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:
- Titrate oxygen on patients with COPD exacerbations to achieve saturations of 88-92%. Want a more detailed discussion with references? Check this out.
- Steroids should be given for all patients with COPD exacerbations. Prednisone 40 mg PO x 5 days seems to be a reasonable dose.
- 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.
- 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
- 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.
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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!
- GOLD: http://www.goldcopd.org
- Prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD): http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009764.pub2/abstract
New, A. Oxygen: kill or cure? Prehospital hyperoxia in the COPD patient. Emerg Med J. 2006 February; 23(2): 144–146.
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.
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.
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]
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.
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.
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.
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.
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