1. COPD “Trying to Expire Not Expire” Dr Esyld Watson HST Emergency Medicine

2. Overview  Background  Definitions  Case  Pre-hospital  ED initial management  ED continued management  Evidence  Cardiac arrest

3. Background  3 million people UK  Most diagnosed late 50s  Predominantly caused by smoking  Airflow obstruction not fully reversible  No simple diagnostic test

4. Definition  No recognised definition  Consider –Over 35 AND –Smoker or ex-smoker AND –Any  Exertional SOB  Chronic cough  Regular sputum  Frequent winter “wheeze” –And do not have asthma

5. Case  999 call SOB  65 year old female known COPD  Increasing SOB and cough 2/7  Can’t speak in sentences

6. Case – Prehospital Assessment  A –Talking one or two words at time  B –RR 30, Sp0 2 77% OA, wheeze throughout  C –HR 110 irreg, BP 187/98  D –GCS 14/15 (E3,V5,M6), BM 10.9  E –Nil of note

7. Case – Prehospital Management  A –Sit upright –High flow oxygen  B –Position, forced expiration –Nebulised salbutamol 5mg –Ipratropium 500mcg –Hydrocortisone 100-200mg IV

8. Case – Prehospital Management  C –IV access –IV fluids –ECG monitoring  D –Monitor  E

9. Where to Manage? Treat at home? Treat in hospital? Able to cope at home? YesNo SOBMildSevere General condition GoodPoor/deteriorating Level of activity Good Poor/confined bed CyanosisNoYes Worsening peripheral oedema NoYes Level of consciousness NormalImpaired Already on LTOT NoYes Social circumstances Good Living alone/not coping Acute confusion NoYes Rapid rate of onset NoYes Significant co-morbidity NoYes Sa02 < 90% NoYes Changes on CXR NoPresent Arterial pH level ≥ 7.35 < 7.35 Arterial Pa02 ≥ 7 kPa < 7kPa

10. Case – Arrival into ED  A –No longer talking  B –RR 36, Sp02 99% 15L –Poor AE little wheeze –Clinically no pneumothorax

11. Case – Arrival in ED  C –HR 136 irreg, BP 178/98 –Large volume radial pulse –Clammy  D –GCS 11/15 (E2V4M5), BM 10.1 –T 38.1

12. Case – Management in ED  A –Position –Consider NP airways - suction  B –Sit upright –CXR –ABG

13. Case – Management in ED  C –ECG shows AF –Bloods and cultures taken as pyrexial  D –Monitor  E

14. Arterial Blood Gases  pH7.15  pC0214.5  P0212.1  HCO3-33  BE4  Lactate3.7

15. ABG Interpretation  Are they hypoxic?  Are they acidotic or alkalotic?  Is it respiratory or circulatory?  Base and Bicarbonate?

16. Arterial Blood Gases  pH7.15  pC0214.5  P0212.1  HCO3-33  BE4  Lactate3.7

17. Specific Therapies  Nebulised bronchodilators  Steroids  Antibiotics  Magnesium  NIV

18. Bronchodilators  Salbutamol –Short acting beta2 agonist –Smooth muscle relaxant –Reversal of bronchospasm –Remember partial effects in COPD  Ipratropium –Antimuscarinic bronchodilator

19. Corticosteroids  Prednisolone –30mg od 7-14 days  Hydrocortisone –100 – 200 mg IV

20. Antibiotics  Purulent sputum  Signs pneumonia  PO doxycycline

21. Magnesium

22. Non-Invasive Ventilation  Hypercapnic ventilatory failure  Clear ceilings care

23. Questions

24. Summary  Keep it simple  ABCDE  Reassess  Hypoxia kills first!