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Chronic Obstructive Pulmonary Disease and Emphysema

para>Acute exacerbation: Use oxygen, inhaled β-agonists, inhaled anticholinergic agents, and oral or IV corticosteroids prednisone (up to 1 mg/kg/day commonly 40 mg/day for 5 days) (7)[A]. Antibiotics should be given for those with moderate/severe exacerbations showing clinical signs of bacterial infection (increased sputum volume, increased sputum purulence); optimal antibiotic therapy has not been determined (3)[B].

Second Line

  • Trial of inhaled corticosteroids for moderate or severe disease (2)[A]May initiate earlier if suggestion of asthmatic component to diseaseSystemic corticosteroids: Prednisone (Deltasone) can be given orally 7.5 to 15 mg/day in selected patients.Long-term monotherapy with steroids (oral or inhaled) is not recommended (2,3)[A].Inhaled corticosteroids are associated with an increased risk of pneumonia (3).
  • Continuous home oxygen: may improve survival; should be initiated for severe resting hypoxemia (PaO2≤ 55 mm Hg or oxygen saturation ≤88%) or PaO2 56 to 59 mm Hg with evidence of hypoxia (i.e., polycythemia or pulmonary hypertension) or pulse oximetry trends ≤88% (1)[A]
  • Theophylline if other long-term treatment is unavailable or unaffordable: 400 mg/day; increase by 100 to 200 mg in 1 to 2 weeks, if necessary (4)[B]Reduce dosage in patients with impaired renal or liver function, age >55 years, or CHFMonitor serum level. Therapeutic range is 8 to 13 μg/mL.Low-dose theophylline may help inflammatory component (4)[B].
  • Combination of inhaled corticosteroid, long-acting β-agonist, and anticholinergic indicated for severe disease. Several combination medications are now available (2)[A].
  • Mucolytic agents may improve secretions but do not improve outcomes.
  • Phosphodiesterase-4 inhibitor (PDE4) inhibitor (roflumilast) in severe chronic bronchitis may reduce exacerbations (2)[B].
  • α1-Antitrypsin, if deficient: 60 mg/kg/week to maintain level >80 mg/dL
  • PrecautionsSympathomimetics: excessive use may be dangerous. May need to reduce dosage or use levalbuterol (Xopenex) in patients with cardiovascular disease, hypertension (HTN), hyperthyroidism, diabetes, or seizures. Anticholinergics: narrow-angle glaucoma, benign prostatic hyperplasia, bladder neck obstructionCorticosteroids: weight gain, diabetes, adrenal suppression, osteoporosis, infection (pneumonia)
  • Sympathomimetics may be aerosolized.
  • Anticholinergics: Ipratropium (Atrovent) may be aerosolized or combined with albuterol (Combivent Respimat).

ISSUES FOR REFERRAL

Severe exacerbation, frequent hospitalizations, age <40 years, rapid progression, weight loss, severe disease, or surgical evaluation

ADDITIONAL THERAPIES

  • Adequate hydration and pulmonary hygiene
  • Consider postural drainage, flutter valve, or other devices to assist mucus clearance.
  • Pulmonary rehabilitation (1,2,3)[A]
  • Intermittent, noninvasive ventilation may help in severe chronic respiratory failure.
  • Short course of antibiotics (5 to 10 days) for acute exacerbations (2)[B]
  • Immunizations
  • Supplemental oxygen if indicated

SURGERY/OTHER PROCEDURES

  • Lung reduction surgery (selected cases)
  • Lung transplantation (selected cases)

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

  • Outpatient treatment is usually adequate.
  • Exacerbation with acute decompensation (hypoxemia, hypercarbia)
  • Serious comorbidities (i.e., decompensated CHF)
  • Systemic steroids reduce recovery time and improve hypoxia (2,7)[A]
  • Supplemental oxygen and short-acting bronchodilators should be given (3).

ALERT

If not already in place, have patient delineate an advance directive.

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  • Progressive nature of disease and severity of treatment methods (ventilation, etc.) make revisiting patient preferences beneficial.
  • Acute respiratory failure may require ICU and invasive or noninvasive ventilation (NIV) (2)[A].
  • Systemic steroids (prednisone 40 mg/day for 5 days or equivalent) have been shown to reduce recovery time and improve hypoxia (7)[A].

Nursing

Teach proper inhaler use.

Discharge Criteria

  • Ability to ambulate (3)
  • Hypoxia can be treated with home oxygen (may only be temporary) (2)[A]
  • Inhaled short-acting β-agonist therapy no more frequently than q4h (3)
  • Ability to eat and sleep without interruption caused by dyspnea (3)

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • May taper or stop oral steroids as outpatient
  • If pneumonia caused exacerbation, need to follow CXR or chest CT until clear or stable
  • Pulmonary rehabilitation for exertional dyspnea (1)[A]

Patient Monitoring

  • Severe or unstable patients should be seen monthly. When stable, see every 6 months.
  • Check theophylline level with dose adjustment, then check every 6 to 12 months.
  • With use of home oxygen, check ABGs yearly or with change in condition. Frequently monitor saturation (pulse oximetry). Some patients only desaturate at night, thus only need nocturnal oxygen.
  • Yearly spirometry
  • Travel at high altitude with supplemental oxygen if necessary.
  • Baseline Chest CT for patients aged 55 to 74 years with a 30 pack/year smoking history to look for lung nodules (5)[B]
  • Discuss advance directive and health care proxy.

DIET

A high-protein low-carbohydrate diet may benefit those with hypercarbia.

PATIENT EDUCATION

American Lung Association: www.lung.org/lung-disease/copd/

PROGNOSIS

  • Patient's age and postbronchodilator FEV1 are the most important predictors of prognosis.
  • Supplemental O2, when indicated, is shown to increase survival (may only need at night) (1)[A].
  • Smoking cessation improves prognosis-consider E-cigarettes (2).
  • Malnutrition, cor pulmonale, hypercapnia, and pulse >100 indicate a poor prognosis.

COMPLICATIONS

  • Malnutrition, poor sleep quality, infections, secondary polycythemia
  • Acute or chronic respiratory failure, bullous lung disease, pneumothorax
  • Arrhythmias, cor pulmonale, pulmonary HTN

REFERENCES

11 Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011;155(3):179-191.22 Vestbo J, Hurd SS, Agust AG, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013;187(4):347-365.33 Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of COPD. Revised 2013. http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html44 Lamprecht B, McBurnie MA, Vollmer WM, et al. COPD in never smokers: results from the population-based burden of obstructive lung disease study. Chest. 2011;139(4):752-763.55 Detterbeck FC, Mazzone PJ, Naidich DP, et al. Screening for lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5)(Suppl):e78S-e92S.66 Csikesz NG, Gartman EJ. New developments in the assessment of COPD: early diagnosis is key. Int J Chron Obstruct Pulmon Dis. 2014;9:277-286.77 Leuppi JD, Schuetz P, Bingisser R, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA. 2013;309(21):2223-2231.

SEE ALSO

Bronchitis, Acute

CODES

ICD10

  • J44.9 Chronic obstructive pulmonary disease, unspecified
  • J43.9 Emphysema, unspecified
  • J42 Unspecified chronic bronchitis
  • E84.0 Cystic fibrosis with pulmonary manifestations
  • J47.9 Bronchiectasis, uncomplicated
  • J44.0 Chronic obstructive pulmon disease w acute lower resp infct
  • J44.1 Chronic obstructive pulmonary disease w (acute) exacerbation

ICD9

  • 496 Chronic airway obstruction, not elsewhere classified
  • 492.8 Other emphysema
  • 491.20 Obstructive chronic bronchitis without exacerbation
  • 493.20 Chronic obstructive asthma, unspecified
  • 493.22 Chronic obstructive asthma with (acute) exacerbation
  • 491.21 Obstructive chronic bronchitis with (acute) exacerbation
  • 277.02 Cystic fibrosis with pulmonary manifestations
  • 491.22 Obstructive chronic bronchitis with acute bronchitis

SNOMED

  • 13645005 Chronic obstructive lung disease (disorder)
  • 87433001 Pulmonary emphysema (disorder)
  • 63480004 Chronic bronchitis (disorder)
  • 195949008 Chronic asthmatic bronchitis (disorder)
  • 86555001 Cystic fibrosis of the lung (disorder)
  • 12295008 Bronchiectasis (disorder)
  • 195951007 Acute exacerbation of chronic obstructive airways disease (disorder)

CLINICAL PEARLS

  • Consider screening PFTs on any high-risk patient.
  • Overnight oximetry if daytime SaO2 is borderline.
  • Influenza/pneumococcal vaccines should be current.
  • Advance directive before patient is seriously ill.
  • Consider chest CT for patients age 55 to 74 years with a 30 pack/year smoking history for lung cancer screening.