4-21
predicted
Re-examine environment for source of allergens and triggers. Consult specialist in allergy, pulmonary,
or internal medicine.
- Treat as an outpatient if no severe history, and patient is able to talk and achieve > 70% of peak ow after
initial therapy. Otherwise, evacuate for intensive bronchodilator therapy.
Alternative: Ipratropium nebulizer or MDI instead of albuterol.
Primitive: Eliminate irritants and allergens if known, caffeine in coffee has been shown to have some
bronchodilation effects (40-180 mg/cup brewed)
Patient Education
General: Understand disease medications, inhalers, nebulizers and peak flow meters. Monitor symptoms,
peak flow rates. Have a pre-arranged action plan for exacerbations or emergencies. Give a written action
plan and school plan to caretakers of asthmatic children.
Prevention: Investigate and control triggering factors (pollutants, exercise, house-dust mite, molds, animal
dander) if symptoms are severe. Get annual influenza immunization. Avoid aspirin and aspirin containing
medications. Avoid sulfites and tartrazine (food additives).
No Improvement/Deterioration: Return immediately if symptoms worsen.
Follow-up Actions
Return Evaluation: Evaluate for on-going control of symptoms, and alter medications as outlined above.
Evacuation/Consultation criteria: Evacuate severe asthmatics and those with a history of emergent
attacks, once they are stable. Evacuate moderate asthmatics that are not able to complete the mission, since
they may worsen and require intensive therapy during the mission. Consult primary care physician, internist
or pulmonologist as needed.
Respiratory: Chronic Obstructive Pulmonary Disease
COL Warren Whitlock, MC, USAIntroduction: Chronic obstructive pulmonary disease (COPD) encompasses several disease processes
including emphysema, chronic bronchitis and a mixture of these two (including long-standing, poorly con-
trolled asthma). COPD reduces the lungs’ capability to ventilate by obstructing the airway through different
mechanisms. Emphysema occurs because of airway collapse on exhalation, causing air-trapping. Only about
25% of cigarette smokers develop emphysema, but those that show early disease will continue to lose
function for as long as they smoke and for some time after they quit. In chronic bronchitis and in some long-
standing asthma, airways are narrowed by reactive smooth muscle constriction, mucus and secretions. The
clinical criteria used to diagnose chronic bronchitis is a productive cough for 3 months during 2 consecutive
years, and spirometry to confirm expiratory airflow obstruction (reduced FEV1/FVC ratio). Patients with
chronic bronchitis (many smokers) usually have a mixed obstructive airway disease including emphysema
and recurrent respiratory tract infections.
Subjective: Symptoms
Recurrent or persistent shortness of breath, wheezing, dry or productive cough and smoking history.
Focused History: Quantity: How long have you smoked tobacco, or when did you quit? (Most will
have a long smoking history.) Quality: Do you cough up any mucus? (emphysema—dry, non-productive
cough; chronic bronchitis-- almost always productive) What color is your sputum? (White secretions generally
suggest no infection; green or yellow indicates a bacterial infection.) How long have you been coughing
up mucus or sputum? (Productive cough daily for 3 months in 2 years is evidence of chronic bronchitis.)
Duration: Have you had the influenza and pneumonia vaccinations? (important preventive regimens for all
COPD patients). Alleviating Factors: What seems to improve your symptoms? (Bronchodilators will help
partially; avoiding smoking is the best alleviator.)