Dyspnea in the ED I – Asthma and COPD - PowerPoint Presentation

Slide1

Dyspnea in the ED I – Asthma and COPD

SDMH EMC 2015Slide2

1 - AsthmaSlide3

Objectives

Understand assessment of acute asthma in adults

Outline management strategy dependent upon severity

Approach to initial management of the severe asthmatic

Safe discharge of the asthmatic patientSlide4

Pathophysiology

IgE

mediated response in 85% patients

Mucosal inflammation triggers bronchospasm

Inflammatory mucous plugs airways

Net effect of cross sectional airways obstruction and progressive gas trapping Slide5

Clinical presentation

Typically known asthmatic.

Symptoms of cough/wheeze and

dyspnoea

required

Attack pattern may vary from sudden and acute to moderately deteriorating over days

Often ‘treated at home’ with salbutamolSlide6

Is it asthma?

Consider alternate diagnoses if history doesn’t support asthma

Unusual for first presentation in adulthood to the ED

Also consider alternate causes for dyspnea in asthmatics not responding to normal treatment (

eg

bronchitis)

MIMICS -

Pulmonary

oedema

(‘cardiac asthma’)

Pneumonia/pneumonitis

Upper airways obstruction

Aspiration (FB or gastric)

Carcinoma with bronchial obstruction

Vocal cord dysfunction

Anxiety/panic attackSlide7

Risks for worse outcome

Past history of sudden severe attacks – ‘brittle asthma’

Past history of ICU admission (not necessarily intubated)

Hospitalized >2/

yr

ED presentation >3/

yr

Use >2 MDI’s in last 4/52

Presenting whilst on steroid treatment (or recent cessation)Slide8

Severity

Mild

Mod-Severe

Life-Threatening

Speech

Sentences

Words

Nil

Posture

Walking

‘Tripod’

Exhausted

Breathing

Nil



Mild

distress

Accessory usage/recession

Severe

distress/poor effort

Conscious level

Alert

-

Drowsy

Skin

Normal

-

Cyanosed/pallor

RR

<25

>25

Bradypnoea

Auscultation

Wheezes

-

Silent

Sats

>94%

90-94%

<90%Slide9

Treatment

Mild-Moderate

Severe

Life-threatening

Salbutamol

4-12 puffs spacer

12 puffs spacer OR

nebuliser

2 x 5mg

nebulised

and commence continuous

O2

No required

Sats

92-95%%

Sats

92-95%

Steroids

50mg Prednisone PO

50mg Prednisone PO

Hydrocortisone 100mg QID IV

Repeat

treatment ?

Observe

for 60mins

Repeat salbutamol

x 20 minutely spacer

Continuous

nebulisation

Ipratropium

Optional

Add 4-8

puffs 20 minutely spacer

Add

500mcg neb 20 minutely first hour

First

hour outcome



Resolved? Check

spirometry

. Aim d/c if safe and FEV1>60%

Persisting

dyspnoea

,

Spirometry

<60% - Admit

Ongoing life

threatening asthma;

escalate treatment, involve ICU

+ MgSO4

10mmol

+ NIPPV

+ IV salbutamolSlide10

Testing

Most asthma presentations need no testing

All presentations



S

pirometry

or PEFR prior to discharge

Life threatening

–

CXR (

PTx

, Pneumonia),

UEC(K),

VBG/ABG(CO2) should be undertakenSlide11

Discharge

Consider overnight admission for severe asthma even if settles in ED

Patient must be able to manage asthma (check technique)

Ensure patient has medication and spacer device

Has means to return to ED

Course prednisone 5 days and follow up with regular provider

Prescribe inhaled preventer?Slide12

Questions?Slide13

2 - COPDSlide14

Objectives

Understand the differences between the asthma patient and COPD

pt

in the ED

Outline treatments with efficacy in the acute exacerbation of COPD

Managing the

severe exacerbation of COPDSlide15

COPD vs AsthmaSlide16

COPD typesSlide17

Clinical presentation

75% infective – URTI, 50% viral

Non-infective – cold weather, resp. irritant

Consider precipitants and differentials:

PE,

PTx

, Pneumonia, CHF, ACS, Arrhythmia, Acute

A

bdomen

Typical story –

D

yspnoea

, cough/wheeze, increased sputum production and purulence. Fever unusual.

Physical signs – Cyanosis,

tachypnoea

, wheezes, signs RHFSlide18

Investigations

Bloods typically

unhelpful.

WCC?

CXR

VBG/ABG assess CO2

Spirometry

not

helpful in known COPD

ECG

Role of troponin, D-dimer, BNP unclear and should not be routinely orderedSlide19

Assessment

Severity less rigorously applied than asthma.

Assessment

WoB

,

LoC

and o2/Co2 evaluation

Best evaluation after 1

hr treatmentSlide20

Treatment

O2 + Assisted ventilation

Bronchodilator

Steroids

AntibioticsSlide21

O2 and assisted ventilation

O2 target 88-92% acceptable

NIPPV should be instituted if hypercapnoea identified, or severe

WoB

not rapidly relieved with bronchodilator

CPAP/

BiPAP

equivalent outcomes

?role for HFNP O2

Ceiling of care should be determined

earlySlide22

Brochodilator

Salbutamol 10-12 puff spacer if moderate

5mg

nebulised

if severe

Ipratropium more effective in COPD than asthma

6 puffs spacer, or 500mcg

nebulised

Repeated as required Slide23

Corticosteroids

Shortens length of admission, and return of baseline lung function

Oral / IV routes equivalent onset and effectiveness

Prednisone 50mg daily 5/7 OR hydrocortisone 100mg

qidSlide24

Antibiotics

Only if

infective

exacerbation felt to be present

Routine sputum cultures not recommended unless frequent exacerbations/treatment failure

Controversial effect in shorter

LoS

or return to baseline

Amoxycillin

or doxycycline 5 day course recommended

IV NOT indicated unless pneumonia felt to be presentSlide25

The severe COPD

O2 to titrate to 88% (no greater then FiO2 40%)

BiPAP

12/6 @ 30-40% with inline

nebulisation

IV hydrocortisone 100mg IV

Assess if potentially for intubation

Observe for 1

hr

– ICU consultation.

If intolerant

BiPAP

, consider 0.25mg/kg ketamine, or switch to CPAP 6-8cmSlide26

Questions?Slide27

Summary

Spacers for mild/mod asthma. Minimal testing needed for most.

Spirometry

whenever possible for asthma

ED asthma = prednisone course

Early NIPPV for COPD if moderate/severe

Oral antibiotics only for most

pt’s

Consider other causes for COPD exacerbation