Professional Documents
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Inpatient
AMS= altered mental status, ABG = arterial blood gas, EC3 = Emergency Critical Care Center, CCMU = Critical Care Medical Unit,
NIV = Non-invasive ventilation, VBG = venous blood gas
*This algorithm represents a logical approach, but there is no strong evidence to guide decisions about when to use sputum cultures or
empiric antipseudomonal antibiotics.
AFB= acid-fast bacilli, FEV1= forced expiratory volume measure, HRCT = high resolution computed tomography, NIPPV= non-invasive
positive pressure ventilation.
Symptom Severity
Either dyspnea symptoms (mMRC) or symptom impact (CAT) can be used
Exacerbation Risk
During the past year, how many exacerbations occurred? How many of the exacerbations required hospitalization?
Low risk 0 – 1 exacerbations and 0 hospitalized exacerbations
Increased risk ≥ 2 exacerbations or ≥ 1 hospitalized exacerbation
Formoterol: 1
capsule INH BID
Salmeterol: 1 puff
INH BID
Inhaled Patients with FEV1 < 50 There are many combination
corticosteroids and at least 1 AECOPD products containing both
yearly corticosteroids and long-acting
bronchodilators (e.g., Advair,
Symbicort)
Antibiotics Azithromycin Criteria for use: FEV1 < 250 mg PO daily, or Exclusion criteria: allergy to
(prophylaxis) 50% , recurrent 500 mg PO TIW, macrolides, prolonged QT
exacerbations (at least 2 duration uncertain interval (QTc > 450
in the prior year), and (literature reports milliseconds), or taking
not currently smoking up to 12 months) concomitant medications that
cause prolongation of the QT
interval
Phosphodiesterase Roflumilast Patients with COPD 500 mcg PO daily Avoid use in patients with a
-4 inhibitor associated with chronic history of depression with
bronchitis and a history suicidal behavior/ideations;
of frequent or severe instruct patients/caregivers to
exacerbations report psychiatric symptoms
and consider discontinuation of
therapy in such patients
O2 Usually Criteria for use of Target O2 saturation > 90%
delivered via continuous home O2: long-term.
nasal cannula Room air O2 saturation <
89% (or paO2 <56), Note: Patients can also qualify
OR for ambulatory home O2 if they
Room air O2 saturation of meet the criteria for home
89% (or paO2 of 56-59) oxygen while ambulating, even
+ one of the following if they do not meet those
three features: LE edema criteria at rest
suggestive of CHF,
pulmonary HTN/cor
pulmonale, or
erythrocytosis
(hematocrit > 56%)
*See the ambulatory COPD guideline for additional information about chronic medications.
BID= twice daily, CHF= chronic heart failure, FEV1= Forced expiratory volume measure, HTN= hypertension, INH=
inhalation, LE= lower extremity, PO= orally, TIW= three times per week.
Table 6. The Key Elements of Hospital Discharge for Patients with AECOPD
Key element Notes
Ensure the patient’s • The patient’s dyspnea should be improved to the point that the patient can eat, sleep,
discharge readiness walk, and correctly use inhaler medications (assuming that the patient was able to do
these things at baseline).
• The patient should be clinically stable for 12-24 hours, with short-acting
bronchodilators required no more frequently than every 4 hours.
Ensure an appropriate • Complete antibiotic and corticosteroid courses, if initiated in the hospital.
COPD medication • Inhaler regimen should include, at minimum, a long-acting bronchodilator and a rescue
regimen at discharge inhaler (see the ambulatory COPD guideline for additional information on chronic
inhaler management).
• Consider inhaled corticosteroids and prophylactic antibiotics on a case-by-case basis
(Table 3B).
Ensure patient education • All patients should be educated on the importance of adherence to the inhaler regimen,
about critical elements of correct inhaler technique, and counseled on smoking cessation if appropriate. (At UM,
care, including correct education about respiratory medications is provided by the respiratory therapist.)
inhaler technique
Assess the patient’s need for •
Home O2 should be provided if the patient meets the following criteria:
home O2 - Room air O2 saturation < 89% (or pO2 <56), or
- Room air O2 saturation of 89% (or pO2 of 56-59) + one of the following three
features: LE edema suggestive of CHF, pulmonary HTN/cor pulmonale, or
erythrocytosis (hematocrit > 56%).
Refer eligible patients for • CMS requires PFT’s demonstrating at least moderate disease (FEV1/FVC < 0.70 and
pulmonary rehabilitation FEV1 <80% predicted) to qualify for pulmonary rehabilitation.
Ensure that the patient has • At the time of discharge, consider the use of an assessment tool to estimate
appropriate, timely readmission risk (at UH, the LACE score is automatically calculated for all patients,
follow-up see Table 7).
- At UH, we recommend that patients at high risk for readmission be seen 7-10 days
after discharge, and patients at moderate or low risk be seen within one month of
discharge.
• Followup in a clinical setting familiar with transitional care can be beneficial. (At UM,
schedule patients through the COPD Transitional Care Management Clinic, see
Appendix A).
• Schedule full PFT’s (including bronchodilators) 4-6 weeks after AECOPD, if not
previously performed.
CHF=congestive heart failure, CMS= Centers for Medicare and Medicaid Services, HTN=hypertension, LE= lower
extremity, PFT= pulmonary function testing, UM= University of Michigan.
9 UMHS Chronic Obstructive Pulmonary Disease May 2016
Table 7. LACE Index for the Quantification of Risk of Death or Unplanned Readmission Within
30 Days After Discharge
Attribute Value Points*
Length of stay, d (“L”) <1 0
1 1
2 2
3 3
4-6 4
7-13 5
≥ 14 7
Acute (emergent) admission (“A”) Yes 3
Comorbidity (Charlson comorbidity index score †) (“C”) 0 0
1 1
2 2
3 3
≥4 5
Emergency department visit during previous 6 mo (“E”) 0 0
1 1
2 2
3 3
≥4 4
*
A patient’s final LACE score is calculated by summing the points of the attributes that apply to the patient.
†
The Charlson comorbidity index score was calculated using 1 point for history of myocardial infarction, peripheral vascular
disease, cerebrovascular disease or diabetes without complications; 2 points for congestive heart failure, chronic obstructive
pulmonary disease, mild liver disease or cancer; 3 points for dementia or connective tissue disease; 4 points for moderate to
severe liver disease or HIV infection; and 6 points for metastatic cancer.2
If AECOPD is suspected and patient’s SpO2 is < 88%, an Pulmonary embolus should always be considered in patients
initial venous blood gas (VBG) should be obtained. (An presenting with suspicion for AECOPD because of the high
initial ABG may be obtained instead, however VBG is rate of this diagnosis. D-dimer testing should only be
associated with reduced pain and time to collection).6 A considered in patients with low risk for PE (based on Well’s
VBG can provide screening for respiratory acidosis and criteria, or other clinical assessment of pre-test probability).
hypercarbia, without the pain and risks associated with Of note, the d-dimer may be elevated, despite lack of PE, due
arterial puncture. Correlation between VBG and ABG is to the inflammatory process associated with AECOPD.
excellent for both pH and HCO3 measurement for patients Overall, pulmonary embolus protocol CT scans (PECT) are
that are not in shock or affected by mixed respiratory and not routinely recommended in the diagnostic work-up of
metabolic acid-base disorders.4 In several studies, a venous AECOPD, but should be utilized when pulmonary embolism
pCO2 ≥ 45 mmHg has demonstrated 100% sensitivity in remains a significant concern.3
detecting arterial hypercarbia. Stated conversely, a pvCO2 ≤
45 mmHg had a 100% negative predictive value for the Finally, ruling out concomitant viral or bacterial respiratory
presence of a paCO2 ≥ 50 mmHg.7-10 Assuming the pH is infection is paramount, as this is the most common trigger
abnormal (ruling out chronic compensated hypercarbia), a for AECOPD (refer to section on History). An influenza
VBG is generally sufficient to use as a screening test for swab should be considered in the appropriate seasons.
acute respiratory acidosis, and can help inform decisions Procalcitonin may have utility in confirming the presence or
regarding initiation of medical management and the need for absence of a concomitant infection, but there is lack of
non-invasive ventilation.11 However, the correlation between confirmatory evidence to support its routine use in the acute
paCO2 and pvCO2 is limited, and an ABG must be obtained presentation (see the discussion on procalcitonin in the
when assessing the degree of hypercarbia (see Table 2). Antibiotics section, below). Likewise, sputum cultures are
not routinely recommended for AECOPD, however
Additionally, an ABG should be obtained when SpO2 is less circumstances exist where they can be of benefit in guiding
than 92%12 with evidence of altered mental status and/or therapy (see the sections on Antibiotics and Refractory
respiratory distress, and prior to initiation of non-invasive or AECOPD, below).
mechanical ventilation,4 when time allows, in order to guide
the effect of therapy. However, if an arterial line is not Assessment of Severity and Intensity of Care (Figure 1).
present, the provider may elect to obtain a VBG and ABG at All patients presenting with AECOPD require an assessment
the same time. If the VBG is found to correlate closely with of the severity of illness, which will determine the intensity
the ABG pH value, and the provider is satisfied knowing the of the treatment required (i.e., the need for hospitalization,
pH trend (but not the absolute value of hypercarbia), a VBG ventilator support, or intensive care). This assessment is
may be use subsequently to follow the patient’s response to based principally on the clinical assessment described above.
treatment. This might avoid the need for serial arterial In addition, the patient’s response to initial treatment (e.g.,
punctures in some situations. supplemental oxygen, inhaled beta-agonists) should be
considered. Patients that do not respond quickly to these
If congestive heart failure (CHF) is in the differential measures may require more intensive interventions.
diagnosis, a brain natriuretic peptide (BNP) level should be
12 UMHS Chronic Obstructive Pulmonary Disease May 2016
Use of Non-Invasive Positive Pressure Ventilation Treatment
(NIPPV) (Figure 1). Patients should be started on non-
invasive positive pressure ventilation (NIPPV) support if The acute treatment of AECOPD is multimodal, and often
there is clinical evidence of worsening respiratory distress includes the use of inhaled bronchodilators; the
despite supplemental oxygen use (e.g., fatiguing respiratory administration of corticosteroids and antibiotics; and the use
muscles, retractions, use of accessory muscles) or if there is of supportive respiratory therapies, including supplemental
evidence of acute respiratory acidosis on VBG or ABG (pH oxygen and ventilatory support (see Table 3). Of note, there
< 7.35 and pCO2 > 45 mmHg) as shown in Figure 1. Early is very little evidence to support the use of mucolytics or
use of NIPPV in AECOPD with respiratory failure is cough suppressants in the treatment of these patients.
associated with lower mortality, more rapid improvement in
ABG values, lower endotracheal intubation rate, less Inhaled bronchodilators. Patients hospitalized with
treatment failures and shorter hospital lengths of stay14 (see AECOPD should be treated with inhaled albuterol, with dose
also the section on NIPPV, below). and frequency titrated to effect (Table 3A).3,16
Determining Need for Hospital Admission (Figure 1). The A short-acting anticholinergic, such as ipratropium, can be
criteria for hospital admission for AECOPD are listed in used in combination with the albuterol, although it is
Figure 1. uncertain if the combination results in greater efficacy than
monotherapy.16 Ipratropium can also be used alone,
Patients more likely to be admitted to the hospital include especially for patients who do not tolerate albuterol (see
those who have the following characteristics: Table 3).
- Required hospital admission for AECOPD in preceding
12 months Levalbuterol (a formulation containing only the R-isomer of
- Have more severe airflow limitations (severe or very albuterol) is not recommended for routine use in patients
severe disease by spirometry, see Table 1) with AECOPD. Although there is some evidence that
levalbuterol may provide bronchodilation with less beta-
- Worsening cough, wheeze or dyspnea
adrenergic side effects than albuterol,17 there is only limited
- Overall poor health status clinical data supporting its use, and no data directly
- Older age supporting its use in AECOPD.
- Radiologic evidence of emphysema
- Increased evidence of systemic inflammation (elevated Metered-dose inhalers (MDI’s) are the preferred delivery
WBC, CRP, fibrinogen) method for short-acting bronchodilators.3,18 Exceptions
Overall, the need for hospitalization for AECOPD is should be considered when the patient condition (e.g., severe
associated with poorer prognosis and increased mortality.15 dyspnea, anxiety) or preference warrants the use of a
nebulizer. There does not appear to be a difference in FEV1
Determining Need for Intensive Care Unit Admission. response when comparing MDI’s and small volume
Evaluation by and subsequent admission to critical care units nebulizer as the route of medication delivery. Per UMHS
(at UMHS, the Emergency Critical Care Center [EC3, for ED policy, respiratory therapists are empowered to determine the
patients] or the Critical Care Medicine Unit [CCMU]) should appropriate mode of medication delivery, and update the
be considered when there is a noted lack of improvement in electronic medical record orders, when appropriate (UMHS
response to a trial of urgent/emergent therapies (e.g., oxygen, staff can view the policy at
bronchodilators, steroids, antibiotics, NIPPV). This may be http://www.med.umich.edu/i/respcare/uhcvc/pdfs/4 1 3
ascertained by the patient’s subjective symptoms, clinical Aerosolized Bronchodilator Protocol.pdf).
appearance, or worsening hypoxemia or respiratory acidosis
despite use of oxygen and/or NIPPV. Additionally, the need In most cases, the patient’s long-acting bronchodilators can
for endotracheal intubation and invasive ventilation and/or be withheld in the acute phase of the illness when they are
hemodynamic instability should prompt evaluation by EC3 being treated with frequent, short-acting bronchodilators.
or the ICU. Similarly, inhaled corticosteroids are often held while the
patient is treated with systemic corticosteroids. However,
In general, ED patients transferred to EC3 will undergo an when symptoms improve and inhaled bronchodilator therapy
extended period of evaluation and treatment. If the patient is is not required more frequently than every four hours,
able to be extubated/weaned off of NIPPV, has serial ABGs patients should be transitioned to their expected outpatient
or VBG demonstrating improvement in hypercarbia and/or inhaled medication regimen. If a nebulizer has been used, the
hypoxemia on FIO2≤40% and demonstrates hemodynamic patient should be transitioned to an MDI, if applicable. Prior
stability, admission to a non-ICU setting may be considered. to patient discharge, a long-acting bronchodilator (a long-
If these clinical endpoints are unable to be met within six acting anticholinergic or a long-acting beta-2-agonists)
hours of EC3 transfer, admission to the CCMU should be should be resumed, or added if the patient was not already
considered and the CCMU fellow consulted. taking one at the time of admission. Additional
recommendations for the chronic medical management of
patients with COPD can be found in the ambulatory COPD
guideline.
23. Niewoehner DE, Erbland ML, Deupree RH, et al. Effect 34. Domenech A, Puig C, Marti S, et al. Infectious etiology
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and control of seasonal influenza with vaccines:
Recommendations of the advisory committee on
immunization practices (ACIP) -- united states, 2014-15
1. Baseline evaluation
a. What device/dose do you take at home? How often?
b. Can you walk me through your technique (verbalize)?
c. Can you demonstrate (without activation of medication, i.e. pantomime)?
i. Assess baseline technique via verbalization and pantomime.
ii. Record baseline score.
2. Correct the issues identified and demonstrate technique to patient (pantomime).
3. Teach-back evaluation
a. Have patient prepare and administer medication through device.
b. Assess teach-back technique and record score.
i. If successful use of device, allow patient to administer 2nd dose (if applicable).
ii. If unsuccessful attempt, assist patient in dose(s).
- If patient demonstrates correct technique on their device (achieves 100%), continue to assess technique with subsequent
treatments and correct issues, if needed.
- If not 100% correct, perform additional teach-back session(s) during subsequent scheduled treatment time(s) until 100% correct
or max of 3 sessions completed. Record score when 100% achieved or score at end of 3 sessions. Continue to assess technique
with subsequent treatments.
- If successful technique felt unlikely – e.g. dementia – recommend different device or delivery mode (e.g. nebulizer) to team for
outpatient regimen.
Baseline Teach-back