smoking) and be provided with appropriate follow-up

information.

SUGGESTED READING

Cydulka RK. Acute astluna in adults. In: Tintinalli JE, Stapczynski

JS, Ma OJ, Clince DM, Cydulka, RK, Meckler GD. Tintinalli's

Emergency Medicine: A Comprehensive Study Guide. 7th ed.

New York, NY: McGraw-Hill, 20 1 1, pp. 504--5 11.

National Heart Lung and Blood Institute. Expert Panel Report 3:

Guidelines for the Diagnosis and Management of Asthma:

Managing Exacerbations of Asthma. http://www.nhlbi.nih.

gov/ guidelines/asthma/, Accessed April l6, 2007, pp. 3 73-405.

Pollart SM, Compton RM, Elward KS. Management of acute

asthma exacerbations. Am Fam Phys. 2007;84:40-47.

Chronic O bstructive

Pu l monary Disease

David H. Rosenbaum, MD

Key Points

• Respiratory infections are responsible for most acute

exacerbations of chronic obstructive pulmonary

disease (COPD).

• Beta-adrenergic agonists and anticholinergic drugs

remain the primary bronchodilators and are most effective when used together.

• Steroids should be given to nearly all patients presenting to the emergency department (ED) with COPD

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is defined

as an illness characterized by irreversible, progressive air ­

way obstruction that is associated with inflammatory pulmonary changes. It is extraordinarily common, and

patients with exacerbations of COPD will continue to

inundate emergency departments (EDs) in search of respiratory relief. In the United States, COPD is the fourth most

common cause of death.

The use of the term COPD encompasses patients

with chronic bronchitis and emphysema, as well as those

patients with asthma who have a component of irreversible

airflow obstruction. Airflow obstruction is the end result

of a process that begins with particulate air pollution

exposure ( usually from tobacco smoke) . Particulate

exposure initiates a cascade of events, including airway

inflammation and narrowing of the small airways, as

well as airway destruction and remodeling in the setting

of diminished repair mechanisms and fibrosis, resulting

in fixed airflow obstruction and air trapping. Although

there are clearly pathophysiologic differences between

these groups, their evaluation and treatment is largely

the same.

95

exacerbations, and ongoing therapy should be pre ­

scribed for those patients who are discharged.

• Antibiotics are an important adjunct to therapy,

although their use should be gu ided by the patient's

signs and symptoms.

• Noninvasive ventilation is a critical component of

therapy that is best used early in the ED course to avoid

the need for intubation.

A COPD exacerbation is an event characterized by a

worsening of the patient's respiratory symptoms beyond

the normal day-to-day variation. Typically, this involves

one or all of the following: worsening dyspnea, increased

sputum as well as a change in the character of sputum, and

an increase in the frequency and severity of cough.

CLINICAL PRESENTATION

..... History

The critical aspects of the history in evaluating patients

with dyspnea due to a presumed COPD exacerbation are

to establish the patient's baseline function, assess the sever ­

ity of the exacerbation, determine a cause, and rule out

disorders that may mimic a COPD exacerbation. Most

patients experiencing a COPD exacerbation present with

complaints of increased dyspnea in the setting of a recent

onset respiratory infection (ie, upper respiratory infec ­

tion). As a result, they may complain of a productive or

sometimes a nonproductive cough that differs from their

baseline cough, rhinorrhea and nasal congestion, and

fevers and chills, as well as the constitutional symptoms

that frequently accompany systemic illness. Most such

CHAPTER 22

patients are chronically ill and often quite frail, so the key

to determining the severity of the exacerbation is establishing their baseline health. To do this, it helps to ascertain

their oxygen use, their current treatment regimen, their

level of function and ability to perform activities of daily

living, the frequency of hospitalizations and the timing of

their most recent hospitalization, their history of mechanical ventilation, and any comorbid illnesses ( eg, ischemic

heart disease and congestive heart failure [CHFJ).

Patients who present with symptoms that seem to

develop over a long period of time may actually have

underlying CHF, whereas patients with abrupt onset symp ­