4d • Paramedic Talk
CPAP or Neb for COPD?
Start a nebulizer FIRST when the primary problem is bronchospasm, not fatigue
Clinical picture favoring nebulizer first
- Mild to moderate respiratory distress
- Wheezing is prominent
- Good air movement
- Speaking in full sentences or short phrases
- SpO₂ ≥ 90% on low-flow oxygen
- Normal mental status
- Minimal accessory muscle use
- EtCO₂ normal or mildly elevated
Why this makes sense
- Bronchodilators reduce airway resistance
- Treats the root cause (bronchoconstriction)
- May prevent progression to respiratory fatigue
- CPAP would add unnecessary positive pressure early
Examples
- COPD patient with wheezing after exertion
- Emphysema patient with an acute bronchospastic component
- “Tight” lungs but not tiring
Start CPAP FIRST when the problem is work of breathing or hypoxemia
Skip straight to CPAP (with neb inline if possible) when you see:
- Severe respiratory distress
- Accessory muscle use / tripod positioning
- One- or two-word dyspnea
- SpO₂ <90% despite O₂
- Tachypnea >25–30
- Signs of fatigue
- Diminishing breath sounds (air trapping)
- Rising EtCO₂ or mental status changes
Why
- CPAP reduces work of breathing immediately
- Prevents respiratory muscle exhaustion
- Neb alone may be too slow or ineffective
The “gray zone” (very common in EMS)
Best practice in many systems:
- CPAP + inline nebulizer simultaneously
This addresses:
- Airway collapse + air trapping (CPAP)
- Bronchospasm (nebulizer)
This is especially useful when:
- Patient is borderline severe
- You don’t want to delay either therapy
- Transport time is >10–15 minutes
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CPAP or Neb for COPD?
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