A pulmonologist answers some of the most common questions he hears from colleagues and students about COPD exacerbations and their management.
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)
Should I use noninvasive ventilation (NIV) for COPD exacerbations?
Finally, an easy question! The answer is an unequivocal yes! For patients with COPD exacerbations who have acute or chronic respiratory failure, patients on NIV had a lower mortality and shorter hospitalization, and were less likely to need intubation. Note that patients with a high aspiration risk, facial deformities, inability to cooperate, or severe change in mental status were often excluded from these studies and should also be excluded in real life from NIV. The exact device, duration, and settings for NIV varied tremendously in the pivotal studies, and also vary tremendously among treating physicians across the country; thus, it is hard to give specific recommendations on settings and duration of therapy.
What should I do to prevent readmission to the hospital within 30 days?
Literally, the million-dollar question! Hospitals are under tremendous financial pressure to ensure that patients with certain condition, including COPD, are not readmitted within 30 days of discharge. I was put in charge of an emergency task force at my hospital to try to address this issue. Some of the changes our group implemented included:
1. Implementation and “marketing” of a COPD exacerbation standardized order set
2. Early ambulation program
3. Ensure that patients had follow-up appointments with a physician within a week of discharge
4. Calls by a specialized nurse to a physician whose patient’s length of stay exceeded 7 days
5. Emails to all pulmonary physicians showing the length of stay and readmission rate of the competing pulmonary groups monthly
Were any of these changes evidence based? No. Were they cost-effective? Unknown. Did they improve quality or patient-centered outcomes? Unknown. However, our length of stay in the hospital decreased after the above changes were implemented.The effect on 30-day readmission was less clear; however, we stayed under national averages and were recently commended for our COPD treatment by a national magazine (US News and World Report) and a national grading organization (Healthgrades).
COPD exacerbations have a major health care cost to patient and a large economical cost to society. I hope I have answered some of your more common questions regarding the treatment of this condition.
Global Initiative for Chronic Obstructive Lung Disease. Gold Guidelines. www.goldcopd.org Accessed August 11, 2017
Wedzicha JA ERS Co-Chair, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2017;49(3).