Chronic Obstructive Pulmonary Disease (COPD) Exacerbation

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COPD Exacerbation

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COPD exacerbation
-DDx includes: heart failure vs acute bronchitis vs pulmonary embolism vs asthma.
-Dx is acute COPD exacerbation due to hx, wheezing on exam and CXR findings.
-Concern for decline due to respiratory rate, accessory muscle use, difficulty speaking in full sentences and mental status change. 
-Precipitant of exacerbation by viral infection vs bacteria infections vs pollution/smoking.
–Will admit to telemetry.
-Start bronchodilators, Duonebs, inhaled and systemic steroids and antibiotics (azithromycin +/- broad spectrum). Will start albuterol 2.5 mg q1-4h, ipratropium 0.5mg q4h followed by Duonebs q4-6h + prn. Solumedrol initial at 125mg followed by 40-60mg q12h. Taper based on response. Abx to cover for gram negative and will consider covering for pseudomonas if from health care facility until cultures return.
-Nasal canula and intermittent BIPAP, low threshold for intubation if more dyspneic; as concerns for tiring out. Goal O2 saturation is 88%-92%.
-Obtain ABG to assess both hypoxemia and hypercapnia.
-If dyspnea and mental status worsening in 30-60 minutes after initial treatment and ABG shows acidosis <7.25, will transfer to ICU.
-Follow CXR, CBC, BNP, D-dimer, viral panel, troponins, CMP, procalcitonin.
-Obtain respiratory and blood cultures.
-Will need pneumonia vaccine, influenza vaccine and smoking cessation education prior to discharge.
-Outpatient spirometry and pulmonary function test to classify GOLD status.
-Will consult palliative care if GOLD stage IV and multiple admissions in past 3 months with guarded prognosis.
-Will need LAMA + LABA + pulmonary rehab at discharge.