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

2. 1 - Asthma

3. 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

4. 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

5. 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

6. 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

7. 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)

8. 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%

9. 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 %
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

10. 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

11. 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?

12. Questions?

13. 2 - COPD

14. 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

15. COPD vs Asthma

16. COPD types

17. 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

18. 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

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

20. Treatment O2 + Assisted ventilation Bronchodilator Steroids
Antibiotics

21. 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

22. 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

23. 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

24. 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

25. The severe COPD O2 to titrate to 88% (no greater then FiO2 40%)
BiPAP 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

26. Questions?

27. 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