COPD Key Notes:
1. COPD on the exam is typically referring to emphysema/chronic bronchitis patient.
2. Always interpret ABG from a chronic respiratory acidosis standpoint
a. Most important value to look at is pH – should be 7.35-7.40
b. If <7.35 = acute respiratory failure
i. NPPV unless contraindicated.
ii. Intubate if not improving or worsening.
iii. If improving CO2, but pH is still less than 7.35, increase IPAP.
iv. You can also increase IPAP to fix air hunger.
c. If >7.40 = acute hyperventilation
i. Fix oxygenation by giving or increasing O2 or determine other cause of
hyperventilation.
ii. Treat to keep SpO2 >86-88% or PaO2 55-60 torr (do not go over 70 torr)
3. Pharmacology
a. Give bronchodilators/anti-inflammatories - both beta-2 and LAMA (these are VERY
important for COPD).
i. They may have you give a SAMA (Atrovent) instead of albuterol for acute wheezing
in the ED
ii. Muscarinic drugs have been found to have more impact on FEV1 than beta 2 drugs
1. Use Atrovent for short-acting
2. Use Spiriva for long acting or one of the LABA/LAMA combos – remember
that Spiriva is a DPI and requires dexterity and fast inspiration
iii. Long-acting LABA drug by itself is usually Serevent (salmeterol) if by itself, but this is
rarely mentioned
b. Inhaled steroids or combo LABA/ICS drugs (although they are recommending ICS only if
eosinophils are high now)
i. It is still pretty common for them to use Advair (salmeterol/fluticasone) – also a DPI
c. Newer drugs have LABA/LAMA combos and these are being seen on the exam (Anoro). Just
know that this is for COPD and NOT asthma and is a DPI.
d. Additional drugs may include IV steroids (solumedrol), IV antibiotics (if infection is
indicated), anti-anxiety medications when appropriate.
4. PEP therapy if evidence of retained secretions because this will keep airways from collapsing on
exhalation, while also moving secretions up to the large airways. Look for PEP or
Oscillatory/Vibratory PEP.
5. Oxygen therapy – choose a high flow system over low flow in most situations, avoid high FiO2 unless
absolutely necessary.
a. Look for oxygen induced hypoventilation if the patient is on high FiO2, PaO2 or SpO2 is high,
AND the patient is lethargic – decrease the FiO2 if this is presented.
b. You usually want to start FiO2 between 24-35%.
c. Choosing a nasal cannula may be appropriate, but only if the choice is between a 2 L/min NC
and a high flow system that has a high FiO2 (.50 or greater). Or you can choose it if no high
flow system is offered as an answer.
