COPD: EXACERBATIONS

Question 1

How are exacerbations of COPD managed?

Answer 1

• Bronchodilator can be administered through a nebuliser if necessary and O2 is given if appropriate
• IV aminophylline given if the response to nebuliser bronchodilators is poor
• A short course of PO prednisolone for 7-14 days should be given if increased breathlessness interferes with daily activities
• Abx if sputum becomes more purulent than usual, or if there are other signs of infection (e.g. Amoxicillin)

Question 2

Patients that present to hospital/community with an exacerbation

Answer 2

Short course of prednisolone along with other therapies

Question 3

Inadequate response to nebulised bronchodilators

Answer 3

Aminophylline

Question 4

If necessary, oxygen should be given

Answer 4

to keep oxygen saturation of arterial blood levels in range

Question 5

Add on therapy in exacerbations
If a single bronchodilator (e.g. LAMA OR LABA) fails to control exacerbations:

Answer 5

1. If a single bronchodilator (e.g. LAMA OR LABA) fails to control exacerbations:
   - Measure blood eosinophil
   - If lower than 300: LABA + LAMA
   - If higher than 300 or more:
   LABA + LAMA + ICS

Question 6

If LABA + LAMA fails to control exacerbations:

Answer 6

• Measure blood eosinophil
• If less than 100: Consider Roflumilast or Azithromycin
• If 100 or more: LABA +
  LAMA + ICS

Question 7

If LABA + LAMA + ICS fails to control exacerbations:

Answer 7

• Add Roflumilast
  or
• Add macrolide e.g.
  Azithromycin TDS a week

Question 8

How would you decide between Roflumilast or
Azithromycine as an add-on if triple therapy fails to control COPD?

Answer 8

Add Roflumilast if:
- FEV1 < 50% and the patient has chronic bronchitis

Add Azithromycin if:
- The patient is a former smoker
- Evidence for efficacy is noted in those who do not smoke

Question 9

Which prophylactic antibiotic is used in
COPD? What further monitoring is required?

Answer 9

Macrolide e.g. azithromycin three times a week (e.g. Mod, Wed, Fri)
- non-smokers
- measure baseline ECG (macrolides cna cause QT)

Question 10

When is oxygen
treatment indicated?

Answer 10

1. Long-term (15 hours a day)
   - if the patient is hypoxemic
   (Pa02 < 7.3 КрА)
2. During exacerbations

Question 11

What concentration of oxygen is given and why?

Answer 11

• Use 24-28% 02 (whereas asthma is 40-60%)
• Low oxygen concentration is given because COPD patients are at high risk of
  hypercapnic respiratory failure

Question 12

What is the target concentration of oxygen in COPD?

Answer 12

88-92%

Question 13

What is a potential hazard with oxygen therapy?

Answer 13

• Hypercapnic respiratory failure (give low oxygen concentration)
• Smoking near cylinders (fire risk)