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Respiratory Emergencies
Eileen Humphreys PA-C, EMT-I
Respiratory Cycle
• Inspiration
• Active process that uses contractions of
several muscles to increase the size of the
chest cavity
• Diaphragm lowers and ribs move up and
out
• The expanding size of the chest cavity pulls
air in
Respiratory Cycle
• Expiration
• Passive process that uses relaxation of
muscles to decrease chest cavity size and
allow air to move out
• Diaphragm moves up and ribs move down
and in
Respiratory Cycle
• Oxygen and carbon dioxide are exchanged
in the alveoli and capillaries of the lungs as
well as the capillaries of the body
• Critical to support life
Respiratory Emergencies
• May be a result of head/neck/chest
injuries
• Emotional distress
• Obstruction to the upper or lower
respiratory tract
• Fluid or collapse of the alveoli
• Cardiac compromise
• Allergic reaction
Respiratory Emergencies
• Dyspnea
• shortness of breath
• difficulty breathing
Respiratory Emergencies
• Apnea
• respiratory arrest
Respiratory Emergencies
• Hypoxia
• inadequate supply of oxygen
Bronchoconstriction
• Bronchioles of the lower airway are
significantly narrowed
• Also called bronchospasm
• Usually results in wheezing
Bronchoconstriction
• Can be opened up by use of a
bronchodilator such as Albuterol
• Relaxes the bronchioles
• Called a Beta 2 agonist
Respiratory Emergencies
• Scene size-up may give important clues
• Look for oxygen tanks,tubing, masks
Initial Assessment
• General impression
• usually in a tripod position
• patient lying in a supine or reclining
position may be in mild distress or in such
distress that they have become too
exhausted to stay upright
Initial Assessment
• Frightened or confused facial expression
may indicate severe distress
• Speech-usually limited or absent
• If speech is normal-airway is open and
clear with minimal distress
Initial Assessment
• Restlessness, agitation, combativeness,
confusion, and unresponsiveness can be
caused by inadequate oxygenation to the
brain
Initial Assessment
• Listen for crowing, snoring, stridor, or
gurgling
• Indicates partial airway obstruction
• Look for adequate rise and fall of chest,
exchange of oxygen, volume exchanged
Initial Assessment
• Skin
• Cyanosis to the neck or chest indicates
severe respiratory distress
Respiratory Emergencies
• All patients in respiratory distress are
priority transport
• Decline very rapidly
• SAMPLE history for responsive patients
• Use OPQRST to gather information of
symptoms
• Rapid trauma assessment for
unresponsive patients
Physical Exam
• Assess the skin for discoloration
• Assess the neck for tracheal deviation,
retractions, JVD (jugular venous distention)
• Assess the chest for retractions of the
intercostal spaces, asymmetrical chest
rise, subcutaneous emphysema
• Auscultate the lungs for equal breath
sounds
• Wheezing- musical sound caused by
bronchospasm or fluid in the lungs
• Rhonchi-snoring or rattling sounds
• Crackles-bubbling or crackling noises
heard on inhalation. Associated with fluid
and heard first at bases
Assessing Adequate Breathing
• Patient does not appear to be in distress
• Can speak in full sentences without
stopping to catch their breath
• Color will be normal
• Mental status and orientation (person,
place, time) will be normal
Assessing Adequate Breathing
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• Rate:
Adult- 12 to 20 per minute-12
Child- 15 to 30 per minute-20
Infant-25 to 50 per minute-20
• Rhythm:
Regular and even
Inspiration and expiration usually last
about the same length of time
Assessing Adequate Breathing
• Quality:
• Breath sounds will be present and equal
bilaterally
• Both sides of chest should rise and fall
equally and adequately
• Unlabored-should not require effort
Treatment of Adequate Breathing
• If patient is breathing at a slightly
abnormal rate but it is adequate:
• 15 lpm via NRB
• Monitor closely
• Be on the lookout for beginnings of
inadequate breathing or respiratory arrest
• Intervene quickly if condition worsens
Assessing Inadequate Breathing
• Not adequate to support life and will
progress to death unless there is
intervention
• Rate-can be too fast or slow
• Agonal respirations-dying respirations
which are sporadic, irregular breaths seen
just before resp. arrest. Shallow, gasping
• Rhythm-may be regular or irregular
Assessing Inadequate Breathing
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• Quality:
Breath sounds may be diminished or
absent
Depth (tidal volume) will be shallow,
inadequate
Chest expansion-may be unequal or
inadequate
Respiratory effort may be increased
Assessing Inadequate Breathing
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• Quality:
Accessory muscle use seen
Skin may be pale or cyanotic
Skin may be cool and clammy
Snoring or gurgling in unresponsive
patients or patients with diminished
responsiveness
Treatment of Inadequate
Breathing
• Inadequate breathing with abnormal rate
• Begin artificial ventilations with either the
pocket mask or BVM
• Ventilate 12 times per minute for adults
• Ventilate 20 times per minute for
children/infants
Treatment of Inadequate
Breathing
• You may have to treat a patient with
inadequate breathing who is awake
enough to fight artificial ventilations
• In this case contact medical direction and
transport immediately
Patient Care for Inadequate
Breathing
• If properly performed, pulse rate will return
to normal (in adults pulse usually
increases in resp. distress)
• If pulse stays high re-evaluate the
technique
• Color will return to normal if ventilations
are adequate
Patient Care
• If pulse does not return to normal reevaluate airway, ventilations, O2 canister
(empty), tubing (kinked)
• If chest does not rise or pulse does not
return to normal, increase ventilation force
after assuring proper technique
Respiratory arrest
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Confirm unresponsiveness
Open airway by jaw thrust or chin-lift
Look, listen, feel for 3-5 seconds
If not breathing
Give 1 full breath lasting 2 seconds and
allow patient to exhale
Respiratory arrest
• If the air goes in, give breaths every 5
seconds with each breath lasting 2
seconds and allow to passively exhale
between breaths
• If no air goes in, reposition head
• Check pulse frequently to monitor cardiac
status
COPD
• Chronic obstructed pulmonary disease
• Chronic Bronchitis
• Emphysema
Chronic Bronchitis
• Usually has a productive cough for 3
months out of the year for 2 years
• Edema, inflammation and excessive mucus
production of the bronchioles/bronchi
• Restricted air movement
• Gas exchange is compromised
• Retained CO2
Chronic Bronchitis
• Overweight
• Productive cough
• Rhonchi
Emphysema
• Loss of elasticity of the alveolar walls
• Distention of the sacs causing air trapping
• Air movement is restricted and patient
retains carbon dioxide
Emphysema
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Thin, barrel chest
Non-productive cough
Prolonged exhalation
Pursed lip breathing
Wheezing and rhonchi
Treatment of COPD
• Ensure open airway, adequate breathing,
supplemental oxygen, position of comfort
Hypoxic Drive
• COPD patients
• Low levels of oxygen in the body stimulate
breathing
• In theory too much oxygen can cause the
body to reduce or stop breathing
• Usually occurs with high concentrations of
O2 over 24 hours
Hypoxic Drive
• Not normally a problem in prehospital
environments
• Always give high flow oxygen to those who
need it
Asthma
• Reversible narrowing of the lower airways
• Edema, bronchospasm, and increased
mucus production
• Mucus production block smaller airways
and causes air to be trapped in the alveoli
Asthma
• Exhalation becomes difficult and patients
must force air out past constricted airways
• This causes wheezing on exhalation
• Exhalation becomes an active process
Asthma
• Lack of wheezing or lung sounds in a
patient suffering from an asthma attack is
ominous
• Status asthmaticus-prolonged attack
which does not respond to oxygen or
medication
Pneumonia
• Viral or bacterial disease infecting the
lower respiratory tract
• Causes lung inflammation
• Poor gas exchange
Pneumonia
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• Signs/symptoms
fever/chills
cough
dyspnea
chest pain-localized, sharp, worse with
breathing
rhonchi/crackles
Pulmonary Embolus
• Sudden blockage of blood flow through a
pulmonary artery or branches
• Due to blood clot, air bubble, foreign body,
fat particle
• Decrease in gas exchange
• Hypoxia
Pulmonary Embolus
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• Risk factors
recent surgery
prolonged immobilization
multiple fractures
thrombophlebitis
chronic atrial fibrillation
medications (OCP’s)
Pulmonary Embolus
• Suspect if sudden onset of unexplained
dyspnea, hypoxia, tachypnea, and stabbing
chest pain
• Will have normal breath sounds and
adequate volume
Acute Pulmonary Edema
• Excessive amount of fluid between alveoli
and capillary space
• Disturbs gas exchange
• Causes hypoxia
• Cardiogenic and non-cardiogenic
Acute Pulmonary Edema
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• Signs/symptoms
dyspnea worse with exertion
orthopnea
blood tinged sputum
tachycardia
pale, moist skin
swollen lower extremities
Respiratory-Pediatric Patients
• Remember the most common cause of
cardiac problems in pediatrics is---???
• Respiratory intervention must begin
quickly and be monitored at all times
• Know the difference in structures from
adults
Inadequate Pediatric Breathing
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• Early signs
accessory muscle use
retractions
tachypnea
tachycardia
Inadequate Pediatric Breathing
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nasal flaring
coughing
cyanosis to the extremities
grunting (Bad Bad Sign)-seen in infants
during exhalation signaling imminent
failure
Pediatric Respiratory Failure
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Altered mental status
Pulse rises early then drops fast
Bradycardia
Hypotension
Irregular breathing pattern
Pediatric Respiratory Failure
• Seesaw pattern-abdomen and chest move
in different directions
• Limp appearance
• Head bobbing with each breath
Pediatric Problems
• Distinguish whether the airway problem is
upper or lower
Pediatric Problems
• Stridor and crowing indicate upper airway
obstruction
• Usually due to edema or foreign body
obstruction
• Wheezing is sign of lower airway problem
Epiglottis
• Inflammation of the epiglottis
• History of sore throat, fever, stridor
• Child sits upright leaning forward, sits the
neck out, drooling
• Life-threatening emergency
• Do not inspect the airway as
bronchospasm may completely obstruct
the airway
Croup
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Swelling of the larynx, trachea, and bronchi
Sore throat and fever worse at night
Seal-like cough
Cool night air usually helps
Patient Care-Pediatrics
• Monitor airway and breathing constantly
• Nothing is more important than adequate
airway care
• Ensure adequate breathing
• Intervene quickly and appropriately when
necessary
• If in doubt-Treat as inadequate breathing
Patient Care-Pediatrics
• If pulse remains low or breathing
inadequate re-evaluate airway,
ventilations, O2 canister (empty), tubing
(kinked)
• If chest does not rise or pulse does not
return to normal, increase ventilation force
after ensuring proper technique
Treatment
• Oxygen is a drug
• It must be administered correctly and
monitored
MDI’s
• Metered dose inhalers
• Delivers a precise dose of medication each
time canister is depressed
MDI’s
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• Bronchodilators
Albuterol- Proventil, Ventolin
Atrovent
Serevent
• Steroids
Vanceril
Aerobid
Azmacort
MDI’s
• Before using
• patient must have signs & symptoms of
breathing difficulty
• has a physician prescribed MDI
• approval from medical control
Contraindications
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Not responsive enough to follow directions
Medication out of date
Not prescribed for the patient
Permission not granted by medical control
Patient has already taken the maximum
allowed dose prior to arrival
Administration
• Check name of medicine, date, and name
prescribed to
• Obtain medical control order
• Shake canister for 30 seconds
Administration
• Have patient
• exhale fully
• wrap lips around opening
• inhale slowly as you depress canister (5
seconds)
• hold breathe for 10 seconds
• exhale slowly
MDI’s
• Side effects include:
• tachycardia
• arrhythmia
• anxiety
• nervousness