COPD Exacerbation - Hospital

Tobacco Dependence.

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Offer Nicotine Patch upon hospital admission.

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An opportunity to quit smoking.

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HPI questions for the diagnosis of COPD exacerbation

😟 3 CARDINAL SYMPTOMS:

-Increased sputum production, increased dyspnea, or change in sputum color?

😟 Increased baseline cough or new cough?

😟 Wheezing? Fatigue/decrease in ability to perform activities (walk, bathe, etc)?

🚬 # of smoking pack years and if still smoking? or second hand smoke exposure?

⛔ Noncompliant with inhalers?

😟 How many prior COPD exacerbations and did they need hospitalization? Intubation?

😟 Use of oxygen at home and if needing higher amount of oxygen than baseline?

😟 URI symptoms: Sore throat? Nasal congestion? Sick Contacts

What to look for on PHYSICAL EXAM

• Paint the picture: Tripod position, Labored or unlabored breathing, Speaking shorter sentences, Tired appearing, Accessory muscle use
• Wheezing: either Expiratory or both Inspiratory & Expiratory (both usually indicates more severe exacerbation).
• Prolonged expiratory phase, poor air movement (breath sounds are diminished)
• DDx: Crackles for PNA, Edema for CHF/PE, Murmurs
• Be sure to have them take big, deep breath cause they often take shallow breaths and so you won’t hear much.
• Severe exacerbations might not have much air movement cause the lungs are super tight so might not hear wheezing until they start to improve & expand lungs more.

Differentials and Causes of COPD exacerbations? 🐔 or 🥚

How to diagnose COPD flare in the hospitalized patient if no prior history

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The DIAGNOSIS during an exacerbation is mainly clinical:

• Risk factors (hx of smoking/second-hand smoke, occupational or environmental fume/dust exposures?)
• Chronic cough often with sputum (usually worse in morning), dyspnea
• Wheezing on exam, prolonged expiratory phase
• Imaging studies: flattening of diaphragm or emphysematous changes
• Absence of an alternative diagnosis

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After acute episode improves, SPIROMETRY = gold standard for dx.

R.T. can sometimes perform in hospital if needed

Diagnostic studies

✅ ABG if meeting Resp Failure criteria or labored breathing or encephalopathic or pulse ox <88%

-If low pH, then repeat ABG after a couple hours to assess response to treatment

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✅Troponin x3, daily BMP and CBC, Respiratory Pathogen Panel swab, Influenza swab if in season, Consider if suspicious for PE or PNA: D-dimer, procalcitonin, blood culture x2. BNP if concern for concomitant CHF exacerbation.

✅ Vitamin D-25 level (severe deficiency needs replacement as it has been shown to reduce exacerbations).

✅ CXR 2-views

✅ EKG

✅ Echo

Consider CT chest with or without contrast (ILD, tumors, PNA not showing up on CXR)

Consider CT Angio Chest (PE, Aortic aneurysm/dissection)

When to suspect if it’s NOT just COPD exacerbation?

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Does your history, exam, and diagnostics support the diagnosis of COPD exacerbation? Does it all fit the picture and make sense?

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If significant hypoxia/tachypnea BUT lung exam and CXR are fairly normal, then COPD would not account for the significant hypoxia. Consider other DDx.

Treatment of Inpatient COPD exacerbations

The GOLD Guidelines for COPD

is your main reference that’s updated yearly

CORE TREATMENTS

• Oxygen
• Magnesium IV
• Systemic Steroids
• Nebulizers/Inhalers
• Antibiotics
• Prevention

Tx of COPD exacerbations: Nebulizers + Magnesium

Nebulizers: Albuterol TID neb + Ipratropium neb TID + Budesonide neb BID. With Covid patients, inhalers are preferred to reduce spread.

Give Magnesium 2G IV x1 over 20 mins (bronchodilator effect and associated with reduced hospitalization/length of stay)

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Use the hospital COPD protocol order set:

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Tx of COPD exacerbations: Systemic Steroids

IV or PO?

Equal in efficacy, but in more severe exacerbations give IV.

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High or Low dose?

If going to ICU, it’s reasonable to give methylprednisolone 60mg IV q6-8hrs. If less severe, studies suggest equal outcomes using lower dose steroid options: prednisone 40mg PO QD, dexamethasone 6mg PO/IV QD, or methylprednisolone 40mg IV QD.

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Longer or Shorter duration?

Studies suggest using shorter duration of 5 days

for exacerbations as efficacy is similar to longer durations of 14+ days.

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No need to taper if course is shorter than 3 weeks as adrenal atrophy is unlikely to occur that quickly. If 3 or more weeks, then need to taper to avoid adrenal crisis.

Tx of COPD exacerbations: Antibiotics if no signs of infection?

It’s reasonable to give antibiotics for all patients admitted to hospital for COPD exacerbations.

The GOLD guidelines suggest using the cardinal symptom criteria for antibiotics:

1) change in SPUTUM COLOR

3 CARDINAL SYMPTOMS 2) increased sputum production

3) increased dyspnea

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💊 Give antibiotics if ALL THREE cardinal symptoms are present.

💊 Give antibiotics if there is a change in SPUTUM COLOR (PURULENCE) AND if one of the two: increased sputum production or dyspnea.

💊 Give antibiotics if patient is intubated or ICU level of care.

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If you suspect PNA, then must start standard inpatient PNA antibiotics.

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Which antibiotic to give for COPD exacerbations without PNA?

This is UNCERTAIN. One approach: Does patient have prior isolated culture of Pseudomonas, OR severe COPD (use of chronic oxygen, bronchiectasis, frequent/chronic systemic steroid use), OR exposure to broad spectrum IV antibiotics in the past 3 months?

Order sputum gram stain/culture while empirically starting ONE of the following antipseudomonal abx for 5 days:

• Piperacillin-Tazobactam 4.5g IV q6hrs
• Cefepime 2g IV q8hrs
• Ceftazidime 2g IV q8hrs.

Narrow down the antibiotic as soon as possible based on culture results (if no growth on culture or only resp flora then downgrade antibiotic).

NO sputum culture, and start standard therapy with ONE of the following for 5 days:

• Levofloxacin 500-750 mg IV/PO QD
• Azithromycin 500mg IV/PO QD x 3 days if local Strep PNA resistance patterns are <25%
• Ceftriaxone 1g IV QD

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Augmentin 875/125mg PO BID is another option. Doxycycline has been tested for COPD flares with conflicting data on effectiveness.

YES

NO

Assessing Improvement and Criteria for Discharge

🏡 Improvement in symptoms (cough, dyspnea, phlegm, DOE, energy, etc).

🏡 Improvement in exam (less wheezing, better air movement, speaking longer sentences).

🏡 Needing less supplemental oxygen each day and hopefully off NC oxygen if they don’t usually need it or back to their baseline oxygen level.

🚶 Able to walk independently or with walker. Order Physical Therapy evaluation to see if patient can demonstrate good mobility or if need SNF placement.

🏡 May need short term NC oxygen at home until their exacerbation improves more. Generally, this should only be done if they are needing ≤ 2 L/min NC oxygen, or if desatting with exertion. Otherwise, they might not be ready to go home yet.

What to do if not improving after 72 hours

• Order CT Chest without contrast (or CT Angio chest if elevated D-dimer).
• Consult Pulmonologist.
• Consider ID consult and sputum culture/gram stain (consider acid-fast stain for MAC).
• Reassess if any other contributing factors: CHF, CAD, PNA, PE, heart valve dz, etc.
• If severe and still ICU/high oxygen demand, then could continue steroids for up to 10-14 days and then stop or taper (pulmonologist will guide this).
• If chronic, end-stage with recurrent exacerbations then consult palliative care team or have a goals of care discussion.

Discharge Inhalers

• Once daily inhalers are preferred for better compliance (if covered/affordable).
• Nebulizer is beneficial for most (w/ albuterol + ipratropium), especially if too elderly to coordinate the breath needed for inhalers.
• Respimat inhalers are preferred for elderly as they need less coordination for effectiveness.
• Ideally: LAMA+LABA or LAMA+LABA+ICS if blood eosinophils ≥300 cells/µL

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Inhalers are expensive so verify if covered by their insurance and if copay is affordable.

Prevention of Exacerbations

• Give upon discharge: PNA 20 or 23+13 vaccine and Flu vaccine (if in season).
• Recommend: Covid vaccines
• Pulmonary Rehab referral or if rehab not available then light exercise 2-3 times per week for 30 mins.
• F/u appointment within a week of hospital DC with PCP or Geriatric high risk clinic.
• Smoking cessation (offer nicotine patch on hospital admission and discharge)
• Preventative measures: Mask wearing, frequent hand washing, and minimizing social gatherings

Speak Medicare: DOCUMENTATION

“COPD Exacerbation” is the minimum diagnosis you need.

ADD other related diagnoses in your Plan and DC summary if meeting criteria:

-ACUTE HYPOXIC RESPIRATORY FAILURE DUE TO COPD exacerbation

-Acute Resp Failure criteria: At anytime, Pulse ox <92%, or pO2 <60, or pCO2 >45 (hypercapnic) AND requiring ≥4L oxygen via NC, or >24% FiO2 (masks or HFNC), or BiPAP, or Intubation.

-ACUTE ON CHRONIC HYPOXIC RESPIRATORY FAILURE DUE TO COPD exacerbation (if on home oxygen)

-RESPIRATORY ACIDOSIS DUE TO COPD exacerbation (seen on ABG)

-HYPOXIC ENCEPHALOPATHY DUE TO COPD (if confused on admission OR if you note their mentation has improved with treatment of COPD which indicates there was encephalopathy present on admission).

-Acute Myocardial Injury OR Type 2 MI OR Chronic Myocardial Injury DUE TO COPD (if elevated trops)

-TOBACCO DEPENDENCE (“Use Disorder” might not be recognized by Medicare yet)

“Acute Respiratory Distress/Insufficiency” is NOT recognized by Medicare.

References

-GOLD GUIDELINES REPORT: https://goldcopd.org/2022-gold-reports-2/

-Chronic Obstructive Pulmonary Disease (COPD), Zab Mosenifar, MD https://emedicine.medscape.com/article/297664-overview

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-Acute exacerbation of COPD (AECOPD). May 19, 2020 by Josh Farkas. https://emcrit.org/ibcc/aecopd/

-COPD Exacerbations: Management. James K Stoller, MD, MS. https://www.uptodate.com/contents/copd-exacerbations-management#H12

Pictures from various sources:

https://www.med.umich.edu/1info/FHP/practiceguides/InptCOPD/COPD.final.pdf

https://www.nejm.org/doi/full/10.1056/NEJMvcm2035240

http://www.louisvillelectures.org/the-ll-blog-1/2021/oxygen-devices

https://rk.md/2020/oxygen-therapy-systems/

https://www.grepmed.com/images/9034/management-comparison-devices-flow-delivery

https://opencriticalcare.org/resources/oxygen-delivery-device-graphics/

https://www.medscape.com/viewarticle/928524

COPD Admit Orders (for reference only)

Admit to: Inpatient Telemetry for most. If only mild exacerbation then consider observation telemetry.

ICU criteria: if needing HFNC, Bi-Pap, or Intubation, OR if severe respiratory distress or lethargic/encephalopathic, OR if pH remains <7.35 despite initial treatments, OR hypotensive.

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Vitals: continuous pulse oximetry, keep NC oxygen 88-92% (USE COPD ADMIT ORDER SETS).

Diet: regular (unless other comorbid conditions needing specific diet).

Activity: as tolerated, order P.T. evaluation for early mobilization.

Fluids: none (saline lock), unless NPO or not tolerating PO intake

Labs: ABG if meeting Resp Failure criteria or labored breathing or encephalopathic or pulse ox <88% (and if low pH, then repeat ABG after a couple hours), Troponin x3, daily BMP and CBC, vitamin D-25 level, Respiratory Pathogen panel swab, Influenza swab if in season. Consider if suspicious for PE or PNA: D-dimer, procalcitonin, blood culture x2. BNP if concern for concomitant CHF exacerbation.

Diagnostics: CXR, EKG, consider CT chest if new diagnosis or recurrent flares

Meds: Use COPD order set (Nebs: albuterol, ipratropium, and budesonide), Prednisone/Methylprednisolone 40mg IV/PO QD x5-7 days or Dexamethasone 6mg IV/PO QD x5-7 days, Levofloxacin 500mg PO/IV QD x5-7 days or Azithromycin 500mg PO/IV QD x3 days, Magnesium 2G IV x1, Nicotine patch, DVT prophylaxis (Lovenox 40mg SQ QD)

Consults: Pulmonology if needing >5L oxygen, significant or persistent Acidosis on ABG, Encephalopathy/lethargy, continued labor breathing despite initial tx, unclear diagnosis, or other signs of impending need for intubation.

Indications for hospital admission (for reference only)

• Worsening/lack of improvement with outpatient treatments
• Encephalopathy/Lethargy
• Worsening hypoxia/hypercap or increased oxygen demand compared to baseline
• Not tolerating PO or inhaler medications
• Not improving with ER treatments
• Comorbid, high-risk conditions: CHF, PNA, ESRD/CKD, Cirrhosis, fragile elderly patient
• Poor social resources and inability to follow up.

Tx of COPD exacerbations: Low Flow Oxygen therapy

Nasal Cannula (NC) oxygen

(1-6 L/min, 24-50% FiO2)

Simple face mask

(5-10 L/min, 35-60% FiO2)

Venturi-mask oxygen

(2-15 L/min, 24-50% FiO2)

Non-rebreather mask

(10-15 L/min, 60-90% FiO2)

Keep the patient’s pulse ox level 88-92%, accept up to 95%

Oxymizer (reservoir that makes NC more efficient)

Respiratory Therapist will help decide which device to use

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Tx of COPD exacerbations: High Flow Oxygen therapy usually in ICU

High Flow Nasal Cannula (HFNC)

(15-60 L/min, FiO2 30-100%)

R.T. and Pulmonologist will usually manage the settings

BiPAP

(Bi-Level: Inspiratory & Expiratory

Positive Airway Pressure support)

Intubation