COPD Exacerbation
Patient Presentation:
60 year old female, S.K., was brought to the emergency room with complaints of difficulty breathing, wheezing, a productive cough, and chest and abdominal pain x 2 days. The patient was in visible respiratory distress, coughing, clenching her stomach, and bent over sitting in a tripod position leaning on the wall for support. Upon assessment the patient was extremely fatigued, using accessory muscles to breath and had audible wheezes bilaterally. Once connected to the monitor, vital signs included: BP 189/98, HR 135, 37.5 °C, RR=30 and an oxygen saturation of 85%. The patient was quickly placed on 100% NRB mask. After 15 minutes, the patient’s oxygen saturation increased to 98% but she still had very labored breathing and bilateral wheezes so she was transitioned to 50% BiPAP® 10/5. The patient’s sister gave a short past medical history of hypertension, atrial fibrillation, COPD, and a smoker of about 4-6 cigarettes a day. The sister reported that she thinks her sister had been smoking more because of stress.
Differential Diagnosis:
COPD exacerbation, pneumonia, pulmonary embolism, pulmonary edema, CHF
Diagnosis:
ABG: pH 7.29, PaCO2 60, PaO2 55. EKG showed sinus tachycardia. Chest CT angiogram was negative for a PE. BMP, CBC, liver enzymes, urinalysis, and cardiac enzymes were all within normal limits. Blood cultures x2, sputum culture, and a urine culture were obtained. The attending physician diagnosed the patient with an acute COPD exacerbation based on the symptoms and lab work presented but also ordered 10 mg of Lasix® IV and a stat echocardiogram.
Treatment:
The patient was transferred to the medical ICU for further care. The patient received q1 hour ipratropium + albuterol (Combivent®) nebulizer treatment for the first four hours, then q4 hour treatments with q2 hour treatments PRN. A fentanyl PCA was ordered for pain control and a Lidoderm® patch was applied to her stomach for musculoskeletal pain while coughing. 125 mg of Solu-Medrol® IV was ordered q6 hours. 500 mg azithromycin IV x 24 hours and 1 gm Ceftriaxone® IV q8 hours were administered. An arterial line was placed for frequent arterial blood gases. The patient was kept on 50% BiPAP 10/5 for 24 hours then transitioned to 30% CPAP of 5. Daily P‐CXR’s were obtained and strict intake and output were measured. The echocardiogram was obtained and showed nothing remarkable with an ejection fraction of 55%.
Outcome:
The patient remained in the ICU for 48 hours and successfully transitioned to 2 L NC. She was discharged to a medical floor with q4 hour vital sign monitoring and continuous pulse oximetry.
Case created by Sarah Keller, 2012.