So what are the signs and the symptoms that patients who have a COPD exacerbation
are gonna come to the emergency department with or an asthma exacerbation?
Classic things are that your patient will have a cough.
You know, often times patients who smoke or patients who have obstructive lung disease may have a chronic cough.
So you wanna ask them if their cough has changed in any way.
Is there cough normally dry and now they're producing sputum.
That information can help you along the way.
For the most part, these patients will have a gradual onset of symptoms.
It's rare that you have a patient who all of a sudden become short of breath
when they're coming in with an exacerbation of an obstructive lung disease.
This is something that generally happens over a period of time.
You know, often times it may develop gradually and just get progressively worse
to the point when they come into the emergency department that they're in severe respiratory distress.
But it's rare that it happens like that. It's rare that it happens very suddenly.
This is more often a gradual onset a worsening of a chronic problem.
Patients may have hypoxia.
It's important to remember, especially in those patients with COPD, they may have chronic hypoxia.
And some patients actually have such severe COPD that they need to be on home oxygen.
They need to be in oxygen when they are in their house –
are or when they're out kind of running daily errands.
Patients with COPD have a characteristic form of hypoxia and hypercapnia
because of impaired CO2 removal in the advance phase of COPD.
This results in CO2 retention.
Chronic hypercapnia increases H+ concentration causing respiratory acidosis and renal adaptive changes
occur mainly in the proximal tubular cells with increased bicarbonate reabsorption.
And patients know there are different oxygen requirements.
So patients know that they're on two liters or four liters.
At home is general – generally the average.
Something that can happen, that can prompt someone to have an exacerbation
or if they ran out of oxygen in their house or at home.
So you wanna assess their level of hypoxia and you wanna see what their baseline is.
So again, patients with COPD may not have a baseline even on those two – two liters of oxygen.
Normal oxygen saturation, they generally live –
we say, they live at a slightly lower oxygen saturation from the average person or the average person with healthy lungs.
So whereas a normal person with healthy lungs will have an O2 sat on room air,
around 98-100%, someone who has chronic obstructive lung disease will have a lower oxygen saturation at their baseline.
You know again, that's mainly a COPD patient, less so in the asthma patients.
You also wanna see their level of respiratory distress.
This is whether or not a patient is able to speak full sentences.
Whether they're able to speak one word sentences if they're using their accessory muscles.
Those are all kind of the key things that we wanna think about here.
So when we're doing our physical exam, we wanna definitely focus on our pulmonary exam.
Is the patient have wheezing on exam?
Wheezing is the classic thing that you're gonna hear both with obstructive lung disease as well as asthma.
Once you hear wheezing if you've never heard it before, I promise you,
you will remember what it sounds like because you may potentially might not have ever heard wheezing
before when you're examining a patient.
Definitely it's something that comes from the lower airways.
Sometimes patients – you can hear it audibly, and sometimes patients can sort of make their own wheeze.
So definitely when you're thinking about that, keep that in mind.
It's important to know though that obstructive lung disease is not the only thing that wheezes,
every so patients can get what we call it cardiac wheeze.
And that's due to CHF or congestive heart failure.
So if you hear wheezing, often times the first thing that you think about is obstructive lung disease
but don't forget about the cardiac wheeze that can sometimes happen for those patients.
Tripod position is basically patients will come in sitting upright in bed,
kind of leaning forward with one arm forward, will be the classic position that patients with obstructive lung disease will be in.
Again, if your patient is not sitting up, go ahead and sit them up in bed by but a –
but a majority of these patients are gonna be presenting either sitting up or in that tripod position.
You also wanna think about accessory muscle use.
So when we're looking at patients
and you’re looking at someone who's breathing normally,
they're not gonna be necessarily using the muscle in their neck or the muscles in their abdomen
to help them breathe but as respiratory distress becomes more severe,
patients need to use these additional muscles in order to help them
and adequately be able to inspire the air – so in order to be able to breathe in.
Accessory muscle use is a very important thing that you wanna look for especially in those young or asthmatic patients.
A pediatric patients, for the most part, sometimes they're not able to adequately communicate with you
and that accessory muscles use can really help you out a lot in trying to figure out their work of breathing.
You know there are certain important historical questions
that will really put you in a good place when trying to figure out appropriate treatment and disposition for your patients.
The key things that you wanna ask about are; have you ever bee intubated in the past?
So have you been on a ventilator machine?
Sometimes it's actually hard, patients may not –
you will be surprised how many patients actually don't know whether they have had this before.
You can look in the medical record to also try and figure this out.
I – any prior hospitalization for your asthma or COPD.
Asthma, less people generally are admitted to the hospital
but as COPD becomes more of a long-term problem and people get exacerbations,
definitely patients do get admitted. When was your most recent steroid course?
We'll talk about the treatment for obstructive lung disease but one of the big things that is administered are steroids.
I am – when you're giving steroid medication, patients who get that very frequently,
it's important to know that.
It has certain prognostic implications as to whether or not your patient may need to be admitted to the hospital.
So I always keep in mind, if someone just finished their course of steroids,
and already they're back in the emergency department with wheezing,
that makes me very worried that they may have to be admitted to the hospital –
or more concerned about their symptoms.
I also think about – ask patients about any usual triggers or frequency of their symptoms.
So for example, do they normally get triggered by the seasons changing, by allergies?
do they get triggered if they've been in a house with someone who is smoking, by being around a cat,
There’s lots of different things that trigger patients to have asthma symptoms.
It's also important to know, do you get symptoms every day, every week, once a year,
cuz all of that again, has implications in what you're gonna do for the patient in the emergency department.
The other thing that's important here is that these patients –
especially patients with asthma and COPD often times really know their bodies and understand their bodies.
So sometimes, we're talking here generally about the patient
who's in more severe respiratory distress but in mild or moderate cases,
it's very helpful to talk with your patient and say, "How do you feel compared with your baseline?"
That's a very important thing to think about and to talk to your patient about.
And can often times, again, also help you out figure out your next steps.