BEYOND THE BASICS: COPD
Chronic obstructive pulmonary diseases are common and potentially serious calls.
The choice of delivery device is somewhat subjective and should never be made based solely on pulse oximetry readings. The patient's perception of breathing difficulty and outward signs of distress are vital considerations in oxygenation decisions.
A patient who calls to note sputum changes and possible infection with mimimal respiratory distress could likely be placed on a nasal cannula or continued on a cannula at home. Patients with more severe distress would benefit from the non-rebreather mask.
Medications
Medications for COPD patients can be grouped into two broad categories: acute and long-term. Acute medications treat bronchospasm, while long-term medications help reduce inflammation and mucus secretion. Medications to reduce secretions can be used acutely in exacerbation.
Beta agonists are the treatment of choice for acute COPD exacerbation. This can be done with a metered dose inhaler (assisted at the BLS level) or by nebulization, which is widely available to ALS providers and to a growing number of BLS providers. Albuterol is the most common medication used in this regard. Services may also use Xopenex (levalbuterol). Treatment with beta agonists is frequently beneficial with limited side effects.
Steroids and anticholinergics are used to reduce inflammation and mucus production. Many patients have inhalers containing these medications for home use. Atrovent (ipratropium) is an example of an anticholinergic medication used to reduce secretions.
Corticosteroids are used to reduce airway inflammation and secretions. Flovent (fluticasone) and Pulmicort Turbuhaler (budesonide) are commonly prescribed inhaled corticosteroids. The Advair Diskus (fluticasone propionate and salmeterol) combines the steroid with a longer-acting beta agonist.
Prednisone and other oral steroids may be used to manage severe COPD and acute exacerbations, but, in addition to their increased effectiveness, they are likely to produce more significant side effects than the inhaled corticosteroids when used for a prolonged period of time at high doses. Doses over 10 mg are considered high, because they exceed the intrinsic glucocorticoid production rate of 10 mg per day.
It is important to note that anticholinergics and inhaled steroids (including the Advair Diskus) should not be confused with beta agonist medications designed to provide immediate bronchodilation for acute COPD exacerbation.
The use of metered-dose inhalers versus nebulizers for medication delivery also warrants discussion in this article. The metered-dose inhaler, when used properly, provides a very effective means of delivering medication to the tracheobronchial tree. Because the medication in the MDI is a fine powder, proper use of the device is critical to ensure the medication is actually distributed throughout the airway and not simply deposited on the tongue and oral mucosa, where it will have no effect. Spacer devices used in combination with the MDI help patients deliver medication to the airway efficiently.
The nebulizer is helpful in providing a continuous flow of medication into the patient's airway and also when patients have difficulty following instructions or timing breaths when using an MDI. It can only be used in patients who are able to breathe adequately. Nebulized medications may be administered through a BVM when tubing is used to allow air flow through the nebulizer. The tubing and connection can be created or bought specifically for this purpose.
Chronic obstructive pulmonary diseases are common and potentially serious calls. Your knowledge of pathophysiology, assessment and treatment of emphysema and chronic bronchitis are vital to your function as an EMS provider at any level.
Daniel D. Limmer, AS, EMT-P, is a paramedic with Kennebunk Fire-Rescue in Kennebunk, ME, and EMS Program Coordinator at York County Community College in Wells, ME. He is the author of several EMS textbooks and a nationally recognized lecturer.
Joseph J. Mistovich, MEd, NREMT-P, is a professor and chair of the Department of Health Professions at Youngstown (OH) State University, author of several EMS textbooks and a nationally recognized lecturer.
