2014 GOLD Update on COPD Exacerbation

Definition

 
An acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day- to-day variations and leads to a change in medication
 

Etiology

 
The most common causes appear to be respiratory tract infections (viral or bacterial)
 

Assessment

 
•   Arterial blood gas measurements (in hospital): PaO2 < 8.0 kPa (60 mmHg) with or without PaCO2 > 6.7 kPa, (50 mmHg) when breathing room air indicates respiratory failure.
•   Chest radiographs: useful in excluding alternative diagnoses.
•   ECG: may aid in the diagnosis of coexisting cardiac problems. 

 

Spirometric tests are not recommended during an exacerbation because they can be difficult to perform and measurements are not accurate enough.

 

Treatment

 
  • 
Oxygen

Supplemental oxygen should be titrated to improve the patient’s hypoxemia with a target saturation of 88-92%.
 
  • Bronchodilators

Short-acting inhaled beta2-agonists with or without short- acting anticholinergics are the preferred bronchodilators for treatment of an exacerbation.
 
  • Systemic Corticosteroid

Systemic corticosteroids shorten recovery time, improve lung function (FEV1) and arterial hypoxemia (PaO2), and reduce the risks of early relapse, treatment failure, and length of hospital stay.
 
A dose of 40 mg prednisone per day for 5 days is recommended
 
  • Antibiotics

 Antibiotics should be given to patients:
•   With the following three cardinal symptoms: increased dyspnea, increased sputum volume, increased sputum purulence;
•   With increased sputum purulence and one other cardinal symptom;
•   Who require mechanical ventilation 

 
  • Adjunct Therapies

Patients hospitalized because of exacerbations of COPD are at increased risk of deep vein thrombosis and pulmonary embolism; thromboprophylactic measures should be enhanced.
 

Disposition

 

Patients with characteristics of a severe exacerbation should be hospitalized
 
 Indications for Hospital Assessment or Admission
•   Marked increase in intensity of symptoms
•   Severe underlying COPD
•   Onset of new physical signs
•   Failure of an exacerbation to respond to initial medical management
•   Presence of serious comorbidities
•   Frequent exacerbations
•   Older age
•   Insufficient home support
 

Gemma C Morabito, MD - Editor in-chief www.medicinadurgenza.org

Global Initiative for Chronic Obstructive Lung Disease
Pocket Guide to COPD Diagnosis, Management and Prevention, Updated 2014