Chronic obstructive pulmonary disease exacerbation resident survival guide: Difference between revisions

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{{Family tree |border=2|boxstyle=background:WhiteSmoke;|)|B1|B1=<div style="float: center; text-align: left; height: 13em; width: 41em; padding: 1em">'''Indications for Hospital Assessment or Admission''' <BR> ❑ Marked increase in intensity of symptoms (eg, sudden development of resting dyspnea) <BR> ❑ Severe underlying COPD <BR> ❑ Onset of new physical signs (eg, cyanosis, peripheral edema) <BR> ❑ Failure of an exacerbation to respond to initial medical management <BR> ❑ Presence of serious comorbidities (e.g., heart failure or newly occurring arrhythmias) <BR> ❑ Frequent exacerbations <BR> ❑ Older age <BR> ❑ Insufficient home support</div>}}
'''Oxygen Supplement''' <BR> ❑ Pulse oximetry (maintain Sa<sub>O<sub>2</sub></sub> ≥88—92%) <BR> ❑ Arterial blood gas (if acute or acute-on-chronic respiratory failure is suspected)<sup>†</sup>


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{{Family tree |border=2|boxstyle=background:WhiteSmoke;|)|C1|C1=<div style="float: left; text-align: left; height: 13em; width: 36em; padding: 1em">'''Assessment of Exacerbation''' <BR> ❑ Pulse oximetry (for tracking and/or adjusting supplemental oxygen) <BR> ❑ Arterial blood gases (if acute or acute-on-chronic resp. failure is suspected)'''†''' <BR> ❑ Acid-base status (before initiating mechanical ventilation) <BR> ❑ Chest radiographs (to exclude alternative Dx) <BR> ❑ ECG (Dx of coexisting cardiac problems) <BR> ❑ Whole-blood count (to identify polycythemia, anemia, or leukocytosis) <BR> ❑ Empirical ABx (if ⊕ purulent sputum) <BR> ❑ Biochemical tests (electrolyte disturbances, hyperglycemia, etc.)</div>}}
'''Indications for ICU Admission'''<BR>❑ Hemodynamic instability <BR> ❑ Changes in mental status (confusion, lethargy, coma) <BR> ❑ Severe dyspnea that responds inadequately to initial emergency therapy <BR> ❑ Worsening hypoxemia (Pa<sub>O<sub>2</sub></sub> <40 mm Hg) and/or respiratory acidosis (pH <7.25)
 
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'''Indications for Hospitalization''' <BR> ❑ Marked increase in intensity of symptoms (eg, sudden development of resting dyspnea) <BR> ❑ Severe underlying COPD (GOLD 3—4 categories) <BR> ❑ Onset of new physical signs (eg, cyanosis, peripheral edema) <BR> ❑ Failure of an exacerbation to respond to initial medical management <BR> ❑ Presence of serious comorbidities (eg, heart failure or newly occurring arrhythmias) <BR> ❑ Frequent exacerbations (≥2 events per year) <BR> ❑ Older age (>65 years) <BR> ❑ Insufficient home support
 
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'''Assessment of Severity of Exacerbation''' <BR> ❑ Chest radiograph (exclude alternative diagnoses) <BR> ❑ ECG (check coexisting cardiac problems) <BR> ❑ Whole-blood count (identify polycythemia, anemia, or leukocytosis) <BR> ❑ Electrolytes and glucose (identify electrolyte disturbances or hyperglycemia)
 
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'''†''' <small>''Pa<sub>O<sub>2</sub></sub> <60 mmHg with or without Pa<sub>CO<sub>2</sub></sub> >50 mmHg in ambient air''</small>
 
 
 
 
 
 
 
 
'''†''' <small>''Pa<sub>O<sub>2</sub></sub> <60 mm Hg with or without Pa<sub>CO<sub>2</sub></sub> >50 mm Hg in ambient air''</small>


==Do's==
==Do's==

Revision as of 17:13, 11 December 2013

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Abdurahman Khalil, M.D. [2]

Definition

  • An exacerbation of COPD is an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication.[1][2][3]
  • The diagnosis of an exacerbation relies exclusively on the clinical presentation of the patient complaining of an acute change of symptoms (baseline dyspnea, cough, and/or sputum production) that is beyond normal day-to-day variation.[4]

Causes

Life Threatening Causes

Include conditions which may result death or permanent disability within 24 hours if left untreated, and some of them may mimic and/or aggravate exacerbations:

Common Causes

Differential Diagnosis

Management

COPD Exacerbation
❑ Cough ↑
❑ Dyspnea ↑
❑ Sputum ↑
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Oxygen Supplement
❑ Pulse oximetry (maintain SaO2 ≥88—92%)
❑ Arterial blood gas (if acute or acute-on-chronic respiratory failure is suspected)†

Indications for ICU Admission
❑ Hemodynamic instability
❑ Changes in mental status (confusion, lethargy, coma)
❑ Severe dyspnea that responds inadequately to initial emergency therapy
❑ Worsening hypoxemia (PaO2 <40 mm Hg) and/or respiratory acidosis (pH <7.25)

Indications for Hospitalization
❑ Marked increase in intensity of symptoms (eg, sudden development of resting dyspnea)
❑ Severe underlying COPD (GOLD 3—4 categories)
❑ Onset of new physical signs (eg, cyanosis, peripheral edema)
❑ Failure of an exacerbation to respond to initial medical management
❑ Presence of serious comorbidities (eg, heart failure or newly occurring arrhythmias)
❑ Frequent exacerbations (≥2 events per year)
❑ Older age (>65 years)
❑ Insufficient home support

Assessment of Severity of Exacerbation
❑ Chest radiograph (exclude alternative diagnoses)
❑ ECG (check coexisting cardiac problems)
❑ Whole-blood count (identify polycythemia, anemia, or leukocytosis)
❑ Electrolytes and glucose (identify electrolyte disturbances or hyperglycemia)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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† PaO2 <60 mm Hg with or without PaCO2 >50 mm Hg in ambient air

Do's

  • Monitor fluid balance,nutrition and patient condition closely.
  • Consider subcutaneous heparin or low molecular weight heparin.
  • Treat associated conditions if exist(e.g., heart failure,arrhythmias).

Don'ts

  • Spirometry is not recommended during an exacerbation because it can be difficult to perform and measurements are not accurate enough.

References

  1. ↑ Burge, S.; Wedzicha, JA. (2003). "COPD exacerbations: definitions and classifications". Eur Respir J Suppl. 41: 46s–53s. PMID 12795331. Unknown parameter |month= ignored (help)
  2. ↑ Celli, BR.; Barnes, PJ. (2007). "Exacerbations of chronic obstructive pulmonary disease". Eur Respir J. 29 (6): 1224–38. doi:10.1183/09031936.00109906. PMID 17540785. Unknown parameter |month= ignored (help)
  3. ↑ Rodriguez-Roisin, R. (2000). "Toward a consensus definition for COPD exacerbations". Chest. 117 (5 Suppl 2): 398S–401S. PMID 10843984. Unknown parameter |month= ignored (help)
  4. ↑ Vestbo, J.; Hurd, SS.; Agustí, AG.; Jones, PW.; Vogelmeier, C.; Anzueto, A.; Barnes, PJ.; Fabbri, LM.; Martinez, FJ. (2013). "Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary". Am J Respir Crit Care Med. 187 (4): 347–65. doi:10.1164/rccm.201204-0596PP. PMID 22878278. Unknown parameter |month= ignored (help)
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