CP 4.9: Chronic Obstructive Pulmonary Disease

Updated:
Reviewed: 

Purpose

The Community Paramedic (CP) will work together with the health care team in meeting goals of COPD management which include:

• Prevention of disease progression
• Reduction in frequency and severity of exacerbations
• Alleviation of dyspnea and other respiratory symptoms
• Improvement of exercise tolerance
• Prompt treatment of exacerbations and complications
• Improvement in health status
• Reduction in mortality
  
  

Policy Statements

In response to a referral from a health authority or primary health care provider, the (CP) will visit a patient with stable COPD.  In addition to performing a focused chest assessment, assess the patient’s self-management of disease, including an understanding of the need to stop smoking (if applicable), recognition of signs and symptoms of an exacerbation, correct use of inhaler(s), need for flu and pneumococcal vaccinations, and daily exercise.

It is expected that the CP will document findings and report them to the primary health care provider and collaborate with other health care team members to provide support as appropriate.

Procedure

1. OBTAIN and REVIEW patient’s health history, COPD flare-up action plan (if available), and care plan prior to appointment.
2. REFER to Request for Service form, care plan, and/or COPD flare-up action plan for direction with respect to assessment, patient specific care parameters/interventions, and patient teaching as required.
3. If the patient is a smoker, ENCOURAGE them to quit smoking and suggest smoking cessation strategies such as nicotine replacement therapy, which can be initiated at the community pharmacy level, or suggest he/she speak to their primary care provider for other medications that may help.
4. ASSESS patient’s current level of dyspnea using a quantitative rating scale (e.g. numeric scale): on a scale 0-10, have the patient indicate how much shortness of breath they are experiencing at the time.  0=no shortness of breath; 10=shortness of breath as bad as can be.
5. PERFORM physical exam including:
   • Vital signs (T, P, RR, BP)
   • Pulse oximetry
   • Level of consciousness
   • Chest auscultation
   • Chest wall movement and shape/abnormalities
   • Accessory muscle use
   • Ability to complete full sentence in a single breath
   • Presence of peripheral edema
   • Note worsening of concurrent conditions such as angina or diabetes

6. If patient’s self-report of current dyspnea is worse than usual and/or physical exam shows increased work of breathing, such as: escalated RR; HR; increased or decreased BP; diminished breath sounds; end expiratory wheeze and/or inspiratory crackles; shallow inspiratory depth with reduced chest wall expansion; respiratory accessory muscle use; sputum and cough change, or there is worsening of concurrent conditions, REVIEW patient’s current flare-up action plan for direction.  If the patient does not have an action plan, CONTACT health care provider for direction.

   NOTE: All patients with COPD should have a flare-up action plan, which often includes having access to steroids and antibiotics that can be initiated at the first sign of an acute exacerbation and does not require a visit to their primary care provider.

7. If no change in usual or current level of dyspnea (RR within normal limits, breath sounds reduced with or without end expiratory wheeze and/or inspiratory crackles, adequate inspiratory depth and chest wall expansion, minimal or no respiratory accessory muscle use, may have clear or white sputum and daily cough), CONTINUE with interventions.

8. ASSESS patient's understanding of COPD and the disease process, then REVIEW the patient’s current flare-up action plan and ensure that the patient would be able to access medications if needed (i.e. medications or a prescription on file at the pharmacy).  Reinforce to the patient that should a flare-up occur, he/she should notify a health care provider for follow-up.
9. ENSURE patient has had their annual flu vaccine and their pneumococcal vaccine.
10. ASSESS current use of inhaled medications with the patient and reinforce directions on prescription labels for each inhaler.
11. OBSERVE patient using their inhaler device and REVIEW technique as needed.  If using an aerosolized metered-dose inhaler (MDI), a spacer is strongly recommended.  REVIEW priming/preparation of inhalers for those that are not used regularly, and cleaning instructions for inhaler device (weekly rinse to prevent medication build-up) and the spacer (wash in warm soapy water weekly and leave to air dry to reduce static).  If using a spacer, CHECK device for cracks or a broken valve.
12. ASSESS self-management strategies: exercise; stress management; nutrition; sleeping patterns; breathing; and coughing exercises.
13. REVIEW triggers for exacerbations of symptoms (e.g., poor air quality, smoke, strong fumes, scents, cold air, hot/humid air) and early warning signs of an exacerbation (e.g., worsening dyspnea and work of breathing, change in cough or sputum, etc).
14. COMMUNICATE with health care provider or health care team if parameters have deviated from patient’s normal ranges as noted on care plan or if any other concerns arise.
    
    

Documentation

DOCUMENT details of the visit on the CP progress notes and notify primary health care provider or health care team of findings and any concerns.

Patient Education Resources

COPD – A Guide for Patients

BREATHE – The Lung Association: COPD

BC Smoking Cessation Program

References

1. Bailey LB, et al. Patient Information: Asthma Inhaler Techniques in Adults. In UpToDate. 2015. [Link]
2. BC Guidelines. Chronic Obstructive Pulmonary Disease. 2011. [Link] 
3. O’Donnel DE, et al. Canadian Thoracic Society Recommendations for Management of Chronic Obstructive Pulmonary Disease - 2008 Update - Highlights for Primary Care. 2008. [Link] 
4. RNAO Nursing Best Practice Guideline. Nursing Care of Dyspnea: the 6^th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease. 2005. [Link]
5. RX Files. COPD: New Drugs, New Devices and Considerations for Best Practice. 2015. [Link] 
6. World Health Organization. Chronic Respiratory Diseases – COPD Management. 2016. [Link]