00:01
Now what do we do
for management?
So we talked about a few different
categories here.
00:05
So in a patient who's in
severe respiratory distress.
00:08
This is your patient who's working
very, very hard to breathe.
00:11
We want to think about
doing a few things.
00:14
So non-invasive
positive pressure ventilation
is going to be a key
first step here.
00:19
And this consists of either
CPAP or BiPAP.
00:22
And what it does is it helps
keep the alveoli expanded.
00:25
It helps to recruit
more functional lung tissue.
00:28
And we know that
studies have shown
that when a patients are
administered this
you will have
COPD exacerbations
or asthma exacerbations,
that they have less time spent
in the ICU,
less time spent in a
hospitalization.
00:41
And this is a situation where
patients can really benefit greatly
from this non-invasive ventilation.
00:47
The other thing to think about,
especially for patients who present
with asthma exacerbations
more than COPD
is using epinephrine.
00:54
Epinephrine can very potently
dilate the bronchioles
and can really help with the
patient's shortness of breath.
01:03
And then the last thing
to think about
is IV magnesium.
01:06
IV magnesium is also
a bbronchodilator
and can be administered
for patients
who are having
severe shortness of breath.
01:13
The last thing on the list here
is that we also want to make sure
that we give albuterol
or bronchodilator medication
that's inhaled.
01:20
And for patients
who have COPD as well,
Atrovent or ipratropium
should be added on as well.
01:26
Now for the mild to moderate
respiratory distress.
01:29
Again, we want to definitely
administer albuterol.
01:32
and ipratropium
inhalational treatment.
01:35
And we also want to give steroids.
01:36
And we want to give steroids
also for those patients
who are in severe
respiratory distress as well.
01:41
We'll talk more about steroids
in a moment,
and the best way
to administer those.
01:46
And then for COPD patients,
we want to consider adding on
azithromycin
or an equivalent antibiotic.
01:52
And we do that,
and studies have shown
that azithromycin
can be beneficial for patients
who have a change in their
sputum production.
01:59
I mentioned that patients
can have a chronic cough.
02:01
So patients may have a cough
all the time.
02:03
But if they have any change
in their cough
or any change
in their sputum production,
adding on azithromycin
may be of benefit to them.
02:10
And also may decrease some of that
inflammation of the airways,
which is why we often reach
for this medication first.
02:16
If you're patient has an allergy
to this medication,
you can go ahead and replace it
with an equivalent medication
that could treat
community-acquired pneumonia.
02:27
Now addressing steroids
for a moment.
02:29
Steroids, should you
give them intravenously?
Or should you give them orally?
Almost all patients who present with
the exacerbations of COPD or asthma
should be given steroids.
02:39
And steroids helped
by really cutting down
on that inflammation
within the lung tissue.
02:44
It's important to note though,
that both IV and oral steroids
take effect in a
similar amount of time.
02:49
So giving a steroid, it's not
going to take effect immediately.
02:52
It's not going to be
an immediate effect.
02:54
IV and oral steroids take effect
in a couple of hours essentially.
02:58
So it's not going to be immediate.
03:00
And actually,
you don't need to put an IV
and if your patient otherwise
doesn't need one.
03:04
You can just give them
an oral dose of prednisone.
03:07
If your patient does need
IV steroid,
generally, you can reach for either
Solu-Medrol or dexamethasone
as your IV steroid
for these patients.
03:16
So if a patient can take
oral medications,
no need to place an IV.
Strictly for steroid administration.
03:21
Go ahead and give that
oral steroid instead.
03:24
Again, let's think about
albuterol, inhalers
versus a nebulizer.
03:28
So in inhaler can be delivered
using a metered dose inhaler.
03:31
So that's your classic thing
that patients will go home.
03:33
They'll go home with
an inhaler or puffer
that they can use at home.
03:37
When patients come
to the emergency department,
generally, they're
expecting treatment
with nebulized albuterol
and ipratropium.
03:44
And that's basically,
you put a mask on a patient
and it's a nebulizer mask.
03:47
And it's hooked up to the wall
either using oxygen or using air
and that medication
is nebulized.
03:54
And the patient inhales
those medications.
03:56
And although
that is the expectation
that patients expect
when they come to the ED,
a metered dose inhaler,
so the inhaler that
they go home with
when used properly
has actually been found
to be equally effective,
for these patients.
04:10
So although most patients
really feel
as if the nebulizer treatment
helps some more
and it's what they expect
when they come to the
emergency department
is not necessarily needed
for all patients.
04:20
And if you are able to use
inhaler effectively,
it can be equally
as good for a patient.
04:28
In the ED we always think about
the disposition.
04:30
So we always say our patient
can't stay there forever, right?
So we always need to think about,
where they're going to go?
Are they going to go to
their house?
Or are they going to need
to be admitted to the hospital.
04:41
Now in order to figure this out,
we want to reassess our patient.
04:44
Our reassessing our patient
is very key for all patients
who come in
with respiratory distress
to see if the treatments
that we gave them
have made them better.
04:53
One way that we can reassess
the patient
is by checking a peak flow.
04:56
And a peak flow is checked
by having a patient
kind of forcibly exhale
into a peak flow meter.
05:02
Patients who have asthma oftentimes
will know their baseline peak flow.
05:06
So they'll know
where they generally fall.
05:08
And if not, you can perform
some kind of
weight based calculation.
05:11
The key thing here is you
potentially want to check this
before you give the patient
any treatment
and then you get
check it again.
05:17
after you've given them
a treatment.
05:18
And you see if there's been
an improvement in this number.
05:21
So checking the peak flow
can really help patients
or help you figure out what
to do with your patient next.
05:26
You also want to check an
ambulatory oxygen saturation.
05:30
especially for your patients
who have COPD.
05:33
It's important
if they're on home oxygen,
that you check it using their
baseline amount of oxygen
that they're on at home.
05:39
Otherwise, you might not really know
how to interpret your results.
05:42
Generally, when checking in
ambulatory oxygen saturation,
you have a patient hooked up
to a pulse ox machine
and you walk them around
the emergency department
for a couple of minutes
and you see what their
oxygen levels do.
05:54
A patient can also
report to you symptoms, right?
So when they go home,
a patient is not just going to be
laying in bed
or sitting in bed.
06:01
They're going to need
to walk around their house.
06:03
They're going to need
to walk to the bathroom.
06:05
So having them see how they feel
when they walk around
it is also really,
really important.
06:09
So if a patient walks around,
even if their oxygen levels
stay reasonably normal,
if they're in severe
respiratory distress,
you want to go ahead
and consider admitting
that patient
to the hospital, right?
Or having them be observed
for a longer period of time.
06:24
In this disposition part,
this is also where
talking with the patient
really is very important.
06:29
So talking with someone
and saying, "How do you feel?"
Patients oftentimes
with chronic conditions
know their bodies best.
06:35
So do you feel okay to go home?
Do you feel well enough to go home?
And I oftentimes
will really trust a patient
when they're telling me that
they really don't feel well enough
to go home.
06:44
or that they do potentially.
06:45
Because they really sometimes
know their bodies best.
06:50
So in conclusion,
when patients come in
with severe respiratory distress.
06:54
Always treat and evaluate
at the same time.
06:56
You might not necessarily always
know exactly what's going on,
but go ahead and get some
treatment started.
07:02
Evaluate your patient.
07:03
Try and get as much history
as you can
in those initial phases.
07:06
Be sure to ask about prior
intubations and hospitalizations.
07:10
because that can help you
determine disposition
and what you're going to do
with your patient ultimately.
07:16
Checking a blood gas
can help you determine
the need for ventilator support.
07:19
If someone has
a very high pCO2 level,
if someone has a
normalizing pH and pCO2
in those asthma patients,
patients who are acidotic,
so who the pH is low
because the pCO2 is high.
07:31
For those patients,
you're going to want to definitely
start thinking about starting them
on that non-invasive ventilation,
or potentially intubating them
if there's shortness of breath
is very severe.
07:43
So you're definitely going to want
to be thinking about that.
07:47
Also important to remember
that almost all patients
who come to the EG
with exacerbations of
obstructive lung disease
should get steroids.
07:53
So for that COPD patient as well as
for that asthmatic patient
who come in
administering steroids
is generally pretty universal.
08:00
It would be a rare situation
where that patient
wouldn't necessarily
go home on steroids.
08:06
Also, you want to make sure
you're reassessing your patient
to help determine disposition.
08:10
You want to make sure
that your patient can ambulate
having their oxygen saturations
stay reasonably okay,
and that they're not in
severe shortness of breath
when they walk around,
potentially also consider
checking the peak flow
both before and after treatment
to help figure out
what you should do
for your patient next.
08:26
Always ensure that these
patients have good follow up
with their primary care doctor
and give them good
return precautions
to come back to the ED.