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MEDICAL DECISION MAKING

The fundamental challenge in evaluating patients with a

presumed COPD exacerbation is to exclude alternative

diagnoses that may mimic COPD, such as pneumonia,

CHF, PE, pneumothorax, or an acute coronary syndrome.

In concert with a CXR, the history and physical is ordinarily sufficient to establish the diagnosis and initiate treatment. Some patients may require more extensive testing,

including BNP or d-dimer levels, as well as cardiac markers. However, most patients present with a self-diagnosis,

and there is little ambiguity to the underlying process

(Figure 22-2).

TREATMENT

Patients should receive an IV line, monitor, and oxygen. If a

patient appears clinically unstable, with significant tachypnea,

accessory muscle use, diaphoresis, and hypoxia, then he or

she should be intubated using rapid sequence intubation. In

such cases, there is no indication for delaying intubation to

obtain a blood gas or CXR or to do any other diagnostic

studies.

In somewhat more stable patients, a trial of bilevel positive airway pressure (BPAP) is appropriate. BPAP (often

referred to as BiPap, which is a brand name of a specific

ventilator) is particularly useful because it actually assists in

ventilating patients by delivering a higher inspiratory positive airway pressure (IPAP) in concert with a lower expiratory positive airway pressure (EPAP). The pressure difference

between these numbers is what drives ventilation. Typical

initial settings are 10/5 (IPAP =10, EPAP = 5). BPAP is most

effective when used early in the ED course as a means to

avoid intubation,