RESPIRATORY DISTRESS (ASTHMA, COPD)
ALL LEVELS
DESIGNATION OF CONDITION
Constriction of the small airways of the lungs resulting in bronchoconstriction, in- creased secretions and wheezing. The patient will almost always have a pertinent history and will be suffering from some degree of dyspnea. Wheezing may not be present and lack of wheezing with decreasing breath sounds is often a sign of impending respiratory arrest. Signs and symptoms may include any or all of the following: inspiratory wheezing, rapid and/or shallow respiratory rate, nasal flaring, and use of accessory muscles. Patient may complain of difficulty in breathing, and cyanosis may be present. LOC may be decreased, diminishing or silent bilateral lung sounds, wheezing, stridor, and/or sternal retractions. The patient may be tachycardic, diaphoretic, with tripod positioning. “See Saw” breathing may be present in children.
EMPHASIS ON PATIENT CARE
1. Airway maintenance, adequate oxygenation
a. COPD SpO2 goal 88-92% all other conditions >94%
2. Primary Management - Assess ABC’S and manage as indicated.
3. Initiate transport to an appropriate medical facility.
4. Consider CPAP as an early intervention (Basic level).
5. Secondary Management - History, physical exam, vital signs
6. If patient is in moderate to severe respiratory distress and acute asthma or COPD is suspected:
a. Adults - administer ALBUTEROL [2.5 - 5.0 mg] and IPRATROPIUM [0.5mg], diluted in 2.5mL of a sterile isotonic solution, over a 5-15 minute period. Some patients may need continuous nebulizer treatment during the entire transport. Providers are encouraged to deliver nebulized ALBUTEROL and IPRATROPIUM via bag valve mask for patients who are unable to provide effective respiratory exchange. Do not delay transportation waiting for the medication to take effect.
b. Children – Refer to the Respiratory Distress – Pediatric SOB Treatment Guidelines.
7. If no improvement and the patient is refractory to other treatments, administer EPINEPHRINE 1:1,000 [0.3mg] using a pre-measured, pre-filled device or 0.3mL TB syringe IM/SQ
AEMT
1. Consider CPAP early.
2. In-route, initiate an IV/IO of isotonic solution at a TKO rate
3. Consider METHYLPREDNISOLONE [125mg] IV/IO for adults or DEXAMETHASONE 0.6 mg./kg. (0.06 ml./kg.) drawn up with a TB (1 ml.) syringe. Remove needle and administer orally. Maximum dose 10 mg. (1 ml.). Check vial concentration; usual is 10 mg./ml.)
PARAMEDIC
1. Consider CPAP early.
2. If no relief is noted and the patient is unable to exchange oxygen due to bronchoconstriction:
a. Adult - administer EPINEPHRINE 1:1,000 (1 mg./ml.) 0.3 ml. IM in anterolateral thigh. SQ acceptable.
3. Consider MAGNESIUM SULFATE [2 grams/10 min] IV infusion in adults.
4. Consider METHYLPREDNISOLONE [125mg] IV/IO for adults or DEXAMETHASONE 0.6 mg./kg. (0.06 ml./kg.) drawn up with a TB (1 ml.) syringe. Remove needle and administer orally. Maximum dose 10 mg. (1 ml.). Check vial concentration; usual is 10 mg./ml.)
4. Do not delay transport while administering Albuterol. You may continue treatment in-route to hospital. Monitor respiratory rate and depth closely. Avoid hyperinflation of the chest and lungs during positive pressure ventilation.
5. Do not delay transport to administer steroids. Onset of action is delayed and effects may not be observed in the field.
CAUTION: Administration of Beta-agonists to patients with coronary artery disease. Obtain ECG and Contact medical control for medication orders if in doubt.
PEARLS:
RAD: Reactive Airway Disease.
• Beware of patients with a "silent chest" as this may indicate severe bronchospasm and impending respiratory failure.
• Remember that not all wheezing is caused by asthma and that not all asthmatics wheeze.
• Patients with congestive heart failure may present with lung sounds that mimic asthma ("cardiac wheeze").
ALL LEVELS
DESIGNATION OF CONDITION
Constriction of the small airways of the lungs resulting in bronchoconstriction, in- creased secretions and wheezing. The patient will almost always have a pertinent history and will be suffering from some degree of dyspnea. Wheezing may not be present and lack of wheezing with decreasing breath sounds is often a sign of impending respiratory arrest. Signs and symptoms may include any or all of the following: inspiratory wheezing, rapid and/or shallow respiratory rate, nasal flaring, and use of accessory muscles. Patient may complain of difficulty in breathing, and cyanosis may be present. LOC may be decreased, diminishing or silent bilateral lung sounds, wheezing, stridor, and/or sternal retractions. The patient may be tachycardic, diaphoretic, with tripod positioning. “See Saw” breathing may be present in children.
EMPHASIS ON PATIENT CARE
1. Airway maintenance, adequate oxygenation
a. COPD SpO2 goal 88-92% all other conditions >94%
2. Primary Management - Assess ABC’S and manage as indicated.
3. Initiate transport to an appropriate medical facility.
4. Consider CPAP as an early intervention (Basic level).
5. Secondary Management - History, physical exam, vital signs
6. If patient is in moderate to severe respiratory distress and acute asthma or COPD is suspected:
a. Adults - administer ALBUTEROL [2.5 - 5.0 mg] and IPRATROPIUM [0.5mg], diluted in 2.5mL of a sterile isotonic solution, over a 5-15 minute period. Some patients may need continuous nebulizer treatment during the entire transport. Providers are encouraged to deliver nebulized ALBUTEROL and IPRATROPIUM via bag valve mask for patients who are unable to provide effective respiratory exchange. Do not delay transportation waiting for the medication to take effect.
b. Children – Refer to the Respiratory Distress – Pediatric SOB Treatment Guidelines.
7. If no improvement and the patient is refractory to other treatments, administer EPINEPHRINE 1:1,000 [0.3mg] using a pre-measured, pre-filled device or 0.3mL TB syringe IM/SQ
AEMT
1. Consider CPAP early.
2. In-route, initiate an IV/IO of isotonic solution at a TKO rate
3. Consider METHYLPREDNISOLONE [125mg] IV/IO for adults or DEXAMETHASONE 0.6 mg./kg. (0.06 ml./kg.) drawn up with a TB (1 ml.) syringe. Remove needle and administer orally. Maximum dose 10 mg. (1 ml.). Check vial concentration; usual is 10 mg./ml.)
PARAMEDIC
1. Consider CPAP early.
2. If no relief is noted and the patient is unable to exchange oxygen due to bronchoconstriction:
a. Adult - administer EPINEPHRINE 1:1,000 (1 mg./ml.) 0.3 ml. IM in anterolateral thigh. SQ acceptable.
3. Consider MAGNESIUM SULFATE [2 grams/10 min] IV infusion in adults.
4. Consider METHYLPREDNISOLONE [125mg] IV/IO for adults or DEXAMETHASONE 0.6 mg./kg. (0.06 ml./kg.) drawn up with a TB (1 ml.) syringe. Remove needle and administer orally. Maximum dose 10 mg. (1 ml.). Check vial concentration; usual is 10 mg./ml.)
4. Do not delay transport while administering Albuterol. You may continue treatment in-route to hospital. Monitor respiratory rate and depth closely. Avoid hyperinflation of the chest and lungs during positive pressure ventilation.
5. Do not delay transport to administer steroids. Onset of action is delayed and effects may not be observed in the field.
CAUTION: Administration of Beta-agonists to patients with coronary artery disease. Obtain ECG and Contact medical control for medication orders if in doubt.
PEARLS:
RAD: Reactive Airway Disease.
• Beware of patients with a "silent chest" as this may indicate severe bronchospasm and impending respiratory failure.
• Remember that not all wheezing is caused by asthma and that not all asthmatics wheeze.
• Patients with congestive heart failure may present with lung sounds that mimic asthma ("cardiac wheeze").