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    Chronic Obstructive Pulmonary Disease (COPD) – Treatment

    Respiratory

    Last Updated Jan 06, 2020
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    Context

    Acute Exacerbations of COPD (AECOPD) negatively impact health status and disease progression.

    Recommended Treatment

    More than 80% of exacerbations are managed on an outpatient basis with pharmacological therapies including bronchodilators, corticosteroids, and antibiotics.

    Drug Treatments

     

    Oxygen

    • Titrate oxygen saturation to 88-92%.
    • Avoid overoxygenation.

    Bronchodilators

    • Short-acting beta2-agonists, with or without short-acting anticholinergics.
    • No difference between both or their combination.
    • No difference in clinical outcomes between inhaled use with a spacer and nebulized administration of these agents.

    Corticosteroids

    • Improve lung function, oxygenation, risk of early relapse, treatment failure, and the length of hospitalization.
    • Duration: 5-7 days.
    • Oral is equivalent to intravenous
    • Choice based on patient´s clinical condition.

    Antibiotics

    • Recommended for patients with:
      • all three cardinal symptoms:
        • increase in dyspnea,
        • sputum volume, and
        • sputum purulence;
      • two cardinal symptoms, if increased purulence of sputum is a symptom;
      • require mechanical ventilation (invasive or noninvasive).
    • Strong benefit among patients admitted to ICU.
    • Duration: 5-7 days.
    • Adjust to local antibiogram.

     

    • UK National Institute for Health and Care Excellence (NICE) Guidelines 2019
      • Oral
        • Amoxicillin 500 mg TID.
        • Doxycycline 200 mg 1st day then 100 mg/day for total 5 days (note dosage).
        • Clarithromycin 500 mg BID.
        • If higher risk complications: Clavulin 500/125 mg TID 5 days or Septra DS 1 Tab BID 5 days.
      • IV (can’t take po/severely unwell)
        • Amoxicillin 500 mg TID.
        • Piperacillin/tazobactam 4.5 G TID.

    Magnesium Sulfate

    • Role remains uncertain.

    Methylxanthines

    • Not routinely recommended.

     

    Non-Drug Treatments

     

    Non-Invasive Ventilation (NIV)

    First-line in patients admitted with acute hypercapnic respiratory failure:

    • Improves gas exchange, work of breathing, mortality and intubation rate.
    • BiPAP is preferred to CPAP.

    Indications

    • Respiratory rate of >28 breaths/min.
    • Signs of respiratory fatigue or increased work of breathing.
    • PaCO2 >45mmHg with a pH <7.35.
    • Persistent hypoxemia.

    Contraindications

    • Absolute
      • Need endotracheal intubation.
      • Decreased level of consciousness.
      • Excess respiratory secretions.
      • Risk of vomiting and aspiration.
      • Inability to tolerate.
      • Unable to obtain a seal (craniofacial abnormalities, beard).
    • Relative
      • Haemodynamic instability.
      • Severe hypoxia and/or hypercapnia.

    NIV failure

    • Progressive respiratory distress or rising respiratory rate.
    • Decreasing level of consciousness.
    • Haemodynamic instability.
    • Worsening pH, PCO2, PO2.
    • Worsening PaO2/FiO2 ratio.

    Indications for Mechanical Ventilation

    • NIV contraindication or failure.
    • Respiratory or cardiac arrest.
    • Worsening respiratory fatigue.
    • Decreased level of consciousness.
    • Hemodynamic instability.
    • Persistent hypoxemia.

    Delayed Sequence Intubation – increasingly used

    • To optimize oxygenation conditions prior to intubation.
    • Ketamine 0.5-1 mg/kg.
    • Dexmedetomidine.

    Rapid Sequence Intubation

    • Propofol or Ketamine are recommended.
    • No difference in muscle relaxant:
      • Succinylcholine 1.5 mg/kg.
      • Rocuronium 1 mg/kg.

     

    Clinical Pathway

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    Criteria For Hospital Admission

    • Severe symptoms at rest or with walk test.
    • Oxygen saturation < 89%.
    • Altered mental status.
    • Acute respiratory failure.
    • Failure to respond to medical treatment.
    • Significant comorbidities.
    • Insufficient home support.

    Criteria For Safe Discharge Home

    Patients treated as outpatients should receive:

    Education

    • Inhaler technique.
    • Use of a spacer.
    • Smoking cessation assistance.
    • Vaccinations.
    • Strategies to prevent further exacerbations.

    Medical management

    • Short-acting inhaled beta-2 agonists, with or without short-acting anticholinergics.
    • Corticosteroid short course.
    • Antibiotics  (patients with a change in their sputum).
    • Long-acting inhaled bronchodilators with or without inhaled corticosteroids.

    Scheduled follow-up

    Quality Of Evidence?

    Justification

    Moderate

    Related Information

    Reference List

    Relevant Resources

    RELEVANT CLINICAL RESOURCES

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    RELEVANT VIDEO

    04:53

    Noninvasive Positive Pressure Ventilation (BiPAP/CPAP)

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