BEYOND THE BASICS: COPD

     While it might appear easy to determine the difference between the two, many signs and symptoms overlap, including lung sounds, shortness of breath and JVD.

     The patient with congestive heart failure may differ from the COPD patient in that:

• The CHF patient often presents with bibasilar rales.
• The CHF patient may experience more pronounced orthopnea and paroxysmal nocturnal dyspnea.
• The CHF patient may experience acute weight gain with edema and ascites on a more acute basis.
• The COPD patient may present with a productive cough with purulent sputum.

     Pneumonia is another potential differential diagnosis for COPD, as the patient may have a productive cough and purulent sputum. The pneumonia patient may also exhibit fever, chills, night sweats and other signs of acute infection. It should be noted that patients who are in a weakened condition and who have pneumonia are also at risk for developing sepsis. Pneumonia typically involves a single lobe or congruent lobe and therefore presents with unilateral (or lobar) rales on auscultation.

     Pulmonary embolus (PE) is an elusive diagnosis for many reasons. Most notable is its rapid onset and high rate of death. A large percentage of pulmonary emboli are actually diagnosed at autopsy. The symptoms most common in pulmonary embolus (hemoptysis, dyspnea and chest pain) are actually found together in a small percentage of patients presenting with pulmonary embolus. Signs and symptoms that may resemble COPD include tachypnea, rales, wheezing, shortness of breath and tachycardia. In roughly 20% of all patients diagnosed with a PE, the ECG demonstrates the S₁, Q₃, T₃ pattern as explained below:

     S₁: Prominent S wave in Lead I

     Q₃: Q wave in Lead III

     T₃: Inverted T wave in Lead III

     Notable differences between pulmonary embolus and COPD include rapid onset of symptoms, which may include pleuritic chest pain, chest pain, pain in the back or shoulders and occasionally abdominal pain. Although not necessarily causes of pulmonary embolus, a history of birth control use (not including condoms), prior embolus, deep vein thrombosis, recent surgery and immobility (which may be common in patients with severe COPD) are significant.

     A patient with emphysema or chronic bronchitis may also have a history of reactive airway disease or asthma. It is difficult to differentiate between the conditions; however, they are treated identically. When asthma is the cause of respiratory distress, there may be a quicker response to beta agonists when compared with treatment of emphysema or chronic bronchitis.

     There are certain realities and limitations when making a field diagnosis. Due to the similarity of many conditions, treatment choices are made based on field assessment findings. Definitive diagnosis depends on several factors, including pulmonary function studies and radiographic images.

Treatment Decisions
     After a careful work-up, the patient experiencing a COPD exacerbation will require interventions to improve oxygenation and relieve shortness of breath. In severe cases, ventilatory support with a BVM will be required to assure adequate ventilation.

     All patients experiencing shortness of breath will receive oxygen. Much has been said over the years--and much misinformation exists--in reference to hypoxic drive in COPD patients. The axiom "All patients who need oxygen should receive it in the field" remains both accurate and a standard of care.

     Twenty years ago, ambulances carried three types of oxygen delivery devices: cannulas, masks and Venturi masks. Venturi masks went by the wayside, and cannulas became a distant second choice to the non-rebreather mask, which delivered high concentrations of oxygen to almost all patients.

     A middle ground has developed where patients with minor respiratory distress receive oxygen via cannula. The non-rebreather mask is still available to deliver high concentrations of oxygen to patients in moderate to severe distress.