What is the treatment for a patient with difficulty breathing, possibly with a history of Chronic Obstructive Pulmonary Disease (COPD) or asthma?

Treatment for Difficulty Breathing in COPD/Asthma

For acute severe breathlessness in adults with COPD or asthma, immediately administer nebulized bronchodilators (salbutamol 5 mg or terbutaline 10 mg) plus controlled oxygen therapy targeting 88-92% saturation, along with oral corticosteroids, and if no improvement occurs, add ipratropium bromide 500 µg and consider hospital admission. 1

Initial Assessment and Oxygen Management

When a patient presents with difficulty breathing and suspected COPD or asthma:

• Assess severity immediately by evaluating whether the patient can complete sentences, respiratory rate (>25/min indicates severe), heart rate (>110/min indicates severe), and peak expiratory flow (<50% best indicates severe) 1

• Obtain arterial blood gases to assess pH, PaCO₂, and PaO₂, and evaluate respiratory rate, work of breathing, mental status, and ability to protect airway 2

• Administer controlled oxygen therapy using a Venturi mask at 24-28% or nasal cannula at 1-2 L/min, targeting oxygen saturation of 88-92% to avoid worsening hypercapnia 2, 3. This is critical because over-oxygenation can worsen respiratory acidosis in COPD patients 2

Bronchodilator Therapy

Nebulized bronchodilators are the cornerstone of acute treatment:

• Administer nebulized salbutamol 5 mg (or terbutaline 10 mg) immediately 1, 4. The entire 3 mL vial should be nebulized over 5-15 minutes 1

• Repeat every 4-6 hours if improvement occurs 1. If no improvement after initial dose, repeat at 30 minutes 1

• Add ipratropium bromide 500 µg to the β-agonist if the patient does not improve after initial bronchodilator therapy 1

• Nebulizers should run with oxygen flow rate of 6-8 L/min for acute severe asthma, or use electrical compressors with simultaneous nasal oxygen at 4 L/min 1

Corticosteroid Therapy

• Administer oral corticosteroids immediately (prednisone 30-40 mg/day for 10-14 days or equivalent IV if oral route not tolerated) 3. This should be given alongside bronchodilators, not delayed 1

Non-Invasive Ventilation Considerations

If respiratory acidosis develops (pH <7.35 with PaCO₂ >6 kPa/45 mmHg) despite optimal medical therapy, initiate BiPAP:

• Start with IPAP 12-15 cm H₂O, EPAP 4-5 cm H₂O, backup rate 12-15 breaths/min 2

• Reassess arterial blood gases after 30-60 minutes of NIV to monitor for improvement 2

• NIV has 80-85% success rates and reduces mortality, intubation rates, and hospital length of stay 2

Criteria for Intubation

Proceed to intubation if:

• NIV failure (worsening arterial blood gases/pH within 1-2 hours, or lack of improvement after 4 hours) 2
• Severe acidosis (pH <7.25) 2
• Life-threatening hypoxemia (PaO₂/FiO₂ ratio <200 mmHg despite oxygen) 2
• Severe tachypnea (>35 breaths/min) 2
• Respiratory arrest, cardiovascular instability, impaired mental status, or inability to protect airway 2

Common pitfall: Delaying intubation when NIV is clearly failing increases mortality 2. However, avoid inappropriate nihilistic attitudes—COPD patients requiring intubation have better ICU survival than patients with other causes of respiratory failure 2

Long-Term Oxygen Therapy

For patients with chronic hypoxemia (PaO₂ <7.3 kPa/55 mmHg on room air when stable):

• Prescribe long-term oxygen therapy (LTOT) which improves survival (5-year survival improves from 25% to 41%), reduces secondary polycythemia, and prevents progression of pulmonary hypertension 1

• Therapeutic goal is to maintain SpO₂ >90% during rest, sleep, and exertion 1

• If oxygen is prescribed during an exacerbation, recheck arterial blood gases in 30-90 days 1

Pulmonary Rehabilitation

• Refer for pulmonary rehabilitation for patients with dyspnea, reduced exercise tolerance, or impaired health status 1. This improves multiple outcomes including dyspnea, exercise ability, and health status despite minimal effect on pulmonary function 1

Special Considerations

• In elderly patients with COPD, β-agonists may rarely precipitate angina, so first treatment should be supervised 1

• For patients unable to use inhalers (developmental challenges, severe distress), nebulizer therapy eliminates the need for inspiratory flow coordination 5

• Avoid using "dryness" as nebulizer endpoint—patients should nebulize until about one minute after "spluttering" occurs 1

• Consider antibiotics if there are changes in sputum characteristics (purulence and/or increased volume) 3