This is Part II of my discussion with Michael Perlmutter on asthma and COPD management. In this episode we discuss interventions used for advanced/severe asthma exacerbations including magnesium, epinephrine, ketamine, non-invasive positive pressure ventilation, and advanced airway management.

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Instagram: @paramedicpractitioner
Email: amerelman@gmail.com
Twitter: @amerelman


Image: PulmCrit

References and Further Reading
UpToDatehttps://emedicine.medscape.com/article/296301-overview
https://canadiem.org/management-of-severe-asthma/
http://www.emdocs.net/critical-asthma-patient-pearlspitfalls-of-management/
https://rebelem.com/rebelcast-crashing-asthmatic/
https://emcrit.org/ibcc/asthma/
https://asthma.net/treatment/prevention/
https://www.jems.com/2018/04/01/a-modern-approach-to-basic-airway-management/
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1742-6723.2009.01195.x
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157154/
https://err.ersjournals.com/content/22/129/227.full
https://www.ncbi.nlm.nih.gov/books/NBK430901/
https://www.ncbi.nlm.nih.gov/pubmed/11406055
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2743582/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434661/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169834/
https://www.ncbi.nlm.nih.gov/pubmed/23235634
https://www.ncbi.nlm.nih.gov/pubmed/22479740
https://www.ncbi.nlm.nih.gov/pubmed/26033128
https://www.ncbi.nlm.nih.gov/pubmed/25447559
https://www.ncbi.nlm.nih.gov/pubmed/27289336
https://www.ncbi.nlm.nih.gov/pubmed/18922662
https://www.ncbi.nlm.nih.gov/pubmed/28754601
https://www.ncbi.nlm.nih.gov/pubmed/24865567
https://www.ncbi.nlm.nih.gov/pubmed/24731521
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3777369/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6036522/

In this two-part series I discuss asthma and COPD. These diseases are complex and have a spectrum of severity and presentation. The sickest of these patients require prompt, aggressive care to prevent further deterioration so a thorough understanding of the disease is essential. Michael Perlmutter, flight/critical care paramedic and medical student, joins me for a great conversation on prehospital management of these diseases. This is Part I which covers pathophysiology, diagnosis, and early management. Part II will be released in a couple weeks and will cover treatments used in our more critical patients and advanced stages of exacerbations. As always, please follow us on our various social media accounts and let me know if you have any questions, feedback, or personal experiences to share.


Note: in the podcast at one point I say ipratropium and tiotropium are muscarinics but they are muscarinic antagonists.


Facebook: https://www.facebook.com/paramedicpractitioner/
Instagram: @paramedicpractitioner
Email: amerelman@gmail.com
Twitter: @amerelman

Below are some quick guides to home management of asthma and COPD. The treatment approaches between the two diseases vary. One of the biggest differences is that asthma patients are started on inhaled steroids relatively early in their progression but if you see a patient with COPD on an inhaled steroid, they are likely late in their disease process. By looking at a patient’s home medications you can infer some information about the severity and pathophysiology of their underlying disease.

Image: PulmCrit

References:

References
UpToDate
https://emedicine.medscape.com/article/296301-overview
https://canadiem.org/management-of-severe-asthma/
http://www.emdocs.net/critical-asthma-patient-pearlspitfalls-of-management/
https://rebelem.com/rebelcast-crashing-asthmatic/
https://emcrit.org/ibcc/asthma/
https://asthma.net/treatment/prevention/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157154/
https://www.ncbi.nlm.nih.gov/books/NBK430901/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434661/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169834/
https://www.ncbi.nlm.nih.gov/pubmed/23235634
https://www.ncbi.nlm.nih.gov/pubmed/22479740

This is part 2 of a 2 part series called “how we make easy airways harder”. In this episode I focus on improving endotracheal intubation and avoiding common errors that make airway interventions less likely to be successful.

Airway Checklist Examples

Anything worse than grade 2a is ideally managed using a bougie. Image: nurse-anesthesia.com
Grade 3a should be optimized if possible but can usually be managed using a bougie. Grade 3b cannot be intubated and must be optimized.

Reference:

This is part 1 of a 2 part series called “how we make easy airways harder”. In this episode I focus on improving basic airway skills and avoiding common errors that make airway interventions less likely to be successful.

Ear-to-sternal-notch positioning
Patient sitting upright with ear-to-sternal notch positioning. Known as back up, head elevated (BUHE)
The ideal mask seal using a BVM. The index and middle fingers pull the mandible forward maintaining airway patency.

Reference: