#Order
▪︎Imp: COPD exacerbations
▪︎Cond: Emergency
▪︎Diet: temporary NPO
▪︎Act: CBR- bed sides up
▪︎pos: semi- sitting
▪︎IV line fix
▪︎ECG
*Look for arrhythmia, ischemia, cor pulmonale
▪︎Check V.S
▪︎POM and CM
▪︎O2 therapy with nasal cannula 4L/min or mask 6-10 lit/min if sat<90%
*Provide supplemental oxygen to target a pulse oxygen saturation of 88 to 92%
* high FiO2 usually not needed and can contribute to hypercapnia (high FiO2 requirement should prompt consideration of alternative diagnosis [eg, PE]).
*SpO2 >93% associated with higher inpatient mortality.
▪︎BS glucometery
▪︎CBC, electrolytes (Na+, K+, Cl–, HCO3–), BUN, and creatinine, BS,.(also obtain cardiac troponin, BNP, orNT-proBNP, if diagnosis is uncertain.)
▪︎VBG in all severe copd exacerbation patients
▪︎PCR influenza and covid
*if influenza is suspected, start the antiviral
▪︎Portabl CXR
*Look for signs of pneumonia, acute heart failure, pneumothorax.
▪︎CTPA
*When evidence of acute infection (eg, purulent phlegm, pneumonia) is absent and chest radiograph is unrevealing, obtain CTPA for possible PTE.
▪︎NIV mask
* Contraindications to NIV include: Severely impaired consciousness, inability to clear secretions or protect airway, high aspiration risk.
* Obtain ABG after two hours of NIV and compare with baseline: Worsening or unimproved gas exchange and pH <7.25 are indications for invasive ventilation.
▪︎Consider intubation if needed
▪️Albuterol(Salbutamol) 2.5 mg diluted to 3 mL via nebulizer OR 2 to 4 inhalations from MDI every hour for 2 or 3 doses; up to 8 inhalations may be used for intubated patients, if needed. *(Inhaled beta agonist)
▪️Ipratropium(Atrovent) 500 mcg (can be combined with albuterol) in 3 mL via nebulizer OR 2 to 4 inhalations from MDI every hour for 2 to 3 doses.
*(Short-acting muscarinic antagonist (anticholinergic agent))
▫️OR - Combivent solution (salbutamol/ipratropium bromide-3mg/0.5mg)
*برای تجویز، کل محتوی ویال (۳ میلی‌گرم سالبوتامول + ۰.۵ میلی‌گرم ایپراتروپیوم) را با سرم فیزیولوژیک تا حجم نهایی ۳ تا ۵ میلی‌لیتر رقیق کرده و با نبولایزر طی ۱۰ تا ۱۵ دقیقه استنشاق می‌شود. این دوز را می‌توان هر ۲۰ دقیقه تا سه بار در ساعت اول (در حمله شدید) و یا حداکثر ۳ ساعت اول تکرار کرد و سپس بر اساس پاسخ بیمار ادامه داد.(هر ۴-۱ ساعت)
*۵۰۰میکروگرم همون ۰.۵ میلی گرم میشه
▪️Amp Methylprednisolone 60 mg to 125 mg IV, repeat every 6 to 12 hours or tab prednisolone 40mg stat then Daily for 5-14 days.
▪️Antibiotics selection based on Pseudomonas risk factor(s).
(Inpatient vs outpatient)
❗️Pseudomonas infection risk factors:
-Broad spectrum antibiotic use in the past 3 months;
-Chronic colonization or previous isolation of Pseudomonas aeruginosa from sputum (particularly in past 12 months);
-Very severe underlying COPD (FEV1 <30% predicted);
- Bronchiectasis on CT
-Chronic systemic glucocorticoid use.
▫️Without Pseudomonas risk factor(s):
Ceftriaxone 1 to 2 gr IV, or Cefotaxime 1 to 2 gr IV, or Levofloxacin 500 mg IV or orally, or Moxifloxacin 400 mg IV or orally
OR
▫️With Pseudomonas risk factor(s):
Piperacillin-tazobactam 4.5 grams IV, or Cefepime 2 gr IV, or Ceftazidime 2 gr IV
▪️Oseltamivir 75 mg orally every 12 hours or peramivir 600 mg IV once (for patients unable to take oral medication). For 5 days.
*if influenza suspected
▪️Sputum culture
*may be helpful in patients who are strongly suspected of having a bacterial infection but fail to respond to initial antibiotic therapy
Appendix:
▪︎Criteria for ICU admission include:
- Patients with high-risk comorbidities (pneumonia, cardiac arrhythmia, heart failure, diabetes mellitus, renal failure, liver failure).
- Continued need for NIV or invasive ventilation
- Hemodynamic instability
- Need for frequent nebulizer
treatments or monitoring
▪️قانون کلی jet nebulizer: حتما روی 8-6 L/min اکسیژن میذاریم، دو دارو رو باهم مخلوط نمیکنیم، حداکثر ۴ سی سی میریزیم و دارو رو با نرمال سالین(نه آب مقطر) مخلوط میکنیم.
▪︎نبولایزر pulmicort(بودوزوناید) جایگاهی در حمله آسم یا COPD ندارد.
پایان.
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