COPD

Some principles in the management of acute COPD exacerbations:

1. Stability: patients should be in a setting where their vital signs can be monitered closely.

2. Oxygen: can be delivered with increasing capacity. Note that if you are requiring more intense oxygenation, consider other etiologies of hypoxia such as pulmonary embolism. Oxygen can be delivered by....

• nasal prongs
• venturi masks (delivered in increasing FiO2's)
• non-rebreathing masks
• non-invasive positive pressure ventilation
• intubation

3. Anticholinergic Agents: short acting ones like Ipratropium Bromide, in frequent and large doses.

4. Beta Agonists: also short acting ones like Salbutamol, also in frequent and large doses.

5. Steroids: administered PO for most, or IV if your patient is very ill and/or will not tolerate PO meds. Commonly used doses include Prednisone 40-60 mg PO daily, or Methylprednisolone 125 mg IV given 2 times per day. Treatment usually lasts from 5-10 days.

6. Antibiotics: Indicated in moderate to severe exacerbations. This includes patients who have 2/3 of:

• increased dyspnea
  
• increased sputum purulence
  
• increased sputum production

or those requiring invasive ventilation.

7. When the dust settles: After the acute event it is important to counsel patients on smoking cessation, ensure they have their proper vaccines, re-evaluate their medications and ensure they are taking them properly, and possibly arrange for pulmonary rehabilitation.

Links:
A good paper on infections in COPD from NEJM.
A review on the management of COPD exacerbations in a case-based approach.