Obstructive Lung Diseases: Management

00:01 Now what do we do for management? So we talked about a few different categories here.

00:05 So in a patient who's in severe respiratory distress.

00:08 This is your patient who's working very, very hard to breathe.

00:11 We want to think about doing a few things.

00:14 So non-invasive positive pressure ventilation is going to be a key first step here.

00:19 And this consists of either CPAP or BiPAP.

00:22 And what it does is it helps keep the alveoli expanded.

00:25 It helps to recruit more functional lung tissue.

00:28 And we know that studies have shown that when a patients are administered this you will have COPD exacerbations or asthma exacerbations, that they have less time spent in the ICU, less time spent in a hospitalization.

00:41 And this is a situation where patients can really benefit greatly from this non-invasive ventilation.

00:47 The other thing to think about, especially for patients who present with asthma exacerbations more than COPD is using epinephrine.

00:54 Epinephrine can very potently dilate the bronchioles and can really help with the patient's shortness of breath.

01:03 And then the last thing to think about is IV magnesium.

01:06 IV magnesium is also a bbronchodilator and can be administered for patients who are having severe shortness of breath.

01:13 The last thing on the list here is that we also want to make sure that we give albuterol or bronchodilator medication that's inhaled.

01:20 And for patients who have COPD as well, Atrovent or ipratropium should be added on as well.

01:26 Now for the mild to moderate respiratory distress.

01:29 Again, we want to definitely administer albuterol.

01:32 and ipratropium inhalational treatment.

01:35 And we also want to give steroids.

01:36 And we want to give steroids also for those patients who are in severe respiratory distress as well.

01:41 We'll talk more about steroids in a moment, and the best way to administer those.

01:46 And then for COPD patients, we want to consider adding on azithromycin or an equivalent antibiotic.

01:52 And we do that, and studies have shown that azithromycin can be beneficial for patients who have a change in their sputum production.

01:59 I mentioned that patients can have a chronic cough.

02:01 So patients may have a cough all the time.

02:03 But if they have any change in their cough or any change in their sputum production, adding on azithromycin may be of benefit to them.

02:10 And also may decrease some of that inflammation of the airways, which is why we often reach for this medication first.

02:16 If you're patient has an allergy to this medication, you can go ahead and replace it with an equivalent medication that could treat community-acquired pneumonia.

02:27 Now addressing steroids for a moment.

02:29 Steroids, should you give them intravenously? Or should you give them orally? Almost all patients who present with the exacerbations of COPD or asthma should be given steroids.

02:39 And steroids helped by really cutting down on that inflammation within the lung tissue.

02:44 It's important to note though, that both IV and oral steroids take effect in a similar amount of time.

02:49 So giving a steroid, it's not going to take effect immediately.

02:52 It's not going to be an immediate effect.

02:54 IV and oral steroids take effect in a couple of hours essentially.

02:58 So it's not going to be immediate.

03:00 And actually, you don't need to put an IV and if your patient otherwise doesn't need one.

03:04 You can just give them an oral dose of prednisone.

03:07 If your patient does need IV steroid, generally, you can reach for either Solu-Medrol or dexamethasone as your IV steroid for these patients.

03:16 So if a patient can take oral medications, no need to place an IV. Strictly for steroid administration.

03:21 Go ahead and give that oral steroid instead.

03:24 Again, let's think about albuterol, inhalers versus a nebulizer.

03:28 So in inhaler can be delivered using a metered dose inhaler.

03:31 So that's your classic thing that patients will go home.

03:33 They'll go home with an inhaler or puffer that they can use at home.

03:37 When patients come to the emergency department, generally, they're expecting treatment with nebulized albuterol and ipratropium.

03:44 And that's basically, you put a mask on a patient and it's a nebulizer mask.

03:47 And it's hooked up to the wall either using oxygen or using air and that medication is nebulized.

03:54 And the patient inhales those medications.

03:56 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.

04:10 So although most patients really feel as if the nebulizer treatment helps some more and it's what they expect when they come to the emergency department is not necessarily needed for all patients.

04:20 And if you are able to use inhaler effectively, it can be equally as good for a patient.

04:28 In the ED we always think about the disposition.

04:30 So we always say our patient can't stay there forever, right? So we always need to think about, where they're going to go? Are they going to go to their house? Or are they going to need to be admitted to the hospital.

04:41 Now in order to figure this out, we want to reassess our patient.

04:44 Our 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.

04:53 One way that we can reassess the patient is by checking a peak flow.

04:56 And a peak flow is checked by having a patient kind of forcibly exhale into a peak flow meter.

05:02 Patients who have asthma oftentimes will know their baseline peak flow.

05:06 So they'll know where they generally fall.

05:08 And if not, you can perform some kind of weight based calculation.

05:11 The key thing here is you potentially want to check this before you give the patient any treatment and then you get check it again.

05:17 after you've given them a treatment.

05:18 And you see if there's been an improvement in this number.

05:21 So checking the peak flow can really help patients or help you figure out what to do with your patient next.

05:26 You also want to check an ambulatory oxygen saturation.

05:30 especially for your patients who have COPD.

05:33 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.

05:39 Otherwise, you might not really know how to interpret your results.

05:42 Generally, when checking in 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.

05:54 A patient can also report to you symptoms, right? So when they go home, a patient is not just going to be laying in bed or sitting in bed.

06:01 They're going to need to walk around their house.

06:03 They're going to need to walk to the bathroom.

06:05 So having them see how they feel when they walk around it is also really, really important.

06:09 So if a patient walks around, even if their oxygen levels stay reasonably normal, if they're in severe respiratory distress, you want to go ahead and consider admitting that patient to the hospital, right? Or having them be observed for a longer period of time.

06:24 In this disposition part, this is also where talking with the patient really is very important.

06:29 So talking with someone and saying, "How do you feel?" Patients oftentimes with chronic conditions know their bodies best.

06:35 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.

06:44 or that they do potentially.

06:45 Because they really sometimes know their bodies best.

06:50 So in conclusion, when patients come in with severe respiratory distress.

06:54 Always treat and evaluate at the same time.

06:56 You might not necessarily always know exactly what's going on, but go ahead and get some treatment started.

07:02 Evaluate your patient.

07:03 Try and get as much history as you can in those initial phases.

07:06 Be sure to ask about prior intubations and hospitalizations.

07:10 because that can help you determine disposition and what you're going to do with your patient ultimately.

07:16 Checking a blood gas can help you determine the need for ventilator support.

07:19 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.

07:31 For those patients, you're going to want to definitely start thinking about starting them on that non-invasive ventilation, or potentially intubating them if there's shortness of breath is very severe.

07:43 So you're definitely going to want to be thinking about that.

07:47 Also important to remember that almost all patients who come to the EG with exacerbations of obstructive lung disease should get steroids.

07:53 So for that COPD patient as well as for that asthmatic patient who come in administering steroids is generally pretty universal.

08:00 It would be a rare situation where that patient wouldn't necessarily go home on steroids.

08:06 Also, you want to make sure you're reassessing your patient to help determine disposition.

08:10 You want to make sure that your patient can ambulate having their oxygen saturations stay reasonably okay, and that they're not in severe shortness of breath when they walk around, potentially also consider checking the peak flow both before and after treatment to help figure out what you should do for your patient next.

08:26 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.