What do we do for management?
So we talk about a few different categories here.
So in a patient who is in severe respiratory distress.
This is your patient who’s working very, very hard to breathe.
We wanna think about doing a few things.
So noninvasive positive pressure ventilation is gonna be a key first step here.
And this consists of either CPAP or BiPAP
and what it does is it helps keep the alveoli expanded.
It helps to recoup more functional lung tissue
and we know that studies have shown
that when patients are administered this who have COPD exacerbations
or asthma exacerbations that they have less time spent in the ICU,
less time spent in a hospitalization,
and this is a situation where patients can really benefit greatly
from this noninvasive ventilation.
The other thing to think about
especially for patients who present with asthma exacerbations
more than COPD is using epinephrine.
Epinephrine can very potently dilate the bronchioles
and can really help with the patient’s shortness of breath,
and then the last thing to think about is IV magnesium.
IV magnesium is also a bronchodilator and can be administered for patients
who are having severe shortness of breath.
The last thing on the list here is that we also wanna make sure that we give albuterol
or bronchodilator medication that’s inhaled
and for patients who have COPD as well,
Atrovent or ipratropium should be added on as well.
Now, for the mild to moderate respiratory distress,
again, we wanna definitely administer Albuterol
and ipratropium inhalational treatment,
and we also wanna give steroids, and we wanna give steroids also
for those patients who are in severe respiratory distress as well.
We’ll talk more about steroids in a moment and the best way to administer those.
And then, for COPD patients, we wanna consider adding on azithromycin
or an equivalent antibiotic, and we do that and students have shown
that azithromycin can be beneficial for patients
who have a change in their sputum production.
I mentioned that patients can have a chronic cough.
So patients may have a cough all the time,
but if they have any change in their cough
or any change in their sputum production,
adding on azithromycin may be a benefit to them
and also may decrease some of that inflammation of the airways,
which is why we often reach for this medication first.
If your patient has an allergy to this medication,
you can go ahead and replace it with an equivalent medication
that could treat community acquired pneumonia.
Now, addressing steroids for a moment, steroids should you give them intravenously?
Or should you give them orally?
Almost all patients who present with exacerbations of COPD or asthma
should be given steroids and steroids help by really cutting down
on that inflammation within the lung tissue.
It’s important to note though that both IV and oral steroids
take effect in a similar amount of time.
So giving a steroid, it’s not gonna take effect immediately,
it’s not gonna be an immediate effect.
IV and oral steroids take effect in a couple of hours essentially
so it’s not gonna be immediate
and actually, you don’t need to put an IV in if your patient otherwise doesn’t need one.
You can just give them an oral dose of prednisone.
If your patient does need IV steroids generally,
you can reach for either Solu-Medrol or dexamethasone as your IV steroid for these patients.
So if a patient can take oral medications, no need to place an IV
strictly for steroid administration, go ahead and give that oral steroid instead.
Again, let’s think about Albuterol inhalers versus a nebulizer.
So an inhaler can be delivered using a metered dose inhaler.
So, that’s your classic thing that patients will go home with.
They’ll go home with an inhaler or a puffer that they can use at home.
When patients come to the emergency department,
generally, they’re expecting treatment with nebulized Albuterol and ipratropium
and that’s basically you put a mask on a patient and it’s a nebulizer mask
and it’s hooked up to the wall either using oxygen or using air,
and that medication is nebulized and then, the patient inhales those medications.
And although that is the expectation that patients expect when they come to the ED,
a metered dose inhaler, so the inhaler that they go home with,
when used properly has actually been found to be equally effective for these patients.
So although most patients really feel as if the nebulizer treatment helps them more
and it’s what they expect when they come to the emergency department,
it’s not necessarily needed for all patients.
If you are able to use inhaler effectively, it can be equally as good for a patient.
In the ED, we always think about the disposition.
So we always say our patient can’t stay there forever, right?
So, we always need to think about where they’re gonna go.
Are they gonna go to their house
or are they gonna need to be admitted to the hospital?
In order to figure this out, we wanna reassess our patient.
Reassessing our patient is very key for all patients who come in with respiratory distress
to see if the treatments that we gave them have made them better.
One way that we can reassess the patient is by checking a peak flow
and a peak flow is checked by having a patient
kind of forcibly exhale into a peak flow meter.
Patients who have asthma oftentimes will know their baseline peak flow
so they know where they generally fall
and if not, you can perform some kind of weight base calculation.
The key thing here is you potentially wanna check this
before you give the patient any treatment
and then you check it again after you’ve given them treatment
and you see if there’s been an improvement in this number.
So, checking a peak flow can really help patients
or help you figure out what to do with your patient next.
You also wanna check an ambulatory oxygen saturation
especially for your patients who have COPD.
It’s important if they’re on home oxygen that you check it
using their baseline amount of oxygen that they’re on at home,
otherwise, you might not really know how to interpret your results.
Generally, when checking an ambulatory oxygen saturation,
you have a patient hooked up to a pulse ox machine
and you walk them around the emergency department for a couple of minutes
and you see what their oxygen levels do.
This can also – a patient can also report to you symptoms, right?
So when they go home, a patient’s not just gonna be lying in bed or sitting in bed,
they’re gonna need to walk around their house,
they’re gonna need to walk to the bathroom.
So having them see how they feel when they walk around
is also really, really important.
So if a patient walks around even if their oxygen levels stay reasonably normal,
if they’re in severe respiratory distress,
you wanna go ahead and consider admitting that patient to the hospital, right?
Or having them be observed for a longer period of time.
In this disposition part, this is also where talking with a patient really is very important.
So talking with someone and saying, “How do you feel?”
Patients oftentimes with chronic conditions know their bodies best,
so, “Do you feel okay to go home?” “Do you feel well enough to go home?”
And I oftentimes will really trust a patient when they’re telling me
that they really don’t feel well enough to go home
or that they do potentially because they really sometimes know their bodies best.
So in conclusion, when patients come in with severe respiratory distress,
always treat and evaluate at the same time.
You might not necessarily always know exactly what’s going on
but go ahead and get some treatment started, evaluate your patient,
try and get as much history as you can in those initial phases.
Be sure to ask about prior intubations and hospitalizations
because that can help you determine disposition
and what you’re gonna do with your patient ultimately.
Checking a blood gas can help you determine the need for ventilator support
if someone has a very high PCO2 level,
if someone has a normalizing pH and PCO2 in those asthma patients,
patients who are acidotic so who the pH is low because the PCO2 is high.
For those patients, you’re gonna wanna definitely start thinking about starting them
on that noninvasive ventilation or potentially intubating them
if their shortness of breath is very severe,
so you’re definitely gonna wanna be thinking about that.
Also, important to remember that almost all patients who come to the ED
with exacerbations of obstructive lung disease should get steroids.
So for that COPD patient as well as for that asthmatic patient who come in,
administering steroids is generally pretty universal.
It’d be a rare situation where that patient wouldn’t necessarily go home on steroids.
Also, you wanna make sure you're reassessing your patient
to help determine disposition.
You wanna make sure that your patient can ambulate
having their oxygen saturation stay reasonably okay
and that they’re not in severe shortness of breath when they walk around.
Potentially, also consider checking a peak flow but before and after treatment
to help figure out what you should do for your patient next.
Always ensure that these patients have good follow-up
with their primary care doctor
and give them good return precautions to come back to the ED.