by Ramin Tabatabai, David Hoffman, and Tiffany Abramson
A 68-year-old male presents to the emergency department (ED) with audible wheezing, and he is in severe respiratory distress. He is speaking in 2-3 word sentences, and he is diaphoretic and slightly confused. Per the paramedic report, the patient is a two pack per day smoker. On physical examination, the patient demonstrates poor air movement, and you note that he has a “barrel chest.” As you pick up the phone to call the respiratory therapist for airway management, you wonder, “What other interventions should I initiate and are there other diagnoses I should be considering?”
General Approach and Critical Bedside Actions
Although COPD patients may frequently visit ED, some of these presentations may require critical interventions such as intubation. Therefore, the ABC sequence should be followed in all these cases to understand an immediate life-threatening situation.
The most patients require Oxygen therapy to keep pulse oximetry 88-92%. Establishment of intravenous (IV) line and fluid replacement may be necessary for severe attacks. Cardiac monitor and electrocardiogram (ECG) to assess cardiac ischemia or arrhythmia is mandatory for every case. While these activities are going on simultaneously, the emergency physicians’ primary role is to rule out other life-threatening causes of dyspnea. Inhaled beta-agonist bronchodilator (e.g., Albuterol), Inhaled anticholinergic bronchodilator (e.g., Ipratropium), and oral glucocorticoid therapy (IV steroids only if unable to tolerate PO) are the mainstay of the treatment in the majority of the patients. BiPAP therapy for moderate to severe exacerbations should be kept in mind. Antibiotic therapy should be started for any acute exacerbation requiring admission or discharged patients with increased sputum purulence.
During the initial evaluation and ongoing bedside treatments, emergency physician lists causes of this attack in his/her mind. Two major challenges exist in evaluating the patient with suspected COPD. First, the differential diagnosis for dyspnea is broad and distinguishing COPD from alternative causes can be difficult. Second, patients with COPD may harbor concomitant cardiopulmonary disease.
COPD should be considered in anyone with risk factors and dyspnea, chronic cough or sputum production. Major risk factors include smoking and environmental exposures. Pathological changes that occur in the lung causes air trapping and progressive airflow limitation. COPD is, therefore, a chronic, progressive disease, usually with an indolent course of gradual decline in airflow and physical activity level secondary to dyspnea.
The etiologies of acute exacerbation can be classified into four different groups (infectious, pollution, destabilizers, idiopathic). Although approximately 70% of exacerbations are due to infection (Viral or Bacterial), it is important to consider other potential triggers or etiologies such as Pneumothorax, Pulmonary Embolism (PE), Congestive Heart Failure (CHF), Pneumonia, Pericardial Effusion, Lobar Atelectasis, Anaphylaxis, Airway Obstruction, and Trauma.
Acute exacerbation of COPD is often confused with pulmonary edema secondary to CHF. Cardiac “wheeze” is easily mistaken for the wheeze classically heard in acute COPD exacerbation. Further complicating matters, these diagnoses are not mutually exclusive and can often present together in a mixed picture. A thorough evaluation of clinical evidence of CHF is therefore critical in the evaluation of the wheezing acute COPD exacerbation patient.
Additional diagnoses should be considered when an acute COPD exacerbation is more severe than previous or if the patient deteriorates rapidly. One such disease is PE, which can occur in COPD patients due to sedentary lifestyles, increased venous stasis, and increased blood viscosity. Pneumothorax is another critical consideration as COPD patients. As a traditional knowledge, COPD patients have increased risk for ruptured bullae. Other lethal causes of exacerbation and dyspnea are not limited to but include pneumonia and lobar atelectasis secondary to bronchial plugging.
History and Physical Examination Hints
In the ED, providers are predominately concerned with acute COPD exacerbation. An exacerbation is defined as an acute event that leads to a worsening of the patient’s respiratory symptoms, beyond normal day-to-day variation and leads to a change in medication.
The physician’s first action in the evaluation of a dyspneic patient with suspected acute COPD exacerbation is airway, breathing and circulation, and assessment of vital sign abnormalities. These are used to determine whether the patient will require immediate intervention. Any of the following signs on initial visual inspection indicate severe acute COPD exacerbation: “tripoding,” inability to speak in full sentences, confusion, agitation, use of accessory respiratory muscles, paradoxical chest wall movements, worsening or new onset central cyanosis, development of peripheral edema, or hemodynamic instability.
A thorough examination will involve cardiopulmonary evaluation to assess for the presence of wheeze and auscultation to estimate the degree of tidal volume that occurs with each ventilation. Markedly decreased air movement indicates severe disease. Other findings in chronic COPD may include a thin, barrel-chested appearance or plethoric, cyanotic appearance.
One important sequela of COPD is cor pulmonale. Long-standing increased pulmonary pressures can lead to right-heart strain and eventual right heart failure. Patients can therefore present with acute COPD exacerbation along with CHF findings of jugular venous distention and peripheral edema.
Finally, a thorough history should be obtained by evaluating risk factors, previous exacerbations, the frequency of exacerbations, and prior intubations. While there are many predictors of a COPD exacerbation, the best is a history of prior exacerbations.
Emergency Diagnostic Tests and Interpretation
Every patient in respiratory distress should be placed on continuous pulse-oximetry and cardiac monitoring.
An electrocardiogram is useful in identifying classic patterns (cor pulmonale and dysrhythmias) associated with COPD as well as evaluating for ischemia.
The chest radiograph (CXR) should be ordered to evaluate the presence of other treatable diagnoses. CXR findings in COPD may include a small cardiac silhouette, hyperinflated lung fields, or bullae. Alternative findings may consist of an enlarged heart, effusion or parenchymal consolidation.
What is your diagnosis in the given Chest X-ray of a dyspneic patient?
Ultrasound should be used when available for the rapid information it provides. A cardiac and lung ultrasound can help both establish and rule out diagnoses by evaluating for pericardial effusion, cardiac squeeze, B-lines, and lung sliding.
The following US video shows A (normal) and B-lines in the lung.
It is important to note that while spirometry is essential to the formal diagnosis of COPD in the outpatient setting, there is no role for its use in the emergency room.
Blood tests have little utility because their results do not change treatment or disposition. The argument can be made for the measurement of brain natriuretic peptide (BNP), which reflects the stretching of myocardial tissue and can, therefore, indicate decompensated heart failure.
Emergency Treatment Options
Bedside Critical Actions and Stabilization
The emergency physician must first decide whether the patient requires respiratory assistance. Oxygenation and ventilatory support are mainstay therapies. Patients with hypoxemia need supplemental oxygen with a targeted oxygen saturation goal of 88-92%. This target has been set because high flow oxygen has been associated with carbon dioxide retention, hypercapnia, respiratory acidosis and respiratory failure. Oxygen delivery is dependent on the severity of the patient’s respiratory status and mentation, ranging from the nasal cannula to mechanical ventilation. Noninvasive positive pressure ventilation via BiPAP is an effective treatment for patients in moderate to severe respiratory distress. It decreases treatment failure, reduces complications, shortens hospitalizations, and improves mortality rate. Specifically, a Cochrane review in 2004, demonstrated the use of BiPAP led to decreased mortality (number need to treat, NNT=10), reduction in treatment failure (NNT=5) and decreased need for intubation (NNT=4). Patients with BiPAP failure, however, require intubation and mechanical ventilation. Once intubated, ventilator management and strategy should focus on a prolonged Inspiration and Expiration ratio and low respiratory rate with small tidal volume.
For patients with a high suspicion for acute COPD exacerbation, empiric treatment with beta-agonist bronchodilators (e.g., albuterol) and anticholinergics (e.g., ipratropium) is generally safe and is considered 1st line therapy. Efficacy between MDI and nebulizer is equivalent, however moderate to severe patients may be unable to use MDI. Nebulized dosing for albuterol should be 2.5 to 5mg and 0.5mg for ipratropium. Combination of both medications is synergistic and relatively safe; however, caution is advised in patients with cardiac disease.
Corticosteroids are the other first-line treatment in acute COPD exacerbation. Studies have demonstrated shorter recovery time, length of stay in the hospital and an NNT=10 to avoid treatment failure. Oral and IV glucocorticoids have similar efficacy, with a recommended dose of prednisone 40 mg PO and methylprednisolone 1-2mg/kg IV. A 5-day course is sufficient and preferable to the side effects caused by longer regimens.
Antibiotic administration is controversial. To simplify this debate, antibiotics for patients with both increased sputum purulence and dyspnea or those requiring hospitalization are recommended. The antibiotic choice should be selected based on the suspected pathogen and whether the patient has risk factors for Pseudomonas. First line outpatient antibiotic choices include doxycycline, a beta-lactam, and sulfamethoxazole-trimethoprim (for 5-7 days) and for hospitalized patients contains fluoroquinolones (e.g., levofloxacin) or a beta-lactam with pseudomonas coverage (e.g., cefepime).
Pediatric, Geriatric, Pregnant Patient and Other Considerations
COPD is a chronic disease with a peak incidence in the 5th to 6th decade of life. It has been linked to many comorbid conditions making the geriatric population high–risk. Additionally, studies have demonstrated that morbidity in COPD increases with age. Providers, should, therefore, demonstrate greater caution with geriatric patients and have a lower threshold to admit.
COPD is not a well-defined disease in the pediatric population and is extremely rare in pregnant patients. Even children with α1-antitrypsin deficiency do not develop symptoms until 20-50 years of age. Interestingly, however, the diagnosis of “asthma” in childhood, has been associated with a 10-fold risk for COPD in the future and there is mounting evidence that genetics has a considerable role to play in the development of the disease.
Criteria for hospitalization include an exacerbation failing to improve back to baseline. The GOLD collaborators have outlined the criteria for admission and discharge and further delineated criteria for ICU admission versus ward (Table). Criteria for ICU admission revolve around respiratory failure and altered mental status.
COPD Admission and Discharge Criteria (GOLD)
|Failure to respond to initial medical management|
|A marked increase in the intensity of symptoms|
|Severe underlying COPD, severe comorbidities or old age|
|Insufficient home resources|
|Persistent or worsening hypoxia despite supplemental oxygen
|Need for invasive mechanical ventilation|
|Change in mental status|
|The frequency of medication use <4hrs|
|Dyspnea does not negatively effect sleeping, eating or basic functions|
|Able to complete ADLs and understands medications|
If a patient is discharged, instructions should include updating vaccination status, education regarding proper medication use, smoking cessation and ensuring the patient has proper follow up with appropriate referrals.
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Links To More Information
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- O2 and CO2 Retention in COPD. Updated March 2014. Available from: http://lifeinthefastlane.com/ccc/oxygen-and-co2-retention-in-copd/ Accessed Dec 10, 2015.
- ECG in COPD http://lifeinthefastlane.com/ecg-library/copd/. Updated on November 2015. Accessed Dec 10, 2015.
- COPD/Shortness of Breath. EM Basic. Updated December 2013. Available from: http://embasic.org/copdshortness-of-breath/. Accessed Dec 10, 2015.