Is Epi appropriate for 55+ pt with suspected severe acute COPD with silent chest requiring BVM Ventilation & a Hx of Asthma?

Question#: 657

Question:

I have a question with regards to the bronchoconstriction medical directive as it relates to COPD exacerbation. In a 55+ y/o pt with suspected severe acute COPD with silent chest requiring bvm ventilation and a hx of asthma is epi appropriate? Even if the episode is clearly COPD related?

Answer:

In younger individuals with an isolated diagnosis of asthma in extremis, epinephrine works to reverse bronchoconstriction. Patients with severe respiratory disease (i.e. COPD), however, typically don't have reversible airways. Their lung compliance has diminished as well as they typically have combined pathology of poor diffusion capacity (oxygen doesn't move across the alveoli easily) therefore they sit on a fine line of respiratory failure.

These patients become distressed anxious and their oxygen saturation will drop. If they're on oxygen at home (COPD is the most common reason), pulmonary fibrosis, pulmonary HTN, CHF - never Asthma) this means they qualified because they become hypoxic (ie sats dropped during assessment to less than 85%), therefore their O2 saturation's are normally low. So finding a patient in distress with sats of 72 are concerning but shouldn't contribute to over aggressive therapy.

Calming and controlled management will support the breathlessness and in many cases medication's will make little difference with significant patient risk, particularly in regards to epinephrine.

Important Management steps:

1. Supplement oxygen (provide till sats 88-92%)
2. Calm and reassure patient (so important)
3. If wheeze on exam Ventolin if tolerated
4. CPAP/BiPAP (helps with compliance) create no more risk than BVM and from multiple provinces who didn't provide wording around CPAP as a high risk AGP and used during COVID transmission was zero (BC, Quebec)
5. BHP consultation during any of these steps

Please do not provide epinephrine to this cohort without having these discussions with the BHP, as mentioned in Dr. Dionne's video (https://rppeo.wistia.com/medias/za3kzkmfkf)

If you have any additional questions or concerns, simply let us know.