as opposed to being deployed on the verge

of intubation as a "rescue therapY:' However, the only absolute contraindications to its use are respiratory arrest, inability to fit the mask, and patient noncompliance. When used

appropriately, BPAP use in patients with COPD exacerbations has been shown to decrease intubation, mortality,

hospital length of stay, and number of days patients spend in

intensive care unit settings.

Most patients presenting with a COPD exacerbation do

not present in extremis but with moderate to severe respiratory distress and hypoxia. Hypoxemia is the critical life

threat in this group of patients and should never be left

untreated. Although it's true that PaC02 levels rise in

COPD patients to whom oxygen is administered, only a

very small fraction of patients experience enough of a rise

to cause CNS depression and a depressed respiratory effort

(called "C02 narcosis"). However, oxygen should be limited to only what is needed, with a target oxygen saturation

(Sa02

) of 90-94% (Pa02 of 60-65 mmHg). Venturi masks

provide a convenient means of titrating oxygen delivery

more accurately.

Despite the prevalence of COPD, there are few evi ­

dence-based guidelines regarding pharmacologic therapy.

However, the conventional triad of short-acting bronchodilators, steroids, and antibiotics remains unchanged. In

COPD patients, beta-adrenergic agonists (albuterol 2.5 mg

in 3 mL of saline) are used in concert with anticholinergic

agents (ipratropium bromide 0.5 mg in 3 mL saline) via a

nebulizer.

Steroids should be given to all patients presenting to the

ED with a COPD exacerbation. Although steroids are not

as effective in COPD patients as in patients with asthma,

steroids reduce treatment failures and obstructive symptoms, as well as hospital length of stay with an uncertain

effect on mortality. In the ED, methylprednisolone is the

preferred parenteral agent (Solu-Medrol 125 mg IV),

although patients with mild exacerbations can be given

80 mg of prednisone orally. All patients should receive a

prescription for 40-60 mg of prednisone to be taken daily

for at least 1 week after discharge. Steroid prescriptions

do not need to be tapered when prescribed for less than

3 weeks.

CHAPTER 22

Suspected COPD

exacerbation

CXR

CBC,

Electrolytes,