COPD Exacerbation
Patient Presentation:
L.Y., a 62 year old female presents to the ER via ambulance. The patient arrived on a CPAP machine, placed by the paramedics en route, due to an on scene oxygen saturation of 76%. The patient’s breathing is notably labored and the patient is too fatigued to answer any questions. The patient is tripoding and using accessory muscles to breath. The patient is tachypneic, anxious, diaphoretic, has clubbed fingers, a barrel shaped chest, and grey/blue nail beds. On arrival the patient’s oxygen saturation is 86% on CPAP.
The paramedics report that the patient’s family told them she has a history of COPD with previous intubations and has been experiencing shortness of breath, worsening over the past several days. The family relays that the patient recently allowed a grandson, who smokes, to move in with her, and that this may be the cause for the decline in her condition.
The patient is transferred from the ambulance stretcher to an ER bed and placed on a non-rebreather (NRB) mask (the CPAP machine is removed by the paramedics). The attending ER physician is immediately notified that a patient in respiratory distress has arrived and the respiratory therapist is paged STAT to the ER. Initial Vital Signs: BP 160/90, HR 112, RR 32, O2 Sat 84% on NRB, Temp. 98.4.
Differential Diagnosis:
COPD Exacerbation, CHF Exacerbation, ARDS, Pneumonia
Diagnosis:
Immediately upon arrival, the patient had an EKG showing sinus tachycardia. Labs, blood cultures, and an i-STAT® ABG were obtained, and two 18 gauge peripheral IVs were placed. The patient was placed on a cardiac monitor, pulse oximeter, and NIBP monitor. The patient was placed on BiPAP by the hospital’s respiratory therapist, and the patient’s O2 Sat rose to 92%, but the patient continued to show signs of severe respiratory distress. A STAT chest x-ray and STAT CT scan of the chest were ordered. The i-STAT® ABG showed critical high PaCO2 (98), critical low PaO2 (46), and low pH (7.19). The ER Attending was made aware of the ABG values; the patient was diagnosed with a severe COPD exacerbation, and prepped for immediate intubation.
Treatment:
In the emergency department the patient was quickly intubated and placed on a ventilator. Prior to intubation, the patient was manually ventilated with a bag-valve mask and medicated with etomidate and succinylcholine. Post-Intubation, the patient had a repeat chest x-ray, a nasogastric tube was placed, a Foley catheter was placed, and the patient was started on a propofol drip for sedation. The patient’s O2 sat rose to 100%, on mechanical ventilation. Respiratory treatments were provided by the hospital’s respiratory therapist. The patient was admitted to the hospital’s Intensive Care Unit for further evaluation and monitoring.
Outcome:
The patient was quickly transferred to the hospital’s ICU from the ER.