If an elderly pt is presenting with severe shortness of breath with no prior hx of COPD but is a smoker, has clear lung sounds can we assume the pt is having a COPD exacerbation and treat under the bronchoconstriction and CPAP directives if they meet the conditions/indications or do they need to have a known hx? How do we differentiate between other possible causes such as a PE.

As you allude to in your question, it can be very difficult to determine the cause of shortness of breath in the prehospital world. You have only your history and physical exam to decide how best to treat the patient, as required. 

If the patient has signs of bronchoconstriction, you may go ahead and treat using the Bronchoconstriction Medical Directive, without a known formal diagnosis of COPD.  Signs of bronchoconstriction can include the absence of a wheeze, with respiratory distress and decreased breath sounds. In these situations, the classic wheeze associated with bronchoconstriction may be absent secondary to very poor air movement, thus not generating the wheeze associated with turbulent airflow through constricted airways.  However full breath sounds without wheeze is unlikely to be bronchoconstriction. 

Regarding CPAP, the Conditions state that patients must have “Severe respiratory distress” and “Signs and/or symptoms of acute pulmonary edema or COPD”. The OBHG Companion Document adds to this that “CPAP should be considered as an additive therapy to the bronchoconstriction (specifically COPD exacerbation) or acute pulmonary edema medical directives.” Therefore, CPAP should only be administered with signs of bronchoconstriction, but also does not require a stated formal diagnosis. 

Airway/Breathing,Bronchoconstriction,Continuous Positive Airway Pressure (CPAP)

Chronic Obstructive Pulmonary Disease, Continuous Positive Airway Pressure, COPD, CPAP, DDx, Differential Diagnosis, Lung Sounds, Physical Exam, Prior Hx

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