COPD management

Classic representation of
"blue bloater" on left- hypoxia, CO2 retention, possible R heart failure.
"pink puffer" on right- preserved blood gases, cachexia, dyspnea
Most COPD patients have features of both, and this classification is not frequently used

COPD stages and therapy
(from GOLD initiative)

Stage:
0: At risk- pts with chronic symptoms, normal spirometry, exposure to risk factors
Tx: Avoid triggers, smoking cessation, flu vaccine, education

1: Mild COPD- FEV1/FVC below 70% , FEV1 over 80% of predicted, with or without symptoms
Tx: Above, and short-acting bronchodilator

2: Moderate COPD- FEV1/FVC below 70%, FEV1 50-80% predicted
Tx: Above, and regular LA bronchodilator (e.g. tiotroprium), pulmonary rehab

3: Severe COPD- FEV1/FVC below 70%, FEV1 30-50%

Tx: Above, and home O2 if PaO2 below 55

Other treatments rarely used: Theophylline, lung reduction surgery

Etiologies of exacerbations:

Majority are infection-related (80%)- H. Flu (20-30%); S. Pneumo (10-15%); M. Catarrhalis (10-15%); P. Aeruginosa (5-10%); Rhinoviruses (20-25%).

15-20% are from other causes (air pollution, irritants increasing bronchomotor tone)

Treatment components are

1) Bronchodilators (B-ag and anticholinergic)

2) Systemic steroids

3) ABx

4) Ventilatory support if needed (including BiPAP)

Abx choices:

Mild exacerbation: 1 of increased dyspnea, increased sputum purulence, increased sputum volume

Tx: No antibiotics; increase bronchodilator. Symptomatic therapy and monitoring symptoms

Moderate or severe 2 of above 'cardinal symptoms'

In complicated COPD (i.e. at least 1 of age over FEV1 below 50%, over 3 exacerbations per year)

Tx: Respiratory fluoroquinolone, amox-clav; consider cipro if risk for pseudomonas, and obtain sputum culture

In uncomplicated (i.e. none of above) Tx: macrolide, cephalosporin, doxycycline, TMP-SMX .

If abx in previous 3/12, switch classes

Steroids: Trials have demonstrated benefit of systemic steroids for vs. placebo. No mortality benefit, but shorter length of stay, PFT improvement, and symptomatic improvement.

Original trial used Solumedrol 125mg IV q8h; no advantage to this high dose over Prednisone 40-60mg PO x 5-7d. No need for taper of this duration.

Links:

Click here for a NEJM review on COPD exacerbations

Click here for the TORCH trial of inhaled corticosteroids in COPD

Click here for the GOLD initiative for COPD staging and management