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A N E V I D E N C E - B A S E D A P P ROAC H T O E M E RG E N C Y M E D I C I N E
Guidelines
There are several guidelines that address the diagnosis and management of
chronic obstructive pulmonary disease (COPD). Influential guidelines published in the mid-1990s include those by the American Thoracic Society,1 the
European Respiratory Society,2 and the British Thoracic Society.3 More recent is
the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop
Summary (also available online at http://www.goldcopd.com).4 It represents a
combined effort of the World Health Organization and the National, Heart,
Lung, and Blood Institute of the National Institutes of Health. This guideline is
Associate Editor
Andy Jagoda, MD, FACEP, Professor
of Emergency Medicine; Director,
International Studies Program,
Mount Sinai School of Medicine,
New York, NY.
Editorial Board
Judith C. Brillman, MD, Residency
Director, Associate Professor,
Department of Emergency
Medicine, The University of
New Mexico Health Sciences
Authors
Mary T. Ryan, MD
Attending Physician, Department of Emergency
Medicine, Lincoln Medical and Mental Health Center,
Bronx, NY; Clinical Instructor in Emergency Medicine,
Weill College of Medicine, Cornell University, New
York, NY.
Michael S. Radeos, MD, MPH
Attending Physician, Department of Emergency
Medicine, Lincoln Medical and Mental Health Center,
Bronx, NY; Assistant Professor in Emergency Medicine,
Weill College of Medicine, Cornell University, New
York, NY.
Peer Reviewers
Rita K. Cydulka, MD, MS
Associate Professor, Case Western Reserve University;
Faculty, MetroHealth Medical Center Emergency
Medicine Residency, Cleveland, OH.
David Della-Giustina, MD
Program Director, MadiganUniversity of Washington
Emergency Medicine Residency, Tacoma, WA.
CME Objectives
Editor-in-Chief
April 2002
Volume 4, Number 4
of the airspace distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious
fibrosis.1 Chronic bronchitis is defined as the presence of
chronic productive cough for three months in each of two
successive years in a patient in whom other causes of
chronic cough have been excluded. However, McCrory et
al admit that in fact, separating these entities is difficult
both when evaluating clinical studies and when practicing
clinical medicine.
GOLD updates the definition of COPD as a disease
state characterized by airflow limitation that is not fully
reversible. (See Table 1.) The airflow limitation is usually
both progressive and associated with an inflammatory
response of the lungs to noxious particles or gases. While
these various definitions are a necessary irritation, the
emergency physician should consider COPD in any patient
with cough, sputum production, or dyspnea.
Diagnostic Uncertainty
Beyond the confusion associated with the evolving definition of COPD, there is evidence to suggest that physicians
are not very good at diagnosing this diseaseeven when
the presentation is relatively straightforward. In one study,
the authors presented a clinical scenario to 75 primary care
providers in Canada and asked them to provide a diagnosis.7 The case involved a 52-year-old smoker with recurrent
respiratory infections and wheeze. Half of the primary care
physicians were told that the patient had history of chronic
bronchitis, while the other half were not. The physicians
who were given a history of chronic bronchitis diagnosed
COPD twice as often as those who were not told this fact. A
more recent study presented a similar scenario to primary
care providers in the U.S. and Canada.8 This time, they
randomized primary care physicians so that half received
the scenario with the patient as a male, while the other half
were given the identical scenario with the patient as a
female. They found that 65% of the physicians diagnosed
COPD in the male patient, while only 49% diagnosed the
woman with COPD (P < 0.05). Systematic under-diagnosing
of women with COPD may also occur in the ED.9
Definitions
The McCrory article and the older guidelines separate
COPD into chronic bronchitis, emphysema, and asthma,
while the GOLD guidelines do not. This distinction is
problematic because emphysema is defined anatomically,
while chronic bronchitis is determined by clinical criteria.
According to the American Thoracic Society Guidelines,
emphysema is an abnormal permanent enlargement
Characteristics
Normal spirometry
Chronic symptoms (cough, sputum
production)
I: Mild COPD
Epidemiology
In 1990, the World Health Organization reported the
prevalence of COPD to be 9.34/1000 in men and 7.33/1000
in women. The exact prevalence of COPD in the U.S. is
unknown, but it is estimated that approximately 14 million
Americans suffer from this condition.10 (This number is
likely an underestimate, since COPD remains underdiagnosed in the primary care setting.11) While data on ED
visits for COPD are difficult to find, data on COPD discharges are easily available.12 In 1998, nearly 700,000 people
were discharged from the hospital with a diagnosis of
COPD. The rate of women discharged for COPD exceeded
men in 1992, and the ratio of women to men has been
increasing yearly since then. There is clear evidence that the
prevalence of COPD has doubled in the past few decades in
women while remaining relatively stable in men.13 This may
reflect a combination of increased prevalence of smoking
April 2002
Differential Diagnosis
Etiology
Asthma
While there are differences between asthma and COPD, it is
important to realize that about 10% of those with COPD
may also have clinical features of asthma. This subgroup is
also referred to as wheezy bronchitis (see Figure 1) and
should be treated as asthma.20 Because it is difficult to
identify this entity based on the ED history and physical
exam, patients with evidence of bronchospasm should be
treated as if they have a reversible condition.
Pathophysiology
The hallmarks of COPD include chronic airflow obstruction
of the small airways and enzymatic destruction of the lung
Figure 1. Overlap between asthma and COPD. Approximately 10% of patients with COPD also have asthma and
therefore share pathologic features.
~10%
COPD
Neutrophils
Mild to no airway hyperreactivity
Mild to no bronchodilator response
Mild to no corticosteroid response
Generally begins in adulthood
Asthma
Eosinophils
Airway hyperreactivity
Bronchodilator response
Corticosteroid response
Generally begins in childhood
Often associated with atopy
Wheezy bronchitis
Used with permission from: Barnes PJ. Mechanisms in COPD. Differences from asthma. Chest 2000;117:10S-14S.
April 2002
Pneumothorax
COPD is a known risk factor for a secondary pneumothorax, particularly when emphysema produces pleural blebs.
Clinical clues may include asymmetrical chest expansion or
breath sounds and, in the case of tension pneumothorax,
hypotension or tracheal deviation. However, small pneumothoraces can easily be missed on clinical exam yet still
produce acute decompensation. Patients on positive
pressure ventilation are at increased risk of developing a
tension pneumothorax.
A chest x-ray is generally adequate to make the
diagnosis, and expiratory films can be helpful in detecting
small pneumothoraces.35
Pulmonary Embolism
The emergency physician must consider PE in any patient
with acute dyspnea. In general, clinical risk factors for PE
Pneumonia
Fever is an important clue to the diagnosis of pneumonia.
Consider obtaining a rectal temperature in patients who
present with a normal oral temperature but who appear
sicker or are hot to the touch. Two ED studies have found
that oral temperatures may be falsely normal in patients
with tachypnea and/or mouth breathing.36,37 However, the
chest film is the best ED screening test for pneumonia.
Lobar Atelectasis
Lobar atelectasis is another important consideration in the
April 2002
History
History Of Present Illness And Review Of Systems
Determine the presence of fever, changes in sputum
production, hemoptysis, and whether or not the patient has
chest pain. Other important questions may include whether
the patient experiences orthopnea and changes in exercise
tolerance. Ascertain the acuity of onset and how rapidly the
patient is deteriorating. If the deterioration is very acute,
consider PE, ACS, CHF, and pneumothorax in the differential diagnosis.
It is tempting to assume that shortness of breath
in a patient with a history of COPD reflects an acute
exacerbation of the disease. This may not be so, especially if
the patient complains of atypical symptoms. Some associated symptoms may be especially revealing, such as the
unilateral leg swelling that may occur with deep venous
thrombosis (DVT).
Establish the patients baseline status. This is
important in ascertaining how acutely ill the patient is and
will help determine the need for hospital admission or
discharge. It may also provide indirect information about
how well the patients disease is controlled on the current
medication regimen or if noncompliance is a factor. The
following questions may be helpful:
When was your last ED visit?
Have you ever been admitted? When was the
last admission?
Have you ever been intubated?
Do you have oxygen at home? How many hours
a day do you need it?
How bad is this attack?
Prehospital Care
The priority of prehospital care in acute exacerbations of
COPD is to ensure maintenance of the airway. If the patient
is obtunded or unable to ventilate effectively, assisted
ventilation (usually by tracheal intubation) is essential.
Although there are airway adjunctslaryngeal mask
airway and the Combitubethat may provide temporizing
measures in a difficult, non-obstructed airway, they may not
allow effective ventilation due to high airway pressures.
These interventions may result in gastric insufflation instead
of proper ventilation. Pulse oximetry may be helpful in
patients who show signs of respiratory distress or altered
mental status.
Clinical trials demonstrate that the prehospital administration of either aerosolized albuterol or subcutaneous
terbutaline significantly reduces respiratory distress in
patients with bronchospasm.38,39 While aerosolized
ipratropium is not well-studied in the prehospital setting,
there is no apparent reason why it would be any less
effective in the ambulance than in the ED.
Studies on the prehospital use of noninvasive ventilation (NIV), such as CPAP or BiPAP, are limited; most trials
involve CHF rather than COPD. One study examining the
utility of BiPAP in the field found it to be safe and easy to
use. Although the pre- and post-treatment oxygen saturation levels were greater for the BiPAP group (13.71% vs
6.69%) than the control group, no statistical differences were
noted between the groups for mortality, intubation rate, or
length of hospital stay.40 (However, note that the patients
studied were those believed to have an exacerbation of
CHF, not COPD. Further, the outcome measure was a
change in SaO2.)
Medication History
Changes in medication regimens or doses, either intentional
or accidental, may cause patients with COPD to deteriorate.
Find out whether the patient uses an inhaler. Is the patient
currently taking steroids; if not, when was he or she last on
steroids? For patients on home oxygen, determine how
many liters per minute they use. Specifically ask if they
take a theophylline preparation (such as Uniphyl,
Theo-Dur, or Theolair).
If noncompliance seems to be an important contributing factor, attempt to establish why it has occurred and
address practical difficulties the patient may face. Manipulation and coordination of metered-dose inhalers (MDIs) may
be difficult. Sending a patient home without addressing
these issues invites an ED relapse.42 Some patients may be
reluctant to admit noncompliance to the physician. Nonconfrontational questions may include: Have you run out
of your medication? How do you take your medication?
April 2002
Circulation
Determine whether the patient is in overt shock by palpating peripheral pulses and evaluating the skin color and
temperature. If the patient has signs of hemodynamic
compromise, consider tension pneumothorax, cardiogenic
shock, theophylline toxicity, dehydration, or sepsis.
The cardiac exam may provide clues to CHF, such as a
gallop rhythm. Edema of the extremities can occur in many
conditions (including advanced COPD in association with
pulmonary hypertension), but unilateral leg swelling should
raise concern for DVT and PE. A positive hepatojugular
reflux provides strong evidence for CHF.
Patient Monitoring
ECG Monitoring
There is little evidence to recommend routine ECG
monitoring in the patient with an acute exacerbation of
COPD. However, in most EDs, patients in distress and
those with unclear reasons for decompensation are placed
on monitors. Monitoring is also useful in patients suspected
of dysrhythmias.
Physical Examination
Quickly assess the patients distress upon entering the room.
Is he or she anxious or lethargic? Is he or she diaphoretic,
cyanotic, or in extremis? An ABCs approach may help.
Pulse Oximetry
Pulse oximetry allows for continuous noninvasive monitoring of oxygenation and is an important adjunct in the care of
a patient with an acute exacerbation of COPD.45 While
values less than 92% are worrisome, some patients with
COPD are chronically hypoxic. A review of the patients
medical record may provide a useful comparison value.
While pulse oximetry is of value in monitoring
oxygenation, it has important limitations. Of particular
concern in COPD is the fact that it gives no indication of
how well the patient is ventilating. Significant hypercarbia
can remain undetected.
Airway
Determine whether the patient has a patent airway. If not, it
is likely that the patient will need emergent endotracheal
intubation. Suction secretions as needed.
Breathing
This is the most important aspect of the physical examination in the patient with respiratory distress. Assess the
respiratory rate and effort. Tachypnea is a common finding
in acute exacerbations of COPD. Bradypnea is ominous, and
assisted ventilation should be strongly considered. Note the
use of accessory muscles, pursed lips, intercostal retractions,
and if the patient is sitting in a tripod position (leaning
forward with extended arms on knees)all are signs of
respiratory distress. Patients who are unable to converse, or
those who speak only in short sentences, are in trouble.
Assess the patients mental status; lethargy may occur with
hypoxia, hypercarbia, or both.
Next, determine whether the trachea is midline, and
observe the neck veins. Tracheal deviation is a late finding
of tension pneumothorax. If the neck veins distend during
inspiration (Kussmauls sign), the patient has a significant
increase in right-sided venous pressurepossibly due to
right ventricular infarction, tension pneumothorax, pulmonary embolism, or pericardial tamponade.44
Observe the chest wall movement. An asymmetrical
chest rise may occur with pneumothorax. During chest
auscultation, assess for symmetrical breath sounds. Asymmetry may be due to a wide variety of pathologies, including pneumothorax, atelectasis, pneumonia, effusion, or
splinting. Wheezes and rales may occur with COPD or with
CHF, foreign bodies, or interstitial lung disease. A silent
Capnometry
Some authorities believe that dynamic capnometry may
help in assessing CO2 retention and provide useful information regarding the severity of airway obstruction. However,
while the association between capnometry values and
airflow obstruction has been studied in asthma,46 its utility
in acute exacerbations of COPD is not well-established.
IV Line
Patients with mild acute exacerbations of COPD may not
need IV access. However, patients who present with severe
acute exacerbations of COPD should have at least one
reliable IV line through which parenteral medications may
be given, especially if the need for rapid sequence intubation is likely.
Diagnostic Studies
Spirometry
According to the joint guidelines by American College of
PhysiciansAmerican Society of Internal Medicine and the
American College of Chest Physicians, acute spirometry
April 2002
April 2002
Treatment
Sputum Analysis
In the past, sputum induction and evaluation was common
practice. However, both the safety and value of sputum
induction are in question. Grams stains correlate poorly
with cultures.60 Sputum induction with hypertonic saline
has been associated with worsening bronchoconstriction in
patients with COPD.61
While microscopic evaluation of sputum is unnecessary, visual inspection of a patients sputum, while unappealing, is useful. Stockley et al recently noted that sputum
color may have clinical significance.62 They found that the
presence of green/purulent sputum was 94.4% sensitive
and 77.0% specific for a high-yield bacterial load. Other
studies suggest that a visual screen (or historical report) of
purulent sputums may identify those patients most likely to
benefit from antibiotic therapy.63
Oxygen Therapy
Supplemental oxygen is an essential part of ED therapy for
acute exacerbations of COPD. Administer oxygen to all
patients with acute exacerbations of COPD who present in
respiratory distress or have room air oxygen saturation
below 90%-92%.
A variety of delivery systems are available, including
nasal cannula and non-rebreather or Venturi masks.
Regardless of the mode of delivery, therapy should deliver
enough oxygen to support vital organ function (PaO2 60
mmHg, or SaO2 90%).4
This cutoff of 90% appears to be a consensus of existing
guidelines4 as well as recent clinical trials of oxygen therapy
in acute exacerbations of COPD.71 Agusti et al performed a
randomized, crossover controlled trial of supplemental
oxygen in 18 patients presenting with acute exacerbations of
COPD. They found that while Venturi masks were slightly
better than nasal prongs at maintaining SaO2 of 90% or
greater, neither route worsened respiratory acidosis.71
This slight advantage of the Venturi mask may be more
than offset by patient discomfort (i.e., inability to tolerate
the mask).
In the patient with normal physiology, elevations of
CO2 are responsible for the respiratory drive. Many patients
with advanced COPD lack this physiologic prompt and
depend on hypoxia for their respiratory stimulus. If too
much oxygen is given, some patients will develop hypercapnia. The risk of this going undetected in a closely
monitored setting appears to be small.72 When acute distress
arises, provide necessary oxygen to maintain the pulse
oximeter at 90% or greater. As the patients clinical condition
improves, the concentration of oxygen can be reduced.
Chest X-Ray
Tsai et al studied guidelines for the selective ordering of
chest x-rays in patients admitted for obstructive airway
disease.64 They recommended obtaining a chest x-ray for
any patient with complicated COPD. Complicated was
defined as fever, significant distress, heart disease, IV drug
abuse, seizures, immunosuppression, other pulmonary
disease, or prior thoracic surgery.
Emerman and Cydulka recommend a more liberal
approach. They argue that the emergency physician
consider a chest x-ray for all patients presenting with COPD,
as clinical criteria in their study were unable to accurately
predict patients with a positive radiograph.65 A chest x-ray
may offer early clues to other important diagnoses, such as
pneumonia, CHF, pleural effusion, aortic dissection, and
pneumothorax.4,66
Electrocardiogram
Inhaled Therapy
-agonists And Anticholinergics
In addition to oxygen, inhaled -agonists and anticholinergics are the cornerstones of therapy for acute exacerbations of COPD. Medications can be given by either smallvolume nebulizer or MDI with spacer. The mode of delivery
is not important for most patients with acute exacerbations
of COPD. Berry et al conducted a prospective, crossover
double-blind trial of these modes in 20 patients admitted to
the hospital for acute exacerbations of COPD.73 They found
no significant differences in the FEV1, forced vital capacity
(FVC), or Borg dyspnea score when comparing MDI to
nebulization. A recent systematic review of the literature
also found no difference in clinical effectiveness between
nebulizers and MDIs in patients with COPD.74
The addition of a spacer chamber is an important adjunct
when using the MDI and dramatically increases effective drug
delivery.75 Most of the literature documenting the equivalence of MDIs and nebulizers involves the use of a spacer
and has been limited to patients with mild-to-moderate
exacerbations. Patients do not need to be able to hold their
breath for 10 seconds when using MDIs with spacers. One
recent study showed that taking six normal tidal breaths per
puff (using a spacer chamber) is therapeutically equivalent
April 2002
Corticosteroids
While there is a small percentage of COPD patients for
whom corticosteroids improve outcome, it is not always
possible to predict who these patients are. Wood-Baker et al
systematically reviewed the use of oral corticosteroids in
acute exacerbations of COPD.87 They noted a significant
improvement in FEV1, but this was not sustained past 72
hours. In their review, there were fewer treatment failures
with IV or PO steroids.
Dosing and route of steroid administration vary widely.
ED dosages may vary from 0.5-1.5 mg/kg for oral or
parenteral steroids, and the subsequent doses may range
from 0.5-1.0 mg/kg per day for several days to a week.
Short-term steroids are associated with a small increase in
increase in adverse events, such as hyperglycemia.
While the literature remains spotty, oral corticosteroids
may suffice for most ED patients with an acute exacerbation
of COPD.
Methylxanthines
Barr et al systematically reviewed methylxanthines
(i.e., aminophylline) in acute exacerbations of COPD and
found that the use of aminophylline did not significantly improve
FEV1 and had no effect on hospital admission.88 If a patient
comes to the ED with an acute exacerbation of COPD and is
already on theophylline, check a serum theophylline level.
Adverse events secondary to toxicity, including death, are
more common among those with chronic use of theophylline. In a prospective study by Shannon, elderly patients
were more likely to experience severe toxicity, including
fatal cardiac arrhythmias.89
Combination Therapy
Multiple studies show that the combination of albuterol and
ipratropium provides superior bronchodilation than treatment
with either component alonewithout additional side effects.78-81
The combination of -agonists and anticholinergics may be
cost-effective as well. In one controlled trial, over 1000
patients were randomized to ipratropium alone, albuterol
alone, or the combination therapy. When the total costs of
therapy were examined (including costs associated with
decompensation and hospitalization), combination therapy
was less expensive than albuterol alone.82
Antibiotics
Dosing
Inhaled Corticosteroids
While inhaled corticosteroids appear to be beneficial in
April 2002
Continued on page 13
Respiratory arrest?
Severe dyspnea or profound tachypnea?
Yes
Life-threatening hypoxemia?
No
Moderate-to-severe dyspnea?
Respiratory rate > 25 breaths per minute?
The evidence for recommendations is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended.
Definitive, excellent evidence provides support. Class II: Acceptable and useful. Good evidence provides support. Class III: May be acceptable,
possibly useful. Fair-to-good evidence provides support. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a
patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2002 EB Practice, LLC. EB Practice, LLC (1-800-249-5770) grants each subscriber limited copying
privileges for educational distribution within your facility or program. Commercial distribution to promote any
product or service is strictly prohibited.
Emergency Medicine Practice
10
April 2002
Fever?
Significant distress?
Heart disease?
Intravenous drug abuse?
Seizures?
Immunosuppression?
Other pulmonary disease?
Prior thoracic surgery?
Diagnosis unclear?
No
Yes
No
Severe distress?
Irregular heart rate?
Signs of right heart failure?
No
The evidence for recommendations is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended.
Definitive, excellent evidence provides support. Class II: Acceptable and useful. Good evidence provides support. Class III: May be acceptable,
possibly useful. Fair-to-good evidence provides support. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a
patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2002 EB Practice, LLC. EB Practice, LLC (1-800-249-5770) grants each subscriber limited copying
privileges for educational distribution within your facility or program. Commercial distribution to promote any
product or service is strictly prohibited.
April 2002
11
Severe dyspnea?
Confusion or lethargy?
Worsening acidemia, hypoxemia, and
hypercapnia?
Mechanical ventilation?
Yes
No
Yes
No
Yes
Yes
No
No
The evidence for recommendations is graded using the following scale. For complete definitions, see back page. Class I: Definitely recommended.
Definitive, excellent evidence provides support. Class II: Acceptable and useful. Good evidence provides support. Class III: May be acceptable,
possibly useful. Fair-to-good evidence provides support. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a
patients individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2002 EB Practice, LLC. EB Practice, LLC (1-800-249-5770) grants each subscriber limited copying
privileges for educational distribution within your facility or program. Commercial distribution to promote any
product or service is strictly prohibited.
Emergency Medicine Practice
12
April 2002
Assisted Ventilation
When COPD is complicated by respiratory failure, hypoxia
and respiratory acidosis ensue. Unless timely ventilatory
assistance is given, worsening respiratory failure and death
are likely to follow. The traditional intervention has been
endotracheal intubation and mechanical ventilation. In
recent years, there has been an increased interest in the use
of NIV in COPD. Some have even proposed it as a new
standard of care.91 While NIV in emergency medicine has
been comprehensively reviewed in a recent edition of this
publication (see the July 2001 issue of Emergency Medicine
Practice, Noninvasive Airway Management Techniques:
How And When To Use Them), several points should
be reinforced.
Utility
NIV augments respiratory function and improves alveolar
ventilation by increasing tidal volume and preventing
collapse of distal airways. This reduces the respiratory work
and can improve both clinical parameters and gas exchange.
Multiple well-designed studies show that in properly
selected patients with COPD, NIV improves blood gases
and pH, reduces the need for tracheal intubation, and
decreases length of hospital stay.4,92-95 Brochard et al demonstrated a reduction in mortality, complications, and length of
stay when NIV was compared with traditional means of
invasive ventilation in patients with COPD.91 Plant et al
showed that NIV was both feasible and beneficial outside
the setting of the ICU.96 The Joint Guidelines support the
role of NIV in COPD.97 While NIV is clearly beneficial in
select patients with COPD, the literature shows mixed
results in patients with asthma.
Advantages/Disadvantages
In the proper circumstances, NIV offers several advantages
over intubation. Patients can be managed outside of the ICU
setting, which reduces ICU time and expense. Complications such as pneumonia occur less commonly, and overall
mortality is reduced. (Plus, who wants to be intubated?)
However, NIV is not without its problems. Some
patients find the mask very uncomfortable and experience
claustrophobia. If facemasks or nasal masks are ill-fitting,
significant air leaks can develop, rendering NIV ineffective.
If the masks are too tight, skin excoriation can develop.
Gastric distension and barotraumas may occur.
Even when patients have been carefully selected, NIV
can fail. Close observation and careful patient monitoring
will allow early detection of impending failure and facilitate
timely endotracheal intubation.
Patient Selection
To obtain maximum benefits, the decision to use NIV in
COPD exacerbation must be made early.96 If supplemental
oxygen provided by non-rebreather mask cannot maintain
oxygen saturation above 90%, consider the need for assisted
ventilation. Other indications include moderate acidosis
(pH 7.30-7.35), moderate-to-severe dyspnea, and respiratory
rate greater than 25 breaths per minute.
Patients must be alert, breathing spontaneously, and
an anticholinergic.
In one study, the combination of albuterol and ipratropium
was ultimately less expensive in terms of total health costs
than using ipratropium alone.82
3. Institute early NIV in suitable candidates.
One meta-analysis of NIV vs. standard therapy showed
a cost savings per patient admission of $3244 Canadian
for every patient treated with NIV compared to
mechanical ventilation.118
Caveat: Ensure that patients treated with NIV have no
contraindications to its use. (See text.)
April 2002
13
Intubation
Special Circumstances
Two interventions should be considered for patients
with acute exacerbations of COPD who present to the
ED: smoking cessation and flu vaccination. While these
issues cannot be comprehensively accomplished in the
ED visit, discussing them with the patient may facilitate
follow-up care.
Smoking cessation is the only proven method to decrease the
decline in lung function and is ultimately the most important
treatment of COPD. The benefits of smoking cessation are
greatest when the smoker quits early in life.4,108,109 A systematic review of influenza vaccination in patients with COPD
demonstrated a reduction in exacerbations.110
Controversies/Cutting Edge
Lung Volume Reduction Surgery
Lung volume reduction surgery is a promising intervention
14
April 2002
Role Of Heliox
Heliox is a mixture of helium and oxygen and has a lower
density than nitrogen-oxygen mixtures. It can decrease
turbulent airflow in obstructed airways and in theory
reduce the work of breathing. Although heliox has been
investigated in COPD, few randomized, controlled trials
have been reported. One such study by deBoisblanc et al
compared heliox to compressed air as the vehicle to deliver
bronchodilators in patients with COPD. Heliox failed to
show any clinical benefit compared to air alone.112
Disposition
The GOLD guidelines suggest admission for any patient
with an acute exacerbation of COPD who fails to respond
to initial medical management, has newly occurring
dysrhythmias or significant comorbidities, or in whom
there is diagnostic uncertainty. ICU admission is suggested
for patients who present with severe dyspnea, confusion
or lethargy, and worsening acidemia, hypoxemia,
and hypercapnia.
Once the patient is stable, it is important to determine
why this exacerbation occurred. Consider an underlying
infection, co-morbid illness (such as CHF or PE), and
medication noncompliance.
N-acetylcysteine
In the past, inhaled N-acetylcysteine (NAC) was used as a
mucolytic (Mucomyst). There is little literature to support its
use for this purpose.
However, oral NAC has been used in chronic stable
April 2002
15
Discharge Medications
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Summary
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References
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Anand SS, Wells PS, Hunt D, et al. Does this patient have deep vein
thrombosis? JAMA 1998 Apr 8;279(14):1094-1099. (Review)
Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for
safe management of patients with suspected pulmonary embolism.
Ann Intern Med 1998 Dec 15;129(12):997-1005. (Prospective, cohort;
1239 patients)
Wicki J, Perneger TV, Junod AF, et al. Assessing clinical probability of
pulmonary embolism in the emergency ward: a simple score. Arch
Intern Med 2001 Jan 8;161(1):92-97. (Regression analysis; 1090 patients)
Tapson VF, Carroll BA, Davidson BL, et al. The diagnostic approach to
acute venous thromboembolism. Clinical practice guideline. American
Thoracic Society. Am J Respir Crit Care Med 1999 Sep;160(3):1043-1066.
(Practice guideline)
Kline JA, Israel EG, Michelson EA, et al. Diagnostic accuracy of a
bedside D-dimer assay and alveolar dead-space measurement for
rapid exclusion of pulmonary embolism: a multicenter study. JAMA
2001 Feb 14;285(6):761-768. (Prospective; 380 patients)
Hartmann IJ, Hagen PJ, Melissant CF, et al. Diagnosing acute
pulmonary embolism: effect of chronic obstructive pulmonary disease
on the performance of D-dimer testing, ventilation/perfusion
scintigraphy, spiral computed tomographic angiography, and
conventional angiography. ANTELOPE Study Group. Advances in
New Technologies Evaluating the Localization of Pulmonary
Embolism. Am J Respir Crit Care Med 2000 Dec;162(6):2232-2237.
(Multicenter, prospective, comparative; 627 patients)
Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute
cardiac ischemia in the emergency department. N Engl J Med 2000 Apr
20;342(16):1163-1170. (Multicenter, prospective; 10,689 patients)
Aitchison F, Bleetman A, Munro P, et al. Detection of pneumothorax by
accident and emergency officers and radiologists on single chest films.
Arch Emerg Med 1993 Dec;10(4):343-346. (Comparative; 233 pairs of
films)
Tandberg D, Sklar D. Effect of tachypnea on the estimation of body
temperature by an oral thermometer. N Engl J Med 1983 Apr
21;308(16):945-946. (Prospective)
Kresovich-Wendler K, Levitt MA, Yearly L. An evaluation of clinical
predictors to determine need for rectal temperature measurement in
the emergency department. Am J Emerg Med 1989 Jul;7(4):391-394.
(Cross-sectional, comparative; 366 patients)
Zehner WJ Jr, Scott JM, Iannolo PM, et al. Terbutaline vs albuterol for
out-of-hospital respiratory distress: randomized, double-blind trial.
Acad Emerg Med 1995 Aug;2(8):686-691. (Randomized, controlled trial;
83 patients)
Dickinson ET, OConnor RE, Megargel R. The prehospital use of
nebulized albuterol on patients with wheezing whose chief complaint
is shortness of breath. Del Med J 1992 Nov;64(11):679-683. (Prospective;
62 patients)
Craven RA, Singletary N, Bosken L, et al. Use of bilevel positive
airway pressure in out-of-hospital patients. Acad Emerg Med 2000
Sep;7(9):1065-1068. (Prospective; 71 patients)
Holleman DR Jr, Simel DL, Goldberg JS. Diagnosis of obstructive
airways disease from the clinical examination. J Gen Intern Med 1993
Feb;8(2):63-68. (Prospective, observational)
Dolce JJ, Crisp C, Manzella B, et al. Medication adherence patterns in
chronic obstructive pulmonary disease. Chest 1991 Apr;99(4):837-841.
(78 patients)
Dolly FR, Block AJ. Increased ventricular ectopy and sleep apnea
following ethanol ingestion in COPD patients. Chest 1983
Mar;83(3):469-472.
McGee SR. Physical examination of venous pressure: a critical review
[see comments]. Am Heart J 1998;136(1):10-18. (Review; 78 references)
Jones J, Heiselman D, Cannon L, et al. Continuous emergency
department monitoring of arterial saturation in adult patients with
respiratory distress. Ann Emerg Med 1988 May;17(5):463-468.
(Prospective; 40 patients)
Yaron M, Padyk P, Hutsinpiller M, et al. Utility of the expiratory
capnogram in the assessment of bronchospasm. Ann Emerg Med 1996
Oct;28(4):403-407. (Prospective; 48 patients)
Emerman CL, Connors AF, Lukens TW, et al. Relationship between
arterial blood gases and spirometry in acute exacerbations of chronic
obstructive pulmonary disease. Ann Emerg Med 1989 May;18(5):523527. (70 patients)
Emerman CL, Cydulka RK. Use of peak expiratory flow rate in
emergency department evaluation of acute exacerbation of chronic
obstructive pulmonary disease. Ann Emerg Med 1996 Feb;27(2):159-163.
(Comparative; 199 patients)
McCrory DC, Brown C, Gelfand SE, et al. Management of acute
exacerbations of COPD: a summary and appraisal of published
April 2002
50.
51.
52.*
53.
54.
55.
56.
57.*
58.
59.*
60.
61.
62.*
63.*
64.
65.*
66.*
67.
68.
69.
70.
71.
72.
73.*
17
74.
75.
76.
77.*
78.
79.*
80.*
81.
82.*
83.
84.
85.*
86.*
87.*
88.*
89.*
90.
91.
92.*
93.*
94.*
95.*
96.* Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation
for acute exacerbations of chronic obstructive pulmonary disease on
general respiratory wards: a multicentre randomised controlled trial.
Lancet 2000 Jun 3;355(9219):1931-1935. (Randomized, controlled trial;
236 patients)
97.* Bach PB, Brown C, Gelfand SE, et al. American College of PhysiciansAmerican Society of Internal Medicine, American College of Chest
Physicians. Management of acute exacerbations of chronic obstructive
pulmonary disease: a summary and appraisal of published evidence.
Ann Intern Med 2001 Apr 3;134(7):600-620. (Meta-analysis, practice
guideline)
98. Smith DC, Bergen JM, Smithline H, et al. A trial of etomidate for rapid
sequence intubation in the emergency. J Emerg Med 2000;18:13-16.
(Prospective; 34 patients)
99. Bergen JM, Smith DC. A review of etomidate for rapid sequence
intubation in the emergency department. J Emerg Med 1997 MarApr;15(2):221-230. (Review; 162 references)
100. Laurin EG, Sakles JC, Panacek EA, et al. A comparison of succinylcholine and rocuronium for rapid-sequence intubation of emergency
department patients. Acad Emerg Med 2000 Dec;7(12):1362-1369.
(Prospective, comparative; 520 patients)
101.* Tuxen DV. Detrimental effects of positive end-expiratory pressure
during controlled mechanical ventilation of patients with severe
airflow obstruction. Am Rev Respir Dis 1989 Jul;140(1):5-9. (6 patients)
102.* Pepe PE, Marini JJ. Occult positive end-expiratory pressure in
mechanically ventilated patients with airflow obstruction: the autoPEEP effect. Am Rev Respir Dis 1982 Jul;126(1):166-170. (Case report)
103. Sydow M, Golisch W, Buscher H, et al. Effect of low-level PEEP on
inspiratory work of breathing in intubated patients, both with healthy
lungs and with COPD. Intensive Care Med 1995 Nov;21(11):887-895.
(Controlled; 12 patients)
104.* Corbridge TC, Hall JB. Techniques for ventilating patients with
obstructive pulmonary disease. J Crit Illness 1994 Nov;9(11):1027-1036.
(Review; 22 references)
105.* Jain S, Hanania NA, Guntupalli KK. Ventilation of patients with
asthma and obstructive lung disease. Crit Care Clin 1998;14:685-705.
(Review)
106. Georgopoulos D, Mitrouska I, Markopoulou K, et al. Effects of
breathing patterns on mechanically ventilated patients with chronic
obstructive pulmonary disease and dynamic hyperinflation. Intensive
Care Med 1995 Nov;21(11):880-886. (Randomized, controlled trial; 9
patients)
107.* Williams TJ, Tuxen DV, Scheinkestel CD, et al. Risk factors for
morbidity in mechanically ventilated patients with acute severe
asthma. Am Rev Respir Dis 1992 Sep;146(3):607-615. (Retrospective, 88
patients; prospective, 22 patients)
108.* Pride NB. Smoking cessation: effects on symptoms, spirometry and
future trends in COPD. Thorax 2001 Sep;56 Suppl 2:ii7-10. (Review)
109.* Xu X, Dockery DW, Ware JH, et al. Effects of cigarette smoking on rate
of loss of pulmonary function in adults: a longitudinal assessment. Am
Rev Respir Dis 1992 Nov;146(5 Pt 1):1345-1348. (Cross-sectional; 8191
patients)
110.* Cates CJ, Jefferson TO, Bara AI, et al. Vaccines for preventing influenza
in people with asthma (Cochrane Review). Cochrane Database Syst Rev
2000;(4):CD000364. (Systematic review)
111. Hensley M, Coughlan JL, Gibson P. Lung volume reduction surgery
for diffuse emphysema(Cochrane Review). Cochrane Database Syst Rev
2000;2. (Systematic review)
112. deBoisblanc BP, DeBleiux P, Resweber S, et al. Randomized trial of the
use of heliox as a driving gas for updraft nebulization of
bronchodilators in the emergent treatment of acute exacerbations of
chronic obstructive pulmonary disease. Crit Care Med 2000
Sep;28(9):3177-3180. (Randomized, controlled trial; 25 patients)
113. Grandjean EM, Berthet P, Ruffmann R, et al. Efficacy of oral long-term
N-acetylcysteine in chronic bronchopulmonary disease: a metaanalysis of published double-blind, placebo-controlled clinical trials.
Clin Ther 2000 Feb;22(2):209-221. (Meta-analysis)
114.* Appleton S, Smith B, Veale A, et al. Long-acting beta2-agonists for
chronic obstructive pulmonary disease. Cochrane Database Syst Rev
2000;(2):CD001104. (Systematic review)
115.* Rennard SI, Anderson W, ZuWallack R, et al. Use of a long-acting
inhaled beta2-adrenergic agonist, salmeterol xinafoate, in patients with
chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2001
Apr;163(5):1087-1092. (Randomized, controlled trial; 405 patients)
116.* van Noord JA, Bantje TA, Eland ME, et al. A randomised controlled
comparison of tiotropium and ipratropium in the treatment of chronic
obstructive pulmonary disease. The Dutch Tiotropium Study Group.
Thorax 2000;55:289-294. (Randomized, controlled trial)
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April 2002
April 2002
19
63. All of the following are true of inhaled anticholinergic agents in COPD except:
a. Their actions are mediated through muscarinic
receptors.
b. They work in a synergic manner with -agonists.
c. They are associated with very few side effects.
d. Used alone, they are superior to -agonists in
COPD.
20
April 2002