Episode 20: COPD Part 2

Episode 20 is Part 2 of Dr. Kochert’s lecture on COPD.  In Part 2, Dr. Kochert discusses the tough question regarding antibiotics in COPD exacerbations, smoking cessation in the ED, and finishes with a Q/A discussing some of the finer points of the lecture and managing COPD patients.  Thanks again to Dr. Kochert for allowing me to post his lecture.  Making a great lecture like this takes a bunch of work, and he gives a great comprehensive review.  

Here is the final summary for the whole COPD talk:

  1. Titrate oxygen on patients with COPD exacerbations to achieve saturations of 88-92%.  Want a more detailed discussion with references?  Check this out
  2. Steroids should be given for all patients with COPD exacerbations.  Prednisone 40 mg PO x 5 days seems to be a reasonable dose.  
  3. Have a low threshold for non-invasive positive pressure ventilation (NIPPV).  It has been shown to reduce mortality and intubation rates.  jump on it early.  Again, as discussed in Episode 19, there has not been any great evidence to show CPAP or BiPAP is better.  Talk with your friendly neighborhood respiratory therapist and see what the standard is at your shop.  
  4. The evidence for antibiotics is not totally clear, but, based on available evidence, give antibiotics to:
    • Patients admitted for COPD exacerbation (especially intubated patients)
    • Outpatients with purulent sputum
  5. Discuss smoking cessation in the ED.  This is a teachable moment.  As Dr. Kochert said, peri-intubation may not be the best time, but otherwise this can definitely impact patients in a positive way.  

Two Reminders:

1. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Other blogs (See EMCrit and R.E.B.E.L EM) have had nice success with this, as it gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  

2. Below you will find the III/Asynchronous Learning Quiz for Episodes 19/20.  After answering the short questions in the quizzes, you can print out a certificate that says you spent time listening to the podcast and doing the quiz.  My hope is, that with approval from your individual US EM Residency program directors, you can count this toward individual interactive instruction time (also known as asynchronous learning) if you are in a US EM residency program.  As stated, make sure your program director approves of this before you go chalking this up as asynchronous time.  

Remember, if you have feedback, or questions for me or Dr. Kochert, I want to hear from you!

Email: bobstuntzmd@gmail.com

Twitter: @BobStuntz

Google+

References

  1. GOLD: http://www.goldcopd.org
  2. Prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD): http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009764.pub2/abstract
  3. New, A.  Oxygen: kill or cure? Prehospital hyperoxia in the COPD patient.  Emerg Med J. 2006 February; 23(2): 144–146.

  4. Austin MA et al. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: Randomised controlled trial. BMJ 2010 Oct 18; 341:c5462.

  5. Quon BS, Gan WQ and Sin DD. Contemporary management of acute exacerbations of COPD: a systematic review and meta-analysis. Chest. 2008; 133:756–66.

  6. Leuppi JD et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: The REDUCE randomized clinical trial. JAMA 2013;309:2223. [PMID: 23695200]

  7. Nouira S, Marghli S, Belghith M, Besbes L, Elatrous S, Abroug F.  Once daily oral ofloxacin in chronic obstructive pulmonary disease exacerbation requiring mechanical ventilation: a randomised placebo-controlled trial.  Lancet. 2001 Dec 15;358(9298):2020-5.

  8. Miravitlles M, Moragas A, Hernández S, Bayona C, Llor C.  Is it possible to identify exacerbations of mild to moderate COPD that do not require antibiotic treatment?  Chest. 2013 Nov;144(5):1571-7. doi: 10.1378/chest.13-0518.

  9. http://www.acep.org/Clinical—-Practice-Management/Smoking-Cessation/

  10. Prochazka A, Koziol-McLain J, Tomlinson D, Lowenstein SR.  Smoking cessation counseling by emergency physicians: opinions, knowledge, and training needs.  Acad Emerg Med. 1995 Mar;2(3):211-6.

  11. Katz DA, Vander Weg MW, Holman J, Nugent A, Baker L, Johnson S, Hillis SL, Titler M.  The Emergency Department Action in Smoking Cessation (EDASC) trial: impact on delivery of smoking cessation counseling.  Acad Emerg Med. 2012 Apr;19(4):409-20. doi: 10.1111/j.1553-2712.2012.01331.x.

Enjoy the podcast!


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Knowledge + advocacy saves lives Episode 157 September 1,…



Knowledge + advocacy saves lives
Episode 157

September 1, 2014


YOU MUST BE THE EXPERT AT READING ECG’s!

Don’t assume that your consultants know more than you!

Knowledge of ECGs & advocacy for patients will save lives! 


Want to make sure you never miss these type of cases? Check out these links and save a life…

aVR, the forgotten lead you need to remember

Why Brugada syndrome needs an EP study

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Fellowship Exam Resources: 2015 Onward

I have just spent the last couple of hours trawling through the 20-odd websites that have ACEM Fellowship Exam specific material looking for tips and advice for the upcoming 2015 Exams. And I was startled by the total lack of information! I have therefore started a new, free page listing links to resources that I […]

Severed snake head bites, kills chef in China

Indonesian spitting cobra

Indonesian spitting cobra

USA Today reports that a chef in China died recently after being bitten by the decapitated head of an Indonesian spitting cobra, possibly Naja sputatrix. Chef Peng Fan beheaded the snake in preparation for making traditional cobra soup at his restaurant in Guangdong province. Ten to twenty minutes later, when he was disposing of the head, it bit him. “We did not know what was happening” one diner said, “but could hear screams coming from the kitchen.”  The chef was dead before medical help could arrive. Cobra venom is predominantly neurotoxic and cardiotoxic. Death could have come to the chef from respiratory arrest and asphyxia, or cardiac arrhythmia. Although such a case is extremely rare, it’s well known that some snakes can maintain reflexic biting action for up to an hour after being separated from the body. This is also true for rattlesnakes and copperheads, among other species. In fact, even after all reflex activity has ceased, venom remaining on the snake’s fangs can cause medical problems if it punctures the skin.

Student Corner: How to Read a Chest X-Ray Follow Up

Here is the same CXR from last time.

 

CXR UL pna

Here’s some further information about the case:

Pt is a 52 y/o man with a history of smoking, atrial fibrillation, and HTN that presents to the ED today with a 2-3 day history of fatigue, weakness, fever, generalized body pains, drenching night sweats, increased urinary frequency, L ear discomfort, throat discomfort and blurry vision in the morning. The symptoms came on suddenly and have been constant since the beginning of the episode. The fatigue and weakness cause the patient to want to “drop into a hole” and sleep. His nightly sleep patterns have been disrupted by his night sweats and his increased urinary frequency. The night sweats are drenching and he often wakes up in the middle of the night with his shirt completely soaked. Around 8-9 AM in the morning he reports being cold and getting chills. He also has some lower sternal chest pain that occurs mostly with deep breathing. The pain does not radiate. The pt has a 30-35 year history of smoking cigarettes and drinking 15-20 alcoholic drinks/week. The pt stopped smoking yesterday with the intent to quit.

The pt has no change in appetite or weight, no new masses or lumps anywhere on his body and no syncope or LOC. The pt denies any history of similar symptoms. The pt denies any family history of these symptoms. The pt denies any sick contacts. The pt’s wife does not have similar symptoms. The patient has no N/V or history of recent travel. The pt was routinely tested for tuberculosis 2 years ago as part of an employment physical and the test was negative.

Vitals: BP 142/106 | Pulse 105 | Temp(Src) 100.6 °F (38.1 °C) (Oral) | Wt 228 lb (103.42 kg) | BMI 31.36 kg/m2 | SpO2 99%

Physical Exam: 

General appearance – alert, well appearing, and in no distress; slightly pale

Eyes – PERRLA, EOMI

Ears – bilateral TM’s and external ear canals normal

Mouth – mucous membranes moist, pharynx normal without lesions

Neck – supple, no significant adenopathy

Lymphatics – no palpable lymphadenopathy, no hepatosplenomegaly

Chest – clear to auscultation, no wheezes, rales or rhonchi, symmetric air entry

Heart – normal rate, regular rhythm, normal S1, S2, no murmurs, rubs, clicks or gallops, no pericardial rub on auscultation with patient leaning forward

Abdomen – mild suprapubic ttp without rebound/guarding

Neurological – alert, oriented, normal speech, no focal findings or movement disorder noted, CN 2-12 grossly intact

Skin – normal coloration and turgor, no rashes, no suspicious skin lesions noted

With all of that in mind, let’s take a look at the x-ray again. The last post went through the ABCDE methodology to review the image and the A through D aspect was pretty well outlined there. The airway is patent, there is no obstruction and it lines up with the cervical spinous processes. The bones have no step-offs or other evidence of fractures and there are 10 ribs visible. The cardiac silhouette is not enlarged (in other words, not more than twice the width of the chest cavity) and the AP window sits between the aortic arch and pulmonary artery. The diaphragm has normal contour and the costo-vertebral angle is sharp.

The E is where things get interesting. One of the ways I like to do it is to try and look for asymmetry in the lung fields. And I think I see something!

CXREXoriginal-finalread

The blue circle seems like a focal area of consolidation (either liquid or solid). That same “opacity” is not present on the corresponding place on the L lung field.  I think its important to note that this finding has a large differential diagnosis attached to it, even if you put the finding on the x-ray in context with the case presentation. Most of the diagnoses on the list would be infectious, like TB or pneumonia, but other possibilities include lung cancer, edema, hemorrhage and systemic inflammatory conditions like sarcoidosis.

The radiologist read that image as most likely a case of lobar pneumonia. There was some hedging by the radiologist on the read because the lateral film was taken from L to R, therefore the opacity in the R lung field was very hard to see (that’s why I didn’t include a lateral view as well, but we can save that particular x-ray type for another post). In general, you want to get two views on any pathology on x-ray because it’s important to try and construct a 3D image in your head about where the pathology is located.

In any case, his patient presented with fever, cough, loss of energy, chills and body aches, with all of those symptoms having an acute onset. This makes an infectious process more likely (I say “more likely” because as everyone in medicine learns at some point or another, it is very dangerous to talk and think in absolutes). He was treated empirically with antibiotics for pneumonia.

Hopefully this example helps you to have a system in place when you look at any chest x-ray. If you have any questions, feel free to drop them in the comments and I’ll do my best to answer them.  Also, if you have any requests for certain types of images you would like to see for the next post, also let me know in the comments. Until next time!

Author: Jaymin Patel


Filed under: Chest XR, How To's, Non-Trauma, Student Corner