1、Acute Exacerbation of Chronic Obstructive Pulmonary Disease.Prof.Ashraf M.Hatem,MD,FCCP1Definition of Acute exacerbation:The definition of COPD exacerbation is an acute change in a patients baseline dyspnoea,cough and/or sputum beyond day-to-day variability sufficient to warrant a change in therapy.
2、Causes of exacerbation can be both infectious and non-infectious e.g.air pollution.2 Most commonly encountered organisms:-Streptococcus pneumoniae-Hemophilus influenzae-Moraxella catarrhalis The cause in one third of exacerbations remains unidentified34Classification of Severity of Acute Exacerbatio
3、n of COPD The Operational Classification of Severity is as follows:Level I:ambulatory(outpatient),Level II:requiring hospitalisation,and Level III:acute respiratory failure.5The Operational Classification of Severity of COPD exacerbationLevel ILevel IILevel IIIClinical historyCo-morbid conditionsHis
4、tory of frequent exacerbationsSeverity of COPD+Mild/moderate+Moderate/severe+SeverePhysical findingsHaemodynamic evaluationUse accessory respiratory muscles,tachypnoeaPersistent symptoms after initial therapyStableNot presentNoStable+Stable/unstable+Diagnostic proceduresOxygen saturationArterial blo
5、od gasesChest radiographBlood testsSerum drug concentrationsSputum gram stain and cultureElectrocardiogramYesNoNoNoIf applicableNoNoYesYesYesYesIf applicableYes YesYesYesYesYesIf applicableYesYes6 Indications for hospitalisation of patients with a COPD exacerbation Presence of high-risk co-morbid co
6、nditions,including pneumonia,cardiac arrhythmia,congestive heart failure,diabetes mellitus,renal or liver failure Inadequate response of symptoms to outpatient management Marked increase in dyspnoea Inability to eat or sleep due to symptoms Worsening hypoxaemia Worsening hypercapnia Changes in menta
7、l status Inability of the patient to care for her/himself Uncertain diagnosis Inadequate home care7Level I:outpatient treatmentPatient educationCheck inhalation techniqueConsider use of spacer devicesBronchodilatorsShort-acting 2-agonist and/or ipratropium MDI with spacer or hand-held nebulizer as n
8、eededConsider adding long-acting bronchodilator if patient is not already using it.Corticosteroids(the actual dose may vary)Prednisone 3040 mg per os q day for 10 daysConsider using an inhaled corticosteroid Antibiotics May be initiated in patients with altered sputum characteristics Choice should b
9、e based on local bacteria resistance patterns -Amoxicillin/ampicillin,cephalosporins -Doxycycline -MacrolidesIf the patient has failed prior antibiotic therapy consider:-Amoxicillin/clavulanate -Respiratory fluoroquinolones8Level II:treatment for hospitalised patientBronchodilators-Short acting 2-ag
10、onist(albuterol,salbutamol)and/or-Ipratropium MDI with spacer or hand-held nebuliser as neededSupplemental oxygen(if saturation 90%.Main delivery devices include nasal cannula and venturi mask.Alternative delivery devices include nonrebreather mask,reservoir cannula,nasal cannula or transtracheal ca
11、theter.11 Arterial blood gases should be monitored for arterial oxygen tension(Pa,O2),arterial carbon dioxide tension(Pa,CO2)and pH.Arterial oxygen saturation as measured by pulse oximetry(Sp,O2)should be monitored for trending and adjusting oxygen settings.12 Prevention of tissue hypoxia supersedes
12、 CO2 retention concerns.If CO2 retention occurs,monitor for acidosis.If acidaemia occurs,consider mechanical ventilation.1314MEASURES TO MOBILIZE AIRWAY SECRETIONSIN HOSPITALIZED PATIENTS WITH COPD Directed coughing,“huff coughing.”Benefit extrapolated from experience in cystic fibrosis Chest physio
13、therapy:manual or mechanical chest percussion and postural drainage.Benefit extrapolated from experience in cystic fibrosis.Can cause transient fall in FEVI.Assumed role limited to patients with 25 ml sputum per day or lobar atelectasis from mucus plugging Intermittent positive pressure breathing(IP
14、PB).Not indicated;no proven benefit In COPD Positive expiratory pressure(PEP).Benefit extrapolated from experience in cystic fibrosis.No reported experience in acute exacerbations of COPD.15 Bland aerosol therapy.No demonstrated benefit in COPD unless artificial airway is in place.May cause bronchos
15、pasm in nonintubated patients.Systemic hydration.No demonstrated benefit beyond repletion of intravascular volume to euvolemia.Nasotracheal suctioning.Limited benefit;tolerated only for short periods Mini-tracheotomy.Possible temporary benefit in patients with persistent airway secretions causing re
16、spiratory deterioration.16Indications for ICU Admission Severe dyspnea that responds inadequately to initial emergency therapy.Confusion,lethargy,coma.Persistent or worsening hypoxemia(PaO2 8.0 kPa,60 mm Hg),and/or severe/worsening respiratory acidosis(pH 7.25)despite supplemental oxygen and NIPPV.1
17、7Assisted ventilation Noninvasive positive pressure ventilation(NPPV)should be offered to patients with exacerbations when,after optimal medical therapy and oxygenation,respiratory acidosis(pH 7.36)and or excessive breathlessness persist.All patients considered for mechanical ventilation should have
18、 arterial blood gases measured.18 If pH 7.30,NPPV should be delivered under controlled environments such as intermediate intensive care units(ICUs)and/or high-dependency units.If pH 7.30,NPPV should be delivered under controlled environments such as intermediate intensive care units(ICUs)and/or high
19、-dependency units.19 If pH 35 breaths per minute.Life-threatening hypoxemia(PaO2 5.3 kPa,40 mm Hg or PaO2/FiO2 200 mm Hg).Severe acidosis(pH 8.0 kPa,60 mm Hg).24 Respiratory arrest.Somnolence,impaired mental status.Cardiovascular complications(hypotension,shock,heart failure).Other complications(met
20、abolic abnormalities,sepsis,pneumonia,pulmonary embolism,barotrauma,massive pleural effusion).NIPPV failure(or contraindication to NIPPV).25Mechanical Ventilation Assisted ventilation should be considered for patients with acute exacerbations of COPD when pharmacologic and other nonventilatory treat
21、ments fail to reverse clinically significant respiratory failure.The clinician must aim to avoid complications associated with mechanical ventilation and should initiate weaning and discontinuation of mechanical ventilation as soon as possible.26 The main goals of assisted positive pressure ventilat
22、ion in acute respiratory failure complicating COPD are:-Resting of ventilatory muscles,and-Restoration of gas exchange to a stable baseline.Allow for permissive hypercapnea(except in cerebral edema,myocardial ischemia,LVF.)27 There are three specific pitfalls in ventilating patients with COPD:i-Over
23、ventilation,resulting in acute respiratory alkalemia,ii-Initiation of complex pulmonary and cardiovascular interactions that may result in systemic ypotension.iii-Creation of intrinsic positive end-expiratory pressure(PEEP),or“auto-PEEP,”especially if expiratory time is inadequate or if dynamic airf
24、low obstruction exists28 The three ventilatory modes most widely used for managing patients with COPD are:-Assist-control ventilation(ACV),-Intermittent mandatory ventilation(IMV),and-Pressure support ventilation(PSV).PSV provides increased patient comfort,promotes patient synchrony with the ventila
25、tor,and facilitate weaning from mechanical ventilation in the patient who maintains adequate ventilatory drive.29 Avoidance of risk factor(s);influenza vaccination Add short-acting bronchodilator when needed Add regular treatment with one or more long-acting bronchodilators Add rehabilitation Add lo
26、ng-term oxygen if chronic respiratory failureConsider surgical treatments Add inhaled glucocorticids if repeated exacerbations Stage0:At RiskI:MildII:ModerateIII:SevereIV:Very Severe30Discharge Criteria for Patients With Exacerbations of COPD Inhaled 2-agonist therapy is required no more frequently
27、than every 4 hrs.Patient,if previously ambulatory,is able to walk across room.Patient is able to eat and sleep without frequent awakening by dyspnea.Patient has been clinically stable for 12-24 hrs.31 Arterial blood gases have been stable for 12-24 hrs.Patient(or home caregiver)fully understands cor
28、rect use of medications.Follow-up and home care arrangements have been completed (e.g.,visiting nurse,oxygen delivery,meal provisions).Patient,family,and physician are confident patient can manage successfully.32Strategies to Help the PatientWilling to Quit Smoking(5 As)ASK:Systematically identify a
29、ll tobacco users at every visit.Implement an office-wide system that ensures that,for EVERY patient at EVERY clinic visit,tobacco-use status is queried and documented.ADVISE:Strongly urge all tobacco users to quit.In a clear,strong,and personalized manner,urge every tobacco user to quit.ASSESS:Deter
30、mine willingness to make a quit attempt.Ask every tobacco user if he or she is willing to make a quit attempt at this time(e.g.,within the next 30 days).ASSIST:Aid the patient in quitting.Help the patient with a quit plan;provide practical counseling;provide intra-treatment social support;help the p
31、atient obtain extra-treatment social support;recommend use of approved pharmacotherapy except in special circumstances;provide supplementary materials.ARRANGE:Schedule follow-up contact.Schedule follow-up contact,either in person or via telephone.33Long Term Oxygen Therapy Oxygen administration 15 h
32、ours/day.Indications:-PaO2 55 mmHg or SaO2 89%if there is evidence of Pulmonary hypertension,CHF,or Polythycemia (Hematocrit 55%)34Pulmonary Rehabilitation Goals:-Reduce symptoms-Improve QOL-Promote physical and emotional participation in every day life Program should be at least 2 months.Aim is to
33、strengthen inspiratory muscles and increase endurance.35Surgical Treatment Bullectomy LVRS and Bronchoscopic volume reduction Lung transplantation36Assessment 4-6 Weeks After Discharge from Hospital Ability to cope in usual environment.Measurement of FEV1.Reassessment of inhaler technique.Understanding of recommended treatment regimen.Need for long-term oxygen therapy and/or home Nebulizer(for patients with very severe COPD).37THANK YOU38
