COPD EXACERBATION Flashcards
MANAGEMENT
AIRWAY / BREATHING
02: Goal Saturation 88% -92%
BiPAP: IPAP 8-12 / EPAP 4-5
OR
Nasal cannula: up to 6 L/min can be delivered at an FiO2 of 40%.
OR
Non-rebreather: FiO2 up to 90%.
OR
High-flow nasal cannula: up to 60 L/min
Avoid aggressive BVM
Intubate if BiPAP is contraindicated
PUFFERS
Salbutamol MDI + Spacer (4-8 puffs q 20 min x 3 THEN 1-4 hrs)
AND
Ipratropium MDI + Spacer (4-8 puffs q 20 min x 3 then PRN)
Hold Home Bronchodilators
STEROIDS
Methylpredisolone 125 mg IV
OR
Dexamethasone 6-12 mg
THEN
Prednisone 40-60 mg PO daily for 5-10 days
INPATIENT ANTIBIOTICS
No Pseudomonas Risk:
Ceftriaxone 1 g IV q24h or
Cefotaxime IV q12h or
Levofloxacin 500 mg PO/IV q24h or
Moxifloxacin 400 mg PO/IV q24h
Pseudomonas Risk:
Levofloxacin 750 mg PO/IV q24h or
Cefepime 2 g IV q8h or
Piperacillin-tazobactam 4.5 g IV q8h
OUTPATIENT ANTIBIOTICS
Simple:
Amoxicillin 500 mg PO tid x 7 days
OR
Doxycycline 100 mg PO q 12 h
OR
Azithromycin 500 mg PO THEN 250 mg PO q 24 hr
Complicated:
Amoxi/Clav 875mg PO BID
OR
Ciprofloxacin 500 mg PO q 12 hr (if Pseudomonas risk)
TREAT PER LOCAL RESISTANCE PATTERNS
AGGITATION
Trial Presedex 1-1.4 mcg/kg/hr if unable to tolerate BiPAP
INVESTIGATIONS
CBC
Lytes
Extended Lytes
CXR
ECG: evaluate for ischemia, dysrhythmias, right heart strain, right ventricular hypertrophy
VBG
+/-Troponin
+/- Pro BNP
+/- D-Dimer
+/- Viral Panel
+/- Sputum Culture
REASSESSMENT
q 1 hr: RR, Sp02, work of breathing, auscultation
Trial of ambulation
DISPOSITION: ADMISSION
Inadequate response to initial ED management
Cormorbidities
> 3 exacerbations per year
DOCUMENTATION
HISTORY
Clinical Features / PP:
Increased Dyspnea
Increased Cough
Increased Sputum / Production or colour
Precipitants:
Trauma
Medication non-adherence
Beta Blocker, Opioids, or other new medication
Infection
Cold Weather or air pollution
Severity:
Frequency of exacerbation
Hospitalizations
FEV1
Previous NIPPV settings
Home 02 flow rate
Comorbidities
CRITICAL DDX / PN
Sudden Onset (PE, PTX)
Fevers and Chills (PNA)
Chest Pain / Heaviness (ACS / CHF)
REASSESSMENT
q 1 hr: RR, Sp02, work of breathing, auscultation, trial of ambulation
DISCHARGE CHECKLIST
Trial of Ambulation to assess symptoms, desaturation and exercise capacity
Review new medications and maintenance therapies.
Ask the patient to perform a “teach-back”
Supervise proper inhaler technique at the bedside.
Assess the patient’s readiness to stop smoking and educate the patient on how cessation will stop the progression of their disease.
Close outpatient follow-up (within 1 wk) after discharge is necessary and is associated with fewer exacerbation-related readmissions.
Winnepeg criteria for antibiotics
2/3 of
1. Sputum purulence
2. Sputum volume
3. Dyspnea
OR
CRP>40
BiPAP Guidelines
BiPAP: follow tidal volume & minute ventilation
Sp02 88-92%
Mental Status
Titrate the driving pressure (IPAP-EPAP) to maintain and adequate Vt and reduce work of breathing (IPAP by 3-5 cm H20).
Do not exceed IPAP of 20 cm H20
Intubation / Ventilator Guidelines
Use large diameter ETT (8-0)
Initial Ventilator Settings: Vt 6-8 mL/kg, FiO2 40%, PEEP 5, flow rate 60-80 L/min. rr 14
