• Acute exacerbations of COPD (AECOPD) defined as worsening dyspnea, cough, and/or sputum production; which leads to a change in treatment.
• Fourth leading cause of death worldwide.
• Approximately 138,500 individuals ≥ 45 years old in BC have COPD – underdiagnosed.
• AECOPD identifies patients with a significantly higher mortality risk compared to stable COPD patients.
• 20% require hospitalization.

AECOPD is a clinical diagnosis, several scoring systems have been created (Ottawa COPD severity score, DECAF, and BAP-65) but none have sufficient sensitivity/specificity to be used routinely.

Most of the patients with mild to moderate exacerbations do not come to the ED.

Important historical factors

• comorbid conditions
• drugs – prescribed and illicit
• smoking history
• previous exacerbations, including treatment required
• need for mechanical ventilation, and
• frequency of hospitalizations.

Triggers

• Infections (virus or bacteria) most common
• Environmental – irritants and extreme weather
• Left ventricular failure
• Sputum retention (chest trauma – poor inspiration, diminished cough reflex)
• Pulmonary embolism
• Pneumothoraces, and
• Medications such as opioids, beta-blockers, antihistamines, antitussives, diuretics.

Vital signs

• Tachypnea
• Tachycardia
• Hypoxia/cyanosis)
• Respiratory effort/accessory muscle use and mental status

Evidence of respiratory fatigue.

Blood gases

• Venous gases
  • pH and pCO2 correlate well with arterial blood gases.

Monitoring for hypercapnia after the initiation of supplemental oxygen. VBG, mental status and respiratory drive).

Chest X-Ray

• Precipitating causes (i.e pneumonia).
• Differential diagnosis (infiltrates, lung masses, pneumothoraces, pulmonary edema, etc).

Point-of-care ultrasound can quickly narrow the differential diagnosis for dyspnea

• heart, lungs, and deep veins.

ECG

• Arrhythmia and/or ischemia
• ECG findings with COPD: (link to ECG )
  • Right heart strain
  • RV hypertrophy
  • P pulmonale
  • RAD, RBBB
  • ST depression or inversion in V1-V3.

Consider

• Troponin
• BNP or NT- proBNP
• Sputum Gram stain and culture
• Respiratory viral swab
• CT Chest.

If the patient fails to improve, consider pulmonary embolism and CHF.

1. Wedzicha JA Ers Co-Chair, et al. Management of COPD Exacerbations: A European Respiratory Society/American Thoracic Society Guideline. Eur Respir J. 2017 Mar 15;49(3). pii: 1600791.

   
   

2. Cochrane Database

    

    

   
   

3. BCGuidelines.ca – COPD