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Pulmonary Diseases & Disorders: Assessment Pulmonary Diseases & Disorders Epidemiology 28% of all EMS Chief Complaints in the US >200,000 deaths annually due to respiratory emergencies Pulmonary Diseases & Disorders Many, many pulmonary diseases Difficult to learn all pathophysiologies All can be categorized as affecting: Ventilation Diffusion (Respiration) Perfusion Treatment can be focused on identifying and treating source of ventilatory/respiratory impairment Sources of Pulmonary Impairment Pulmonary Diseases Disorders of the Pulmonary System Non-Pulmonary Disorders/Disease Impairing Ventilation or Respiration What examples can you list for each of these? Sources of Pulmonary Impairment Ventilation Upper Airway Trauma Epiglottitis FBAO Inflammation of tonsils Lower Airway Trauma Obstructive lung disease Mucous accumulation Smooth muscle spasm Airway edema Sources of Pulmonary Impairment Ventilation Chest Wall Impairment Trauma Hemothorax Pneumothorax Empyema Pleural inflammation Neuromuscular diseases Neurologic Control Brainstem dysfunction Phrenic or spinal nerve dysfunction Sources of Pulmonary Impairment Diffusion Inadequate FiO2 Diseased alveoli asbestosis COPD inhalation injury Capillary bed disease atherosclerosis Interstitial space disease High pressure pulmonary edema High permeability pulmonary edema Sources of Pulmonary Impairment Perfusion Inadequate blood Impaired blood flow pulmonary embolus volume or hemoblogin Capillary wall hypovolemia pathology anemia trauma Risk Factors for Pulmonary Disease Intrinsic Risk Factors Genetic predisposition asthma COPD carcinoma Cardiac or Circulatory pathologies Source for pulmonary edema Source for pulmonary emboli Stress Risk Factors for Pulmonary Disease Extrinsic Factors Smoking prevalence of COPD & carcinomas severity of pulmonary disease Environmental Factors prevalence of COPD & asthma severity of all obstructive disorders Function of the Pulmonary System Gas Exchange System ~10,000 liters of air are filtered, warmed and humidified daily Oxygen diffused into blood Carbon dioxide excreted from the body Function of the Pulmonary System Physiology of Ventilation Requires neurologic initiation (brainstem) Nerve conduction pathways between brainstem and muscles of respiration Intact & patent Upper and Lower airways Intact & non-collapsed alveoli Function of the Pulmonary System Physiology of Respiration Simple diffusion process at the pulmonarycapillary bed Diffusion Requirements Intact, non-thickened alveolar walls Minimal interstitial space & without additional fluid Intact, non-thickened capillary walls Function of the Pulmonary System Physiology of Perfusion Process of circulating blood through the capillary bed Perfusion Requirements Adequate blood volume Adequate hemoglobin Intact, non-occluded pulmonary capillaries Functioning Left Heart Control of Ventilation Control ventilation in response to physiologic needs Driven 1° by pH of CSF influenced largely by PaCO2 2° drive = PaCO2 3° drive = PaO2 detected by chemoreceptors very small population with severe COPD Nervous System Effect on Ventilation Medulla Stimulation Phrenic Nerve Innervation of the diaphragm Spinal Nerves at Thoracic levels Innervation to initiate ventilation of intercostal muscles Hering-Breuer reflex Prevents overinflation General Assessment Size-Up Environment Airborne Hazards Number of patients Needs • Specialized rescue equipment • Protective equipment Is the environment creating or exacerbating the pulmonary condition? General Assessment Initial Goal Identify potentially life-threatening pulmonary conditions Perform minimal PE & Hx Initiate immediate & appropriate therapies Then, continue PE & Hx Try to determine if origin is ventilation, diffusion, perfusion or combination General Assessment Signs of potentially life-threatening pulmonary condition altered mental status absent signs of ventilation Audible stridor or wheezing Able to speak in short phrases only Sustained Tachycardia Pallor / Diaphoresis Accessory muscle use / Retractions Assessment: H&P Present History (focused hx) Chief Complaint Dyspnea • “Subjective sensation that breathing is excessive, difficult or uncomfortable CP Cough, Hemoptysis Associated Fever, Symptoms Chills sputum production Fatigue Assessment: H&P Present History (focused hx) Sputum Findings amount of sputum infection Thick green or brown pneumonia or infection Yellow or gray allergic or inflammatory response Hemoptysis tuberculosis or carcinoma Pink, frothy severe pulmonary edema Assessment: H&P HX of Present Illness How long has dyspnea been present? Gradual or sudden onset? What aggravates or alleviates? Hx of orthopnea? Coughing? Productive cough? What does sputum look/smell like? Pain? What does the pain feel like? Assessment: H&P Listen - To Pt. Breathe or Talk Noisy Breathing is Obstructed Breathing Not All Obstructed Breathing is Noisy Snoring - Tongue Blocking Airway Stridor - “Tight” Upper Airway from Partial Obstruction Observe Breathing Tachypnea Bradypnea Assessment: H&P Observe Body Positioning Tripod Legs in dependent position Mental Status Ventilatory Effort Accessory muscle use / retractions Abdominal muscle use Chest wall expansion Nasal flaring, pursed lips Assessment: H&P Physical Exam of the Chest Increased A-P Lung Diameter Sounds Abnormal: stridor, wheezing, rhonchi, rales, pleural rub Chest expansion Symmetrical Findings Evidence of Trauma Assessment: H&P Physical Exam Cyanosis? Late, unreliable sign of Hypoxia Oxygenate Immediately! Especially If: Decreased LOC Possible Shock Possible Severe Hemorrhage Chest Pain Chest Trauma Respiratory distress or dyspnea HX of any Kind of Hypoxia Assessment: H&P Physical Exam Vital Signs Skin Color, Temp & Moisture Respiratory Rate • No an accurate lone indicator of respiratory status unless very slow Respiratory Rhythm/Pattern Pulse • Bradycardia vs Tachycardia Blood Pressure Assessment: H&P Physical Exam - Circulatory assessment Is the heart beating? Is there major external hemorrhage? Is the Pt. Perfusing vital organs? Effects of hypoxia: Early in adults - Tachycardia Late in adults - Bradycardia Children - Bradycardia Assessment: H&P Don’t let respiratory failure distract you from assessing for circulatory failure. Vascular Access Assessment: H&P Physical Exam Extremities Peripheral Cyanosis Clubbing Carpopedal spasm Peripheral edema Assessment: H&P Diagnostic Testing Pulse oximetry Saturation Inaccuracies & Disadvantages Peak Flow Meter Baseline measurement for obstructive lung disease Often available from patient Capnometry real-time assessment of endotracheal tube placement quantitative vs qualitative Assessment: H&P Past History Similar Episodes in Past Patient’s description of acuity “What happened last time you had an episode this bad?” Chronic Symptoms Acute, Seasonal SOB episodes Seasonal Allergies Chronic cough Recurrent flu, pulmonary infection or SOB Assessment: H&P Past History Known diagnosis Does the present H&P correlate with this past history? • CHF • Hypertension • Renal Failure Previous intubation or hospitalization Aggravating Factors (e.g. smoking) Assessment: H&P Past History Medications Class, Route, Frequency of Use Pulmonary • • • • Sympathomimetics Corticosteroids MAST Cell Stabilizer Methylxanthines Cardiovascular • Diuretics • Antihypertensives • Cardiac glycosides Assessment: H&P Disability Restlessness, anxiety, combativeness = HYPOXIA Until Proven Otherwise Drowsiness, lethargy = HYPERCARBIA When the patient stops fighting, he is not necessarily getting Better!! Other Adventitious Sounds Cough Forced exhalation against partially closed glottis Reflex response to mucosa irritation Determine circumstances At work Postural changes Lying down Productive vs non-productive Other Adventitious Sounds Sneeze Forced exhalation via nasal route Clears nasal passages Reflex response to mucosa irritation Sigh Slow, deep inspiration - Prolonged, audible exhalation Reexpands areas of atelectasis Other Adventitious Sounds Hiccough Hiccups, singultus Spasm of diaphragm followed by glottic closure No useful purpose Benign, transient