History:

 

• Asthma/COPD
  • Chronic bronchitis
  • Emphysema
  • CHF
• Home Treatment
  • Oxygen
  • Nebulizer
• Medications
  • Theophylline
  • Steroids
  • Inhalers
• Toxic exposure/smoke

 

Significant Findings:

 

• Shortness of breath
• Absence of lung sounds
• Pursed lip breathing
• Decreased ability to speak
• Increased respiratory rate and effort
• Wheezing/rhonchi
• Use of accessory muscles
• Tachycardia
• Barreled chest
• Chronic signs of hypoxia
• waveform capnography indicative of constriction

 

Differential:

 

• Asthma
• Anaphylaxis
• Aspiration
• COPD (emphysema/bronchitis)
• Pleural effusion
• Pneumonia
• Pulmonary embolus
• Pneumothorax
• Cardiac (MI or CHF)
• Pericardial tamponade
• Hyperventilation
• Inhaled toxin (carbon monoxide/etc.)

 

Treatment:

 

• Oxygen and O2 sat

• Combivent (DuoNeb) and/or Albuterol (Ventolin)
• 5 mg; via nebulizer ; may repeat Albuterol once.

• 12-Lead EKG

• Initiate IV

 

Moderate: ?

 

• Speak in short sentences
• RR 30 - 40
• O2 sat: 91-94 on room air
• Diminished lung sounds
• Normal mental status
• Accessory muscle use

 

• Consider CPAP at 5 cm/H20; monitor closely for signs of barotrauma
• DO NOT increase pressure
• Consider Conscious Sedation
• Consider Methylprednisolone (Solumedrol) 125 mg IV/IO
• Consider Terbutaline (Breathine) 0.25 mg SQ q 20 mins, Max 0.5 mg

 

Life threatening/severe exacerbation:?

 

• 1-2 word sentences
• RR >40 or <10
• O2 sat <91% on room air
• Little or no lung sounds
• Accessory muscle use with tripod position
• Diaphoretic and anxious
• High EtCO2

 

• Consider CPAP at 5 cm/H2O
• Consider Methylprednisolone (Solumedrol) 125 mg IV/IO
• Consider Magnesium Sulfate 2 grams/4 ml IV over 2-3 min

• Consider Epinephrine 1:1,000 0.3 mg IM
• Consider Terbutaline (Breathine) 0.25 mg SQ q 20 mins, Max 0.5 mg

 

PEARLS:

 

• Terbutaline (Breathine) should be administered SQ to the lateral Deltoid area.
• Methylprednisolone (Solumedrol) is for COPD, asthma and anaphylaxis only!

• Magnesium Sulfate is administered by putting 2 grams/4 mL in a 50 mL bag with a 10 gtt set at 50 drops per minute.

• Pulse oximetry should be monitored continuously if initial saturation is less than or equal to 96%, or there is a decline in patient status despite normal pulse oximetry readings

• Contact (Medical Control) prior to administering Epinephrine in patients who are greater than 50 years of age, have a history of cardiac disease, hypertension, or if the patient's heart rate is greater than 150. Epinephrine may precipitate cardiac ischemia.
• A silent chest is respiratory distress is a pre-respiratory arrest signs.
• EtCO2 should be used when respiratory distress is significant and does not respond to initial beta-agonist dose.
• All efforts at verbal coaching should be utilized prior to conscious sedation.

• For Conscious Sedation, see Sedation/Anxiety protocol. Dose should be titrated to provide comfort without causing unconsciousness or respiratory failure. Be sure to monitor patient's breathing/ventilations, blood pressure and O2 saturation.
• Combivent (DuoNeb) is packaged as 3.5 MG.