COAD - A Clinical Approach

  • A mistake is to not consider acute pulmonary oedema as a cause for dyspnoea and wheeze
  • ASSESSMENT

    MANAGEMENT

    • Place in monitored area (if Moderate/Severe episode)
    • Oxygen (maintain SaO2 > 93) [if CO2 retention an issue keep SaO2 between 90-93%]
    • If severely unwell, CPAP or Intubation and ventilation may be eventually required (see Ventilation Strategy for Acute Asthma) - Remember ventilatory support is generally a last resort
    • Commence treatment
    • Monitor treatment (see Assessing severity)
    • Address complications of treatment (e.g. anaphylaxis, hypokalemia, arrhythmias)
    • Treat complications (e.g. pneumothorax)
    • Treat/Avoid precipitants
    • Treat infection aggressively e.g. cefotaxime 1g IV + roxithromycin 300mg daily

    INVESTIGATONS

    CXR - to exclude pneumothorax

    Mg2+, K+, Ca2+, PO43-- - deficiencies may contribute to respiratory muscle weakness 

    Indications for ABG's

    • severe asthma
    • altered mental state
    • SpO2 < 90%
    Do not delay treatment in severe exacerbations to take ABGs

    DISPOSAL

    Admit the following:

    Significant deterioration from:

    Admit HDU/ICU if:

    • Respiratory failure
    • Persistent Moderate/Severe asthma following aggressive treatment

    Discharge

    If after 2 hours after last nebulisation:

    DISCHARGE PLAN

    • Prednisolone 50mg daily (3-5 days) if previously had response to steroids [no need to taper unless course duration > 2 weeks)
    • Generous use of antibiotics  (if increase or change in colour of sputum, presence of fever or pleuritic pain, focal chest signs) e.g. roxithromycin 300mg daily or augmentin duo forte i bd (5-10 days)
    • Give asthma discharge advice handout
    • GP review within 48 hours.