copd exacerbations in older persons

COPD EXACERBATIONS IN OLDER PERSONS

Carlos Fragoso, MDYale University School of MedicineVA Connecticut Healthcare System

… No Conflicts of Interest

True or False

Re. COPD exacerbations …

Age is a predisposing factor● Sputum analysis should be performed routinely

Respiratory failure is the most common cause of death

Outline

● EpidemiologyRisk Factors

● Pathophysiology● Management

● Follow-Up

ATS/ERS Guidelines: http://www.thoracic.org/clinical/copd-guidelines/index.phpGOLD Guidelines: Am J Respir Crit Care Med 2007;176:532-555. The 2009 report is available online at http://www.goldcopd.comCTS COPD guidelines: Can Respir J 2007;14 (Suppl B):5B-32B.

Epidemiology … Definition

A COPD exacerbation refers to acute worsening of respiratory symptoms,* requiring a change in management

* Up to 50% may go unreported

Cardinal symptoms: dyspnea, sputum purulence/volumeMild exacerbation: one cardinal symptom Moderate exacerbation: 2 of 3 cardinal symptomsSevere exacerbation: 3 cardinal symptoms

● Plus one or more of the following: URI, fever, wheezing or coughing, or ↑ RR or HR.

Epidemiology … Outcomes

COPD accounts for over 500,000 hospitalizations (USA)

High relapse rates:–1/3rd of patients discharged from the ED have recurrent symptoms within 2-weeks, requiring hospitalization in 17%– Of those hospitalized in hypercapneic respiratory failure, about 50% will be readmitted within 6 months

● High morbidity and mortality:– For those requiring an ICU admission, there are progressive decrements in functional status and quality of life, with mortality rates of 30-50%

Outline

● EpidemiologyRisk Factors

● Pathophysiology● Management

● Follow-Up

Predisposing Factors

Age● Multimorbidity● Low physical activity

Low SESChronic bronchitis Low FEV1Chronic respiratory failure

● Escalating use of bronchodilators or corticosteroids● Prior exacerbation (ED, hospitalization)

Aging as a predisposing factor

Associated with airflow limitation and air trappingAJRCCM 2008;177:253-60.

Aging as a predisposing factor

Two-thirds of older persons have 2 or more chronic conditionswww.cdc.gov/aging

Aging as a predisposing factor

www.cdc.gov/aging

Aging as a predisposing factor

MMWR 2008; 57(45):1229-32.

Precipitating Factors

● Infection: ~ 60%– Bacteria: S pneumoniae, H influenzae, M catarrhalis, Enterobactericae, P aeruginosa

– Viruses: Rhinovirus, Influenza, Parainfluenza, RSV, Coronavirus

● Pollutants: ~ 10%Ozone, sulphur dioxide, nitrogen dioxide, particulate matter, biomass fuels

● Unknown: ~ 30%

Prevalence of chronic bronchitis relative to active smoking

Precipitating Factors

Eur Respir Mono 2006;38:41-70.

Precipitating Factors

Physician visits in the continuous smoking groupAJRCCM 2001;164:358-64

Precipitating Factors

AJRCCM 2002;166;675-679.

Precipitating Factors

Thorax 2006;61;164-168.

Perpetuating Factors

Depression and anxiety –

● adds to disability caused by physical illness● reduces adherence to medications● risk factor for cognitive decline● prolongs COPD exacerbations● increases frequency of hospital admissions

Int J Geriatr Psychiatry 2000; 15: 1090-1096 Int J Geriatr Psychiatry 1997; 12: 817-824

Outline

● EpidemiologyRisk Factors

● Pathophysiology● Management

● Follow-Up

Pathophysiology … BaselineSmall airways and alveolar destruction, with pulmonary

vascular remodeling

Sarcopenia and reduced central respiratory drive

Pathophysiology … Exacerbation

airway inflammation, mucous hypersecretion, and bronchoconstriction, resulting in impaired gas exchange and

respiratory muscle fatigue

Pathophysiology … Comorbidities

In one autopsy-based study, of 43 decedents hospitalized with a COPD exacerbation (median age 70), the cause of death was heart failure in 16 (37%), pneumonia in 12 (28%), thromboembolism in 9 (21%), but respiratory failure in only 6 (16%).

Of the decedents, 33 (77%) had 1 or more comorbidities, with the most common being chronic heart failure (25; 58%).

Chest 2009;136:376-80.

Outline

● EpidemiologyRisk Factors

● Pathophysiology● Management

● Follow-Up

Management … Admission Criteria

Marked increase in dyspnea, associated with changes in vital signs, cyanosis, or peripheral edema

Severe COPD: FEV1<50%Pred, chronic respiratory failure, prior exacerbations

Arrhythmias

Comorbidities

Older age

Inadequate home support

Management … ICU Criteria

Severe dyspnea refractory to initial emergency therapy

Change in mental status (delirium)

Severe respiratory failure: … PaCO2 >60 torr, pH <7.25

Hemodynamic instability

Management … Evaluation

CBC, CHEM7, theophylline level (if on medication)

ABG … if no prompt improvement in response to initial Rx

ECG

CXR

Blood cultures … if febrile

Sputum gram stain and culture … if poor response to empiric antibiotics or pseudomonas is suspected

does not distinguish pathogens versus colonizing flora

Management … Bronchodilators

A short-acting beta-2 agonist is effective (Evidence A) … with or without an anticholinergic (Evidence B)

● Albuterol: 2.5 mg by nebulizer every one to four hours, or 4 to 8 puffs (90 mcg/puff) by MDI with a spacer every one to four hours.

● Ipratropium: 500 mcg by nebulizer every four hours, or 2 puffs (18 mcg/puff) by MDI with a spacer every four hours.

● Methylxanthines: controversial …Limited efficacy in COPD exacerbations, ↑ side effects

Management … Steroids

Effective treatment for exacerbations; ↓ recovery time, ↑ FEV1, ↑ PaO2 (Evidence A)

● Prednisone 40-60 mg po per day for 7-14 days.● Methylprednisolone 60-125mg IV Q6H (3 days), followed by prednisone (60, 40, and 20-mg po QD, each for 4-days)

NEJM 1999;340:1941-1947

Management … Antibiotics

Antibiotics may be useful, if the exacerbation is associated with ↑ dyspnea and sputum purulence or volume (moderate-to-severe), or requires mechanical ventilation (Evidence B)

H influenza, S pneumoniae, M catarrhalis, C pneumoniae

Beta-lactamase resistant species Enterobacteriaceae

P aeruginosa

Antibiotics based on local resistance patterns● No role for mucolytics or chest PT

Management … Antibiotics

If <65 years, FEV1 >50% Pred, no prior Abx, no comorbidity… Advanced macrolide (azithromycin), or doxycycline, or cephalosporin (cefuroxime), or trimethoprin/sulfamethoxazole.

● If >65 years, FEV1 <50% Pred, prior Abx, comorbidity… Respiratory fluoroquinolone (gatifloxacin, levofloxacin, moxifloxacin) or amoxicillin/clavulanate.

Consider sputum analysis, if worsening clinical status or inadequate response in 72-hrs.

Management … Antibiotics

Suspect P aeruginosa: prior isolation, recent Abx use or hospitalization, FEV1 <50%Pred, and/or systemic steroid use

– order sputum gram stain and culture

– consider dual antibiotic therapy: levofloxacin, ciprofloxacin, piperacillin-tazobactam, cefepime, and/or ceftazidine.

Management … Oxygen

Adequate oxygenation (PaO2 60-70 torr, SpO2 90-94%)

● Prevention of hypoxia trumps CO2 retention concerns

● Venturi mask: delivers a precise FiO2 of 24, 28, 31, 35, 40, 50, or 60%; ↑ FiO2 gradually – monitor PaO2 & PaCO2.

Management … Oxygen

Nasal cannula can provide up to 40% FiO2 (6 L/min) … Variations in ventilation and entrainment of RA affect FiO2

Simple facemask can provide up to 55% FiO2 (6-10 L/min)… Variations in ventilation and entrainment of RA affect FiO2

Non-rebreathing masks with a reservoir, one-way valves, and tight seal can deliver up to 90% FiO2.… suspect comorbidity if high FiO2 required (HF, PNA, PE)

Management … Noninvasive Ventilation

Improves respiratory acidosis and dyspnea, and decreases intubation rates, length of hospitalization, and mortality (Evidence A)

Selection criteria:– Moderate to severe dyspnea (use of accessory muscles, paradoxical abdominal motion, >25 breaths/min)– Hypercapneic respiratory failure: pH <7.35, PaCO2 >45 torr

Settings: CPAP (4–8 cmH2O) and PSV (10–15 cmH2O) provides the most effective mode of NIV

Management … Noninvasive Ventilation

Exclusion Criteria:

– Respiratory arrest– Cardiovascular instability (hypotension, arrhythmias, ACS)– Delirium (uncooperative)– Secretions (viscous, copious)– High aspiration risk– Craniofacial trauma– Nasopharyngeal abnormalities– Burns– Extreme obesity

Management … Comorbidities

Monitor fluid balance and nutrition

● DVT prophylaxis

● Identify and manage associated conditions … heart failure, arrhythmias, pneumonia, pulmonary embolism

Management … Hospital Discharge

● ABG stable for 24-hours

● Clinically stable for 24-hours– Able to eat and sleep w/o frequent disruption by dyspnea– If previously ambulatory, able to walk across room– Beta-2 agonist no more frequent than every 4-hours

● Home follow-up– Patient/caregiver understand treatment plan– Referrals completed (VNA, O2, nebulizer, meals, etc)

Home-Based ManagementRam et al. HOSPITAL AT HOME FOR PATIENTS WITH ACUTE EXACERBATIONS OF COPD: systematic review of evidence. BMJ 2004; 329: 315-320.

7 studies: randomized to “hospital-at-home” or “inpatient” –No difference in readmission or mortality rates; less costly.

Exclusion criteria for “hospital-at-home”:Impaired consciousnessAcute changes on radiography or ECGArterial pH < 7.35Comorbidities“Social problems”

Outline

● EpidemiologyRisk Factors

● Pathophysiology● Management● Follow-Up

Follow-up … Respiratory

At 4-6 weeks post discharge –

Revisit smoking statusReview vaccination statusSpirometry

● Reinforce inhaler technique… Tiotropium and combined [beta-2 agonist and CS]● Assess need for home oxygen and nebulizer● Evaluate understanding of treatment regimen… review written action plan for exacerbations

Follow-up … Comprehensive

Follow-up… Pulmonary Rehab

Benefits include (Evidence A) –

● Improves dyspnea and exercise capacity ● Improves health-related quality of life● Reduces number and duration of hospitalizations

Geriatrics-based providers are uniquely qualified to coordinate the care of older persons with COPD, given their expertise in

multimorbidity and geriatric syndromes.

Pulmonary consultation should be sought in the setting of escalating respiratory symptoms and/or respiratory failure

Re. COPD exacerbations …

Age is a predisposing factor TRUE

● Sputum analysis should be performed routinely FALSE

Respiratory failure is the most common cause of death FALSE