3/18/11

Management of the Hospitalized Patient with COPD

March 26, 2011 Focus on Respiratory Care & Sleep Medicine Conference

Jennifer S. Williams, MMS, PA-C Mayo Clinic in Arizona, Instructor in Medicine Midwestern University, Clinical Instructor Kari J. Williams, ANP-BC, ACNP-BC, RN Mayo Clinic in Arizona

Objectives
List the etiologies, signs, and symptoms of a COPD exacerbation Describe indications for hospitalization during a COPD exacerbation Discuss treatment options for the hospitalized patient with a COPD exacerbation Identify perioperative risks for the hospitalized patient with COPD Determine perioperative treatment methods for the hospitalized patient with COPD

Chronic Obstructive Pulmonary Disease

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Chronic Obstructive Pulmonary Disease

Global Initiative for Chronic Obstructive Lung Disease (GOLD)
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases."
http://www.goldcopd.org.

COPD
Chronic bronchitis
Chronic inflammation of bronchial mucous membranes characterized by chronic cough
Productive cough for 3 months in at least 2 consecutive years

Emphysema
Abnormal enlargement of distal air spaces and destruction of bronchial walls and alveoli without fibrosis http://www.prlog.org/10955996-study-links-exerciseto-stronger-breathing-muscles-for-copd.html

Etiology
Tobacco use or exposure Chemical/toxin exposure Air pollution 1-antitrypsin deficiency

http://blog.epiren.com/2009_08_01_archive.html

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Pathophysiology
Exposure to irritant Chronic inflammation
Small airway disease Parenchymal destruction

Chronic airflow limitation

Adapated from http://www.goldcopd.org.

Pathophysiology

http://www.mayoclinic.com/health/medical/IM00989

Symptoms
Dyspnea Chronic productive cough Wheezing Chest tightness exercise capacity Fatigue Anorexia and weight loss in severe disease

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Physical Examination
Hypoxia Tachypnea Shallow, pursed-lip breathing breath sounds Prolonged expiratory phase Rhonchi Wheezes Barrel-shaped chest Cyanosis Clubbing

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Pulmonary function tests (PFTs)

Forced expiratory volume in one second (FEV1) FEV1/forced vital capacity (FVC) Diffusing capacity of the lung for CO (DLCO) Total lung capacity (TLC) Residual volumes

FEV1/FVC <70% post-bronchodilator that is not fully reversible

airflow limitation

COPD PFTs

http://www.mayoclinic.com/health/medical/IM01608

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PFTs and COPD Staging

Stage 1: Mild II: Moderate III: Severe IV: Very severe FEV1/FVC <70% <70% <70% <70% FEV1 80% predicted 50% 30% FEV1 <80% predicted FEV1 < 50% predicted

FEV1 < 30% predicted or FEV1 < 50% predicted + chronic respiratory failure
Adapated from http://www.goldcopd.org.

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COPD CXR

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Chest Radiograph (CXR)

Findings
Hyperinflation
Diaphragm flattening retrosternal air space

AP diameter Parenchymal bullae or subpleural blebs Enlargement of central pulmonary arteries Vertical and narrow heart sillouette
Prominent right heart border

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COPD CT Scan

www.uptodate.com

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Arterial Blood Gas (ABG)

Obtain if:
Signs of respiratory failure
Hypoxemia or hypercapnia are suspected

If FEV1 < 50% predicted Clinical signs of right heart failure

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Treatment
Tobacco cessation Inhalers and small volume nebulizers (SVNs) Glucocorticosteroids Methylxanthines Pulmonary rehabilitation Additional treatment methods

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Tobacco Cessation
Only way to slow progression of COPD Slows the decline in FEV1 in middle-aged smokers with mild airway obstruction Ex-smokers need up to six months to recover alveloar macrophage antimicrobial function

http://hometestingblog.testcountry.com/?tag=no-smoking

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Tobacco Cessation
5% success rate with simply telling a patient to quit Cessation methods
Nicotine transdermal patch Nicotine gum Pharmacologic agents Behavior modification
CURRENT Medical Diagnosis and Treatment. 2007

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Inhalers and SVNs

Bronchodilators
Most important agents in pharmacologic management of COPD Improve symptoms, exercise tolerance, and overall health status

http://www.asthmaready.org/Story.aspx?storyid=20

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Inhalers and SVNs

Anticholinergics
Short-acting
Ipratropium bromide (Atrovent)

Long-acting
Tiotropium (Spiriva)

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Inhalers and SVNs

2-agonists

Short-acting
Salbutamol (Albuterol) Levalbuterol (Xopenex)

Long-acting
Salmeterol (Servent)

Short-acting

2-agonist

+ anticholinergic

Ipratropium + salbutamol (Combivent)

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Glucocorticosteroids
Oral Inhaled
For symptomatic patients with Stage III/IV COPD or with repeated exacerbations
Beclomethasone (QVAR) Budesonide (Pulmicort) Fluticasone (Flovent)

Glucocorticosteroid + long-acting
Fluticasone/Salmeterol (Advair) Budesonide/Formoterol (Symbicort)

2-agonist

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Methylxanthines
Theophylline
Use is controversial Toxicity
Dose-dependent Symptoms
Cardiac arrhythmias, seizures, headache, nausea, heartburn

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Recommended Treatment by Stage

Risk Factors, Vaccines Short-acting bronchodilator when needed 1 longacting bronchodilator when needed; rehab Inhaled steroids if repeated exacerbations Long-term oxygen if chronic respiratory failure; consider surgery

Stage I: Mild Stage II: Moderate Stage III: Severe Stage IV: Very Severe

+ + + +

+ + + + + + + + + +

Adapated from http://www.goldcopd.org.

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Additional Treatment
Avoidance of irritants Energy conserving techniques and pulmonary rehabilitation Influenza and pneumococcal vaccinations Supplemental oxygen Opioids Surgery
Bullectomy, lung volume reduction, lung transplantation

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COPD Exacerbation

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COPD Exacerbation
Global Initiative for Chronic Obstructive Lung Disease (GOLD)
An event in the natural course of the disease characterized by a change in the patients baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD

http://www.goldcopd.org.

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Etiology
Viral infection
Detectable in sputum/nasal lavage in 56% of patients Most commonly Picornaviruses (36%), Influenza A (25%), and Respiratory Syncytial Virus (22%)

Bacterial infection

Chronic lower airway bacterial colonization Most commonly Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis
Clinics in Chest Medicine. 2007

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Etiology
Environmental pollution
Particulate matter from diesel exhaust

Changes in environmental temperature Worsening of underlying comorbid conditions (HF/CKD) can precipitate an exacerbation Often, a clear precipitant is not apparent.

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Pathophysiology
Expiratory flow limitation with mucus production, airway edema, and bronchoconstriction end-expiratory volume with dynamic hyperinflation Impairment of respiratory muscles Dyspnea, tachypnea, and difficulty of muscles to cope with respiratory demand

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Symptoms
Increased:
Dyspnea (64%) Sputum purulence (42%) Sputum volume (26%) Wheeze (35%) Nasal symptoms (35%) Cough (20%) Mental status change
Clinics in Chest Medicine. 2007

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CXR

CT Scan

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ABG
Findings
Compensated respiratory acidosis with worsening acidemia Serial ABGs Comparison to baseline PaO2 <60 mmHg and/or SaO2 <90% with or without PaCO2 >50 mmHg when breathing room air respiratory failure

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Diagnostic Studies
Sputum culture
Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis

PFTs
Not recommended

Influenza screening CBC and BMP ECG

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Indications for Hospitalization

Marked in intensity of symptoms Severe underlying COPD at baseline Onset of new physical signs
Cyanosis, peripheral edema

Failure to respond to initial medical management Significant comorbidities Frequent exacerbations Newly occurring arrhythmias Older age Insufficient home support
http://www.goldcopd.org.

Indications for ICU Admission

Severe dyspnea that responds inadequately to initial emergency therapy Changes in mental status Persistent or worsening hypoxemia (PaO2 <40 mmHg) and/or severe/worsening hypercapnia (PaCO2 >60 mmHg) and/or severe/worsening respiratory acidosis (pH <7.25) despite supplemental oxygen and noninvasive ventilation Need for invasive mechanical ventilation Hemodynamic instability
http://www.goldcopd.org.

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The Hospitalized COPD Patient

10% in-hospital mortality rate
25% require ICU admission
24% mortality rate if admitted to the ICU

More commonly admitted in the winter months

50% more common at this time due to illnesses in viral

Chest. 2008

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Treatment
Tobacco cessation Oxygen Inhalers and small volume nebulizers (SVNs) Glucocorticosteroids Antibiotics Non-invasive positive pressure ventilation (NIPPV) Invasive mechanical ventilation

Oxygen
Goal To prevent acidosis and tissue hypoxia
PaO2 >60 mmHg SaO2 > 90%

Watch for CO2 retention

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Inhalers and SVNs

Bronchodilators
Short-acting
2-agonists*

Salbutamol (Albuterol) Levalbuterol (Xopenex)

Anti-cholinergic
Ipratropium bromide (Atrovent) Tiotropium (Spiriva)

Significantly improve the FEV-1 Additive effect when used in conjunction with each other

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Glucocorticosteroids
Associated with improved lung function, length of hospitalization, and in treatment failure PO vs. IV
Low-dose oral steroids were not associated with worse outcomes than high-dose intravenous therapy.
JAMA. 2010

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Antibiotics
Indications
Symptoms suggestive of an underlying infectious etiology
dyspnea, sputum volume, and sputum purulence sputum purulence + dyspnea or sputum volume

Severe exacerbation, requiring mechanical ventilation

Invasive or non-invasive

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Antibiotics
Choice of antibiotic and duration of treatment depend on the severity of the exacerbation
First line
Amoxil (Amoxicillin) Doxycycline Trimethoprim/Sulfamethoxazole (Bactrim)

Second line
2nd and 3rd generation cephalosporins Flouroquinolones

Antibiotics
Consider Gram-negative bacilli and Pseudomonas aeruginosa in the following patients:
Severe COPD at baseline Elderly Receiving multiple or frequent antibiotics Requiring mechanical ventilation Recent hospitalization Are more susceptible to resistant pathogens

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The Evidence
Compared to placebo:
Systemic glucocorticosteroids
treatment failure by 46% length of hospital stay by 1.4 days FEV1 by 0.13 L three days after therapy

Antibiotics
treatment failure by 46% in-hospital mortality by 78%
Chest. 2008

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NIPPV
BiPAP and CPAP High-flow oxygen Advantages
need for endotracheal intubation length of hospitalization mortality

http://emedicine.medscape.com/article/304235-overview

NIPPV
Indications
Moderate to severe dyspnea with the use of accessory muscles/paradoxic abdominal motion Moderate to severe acidemia (pH < 7.35) and/or hypercapnia (PaCO2 > 45 mm Hg) Respiratory rate > 25 breaths per minute
http://www.goldcopd.org.

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NIPPV
Contraindications
Respiratory arrest CV instability
Hypotension, MI, arrhythmias

Diminished mental status Inability or unwillingness of patient High aspiration risk Copious secretions Extreme obesity Recent facial/gastroesophageal surgery Craniofacial trauma
http://www.goldcopd.org.

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The Evidence
Compared to standard therapy
NIPPV
risk of intubation by 65% in-hospital mortality by 55% length of hospital stay by 1.9 days

Chest. 2008

Discharge Criteria
Inhaled

2-agonist therapy Q4 hours Ambulation without significant symptoms Clinical stability for 12-24 hours Appropriate home and follow-up arrangements Patient understanding of outpatient treatment plan

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Preventing Future Exacerbations

Tobacco cessation Self-management education Vaccinations Pulmonary rehabilitation ? prophylactic antibiotics

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Perioperative Management of Patients with COPD

Surgical Complications
Cardiac Pulmonary
Pneumonia Atelectasis airflow obstruction COPD exacerbation risk of acute respiratory failure

Considerations
COPD severity Tobacco use Age >60 Obesity Heart failure Poor general health status/performance status

Thorough history and physical examination needed to identify risk factors

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Factors Associated with Increased Risk

Type of surgery
Abdominal, thoracic, vascular, head and neck, neurosurgery, emergency surgery

Surgical site
risk as incision approaches diaphragm

Length of surgery
Prolonged surgery (>3 hours)

Anesthesia
General > epidural or spinal

Preoperative Interventions
Tobacco cessation
Moller et al (2002): Hip and knee replacements
Cessation 6-8 weeks preoperatively postoperative morbidity

Wein (2009): CABG

Cessation weeks prior have risk of postoperative respiratory complications
Due to transient in sputum production

Improves wound healing

Preoperative Interventions
CXR PFTs
Not routinely recommended
But recommended prior to lung resection

ABG
Recommended prior to lung resection

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Preoperative Interventions
Patients with symptomatic COPD should receive daily inhaled ipratropium or tiotropium prior to surgery. Patient education
Lung expansion maneuvers

Preparation is key!
incidence of pulmonary complications in those receiving preoperative preparation
Combination of bronchodilators, antibiotics, and glucocorticosteroids if necessary

When to Proceed
If COPD exacerbation is present, do not proceed with surgical procedure. If COPD stable, treat with traditional treatment modalities.

Postoperative Interventions
Lung expansion modalities
Incentive spirometer Cough and deep breathing risk of pulmonary complications by Chest percussion Suctioning Early ambulation Intermittent positive-pressure breathing
Can cause abdominal distention

NIPPV

http://healthpages.org/wp-content/uploads/2010/06/ incentive-spirometer-300x300.jpg

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Postoperative interventions
Pain control
Leads to earlier ambulation Improves ability to breathe deeply Epidural analgesia vs. opioids

Use of nasogastric tube as needed

risk of atelectasis and pneumonia

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Postoperative Interventions
Inhaled beta-agonists
As needed for symptomatic wheezing

Glucocorticosteroids
Persistent wheezing/functional limitations despite bronchodilator therapy

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References
Ali, NK. Evidence-based approach to acute exacerbations of chronic obstructive pulmonary disease. Hospital Physician. 2009; 38: 9-16. From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2010. Available from: http://www.goldcopd.org. Hurst JR, Wedzicha JA. The biology of a chronic obstructive pulmonary disease exacerbation. Clinics in Chest Medicine. 2007; 28: 525-536. Lindenauer PK, Pekow PS, Lahti MC, Lee Y, et al. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA. 2010; 303(23): 2359-2367.

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References
Moller AM, Villebro N, Pedersen T, Tonneson H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002; 359: 114-117. Papadakis MA, McPhee SJ. Current Consult Medicine. New York, NY: McGraw Hill Lange; 2007. Papadakis MA, McPhee SJ, Tierney LM. CURRENT Medical Diagnosis and Treatment. McGraw Hill Lange; 2007. Poon CA, Becker, KA, Littner, MR. Noninvasive positive airway pressure in hypercapnic respiratory failure in noncardiac medical disorders. Sleep Medicine Clinics. 2010; 5: 451-470.

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References
Qaseem A, Snow V, Fitterman N, Hornbake ER, et al. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Annals of Internal Medicine. 2006; 144(8): 575-581. Quon BS, Gan WQ, Sin DD. Contemporary management of acute exacerbations of COPD: a systematic review and metanalysis. Chest. 2008; 133: 756-766. Wien RO. Preoperative smoking cessation: impact on perioperative and long-term complications. Arch Otolaryngol Head Neck Surg. 2009; 135(6): 597-601. Wojciechowski B. Management of COPD exacerbations. Focus Journal. 2010; 22-23 and 35. www.uptodate.com

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