Transcript: Should You Use Antibiotics in a COPD Exacerbation? Case Study for Nurse Practitioners

Liz Rohr:

Well, hey there. It's Liz Rohr from Real World NP, and you're watching NP Practice Made Simple, the weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients. So this week's video I'm really excited about. I'm always excited, but I'm especially excited because it's piggybacking off of last week's video talking about when to use antibiotics. I'm going to be talking about COPD and COPD exacerbation.

So from this video, you're going to be able to know what is an exacerbation, who has one, how to treat them, when you need to use antibiotics, and if you do which ones, when to send them to the ER, and just general principles of management of COPD and primary care, just kind of a little checklist for you to follow along with. And on that note, I have a COPD management cheat sheet to download below this video, if you want to check that out, to follow along within this video. There's going to be a couple of tables talking about all of the medications, the vaccines, all that good stuff. So definitely check it out. Without further ado, I'm going to be sharing my screen with you.

All right. So let's hop into the case study. So this is Carolyn. She's 62 years old. She is complaining of a cough, and she has a history of COPD. She is a new patient to you effectively, if you want to treat it this way. When you're a new nurse practitioner, most patients are going to be new to you. So I feel like it's most helpful to frame it in that way. This is not her real name or her photo. She woke up this morning with a lot of coughing and wheezing, and she's needing to use her nebulizer every two hours. She's been coughing up green phlegm since yesterday, which is not usual for her. And she typically has some dyspnea on when she's hurrying or walking up stairs, but otherwise she can walk without breathlessness.

But yesterday and today, she's dyspneic on exertion, that's what that DOE stands for, with level of ground walking, but not at rest. So she's sitting comfortably, but as soon as she starts walking, she gets a little bit short of breath. And she hasn't had this happen in over a year, which is important when we get into talking about COPD exacerbation. So, past medical history, surgical history, according to her, because we don't have her records, she's a brand new patient. She has a history of COPD and hypertension, and she hasn't had any surgeries before. Her family history, just unknown, nothing contributory there. She smokes a pack a day and she has since age 20, so that's about 42 pack years. No alcohol or drugs.

So blood pressure today is 138 over 86. Her heart rate is 90, and oxygen is 94, and her BMI is 31. So, she's taking Ipratropium/Albuterol nebulizer as needed right now. Before she was having new symptoms, she really only used Albuterol metered dose inhaler, MDI, just as needed. She wasn't using it on a regular basis. So for an ROS, just to recap, the positives are that she's having dyspnea on exertion, wheezing, shortness of breath and coughing.

Her ROS is negative though, importantly. No fever, no chills, no chest pain, rashes, nausea, vomiting, diarrhea. So nothing acutely happening in the way of... Well, hold that thought. Before I get ahead of myself, no edema, no ear pain, sore throat, facial pain, or rhinorrhea. All of this stuff is relevant in a second. Physical exam, I'm just trying to keep this on one page, so sorry it's a little bit crunched in there, but the main specifically contributory physical exam findings are that she's nontoxic in appearance.

She has no acute distress. She's sitting pretty comfortably. She doesn't really look dyspneic. Her rest rate is a little bit elevated. I didn't put that on her vitals, but it was about 22, 24. Her lung sounds, when she's walking around, you can tell she's working a little bit harder. Her lung sounds are showing inspiratory and expiratory wheezing throughout, with just no crackles or other... I believe it's adventitious lung sounds is the official name for anything weird sounding. So cardiovascular wise, her regular rate and rhythm, she doesn't have any edema. And then otherwise, she's alert, oriented, appropriate affect and mood. So COPD exacerbations, what does that mean? So it's any worsening of respiratory symptoms outside of the day-to-day variations that leads to a medication change. Super kind of broad and not that helpful, right?

I'll get into it more in a second though. So that's based on the GOLD guidelines by the National Heart, Lung and Blood Institute, and also the World Health Organization. Those are the two guidelines I'm following with this presentation. So what does this actually mean? So according to World Health Organization, it's an increased cough and sputum purulence compared to what they had before. This is what I found in up-to-date. It has to do with the authors who wrote the up-to-date article about COPD exacerbations and expert pulmonologists. And I find this a little bit more clinically helpful. So there's three markers. There's one that's increased dyspnea, increased sputum and then increased purulence of sputum. And so if you have one or two of those, that's considered to be exacerbation. If there's one of those, that could be consistent with an exacerbation. If there's two or more of them, that can be kind of marking the severity, which hold that thought, I'm going to get more into that in a second.

So what are the steps? So number one is always triage. Can you safely treat them out patient or do they have to go to the hospital? So, triage has to do with the alarm signs. So do they have signs of agonal breathing, really severe dyspnea at rest? Do they have signs of cyanosis or their SpO2 is less than 88% despite you giving them oxygen? That's really unnerving. Do they have any more severe signs of lethargy, confusion,` edema? And then is this a marked increase over baseline compared to before? So like I said, what's really important to... And I'll touch on this more in a second. What is their baseline? So normally, she's doing pretty well. She doesn't really have dyspnea on exertion. She really only gets it with strenuous exercise, and she really only needs every once in a while that albuterol PRN.

And so if she went from that to just really, really severe, that would be much more concerning than if she was already pretty severe and it was just kind of slightly increased, if that makes sense. So other things that are really important to consider, is this person very frail, or do they have other co-morbidities that could complicate the management and they might need them to be inpatient admitted. So, especially for a pneumonia. So are you worried about them having signs of a fever or other crackles or other kind of adventitious lung sounds and you're listening to them? Do they have a history of arrhythmias, heart failure? That's definitely more concerning. Diabetes, a lot of people have diabetes and that doesn't necessarily mean that they have to go to the hospital, but that's just kind of something to think about, keeping in the back of your mind if they're more on the severe side and you're a little bit more concerned about them.

And then do they have any renal or liver failure? So after you've kind of triaged them, the next step is antibiotics or not. So, treatment, once you've established that they have a COPD exacerbation, like I said, the increase in dyspnea, increase in sputum production or increase in sputum purulence, you want to treat them as an exacerbation and then decide whether or not they need antibiotics. So everybody gets a bronchodilator, either a SABA or a SAMA, and so short-acting beta agonist and short-acting muscarinic antagonist, or the anticholinergics. Actually, I mentioned this in the intro, but if you want to download that COPD cheat sheet, I talk about the different medications and the different categories for what level of COPD we're talking about here. But anyway, for the exacerbations, everybody gets that. And you can either do that through a meter dose inhaler, so just the kind of pump inhalers, versus a nebulizer.

The data doesn't necessarily support one over the other, but I find that my patients tend to prefer the nebulizers when they get the exacerbations. I think it's probably just a better delivery. They're probably using it more accurately than the meter dose inhalers. And then oral glucocorticoids have shown benefits over placebo in terms of adding that as well. So that is part of the standard of care. And so typically, the standard is prednisone 40 milligrams for five days, and that's a burst, quote-unquote, called a burst. You don't have to worry about a taper necessarily for people with COPD. When you're giving steroids, you want to think about a taper if you have somebody... Definitely if you're getting consistently giving steroids for more than three weeks, you definitely want to taper somebody off.

But if it's less than three weeks, I typically only do tapers for certain conditions, like if you're worried about something being refractory. If you have sort of a greater than 20% body rash rate and you want to make sure that it doesn't come right back as soon as you take it off, those kinds of things. You don't necessarily see that kind of refractory bounce back of severe symptoms with COPD exacerbations, in my experience. You definitely want to be mindful of that if they come off of them and then they're getting worse again. Maybe they need more support. And then in terms of the question of, can I just use an inhaled corticosteroid instead of prednisone, it's not been studied. So I don't recommend substituting that. And that's just not recommended in general in the literature.

So antibiotics, the GOLD guidelines come into play when what they say is when somebody is moderately or severely ill with increased cough and sputum purulence. Again, like that World Health Organization, that's the main criteria, so it seems like everybody would. Or if they need hospitalization. Another one, again, I was referencing the up-to-date article that I kind of feel like is more concretely guiding, is using that two to three criteria that I was talking about, so the increased dyspnea, increased sputum production and then increased sputum purulence. So if they have at least two of those, then you want to consider giving them antibiotics. And really the rationale there is based on studies of the people who have moderate to severe COPD exacerbations and their outcomes. So it's based on studies that just show those increased outcomes. It's not necessarily because you're worried that they have a pneumonia, if that makes sense.

It's a little bit of a leap, but kind of what you're thinking about is you're targeting the specific microbes that could be making things more complicated and leading to things like a pneumonia, so Haemophilus influenza, Maroxella catarrhalis, strep pneumoniae, things like that. And then what you want to figure out is if they meet the criteria for needing antibiotics, are they complicated or are they uncomplicated? And there's kind of three levels here. So number one is uncomplicated, which is just as is. And I'll talk about the complicated factors. So if they don't have any of those, they're considered uncomplicated. And so those people will get a macrolide usually. Azithromycin is an option. Second or third generation cephalosporin, like a cefdinir, I feel like is the most readily available at the pharmacy. Doxycycline or trimethoprim-sulfamethoxazole, most people know as Bactrim.

So complicated is if you have any of these risk factors, and that's age greater than 65 years, their FEV1 is less than 50, so they've got pretty severe COPD, or they've had greater than two exacerbations in a year, or they have known cardiac disease. And you just want to choose a different antibiotic for those people. So that's amoxicillin clavulanate or any of the fluoroquinolones, because they just may have increased antibiotic resistance there. And then do they have a risk for pseudomonas? So that's kind of complicated level 1B. So if they've been hospitalized in the last three months, they have any colonization of pseudomonas that's known, if they've had any treatment for pseudomonas in the past, or if they've had frequent antibiotics in the last year, or they have a comorbid bronchiectasis, which you wouldn't know with this patient necessarily unless she told you those things.

So you'd want to kind of ask about those things. And so those people need Ciprofloxacin specifically is what I found in the literature, not necessarily any fluoroquinolone. And for those people, you need a sputum culture and a gram stain, because you really get a little bit more concerned about that. This really does not come up very often in primary care, but I included it just in case you're kind of seeing these more complicated patients. If they're in that level, they definitely need pulmonary involvement. And if you feel like you're getting to this place of they have a risk for pseudomonas and you need to send out those tests, me personally, if I was getting there, I would probably give a phone call to the pulmonologist that I was working with, that was working with this patient, and just be like, "Hey, FYI, this is what's going on. Just so you know. Any other recommendations you have?" Things like that.

So, oops, I did not animate this slide very nicely. So, number one is triage, home or hospital. Number two is deciding if you're going to treat them for an exacerbation, do they need antibiotics? And number three is what is their follow-up care. So all patients with COPD need these things. So number one is to identify and avoid triggers, talking about smoking cessation. And maybe you're talking about it at this visit, or maybe you're talking about it the next time you see them. It depends on how overwhelmed the patients get, but things to think about. Making sure they're using their inhalers correctly, medication adherence. You want to kind of check in with that every time you see the patient. So especially for this patient with an exacerbation, I definitely would go through that if they didn't have a nebulizer. Like, "Do you know how to use your meter dose inhaler? Are you using a spacer?" Things like that.

And how often are you taking your medications? For her, again, she was only taking it PRN, and that's how it was prescribed. So we don't have to necessarily worry about that as much. But you always want to think about vaccines. So making sure that their tetanus is up-to-date. Tetanus, Tdap rather with pertussis in there, is once as an adult and then a TD booster every 10 years. Pneumococcal, there's a couple of rules about that. But if you download that cheat sheet, I'll talk about the different rules that we have for the pneumococcal vaccines. And then a seasonal influenza vaccine. And then just anybody with COPD, you want to kind of make sure that they're on a lifestyle regimen of exercise and general healthy diet, and also thinking about weight management. So this patient, for example, her BMI is 31. Increasing BMIs, especially in the obese range, can lead to more dyspnea, which makes total sense.

So you want to kind of think about that. Again, I'm not talking about weight management during an exacerbation visit, but these are just kind of holistic, checking in about COPD management. And again, lung cancer screening. We're probably not going to talk about this at this visit, but you want to think about she probably needs lung cancer screening. And what are the risks and benefits of doing that? What does that mean? Things like that, because that's more of a discussion. I find that most people are a little bit resistant to lung cancer screening. I think that they're a little bit scared of what it means and what it can do for them, but we can find things early. So the criteria there is aged 55 to 74, but considerations of up to 80, depending on their clinical condition, if they could undergo and withstand some kind of lung cancer treatment.

And then the criteria also is that they need to have a 30 pack year smoking history. And if they've quit, they need to have quit within the last 15 years to qualify for the lung cancer screening. If they quit 30 years ago, they don't qualify. And pulmonary rehabilitation came up in the literature of what I was reading a lot, and this has to do with a more comprehensive kind of lifestyle exercise program that I believe would be done by a pulmonology office. I haven't really seen that much in a clinical practice. Maybe this is a newer thing, or maybe I'm just not seeing it as much. But it's not something I've ever ordered or referred somebody for, but I'd probably make sure that they were hooked in with pulmonology if they had a diagnosis of COPD. And they can kind of decide how do they assist them with that and how often they want to be monitoring them.

And then there's a question of annual spirometry. I believe those are in the GOLD guidelines. I couldn't really find good stuff about that, but annual spirometry is in there. So in terms of pulmonary function test versus spirometry, spirometry is part of those. That's kind of getting into a little bit more. If you have questions about that, definitely let me know, but I'm not going to be doing that myself. I'm going to make sure that they're with pulmonology, and they are going to order that test and follow up on that. And then there's the question of getting a baseline ABG, arterial blood gas. And again, I'm not going to order that. That's a very painful test. And I couldn't necessarily find guidelines about that, but I've definitely seen that in clinical practice of having that as a baseline so that when they get hospitalized, then they do an ABG, arterial blood gas, they'll see where they are compared to their normal.

And then a baseline chest x-ray as well, especially the first time they're getting diagnosed. And so one of the things you want to think about is the assessment of the GOLD classification. And so it used to be, I think when I was in school, they based it on the FEV1 in terms of severity of COPD. And then they gave your medications based on that. But I believe the revised guidelines have to do with just symptoms. Because even if somebody has worse COPD, meaning a lower FEV1, they're at higher risk for exacerbations, but it doesn't necessarily guide their medications by the evidence of what they found. So this table is going to be a lot. So just I'll walk you through it. There's ABCD. Basically, you want to classify your symptoms as mild or moderate, mild or moderate to severe, and then their risk for worsening.

And so level A is that they have mild and infrequent symptoms. And so symptoms can be measured by a couple of different ways. It's kind of, like I said, breathless with strenuous exercise, but otherwise they're kind of doing fine. There are some scoring tools which I'll include in that handout, which I actually haven't used myself but I'm thinking about using. And also, I have yet to explore this app, but there is an app with the GOLD COPD guidelines where you can kind of type your symptoms in and then they'll give you recommendations from there. But again, I have to play with it a little bit, but I'm pretty excited to play with that. So if they haven't had an exacerbation in a year, they have mild symptoms overall, you can do that combination. You can either do the solitary albuterol PRN, which is what this patient... This patient is a level A, because that was her baseline information.

And you can consider that, or just ipratropium, or a combination of the albuterol ipratropium inhalers. And then level B is just they have more moderate symptoms, but they still are a low risk, meaning that they haven't had any exacerbations, either zero or one in the last year, and they've never been hospitalized. And that kind of gives you your treatment options of a LAMA or LABA, which is long-acting anticholinergic as well as a beta agonist. And again, this is all in the handout if you want to download that. And then level C is going back to that mild and infrequent, but they have more exacerbations in a year and they've been hospitalized. And then level D, which is kind of the hardest, worst case scenario is that they have moderate to severe symptoms on a regular basis, and they also are getting hospitalized multiple times or having multiple exacerbations per year.

And their treatment is guided on there. And again, I don't want to be too wordy on this, so you can download that and take a look at that. And I also have examples of what the medications are on there too, so you don't have to just think about LAMA, like, "What are we talking about here? Are we talking about tiotropium, Spiriva, things like that?" So again, so what's next? Let's go back to Carolyn. So again, we can continue with outpatient management because she's not severely above her baseline. She doesn't have any signs of cyanosis, and her O2 is greater than 88%, and it's not refractory to oxygenation. She doesn't have any signs of comorbid exacerbations. I'm not worried about a pneumonia here. She doesn't have AFib. She doesn't have diabetes that we know of. Things like that.

Again, going back to those GOLD symptoms baseline, she's level A in her baseline symptoms. And where she is right now is only at moderate to severe in terms of the exacerbation type. So she has a moderate exacerbation, again, going back to those three things, two out of three or three out of three. She has an increase in sputum, increase in purulence, and then she has an increase in dyspnea. So she's considered a moderate exacerbation at least. And then she doesn't have any risk factors for the complication of the exacerbation rate. So the age, recent hospitalization, things like that. Again, all in the handout. So management for her, so we're going to continue inhalers, add prednisone and then add azithromycin for her.

We're going to review the alarm signs and symptoms of when to go to the hospital, so just in case this medication treatment, therapy doesn't work. And we're going to review her records. Again, she's a brand new patient, so we're going to get the records from her last PCP. She's going to need a pulmonology eval. I definitely, again, hook people who have COPD in with a pulmonologist. Whether or not they see them once a year, every six months is kind of up to their determination. But they're going to decide when and how often she needs to have those pulmonary function tests versus spirometry. And then they can decide again about that pulmonary rehabilitation if they have access to a program like that.

Again, going back to vaccines, bringing up the flu vaccine, the tetanus and the pneumococcal vaccine. She declines today, but again, we don't really have records, so we'll kind of check on those once we get those. And then lung cancer screening, I did bring it up. I'm a little overly ambitious sometimes. But she said she's going to consider it. So again, just kind of recap of all the management things that I said. And yeah, and I'm going to have her come back in three months. I'm going to request the previous records from PCP. We might talk about weight management, things like that.

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