Copd
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1. The document discusses the evaluation and treatment of COPD exacerbations in the emergency department. Common causes of exacerbation include viral and bacterial infections. 2. Initial treatment involves bronchodilators, steroids, oxygen supplementation, and antibiotics if pneumonia is present. Ventilation may be considered for severe exacerbations. 3. Upon discharge, the focus shifts to optimizing inhaler therapy and assessing eligibility for pulmonary rehabilitation to reduce readmissions.
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The document provides information about Acute Respiratory Distress Syndrome (ARDS) including its definition, pathophysiology, diagnosis, management, and prognosis. ARDS is defined as rapid onset hypoxemia and diffuse pulmonary infiltrates leading to respiratory failure. It is caused by direct lung injury from conditions like pneumonia or indirect injury from sepsis or trauma. Diagnosis involves criteria of acute onset, hypoxemia with PaO2/FiO2 ≤200, and no heart failure. Management focuses on treating the underlying cause and providing ventilator support using low tidal volumes per the ARDSNet protocol to reduce ventilator-induced lung injury. Prognosis depends on risk factors and mortality ranges from 26-44%.
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DLCO/TLCO measures the ability of the lungs to transfer carbon monoxide from the alveoli to the blood. It estimates the surface area and thickness of the alveolar-capillary membrane. CO is used instead of oxygen because its transfer is diffusion limited and it binds readily to hemoglobin. A single-breath hold method is most common where the patient inhales a gas mixture and holds their breath for 10 seconds while CO uptake is measured. DLCO can help identify interstitial lung diseases, emphysema, pulmonary hypertension and assess treatment response. Reduced DLCO may be due to decreased surface area from conditions like emphysema, or increased membrane thickness from fibrosis. Adjustments are made
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Copd&anesthesia
This document discusses COPD pathophysiology and anesthetic management. It begins by defining COPD and describing its risk factors such as smoking. It then explains the disease pathogenesis involving inflammation, tissue destruction, and proteinase-antiproteinase imbalance. Pathology of the large and small airways and parenchyma are described. Outcomes like airflow obstruction and hyperinflation are discussed. The GOLD classification stages COPD severity. Treatment includes smoking cessation, bronchodilators, pulmonary rehabilitation and managing exacerbations. The document outlines pre-operative assessment including history, exams, investigations like CXR and PFTs. It provides guidance on pre-operative preparation and intraoperative and postoperative risk reduction strategies like regional anesthesia
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Presentation on ventilatory management in Acute Hypercapnic Respiratory Failure
Updated information till 17/8/16
For powerpoint format, contact dr.vitrag@gmail.com
http://www.medicalgeek.com/presentation/36513-ventilatory-management-acute-hypercapnic-respiratory-failure-presentation.html
Download review articles and guidelines for ventilatory management in COPD & Asthma
http://www.medicalgeek.com/articles-and-news/36514-articles-ventilatory-management-copd-asthma.html
Mechanical Ventilation for severe Asthma
1) Mechanical ventilation may be required for severe, life-threatening asthma to prevent respiratory failure and death. Non-invasive ventilation can be tried initially but intubation may be needed.
2) Permissive hypercapnia is recommended to avoid additional lung injury from mechanical ventilation, allowing CO2 levels up to 90 mmHg if oxygenation is adequate. Sedation and sometimes paralysis are used while ventilating to reduce lung injury.
3) Weaning from mechanical ventilation begins with spontaneous breathing trials once the patient's CO2 levels normalize at a low ventilation rate and airway resistance decreases. Rescue therapies like ECMO may be required in rare cases that do not respond to usual treatments.
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This document provides an overview of ARDS (acute respiratory distress syndrome) including its history, definition, pathophysiology, assessment, and treatment strategies. ARDS is characterized by acute hypoxemia, stiff lungs, and diffuse pulmonary infiltrates caused by inflammatory lung injury from direct or indirect insults. Key evidence-based treatment strategies discussed include lung protective ventilation with low tidal volumes, higher PEEP levels, targeting driving pressure, prone positioning, and rescue therapies like recruitment maneuvers which can improve oxygenation but their benefits are uncertain. The PROSEVA trial showed a significant reduction in 28-day mortality for prone positioning in severe ARDS patients.
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1. Interstitial lung diseases (ILDs) involve the lung parenchyma including the alveoli, capillaries, and tissues between them.
2. Patients commonly present with progressive dyspnea, cough, and interstitial opacities on imaging.
3. A thorough evaluation includes pulmonary function tests, imaging, biopsy, and ruling out other known causes to identify the underlying ILD.
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Ards new
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- The document discusses the definition, pathogenesis, clinical presentation, diagnosis, and management of ARDS. The primary goals of management are treating the underlying cause, maintaining oxygenation levels through ventilation strategies like low tidal volumes, and preventing further lung injury.
- Low tidal volume ventilation, which aims to limit overexpansion of alveoli, is the best proven strategy to improve survival based on current evidence. Other adjuncts like prone positioning and PEEP may also help optimize oxygenation in some cases.
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1. Hypoxemia, defined as low oxygen levels in arterial blood, can be caused by hypoventilation, low inspired oxygen, right-to-left shunts, ventilation-perfusion mismatching, or diffusion impairment in the lungs.
2. Physical exam and arterial blood gas analysis are used to diagnose hypoxemia and its underlying causes. Treatment focuses on oxygen supplementation, treating the underlying condition, correcting acid-base imbalances, and mechanical ventilation if needed.
3. The causes, mechanisms, diagnosis and management of hypoxemia are complex but critical for treatment of respiratory failure.
Ards
This document defines acute respiratory distress syndrome (ARDS) and discusses its pathophysiology, risk factors, diagnosis, management, and ventilator strategies. ARDS is defined as acute onset bilateral pulmonary infiltrates, hypoxemia, and no heart failure. It was initially defined in 1971 and revised definitions in 1988 and 1994 established clearer criteria. Common causes are pneumonia, aspiration, and sepsis. Management involves treating the underlying cause, supportive ICU care, and lung protective ventilation with low tidal volumes (6 ml/kg) and moderate PEEP levels. Adjuncts like conservative fluid management, prone positioning, and recruitment maneuvers may provide benefits.
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Pulmonary function test and bronchial challenge test
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Presented by Kullapornpas Benyajirapach, MD.
June28, 2019Copd
1. Chronic Obstructive Pulmonary Disease (COPD) refers to a group of lung diseases including chronic bronchitis and emphysema that are characterized by persistent airflow obstruction and breathing-related problems.
2. The primary symptoms of COPD include cough, sputum production, and shortness of breath with exertion.
3. The main risk factor for COPD is tobacco smoke, accounting for 80-90% of COPD cases. Management of COPD focuses on relieving symptoms, preventing progression, reducing complications, and improving quality of life through smoking cessation, medications, pulmonary rehabilitation, oxygen therapy and surgery.
Case history of amiodarone induced pulmonary toxicity
A 75-year-old Sudanese male presented with acute myocardial infarction and was treated including with amiodarone due to frequent PVCs on ECG. He was discharged after improvement but returned two weeks later with shortness of breath, dry cough, and fever. Examination found signs of bilateral lung fibrosis. He was diagnosed with amiodarone-induced interstitial pneumonitis-fibrosis based on radiological findings and improved after stopping amiodarone and receiving steroids and supportive care. Literature review discussed amiodarone-induced pulmonary toxicity as a serious adverse effect, with interstitial pneumonitis-fibrosis being common, and management involving discontinuing amiodarone and considering steroids
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Copd phenotypes
The document discusses various COPD phenotypes including:
1) Asthma-COPD overlap phenotype characterized by incompletely reversible airway obstruction and asthma-like features.
2) Frequent exacerbator phenotype defined as 2 or more exacerbations per year which increases health risks.
3) Upper lobe-predominant emphysema phenotype where surgical lung volume reduction may help.
4) Infrequent exacerbator phenotype experiencing less than two exacerbations per year requiring only bronchodilators.
5) Alpha-1 antitrypsin deficiency phenotype which is a genetic cause of panlobular emphysema.
Ventilator Graphics
The document discusses basic principles of mechanical ventilation including factors that can lead to ventilatory failure, airway resistance, lung compliance, hypoventilation, V/Q mismatch, intrapulmonary shunting, and diffusion defects. It also covers different types of ventilator waveforms including pressure, volume, flow and pressure/volume loops which can be used to assess a patient's respiratory status and response to therapy.
4 Restrictive Lung Diseases
This document discusses restrictive lung diseases including interstitial lung fibrosis and asbestosis. It defines interstitial pulmonary fibrosis as a chronic, fibrosing interstitial pneumonia of unknown cause typically affecting adults over 50. Usual interstitial pneumonia is the most common form and has a median survival of 3 years. Asbestosis is an occupational lung disease caused by inhalation of asbestos fibers, which can lead to pleural thickening, effusions, rounded atelectasis or fibrosis. Prevention focuses on never disturbing asbestos materials and smoking cessation.
Interstitial Lung Diseases [ILD] Approach to Management
Diffuse (interstitial) lung disease includes a wide variety of relatively uncommon conditions presenting with characteristic clusters of clinical features and marked by an immune response. There are over 200 specific diffuse lung diseases, many of unknown etiology. The combined incidence is 50 per 100,000, or 1 in 2000 people. Because these conditions cause aberrant lung function, morbidity and mortality due to lung injury and fibrosis are not uncommon. Both environmental and genetic factors are believed to contribute to the development of diffuse lung disease. Antigen processing and presentation are important in the development of the immune response seen in the disease, and it is thought that the likely candidate genes predisposing patients to this category of disease are those of the major histocompatibility complex. Genes that affect the immune, inflammatory, and fibrotic processes may also influence who develops the disease. If we can identify the genes that cause diseases characterized by lung injury and fibrosis, we can eventually develop genetic interventional approaches to treatment.
COPD overview and update
Chronic obstructive pulmonary disease (COPD) is the 3rd leading cause of death in Bangladesh, affecting over 6 million people. The primary cause is tobacco smoke. COPD is diagnosed through spirometry showing airflow limitation. Management includes smoking cessation, vaccinations, pharmacotherapy like bronchodilators and steroids, pulmonary rehabilitation, oxygen therapy, and surgery in severe cases. Exacerbations are acute worsening of symptoms and managed with oxygen, steroids, and antibiotics. Hospital admission is needed for severe exacerbations or inadequate response to home treatment.
ARDS
This document discusses ARDS (acute respiratory distress syndrome), including its history, definitions, pathophysiology, and evidence-based treatment strategies. ARDS is characterized by diffuse pulmonary inflammation and reduced lung compliance. Traditional ventilator strategies have been shown to cause ventilator-induced lung injury, so current recommendations focus on lung-protective ventilation with low tidal volumes and high PEEP. Additional rescue therapies for refractory hypoxemia include recruitment maneuvers, proning, and ECMO. Proper diagnosis requires consideration of alternative conditions and use of diagnostic tools like echocardiogram, bronchoscopy, and chest CT scan.
Refractory Asthma
This document discusses refractory asthma, defining it as asthma that remains difficult to control despite extensive evaluation and management over at least 6 months. It outlines the major and minor criteria used to define refractory asthma according to the American Thoracic Society. It also discusses the epidemiology, pathophysiology, clinical presentation, risk factors, diagnostic workup, and management approaches for refractory asthma. Management involves high-dose inhaled corticosteroids and additional controller medications, along with addressing comorbidities and adherence issues. Immunomodulators may be considered for patients with uncontrolled asthma despite optimal conventional treatment.
Respiratory failure
This document provides an overview of respiratory failure, including its causes, types, symptoms, diagnosis, and management. It begins by defining respiratory failure as the failure of the respiratory system in gas exchange functions of oxygenation and carbon dioxide elimination. Respiratory failure is then classified based on PaO2 and PaCO2 levels into hypoxemic (Type I) and hypercapnic (Type II) types. Common causes, clinical features, investigations, and general management principles are discussed for respiratory failure. Key aspects of managing hypoxemia and hypercapnia are also summarized.
Ventilatory management of Acute Hypercapnic Respiratory Failure
Presentation on ventilatory management in Acute Hypercapnic Respiratory Failure
Updated information till 17/8/16
For powerpoint format, contact dr.vitrag@gmail.com
http://www.medicalgeek.com/presentation/36513-ventilatory-management-acute-hypercapnic-respiratory-failure-presentation.html
Download review articles and guidelines for ventilatory management in COPD & Asthma
http://www.medicalgeek.com/articles-and-news/36514-articles-ventilatory-management-copd-asthma.html
Mechanical Ventilation for severe Asthma
1) Mechanical ventilation may be required for severe, life-threatening asthma to prevent respiratory failure and death. Non-invasive ventilation can be tried initially but intubation may be needed.
2) Permissive hypercapnia is recommended to avoid additional lung injury from mechanical ventilation, allowing CO2 levels up to 90 mmHg if oxygenation is adequate. Sedation and sometimes paralysis are used while ventilating to reduce lung injury.
3) Weaning from mechanical ventilation begins with spontaneous breathing trials once the patient's CO2 levels normalize at a low ventilation rate and airway resistance decreases. Rescue therapies like ECMO may be required in rare cases that do not respond to usual treatments.
ARDS
This document provides an overview of ARDS (acute respiratory distress syndrome) including its history, definition, pathophysiology, assessment, and treatment strategies. ARDS is characterized by acute hypoxemia, stiff lungs, and diffuse pulmonary infiltrates caused by inflammatory lung injury from direct or indirect insults. Key evidence-based treatment strategies discussed include lung protective ventilation with low tidal volumes, higher PEEP levels, targeting driving pressure, prone positioning, and rescue therapies like recruitment maneuvers which can improve oxygenation but their benefits are uncertain. The PROSEVA trial showed a significant reduction in 28-day mortality for prone positioning in severe ARDS patients.
interstitial lung diseases
1. Interstitial lung diseases (ILDs) involve the lung parenchyma including the alveoli, capillaries, and tissues between them.
2. Patients commonly present with progressive dyspnea, cough, and interstitial opacities on imaging.
3. A thorough evaluation includes pulmonary function tests, imaging, biopsy, and ruling out other known causes to identify the underlying ILD.
Respiratory Failure by Dr. Sookun Rajeev Kumar
Respiratory failure occurs when the lungs fail to oxygenate the blood or eliminate carbon dioxide. It can be classified as type I (hypoxemic) or type II (hypercapnic). Common causes include pneumonia, COPD, pulmonary embolism, and cardiac failure. Diagnosis involves blood gas analysis, imaging, and identifying the underlying cause. Management focuses on treating the cause, supporting oxygenation and ventilation, and mechanical ventilation if needed. Type II respiratory failure requires careful oxygen therapy to prevent worsening acidosis.
Ards new
- ARDS is an acute respiratory condition characterized by diffuse lung inflammation and fluid buildup in the lungs, causing hypoxemia. Common causes include sepsis, aspiration, and pneumonia.
- The document discusses the definition, pathogenesis, clinical presentation, diagnosis, and management of ARDS. The primary goals of management are treating the underlying cause, maintaining oxygenation levels through ventilation strategies like low tidal volumes, and preventing further lung injury.
- Low tidal volume ventilation, which aims to limit overexpansion of alveoli, is the best proven strategy to improve survival based on current evidence. Other adjuncts like prone positioning and PEEP may also help optimize oxygenation in some cases.
Approach to hypoxemia
1. Hypoxemia, defined as low oxygen levels in arterial blood, can be caused by hypoventilation, low inspired oxygen, right-to-left shunts, ventilation-perfusion mismatching, or diffusion impairment in the lungs.
2. Physical exam and arterial blood gas analysis are used to diagnose hypoxemia and its underlying causes. Treatment focuses on oxygen supplementation, treating the underlying condition, correcting acid-base imbalances, and mechanical ventilation if needed.
3. The causes, mechanisms, diagnosis and management of hypoxemia are complex but critical for treatment of respiratory failure.
Ards
This document defines acute respiratory distress syndrome (ARDS) and discusses its pathophysiology, risk factors, diagnosis, management, and ventilator strategies. ARDS is defined as acute onset bilateral pulmonary infiltrates, hypoxemia, and no heart failure. It was initially defined in 1971 and revised definitions in 1988 and 1994 established clearer criteria. Common causes are pneumonia, aspiration, and sepsis. Management involves treating the underlying cause, supportive ICU care, and lung protective ventilation with low tidal volumes (6 ml/kg) and moderate PEEP levels. Adjuncts like conservative fluid management, prone positioning, and recruitment maneuvers may provide benefits.
Hepatopulmonary Syndrome By Dr.Tinku Joseph
This document provides information about hepatopulmonary syndrome (HPS). It defines HPS as the presence of liver disease, impaired oxygenation, and intrapulmonary vascular abnormalities. The pathophysiology involves widespread pulmonary vasodilatation leading to ventilation-perfusion mismatching and right-to-left shunting, causing hypoxemia. Clinical features include signs of liver disease in most patients and dyspnea in some. Diagnosis requires confirming the three criteria through tests like contrast echocardiography to detect intrapulmonary shunting.
Bronchiectasis
This document discusses bronchiectasis, defined as abnormal permanent dilation of the bronchi. It covers the types (tubular, varicose, cystic), diagnosis (clinical features and chest CT), pathophysiology (Cole's vicious cycle hypothesis involving infection and inflammation causing tissue damage), etiologies (post-infectious, mucociliary disorders like cystic fibrosis, immunodeficiency, rheumatological conditions), and relationship to COPD (similar inflammation and airflow obstruction features). The document is intended to provide an overview of bronchiectasis for medical students.
Pulmonary function test and bronchial challenge test
Pulmonary function test and bronchial challenge testChulalongkorn Allergy and Clinical Immunology Research Group
Pulmonary function test and bronchial challenge test
Presented by Kullapornpas Benyajirapach, MD.
June28, 2019What's hot (20)
Interstitial Lung Diseases [ILD] Approach to Management
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3. The main risk factor for COPD is tobacco smoke, accounting for 80-90% of COPD cases. Management of COPD focuses on relieving symptoms, preventing progression, reducing complications, and improving quality of life through smoking cessation, medications, pulmonary rehabilitation, oxygen therapy and surgery.
Case history of amiodarone induced pulmonary toxicity
A 75-year-old Sudanese male presented with acute myocardial infarction and was treated including with amiodarone due to frequent PVCs on ECG. He was discharged after improvement but returned two weeks later with shortness of breath, dry cough, and fever. Examination found signs of bilateral lung fibrosis. He was diagnosed with amiodarone-induced interstitial pneumonitis-fibrosis based on radiological findings and improved after stopping amiodarone and receiving steroids and supportive care. Literature review discussed amiodarone-induced pulmonary toxicity as a serious adverse effect, with interstitial pneumonitis-fibrosis being common, and management involving discontinuing amiodarone and considering steroids
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The document discusses chronic obstructive pulmonary disease (COPD), including its definition as a progressive lung disease characterized by limited airflow; causes such as smoking, air pollution, and genetic factors; symptoms like breathlessness, cough, and sputum production; diagnostic tests and medical management including bronchodilators, antibiotics, and oxygen therapy; preventive measures like smoking cessation and flu vaccines; and nursing interventions focused on assessment, education, and managing complications. COPD encompasses chronic bronchitis and emphysema and is a serious lung condition caused primarily by smoking.
COPD.pdf
Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease characterized by obstructed airflow from the lungs. It has four stages ranging from mild to very severe. The two most common conditions that contribute to COPD are emphysema and chronic bronchitis. Signs and symptoms include shortness of breath, cough, wheezing, and lack of energy. Treatment involves bronchodilator inhalers, steroid inhalers, antibiotics, pulmonary rehabilitation, and oxygen therapy. The goals of treatment and nursing care are to maintain airway patency, facilitate gas exchange, prevent complications, and slow disease progression.
copdppt-210122180445 (1).pdf
Chronic obstructive pulmonary disease (COPD) refers to chronic conditions like chronic bronchitis and emphysema that obstruct airflow from the lungs. Cigarette smoking is the leading cause of COPD. The document defines COPD and describes its symptoms, risk factors, diagnosis, treatment through medications and surgery, complications, and approaches to managing the disease.
Ckd chief (2)
This document discusses chronic kidney disease and its management. It defines chronic kidney disease as kidney damage and decreased kidney function for over 3 months. It then discusses the pathophysiology of chronic renal failure, noting the loss of nephrons and failure of kidney roles in fluid balance, waste excretion, and hormone regulation. Common causes of chronic kidney disease are listed, and the progression from initial insult to end stage renal disease is described. Diagnosis involves history, exam, and blood and urine tests to assess kidney function and check for underlying etiologies. Treatment focuses on slowing progression, managing complications, and preparing for renal replacement therapies like dialysis and transplantation.
chronic obstructive pulmoary disease
COPD is a progressive lung disease characterized by airflow obstruction caused by chronic bronchitis or emphysema. It is the fourth leading cause of death in the US. Symptoms include cough, sputum production, and shortness of breath. Management involves smoking cessation, bronchodilators, corticosteroids, oxygen therapy, and lifestyle changes. Nurses play a key role in assessing patients, educating on self-management, and providing interventions to improve breathing and nutrition.
COPD(chronic obstructive pulmonary disease) ppt slideshare
chronic obstructive pulmonary disease and its management
chronic obstructive pulmonary disease is a chronic inflammatory lung disease that causes obstructed airflow from the lungs.
COPD typically has a clear cause and a clear path of prevention, and there are ways to slow the progression of the disease.
COPD . pptx.pptx chronic obstruction pulmonary disease
This document provides information about chronic obstructive pulmonary disease (COPD), including its causes, stages, symptoms, diagnosis, and treatments. The main causes of COPD are smoking and air pollution. There are four stages of COPD that increase in severity from mild shortness of breath to life-threatening symptoms. Diagnosis involves pulmonary function tests, imaging, and other exams. Treatments include bronchodilators, corticosteroids, antibiotics, and pulmonary rehabilitation.
COPD (CHRONIC PULMONARY OBSTRUCTIVE DISEASE) by SUKHERA
COPD, EMPHYSEMA, CHRONIC BRONCHITIS,LUNG DISEASE, OBSTRUCTIVE LING DISEASE, PHYSIOLOGY, KINGS COLLEGE,DPT DEPARTMENT ALL necessary information regarding lung disease which you should know
Case study patient with copd
1. JS, a 74-year-old man with COPD, heart failure, and pneumonia, presents with shortness of breath and fever. His medical history and physical exam reveal severe COPD and risk factors for exacerbation.
2. Chest X-ray confirms right lower lobe pneumonia. ABG results show respiratory acidosis. The patient is treated with antibiotics and oral steroids in the hospital with improvement.
3. Proper management of COPD includes educating patients about self-care, monitoring for exacerbations, promoting smoking cessation, and referring to pulmonary rehabilitation.
Chronic obstructive pulmonary disease
COPD is a common lung disease characterized by persistent airflow limitation caused by damage to the lungs, usually from smoking. It is the fourth leading cause of death. Symptoms include shortness of breath, chronic cough, and sputum production. Diagnosis is confirmed by pulmonary function tests showing airflow limitation that is not fully reversible. Treatment focuses on reducing symptoms and exacerbations through bronchodilators, inhaled corticosteroids, pulmonary rehabilitation, oxygen therapy, and managing comorbidities.
Lung specialist script
Respiratory disease is common worldwide and smoking can damage the respiratory system. Chronic obstructive pulmonary disease (COPD) is one of the most common lung diseases, making it difficult to breathe, with the two main forms being chronic bronchitis and emphysema. The causes of COPD include exposure to certain gases or fumes in the workplace, exposure to heavy amounts of second-hand smoke, and frequent use of cooking gas without proper ventilation. There is no cure for COPD but symptoms can be relieved and progression slowed through medications like inhalers and inhaled steroids, and by stopping smoking.
copd.pptx
This document discusses chronic obstructive pulmonary disease (COPD). It defines COPD as a preventable disease characterized by airflow limitation caused by significant exposure to noxious particles. COPD includes chronic bronchitis and emphysema. Chronic bronchitis is defined as cough and sputum for at least 3 months per year for two years. Emphysema involves abnormal enlargement of airspaces. Causative factors include tobacco smoke, indoor air pollution, and occupational exposures. Symptoms include cough, sputum production and breathlessness. Signs may include wheezing and prolonged expiration. Spirometry is important for diagnosis and classification of severity. Treatment involves smoking cessation, vaccinations, bronchodilators, inh
Copd
COPD is a progressive lung disease characterized by airflow obstruction caused by chronic bronchitis or emphysema. Common symptoms include cough, sputum production, and shortness of breath. Risk factors include cigarette smoking, air pollution, and genetic factors. Diagnosis involves assessing symptoms and medical history, along with spirometry to measure lung function. Treatment focuses on smoking cessation, bronchodilators, pulmonary rehabilitation, oxygen therapy, and managing complications. Nursing care emphasizes airway clearance, breathing exercises, nutrition, activity, education, and symptom management.
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Copd
- 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