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Asthma and COPD

Category: Medical Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf Last updated: 2026-04-04

Overview

Asthma and COPD (emphysema and chronic bronchitis) are obstructive lung diseases causing bronchoconstriction, increased secretions, air trapping, and wheezing. Both present with dyspnea and wheezing, but differ in their underlying pathophysiology and patient populations. Asthma is typically episodic and reversible; COPD is progressive and largely irreversible, most common in older smokers.

The EMT-B priority: recognize the degree of respiratory distress, administer oxygen, assist ventilation as needed, and understand when the patient is deteriorating toward respiratory failure.

Key Points

  • Silent chest is ominous — in severe asthma, bronchospasm is so complete that no air moves and no wheeze is heard; diminishing breath sounds in a distressed patient = impending respiratory arrest
  • "See-saw" breathing and head bobbing in children = respiratory failure
  • Tripod positioning: patient leaning forward on arms, unable to lie flat — indicates significant work of breathing
  • Pulsus paradoxus (BP drop >10 mmHg on inspiration) is a sign of severe obstructive disease
  • COPD patients: "blue bloater" (chronic bronchitis — cyanotic, productive cough, fluid retention) vs. "pink puffer" (emphysema — thin, barrel chest, pursed-lip breathing, less hypoxic at rest)
  • The "hypoxic drive" concern in COPD: do not withhold oxygen from a hypoxic COPD patient — titrate to SpO2 88–92% to avoid hyperoxia-induced hypercapnia, but hypoxia is always the more immediate threat
  • Bronchodilators (albuterol) are first-line treatment — ALS/EMT-I/P scope in NM; EMT-B manages airway and oxygen

Assessment Relevance

History (history-taking): - SAMPLE: Known asthma or COPD? Current medications — bronchodilators (albuterol inhaler, nebulizer), steroids, O2 at home? Prior intubations or ICU admissions for respiratory failure (indicates severe disease)? Triggers (allergens, cold air, exercise, respiratory infection, smoke)? Compliance with medications? Last exacerbation? - OPQRST: Onset (sudden = more likely asthma; gradual = COPD exacerbation); provoked by (infection, allergen, exertion); quality (wheeze, stridor, productive cough); severity; time course

Physical exam (secondary-assessment): - Respiratory rate, depth, effort — count for 30 seconds; tachypnea with shallow breaths = increased dead-space ventilation - Accessory muscle use: SCM, scalene, intercostal retractions - Lung sounds: bilateral wheeze (expiratory > inspiratory); decreased/absent sounds in severe disease; rales may indicate concurrent infection or CHF - SpO2: normal 95–100%; below 90% = severe hypoxia - Skin: cyanosis (central = late finding, severe hypoxia), flushing from bronchodilators - Capnometry/ETCO2 if available: elevated ETCO2 = air trapping or respiratory failure

Severity assessment (mild/moderate/severe/near-arrest): - Mild: speaks in full sentences, mild wheeze, SpO2 >94% - Moderate: speaks in phrases, moderate wheeze, accessory muscle use, SpO2 90–94% - Severe: speaks in single words or cannot speak, marked wheeze or silent chest, tripod positioning, SpO2 <90% - Near-arrest: altered mental status, paradoxical breathing, silent chest, cyanosis

Procedures

  1. Scene size-up (scene-size-up): identify NOI; look for inhalers, nebulizers, home O2 equipment
  2. Primary assessment (primary-assessment): assess respiratory rate, depth, effort; SpO2; AVPU
  3. Position: upright or tripod (do not force the patient to lie down — worsens breathing)
  4. Oxygen administration:
  5. Nasal cannula 2–4 LPM for mild distress; upgrade as needed
  6. NRB mask 10–15 LPM for severe distress (see oxygen-administration)
  7. BVM ventilation if breathing absent or inadequate (see bvm-ventilation)
  8. Request ALS intercept for moderate-to-severe distress
  9. Transport; do not delay for treatment
  10. If patient has own inhaler/nebulizer and can self-administer, encourage use en route
  11. Reassessment (reassessment): every 5 minutes; monitor for silent chest, altered LOC

NM Protocol Notes

From NM EMS Treatment Guidelines (2022) — Asthma/COPD:

EMT-B scope: - Primary assessment; airway management as indicated - Oxygen: escalate NC → simple face mask → NRB mask as needed to maintain normal oxygenation - Suction mouth/nose via bulb, Yankauer, or suction catheter if excessive secretions - Pulse oximetry and ETCO2 monitoring as adjunct - Transport; do not delay while waiting for medication effect — continue treatment en route - Consider ILS/ALS intercept

Bronchodilator medications (EMT-B scope with standing order in NM): - ALBUTEROL 5.0 mg nebulized (adults) or 1.25–2.5 mg (pediatric), diluted in 3 cc sterile isotonic solution over 5–15 minutes; may need continuous treatment during transport - LEVALBUTEROL 0.63–1.25 mg (adult) or 0.31–0.63 mg (pediatric) — alternative to albuterol - Albuterol via BVM: providers encouraged to deliver nebulized albuterol via BVM for patients unable to provide effective respiratory exchange - IPRATROPIUM (Atrovent) 250–500 mcg (0.25–0.5 mg) nebulized in conjunction with albuterol (Basic, Intermediate, Paramedic); NOT recommended for pediatric patients

ALS medications (EMT-I/P scope): - METHYLPREDNISOLONE 2 mg/kg IV/IO (max 125 mg) — for severe exacerbation - DEXAMETHASONE 10 mg IV/IO/IM (adult); 0.6 mg/kg IV/IO/IM (pediatric, max 10 mg) — alternative steroid - EPINEPHRINE 1:1,000 0.3 mg IM — for severe asthma refractory to albuterol (using auto-injector or pre-filled device; EMT-B and FR may assist) - MAGNESIUM SULFATE 2.0 g SIVP/IO (adult); 25–50 mg/kg over 10–20 min, max 2.0 g (pediatric status asthmaticus) — ALS only - CPAP/BiPAP for severe respiratory distress (CPAP at First Responder level; BiPAP paramedic only)

NM protocol cautions: - Avoid hyper-inflation during positive pressure ventilation — air trapping in obstructive disease - Do not delay transport for albuterol — continue nebulization en route - Lack of wheeze + decreasing breath sounds = impending respiratory arrest — escalate immediately

NREMT Relevance

  • Silent chest = impending respiratory arrest (not improvement) — common NREMT trap question
  • COPD oxygen delivery: titrate to target SpO2 88–92% (not 100%) — but never withhold from hypoxic patient
  • Tripod positioning: do NOT force patient to lie flat
  • Albuterol = bronchodilator = first-line medical treatment for asthma/COPD exacerbation
  • BVM ventilation for absent/inadequate breathing in asthma patient
  • Severe COPD history with prior intubations = high-acuity indicator

Sources

  • raw/protocols/nm-sop-guidelines-treatment-2022.pdf — Asthma/COPD protocol (p. 49–50)