Acute Exacerbations of COPD

Question 1

Presentation:

Answer 1

1. Increasing cough
2. Breathlessness
3. Wheeze
4. Decreased exercise capacity

Question 2

Differential diagnosis:

Answer 2

1. Asthma
2. Pulmonary oedema
3. Upper respiratory tract obstruction
4. PE
5. Anaphylaxis

Question 3

Investigations:

Answer 3

1. ABG
2. Bloods: FBC; U&E; CRP, Theophylline level if patient on therapy at home
3. Blood cultures if pyrexial
4. CXR to exclude pneumothorax & infection
5. ECG
6. Send sputum for culture if purulent

Question 4

Initial Mx of AE COPD:

Answer 4

1. Controlled O2 therapy if SaO2 <88% or Pa O2 <7 kPa - Start at 24–28%, aim sats 88–92%
2. Nebulized bronchodilators - Salbutamol 5mg/4h and ipratropium 500μg/6h
3. Investigations - CXR, ABG
4. Steroids - IV hydrocortisone 200mg and oral prednisolone 30mg OD (continue for 7–14d)
5. ABx - Use if evidence of infection, eg amoxicillin 500mg/8h PO
6. Physiotherapy to aid sputum expectoration

Question 5

If NO response to nebulizers and steroids:

Answer 5

1. Consider IV aminophylline

Question 6

If NO response to IV aminophylline:

Answer 6

1. NIPPV if - RR >30 or pH <7.35, or Pa CO2 rising despite best medical Rx
2. Intubation & ventilation if pH <7.26 & Pa CO2 is rising despite non-invasive ventilation
3. Consider a respiratory stimulant drug - doxapram 1.5–4mg/ min IV - It is a short-term measure, used only if NIV is not available