Rosen & Barkin's 5-Minute Emergency Medicine Consult (159 page)

• CXR:
  
  • Pneumothorax
    
  • Pneumonia
    
  • CHF
    
  • Lobar collapse
    
• Chest CAT scan:
  
  • When needed to evaluate for pulmonary embolus or further characterize disease
    

• Pulse oximetry
  
• ECG
  
• Pulmonary function tests
  
• Echocardiography:
  
  • To diagnose left or right ventricular failure or strain
    

• Pneumothorax
  
• CHF
  
• Pneumonia
  
• Pulmonary embolus
  
• Upper airway obstruction
  
• Asthma
  
• Restrictive lung disease
  
• ARDS
  
• Pleural effusions
  
• Acute coronary syndrome
  
• Pericardial effusion
  
• Metabolic derangement
  

TREATMENT

Supplemental oxygenation:

• 100% via nonrebreather
  
• Do not withhold for fear of CO
  ₂
  retention.
  
• Initiate nebulized bronchodilator therapy.
  

• Oxygen therapy:
  
  • Maintain oxygen saturation >90–92%.
    
  • Patients at risk for CO
    ₂
    narcosis are those with slow respiratory rate.
    
  • Monitor closely for ventilation suppression.
    
• Noninvasive ventilation:
  
  • Treatment of choice in hypercapneic respiratory failure if ventilatory support required
    
  • May prevent intubation
    
  • May help resolve hypercarbia
    
• Intubation for airway control:
  
  • Clinical tiring
    
  • Altered mental status
    
  • Inability to comply with emergent therapy
    
  • Ineffective ventilation
    
  • CO
    ₂
    narcosis
    

• Continuous ECG and pulse oximetry monitoring
  
• Bronchodilator therapy
  
• β-Agonists:
  
  • Albuterol
    
• Anticholinergics:
  
  • Ipratropium bromide
    
• Corticosteroids:
  
  • Anti-inflammatory effects
    
  • Reduce relapses
    
  • Methylprednisolone or prednisone
    
• Antibiotics:
  
  • Fever, increased sputum production, and/or dyspnea
    
  • Macrolides also may have anti-inflammatory effects unrelated to their antibacterial role
    
• Methylxanthines
  
  • Theophylline
    
• Ventilator settings:
  
  • Allow sufficient expiratory time to minimize air trapping and subsequent barotrauma.
    
  • Permissive hypercapnia
    

• Albuterol: 2.5 mg nebulized q10–30min
  
• Azithromycin: 500 mg PO/IV once, then 250 mg/d PO for 4 days
  
• Ceftriaxone: 1 g IV q24h
  
• Ipratropium bromide: 0.5 mg nebulized q6h
  
• Levofloxacin: 500 mg PO/IV q24h
  
• Methylprednisolone: 125 mg IV q6h
  
• Prednisone: 40–60 (1–2 mg/kg) mg/d PO for 5 days
  
• Terbutaline: 0.25 mg SC q30min
  

• Albuterol
  
• Ipratropium bromide
  
• Prednisone or methylprednisolone
  

FOLLOW-UP

• ICU admission:
  
  • Intubated patients
    
  • CO
    ₂
    narcosis with oxygen saturation <90%
    
  • Clinical tiring in the ED
    
  • Severe acidosis
    
  • Concomitant cardiac or pulmonary disease
    
  • Acute coronary syndrome
    
  • Arrhythmia
    
  • CHF
    
  • Pulmonary embolism
    
• Regular hospital bed:
  
  • COPD patients with an additional pulmonary insult:
    
    • Pneumonia
      
    • Lobar collapse
      
    • Increased work of breathing
      
• Exercise intolerance
  
• Failure to improve in ED
  
• Failed outpatient treatment
  
• 3 criteria can predict mortality at admission:
  
  • Age >70 yr
    
  • Number of clinical signs of severity:
    
    • Cyanosis, accessory muscle use, etc.
      
  • Dyspnea at baseline
    

• Mild flare
  
• Resolution in ED
  
• Ambulatory oxygen saturation >92%
  

• Smoking cessation
  
• Ensure vaccinations are up-to-date (influenza annually, pneumococcal at least once).
  
• Identify and avoid triggers (e.g., cold air, perfumes)
  
• Possible referral for lung volume reduction surgery
  

• Noninvasive positive pressure ventilation is the therapy of choice when optimal medical therapy is insufficient
  
• Nebulized steroids may be used more for acute exacerbation of COPD in the future.
  
• Patients with COPD are at increased risk for diabetes, hypertension, and cardiovascular disease.
  
• Consider routine influenza and pneumococcal vaccinations for those with COPD.
  

• Agusti A, Barnes PJ. Update in chronic obstructive pulmonary disease 2011.
  Am J Respir Crit Care Med
  . 2012;185:1171–1176.
  
• Celli BR. Update on management of COPD.
  Chest
  . 2008:133:1451–1462.
  
• Cosio MG, Saeta M, Agusti A. Immunologic aspects of chronic obstructive pulmonary disease.
  N Engl J Med
  . 2009;360:2445–2454.
  
• Macky AJ, Hurst JR. COPD exacerbation: Causes, prevention and treatment.
  Med Clin N Am.
  2012;96;789–809.
  
• Rosenberg SR, Kalhan R. An integrated approach to the medical treatment of chronic obstructive pulmonary disease.
  Med Clin N Am
  . 2012;96:811–826.
  
• Sutherland ER, Cherniack RM. Management of chronic obstructive pulmonary disease.
  NEJM
  . 2004;350:2689–2697.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Asthma
  
• Congestive Heart Failure
  
• Dyspnea
  
• Pulmonary Embolism
  

CODES

• 491.9 Unspecified chronic bronchitis
  
• 492.8 Other emphysema
  
• 496 Chronic airway obstruction, not elsewhere classified
  

BASICS

• Progressive process of inflammation, cellular injury and necrosis, diffuse fibrosis, and formation of regenerative nodules
  
• Loss of lobular and vascular architecture
  
• Irreversible in advanced stages
  
• Intrahepatic portal hypertension owing to increased resistance at the sinusoid, compression of the central veins, and anastomosis between the arterial and portal systems
  
• 10th leading cause of death in US
  

• Chronic alcohol abuse (most common cause in US)
  
• Chronic viral hepatitis, B or C (2nd most common cause in US)
  
• Autoimmune hepatitis
  
• Biliary cirrhosis, primary (PBC) or secondary (sclerosing cholangitis)
  
• Metabolic:
  
  • Hereditary hemochromatosis
    
  • Wilson disease
    
  • Porphyria
    
• Drugs:
  
  • Acetaminophen
    
  • Methotrexate
    
  • Amiodarone
    
  • Methyldopa
    
• Hepatic congestion:
  
  • Right-sided heart failure
    
  • Pericarditis
    
  • Budd–Chiari syndrome (hepatic venous outflow obstruction)
    
• Infiltrative:
  
  • Sarcoidosis
    
  • Amyloidosis
    
  • Nonalcoholic steatohepatitis (NASH)
    
  • Hepatocellular carcinoma, diffusely infiltrating
    
• Infections:
  
  • Brucellosis
    
  • Echinococcosis
    
  • Tertiary syphilis
    
  • Schistosomiasis