prescribing in acute exacerbation of COPD

Question 1

how might someone with an acute exacerbation of COPD present

Answer 1

winter, triggered by viral or bacterial infection. increasing cough, breathlessness and wheeze and decreased exercise tolerance.

dd - asthma, pulmonary oedema, URTobstruciton, PE, anaphylaxis.

Question 2

immediate management of the acute exacerbation

Answer 2

1 - salbutamol 5mg/4h
2 - ipratropium 500microg/6h
3 - controlled oxygen. start at 24-28% (blue or white/ 2 or 4l/min) . aim for 88-92%. adjust according to ABG to get pao2 over 8 but not let paco2 rise more than 1.5
4 - hydrocortisone 200mg IV and prednisolone 30mg PO OD for 1-2weeks.

5 - antibiotics if evidence of bacterial infection e.g. amoxicillin 500mg/8h PO

6 - CXR, ABG, physio to aid mucus removal. look for the cause of the exacerbation. blood cultures if pyrexial.

Question 3

if the COPD doesn’t respond to immediate management what is the escalation?

Answer 3

1 - consider IV aminophylline

then:
1 - NIV (positive pressure) if RR or pH or paco2 get worse.
2 - consider intubation if pH under 7.26 and CO2 rising despite NIV.
3 - consider a respiratory stimulant drug if PT is not suitable for ventilation e.g. doxapram.

Question 4

define COPD

Answer 4

a common progressive respiratory disorder characterised by airway obstruction (FEV1 under 80% and FEV1/FVC under 70%) with little or no reversibility. it includes chronic bronchitis and emphysema.

chronic bronchitis is a clinical diagnosis of chronic cough and sputum production for most of 3 months of 2 successive years.

emphysema is a histological diagnosis of enlarged air spaces distal to the terminal bronchioles, with distruction of the alveolar walls.