ASTHMA / COPD

History to be obtained:

1. Time of onset
    
2. Associated  symptoms ( fever, cough, chest pain)
    
3. Medications, Compliance with meds
    
4. Last intubation, and # of  intubations, Last admission, Baseline PF
    
5. Recent URI (TWAR has been found to be a cause)
    
6. Environmental allergies
    
7. GERD

Initial  Treatment:

1. If pt is not in extremis:
    
1. O2 2-6L/min via NC
    
2. 2 agonists  q20-30min  x3  via  nebulizer ( Albuterol ). Tachycardia is usually not an indication to "slow down" the treatment, but rather an indication  that pt is still  in  distress and further treatment is needed. Pt can be treated alternatively with ipratropium (Atrovent) which causes less tachycardia.  Some studies have also shown benefit of adding  MgSO4  1-2gm IV in severe cases.
    
2. If pt is having severe attack (gasping for air, almost speechless):
    
1. Epinephrine 0.3mg sq q20-30min x3 or Terbutaline 0.25mg sq q20 min x 3 Epinephrine while beneficial for Asthma by causing bronchodilation,may not be so for COPD  because in  this entity bronchoconstriction is not the main reason for "not moving  the air". 
    
2. 2 agonists as above
    
3. If pt has AMS, cyanosis, impending RF:
    
1. Intubate STAT. Ketamine is good choice since it is a bronchodilator, but it causes bronchorrhea and pt should be given  Atropine 0.4-06 mg IV/IM/PO.  In many ERs once pt is intubated, CO2 detectors are used to see if pt is intubated properly. This may be falsely negative in severe bronchospasm, because even though pt has retained CO2, he/she is , unable to blow it out  for it to be detected.  Also, for sedation purposes, benzodiazepines are a better  choice  than  opiates as these may worsen broncospasm by causing the release of  histamine. Complications of Intubation are barotrauma and hypotension. The latter may be a sign of  tension pneumothorax.  Pts, once intubated, benefit from RR of  8 - 10/min in order  to blow off CO2. Do not hyperventilate!   Hyperventilation, while  supplying O2, may not give enough time to exhale the CO2.  Also important  is the Respiratory Ratio, which should be 1:2 or 1:3. The TV should be 8 ml/kg, to avoid barotrauma.
    
2.  Admit to ICU.

1.     Good Response:

1. Resolution of symptoms with bagonists  and  baseline PF®  DC home on  meds.

2.      Incomplete Response  or Poor Response, i.e. PF <70%  or <40%
         (respectively) of predicted:.

1. Start steroids IV (solumedrol 125mg) or PO (prednisone 60mg). Steroids are recommended  if no resolution  of  S&S of asthma noted with first 2 or 3 nebulized 2-agonists
2. Continue treatment q hour  with nebulizers
3. Consider  sq b2 agonists (Epinephrine or  Terbutaline)
4. Antibiotics if COPD  or suspected infection in asthmatic
5. Theophylline has no place in ER unless pt takes it chronically and levels  are low. These  patients may benefit from oral supplementation.
6. IVF. No evidence exists that supports the idea that IVF alters bronchial secretion viscosity to promote clearance. However,  RR does promote loss of  fluids (insensitive water loss) and dehydration may occur.
7. Reevaluate and make disposition within 4hrs:
• if good response ® DC
• if incomplete response - individualized decision depending on pt's compliance, close F/U, sanitary conditions at home, past hx of asthma, simple exercise tolerance, MS.
• if poor response ® admit.                                                                                            

Special word about patients that are obese and those that suffer from sleep apnea when they present with symptoms of simple URI or nasal congestion. It is prudent to admit theme for  observation since these patients may be "tipped over" by simple URI, and may decompensate rapidly and go into respiratory distress. It is therfore prudent to admit them for  observation

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