COPD: Emphysema Part 2

If you missed Part 1, go check it out.

When we meet COPD patients in the field, they should already have been diagnosed with COPD and be given a treatment regimen to follow to ease the symptoms. A lot of the time, we get called when those home treatments and remedies fail to control an exacerbation. COPD exacerbates usually from environment triggers like of the diseases in this field. We can target our treatment based on the type of trigger.

Assessment

If there is no family or caregivers nearby to tell you about the patient and the patient can’t tell you, you can usually find a lot of bronchodialators lying around. Medications to look for include albuterol, bitolerol, Xopanex, metaproterenol, and terbutaline in the bronchodialator category. A common anticholinergic medication that targets secretions includes ipratropium bromide. Corticosteroids are also a common find, particularly Flovent in this area of the country.

I stated before the appearance of barrel chesting in emphysema patients, in exacerbation you can expect to find peripheral cyanosis, the classic tripoding, where the patient is braced in a forward facing position in order to leverage the accessory respiratory muscles into assisting with inspiration. As you can imagine, when you’re trying to breathe through a straw this is a physically exhausting exercise. Expect them to tire quickly and proceed into respiratory failure, where they’ll simply be too tired to continue to breathe.

In emphysema patients, the use of capnography is a great asset to the pre-hospital provider. Expect PaCO2 to be way above normal, indicating the ventilation-perfusion mismatch. Increasingly high numbers along with altered mental status may indicate hypercapnia, but be sure to screen for head bleeds before beginning any treatment aimed at returning the PaCO2 to a normal range. Hypercapnia in this presentation may also mimic a narcotic overdose, so don’t rely solely on capnography.

Physical finds, will find diminished or nearly absent breath sounds and shallow respirations.

Treatment

If caught early enough, we can use bronchodilators and a simple nebulizer, and true enough most will respond well. COPD patients that have had bad attacks before will know when to call before their symptoms get too bad.

Escalating in scale, the use of CPAP in emphysema is definately appropriate. In fact, the CPAP will allow the patient to relax some as the challenge of maintaining positive airway pressure will be placed on the machine. You can “in-line” the breathing treatment as well.

If the call comes at a later stage, you may find the patient as they begin respiratory failure. I recommend, as a general rule, when you start CPAP treatment you should keep the intubation equipment close by. If the CPAP fails to relieve them, intubation becomes necessary. Memphis Fire purchased the KingVision intubation handle some years ago for all ambulances, and I like to have it handy because it doesn’t involve too much fluff to prepare for use.

I once saw a physician intubate a very fatigued emphysema patient without the use of induction agents or sedatives, her state of collapse was that far gone. Just set a limit to decide when enough is enough.

In another instance, I had an emphysema patient in hypercapnia that I was able to maintain with just a bag valve mask. Her mental status would drop but she would still have a gag reflex, and a BVM was the only alternative. She would slip into lethargy, I would bag her up and she would stay awake for a few minutes, then repeat.

Patients in these levels of distress should be closely monitored using capnography and managed appropriately.

Conclusion

With smoking falling from popularity as it has, we are likely to see an increase in emphysema among growing urban populations as an exposure to environmental pollutants becomes longer. Asthma is also very common in the urban centers, and with similar treatment paths, the urge to dismiss emphysema as simply asthma will lead to a less aggressive treatment plan. Complacency kills patients, so the more complete the history, the more likely you will be when aggressively managing respiratory problems.