What is the role of ketamine in managing Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

From the Guidelines

Ketamine is not typically recommended as a first-line treatment for COPD exacerbations. The most recent and highest quality study, 1, published in 2021, suggests that the goals for management of acute exacerbations of COPD include symptom resolution and recovery from the exacerbation episode via improving airflow and gas exchange, as well as reducing lung inflammation. Typical interventions used for the management of COPD exacerbations include corticosteroids, systemic antibiotics, inhaled bronchodilators, and supplemental oxygen.

Key Considerations

• Standard treatment for COPD exacerbations includes bronchodilators (such as albuterol 2.5-5 mg via nebulizer every 4-6 hours), systemic corticosteroids (prednisone 40-60 mg daily for 5-7 days), and antibiotics if bacterial infection is suspected, as recommended by 1 and 1.
• Oxygen therapy should be titrated to maintain oxygen saturation between 88-92%, as suggested by 1.
• In severe cases requiring mechanical ventilation, ketamine might be considered as an adjunct sedative at doses of 0.5-2 mg/kg IV for induction, followed by 0.5-1 mg/kg/hr infusion if needed, due to its bronchodilatory properties and ability to maintain respiratory drive while providing sedation, as noted in the example answer.
• However, ketamine should be used cautiously as it can increase secretions and potentially worsen respiratory status in some patients, and should only be administered by clinicians experienced in airway management and critical care, with appropriate monitoring of vital signs and respiratory parameters, as emphasized by the need for careful consideration of patient characteristics and clinical scenario.

Additional Recommendations

• The decision to use ketamine should be individualized based on the specific clinical scenario and patient characteristics, taking into account the potential benefits and risks, as well as the availability of other treatment options.
• Nonpharmacologic treatments, such as pulmonary rehabilitation programs, chest physiotherapy, and nutritional supplements, may also be considered as part of a comprehensive management plan for COPD exacerbations, as suggested by 1.

From the FDA Drug Label

Ketamine is a potent bronchodilator suitable for anesthetizing patients at high risk for bronchospasm.

Ketamine can be used for COPD exacerbation as it is a potent bronchodilator. However, its use should be approached with caution and considered on a case-by-case basis, taking into account the patient's overall clinical condition and medical history.

• Key benefits: Bronchodilation, analgesia, and potential for reduced respiratory depression compared to other anesthetics.
• Key considerations: Potential for increased blood pressure, heart rate, and cardiac output, as well as emergence delirium, which can be reduced with benzodiazepines 2 2.

From the Research

Ketamine for COPD Exacerbation

There is no direct evidence in the provided studies regarding the use of ketamine for COPD exacerbation.

Current Treatment Options for COPD

• The mainstays of pharmacological treatment of stable COPD are bronchodilators, including inhaled long-acting beta-agonists (LABA) and anticholinergics 3.
• Inhaled long-acting muscarinic antagonist (LAMA) and LABA combination therapy is recommended for patients with COPD and dyspnea or exercise intolerance 4.
• LAMA/LABA combination therapy has been shown to improve lung function, quality of life, and reduce exacerbation risk compared to LAMA or LABA monotherapy 5, 6.
• Triple therapy with inhaled corticosteroids (ICS), LABA, and LAMA may reduce rates of moderate-to-severe COPD exacerbations and improve health-related quality of life, but may also increase the risk of pneumonia 7.

Limitations of Current Evidence

• There is limited evidence regarding the efficacy and safety of LAMA/LABA combination therapy versus LAMA or LABA monotherapy in maintenance therapy-naïve patients 6.
• The certainty of the evidence for triple therapy is often downgraded due to inconsistency or indirectness 7.

Gaps in Current Research

• There is a need for additional research on the use of ketamine for COPD exacerbation, as well as other treatment options for patients with COPD.
• Further studies are needed to fully understand the benefits and risks of triple therapy with ICS, LABA, and LAMA 7.