly the same with varying doses for outpatient treatment, inpatient treatment and  for those admitted to the intensive care unit.

Patients requiring outpatient treatment are managed with short-acting and/or long-acting bronchodilators, corticosteroids such as prednisolone, and antibiotics such as doxycycline (if infective). Hospitalized patients will require oxygen therapy as the first line of treatment in addition to the above. Those admitted to the ICU will, in addition, require noninvasive ventilation (NIV) or mechanical ventilation.

Effective treatment of a COPD exacerbation aims to relieve the acute symptoms, prevent further deterioration of lung function and a revaluation of the disease to reduce the risk of further flare-ups.  The 8-week period after an initial exacerbation is a high-risk period for recurrence.

About 50% of exacerbations are not reported, which means that these flare-ups have mild symptoms. Those that are reported, are treated either on an outpatient basis or require hospitalization. In the hospital, the more severe cases may require treatment in the intensive care unit.

Indications for hospitalization

A COPD exacerbation is classified according to its severity. A mild or level 1 case can be treated at home with the same COPD treatment by increasing the doses of the medicines.

Moderate or level 2 cases require admission. The physician takes the call and will advise based on his clinical assessment.

Severe or level 3 cases will again require hospitalization. The criteria for hospital admission are that the patient is in respiratory distress or is at the risk of it. Secondly, the presence of any comorbidity such as the COPD complications makes a strong case for hospital admission. Thirdly, the need for ventilator support may require admission to the intensive care unit.

The first step in the management of a COPD exacerbation is to keep the patient away from lung irritants such as dust, smoke, cooking aromas, cigarette smoke including second-hand smoke. Reading the causes and risk factors that can lead to an exacerbation will be useful.

Goals of treatment

Treatment with medicines aims to make the patient’s breathing more comfortable and effortless.  It also aims to reduce the inflammation and the infection due to bacteria and viruses in the lower airways. Thirdly, it aims at treating hypoxemia with oxygen therapy. Lastly, preventing further exacerbations is important in view of the fact that every exacerbation causes significant lung damage.

Mild cases can be treated on an outpatient basis. The moderate to severe exacerbations need hospitalization. The severity of an exacerbation is judged by the following parameters:

  • Pulse oximetry
  • Arterial blood gases
  • FEV1 results by spirometry

 Outpatient management of mild COPD exacerbation

A mild or level 1 COPD exacerbation usually does not need admission and can be managed at home. Choices of drugs include:

Bronchodilators

Bronchodilators are drugs that open up the narrow and clogged airways. They form an essential part of treatment. The first step in outpatient management is to increase the dosage of inhaled short-acting bronchodilators, which the patient was already taking in his stable condition.

According to their mode of action, they are classified as short-acting and long-acting bronchodilators.

Pharmacologically, they are classified into anticholinergics, β2-agonists, and theophylline. The latter is rarely used due to its side effects. Bronchodilator therapy in COPD mainly rests with the former two drugs. The inhalable forms are typically used for quick relief. Inhalers or nebulizers can be used.

If the patient is already taking short-acting anticholinergic bronchodilators (e.g., ipratropium [Atrovent]) for his COPD treatment, its dose should be increased and, in addition, β2-agonists may be required to be added.

Inhaled short-acting β2-agonists are the preferred bronchodilators for both outpatient and inpatient management of exacerbations. Albuterol is preferred due to its lower cost and equal efficiency when compared with levalbuterol.

If the patient is already on a short acting Beta agonist,  (e.g., albuterol, levalbuterol [Xopenex]), increase its dose.

Research indicates that adding a long-acting anticholinergic to a β2-agonist (ipratropium and albuterol) work synergistically and improve the quality of life of COPD patients by relieving the dyspnea and increasing exercise tolerance as compared to using β2-agonists alone.

Recommended doses of inhaled bronchodilators:

  • Albuterol 2.5 mg nebs four times a day or 2 puffs four times a day by metered inhaler with or without a spacer when stable
  • and/or ipratropium 0.25-0.5mg inhaled three or four times  day as required .

Antibiotics

Antibiotics are advised when the sputum is purulent indicated by its yellow or green color. This discoloration is a sign of infection in the airways. Mild exacerbations usually do not require antibiotics due to the absence of infection. In severe cases, antibiotic therapy becomes essential for infective exacerbations or when bronchodilators and steroids do not give relief. Antibiotics play a big role in avoiding treatment failure.

Narrow spectrum antibiotics are first given. If they do not work, broad-spectrum antibiotics are prescribed.

  • Narrow spectrum antibiotics include amoxicillin, ampicillin, trimethoprim/sulfamethoxazole, and doxycycline
  • Broad spectrum antibiotics include a combination of amoxicillin/clavulanate, second- or third- generation cephalosporins, or quinolones

For outpatient patients or those admitted to the hospital, antibiotic selection if required is optimally made based on the results of gram stain sputum culture.

Commonly used antibiotics and their doses:

  • Amoxicillin 500-875mg orally three times a day
  • Doxycycline 100mg orally twice daily
  • Duration: 10 to 14 days

Corticosteroids

Oral corticosteroids are advised along with antibiotics and bronchodilators especially in patients with purulent sputum. Steroids have a strong anti-inflammatory action and help to improve the airflow limitation.

If FEV1 (through spirometry) is less than 50% predicted, use oral prednisone 30-40 mg/day for 7-10 days or budesonide through a nebulizer.

Mucolytic

If you are coughing out a lot of mucus, which you are finding difficult to expectorate, your doctor may prescribe you a drug called a mucolytic. It comes in a tablet or liquid form and makes the mucus thin and easy to cough out.

Hospital management

Patients admitted to a hospital for a COPD exacerbation are the more severe cases and need a more aggressive approach to treatment.  Inpatient mortality of patients with COPD exacerbations is 3 to 4 percent. Patients admitted to the Intensive care unit have a 43 to 46 percent risk of death within the first year after hospitalization.

The indications for hospital admission are:

  • Development of respiratory acidosis as indicated by its initial symptoms such as a headache, anxiety, blurred vision, restlessness, and confusion
  • Presence of complications and comorbidities
  • Need for ventilator support

 Oxygen therapy

If the patient has been advised hospitalization, he is likely with a moderate or serious exacerbation and will require oxygen therapy.

Patients with saturation PaO2 less than 60 mm Hg can be given oxygen through a nasal cannula or oxygen face mask. This will take care of the hypoxemia and reduce the mortality risk.

  • Administer oxygen at 2 to 4 liters per minute through a nasal cannula;
  • Maintain oxygen more than 91% measured by the pulse oximeter . If needed increase oxygen dose.
  • If PCO2 is more than 45, give oxygen through a Venturi mask.

Higher O2 administration increases the risk of respiratory failure. Therefore, close monitoring is essential.

Bronchodilators

Start patient on inhaled anticholinergic bronchodilators such as Ipratropium. Increase dose if necessary.

If there is no relief even after increasing the dose of the Ipratropium, add β2-agonist to anticholinergic bronchodilators. If required, the dose of β2-agonist , too, can be increased for better relief. They improve the dyspnea and increase exercise tolerance.

Aminophylline/theophylline should be avoided due to serious side effects.

Antibiotics

Broad spectrum antibiotics are used if there is no relief with narrow spectrum antibiotics. Use of antibiotics kills the infection, decreases the risk of treatment failure and mortality.

Admitted patients are those with severe exacerbations. Stronger antibiotics become necessary. Usually, the following fourth-generation synthetic fluoroquinolone antibacterials  are preferred.

  • Moxifloxacin: dose 400mg once daily for 5 days
  • Levofloxacin: dose 500mg or 750mg PO once daily for 7 days

Choosing Azithromycin

Maintenance therapy with Azithromycin significantly decreases the frequency of the exacerbations. The higher strength of this antibiotic given over a shorter period of time has advantages and should, therefore, be considered for use in COPD patients who have frequent exacerbations.

Though considered quite safe, the only drawback is its side effect of causing malignant arrhythmia, which can cause sudden cardiac death.

However, the risk of cardiovascular death associated with azithromycin long-term prophylactic therapy in COPD patients is reported to be 1 in 20,000.

Viral infection, especially due to the influenza virus will require anti viral therapy.

Corticosteroids

Corticosteroids are necessarily given to hospitalized patients. Oral tablets can be used. If the patient is unable to tolerate them due to reasons such as GERD, intravenous steroids can be given.

Use of steroids decreases the risk of further exacerbations, treatment failures, and length of hospital stay. It also improves breathing, FEV1, and hypoxemia. Long-term steroid therapy, when given, has to be stopped by gradually tapering the doses .

  • Methylprednisolone 125mg IV 6 hourly for 3 days then reduce the dose to
  • Oral prednisone 60mg daily for 4 to 7 days,
  • followed by 40mg daily for 8 to 11 days and finally,
  • 20mg daily for 12 to 15 days

COPD exacerbation management in ICU

 If the patient exhibits symptoms of respiratory acidosis, he needs admission to the intensive care unit with a 24-hour monitoring of his vital signs.

In addition to the treatment given in the hospital rooms, he will require respiratory assistance with noninvasive positive pressure ventilation (NIPPV), simply called non-invasive ventilation (NIV). If the desired blood gas levels are not achieved  with NIV,  he will require mechanical ventilation –- meaning he will be intubated with an endotracheal tube and put on a ventilator.

Noninvasive Positive Pressure Ventilation (NIPPV)

NIPPV is indicated in patients with worsening respiratory acidosis and persisting hypoxemia when oxygen therapy via nasal cannula or high-flow oxygen mask becomes inadequate.

NIPPV improves respiratory acidosis, normalizes respiratory rate, improves breathlessness, avoids the need for intubation, reduces the mortality, and length of hospital stay.

Mechanical ventilation

Mechanical ventilation is indicated when:

  • The patient cannot tolerate NIPPV
  • Continues to have a progressively worsening hypoxemia, respiratory acidosis, altered mental state , hypercapnia despite NIPPV
  • Has comorbid conditions such as a heart attack or sepsis

COPD exacerbation emergency treatment

Treatment options provided in the Emergency Department include:

Oxygen therapy

Oxygen is the first line of treatment that is administered to the patient of a COPD exacerbation during an emergency that can ease the symptoms. It will help raise the oxygen blood levels, which should be checked by doing the arterial blood gas (ABG) test. The results will also help with the proper titration dose of the oxygen. Venturi masks are better to control the oxygen flow than nasal prongs

Steroids

Systemic steroids, preferably I.V. prednisolone,  is started and given for the first three days followed by oral tablets gradually reducing the doses over the next days.

Antibiotics

Antibiotics, preferably Moxifloxacin or Levofloxacin by intravenous route will help fight the infection on an SOS basis

Bronchodilators

Short-acting bronchodilators are used during an emergency for rapid relief. Start patient on inhaled anticholinergic bronchodilators such as Ipratropium. Add β2-agonistsuch such as Albuterol to  the anticholinergic bronchodilators. Doses can be increased as required.

Outcomes

Once the emergency department has treated the patient’s symptoms, the doctor will decide if the patient is to be discharged with orders or needs admission.

When does a patient qualify for discharge?

A patient with COPD exacerbation admitted to a hospital qualifies for discharge when he fulfills the following conditions:

  • Stable clinical symptoms
  • Fairly normal vital signs
  • Arterial partial pressure of oxygen of more than 60 mm Hg for at least 12 hours
  • Does not require a short-acting bronchodilator (eg. Albuterol) more often than every four hours

Advice on discharge

  • Smoking cessation
  • Avoid all types of lung irritants
  • Immunization against influenza every year and pneumonia once only
  • Pulmonary rehabilitation  program to reduce risk of further exacerbation
  • Long-term oxygen therapy
  • Regular use of inhaled bronchodilators
  • Inhaled corticosteroids as and when necessary
  • Patients who are non-ambulatory should receive prophylactic deep venous thrombosis treatment.

 

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