Acute Exacerbation of Chronic Bronchitis

Aka: Acute Exacerbation of Chronic Bronchitis, COPD Exacerbation Management in the ER, Emergency Management of COPD Exacerbation, COPD Exacerbation Management

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II. Definitions

  1. COPD Exacerbation (GOLD 2023)
    1. Increased Dyspnea or cough and Sputum that occurs over 14 days or more
    2. Caused by airway infection or other triggers (e.g. pollution)

III. Risk Factors: Severe COPD exacerbation

  1. Altered Level of Consciousness
  2. Three or more exacerbations in the last year
  3. Severe COPD with FEV1/FVC ratio <0.70 or FEV1 < 50% of predicted
  4. Body Mass Index 20 kg/m2 or less
  5. Marked increase in symptoms or change in Vital Signs
  6. Sedentary
  7. Poor social support
  8. Non-compliance Home oxygen use
  9. Medical comorbidity
    1. Congestive Heart Failure
    2. Coronary Artery Disease
    3. Pneumonia
    4. Diabetes Mellitus
    5. Renal Failure
    6. Hepatic Failure

IV. Symptoms: Cardiopulmonary

  1. Increased Sputum production or Purulent Sputum
  2. Cough
  3. Dyspnea
  4. Tachypnea
  5. Wheezing
  6. Decreased Exercise tolerance
  7. Chest tightness
  8. Tachycardia

V. Symptoms: General

  1. Fatigue
  2. Fever
  3. Malaise
  4. Confusion
  5. Insomnia

VI. Diagnosis

  1. Cough increases in frequency and severity OR
  2. Sputum production increases in volume and/or changes character (e.g. purulent) OR
  3. Dyspnea increases (or requiring NIPPV or Intubation)

VII. Evaluation: Severity

  1. Do not define exacerbation severity by Spirometry
  2. Mild Exacerbation
    1. COPD controlled with an increase in regular medications
  3. Moderate Exacerbation
    1. COPD controlled with Systemic Corticosteroids or Antibiotics
  4. Severe Exacerbation
    1. COPD controlled with emergency department evaluation or hospitalization

VIII. Evaluation: Testing

  1. Pulse Oximetry in all patients
  2. Chest XRay
    1. Indicated in moderate to severe exacerbations
  3. Severe Exacerbations (emergency department or hospital admission evaluation)
    1. Venous Blood Gas (or Arterial Blood Gas)
    2. Complete Blood Count
    3. Basic chemistry panel
    4. Electrocardiogram
  4. Additional cardiac labs to consider (part of Dyspnea differential diagnosis)
    1. Troponin
    2. Brain Natriuretic Peptide (BNP or ntBNP)

IX. Management: First line management

  1. See COPD Management for Bronchodilator and other COPD specific interventions
  2. Low Flow Oxygen to keep Arterial PaO2 > 60mmHg (O2 Sat 90% or greater)
    1. High Flow Oxygen is associated with worse outcomes
      1. Austin (2010) BMJ 341: c5462 [PubMed]
    2. However, do not limit FIO2 in severe Hypoxemia in CO2 retainers
      1. See Below
      2. Set Oxygen Saturation goal >88-91%
      3. Anticipate pCO2 rise of 12 points
      4. Consider BiPap for pH < 7.25
  3. Systemic Corticosteroids (oral or intravenous)
    1. Indicated in all moderate to severe COPD exacerbations
    2. Prednisone 40 mg orally daily (5 day course is typical)
      1. Five day course of 40 mg daily is sufficient for most COPD exacerbations
        1. Leuppi (2013) JAMA 309(21):2223-31 [PubMed]
      2. Ten day course reduces relapse rate after COPD evaluation in ER
        1. Aaron (2003) N Engl J Med 348:2618-25 [PubMed]
    3. Prednisone 30-60 mg/day orally tapered over 2 weeks or
    4. Methylprednisolone (Solumedrol) 60-125 mg IV every 6 hours
  4. Antibiotics
    1. See Antibiotic Use in COPD Exacerbation for indications
  5. Avoid low efficacy therapies
    1. Mucolytic medications are not shown helpful
    2. Chest physiotherapy is not efficacious
    3. Theophylline not helpful in exacerbations

X. Management: Second-line management

  1. Increased Oxygen Supplementation
    1. Titrate to High Flow Oxygen (e.g. oximizer)
      1. Set O2 Sat goal of 88-91%
    2. Do not limit FIO2 in severe Hypoxemia in CO2 retainers
      1. Anticipate CO2 rise of 12 points
  2. Magnesium Sulfate
    1. Consider in severe COPD exacerbation
    2. Magnesium Sulfate 2 grams IV over 20 minutes
    3. Bronchodilator effect related to inhibition of Calcium influx into Smooth Muscle Cells
    4. As of 2023, studies show similar effect as for Asthma (reduced hospitalization, length of stay, Dyspnea)
      1. Ni (2022) Cochrane Database Syst Rev 5(5): CD013506 [PubMed]
  3. Non-Invasive Positive Pressure Ventilation or NIPPV (e.g. BIPAP)
    1. Mechanism
      1. Supplies the threshold pressures needed to expand collapsed and inflamed airways
    2. Starting
      1. Start early, before the onset of significant respiratory Fatigue
      2. Consider starting BiPap for pH < 7.25 to 7.30
    3. Weaning
      1. Consider weaning bipap when ABG or VBG pH 7.32 or higher
    4. Refractory cases
      1. Consider intubation for pH <7.20
    5. Efficacy
      1. Reduces the need for intubation, ICU admission, mortality
      2. Berg (2012) Intern Emerg Med 7(6): 539-45 [PubMed]
  4. Endotracheal Intubation Indications
    1. Arterial Blood Gas with arterial pH <7.36 and pCO2 >45 mmHg
    2. Respiratory distress and intolerance to NIPPV (see Oxygen Supplementation above)
    3. Severe, unstable comorbidity (e.g. Sepsis, Coronary Artery Disease)

XI. Management: Disposition

  1. Observation Unit Protocol
    1. Inclusion Criteria for observation stay
      1. Continued need for Supplemental Oxygen (or increased from home oxygen baseline)
      2. Persistent symptoms despite 3 nebulizer treatments and Corticosteroids administered
    2. Exclusion Criteria (full hospital admission or ICU instead, consider Non-Invasive Positive Pressure Ventilation)
      1. Increased work of breathing (e.g. accessory Muscle use)
      2. Venous Blood Gas or Arterial Blood Gas with worsening hypercarbia
      3. Oxygen Saturation <90% despite Supplemental Oxygen
      4. New EKG changes (aside from Sinus Tachycardia)
    3. Observation Unit Management
      1. Hourly Vital Signs for first 2 hours, then every 4 hours
      2. Continue Antibiotics (see Antibiotic Use in COPD Exacerbation)
      3. Continue Systemic Corticosteroid (e.g. solumedrol IV or Prednisone orally)
      4. Bronchodilator (e.g. duoneb, AlbuterolInhaler)
        1. Start every 2 hours and wean to every 4 hours with prn Bronchodilator every 2 hours
      5. Observe for 12-24 hours and disposition home or to admission
  2. References
    1. Lee (2018) Crit Dec Emerg Med 32(1): 3-8

XII. Prevention: Discharge Education

  1. See COPD Exacerbation Prevention
  2. See COPD Action Plan

XIII. References

  1. Decramer (2008) Respir Med 102(suppl 1): S3-S15 [PubMed]
  2. Evensen (2010) Am Fam Physician 81(5): 607-13 [PubMed]
  3. Fein (2000) Curr Opin Pulm Med 6:122-6 [PubMed]
  4. Gentry (2017) Am Fam Physician 95(7): 433-41 [PubMed]
  5. Quon (2008) Chest 133(3): 756-66 [PubMed]
  6. Saint (1995) JAMA 273:957-60 [PubMed]
  7. Sethi (2000) Chest 117(5 suppl 2):S380-5 [PubMed]

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