Clinical Notes : Pharmacology

169. COPD (acute exacerbation) prescribing

COPD (acute exacerbation) prescribing

 

Acute exacerbation of COPD 

An exacerbation of COPD is defined as an event characterised by a change in the patient's baseline dyspnoea, cough, and/or sputum that is beyond normal day-to-day variations and is acute in onset.

 

Exacerbations :

  • rates and all-cause mortality tend to be higher during winter months

  • are responsible for much of the morbidity and mortality experienced by people with COPD

  • vary in severity and may be triggered by a range of factors 

    • bacterial pathogens

      • 50% to 70% of exacerbation

      • most common bacterial pathogens : Haemophilus influenzae , Streptococcus pneumoniae , and Moraxella catarrhalis

    • viral pathogens

      • ​most common viral pathogens : rhinovirus, influenza, respiratory syncytial virus, parainfluenza virus, and human metapneumovirus

    • pollutants

    • changes in temperature and humidity

    • smoking​

  • some people at risk of exacerbations may have antibiotics to keep at home as part of their current exacerbation action plan 

 

Treatment 

Sending sputum samples for culture is not recommended in routine practice.

First line treatment of acute exacerbation of COPD includes :

1. short-acting bronchiodilator

2. systemic corticosteroid

3. consider antibiotic

Short-acting bronchiodilator

 

  • salbutamol inhaled 

    • 2.5 to 5 mg nebulised every 20 minutes for up to 2 hours or until clinical improvement,

      • followed by 4-6 hourly dosing;

    • (100 micrograms/dose inhaler) 100-200 micrograms (1-2 puffs) every 20 minutes for up to 2 hours or until clinical improvement,

      • followed by 4-6 hourly dosing

and/or

  • ipratropium inhaled 

    • 0.25 to 0.5 mg nebulised every 20 minutes for up to 2 hours or until clinical improvement,

      • followed by 4-6 hourly dosing;

    • (20 micrograms/dose inhaler) 40 micrograms (2 puffs) every 20 minutes for up to 2 hours or until clinical improvement,

      • followed by 4-6 hourly dosing

Severely dyspnoeic patients with low inspiratory flow rates may have difficulty achieving proper technique and medication delivery from the metered-dose inhaler devices; nebuliser treatment may be easier to use for such patients.

Administration should be observed and a spacer should be used

Systemic corticosteroid

  • prednisolone 

    • 30-40 mg orally once daily for 5-7 days

or

  • methylprednisolone 

    • 40-60 mg/day orally given once daily or in 2 divided doses for 5-7 days

Diabetes is common in patients with COPD, and the need for treatment of hyperglycaemia is more frequently encountered when patients receive systemic corticosteroids

Consider an antibiotic

 

Consider an antibiotic for people with an acute exacerbation of COPD, but only after taking into account:

 

  • Severity of symptoms, particularly

    • changes in their baseline level of

      • dyspneoa

      • cough

      • wheeze

      • sputum production

    • sputum colour changes and increases in volume or thickness beyond the person's normal day-to-day variation

    • presence of fever

    • symptoms worsened rapidly or significantly in past 2-3 days

    • systemically very unwell​​

 

  • previous exacerbation and hospital admission history, and the risk of developing complications

 

  • previous sputum culture and susceptibility results

    • ​sending sputum samples for culture is not recommended in routine practice

 

  • the risk of antimicrobial resistance with repeated courses of antibiotics

  • indications for A+E referral

    • significant comorbidities

      • heart failure

        • new peripheral oedema

        • haemodynamic instability

        • worsened mental status

      • arrhythmias

      • kidney disease

    • failure of outpatient treatment recently prescribed

    • worsening gas exchange

      • measure oxygen saturation with ulse oximeter (in the absence of arterial blood gases)

      • use of accessory respiratory muscles

      • paradoxical respirations

      • cyanosis

    • inability to cope at home

      • older age and frailty

      • exhaustion

 
 
 
 

Indications for A+E referral in COPD exacerbation

COPD (acute exacerbation): antimicrobial prescribing

 

Choice of antibiotic for treating an acute exacerbation: adults aged 18 years and over

 

1. See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, and for administering intravenous antibiotics.

2. Where a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class.

3. People who may be at higher risk of treatment failure include people who have had repeated courses of antibiotics, a previous or current sputum culture with resistant bacteria, or people at higher risk of developing complications.

4. The European Medicines Agency’s Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system. This includes a recommendation not to use them for mild or moderately severe infections unless other antibiotics cannot be used (press release October 2018).

5. Co-trimoxazole should only be considered for use in acute exacerbations of COPD when there is bacteriological evidence of sensitivity and good reason to prefer this combination to a single antibiotic (BNF, October 2018).

6. Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible.

 

Other treatments

 

  • Mucolytics and expectorants

    • do not appear to provide any clear proven benefit, although some patients do experience symptomatic relief

 

  • Airway clearance techniques

    • mechanical vibration and non-oscillating positive expiratory pressure may improve sputum clearance in some patients with copious secretions, but are not uniformly helpful.

    • Other clearance techniques such as manual chest wall percussion are also either not routinely helpful or may have detrimental effects.

    • There is no proven benefit of airway clearance techniques on long-term outcomes following COPD exacerbation, such as reduction in subsequent exacerbation risk

  • Oxygen

    • Oxygen therapy is recommended for patients with acute exacerbations who are hypoxic (PaO2 <60 mmHg, SaO2 ≤90%) and requires referral to A+E

  • Cognitive behaviour Therapy

    • Ask people with COPD if they experience breathlessness they find frightening. If they do, consider including a cognitive behavioural component in their self-management plan to help them manage anxiety and cope with breathlessness.

 

Safety-netting and Follow-up

Ensure all patients treated at home in an OOH setting have clear instructions regarding immediate safety-netting and appropriate follow-up with family GP.

 
NICE.jpg
GOLD.jpg

Chronic obstructive pulmonary disease in over 16s: diagnosis and management

National Institute for Health and Care Excellence  

Guideline NG115

December 2018

Access

 

Global strategy for the diagnosis, management, and prevention of COPD

​Global Initiative for Chronic Obstructive Lung Disease

February 2019

Access

Contemporary management of acute exacerbations of COPD: a systematic review and metaanalysis.

Quon BS, Gan WQ, Sin DD.

Chest. 2008 Mar;133(3):756-66

Access

Antibiotics for exacerbations of chronic obstructive pulmonary disease.

Vollenweider DJ, Jarrett H, Steurer-Stey CA, et al.

Cochrane Database Syst Rev. 2012

Access

Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease.

Walters JA, Tan DJ, White CJ, et al.

Cochrane Database Syst Rev. 2014

Access

The effect of positive expiratory pressure (PEP) therapy on symptoms, quality of life and incidence of re-exacerbation in patients with acute exacerbations of chronic obstructive pulmonary disease: a multicentre, randomised controlled trial.

Osadnik CR, McDonald CF, Miller BR, et al.

Thorax. 2014;69:137-143

Access

Airway clearance techniques for chronic obstructive pulmonary disease.

Osadnik CR, McDonald CF, Jones AP, et al.

Cochrane Database Syst Rev. 2012;(3)

Access

Acute exacerbation of chronic obstructive pulmonary disease

BMJ Best Practice

Last updated: April 2018

Last reviewed: March 2019

Access

COPD

BMJ Best Practice

Last updated: November2018

Last reviewed: March 2019

Access

The antibiotics are available in Ireland :

Amoxicillin as Amoxil, Geramox, Pinamox

Doxycycline as By-mycin, Efracea, Periostat, Vibramycin

Clarithromycin as Clarithromycin Ranbaxy, Clonocid, Clorom, Klacid, Klaram, Klariger

Co-amoxiclav as Augmentin, Amoclav, Germentin

Levofloxacillin as Quinsair, Tavanic

Co-trimoxazole as Septrin

Piperacillin with tazobactam as Hospira Piperacillin/tazobactam, Pipercin, Tazocin

 

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