COPD Patient Hot Case

GENERAL APPROACH

• Stable of illness – acute, respiratory weaning
• Ventilation strategy – NIV, invasive, weaning strategy
• Tracheostomy consideration
• Nutritional state
• Quality of life and prognosis

• Brain
• Cough
• Nerves
• NMJ
• Respiratory Muscles
• Pleura
• Airways (large and small)
• Parenchymal
• Chest wall
• Ventilator asynchrony

• Cardiac failure
• Abdominal distension/failure

INTRODUCTION

CUBICLE

• long stay
• isolation (MDRO)
• sputum

INFUSIONS

– antibiotics (MDRO)
– noradrenaline (sepsis)
– sedation (dexmetetomidine)
– bronchodilators
– steroids
– feeding

VENTILATOR

• type of support (NIV, IPPV)
• mode
• level of support
• level of oxygenation (FiO2, PEEP)
• disease specific questions (dynamic hyperinflation, intrinsic PEEP)
• rapid shallow breathing index (RR/TV)

MONITOR

• temperature
• tachycardia (SIRS)
• ETCO2 (COPD curve on trace indicating differing type alveolar time constants)
• CVP (number, waveform)
• arterial trace (pressure, swing, pulsus paradoxus)

EQUIPMENT

• ICC (pneumothorax)
• surgical scars
• tracheostomy (size, type)
• intra-abdominal drains (fluid, amount)

QUESTION SPECIFIC EXAMINATION

• hands/arms -> head -> chest -> abdo -> legs/feet -> back

-> cardiovascular (cardiac failure)
-> respiratory (tracheostomy, cough, VC, work of breathing, active disease signs)
-> abdominal (distension)

• neurological

-> paralysed
-> quick examination
-> unconscious
-> conscious (analgesia adequate)

• physiotherapy frequency

RELEVANT INVESTIGATIONS

• CXR
• FBC: WCC
• microbiology: sputum, blood cultures
• ABG: gas exchange
• pre-admission spirometry

OPENING STATEMENT

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• severity and stage of disease
• factors contributing to respiratory failure or weaning
• management from here