Question: My question is in regards to pneumonia and continuous positive airway pressure (CPAP). Bacterial infections are a common trigger for chronic obstructive pulmonary disease (COPD) exacerbations.

If we have a patient who has possibly developed a pneumonia (isolated crackles mid lobe in one lung, low grade fever, purulent sputum) but is in respiratory distress with a history of COPD and is showing signs of a COPD exacerbation (decreased breath sounds in bases, showing signs of hypoxia, accessory muscle use, tachypnea, mild diffuse exp wheezes), are we not to treat with CPAP and just use bronchodilators and high flow O2? Thank you!

 Great question. You are correct: pneumonia is a common trigger for COPD exacerbations. Although CPAP is not ideal as a long term solution for patients with pneumonia, respiratory distress and respiratory failure in COPD patients is what we are trying to avoid in the pre-hospital setting.

The reality is that many patients who have been getting CPAP by paramedics probably have had pneumonia given how difficult it is to diagnose without a chest x-ray. Despite this, outcomes are improved with the use of CPAP by paramedics (Ann Emerg Med. 2014;63:600-607.)

The danger here would be to withhold a beneficial therapy from patients who are by definition in respiratory distress based upon a presumptive clinical diagnosis of pneumonia.

Airway/Breathing,Continuous Positive Airway Pressure (CPAP)

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