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.
Oftentimes, 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 their 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 becomes 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.
Oftentimes, 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 on oxygen when they’re in their house
or when they’re out kind of running daily errands.
And patients know their different oxygen requirements.
So, patients know that they’re on two liters or four liters
at home is generally the average.
Something that can happen that can prompt someone to have an exacerbation
or if they run 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 liters of oxygen, normal oxygen saturation.
They generally live – we say they live at a slightly lower oxygen saturation
than the average person or the average person with healthy lungs.
So, whereas a normal person with healthy lungs will have an O2 set on room air,
around 98 to 100%, someone who has chronic obstructive lung disease
will have a lower oxygen saturation at their baseline.
Again, that’s mainly in those COPD patients, 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 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 note though that obstructive lung disease
is not the only thing that wheezes.
Every so often, patients can get what we call a cardiac wheeze
and that’s due to CHF or congestive heart failure.
So, if you hear wheezing, oftentimes, the first thing you think about
is obstructive lunch 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 lunch disease will be in.
Again, if your patient is not sitting up, go ahead and sit them up in bed
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 muscles in their neck
or the muscles in their abdomen to help them breathe.
But as respiratory distresses and becomes more severe,
patients need to use these additional muscles in order to help them
inadequately be able to inspire the air in order to be able to breathe in.
Accessory muscle use is a very important thing that you wanna look for
especially in those younger asthmatic patients.
Pediatric patients for the most part,
sometimes they’re not able to adequately communicate with you
and that accessory muscle use can really help you out a lot
in trying to figure out their work of breathing.
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 been intubated in the past?
So, have you been on a ventilator machine?
Sometimes, it’s actually hard.
Patients may not – you would be surprised how many patients
actually don’t know whether they’ve had this before.
You can look in the medical record to also try and figure this out.
Any prior hospitalizations for your asthma or your 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’s administered are steroids.
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 a 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 and 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’s smoking?
By being around a cat?
There’s lots of different things that can trigger patients to have asthma symptoms.
It’s also important to know, do you get symptoms every day, every week, once a year?
Because all of that again has implications on 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, oftentimes 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 oftentimes again also help you figure out your next steps.