Question of the Week
For August 5, 2014
Your answer is correct.
AzithromycinA long-acting bronchodilatorVancomycin and piperacillin–tazobactamIntravenous heparinNoninvasive positive-pressure ventilation
Key Learning Point View Case Presentation
A patient hospitalized with an exacerbation of chronic obstructive pulmonary disease and no evidence of hypercapnic respiratory failure or pneumonia should be treated with bronchodilator therapy, systemic glucocorticoids, and a fluoroquinolone or a macrolide antibiotic.
In patients hospitalized for an exacerbation of chronic obstructive pulmonary disease (COPD), glucocorticoids and bronchodilators are the mainstays of treatment because they reduce symptoms and often shorten hospital stays. Antibiotics, particularly in the setting of purulent sputum, have been shown to significantly improve outcomes, lower the risk for treatment failure, increase time between exacerbations, and reduce the risk for death in cases of acute exacerbation. About 50% of acute exacerbations are caused by bacterial infection. Currently, fluoroquinolones, doxycycline, or macrolide antibiotics (such as azithromycin) are recommended to treat COPD exacerbations.
Vancomycin and piperacillin–tazobactam are not indicated if the patient has not been hospitalized within the past 90 days.
Long-acting bronchodilators are not indicated for acute exacerbations of COPD. It would be appropriate, however, to consider adding a long-acting bronchodilator to the patient’s outpatient regimen on discharge.
A patient with an unexplained exacerbation may have a pulmonary embolism requiring heparin treatment, but the presence of purulent sputum points to infection rather than pulmonary embolism, and diagnosis should be pursued before treatment.
Noninvasive positive-pressure ventilation has been shown to improve outcomes in patients with COPD exacerbations, but its use is limited to patients with hypercapnia (partial pressure of carbon dioxide >45 mm Hg), persistent hypoxemia, or increased work of breathing.
Last reviewed Feb 2017. Last modified Apr 2014.
Stoller JK. Clinical practice. Acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 2002 Mar 29; 346:988. > View Abstract
Sethi S and Murphy TF. Infection in the pathogenesis and course of chronic obstructive pulmonary disease. N Engl J Med 2008 Nov 29; 359:2355. > View Abstract
Ram FS et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2006 Apr 21. > View Abstract