COPD“Trying to Expire

Not Expire”

Dr Esyld WatsonHST Emergency Medicine

Overview Background Definitions Case Pre-hospital ED initial management ED continued management Evidence Cardiac arrest

Background 3 million people UK Most diagnosed late 50s Predominantly caused by smoking Airflow obstruction not fully

reversible No simple diagnostic test

Definition No recognised definition Consider

– Over 35 AND– Smoker or ex-smoker AND– Any

Exertional SOB Chronic cough Regular sputum Frequent winter “wheeze”

– And do not have asthma

Case 999 call SOB 65 year old female known COPD Increasing SOB and cough 2/7 Can’t speak in sentences

Case – Prehospital Assessment A

– Talking one or two words at time B

– RR 30, Sp02 77% OA, wheeze throughout C

– HR 110 irreg, BP 187/98 D

– GCS 14/15 (E3,V5,M6), BM 10.9 E

– Nil of note

Case – Prehospital Management

A– Sit upright– High flow oxygen

B– Position, forced expiration– Nebulised salbutamol 5mg– Ipratropium 500mcg– Hydrocortisone 100-200mg IV

Case – Prehospital Management

C– IV access– IV fluids– ECG monitoring

D– Monitor

E

Where to Manage?Treat at home? Treat in hospital?

Able to cope at home? Yes No

SOB Mild Severe

General condition Good Poor/deteriorating

Level of activity Good Poor/confined bed

Cyanosis No Yes

Worsening peripheral oedema

No Yes

Level of consciousness Normal Impaired

Already on LTOT No Yes

Social circumstances Good Living alone/not coping

Acute confusion No Yes

Rapid rate of onset No Yes

Significant co-morbidity

No Yes

Sa02 < 90% No Yes

Changes on CXR No Present

Arterial pH level ≥ 7.35 < 7.35

Arterial Pa02 ≥ 7 kPa < 7kPa

Case – Arrival into ED A

– No longer talking B

– RR 36, Sp02 99% 15L– Poor AE little wheeze– Clinically no pneumothorax

Case – Arrival in ED C

– HR 136 irreg, BP 178/98– Large volume radial pulse– Clammy

D– GCS 11/15 (E2V4M5), BM 10.1– T 38.1

Case – Management in ED A

– Position– Consider NP airways - suction

B– Sit upright– CXR– ABG

Case – Management in ED C

– ECG shows AF– Bloods and cultures taken as pyrexial

D– Monitor

E

Arterial Blood Gases pH 7.15 pC02 14.5 P02 12.1 HCO3- 33 BE 4 Lactate 3.7

ABG Interpretation Are they hypoxic? Are they acidotic or alkalotic? Is it respiratory or circulatory? Base and Bicarbonate?

Arterial Blood Gases pH 7.15 pC02 14.5 P02 12.1 HCO3- 33 BE 4 Lactate 3.7

Specific Therapies Nebulised bronchodilators Steroids Antibiotics Magnesium NIV

Bronchodilators Salbutamol

– Short acting beta2 agonist– Smooth muscle relaxant– Reversal of bronchospasm– Remember partial effects in COPD

Ipratropium– Antimuscarinic bronchodilator

Corticosteroids Prednisolone

– 30mg od 7-14 days Hydrocortisone

– 100 – 200 mg IV

Antibiotics Purulent sputum Signs pneumonia PO doxycycline

Magnesium

Non-Invasive Ventilation Hypercapnic ventilatory failure Clear ceilings care

Questions

Summary Keep it simple ABCDE Reassess Hypoxia kills first!