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Acute exacerbation of chronic obstructive pulmonary disease

Summary

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is defined as the acute worsening of respiratory symptoms in a patient with COPD that necessitates additional therapy. The most common trigger of AECOPD is respiratory viral infection. Cardinal symptoms of AECOPD include worsening of dyspnea, increased frequency and severity of cough, and increased volume and/or purulence of sputum. AECOPD is a clinical diagnosis and the diagnostic workup serves primarily to assess the level of severity and evaluate for any underlying trigger and coexisting comorbidities. Management of AECOPD consists primarily of respiratory support, inhaled bronchodilator therapy, and systemic corticosteroids. Antibiotics should be considered in patients with severe AECOPD and patients who are mechanically ventilated. See also “COPD” and “Mechanical ventilation.”

Etiology

Clinical features

Diagnostics

General principles

  • AECOPD is a clinical diagnosis (see “Cardinal symptoms of AECOPD”).
  • The goals of diagnostic evaluation are to:
    • Identify triggers and/or complications (e.g., pneumothorax, ARDS)
    • Rule out alternate diagnoses
    • Identify comorbid diagnoses that affect management and/or prognosis (e.g., chronic respiratory acidosis)
    • Risk-stratify the severity of the exacerbation
    • Assess the response to treatment
  • Consider empiric bronchodilator therapy if the diagnosis is unclear.

Testing should not delay urgent treatment in patients presenting with signs of respiratory failure or distress if clinical criteria of AECOPD are met.

Laboratory studies [2]

  • Arterial blood gas: to assess the level of severity
  • Microbiological studies
    • Nasopharyngeal swab for respiratory virus detection (using NAAT) [5]
    • Sputum Gram stain and culture are recommended for patients with the following: [2]
  • Additional workup for alternate diagnoses and relevant comorbidities: as guided by clinical suspicion
    • CBC
    • D-dimer
    • Troponin
    • BNP/NT-proBNP
    • Vitamin D level: should be checked in all hospitalized patients with AECOPD; < 10 ng/mL corresponds to severe deficiency [2]

PaCO2 on blood gas should be interpreted in relation to the patient's baseline because of chronic CO2 retention.

Imaging [2]

Imaging is not required to confirm the diagnosis but may be used to evaluate for potential triggers (e.g., pneumonia) and/or rule out other causes of dyspnea (see “Differential diagnosis of AECOPD”).

Additional testing

ECG [2]

Pulmonary function testing [2]

Spirometry is not routinely recommended in the assessment of AECOPD. [7]

  • Potential uses include:
    • Confirming the diagnosis for first-time patients (see “Diagnosis of COPD”)
    • Grading the severity of disease for prognostication [8]
  • Interpretation of changes in FEV1: [9][10][11][12]
    • Can predict poor outcomes and treatment failure
    • Correlates poorly with the risk of subsequent exacerbations

Advanced testing

Classification

The following system is recommended to classify AECOPD severe enough to require a hospital visit and is based on clinical and laboratory parameters. For baseline classification, see “COPD classification.” [2]

Classification of AECOPD [2]
Clinical or laboratory parameter AECOPD with life-threatening acute respiratory failure AECOPD with non-life-threatening acute respiratory failure AECOPD without respiratory failure
Respiratory rate
  • > 30/min
  • 20–30/min

Accessory muscle use

  • Yes
  • No

Change in baseline mental status

  • Yes
  • No

Degree of hypoxemia

Hypercapnia

  • Elevated PaCO2
    • Markedly elevated from baseline
    • OR > 60 mm Hg
  • AND/OR pH ≤ 7.25
  • Elevated PaCO2
    • Elevated from baseline
    • OR 50–60 mm Hg
  • No worsening from baseline

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Treatment

The overarching goal of treatment in AECOPD is to minimize the impact of the current exacerbation and prevent subsequent exacerbations. [2]

Approach to the management of AECOPD [2]

The ABCDE approach is indicated for all patients with respiratory distress. See “Classification of AECOPD” section for the clinical and laboratory parameters that define the following categories.

Acute exacerbation of COPD may be a life-threatening emergency. Rapid assessment is recommended to identify patients who require aggressive care and admission to ICU.

Respiratory support

Oxygen therapy

Noninvasive positive pressure ventilation (NIPPV)

NIPPV is the recommended first-line ventilatory strategy in AECOPD with acute respiratory failure. NIPPV is associated with a decreased need for intubation, decreased hospital length-of-stay, and lower mortality. [2]

Invasive mechanical ventilation

Intubation and mechanical ventilation are especially high-risk and complication-prone procedures in AECOPD, and they are generally used as a last resort (see “High-risk indications for mechanical ventilation”). [15][16]

Intubation and mechanical ventilation of patients with AECOPD carries a significant risk of periprocedural cardiac arrest due to rapid oxygen desaturation, dynamic hyperinflation, circulatory shock, and/or severe respiratory acidosis! Countermeasures should be taken prior to performing these procedures (see “High-risk indications for mechanical ventilation”).

Pharmacological therapy for AECOPD [2][17][18][19]

Overview

The following are suggested pharmacological treatment combinations based on symptom severity.

Bronchodilators

Corticosteroids

Antibiotics [2]

The routine use of antibiotics in AECOPD is controversial, but antibiotics are associated with enhanced symptom resolution and a lower risk of treatment failure in patients with moderate to severe AECOPD. [2]

Adjunctive treatment and supportive care [2]

Monitoring and disposition

Monitoring

  • Symptom surveillance and severity assessment, as clinically indicated
  • Continuous pulse oximetry
  • Serial blood gas monitoring

Indications for hospital admission [2]

  • Acute respiratory failure
  • Severe symptoms
  • New physical examination signs
  • Condition refractory to initial medical treatment
  • Significant comorbidity
  • Insufficient home/community support system

Indications for ICU admission [2]

Clinical decision tools [25]

The following assessment measures may help to objectively identify patients at risk of poor medical outcomes.

  • 3-minute walk test [26]
    • Patients undertaking the test are less likely to have a poor clinical outcome if:
      • They can complete a 3-minute walk at their own pace (with aids and/or home oxygen as needed)
      • Highest heart rate is < 120/minute
      • Lowest SpO2 is ≥ 90%
Ottawa COPD Risk Scale (OCRS) [27][28]
Parameters Points

Evaluation on arrival

Prior CABG

1

Prior intervention for PVD

1

Prior intubation for respiratory distress

2

Pulse ≥ 110/min

2

Diagnostic test results

Hemoglobin < 10 g/dL

3

BUN ≥ 34 mg/dL

1

Serum CO2 ≥ 35 mEq/L

1

Ischemic changes on ECG

2

Pulmonary congestion on CXR

1

Evaluation after initial treatment

SpO2 < 90% or pulse ≥ 120/min

2

Interpretation: A higher total score corresponds to an increased risk of serious short-term outcomes.

  • Low (0 points): 2% risk
  • Medium (1–2 points): 4–7% risk
  • High (3–4 points): 12–20% risk
  • Very high (> 5 points): 33–91% risk

Acute management checklist

Respiratory support

Medical therapy

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last updated 09/15/2020
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