Dyspnea in the ED I – Asthma and COPD SDMH EMC 2015

1 - Asthma

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 patient

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

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 salbutamol

Is it asthma? MIMICS - 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) Pulmonary oedema (‘cardiac asthma’) Pneumonia/pneumonitis Upper airways obstruction Aspiration (FB or gastric) Carcinoma with bronchial obstruction Vocal cord dysfunction Anxiety/panic attack

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)

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%

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 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 salbutamol

Testing Most asthma presentations need no testing All presentations  Spirometry or PEFR prior to discharge Life threatening – CXR (PTx, Pneumonia), UEC(K), VBG/ABG(CO2) should be undertaken

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?

Questions?

2 - COPD

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 COPD

COPD vs Asthma

COPD types

Clinical presentation 75% infective – URTI, 50% viral Non-infective – cold weather, resp. irritant Consider precipitants and differentials: PE, PTx, Pneumonia, CHF, ACS, Arrhythmia, Acute Abdomen Typical story – Dyspnoea, cough/wheeze, increased sputum production and purulence. Fever unusual. Physical signs – Cyanosis, tachypnoea, wheezes, signs RHF

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 ordered

Assessment Severity less rigorously applied than asthma. Assessment WoB, LoC and o2/Co2 evaluation Best evaluation after 1 hr treatment

Treatment O2 + Assisted ventilation Bronchodilator Steroids Antibiotics

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 early

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

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 qid

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 present

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 6-8cm

Questions?

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