Term
| inflammation of the large bronchi |
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Definition
| what is acute bronchitis? |
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Term
cold air
cold, damp climates
high pollution areas
smoking
viral infections |
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Definition
| etiology of acute bronchitis |
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Term
infection of trachea and bronchi
edematous mucus membranes
increased bronchial secretions
destruction of respiratory epithelium
impaired mucociliary activity |
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Definition
| pathogenesis of acute bronchitis |
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Term
Signs and Symptoms:
cough persisting > 5 days to weeks
coryza (rhinitis, head cold), sore throat, malaise, headache
fever rarely > 39C
Physical Exam:
rhonchi or coarse, moist, bilateral rales
purulent sputum in ~50% of patients
Chest X-Ray: normal |
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Definition
| clinical presentation of acute bronchitis |
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Term
provide comfort
avoid/treat dehydration
avoid/treat respiratory compromise
symptomatic and supportive care: antipyretics, rest, fluids, vaporizer use
may consider antitussives
discourage routine use of antibiotics
consider possibility of bacterial infection in certain populations (previously healthy with persistent fever or respiratory symptoms > 4-6 days, elderly patients, or immunocompromised): empiric therapy against suspected bacterial pathogens
viral epidemics |
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Definition
| treatment of acute bronchitis |
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Term
underlying COPD
acute onset
change in baseline dyspnea, cough, and/or sputum |
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Definition
| definition of a COPD exacerbation |
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Term
increased neutrophils and eosinophils in sputum
primary physiologic changes -> poor gas exchange, increased muscle fatigue |
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Definition
| pathophysiology of an acute COPD exacerbation |
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Term
acute bacterial infection
pollution
smoking
up to 30% - no identifiable cause |
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Definition
| most common causes of an acute COPD exacerbation |
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Term
increased SOB
increased SPUTUM VOLUME
increased SPUTUM PURULENCE |
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Definition
| CARDINAL SYMPTOMS of an acute COPD exacerbation |
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Term
INCREASED SOB
INCREASED SPUTUM VOLUME
INCREASED SPUTUM PURULENCE
wheezing and chest tightness
increased cough
fever
changes in mental status
decreased exercise tolerance
increased use of SABA
nasal flaring
use of accessory muscles for respiration
non-specific: increased HR, RR, fatigue, and insomnia |
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Definition
| signs and symptoms of an acute COPD exacerbation |
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Term
ACUTE CHANGES IN ABG FROM BASELINE
decrease in PaO2 of 10-15 mmHg (hypoxia) from baseline
and/or
SaO2 < 90%
and/or
PaO2 < 60 mmHg
increased PaCO2 that decreases serum pH to < 7.3 (hypercapnia) |
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Definition
| assessment of respiratory status for acute COPD exacerbations |
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Term
Chest Radiography:
new infiltrates
limited value
useful for finding alternative diagnosis
Sputum Cultures:
gram stain
cells: neutrophils (> 25) and epithelials (< 10) to ensure the sample isn't contaminated by skin
speciation and sensitivities
colonization: may be something patient always has |
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Definition
| diagnostic tests for acute COPD exacerbations |
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Term
pneumonia
CHF
AMI
PE
pneumothorax
pleural effusion
cardiac arrhythmia |
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Definition
| differential diagnosis of acute COPD exacerbation |
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Term
MILD
1 cardinal symptom plus ONE of:
URTI within 5 days
fever
increased wheezing
cough
increased RR or HR
MODERATE
2 cardinal symptoms
SEVERE
3 cardinal symptoms |
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Definition
| staging of COPD exacerbations - mild, moderate, and severe |
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Term
mild exacerbation
no respiratory distress
no comorbidities |
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Definition
| when can an acute COPD exacerbation be treated at home? |
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Term
significant increase in intensity of symptoms (symptoms at rest, change in vital signs)
severe underlying COPD
onset of new physical symptoms (cyanosis, peripheral edema)
inadequate response to initial medical management for exacerbation
significant comorbidities
frequent exacerbations
newly occuring arrhythmia
diagnostic uncertainty
insufficient home support |
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Definition
| when should an acute COPD exacerbation be treated in the hospital? |
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Term
severe dyspnea with inadequate response to initial emergency therapy
changes in mental status
severe/worsening of hypoxemia (PaO2 < 40 mmHg)
severe/worsening hypercapnia
severe/worsening of respiratory acidosis (pH < 7.25)
need for invasive mechanical ventilation
hemodynamic instability |
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Definition
| when should an acute COPD exacerbation be treated in the ICU? |
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Term
bronchodilator therapy: increase dose/frequency of home beta-agonists and/or anticholinergics
systemic NOT inhaled glucocorticoids |
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Definition
| home management of an acute COPD exacerbation |
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Term
controlled oxygen therapy
bronchodilator therapy
glucocorticoids
+/- antibiotics |
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Definition
| hospital management of an acute COPD exacerbation |
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Term
CORNERSTONE OF THERAPY
GOAL PARAMETERS:
SaO2 > 90%
and/or
PaO2 > 60 mmHg
types of O2 delivery systems in order of least to greatest O2 provided:
room air
nasal cannula
simple face mask
partial re-breather
non-re-breather |
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Definition
| oxygen therapy for hospital management of an acute COPD exacerbation |
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Term
FIRST LINE = SABA = ALBUTEROL
anticholinergics = ipratropium
can be used concurrently or alternating with albuterol
a combination of albuterol + ipratropium can be used: more convenient, not more effacious |
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Definition
| bronchodilator therapy for hospital management of an acute COPD exacerbation |
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Term
place in therapy:
moderate to severe exacerbation
wheezing patient
oral and IV have same efficacy
inhaled SHOULD NOT BE USED |
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Definition
| glucocorticoid therapy for hospital management of an acute COPD exacerbation |
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Term
place in therapy:
any one of the following
3 cardinal symptoms
2 of 3 cardinal symptoms if increased sputum purulence is 1 or 2 symptoms
mechanical ventilation needed
selection of antibiotic influenced by patient characteristics
empiric therapy for the most likely organism
duration: 7-10 days
if concerned for MRSA add vancomycin or linezolid
if flu season consider influenza virus |
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Definition
| antibiotic therapy for hospital management of an acute COPD exacerbation |
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Term
characteristics:
< 4 exacerbations/year
no comorbidities
FEV1 > 50% predicted
likely pathogens:
S. pneumoniae
H. influenzae
M. catarrhalis
H. parainfluenzae
recommended antibiotics:
macrolide
2nd or 3rd generation cephalosporin
beta lactam + beta lactamase inhibitor |
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Definition
| characteristics of an uncomplicated acute COPD patient, likely pathogens, and recommended antibiotics |
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Term
characteristics:
age > 65
> 4 exacerbations/year
FEV1 < 50% but > 35% predicted
likely pathogens:
S. pneumoniae
H. influenzae
M. catarrhalis
H. parainfluenzae
drug-resistant pneumococci, H. flu, M. cat
some enteric GNR
recommended antibiotics:
beta-lactam + beta-lactamase inhibitor
2nd or 3rd generation cephalosporin
fluoroquinolone |
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Definition
| characteristics of a complicated acute COPD patient, likely pathogens, and recommended antibiotics |
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Term
characteristics:
chronic bronchial sepsis
chronic corticosteroids
NH/LTCF resident
> 4 exacerbations/year
FEV1 < 35% predicted
likely pathogens:
S. pneumoniae
H. influenzae
M. catarrhalis
H. parainfluenzae
drug-resistant H. flu, pneumococci, M. cat
enteric GNR
Pseudomonas
recommended antibiotics:
fluoroquinolone
beta-lactam + beta-lactamase inhibitor
3rd or 4th generation cephalosporin with activity against Pseudomonas = ceftazidime, cefepime |
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Definition
| characteristics of a complicated acute COPD patient with risk of Pseudomonas, likely pathogens, and recommended antibiotics |
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Term
NON-INVASIVE MECHANICAL VENTILATION:
BiPAP: Bi-positive airway pressure
CPAP: continuous positive airway pressure
FIRST LINE IF APPROPRIATE
improves respiratory acidosis
decreases: RR, severity of breathlessness, length of hospital stay, intubation rate
NIV success rate ~ 80-85%
indications of NIV:
moderate to severe dyspnea with use of accessory muscles and/or paradoxical abdominal motion
moderate to severe acidosis (pH < 7.35)
moderate to severe hypercapnia (PaCO2 > 45 mmHg)
respiratory rate > 25 breaths/minute
relative contraindications for NIV:
respiratory arrest
cardiovascular instability
changes in mental status
high aspiration risk
craniofacial trauma or recent craniofacial surgery
INVASIVE MECHANICAL VENTILATION
for those intolerate of BiPAP or with contraindications to BiPAP
consider risk vs. benefit for end-stage COPD
consider complications:
ventilator-associated pneumonia
barotrauma
failure to extubate from invasive ventilation - may be able to extubate to NIV, may necessitate tracheostomy |
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Definition
| ventilatory support for an acute COPD exacerbation |
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Term
stable for 12-24 hours
ABG stable for 12-24 hours
inhaled SABA < every 4 hours
pre-hospital exercise tolerance
eat and sleep without frequent dyspnea
education on medications and inhaler use
follow-up and home care arrangements |
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Definition
| appropriate hospital dischargep |
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Term
baseline SOB
lower BMI
older age
CHF
extrapulmonary organ failure
low serum albumin levels
cor pulmonale
mechanical ventilator > 72 hours |
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Definition
| predictors of poor survival from an acute COPD exacerbation |
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