acute exacerbation of COPD Flashcards
diagnosis of exacerbation ?
ABG
CXR to exclude pneumothorax and infection.
FBC; U&E; CRP. Theophylline level if patient on therapy at home.
ECG.
Send sputum for culture if purulent
what is the management of COPD exacerbation?
Look for a cause, eg infection, pneumothorax.
Invasive ventilation for exacerbations of COPD may not be appropriate: it can be difficult to wean patients off ventilatory support, and brings with it the risk of ventilator-asso- ciated pneumonias and pneumothoraces from ruptured bullae
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1) Nebulized bronchodilators
Salbutamol 5mg/4h and ipratropium 500mcg/6h
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2) Ensure oxygenation then treat the reversible
The greatest danger is hypoxia, which probably accounts for more deaths than hypercapnia. Don’t leave patients severely hypoxic.
However, in some patients, who rely on their hypoxic drive to breathe, too much oxygen may lead to a reduced respiratory rate and hypercapnia, with a consequent fall in conscious level.
Whenever you initiate or change oxygen therapy, do consider an ABG within 1h.
Controlled oxygen therapy if SaO2 <88% or PaO2 <7 kPa:
evidence of CO2 retention. Start with 24–28% O2 in such patients
aim sats 88–92%
Monitor the patient carefully. Aim to raise the PaO2 above 8.0kPa with a rise in
PaCO2 <1.5kPa
prescribe O2 as if it were a drug.
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3) Steroids
IV hydrocortisone 200mg and oral prednisolone 30mg OD (continue for 7–14d)
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4) Antibiotics:
Use if evidence of infection, eg amoxicillin 500mg/8h PO, alternatively clarithromycin or doxycycline
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5) Physiotherapy to aid sputum expectoration
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6) If no response to nebulizers and steroids:
Consider IV aminophylline*
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7) If no response:
1 Consider non-invasive positive pressure ventilation† (NIPPV) if respiratory rate >30 or pH <7.35, or Pa CO2 rising despite best medical treatment. OR:
2 Consider a respiratory stimulant drug, eg doxapram 1.5–4mg/ min IV in patients who are not suitable for mechanical ventila- tion. SE: agitation, confusion, tachycardia, nausea. It is a short-term measure, used only if NIV is not available
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8)
Consider intubation and ventilation if pH <7.26 and Pa CO2 is rising despite non-invasive ventilation only where appropriate
