This practice guideline contains changes related to COVID-19.
Chronic obstructive pulmonary disease (COPD) is a progressive, degenerative structural lung disorder that results in impaired ventilation. It is the result of persistent lung irritation from any of a number causes, including but not limited to, smoking, chemical exposure, and repeated infections. It includes progressive lung diseases such as emphysema. Although COPD cannot be cured, it can be managed. Patients with COPD often live with some degree of respiratory distress and frequently seek help during exacerbations of their disease, which are often prompted by respiratory tract infections.
COPD is primarily a disease of ventilation. Treatment should be directed towards improving overall airflow with bronchodilators and steroids.
Critical hypercarbia can develop in patients with COPD despite high respiratory rates and apparently effective tidal volumes due to changes in the alveoli and pulmonary circulation. Monitor patients closely for signs of impending respiratory failure (a falling level of consciousness, a decreasing respiratory rate, decreasing tidal volumes) and intervene early if necessary.
Oxygen therapy should be titrated based on what is typical for the patient. Although oxygen should never be withheld from patients who are acutely short of breath, its administration should be a considered act with due care and attention. Patients living with COPD are often very aware of their oxygen saturation when not in crisis; they, or their caregivers, can be used as a resource to guide oxygen therapy.
When patients report a history suggestive of respiratory infections, paramedics and EMRs/FRs must use appropriate personal protective equipment and should avoid all aerosol generating procedures until protective measures are in place.
Recognize that treatment options for COPD exacerbations in the out-of-hospital environment are limited. Extrication and conveyance should be accomplished as soon as practical and safe. Do not exert patients during movement.
Patients with COPD are at significant risk for recurrent hospital admissions due to exacerbation of their disease.
Community paramedics should refer to the CP COPD guidelines for additional management information.
Patients with COPD often have comprehensive management plans prescribed by their care team. These plans reflect an individual’s condition and describe a series of actions to be taken based on symptoms. Compliance with the action plan, and response to treatment, should form part of any investigation into an exacerbation of COPD.
Complete relief of symptoms, including audible wheezes, is frequently not possible. Although paramedics and EMRs/FRs should be aggressive in attempting to relieve dyspnea, therapeutic end points should be set with reference to the patient’s normal condition.
In the absence of patient-specific information, paramedics and EMRs/FRs should consider observable signs that describe the degree of distress. The ratio of inspiratory time to expiratory time is an important clinical clue to the effectiveness of therapy, as is the tidal volume with each breath.
Paramedics and EMRs/FRs should consider the possibility of concurrent disease processes and seek evidence to include or exclude other diagnoses.
If a patient continues to deteriorate despite aggressive therapy, consider the possibility of barotrauma and pneumothorax.
First Responder (FR) Interventions
Minimize patient activity and do not exert patients during movement
CPAP should be used with extreme caution. Paramedics will wear airborne PPE when administering CPAP. If possible, CPAP should be discontinued prior to entering the emergency department and resumed when the patient is in an appropriate patient care area (i.e. negative pressure room).
Consider anesthetic gas if unable to transport due to severe refractory bronchospasm. This is a temporizing measure until safe transport is possible. Must have an anesthetist capable of using the equipment and medication.