Situation- David presented to the Emergency Department at 2200 hrs. Upon assessment he was sitting in a tripod position and found to have a barrel chest. David presents with fever, sore throat, productive cough, yellow phlegm and dyspnoea.
Background- David tested positive for COVID-19 three days ago through a rapid antigen test. Wife Linda indicated symptoms had progressively worsened with no relieving factors noted. David had similar episode a year ago with an acute exacerbation of chronic obstructive pulmonary disease (COPD) requiring hospitalisation. David has an increasing amount of purulent mucus which appears as yellow phlegm. He self-medicated with a Ventolin inhaler prior to admission but this had not resolved his symptoms
Past Medical History- COPD, hypertension, hyperlipidaemia. He was a previous smoker for 30 years however he quit when he was diagnosed with COPD 10 years ago.
Current Regular Medications taken:
- Ipratropium (Atrovent) via nebulizer once a day
- Salbutamol (Ventolin) puffer PRN
- Lipitor 40mg daily
- Not up to date on his annual pneumococcal and influenza vaccinations
A to G Assessment
Airway- Patent, own
Breathing- RR-30 b/min, SPO2 78% on room air, Increased Shortness Of Breath (SOB)
Auscultation: Diminished breath sounds bilaterally, with wheezing and crackles in the lung bases. Using accessory muscles of respiration ++.
Circulation- Heart Rate (HR) Regular- 128 b/min-Sinus tachycardia. BP- 168/85 mmHg.
Capillary Refill Time 3 sec, peripherally cool, heart sounds dual no murmur.
Disability- GCS-14/15 E4V4M6, confused and distressed +
Exposure- Febrile, skin intact, IV cannula right cubital fossa
Abdo: bowel sounds present in all four quadrants with a soft, nontender abdomen
Fluid- IVF fluids in progress TKVO, Nil by mouth
Glucose- BSL- 5.8 mmol/L
Imaging: Chest X-ray showing hyperinflated lungs with increased interstitial markings consistent with COPD exacerbation.
Lab tests
- CBC
| Result | Reference Range | |
| Haemoglobin | 153 g/L | 120-140 g/L |
| White blood cells | 15.0×10^9/L | 4.0-11.0×10^9/L |
| Neutrophils | 11.0×10^9/L | 2.0-7.5×10^9/L |
| Platelets | 200×10^9/L | 150-400×10^9/L |
| C Reactive Protein
(CRP) |
25 mg/L | <3mg/L |
- 2- COVID-19 PCR Test: Positive
- ABG on room air (at 2200hrs)
| Result | Reference Range | |
| pH | 7.30 | 7.35-7.45 |
| PaO2 | 55 mmHg | 80-100 mmHg |
| PaCO2 | 60 mmHg | 35-45 mmHg |
| HCO3- | 28 mmol/L | 22-26 mmol/L |
| SpO2 | 78% | (88-92% COPD) |
| BE | -4 mmol/L | -2 to +2 mmol/L |
Clinical Impression: Infective Exacerbation of COPD COVID 19 +ve
Recommendations
- Continuous monitoring of vital signs- Transfer to High Dependency Unit
- COVID-19 Management: Isolate the patient in a negative pressure room, implement infection control precautions, and monitor for progression of COVID-19 symptoms
- Controlled oxygen therapy -Continuous pulse oximetry, to keep O2 between 88% to 92%
- Sit patient in high fowlers position
- 4/24 ABGs
- Salbutamol (Ventolin) nebuliser 2/24
- Ipratroprium (Atrovent) via nebuliser 6/24
- Prednisolone (40–50 mg daily)
- 12- lead ECG 6th hourly
- Blood troponin
- Sputum culture
- IV Azithromycin (Zithromax) 500 mg on day 1 , followed by 250 mg once daily for the next four days.
- 300 mg nirmatrelvir with ritonavir 100 mg taken together orally every 12 hours for 5 days.
- Pulmonary function tests Spirometry when patient is stable