What conditions can mimic an acute exacerbation of chronic obstructive pulmonary disease (COPD) and require different diagnostic and treatment modalities?
What inpatient therapeutic modalities can help reduce mortality or length of stay for patients with exacerbation of COPD?
What medications should be utilized for a patient who is being discharged after an acute exacerbation of COPD to prevent further exacerbations?
What are the appropriate situations for use of noninvasive ventilation for patients with an acute exacerbation of COPD?
Other than medications, what modalities need to be considered and discussed with a patient at the time of discharge after an acute exacerbation of COPD?
Definition and Background
Chronic obstructive pulmonary disease (COPD) is a group of clinical and pathological pulmonary disorders that are preventable and treatable and are characterized by airflow limitation that is not fully reversible. The most common phenotypes of COPD are emphysema and chronic bronchitis. Emphysema is generally defined by pathologic and physiologic criteria as irreversible enlargement of the airways and loss of elastic recoil. Clinically, emphysema is characterized by dyspnea along with an expanded chest, decreased breath sounds, radiographic lucency, and flattening of the diaphragms. Chronic bronchitis is defined clinically by the finding of cough and sputum production on most days of at least 3 months per year for 2 consecutive years. Pathologically, the hallmark of chronic bronchitis is large airway inflammation and the hypertrophy and hyperplasia of the mucous-secreting goblet cells. The diagnosis of COPD requires spirometry which should be obtained in patients (at a time free of exacerbation) who exhibit cough, sputum production, dyspnea or risk factors/exposure history. COPD is defined clinically by airflow limitation on pulmonary function tests that is not fully reversible. The severity of COPD is classified by the degree of limitation in the forced expiratory volume in 1 second (FEV1) (Table 239-1).
Table 239-1 GOLD Criteria for Chronic Obstructive Pulmonary Disease Severity |Favorite Table|Download (.pdf)
Table 239-1 GOLD Criteria for Chronic Obstructive Pulmonary Disease Severity
|0||At risk||Chronic cough, sputum production||Normal|
|I||Mild||With or without chronic cough or sputum production||FEV1/FVC < 0.7 and FEV1 80% predicted|
|II||Moderate||With or without chronic cough or sputum production||FEV1/FVC < 0.7 and 50% FEV1 < 80% predicted|
|III||Severe||With or without chronic cough or sputum production||FEV1/FVC < 0.7 and 30% FEV1 < 50% predicted|
|IV||Very severe||With or without chronic cough or sputum production||FEV1/FVC < 0.7 and FEV1 < 30% predicted|
|FEV1 < 50% predicted with respiratory failure or signs of right heart failure|
Hospitalists often manage patients presenting with new symptoms consistent with COPD, patients with acute exacerbations of underlying COPD, and patients whose COPD complicates the course of care for other medical conditions. In this chapter, we will review best practices for each of these scenarios and solutions for optimizing care of these patients ...