Patient might be smoking currently or might have quit but smoked for several years in the past. They present with cough, SOB, increased Sputum production and must be getting worse gradually or suddenly. Some might be on Oxygen already. Lot of patients continue to smoke even though they are on supplemental oxygen.
ER:
Routine Labs, CXR, EKG.
Respiratory virus panel RT-PCR to rule out common viral infections. This test rules out COVID too.
Supplemental Oxygen via Nasal cannula.
Duonebs-Albuterol + Atrovent q 4-6hrs.
ABG if very short of breath to see PCO2 elevation–>BiPap if needed for elevated.
Solumedrol 125mg IV one dose.
Antibiotic if suspecting infection with increased sputum production or with purulent sputum-ceftriaxone plus Azithromycin or Levofloxacin alone.
Hospitalist:
Telemetry in observation status. Can make inpatient status if patient needs BiPap.
Continue IV antibiotics-Ceftriaxone plus Azithromycin if infection suspected, not all patients need antibiotics. Sputum C/S if suspecting pneumonia.
IV solumedrol 40mg IV q 12 hrs. Increase dose if very short of breath like 60mg Q 8hrs. Many times, just PO prednisone 40mg once a day is sufficient in mild cases.
Some patients need 5 days of Prednisone and some severe COPD patients need slow tapering of Prednisone over a period of 10-14 days.
Pulmonary consult for severe COPD especially if started on BiPap.
ICU consult if ABG does not improve after 1-2 hrs of BiPap placement.
Offer Nicotine patch and gums if smoker, Counselling to quit smoking
Oxygen to maintain oxygen saturation of 90-92%
Duonebs [Albuterol + Ipratropium] q 6hrs
6 min walking Desat study prior to discharge for Home Oxygen set up if required–> Consult Case Manager for that.
PT and OT evaluation if patient is very old and sick –>for possible pulmonary rehab placement
PFTs (Pulmonary Function Tests) as out patient, not done in the inpatient setting as they have to be done once patient is completely back to baseline after acute illness resolves.
Influenza [if it’s the season] and Pneumonia vaccines.
Pulmonary follow up in one week in severe COPD cases to prevent readmission.
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Some Oxygen Delivery Instruments:
Room air=21% oxygen.
Every 1 LPM of O2 via NC increases O2 % by 4%, Use humidifier at higher O2 flows.
Venti Mask-used for accurate Oxygen supply to prevent Over Oxygenation especially in CO2 retainers.
Simple Face Mask.
NRB mask provides 100% Oxygen.
BiPAP in hypercapnic respiratory failure to improve CO2 retention.
Intubation in some if patient is very sick and unable to improve with BiPap.
