Updates in Treatment Options for Asthma and C.O.P.D. Patients

1
Updates in Treatment Options for Asthma and
C.O.P.D. Patients
Jim Holliman, M.D., F.A.C.E.P. Program Manager,
Afghanistan Healthcare Sector Reconstruction
Project Center for Disaster and Humanitarian
Assistance Medicine, Uniformed Services
University Bethesda, Maryland, U.S.A.
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Asthma and C.O.P.D. Lecture Objectives

• Know presenting signs symptoms
• Be able to assess case severity
• Know medication and other treatment options
• Be able to formulate appropriate plans of care
• Know indications for admission

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Asthma Definition General Demographics

• Is a chronic inflammatory disorder of the
  airways, with airflow obstruction airway
  inflammation, recurring wheezing, dyspnea,
  cough
• Prevalence, morbidity, mortality has increased
  since 1980's
• Age - adjusted death rate for ages 5 to 34
  increased 40 from 1982 to 1992
• About 5000 deaths per year in U.S.
• However Rowe and Camargos editorial in 2006
  notes improved control and decreasing mortality
  in some countries
• About 2 million E.D. visits in U.S. per year

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This prevalence trend is still true
5
Morbidity and mortality aspects of asthma
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Triggers of asthma
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Additional triggers of asthma
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Markers of a Potentially Fatal Asthma Attack

• Historical factors
• Hyperacute exacerbation
• Lack of steroid use
• Non-compliance
• Psychiatric illness
• gt 3 hospital admissions
• Prior intubation or barotrauma

• Physical findings
• Altered mental status
• Diaphoresis
• Inability to speak
• PEFR lt 100 L / min.

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Diagnostic Assessments to Consider for Asthma

• Peak Expiratory Flow Rate (PEFR)
• Pulse oximetry
• Arterial blood gas (ABG)
• Hematology chemistry studies
• Chest X-ray (CXR)

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PEFR Considerations for Asthma

• Probably the single most useful assessment test
• Can stratify patients into severity groups
• lt 25 Severe (impending resp. failure)
• 25 to 50 moderate to severe
• 50 to 70 mild to moderate
• gt 70 mild (can be discharged if at this
  value)
• Initial value not highly correlated with
  admission rate but higher risk if lt 100 or
  improves lt 60 with Rx
• Should usually not discharge if lt 250 L / min.

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Pulse Oximetry Considerations for Asthma

• Trend toward lower initial values correlating
  with higher chance of admission, but not very
  sensitive
• Especially helpful in patients unable to perform
  PEFR and in kids
• Can be at normal levels in some with severe
  bronchospasm

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ABG Considerations for Asthma

• Initial ABG is poor predictor of outcome and
  rarely influences therapy
• NOT recommended routinely
• Indications
• Suspected respiratory failure
• Altered mental status (need to know pCO2)
• Pulse oximeter unable to track, hypoxia is
  suspected
• Worsening despite therapy

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Hematology and Chemistry Studies for Asthma

• Generally are NOT needed for most cases
• WBC count NOT reflective of severity or
  associated infection
• Most patients are not dehydrated, and do not have
  electrolyte abnormalities (except
  pseudohypokalemia from beta agonists)
• Only useful test might be theophylline level if
  the patient is taking a methylxanthine

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CXR Considerations for Asthma

• NOT routinely needed for "typical" exacerbations
• May be needed for
• New onset asthma (especially in kids)
• Unclear Dx (e.g., R / O CHF, foreign body, etc.)
• Asthma refractory to treatment
• Respiratory failure
• ETT placement
• Strong clinical suspicion for infection
• Chest pain (R / O pneumo - thorax or -
  mediastinum)

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26 year old male with asthma and chest pain
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Same patient with arrows denoting
pneumomediastinum
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General E.D. Management Scheme for Asthma

• Triage
• Primary treatments
• Beta agonists
• Corticosteroids
• Secondary (or "refractory") treatments
• Anticholinergics
• Magnesium, leukotriene inhibitors, Heliox,
  antibiotics, ketamine, mucolytics
• Disposition

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Triage Considerations for Asthma

• All patients with acute asthma should be quickly
  taken to a monitored treatment area
• Initial nursing interventions
• Pulse oximetry
• Oxygen by nasal prongs (or blow-by mask for kids)
• Cardiac monitor (if moderate to severe)
• PEFR
• IV line if severe
• Notify physician

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Main Therapy for Acute Asthma Exacerbations
Inhaled Beta Agonists

• MDI-spacer delivery may be equivalent to
  traditional nebulizer
• The patient may think MDI Rx in E.D. will be
  ineffective since has already tried it at home
• Continuous nebulization may be more effective in
  severe cases, but no difference for moderate
  cases (although takes less E.D. personnel time)
• Albuterol doses are 10 to 30 mg / hr for adults,
  5 to 7.5 mg / hr for kids

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Choices for Short Acting Beta Agonists (SABAs)

• Albuterol (Ventolin, Proventil)
• PO 0.1 to 0.2 mg/kg/dose up to 12 mg/day
• MDI one to two puffs q 20 minutes X 3 or
• 2.5 mg of 0.5 solution via nebulizer q 20
  minutes X 3
• Levalbuterol (Xopenex)
• R isomer of albuterol
• MDI 1 to 2 puffs q 4 h
• Not shown superior to racemic albuterol (but is
  more expensive)
• Metaproterenol (Alupent)
• Same doses for MDI and nebulizer as albuterol
• No big comparative studies versus albuterol

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Considerations for Parenteral Use of Beta Agonists

• Subcutaneous may be useful for rare patient not
  able to receive aerosol
• Terbutaline probably safest (0.01 mg/kg, max. 0.3
  mg)
• Epinephrine (same dose causes more HBP)
• For "crashing" patient, give IV
• 0.1 mg diluted and via SLOW IV push
• then 0.4 mcg/kg/min IV drip
• Prior to discharge, can give Susphrine (epi
  tannate in oil) SQ at 0.005 mg/kg (more useful
  for allergic reactions) although availability of
  this med has decreased

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Long Acting Beta Agonists (LABAs)

• Salmeterol (Serevent) MDI 50 mcg bid
• Onset in 10 to 20 minutes duration 12 hours
• Twice as expensive as albuterol
• Useful for nocturnal asthma
• May be useful prior to E.D. discharge to help
  prevent early relapse
• Formoterol (Oxis, Foradil) MDI 12 to 25 mcg bid
• Note FDA black box warning for these

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Clinical Use Guidelines for the LABAs

• NOT to be used as monotherapy for long term
  control of asthma
• Recommended in combination with Inhaled
  Corticosteroids (ICS) for long term control in
  moderate and severe persistent asthma
• NOT to be used frequently or chronically before
  exercise because this may mask poorly controlled
  asthma

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Other Medications for Acute Asthma

• "Primary" Meds
• Corticosteroids
• Anticholinergics
• Magnesium
• "Secondary" Meds
• Methylxanthines
• Ketamine
• Heliox
• Halothane
• Leukotriene inhibitors

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Use of Systemic Steroids in Asthma

• Clearly shown to decrease admission relapse
  rates
• Oral route is fine for most
• 40 to 60 mg prednisone / day for adults
• 2 mg / kg per day for kids
• 5 day duration best (typical length of attack)
• taper usually not needed
• IV only for severe dyspnea, emesis, altered
  mental status, or intubated (IV versus PO shows
  same acute effects)
• Methylprednisolone, hydrocortisone, dexamethasone

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Use of Inhaled Steroids for Asthma

• Regular use decreases need for beta agonists
  relapse rates
• Use during an acute attack may just increase
  cough
• Use of spacer and post-Rx mouth rinse decrease
  side effects (dysphonia, oral Candidiasis)

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Choices of Inhaled Steroids for Asthma (via MDIs)

• Fluticasone (Flovent) 250 to 500 mcg bid
• Budesonide (Pulmicort, Rhinocort) 200 to 800 mcg
  bid
• Triamcinolone (Azmacort) 2 to 4 puffs bid to qid
• Beclomethasone (Vanceril, Beclovent) 84 to 840
  mcg per day
• Virtually all patients should be on one of these
  after discharge

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Use of Anticholinergics for Acute Asthma

• Inhaled (via MDI or nebulizer) these decrease
  bronchospasm by reducing vagal tone
• Atropine (0.2 to 0.5 mg)
• Glycopyrrolate (Robinul) 0.2 to 0.4 mg
• Ipratropium (Atrovent) 250 to 500 mcg
• Several studies show mild added benefit when
  added to first three beta agonist nebulizations
  in E.D. (not helpful after this)
• Ipratropium has low rate of side effects
• May help undefined subsets of patients

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Use of Magnesium for Acute Asthma

• Acts as smooth muscle relaxer suppresses
  neutrophil burst response
• Conflicting results of efficacy in different
  studies ( ? inadequate dosing in some)
• Clearly safe few side effects
• 2.0 to 5.0 gm IV dose reasonable to try for
• Severe symptoms
• Respiratory failure
• Non-response to standard Rx

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Use of Methylxanthines for Asthma

• Problems with aminophylline
• weak bronchodilator
• high rate adverse side effects
• narrow toxic / therapeutic window
• requires monitoring of serum levels (goal 5 to 15
  mcg/ml)
• many medication interactions
• Clearly shown to add no benefit to acute Rx with
  beta agonists steroids
• However, slow release forms (Slo-Bid, Theo-Dur,
  Uniphyl) may be useful in some patients for
  chronic maintenance
• 5 to 8 mg/kg/day

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Use of Ketamine for Acute Asthma

• Dissociative anesthetic
• Relaxes bronchial smooth muscle
• Excellent agent for RSI for critically ill
  asthmatic
• 2 mg / kg IV or 4 mg / kg IM
• Continued infusion 1 to 2.5 mg / kg / hr
• May cause
• Laryngospasm
• Hypertension
• Hallucinations

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Use of Heliox for Acute Asthma

• Is premixed air 20 and helium 80
• Gas density is lower than air so flow resistance
  is less
• Somewhat limited usefulness for asthma because as
  more O2 is blended in, the gas density
  re-increases (max. O2 is 40 )
• Expensive if used for extended period
• No major extended benefits in controlled studies

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Use of Leukotriene Receptor Antagonists (LTRAs)
for Asthma

• Leukotrienes are released from mast cells,
  eosinophils, and basophils and mediate
• bronchoconstriction
• mucus secretion
• airway mucosal edema
• The LTRAs are useful for
• Treatment of stable, mild, persistent asthma, and
  prophylaxis of exercise induced asthma
• decrease airway response to cold allergens
• Role in acute asthma not yet clear (IV
  montelukast is in phase 3 research trials)

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Choices of LTRAs for Asthma

• Montelukast (Singulair)
• 10 mg PO hs or two hours before exercise
• Systemic eosinophilia and vasculitis consistent
  with Churg-Strauss Syndrome rarely reported
• Zafirlukast (Accolate)
• 20 mg PO bid
• Rarely has caused liver failure

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Another Category of Meds 5-Lipoxygenase
Inhibitors

• Zileuton (Zyflo, Zyflo CR)
• Inhibits leukotriene formation
• Dose 600 mg pc and hs for Zyflo
• Dose 1200 mg bid for Zyflo CR
• Can cause liver failure
• Not studied for acute use

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Still Another Category of Meds Mast Cell
Degranulation Inhibitor

• Cromolyn (Intal)
• Inhibits degranulation of sensitized mast cells
• Attenuates bronchospasm caused by exercise, cold
  air, aspirin, and environmental pollutants
• MDI dose 2 puffs qid or two puffs 15 to 60
  minutes prior to exercise
• Rarely has caused liver impairment

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And the Final Category of Asthma Medication
Omalizumab (Xolair)

• Recombinant DNA-derived immunoglobulin G
  monoclonal antibody which binds selectively to
  human immunoglobulin E on the surface of mast
  cells and basophils and then reduces mediator
  release
• Used when Sx are not controlled by inhaled
  steroids
• Dose 150 to 375 mg SQ q 2 to 4 weeks
• Annual cost 12,000 to 15,000
• Can cause anaphylaxis

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Combination Medications Available for Asthma

• Ipratropium and albuterol (Combivent)
• Nebulizer 3 ml q 20 min X 3 doses
• MDI 4 to 8 puffs q 20 min X 3
• Salmeterol and Fluticasone (Advair Diskus)
• 3 dosage forms
• 100, 250, or 500 mcg fluticasone with 50 mcg
  salmeterol
• One inhalation bid

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Expert Panel 3 (2007) List of Ineffective
Treatments for Asthma

• Methotrexate
• Cyclosporin
• Colchicine
• Acupuncture
• Chiropractic
• Homeopathy
• Breathing techniques
• Yoga

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Airway Management in Asthma

• Endotracheal intubation should be required in lt
  5 of admitted pts.
• Indications for ETT
• Altered mental status due to hypercarbia or
  hypoxia
• Progressive resp. failure or resp. acidosis
  despite maximal Rx
• Base decision on clinical situation (not a
  particular value of pCO2 or pO2 or pH)
• Always preoxygenate ETT attempt should be made
  by most experienced operator

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Considerations About Nasotracheal Intubation of
the Asthmatic Patient

• Advantages
• Can leave pt. sitting up ( resp. distress may
  worsen if forced supine)
• Pt.'s resp. effort often makes the procedure easy
• Tube may be more comfortable for pt.
• Tube less likely to be dislodged
• Disadvantages
• May cause epistaxis
• Requires smaller tube diameter than oral (so more
  airflow resistance)
• May predispose pt. to sinusitis later

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Considerations About Orotracheal Intubation of
the Asthmatic Patient

• Advantages
• Method of choice if pt. apneic or markedly
  bradypneic
• No predisposition to epistaxis or sinusitis
• Larger diameter tube can be used (may permit
  later bronchoscopy)
• Disadvantages
• Generally requires "full" Rapid Sequence
  Intubation (RSI) technique supine position
• May be less comfortable for pt. more likely to
  dislodge

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Options for RSI Meds for the Asthmatic Patient

• For nasal ETT may only need etomidate or
  benzodiazepine IV (after topical anesthesia in
  nose)
• Usual oral ETT sequence
• Preoxygenate
• Lidocaine 1.0 to 1.5 mg/kg IV
• Ketamine 1.0 to 2.0 mg/kg IV
• /- benzodiazepine 1 to 5 mg IV
• Succinylcholine 1.0 to 1.5 mg/kg IV
• Perform intubation

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General Considerations for Mechanical Ventilation
of the Asthmatic Patient

• Mortality of ventilated pts. prior to 1984
  reported as 20 to 40
• Current mortality lt 10 using "permissive
  hypercapnia"
• uses smaller tidal volumes
• goal is to limit barotrauma
• does not require normalization of pCO2 or pH

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Specific Guidelines for Mechanical Ventilation of
the Asthmatic Patient

• 1. Volume control (A/C or SIMV) preferred over
  pressure control to avoid overventilation
• 2. Tidal volume set at 5 to 8 ml/kg
• 3. Initial rate set at 6 to 10 breaths per min.
• allows increased time for exhalation avoids
  dynamic hyperinflation ("breath stacking")

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Specific Guidelines for Mechanical Ventilation of
the Asthmatic Patient (cont.)

• 4. Set FIO2 to keep arterial pO2 gt 60 mm Hg
• Should be lt 50 to avoid O2 toxicity if
  ventilation prolonged
• 5. Set PEEP adjusted to 75 to 80 of measured
  auto-PEEP level
• Make sure endogenous (auto) PEEP does not exceed
  the amount dialed on the ventilator
• 6. Set Peak Insp. Flow Rate 70 to 90 L/min
• Produces rapid inspiration allowing time for
  exhalation
• End-inspiratory plateau pressures should be lt 35
  mm Hg

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Specific Guidelines for Mechanical Ventilation of
the Asthmatic Patient (cont.)

• 7. Sedation to prevent tachypnea allow pt. to
  rest
• 8. Aerosolized beta agonists should be given via
  ventilation circuit (continuous Rx can be done)
• 9. As wheezing improves, may increase TV rate
• 10. Monitor for barotrauma (risk greater if
  end-insp. plateau pressure gt 35 mm Hg)
• 11. Monitor for clinical improvement allowing
  extubation

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Complications of Mechanical Ventilation of the
Asthmatic Patient

• Barotrauma due to alveolar rupture
• Pneumomediastinum, pneumothorax, or SQ emphysema
• Should usually treat with chest tube
• May need to reset ventilation parameters to
  decrease end-inspiratory plateau pressure
• Prolonged muscle weakness
• Can be due to prolonged effect of paralytic agent
  used for intubation (esp. if renal insufficiency)
• May be partly due to steroid Rx
• Can be a myopathic syndrome with increased muscle
  enzymes require ventilation for several weeks

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Education of the Asthmatic Patient to be
Discharged from the E.D.

• Consider pt. education regarding the following
  items prior to D/C
• MDI / spacer use training
• Review of medications
• Self use of short course oral steroids
• Home use of PEFR
• Identify PEFR 's for which pt. should come to
  E.D.
• Arrange F/U with primary care doctor
• Asthma diary
• Identify avoidable triggers (shoot any cats in
  the house)

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Other Considerations for Education of the
Asthmatic Patient

• Make sure family members are also educated re
  meds severity assessment
• Emphasize planning early response to minimize
  time lost from school or work
• Remember it is a chronic recurrent disease, so
  limit diagnostic tests unless there are atypical
  features or severity of an attack

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Asthma Lecture Summary

• Assess severity at presentation
• Start multiple simultaneous Rx if severe
• Decide if diagnostic studies needed
• Monitor for response to Rx
• Consider second line Rx's intubation
  ventilation for refractory cases
• Provide careful education post - E.D. planning
  for discharged pts.

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Chronic Obstructive Pulmonary Disease (COPD)

• Refers to triad of disease processes
• Asthma (airway reactivity)
• Bronchitis (airway inflammation)
• Emphysema (airway collapse)
• All 3 coexist to some degree in same pt.
• Definitions
• Chronic bronchitis chronic cough with sputum
  production for at least 3 months / yr. for at
  least 2 yrs.
• Emphysema enlargement of distal air passages
  due to alveolar septal destruction (
  obliteration of pulm. capillary bed)

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COPD Epidemiology

• 4th leading cause of death in U.S.
• Leading cause of death in smokers gt age 55
• 12.5 million in U.S. have chronic bronchitis
• 14 million in U.S. have emphysema
• 2nd most common cause of permanent disability
• Huge economic impact

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Risk Factors to Develop COPD

• Major factor is cigarette smoking
• Less common factors
• Inhalation of "second hand" smoke
• Occupational exposure
• Cystic fibrosis
• Alpha 1 antitrypsin deficiency
• Intravenous drug abuse

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Pathophysiologic Features of COPD

• airflow
• lung volumes, hyperinflation
• V/Q mismatch
• Arterial hypoxemia hypercarbia
• Often intrinsic airway inflammation
• Note typical inflammatory cells in COPD are
  usually neutrophils, whereas they are usually
  eosinophils in asthma

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Sequence of Pathophysiologic Events with COPD

• Parenchymal destruction continues
• Distal air spaces enlarge
• Loss of elastic recoil
• Increases lung volumes when resp. rate
• Expiratory time then
• Hyperinflation results

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Pathophysiologic Results of Dynamic
Hyperinflation in COPD

• Inspiratory muscle dysfunction
• Acts at stiffer portion of its volume - pressure
  relationship
• Muscle fibers forced from vertical to horizontal
  position
• Increased reliance on accessory muscle fibers
• Causes increased work of breathing increased
  dyspnea

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Goals of the E.D. Evaluation of the COPD Patient

• Rapidly stabilize the pt. in resp. failure
• Identify precipitating causes
• Treat complications
• Rule out or treat concurrent conditions

63
Clinical Presentation of Patients with
Exacerbations of COPD

• Dyspnea most common may be severe
• Other Sx may or may not be present
• Chest pain may be
• Diffuse or vague
• Pleuritic
• Chest wall (from cough injury)
• Cough
• Fever
• Altered mental status
• Apprehension

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Signs Associated with COPD Exacerbations

• Dyspnea
• Tachypnea
• Tachycardia
• Ashen skin color or cyanosis
• Diaphoresis
• Accessory muscle use
• Intercostal retractions
• Rales / rhonchi / wheezes / decreased BS
• Apprehension

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Signs of Severe or Critical Airflow Obstruction
in a COPD Exacerbation

• Altered mental status
• Inability to speak
• "Silent chest" (no or limited audible BS)
• Combativeness / seizures

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Differential Dx of COPD Exacerbation

• CHF
• Acute myocardial ischemia
• Airway obstruction
• Pneumonia
• Pneumothorax
• Pulmonary embolus
• Pleural effusion
• Acute aortic dissection
• Allergic reaction

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Caveats About Differential Dx of COPD Exacerbation

• COPD exacerbation may coexist or be concurrent
  with any of Dx's on previous slide
• Particularly CHF may cause COPD exacerbation
  vice versa
• PEFR gt 150 L/min suggestive of Dx of CHF
• Pulm. embolus particularly difficult to Dx in
  COPD pt.

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Spirometry Use for COPD Exacerbation

• Should be performed on all pts.
• Determine initial severity
• Determine response to Rx
• Clinical eval. alone is unreliable at estimating
  airflow obstruction
• Many pts. with post-Rx FEV1 gt 40 can be safely
  discharged
• Another discharge criterion is PEFR gt 250
  (assuming pt.'s baseline PEFR is gt 300 need to
  know pt.'s prior PFT's to determine this)

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Use of ABG's in COPD Exacerbation

• Some recommend on all pts.
• I favor using only in pts. who
• Appear critical at presentation
• Do not respond well to Rx
• Have altered mental status
• ALL pts. should have continuous pulse oximetry
• Pt. can have hypoxemia even when pulm. function
  approaches 50 of normal

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Use of CXR in COPD Exacerbation

• CXR should be obtained on all pts.
• At least 15 of CXR's show a directly treatable
  finding
• Pneumonia
• Pleural effusion
• Pneumothorax
• Atelectasis
• Aortic dissection
• Also allows R/O CHF

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E.D. Management of COPD Exacerbations

• For ALL Pts.
• Oxygen
• Beta agonist aerosol
• Consider SQ terbutaline if unable to take aerosol
• Anticholinergic aerosols
• For some pts.
• Corticosteroids
• Antibiotics
• Diuretics
• CPAP / BiPAP / Intubation / Ventilation

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Considerations for O2 Therapy for COPD
Exacerbations

• Risk of eliminating hypoxic drive ( causing
  further resp. acidosis / failure) is overstated
• Only applies to lt 5 of COPD population
• Venturi mask can be used to give precise
  regulated O2 concentrations
• Pts. that develop resp. acidosis with O2 Rx
  usually need to be intubated ventilated anyway

73
Anticholinergic Med Choices Doses for COPD
Exacerbations
Medication
Dose
Ipratropium
0.5 mg
Atropine
1 to 2 mg (0.025 mg/kg)
Glycopyrrolate
0.2 to 1.0 mg
Ipratropium preferred because of less side
effects such as tachycardia
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Considerations in Use of Corticosteroids for Rx
of COPD Exacerbation

• Not of benefit to all pts. with COPD
• Should be considered if
• Pt. on chronic steroid Rx
• Wheezing component is prominent
• Allergic trigger
• Prior response to steroids
• IV versus PO is equivalent

75
Considerations in Use of Antibiotics for COPD
Exacerbation

• Not indicated for all pts.
• Usually indicated for COPD exacerbation with
• Fever / chills
• Increased sputum production
• Change in color of sputum
• Persistent increased cough
• Atelectasis or infiltrate on CXR
• Most common pathogens
• Strep pneumoniae (with increasing rates of PCN
  resistance)
• Hemophilus influenzae
• Moraxella (Branhamella) catarrhalis

76
Antibiotic Choices for COPD Exacerbation

• Best first line agents
• Azithromycin
• Cefuroxime
• Trimethoprim - sulfa
• ? levofloxacin
• Problems with other choices
• Doxycycline, amoxicillin resistance
• Erythromycin no H. flu coverage
• Amoxil / clavulanate cost, side effects
• Clarithromycin cost, drug interactions, taste

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Ventilatory Assistance Considerations for COPD
Exacerbation

• 3 of COPD pts. require ETT ventilation for
  resp. failure
• Indications complications same as for asthma
• Need to be careful to avoid barotrauma
• Intubated COPD pts. have higher mortality
  longer time on ventilator than asthma pts.
• CPAP or BiPAP can be tried prior to ETT

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Disposition Considerations for COPD Exacerbation

• Indications for hospital admission
• Persistent hypoxemia (O2 sat. lt 90)
• Persistent hypercarbia / resp. acidosis
• Persistent dyspnea
• Overt resp. failure
• Altered mental status
• Usually if associated pneumonia
• Pneumothorax
• "Borderline " admission candidate may be
  considered for observation unit first

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Suggested E.D. Management of COPD Exacerbation

• Immediate O2 beta 2 aerosol
• Rapid CXR to R/O CHF or pneumothorax
• Evaluate for cardiac ischemia (EKG)
• Consider other Dx tests
• Early PEFR repeat after each Rx
• Continued Rx (aerosols, /- steroids, /-
  antibiotics, etc.)
• Monitor for response
• ETT / ventilation if worsening
• Admission if not improving satisfactorily

80
Adjunctive Treatments to Consider for COPD
Exacerbations

• Phosphodiesterase-4 Inhibitors
• Reduce inflammation via macrophages and
  lymphocytes
• Cilomilast 15 mg PO bid
• Mucolytic agents
• N-acetycysteine
• Efficacy debatable
• Referral for surgical bullectomy, lung volume
  reduction surgery, or lung transplantation

81
Web Sites with Useful Clinical Guidelines for
Asthma and COPD

• Expert Panel Report 3 Summary Report 2007
• 440 pages summary is 74 pages
• http//www.nhlbi.nih.gov/guidelines/asthma/asthgdl
  n.htm
• http//www.medscape.com/viewarticle/564670 , and
  564654
• emedicine.com has 4 nice articles under both
  emergency medicine and pulmonology
• http//www.emedicine.com/med/topic177.htm , 373
• http//www.emedicine.com/emerg/topic43.htm , 99