This brief report will summarize the common questions I get from colleagues and students about COPD exacerbations. Guidelines will be relied on for answers, but I will introduce my own personal approaches and biases as well!
When should a patient be admitted with a COPD exacerbation?
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines suggest the following potential indicators for hospitalization:
1. Severe symptoms such as sudden worsening of resting dyspnea, high respiratory rate, desaturation, drowsiness, or confusion
2. Acute respiratory failure
3. Onset of new physical signs such as cyanosis or peripheral edema
4. Failure of initial medical management
5. Presence of serious comorbidities
6. Insufficient home support
These criteria are mostly subjective. My basic approach is if my patient has failed outpatient therapy, or is in the emergency department and "looks bad” after initial treatment, it’s time to be admitted to the hospital.
Which antibiotics should I use?
Very simple question, but a very hard one to answer! The guidelines are generally useless in this regard. The GOLD guidelines suggest a duration of 5 to 7 days but don’t really state what to choose. The American Thoracic Society/European Respiratory Society (ATS/ERS) guidelines state that antibiotic choice should depend on local pathogens and resistance patterns. My go-to antibiotics of the past decade were macrolides for mild to moderate exacerbations, and quinolones for moderate to severe exacerbations. However, both classes of medications have come under fire lately: macrolides for prolongation of the QT interval, and quinolones for QT prolongation, and association with tendon rupture and C. diff. infection. In my hospital, many of my colleagues have replaced macrolides with doxycycline, and quinolones with either cephalosporins or Augmentin. However, my feeling is that the evidence for the use of doxycycline is lacking in COPD exacerbations. In fact, a recent, large, double-blind study showed no added efficacy of doxycycline vs placebo in a large cohort of COPD exacerbations. Thus, I generally favor the use of Augmentin for almost all severe outpatient exacerbations, and I use Augmentin or cephalosporins for inpatient exacerbations. I still use quinolones when I suspect Pseudomonas infection, and I still use macrolides for milder outpatient exacerbations or penicillin allergies.
What dose of steroids should I use?
Again, not an easy question to answer, although the GOLD guidelines are rather emphatic and recommend 40 mg of prednisone or the equivalent for 5 days and then stop, for both inpatients and outpatients. The ATS/ERS guidelines recommend oral steroids for 9 to 14 days with a dose not specified for outpatient exacerbations, and oral steroids at an unspecified dose or duration for inpatient exacerbations. My own practice has been to reduce both the amount and duration of steroids I have been using in my patients, since recent literature comparing higher dose or duration treatment to lower has shown no differences. For outpatient exacerbations, I generally treat with prednisone 40 mg from 5 to 14 days, depending on the intensity of the exacerbation as well as the response of the patient to treatment. For inpatients, I generally start with intravenous steroids for a few days, usually at a dose of 40 mg of Solu-Medrol twice daily, and then change to prednisone 40 mg on day 3 and continue for a total of 7 to 14 days. Unless I plan on continuing steroids for more than 2 weeks, I no longer taper steroids.
My patient is taking Spiriva and Advair. Should I leave him on them while he gets short-acting bronchodilators by nebulizer in the hospital for his exacerbation?
Surprisingly, there are no data on this question. The GOLD guidelines acknowledge this but recommend that patients be kept on their long-acting bronchodilators. My practice is to discontinue them, then change the patient to prn nebulizers toward the end of the hospitalization, and reinstitute the maintenance medications at that point.
Next: Should I use noninvasive ventilation? (please click below)