04.03 Acute Respiratory Distress

So we are not going to go deep into all the patho and anatomy behind these disease processes. There are some great lessons in our med-surg sections so if you need a refresher, go check them out. 

We need to remember that asthma is a disease of triggers. Something caused the exacerbation your patient is having. It could be dust, pollen, a new floor cleaner, it could even be something in the ED itself, a new medication, a strange perfume that wafts by. The point is, these exacerbations are caused by some external factor. 

COPD, as we know, is a combination condition. occurs when the patient is suffering from chronic bronchitis or emphysema along with asthma.

We know asthma. We have seen asthma. So let's review some of the symptoms. They will have that telltale wheeze, which usually starts as an expiratory wheeze and changes to both inhalation and exhalation as the process progresses.  They could have that intractable cough along with accessory muscle use. It's no surprise what with not being able to breathe and all. So now they can't breathe, they are sucking air. Do we think they can talk well, probably not? And if you listen to their lungs, guess what, you are probably not going to hear a lot of air movement at all. 

So our COPDers. When they are having that real good exacerbation we can see it. They are going to have some difficulty breathing, some fast breathing, and their O2 sats will be low. If we can get a sputum sample, we will see changes in the color, brown, green, if they have been coughing a while, a little red in there. Grab your stethoscope and you are going to hear all kinds of fun lung sounds. Ronchi, wheezes, crackles. Make sure to document where you are hearing these things, upper lobes, lower lobes, left, right? If we watch them, we will see that classic pursed-lip breathing as they are basically trying to blow off carbon dioxide. Like our asthmatics, you can see those sternal and clavicular retractions as they use their accessory muscles. As it progresses you can see some jugular venous distention and hepatomegaly as the blood starts to pool in the vasculature.

We need to treat, right. With our asthmatics, we want to start in a position of comfort. However, they want to sit, let them sit. This is not the time to tell you, patient, that they need to lay back in the bed. Whatever the need to to to facilitate their breathing, let them do. You want a little information if you can get it. Like how long as this attack been going on and have they had previous episodes like this, and most importantly, have they had to be intubated for a previous exacerbation. While you are getting this info, you need to actually treat them. Get a non rebreather on them and get some IV access. We can hook up the nebulizer and give the albuterol and Atrovent to try and open up that airway. Keep an eye on the heart rate as those nebulized bronchodilators tend to cause a little tachycardia. You want to try to get a peak flow before and after treatment..and why, well you want to know if what you are doing is actually effective.

And we can consider IV meds like mag sulfate and steroids like solumedrol. If all this fails and our patient cant protect their own airway, we are going to have to intubate.

Our COPDers are a little different when it comes to treatment. We want to keep an eye on the O2 sat but remember that they tend to run low. 90-92%^ is pretty good for them. Get some O2 on to maintain that sat. I know I know, but professor mike, what about the hypoxic drive and not giving Oxygen to a COPD patient! Listen, people, this is the ED. The amount of O2 we are going to give will most likely not kick in the hypoxic drive and frankly, if there sat is dropping we have to get it back up. We can live without oxygen, remember. So yea, don't withhold the oxygen here. Like our asthmatics, we want to open up the airway with some of those nebulized medications. IV access is obvious so we can get them some steroids and possibly antibiotics if we believe there is an infection brewing. We can also get some positive pressure ventilation via BiPap to try to blow off some of the fluid building in the lungs. We try to do this before getting to intubation. And of course, put these patients in a position of comfort, high fowler's usually the best bet.

We need sound clinical judgment here. We need to be able to identify the disease process and treat accordingly. With both of these conditions, we need to always think about getting them oxygen and making sure their sat is where it needs to be.