COPD -

Exacerbation

Associate Professor Mark Hurwitz

Director

Respiratory and Sleep Medicine

The Canberra Hospital

COPD - Exacerbation

Exacerbation

Event characterised by a worsening of the patients

respiratory symptoms that is beyond normal day to

day variations and leads to a change in medication.

Generally includes the following symptoms

• increased cough frequency and severity

• increased sputum volume and/or change in

character

• increased dyspnoea

Risk Factors

Candidates with:

Increasing age

Productive cough

Antibiotic therapy

Recent hospitalisation (12 months)

Chronic sputum production

COPD - Exacerbation

COPD - Exacerbation

Risk Factors cont’d...

Candidates with:

Eosinophilia

Co-morbidities

- OCAD

- Cardiac failure

- Diabetes

Progression of the disease

COPD - Exacerbation

Exacerbation Risk

Severity of COPD

History of exacerbations

Hospitalisation for exacerbations

Number of exacerbations

0-1 = Low Risk

>2 = High Risk

Mild to moderate COPD – Low Risk

Severe or very severe – High Risk

COPD - Exacerbation

Oesophageal Reflux

Additional risk for exacerbation

Increased exacerbations = increased reflux

? Benefit from proton pump inhibitor – open mind

Pulmonary Hypertension

Increased risk of exacerbation.

COPD - Exacerbation

Triggers

Respiratory infections 70% of exacerbations

Viral and bacterial infection

Pollution; pulmonary embolism or idiopathic 30%

Idiopathic -

- Coronary Artery Disease

- Cardiac Failure

- Aspiration

- Pulmonary Embolism

COPD - Exacerbation

Clinical Manifestations

Dyspnoea

Productive cough/sputum

Respiratory Failure

Hypoxia

COPD - Exacerbation

Clinical Manifestations

History – increased and worsening of respiratory

symptoms

Time course

Comparison to baseline

Compromise

Sputum characterisation

Hospitalisation

Number of exacerbations

Corticosteroids

COPD - Exacerbation

Clinical Finding

Shortness of breath

Wheeze/Ronchi

Increased respiratory rate

Difficulty speaking

Work of breathing

Reduced mental status

Flap

Alternative diagnosis

COPD - Exacerbation

Evaluation and Diagnosis

Confirm

Cause

Severity

Co-Morbidity

COPD - Exacerbation

Evaluation and Diagnosis

Initial evaluation

Mild:

- Clinical assessment

- Oximetry

COPD - Exacerbation

Evaluation and Diagnosis

Oximetry

CXR

Laboratory studies

Arterial Blood Gas

Additional Tests

ECG

Sputum

Viral Swabs

COPD - Exacerbation

Differential Diagnosis

Heart Failure

Pulmonary Embolism

Pneumonia

Pneumothorax

Chronic sputum production

Chest Xray

Home or Hospital

COPD - Exacerbation

Hospital

Not responded as outpatient

New Signs

Increasing severity

Severity

Frequency

Co-morbidities

Frailty

No support

COPD - Exacerbation

Bronchodilators

Beta Adrenergic Agonists

Anti Cholinergic Agents

Corticosteroids

Antibiotics

Oxygen

COPD - Exacerbation

Supportive Care

Smoking Cessation

Thromboprophylaxis

Mucolytics

COPD - Exacerbation

Management

Methylxanthine (Theophylline)

Antibiotics

Physiotherapy – Bubble PEP

Ventilation – Non invasive

Prognosis

Increased morbidity

Increased mortality

COPD - Exacerbation

Prevention

Smoking Cessation

Pulmonary Rehabilitation

Increased Activity

Vaccination

Combined bronchodilators

Antibiotics

Management Plan

COPD - Exacerbation

Additional Thoughts

Pollution

Medication -

Bronchodilators

Antibiotics

Beta Blockers

COPD - Exacerbation

New Thoughts

Corticosteroids

Beta Blockers

Co-morbidity

Pollution

Fatigue

COPD - Exacerbation

Non Pharmacological Management

Vaccination

Influenza

Pneumococcus

Smoking Cessation

Rehabilitation

Oxygen

COPD - Exacerbation

Pharmalogical

Symptom evaluation not only Spirometry

Combined therapy as first line and the role of

Inhaled Corticosteroids.

COPD - Exacerbation

Co-morbidities

Cardiovascular

Osteoporosis

Gastro oesophageal reflux

Anxiety & Depression

Sleep Apnoea

Palliative Care