Practical Pearls from the GOLD Guidelines on COPD

By Juan Garcia, MD, FCCP; and Stephen Jenkinson, MD, FCCP

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Manage Exacerbations

Patients with COPD will have usually two to four exacerbations of their disease symptoms per year, with some requiring hospitalization. The most common causes of an exacerbation are pulmonary infections and air pollution, but the exact cause of about one third of severe exacerbations cannot be identified and may be related to reactive airway disease. Other conditions that may produce the symptoms of an acute exacerbation of COPD include pneumonia, myocardial ischemia, congestive heart failure, pneumothorax, pleural effusion, pulmonary embolism, cardiac arrhythmia, esophageal reflux, and noncompliance with medications. Treatment of exacerbations should consist of inhaled bronchodilators and systemic corticosteroids. Theophylline can be used in selected cases.

Pearl: An increase in sputum volume and purulence points to a bacterial cause. Green sputum has a high predictability for infection. Antibiotics should be administered.

Pearl: There is a high incidence of Haemophilus influenzae infections in patients with a COPD exacerbation due to infection. Other important bacterial causes include Streptococcus pneumoniae, Moraxella catarrhalis, and Pseudomonas aeruginosa.12

Pearl: Even if results of a barium swallow test are negative, 24-h pH measurements of the esophagus may still be needed to diagnose esophageal reflux. The pH measurement test is a better test of the presence of acid reflux. The normal DeMeester score is < 15 (95th percentile) when using pH measurement testing.

Pearl: Begin anticoagulant therapy immediately if you suspect pulmonary embolism during work-up of a patient, unless there is a specific contraindication for anticoagulation (document in the patient’s chart the reasoning for the contraindication).

Pearl: When the patient is admitted into the hospital, arterial blood gas measurement is essential to assessing the severity of the exacerbation.

Pearl: Noninvasive positive pressure ventilation (NIPPV) improves blood gases and pH, reduces hospital mortality, decreases the need for invasive mechanical ventilation, and decreases hospital stay. Not all patients are candidates for NIPPV13.

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