Acute respiratory failure with Hypoxia and Hypercarbia
COPD exacerbation

-- days of , S/G Onset, W/U/I Progression and C/I course.
-- ASx +: (dyspnea), Increased purulent cough, Increased sputum production, Fatigue
-- DENIES chest pain, fever/chills, hemoptysis, leg swelling or calf pain, recent travel/immobilization, and orthopnea/PND and sick contact
-- Hx: COPD (Date), last PFT , multiple prior exacerbations with last hospitalization ( *** ), No hx of intubation, smoking,
-- PE: worsening hypoxia or hypercarbia
-- W/U: CBC, BMP,VBG, BNP, Resp Cx, RVP , EKG, CXR, CT?, Echo?
-- MEDS: inhalers _
-- Etiology/DDx: infection, missed home medications, weather, smoke; rule out CHF, PNA, PTX, PE

Plan (COPD add On)

• scheduled duonebs q4h / albuterol q2 PRN; space as able,

• Prednisone 40mg x5d

• PO prednisone 40mg for 5 days; If unable to take PO, give methylprednisolone 40 mg IV daily, then transition to prednisone when able.

• CTX 1g IV, Azithromycin 500mg for three days, (Cefepime 2g (5–7 days) if risk of PsA), On DC Augmentin 875/125 mg BID alone to complete ~5 day

• Monitoring daily CBC, BMP, tele

• Bronchopulmonary hygeine: PEP/flutter

• PT/OT for eval

• ED/IP/OBG NicWiPP Protocol ADD-ON

• consider Pulm consult if refractory or in need of Roflumilast (FEV1 < 50%) or Dupilumab (Eso>300)

• O2 prn to maintain SpO2 88-92%

• Smoking cessation counseling

• NIPPV if resp acidosis, dyspnea, increased WOB; Mechanical ventilation if pH <7.26, PaO2 <55-60 or worsening hypercapnia despite NIPPV

• VBG PRN for worsening respiratory status 

• Discharge with Vitamin D as needed (Vitamin D is given to prevent steroid-related bone loss and address common deficiency in COPD patients)

Meds

Home: Trelegy (ICS [fluticasone] / LABA [vilanterol] / LAMA [umeclidinium])  

Inpatient: Dulera (ICS [mometasone] / LABA [formoterol]) + Spiriva (LAMA [tiotropium]) 

ICU: Budesonide (ICS [budesonide]) + scheduled Duoneb (SABA [albuterol] / SAMA [ipratropium], nebulized).

mMRC 0–1 → A

mMRC ≥2 → B

Exacerbations → E