Managing Acute Exacerbations of COPD

Alla Marks, PharmD, MBA

US Pharmacist. 2009;34(7):HS-11- HS-15.

Introduction

Exacerbations are an important outcome measure in chronic obstructive pulmonary disease (COPD) due to their profound effect on the patient's quality of life and prognosis. It has been estimated that patients with COPD suffer one to four exacerbations per year, and up to 70% of the direct health care costs associated with the disease are due to severe exacerbations, particularly those requiring hospitalization.^[1,2] Less than one-third of exacerbations are reported, and although some may not be serious enough to warrant an emergency visit or hospitalization, they have been shown to have an important impact on the patient's health status.^[3] Exacerbations are not random events but cluster together in time such that there is a high-risk period for recurrence in the 8-week period after an initial exacerbation.^[4] They also become more frequent and severe as the severity of the underlying COPD increases and contribute to further impairment in lung function.^[5]

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Cite this: Managing Acute Exacerbations of COPD - Medscape - Jul 01, 2009.

Table 1. Indications for Hospitalization
Indications for Hospitalization
Hospital Room
Marked increase in symptom intensity^a
Severe COPD
Onset of new physical signs
No response to outpatient management
Significant comorbidities^b
Frequent exacerbations
Diagnostic uncertainty
Older age
Insufficient home support
Intensive Care Unit
Severe dyspnea not responsive to emergency therapy
Changes in mental status
Hypoxemia, hypercapnia, and/or acidosis despite supplemental oxygen and NIV
Need for invasive ventilation
Hemodynamic instability

^aSputum changes, dyspnea, chest tightness, malaise, fatigue,
decreased exercise tolerance, fever, wheezing, decreased breath
sounds, increased need for bronchodilators.
^bPneumonia, arrhythmia, congestive heart failure, diabetes,
renal or hepatic failure.
COPD: chronic obstructive pulmonary disease; NIV: noninvasive
ventilation.
Source: References 6, 7, 16

Table 2. Antibiotic Recommendations
Antibiotic Recommendations
Patient Characteristics	Pathogens	Therapy (no particular order)
Uncomplicated exacerbations < 4 per year No comorbidities FEV₁ > 50% predicted Resistance uncommon	Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Haemophilus parainfluenzae	Azithromycin or clarithromycin 2nd- or 3rd-generation cephalosporin doxycycline
Complicated exacerbations Age ≥ 65 years > 4 per year FEV₁ 36%-49% predicted	Above plus drug-resistant pneumococci, beta-lactamase- producing H influenzae, and M catarrhalis	Amoxicillin/clavulanate fluoroquinolone with enhanced pneumococcal activity (levofloxacin, gemifloxacin, or moxifloxacin
Complicated exacerbations with risk of pseudomonas aeruginosa Chronic bronchial spesis^b Chronic corticosteroids Nursing home resident > 4 per year FEV₁ > 35% predicted	Enteric gram-negatives Above plus P aeruginosa	Levofloxacin^a Possible IV therapy: beta-lactamase- resistant penicillin with antipseudomonal activity 3rd- or 4th-generation cephalosporin with antipseudomonal acitivity

^a Fluoroquinolone with enhanced pneumococcal/antipseudomonal activity.
^b In spesis, addition of aminoglycoside considered for double antipseudomonal coverage.
FEV₁: forced expiratory volume in one second.
Source: References 6, 7, 16

Table 3. Discharge Criteria
Discharge Criteria
Inhaled beta₂-agonist no more than every 4 h
Patient able to walk across room
No frequent awakening due to dyspnea
Patient clinically stable for 12-24 h
Correct use of medications understood
Follow-up/home care arrangements completed

Source: References 6, 7

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Managing Acute Exacerbations of COPD

Introduction

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Tables

References

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