Formative Assessment for Simulation Training (FAST)—COPD Exacerbation

Date: Examiner: Examinee(s):

Learning Objectives: 1. Assess patient as stable vs. unstable and diagnose COPD exacerbation2. Conduct appropriate work up of COPD exacerbation and COPD staging3. Discuss adjunctive therapy for a COPD exacerbation, including non-invasive positive pressure

ventilation4. Review the indications for intubation of a COPD patient and basic ventilator therapy

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SCENARIO ALGORITHMSET UP

Sim Man w/ live video feed & mic OR older standardized patient

Instructor will control Sim Man and monitor case from video room and be voice of patient if possible

Resident will play role of RN ECG available @ monitor CXR available @ monitor ABG, CBC, Chem 10, trop available Need Bipap/CPAP and/or vent

PRE ARRIVAL 65 yo male with inc SOB, cough, yellow

sputum x 1 day; “cold” symptoms x 3 days HR 125 BP 138/79 RR 30 Pox 84% T99.9

ARRIVAL No change PMH—COPD (1 hosp in past yr), DMII,

HTN, HLP Meds—Albuterol, Spiriva, Metformin,

Zestoretic, Lipitor, ASA All—None SH—Tob x 1 ppd x 40 yrs, quit 5 yrs ago;

no ETOH; retired, lives c wife

PRIMARY SURVEYABCs WNL except tachypnea/tachycardia

as above; bilateral wheezing, some accessory muscle use, mild to mod distress/ill appearing

SECONDARY SURVEYPt slowly decompensates and requires NPPV and/or intubation

LABS & IMAGES CXR—COPD w/o evid of PNA Labs—see handout ECG—COPD—Rt axis dev, P pulmonale,

and RBBB

DISPOSITIONICU

ABG: 7.33/55/49/18 MS = Milestone CBC: 12.5/15.2/45.8/185 diff 70% neutron, 6 bands ME = Meets ExpectationsCMP: 130/4.0/117/18/24/1.2/190 nl LFT’s, alk phos, Ca/Mg/Phos NI = Needs ImprovementCK/Trop: wnl, d-dimer: wnl, BNP: wnl

CRITICAL ACTIONS MS ME NI SUSTAIN IMPROVEPlace safety net—IV, O2, monitor & begin ABCs

 ID COPD exacerbation and pt as unstable.

   Take thorough H/P and discuss diff dx and diagnostic testing

   Give nebs

   Give abx

   Give steroids    Place pt on BIPAP and/or intubate and choose appropriate settings    Choose appropriate sedation agents and dosesTx in ER/Ward then move to ICU

  

Demonstrate effective communication including closed loop feedback

TOTAL

Formative Assessment for Simulation Training (FAST)—COPD Exacerbation

Introduction

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) defines an exacerbation of chronic obstructive pulmonary disease (COPD) as an acute increase in symptoms beyond normal day-to-day variation. This generally includes an acute increase in one or more of the following cardinal symptoms:

Cough increases in frequency and severity Sputum production increases in volume and/or changes character Dyspnea increases

Causes of an Acute Exacerbation of a COPD Patient

Superimposed infection Continued smoking Non-compliance Lack of usual medications or oxygen therapy Spontaneous pneumothorax The single best predictor of exacerbations was a history of exacerbations, regardless of COPD severity.

Typical Signs of a Patient with a COPD Exacerbation

Pursed lip breathing Cyanosis Use of accessory muscles Intercostal retractions Barrel chest Hyper-resonant chest Wheezing, rhonchi, rales Prolonged expiratory phase Tachycardia Mental status changes w/sig hypoxia, elevated CO2 Signs of CHF if cor pulmonale (Pulm HTN) –JVD, LE edema, hepatomegaly

Initial Action and Primary Survey

1. ABC’s: Begin by assessing airway, breathing, and circulation. Obtain vital signs including the pulse oximetry reading.2. Give Oxygen. Apply controlled oxygen to all hypoxic patients who present with suspected COPD. In general, use a delivery system such as a

Venturi mask or nasal cannula. Avoid routine use of a non-rebreather mask with 15 L/min of oxygen, unless the patient is not responding to lower flow rates. In some patients with chronic carbon dioxide retention, high flow oxygen may cause respiratory depression with the rapid rise in oxygen depressing the central ventilatory drive.

3. Safety net: Place the ill patient on the monitor, attach continuous pulse oximetry, and insert an intravenous line. Observe the patient’s work of breathing and mental status, looking for signs of respiratory distress and fatigue. COPD patients MAY require immediate intubation or non-invasive ventilatory support.

Formative Assessment for Simulation Training (FAST)—COPD Exacerbation

Diagnostic Testing

Since COPD patients are typically older with a history of smoking and multiple co-morbidities they require a broad differential diagnosis such as CHF, acute coronary syndrome, pulmonary embolus, pneumothorax, pericardial effusion, and pneumonia

Chest X-Ray: chest radiograph is the most common study necessary in evaluating the COPD patient. A typical chest x-ray will show increased AP diameter, flattening of the diaphragm, decreased lung markings and the absence of another acute abnormality, such as pneumothorax, pulmonary edema or infiltrate. Significant abnormalities such as pneumonia, pulmonary edema or pneumothorax will require a change in therapy.

Electrocardiography: EKG is rarely specific in COPD, but frequently necessary in the evaluation of elderly patients with multiple co-morbidities to help exclude other disease processes.

Common EKG Features of COPD

Low voltage, right axis deviation and rightward axis deviation P pulmonale- peaked P waves in II, III, aVF, rt axis deviation, RBBB, low voltage QRS Right atrial hypertrophy Tachycardia Multifocal atrial tachycardia (rare, but specific to COPD)

Laboratory Testing: arterial blood gas (ABG) if the patient is critically ill and not responding to standard treatment. Evaluate for degree of hypoxia, acidosis, and CO2 retention. Serial arterial blood gases may be needed to assess trends in the ill patient.

pH PCO2 Pa02 O2 SatNormal ABG 7.4 40 60-90 >95%

Compensated 7.39 50 60-90 >92%Decompensated <7.35 Rising Falling <92%

Several studies may be indicated to exclude other diagnoses: d-dimer (with subsequent chest CT angiography if positive) in patients felt to be at risk for PE or in non-responders to standard treatment. Cardiac enzymes may be indicated in patients who you suspect are at risk for an acute coronary syndrome. Obtaining a newly elevated BNP may suggest a component of congestive heart failure.

Admission Criteria: 2004 position paper from the American Thoracic Society/European Respiratory Society (ATS/ERS)::

Inadequate response of symptoms to outpatient management

Marked increase in dyspnea

Inability to eat or sleep due to symptoms

Worsening hypoxemia

Worsening hypercapnia

Changes in mental status

Inability to care for oneself (ie, lack of home support)

Uncertain diagnosis

Formative Assessment for Simulation Training (FAST)—COPD Exacerbation

High risk comorbidities including pneumonia, cardiac arrhythmia, heart failure, diabetes mellitus, renal failure, or liver failure

Acute respiratory acidosis justifies hospitalization.

Treatment: In general, treatment revolves around use of bronchodilators, corticosteroids, and antibiotics to treat superimposed infection.

Oxygen: goal of PaO2 of 60-70 and/or O2 sat of 90-94%. Venturi masks are preferred as they deliver precise FiO2. Nasal cannulae can provide flow rates up to 6 L (FiO2 40%). Avoid high flow O2—not necessary and may inc CO2 retention/dec resp drive.

Bronchodilators: After oxygen, the use of bronchodilators to treat acute decompensation is the initial treatment. Inhaled albuterol, the preferred beta-agonist, provides the most rapid response in most patients. Even after multiple doses a clinical response may occur. The only limiting factor to ongoing use is tachycardia and other cardiovascular side effects such as ischemia. There is no role for long acting beta-agonists such as salmeterol in treatment of the acute exacerbation. Give albuterol (2.5mg) tx’s every 1-4 hrs. No role for cont albuterol nebs in COPD. Use of anti-cholinergic bronchodilators such as ipatropium bromide, is also first line therapy. Ipatropium is typically given every 4 hours (500mcg), not in stacked or repeated doses like albuterol. Systematic review has not shown combination therapy with beta-agonists to be superior, but it is frequently used.

Steroids: An IV steroid such as methlyprednisolone OR prednisone orally should be started. The optimum regimen is not established, but typical regimens are 10-14 days. Corticosteroids have been shown to improve lung fxn, reduce treatment failure, dec hospital stay, and the need for additional medical therapy. Complications of steroid use are worsening hypertension, elevated blood sugars, gastritis, and even steroid psychosis. Usually PO doses(30-40mg qd) if going to ward, IV doses(60mg qd to qid) if going to ICU. No role for inhaled corticosteroids in COPD exacerbation.

Antibiotics: Empiric antibiotics are used if signs of infection are present and in patients with moderate to severe exacerbations. Exam and historical features that suggest infection are dyspnea, color change of sputum, and increased volume of sputum. Multiple appropriate antibiotic options are available. Common options include macrolides, fluoroquinolones, tetracyclines and cephalosporins. Complications of antibiotics include: allergic reaction, gastritis, and C dificile colitis.

Adjunctive Therapy for Decompensated Patients: Continuing respiratory decompensation with worsening carbon dioxide retention and hypoxia despite standard treatment are indications for adjuctive therapy with non-invasive positive pressure ventilation (NPPV) or endotracheal intubation. The decision to initiate one of these adjunctive therapies can be a purely clinical one, based on overall assessment of work of breathing, or via direct measurement of arterial blood gases. There is no absolute guideline for level of carbon dioxide and it is not uncommon for severely affected patients to be awake and relatively stable with a PC02 over 60. However, worsening acidosis and unresponsive hypoxia are good markers for the need for adjunctive therapy.

Non-invasive positive pressure ventilation is a mode of mechanical ventilation given by facemask that aids oxygen delivery and decreases work of breathing). It is the next logical step in therapy for the patient not responding to standard treatment. However, it should be started early before acute neurologic deterioration or respiratory depression occurs. An experienced respiratory therapist is invaluable in managing these patients and will help guide the clinician in determining the optimal oxygen flow and pressure settings.

Rapid sequence intubation (RSI ) may be necessary for airway control, correction of hypoxia, and correction of carbon dioxide retention. After intubation and sedation, the ventilator is set with a tidal volume of 4-5 ml per kg of ideal body weight (best calculated by length measurement of the patient). The initial oxygen flow is typically 50-100% depending on pulse oximetry and blood gas measurement. The initial mode of ventilation is typically assist control with a fixed number of ventilations being delivered even if the patient is paralyzed or taking insufficient breaths per minute

Pearls and Pitfalls

Assess what patient factors may have caused the exacerbation

Formative Assessment for Simulation Training (FAST)—COPD Exacerbation

Always consider alternate diagnoses such as PE, ACS, pneumonia, and CHF in the COPD patient Give oxygen early and give enough Use a combination of bronchodilators, steroids, and consider antibiotics in moderate and severe exacerbations Start NIPPV early in patients who have persistent increased work of breathing

Formative Assessment for Simulation Training (FAST)—COPD Exacerbation

Formative Assessment for Simulation Training (FAST)—COPD Exacerbation

Formative Assessment for Simulation Training (FAST)—COPD Exacerbation

Formative Assessment for Simulation Training (FAST)—COPD Exacerbation

Appendices:

Initial ABG:

pH: 7.33PCO2: 55PO2: 49Bicarb: 18

Subsequent ABG (after appropriate intervention):pH: 7.38PCO2: 45PO2: 70Bicarb: 19

Other labs:CBC: 12.5/15.2/45.8/185CMP: 130/4.0/117/18/24/1.2/190CK: wnlTrop: wnld-dimer: wnlBNP: wnl

Formative Assessment for Simulation Training (FAST)—COPD Exacerbation

Formative Assessment for Simulation Training (FAST)—COPD Exacerbation

Formative Assessment for Simulation Training (FAST)—COPD Exacerbation

Formative Assessment for Simulation Training (FAST)—COPD Exacerbation