Exacerbation of COPDExacerbation of COPD

Tamsil SyafiuddinTamsil Syafiuddin

20052005

AECBAECB

Outline of discussion• Diagosis of COPD• Diagnosis acute exacerbation of COPD• Impact of acute exacerbation COPD• Treatment of acute exaerbation COPD

Definition of Definition of CChronic hronic OObstructive bstructive PPulmonary ulmonary DDisease (isease (COPDCOPD))

• COPD is a disease state characterized by airflow limitation that is not fully reversible

• The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.

R. A. Pauwels et al. AJCCM 2001; 163:1256-76NHLBI/WHO Global Initiative (GOLD)

DIAGNOSIS OF COPDDIAGNOSIS OF COPD

• A diagnosis of COPD should be considered in any patient who has symptoms of cough, sputum production, or dyspnea, and/or a history of exposure to risk factors for the disease.

• The diagnosis is confirmed by spirometrie

R. A. Pauwels et al. AJCCM 2001; 163:1256-76NHLBI/WHO Global Initiative (GOLD)

How to Diagnosis/How to thing

Data:

Analysis

Planning

Lung/COPD ?

Heart/LVF?

Cough ?Dyspnoe ?Wheezing ?Age?

Risk factors?

Radiologic examinations?

Spirometri

PEFR

Data

• Pathogenic bacteria are found in 50 - 80% of patients experiencing AECB.

AECBAECB

R. A. Pauwels et al. AJCCM 2001; 163:1256-76NHLBI/WHO Global Initiative (GOLD)

Importance of ExacerbationsImportance of Exacerbations

1Burrows. NEJM 1969; 280:397-4042Miravitlles. Respir Med 1999; 93:173-179

• Exacerbations are the most common observable cause of death in prospective studies1

• COPD patients suffered mean of 2 AE/year, with a high drug use; 10% required admission2

Causative Pathogens in LRTI I

H. influenzae S. pneumoniae Branhamella catarrhalis Mycoplasma/Chlamydia?

Purulent Bronchitis

Advanced Clinical Disease Klebsiella spp. Proteus spp. Enterobacter spp. P. aeruginosa

Infective Exacerbationsof Chronic Bronchitis

Relation betweenBacteriologic Etiology

and Lung FunctionJörg Eller, MD; Anja Ede, MD; Tom Schaberg, PhD;

Michael S. Niedermann, MD, FCCP; Harald Mauch, MD; and Hartmut Lode, MDChest 1998;113:1542-1548

•Study objective: Possible relationship between functional respirat. impairment (FEV1) and pathogens in AECB

•Setting: 6 pneumology units in Spain

•Patients: 91 with AECB

•Interventions: Quantitative sputum cultures (106 pathogens, <10 squ. cells, >25 granuloc.)

Relationship Between Bacterial Flora in Sputum and Functional Impairment in Patients With

Acute Exacerbations of COPD

Miravitlles M et al. Chest 1999;116:40

•Results: FEV1 <50%, was associated with a high risk of P. aeruginosa or H. influenzae isolation (OR; 6.62)

•Conclusions: Pat. with the greatest degree of functional impairment presented a higher probability

of P. aeruginosa or H. influenzae

Relationship Between Bacterial Flora in Sputum and Functional Impairment in Patients With Acute Exacerbations of

COPD

Miravitlles M et al. Chest 1999;116:40

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es M

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199

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Changes in Bronchial Inflammation during acute exacerbations of chronic

bronchitis

S. Gompertz, C. O‘Brien, D.L. Bayley, S.L.Hill R.A. Stockley

Europ Respir J 2001; 17:1112-1119

Inflammatory mediators at presentation

Mucoid Purulentbronchitics bronchitics

MPO units x mL-1 0.48 (0.37-0.69) 0.62 (0.42-1.50)+NE nM 0.0 (0.0-0.0) 7.6 (0.8-13.8)***IL8 nM 2.4 (07-4.7) 5.5 (2.8-12.6)***LTB4 nM 3.4 (1.1-11.3) 7.1 (4.6-15.2)+Albumin ratio % 0.4 (0.3-0.9) 1.4 (0.7)-3.1)***

Data are presented as median (interquartile range). MPO:myeloperoxidase; NE: neutrophil elastase; IL-8 interleukin-8; LTB4:leukotriene B4; +: p < 0.025;***: p < 0.001

The Vicious Circle of Respiratory Decline in Chronic Bronchitis

Breathing in COPD

Normal Alveolar Emptying

Alveolar Emptying in COPD

In COPD, airflow is limited because alveoli lose their elasticity, supportive structures are lost, and small airways are narrowed

Breathing in COPD

Air Trapping Air Trapping Occurs in patients with COPDOccurs in patients with COPD Results in an increase in the work of breathing Results in an increase in the work of breathing Places respiratory muscles at a mechanical disadvantagePlaces respiratory muscles at a mechanical disadvantage Contributes to the sensation of breathlessness (dyspnea)Contributes to the sensation of breathlessness (dyspnea)

NormalNormal HyperinflationHyperinflation

Images courtesy of Denis O’Donnell, Queen’s University, Kingston, CanadaImages courtesy of Denis O’Donnell, Queen’s University, Kingston, Canada

Chronic Obstructive Pulmonary Disease (COPD)Chronic Obstructive Pulmonary Disease (COPD)

TreatmentTreatment

The 3 major goals of the comprehensive The 3 major goals of the comprehensive treatment of COPDtreatment of COPD : :

•Lessen airflow limitationLessen airflow limitation

•Prevent and treat secondary medical complications Prevent and treat secondary medical complications (eg, hypoxemia, infection) (eg, hypoxemia, infection)

•Decrease respiratory symptoms and improve QoLDecrease respiratory symptoms and improve QoL

The goal of the treatment of COPD The goal of the treatment of COPD

to improve to improve daily livingdaily living and and quality of lifequality of life by by

preventingpreventing symptoms symptoms and and exacerbationsexacerbations

optimal lung functionoptimal lung function

•Smoking cessation is the most important thing to improve COPD symptoms

preventingpreventing symptoms symptoms and and exacerbationsexacerbations

Acute exacerbation of COPD is one of the major reasons for hospital admission in the

United States.

Bronchodilators

• Inhaled beta2 agonists are the treatment of choice for acute exacerbations of COPD

•Usually delivered via a nebulizer

•Adding Xanthin to the combination of bronchodilators can be beneficial

• Inhaled anticholinergic agent is also usually added.

•Corticosteroids are used if do not improve sufficiently after trying other drugs or who develop an exacerbation.

Sharma S, Graham L, Pulmonary and Critical Care Medicine, University of Manitoba, Lung and Airway, 2004

Hospitalized :Hospitalized :

•develop severe develop severe respiratory dysfunctionrespiratory dysfunction•serious serious respiratory diseases (eg, pneumonia, acute respiratory diseases (eg, pneumonia, acute

bronchitis)bronchitis)

The purpose of hospitalization is to The purpose of hospitalization is to treat symptomstreat symptoms and and to to preventprevent further deterioration/lung functions. further deterioration/lung functions.

This therapy is most beneficial for people This therapy is most beneficial for people whose exacerbations are characterized by at whose exacerbations are characterized by at

least 2 of the following (ie, Winnipeg criteria): least 2 of the following (ie, Winnipeg criteria):

•increased shortness of breath,increased shortness of breath,• increased sputum production, increased sputum production,

•and increased sputum purulence.and increased sputum purulence.

AntibioticsAntibiotics

American Thoracic Society Proposed Classification of

AECBsType Core organisms Features

Uncomplicated H. influenzae, S. pneumoniae <4 exacerbations per yearM. catarrhalis, H. parainfluenzae No comorbidity

Complicated Increased risk of drug-resistant <64 years oldS. pneumoniae and Gram- <4 exacerbations per year negative bacilliComorbidityCost of failure greater

Suppurative Risk of P. aeruginosa Chronic steroid useFEV1 <35% of predicted

American Thoracic Society. Am J Respir Crit Care Med 2001,

Winnipeg criteria for AECBWinnipeg criteria for AECB

Typ I Typ II Typ III*Dyspnoe

Sputum purulent

Sputum volume

Anthonisen et al. Ann Intern Med 1987

American Thoracic Society Proposed Treatment

Guidelines for AECBsType Agent

Uncomplicated New macrolide (azithromycin, clarithromycin), cephalosporin (cefuroxime, cefpodoxime, cefprozil) doxycycline

Complicated Fluoroquinolone, amoxicillin/claculanic

Suppurative Ciprofloxacin

American Thoracic Society. Am J Respir Crit Care Med 2001,

General guidelines that are used in determining the ideal time to begin ventilatory support are as follows:

•progressive worsening of respiratory acidosis and/or an altered mental state.

•significant hypoxemia despite supplemental oxygen.

Assisted ventilation/ICUAssisted ventilation/ICU

Admitted to the intensive care unit (ICU) if require the following symptoms:

•Confusion

•Lethargy

•Respiratory muscle fatigue

•Worsening hypoxemia (not enough oxygen in the blood)

•Respiratory acidosis (retention of carbon dioxide in the blood)

How to Diagnosis/How to thing

Data:

Analysis

Planning

Lung/COPD ?

Heart/LVF?

Cough ?Dyspnoe ?Wheezing ?Age?

Risk factors?

Radiologic examinations?

Spirometri

PEFR

Data

Missed diagnosis COPD