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The Acute Presentation Of Chronic Obstructive Pulmonary Disease In The Emergency Department: A Challenging Oxymoron

November 2008

Few medical conditions rival chronic obstructive pulmonary disease (COPD) in prevalence, burden on medical resources, acuity, and frequency of presentation. hardly a shift goes by in most emergency departments (EDs) without the opportunity to manage the dyspneic emphysematous or bronchitic patient, with hospital admission being a frequent outcome. Compared to the attention paid to cardiovascular disease, diabetes, cancer, and infectious diseases, COPD is virtually invisible. Although there have been efforts in recent years to refocus the medical community on early diagnosis and optimal treatment of COPD, this disease is still seen by both healthcare providers and the public as a largely untreatable, progressive, end-stage consequence of cigarette smoking.

Many patients with a diagnosis of COPD label themselves as having asthma, chronic bronchitis, or emphysema. This confusion in large part reflects a similar confusion among health care providers and in the medical literature. Although each of these terms has a specific clinical or pathological definition, in reality there is significant overlap among all of these entities. Clinical decision making should thus be guided by the specific presentation of each individual patient.

The presentation of COPD to the ED often results in a diagnostic dilemma, since patients with COPD frequently have comorbidities that make it difficult to pinpoint the underlying reason for their acute presentation. In addition, the serious prognostic implications of COPD exacerbations are underappreciated by emergency physicians, often because their ultimate morbidity and mortality are delayed by days or weeks.

This issue of Emergency Medicine Practice reviews the most recent evidence-based recommendations for the management of COPD exacerbations. In addition, some of the more challenging practical issues that surface when dealing with the chronic lung disease patient who presents with acute dyspnea are addressed, such as:
 

  • How to best assess respiratory status: is an ABG necessary?
  • When to order a BNP: is BNP helpful in differentiating COPD from CHF exacerbations?
  • How to deliver oxygen therapy: how much is too much?
  • How to administer bronchodilators: which ones, how often, and by which route?
  • When to consider other underlying diagnoses: is a workup for pulmonary embolism (PE) or acute coronary syndrome (ACS) warranted?
  • When to consider outpatient management: who is safe to send home?
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