COPD?

[emt322632]

Been a while since I posted here:-) Just want to get some opinions on a recent call I had...

66 y.o. female c/o severe difficulty breathing. She has a hx of COPD for which she is not being treated, pt. states she had been smoking a cigarette about an hour before onset of symptoms. Cyanosis noted around lips, bilateral upper wheezes, no a/e in bases. Pt. SpO2 on 15 lpm nrb is 92%...

Only other med hx is HTN, she takes lopressor for that....

Vitals are: Resps: 28 labored, pulse is 110 regular, BP is 140/100.

She is extremely anxious, coach her breathing down slightly with the NRB on while preparing to travel the COPD route with her...

Give duo-neb of atrovent and albuterol, pt states some relief, however cyanosis is still noted and her effort in breathing really hasn't decreased at all. Establish an IV, cardiac monitor showing sinus tach at 110. Begin to hear some rhonchi and pt begins coughing up yellow sputum...start her on 2nd neb, just albuterol this time, give 125mg solumedrol as well..

We don't have CPAP, though I would have killed for it...

Get to the hospital and they ask me if I gave her lasix...I sat there and wonder why would I do that, this is straight forward COPD, but I don't say it...

Before we leave they have her on BiPAP...

So my question...did I miss anything, and would anyone have done something different given the presentation?

[Medic26]

Did the patient have a fever, how long had she been producing yellow sputum and has she ever had pneumonia in the past? From the sounds of it, this patient is probobly mildly short of breath all the time and has learned to live with it. Sometimes they are just too far gone for you to see any drastic improvements in what short time we spend with them.

[emt322632]

No recent illness, the yellow sputum was new. No hx of pneumonia to my knowledge. Agreed with the too far gone issue, just like 2nd opinions:-)

[Kaisu]

I don't think you missed anything.. sounds like acute inflammation of the bronchi - probably in response to the cig... lady needs to QUIT SMOKING - and long term treatment with a steroidal anti-flammatory... nothing for pre-hospital care...

[medic001918]

On the surface, it sounds like pneumonia to me as well. In that case, the combivent is not the best choice of nebulized meds that we can give to these patients due to the anticholinergic effect of atrovent.

From the picture you presented, I'm not sure that CPAP would have been the ideal treatment either, but I wasn't there to see just what kind of distress she was in. The best thing for pneumonia patient's (and in the case of COPD it's not detrimental) is fluids. A simple albuterol neb will sometime's cause them cough hard enough to actually bring up the phlegm and let you see what's going on.

I don't think you did anything wrong. The only thing that you did that I'm not totally sure that I would have done was the solumedrol. But this also depends too on if the patient has a fever. That's a telling sign quite often of another etiology.

Shane

NREMT-P

[Doczilla]

It sounds like you did fine with this patient. I don't see any big misses here.

The use of CPAP in mixed cause or undifferentiated acute respiratory distress has shown mixed results, but hasn't shown harm. I don't see any problem with trying it in this patient.

The lasix question may not have been a loaded one. In treatment of respiratory failure, even with wheezes, some providers will throw lasix at just about anything. They may have just been checking. You were right not to give it.

The steroids were a good idea, even if it does turn out to be pneumonia. The most immediate problem is bronchospasm, which will be partly alleviated by the solu-medrol. For pneumonia in a COPD patient, steroids will frequently be needed to attenuate the inflammatory response causing the wheezing.

For this COPD patient, only a chest xray will tell you if it really is pneumonia. If she has a fever, that strengthens the diagnosis. The sputum is not necessarily telling by itself; COPD patients hypersecrete mucus.

This case illustrates the complexity of a patient that seems relatively straightforward on first impression. Field diagnosis in respiratory distress is frequently inaccurate (as is ED diagnosis before xrays and bloodwork), and it's never a bad thing to question your initial impression of the patient.

'zilla

[Medic26]

The use of CPAP in mixed cause or undifferentiated acute respiratory distress has shown mixed results, but hasn't shown harm. I don't see any problem with trying it in this patient.

When we first started to use CPAP here about 4 years ago, the first patient in our region to get CPAP was a COPD patient......this happened by mistake and that provider no longer works here but it has worked a few times for us since we started using it on severe distress patients who show no improvements with standard treatments.

[als_medic_uk]

The use of a diuretic in COPD patients is not all that uncommon. If the patient were to have taken furosemide by direct inhalation that may have proved beneficial by alleviating the feeling of dyspnoea, there is also considerable bronchodilation post inhalation.

Sometimes COPD can be mistaken for CHF symptomatically.

Regards

[whit72]

Quick question.

How definitive are the findings with the Hepatojugular reflux. Could you base your treatment on its findings?

[VentMedic]

The use of a diuretic in COPD patients is not all that uncommon. If the patient were to have taken furosemide by direct inhalation that may have proved beneficial by alleviating the feeling of dyspnoea, there is also considerable bronchodilation post inhalation.

Sometimes COPD can be mistaken for CHF symptomatically.

Nebulized furosemide as off label use has been tried periodically for at least 30 years. Many of the studies have been critiqued to death. It has never gained any type of recognition or popularity in mainstream USA except in some hospice situations.

Feeling of dyspnea alleviates: Is the neb ran off a 7 L/m O2 flow?

Mouthpiece? Possibly a little "CPAP" effect. The same effect was found when runnig 7 L/M of compressed air and placebo on COPD with DOE in pulmonary labs.

The patient may also need to be pre or post treated with an albuterol tx to tolerate the lasix neb.

FEV1 changes? see above. I'd like to see plethysmography results.

Nebulizing off label medications in the back of an ambulance can present possible hazards to the crew. Albuterol and Atrovent are bad enough after repeated exposures. We try to use filtered nebulizers or an isolation room as well masks for staff with direct contact if running off label in the ER.

Furosemide might be seen nebulized in the neonate more commonly.

It can be part of hospice programs for terminally ill cancer patients.

I have found nebulized morphine and fentanyl to work well in giving some relief to the end-stage cancer or COPD patient.

http://www.medscape.com/viewarticle/545484?rss

http://www.factsandcomparisons.com/assets/...nov2004_off.pdf

It was mentioned the pt was put on BiPAP. Regular CPAP, especially some of the models carried by EMS today, could actually increase pt's work of breathing and lead to respiratory failure quicker. This would also be dependent on pt's air-trapping and secretions.