Breathlessness- COPD exacerbation

A 67 year old woman is admitted with worsening SOB on exertion to the ED. She has a background of COPD, HFREF, and T2DM. She is waiting to be clerked, and the nurse in the ED has requested a review for this patient as she is more breathless. How would you approach this patient and what are the next steps?

Answer:

I would start by getting a focused history if the patient is able to give a brief history and ask about the speed of onset of symptoms and other associated respiratory symptoms such as cough, sputum, chest pain, and difficulty lying flat. I would also ask about significant past medical history of cardiorespiratory problems and how well controlled her COPD was. Additionally, I would inquire about significant risk factors, specifically smoking history and exposure to asbestos. After this, I would proceed with a focused assessment using the A to E approach.

Airway: I would ensure the airway is patent and if necessary, insert an airway adjunct such as OP or NP airway. If the patient is tolerating an airway adjunct, I would be really worried and seek the help of the critical care team after my assessment.

Breathing: I would look at the observations, specifically the oxygen saturation and the respiratory rate. If the patient is hypoxic or if the patient has increased work of breathing, I’ll start the patient on supplemental oxygen therapy ensuring she is on scale 2 of oxygen. I would also get an ABG for this patient to assess the pH, pO2, pCO2, HCO3, and lactate levels.

Circulation: I would look at the observations, specifically the BP, heart rate, and CRT. If there is evidence of hypotension or tachycardia, I would give a fluid challenge to see if there is an adequate response. If the patient remains hypotensive despite the first fluid challenge, I would give another fluid challenge and ensure the critical care team is aware of the patient. I would also ensure the patient has a working cannula and send basic bloods including septic screening. I would also request an ECG for the patient.

Disability: I would check the patient’s blood glucose, temperature, and perform a focused neurological assessment that includes GCS. Specifically, if the GCS is less than 8 or if there are focal neurological deficits, I would be concerned and investigate this further.

Question – At this stage, the interviewer can interrupt and provide the following information:

The patient is normotensive, tachycardic, and has increased work of breathing with SpO2 of 80% on air. Her ABG shows pH 7.2, pO2 10, pCO2 8, HCO3 32, lactate 1.8. Her chest examination reveals bilateral basal crackles with evidence of polyphonic wheeze. What would you do next?

Answer:

Based on the above information, she is in type 2 respiratory failure and likely has an exacerbation of COPD. In the first instance, I would sit the patient up and give the minimum amount of O2 to maintain sats ≥88% (aim for pO2 78kpa) as part of controlled oxygen therapy. I would give salbutamol 2.5mg ± ipratropium 500mcg nebulized (driven by air, leaving nasal O2 cannulae on under the mask if necessary) and prednisolone 30mg PO (or hydrocortisone 200mg IV). I would send sputum for M,C+S and arrange a chest X-ray.

I would also start the patient on antibiotics (PO doxycycline and IV Co-amoxiclav). I would escalate this to a senior and aim to do a repeat ABG after 1 hour to see if the controlled oxygen therapy has worked.

Question – The patient continues to deteriorate and the repeat ABG is unchanged. What would you do now?

Answer:

This would be quite concerning, and I would immediately escalate this to the senior as the patient would likely need to be commenced on NIV (Non-invasive ventilation). I would discuss with the ED nurse in charge and try to arrange a bed in the ED resuscitation area for the patient to be monitored closely, with regular ABGs to be done once NIV is commenced. I would also update the family and next of kin (NOK) about the progress and clinical status. I will ensure that the critical care team is aware of the patient as well.