Introduction
Chronic obstructive pulmonary disorder disease (COPD) is among the major causes of morbidity and mortality in Australia and around the world. Approximately, over 2 million people suffer from this condition in Australia and the majority of them end up in the emergency department due to exacerbations. Hospitalization from this condition can be avoided with proper pre-hospital diagnosis and treatment. However, the management of COPD at the emergency department is complex as its symptoms overlap with those of other related conditions like asthma. Besides, due to the severity of some cases, paramedics do not have enough information concerning the patient or time to establish the underlying disease. In this case, one has to use the available objective findings and make a decision to initiate the recommended emergency practices for dealing with COPD like intubation and ventilator therapy. Paramedics have to decide whether the benefits of initiating treatment outweigh the associated risks for the patient. This paper reviews the available literature to establish whether paramedics can differentiate between COPD and other related conditions and intervene in time to avoid unnecessary hospitalization.
Methods
A structured search strategy was used. Keywords were searched in bibliographic databases like CINAHL (via EBSCOhost), MEDLINE, PubMed, and PsycInfo. The main search terms used were pre-hospital, COPD, diagnosis, paramedics, and Australia. The search was restricted to articles published after 2012. Additionally, it was restricted to Australia as this paper focuses on practices in this country. The articles had to be published in English. Review articles were excluded. All articles considered for this study involved paramedics in Australia and the diagnosis of COPD in their line of work.
Results
The search strategy generated 206 result hits and only three were selected as they addressed the diagnosis of COPD procedures that paramedics use in Australia.
104 articles were discarded because they were published before 2012 thus outdated. The remaining 59 articles were excluded as they addressed the COPD diagnosis in other countries or hospitals. Finally, 40 sources were discarded for they were reviews on the subject. One of the selected articles by Williams et al. addressed whether paramedics differentiate between COPD and asthma. This retrospective cohort study was carried out in Perth between July 2012 and June 2013. Two retrospective studies by Khialani, Sivakumaran, Keijzers, and Sriram and Gerber, Moynihan, Klim, Ritchie, and Kelly sought to establish whether the emergency department’s management of COPD followed the laid down guidelines. It was established that while paramedics complied with the set guidelines when handling COPD cases, it was difficult to differentiate it from other related conditions like asthma.
Discussion
Paramedics misdiagnose COPD in most emergency cases as it shares common symptoms with other related conditions. For instance, in a study by Williams et al., it was established that paramedics identified asthma correctly in 41 percent of patients and 57 percent of COPD cases as compared to the final discharge diagnosis. These percentages indicate an underlying problem in the diagnosis of COPD. The complexity of diagnosing COPD amongst paramedics is occasioned by the lack of clear criteria on how to identify the condition and differentiate it from other respiratory complications. Besides, paramedics do not have enough time to carry out extensive diagnostic procedures to determine the underlying problem as some cases are severe and the immediate goal is to relieve the patient’s respiratory distress. Furthermore, paramedics do not have the medical history of the patient and this aspect may lead to the wrong diagnosis due to the lack of correlative conclusions.
Paramedics are keen to follow the set procedures in the COPD diagnosis but they make mistakes at times due to overlapping elements in the given clinical practice guidelines (CPGs). A study by Gerber, Moynihan, Klim, Ritchie, and Kelly revealed high compliance rates amongst paramedics in following the set CPGs when dealing with COPD cases. However, different respiratory complications are given individual CPGs and thus it becomes difficult for paramedics to go through all the guidelines to determine the condition being dealt with. As mentioned earlier, most cases involving paramedics are an emergency that requires quick decision-making to avoid undesirable outcomes. However, the overriding issue is whether differentiating the underlying respiratory problems affects the expected outcomes. In other words, if paramedics treated asthma while the underlying condition is COPD, would the expected health outcomes be affected by such misdiagnosis.
Williams et al. note that the current CPGs for addressing different respiratory complications overlap, which complicates the process of identifying the underlying condition. Besides, the proposed treatment courses are similar in most cases. The immediate objective when handling respiratory distress is to relieve the patient by relieving hypoxia. Therefore, while identifying COPD accurately in pre-hospital set-ups will reduce unnecessary hospitalization, paramedics should focus on the immediate goals of relieving pain and saving lives. Given this realization, the involved parties should come up with a single CPG for addressing emergency respiratory cases in pre-hospital set-ups. This way, paramedics will have enough time to focus on life-saving tasks. Additionally, a comprehensive diagnosis may not be possible in the absence of a patient’s medical history and even if COPD was identified correctly, further diagnosis may be required based on subjective and objective assessment. Therefore, the available literature does not establish the importance of accurate diagnosis of severe COPD in the pre-hospital set-up.
Conclusion
Severe COPD contributes significantly to hospitalization cases in Australia. Accurate diagnosis of this disease amongst paramedics would contribute to the avoidance of some hospitalization incidents. However, the available literature shows that the majority of severe respiratory conditions demand a similar approach to relieve distress and hypoxia. Besides, current CPGs overlap in diagnosis and treatment, and thus paramedics end up misdiagnosing COPD. However, accurate or wrong diagnosis of this condition does not change the expected health outcomes. As such, there needs to be a single CPG guideline for all respiratory problems for paramedics to focus on immediate life-saving goals like alleviating hypoxia. Further research is needed to establish the long-term effects of placing all respiratory emergency cases under one CPG in pre-hospital set-ups.
References
Gerber A, Moynihan C, Klim S, Ritchie P, Kelly AM. Compliance with a COPD bundle of care in an Australian emergency department: a cohort study. The Clinical Respiratory Journal. 2018; 12(2): 706-711.
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Williams TA, Finn J, Fatovich D, Perkins GD, Summers Q, Jacobs I. Paramedic differentiation of asthma and COPD in the prehospital setting is difficult. Prehospital Emergency Care. 2015; 19(4): 535-543.
Khialani B, Sivakumaran P, Keijzers G, Sriram K. Emergency department management of acute exacerbations of chronic obstructive pulmonary disease and factors associated with hospitalisation. Journal of Research in Medical Sciences. 2014; 19(4): 297–303.
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