COPD Exacerbations

[@Cloudshaper]

Great video! However, with the growing antibiotics resistance, I don't think every admissable patient should receive this treatment. An estimated half of all COPD exacerbations are caused by viral infections. You should give antibiotics if the patient is clinically affected, has increased purulence of sputum from baseline AND either dyspnea or increased sputum production.

[@StrongMed]

Thanks for your great comment and the very reasonable concern you expressed about antibiotic overuse (I've pinned it so more people can see it). The use of antibiotics in COPD exacerbations without overt pneumonia is the most controversial aspect of its treatment, and the one in which I see the greatest variability in how clinicians practice. The GOLD group (responsible for the most-cited guidelines on COPD management) summarizes their view on antibiotics as follows (goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf): "In summary, antibiotics should be given to patients with exacerbations of COPD who have three cardinal symptoms: increase in dyspnea, sputum volume, and sputum purulence; have two of the cardinal symptoms, if increased purulence of sputum is one of the two symptoms; or require mechanical ventilation (invasive or non-invasive). The recommended length of antibiotic therapy is 5-7 days." That sounds more or less the same as what you've suggested (and with which I would agree) - but, at least in the population of patients I see, the clear majority of them who are sick enough to warrant admission for a COPD exacerbation meet that criteria (or concurrently have overt pneumonia). (For what it's worth, not that UpToDate should be the primary driver of clinical practice decisions, but the authors of the relevant article there explicitly state that they use antibiotics for any patients with 2 or more of the 3 cardinal symptoms, irrespective of whether or not increase sputum purulence is one of them.) There has been some research into using biomarkers like CRP and procalcitonin to better guide which patients with excerabations should get antibiotics, but IMHO, those studies are not (yet) convincing enough to adopt for routine practice on *inpatients*. (See other comment below re: recent NEJM paper on use of CRP for this)

[@cedriccheung3258]

I am an ID doc in NYC who has started volunteering in the hospital as a hospitalist. I haven't done general inpatient medicine for 17 years since the end of my residency. So I've been binge watching over 40+ videos from your entire playlist, and they are a godsend! I feel like I've gone through a whole residency all over again and feel much more confident taking care of these really sick COVID patients. Thanks Dr. Strong!

[@StrongMed]

Dr. Cheung, you are so very welcome! I have so much respect for everyone in NYC, particularly those who are stepping into new roles. Good luck, and stay safe! (Random coincidence, but I think we actually overlapped our time at NYU - I graduated med school there in 2003.)

[@cedriccheung3258]

@@StrongMed Yes I would have been a 3rd year resident in Medicine

[@lori6911]

Thank you for all this information. I just recently found out why my specialist had perscribed azithromycin during my most recent exacerbation. she never explained this to me. It was videos like yours that gave me the information that my doctor should have explain to me. I never knew that it is actual bacterial or viral infections that can cause exacerbations. You would think that one of my specialists would have explained this to me. none of the “official” COPD web site state that viral or bacterial infections make up a good portion of the reason for exacerbations. I find this deplorable. if I’m wrong about the website, I hope somebody sends a link. I’d love to see it. I’m being sincere about this.. Thank you for all this information. It helps people like me understand what we need to know.

[@khursheedalam7872]

Thank you so much for this series Hope you will continue it for acute emergency managment series for intern Heartly congratulation to u for your effort Thank u from bottom of my heart

[@Dariovich]

This video is super useful for me. I have my practice in a rural comunity on northern mexico. Here we have a lot of elderly people with COPD due to the way they used to cook or their labor on the corn fields. I have seen a lot of new patients in carpenters that dont use their protection gear while cutting o painting due to extreme heat in the summer time. Thanks for your time and effort!

[@DrAdnan]

This is high yield for rotations 👏👏

[@sunving]

Thank you Dr Strong. I happened to read your reply below. Thanks

[@mickeysingh7443]

Sir thank you so so much for this ...

[@BawseUpInTech]

I have covid with a history of copy exberation. This was very helpful! Thank you!

[@michapacia3083]

This series is awesome!

[@JustDawdling]

I love how different your intro music can be between your videos haha.

[@SKARTHIKSELVAN]

Thanks for your efforts.

[@larryfelder4404]

Nicely done.

[@sarahmina1442]

Thank you for the lecture. Is there a difference between an exacerbation and a decompensation of COPD?

[@StrongMed]

The use of those two terms (exacerbation vs. decompensation) may vary depending upon country. In the US, my impression is that "COPD exacerbation" is a far more common term for clinicians to use than "COPD decompensation", but that the two terms are more or less synonyms here. This may be splitting hairs, but I would draw a subtle distinction between "a COPD decompensation" (which is again, an uncommon term in the US) and "decompensated COPD". To me, "a COPD decompensation" implies a discrete, relatively brief stepwise decline in lung function or symptom control which can, in most cases, be successfully treated to return the patient to their previous baseline. Whereas "decompensated COPD" can instead imply COPD that is chronically not well controlled, where the patient may or may not be able to return to a comfortable baseline.

[@gotlactose]

Any comments on the recent NEJM paper on using CRP to guide antibiotic therapy?

[@StrongMed]

Thanks for bringing this up! (This is a downside to prerecording these videos...) I think the paper (www.nejm.org/doi/full/10.1056/NEJMoa1803185) is reasonably good, but would hesitate just a little before applying it too broadly and dogmatically - the patients studied were presenting to primary care clinics, so almost certainly were less ill on average compared to the typical patient who presents with a COPD exacerbation to an emergency room (where an intern, or hospitalist, is more likely to encounter them). As additional possible evidence that these patients were relatively healthy (for patients with COPD), the authors reported

[@cornelbacauanu1544]

@@StrongMed Dr Strong , Thank you for the explanation and for the link to NEJM provided . Unfortunately the link does not open the article . Thank you again .

[@sanbetski]

As always, awesome videos Dr. Strong! More power! With regards to PE work up, would it be reasonable to just get D dimer first before looking into chest CT versus a VQ scan?

[@StrongMed]

When I talk about working up a suspected COPD exacerbation for PE, I mean just applying the same PE algorithm that I would for a patient who presented to the ED with pleuritic chest pain (combining the PERC rule and Wells score). Of course, since almost all patients with COPD are over 50 and/or have a presenting O2 sat

[@briandwyer9457]

Thank you kindly

[@rumit9946]

Thanks

[@StrongMed]

Thank you!

[@bluejeans8001]

Nice👍👍👍

[@drkhaled13]

thanks

[@cindybain6054]

I've been diagnosed with asthma and bronchitis and COPD and emphysema. I have lost my voice.

[@anaandronic101]

wowww soo gooddd! TY!

[@davidkropodra]

my best friends grandpa light up a smoke hooked up to oxygen.........burned his lungs

[@WilliamLeonard-cs8cz]

No.

[@just.8797]

"The terminal decline of respiratory functions many COPD patience unfortunately experience". *Rock music starts playing*

[@LaneCodeRedCarnivore]

Side effects of steroids could be lessened if the Docs dealt with the effects of steroids depleting magnesium and Vit D , especially since most people are deficient before the steroid !!

[@StrongMed]

I am not aware of any effect of steroids depleting Mg or Vit D, and could find no mention of these in a quick search of the medical literature. It is true that long-term steroid use carries significant risk of osteoporosis which might be partially mitigated by Vitamin D supplementation, it wouldn't be an issue with only the 5-14 days (usually 5-7) of steroids used in COPD exacerbations. The most notable side effects from short-term steroid use are hyperglycemia, fluid retention, and less commonly, neuropsychiatric effects.