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Assess severity.1 Oxygenate/ventilate, give short-acting BDs, determine disposition - If life-threatening acute resp failure:1 oxygenate, ventilate (NIV preferred if not contraindicated),2 target pulse ox 88%-92% sat; ✓frequent ABG/VBG3 for ↑PaCO2/acidosis
- If non-life-threatening:1 Supplemental O24 target pulse ox 88%-92% sat; ✓frequent ABG/VBG3 for ↑PaCO2/acidosis. If ↑work of breathing or impaired gas exchange: Consider ventilation;2 NIV preferred if not contraindicated
- Short-acting BDs:5 SABA (albuterol, levalbuterol) +/- SAMA (ipratropium) [C]. Use spacer or NEB5 hourly x2-3 doses, then q2-4h
- Systemic steroids: prednisone 40 mg/day x5 days;6 (alternative: budesonide NEB)
- Hx/Lab/Imaging:7 Assess sx, blood gases, ✓CXR
- PO steroids:6 Consider prednisone 40 mg/day x5 days (alternative: budesonide NEB)
- If bacterial infxn signs or if mech ventilation: Give abx8 x5-7 days
- Avoid methylxanthines due to side effects
- Eval/tx other conditions: (eg, HF, arrhythmias, PE); monitor fluid balance (eg, diuretics if needed)
- Consider DDx: ACS, CHF, PE, pneumonia, pleural effusion, pneumothorax
- Test for COVID-19 w/ new or worsening resp sx, fever, loss of taste and/or smell9,10
Once stabilized, determine disposition, continue tx - Assess hospitalization indications,11 level of care needs, and resp unit/MICU indications12
- Start/restart long-acting BD5 ASAP, continue short-acting BD, O2 if needed, etc
- VTE prophylaxis if hospitalized
Footnotes 1 Assess severity:
• Life-threatening acute resp failure | RR >30, accessory muscle use, acute ∆ MS, O2 via Venturi mask or requiring FiO2 >40%, ↑PaCO2 vs baseline (or >60 mmHg) or pH ≤7.25
• Nonlife-threatening acute resp failure | RR >30, accessory muscle use, no ∆ MS, hypoxemia improves w/ O2 (eg, FiO2 35%-40% Venturi mask), ↑PaCO2 vs baseline (or 50-60 mmHg)
• No resp failure | RR 20-30/min, no accessory muscle use, no ∆ MS; hypoxemia improves w/ O2 (eg, 28%-35% FiO2 Venturi mask) w/o ↑PaCO2
2 Use noninvasive first, if not absolutely contraindicated; noninvasive ventilation ↑gas exchange, ↓breathing work, ↓need for intubation, ↓hospitalization duration, ↑survival [A]. If used, consider admit to respiratory unit/MICU rather than manage in ED/hospital ward.
Noninvasive (nasal/face mask) ventilation indications:
• Resp acidosis (PaCO2 ≥45 mmHg, pH ≤7.35), or
• Severe SOB w/ signs of resp muscle fatigue and/or ↑work of breathing (eg, accessory muscle use, paradoxical abdomen motion, intercostal retractions)
• Persistent hypoxemia despite O2
Invasive ventilation indications:
• Failure of (or inability to tolerate) noninvasive ventilation
• S/P resp/cardiac arrest
• ↓consciousness, psychomotor agitation inadequately controlled w/ sedation
• Massive aspiration/persistent vomiting
• Persistent inability to remove resp secretions
• Severe hemodynamic instability w/o response to fluids/vasoactive meds
• Severe arrhythmias (ventricular, supraventicular)
3 VBG to ✓bicarb & pH accurately compares w/ ABG; however, more data needed on VBG for guiding decisions in acute resp failure.
4 High-flow (Venturi) masks offer better accuracy/control vs nasal prongs. High-flow O2 nasal cannula may reduce intubation need.
5 Bronchodilators:
• Route: No significant FEV1 difference b/t MDI (w/ or w/o spacer) vs NEB, though NEB may be easier for sicker pts; continuous NEB not recommended.
• If NEB used, air-driven preferred vs O2 driven to avoid potential ↑PaCO2. Use standard COVID-19 precautions; keep circuit intact; use mesh nebulizer in ventilated pts.
• Continue long-acting BD during exac or start ASAP before hospital d/c. Long-acting BDs include LAMA (aclidinium, glycopyrrolate, tiotropium, umeclidinium) and LABA (arformoterol, formoterol, indacaterol, olodaterol, salmeterol).
• Theophylline/aminophylline not recommended d/t side effects [B]. Resp stimulants not recommended for acute resp failure.
6 Systemic steroids: prednisone 40 mg/day x5 days [B]. Oral is as effective as IV; nebulized budesonide (more expensive) may be alternative to PO in some pts. Steroids ↑FEV1 & oxygenation, ↓recovery time/hospitalization duration; use <5-7 days [A]. Even short burst assoc w/ ↑risk of ↑pneumonia, sepsis and death. Confine use to pts w/ significant exacs.
7 Use spirometry, bronchoscopy, & other aerosol-generating tests only when medically essential. Consider chest CT to help distinguish COVID-19 effects from other causes of exac.
8 Abx use controversial. When indicated (eg, ↑sputum purulence), can ↓recovery time/hospitalization duration, ↓early relapse risk/tx failure [B]; duration: 5-7 days [B]. PO route preferred, if practical. Abx should be given in pts who require ventilation (invasive or not).
Select abx based on local resistance patterns: aminopenicillin w/ clavulanic acid, macrolide, tetracycline. If frequent exac (2+/yr), severe airflow limits, and/or exac requiring ventilation: cx sputum/lung material to eval for Pseudomonas/other GNR/resistant organisms. CRP not recommended; procalcitonin protocols may be valuable to trigger abx, but evidence quality low to mod.
9 Positive SARS-CoV-2 testing does not exclude the potential for other resp pathogens.
10 Pts w/ COVID-19 should continue taking oral & inhaled resp meds for COPD.
11 Hospitalization indications: Potential indications: acute resp failure, severe sx (suddenly worse dyspnea @ rest, high RR, decreased sat, ∆ MS), new signs (eg, cyanosis, peripheral edema), serious comorbidities (eg, HF, new arrhythmias, etc), failure to respond to initial medical mgmt, or insufficient home support.
12 Resp unit/MICU indications: severe SOB not responding to initial emergency tx; ∆ MS; persistent/worsening PaO2 (<40 mmHg) or severe/worsening pH (<7.25) despite O2 & noninvasive ventilation; need for invasive ventilation; hemodynamic instability.
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At discharge from ED/Inpt
Plan d/c for stable pts - Start maintenance tx w/ long-acting BDs1 ASAP prior to d/c; determine maintenance tx according to GOLD COPD groups
- Add short-acting BD1 for sx rescue
- ✓inhaler technique
- ✓pt understanding of steroids2/abx3 duration
- Assess need for outpt O2
- Create COPD exac action & mgmt plan w/ educational component
- Smoking cessation
- Consider shielding measures (eg, masking, social distancing, handwashing) to prevent future exac in winter months
- Arrange f/u <4wk and 12-16wk;4 reassess needs for medications, O2, etc
Footnotes 1 Bronchodilators:
• Route: No significant FEV1 difference b/t MDI (w/ or w/o spacer) vs NEB, though NEB may be easier for sicker pts; continuous NEB not recommended.
• Long-acting BDs include LAMA (aclidinium, glycopyrrolate, tiotropium, umeclidinium) and LABA (arformoterol, formoterol, indacaterol, olodaterol, salmeterol).
• Theophylline/aminophylline not recommended d/t side effects [B].
2 Systemic steroids: Oral is as effective as IV. Use for <5-7 days [A].
3 Abx. When used, give for: 5-7 days. PO route preferred, depending on ability to consume PO and drug pharmacokinetics.
4 Pts w/ COVID-19:
• Advise re self-quarantine & transmission mitigation
• Ensure adequate supplies of home meds
• Consider remote (phone/online) f/u
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Start w/ short-acting beta-2-agonists +/- short-acting anticholinergics for outpt exac1 - Assess O2 sat by pulse ox
- If severe exac: Assess for ED/hospitalization1
- Increase short-acting inhaled BDs:2 SABA (albuterol, levalbuterol) +/- SAMA (ipratropium) [C]. Dose 1 puff q1h x2-3 doses, then q2-4h based on response. BD may suffice for mild exac. Use spacer or NEB2
- If ↑bacterial signs: Consider PO abx3 x5-7 days in pts w/ ↑SOB + ↑sputum + ↑purulence (or ↑purulence + either ↑SOB or ↑sputum)
- Consider PO steroids:4 prednisone 40 mg/day x5 days; PO steroids and/or abx (in addition to short-acting BD) may suffice for mod exac
- Continue long-acting BD (LAMA and/or LABA)2 throughout exac
- Test for COVID-19 w/ new or worsening resp sx, fever, loss of taste and/or smell5,6
Mitigate risks, plan f/u - Prevent future exac w/ long-acting BD2 and other maintenance tx based on GOLD COPD group recommendations
- ✓inhaler technique
- COPD exac action plan w/ educational component
- Smoking cessation
- Consider shielding measures (eg, masking, social distancing, handwashing) to prevent future exac in winter months
- Arrange f/u <4wk and 12-16wk;7 reassess needs for medications, O2, etc
Footnotes 1 Exacerbation.
• Acute resp sx worsening (eg, SOB) leading to additional tx. Typically lasts 7-10 days, some longer (20% of pts aren’t @ baseline 8wk later). Frequent exac defined as 2+/yr.
• Potential hospitalization indications: acute resp failure, severe signs/sx (worsening dyspnea @ rest, high RR, decreased sat, ∆ MS), new signs (cyanosis, peripheral edema), serious comorbidities (HF, new arrhythmias, etc), failure to respond to initial medical mgmt, or home insufficient support.
2 Bronchodilators.
• Long-acting BDs include LAMA (aclidinium, tiotropium, umeclidinium) and LABA (arformoterol, formoterol, indacaterol, olodaterol, salmeterol).
• Route: No significant FEV1 difference b/t MDI (w/ or w/o spacer) vs NEB, though NEB may be easier for sicker pts; continuous NEB not recommended.
• Theophylline/aminophylline not recommended d/t side effects [B].
3 Abx use controversial. When indicated ( ↑dyspnea, ↑ sputum purulence/volume), can ↓recovery time/hospitalization duration, ↓early relapse risk/tx failure [B]; duration: 5-7 days. PO route preferred, depending on ability to consume PO and drug pharmacokinetics.
Select abx based on local resistance patterns: aminopenicillin w/ clavulanic acid, macrolide, tetracycline. If frequent exac (2+/y), severe airflow limits, and/or exac requiring ventilation: cx sputum/lung material, to eval for Pseudomonas/other GNR/resistant organisms. Outpt sputum cx not feasible/reliable to guide tx; CRP not recommended; procalcitonin protocols may be valuable to trigger abx, but evidence quality low to mod.
4 Systemic steroids. May be less effective in pts w/ lower levels of blood EOS. Consider prednisone 40 mg/day x5 days [B]. Oral is as effective as IV. Steroids ↑FEV1 & oxygenation, ↓recovery time/hospitalization duration; use <5-7 days [A].
5 Positive SARS-CoV-2 testing does not exclude the potential for other resp pathogens.
6 Pts w/ COVID-19 should continue taking oral & inhaled resp meds for COPD.
7 Pts w/ COVID-19:
• Advise re self-quarantine & transmission mitigation
• Ensure adequate supplies of home meds
• Consider remote (phone/online) f/u
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