COPD


BACKGROUND
 

Chronic inflammatory airway disease with progressive airflow limitation resulting in:

Clinical Features

  • Increased Dyspnea
  • Increased wheezing
  • Increased oxygen requirement
  • Increased sputum volume and purulence (productive cough)
  • Increased work of breathing
  • Cor Pulmonale

Differential Dx

Critical Differential Diagnosis of Chronic Obstructive Pulmonary Disease (COPD) Exacerbations
Diagnosis Clinical Clues and Diagnostic Testing Pitfalls
Asthma More likely in the younger patient (<50 y old). Can coexist with COPD.
  More likely in nonsmokers.
 
Many patients are labeled with asthma but truly have COPD due to lung damage from smoking or other irritants.
CHF Historical elements of some assistance, specifically orthopnea (LR 2.0) and dyspnea with exertion (LR 1.3).  Can coexist with COPD.
 

 

 

 

 
Same historical elements frequently found in COPD as well. Underlying COPD can mask the radiographic findings of CHF.
Presence of jugular venous distention somewhat helpful; however, hepatojugular reflux has been shown to be more reliable.  Many conditions can falsely elevate (particularly cor pulmonale) or decrease the BNP level (particularly obesity). 
Wheezing present in both conditions and therefore not particularly helpful.  
Chest radiograph helpful with presence of interstitial edema.  
BNP shows much promise, most helpful if <100 picograms/mL (not likely to be CHF) or if >500 picograms/mL (very likely to be CHF).
 
 
PE Seek out key risk factors such as older age, recent surgery or trauma, prior venous thromboembolic disease, hereditary thrombophilia, malignancy, smoking, and use of medications containing estrogen. 20%–25% of patients with a severe COPD exacerbation with an unclear trigger have a PE.
 
 

 

 
Historical clues suggesting PE include sudden onset of symptoms and syncope or near-syncope, patients with an exacerbation severe enough to warrant hospitalization with intermediate-to-high pretest probability may require further testing.
 
"Classic" presentation of PE (pleuritic chest pain, dyspnea, tachycardia, and hypoxia) rarely encountered; however, at least one element usually present.
D-dimer testing may be of assistance in patients with sufficiently low pretest probability as determined by various clinical decision rules in the literature.  Physical exam offers no clues to diagnosis in 28%–58% of patients. 
The imaging test of choice is frequently CT angiography of the chest due to accuracy and ability to provide additional useful information.
 
Many conditions can cause a falsely elevated D-dimer. 
ACS An ECG should be considered for all ED patients with dyspnea and risk factors for ACS. Dyspnea can be the main presenting complaint for patients with ACS—in the Global Registry of Acute Coronary Events registry, dyspnea was the primary complaint 49.3% of the time.
 
Pneumothorax Chest radiography is primary test; however, US and CT are more sensitive.
 
COPD is a major risk factor for spontaneous pneumothorax.
Pneumonia Chest radiography and, possibly, CT scans, as appropriate, will be helpful. Frequently coexists with a COPD exacerbation.
Oral temperatures are frequently unreliable in tachypneic patients.
 
 

Diagnosis

Laboratory evaluation.
  Chest x-ray.
  CBC with differential.
  Electrolytes.
  ABG, as needed.
  ECG, Pro-BNP
  If the patient is able to cooperate, a peak expiratory flow rate (PEFR) of <100 L/minute OR an FEV1 of <1.00 L in a patient without chronic severe obstruction indicates a severe exacerbation
  Acute hypercapnia:
  Relationship between bicarbonate (HCO3) and PaCO2.
   HCO3 increases 1 mEq/L for every 10 mm Hg increase in PaCO2, or 1:10
  Chronic hypercapnia:
   Relationship between bicarbonate (HCO3) and PaCO2.
   HCO3 increases 3.5 mEq/L for each 10 mm Hg increase in PaCO2 or 3.5:10
At all times.
  Monitor fluid and electrolyte balance.
  Identify and treat associated conditions (e.g., heart failure, arrhythmias).
  Continuous monitoring of cardiorespiratory status.

USPSTF Dec 2013
** Annual lung CT scans
now recommended in those with

  • > 30 pack yr
  • Age 55-80 yr 

 

Treatment

Summary of ED Management of Chronic Obstructive Pulmonary Disease Exacerbations
Assess severity of symptoms.
  Administer controlled oxygen therapy.
  Perform arterial blood gas measurement after 20–30 min if arterial oxygen saturation remains <90% or if concerned about symptomatic hypercapnia.
Administer bronchodilators.
  β2 Agonists and/or anticholinergic agents by nebulization or metered dose inhaler with spacer.
  •  [Duoneb updraft] Albuterol 0.5 mg and ipratropium 0.5 mg in 2.5 mL NS q1-2h until peak flow meter ≥200-250 L/min, then q4h prn 
Consider adding IV methylxanthine, if needed.
Add corticosteroids.
  PO or IV
  • Prednisone 40 mg PO
  • Methylprednisolone 125 mg IV
  • Dexamethasone : 16 mg orally once daily OR  4-8mg IV
Consider antibiotics.
  If increased sputum volume, change in sputum color, fever, or suspicion of infectious etiology of exacerbation.
  • Levofloxacin : 750 mg orally once daily for 3-10 days, or 750 mg orally once daily for 5-10 days
Consider noninvasive mechanical ventilation.
Laboratory evaluation.
  Chest x-ray.
  CBC with differential.
  CMP
  ABG, as needed.
  ECG, as needed.
At all times.
  Monitor fluid and electrolyte balance.
  Identify and treat associated conditions (e.g., heart failure, arrhythmias).
  Continuous monitoring of cardiorespiratory status.
 

Acute Exacerbation

1. Oxygen
  • Long-term oxygen therapy reduces COPD mortality. The primary goal of long-term oxygen therapy is to increase the baseline PaO2 to 60 mm Hg or the arterial oxygen saturation (SaO2) to 90% at rest.
  • Criteria for long-term oxygen therapy are a PaO2 55 mm Hg, an SaO2 88%, or a PaO2 between 56 and 59 mm Hg when pulmonary hypertension, cor pulmonale, or polycythemia are present.
2. Inhaled β-agonists and anticholinergics
  • Albuterol inh: 2.5 mg neb every 20 minutes for up to 2 hours or until clinical improvement in dyspnea and gas exchange noted, or development of adverse effects
    +
  • Ipratropium bromide inhaled : (17 micrograms/dose inhaler), 34 micrograms (2 puffs) every 2-4 hours via a spacer; OR 500 micrograms nebulized three to four times daily with doses given 6-8 hours apart

     
  • Limit the use of antihistamines, antitussives, and decongestants.
  • Expectorants are not of clear benefit.
3. Systemic steroids
  • Prednisone 40 mg PO
  • Methylprednisolone 125 mg IV
  • Dexamethasone : 16 mg orally once daily OR  4-8mg IV
4. Antibiotics (Indicated in cases with increased sputum volume and purulence)
  • cefuroxime axetil : 500 mg orally twice daily for 3-10 days; 750 mg intravenously every 8 hours
  • amoxicillin/clavulanate : 875 mg orally twice daily for 3-10 days 
  • trimethoprim/sulfamethoxazole : 160/800 mg orally twice daily for 3-10 days
  • levofloxacin : 500 mg orally once daily for 3-10 days, or 750 mg orally once daily for 5 days
  • ciprofloxacin : 500 mg orally twice daily for 7-10 days
  • moxifloxacin : 400 mg orally/intravenously once daily for 3-10 days
  • ampicillin/sulbactam : 1.5 to 3 g intravenously every 6 hours  
  • ticarcillin/clavulanate : 3.1 g intravenously every 6 hours  
  • piperacillin/tazobactam : 3.375 g intravenously every 6 hours  
  • azithromycin : 500 mg orally on day one, followed by 250 mg once daily for 4 days
  • clarithromycin : 500 mg orally twice daily for 3-10 days
  • vancomycin : 500-1000 mg intravenously every 12 hours
Non-Invasive Ventilation
  • Early NIIV is very effective to avoid intubation in severe exacerbations
  • Contraindicated with respiratory arrest, hemodynamic instability, or altered mental status

Indications for Invasive Mechanical Ventilation

Severe dyspnea with use of accessory muscles and paradoxical abdominal motion
Respiratory rate >35 breaths/min
Life-threatening hypoxemia: PaO2 <50 mm Hg (<5.3 kPa) or PaO2/fraction of inspired oxygen <200 mm Hg
Severe acidosis (pH <7.25) and hypercapnia (PaCO2 >60 mm Hg or >8.0 kPa)
Respiratory arrest
Somnolence, impaired mental status
Cardiovascular complications (hypotension, shock, heart failure)
Noninvasive positive pressure ventilation failure

Indications & Relative Contraindications for Noninvasive Ventilation

Selection criteria Moderate to severe dyspnea with use of accessory muscles and paradoxical abdominal motion
Moderate to severe acidosis (pH 7.35) and/or hypercapnia (PaCO2 >6.0 kPa, 45 mm Hg) 
Respiratory frequency > 25 breaths/min
Exclusion criteria (any) Respiratory arrest
Cardiovascular instability (hypotension, arrhythmias, myocardial infarction)
Change in mental status; uncooperative patient
High aspiration risk
Viscous or copious secretions
Recent facial or gastroesophageal surgery
Craniofacial trauma
Fixed nasopharyngeal abnormalities
Burns
Extreme obesity
 
Consider concomitant CHF, PNA, PTX, PE, lobar atelectasis
Smoking cessation and home oxygen are the only 2 interventions shown to lower mortality
 

Chronic COPD




 
Severity of airflow limitation in COPD (based on postbronchodilator FEV1)
In patients with FEV1/FVC <0.7:
GOLD 1 Mild FEV1 ≥80 percent predicted
GOLD 2 Moderate 50 percent ≤ FEV1 , <80 % predicted
GOLD 3 Severe 30 percent ≤ FEV1 , <50 % predicted
GOLD 4 Very Severe FEV1 <30 % predicted
FEV1: forced expiratory volume in one second; FVC: forced vital capacity; respiratory failure
 
Category Symptoms Risk Suggested treatment
All     Avoidance of risk factor(s), such as smoking
Annual influenza vaccination
Pneumococcal vaccination
Regular physical activity
Long-term oxygen therapy if chronic hypoxemia
A Less symptomatic
Mild or infrequent symptoms

(ie, breathless with strenuous exercise or when hurrying on level ground or walking up a slight hill)*

 

Low risk:
FEV1/FVC <0.7

and

FEV1 ≥50 % predicted (GOLD I, II)

and

0 or 1 exacerbations in the past year
First choice: 
Short-acting bronchodilator when needed: anti-cholinergic alone or beta-agonist alone
  • Albuterol inhaled: (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) every 4-6 hours when required
  • Atrovent HFA (ipratropium bromide inhaled) 2 puffs inhaled qid. Max: 12 puffs/day

Second choice: 
Long-acting anticholinergic or long-acting beta agonist or short-acting beta-agonist

  • Spiriva HandiHaler (tiotropium inhaled) : (18 micrograms/dose inhaler) 18 micrograms (1 puff) once daily
    -- OR --
  • Salmeterol inhaled : (50 micrograms/dose inhaler) 50 micrograms (1 puff) twice daily
    -- OR --
  • Albuterol inhaled: (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) every 4-6 hours when required

and
Short-acting anticholinergic PRN

  • Atrovent HFA (ipratropium bromide inhaled) 2 puffs inhaled qid. Max: 12 puffs/day

Alternative: theophylline

B More symptomatic
Moderate to severe symptoms

(ie, patient has to walk more slowly than others of same age due to breathlessness, has to stop to catch breath when walking on level ground at own pace, or has more severe breathlessness)*
Low risk:
FEV1/FVC  <0.7

and

FEV1 ≥50 % predicted (GOLD I, II)

and

0 or 1 exacerbations in the past year

Short-acting bronchodilator when needed and pulmonary rehabilitation

  • Albuterol inhaled: (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) every 4-6 hours when required
  • Atrovent HFA (ipratropium bromide inhaled) 2 puffs inhaled qid. Max: 12 puffs/day

First choice: regular treatment with a long-acting bronchodilator

  • Salmeterol inhaled : (50 micrograms/dose inhaler) 50 micrograms (1 puff) twice daily
    OR
  • Formoterol inhaled : (12 micrograms/dose inhaler) 12 micrograms (1 puff) every 12 hours
    OR
  • Indacaterol inhaled : (75 microgram/capsule inhaler) 75 micrograms (1 capsule) once daily

Second choice: regular treatment with a long-acting beta agonist and long-acting anticholinergic

  • Salmeterol inhaled : (50 micrograms/dose inhaler) 50 micrograms (1 puff) twice daily or
  • Formoterol inhaled : (12 micrograms/dose inhaler) 12 micrograms (1 puff) every 12 hours or
  • Indacaterol inhaled : (75 microgram/capsule inhaler) 75 micrograms (1 capsule) once daily
    -- AND --
  • Spiriva HandiHaler (tiotropium inhaled) : (18 micrograms/dose inhaler) 18 micrograms (1 puff) once daily
Alternatives: short-acting beta-agonist and/or short-acting anticholinergic, theophylline
  • Combivent Respimat 1 puff inhaled qid. Max: 6 puffs/24h
  • Duoneb
C

Less symptomatic

Mild or infrequent symptoms

(ie, breathless with strenuous exercise or when hurrying on level ground or walking up a slight hill)

 

High risk:
 

FEV1/FVC <0.7

and

FEV1 <50 %predicted (GOLD III, IV)

OR

≥2 exacerbations per year or one hospitalization for an exacerbation

 

Short-acting bronchodilator when needed and pulmonary rehabilitation

  • Albuterol inhaled: (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) every 4-6 hours when required
  • Atrovent HFA (ipratropium bromide inhaled) 2 puffs inhaled qid. Max: 12 puffs/day

First choice: regular treatment with a combination long-acting beta agonist and inhaled glucocorticoid or a long-acting anticholinergic

  • Advair HFA (fluticasone propionate/salmeterol inhaled) : (250/50 micrograms/dose inhaler) 1 puff twice daily
  • Symbicort( budesonide/formoterol inhaled) : (160/4.5 micrograms/dose inhaler) 2 puffs twice daily
  • Dulera (mometasone/formoterol inhaled) : (100/5 micrograms/dose inhaler; 200/5 micrograms/dose inhaler) 2 puffs twice daily
  • Breo Ellipta (fluticasone furoate/vilanterol inhaled) : 100/25 micrograms/dose inhaler) 1 puff once daily
    -- OR --
  • Spiriva HandiHaler (tiotropium inhaled) : (18 micrograms/dose inhaler) 18 micrograms (1 puff) once daily

Second choice: regular treatment with a long-acting anticholinergic and a long-acting beta agonist

  • Salmeterol inhaled : (50 micrograms/dose inhaler) 50 micrograms (1 puff) twice daily or
  • Formoterol inhaled : (12 micrograms/dose inhaler) 12 micrograms (1 puff) every 12 hours or
  • Indacaterol inhaled : (75 microgram/capsule inhaler) 75 micrograms (1 capsule) once daily
    -- AND/OR --
  • Spiriva HandiHaler (tiotropium inhaled) : (18 micrograms/dose inhaler) 18 micrograms (1 puff) once daily

Alternatives: phosphodiesterase-4 inhibitor, SABA and/or SAMA, theophylline

Consider surgical treatments
D

More symptomatic

Moderate to severe symptoms

(ie, patient has to walk slower than others of same age due to breathlessness, has to stop to catch breath when walking on level ground at own pace, or has more severe breathlessness)

 

High risk:
 

FEV1/FVC  <0.7

and

FEV1 <50 % predicted (GOLD III, IV)

OR

≥2 exacerbations per year or one hospitalization for an exacerbation

 

Short-acting bronchodilator when needed and pulmonary rehabilitation

  • Albuterol inhaled: (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) every 4-6 hours when required
  • Atrovent HFA (ipratropium bromide inhaled) 2 puffs inhaled qid. Max: 12 puffs/day

First choice: regular treatment with combination inhaled glucocorticoid and a long-acting beta agonist and/or long-acting anticholinergic

  • Advair HFA (fluticasone propionate/salmeterol inhaled) : (250/50 micrograms/dose inhaler) 1 puff twice daily
  • Symbicort( budesonide/formoterol inhaled) : (160/4.5 micrograms/dose inhaler) 2 puffs twice daily
  • Dulera (mometasone/formoterol inhaled) : (100/5 micrograms/dose inhaler; 200/5 micrograms/dose inhaler) 2 puffs twice daily
  • Breo Ellipta (fluticasone furoate/vilanterol inhaled) : 100/25 micrograms/dose inhaler) 1 puff once daily
    -- AND/OR --
  • Spiriva HandiHaler (tiotropium inhaled) : (18 micrograms/dose inhaler) 18 micrograms (1 puff) once daily

Second choice: regular treatment with one of the following combinations:

- Inhaled glucocorticoid and a long-acting beta agonist PLUS a long acting anticholinergic

  • Advair HFA (fluticasone propionate/salmeterol inhaled) : (250/50 micrograms/dose inhaler) 1 puff twice daily
  • Symbicort( budesonide/formoterol inhaled) : (160/4.5 micrograms/dose inhaler) 2 puffs twice daily
  • Dulera (mometasone/formoterol inhaled) : (100/5 micrograms/dose inhaler; 200/5 micrograms/dose inhaler) 2 puffs twice daily
  • Breo Ellipta (fluticasone furoate/vilanterol inhaled) : 100/25 micrograms/dose inhaler) 1 puff once daily
    -- PLUS  --
  • Spiriva HandiHaler (tiotropium inhaled) : (18 micrograms/dose inhaler) 18 micrograms (1 puff) once daily

- Inhaled glucocorticoid and a long-acting beta agonist PLUS a phosphodiesterase-4 inhibitor

  • Breo Ellipta (fluticasone furoate/vilanterol inhaled) : 100/25 micrograms/dose inhaler) 1 puff once daily
  • Advair HFA (fluticasone propionate/salmeterol inhaled) : (250/50 micrograms/dose inhaler) 1 puff twice daily
  • Symbicort( budesonide/formoterol inhaled) : (160/4.5 micrograms/dose inhaler) 2 puffs twice daily
  • Dulera (mometasone/formoterol inhaled) : (100/5 micrograms/dose inhaler; 200/5 micrograms/dose inhaler) 2 puffs twice daily
    -- PLUS --
  • Roflumilast : 500 micrograms orally once daily

- Long-acting anti-cholinergic and a long-acting beta agonist

  • Salmeterol inhaled : (50 micrograms/dose inhaler) 50 micrograms (1 puff) twice daily or
  • Formoterol inhaled : (12 micrograms/dose inhaler) 12 micrograms (1 puff) every 12 hours or
  • Indacaterol inhaled : (75 microgram/capsule inhaler) 75 micrograms (1 capsule) once daily
    -- AND --
  • Spiriva HandiHaler (tiotropium inhaled) : (18 micrograms/dose inhaler) 18 micrograms (1 puff) once daily

- Long-acting anticholinergic and a phosphodiesterase-4 inhibitor

  • Spiriva HandiHaler (tiotropium inhaled) : (18 micrograms/dose inhaler) 18 micrograms (1 puff) once daily
    -- AND --
  • Roflumilast : 500 micrograms orally once daily

Alternatives: Carbocysteine, short-acting beta-agonist and/or short-acting anticholinergic, theophylline

Consider surgical treatments

 


Short-acting bronchodilator
  • albuterol inhaled: (90 micrograms/dose inhaler) 90-180 micrograms (1-2 puffs) every 4-6 hours when required
  • Atrovent HFA (ipratropium bromide inhaled) 2 puffs inhaled qid. Max: 12 puffs/day
  • Combivent Respimat 1 puff inhaled qid. Max: 6 puffs/24h
Long-acting bronchodilator
  • salmeterol inhaled : (50 micrograms/dose inhaler) 50 micrograms (1 puff) twice daily or
  • formoterol inhaled : (12 micrograms/dose inhaler) 12 micrograms (1 puff) every 12 hours or
  • indacaterol inhaled : (75 microgram/capsule inhaler) 75 micrograms (1 capsule) once daily
    -- AND/OR --
  • Spiriva HandiHaler (tiotropium inhaled) : (18 micrograms/dose inhaler) 18 micrograms (1 puff) once daily
Inhaled corticosteroid
  • Beclomethasone dipropionate inhaled : (40 or 80 micrograms/dose inhaler) 80-240 micrograms/day given in 2 divided doses
  • Budesonide inhaled : (90, 100, 180, 200, or 400 micrograms/dose inhaler) 180-600 micrograms/day given in 2 divided doses
  • Fluticasone propionate inhaled : (44, 110, 220 micrograms/dose inhaler) 88-440 micrograms/day given in 2 divided doses
Combination long-acting bronchodilator plus inhaled corticosteroid
  • Breo Ellipta (fluticasone furoate/vilanterol inhaled) : 100/25 micrograms/dose inhaler) 1 puff once daily
  • Advair HFA (fluticasone propionate/salmeterol inhaled) : (250/50 micrograms/dose inhaler) 1 puff twice daily
  • Symbicort( budesonide/formoterol inhaled) : (160/4.5 micrograms/dose inhaler) 2 puffs twice daily
  • Dulera (mometasone/formoterol inhaled) : (100/5 micrograms/dose inhaler; 200/5 micrograms/dose inhaler) 2 puffs twice daily
Smoking cessation
  • All patients should be strongly recommended not to start smoking, or to stop if they are current smokers. Smoking cessation is a primary goal in management of COPD.
  • Nicotine-replacement therapy or other drug therapies in conjunction with appropriate nonpharmacologic therapies should be used.
Vaccination
  • Influenza
  • Pneumonia

 

Goals of COPD Management

  • Relieve disabling dyspnea
  • Improve exercise tolerance
  • To reduce long-term function decline
  • Prevent and treat exacerbations
  • Reduce hospitalizations and mortality
  • Improve health-related quality of life
  • * Tobacco cessation and O2 Rx are the only interventions proven to prolong survival of patients with COPD*

Disposition & Follow-up

Indications for Hospital Admission for Acute Exacerbations of Chronic Obstructive Pulmonary Disease
Marked increase in intensity of symptoms, such as sudden development of resting dyspnea
Background of severe chronic obstructive pulmonary disease
Onset of new physical signs (e.g., cyanosis, peripheral edema)
Failure of exacerbation to respond to initial medical management
Significant comorbidities
Newly occurring arrhythmias
Diagnostic uncertainty
Older age
Insufficient home support

 
Indications for ICU Admission of Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Disease
Severe dyspnea that responds inadequately to initial emergency therapy
Confusion, lethargy, coma
Persistent or worsening hypoxemia: PaO2 <50 mm Hg (<6.7 kPa)
Severe or worsening hypercapnia: PaCO2 >70 mm Hg (>9.3 kPa) 
Severe or worsening respiratory acidosis (pH <7.30) despite supplemental oxygen and noninvasive positive pressure ventilation


Discharge:
If the patient is stable enough for discharge, arrange the following:
(1) adequate supply of home oxygen, if needed
(2) adequate and appropriate bronchodilator treatment
(3) consideration of a short course of oral corticosteroids  and
(4) a follow-up appointment with the primary care physician

 

ADMISSION ORDERS

1. Admit to:
2. Diagnosis: Exacerbation of COPD
3. Condition:
4. Vital Signs: q4h. Call physician if P >130; R >30, <10; T >38.5°C; O2saturation <90%.
5. Activity: Up as tolerated.
6. Nursing: Pulse oximeter. Measure peak flow with portable peak flow meter bid. No sedatives.
7. Diet: No added salt, no caffeine. Push fluids.
8. IV Fluids: D5 1/2 NS with 20 mEq KCL/L at 125 cc/h.
9. Special Medications:
  • Oxygen 1-2 L/min by NC or 24-35% by Venturi mask, keep O2 saturation 90-91%.
     
  • Beta-Agonists, Acute Treatment:
    • [Duoneb updraft] Albuterol 0.5 mg and ipratropium 0.5 mg in 2.5 mL NS q1-2h until peak flow meter ≥200-250 L/min, then q4h prn 
      OR
    • Levalbuterol (Xopenex) 0.63-1.25 mg by nebulization q6-8h prn.
    • -Albuterol (Ventolin) MDI 2-4 puffs q4-6h.
    • -Albuterol/Ipratropium (Combivent) 2-4 puffs qid.
       
  • Maintenance Corticosteroids and Anticholinergics:
    • Triamcinolone (Azmacort) MDI 2 puffs qid or 4 puffs bid.
    • Beclomethasone (Beclovent) MDI 4-8 puffs bid with spacer, followed by gargling with water OR
    • Flunisolide (AeroBid) MDI 2-4 puffs bid OR
    • Ipratropium (Atrovent) MDI 2 puffs tid-qid OR
    • Fluticasone (Flovent) 2-4 puffs bid (44 or 110 mcg/puff).
       
  • Systemic Corticosteroids
    • Methylprednisolone (Solu-Medrol) 125 mg IV x1 NOW
      Then choose from following...

     - MODERATE  Exacerbation:
    Option 1
    : MethylPREDNISolone (MEDROL) IV followed by PO taper
    MethylPREDNISolone (SOLU-MEDROL) 40 mg, IV, q 8 hr, x 6 doses (48 hrs)
    Then
    methylPREDNISolone (MEDROL) tablet
    24 mg, Oral, DAILY AFTER BREAKFAST, x1 dose
    Then
    20 mg, Oral, DAILY AFTER BREAKFAST, x1 dose
    Then
    16 mg, Oral, DAILY AFTER BREAKFAST, x1 dose
    Then
    12 mg, Oral, DAILY AFTER BREAKFAST, x1 dose
    Then
    8 mg, Oral, DAILY AFTER BREAKFAST, x1 dose
    Then
    4 mg, Oral, DAILY AFTER BREAKFAST, x1 dose
    Then Stop

    Option 2
    : MethylPREDNISolone (MEDROL) oral taper

    MethylPREDNISolone (MEDROL) tablet
    24 mg, Oral, DAILY AFTER BREAKFAST, x1 dose
    Then
    20 mg, Oral, DAILY AFTER BREAKFAST, x1 dose
    Then
    16 mg, Oral, DAILY AFTER BREAKFAST, x1 dose
    Then
    12 mg, Oral, DAILY AFTER BREAKFAST, x1 dose
    Then
    8 mg, Oral, DAILY AFTER BREAKFAST, x1 dose
    Then
    4 mg, Oral, DAILY AFTER BREAKFAST, x1 dose
    Then Stop


    - SEVERE Exacerbation
    Option 1:
     MethylPREDNISolone (MEDROL) IV followed by PO taper

    methylPREDNISolone (SOLU-MEDROL) 80 mg, IV, q8h, 6 doses (48 hrs). First dose now
    Then
    methylPREDNISolone (MEDROL) tablet
    24 mg, Oral, TWO TIMES DAILY WITH MEALS, x2 doses
    Then
    20 mg, Oral, TWO TIMES DAILY WITH MEALS, x2 doses
    Then
    16 mg, Oral, TWO TIMES DAILY WITH MEALS, x2 doses
    Then
    12 mg, Oral, TWO TIMES DAILY WITH MEALS, x2 doses
    Then
    8 mg, Oral, TWO TIMES DAILY WITH MEALS, x2 doses
    Then
    4 mg, Oral, TWO TIMES DAILY WITH MEALS, x2 doses
    Then Stop

    Option 2: methylPREDNISolone (MEDROL) oral twice daily taper
    methylPREDNISolone (MEDROL) tablet
    24 mg, Oral, TWO TIMES DAILY WITH MEALS, x2 doses
    Then
    20 mg, Oral, TWO TIMES DAILY WITH MEALS, x2 doses
    Then
    16 mg, Oral, TWO TIMES DAILY WITH MEALS, x2 doses
    Then
    12 mg, Oral, TWO TIMES DAILY WITH MEALS,  2 doses
    Then
    8 mg, Oral, TWO TIMES DAILY WITH MEALS, x2 doses
    Then
    4 mg, Oral, TWO TIMES DAILY WITH MEALS, x2 doses
    Then Stop

Antibiotics:

- Less Severe Exacerbations

  • Antibiotic therapy is recommended for patients whose symptoms suggest bacterial infection, more specifically, patients with at least 2 of the following criteria:
  • Increased sputum purulence (must be present) AND either increased dyspnea or increased sputum volume
    • Option 1: CefTRIAXone (ROCEPHIN) 1,000 mg IV q24h + azithromycin (ZITHROMAX) 500 mg IV q24h
    • Option 2: CefTRIAXone (ROCEPHIN) 1,000 mg IV q24h + doxycycline (VIBRAMYCIN) 100 mg IV BID
    • Option 3: Azithromycin (ZITHROMAX) 500 mg IV q24h

- Severe Exacerbations

  • Antibiotic therapy is recommended for patients whose symptoms suggest bacterial infection, more specifically, patients with at least 2 of the following criteria:
  • Increased sputum purulence (must be present) AND either increased dyspnea or increased sputum volume.
    • Option 1: Piperacillin-tazobactam (ZOSYN) IVPB 3.375 Gram, IV, EVERY 6 HOURS for 28 doses
    • Option 2: Levofloxacin (LEVAQUIN) 750 mg IV q24h

Acute Bronchitis

  • Ceftazidime (Fortaz) 1 g every 8 h OR
  • Cefepime (Maxipime) 1-2 g every 8-12h OR
  • Piperacillin-tazobactam (Zosyn) 4.5 gm IV q6h OR
  • Ceftriaxone (Rocephin) 2 gm IV q12h      OR
  • Cefotaxime (Claforan) 2 gm IV q6h OR
  • Levofloxacin (Levaquin) 750 mg PO/IV PO qd OR
  • Moxifloxacin (Avelox) 400 mg every 24 hours.

10. Symptomatic Medications:

  • Docusate sodium (Colace) 100 mg PO qhs.
  • Famotidine (Pepcid) 20 mg IV/PO bid OR Lansoprazole (Prevacid) 30 mg qd.
  • Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn headache.

11. Extras: 

  • Portable CXR, ECG, +/- PFTs with bronchodilators (usually outpt. test).

12. Labs: 

  • ABG, CBC, CMP, UA, Pro-BNP. +/- Blood culture, Sputum Gram stain and C&S, +/- alpha 1 antitrypsin level.


     


ITE 2013, Q71
A 52-year-old male with hypertension complains of increased dyspnea for the past 6 months. He reports that he has increased fatigue and dyspnea with normal activities. There is no cough or chest pain. He has a 30-pack-year history of smoking. On examination his blood pressure is 130/85 mm Hg, pulse rate 90 beats/min, respiratory rate 18/min, and O2 saturation 95% on room air. Heart sounds are normal with no murmurs. Auscultation of the lungs reveals bilateral rhonchi.
In addition to ordering a chest radiograph, which one of the following should be performed next in the evaluation of this patient’s dyspnea?

A) A B-type natriuretic peptide (BNP) level
B) A D-dimer level
C) Arterial blood gas measurement
D) Spirometry
E) High-resolution CT of the chest