COPD Exacerbation (Inpatient)

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COPD Exacerbation is one of the most common reasons for admission to the hospital. Here's a streamlined approach (with some key pearls and literature) to make admitting these patients second nature. - Thread - #MedTwitter #MedEd #FOAMEd #tipsfornewdocs #POCM

Check out these @pointofcaremed digital resources for AECOPD: Online Template: pointofcaremedicine.com/pulmonology-and-critical-care/aecopd Podcast: anchor.fm/pointofcarepodcast/episodes/COPD-Exacerbation-Inpatient-e1v11tv YouTube Video: youtu.be/qFl3uQfyPqs @GlassHealthHQ: glass.health/read/tNco9ZUL2Q/

AECOPD is a clinical diagnosis and is broadly defined as a worsening of respiratory symptoms in a COPD patient necessitating further treatment. Cardinal Symptoms: - dyspnea - increased freq and severity of cough - increased volume/purulence of sputum

Here's a checklist to use when admitting a patient with AECOPD. Some key things to remember: - Chart Check - home med fills, prior exacerbations, and intubations - Can't Miss - respiratory failure and PE - Admission orders - include VitD, RVP, steroids, abx if needed

Here is the most pertinent info to collect for your HPI. - Home meds - understand issues with adherence/access, and ensure the patient demonstrates proper inhaler use - Symptoms - dyspnea, sputum, cough, URI sxs, CHF sxs - Trigger - sick contacts, missed meds, etc.

For the physical exam, focus on: - Increased WOB: tachypnea, nasal flaring, retraction, tripoding, pursed lips, difficulty speaking, etc - AMS - Lung sounds: wheezing, rhonchi, rales - Volume exam (JVP, LE edema, POCUS) - e/o DVT (leg swellingg, erythema, pain)

Your DDx should include: - CHF - volume exam, BNP - PNA - WBC, RVP, CXR - PTX - CXR - PE - D-dimer, CTPE (if either indicated)

Here is a sample workup to include in your plan: Some notes: - RVP and procalcitonin can be useful if you are not sure about antibiotics, though they are not necessarily validated for that purpose - VBG will likely show chronic hypercarbia and may not be useful

Treatment is based around: - Bronchodilators - albuterol and ipratropium Q4-6 standing with albuterol q2 PRN - Steroids - PO pred 40mg for 5 days; IV methylpred if severe - Abx: azithro most commonly used, but consider CTX or levoflox if c/f PNA or pip-tazo if c/f PsA

NIPPV is almost always worth trialing before intubation. That being said, if the patient is crashing or has worsening hypercarbia or pH despite these measures, you should not delay intubation.

Pearl #1 Home O2 (if SpO2 <88%) and quitting smoking are the only things that decrease mortality in the outpatient setting

BUT Hyperoxia leads to worse outcomes! Likely due to worsening hypercarbia via: - The Haldane effect - Improper pulmonary vasoconstriction --> V/Q mismatch NOT due to reduced respiratory drive (which seems to be what we were all taught) ncbi.nlm.nih.gov/pmc/articles/PMC3682248/

Pearl #2 Cochrane Analysis: somewhat favors nebs over inhalers in AECOPD, but inhalers deliver a more potent dose, are cheaper, less aerosolizing, and more portable. Start with nebs, then switch to inhalers - an opportunity for inhaler teaching! cochrane.org/CD011826/AIRWAYS_bronchodilators-delivered-nebuliser-versus-inhalers-lung-attacks-chronic-obstructive-pulmonary

Pearl #3 You should use PO steroids if the patient can tolerate it 60mg PO was non-inferior to 60mg IV prednisolone (LOS, treatment failure) (Chest, 2007) pubmed.ncbi.nlm.nih.gov/17646228/

Pearl #4 REDUCE Trial 5 days of steroids is enough 5 days of PO steroids was non-inferior to 14 days (six-month re-admissions) pubmed.ncbi.nlm.nih.gov/23695200/

Pearl #5 Vitamin D supplementation can help reduce mod/severe exacerbations if baseline 25(OH) levels <25. pubmed.ncbi.nlm.nih.gov/30630893/

Pearl #6 There has been increasing attention on disparities inherent in pulse oximeters and the effect of occult hypoxemia, which is 3x more prevalent in black patients when compared to white patients. More here: nejm.org/doi/full/10.1056/nejmc2029240 jamanetwork.com/journals/jamanetworkopen/fullarticle/2785794

Here are some great resources: Shoutout to @thecurbsiders, @COREIMpodcast, @runthelistpod for amazing COPD-related content. use-inhalers.com/ is also amazing for reviewing how to properly use different inhalers so you can make sure your patients are doing it right!

If you remember nothing else: - Clinical Dx - dyspnea, cough, sputum - DDx for hypoxia and resp distress includes CHF, PNA, PTX, PE - Most common etiology is a viral infection - Tx - duonebs, steroids, abx - Trial NIPPV if needed, but don't delay intubation