COPD

Question 1

three hallmark symptoms of COPD?

Answer 1

dyspnea, chronic cough, sputum production

Question 2

cardiopulmonary complications of COPD?

Answer 2

right heart failure

pulmonary HTN

Question 3

how to confirm COPD?

Answer 3

spirometry with a postbronchodilator FEV1–to– forced vital capacity ratio of <0.7

Question 4

what is bronchiectasis?

Answer 4

Bronchiectasis is a condition of chronic cough and daily viscid sputum production associated with irreversible airway dilatation and bronchial wall thickening

Question 5

two classes of puffers for COPD

name one of each

Answer 5

LABA - salmeterol

LAMA - tiotropium

Question 6

patient with history of COPD presents acutely dyspneic.

common triggers of AECOPD

Answer 6

common - infection or respiratory irritant

Question 7

What symptoms on history to elicit AECOPD?

What problem do these symptoms suggest?

Answer 7

• changes in volume and color of sputum, especially an increase in purulence
• increase in sputum volume and change in sputum color suggest a bacterial infection and the need for antibiotic therapy

Question 8

best test for acute evaluation of probable AECOPD?

Answer 8

ABG - help you assess severity and prognosis

Question 9

With ABG… Normal PaO2? What about VBG?

Answer 9

Normal PaO2 is 80-100 mmHg

- should not be assessing PO2 with VBG!

Question 10

With ABG.. Normal range of PaCO2?

When PaCO2 is high, what acid base disturbance?

Answer 10

Normal PaCO2 is 35-45

Respiratory acidosis is present if the partial pressure of carbon dioxide (PCO2) is >44 mm Hg.
If the pH is <7.35, there is an acute and uncompensated component of respiratory or metabolic acidosis present.

Question 11

Respiratory failure at what PaO2?

Answer 11

Respiratory failure typically shows an arterial PaO2 of <60 mm Hg (or an arterial SaO2 <90% in room air)

Question 12

ED management of AECOPD (10)

Answer 12

1. Assess severity of symptoms - ABG
2. Administer controlled oxygen (target arterial oxygen saturation of 88%–92%)
3. Continuous cardiovascular status monitoring
4. Perform arterial blood gas measurement after 20–30 min if arterial oxygen saturation remains <90% or if concerned about symptomatic hypercapnia
5. Administer bronchodilators - β2-Agonists and/or anticholinergic agents by nebulization or metered-dose inhaler with spacer
6. Add oral or IV corticosteroids
7. Consider antibiotics if increased sputum volume, change in sputum color, fever, or suspicion of infectious etiology of exacerbation
8. Consider noninvasive mechanical ventilation
9. Evaluation may include chest radiograph, CBC with differential, basic metabolic panel, ECG
10. Address associated comorbidities - ddx…

Question 13

What percent of patients with a severe COPD exacerbation with an unclear trigger have a PE?

Answer 13

20-25%

Question 14

Critical Differential Diagnosis of Chronic Obstructive Pulmonary Disease (COPD) Exacerbations

hint: heart (2), lung (4)

Answer 14

1. ACS - trop
2. CHF - hx dyspnea with exertion, cardiomegaly on CXR, JVD, BNP
3. PE - d-dimer/CTPE
4. Pneumothorax - CXR (or PoCUS!)
5. Pneumonia - CXR
6. Asthma - history

Question 15

Mainstay of acute medication treatment of AECOPD?

Answer 15

SABA (ventolin) +/- SAMA (ipratropium)

Do not use long-acting inhaled anticholinergics, such as tiotropium, aclidinium, and glycopyrronium, for the acute management of COPD

Question 16

Should you use steroids in AECOPD?

Answer 16

yes.
A short course (5 to 7 days) of systemic steroids (50 mg) improves lung function and hypoxemia and shortens recovery time in acute COPD exacerbations.
No benefit of IV administration unless unable to take PO

Question 17

When should you prescribe abx for AECOPD?

Answer 17

Prescribe antibiotics in moderately or severely ill patients if there is evidence of infection, such as change in volume of sputum and increased purulence of sputum.

Question 18

you check the guidelines for AECOPD, indications for abx, your patient meets criteria…
what are 3 common abx for this?

Answer 18

macrolides (azithromycin),
tetracyclines (doxycycline),
trimethoprim-sulfamethoxazole.

Question 19

Your AECOPD patient was recently on abx and recently hospitalized. What bug should cross your mind?

Answer 19

Pseudomonas aeruginosa

• if: admission and/or antibiotic course in past
  3 months, prior culture showing Pseudomonas infection, or concomitant bronchiectasis

Question 20

three most common bugs in COPD exacerbation?

Answer 20

most common pathogens associated with COPD exacerbation:
Streptococcus pneumoniae,
Haemophilus influenzae,
Moraxella catarrhalis.

Question 21

indications for NIPPV with AECOPD patient?

hint: lab (3), clinical (1)

Answer 21

Acidosis (pH <7.36)
hypercapnia (PaCO2 >50 mm Hg)
oxygenation deficit (PaO2 <60 mm Hg or SaO2 <90%) 

Severe dyspnea with clinical signs such as respiratory muscle fatigue or increased work of breathing

Question 22

Indications for mechanical ventilation (intubation)

4

Answer 22

Use assisted mechanical ventilation when there is 
evidence of respiratory muscle fatigue, 
worsening respiratory acidosis, 
deteriorating mental status, 
or refractory hypoxemia

Unable to tolerate noninvasive ventilation (NIV) or NIV failure
Respiratory or cardiac arrest
Respiratory failure
Decreased consciousness or increased agitation
Massive aspiration
Persistent inability to remove respiratory secretions Hypotension
Persistent hypoxemia despite optimal respiratory treatment
Hemodynamic instability