Day 1- COPD Exacerbation

  1. Respiratory Support

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  • O2 by NP or venturi mask to keep oxyhemoglobin saturation >92%, or if CO2 retainer between 88-92% (check previous pCO2 levels)

  • Consider BiPAP for patients with the following present:

    • severe dyspnea with clinical signs suggestive of respiratory muscle fatigue

    • pH<7.35

    • PaCO2>45mmHg

    • RR>25

  • If BiPAP required, call RT for support. Preform trial for 2 hours and then repeat ABG/VBG to assess efficacy

  • Invasive ventilation should be considered if contraindications to, or failure of, NIPPV

2. Inhalers

  • Short-acting B-agonist:

    • Ventolin 2-4 puffs by MDI via aero chamber q4hrs while awake + q1hr PRN (or ventolin 2.5mg by nebulizer q1-4hr)

  • Short acting anticholinergic:

    • Ipatropium 2-4 puffs MDI via aero chamber q4hr while awake + q1hr PRN

3. Steroids

  • Prednisone 40mg PO daily x 5 days (GOLD guidelines)

4. Antibiotics

  • Patient can have an infectious COPDe (including viral or pneumonia) or non-infectious COPDe

    • It is important to remember that non-infectious COPDe does not require Abx

  • If patient fulfills Winnepeg’s Criteria (see infographic)

    • Organisms include Haemophilus Influenza, Morazella Catarrhalis and Streptococcus Pneumonia

      • Narrow spectrum: Amoxicillin 500mg PO TID, doxycycline 100mg PO BID

      • Broad spectrum: Amoxicillin/Clavulanate: 500mg PO TID x 5 days, levofloxacin 500mg PO x 5 days

      • If chest X-RAY shows infiltrate (pneumonia), ceftriaxone 1g IV q24hrs x 5 days and azithromycin 500mg PO x 1 (then 250mg PO daily x 4 days) can be used

After exacerbation:

  • Review home inhalers (does patient need escalation in therapy?)

  • If difficult to wean off O2, consider assessing need for home oxygen

  • Consider in-patient or out-patient Respirology consult

  • Smoking cessation counselling

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