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Awaiting dx, severity and tx setting assessment
Determine severity and need for oxygenation/ventilation. Evaluate dyspnea using VAS (0-10), sputum color/volume. Check vital signs, use of accessory muscles, SpO2 +/- ABG, CXR, and CRP. (VBG to assess bicarb and pH is accurate vs. ABG; more data needed on VBG for guiding decisions in acute resp failure.) Determine tx setting (outpt vs. inpt). Initiate tx w/ SABAs. Severity - Mild: dyspnea VAS <5; RR <24; HR <95; SaO2 ≥92% (or pt’s usual O2 Rx) AND change in SaO2 ≤3%; CRP <10.
- Moderate (meets 3 of 5): dyspnea VAS ≥5; RR ≥24; HR ≥95; SaO2 <92% on RA (or pt’s usual O2 Rx) AND/OR change in SaO2 >3%; ABG w/ PaO2 ≤60 mmHg and/or PaCO2 >45 w/o acidosis; CRP ≥10.
- Severe: dyspnea VAS ≥5; RR ≥24; HR ≥95; SaO2 <92% on RA (or pt’s usual O2 Rx) AND/OR change in SaO2 >3%; ABG shows new-onset/worsening hypercapnia and acidosis (PaCO2 >45 mmHg and pH <7.35).
Indications for hospitalization - Severe sx (e.g., sudden worsening resting dyspnea, ↑RR, ↓SaO2, confusion, drowsiness)
- Acute resp failure
- New cyanosis, periph edema
- Failure to respond to initial tx
- Serious comorbidities (e.g., HF, new arrhythmia)
- Insufficient home support
Evaluate inpt candidates for resp failure. - Life-threatening acute resp failure: RR >24, accessory muscle use, acute ∆ MS, hypoxemia not improved w/ O2 via Venturi mask or requiring FiO2 >40%, ↑PaCO2 vs. baseline (or >60 mmHg) or pH ≤7.25.
- Non–life-threatening acute resp failure: RR >24, accessory muscle use, no ∆ MS, hypoxemia improves w/ O2 (e.g., FiO2 >35% Venturi mask), ↑PaCO2 vs. baseline (or elevated 50-60 mmHg).
- No resp failure: RR ≤24, no accessory muscle use, no ∆ MS, hypoxemia improves w/ O2 (24%-35% FiO2 Venturi mask) w/o ↑PaCO2.
Oxygenate as needed. Target pulse ox 88% to 92%. - High-flow (Venturi) masks offer better accuracy/control vs. nasal prongs.
- High-flow O2 nasal cannula may reduce need for intubation.
Assess need for assisted ventilation and initiate if appropriate. Use NIV first, if not absolutely contraindicated; NIV improves gas exchange, decreases breathing work, need for intubation, and hospitalization duration, and improves survival [A]. - NIV (nasal/facemask) indications:
◦ Resp acidosis (PaCO2 ≥45 mmHg, pH ≤7.35)
◦ Severe dyspnea w/ signs of resp muscle fatigue and/or ↑work of breathing (e.g., accessory muscle use, paradoxical abdomen motion, intercostal retractions)
◦ Persistent hypoxemia despite O2
- Invasive ventilation indications:
◦ Failure of and/or can’t tolerate NIV
◦ S/P resp/cardiac arrest
◦ ↓consciousness, psychomotor agitation inadequately controlled w/ sedation
◦ Massive aspiration/persistent vomiting
◦ Persistent inability to remove resp secretions
◦ Severe hemodynamic instability w/o response to fluids/vasoactive meds
◦ Severe arrhythmias (ventricular, supraventricular)
◦ Life-threatening hypoxemia in pts unable to tolerate NIV
Initiate short-acting BDs: SABA ( albuterol, levalbuterol ( MDI, NEB)) +/- SAMA (ipratropium ( MDI, NEB)) [C]. Use spacer or NEB hourly x2-3 doses, then q2-4h. - Route: No significant FEV1 difference between MDI (w/ or w/o spacer) vs. NEB, though NEB may be easier for sicker pts; continuous NEB not recommended.
- If NEB used, air-driven preferred vs. O2-driven to avoid potential ↑PaCO2. Use standard COVID-19 precautions; keep circuit intact; use mesh NEB in ventilated pts.
Confirm dx and etiology. - Viral testing, sputum cx
- Consider DDx.
◦ Most frequent: pneumonia, PE, CHF.
◦ Less frequent: pneumothorax, pleural effusion, MI, arrhythmias.
◦ Test as appropriate (CXR, d-dimer, CT, pro-BNP/BNP, echo, ECG, troponin). - Test for COVID-19 w/ new or worsening resp sx, fever, loss of taste and/or smell. Positive SARS-CoV-2 testing does not exclude the potential for other resp pathogens. Consider chest CT to help distinguish COVID-19 effects from other causes of exac.
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Oxygenate/ventilate, follow serial blood gases and SaO2, give short-acting BDs, start systemic steroids. Admit to MICU if using NIV/ventilator. - If life-threatening acute resp failure: oxygenate, ventilate (NIV preferred if not contraindicated), target pulse ox 88% to 92% sat; check frequent ABG/VBG for ↑PaCO2/acidosis.
- If non–life-threatening: Supplemental O2 to target pulse ox 88% to 92% sat, check frequent ABG/VBG for ↑PaCO2/acidosis. If ↑work of breathing or impaired gas exchange: Consider ventilation; NIV preferred if not contraindicated. High-flow nasal tx benefits unclear.
Indications for resp care unit or MICU admission - Severe dyspnea w/ inadequate response to initial tx
- Mental status changes (lethargy, coma)
- Persistent or worsening hypoxemia (PaO2 <5.3 kPa or <40 mmHg) and/or worsening resp acidosis (pH <7.25) despite supplemental O2 + NIV
- Need for NIV
- Hemodynamic instability/need for vasopressors
Give short-acting BDs: SABA ( albuterol, levalbuterol ( MDI, NEB)) +/- SAMA (ipratropium ( MDI, NEB)) [C]. Use NEB hourly x2-3 doses, then q2-4h. Continuous NEB not recommended. Air-driven NEB preferred vs. O 2-driven to avoid potential ↑PaCO 2. Use standard COVID-19 precautions; keep circuit intact; use mesh NEB in ventilated pts. Give systemic steroids: prednisone 40 mg/day x5 days [A]. Oral is as effective as IV; nebulized budesonide (more expensive) may be alternative to PO in some pts. Steroids ↑ FEV 1 and oxygenation, ↓ recovery time/hospitalization duration; use ≤5 days [A]. Even short burst assoc w/ ↑risk of pneumonia, sepsis, and death. Confine use to pts w/ significant exac. Give abx x5-7 days. Use controversial but indicated in pts who require ventilation (invasive or not). When indicated (e.g., ↑sputum purulence/volume, dyspnea), can ↓ recovery time/hospitalization duration, ↓ early relapse risk/tx failure [B]; duration: 5 days [B]. - Select abx based on local resistance patterns: aminopenicillin w/ clavulanic acid, macrolide, tetracycline, or quinolone (in selected pts). If frequent exac (2+ per year), severe airflow limits, and/or exac requiring ventilation: cx from sputum/lung material to evaluate for Pseudomonas/other GNRs/resistant organisms.
- Use of procalcitonin to guide abx tx not recommended; if CRP low, may consider withholding abx, though more data needed.
Provide VTE prophylaxis (SC heparin/LMWH). Identify and treat associated conditions (HF, arrhythmias, PE, etc.). Assess for vit D deficiency. Methylxanthines not recommended due to side effects [B]. Resp stimulants not recommended for acute resp failure. Plan d/c for stable pts. - Start maintenance tx w/ long-acting BDs ASAP prior to d/c; determine maintenance tx according to GOLD COPD groups.
- Add short-acting BD for sx rescue.
- Check inhaler technique.
- Check pt understanding of withdrawal of steroids/abx.
- Assess need for outpt O2.
- Identify/address all clinical/investigational abnormalities.
- Create COPD exac action and mgmt plan w/ educational component.
- Smoking cessation
- Consider shielding measures (e.g., masking, social distancing, handwashing) to prevent future exac in winter months.
- Arrange f/u at <4wk and at 12-16wk; reassess needs for meds, O2, etc.
- Pts w/ COVID-19: Advise regarding self-quarantine and transmission mitigation. Ensure adequate supplies of home meds. Consider remote (phone/online) f/u.
F/u 1-4wk - Evaluate ability to cope in usual environment.
- Review understanding of tx regimen.
- Reassess inhaler techniques.
- Reassess need for long-term O2.
- Document physical activity capacity and evaluate eligibility for pulm rehab.
- Document sx: CAT or mMRC.
- Determine status of comorbidities.
F/u 12-16wk - Evaluate ability to cope in usual environment.
- Review understanding of tx regimen.
- Reassess inhaler techniques.
- Reassess need for long-term O2.
- Document capacity for physical activity and activities of daily living.
- Document sx: CAT or mMRC.
- Measure spirometry: FEV1.
- Determine status of comorbidities.
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Start w/ short-acting beta-2 agonists +/- short-acting anticholinergics for mild exac. - Assess O2 sat by pulse ox.
- Increase short-acting inhaled BDs: SABA (albuterol, levalbuterol (MDI, NEB)) +/- SAMA (ipratropium (MDI, NEB)) [C]. Dose: 1 puff q1h x2-3 doses, then q2-4h based on response. BD may suffice for mild exac. Use spacer or NEB. No significant FEV1 difference between MDI (w/ or w/o spacer) vs. NEB, though NEB may be easier for sicker pts; continuous NEB not recommended.
- If ↑bacterial signs: Consider PO abx for ≤5 days in pts w/ ↑SOB + ↑sputum + ↑purulence (or ↑purulence + either ↑SOB or ↑sputum). Use controversial.
◦ When indicated, can ↓ recovery time/hospitalization duration, ↓ early relapse risk/tx failure [B]; duration: ≤5 days in outpts.
◦ Select abx based on local resistance patterns: aminopenicillin w/ clavulanic acid, macrolide, tetracycline, or quinolone (in selected pts). If frequent exac (2+ per year), severe airflow limits, and/or exac requiring ventilation: cx from sputum/lung material to evaluate for Pseudomonas/other GNRs/resistant organisms. Outpt sputum cx not feasible/reliable to guide tx. Procalcitonin not recommended; if low CRP, may be safe to withhold abx, but supporting evidence is limited. - Give PO steroids: prednisone 40 mg/day for ≤5 days [A]. May be less effective in pts w/ low eosinophil levels.
- Continue long-acting BD (LAMA and/or LABA) throughout exac.
- Methylxanthines not recommended due to side effects [B].
- Test for COVID-19 w/ new or worsening resp sx, fever, loss of taste and/or smell. Positive SARS-CoV-2 testing does not exclude the potential for other resp pathogens. Pts w/ COVID-19 should continue taking PO and inhaled resp meds for COPD.
Mitigate risks, plan f/u. - Prevent future exac w/ long-acting BD and other maintenance tx based on GOLD COPD group recommendations.
- Check inhaler technique.
- Create COPD exac action and mgmt plan w/ educational component.
- Smoking cessation
- Consider shielding measures (e.g., masking, social distancing, handwashing) to prevent future exac in winter months.
- Arrange f/u at <4wk and at 12-16wk; reassess needs for meds, O2, etc.
- Pts w/ COVID-19: Advise regarding self-quarantine and transmission mitigation. Ensure adequate supplies of home meds. Consider remote (phone/online) f/u.
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