CCS Interactive Case 9

Question 1

65 y/o M w/ +smoking history and COPD presents to ED w/progressively worsening SOB and wheezing, worsening cough productive of yellow sputum. Vitals are stable, one prior hospitalization for COPD exacerbation, only medication is inhaled albuterol

DDx?

Answer 1

COPD exacerbation

CHF, pneumonia, acute MI, pulmonary embolism

Question 2

Exam findings:
Moderate respiratory distress, accessory muscle use, increased AP chest diameter, decreased breath sounds, diffuse rhonchi and wheezing, prolonged expiration. No JVD or peripheral edema

Next steps?

Answer 2

Pulse ox and/or ABG to assess oxygenation and CO2 retention, PEFR, ECG, CXR, CBC, BMP

Question 3

CBC, BMP, ECG WNL. PEFR is reduced. CXR without acute infiltrates. Pulse ox/ABG reveals hypoxia.

Acute management?

Answer 3

Inhaled O2

Nebulized beta adrenergic agonist + inhaled anticholinergic

PO steroids (prednisone, methylpred), IV steroids reserved for severe exacerbation, poor response to oral steroids, inability to take oral meds

Empiric ABX if moderate/severe or signs of underlying infection (outpatient - TMP-SMX or doxycycline; inpatient - levofloxacin, moxifloxacin, ceftriaxone, or cefotaxime)

Sputum gram stain in moderate/severe cases only if empiric ABX don’t work

NIPPV if PCO2 >45 or pH <7.3

Mechanical ventilation and ICU if severe acidosis, respiratory distress, or hypoxemia despite O2

Maintain PaO2 of at least 60-70 mm Hg (or O2 sat of at least 90-94%)

Question 4

Indications for hospitalization?

Answer 4

Marked dyspnea, inability to eat or sleep due to symptoms, increasing hypoxemia, increasing hyeprcapnia, respiratory acidosis, AMS, inability to care for oneself, presence of comorbidities, failure of outpatient management

Question 5

As symptoms, pulse ox, and PEFR improve

Answer 5

Transfer from ER to ward
Convert steroids from IV to PO
Convert albuterol/ipratropium from nebulier to MDI
Assess for home O2 needs (discharge on home O2 if PaO2<55 or SaO2 <88%)

Question 6

When PEFR and symptoms have retunred to baseline

Answer 6

Pneumovax/influenza vaccine
Counseling (smoking cessation)
DC to home

Question 7

Sequence

Answer 7

Immediately: elevate head of bed, pulse oximetry, oxygen, IV access, cardiac monitor
Exam: focused (general, HEENT/Neck, chest/lung, CV, abd, extr/spine)
Order: PEFR Q1hr, CXR (PA, lateral), ABG, ECG, CBC, BMP, albuterol nebulizer continuous (all stat)
Clock: advance by 30 minutes - results - note low PEFR, O2, abnormal CXR
Order: ipratropium nebulizer, IV methylprednisolone, oral or IV ABX
Monitor: cardiac monitor, pulse ox, pEFR
Clock: advance by 4 hours, patient improves, case ends
Final orders: counseling, influenza, pneumococcal vaccines
Dx: acute exacerbation of COPD