GIM Question 8 Instructor

How do you define an acute COPD exacerbation?
Chronic obstructive pulmonary disease (COPD) is a respiratory condition characterized by progressive airway obstruction and lung hyperinflation.
Characteristic findings of COPD on pulmonary function tests (PFTs) include:

• FEV1/FVC <0.7
• FVC <0.8
• Post-bronchodilator FEV1 <80% of predicted

Acute COPD exacerbations can occur frequently, and are defined as a sudden worsening of dyspnea, cough and/or sputum production in the context of chronic COPD, necessitating an increase in the use of maintenance medications. COPD exacerbations are often precipitated by respiratory infections.

How would you manage an acute COPD exacerbation?
Management of an acute COPD exacerbation:

• Ventolin + Atrovent (β-agonist and anticholinergic)
• Prednisone 30-40mg PO daily for 5-14d
• Antibiotics:
  • Simple exacerbations (dyspnea, increased sputum, purulence) – Amoxicillin, cephalosporins (2^nd or 3^rd generation), doxycycline, macrolides, septra
  • Complex exacerbations (as above + FEV₁<50%, or ≥4 or more exacerbations/year, or ischemic heart disease, or use of home oxygen, or chronic oral steroid use) – Fluoroquinolones, Clavulin
• Maintain Sp02 at 88-94% (BiPAP if required)

Resources

1. MacIntyre N et al. Interpretative strategies for lung function tests. Eur Respir J. 2005, 26:948-968.
2. O’Donnell et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease – 2008 update – highlights for primary care. Can Respir J. 2008, 15(Suppl A):1A-8A.
3. Quon BS, Gan WQ and Sin DD. Contemporary Management of Acute Exacerbations of COPD: A Systemic Review and Metaanalysis. Chest. 2008, 133:756-766.
4. Stanbrook MB. ACP Journal Club: review: antibiotics reduce treatment failure in acute chronic obstructive pulmonary disease exacerbations. Ann Intern Med. 2013, 158:JC5.