A. Patient with Signs Symptoms of COPD Exacerbation - Acute exacerbation is defined as a recent deterioration of the person's clinical and functional state that is due to worsening of their COPD. Typical symptoms and signs of COPD exacerbation are given below (adapted from the European Respiratory Society Consensus Statement, Siafakas 1995).
 

• Worsening dyspnea, sometimes at rest
• Increased cough
• Increased sputum production, often with change in character from mucoid to purulent
• Development or increase in wheezing
• Loss of energy
• Fever
• Increased respiratory rate
• Tachycardia
• Increased cyanosis
• Use of accessory muscles
• Peripheral edema
• Loss of alertness
• Worsening airflow obstruction by FEV₁ or peak expiratory flow rate
• Worsening of arterial blood gases or pulse oximetry O₂ saturation.

1. Is There Evidence of Severe Exacerbation?
 

a. Parameters that suggest a serious COPD exacerbation
 
• The decision whether to manage the patient initially at home or refer for acute evaluation depends, not only on the severity of the exacerbation, but also on many factors, including the severity of the underlying COPD, comordibities, the medical sophistication, judgment and reliability of the patient and caregivers, and distance from the Medical Center or clinic.
• Loss of alertness or a combination of two or the other parameters suggests a severe exacerbation and a need for referral to the ED. These parameters are not designed to replace a provider's judgment for need for referral. Some of these criteria, such as dyspnea at rest or loss of alertness may be noted while attempting to evaluate the severity of the exacerbation on a telephone call.

B. Patient with a Diagnosis of COPD - Chronic obstructive pulmonary disease (COPD) is defined by the American Thoracic Society (ATS) in Standards for the Diagnosis and Care of Patients with Chronic Obstructive Pulmonary Disease (1995). Further detail on lung function testing is found in another ATS publication (1991).  

1. Definitions
 
a. Chronic obstructive pulmonary disease (COPD) is a disorder characterized by the presence of airflow obstruction due to chronic bronchitis or emphysema; the airflow obstruction is generally progressive, may be accompanied by airway hyperreactivity, and may be partially reversible.

b. Chronic bronchitis is defined as the presence of chronic productive cough for 3 months of each of two successive years in a patient in whom other causes of chronic cough have been excluded.

c. Emphysema is defined as abnormal permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.

d. Asthma is by definition associated with reversible airflow obstruction. Patients with asthma whose airflow obstruction is completely reversible are not considered to have COPD. The obstruction in many patients with COPD may include a significant reversible component. Some patients with asthma may develop irreversible airflow obstruction indistinguishable from COPD.



2. Characterization of COPD 


a. History 


(1) Smoking - Age at initiation, quantity smoked per day, whether or not still smoker and if not, date of cessation

(2) Environmental (chronological) - May disclose important risk factors

(3) Cough (chronic, productive) - Frequency and duration, whether or not productive (especially on awakening)

(4) Wheezing

(5) Acute chest illnesses - Frequency, productive cough, wheezing, dyspnea, fever

(6) Dyspnea



b. Physical Examination of Chest
 
Airflow obstruction evidenced by:
• Wheezing during auscultation on slow or forced breathing
• Forced expiration time of more than 6 seconds
  
  
Severe emphysema indicated by:
• Overdistention of lungs in stable state, low diaphragmatic position
• Decreased intensity of breath and heart sounds 
  
  
Severe disease suggested by (characteristics not diagnostic):
• Pursed-lip breathing
• Use of accessory respiratory muscles
• Indrawing of lower interspaces
  
  
c. Other - Unusual positions to relieve dyspnea at rest, digital clubbing (suggests possibility of lung cancer or bronchiectasis), and mild dependent edema that may be seen in absence of right heart failure.

d. Laboratory
 

(1) Chest radiography -Diagnostic only of severe emphysema but essential to exclude other lung diseases

(2) Spirometry (pre- and postbronchodilation) - Essential to confirm presence and reversibility of airflow obstruction and to quantify maximum level of ventilatory function (ATS 1995)

(3) Lung volumes - Measurement of more than forced vital capacity is not necessary except in special circumstances (e.g., presence of giant bullae)

(4) Carbon monoxide diffusing capacity - Unnecessary except in special instances (e.g., dyspnea out of proportion to severity of airflow limitation)

(5) Arterial blood gases are not needed in staged mild disease, but remain the standard for determining the need for oxygen therapy

(6) Alpha₁-antitrypsin (AAT) - AAT deficiency accounts for less than 1 percent of COPD. Obtain a serum AAT level to screen for AAT deficiency in the following situations:
 

• Chronic bronchitis with airflow obstruction in a never smoker
  
  
• Bronchiectasis, especially in the absence of clear risk factors for the disease
  
  
• Premature onset of COPD with moderate or severe impairment before age 50
  
  
• A predominance of basilar emphysema; development of unremitting asthma, especially in a patient under age 50
  
  
• A family history of AAT deficiency or of COPD onset before age 50
  
  
• Cirrhosis without apparent risk factors (ATS 1995). If diagnosis of COPD on asthma is made, refer to specialist for recommendations for therapy.
  
  
(7) Are symptoms controlled since last visit? - Client may exhibit symptoms of dyspnea and/or wheezing. Dyspnea may be at rest or disproportionate to the degree of breathlessness expected for a given activity.

(8) If on therapy, reevaluate or begin trial of therapy with inhaled anticholinergic (IAC). A trial of IAC therapy is recommended in apparently asymptomatic patients with an FEV₁ of less than 50 percent of predicted, since this degree of obstruction is usually associated with dyspnea. This is based on the well-known phenomenon of patients "adapting to their disability." Such a lack of symptoms may result from the patient's avoiding activities or simply thinking along the lines of "Doesn't everyone get short of breath doing this activity at my age?"
 

Ipratropium and short-acting inhaled beta2-agonist in typical doses (2 to 4 inhalations) on a scheduled rather than prn use are generally equally effective as bronchodilators, although some studies suggest that ipratropium has a greater peak and a longer duration of action. The side effects of each are similar, except for increases in heart rate and tremor, (neither of which is typical at these doses) occur almost exclusively with beta2-agonist. Dyspnea may be improved to a greater extent with inhaled beta2-agonist. Some patients will have a response to one but not the other, so in any trial of therapy, both should be tried if improvement is not optimal with the first choice. There is evidence that ipratropium improves baseline pulmonary function (after withholding ipratropium for 6 to 12 hours) whereas beta2-agonist do not. 

1. The primary care provider should discuss with the patient principles of responsible self-management of exacerbations as well as long-term management of COPD.

2. Patients should know how to recognize an exacerbation, features of a severe exacerbation, and steps to take in initial home self-management. These may include maximal bronchodilator therapy, and antibiotics for purulent bronchitis. Additional corticosteroid therapy should be considered in consultation with the primary care provider for those who are steroid responsive.

3. This plan should be provided in the form of written or verbal instructions with guidance for contacting the primary care provider if in doubt about the course of action or if there is deterioration in the patient's condition.

1. Evidence of Improvement of COPD Exacerbation Includes:
 
a. Decrease in cough, sputum production or dyspnea

b. Decrease respiratory rate

c. Decrease heart rate

d. Increase in function and endurance

1. Precautions when Using Beta2-Agonists
 
• Watch for nonimprovement or paradoxical deterioration with aerosol use.
  
  
• Use spacers to improve compliance.
  
  
• Avoid overuse; check number of metered dose inhalers (MDIs) used per month against number of puffs per MDI (200 to 300+, depending on brand).
  
  
• Instruct client on maximum number of puffs per day (usually 8 to 12) and on number allowed during an exacerbation (e.g., 12 to 24 over 3 to 4 hours) before additional intervention is required.
  
  
• If a long-acting agent is used, caution client that frequent use must be avoided.
  
  
• Home updraft nebulizers with inhalant solutions providing large dosages are rarely needed.
  
  
2. Precautions when Using Theophylline
 
• Initiate treatment with a low dose (e.g., 400 mg/day) and adjust after a few days.
  
  
• Reduce dosage if drug clearance is likely to be impaired because of illness, liver malfunction, or concomitant drugs.
  
  
• Do not allow any additional theophylline preparation to be taken.
  
  
• Drug must be taken at the same time each day with respect to meals.
  
  
• When symptoms change, acute illness develops, new drugs are added, or symptoms suggestive of toxicity develop, check serum level of theophylline.
  
  
• Aim for a serum level of 5 to 12 g/ml; adjust dosage and follow serum level when indicated.

3. Precautions when Using Ipratropium
 
• Clients should generally use a spacer and should avoid spraying into eyes.
  
  
• Be prepared to increase dose if necessary from 2 to 3 puffs 3 to 4 times a day to 6 to 8 puffs 3 to 4 times a day, if tolerated.
  
  
• Caution client that onset of effect is relatively slow; additional doses should not be taken for acute symptom relief.
  
  
• Monitor for side effects, e.g., tachycardia, dry mouth, glaucoma, prostatism, or bladder neck obstruction.
  
  
4. Precautions when Using Oral Steroids
 
• Reduce dosage to lowest effective daily dose or to alternate-day dosing as quickly as symptoms allow.
  
  
• Monitor for hypertension, diabetes, weight gain, mental changes, infections, central polar cataracts, skin thinning, purpura, osteoporosis, and osteonecrosis.
  
  
• Distinguish psychological benefit from true pulmonary benefit by following forced expiratory volume in 1 second (FEV₁) for 2 weeks after initiating therapy
  .
• Administer prophylactic calcium therapy to women; treat osteoporosis appropriately.
  
  
• Steroid-dependent clients require steroid coverage during any crisis for many months after stopping steroids.
  
  
• Repeatedly evaluate client to determine whether steroid therapy can be discontinued.
  
  
5. Precautions when Using Aerosol Steroids
 
• Seek objective evidence of the value of this therapy, because its use may decrease compliance with other aerosol usage.
  
  
• Use a spacer; monitor for oral thrush and laryngeal dysfunction.
  
  
• Be aware that aerosol steroid side effects may occur in skin, bone, etc.
  
  
• When introducing aerosol steroids in a client on an oral steroid, wean slowly off the oral drug.
  
  

6. Recommendation - The fewest inhalers with the fewest inhalations at the least frequent interval consistent with a client's inhaler needs should be used to improve compliance. A similar principle applies to oral medications.

7. Recommendation - MDI with, if necessary, a spacer is preferred unless not recommended by manufacturer; a hand-held nebulizer should be used only if client unable to use an MDI.

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