Infective exacerbation of COPD

Question 1

A 61 year old woman with a history of chronic obstructive pulmonary disease (COPD) presents complaining of increasing shortness of breath and a cough productive of yellow phlegm. The patient uses 2L of 02 at home. you find an ill-appearing, dyspneic woman speaking in short sentences. her oxygen saturation is currently 85% on 4L of 02 by nasal cannula. How would you assess and manage her?

Answer 1

Impression
Likely an infective exacerbation of COPD given the history of COPD and current worsening of 02 sats in setting of infective sx. 70% of exacerbations are infective, mostly viral or polymicrobial in nature. ABx only have utility in severe exacerbations requiring hospitalisation.

DDX
Consider likely aetiology; viral, bacterial, COVID-19
- Respiratory: pneumonia, PE, interstitial lung disease, TB, malignancy, viral pneumonia with superimposed bacterial infection
- Cardiac: ACS, heart failure
- Other: panic attack

Question 2

IE COPD - Assessment

Answer 2

Assessment
Would take A to E approach given low sats and call for senior help.
- check notes for previous admissions, to see if C02 retainer (will affect target 02 saturations
- transfer to resus bay if HD unstable

A - patent, maintaining, suction as required, airway adjuncts as required
B - RR/SP02 monitoring. Likely target 88-92% sats given likely C02 retainer. Sputum culture likely just to grow colonial organisms that are endemic, low diagnostic utility however would perform. CXR at bedside. Supplemental 02 through NP up to 6L, then via Hudson/non-rebreather if require more. Co
0 administer SABA/SAMA via MDI + spacer or nebuliser
0 systemic glucocorticoids
0 antibiotics for infective exacerbation if severe (conjecture regarding utility, are used if severe and disposition is ICU/hospital admission)
0 consider intubation depending on response +/- PPV
C - BP/Hr monitoring. ECG. IVC access for cultures if septic, other initial bloods (VBG, FBC (erythrocytosis), UEC, LFT,CRP).
D - GCS - inform ?intubation

Question 3

IE COPD - History

Answer 3

History

• PC: cough - volume, colour, more than usual? cough, SOB - worse than usual? exercise tolerance (metres before out of breath - worse than usual? characterise timing, onset, progression of this presentation.
• associated sx: fevers, chills, night sweats, unintended weight loss
• PMHx: when diagnosis of COPD, previous hospitalisations? any time in ICU? (for GOLD severity scale/exacerbation risk)
• Medications, allergies
• SNAP - curent smoker? occupational exposures, etc

Question 4

IE COPD - Examination

Answer 4

Examination

• general appearance + vitals
• resp exam: reduced air entry, wheeze, crackles, reduced lung expansion, expanded chest
• cardiac examination: murmurs, peripheral oedema, JVP

Question 5

IE COPD - investigations

Answer 5

Investigations

• Bedside: sputum sample, urine MCS, ECG, VBG/ABG
• Bloods: cultures, FBC (WCC, erythrocytosis), CRP, EUC,
• imaging: CXR, CT chest if diagnostic uncertainty

Other
- apply GOLD severity scoring system based on

Question 6

IE COPD Management

Answer 6

Management
Acutely
- as per A to E assessment in order to stabilise patient
- dispositioning according to severity assessment (outpatient management or for inpatient/ICU treatment)

Treatment

• non-pharm with supplemental 02
• pharm: SABA +/- SAMA (ipatropium bromide) MDI vs nebulised, systemic corticosteroids +/- antibiotics (amoxicillin or doxycycline, refer to ETG for definitive/consult with ID)

Long-term

• GP follow-up
• review of treatment plan and optimise, ideally install appropriate COPD exacerbation management plan