Case Study: Managing a Critically Unwell COPD Exacerbation in the ED

Patient Presentation

Mr. A is a 68-year-old man with a long-standing history of severe chronic obstructive pulmonary disease (COPD). He arrives in the Emergency Department via ambulance, having been found at home confused, with shallow breathing and accessory muscle use. On arrival:

• Respiratory rate: 35/min, shallow

• SpO₂: 82% on room air, 90% on a non-rebreather mask

• Heart rate: 125 bpm, irregularly irregular

• Blood pressure: 155/85 mm Hg

• GCS: 12 (opens eyes to speech, confused speech, localizes pain)

• Accessory history: Family reports progressive dyspnea over 3 days, increased sputum production, and a recent URTI. He is on home oxygen 2L 24/7, inhaled tiotropium, and salbutamol as needed.

An arterial blood gas obtained on 15 L non-rebreather shows:

• pH 7.10

• PaCO₂ 78 mm Hg

• PaO₂ 58 mm Hg

• HCO₃⁻ 30 mEq/L

Mr. A’s rising PaCO₂, falling pH, and decreased level of consciousness indicate impending ventilatory failure. After initial medical therapy fails to improve ventilation (bronchodilators, steroids, IV antibiotics, and noninvasive ventilation trial for 30 minutes), the decision is made to secure his airway and proceed with invasive mechanical ventilation.

Initial Management for COPD Exacerbation

Before intubation, optimize reversible factors and oxygenation:

1. Bronchodilators

   • Nebulized salbutamol: 5 mg nebulizer continuous or Q20min

   • Ipratropium bromide: 500 mcg nebulizer (combine with salbutamol)

2. Systemic Corticosteroids

   • IV Hydrocortisone: 50 mg IV bolus, then 50 mg q 6 h

   • Alternatively, IV Methylprednisolone 125 mg once

3. Antibiotics (if suspicion of bacterial bronchitis/pneumonia)

   • IV Amoxicillin–clavulanate: 1.2 g IV q 8 h

4. Diuretics (if volume overload suspected)

   • IV Furosemide: 20–40 mg IV bolus

5. Noninvasive Ventilation (NIV)

   • BiPAP settings:

     • IPAP 12–14 cm H₂O, EPAP 5–8 cm H₂O

     • FiO₂ to achieve SpO₂ 88–92 %

   • Trial for 20–30 minutes; monitor for improvement in minute ventilation and mental status

When Mr. A’s respiratory drive remains inadequate (PaCO₂ rising, GCS falling), indications for intubation become clear:

• Deteriorating level of consciousness (GCS ≤ 12)

• Inability to protect airway

• Severe respiratory acidosis (pH < 7.25) despite NIV

Airway Strategy: RSI vs Modified (Delayed) Sequence Intubation

In COPD patients, prep and choice of induction technique can reduce complications:

Rapid Sequence Intubation (RSI)

Pros:

• Minimizes aspiration risk

• Predictable timing, quick control of airway

  Cons:

• Higher risk of hemodynamic instability (especially with sedative agents)

• Less time to preoxygenate thoroughly

Delayed Sequence Intubation (DSI)

• Administer a sedative alone (e.g., low-dose ketamine 0.5 mg/kg) to facilitate better preoxygenation on NIV or high-flow nasal cannula (HFNC)

• Once adequately preoxygenated, administer paralytic (rocuronium) and deeper induction agent

Why DSI can help in COPD:

• Allows for improved preoxygenation with BiPAP/HFNC in a patient who cannot tolerate a mask due to agitation or high respiratory drive

• Preserves spontaneous ventilation longer, reducing sudden desaturation

Choice for Mr. A: Because his GCS is 12 but still protecting his airway and he is agitated, a DSI approach can be used to improve preoxygenation on BiPAP. However, if time is critical (GCS ≤ 8 or severe fatigue), classic RSI is chosen.

Induction & Paralysis Dosing (RSI Drugs Cheat Sheet)

Below is a concise adult dosing table—printable and pocketable—for rapid reference in the ED:

Key Considerations for COPD:

• Hemodynamics: Avoid propofol if hypotensive—use etomidate or ketamine.

• DSI Sedation Dose: Ketamine 0.5 mg/kg IV (for 70 kg, that’s 35 mg). Observe for improved preoxygenation.

• Paralysis: Rocuronium preferred if succinylcholine contraindicated (e.g., hyperkalemia); otherwise succinylcholine can be used for shorter duration.

Securing Ventilation: Best Mode for COPD & Ventilation Strategies

After intubation, the primary goal is to correct hypercapnia and hypoxemia while minimizing barotrauma and dynamic hyperinflation.

Mode Choice

• Pressure-Controlled Ventilation (PCV) or SIMV + Pressure Support

  • Allows control of peak pressures, facilitates patient-triggered breaths

Initial Settings for Mr. A (COPD Exacerbation)

• Tidal Volume (V_T): 6–8 mL/kg ideal body weight (e.g., 6 mL/kg × 70 kg → 420 mL)

• Respiratory Rate (RR): 10–12 breaths/min (permit prolonged exhalation)

• I:E Ratio: 1:4 (prolonged expiratory time to prevent air trapping)

• PEEP: 3–5 cm H₂O (minimal to avoid increasing intrinsic PEEP but maintain alveolar patency)

• Inspiratory Flow Rate: 80–100 L/min (short inspiratory time, longer expiratory time)

• FiO₂: Start at 100 % and rapidly wean aiming for SpO₂ > 88 %

Why these settings?

• Low V_T reduces alveolar overdistension.

• Slow RR and 1:4 I:E ratio prevent breath stacking and dynamic hyperinflation.

• Minimal PEEP avoids worsening auto-PEEP, a common source of hypotension and reduced venous return.

Monitoring & Titration

• Waveforms: Watch for flow not returning to baseline before next breath—sign of air trapping.

• Peak & Plateau Pressures: Keep plateau < 30 cm H₂O.

• Blood Gases: Repeat ABG 15–30 minutes after intubation:

  • Target pH ≥ 7.30 (accept permissive hypercapnia if pH > 7.20)

  • PaO₂ 60–80 mm Hg (SpO₂ > 88–92 %)

Sedation & Analgesia (ICU Cheat Sheet Snippet)

• Fentanyl: 1–2 mcg/kg/hr (bolus 1 mcg/kg if needed)

• Propofol: 20–50 mcg/kg/min (bolus 0.5 mg/kg for deeper sedation)

• Midazolam: 0.02–0.1 mg/kg/hr (bolus 0.05 mg/kg as needed)

Aim: Keep Richmond Agitation-Sedation Scale (RASS) at –2 to –3 (moderate sedation) so Mr. A is comfortable on the ventilator but not excessively oversedated.

Integrating the Mini-Card PDF into Your Workflow

You’ve seen table snippets above for RSI dosing and COPD ventilation settings. To avoid memorizing or scribbling on paper, download the Free Emergency Medicine Mini-Card PDF. It consolidates:

• Adult & Pediatric Dosing (Ketamine, Etomidate, Rocuronium, Succinylcholine)

• Ventilation Strategies for ARDS, Neuroprotection, and Obstructive (COPD)

• Sedation Infusions & Pressor Cheat Sheets

How to Download:

1. Click the button below.

2. Enter your email address.

3. Instantly receive the Mini-Card PDF in your inbox—no extra apps, completely free.

Summary & Key Takeaways

1. Early Medical Management: Aggressive bronchodilators, steroids, antibiotics, and NIV—before considering intubation.

2. Airway Choice (RSI vs DSI): In COPD with borderline GCS, a brief DSI with ketamine (0.5 mg/kg) can optimize preoxygenation. Use etomidate or ketamine for induction in hemodynamically tenuous patients.

3. RSI Drug Dosing: Keep a pocketable “RSI drugs cheat sheet” ready—ketamine 1.5 mg/kg, etomidate 0.3 mg/kg, rocuronium 1.2 mg/kg, succinylcholine 1.5 mg/kg.

4. Ventilation Strategy for COPD: Pressure-Controlled or SIMV + PS, V_T 6–8 mL/kg, RR 10–12, I:E 1:4, minimal PEEP (3–5 cm H₂O), high inspiratory flow.

5. Sedation & Analgesia Cheats: Fentanyl 1–2 mcg/kg/hr, propofol 20–50 mcg/kg/min, midazolam 0.02–0.1 mg/kg/hr—adjust to maintain RASS –2 to –3.

By following this structured, case-based approach—coupled with the Mini-Card PDF—you’ll streamline decision-making, reduce calculation errors, and maintain focus on patient care. Bookmark this post, download the Mini-Card, and share this resource with your ED and ICU teammates.

Good luck on your next shift, and may your ventilator settings always be lung-protective!

— Cat the Medic

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