Download COPD - Adirondack Area Network

COPD
Rada Jones MD
09/12/06
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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.
The calls
1.
2.
3.
4.
5.
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.
Dyspnea
Subjective feeling of difficult, labored or
uncomfortable breathing
 “Shortness of breath”
 “Not getting enough air”
 “Breathlessness”
 “Difficulty breathing”
 “Having trouble breathing”
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Dyspnea: Differential diagnosis
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MI
CHF
Asthma
COPD exacerbation
Pneumonia
PE
Pericarditis
Myocarditis
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Pneumothorax
Anemia
Allergic reaction
Anxiety
Foreign body
Toxic exposure
Cardiac tamponade
DKA
Sorting it out
Age
 HPI
 PMH
 Ask patient
 PE
 EKG
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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
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HPI
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Sudden onset:
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FB
allergic rxn
PE
Pneumothorax
Trauma
Gradual onset
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CHF
COPD exacerbation
Asthma
pneumonia
HPI
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Associated symptoms
Fever : infection
 Cough
 Pain – esp. chest pain :cardiac vs. pulmonary
 Hemoptysis: bronchitis vs. PE
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Aggravating and alleviating factors
Position
 Environment: Smoke, fumes, humidity
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Sick contacts
PMH
Asthma
 CHF
 COPD
 DM
 HIV
 Allergies
 Medications
 Home oxygen
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PE
Physical appearance
 Vitals
 Lung sounds
 Heart sounds
 Stridor
 Edema
 Neck veins
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Physical appearance
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Color
Cyanotic: hypoxia vs. methemoglobinemia
 Flushed: sepsis
 Pale: anemia
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Speaking in full sentences vs gasping for
breath
 Retractions, use of accessory muscles
 Alert vs. obtunded
 Signs of trauma
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Vitals
Pulse ox on RA
 Breathing rate
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Tachypnea
 Bradypnea
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 drugs
 trauma
Heart rate
 Blood pressure
 Temperature
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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
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Lung sounds
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Wheezing
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Crackles
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CHF
Fibrosis
Pneumonia
Quiet lungs
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Asthma
CHF
Bilateral: Hyperinflation
One side: Pneumothorax vs consolidation
http://www.med.ucla.edu/wilkes/lungintro.htm
Heart sounds
Distant: hyperinflated lungs vs. tamponade
 S3, S4: CHF
 Rubs: pericarditis; Best heard leaning
forward.
 http://www.med.ucla.edu/wilkes/Rubintro.h
tm
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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?
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Most likely CHF
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?
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Consider MI, check EKG
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?
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Most likely asthma exacerbation
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?
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Consider pneumothorax, check neck veins
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?
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Most likely COPD exacerbation
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?
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Possibly CHF
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?
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Think PE
What if…
O2 sat 100%, RR26, HR100
 Fainted ten minutes ago
 Had orthopedic surgery a week ago
 Or: Just drove over from California
 Smokes
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Still think PE
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?
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Could be anxiety, but don’t forget PE
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?
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Think pneumonia, sepsis
What if…
Found on the sidewalk
 Disheveled, pale, hard to arouse
 O2 sat 90%, RR 6
 Pinpoint pupils
 Dx?
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Possible OD
Management - ABC
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Airway: Protect if necessary.
Breathing
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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
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
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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
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Signs/Symptoms
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Dyspnea and orthopnea
Progressive hypoxemia
Tachypnea, tachycardia
Cyanosis
Increased BP
Apprehension
Tripod position, pursed lip exhalation,
diaphoresis
Eventually hypercapnia, confusion, obtundation
COPD Exacerbation Management
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
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Circulation