Chronic obstructive pulmonary disease exacerbation resident survival guide: Difference between revisions
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'''2. 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)</div>}} | '''2. 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)</div>}} | ||
{{Family tree |!| | |!|}} | {{Family tree |!| | |!|}} | ||
{{Family tree |border=2|boxstyle=background:WhiteSmoke;|!| | | {{Family tree |border=2|boxstyle=background:WhiteSmoke;|!| |D1|D1=<div style="float: left; text-align: left; height: 23em; width: 40em; padding: 1em">'''2a. Indications for Noninvasive Mechanical Ventilation''' <BR> ❑ Respiratory acidosis (arterial pH < 7.35 or Pa<sub>CO<sub>2</sub></sub> >45 mm Hg) <BR> ❑ Severe dyspnea with sings of respiratory muscle fatigue <BR> ❑ Increased work of breathing | ||
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'''2b. Indications for Invasive Mechanical Ventilation''' <BR> ❑ | '''2b. Indications for Invasive Mechanical Ventilation''' <BR> ❑ Diminished consciousness, psychomotor agitation inadequately controlled by sedation <BR> ❑ Severe hemodynamic instability without response to fluids and vasoactive drugs <BR> ❑ Respiratory pauses with loss of consciousness or gasping for air <BR> ❑ Life-threatening hypoxemia in patients unable to tolerate NIV <BR> ❑ Persistent inability to remove respiratory secretions <BR> ❑ Heart rate <50/min with loss of alertness <BR> ❑ Unable to tolerate NIV or NIV failure <BR> ❑ Severe ventricular arrhythmias <BR> ❑ Respiratory or cardiac arrest <BR> ❑ Massive aspiration</div>}} | ||
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'''3. Indications for Hospitalization''' <BR> ❑ Marked increase in intensity of symptoms (eg, sudden development of resting dyspnea) <BR> ❑ Presence of serious comorbidities (eg, heart failure or newly occurring arrhythmias) <BR> ❑ Failure of an exacerbation to respond to initial medical management <BR> ❑ Onset of new physical signs (eg, cyanosis, peripheral edema) <BR> ❑ Severe underlying COPD (GOLD 3—4 categories) <BR> ❑ Frequent exacerbations (≥2 events per year) <BR> ❑ Insufficient home support <BR> ❑ Older age (>65 years) | |||
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'''4. Assessment of Severity of Exacerbation''' <BR> ❑ Sputum purulence <BR> ❑ ECG (identify coexisting cardiac problems) <BR> ❑ Chest radiograph (exclude alternative diagnoses) <BR> ❑ Whole-blood count (identify polycythemia, anemia, or leukocytosis) <BR> ❑ Electrolytes and glucose (identify electrolyte disturbances or hyperglycemia)</div>}} | |||
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'''Severe Exacerbation''' <BR> ❑ Consider inpatient management <BR> ❑ Assess symptoms, ABG, and CXR <BR> ❑ Monitor fluid balance and nutrition <BR> ❑ Identify and treat associated conditions <BR> ❑ Consider subcutaneous heparin or LMWH <BR> ❑ Controlled oxygen therapy (use NIV if indicated) <BR> ❑ Antibiotics (if ↑ sputum purulence or ⊕ bacterial infection) <BR> ❑ Corticosteroids <BR> ❑ Bronchodilators <BR> ▸ Increase doses/frequency of short-acting bronchodilators <BR> ▸ Combine short-acting β2-agonists and anticholinergics <BR> ▸ Use spacers or air-driven nebulizers | |||
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'''Moderate Exacerbation''' <BR> ❑ Consider outpatient management <BR> ❑ Require a short course of antibiotics or oral corticosteroids | |||
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''' | '''Mild Exacerbation''' <BR> ❑ Consider outpatient management <BR> ❑ Require change of inhaled treatment by the patient</div>}} | ||
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Revision as of 03:31, 15 December 2013
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Abdurahman Khalil, M.D. [2]
Definition
- 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
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
Common Causes
- Respiratory tract infections (~½)
- Unknown (~⅓)
- Air pollutants
Treatment Setting and Severity
COPD Exacerbation ❑ Cough ↑ ❑ Dyspnea ↑ ❑ Sputum ↑ | |||||||||||
1. Oxygen Supplement ❑ Pulse oximetry (maintain SaO2 ≥88—92%)[5] ❑ Arterial blood gas (if acute or acute-on-chronic respiratory failure is suspected) | |||||||||||
2. 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) | |||||||||||
2a. Indications for Noninvasive Mechanical Ventilation ❑ Respiratory acidosis (arterial pH < 7.35 or PaCO2 >45 mm Hg) ❑ Severe dyspnea with sings of respiratory muscle fatigue ❑ Increased work of breathing 2b. Indications for Invasive Mechanical Ventilation ❑ Diminished consciousness, psychomotor agitation inadequately controlled by sedation ❑ Severe hemodynamic instability without response to fluids and vasoactive drugs ❑ Respiratory pauses with loss of consciousness or gasping for air ❑ Life-threatening hypoxemia in patients unable to tolerate NIV ❑ Persistent inability to remove respiratory secretions ❑ Heart rate <50/min with loss of alertness ❑ Unable to tolerate NIV or NIV failure ❑ Severe ventricular arrhythmias ❑ Respiratory or cardiac arrest ❑ Massive aspiration | |||||||||||
3. Indications for Hospitalization 4. Assessment of Severity of Exacerbation ❑ Sputum purulence ❑ ECG (identify coexisting cardiac problems) ❑ Chest radiograph (exclude alternative diagnoses) ❑ Whole-blood count (identify polycythemia, anemia, or leukocytosis) ❑ Electrolytes and glucose (identify electrolyte disturbances or hyperglycemia) | |||||||||||
Severe Exacerbation Moderate Exacerbation Mild Exacerbation ❑ Consider outpatient management ❑ Require change of inhaled treatment by the patient | |||||||||||
Management
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
- ↑ Burge, S.; Wedzicha, JA. (2003). "COPD exacerbations: definitions and classifications". Eur Respir J Suppl. 41: 46s–53s. PMID 12795331. Unknown parameter
|month=ignored (help) - ↑ 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) - ↑ 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) - ↑ 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) - ↑ Austin, MA.; Wills, KE.; Blizzard, L.; Walters, EH.; Wood-Baker, R. (2010). "Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial". BMJ. 341: c5462. PMID 20959284.