COPD

Chronic COPD Management

Pt > 45 y/o with 40+ pack/year smoking history, chronic air pollution/occupational dust exposure presents with dyspnea. Reports chronic cough, wheezing. Family history includes alpha-1 antitrypsin deficiency. Maximal laryngeal height < 4 cm, diminished breath sounds, wheezing on exam.

• Administer COPD Assessment Test (CAT)

• Refer for spirometry: Evaluate for FEV1/FVC < 0.7, peak flow < 350 L/min

• Imaging

  • Previous x-ray shows lung hyperinflation with flattened hemidiaphragms

  • Dyspnea out of proportion to spirometry: Consider

    • Echocardiogram to rule out pulmonary arterial hypertension

    • CT angiography to rule out pulmonary embolism

• Treatment

  • Vaccination: Administer yearly influenza vaccine

    • Age 19-64 years: 1 dose PPSV23

    • Age 65+ years: 1 dose PCV13 followed by PPSV23 in 1 year

  • GOLD category 1-2 (FEV1/FVC ≥ 50%) and ≤ 1 exacerbation per year

    • A. CAT < 10: Albuterol ER 4 mg BID (SABA)

    • B. CAT ≥ 10: Add tiotropium (anticholinergic) 1 puff/day

  • GOLD category 3-4 (FEV1/FVC < 50%) or 2+ exacerbations per year

    • C. CAT < 10: Albuterol ER 4 mg BID + tiotropium 1 puff/day + pulmonary rehab referral

    • D. CAT ≥ 10: Albuterol ER 4 mg BID + fluticasone/salmeterol 1 puff BID + pulmonary rehab referral; consider roflumilast

  • Resting SPO2 < 88% or PaO2 < 60 mmHg: Start supplemental oxygen and refer to pulmonology

• Smoking cessation: Pt advised to stop smoking to reduce further FEV1 decline

Notes

• FEV1 GOLD category

  • Category 1: ≥ 80%

  • Category 2: 50-79%

  • Category 3: 30-49%

  • Category 4: < 30%

• Treatment: See Obstructive Lung Disease Medications for further details

  • Supplemental oxygen

    • Decreases mortality when indicated

    • The only proven therapy for COPD-related PAH

  • Tiotropium and salmeterol have been shown to reduce hospitalization

  • Avoid short acting anticholinergics in patients with cardiac disease

  • Fluticasone/salmeterol = corticosteroid/LABA (brand name Advair)

  • Roflumilast (Daliresp) = PD4 inhibitor

COPD Exacerbation

Pt > 45 y/o with 40+ pack/year smoking history presents with acute on chronic dyspnea. Reports recent sick contact and exposure to allergens followed by increased dyspnea, sputum volume, and sputum purulence. Acute dyspnea worse with exertion. SPO2 < 90%, diffuse wheezing bilaterally on exam.

• Admit to inpatient for any of the following: Failed outpatient therapy, rapidly worsening dyspnea/hypoxia/hypoxemia, altered mental status

• CBC, BMP and consider ABG

• CXR to exclude pneumonia, pneumothorax, pulmonary edema, pleural effusion

• Initial treatment

  • Duoneb (albuterol 2.5 mg/ipratropium 0.5 mg) 1 vial q4h while awake

  • Prednisone 50 mg x 5 days to reduce risk of symptom relapse

  • Home medications

    • Hold Spiriva (tiotropium) 1 puff qd; restart upon discharge

    • If CAT ≥ 10 with FEV1 < 50% or 2+ exacerbations in the past year, start Advair 1 puff BID at discharge

  • Titrate O2 to maintain SPO2 > 88% and consider CPAP if evidence of chronic hypercapnia

• Antibiotic coverage for moderate to severe exacerbations involving increased sputum purulence

  • No additional risk factors: Azithromycin 500 mg x 1 day followed by 250 mg x 4 days

  • Concern for PNA or risk factors for poor outcome (age ≥ 65 years, ≥ 2 exacerbations/year, h/o cardiac disease): Augmentin 875 mg BID x 5 days

  • Pseudomonas risk factors (previous infection, frequent hospitalization, systemic glucocorticoids)

    • Obtain sputum gram stain and culture

    • Consider adding Zosyn 4.5 g IV q6h if condition deteriorates

• Vaccination and smoking cessation: See section on chronic COPD management (above)

Notes

• Three cardinal symptoms: Increased dyspnea, increased sputum volume, and increased sputum purulence

• Pathogens associated with pneumonia risk: S. pneumoniae, H. influenza, Moraxella

• Antibiotic therapy x 5-7 days during exacerbations

  • Only beneficial for patients who meet one of the following criteria (GOLD 2019):

    • Increased sputum purulence + at least one additional cardinal symptom

    • Moderate to severe exacerbation (meet one of the following): Accessory muscle use, RR > 30 BPM, change in mental status, PaCO2 > 50 mmHg

    • Require mechanical ventilation

  • If appropriate, may shorten recovery time and reduce risk of early relapse, treatment failure, hospitalization duration

• Continuous antibiotic prophylaxis, e.g. azithromycin 250 mg MWF may reduce exacerbation frequency, but is not effective beyond 1 year