 Welcome back to COPD Part 2. In this section, we'll discuss the investigation and treatment of patients with COPD exacerbations. We'll separate investigation into blood work and imaging. We often do basic labs such as CPC, electrolytes, renal function. We sometimes would order a venous blood gas. In patients who are not improving with treatment, we sometimes order an arterial blood gas. How would these blood work results be abnormal? In patients with a potential infection, they may have an increased white blood cell count. Patients with COPD are often hemoconcentrated. We look at the other blood work to look for electrolytes, abnormalities, and renal insufficiency. What about the blood gases? A typical venous blood gas of a COPD patient would be CO2 retention. We can often compare the patient's VBG during exacerbation to their baseline to know how sick they are at this point. If the patient is not responding to treatment, if we do their ABG, this is what it would show. We will see a rapidly rising PCO2 and a decreasing PO2. In patients with stories that are suspicious for acute coronary syndrome, we would want to add in cardiac markers as well. In those patients, we would want to obtain an ECG. There are typical ECG changes in patients with COPD. Particularly during an exacerbation, we will see tachycardia. If we look at a rhythm strip, the tachycardia would often look like this. You notice that in this rhythm strip here, that the P-ways that are pointed out by the arrows, they have different morphology, meaning that the impulses come from different foci in the atrium, also known as multifocal atrio tachycardia or MAT. This arrhythmia is secondary to the underlying process and therefore to treat it, we want to treat the COPD exacerbation. On the ECG, we will also want to look for other abnormalities. Specifically, we want to look for any cardiac cause that might be mimicking a COPD exacerbation, such as this ECG. Do you see what the abnormality is? We see ST elevations in the anterior elites and therefore this patient is having a STEMI and so we need to initiate treatment for that. In terms of imaging, there are a few modalities we might want to use in patients with a COPD exacerbation. They include chest x-ray, ultrasound and CT scan. Chest x-ray is the most commonly used imaging in patients with COPD exacerbation. There are a few things we look for. In a typical COPD patient, they have hyperinflated lungs with flattened diaphragm. On a chest x-ray, it would look like this. Do you see that the lungs are hyperinflated? What do you think of the diaphragm? They are flattened a bit from their regular dome shape. This is a very typical chest x-ray of a patient with COPD. Now, what do we look for during an exacerbation? Well, we look for triggers as we talked about in part 1. What are those triggers again? Specifically in the lungs, they can be an infection, P.E., and rupture of a blood leading to pneumothorax. Therefore, in a patient with an exacerbation, we want to look for that specifically on the chest x-ray. What do you think of this chest x-ray? If you look at the right side of the lung, you should be able to see a pneumothorax. Here's the pleura. What do you think of this chest x-ray? Do you see the consolidation in the right lung? This patient might have pneumonia as a trigger. As you know, chest x-ray is not sensitive enough to pick up P.E., and therefore the patient that we think they have a pulmonary embolism as a cause for their COPD exacerbation, we need to move on to CT. We can also use bedside ultrasound to pick up a pneumothorax. Let's move on to treatment in patients with the COPD exacerbation, after we have excluded other causes for their shortness of breath. It consists of oxygen, bronchodilators, steroids, antibiotics, BIPAP, and intubation. First, oxygen. We want to give the patients who are hypoxic oxygen. However, since the patients with COPD are often CO2 retainers, higher O2 might cause respiratory depression. We want to titrate the oxygen so the set is about 90%. We do this by giving oxygen by nasal prongs or venturi mask. Next is bronchodilators. Subutimol is the main bronchodilator. It can be given as an ambulized version or by puffers. It can also be given continuously until the patients start to improve. We often start with three back-to-back treatment first. In terms of side effects, subutimol causes tachycardia and hypochlamia. We sometimes add epitropium as a second bronchodilator, usually as a single initial dose. Subutimol is the main treatment. Steroid is key in patients in COPD exacerbation. It can be given as an IV metho-pranazone or PO-pranazone. Since the steroid takes a few hours to work, it's important that we start this steroids early. Antibiotics are given to patients with the following. They have an ammonia documented on the chest x-ray, or they have symptoms that suggestive of an infection that include fever, increased sputum production, or change in the sputum color. The antibiotics of choice include doxycycline, flonokinolones, and cephalosporins. In the patients who are having a moderate to severe exacerbation, we want to consider using non-invasive positive pressure ventilation with BIPAP. A mask is applied to the face of the patient that supplies positive AOA pressure. BIPAP can only be used in patients who are awake, and we want to consider it early in patients with a bad exacerbation. BIPAP is extremely useful in preventing intubation in patients with a bad COPD exacerbation. In patients who do not have access to BIPAP, or are failing BIPAP, with a falling oxygen saturation and a worsening acidosis, we would intubate them. How do we disposition patients who have COPD exacerbation? The patient can go home if, after a few hours of treatment in the emergency department, their oxygen saturation is normal both at rest and on exertion. These patients can go home. They need to be on 10 to 14 days of oral steroid and antibiotics if indicated. What if their oxygen is normal at rest, but when they walk their oxygen saturation decreases? Those patients need to be admitted. For those who have a drop-sat during ambulation or exertion, they need to be admitted to the ward. And those who are intubated and cannot come off the BIPAP need to be admitted to an ICU setting. In summary, we discussed the investigation and treatment in patients with COPD exacerbation. Investigation includes blood work, ECGs if indicated, chest x-ray and sometimes CT or ultrasound. Treatment includes closely titrated oxygen, bronchodilators, antibiotics, steroids, BIPAP and intubation, with a special caveat that both BIPAP and steroids need to be done early. We hope you find this useful. 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