Staging Of COPD Based On Post-Bronchodilator Spirometric Criteria

Chronic Obstructive Pulmonary Disease Risk Management Pitfalls

3. “I didn’t give inhaled bronchodilators because he was so tachycardic.” Although tachycardia may be a side effect of inhaled bronchodilators, it is rarely if ever hemodynamically significant, and hemodynamic compromise is of secondary concern if respiratory failure is untreated (“B comes before C”).

4. “I thought the rule about giving too much oxygen is just for internists on the ward.” For reasons that remain contentious and poorly understood, some patients will develop worsened hypercapnic respiratory failure in the face of hyperoxia. We currently have no way of identifying which patients will develop this response. In the absence of a compelling argument in favor of hyperoxia, the prudent approach is to give no more oxygen than is necessary to achieve an SaO2 in the range of 88%–92%.

5. “His ABG didn’t indicate that he required intubation,” or the closely related “His pulse-ox was just fine until…” Numeric values may be deceptive, especially in the COPD patient, who may have striking and unpredictable abnormalities at baseline and even more so when acutely decompensated. Therefore, it is of paramount importance that decisions regarding airway management and aggressive management be based on integration of the overall clinical picture rather than one or two laboratory or monitoring values.

6. “I adjusted the ventilator to weight-appropriate settings.” Permissive hypercapnia is an effective strategy to maintain oxygenation while avoiding iatrogenic VILI. While it can be very uncomfortable to leave a patient at a pH of 7.20, carbon dioxide narcosis is no longer of concern once a patient is intubated, and the mild acidemia does not appear to be of clinical consequence.

Chronic Obstructive Pulmonary Disease Case Study

Case Study:
A 57-year-old male is brought in by paramedics from home after he called 911 saying, “I can’t breathe.” He is thin, has weathered skin, and is visibly dyspneic. His pulse oximetry reading is 84% despite receiving home oxygen via nasal cannula. When you listen to his lungs, you hear almost nothing. Fifteen minutes ago, you sent a patient with septic shock to your hospital’s last ICU bed. What strategies can you employ to rapidly turn this patient around and prevent him from getting intubated?

A 78-year-old female with a history of “heart problems” and “chronic bronchitis” is brought in by family members who report that she has been increasingly fatigued over the past day and complaining of “not breathing right.” She reports that her inhalers are not helping her like they should. She has mild hypoxia, scattered wheezes, lower extremity edema, and cardiomegaly on chest x-ray. How can the relative roles of cardiac and pulmonary disease be elucidated in her current presentation? How useful would a BNP value be in your management? Should you consider pulmonary embolism highly in your differential diagnosis?

Case Study Conclusion:
While simultaneously starting nebulized bronchodilators and steroids for the 57-year-old male, you call for chest x-ray and BiPAP. Although it takes a few minutes for respiratory therapy to set things up, the patient responds well to therapy and begins to turn around. An hour after arrival, he is tolerating BiPAP well and appears much more comfortable. His venous blood gas shows only mild acidosis and hyponatremia. His chest x-ray is unremarkable, but he describes a marked change in the quality of his sputum over the past several days, so you start antibiotics. After several hours of observation, you feel comfortable admitting him to the medicine ward.

Given her age, comorbidities, and the unclear clinical circumstances, you treat the 78-year-old female aggressively for both decompensated COPD and heart failure. You forgo the BNP, since it would be unlikely to change your clinical management. You give her aspirin, nitrates, bronchodilators, steroids, and antibiotics. She has been largely sedentary and has normal renal function, so you order a CT angiogram of her chest. Meanwhile, she reports that the bronchodilators and nitrates have made her breathing feel better. After confirming that the CT shows no pulmonary emboli, you admit the patient to a telemetry-monitored bed where she can continue to have serial troponins drawn.