COPDCOPD

Rada Jones MDRada Jones MD

09/12/0609/12/06

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

The calls The calls

1.1. 75 years old female with difficulty breathing for 75 years old female with difficulty breathing for the last three days. the last three days.

2.2. 19 years old male with difficulty breathing since 19 years old male with difficulty breathing since this morningthis morning

3.3. 65 years old male with difficulty breathing, 65 years old male with difficulty breathing, worse since yesterday.worse since yesterday.

4.4. 35 year old female. Difficulty breathing for 15 35 year old female. Difficulty breathing for 15 minutes.minutes.

5.5. 48 year old male with difficulty breathing for 1 48 year old male with difficulty breathing for 1 day. day.

DyspneaDyspnea

Subjective feeling of difficult, labored or Subjective feeling of difficult, labored or uncomfortable breathinguncomfortable breathing

““Shortness of breath”Shortness of breath” ““Not getting enough air”Not getting enough air” ““Breathlessness”Breathlessness” ““Difficulty breathing”Difficulty breathing” ““Having trouble breathing”Having trouble breathing”

Dyspnea: Differential diagnosisDyspnea: Differential diagnosis

MIMI CHFCHF AsthmaAsthma COPD exacerbationCOPD exacerbation PneumoniaPneumonia PEPE PericarditisPericarditis MyocarditisMyocarditis

PneumothoraxPneumothorax AnemiaAnemia Allergic reactionAllergic reaction AnxietyAnxiety Foreign bodyForeign body Toxic exposureToxic exposure Cardiac tamponadeCardiac tamponade DKADKA

Sorting it outSorting it out

AgeAgeHPIHPIPMHPMHAsk patientAsk patientPEPEEKGEKG

AgeAge

Infants/toddlers: Infectious, asthma, FBInfants/toddlers: Infectious, asthma, FBChildren: Asthma, croup, pneumonia, DKAChildren: Asthma, croup, pneumonia, DKAYoung adults: Asthma, Pneumothorax, Young adults: Asthma, Pneumothorax,

anxiety, pneumonia, PEanxiety, pneumonia, PEMiddle aged: MI, COPD, CHF, PEMiddle aged: MI, COPD, CHF, PEElderly: COPD, Pneumonia, CHF, MI, Elderly: COPD, Pneumonia, CHF, MI,

sepsissepsis

HPIHPI Sudden onset: Sudden onset:

FBFB allergic rxnallergic rxn PEPE PneumothoraxPneumothorax TraumaTrauma

Gradual onsetGradual onset CHFCHF COPD exacerbationCOPD exacerbation AsthmaAsthma pneumonia pneumonia

HPIHPI

Associated symptomsAssociated symptomsFever : infectionFever : infectionCough Cough Pain – esp. chest pain :cardiac vs. pulmonaryPain – esp. chest pain :cardiac vs. pulmonaryHemoptysis: bronchitis vs. PEHemoptysis: bronchitis vs. PE

Aggravating and alleviating factorsAggravating and alleviating factorsPositionPositionEnvironment: Smoke, fumes, humidityEnvironment: Smoke, fumes, humidity

Sick contactsSick contacts

PMHPMH

AsthmaAsthmaCHFCHFCOPDCOPDDMDMHIVHIVAllergiesAllergiesMedicationsMedicationsHome oxygenHome oxygen

PEPE

Physical appearancePhysical appearanceVitalsVitalsLung soundsLung soundsHeart soundsHeart soundsStridorStridorEdemaEdemaNeck veinsNeck veins

Physical appearancePhysical appearance

ColorColorCyanotic: hypoxia vs. methemoglobinemiaCyanotic: hypoxia vs. methemoglobinemiaFlushed: sepsisFlushed: sepsisPale: anemiaPale: anemia

Speaking in full sentences vs gasping for Speaking in full sentences vs gasping for breathbreath

Retractions, use of accessory musclesRetractions, use of accessory musclesAlert vs. obtundedAlert vs. obtundedSigns of traumaSigns of trauma

VitalsVitals

Pulse ox on RAPulse ox on RABreathing rateBreathing rate

TachypneaTachypneaBradypneaBradypnea

drugsdrugstraumatrauma

Heart rateHeart rateBlood pressureBlood pressureTemperatureTemperature

Listening to the heart and lungsListening to the heart and lungs

Not over clothingNot over clothingRequest silence if possibleRequest silence if possibleBack, bilaterally, at least three levelsBack, bilaterally, at least three levelsLeft chest, at least twoLeft chest, at least twoBoth axillaeBoth axillaeMouth open, no throat soundsMouth open, no throat sounds If necessary, have them cough and listen If necessary, have them cough and listen

againagain

Lung soundsLung sounds WheezingWheezing

AsthmaAsthma CHFCHF

CracklesCrackles CHF CHF FibrosisFibrosis PneumoniaPneumonia

Quiet lungsQuiet lungs Bilateral: HyperinflationBilateral: Hyperinflation One side: Pneumothorax vs consolidationOne side: Pneumothorax vs consolidation

http://www.med.ucla.edu/wilkes/lungintro.htmhttp://www.med.ucla.edu/wilkes/lungintro.htm

Heart soundsHeart sounds

Distant: hyperinflated lungs vs. tamponadeDistant: hyperinflated lungs vs. tamponadeS3, S4: CHFS3, S4: CHFRubs: pericarditis; Best heard leaning Rubs: pericarditis; Best heard leaning

forward. forward. http://www.med.ucla.edu/wilkes/http://www.med.ucla.edu/wilkes/

Rubintro.htmRubintro.htm

75 years old female with difficulty 75 years old female with difficulty breathing for the last three daysbreathing for the last three days

Alert, speaking in full sentencesAlert, speaking in full sentencesO2 sat 95%, RR20, HR 62O2 sat 95%, RR20, HR 62MI 3 and 1 years agoMI 3 and 1 years agoH/o CHF and DMH/o CHF and DMOn lopressor and lasix On lopressor and lasix Crackles, leg edemaCrackles, leg edemaDX? DX?

Most likely CHFMost likely CHF

What if…What if…

No cardiac historyNo cardiac historySmokerSmokerPressure in the chest, “feeling like an Pressure in the chest, “feeling like an

elephant sitting on my chest” but no painelephant sitting on my chest” but no painStarted while digging a hole to plant a treeStarted while digging a hole to plant a treeOn/off sinceOn/off sinceDX?DX?

Consider MI, check EKGConsider MI, check EKG

19 years old male with difficulty 19 years old male with difficulty breathing since this morningbreathing since this morning

Pale, sitting upPale, sitting upAlert, speaking in short sentencesAlert, speaking in short sentencesO2 sat 92%, RR28O2 sat 92%, RR28History of asthma, intubated multiple timesHistory of asthma, intubated multiple timesOut of Albuterol since 3 days agoOut of Albuterol since 3 days agoDX? DX?

Most likely asthma exacerbationMost likely asthma exacerbation

What if…What if…

No asthma historyNo asthma historyGot very drunk last night and got into a Got very drunk last night and got into a

fight, then fell asleepfight, then fell asleepHas sharp L sided chest pain with Has sharp L sided chest pain with

breathingbreathingDry blood on faceDry blood on faceDiminished breath sounds on LDiminished breath sounds on LDX?DX?

Consider pneumothorax, check neck veinsConsider pneumothorax, check neck veins

65 years old male with difficulty 65 years old male with difficulty breathing, worse since yesterdaybreathing, worse since yesterday

Slightly purpleSlightly purpleSitting up, breathing through pursed lipsSitting up, breathing through pursed lipsShort sentencesShort sentencesCoughs a lot, green sputumCoughs a lot, green sputumSmoker for 40 yearsSmoker for 40 yearsHistory of emphysemaHistory of emphysemaDx?Dx?

Most likely COPD exacerbationMost likely COPD exacerbation

What if…What if…

History of MI 5 years agoHistory of MI 5 years agoCABG x 3CABG x 3On lasix, but ran out a week agoOn lasix, but ran out a week agoEdema to kneesEdema to kneesCelebrated his birthday yesterday; Had Celebrated his birthday yesterday; Had

barbecue and chips, pickles and a few barbecue and chips, pickles and a few beers. beers.

Dx?Dx?

Possibly CHFPossibly CHF

35 year old female. Difficulty 35 year old female. Difficulty breathing for 15 minutes.breathing for 15 minutes.

O2 sat 92%, RR 32, HR 140O2 sat 92%, RR 32, HR 140Gray, gasping for breathGray, gasping for breath4 months pregnant4 months pregnantNo other historyNo other historyDX?DX?

Think PEThink PE

What if…What if…

O2 sat 100%, RR26, HR100O2 sat 100%, RR26, HR100Fainted ten minutes agoFainted ten minutes agoHad orthopedic surgery a week agoHad orthopedic surgery a week agoOr: Just drove over from California Or: Just drove over from California SmokesSmokes

Still think PEStill think PE

What if…What if…

Vitals normal, except RR32Vitals normal, except RR32Looks wellLooks wellSmokesSmokes Is on OCPsIs on OCPsHas a flutter in the chest and feels dizzyHas a flutter in the chest and feels dizzyHad a fight with boyfriend half an hour agoHad a fight with boyfriend half an hour agoHas history of panic attacksHas history of panic attacksDX?DX?

Could be anxiety, but don’t forget PECould be anxiety, but don’t forget PE

48 year old male with difficulty 48 year old male with difficulty breathing for 1 day. breathing for 1 day.

Flushed, sleepy, hard to arouseFlushed, sleepy, hard to arouseO2 sat 91%, RR22O2 sat 91%, RR22Feels febrile, lips dry, very thinFeels febrile, lips dry, very thinCracles throughoutCracles throughoutH/o HIVH/o HIVDX?DX?

Think pneumonia, sepsisThink pneumonia, sepsis

What if…What if…

Found on the sidewalkFound on the sidewalkDisheveled, pale, hard to arouseDisheveled, pale, hard to arouseO2 sat 90%, RR 6O2 sat 90%, RR 6Pinpoint pupilsPinpoint pupilsDx? Dx?

Possible ODPossible OD

Management - ABCManagement - ABC

Airway: Protect if necessary. Airway: Protect if necessary. BreathingBreathing

The single most important treatment: Supplementary The single most important treatment: Supplementary O2 for O2 sat > 90. Works immediately. O2 for O2 sat > 90. Works immediately.

Sitting up often helps breathingSitting up often helps breathing Nebulizer treatment for asthma, COPD; Nebulizer treatment for asthma, COPD; Bag if necessaryBag if necessary Decompress tension pneumothoraxDecompress tension pneumothorax

CirculationCirculation

Therapy onset timeTherapy onset time

Oxygen: 1minOxygen: 1minAlbuterol: 15 to 30 min Albuterol: 15 to 30 min Atrovent: 15 to 30 minAtrovent: 15 to 30 minLasix: 30 min to 1 hrLasix: 30 min to 1 hrSteroids: 4 to 6 hrsSteroids: 4 to 6 hrs

COPDCOPD

Airflow obstruction due to chronic Airflow obstruction due to chronic bronchitis or emphysemabronchitis or emphysema

Rare before 40Rare before 4090% smokers90% smokersMortality for average COPD exacerbation Mortality for average COPD exacerbation

hospitalization: 5 to 14%hospitalization: 5 to 14%Decompensation due to URI, Decompensation due to URI,

bronchospasm, noncompliance, othersbronchospasm, noncompliance, others

Signs/SymptomsSigns/Symptoms

Dyspnea and orthopneaDyspnea and orthopnea Progressive hypoxemiaProgressive hypoxemia Tachypnea, tachycardiaTachypnea, tachycardia CyanosisCyanosis Increased BPIncreased BP ApprehensionApprehension Tripod position, pursed lip exhalation, Tripod position, pursed lip exhalation,

diaphoresisdiaphoresis Eventually hypercapnia, confusion, obtundationEventually hypercapnia, confusion, obtundation

COPD Exacerbation ManagementCOPD Exacerbation Management

AirwayAirwayBreathingBreathing

O2 to sat > 90%O2 to sat > 90%Nebulized albuterol q20minNebulized albuterol q20minNebulized atrovent 1 dose with albuterolNebulized atrovent 1 dose with albuterolSolumedrol typical dose 125mgIVSolumedrol typical dose 125mgIV (Methylxanthines, antibiotics)(Methylxanthines, antibiotics)Assisted ventilation if neededAssisted ventilation if needed

CirculationCirculation