Chronic obstructive pulmonary disease

Oxygen

Inhaled beta-agonists

Inhaled anticholinergics

Corticosteroids

Antibiotics

Noninvasive ventilation

Intubation

Ventilator management

Manage ABCs
- Patients should be placed on supplemental oxygen therapy as needed to maintain adequate oxygen saturations of 88–92%.
- Beware of over-oxygenating the COPD patient as this can lead to worsening ventilation–perfusion mismatch and apnea.
- Patients must be monitored for signs of impending respiratory failure.
Medications (Table 31.1)
- Inhaled beta-agonists:
  - Inhaled albuterol is the initial rescue medication of choice.
  - Common side effects include tremor, nervousness, tachycardia, palpitations, headache, and hyperglycemia.
  - Delivered by nebulizer or metered-dose inhaler (MDI) with spacer device.
- Inhaled anticholinergics:
  - Ipratropium bromide is an effective therapy and treats airway smooth muscle constriction and airway secretions.
  - Although previously suggested to be more effective than beta2-agonists in acute COPD, recent data suggests that anticholinergics should be used as adjuncts in most cases.
- Corticosteroids:
  - Systemic corticosteroids are critical in COPD exacerbations to address the inflammatory component of the disease.
  - Administer early in treatment as they do not take effect for hours. There is no difference between enteral and parenteral administration.
  - There is no benefit to high-dose steroids.
- Antibiotics:
  - For most moderate/severe COPD exacerbations, it is appropriate to start antibiotics with coverage for common respiratory pathogens. Mortality benefit has been demonstrated when antibiotics are given to all patients admitted to the hospital for COPD exacerbation.
  - Common classes include macrolides and fluoroquinolones.
Airway and ventilatory support
- Noninvasive positive pressure ventilation:
  - CPAP and BiPAP may be considered for certain patients with moderate to severe COPD exacerbations.
  - NPPV decreases the work of breathing, but requires a patient to have a patent airway and be compliant with the therapy.
  - Patients receiving NPPV must be carefully monitored for signs of decompensation including altered mental status, hemodynamic instability, worsening hypercarbia, vomiting, and increased dyspnea.
  - If noninvasive methods fail, the patient will require intubation.
- Intubation:
  - If intubation is required, use the largest tube possible that will not cause damage to decrease airway resistance during mechanical ventilation.
- Ventilator management:
  - The goal of ventilator management in the COPD patient is to oxygenate and ventilate without causing barotrauma and hemodynamic instability.
  - May require low tidal volumes, low respiratory rates, long expiratory times, and high inspiratory flow rates.
  - Permissive hypercapnia may be required. Follow capnography or ABG values to adjust ventilator settings.
  - Pharmacological therapy should continue once the patient is intubated.