Updates in
Treatment Options for
Asthma and C.O.P.D.
Patients
Jim Holliman, M.D., F.A.C.E.P.
Program Manager, Afghanistan Healthcare Sector
Reconstruction Project
Center for Disaster and Humanitarian Assistance
Medicine, Uniformed Services University
Bethesda, Maryland, U.S.A.
Asthma and C.O.P.D.
Lecture Objectives
ƒ Know presenting signs & symptoms
ƒ Be able to assess case severity
ƒ Know medication and other treatment
options
ƒ Be able to formulate appropriate plans
of care
ƒ Know indications for admission
Asthma : Definition &
General Demographics
ƒ Is a chronic inflammatory disorder of the airways, with
airflow obstruction & airway inflammation, & recurring
wheezing, dyspnea, & cough
ƒ Prevalence, morbidity, & mortality has increased since
1980's
ƒ Age - adjusted death rate for ages 5 to 34 increased 40
% from 1982 to 1992
ƒ About 5000 deaths per year in U.S.
ƒ However Rowe and Camargo’s editorial in 2006 notes
improved control and decreasing mortality in some
countries
ƒ About 2 million E.D. visits in U.S. per year
This prevalence trend is still true
Morbidity and mortality aspects of asthma
Triggers of asthma
Additional triggers of asthma
Markers of a Potentially Fatal
Asthma Attack
ƒ Historical factors :
–Hyperacute
exacerbation
–Lack of steroid use
–Non-compliance
–Psychiatric illness
–> 3 hospital
admissions
–Prior intubation or
barotrauma
ƒ Physical findings :
–Altered mental status
–Diaphoresis
–Inability to speak
–PEFR < 100 L / min.
Diagnostic Assessments to
Consider for Asthma
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Peak Expiratory Flow Rate (PEFR)
Pulse oximetry
Arterial blood gas (ABG)
Hematology & chemistry studies
Chest X-ray (CXR)
PEFR Considerations for
Asthma
ƒ Probably the single most useful assessment test
ƒ Can stratify patients into severity groups :
– < 25 % : Severe (impending resp. failure)
– 25 to 50 % : moderate to severe
– 50 to 70 % : mild to moderate
– > 70 % : mild (can be discharged if at this value)
ƒ Initial value not highly correlated with admission
rate but higher risk if < 100 or improves < 60 with
Rx
ƒ Should usually not discharge if < 250 L / min.
Pulse Oximetry Considerations for
Asthma
ƒ Trend toward lower initial values correlating
with higher chance of admission, but not very
sensitive
ƒ Especially helpful in patients unable to
perform PEFR and in kids
ƒ Can be at normal levels in some with severe
bronchospasm
ABG Considerations for
Asthma
ƒ Initial ABG is poor predictor of outcome
and rarely influences therapy
ƒ NOT recommended routinely
ƒ Indications :
–Suspected respiratory failure
–Altered mental status (need to know pCO2)
–Pulse oximeter unable to track, & hypoxia is
suspected
–Worsening despite therapy
Hematology and Chemistry
Studies for Asthma
ƒ Generally are NOT needed for most cases
ƒ WBC count NOT reflective of severity or
associated infection
ƒ Most patients are not dehydrated, and do
not have electrolyte abnormalities (except
pseudohypokalemia from beta agonists)
ƒ Only useful test might be theophylline level
if the patient is taking a methylxanthine
CXR Considerations for
Asthma
ƒ NOT routinely needed for "typical"
exacerbations
ƒ May be needed for :
–New onset asthma (especially in kids)
–Unclear Dx (e.g., R / O CHF, foreign body, etc.)
–Asthma refractory to treatment
–Respiratory failure
–ETT placement
–Strong clinical suspicion for infection
–Chest pain (R / O pneumo - thorax or - mediastinum)
26 year old male with asthma and chest pain
Same patient with arrows denoting pneumomediastinum
General E.D. Management
Scheme for Asthma
ƒ Triage
ƒ Primary treatments :
–Beta agonists
–Corticosteroids
ƒ Secondary (or "refractory") treatments :
–Anticholinergics
–Magnesium, leukotriene inhibitors, Heliox,
antibiotics, ketamine, mucolytics
ƒ Disposition
Triage Considerations for
Asthma
ƒ All patients with acute asthma should be
quickly taken to a monitored treatment area
ƒ Initial nursing interventions :
–Pulse oximetry
–Oxygen by nasal prongs (or blow-by mask for kids)
–Cardiac monitor (if moderate to severe)
–PEFR
–IV line if severe
–Notify physician
Main Therapy for Acute Asthma
Exacerbations :
Inhaled Beta Agonists
ƒ MDI-spacer delivery may be equivalent to
traditional nebulizer
–The patient may think MDI Rx in E.D. will be
ineffective since has already tried it at home
ƒ Continuous nebulization may be more
effective in severe cases, but no difference
for moderate cases (although takes less
E.D. personnel time)
–Albuterol doses are 10 to 30 mg / hr for adults, 5
to 7.5 mg / hr for kids
Choices for Short Acting Beta
Agonists (SABA’s)
• Albuterol (Ventolin, Proventil)
– PO 0.1 to 0.2 mg/kg/dose up to 12 mg/day
– MDI one to two puffs q 20 minutes X 3 or :
– 2.5 mg of 0.5 % solution via nebulizer q 20 minutes X 3
• Levalbuterol (Xopenex)
– R isomer of albuterol
– MDI 1 to 2 puffs q 4 h
– Not shown superior to racemic albuterol (but is more
expensive)
• Metaproterenol (Alupent)
– Same doses for MDI and nebulizer as albuterol
– No big comparative studies versus albuterol
Considerations for Parenteral
Use of Beta Agonists
ƒ Subcutaneous may be useful for rare
patient not able to receive aerosol
–Terbutaline probably safest (0.01 mg/kg, max.
0.3 mg)
–Epinephrine (same dose; causes more HBP)
ƒ For "crashing" patient, give IV
–0.1 mg diluted and via SLOW IV push
–then 0.4 mcg/kg/min IV drip
ƒ Prior to discharge, can give Susphrine (epi tannate in oil)
SQ at 0.005 mg/kg (more useful for allergic reactions)
although availability of this med has decreased
Long Acting Beta Agonists
(LABA’s)
ƒ Salmeterol (Serevent) MDI 50 mcg bid
ƒ Onset in 10 to 20 minutes & duration 12 hours
ƒ Twice as expensive as albuterol
ƒ Useful for nocturnal asthma
ƒ May be useful prior to E.D. discharge to help
prevent early relapse
ƒ Formoterol (Oxis, Foradil) MDI 12 to 25 mcg bid
ƒ Note FDA black box warning for these
Clinical Use Guidelines for the LABA’s
ƒ NOT to be used as monotherapy for long term
control of asthma
ƒ Recommended in combination with Inhaled
Corticosteroids (ICS) for long term control in
moderate and severe persistent asthma
ƒ NOT to be used frequently or chronically before
exercise because this may mask poorly
controlled asthma
Other Medications for Acute Asthma
ƒ "Primary" Meds
–Corticosteroids
–Anticholinergics
–Magnesium
ƒ "Secondary" Meds
–Methylxanthines
–Ketamine
–Heliox
–Halothane
–Leukotriene inhibitors
Use of Systemic Steroids in
Asthma
ƒ Clearly shown to decrease admission & relapse
rates
ƒ Oral route is fine for most
–40 to 60 mg prednisone / day for adults
–2 mg / kg per day for kids
–5 day duration best (typical length of attack)
–taper usually not needed
ƒ IV only for severe dyspnea, emesis, altered
mental status, or intubated (IV versus PO shows
same acute effects)
ƒ Methylprednisolone, hydrocortisone, dexamethasone
Use of Inhaled Steroids for
Asthma
ƒ Regular use decreases need for beta
agonists & relapse rates
ƒ Use during an acute attack may just
increase cough
ƒ Use of spacer and post-Rx mouth
rinse decrease side effects
(dysphonia, oral Candidiasis)
Choices of Inhaled Steroids for
Asthma (via MDI’s)
ƒ Fluticasone (Flovent) 250 to 500 mcg bid
ƒ Budesonide (Pulmicort, Rhinocort) 200 to 800
mcg bid
ƒ Triamcinolone (Azmacort) 2 to 4 puffs bid to qid
ƒ Beclomethasone (Vanceril, Beclovent) 84 to 840
mcg per day
ƒ Virtually all patients should be on one of these
after discharge
Use of Anticholinergics for Acute
Asthma
ƒ Inhaled (via MDI or nebulizer) these decrease
bronchospasm by reducing vagal tone
–Atropine (0.2 to 0.5 mg)
–Glycopyrrolate (Robinul) 0.2 to 0.4 mg
–Ipratropium (Atrovent) 250 to 500 mcg
ƒ Several studies show mild added benefit when
added to first three beta agonist nebulizations
in E.D. (not helpful after this)
ƒ Ipratropium has low rate of side effects
ƒ May help undefined subsets of patients
Use of Magnesium for Acute
Asthma
ƒ Acts as smooth muscle relaxer &
suppresses neutrophil burst response
ƒ Conflicting results of efficacy in different
studies ( ? inadequate dosing in some)
ƒ Clearly safe & few side effects
ƒ 2.0 to 5.0 gm IV dose reasonable to try for :
–Severe symptoms
–Respiratory failure
–Non-response to standard Rx
Use of Methylxanthines for
Asthma
ƒ Problems with aminophylline :
–weak bronchodilator
–high rate adverse side effects
–narrow toxic / therapeutic window
–requires monitoring of serum levels (goal 5 to 15 mcg/ml)
–many medication interactions
ƒ Clearly shown to add no benefit to acute Rx with beta agonists
& steroids
–However, slow release forms (Slo-Bid, Theo-Dur, Uniphyl)
may be useful in some patients for chronic maintenance
–5 to 8 mg/kg/day
Use of Ketamine for Acute
Asthma
ƒ Dissociative anesthetic
ƒ Relaxes bronchial smooth muscle
ƒ Excellent agent for RSI for critically ill asthmatic
–2 mg / kg IV or 4 mg / kg IM
–Continued infusion 1 to 2.5 mg / kg / hr
ƒ May cause :
–Laryngospasm
–Hypertension
–Hallucinations
Use of Heliox for Acute
Asthma
ƒ Is premixed air 20 % and helium 80 %
ƒ Gas density is lower than air so flow
resistance is less
ƒ Somewhat limited usefulness for asthma
because as more O2 is blended in, the
gas density re-increases (max. O2 is 40
%)
ƒ Expensive if used for extended period
ƒ No major extended benefits in controlled
studies
Use of Leukotriene Receptor
Antagonists (LTRA’s) for Asthma
ƒ Leukotrienes are released from mast cells,
eosinophils, and basophils and mediate :
–bronchoconstriction
–mucus secretion
–airway mucosal edema
ƒ The LTRA’s are useful for :
–Treatment of stable, mild, persistent asthma, and
prophylaxis of exercise induced asthma
–decrease airway response to cold & allergens
–Role in acute asthma not yet clear (IV montelukast
is in phase 3 research trials)
Choices of LTRA’s for Asthma
ƒ Montelukast (Singulair)
ƒ 10 mg PO hs or two hours before exercise
ƒ Systemic eosinophilia and vasculitis
consistent with Churg-Strauss Syndrome
rarely reported
ƒ Zafirlukast (Accolate)
ƒ 20 mg PO bid
ƒ Rarely has caused liver failure
Another Category of Meds : 5Lipoxygenase Inhibitors
ƒ Zileuton (Zyflo, Zyflo CR)
ƒ Inhibits leukotriene formation
ƒ Dose 600 mg pc and hs for Zyflo
ƒ Dose 1200 mg bid for Zyflo CR
ƒ Can cause liver failure
ƒ Not studied for acute use
Still Another Category of Meds :
Mast Cell Degranulation Inhibitor
• Cromolyn (Intal)
– Inhibits degranulation of sensitized mast cells
– Attenuates bronchospasm caused by exercise,
cold air, aspirin, and environmental pollutants
– MDI dose 2 puffs qid or two puffs 15 to 60
minutes prior to exercise
– Rarely has caused liver impairment
And the Final Category of Asthma
Medication : Omalizumab (Xolair)
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Recombinant DNA-derived immunoglobulin G
monoclonal antibody which binds selectively
to human immunoglobulin E on the surface of
mast cells and basophils and then reduces
mediator release
Used when Sx are not controlled by inhaled
steroids
Dose 150 to 375 mg SQ q 2 to 4 weeks
Annual cost $12,000 to $15,000
Can cause anaphylaxis
Combination Medications Available
for Asthma
ƒ Ipratropium and albuterol (Combivent)
ƒ Nebulizer 3 ml q 20 min X 3 doses
ƒ MDI 4 to 8 puffs q 20 min X 3
ƒ Salmeterol and Fluticasone (Advair Diskus)
ƒ 3 dosage forms ;
ƒ 100, 250, or 500 mcg fluticasone with 50
mcg salmeterol
ƒ One inhalation bid
Expert Panel 3 (2007) List of
Ineffective Treatments for Asthma
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Methotrexate
Cyclosporin
Colchicine
Acupuncture
Chiropractic
Homeopathy
Breathing techniques
Yoga
Airway Management in
Asthma
ƒ Endotracheal intubation should be required in <
5% of admitted pts.
ƒ Indications for ETT :
–Altered mental status due to hypercarbia or hypoxia
–Progressive resp. failure or resp. acidosis despite
maximal Rx
–Base decision on clinical situation (not a particular
value of pCO2 or pO2 or pH)
ƒ Always preoxygenate & ETT attempt should be
made by most experienced operator
Considerations About Nasotracheal
Intubation of the Asthmatic Patient
ƒ Advantages :
–Can leave pt. sitting up ( resp. distress may worsen if
forced supine)
–Pt.'s resp. effort often makes the procedure easy
–Tube may be more comfortable for pt.
–Tube less likely to be dislodged
ƒ Disadvantages :
–May cause epistaxis
–Requires smaller tube diameter than oral (so more airflow
resistance)
–May predispose pt. to sinusitis later
Considerations About Orotracheal
Intubation of the Asthmatic Patient
ƒ Advantages :
–Method of choice if pt. apneic or markedly bradypneic
–No predisposition to epistaxis or sinusitis
–Larger diameter tube can be used (may permit later
bronchoscopy)
ƒ Disadvantages :
–Generally requires "full" Rapid Sequence Intubation
(RSI) technique & supine position
–May be less comfortable for pt. & more likely to
dislodge
Options for RSI Meds for the
Asthmatic Patient
ƒ For nasal ETT may only need etomidate or
benzodiazepine IV (after topical anesthesia in
nose)
ƒ Usual oral ETT sequence :
–Preoxygenate
–Lidocaine 1.0 to 1.5 mg/kg IV
–Ketamine 1.0 to 2.0 mg/kg IV
–+/- benzodiazepine 1 to 5 mg IV
–Succinylcholine 1.0 to 1.5 mg/kg IV
–Perform intubation
General Considerations for Mechanical
Ventilation of the Asthmatic Patient
ƒ Mortality of ventilated pts. prior to
1984 reported as 20 to 40 %
ƒ Current mortality < 10 % using
"permissive hypercapnia"
–uses smaller tidal volumes
–goal is to limit barotrauma
–does not require normalization of pCO2 or
pH
Specific Guidelines for Mechanical
Ventilation of the Asthmatic Patient
ƒ 1. Volume control (A/C or SIMV) preferred
over pressure control to avoid
overventilation
ƒ 2. Tidal volume set at 5 to 8 ml/kg
ƒ 3. Initial rate set at 6 to 10 breaths per min.
–allows increased time for exhalation & avoids
dynamic hyperinflation ("breath stacking")
Specific Guidelines for Mechanical
Ventilation of the Asthmatic Patient (cont.)
ƒ 4. Set FIO2 to keep arterial pO2 > 60 mm Hg
–Should be < 50% to avoid O2 toxicity if ventilation
prolonged
ƒ 5. Set PEEP adjusted to 75 to 80 % of measured
auto-PEEP level
–Make sure endogenous (auto) PEEP does not
exceed the amount dialed on the ventilator
ƒ 6. Set Peak Insp. Flow Rate 70 to 90 L/min
–Produces rapid inspiration allowing time for exhalation
–End-inspiratory plateau pressures should be < 35 mm Hg
Specific Guidelines for Mechanical
Ventilation of the Asthmatic Patient (cont.)
ƒ 7. Sedation to prevent tachypnea & allow pt. to
rest
ƒ 8. Aerosolized beta agonists should be given via
ventilation circuit (continuous Rx can be done)
ƒ 9. As wheezing improves, may increase TV & rate
ƒ 10. Monitor for barotrauma (risk greater if endinsp. plateau pressure > 35 mm Hg)
ƒ 11. Monitor for clinical improvement allowing
extubation
Complications of Mechanical
Ventilation of the Asthmatic Patient
ƒ Barotrauma due to alveolar rupture
–Pneumomediastinum, pneumothorax, or SQ emphysema
–Should usually treat with chest tube
–May need to reset ventilation parameters to decrease
end-inspiratory plateau pressure
ƒ Prolonged muscle weakness
–Can be due to prolonged effect of paralytic agent used for
intubation (esp. if renal insufficiency)
–May be partly due to steroid Rx
–Can be a myopathic syndrome with increased muscle enzymes &
require ventilation for several weeks
Education of the Asthmatic Patient to
be Discharged from the E.D.
ƒ Consider pt. education regarding the following items
prior to D/C :
–MDI / spacer use training
–Review of medications
–Self use of short course oral steroids
–Home use of PEFR
ƒ Identify PEFR #'s for which pt. should come to E.D.
–Arrange F/U with primary care doctor
–Asthma diary
–Identify avoidable triggers (shoot any cats in the
house)
Other Considerations for Education of
the Asthmatic Patient
ƒ Make sure family members are also
educated re meds & severity assessment
ƒ Emphasize planning & early response to
minimize time lost from school or work
ƒ Remember it is a chronic recurrent
disease, so limit diagnostic tests unless
there are atypical features or severity of an
attack
Asthma
Lecture Summary
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Assess severity at presentation
Start multiple simultaneous Rx if severe
Decide if diagnostic studies needed
Monitor for response to Rx
Consider second line Rx's & intubation &
ventilation for refractory cases
ƒ Provide careful education & post - E.D.
planning for discharged pts.
Chronic Obstructive
Pulmonary Disease (COPD)
ƒ Refers to triad of disease processes :
–Asthma (airway reactivity)
–Bronchitis (airway inflammation)
–Emphysema (airway collapse)
–All 3 coexist to some degree in same pt.
ƒ Definitions :
–Chronic bronchitis = chronic cough with sputum
production for at least 3 months / yr. for at least 2 yrs.
–Emphysema = enlargement of distal air passages due to
alveolar septal destruction (& obliteration of pulm. capillary
bed)
COPD Epidemiology
ƒ 4th leading cause of death in U.S.
ƒ Leading cause of death in smokers > age
55
ƒ 12.5 million in U.S. have chronic bronchitis
ƒ 14 million in U.S. have emphysema
ƒ 2nd most common cause of permanent
disability
ƒ Huge economic impact
Risk Factors to Develop COPD
ƒ Major factor is cigarette smoking
ƒ Less common factors :
–Inhalation of "second hand" smoke
–Occupational exposure
–Cystic fibrosis
–Alpha 1 antitrypsin deficiency
–Intravenous drug abuse
Pathophysiologic Features of
COPD
ƒ airflow
ƒ lung volumes, hyperinflation
ƒ V/Q mismatch
ƒ Arterial hypoxemia & hypercarbia
ƒ Often intrinsic airway inflammation
ƒ Note typical inflammatory cells in
COPD are usually neutrophils,
whereas they are usually
eosinophils in asthma
Sequence of Pathophysiologic
Events with COPD
ƒ Parenchymal destruction continues
ƒ Distal air spaces enlarge
ƒ Loss of elastic recoil
–Increases lung volumes when resp. rate
–Expiratory time then
–Hyperinflation results
Pathophysiologic Results of
Dynamic Hyperinflation in COPD
ƒ Inspiratory muscle dysfunction
–Acts at stiffer portion of its volume pressure relationship
–Muscle fibers forced from vertical to
horizontal position
–Increased reliance on accessory muscle
fibers
ƒ Causes increased work of breathing &
increased dyspnea
Goals of the E.D. Evaluation of
the COPD Patient
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Rapidly stabilize the pt. in resp. failure
Identify precipitating causes
Treat complications
Rule out or treat concurrent
conditions
Clinical Presentation of Patients
with Exacerbations of COPD
ƒ Dyspnea ; most common ; may be severe
ƒ Other Sx may or may not be present
–Chest pain ; may be :
ƒ Diffuse or vague
ƒ Pleuritic
ƒ Chest wall (from cough injury)
–Cough
–Fever
–Altered mental status
–Apprehension
Signs Associated with COPD
Exacerbations
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Dyspnea
Tachypnea
Tachycardia
Ashen skin color or cyanosis
Diaphoresis
Accessory muscle use
Intercostal retractions
Rales / rhonchi / wheezes / decreased BS
Apprehension
Signs of Severe or Critical Airflow
Obstruction in a COPD Exacerbation
ƒ Altered mental status
ƒ Inability to speak
ƒ "Silent chest" (no or limited audible
BS)
ƒ Combativeness / seizures
Differential Dx of COPD
Exacerbation
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CHF
Acute myocardial ischemia
Airway obstruction
Pneumonia
Pneumothorax
Pulmonary embolus
Pleural effusion
Acute aortic dissection
Allergic reaction
Caveats About Differential Dx
of COPD Exacerbation
ƒ COPD exacerbation may coexist or be
concurrent with any of Dx's on previous
slide
ƒ Particularly CHF may cause COPD
exacerbation & vice versa
–PEFR > 150 L/min suggestive of Dx of CHF
ƒ Pulm. embolus particularly difficult to Dx
in COPD pt.
Spirometry Use for COPD
Exacerbation
ƒ Should be performed on all pts.
–Determine initial severity
–Determine response to Rx
ƒ Clinical eval. alone is unreliable at estimating
airflow obstruction
ƒ Many pts. with post-Rx FEV1 > 40% can be
safely discharged
ƒ Another discharge criterion is PEFR > 250
(assuming pt.'s baseline PEFR is > 300 ; need to know pt.'s
prior PFT's to determine this)
Use of ABG's in COPD
Exacerbation
ƒ Some recommend on all pts.
ƒ I favor using only in pts. who :
–Appear critical at presentation
–Do not respond well to Rx
–Have altered mental status
ƒ ALL pts. should have continuous pulse
oximetry
ƒ Pt. can have hypoxemia even when pulm.
function approaches 50% of normal
Use of CXR in COPD
Exacerbation
ƒ CXR should be obtained on all pts.
ƒ At least 15 % of CXR's show a directly
treatable finding :
–Pneumonia
–Pleural effusion
–Pneumothorax
–Atelectasis
–Aortic dissection
ƒ Also allows R/O CHF
E.D. Management of COPD
Exacerbations
ƒ For ALL Pts. :
–Oxygen
–Beta agonist aerosol
ƒ Consider SQ terbutaline if unable to take aerosol
–Anticholinergic aerosols
ƒ For some pts. :
–Corticosteroids
–Antibiotics
–Diuretics
–CPAP / BiPAP / Intubation / Ventilation
Considerations for O2 Therapy for
COPD Exacerbations
ƒ Risk of eliminating hypoxic drive (&
causing further resp. acidosis / failure) is
overstated
–Only applies to < 5% of COPD
population
ƒ Venturi mask can be used to give precise
regulated O2 concentrations
ƒ Pts. that develop resp. acidosis with O2
Rx usually need to be intubated &
ventilated anyway
Anticholinergic Med Choices &
Doses for COPD Exacerbations
Medication
Dose
Ipratropium
0.5 mg
Atropine
1 to 2 mg (0.025 mg/kg)
Glycopyrrolate
0.2 to 1.0 mg
Ipratropium preferred because of less side
effects such as tachycardia
Considerations in Use of Corticosteroids for
Rx of COPD Exacerbation
ƒ Not of benefit to all pts. with COPD
ƒ Should be considered if :
–Pt. on chronic steroid Rx
–Wheezing component is prominent
–Allergic trigger
–Prior response to steroids
–IV versus PO is equivalent
Considerations in Use of Antibiotics
for COPD Exacerbation
ƒ Not indicated for all pts.
ƒ Usually indicated for COPD exacerbation with :
–Fever / chills
–Increased sputum production
–Change in color of sputum
–Persistent increased cough
–Atelectasis or infiltrate on CXR
ƒ Most common pathogens :
–Strep pneumoniae (with increasing rates of PCN resistance)
–Hemophilus influenzae
–Moraxella (Branhamella) catarrhalis
Antibiotic Choices for COPD
Exacerbation
ƒ Best first line agents :
–Azithromycin
–Cefuroxime
–Trimethoprim - sulfa
–? levofloxacin
ƒ Problems with other choices :
–Doxycycline, amoxicillin : resistance
–Erythromycin : no H. flu coverage
–Amoxil / clavulanate : cost, side effects
–Clarithromycin : cost, drug interactions, taste
Ventilatory Assistance Considerations
for COPD Exacerbation
ƒ 3% of COPD pts. require ETT & ventilation
for resp. failure
ƒ Indications & complications same as for
asthma
ƒ Need to be careful to avoid barotrauma
ƒ Intubated COPD pts. have higher mortality
& longer time on ventilator than asthma
pts.
ƒ CPAP or BiPAP can be tried prior to ETT
Disposition Considerations for
COPD Exacerbation
ƒ Indications for hospital admission :
–Persistent hypoxemia (O2 sat. < 90%)
–Persistent hypercarbia / resp. acidosis
–Persistent dyspnea
–Overt resp. failure
–Altered mental status
–Usually if associated pneumonia
–Pneumothorax
ƒ "Borderline " admission candidate may
be considered for observation unit first
Suggested E.D. Management
of COPD Exacerbation
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Immediate O2 & beta 2 aerosol
Rapid CXR to R/O CHF or pneumothorax
Evaluate for cardiac ischemia (EKG)
Consider other Dx tests
Early PEFR & repeat after each Rx
Continued Rx (aerosols, +/- steroids, +/antibiotics, etc.)
ƒ Monitor for response :
–ETT / ventilation if worsening
–Admission if not improving satisfactorily
Adjunctive Treatments to Consider for
COPD Exacerbations
ƒ Phosphodiesterase-4 Inhibitors
ƒ Reduce inflammation via macrophages and
lymphocytes
ƒ Cilomilast 15 mg PO bid
ƒ Mucolytic agents
ƒ N-acetycysteine
ƒ Efficacy debatable
ƒ Referral for surgical bullectomy, lung volume
reduction surgery, or lung transplantation
Web Sites with Useful Clinical
Guidelines for Asthma and COPD
ƒ Expert Panel Report 3 Summary Report 2007
ƒ 440 pages ; summary is 74 pages
ƒ http://www.nhlbi.nih.gov/guidelines/asthma/asthgdl
n.htm
ƒ http://www.medscape.com/viewarticle/564670 , and
564654
ƒ emedicine.com has 4 nice articles under both
“emergency medicine” and “pulmonology” :
ƒ http://www.emedicine.com/med/topic177.htm , & 373
ƒ http://www.emedicine.com/emerg/topic43.htm , & 99