# 65 y/o male respiratory distress



## rhan101277 (Oct 8, 2011)

Dispatch info:

65 y/o male hx of asthma is having breathing difficulty.
He is awake and alert.
He has difficulty speaking in complete sentences.

You approach to see a 65 y/o male sitting on the edge of his bed at his residence.  He is tachypneic and in the tripod position.  You hear audible wheezing.  You notice a nebulizer with a mask connected nearby.  A decision is made to forgo setting up a pulse ox initially and 15L NRB is immediately applied while a nebulizer treatment is prepared.  Your partner takes vitals.

RR - 52
Blood pressure - 188/112
Pulse ox - 100% on 15L NRB
Sinus Tach on monitor at 110 BPM.
Lung sounds - Diffuse wheezing and rhonchi, bilaterally diminished sounds.
12 lead - No ST elevation
ETCo2 minimal shark fin, tachypneic, 26mmHG

A quick history gathering is attempted but patient can't answer adequately.  You say, "what is going on today."  Pt states "what you think man".  Further history is gleaned from wife, he went to Dr. today for having trouble breathing and nothing was done for him.  Pt denies any chest pain or any pain anywhere for that matter.  Pt takes home neb for asthma but when asked about it, he doesn't know what it is.  Patient is a poor historian.

Patient is loaded into ambulance with a combivent started at 8L, he is still tachypneic, no signs of this being an allergic reaction.  In route he coughs up some sputum, about the consistency and color of mustard.  Not really thick like pneumonia.  Pt has no fever.  The initial treatment is done and patient reports being able to breath easier.  A single albuterol tx is given and patient tolerates it well, at emergency room arrival patient RR is 36.

Solu-medrol is withheld due to the possibility of pneumonia even in the abscence of fever.  Solu-Medrol causes immune system depression.

What would you do differently?


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## IRIDEZX6R (Oct 8, 2011)

Accessory muscle use? Were they full deep breaths? Or short quick ones? I've seen some medics use CPAP or BVM in this situation, not quit sure on their reasoning though.


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## HMartinho (Oct 8, 2011)

Good job.

But, what is the distance to the nearest E.R.?


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## Shishkabob (Oct 8, 2011)

IRIDEZX6R said:


> I've seen some medics use CPAP ... in this situation, not quit sure on their reasoning though.



To potentially decrease the work of breathing, same as with COPD/CHF.  Studies are still being done about it, but more evidence is coming out that CPAP is beneficial for some asthmatics.  I've given it to asthmatics before and had fantastic results.






Hx of cardiac issues?  What meds aside from albuterol (seeing a patient only only albuterol is rare).  Been intubated previously for asthma exacerbation?  Hospitalized for asthma?  


Did the single albuterol treatment decrease work of breathing / wheezing, or just lower rate?  No atrovent?  A mag drip is an option, along with Epi if it gets too far.


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## usalsfyre (Oct 8, 2011)

Good job, the only differences for me are I'd do continuous A&A (till the wheezing subsided) and probably still go ahead with steroids, the immunosuppression from a single dose doesn't outweigh the benefit to an asthma patient. 

Generally pneumonia patients don't have audible wheezing, you might hear some wheezing on auscultation. Explain your reasoning on the worry over pneumonia.


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## rhan101277 (Oct 8, 2011)

usalsfyre said:


> Good job, the only differences for me are I'd do continuous A&A (till the wheezing subsided) and probably still go ahead with steroids, the immunosuppression from a single dose doesn't outweigh the benefit to an asthma patient.
> 
> Generally pneumonia patients don't have audible wheezing, you might hear some wheezing on auscultation. Explain your reasoning on the worry over pneumonia.



Well I have only given Solu-Medrol once and it was needed due to moderate allergic reaction.  When I brought the patient in I watched as the doctor seemed concerned about an infection, but it was an allergic reaction.  I can always learn more and look to improve after every call.  I think he did get some steroid, he was a poor historian and I didn't have a good medication history.  As long as his ETCo2 was good and he didn't de-saturate I was fine with him like he was.  I took us 20 minutes to get to ER.

Some people can die very easily from pneumonia, especially as they get older and their immune system could already be compromised from other medications.  I thought it could be a combination asthma/new onset pneumonia problem.  Though after doing some reading I find out the coughing up mucus can occur in asthma, this is the first time I have seen it.


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## epipusher (Oct 9, 2011)

cpap with inline albuterol and atrovent


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## fast65 (Oct 9, 2011)

I wouldn't really have done anything differently, pretty much keep running a neb of Xoponex/Atrovent all the way to the hospital, and I probably would have given him a dose of Solu-Medrol. Other than that, great job, I don't see a problem with the way you managed this patient.


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## truetiger (Oct 9, 2011)

I'd hold the steroids until I can get a good pmhx. Diabetics and solu-medrol don't mix well. I'd also use xopenex if it was available. He's already tachy, no need to add to it.


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## rhan101277 (Oct 9, 2011)

truetiger said:


> I'd hold the steroids until I can get a good pmhx. Diabetics and solu-medrol don't mix well. I'd also use xopenex if it was available. He's already tachy, no need to add to it.



No Xopenex here, he wasn't extremely tachy if he was I would have called med control.  If he was 130+ that is.  Wish they would get xopenex.

Although Xopenex has less of a change to get you tachy it still can do so.

In adult and pediatric patients with asthma, clinical trials have demonstrated lower mean heart rates in patients using levalbuterol vs racemic albuterol.[4-6] The magnitude of this difference is modest, but it may be clinically significant in patients with a history of arrhythmias, structural heart disease, or cardiac conditions that could worsen with an episode of tachycardia (eg, decompensated heart failure).

Other studies show no difference in mean heart rate when the 2 drugs are compared head-to-head.[7] Because the adverse effect of increased heart rate is common to all beta-agonists, equimolar doses of levalbuterol and racemic albuterol would be expected to result in a similar degree of tachycardia. In other words, the transient tachycardia seen with both levalbuterol and racemic albuterol is most likely dose dependent.

Taken from:

http://www.medscape.com/viewarticle/719008


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## EMSrush (Oct 10, 2011)

I'd give Mag, and consider Epi.


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## jjesusfreak01 (Oct 10, 2011)

EMSrush said:


> I'd give Mag, and consider Epi.



Satting at 100% and Tachycardic already? How do you plan to give the Epi?

I'm not criticizing, just want to know your reasoning on this.


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