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Old 05-28-2012
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Lungs COPD exacerbation...what is the next step ? plz give expln

A 64-year-old man with a history of chronic obstructive pulmonary disease is evaluated in the emergency department for increased dyspnea over the past 48 hours. There is no change in his baseline production of white sputum, but he has increased nasal congestion and sore throat. His medications are inhaled tiotropium, fluticasone, salmeterol, and albuterol. Therapy with methylprednisolone, inhaled albuterol, and ipratropium bromide is started.
The patient is alert but in mild respiratory distress. The temperature is 38.6C (101.5F), the blood pressure is 150/90 mm Hg, the pulse rate is 108/min, and the respiration rate is 30/min. Breath sounds are diffusely decreased with bilateral expiratory wheezes; he is using accessory muscles to breathe. With the patient breathing oxygen, 2 L/min by nasal cannula, arterial blood gases are pH 7.27, PCO2 60 mm Hg (8.0 kPa), and PO2 62 mm Hg (8.2 kPa); oxygen saturation is 91%.

Which of the following is the most appropriate next step?

(A) Increase oxygen to 5 L/min
(B) Intubation and mechanical ventilation
(C) Start aminophylline infusion
(D) Start noninvasive positive-pressure ventilation
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i think B........
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(D) Start noninvasive positive-pressure ventilation
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kaplan says if patient is hypoxemic despite treatment, consider intubation and mechanical ventilation......

wats the answer?????
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Quote:
Originally Posted by K06100 View Post
kaplan says if patient is hypoxemic despite treatment, consider intubation and mechanical ventilation......

wats the answer?????
The points in favor of intubation and mechanical ventilation:
1. Marked acidosis
2. Use of accessory muscles
3. O2 Sats of 91%

But I feel that the next step should be to try out the non-invasive method first since he was just given methylprednisolone, inhaled albuterol, and ipratropium bromide and is likely to improve.

Points against intubation and mechanical ventilation:
1. Alert
2. Mild resp distress
3. RR of 30/min only
4. PO2 of 62 & O2 sats of 91% (unless they drop below 88% I will wait to intubate depending on other parameters)
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Quote:
Originally Posted by Novobiocin View Post
The points in favor of intubation and mechanical ventilation:
1. Marked acidosis
2. Use of accessory muscles
3. O2 Sats of 91%

But I feel that the next step should be to try out the non-invasive method first since he was just given methylprednisolone, inhaled albuterol, and ipratropium bromide and is likely to improve.

Points against intubation and mechanical ventilation:
1. Alert
2. Mild resp distress
3. RR of 30/min only
4. PO2 of 62 & O2 sats of 91% (unless they drop below 88% I will wait to intubate depending on other parameters)
u may be right......actually I have just started my CK prep.....so don't know much details,.......thnx for the detail
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Quote:
Originally Posted by K06100 View Post
u may be right......actually I have just started my CK prep.....so don't know much details,.......thnx for the detail
Don't always believe what I or anyone say. Always confirm.
I may not be right in my explanation since I wrote it from memory (unreliable) from a question I did in UW long time ago.
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Quote:
Originally Posted by Novobiocin View Post
Don't always believe what I or anyone say. Always confirm.
I may not be right in my explanation since I wrote it from memory (unreliable) from a question I did in UW long time ago.
okay ......
but I must tell u I have read ur explanations and they r right in majority of the cases......
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Old 05-28-2012
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NIPPV is an excellent option for patients with COPO exacerbation not responding to standard management. It should be tried before intubation and mechanical ventilation in COPD patients with CO2 retention. (but not crashing)

Consider intubation and mechanical ventilation in patients with:
a. decreased levels of consciousness,
b. cyanosis, or hemodynamic instability
c. persistent hypoxemia despite adequate oxygenation. after CPAP

so i will go first wit CPAP, cuz the pt isn't crashing
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there is a simple 25,35,45 rule of using CPAP in COPD exacerbation
that is
when RR>25,pH<35, PaCO2>45 then use CPAP provided patient is concious and vitals stable.
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Quote:
Originally Posted by tyagee View Post
there is a simple 25,35,45 rule of using CPAP in COPD exacerbation
that is
when RR>25,pH<35, PaCO2>45 then use CPAP provided patient is concious and vitals stable.
Where is this rule. Any links?

pH<35
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Quote:
Originally Posted by Novobiocin View Post
Where is this rule. Any links?

pH<35
this is from qbank


Suitable candidates for NPPV include patients with
moderate to severe dyspnea, use of accessory respiratory muscles, respiration rate greater
than 25/min, and pH less than 7.35 with PCO2 greater than 45 mm Hg (6.0 kPa).
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  #13  
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guys, no need for criteria in the exam, just use CPAP after the classical rx if the respiratory status isn't improve (still high RR,Co2 ...)
and if Crashing (confusion) intubate go easy
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