Acute exacerbation of COPD

Acute exacerbations of COPD are acute worsenings of symptoms in a patient with COPD. It may be caused by viral respiratory infections, bacterial infections, pollution, or stress.

Exacerbations may vary in intensity from mild to very severe and life-threatening. Rapid assessment of the severity is important.

Clinical features

The cardinal symptoms of acute exacerbations are worsening dyspnoea, worsening cough, increased volume and/or purulence of sputum. In severe cases, respiratory failure may occur. If respiratory failure occurs, or if symptoms are severe, or if the patient has serous comorbidities, or if out-patient treatment has failed to improve symptoms, hospitalization is needed.

Diagnosis and evaluation

The diagnosis is based on clinical symptoms of respiratory distress, dyspnoea, and evidence of lower airway obstruction on auscultation (expiratory wheezing, prolonged expiration). If there are severe symptoms, ABG is used to assess the level of severity.

Treatment

In most cases, an increased dose of inhaled bronchodilators is necessary along with a short course of an oral corticosteroids like prednisolone. In Norway, ipratropium and salbutamol are usually administered in a nebulizer 4 times daily for the duration of the exacerbation.

If a bacterial infection is suspected, due to infectious signs or purulent or increased volume of sputum, empiric antibiotics can be given.

In cases more severe cases with respiratory failure, O2 supplement or non-invasive ventilation is used. In very severe cases, ICU admission and invasive ventilation is necessary. Admission to the ICU is indicated if:

If conservative therapy doesn’t work
PaO2 < 40 mmHg
pH < 7,25
Haemodynamic instability

Acute exacerbation of asthma

Acute exacerbations of asthma are characterized by episodes of progressive increase in shortness of breath, cough, wheezing or chest tightness. Severe exacerbations are potentially life-threatening, and treatment requires close supervision and often ICU admission. It usually occurs due to exposure to factors like exercise, air pollution, allergens, or infections.

Clinical features

Patients present with dyspnoea, accessory breathing muscles, chest tightness. They can usually not complete sentences in one breath. They usually have wheezing on auscultation, but the chest can also be silent on auscultation, in which case the situation is life threatening.

ABG shows hypocapnia with normoxaemia or hypoxaemia.

Management

Most cases can be treated with supplemental oxygen, bronchodilators, and systemic glucocorticoids. Magnesium sulphate can be given IV as a smooth muscle relaxant, but the evidence is not strong. Admission to the ICU is indicated if:

If conservative therapy doesn’t work
PaO2 < 60 mmHg
History of near-fatal asthma
Peak expiratory flow rate < 30%

In the ICU, bronchodilators can be repeated as IV. NIV may be attempted, but invasive ventilation has better evidence and is therefore more used. It’s important to look for and treat the underlying problem.