Family Medicine:

Asthma & COPD Exacerbations

Morgan Smith PharmD | PGY-1 Pharmacy Resident
Objectives:
 Discuss guideline recommendations and evidence based medicine to treat asthma
exacerbations
 Discuss guideline recommendations and evidence based medicine to treat COPD
exacerbations
 Understand how to apply current guidelines to clinical practice
Current Guidelines and Evidence Based Medicine
 2018 Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma (GINA)
 2007 Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. National
Heart, Lung, and Blood Institute and National Asthma Education and Prevention Program (NAEPP)
 2011 Asthma care quick reference- Diagnosing and managing asthma. National Heart, Lung, and Blood
Institute and National Asthma Education and Prevention Program (NAEPP)
 2020 Pocket Guide to COPD Diagnosis, Management, and Prevention. Global Initiative for Chronic
Obstructive Lung Disease (GOLD)
Asthma
Asthma Exacerbation/Status Asthmaticus
 Severe airway obstruction unresponsive to standard therapy
 Medical emergency
 Complications:
 Anoxic brain injury
 Pneumothorax
 Respiratory arrest
 Death
 Risk factors:
 History of hospitalization within the past year
 Non-adherence
 NSAID/aspirin induced asthma
 Exercise
 Genetic factors- C3aR/C5aR & anaphylatoxins
 Risk for Exacerbations Respiratory viral
infections

Allergens Air pollution

Bronchoconstriction
Airway edema
Airway hyper- NSAIDs/Aspiri
Tobacco
responsiveness n
Airway remodeling

Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma (GINA). 2018.
 Assess airway,
breathing, and
circulation

Assessment
Drowsiness,
confusions, silent
chest?  Assess patients within 1 hour after
initial treatment

Assess severity of ICU consult, start SABA and

 FEV1/PEF <60% of predicted
signs/symptoms O2, prepare for intubation personal best or no clinical
response, continue treatment as
above and reassess
Mild/Moderate Severe

SABA
SABA
Ipratropium Bromide
Ipratropium Bromide
Oxygen
Oxygen
IV corticosteroids
Oral corticosteroids
IV magnesium
High dose ICS

Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma (GINA). 2018.
 Oxygen Therapy/Supportive Care
 O2 saturation goal: 93-95%
 Nasal cannula or mask
 Controlled low flow oxygen v. high concentration oxygen
 Avoid intubation and mechanical ventilation if possible
 High pressure  alveoli rupture  acute respiratory failure
 Supportive care with fluids and electrolyte repletion

Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma (GINA). 2018.
 Bronchodilators
 Inhaled SABA therapy
GINA 2020 Update:
 Albuterol or albuterol/ipratropium • No longer recommend SABA-only
 SABA + ipratropium treatment for Step 1
 Continuous vs. intermittent SABA • All adult and adolescents with
asthma should receive ICS-
containing controller treatment, to
reduce the risk of serious
exacerbations

Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma (GINA). 2018.
Corticosteroids
 Indication:
 No response to SABA
 Previous exacerbations requiring corticosteroids
 PEF 50% baseline
 Within 1 hour of presentation
 Oral steroids
 Prednisone 40-50mg per day (or equivalent) X 5-7 days
 IV steroids
 Methylprednisolone 40-80mg per day
⎻Onset: 1-2 hours
Magnesium Sulfate
 Mechanism:
 Inhibits calcium channels in bronchial smooth muscles causing muscle relaxation
 Dose:
 2g IV infusion X 1 over 20 minutes
 Reduction in hospital admissions
 Patient who fail to respond to initial treatment
 Patients with persistent hypoxemia
 Adults with FEV1 <25-30% predicted at presentation
Terbutaline/Epinephrine
 Indication: refractory to inhaled B2 antagonist
 Mechanism: bronchodilation
 Dose:
 Terbutaline: 0.25mg/dose
⎻May repeat every 20 minutes for 3 doses
 Epinephrine: 0.01mg/kg (1:1000) IM X 1
 Adverse effects:
 Tachyarrhythmias
Chronic Obstruction Pulmonary Disease (COPD)
COPD Exacerbation
 An acute increase in symptoms beyond normal day-to-day variation
 Acute increase in one or more of the following cardinal symptoms:
 Cough increases in frequency and severity
 Sputum production increases in volume and/or changes character (more purulent)
 Dyspnea increases

Mild Moderate Severe

• SA • SA • Requires
bronchodilators bronchodilators hospitalization
• Antibiotics OR or emergency
systemic room visit
corticosteroids
 Assessment of Symptoms/Risk of Exacerbations
 Modified British Medical Research Council (mMRC) Question
 Measures breathlessness
 COPD Assessment Test (CAT)
 Measures symptomatic impact of COPD

Moderate or Severe Exacerbation History

≥ 2 or ≥ 1 leading to hospital
admission
C D

0 or 1 (not leading to hospital A B

admission)
mMRC 0-1 mMRC 0-1
CAT < 10 CAT < 10
 REVIEW
• Symptoms
• Exacerbations

ADJUST ASSESS
• Escalate • Inhaler technique
• Switch inhaler device • Adherence
• De-escalate • Non-pharmacologically
approaches
Management

Mild Moderate Severe

Outpatient Management Inpatient Management
Patient Education

Bronchodilators Bronchodilators Bronchodilators

Corticosteroids Oxygen Oxygen/ventilatory
support
Antibiotics Corticosteroids Corticosteroids
Antibiotics Antibiotics
Systemic Corticosteroids
 Shorten recovery time, improve FEV1 and hypoxemia
 Oral treatment
⎻ Prednisone 40mg daily for 5 days
 IV treatment
⎻ Methylprednisolone

 Tapering
 Consider tapering if:
⎻ Course lasts more than 2-3 weeks
⎻ Patient taking systemic steroids prior to flare

 Role in therapy:
 Shorten recovery time
 Improves lung function
 Reduces risk of early relapse
 Reduces length of hospital stay
Antibiotics
Patient exhibits 3 cardinal symptoms
Antibiotic
- Increased dyspnea
therapy - Increased sputum volume
warranted - Increased sputum purulence
when: OR 2 cardinal symptoms and 1 is:
- Increased sputum purulence
Patient requires:
- Mechanical ventilation

- Streptococcus pneumonia
Common - H. influenzae
pathogens: - Moraxella catarrhalis
- Mycoplasma pneumonia

Treatment should be given for 5-7 days

Antibiotics
Definition Oral Treatment IV Treatment
Mild exacerbation: • Amoxicillin
• No risk factors for poor • Doxycycline
outcome • TMP/SMX
• Azithromycin
• 3rd generation cephalosporin
Moderate exacerbation: • Amoxicillin-clavulanate • Ampicillin-sulbactam
• Risk factor(s) for poor outcome • Levofloxacin • 3rd generation cephalosporin
• Moxifloxacin • Levofloxacin
• Moxifloxacin
Severe exacerbation: • Ciprofloxacin • Ciprofloxacin
• Risk factor(s) for Pseudomonas • Levofloxacin (high dose) • Levofloxacin (high dose)
aeruginosa* • Beta lactam with P. aeruginosa
activity
* Comorbid disease, severe COPD, frequent exacerbations (>3 per year), antimicrobial use within past 3 months
Phosphodiesterase 4 Inhibitor
 Roflumilast (Daliresp)
 500 mcg tablet orally daily
 FDA approval- reduces moderate to severe exacerbations in patients with
 Chronic bronchitis
 Severe or very severe COPD
 History of exacerbations
Consequences of Exacerbations

Impact on
Negative impact Accelerated lung
symptoms and
on quality of life function decline
lung function

Increased Increased
mortality economic costs
Family Medicine:
Asthma & COPD Exacerbations
Morgan Smith PharmD | PGY-1 Pharmacy Resident