COPD

1. COPD Rada Jones MD 09/12/06

2. 7PM. Things are quiet. Dinner was great, coffee is brewing and you are all debating who’s going to win American idol when the first call comes. Then the other ones. It looks like everybody is having trouble breathing tonight.

3. The calls • 75 years old female with difficulty breathing for the last three days. • 19 years old male with difficulty breathing since this morning • 65 years old male with difficulty breathing, worse since yesterday. • 35 year old female. Difficulty breathing for 15 minutes. • 48 year old male with difficulty breathing for 1 day.

4. Dyspnea • Subjective feeling of difficult, labored or uncomfortable breathing • “Shortness of breath” • “Not getting enough air” • “Breathlessness” • “Difficulty breathing” • “Having trouble breathing”

5. MI CHF Asthma COPD exacerbation Pneumonia PE Pericarditis Myocarditis Pneumothorax Anemia Allergic reaction Anxiety Foreign body Toxic exposure Cardiac tamponade DKA Dyspnea: Differential diagnosis

6. Sorting it out • Age • HPI • PMH • Ask patient • PE • EKG

7. Age • Infants/toddlers: Infectious, asthma, FB • Children: Asthma, croup, pneumonia, DKA • Young adults: Asthma, Pneumothorax, anxiety, pneumonia, PE • Middle aged: MI, COPD, CHF, PE • Elderly: COPD, Pneumonia, CHF, MI, sepsis

8. HPI • Sudden onset: • FB • allergic rxn • PE • Pneumothorax • Trauma • Gradual onset • CHF • COPD exacerbation • Asthma • pneumonia

9. HPI • Associated symptoms • Fever : infection • Cough • Pain – esp. chest pain :cardiac vs. pulmonary • Hemoptysis: bronchitis vs. PE • Aggravating and alleviating factors • Position • Environment: Smoke, fumes, humidity • Sick contacts

10. PMH • Asthma • CHF • COPD • DM • HIV • Allergies • Medications • Home oxygen

11. PE • Physical appearance • Vitals • Lung sounds • Heart sounds • Stridor • Edema • Neck veins

12. Physical appearance • Color • Cyanotic: hypoxia vs. methemoglobinemia • Flushed: sepsis • Pale: anemia • Speaking in full sentences vs gasping for breath • Retractions, use of accessory muscles • Alert vs. obtunded • Signs of trauma

13. Vitals • Pulse ox on RA • Breathing rate • Tachypnea • Bradypnea • drugs • trauma • Heart rate • Blood pressure • Temperature

14. Listening to the heart and lungs • Not over clothing • Request silence if possible • Back, bilaterally, at least three levels • Left chest, at least two • Both axillae • Mouth open, no throat sounds • If necessary, have them cough and listen again

15. Lung sounds • Wheezing • Asthma • CHF • Crackles • CHF • Fibrosis • Pneumonia • Quiet lungs • Bilateral: Hyperinflation • One side: Pneumothorax vs consolidation • http://www.med.ucla.edu/wilkes/lungintro.htm

16. Heart sounds • Distant: hyperinflated lungs vs. tamponade • S3, S4: CHF • Rubs: pericarditis; Best heard leaning forward. • http://www.med.ucla.edu/wilkes/Rubintro.htm

17. 75 years old female with difficulty breathing for the last three days • Alert, speaking in full sentences • O2 sat 95%, RR20, HR 62 • MI 3 and 1 years ago • H/o CHF and DM • On lopressor and lasix • Crackles, leg edema • DX?

18. Most likely CHF

19. What if… • No cardiac history • Smoker • Pressure in the chest, “feeling like an elephant sitting on my chest” but no pain • Started while digging a hole to plant a tree • On/off since • DX?

20. Consider MI, check EKG

21. 19 years old male with difficulty breathing since this morning • Pale, sitting up • Alert, speaking in short sentences • O2 sat 92%, RR28 • History of asthma, intubated multiple times • Out of Albuterol since 3 days ago • DX?

22. Most likely asthma exacerbation

23. What if… • No asthma history • Got very drunk last night and got into a fight, then fell asleep • Has sharp L sided chest pain with breathing • Dry blood on face • Diminished breath sounds on L • DX?

24. Consider pneumothorax, check neck veins

25. 65 years old male with difficulty breathing, worse since yesterday • Slightly purple • Sitting up, breathing through pursed lips • Short sentences • Coughs a lot, green sputum • Smoker for 40 years • History of emphysema • Dx?

26. Most likely COPD exacerbation

27. What if… • History of MI 5 years ago • CABG x 3 • On lasix, but ran out a week ago • Edema to knees • Celebrated his birthday yesterday; Had barbecue and chips, pickles and a few beers. • Dx?

28. Possibly CHF

29. 35 year old female. Difficulty breathing for 15 minutes. • O2 sat 92%, RR 32, HR 140 • Gray, gasping for breath • 4 months pregnant • No other history • DX?

30. Think PE

31. What if… • O2 sat 100%, RR26, HR100 • Fainted ten minutes ago • Had orthopedic surgery a week ago • Or: Just drove over from California • Smokes

32. Still think PE

33. What if… • Vitals normal, except RR32 • Looks well • Smokes • Is on OCPs • Has a flutter in the chest and feels dizzy • Had a fight with boyfriend half an hour ago • Has history of panic attacks • DX?

34. Could be anxiety, but don’t forget PE

35. 48 year old male with difficulty breathing for 1 day. • Flushed, sleepy, hard to arouse • O2 sat 91%, RR22 • Feels febrile, lips dry, very thin • Cracles throughout • H/o HIV • DX?

36. Think pneumonia, sepsis

37. What if… • Found on the sidewalk • Disheveled, pale, hard to arouse • O2 sat 90%, RR 6 • Pinpoint pupils • Dx?

38. Possible OD

39. Management - ABC • Airway: Protect if necessary. • Breathing • The single most important treatment: Supplementary O2 for O2 sat > 90. Works immediately. • Sitting up often helps breathing • Nebulizer treatment for asthma, COPD; • Bag if necessary • Decompress tension pneumothorax • Circulation

40. Therapy onset time • Oxygen: 1min • Albuterol: 15 to 30 min • Atrovent: 15 to 30 min • Lasix: 30 min to 1 hr • Steroids: 4 to 6 hrs

42. COPD • Airflow obstruction due to chronic bronchitis or emphysema • Rare before 40 • 90% smokers • Mortality for average COPD exacerbation hospitalization: 5 to 14% • Decompensation due to URI, bronchospasm, noncompliance, others

43. Signs/Symptoms • Dyspnea and orthopnea • Progressive hypoxemia • Tachypnea, tachycardia • Cyanosis • Increased BP • Apprehension • Tripod position, pursed lip exhalation, diaphoresis • Eventually hypercapnia, confusion, obtundation

44. Airway Breathing O2 to sat > 90% Nebulized albuterol q20min Nebulized atrovent 1 dose with albuterol Solumedrol typical dose 125mgIV (Methylxanthines, antibiotics) Assisted ventilation if needed Circulation COPD Exacerbation Management