In this micro-lecture, we’re going to talk about Chronic Obstructive Pulmonary (COPD) Disease, a disease that is characterised by permanent, destructive changes within the airways. Enrolled students have unlimited access to a rich library of learning materials such as this.
Welcome to this session on Chronic Obstructive Pulmonary Disease. Now COPD, in my opinion, is a very difficult condition to manage from a pre-hospital perspective. The reason being is that COPD, Chronic Obstructive Pulmonary Disease, is a disease that is characterised by permanent, destructive changes within the airways.
What this means is that the interventions that you provide as a paramedic are really only supplemental to make the patient more comfortable because the damage has already been done to the lungs and there’s nothing that you can do as the paramedic that’s actually going to do anything long-term. So of course, your role is to make the patient comfortable, try to maintain their oxygenation, and of course give them the most professional service that you can give them.
The purpose of this session is to discuss COPD in the context of the three diseases that make it up. In other words, what are the three diseases? How are they characterised within the body? Of course, look at the signs and symptoms associated with COPD. Rather than bombard you with massive lists of all the different signs and symptoms, I’ve called out the key signs and symptoms that can help you to manage this if are to be presented with this in the real world or even in the simulated world.
Then we go to talk about the most appropriate pre-hospital treatment of COPD, as well as how you can adapt your history taking for patients who present with COPD. I’d like to use a case study to try and exemplify this case. Now, you’re sent to a private address for a male who is complaining of a chest infection. When you arrive, you are met by an elderly male sitting in his favorite chair. So he hasn’t moved much, but the door is open, and you’re able to go in.
You notice he has home oxygen, so you see that sitting next to his chair, and he has the nasal cannula in his nose. It’s like a transparent translucent tube that goes around his ears and into his nose. He appears to have blue lips and cannot complete a sentence in one breath, but he is conscious, he is alert, and he is looking at you as you come into the house. As you say ‘ambulance’, he’s short of breath like this. Very short of breath, can’t breathe.
Now, let’s just stop there and have a think about what’s occurred here. First of all, you’re being dispatched to a private address, so that’s the first thing. Working out whether this is a private address, it’s in the public, so you’re going to a private address. There’s all sorts of things that you … that’s in your favor here. You’ll be able to have an environment that has got some things in the environment to help you to determine what’s happened.
As you walked in you seen the oxygen straight away, so immediately you are thinking that this person has got a prescription from a medical practitioner of oxygen because you can’t just go into a chemist and buy oxygen. That’s just one example of how the environment’s helped you to make a decision. You’ve also seen that this person is an elderly male.
COPD does predominantly affect the middle aged to the elderly populations with one definition of elderly being around 64 or 65 years of age. There are different definitions of that. Remembering that COPD is a disease predominantly caused by cigarette smoking, so the person must have had a lifetime of cigarette smoking to actually be suffering from one of the conditions of COPD. Immediately, there’s a lot in the history and the environment straight away.
One of the things we’ve got on here is you see a male with an oxygen canister, you see the nasal cannula, you see that he’s pale, he is looking at you. This is what we call the patient assessment triangle. There’s three parts of the patient assessment triangle. That’s looking at the circulation to the skin, so on this occasion he is pale, the work of breathing is quite labored and difficult and can’t complete a sentence in one breath, and the general appearance.
In other words, when you walk into the address, he does look at you and he is relatively alert. That suggests that he’s been in this situation for quite some time because for most of us if we have acute shortness of breath, we tend to lose all situation awareness.
Okay, so COPD then. COPD is a triad of diseases caused predominantly by cigarette smoking, but can also be caused some industrial environments such as coal mining or any environment where you’re trapped with certain chemicals. Now, today’s standards are quite strict. Today employment standards are quite strict. Work, health and safety does everything it can to try and prevent industrial lung diseases, but the evidence still shows that it’s cigarette smoking that causes permanent, destructive changes, and they’re irreversible changes to the airways and we’re going to take a look at those in a moment.
They’re characterized by permanent, permanent being the key word here, because if you’ve got a permanent destruction, it’s impossible for you to do anything more than just make the patient comfortable. Sometimes you can’t even do that. In my own experiences, you will go to patients in the continuum of COPD. For example, at one end of the extremes, you will the patient who is basically in end stages of respiratory failure and they are basically going to die that night.
I use that term ‘die’ quite loosely, you do have to use your words quite directly when you’re talking about certain medical conditions. On one occasion I was called to an elderly patient, it was the middle of the night, 2:00, 3:00, 4:00 in the morning and we were called by the relative, it was the daughter that we were called by. We went upstairs and we had this particular case about an elderly female who wasn’t ventilating.
The daughter was distraught, she was very upset by the fact that her mother couldn’t breathe, as you would be. When we arrived on scene, she was short of breath, she couldn’t breathe, her GCS was about 13, so she wasn’t fully alert. She was pale and sweaty, she was ventilating, so we got her in the back of the ambulance, we ventilated for her using a bag valve mask. We put the mask on her face and ventilated for her.
By today’s standards, ambulance services CPAP, Continuous Positive Airway Pressure, where they use an oxygen-driven device to actually force the oxygen into the patient’s airway and that really doesn’t make the patient more comfortable. But we were doing a manual version of that. We pre-elected the hospital, told them we were coming in with this lady who was not ventilating effectively. When we arrived, all the medical team were there. They greeted the ambulance and we took her into the resuscitation room.
We then went and booked into the hospital, so we went to the administrative side and informed the hospital that we were there so that they could create notes. By the time we came back, all the medical team had gone back to what they were originally doing before we had taken them away because that’s what happens with a pre-alert, they stop doing what they’re doing and they come and deal with the more serious cases. That’s the process of triage, it’s very effective.
When I spoke to the relative, I said, “What’s happening? A minute ago there were three, four doctors and nurses and now there’s nobody. What’s happening?” She said, “Look, it’s end stages of respiratory failure and they can’t do anything for her. They don’t think she’s going to make it through the night.” As you can imagine, going through that as the relative, they’re extremely distressful.
But I can assure you, even being in the back of the ambulance with somebody who is short of breath, you know who is going to die, who is in a lot of discomfort. It does take it’s toll on the family and the paramedics as well, particularly considering that this disease is reversible and … not reversible, but preventable by not cig smoking in the first instance. Again, it can have its toll on you as a clinician as well as on the family members and those around you.
Between 2014 and 2015, there were reported 460,400 people living with COPD in Australia, that was three years ago now. Of course, we don’t know whether the numbers have gone up or down, you’d have to look up the rates of cigarette smoking in Australia. Paramedics will routinely be called to COPD patients who are unable to manage their symptoms. Now on most occasions, patients will be able to … they will do their best to live a quality of life and undertake normal activities of daily living.
In other words, getting up in the morning, trying to work, trying to do their normal duties. Occasionally they will become short of breath and then they will use the home oxygen. Generally speaking, they do not take the home oxygen all the time because it can become addictive and it can be harmful. In addition to that, it actually becomes less effective if they are using it all the time. What that means for you as a paramedic is when you arrive on scene and see somebody with shortness of breath using their oxygen, the patient is not in a good way.
Okay, the COPD triad then. We use these terms ‘chronic bronchitis’. Chronic means long-term. Bronchitis, any word that ends in ‘itis’ is an inflammation of, and ‘bronch’ means bronchial or bronchi, so that’s the lower part of the airways in the lungs. ‘Emphysema’ is a permanently rounded alveoli. In other words, in your lungs you’ve got these small pockets called alveoli which allow the oxygenation and gaseous exchange quicker.
But with emphysema, you have one huge, round pocket which does not help gaseous exchange at all. Then ‘chronic asthma’ means long-term asthma. Again, where you have scarring of the airways because of the way that it’s manifested over the years, which again, affects oxygenation as well as having acute buildup of mucous. Let’s take a look at those in the form of an image.
Chronic bronchitis. On this image here, there’s a normal bronchial tube. Here’s your bronchi here and here’s the bronchial of somebody with bronchitis. Now, difficult to see on this image, but it is inflamed; remembering that the word ‘itis’ is inflammation. But the biggest thing that you can see here is that it’s got mucous production. To be honest, it’s very similar to chronic asthma except with chronic asthma you’re getting scar tissue as well, which again doesn’t help oxygenation.
Typical signs and symptoms of chronic bronchitis include productive cough. Productive means you’re coughing up all this mucous here. When your patient coughs, there’s a lot of bringing the mucous up in the throat and expectorating it. That just means coughing it out or swallowing it, not pleasant at all. Shortness of breath or dyspnea, difficulty breathing because there’s a lack of space here for oxygen to occur, to get down.
Chest discomfort because of that lack of oxygen. Fatigue because it’s hard work. Fatigue just means tiredness. These people are described as ‘blue bloaters’. Now at first it seemed like an offensive term, historically it’s something that’s being used, but they’re still using it in the medical language. Now imagine if there’s no oxygen getting to your lungs, then you are going to look a little bit blue and that’s where this term comes from.
Of course ‘bloater’ means that it’s the shape of the patient, so there’s a shape change as well. Look, this chronic bronchitis and this is one of the three conditions that make up COPD.
Now, emphysema. Here you can see the normal alveoli, these are the pockets that I was referring to. Small, round pockets; small, round tubes that allow air to go in and to oxygenate the blood because you can see the capillary beds just there on the alveoli. These are the terminal ends of respiratory system. In other words, the distal end. They’re right at the very end of the respiratory system and they connect directly with the capillary beds which then takes the oxygen … oxygenated blood, takes it around the system and gives CO2 back to the blood and excretes it.
However, as you can see here, instead of having small alveoli, small pockets, you got one huge pocket and that affects gaseous exchange. Again, signs and symptoms, chronic coughing, shortness of breath, blue-tinged lips, described as a ‘pink puffer’ because these people are not hypoxic, but instead there’s a pink tinge to their face, which is CO2 buildup. There’s a direct change in color from blue to pink and that’s emphysema.
Now as you can see on this one here, chronic asthma, you can see the airway of a mild asthma patient. [inaudible 00:13:44] you can see that there’s some inflammation, constriction, and there’s also some mucous here. This circle here should be nice and round and clear. Chronic asthma with airway [inaudible 00:13:58], so this is what we’re looking with chronic asthma which is why you get COPD. Notice how you’ve got increased mucous production, the muscle has gone thicker.
Compare the muscle wall here, it’s much thicker, which all contributes to reducing air. Increased inflammatory cells, so you’ve got inflammation. Increased fibrosis, which is damaged tissue as well and reduced elasticity as a result of that. Expiratory wheeze, so when these patients are breathing out you can hear the wheeze. Difficulty breathing, chest discomfort.
Now the good news is, if you notice how a lot of these signs and symptoms are the same, your patient says, “I’ve got chronic asthma” or emphysema or bronchitis … Chronic bronchitis, remembering that people can have acute bronchitis where it comes and goes with the seasonal changes, then you can just treat all of those the same way with salbutamol, ipratropium bromide, and oxygen as well. Those are the three key drugs, but again, you’ve got to really follow the guidelines laid out for you by your ambulance service.
Now let’s talk a little bit about history taking, because you’ve got to make your history as close as possible to the disease that you’re inquiring about. Once you’ve made your patient comfortable and you’ve established that it’s COPD, you’ve had a listen to the chest, done some physical history taking, you’ve made your patient comfortable with as many drugs as possible and you’ve sat them up right.
Ask them questions such as: When were you diagnosed with COPD? What was the underlying cause? Because it might not always be cigarette smoking, but on most occasions, it is. This one here, most occasions, your patients are still smoking. Now, that’s not for you really to judge. Remember, you’re going in there and providing non-biased, non-prejudiced care for these patients. The only difference to that is if you arrive in the address and they’re still smoking, now that’s actually harmful for you, so you’re within your legal and ethical rights to say, “Can you just put the cigarette out please just while we are here?”
What was the underlying cause? Has your COPD worsened? In other words, what’s going on? If it hasn’t worsened, why are we here today? Has there been something that’s irritated it? When you start to [inaudible 00:16:22] the text, there are a range of different things that irritate COPD including unexpected exercise, chest infections, and comorbidity of their illnesses.
How do you currently treat it? Now some people will say, “Oh, I’m on oxygen three or four times a day.” Others will say, “I only take oxygen once every few days when I get short of breath.” That gives an idea as to how serious it is. This is the type of information you need to be providing to the hospital staff.
How frequently do you get your exacerbations? How do you manage those exacerbation? Well, when I have it, I usually get the oxygen, sit down, allow my body to recover. Other past medical history of medications, just remembering that COPD is only one illness and patients do tend to have comorbidities.
Of course you can inquire about whether it runs in the family as well as this one here, “What’s your lifestyle like? Are you still living your life or are you struggling to live the activities of daily living? Do you manage to get to the toilet okay? Do you need home care? Do you need social services to come in and help you with those things because those are really, really important things?”
The treatment focuses around identify, maintain, keep and transfer. Identify the cause of the trigger and provide treatment where possible. As I’ve said to you, COPD is permanently there. So really your management really is around helping with shortness of breath and that include maintaining the oxygen levels between 88 and 92%.
When it comes to choosing the right oxygen mask, with the patient in this case study, imagine that you’ve arrived on the scene and you’ve put an oxygen saturation probe on their finger and it says that they’ve got saturations of 80% or 85%. Now you’re going to still have to get those oxygen levels up to between 88 and 92. It’s obvious that their own home oxygen’s not working. You may start by turning their oxygen up or you might replace their oxygen nasal tubing with your own oxygen tubing and turn it up.
Or you may change the mask and use a medium concentration mask or a high [inaudible 00:18:29] concentration mask. Whatever happens, with an oxygen saturation of 80% that you’re struggling to maintain between 88 and 92, you can’t leave them home. You’re going to have to take them to hospital for ventilatory support and/or further assessment in treating that.
We’ve also said that there are some drugs that you can use depending on your guidelines and that includes salbutamol, ipratropium bromide, or Atrovent. These are the two main drugs that you’ll be using.
Keeping the patient relaxed and calm means that they’re not going to be stressed or fatigued or it’s going to minimize stress and fatigue. Last thing that patient needs is you panicking because it’s commonly difficult for the paramedic, particularly when you’re new, to try and not to be stressed when you see that patient.
Then of course, transferring the patient to hospital in an upright position. Making the patient as comfortable as possible is really, really important. Of course, monitoring throughout all of the journey. Monitoring the A’s, the B’s, the C’s continuously throughout, doing your history taking, and of course doing everything you can to make the patient comfortable.
That’s an insight into COPD. When you start to look at COPD from an intensive care view point and start looking at acid-based balances and gasses, the whole subject becomes so much more interesting, but that’s really for another session. Now when you arrive at the workshops, the face to face workshops, you will be shown how to use the oxygen masks, you will be taught a little bit more about COPD, and you will be shown how to use the nasal cannula as well as how to use the nebulizer masks.
In this session we’ve recognized the diseases that make up COPD, identifying the key signs and symptoms, and recognizing the most appropriate pre-hospital treatment of COPD.