I overheard the EMS radio calling in to the emergency department and could immediately hear the urgency in the voice of the paramedic about a patient being brought in.
He told us they were bringing in a 43-year-old woman who was in respiratory distress. He advised of their prehospital treatment and that they would be there in about 5 minutes. I grabbed a quick sip of my coffee and assembled my team to be ready for the patient's arrival.
When I got to the room, the respiratory therapist was already there, getting his supplies ready. One of my nurses was getting the cardiac monitor and IV supplies ready, while another nurse was logging in to the computer at the patient’s bedside. I asked the pharmacist to be available as I hung up my white coat on the back of the door, secured my facemask and grabbed a pair of gloves. We were ready to go when the patient rolled through the door.
The paramedics had put Betsy on their cardiac monitor and were giving her breathing treatments through a mask over her mouth and nose. They had put an IV in her arm. They said they had taken care of Betsy previously and knew she had a history of chronic obstructive pulmonary disease (COPD) from a long history of smoking. Unfortunately, Betsy had frequent episodes of respiratory distress that were occurring with increasing frequency in recent months.
Betsy looked uncomfortable and anxious when she arrived, sitting straight up on the ambulance cot and holding onto the sides of the bed. Her respiratory rate was increased, and I could hear her wheezing over the noise of the air blowing the medications into her facemask. She could only speak one or two words at a time when we were asking her questions, which seemed to make her even more anxious. We moved Betsy over to her emergency department bed, hooked her to our monitor and continued giving her breathing treatments. We also gave her a dose of steroids to decrease inflammation in her lungs and airway. I asked her to try to relax and to focus on slow, intentional breaths.
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I put in orders for lab work and a chest X-ray, and I looked through her previous emergency department and hospital records since she could not initially give me much information. Betsy had been seen in the emergency department several times in the preceding month, each time for difficulty breathing and cough. Betsy had started smoking when she was in her early teens and tried to quit unsuccessfully many times. She had been diagnosed with COPD in her late 30s.
COPD is a chronic lung disease that includes chronic bronchitis and emphysema. With COPD, the airways become inflamed and thicken, which destroys the tissue where oxygen is exchanged and decreases the flow of air into and out of the lung. This results in a decrease in oxygen getting into the blood stream and to the body tissues and leads to the symptom of shortness of breath.
It is estimated that 16 million American’s are affected by COPD, and there are many more who have not been officially diagnosed. In the U.S., tobacco smoke is a primary cause for the development and progression of COPD. Other factors, such as exposure to air pollutants, respiratory infections and genetic factors, can contribute to developing COPD.
While COPD is a chronic condition, there are treatments that can significantly lessen symptoms. For people who smoke, quitting smoking is the most important first step. There are medications, including inhaled medications, that treat symptoms like wheezing and coughing. Avoiding lung infections is also very important because patients with COPD have decreased reserve in their lung function. It is important to stay up to date with immunizations for infections that can seriously affect the lungs, such as flu, pneumonia and COVID-19. Some patients with COPD require supplemental oxygen to keep their oxygen levels in their blood within a normal range.
When I went back in to check on Betsy a short time later, she had finished her inhaled medications and the respiratory therapist was transitioning her to oxygen through her nose to keep her levels within a target range. She was still short of breath but was looking much better than when she had arrived. She said the recent bout of cold weather is what triggered this episode, adding that she would have terrible coughing fits and wheezing anytime she would go outside and breath the cold air. She said she was so short of breath the past week that she wasn’t even able to smoke a cigarette. I jumped at this opportunity to counsel Betsy on why she needed to quit smoking.
I explained to her that the health benefits of quitting smoking start right after the last cigarette smoked. Within 24 hours of the last cigarette, the risk of heart attack is lessened because of decreased constriction of the veins and arteries around the heart and increased oxygen levels in the blood. Once you make it to a week without smoking, you have a nine-times higher chance of successfully quitting. The benefits continue to add up. Within three years of quitting, your risk of heart attack is the same as a nonsmoker and within 10 years of quitting, your risk of dying of lung cancer decreases to the same risk as a nonsmoker.
Betsy, like many of my patients, feel that the damage is done and there is no point in quitting once they have smoked as long as they have. As I explained these benefits to her, she kept nodding her head. I reminded her that she has a lot of life left ahead of her and she could see real benefits in her health by committing to quit. Betsy improved enough to go home, and before she left, she told me that she made quitting smoking her New Year’s resolution and that she was committed to making it happen.
Dr. Erika Kube is an emergency physician who works for Mid-Ohio Emergency Services and OhioHealth.