4-22
Objective: Signs
Using Basic Tools: Vital signs: RR > 18
Inspection: Respiratory system: Labored breathing; use of accessory muscles; “barrel” shaped chest or
increased in diameter due to constant struggle for deep breath (indicates obstructed airways); costal margins
may be pulled paradoxically inward during inspiration.
Auscultation: Rhonchi (secretions in the airway); breath sounds may be diminished
Percussion: Excursion of diaphragm with inspiration/expiration is reduced 2-4 cm.
Using Advanced Tools: Labs: CBC for polycythemia (HCT over 52% suggests chronic hypoxia or nocturnal
hypoxia); sputum for gram stain and culture not generally helpful unless a resistant pathogen is suspected.
Chest x-ray: Maybe normal in mild to moderate COPD, but diaphragms usually flattened in moderate to
severe disease (evaluate for pneumonia or lung cancer also). Pulse oximetry: < 90% saturation. Pulmonary
function tests (if available): evaluate for airway obstruction.
Assessment:
Differential Diagnosis
Moderate to severe persistent asthma - reversible with appropriate treatment, COPD is NOT completely
reversible
Gastroesophageal reflux disease (GERD) - those with recurrent aspiration present with symptoms resembling
chronic bronchitis
Bronchiectasis - a form of chronic scarring of the airways causing frequent bouts of bacterial bronchitis.
Bronchogenic carcinoma - symptoms may improve with treatment of bronchitis since both may be present
Plan:
Treatment
Primary:
- Give bronchodilators as first line therapy: metaproterenol (Alupent), albuterol (Proventil, Ventolin), 1-2
puffs from the metered dose inhaler q 4-6 hrs, which may be increased to q 3 hrs in more severe
cases. (Use of spacer device (AeroChamber, InspirEase) may be beneficial.) The toxicity of theophylline
precludes its use in the field. Ipratropium (Atrovent) 2-4 puffs qid and prn can be used as an alternate
bronchodilator. - Long-acting bronchodilators, such as salmeterol (Serevent) 2 puffs bid, and corticosteroids, such as
prednisone 1.0 mg/Kg/day, should be used in patients with reversible obstruction, as measured by peak
flow meter or pulmonary function tests.
Primitive: Caffeine has some bronchodilation effects and can be effective in some patients.
Belladonna plant (deadly nightshade) was administered in the past by smoking the dried plant for the
anticholenergic effects of the atropine found in the plant. (Not recommended—atropine can have severe
nervous system side effects)
Empiric: Oxygen (low ow 1-2 liters/min) if pulse oximetry shows < 90% saturation. Antibiotics (see Pneumo-
nia Section).
Patient Education
General: Avoid inhaled pollutants. Stop smoking tobacco. This treats emphysema better than medications.
Prevention: Immunize with pneumococcal vaccine and inuenza vaccine.
Follow-up Actions
Return Evaluation: Symptoms that do not improve should be referred for specialty care and additional
special studies.
Evacuation/Consultation criteria: Evacuate unstable patients. Consult primary care physician, internist or
pulmonologist as needed.