COPD Exacerbations: Diagnosis and Management
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COPD Exacerbations: Diagnosis and Management
- 1. COPD ExacerbationsCOPD Exacerbations By- Dr. Armaan SinghBy- Dr. Armaan Singh
- 2. A Tale from the ED “I have an easy admission for you. 70-year-old active smoker with severe COPD, progressively short of breath for three days. Frequent flyer, was here last month with the same complaints. He’s afebrile and tachypneic, with wheezes and poor air movement on both sides. His chest film shows bilateral pneumonia, so I started ceftriaxone and azithromycin. I gave him Solumedrol and nebs, and he looks a little better.”
- 3. Objectives 1. Formulate a differential and workup for an acutely dyspneic patient with COPD 2. Choose appropriate initial therapy and anticipate complications 3. Plan for discharge to reduce readmissions
- 4. Differential
- 5. Precipitants of Exacerbation Acute bronchitis caused by: 1.Viruses 2.H. influenzae 3.Moraxella catarrhalis 4.Strep. pneumoniae 5.P. aeruginosa Three other potentially fatal precipitants: 1.Heart failure 2.Pneumonia 3.Pulmonary embolism
- 6. CXR #1: COPD Suddenly Got Worse
- 7. CXR #2: COPD Exacerbation & Edema
- 8. Initial Interventions 1. Bronchodilators: Duoneb q4h scheduled around-the- clock. 2. Steroids: oral prednisone (after first dose IV Solumedrol in ED) if the patient can swallow. Check fingerstick blood sugars. 3. Oxygen: caution! Titrate to SaO2 90-93% in advanced COPD to avoid hypercapneic respiratory failure 4. Antibiotics …
- 10. Consider Ventilation For … Intractable dyspnea Worsening hypercapnea Refractory hypoxia
- 11. Discharge Planning 1. Optimize the patient’s inhaler regimen 2. Assess eligibility for home oxygen and pulmonary rehabilitation 3. Smoking cessation 4. Followup with PCP in 10-14 days
- 12. A Tale from the ED, Revisited “I have an easy admission for you. 70-year-old active smoker with severe COPD, progressively short of breath for three days. Frequent flyer, was here last month with the same complaints. He’s afebrile and tachypneic, with wheezes and poor air movement on both sides. His chest film shows bilateral pneumonia, so I started ceftriaxone and azithromycin. I gave him Solumedrol and nebs, and he looks a little better.”
- 13. Summary 1. Think of heart failure, pneumonia, and pulmonary embolism in the differential of all cases of COPD exacerbation (although viral respiratory infections are more common) 2. Treat with bronchodilators, systemic glucocorticoids, oxygen, and antibiotics 3. Reevaluate diagnosis and consider ventilation for declining respiratory status
Editor's Notes
- Read the case to the audience. Ask them to think to themselves if there are any questions they’d like to ask the ED, tests to order, or management changes to make. We will return to the case at the end of the presentation.
- “Not all that wheezes is asthma.” Or COPD. There are many disorders in the differential when you are called for a patient with “COPD exacerbation”. (Image: source unknown)
- After establishing COPD as the working diagnosis, it is important to consider what is causing the patient to decompensate. A recent Serbian autopsy series (Chest 2009;136(2):376-380. doi:10.1378/chest.08-2918) of patients admitted with COPD exacerbation identified heart failure (37%), pneumonia (28%), and pulmonary embolism (21%) as the most frequent causes of death within 24 hours of admission.
- Say: “this patient with known COPD presents to the ED with dyspnea and is admitted with a diagnosis of COPD exacerbation. Looking at the CXR, what do you think is causing his symptoms.” Arrow points to right-sided wedge infarct from pulmonary embolism. Source: http://www.imagingpathways.health.wa.gov.au/includes/images/pe/ham.jpg
- Say: “another patient with known COPD, admitted from the ED with COPD exacerbation and bilateral pneumonia. What do you think?” CXR shows vascular congestion and bilateral pleural effusions from heart failure. Source: http://circ.ahajournals.org/content/126/1/138/F1.large.jpg
- Read the slide
- Say: “Antibiotics are indicated for moderate or severe exacerbation” and run through the criteria in the left-hand box. Next say: “the most important aspect of choosing antibiotics is to assess the patient’s risk for Pseudomonal infection” and discuss the right-hand box. (Source: UpToDate: “Management of infections in acute exacerbations of chronic obstructive pulmonary disease”, topic updated 03/27/2012)
- Read the slide. Say: “hypercapneic respiratory failure can be difficult to catch early because the patient gets sleepy and will not show the tachypnea and accessory muscle use that would alarm nurses.” (Source: http://www.himcomed.com/uploads/images/Solunum1.jpg)
- Read slide. Can discuss different steroid tapers.
- Questions for discussion: Is this COPD? If so, what caused the exacerbation? Does the patient need antibiotics? What initial treatments and studies do you want?
- Read slide