Wintertime seems to bring an increased number of patients experiencing respiratory difficulty, so I thought I would review the major cause of our patient’s distress, Chronic Obstructive Pulmonary Disease or COPD.
COPD diseases cause respiratory distress by narrowing and obstructing the airways. The diseases include chronic bronchitis and emphysema.
Asthma is not considered a true COPD, but it is similar. We will discuss it here anyway, as the season seems to exacerbate these patients as well.
Chronic bronchitis is airway congestion caused by an overabundance of mucous or sputum in the airways generally caused by airway lining irritation. A persistent cough is a symptom.
The condition is generally manageable, but if the mucous plugs the bronchioles, it can lead to worsening pulmonary function and cardiac complications. Chronic Bronchitis can be caused or made worse by irritants. Smokers, or people exposed to high levels of air pollution, smoke or toxins are at higher risk.
The obstruction caused by the accumulating mucous impairs air exchange and can cause wheezing. Patients may even feel rattling sensations in the chest and these can be heard when listening to the lungs with a stethoscope.
Recently, asthma has been excluded from COPD but the airflow restriction is similar. Nearly 8 percent of the people in the United States suffer from asthma. Patients suffering from this chronic inflammatory disorder present with wheezing, breathlessness and tightness in the chest.
During acute asthma episodes, the inflammation causes upper airway constriction. These narrowed airways will limit airflow and impair breathing. This is most evident on exhalation. This is due to the fact that inspiration or breathing in is the active part of respiration and exhalation is the passive phase.
Contraction of the intercostal and diaphragm muscles expands the chest during inspiration while the chest wall relaxes on expiration. The characteristic “expiratory” wheeze is heard as the air tries to escape the chest past the constricted upper airways.
These “wheezes” are usually audible to anyone near the patient but if breathing is weak and/or shallow, they can be heard with a stethoscope over the upper chest.
The severity of the asthmatic episode can be determined by the effort to breathe. Normally breathing should be effortless. Acute asthma patients will suffer from difficulty ranging from mild to extreme. A patient having a mild event may have shortness of breath with exertion. Severe asthma episodes bring about a profound shortness of breath typified by patients only being able to speak in short bursts of one or two words.
Treating asthma patients involves oxygen, bronchodilators and steroids. Basic life support providers will focus on oxygen and assisting the patient in using their own inhalers.
Advanced life support units will have nebulized inhaled medications, and medications that can be injected or administered via intravenous lines.
Any patient presenting with difficulty breathing should be given oxygen. Getting oxygen to the patient is the priority and the device used is a response to the amount the patient needs and what the patient will tolerate.
If pulse oximetry is available, oxygen support should target readings of 95 percent or better. If you need a mask to deliver the volume of oxygen your patients needs, but the patient won’t tolerate the mask, a nasal cannula should be considered.
Though the cannula won’t deliver the volume of oxygen you were hoping for it is better that the patient gets some oxygen. If nebulized medications are being given, nebulizer masks will have to be employed.
Some emergency medical services systems have protocols for the use of Continuous Positive Airway Pressure (CPAP) that decreases the work of breathing and improves oxygenation.
Bronchodilators are commonly prescribed to asthma patients and include Albuterol (Proventil and Ventolin), metaproterenol (Alupent), ipratropium (Atrovent), terbutaline (Brethine) and isoetharine.
The patient may be using the inhaler when you arrive or you may need to assist the patient in using the inhaler. As with any medication, overuse can have consequences.
Anxiety, increased heart rate and tremors can be side effects when used appropriately and overdose can cause more serious cardiac complications.
Advanced Life Support teams will be able to administer albuterol by nebulizer, which aerosolizes the medication mixed with saline so it can be inhaled and rapidly absorbed.
Corticosteroids, oral or injected, are a part of both acute and chronic asthma treatment. It’s seldom used in the field however, as it takes hours to have an effect. Steroids work by reducing the inflammation that causes the bronchoconstriction.
In emphysema, the alveoli are not just obstructed, they are destroyed. To maintain close to normal oxygen levels, these patients will increase their rate of breathing. This increased effort to breathe causes muscle wasting and the typical emphysema patient is thin and barrel chested. These patients are also chronically tachycardic.
The typical emphysema patient will present in respiratory distress with rapid heart and respiratory rates. The expiratory phase of ventilation will be drawn out or lengthened. The patient may instinctively try to create positive end expiratory pressure (PEEP) by pursing their lips to force the airways open.
In the past, some protocols actually limited the amount of oxygen delivered to COPD patients. We are normally driven to breathe by elevations in our CO2 levels. The COPD patient has hypoxic drive or is driven to drive by drops in blood oxygen levels. The old protocols were in response to fears that too much oxygen could actually result in respiratory distress.
Today’s protocols reflect the knowledge that hypoxia kills and even in the unlikely situation in which respiratory arrest does occur, ventilating with a bag-mask and high concentrations of oxygen is better than the patient is able to do alone.
Any patient in respiratory distress should be treated with oxygen. Oxygen should be delivered in sufficient quantity to maintain pulse oximetry to at least 95 percent. Advanced life support units will also have the opportunity to administer albuterol treatments, which may have to be repeated in 20 minutes.
For units that don’t have pulse oximetry, respiratory distress should be treated with oxygen by non-rebreather mask with at least 10 liters per minute of oxygen. As mentioned above, some of these patients may not tolerate the mask. The mask feels confining and they may brush it away looking for more air. The hypoxia also causes changes in their level of consciousness and they may bolt or try to escape from caregivers.
A major concern when chronic COPD patients present in profound distress is that they can experience respiratory fatigue. They are so exhausted from working so hard to breathe for so long that they just stop.
EMS teams must be prepared to create an airway and provide ventilations. Advanced life support units will intubate these patients. When breathing for patients it is important to not get carried away by the severity of the scene. Respirations must be maintained between 10 and 20 breaths per minute. Anything more or less causes hypoxia. While it seems obvious that too slow a respiratory rate is harmful it may surprise you that breathing faster is not better. Hyperventilation actually causes hypoxia and it gets worse the longer it goes on.
This was meant to review things that cause the respiratory emergencies you’ll be seeing this winter. What you should remember is that the treatments are fairly simple.
First, position the patient to facilitate breathing. These patients will need to be standing or sitting. You may often find them in a tripod like position leaning forward onto their arms in front of them.
Keep an eye on their airway and be prepared to manage it. Give oxygen in whatever way the patient tolerates. ALS care will include medications to dilate and open the constricted airways.
Watch for respiratory fatigue and be prepared to breathe for your patient when they no longer can for themselves. When you are breathing for your patient, time yourself. Don’t let the caffeine and adrenaline set the rate but stay within normal ranges, at least 10 but no more than 20.
As always with patients in distress, remember they may cough into your face as you approach them.
Protect yourself from diseases that may have contributed to their present crisis. Viral infections can cause the chronic conditions in these patients to flare up.
Editor’s Note: Will Chapleau, who has 30 years of EMS experience. He is the Advanced Trauma Life Support (ATLS) program manager for the American College of Surgeons. He is in charge of the trauma training programs for doctors all over the U.S. in 50 countries around the world. He is the former chief of the Chicago Heights (Ill.) Fire Department. He has served as the chairperson for the Prehospital Trauma Life Support (PHTLS) program since 1996 and has been a member of its international faculty since 1984 and is a board member of the National Association of EMS Educators.