Chronic Obstructive Pulmonary Disease (COPD) – Diagnosis
- Acute exacerbations of COPD (AECOPD) defined as worsening dyspnea, cough, and/or sputum production; which leads to a change in treatment.
- Fourth leading cause of death worldwide.
- Approximately 138,500 individuals ≥ 45 years old in BC have COPD – underdiagnosed.
- AECOPD identifies patients with a significantly higher mortality risk compared to stable COPD patients.
- 20% require hospitalization.
AECOPD is a clinical diagnosis, several scoring systems have been created (Ottawa COPD severity score, DECAF, and BAP-65) but none have sufficient sensitivity/specificity to be used routinely.
Most of the patients with mild to moderate exacerbations do not come to the ED.
Important historical factors
- comorbid conditions
- drugs – prescribed and illicit
- smoking history
- previous exacerbations, including treatment required
- need for mechanical ventilation, and
- frequency of hospitalizations.
- Infections (virus or bacteria) most common
- Environmental – irritants and extreme weather
- Left ventricular failure
- Sputum retention (chest trauma – poor inspiration, diminished cough reflex)
- Pulmonary embolism
- Pneumothoraces, and
- Medications such as opioids, beta-blockers, antihistamines, antitussives, diuretics.
- Respiratory effort/accessory muscle use and mental status
Evidence of respiratory fatigue.
- Venous gases
- pH and pCO2 correlate well with arterial blood gases.
Monitoring for hypercapnia after the initiation of supplemental oxygen. VBG, mental status and respiratory drive).
- Precipitating causes (i.e pneumonia).
- Differential diagnosis (infiltrates, lung masses, pneumothoraces, pulmonary edema, etc).
Point-of-care ultrasound can quickly narrow the differential diagnosis for dyspnea
- heart, lungs, and deep veins.
- Arrhythmia and/or ischemia
- ECG findings with COPD: (link to ECG )
- Right heart strain
- RV hypertrophy
- P pulmonale
- RAD, RBBB
- ST depression or inversion in V1-V3.
- BNP or NT- proBNP
- Sputum Gram stain and culture
- Respiratory viral swab
- CT Chest.
If the patient fails to improve, consider pulmonary embolism and CHF.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
RELEVANT CLINICAL RESOURCES
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Jan 06, 2020
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