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COPD Emergency Department Junior Medical Staff Teaching August 2015 Chronic Obstructive Pulmonary Disease • • • • Definition Causes Pathophysiology Management of stable COPD • • • • • • Acute exacerbation COPD Causes Assessment of AE COPD Differential diagnosis Management of AE COPD Prognosis • What’s topical for COPD? COPD Definition • Airflow obstruction (FEV1/FVC < 0.7) which is not fully reversible • No marked change over several months • Usually progressive To make diagnosis: History, examination, investigations (No single diagnostic test) Causes Smoking (and passive smoking) Others: Occupational/Environmental Genetic Exposures (including Alpha-1-AT deficiency) Pathophysiology Management of Stable COPD • Pharmacological (inhaled bronchodilators and oral drugs eg theophylline, tiopropium, prophylactic antibiotics) • Long Term Oxygen Therapy • Pulmonary Rehab/Physiotherapy • Treat associated problems (depression, pulmonary hypertension, nutrition, etc) • Patient education • Home NIV • Surgery (bullectomy, lung volume reduction, lung transplantation) Acute Exacerbation of COPD British Thoracic Society/NICE guideline CG101 Frequency of acute exacerbations increase as severity of underlying COPD increases Causes of AE COPD • Infective – Bacterial • • • • Strep pneumoniae H. influenzae Moraxella catarrhalis (Staph aureus, Pseudomonas aeruginosa) – Viral • Rhinovirus, parainfluenza, influenza, RSV, coronavirus, adenovirus) • Pollutants nitrogen dioxide, particulates, sulfur dioxide, ozone Assessment of acute exacerbation of COPD: Symptoms Signs Investigations Symptoms • • • • • Worsening breathlessness Cough Increased sputum production Change in sputum colour Marked reduction in activities of daily living Patient may present with acute exacerbation of undiagnosed COPD Consider in patients aged over 35 with a risk factor (usually smoking) Estimated 3 million people in UK have COPD and 2 million of these undiagnosed British Thoracic Society (COPD Guideline) Signs Pursed lip breathing Use of accessory muscles at rest Acute confusion Peripheral oedema NICE CG 101 Sputum to microbiology (If purulent) • • • • FBC u&e (theophylline level – if on methylxanthine) (blood culture – if pyrexial) ECG – sinus tachycardia, arrhythmia, right ventricular hypertrophy, ischaemia Management: Oxygen • Oxygen to achieve a target SpO2, 88-92% for acutely ill patients at risk of hypercapnic respiratory failure – ringed on chart (method of delivery and concentration prescribed on chart) • Use pulse oximetry and ABG to guide therapy British Thoracic Society: Emergency oxygen use in adult patients guideline, October 2008 Management: other drugs • Nebulised short acting bronchodilators • Salbutamol (2.5mg or 5mg) • Ipratropium (500mcg) Air driven if CO2 increased or pH decreased Supplemental oxygen via nasal canula if required • Corticosteroids (to all unless contraindicated) • Antibiotics if increased volume/more purulent sputum, consolidation on CXR, clinical signs of pneumonia, pyrexia NHS Grampian: Infection Management Guidelines: Empirical antibiotic therapy, October 2014: Severe infective exacerbation of COPD: Cotrimoxazole 960mg IV 12hourly Second line – Clarithromycin 500mg IV 12hourly Management: other drugs • Theophylline IV only if inadequate response to nebulised bronchodilators • Doxapram (respiratory stimulant) only when NIV unavailable or inappropriate Management: other treatments • Respiratory physiotherapy including use of positive expiratory pressure masks to help to clear sputum Non-Invasive Ventilation (NIV) “NIV should be used as treatment of choice for persistent hypercapnic ventilatory failure during exacerbations despite optimal medical therapy” Respiratory failure Type 1 paO2<8kPa paCO2 reduced or normal Type 2/hypercapnic (hypoventilation) paO2 < 8kPa paCO2 > 6.1kPa On the wall in ED resus: Before starting NIV • Clearly documented treatment plan to include how to deal with failure of NIV • Ceiling of treatment • Whether escalation to intubation and mechanical ventilation will be appropriate • Decision should include patient and carers if possible Assess level of care needed: • Home – Hospital-at-Home – Assisted discharge schemes • Admission – level of care (palliative to ICU) Age or FEV1 should not be used in isolation to assess suitability: Functional status BMI Oxygen requirement when stable Co-morbidities Patient’s wishes General condition poor/deteriorating Social circumstances….. Prognosis AE COPD admissions, after 3 months: 34% re-admitted 14% dead What’s topical? • COPD Care Bundle Research Project 2015-2016 University of Bristol and British Thoracic Society Evaluating impact of admission and discharge care bundles for patients admitted with COPD on various outcomes. Admission care bundle: What’s topical? Admission care bundle: Pilot study (November 2012 to December 2013): using admission care bundle did not significantly change length of admission or mortality What’s topical? • Hospital-at-Home Run by community respiratory teams in some areas Questions? Summary: Chronic Obstructive Pulmonary Disease • • • • Definition Causes Pathophysiology Management of stable COPD • • • • • • Acute exacerbation COPD Causes Assessment of AE COPD Differential diagnosis Management of AE COPD Prognosis • What’s topical for COPD?