Treat for COPD or Asthma?

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NYMedic828

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My question is basically at what point do you determine to treat for just COPD or asthma?

For example we just had a 75 yo male with a respiratory infection he was in treatment for and had worsening SOB.

History COPD and asthma amongst other things.

He was refractory to his visiting nurses nebulizer treatment and was pretty labored so we immediately gave him decadron and duoneb.

He had some improvement but by arrival at the ER was still in obvious distress. The ER started him on avelox and mag. They drew up the EPI but held off due to his age/HR already being 130.

So here in NYC we have protocols for COPD and a separate one for Asthma. The difference is asthma has the addition of epi/mag.

So what should be the distinguishing factor for giving mag/epi to a COPD'r with history of asthma.
 
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Do you use capnography as part of your protocol? This would help determine if it is a trapping issue due to Asthma, or a COPD issue.


NYMedic828 said:
My question is basically at what point do you determine to treat for just COPD or asthma?

For example we just had a 75 yo male with a respiratory infection he was in treatment for and had worsening SOB.

History COPD and asthma amongst other things.

He was refractory to his visiting nurses nebulizer treatment and was pretty labored so we immediately gave him decadron and duoneb.

He had some improvement but by arrival at the ER was still in obvious distress. The ER started him on avelox and mag. They drew up the EPI but held off due to his age/HR already being 130.

So here in NYC we have protocols for COPD and a separate one for Asthma. The difference is asthma has the addition of epi/mag.

So what should be the distinguishing factor for giving mag/epi to a COPD'r with history of asthma.
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Nope, I wish we did.

We have the capability but aren't supplied with the NCs.

It is a nifty trick though I wish I could do it at work.

Hospitals here don't even use waveform capnography in the ER tho so there must be some thee means of determination.
 
NYMedic828 said:
My question is basically at what point do you determine to treat for just COPD or asthma?

For example we just had a 75 yo male with a respiratory infection he was in treatment for and had worsening SOB.

History COPD and asthma amongst other things.

He was refractory to his visiting nurses nebulizer treatment and was pretty labored so we immediately gave him decadron and duoneb.

He had some improvement but by arrival at the ER was still in obvious distress. The ER started him on avelox and mag. They drew up the EPI but held off due to his age/HR already being 130.

So here in NYC we have protocols for COPD and a separate one for Asthma. The difference is asthma has the addition of epi/mag.

So what should be the distinguishing factor for giving mag/epi to a COPD'r with history of asthma.
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Mag should be way down the line simply in terms of a paucity of support.

Epi in COPD should be weighed against any cardiac Hx and whether it appears they are mounting enough of a sympathetic response on their own.

Otherwise I'd say next in line after B-agonist and parasympatholytics is CPAP/BiPAP, and then epi, and then steroids in your COPD/Asthma patients.
 
Christopher said:
Mag should be way down the line simply in terms of a paucity of support.

Epi in COPD should be weighed against any cardiac Hx and whether it appears they are mounting enough of a sympathetic response on their own.

Otherwise I'd say next in line after B-agonist and parasympatholytics is CPAP/BiPAP, and then epi, and then steroids in your COPD/Asthma patients.
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Unfortunately we don't have cpap/bipap But the hospital did call for it.

As far as epi, I guess you would base that on how their HR is doing? I didn't think EPI would be wise in a 75 year old with a HR already at 130.
 
NYMedic828 said:
Unfortunately we don't have cpap/bipap But the hospital did call for it.

As far as epi, I guess you would base that on how their HR is doing? I didn't think EPI would be wise in a 75 year old with a HR already at 130.
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Yeah, if their HR is 130...they already have substantial quantities of catecholamines raging through their system! Epi is not going to improve their ventilation or oxygenation.

They need support for their work of breathing.

Perhaps an anxiolytic plus BVM/nebs?
 
For us outside the hospital for this particular patient I don't think we should have done more, he was maintaining a sat of 100 on the duoneb, and wasnt in THAT much distress. I doubt the decadron did a thing but we gave it since he takes prednisone religiously for exacerbations but hadn't taken it yet.

I was just thinking about in other scenarios what would we base further treatment on.
 
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Asthma actually is classified as a form of COPD, in that it's an obstructive process. Not sure how different the wave forms would be on capnography.

While COPD has some bronchial hypereactivity, it doesn't have it to the same degree as pure asthma. It just seems that mag wouldn't do much, since the smooth muscles have a minor role in emphysema/chronic bronchitis. and epi would be mostly side effects, with little positive effect on the beta receptors in the lung.

Interesting to think about it. For my part, with "usual" COPD, I would be sticking with DuoNebs, steroids, antibiotics, CPAP, and early ETT.
 
I'd be looking hard at the EKG and later at stained smears of his sputum (for bacteria or white cells, especially eosinophils).
 
Let me get this straight. Your in NYC and you don't have capnography or CPAP? WOW!!

NYMedic828 said:
Unfortunately we don't have cpap/bipap But the hospital did call for it.

As far as epi, I guess you would base that on how their HR is doing? I didn't think EPI would be wise in a 75 year old with a HR already at 130.
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The wave forms for the asthma would appear as a shark fin on the capnography because of the air trapping and the expiratory upstroke would be slanted and not almost straight up. In the COPD patient they would be moving air which would not give you the slanted upstroke but a upstroke that is more straight up.

KellyBracket said:
Asthma actually is classified as a form of COPD, in that it's an obstructive process. Not sure how different the wave forms would be on capnography.

While COPD has some bronchial hypereactivity, it doesn't have it to the same degree as pure asthma. It just seems that mag wouldn't do much, since the smooth muscles have a minor role in emphysema/chronic bronchitis. and epi would be mostly side effects, with little positive effect on the beta receptors in the lung.

Interesting to think about it. For my part, with "usual" COPD, I would be sticking with DuoNebs, steroids, antibiotics, CPAP, and early ETT.
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VirginiaEMT said:
Let me get this straight. Your in NYC and you don't have capnography or CPAP? WOW!!
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We have capnography, we have protocols for CPAP.

As far as capnography goes, we only have ET tube sensors, not sidestream nasal cannulas. But we could use them, if the disposable equipment was provided.

CPAP is just not given through FDNY, some voluntary hospital units do have it.
 
NYMedic828 said:
We have capnography, we have protocols for CPAP.

As far as capnography goes, we only have ET tube sensors, not sidestream nasal cannulas. But we could use them, if the disposable equipment was provided.

CPAP is just not given through FDNY, some voluntary hospital units do have it.
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You could potentially MacGuyver a connection by cutting the ETT mainline connector tubing off and, say routing it through a port on an NRB.
 
beta agonists and anticholinergics are good for the bronchospasm but for those with a lot of accessory muscle use the dynamic airway compression and exudate just makes your management that much more ineffective as aerosolised drug gets bound up in mucouse and doesn't reach an effector site, and without IV management it can take some time to take effect. Our IC boke carry dexemesthesone but isn't really for acute relief, some genious figured they would save hundred of thousands in hospital admission if it were given 30 minutes earlier by ambo's

The CPAP in asthma thread here a fortnight ago was a real eye opener for me, made me go and revisit some of he "dogmas" of ambulance (one which was CPAP is contraindicated in asthma) so i get where the CPAP/BiPAP would be the shizzle in the the hyperinflated compressed airway patient unresponsive to first line therapy

Can only use what you have available mate
 
Do you have a PEEP valve for the BVM?

I would have hooked up the SVN cocktail to the BVM with a PEEP valve.

But, I can use CPAP. So that would have been my first choice with the SVN attached.
 
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