An acute exacerbation of asthma or COPD is characterized by worsening respiratory symptoms such as shortness of breath, cough, and wheezing. Initial treatment involves oxygen, inhaled bronchodilators, and systemic glucocorticoids. Severe exacerbations may require hospitalization for monitoring, additional bronchodilators, and noninvasive ventilation. The goal is to relieve symptoms and improve lung function through aggressive medical therapy to prevent respiratory failure or the need for intubation.

1. Acute Severe Asthma &
COPD Exacerbations
Ni’ma Bader

2. Definition
 An acute state where inflammation, airway edema,
excessive mucus accumulation, and severe
bronchospasm result in a profound airway
narrowing that is poorly responsive to usual
bronchodilator therapy

3. CLINICAL PRESENTATION
 Symptoms
◦ Acute distress and severe dyspnea, shortness of breath,
chest tightness, or burning. The patient is only able to say
a few words with each breath.
 Signs
◦ wheezing on auscultation, dry hacking cough, tachypnea,
tachycardia, pale or cyanotic skin, hyper-inflated chest, and
hypoxic seizures if very severe.

4. INITIAL HOME TREATMENT

5. 0

6. TREATMENT IN EMERGENCY
DEPARTMENT OR URGENT CARE
SETTING

7.  Initial assessment includes history, physical
examination, and objective assessments.
 The brief history will assess for: onset and causes
of the exacerbation; severity of symptoms and if
associated with anaphylaxis; medication use,
adherence, and response to current therapy; and
risk factors for asthma-related death.

8.  The asthma-related risk factors for death
include:
 a history of near-fatal asthma requiring intubation and
mechanical ventilation
 hospitalization or emergency care in the past year
 current or recent use of oral corticosteroids
 no current use of ICSs
 over use of short-acting β2-agonist therapy (more than one
canister per month)
 history of psychiatric disease or psychosocial problems
 poor medication adherence
 lack of a written asthma action plan
 food allergy.

9.  The physical exams:
◦ Vital signs
◦ Any complicating factors such as pneumonia or
anaphylaxis as well as other comorbid conditions that
could be causing acute shortness of breath such as inhaled
foreign body, congestive heart failure, pulmonary infection,
and pulmonary embolism.

10.  Objective assessments
◦ should be made before initiation of oxygen or drug
treatment.
◦ Lung function testing by PEF or FEV1
 should be measured before treatment if possible and
thereafter at one hour after start of treatment and then
periodically until response is achieved or no further
improvement is evident.
◦ Oxygen saturation: preferably by pulse oximetry
◦ Arterial blood gases
◦ A chest X-ray
◦ Complete blood count

11.  Arterial blood gas measurements in
acute asthma are indicated in the
following settings:
 Patients with persistent dyspnea whose PEF is
below 25 percent of normal despite initial
bronchodilator therapy
 Selected patients with a PEF 25 to 50 percent of
normal whose respiratory status is deteriorating
despite intensive therapy
 Patients who are too ill to perform a peak flow
measurement
 Patients who demonstrate signs or symptoms of
hypercapnia, such as depressed consciousness,
inappropriately slow respiratory rate, or myoclonus

12.  Features suggesting an alternate or
comorbid condition
◦ Concomitant symptoms such as fever,
purulent sputum production, urticaria, or
pleuritic chest pain should raise the
possibility of an alternative diagnosis such
as pneumonia, flare of bronchiectasis,
anaphylaxis, or pneumothorax.

13.  A chest radiograph should be obtained
when:
 A complicating cardiopulmonary process is
suspected (eg, temperature >38.3ºC,
unexplained chest pain, leukocytosis, or
hypoxemia)
 When a patient requires hospitalization,
 When the diagnosis is uncertain

14. DETECTING AN EXACERBATION
 Symptoms (R/O other causes)
 Peak flow
 Risk factors for fatal asthma

15. TREATMENT IN EMERGENCY
DEPARTMENT OR URGENT CARE
SETTING

16.  Oxygen
 Inhaled beta agonists
 Inhaled anticholinergics
 Systemic glucocorticoids

17.  Oxygen therapy goals:
◦ Arterial oxygen saturation of
 93% to 95% in adolescents and adults
 94% to 98% in school-aged children and pregnant women or those
with cardiac disease.

18.  Heliox vs. oxygen for nebulized β2-
agonist

19.  Systemic glucocorticoids indication:
◦ A severe exacerbation with a peak expiratory flow ≤50
percent of baseline. Immediate administration is warranted.
◦ A moderate exacerbation with a peak expiratory flow >50
but <70 percent of baseline that does not reverse to normal
after initial bronchodilator therapy.
◦ An asthma exacerbation that occurs despite ongoing daily
or alternate-day oral glucocorticoid therapy. Such patients
require supplemental glucocorticoids above their baseline
dose.

20. Oral vs. IV corticosteroids

24.  Features that help with assessment of severity (may or may not be
present):
◦ Impending respiratory failure:
 Cyanosis, inability to maintain respiratory effort, depressed mental status, SpO2 <90%
 PaCO2 >40 mmHg
◦ Severe exacerbation:
 Speaks in single words
 Sits hunched forward
 Agitated, diaphoretic
 Respiratory rate >30 breaths/minute
 Heart rate >120 beats/minute
 SpO2 (on air) <90%
 PEF ≤50% predicted or personal best
◦ Mild to moderate exacerbation:
 Talks in phrases or sentences
 Prefers sitting to lying
 Not agitated
 Respiratory rate 16 to 30 breaths/minute
 Heart rate 100 to 120 beats/minute
 SpO2 >90%
 PEF >50% but <80% predicted or personal best

25. Indications for hospitalization or
discharge
 Factors favoring continued observation in patients
with a PEF of 40 to 60 percent of predicted are:
 new onset asthma
 multiple prior hospitalizations or emergency department
visits for asthma
 use of oral glucocorticoids at the time of presentation
with the acute deterioration.

26.  Most patients with improving symptoms and a PEF
>60 percent of predicted can be safely discharged,
if they are knowledgeable about their asthma and
have good availability of follow-up care.

27.  Magnesium sulfate
◦ MOA: bronchodilation due to inhibition of
calcium influx into airway smooth muscle
cells
◦ Dosage: single Intravenous dose 2 g infused
over 20 min
◦ Suggested for patients who have a life-
threatening exacerbation or whose
exacerbation remains severe (PEF <40% of
baseline) after one hour of intensive
conventional therapy.
◦ Helpful in reducing hospital admissions

28. Nonstandard therapies
 Anesthetic agents
◦ IV ketamine, inhaled halothane, isoflurane, and
sevoflurane have bronchodilating effects, and have
favorable responses in patients with refractory status
asthmaticus
◦ Mechanism: inhibition of histamine and acetylcholine-
induced bronchoconstriction and acting as a
sympathomimetic agent.
◦ Ketamine has been recommended for rapid induction
of anesthesia in patients with asthma who require
intubation and mechanical ventilation.
◦ Hypotension is often the limiting factor in the
administration of these agents

29.  Enoximone
◦ Phosphodiesterase inhibitors, associated with
ventricular and atrial arrhythmias, hypotension, and
hepatotoxicity.
◦ Further study is needed to evaluate the safety and
efficacy of it
 Parenteral beta-agonists — Intravenous and
subcutaneous beta-agonists are generally
avoided when treating asthma exacerbations in
adults, because inhaled short-acting selective
beta agonists have equal or greater efficacy and
lower incidence of adverse effects (eg,
tachycardia, arrhythmias, myocardial injury)
compared with parenteral beta-agonists.

30.  Exceptions:
◦ patients suspected of having an
anaphylactic reaction
◦ Those unable to use inhaled
bronchodilators for a severe asthma
exacerbation
◦ Epinephrine or terbutaline subcutaneously
are an alternatives.

31.  High-dose inhaled glucocorticoids are
not recommended as an alternative to
oral glucocorticoids for patients with a
discrete asthma exacerbation

32.  Leukotriene receptor antagonists
◦ do not administer leukotriene receptor
antagonists as part of routine treatment of
acute exacerbations, except in patients
whose exacerbation was triggered by
ingestion of aspirin or a nonsteroidal anti-
inflammatory drug (NSAID), events
associated with dramatic overproduction
of leukotrienes.

33. Ineffective therapies
 Methylxanthines
 Empiric antibiotics
 hydration (in the absence of evidence
of dehydration)
 Expectorants such as guaifenesin
 Antihistamines
 Chest physiotherapy.

34. MECHANICAL VENTILATION
 Indication:
 Slowing of the respiratory rate
 depressed mental status
 inability to maintain respiratory effort,
 worsening hypercapnia and associated
respiratory acidosis
 inability to maintain an oxygen saturation >92
percent despite high-flow supplemental oxygen

35.  Virtually every patient who has
suffered an asthma attack severe
enough to require urgent care should
receive an inhaled glucocorticoid as
part of his or her discharge medication
plan

38. Management of exacerbations of
chronic obstructive pulmonary
disease

39. Definition
 acute event characterized by a
worsening of the patient's respiratory
symptoms that is beyond normal day-
to-day variations and leads to a
change in medication

40.  Acute change in one or more of the
following cardinal symptoms:
 Cough increases in frequency and severity
 Sputum production increases in volume and/or
changes character
 Dyspnea increases

41. Clinical features
 Features of COPD exacerbation: Diffuse
wheezing, distant breath sounds, barrel-shaped
chest, tachypnea, tachycardia, smoking >20 pack
years
 Features of severe respiratory insufficiency: Use
of accessory muscles; brief, fragmented speech;
inability to lie supine; profound diaphoresis;
agitation; asynchrony between chest and
abdominal motion with respiration; failure to
improve with initial emergency treatment
 Features of impending respiratory arrest:
Inability to maintain respiratory effort, cyanosis,
hemodynamic instability, and depressed mental
status

42.  Associated features that would
suggest an alternate diagnosis or
comorbidity include:
 Constitutional symptoms (eg, fever, chills, night
sweats)
 Chest pain, chest pressure, or peripheral
edema
 Risk factors for thromboembolic disease or
coronary disease
 Upper respiratory symptoms that might suggest
a viral respiratory infection

43.  RISK FACTORS FOR COPD
EXACERBATION :
 Advanced age
 Duration of COPD
 COPD-related hospitalization within the
previous year
 Theophylline therapy
 Having one or more comorbidities (eg,
ischemic heart disease, chronic heart failure, or
diabetes mellitus)

44. Exacerbation risk
 Low risk: Typically GOLD 1 or 2 (mild
to moderate airflow limitation) and/or 0
to 1 exacerbation per year, no
hospitalization due to an exacerbation
 High risk: Typically GOLD 3 or 4
(severe or very severe airflow
limitation) and/or ≥2 exacerbations per
year or ≥1 hospitalization due to an
exacerbation

45. Staging Acute Exacerbations of
COPD
Mild (type 1)
One cardinal symptoma plus at least
one of the following: URTIb within 5
days, fever without other
explanation, increased wheezing,
increased cough, increase in
respiratory or heart rate >20% above
baseline
Moderate (type 2) Two cardinal symptomsa
Severe (type 3) Three cardinal symptomsa

46. Factors Favoring Hospitalization for Treatment of COPD
Exacerbation
 Presence of high risk comorbidity (eg, pneumonia,
arrhythmia, CHF, diabetes, renal or hepatic failure)
 Suboptimal response to outpatient management
 Marked worsening of dyspnea
 Inability to eat or sleep due to symptoms
 Worsening hypoxemia or hypercapnia
 Mental status changes
 Lack of home support for care
 Uncertain diagnosis

47. Diagnostic testing
Look at S/S
Obtain ABG in all patients with severe COPD exacerbation
Assess oxygen saturation with continuous pulse oximetry
Do not assess peak expiratory flow or spirometry in acute severe COPD
exacerbations as results are not accurate
Obtain portable chest radiograph: Look for signs of pneumonia, acute
heart failure, pneumothorax
Obtain complete blood count, electrolytes (Na+, K+, Cl–, HCO3–), BUN,
and creatinine; also obtain cardiac troponin, BNP, or NT-proBNP, if
diagnosis is uncertain
Test for influenza infection during influenza season
Obtain ECG: Look for arrhythmia, ischemia, cor pulmonale

48. Criteria for ICU admission include:
•Patients with high-risk comorbidities (pneumonia, cardiac arrhythmia,
heart failure, diabetes mellitus, renal failure, liver failure)
•Continued need for NPPV or invasive ventilation
•Hemodynamic instability
•Need for frequent nebulizer treatments or monitoring

49. Monitoring
Perform continual monitoring of oxygen saturation, blood pressure,
heart rate, respiratory rate
Close monitoring of respiratory status
Continuous ECG monitoring
Monitor blood glucose

50. Management
 Provide supplemental oxygen to target
a pulse oxygen saturation of 88 to
92% or PaO2 of 60 to 70 mmHg.

51.  Provide combination of aggressive
bronchodilator therapy and ventilatory
support (NPPV or invasive ventilation)

52.  Noninvasive positive pressure
ventilation (NPPV):
◦ Appropriate for the majority of patients with
severe exacerbations of COPD unless immediate
intubation is needed or NPPV is otherwise
contraindicated
◦ Contraindications to NPPV include: Severely
impaired consciousness, inability to clear
secretions or protect airway, high aspiration risk

53.  Tracheal intubation and mechanical
ventilation:
◦ Indicated for patients with acute respiratory
failure, hemodynamic instability (eg, heart rate
<50/minute, uncontrolled arrhythmia) and those
in whom NPPV is contraindicated or who fail to
improve with NPPV and aggressive
pharmacotherapy

54. Therapy Comments
Antibiotics
Recommended if two or more of the following
are present:
•Increased dyspnea
•Increased sputum production
•Increased sputum purulence
Corticosteroids
Oral or IV therapy may be used.
If IV is used, it should be changed to oral after
improvement in pulmonary status.
If continued longer than 14 days, then the dose
should be tapered to avoid HPA Axis
suppression.
Bronchodilators
MDIs and DPIs equal in efficacy to
nebulization.
β-Agonists also may increase mucociliary
clearance.
Long-acting β-agonists or long-acting
antimuscarinics should not be used for quick
relief of symptoms or on an as-needed basis.
Controlled oxygen therapy
Titrate oxygen to desired oxygen saturation
(>90%).
Monitor arterial blood gas for development of
hypercapnia.
Noninvasive mechanical ventilation
Consider for patients with acute respiratory
failure.
Not appropriate for patients with altered mental
status, severe acidosis, respiratory arrest, or
cardiovascular instability.

55. Pharmacotherapy
Inhaled beta agonist: Albuterol 2.5 mg diluted to 3 mL via nebulizer or 4 to 8
inhalations from MDI every hour
Inhaled anticholinergic agent: Ipratropium 500 micrograms via nebulizer or 4 to 8
inhalations from MDI every four hours
Intravenous glucocorticoid (eg, methylprednisolone 60 mg to 125 mg IV, repeat
every 6 to 12 hours)
Antibiotic therapy: Appropriate for majority of severe COPD exacerbations; select
antibiotic based on likelihood of particular pathogens (eg, Pseudomonas risk factors,
prior sputum cultures, local patterns of resistance)
Antiviral therapy (influenza suspected)*: Oseltamivir 75 mg orally every 12 hours
OR peramivir 600 mg IV once (for patients unable to take oral medication)

56. Patient Characteristics Likely Pathogens Recommended Therapy
Uncomplicated
exacerbations
<4 exacerbations per year
No comorbid illness
FEV1 >50% of predicted
S. pneumoniae
H. influenzae
M. catarrhalis
H. parainfluenzae
Resistance uncommon
Macrolide (azithromycin,
clarithromycin)
Second- or third-generation
cephalosporin
Doxycycline
Therapies not recommendeda:
TMP/SMX, amoxicillin, first-
generation cephalosporins,
and erythromycin
Complicated exacerbations:
Age ≥65 and >4
exacerbations per year
FEV1 <50% but >35% of
predicted
As above plus drug-resistant
pneumococci, β-lactamase–
producing H. influenzae and
M. catarrhalis
Amoxicillin/clavulanate
Fluoroquinolone with
enhanced pneumococcal
activity (levofloxacin,
gemifloxacin, and
moxifloxacin)
Complicated exacerbations
with risk of P. aeruginosa
Chronic bronchial sepsisb
Need for chronic
corticosteroid therapy
Resident of nursing home
with <4 exacerbations per
year
Some enteric gram-negatives
As above plus P. aeruginosa
Fluoroquinolone with
enhanced pneumococcal and
P. aeruginosa activity
(levofloxacin)
IV therapy if required: β-
lactamase resistant penicillin
with antipseudomonal activity
3rd- or 4th-generation
cephalosporin with
antipseudomonal activity

57.  Supportive care
 Cigarette smoking cessation
 Thromboprophylaxis
 Nutritional support

58. Roflumilast
 Is a phosphodiesterase 4 inhibitor indicated
to reduce risk of exacerbations in patients
with severe COPD
 Roflumilast may be beneficial in patients with
severe or very severe COPD who are at high
risk of exacerbation (Group C and D) and are
not controlled by inhaled bronchodilators. It
may also be considered for patients who are
intolerant or unable to use inhaled
bronchodilators or corticosteroids. Roflumilast
is not recommended for us with theophylline
because the drugs share similar
mechanisms.

59. Ultibro
(indacaterol/glycopyrrolate)
 MOA:
◦ Indacaterol: selective long beta 2 agonist
◦ Glycopyrrolate: anticholinergic agent
 Indication: chronic COPD only