Episode 24: COPD and Pneumonia

In this episode we have the continuation of our discussion on Respiratory Emergencies with Dr. Anil Chopra and Dr. John Foote. We discuss key clinical decisions in COPD assessment and management – how to assess for impending respiratory failure, how best to oxygenate the COPD patient, medication pearls and how best to approach intubating the COPD patient. We then review an approach to hemoptysis as well as tricks of the trade for managing massive hemoptysis. Many pearls of pneumonia work-up and management are detailed as well as how to make important disposition decisions.

Dr. Foote and Dr. Chopra answer such questions as: When can a venous blood gas replace an arterial blood gas? Which patients with COPD exacerbation do not require antibiotics? What does the literature tell us about the best oxygen saturation target for patients with COPD exacerbations? Is pneumonia a contraindication to BIPAP in the patient with COPD exacerbation? What’s the newest on COPD disposition? How should we deal with the patient with hemoptysis who is drowning in their own blood? When should we suspect TB pneumonia and how does that change our ED management? Which patients need antibiotic coverage for pseudomonas? What is Healthcare-Associated Pneumonia? What is the best anatomical location for needle decompression of tension pneumothorax? and many many more……..

 

COPD

Sign of Impending Respiratory Failure in COPD

  • Accessory muscle use
  • Sitting up and leaning forward
  • Altered mental status
  • Diaphoresis (‘if the pt is sweating, so should you’)
  • Poor air entry (‘quiet chest’)

Can Venous Blood Gas replace Arterial Blood Gas for COPD?

  • While VBG is accurate enough to guide Rx in DKA, in COPD the PCO2 does not correlate well enough, so our experts recommend using ABG initially to help guide difficult intubation decisions and a VBG to monitor therapy after that

Criteria for COPD exacerbation (and who requires antibiotics)

  • 2 of 3 cardinal symptoms
    1. Increased dyspnea
    2. Increased sputum volume
    3. Increased sputum purulence
  • Abx: 77% decreased mortality!

COPD Oxygen Saturation Target

88-92% or Patient’s Baseline if Known

  • CO2 retention occurs when administering high flow oxygen to maintain a saturation above this target, increasing the risk of altered mental status, decreased respiratory drive and impending respiratory failure.
  • A recent prehospital RCT showed that oxygen treatment titrated by paramedics to achieve arterial oxygen saturations between 88% and 92%, for patients with SOB and COPD history, reduced the risk of death from respiratory failure by 58% for all patients and 78% for patients with confirmed COPD, compared with high flow oxygen. For high flow oxygen treatment in patients with COPD, the number need to harm (NNH) = 14.(1)

COPD Medication Pearls

  • Oral steroids have been shown to be as effective as IV steroids with similar time to onset of action and trend to shorter hospital stay (a 5 day course, no taper)
  • 2.5mg Salbutamol is as effective as 5mg
  • MgSO4 2g IV has been shown in small studies to improve FEV1 & Peak flow, but no mortality benefit
  • No role for aminophylline or heliox
  • Antibiotic duration of 5 days is all that is necessary (no evidence that longer duration of therapy is efficacious)

BIPAP is Very Effective for COPD

  • BIPAP significantly decreases mortality, morbidity, length of hospital stay & need for intubation in COPD, and pneumonia in this setting is not a contraindication

Intubating the COPD patient

  • try to avoid intubation as COPDers have a high risk of barotrauma after intubation
  • keep patient upright as long as possible prior to intubation
  • give NS bolus to help avoid post intubation hypotension
  • attenuate bronchospasm by spraying the airway well and considering Ketamine as the induction agent of choice
  • use a large ETT (8+) to decrease airflow resistance & for suctioning
  • use low tidal volumes (5-7ml/kg) & low vent rates to avoid barotrauma

*FOR COPD, CONSIDER A ‘WALK TEST’ WITH R.T. TO DETERMINE ELIGIBILITY FOR DISCHARGE

 

PNEUMONIA

Pneumonia Assesssment

  • History and physical have poor sensitivity and specificity for pneumonia
  • Up to 30% of pts with pneumonia will have negative initial CXR in the ED, more likely with elderly, dehydration, immunocompromised state
  • RR of 35+ predicts respiratory failure
  • Suspect TB pneumonia in immigrants from high prevalence countries, HIV, prisons/shelters, prolonged weight loss and constitutional symptoms, hemoptysis, apical CXR infiltrate
  • Avoid respiratory floroquinolones in pts suspected of TB pneumonia as it may partially treat TB and make the Dx more difficult during their hospital stay
  • Blood cultures are recommended only for pts sick enough to be admitted who have any of: cavitary infiltrates, pleural effusion, leukopenia, active alcohol abuse, chronic severe liver disease & asplenia, ICU admit
  • Sputum cultures only necessary for suspected TB or MRSA pneumonia

 

IDSA Guidelines for Antibiotics for Pneumonia

  • The ‘4 hours to antibiotics’ rule is no longer recommended and rather antibiotics should be given in a timely manner while the patient is in the ED
  • Outpatient, previously healthy, no abx use in past 3 months: Macrolide or Doxycline
  • Outpatient, co-morbidities or abx use in past 3 months and Non-ICU inpatients: Respiratory Fluoroquinolone or B-lactam + Macrolide
  • ICU: Respiratory fluoroquinolone or B-lactam + Macrolide
  • Cover pseudomonas (imipenem or pip- taz plus cipro or levofloxacin or azithromycin in combination with aminoglycoside) for patients who: steroid dependent, prolonged hospitalization, from nursing home or ICU, structural lung disease
  • Cover MRSA for at risk patients (vancomycin or linezolid)

*THERE IS UP TO 35% PNEUMOCOCCUS RESISTANCE TO MACROLIDES IN CANADA

Healthcare Associated Pneumonia (HCAP)

What is HCAP? Which patients with pneumonia need admission? ICU?……and what’s new with pneumothorax? 

  • Pneumonia that occurs in non- hospitalized patient with extensive health care contact (ie: IV therapy, wound care, IV chemotherapy in prior 30 days, resident in nursing home, hospitalization for 2+ days within prior 90d, attendance at hemodialysis clinic within prior 30d)
  • At higher risk for staph aureus, klebsiella, pseudomonas so need to cover for these according to local patterns

Pneumonia Disposition: The CURB-65 Rule

  • 1 pt each for:
    • Confusion
    • Uremia (BUN>19)
    • RR>30
    • BP<90
    • 65+ age
  • 2+ points = admit
  • 0-1 points = d/c

Modified CURB-65 rule leaves out Uremia and is as predictive without the need for lab testing

  • A study in 2011 showed an association between an O2sat<92% and major adverse events and can be used as a criteria for admission (3)

SMART COP Rule for Pneumonia ICU Admission

    • SBP<90
    • Multilobar
    • Albumin<3.5mg/dL
    • RR>30
    • Tachy>125
    • Confusion
    • O2sat<90
    • PH<7.35
  • 3+points = ICU admit
  • 2 points or less = low risk

 

Needle Decompression for Tension Pneumothorax

In patients with tension pneumothorax requiring immediate needle decompression, the lateral approach that we use for tube thoracostomy, should be considered as an alternative to the traditional anterior approach (2nd intercostal space, mid-clavicular line)

WHY?

  • wall thickness for lateral approach is less than that for anterior
  • there are more vital structures that can be damaged by the needle with anterior approach
  • the lateral approach allows chest compressions to be continued in the case of cardiac arrest

Landmarks for Lateral Approach to Needle Decompression

  • The landmarks for the lateral approach are the same as those for tube thoracostomy and can be identified by the ‘Triangle of Safety’ as in the diagram below

Image from Trauma Monkeys http://www.traumamonkeys.com/blog/needled

 

HEMOPTYSIS

Approach to Hemoptysis

  1. Degree of hemoptysis: streaked sputum vs gross
  2. Rule out ENT or GI source
  3. Consider causes:
    • Cancer
    • Infectious (pneumonia,TB etc)
    • Interstitial (eg: bronchiectasis)
    • Vascluar (PE, CHF, valvular heart dz, aortobronchial fistula)

Hemoptysis Work-Up

  • 90% of pts with cancer as a cause for hemoptysis will have an abnormal CXR
  • Bronchoscopy and/or CT

Management of Massive Hemoptysis

  • Traditional pt position of ‘bleeding lung down’ may worsen ventilation, so some experts recommend prone head down
  • Use 2+ suction catheters & a large ETT
  • When airway is obscured by blood, some experts advocate using a ‘bougie’ which obviates the need to visualize the chords and/or intubating the esophagus first so as to facilitate blind intubation of the airway
  • Advance the ETT into mainstem bronchus of the nonbleeding lung if bleeding continues, with help from anesthetist

For more on COPD and Pneumonia on EM Cases:
Best Case Ever 24: COPD, Baggging and Vent Settings

Key References

  • Austin et al. BMJ. 2010;341:c5462.
  • Mandell et al. Clin Inf Dis; 2007;44:S27-72
  • Sanchez et al.Acad Emerg Med. 2011;18(10), 1022-6
  • Sumit et al. Clin Inf Dis. 2011;52(3), 325-331

 

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About the Author:

Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.

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