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Copyright © 2004, Mosby Inc. All rights reserved. Chapter 17 Respiratory Emergencies Slide 1 Copyright © 2004, Mosby Inc. All rights reserved. Case History A 30-year-old male walks into your headquarters complaining of severe difficulty in breathing. The patient’s wife tells you that this started about 2 hours ago. He tells you that he has asthma and is carrying a metered-dose inhaler. Slide 2 Copyright © 2004, Mosby Inc. All rights reserved. Respiratory System Slide 3 Copyright © 2004, Mosby Inc. All rights reserved. Upper Respiratory Tract Slide 4 Copyright © 2004, Mosby Inc. All rights reserved. Lower Respiratory Tract Slide 5 Copyright © 2004, Mosby Inc. All rights reserved. Muscles of Respiration Slide 6 Copyright © 2004, Mosby Inc. All rights reserved. Inspiration (Active Process) • Diaphragm flattens, increases inferior-superior diameter of chest. • External intercostals pull ribs up, increase anteriorposterior, lateral dimensions. • Chest cavity increases in size – more volume, less gas, decrease in pressure, air rushes in • Inspiration continues until pressure between lung and atmosphere equalizes. Slide 7 Copyright © 2004, Mosby Inc. All rights reserved. Expiration (Passive Process) • Elastic recoil of lungs plus muscle relaxation • Chest cavity decreases in size – less volume, more gas, air rushes out to atmosphere. • Expiration continues until atmosphere and chest pressure are equal. Slide 8 Copyright © 2004, Mosby Inc. All rights reserved. Inspiration and Expiration Slide 9 Copyright © 2004, Mosby Inc. All rights reserved. Diffusion of Oxygen and Carbon Dioxide Slide 10 Copyright © 2004, Mosby Inc. All rights reserved. Pathophysiology – Airway Obstruction • Obstruction by the tongue Unconsciousness Relaxed jaw and epiglottis Obstruction of the pharynx Evidenced by snoring Cleared with manual maneuvers and adjuncts Slide 11 Copyright © 2004, Mosby Inc. All rights reserved. Pathophysiology – Airway Obstruction • Swollen epiglottis and other airway structures Epiglottitis and anaphylaxis Obstruction at or above the vocal cords Evidenced by stridor or crowing Surgical airway may be needed Positive-pressure ventilation can be lifesaving. Slide 12 Copyright © 2004, Mosby Inc. All rights reserved. Pathophysiology – Airway Obstruction • Fluid in airway Aspiration, pulmonary edema, or drowning Evidenced by gurgling Immediate suctioning of the airway is critical. Slide 13 Copyright © 2004, Mosby Inc. All rights reserved. Anatomy Considerations – Infants and Children • Smaller airways • Tongue is larger in relation to mouth. • Trachea Narrower More pliable • Cricoid cartilage Smaller and less rigid Narrowest portion of the airway • Infants and children depend on diaphragm for breathing. Slide 14 Copyright © 2004, Mosby Inc. All rights reserved. Problems Associated with Respiratory Patients • Difficulty breathing • Inadequate breathing (respiratory failure) • Respiratory arrest Slide 15 Copyright © 2004, Mosby Inc. All rights reserved. Adequate Breathing – Rate • Adult: 12-20/min • Child: 15-30/min • Infant: 25-50/min Slide 16 Copyright © 2004, Mosby Inc. All rights reserved. Adequate Breathing • Rhythm Regular Irregular • Quality Breath sounds – present and equal Chest expansion – adequate and equal Minimum effort of breathing • Depth (tidal volume) – adequate Slide 17 Copyright © 2004, Mosby Inc. All rights reserved. Signs of Inadequate Breathing • Very slow respiratory rate • Very rapid respiratory rate • Shallow breathing • Diminished or absent breaths sounds Slide 18 Copyright © 2004, Mosby Inc. All rights reserved. Signs of Inadequate Breathing • Altered level of consciousness • Seesaw breathing (infants and children) • Pale or cyanotic skin color • Cool and clammy skin Slide 19 Copyright © 2004, Mosby Inc. All rights reserved. Increased Work of Breathing • Accessory muscle use • Retractions • Nasal flaring • Sitting upright • Tripod position Slide 20 Copyright © 2004, Mosby Inc. All rights reserved. Inadequate Breathing • Rate – outside of normal ranges • Rhythm – irregular • Quality Breath sounds – diminished or absent Chest expansion – unequal or inadequate Increased effort of breathing – use of accessory muscles – predominantly in infants and children • Depth (tidal volume) – inadequate/shallow Slide 21 Copyright © 2004, Mosby Inc. All rights reserved. Adequate Ventilation • Chest rises and falls with each artificial ventilation. • Rate Adults – 12/min Infants and children – 20/min • Heart rate returns to normal. Slide 22 Copyright © 2004, Mosby Inc. All rights reserved. Inadequate Ventilation • The chest does not rise and fall with artificial ventilation. • The rate is too slow or too fast. • Heart rate does not return to normal with artificial ventilation. Slide 23 Copyright © 2004, Mosby Inc. All rights reserved. Assessing the Patient with Difficulty Breathing Slide 24 Copyright © 2004, Mosby Inc. All rights reserved. Scene Size-up • Scene safety • If trauma Consider mechanism of injury. Provide spinal immobilization. • Be alert for toxic environment. • Body substance isolation If fluids are present in airway, consider need for eyewear, gowns, gloves, and mask. If TB is possible, consider need for HEPA respirator. Slide 25 Copyright © 2004, Mosby Inc. All rights reserved. Initial Assessment – General Impression • Is there obvious life threat, such as respiratory arrest? • In what position is patient found? Bolt upright? Tripod? Sleepy or unresponsive? » May require positive-pressure ventilation • Does patient speak in complete sentences? • Other obvious signs of respiratory distress? Slide 26 Copyright © 2004, Mosby Inc. All rights reserved. Initial Assessment – Airway • Signs of obstruction? Inability to speak Universal choking sign • Sounds associated with obstruction Noisy breathing Crowing or stridor (upper airway) Gurgling (fluids) Snoring (tongue) Audible wheezing (lower airway) Slide 27 Copyright © 2004, Mosby Inc. All rights reserved. Initial Assessment – Airway Management • Manual maneuvers Head tilt/ chin lift Jaw thrust • Use of adjuncts Nasopharyngeal airway Oropharyngeal airway • FBAO maneuvers • Suctioning • Assistance with MDI medication (bronchiole constriction) Slide 28 Copyright © 2004, Mosby Inc. All rights reserved. Initial Assessment – Breathing • Decrease in tidal volume or rate (minute volume) Tidal volume rate = minute volume » Examples: o o o Normal: 500 mL/breath 12 breaths/min = 6000 mL Hypoventilation: 200 mL/breath 12 breaths/min = 2400 mL Hypoventilation: 500 mL 6 breaths/min = 3000 mL • Critical to evaluate Tidal volume (chest rise) Respiratory rate Other signs of hypoxia » Mental state » Skin color Slide 29 Copyright © 2004, Mosby Inc. All rights reserved. Signs and Symptoms of Difficulty Breathing • Shortness of breath • Restlessness • Increased pulse rate Slide 30 Copyright © 2004, Mosby Inc. All rights reserved. Signs and Symptoms of Difficulty Breathing • Pale or cyanotic skin • Coughing • Tripod position Slide 31 Copyright © 2004, Mosby Inc. All rights reserved. Signs and Symptoms of Difficulty Breathing • Shortness of breath • Restlessness • Increased breathing rate • Decreased breathing rate Slide 32 Copyright © 2004, Mosby Inc. All rights reserved. Skin Color Changes • Cyanotic (blue-gray) • Pale • Flushed (red) Slide 33 Copyright © 2004, Mosby Inc. All rights reserved. Signs and Symptoms of Difficulty Breathing • Inability to speak because of breathing efforts • Retractions – use of accessory muscles • Shallow or slow breathing May lead to altered mental status with fatigue or obstruction • Abdominal breathing (diaphragm only) Slide 34 Copyright © 2004, Mosby Inc. All rights reserved. Signs and Symptoms of Difficulty Breathing • Coughing • Irregular breathing pattern • Patient position Tripod position (sitting with feet dangling, leaning forward) • Unusual anatomy (barrel chest) Slide 35 Copyright © 2004, Mosby Inc. All rights reserved. Important Questions • • • • • • • Onset Provocation Quality Radiation Severity Time Interventions Slide 36 Copyright © 2004, Mosby Inc. All rights reserved. Primary Management of Respiratory Emergencies • Airway management • Positive-pressure ventilation • Supplemental oxygen • Positioning • Administration of prescribed inhalers Breathing • Complains of trouble breathing Apply oxygen, if not already done. Assess baseline vital signs. • Has a prescribed inhaler available Consult medical direction. Facilitate administration of inhaler. Slide 38 Copyright © 2004, Mosby Inc. All rights reserved. Breathing • Does not have prescribed inhaler Continue with focused assessment. • Be prepared to intervene with appropriate oxygen administration. Positive-pressure ventilation (if patient will tolerate) Slide 39 Copyright © 2004, Mosby Inc. All rights reserved. Prescribed Inhaler • Generic name Albuterol, isoetharine, metaproterenol, etc. • Trade name Proventil, Ventolin, Bronkosol, Bronkometer, Alupent, Metaprel, etc. Slide 40 Copyright © 2004, Mosby Inc. All rights reserved. Prescribed Inhaler – Indications • Exhibits signs and symptoms of respiratory emergency • Has physician prescribed handheld inhaler? • Specific authorization by medical direction Slide 41 Copyright © 2004, Mosby Inc. All rights reserved. Prescribed Inhaler – Contraindications • Inability of patient to use device • Inhaler is not prescribed for the patient • No permission from medical direction • Patient has already met maximum prescribed dose before EMT arrival. Slide 42 Copyright © 2004, Mosby Inc. All rights reserved. Administration of Inhaler • Check the expiration date. • Check to see if the patient has already taken any doses. • Ensure that the inhaler is at room temperature or warmer. • Shake the inhaler vigorously several times. • Remove oxygen adjunct from patient. • Have the patient exhale deeply. Slide 43 Copyright © 2004, Mosby Inc. All rights reserved. Administration of Inhaler • Replace oxygen adjunct on patient. • Allow patient to breathe a few times. Repeat second dose per medical direction. • If patient has a spacer device, it should be used for more effective results. Slide 44 Copyright © 2004, Mosby Inc. All rights reserved. Actions of Inhaler • Beta-agonist • Dilates bronchioles • Reduces airway resistance Slide 45 Copyright © 2004, Mosby Inc. All rights reserved. Reassessment Strategies • Gather vital signs. • Perform focused reassessment. Patient’s condition may deteriorate. » Consider need for positive-pressure artificial ventilation. Slide 46 Copyright © 2004, Mosby Inc. All rights reserved. Side Effects of Inhaler • Increased pulse rate • Tremors • Nervousness Slide 47 Copyright © 2004, Mosby Inc. All rights reserved. Infant and Child Considerations • Use of handheld inhalers is very common in children. • Retractions are more common in children. • Cyanosis is a late finding in children. • Coughing rather than wheezing may be present in some children. • Use of inhalers is the same if the indications are met by the ill child. Slide 48 Copyright © 2004, Mosby Inc. All rights reserved. Causes of Respiratory Emergencies • Chronic obstructive pulmonary disease • Asthma • Pneumonia • Hyperventilation syndrome • Spontaneous pneumothorax Slide 49 Copyright © 2004, Mosby Inc. All rights reserved. Chronic Obstructive Pulmonary Disease (COPD) • Chronic respiratory condition Chronic bronchitis Emphysema • Primary complaint – dyspnea Bronchoconstriction Slide 50 Copyright © 2004, Mosby Inc. All rights reserved. Chronic Bronchitis • Chronic productive cough for > 3 mo/yr x 2 yrs • Caused by smoking or long-term exposure to environmental pollutants Slide 51 Copyright © 2004, Mosby Inc. All rights reserved. Chronic Bronchitis Bronchial obstruction = poorly ventilated alveoli = poorly oxygenated blood = cyanosis “Blue bloater” Slide 52 Copyright © 2004, Mosby Inc. All rights reserved. Chronic Bronchitis • Signs Cyanosis Edema – ankles, hips, abdomen » Result of right-sided heart failure Jugular venous distention Wheezing, possible crackles Slide 53 Copyright © 2004, Mosby Inc. All rights reserved. Emphysema • Caused by destruction of alveoli • Less lung surface for oxygen to diffuse into blood • Small bronchioles damaged also Collapse on exhalation = air trapped in lungs » Barrel chest » Pursed lips • Body may increase red blood cells and hemoglobin “Pink puffer” Slide 54 Copyright © 2004, Mosby Inc. All rights reserved. COPD • Signs Can only walk short distances Home oxygen Slide 55 Copyright © 2004, Mosby Inc. All rights reserved. COPD • Normal regulation for breathing – carbon dioxide • Patients with COPD retain high levels of carbon dioxide. Regulation for breathing – low oxygen levels • Supplemental oxygen may turn hypoxic drive off, resulting in hypoventilation or respiratory arrest. Be alert. Slide 56 Copyright © 2004, Mosby Inc. All rights reserved. COPD Do not withhold oxygen for COPD patients in shock, with altered mental status, or in severe respiratory arrest. Prepare to assist ventilations. Slide 57 Copyright © 2004, Mosby Inc. All rights reserved. Asthma • Caused by constriction of the lower airways Triggered by stress, infection, or allergy • Signs Dyspnea Upright posture Possible accessory muscle use Flushing Forceful breathing Audible wheezing Fatigue Respiratory failure Slide 58 Copyright © 2004, Mosby Inc. All rights reserved. Pneumonia • Inflammation of alveolar spaces Interferes with normal exchange of oxygen with blood • Signs and symptoms Depend on underlying cause » Dyspnea » Fever » Cough » Sputum production » Crackles or diminished breath sounds Slide 59 Copyright © 2004, Mosby Inc. All rights reserved. Hyperventilation Syndrome • Increase in rate and depth of breathing = decreased amount of carbon dioxide Result: tingling around mouth and fingers, dizziness, possible nausea Often result of anxiety • Check for underlying causes Asthma, COPD • If no other known cause, administer oxygen, and calm reassurance. Slide 60 Copyright © 2004, Mosby Inc. All rights reserved. Spontaneous Pneumothorax • Rupture of part of the lung Allows air to exit the lung into the pleural space Lung may partially or totally collapse • Frequently seen in thin, muscular men Slide 61 Copyright © 2004, Mosby Inc. All rights reserved. Spontaneous Pneumothorax • Signs Sudden onset of dyspnea and pleuritic chest pain Diminished breath sounds on one side • Monitor patient for progression to tension pneumothorax Absent breath sounds on one side Distended neck veins Hypotension Tracheal deviation Slide 62 Copyright © 2004, Mosby Inc. All rights reserved. Croup and Epiglottitis • Usually occurs in children Epiglottitis can occur in adults. • Croup – viral infection that causes swelling and narrowing of the upper airway (below thyroid cartilage) • Epiglottitis – bacterial infection that causes swelling of the epiglottis Slide 63 Copyright © 2004, Mosby Inc. All rights reserved. Croup and Epiglottitis • Signs Fever Dyspnea Coughing Stridor or crowing Increased work of breathing Tripod position Slide 64 Copyright © 2004, Mosby Inc. All rights reserved.