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Management of the Hospitalized Patient with COPD
March 26, 2011 Focus on Respiratory Care & Sleep Medicine Conference
Jennifer S. Williams, MMS, PA-C Mayo Clinic in Arizona, Instructor in Medicine Midwestern University, Clinical Instructor Kari J. Williams, ANP-BC, ACNP-BC, RN Mayo Clinic in Arizona
• List the etiologies, signs, and symptoms of a COPD exacerbation • Describe indications for hospitalization during a COPD exacerbation • Discuss treatment options for the hospitalized patient with a COPD exacerbation • Identify perioperative risks for the hospitalized patient with COPD • Determine perioperative treatment methods for the hospitalized patient with COPD
Chronic Obstructive Pulmonary Disease
Chronic Obstructive Pulmonary Disease
• Global Initiative for Chronic Obstructive Lung Disease (GOLD)
“Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases."
• Chronic bronchitis
Chronic inflammation of bronchial mucous membranes characterized by chronic cough
Productive cough for 3 months in at least 2 consecutive years
Abnormal enlargement of distal air spaces and destruction of bronchial walls and alveoli without fibrosis http://www.prlog.org/10955996-study-links-exerciseto-stronger-breathing-muscles-for-copd.html
• Tobacco use or exposure • Chemical/toxin exposure • Air pollution • 1-antitrypsin deficiency
3/18/11 7 Pathophysiology Exposure to irritant Chronic inflammation Small airway disease Parenchymal destruction Chronic airflow limitation Adapated from http://www.mayoclinic. 8 Pathophysiology http://www.org.goldcopd.com/health/medical/IM00989 9 Symptoms • • • • • • • Dyspnea Chronic productive cough Wheezing Chest tightness exercise capacity Fatigue Anorexia and weight loss in severe disease 3 .
3/18/11 10 Physical Examination • Hypoxia • Tachypnea • Shallow. pursed-lip breathing • breath sounds • Prolonged expiratory phase • • • • • Rhonchi Wheezes Barrel-shaped chest Cyanosis Clubbing 11 Pulmonary function tests (PFTs) Forced expiratory volume in one second (FEV1) FEV1/forced vital capacity (FVC) Diffusing capacity of the lung for CO (DLCO) Total lung capacity (TLC) Residual volumes • FEV1/FVC <70% post-bronchodilator that is not fully reversible airflow limitation COPD PFTs http://www.com/health/medical/IM01608 4 .mayoclinic.
org. 14 COPD CXR 15 Chest Radiograph (CXR) • Findings Hyperinflation Diaphragm flattening retrosternal air space AP diameter Parenchymal bullae or subpleural blebs Enlargement of central pulmonary arteries Vertical and narrow heart sillouette Prominent right heart border 5 .goldcopd.3/18/11 13 PFTs and COPD Staging Stage 1: Mild II: Moderate III: Severe IV: Very severe FEV1/FVC <70% <70% <70% <70% FEV1 80% predicted 50% 30% FEV1 <80% predicted FEV1 < 50% predicted FEV1 < 30% predicted or FEV1 < 50% predicted + chronic respiratory failure Adapated from http://www.
uptodate.com 17 Arterial Blood Gas (ABG) • Obtain if: Signs of respiratory failure Hypoxemia or hypercapnia are suspected If FEV1 < 50% predicted Clinical signs of right heart failure 18 Treatment • • • • • • Tobacco cessation Inhalers and small volume nebulizers (SVNs) Glucocorticosteroids Methylxanthines Pulmonary rehabilitation Additional treatment methods 6 .3/18/11 16 COPD CT Scan www.
asthmaready.org/Story.com/?tag=no-smoking 20 Tobacco Cessation • 5% success rate with simply telling a patient to quit • Cessation methods Nicotine transdermal patch Nicotine gum Pharmacologic agents Behavior modification CURRENT Medical Diagnosis and Treatment. exercise tolerance. 2007 21 Inhalers and SVNs • Bronchodilators Most important agents in pharmacologic management of COPD Improve symptoms. and overall health status http://www.testcountry.aspx?storyid=20 7 .3/18/11 Tobacco Cessation • Only way to slow progression of COPD • Slows the decline in FEV1 in middle-aged smokers with mild airway obstruction • Ex-smokers need up to six months to recover alveloar macrophage antimicrobial function http://hometestingblog.
3/18/11 22 Inhalers and SVNs • Anticholinergics Short-acting Ipratropium bromide (Atrovent) Long-acting Tiotropium (Spiriva) 23 Inhalers and SVNs • 2-agonists Short-acting Salbutamol (Albuterol) Levalbuterol (Xopenex) Long-acting Salmeterol (Servent) • Short-acting 2-agonist + anticholinergic Ipratropium + salbutamol (Combivent) 24 Glucocorticosteroids • Oral • Inhaled For symptomatic patients with Stage III/IV COPD or with repeated exacerbations Beclomethasone (QVAR) Budesonide (Pulmicort) Fluticasone (Flovent) Glucocorticosteroid + long-acting Fluticasone/Salmeterol (Advair) Budesonide/Formoterol (Symbicort) 2-agonist 8 .
rehab Inhaled steroids if repeated exacerbations Long-term oxygen if chronic respiratory failure.goldcopd.3/18/11 25 Methylxanthines • Theophylline Use is controversial Toxicity Dose-dependent Symptoms Cardiac arrhythmias. nausea. heartburn 26 Recommended Treatment by Stage Risk Factors. 27 Additional Treatment • Avoidance of irritants • Energy conserving techniques and pulmonary rehabilitation • Influenza and pneumococcal vaccinations • Supplemental oxygen • Opioids • Surgery Bullectomy. lung transplantation 9 . headache. seizures. Vaccines Short-acting bronchodilator when needed 1 longacting bronchodilator when needed. lung volume reduction.org. consider surgery Stage I: Mild Stage II: Moderate Stage III: Severe Stage IV: Very Severe + + + + + + + + + + + + + + Adapated from http://www.
cough. and/or sputum that is beyond normal day-to-day variations. 2007 10 . and Respiratory Syncytial Virus (22%) • Bacterial infection Chronic lower airway bacterial colonization Most commonly Haemophilus influenzae. and may warrant a change in regular medication in a patient with underlying COPD” http://www. and Moraxella catarrhalis Clinics in Chest Medicine. is acute in onset.org. Influenza A (25%). 30 Etiology • Viral infection Detectable in sputum/nasal lavage in 56% of patients Most commonly Picornaviruses (36%). Streptococcus pneumoniae.goldcopd.3/18/11 28 COPD Exacerbation 29 COPD Exacerbation • Global Initiative for Chronic Obstructive Lung Disease (GOLD) “An event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea.
3/18/11 31 Etiology • Environmental pollution Particulate matter from diesel exhaust • Changes in environmental temperature • Worsening of underlying comorbid conditions (HF/CKD) can precipitate an exacerbation • Often. airway edema. 2007 11 . a clear precipitant is not apparent. 32 Pathophysiology Expiratory flow limitation with mucus production. and bronchoconstriction end-expiratory volume with dynamic hyperinflation Impairment of respiratory muscles Dyspnea. and difficulty of muscles to cope with respiratory demand 33 Symptoms • Increased: Dyspnea (64%) Sputum purulence (42%) Sputum volume (26%) Wheeze (35%) Nasal symptoms (35%) Cough (20%) Mental status change Clinics in Chest Medicine. tachypnea.
3/18/11 34 CXR CT Scan 36 ABG • Findings Compensated respiratory acidosis with worsening acidemia Serial ABGs Comparison to baseline PaO2 <60 mmHg and/or SaO2 <90% with or without PaCO2 >50 mmHg when breathing room air respiratory failure 12 .
goldcopd.3/18/11 37 Diagnostic Studies • Sputum culture Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis • PFTs Not recommended • Influenza screening • CBC and BMP • ECG 38 Indications for Hospitalization • Marked in intensity of symptoms • Severe underlying COPD at baseline • Onset of new physical signs • Cyanosis.org. Indications for ICU Admission • Severe dyspnea that responds inadequately to initial emergency therapy • Changes in mental status • Persistent or worsening hypoxemia (PaO2 <40 mmHg) and/or severe/worsening hypercapnia (PaCO2 >60 mmHg) and/or severe/worsening respiratory acidosis (pH <7.org.goldcopd.25) despite supplemental oxygen and noninvasive ventilation • Need for invasive mechanical ventilation • Hemodynamic instability http://www. peripheral edema • • • • • • Failure to respond to initial medical management Significant comorbidities Frequent exacerbations Newly occurring arrhythmias Older age Insufficient home support http://www. 13 .
2008 41 Treatment • • • • • • Tobacco cessation Oxygen Inhalers and small volume nebulizers (SVNs) Glucocorticosteroids Antibiotics Non-invasive positive pressure ventilation (NIPPV) • Invasive mechanical ventilation Oxygen • Goal To prevent acidosis and tissue hypoxia PaO2 >60 mmHg SaO2 > 90% • Watch for CO2 retention 14 .3/18/11 40 The Hospitalized COPD Patient • 10% in-hospital mortality rate 25% require ICU admission 24% mortality rate if admitted to the ICU • More commonly admitted in the winter months 50% more common at this time due to illnesses in viral Chest.
3/18/11 43 Inhalers and SVNs • Bronchodilators Short-acting 2-agonists* Salbutamol (Albuterol) Levalbuterol (Xopenex) Anti-cholinergic Ipratropium bromide (Atrovent) Tiotropium (Spiriva) • Significantly improve the FEV-1 • Additive effect when used in conjunction with each other 44 Glucocorticosteroids • Associated with improved lung function. and in treatment failure • PO vs. sputum volume. and sputum purulence sputum purulence + dyspnea or sputum volume Severe exacerbation. requiring mechanical ventilation Invasive or non-invasive 15 . IV Low-dose oral steroids were not associated with worse outcomes than high-dose intravenous therapy. length of hospitalization. 2010 45 Antibiotics • Indications Symptoms suggestive of an underlying infectious etiology dyspnea. JAMA.
3/18/11 46 Antibiotics • Choice of antibiotic and duration of treatment depend on the severity of the exacerbation First line Amoxil (Amoxicillin) Doxycycline Trimethoprim/Sulfamethoxazole (Bactrim) Second line 2nd and 3rd generation cephalosporins Flouroquinolones Antibiotics • Consider Gram-negative bacilli and Pseudomonas aeruginosa in the following patients: Severe COPD at baseline Elderly Receiving multiple or frequent antibiotics Requiring mechanical ventilation Recent hospitalization Are more susceptible to resistant pathogens 48 The Evidence • Compared to placebo: Systemic glucocorticosteroids treatment failure by 46% length of hospital stay by 1.4 days FEV1 by 0. 2008 16 .13 L three days after therapy Antibiotics treatment failure by 46% in-hospital mortality by 78% Chest.
medscape.35) and/or hypercapnia (PaCO2 > 45 mm Hg) Respiratory rate > 25 breaths per minute http://www. 17 . MI.goldcopd.3/18/11 49 NIPPV • BiPAP and CPAP • High-flow oxygen • Advantages need for endotracheal intubation length of hospitalization mortality http://emedicine.goldcopd. arrhythmias Diminished mental status Inability or unwillingness of patient High aspiration risk Copious secretions Extreme obesity Recent facial/gastroesophageal surgery Craniofacial trauma http://www. 51 NIPPV • Contraindications Respiratory arrest CV instability Hypotension.org.org.com/article/304235-overview NIPPV • Indications Moderate to severe dyspnea with the use of accessory muscles/paradoxic abdominal motion Moderate to severe acidemia (pH < 7.
9 days Chest. 2008 Discharge Criteria • Inhaled • • • • 2-agonist therapy Q4 hours Ambulation without significant symptoms Clinical stability for 12-24 hours Appropriate home and follow-up arrangements Patient understanding of outpatient treatment plan 54 Preventing Future Exacerbations • • • • • Tobacco cessation Self-management education Vaccinations Pulmonary rehabilitation ? prophylactic antibiotics 18 .3/18/11 52 The Evidence • Compared to standard therapy NIPPV risk of intubation by 65% in-hospital mortality by 55% length of hospital stay by 1.
3/18/11 55 Perioperative Management of Patients with COPD Surgical Complications • Cardiac • Pulmonary Pneumonia Atelectasis airflow obstruction COPD exacerbation risk of acute respiratory failure Considerations • • • • • • COPD severity Tobacco use Age >60 Obesity Heart failure Poor general health status/performance status • Thorough history and physical examination needed to identify risk factors 19 .
emergency surgery • Surgical site risk as incision approaches diaphragm • Length of surgery Prolonged surgery (>3 hours) • Anesthesia General > epidural or spinal Preoperative Interventions • Tobacco cessation Moller et al (2002): Hip and knee replacements Cessation 6-8 weeks preoperatively postoperative morbidity Wein (2009): CABG Cessation “weeks” prior have risk of postoperative respiratory complications Due to transient in sputum production Improves wound healing Preoperative Interventions • CXR • PFTs Not routinely recommended But recommended prior to lung resection • ABG Recommended prior to lung resection 20 . thoracic. neurosurgery. head and neck. vascular.3/18/11 Factors Associated with Increased Risk • Type of surgery Abdominal.
and glucocorticosteroids if necessary When to Proceed • If COPD exacerbation is present. • Patient education Lung expansion maneuvers • Preparation is key! incidence of pulmonary complications in those receiving preoperative preparation Combination of bronchodilators. do not proceed with surgical procedure. antibiotics.jpg 21 . • If COPD stable.org/wp-content/uploads/2010/06/ incentive-spirometer-300x300.3/18/11 61 Preoperative Interventions • Patients with symptomatic COPD should receive daily inhaled ipratropium or tiotropium prior to surgery. treat with traditional treatment modalities. Postoperative Interventions • Lung expansion modalities Incentive spirometer Cough and deep breathing risk of pulmonary complications by Chest percussion Suctioning Early ambulation Intermittent positive-pressure breathing Can cause abdominal distention NIPPV http://healthpages.
Wedzicha JA.3/18/11 64 Postoperative interventions • Pain control Leads to earlier ambulation Improves ability to breathe deeply Epidural analgesia vs. 303(23): 2359-2367. • Lindenauer PK.goldcopd. 2010. et al. 38: 9-16. 2007. Available from: http://www. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. Lahti MC. • Hurst JR. Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2010. opioids • Use of nasogastric tube as needed risk of atelectasis and pneumonia 65 Postoperative Interventions • Inhaled beta-agonists As needed for symptomatic wheezing • Glucocorticosteroids Persistent wheezing/functional limitations despite bronchodilator therapy 66 References • Ali.org. NK. 22 . Management and Prevention of COPD. 28: 525-536. Evidence-based approach to acute exacerbations of chronic obstructive pulmonary disease. Lee Y. 2009. Clinics in Chest Medicine. Pekow PS. • From the Global Strategy for the Diagnosis. JAMA. Hospital Physician. The biology of a chronic obstructive pulmonary disease exacerbation.
Tonneson H.com 23 . Lancet. NY: McGraw Hill Lange. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians.uptodate. • Poon CA. • Wojciechowski B. et al. 2007. KA. 133: 756-766. • Wien RO. 2010. McPhee SJ. Villebro N. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Chest. 2007. 2006. Snow V. Management of COPD exacerbations. McGraw Hill Lange. Hornbake ER. 2009. Noninvasive positive airway pressure in hypercapnic respiratory failure in noncardiac medical disorders. 2008. McPhee SJ. • www. Sleep Medicine Clinics. 68 References • Qaseem A. 359: 114-117. New York. Sin DD. Littner. Fitterman N. 135(6): 597-601. 144(8): 575-581. Current Consult Medicine. Annals of Internal Medicine. Tierney LM. • Quon BS. 2010.3/18/11 67 References • Moller AM. 5: 451-470. MR. Focus Journal. 22-23 and 35. Preoperative smoking cessation: impact on perioperative and long-term complications. Arch Otolaryngol Head Neck Surg. • Papadakis MA. CURRENT Medical Diagnosis and Treatment. 2002. Gan WQ. Contemporary management of acute exacerbations of COPD: a systematic review and metanalysis. • Papadakis MA. Becker. Pedersen T.