A quick overview of the diagnosis and treatment of COPD exacerbations, aimed at medicine interns and clinical students.
Hello on today’s episode of intern crash course i’m discussing copd exacerbations first up what is a copd exacerbation the definition has evolved over time the most recently adopted definition a change in the patient’s typical symptoms of copd that leads to a change in medical therapy or requires hospitalization well that feels completely circular to me so i actually
Prefer a slightly older definition an event in the natural course of the disease characterized by a change in the patient’s baseline dis nia cough and/or sputum that is beyond the normal day-to-day variations and is acute in onset and by acute that time course is more specifically over several hours to several days in addition to the symptoms there are many common
Physical findings in copd exacerbations they include tachycardia tachypnea and hypoxemia wheezing decreased breath sounds which are usually described as poor air movement the use of accessory muscles such as the sternocleidomastoid speaking in short sentences the tripod position in which the patient sits upright leaning forward with their hands or forearms resting
On their knees or bedside table and altered mental status which suggests a particularly severe gas exchange abnormality unfortunately none of these findings are specific for copd but the more which are present the more support there will be for the diagnosis watch out for the common mimics of copd exacerbations including bacterial and viral pneumonia heart failure
And pe in fact in one autopsy study that identified the most common causes of hospital death in patients who had been admitted with the cbd exacerbation all these were more common than copd itself after identifying a probable cbd exacerbation it’s also important to identify a trigger for common triggers are bacterial pneumonia respiratory viruses air pollution
And medication non-adherence we see that pneumonia shows up twice here has both a mimic and as a highlighting how tricky it can be to establish a precise diagnosis for these patients for patients with a possible copd exacerbation initial testing should include a chest x-ray and ecg and abg in most patients sick enough to warrant admission and in some patients and
Evaluation for pulmonary embolism these tests are to help identify those triggers and mimics in whom should you consider a pe evaluation i consider it in any patient who has either features that are atypical for a cvd exacerbation including a highly abrupt onset increased dyspnea as the sole symptom pleuritic chest pain or a decreased paco2 compared to baseline active
Malignancy or a history of venous thromboembolism so now i’ll move on to discuss these specific treatments bronchodilators steroids antibiotics oxygen and bipap and i’ll start with bronchodilators everyone diagnosed with the copd exacerbation should get them most patients should receive both albuterol and petropia the uncommon exceptions are related to the facts that
Albuterol is relatively contraindicated in patients with unstable tachy arrhythmias and petropia m– is relatively contraindicated in patients prone to urinary retention the effectiveness of metered dose inhalers and nebulizers are essentially the same but only if patients are able to use good technique which most older patients in respiratory distress cannot so
It’s typical to start everyone with nebulizers but once a patient has improved it is usually okay to switch them over to an inhaler although leva buner all marketed in the us as open x is often used instead of albuterol in patients prone to tachyarrhythmias there is insufficient evidence to conclude whether or not this is helpful and the short-term concurrent use
Of tiotropium and petropia is probably safe but some hospital pharmacies do not allow it when it comes to almost everyone’s sick enough to come to the idi or to be admitted should get systemic steroids only critically ill patients however should receive iv / oral the optimal dose and duration of steroids is unknown but a general consensus is that anything within
Prednisone 30 to 60 milligrams daily for 5 to 14 days either with without a taper is defensible personally i would only rarely advocate for beyond 10 days and would only rarely advocate for a taper regarding antibiotics most patients sick enough to warrant admission should also receive antibiotics irrespective of the presence of overt infection the specific choice
Depends upon likely pathogens severity of exacerbation risk factors report outcome risk factors for pseudomonas colonization and local resistance patterns a five-day course is probably just as good as a longer course and with fewer side-effects the duration in patients with concurrent clinical pneumonia should be dictated by that latter diagnosis with oxygen only
Provided to achieve a peripheral oh to sot of 88 to 92 percent targeting higher sats risks worsening hypercapnia consider bipap in patients with an acute respiratory acidosis or who subjectively appear in respiratory distress finally what are the considerations prior to discharge anyone still smoking obviously needed smoking cessation counseling ensure that the
Patient is up to date with their pneumococcal and influenza vaccinations evaluate whether the patient would benefit from home oxygen and if your patient qualifies for homo 2 and is still smoking please discuss the very real risks from that combination consider whether the patient would benefit from pulmonary rehab and last consider whether the patient would be
Appropriate for a palliative care consult keep in mind that palliative care does not necessarily equal hospice a palliative care specialist can help prepare a patient and their family for the gradual terminal decline in respiratory function and the frequent hospitalizations that many patients with advanced copd unfortunately experience you
Transcribed from video
COPD Exacerbations By Strong Medicine
