Download Chapter 16: Respiratory Emergencies

Chapter 16
Respiratory Emergencies
National EMS Education
Standard Competencies
Medicine
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression and implement a
comprehensive treatment/disposition plan for
a patient with a medical complaint.
National EMS Education
Standard Competencies
Respiratory
Anatomy, signs, symptoms, and management
of respiratory emergencies including those
that affect the
– Upper airway
– Lower airway
National EMS Education
Standard Competencies
Respiratory (cont’d)
Anatomy, physiology, pathophysiology,
assessment, and management of
–
–
–
–
–
Epiglottitis
Spontaneous pneumothorax
Pulmonary edema
Asthma
Chronic obstructive pulmonary disease
National EMS Education
Standard Competencies
Respiratory (cont’d)
Anatomy, physiology, pathophysiology,
assessment, and management of (cont’d)
–
–
–
–
–
Environmental/industrial exposure
Toxic gas
Pertussis
Cystic fibrosis
Pulmonary embolism
National EMS Education
Standard Competencies
Respiratory (cont’d)
Anatomy, physiology, pathophysiology,
assessment, and management of (cont’d)
– Pneumonia
– Viral respiratory infections
– Obstructive/restrictive disease
National EMS Education
Standard Competencies
Respiratory (cont’d)
Anatomy, physiology, epidemiology,
pathophysiology, psychosocial impact,
presentations, prognosis, and management
of
– Acute upper airway infections
– Spontaneous pneumothorax
– Obstructive/restrictive lung diseases
National EMS Education
Standard Competencies
Respiratory (cont’d)
Anatomy, physiology, epidemiology,
pathophysiology, psychosocial impact,
presentations, prognosis, and management
of (cont’d)
– Pulmonary infections
– Neoplasm
– Pertussis
– Cystic fibrosis
National EMS Education
Standard Competencies
Shock and Resuscitation
Integrates comprehensive knowledge of
causes and pathophysiology into the
management of cardiac arrest and pre-arrest
states.
National EMS Education
Standard Competencies
Shock and Resuscitation (cont’d)
Integrates a comprehensive knowledge of the
causes and pathophysiology into the
management of shock, respiratory failure, or
arrest, with an emphasis on early
intervention to prevent arrest.
Introduction
• Respiratory distress is usually caused by
respiratory system problems.
Epidemiology
• Respiratory distress is one of the most
common EMS dispatches.
– Asthma and COPD are among the top 10
chronic conditions causing restricted activity.
– Pneumonia is one of the most common fatal
illnesses in developing countries.
Epidemiology
• Some respiratory diseases are genetic
while others are caused by external factors.
– Many respiratory diseases are caused by a
combination of factors.
Hypoventilation
• Carbon dioxide accumulates in the blood
when the lungs fail to work properly.
– Combines with water to form bicarbonate ions
and hydrogen ions
• Results in acidosis
Hypoventilation
• Impaired
ventilation is
caused by a
variety of factors.
Hypoventilation
• Carbon dioxide level is directly related to pH
– Hyperventilating patients usually have
respiratory alkalosis.
– Hypoventilating patients usually have
respiratory acidosis.
Hypoventilation
• Causes of hypoventilation include:
– Conditions that impair lung function
• Atelectasis
• Pneumonia
• Pulmonary edema
• Asthma
• COPD
Hypoventilation
• Causes of hypoventilation include (cont’d):
– Conditions that impair mechanics of breathing
• High cervical fracture
• Flail chest
• Severe retractions
• Air- or blood-filled abdomen
• Obesity hypoventilation syndrome
Hypoventilation
• Causes of hypoventilation include (cont’d):
– Conditions that impair neuromuscular apparatus
• Head trauma, intracranial infections, brain tumors
• Serious spinal cord injury
• Guillain-Barre syndrome
• Amyotrophic lateral sclerosis (Lou Gehrig disease)
• Botulism
Hypoventilation
• Causes of hypoventilation include (cont’d):
– Conditions that reduce respiratory drive
• Intoxication
• Head injury
• Hypoxic drive
• Asphyxia
Hypoventilation
• The ultimate manifestation is respiratory
arrest followed by cardiac arrest.
• Initiate aggressive treatment to assist the
patient’s respiratory efforts.
Hyperventilation
• Occurs when people breathe in excess by
increasing rate and/or depth of respiration
– Releases more carbon dioxide than normal
• Results in alkalosis
– Triggered by emotional distress or panic:
hysterical hyperventilation or hyperventilation
syndrome
Hyperventilation
• Causes numbness in hands, feet, and
mouth
• Ultimately leads to carpopedal spasm
– Symptoms often cause more hyperventilation.
Hyperventilation
• Having patient rebreathe carbon dioxide
can be dangerous.
– Patients quickly exhaust the oxygen in the gas
they are breathing.
– Hyperventilation in a patient with acidosis may
be the body’s attempt to raise the pH level.
Hyperventilation
• Treatment may include:
– Sedation
– Psychological support:
• Breathing with the patient
• Having the patient count to two between breaths
• Distraction techniques
• Having the patient sing a song
Anatomy and Physiology
• Respiratory system structures look like an
inverted tree.
Structures of the Upper Airway
• Nostrils and nose
– Air enters through the nostrils.
• Lined with nasal hairs
– Quiet breathing allows air to flow through the
nose.
Structures of the Upper Airway
• Turbinates
– Highly vascular ridges covered with mucus
membrane
• Traps particulates
• Warm and humidify air as it passes
– Many blood vessels—swell and bleed easily
Structures of the Upper Airway
Structures of the Upper Airway
• Mouth and
oropharynx
– Contain blood vessels
and mucous
membrane
– Edema can be
extreme.
– Ask patient if their
tongue feels thick.
– Monitor speech.
© E. M. Singletary, M.D. Used with permission.
Structures of the Upper Airway
• Hypopharynx
– Where the oropharynx and nasopharynx meet
– Gag reflex is profound.
• Triggering may cause vagal bradycardia, vomiting,
and increased intracranial pressure.
• May make airway device use difficult
Structures of the Upper Airway
• Larynx and glottis
– Dividing line between upper and lower airway
– Thyroid cartilage: external landmark
Structures of the Upper Airway
• Larynx and glottis (cont’d)
– Several cartilages support the vocal cords.
• Arytenoid cartilages: found at the distal end of each
vocal cord
• Piriform fossae: pockets of tissue found on either
side of the glottis
• Cricoid cartilage: palpated just below the thyroid
cartilage
Structures of the Upper Airway
• Larynx and glottis (cont’d)
– Cricothyroid membrane: small space between
the thyroid and cricoid cartilage
• Does not contain many blood vessels
• Covered only by skin
• Potential site for cricothyrotomy
Structures of the Upper Airway
• Larynx and
glottis (cont’d)
– Laryngeal
swelling or
trauma can
create lifethreatening
airway
obstruction.
Structures of the Lower Airway
• Tracheobronchial
tree
– Trachea—
trunk of tree
• Carries air to the
lungs
• Extends from the
larynx to the
mainstem
bronchi
Structures of the Lower Airway
• Tracheobronchial tree (cont’d)
– Mainstem bronchi branch into:
• Lobar bronchi
• Segmental bronchi
• Subsegmental bronchi
• Bronchioles
Structures of the Lower Airway
• Bronchi and bronchioles are lined with cilia.
Inset photo: © Dr. Kessel &
Dr. Kardon/Tissue &
Organs/Visuals Unlimited.
© Dr. Kessel & Dr.
Kardon/Tissue &
Organs/Visuals Unlimited
Inset photo: © Dr. Kessel &
Dr. Kardon/Tissue &
Organs/Visuals Unlimited.
Structures of the Lower Airway
• Bronchioles
– Significant amount of gas exchange
Structures of the Lower Airway
• Bronchioles (cont’d)
– Goblet cells produce mucus blanketing.
• Gel layer
• Sol layer
– Smooth muscle surrounds the airway.
• Bronchoconstriction: smooth muscle narrows the
airway.
Structures of the Lower Airway
• Alveoli
– Gas exchange interface
• Deoxygenated blood releases carbon dioxide and is
resupplied with oxygen.
– Made up of two types of cells:
• Type I: almost empty
• Type II: can make new type I cells
Structures of the Lower Airway
• Alveoli (cont’d)
– Function best when
kept partially
inflated
– Collapsed, fluidfilled, or pus-filled
alveoli do not play
a part in gas
exchange.
Structures of the Lower Airway
• Alveoli (cont’d)
– Pulmonary capillary bed
• Pulmonary circulation starts at the right ventricle.
• Pulmonary capillaries are narrow.
– Patients with chronic lung disease and chronic
hypoxia often have thick blood (polycythemia).
• Strains right side of heart, leads to cor pulmonale
Structures of the Lower Airway
Structures of the Lower Airway
• Alveoli (cont’d)
– Interstitial space
• Network of gaps between alveoli and capillaries
• Filled with interstitial fluid
– Conducting airways distributes inspired gas,
which does not participate in ventilation
• Wasted ventilation: dead space (1 mL per pound of
ideal body weight)
Structures of the Lower Airway
• Chest wall
– Forms a bellows system with chest muscles
– The diaphragm is the primary muscle.
• Causes pressure changes to move air in and out
– Ribs maintain pressure.
– Pleural membranes allow organs to move
smoothly.
Structures of the Lower Airway
• Chest wall (cont’d)
– Trauma and
diseases of the
bones and muscles
can significantly
impair air
movement.
• Causes restrictive
lung diseases
Structures of the Lower Airway
• Mediastinum: middle of the chest
– Consists of:
• Heart
• Large blood vessels
• The large conducting airways
• Other organs
Functions of the Respiratory
System
• Respiration—process of oxygen taken into
body and distributed to the cells for energy
– Carbon dioxide is returned to the lungs by the
circulatory system and exhaled.
Functions of the Respiratory
System
• Ventilation
– Movement of air in and out of the lungs
– Best measured by the carbon dioxide level
• Normal breathing removes enough carbon dioxide
to keep acid-base balance.
• PACO2 must be 35 to 45 mm Hg for normal
ventilation.
Functions of the Respiratory
System
• Diffusion
– For oxygen to go from an alveolus to a red
blood cell, it must:
• Diffuse into the alveolar cell and out the other side.
• Diffuse into the capillary wall and out the other side.
Functions of the Respiratory
System
• Diffusion (cont’d)
– Some lung diseases make it difficult for oxygen
to diffuse into the blood.
– Effective diffusion: higher concentration of
oxygen in the alveoli than in the bloodstream
Functions of the Respiratory
System
• Perfusion
– Circulatory component of respiratory system
– Blood must keep flowing through pulmonary
vessels.
– A large embolus can block blood flow to the
lung.
Mechanisms of Respiratory
Control
• Neurologic control
– Centered in the medulla
– At least four parts of brainstem responsible for
unconscious breathing
– Stretch receptors cause coughing if taking too
deep a breath
• Hering-Breuer reflex
Mechanisms of Respiratory
Control
• Neurologic control (cont’d)
– Other neurologic control mechanisms:
• Phrenic nerve innervates diaphragm.
• Thoracic spinal nerves innervate intercostal
muscles.
Mechanisms of Respiratory
Control
• Cardiovascular regulation
– Lungs closely linked to cardiac function
– Heart changes have pulmonary consequences.
– Left-sided heart failure progresses faster than
right-sided heart failure.
Mechanisms of Respiratory
Control
• Cardiovascular regulation (cont’d)
– Mild hypoxia causes increase in heart rate
– Severe hypoxia causes bradycardia.
– Uncorrected hypoxic insults may trigger lethal
cardiac arrhythmia.
Mechanisms of Respiratory
Control
• Cardiovascular regulation (cont’d)
– Various forms of heart failure from:
• Fluid balance changes
• Right-sided heart pumping pressure
• Left-sided heart pumping pressure
Mechanisms of Respiratory
Control
• Muscular control
– Body takes in air
by negative
pressure
– Air through mouth
and nose, over
turbinates, around
epiglottis and
glottis
Mechanisms of Respiratory
Control
• Muscular control (cont’d)
– Thorax: airtight box with diaphragm at bottom
and trachea at top
– Diaphragm flattens during quiet breathing.
• Air is sucked in to fill the increasing space.
Mechanisms of Respiratory
Control
• Muscular control (cont’d)
– Minute ventilation can be increased by:
• Deep breathing
• Rapid breathing
– Accessory muscles cause dramatic pressure
changes when greater amounts of air must be
moved.
Mechanisms of Respiratory
Control
• Muscular control
(cont’d)
– Traumatic opening
in thorax provides
route for air to be
sucked in
• Sucking chest
wound
– Exhalation is a
passive process.
Mechanisms of Respiratory
Control
• Renal status
– Kidneys play a part in controlling:
• Fluid balance
• Acid-base balance
• Blood pressure
– Factor into pulmonary mechanics and oxygen
delivery to body tissues
Assessment of a Patient with
Dyspnea
• Respiratory assessment includes much
more than listening to the patient’s lungs.
– Many respiratory ailments are life threatening.
– Respiratory assessment should be done early.
Scene Size-Up
• Observe standard precautions.
• Use proper PPE.
• Evaluate scene safety for:
–
–
–
–
Decreased oxygen concentrations
Carbon monoxide
Irritant gasses
Highly contagious respiratory illness
Scene Size-Up
• Respiratory diseases
can impair:
–
–
–
–
Ventilation
Diffusion
Perfusion
Combination of all
three
• Rapid-onset dyspnea
may be caused by:
–
–
–
–
Acute bronchospasm
Anaphylaxis
Pulmonary embolism
Pneumothorax
Primary Assessment
• Form a general impression.
– Body type may be associated with condition
• Emphysema: barrel chest, muscle wasting, pursedlip breathing, tachypneic
• Chronic bronchitis: sedentary, obese, sleep upright,
spit-up secretions
Primary Assessment
• Observe condition during typical exertion.
– Tachycardia, diaphoresis, and pallor can be
triggered by:
• Increased work of breathing
• Anxiety
• Hypoxia
Primary Assessment
• Position and
degree of distress
– Prefer sitting
positions, such as
tripod position
– Lying flat may be a
sign of sudden
deterioration.
– Ominous sign:
head bobbing
Primary Assessment
• Breathing alterations
– Can be complex and involve:
• Problems with the airway branches
• Difficulties at the alveolar level
• Problems with the muscles and nerves
• Problems with the rigid structure of the thorax
• Increased work of
breathing
– Patients using
accessory muscles
to breathe are in
danger of tiring out.
• Infants and small
children are in
danger of collapse
of flexible sternum
cartilage.
Courtesy of Health Resources and Services Administration, Maternal and Child Health
Bureau, Emergency Medical Services for Children Program.
Primary Assessment
Primary Assessment
• Increased work of
breathing (cont’d)
– Profound
intrathoracic
pressure changes
can cause
peripheral pulses
to weaken or
disappear.
Primary Assessment
• Altered rate and depth of respiration
– Patient with adequate rate but low volume will
have inadequate minute volume.
• Respiratory rate × tidal volume = minute volume
– Monitor trends in respiratory rates.
– Note inspiratory-to-expiratory (I/E) ratio.
Primary Assessment
• Abnormal breath
sounds
– Auscultate lungs
systematically.
– Some conditions
are gravitydependent and
others diffuse
throughout the
lungs.
Primary Assessment
• Abnormal breath sounds (cont’d)
– Breath sounds are created by airflow in the
large airways.
Primary Assessment
Primary Assessment
• Abnormal breath sounds (cont’d)
– Some conditions cause normal breath sounds
to be heard in abnormal places.
– Sounds move better through fluid than in air.
– Quality of sounds is dependent on the amount
of tissue between stethoscope and structures.
Primary Assessment
• Abnormal breath
sounds (cont’d)
– Continuous:
wheezes
– Discontinuous:
crackles
• Rales
• Rhonchi
• Pleural friction rub
Primary Assessment
• Abnormal breath sounds (cont’d)
– Audible sounds include:
• Stridor—upper airway obstruction
• Grunting—lower airway obstruction
• Death rattle—patients can’t clear secretions
– The most ominous sounds are no sounds.
Primary Assessment
• Abnormal breath sounds (cont’d)
– Noisy breathing
• Snoring: Partial obstruction of the upper airway by
the tongue
• Gurgling: Fluid in the upper airway
• Stridor: Narrowing from swelling
– Quiet breathing
• Hyperventilation
• Shock
Primary Assessment
• Sputum
– Has color or amount changed from normal?
Primary Assessment
• Abnormal breathing patterns
– May indicate neurological insults
• Brain trauma or any disturbance may depress
respiratory control centers in the medulla.
• Brain injuries may damage or deprive blood flow.
Primary Assessment
Primary Assessment
• Most respiratory centers are in and around
the brainstem.
Primary Assessment
• Circulation
– Assess skin color.
• Note generalized
cyanosis.
• Pink in healthy
patients
© Logical Images/Custom Medical Stock Photo
Primary Assessment
• Circulation (cont’d)
– Cyanosis
• Healthy hemoglobin levels: 12 to 14 g/dL
• Cyanosis begins at about 5 g/dL desaturation
– Chocolate brown skin
• May occur from high levels of methemoglobin
– Pale skin
• Caused by a blood flow reduction to small vessels
Primary Assessment
• Circulation (cont’d)
– Check for dehydration:
• Dry, cracked lips
• Dry, furrowed tongue
• Dry, sunken eyes
Primary Assessment
• Transport decisions
– Usually transported to closest hospital
• If available, consider pediatric centers.
• If renal failure, consider a facility that can provide
emergency dialysis.
• If multiple emergency departments are available,
consider taking patient to his or her preferred
facility.
History Taking
• Investigate chief complaint
– Increased cough
– Change in amount or color of sputum
– Fever
– Wheezing
– Dyspnea
– Chest pain
History Taking
• Patient may know exact problem.
– Asthma with fever
– Failure of a metered-dose inhaler
– Travel-related problems
–
–
–
–
Dyspnea triggers
Seasonal issues
Noncompliance with therapy
Failure of technology or running out of medicine
History Taking
• SAMPLE history
– Signs and symptoms
– Allergies
– Medications
• Antihistamines
• Antitussives
• Bronchodilators
• Diuretics
• Expectorants
– Pertinent past medical
history
– Last oral intake
– Events preceding the
onset of the complaint
Secondary Assessment
• Neurologic assessment
– Note level of consciousness.
• Decline in PaO2: restlessness, confusion, and
combative behavior
• Increase in PaCO2: sedative effects
– If lungs are not functioning correctly, oxygen
may not be delivered and carbon dioxide may
not be removed.
Secondary Assessment
• Neck exam
– Jugular venous
distention
• Common with
asthma or COPD
• Rough measure of
pressure in right
atrium
© ejwhite/ShutterStock, Inc.
Secondary Assessment
• Neck exam (cont’d)
– Note trachea for deviation.
Courtesy of Stuart Mirvis, MD
• Sign of tension pneumothorax
Secondary Assessment
• Chest and abdominal exam
– Pressing on the liver when in respiratory
distress and semi-Fowler’s position will cause
the jugular veins to bulge.
• Hepatojugular reflex
– Feel for vibrations in the chest as the patient
breathes.
Secondary Assessment
• Examination of the
extremities
–
–
–
–
–
–
Edema
Cyanosis.
Pulse
Pulsus paradoxus
Temperature
Distal clubbing
© Jones & Bartlett Learning. Photographed by Kimberly Potvin.
© Mediscan/Visuals Unlimited
Secondary Assessment
• Vital signs
– Patients under stress can be expected to have
tachycardia and hypertension.
– Ominous signs:
• Bradycardia
• Hypotension
• Falling respiratory rates
Secondary Assessment
• Stethoscope
– Diaphragm is for high-pitched sounds.
– Bell is for low-pitched sounds.
– The longer the tubing, the more extraneous
noise that is heard.
Secondary Assessment
• Pulse oximeter
– Noninvasive way to measure the percentage of
hemoglobin with oxygen attached
– Oxygen saturation over 95% = normal
Secondary Assessment
• Pulse oximeter (cont’d)
– Oxygen saturation should match patient’s
palpated heart rate.
– If hemoglobin level is low, the pulse oximetry
result will be high.
– Does not differentiate between oxygen or
carbon monoxide molecules
Secondary Assessment
• Pulse oximeter
(cont’d)
– Oxyhemoglobin
dissociation curve
• Relationship
between oxygen
saturation and
amount of oxygen
dissolved in the
plasma (PaO2).
Secondary Assessment
• End-tidal carbon dioxide detector
– Capnometry: ETCO2 monitoring
– Wave capnography: ETCO2 monitoring that
measures carbon dioxide and plots a waveform
graph
Secondary Assessment
• End-tidal carbon
dioxide detector
(cont’d)
– Colorimetric
detector indicates
whether carbon
dioxide is present
in reasonable
amounts
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
Secondary Assessment
• End-tidal carbon dioxide detector (cont’d)
– Special sensor can measure the percentage of
carbon dioxide and display a waveform
• Waveform capnography
LIFEPAK® defibrillator/monitor. Courtesy of Medtronic.
Secondary Assessment
• End-tidal carbon dioxide detector (cont’d)
– ETCO2 of less than 10 torr: less-than-optimal
CPR compressions
– Sudden increase in ETCO2: spontaneous
circulation return
Secondary Assessment
• Peak expiratory flow
– Maximum rate at which a patient can expel air
– Normal values: 350 to 700 L/min
• Variable by age, sex, and height
– Inadequate level: 150 L/min
Reassessment
• Interventions
– Oxygen (keep saturations above 93%)
– IV line
– Psychological support
Reassessment
• Interventions (cont’d)
– Sympathetic: speeds
heart rate
– Parasympathetic:
slows heart rate
• Anticholinergic
medications block the
parasympathetic
response.
Reassessment
• Interventions (cont’d)
– Ipratropium is used today.
• Combination of albuterol and ipratropium
– Anticholinergics are a central component to
manage COPD.
Reassessment
• Aerosol therapy
– Nebulizers deliver fine mist of liquid medication.
• Need gas flow of at least 6 L/min to keep particles
optimal size.
Reassessment
• Aerosol therapy (cont’d)
– A nebulizer can be attached to:
• A mouthpiece
• Face mask
• Tracheostomy collar
• Can also be held in front of the patient’s face (blowby technique)
Reassessment
• Aerosol therapy (cont’d)
– Can disperse other drugs through aerosols:
• Corticosteroids
• Anesthetic agents
• Antitussives
• Mucolytics
Reassessment
• Metered-dose
inhalers
– Small, easy to
carry and use,
convenient
– Ambulance
metered-dose
inhalers should
have spacers.
Reassessment
• Metered dose inhalers (cont’d)
– To avoid common errors:
• Inhale deeply at discharge.
• Suck medication out of the bottom.
• Flow should be smooth and low-pressure.
• Inhale deeply; hold breath for a few seconds.
• Make sure the inhaler contains medication.
• Keep the spacer and canister holder clean.
• After using corticosteroid inhaler, rinse mouth.
Reassessment
• Failure of a metered-dose inhaler
– Must be properly used.
• Contraindicated if patient cannot move enough air
into the lungs.
• Patient may not realize the inhaler is empty.
• Patient may inhale at the wrong time.
Reassessment
• Dry powder inhalers
– May be dispensed by means of a plastic disk
• Patient inhales deeply to suck out the powder.
– Other devices require the patient to insert a
capsule of powdered medication.
Reassessment
• Communication and documentation
– Contact medical control:
• To report change in level of consciousness or
increased breathing difficulty
• Before assisting with prescribed medication
– Document changes, times occurred, orders
given by medical control.
Emergency Medical Care
• Goal is to:
– Provide supportive care.
– Administer supplemental oxygen.
– Provide monitoring and transport.
Ensure Adequate Airway
• Remove items from mouth.
• Suction if necessary.
• Keep airway in optimal position.
Decrease the Work of
Breathing
• Muscles work harder during respiratory
distress.
– Use substantial energy to compensate for
respiratory distress.
• Requires more oxygen and ventilation
• May fatigue to point of decompensation
Decrease the Work of
Breathing
• To decrease the work of breathing:
– Help the patient sit up.
– Remove restrictive clothing.
– Do not make the patient walk.
– Relieve gastric distention.
– Do not bind the chest or have the patient lie on
the unaffected lung.
Provide Supplemental Oxygen
• Administer in effective concentrations.
– Reassess, then adjust as needed.
– Pulse oximetry is a good guide to oxygenation.
• Concentrations higher than 50% should be
used only with hypoxia that does not
respond to lower concentrations.
Administer a Bronchodilator
• Many can benefit from bronchodilation.
– Those without bronchospasms will benefit only
slightly.
– Bronchodilators are ineffective in cases of:
• Pneumonia
• Pulmonary edema
• Heart disease
Administer a Bronchodilator
• Fast-acting bronchodilators
– Most stimulate beta-2 receptors in lung
• Provide almost instant relief
– Albuterol is the most common beta-2 agonist.
Administer a Bronchodilator
• Slow-acting bronchodilators
– Do not provide immediate symptom relief
– Daily dose reduces frequency/severity of
attacks
– Common medications include:
• Salmeterol
• Cromolyn
Administer a Bronchodilator
• Methylxanthines
– Declining use because of adverse effects
• Overdose can cause cardiac dysrhythmias and
hypotension.
• Carefully monitor level in bloodstream.
Administer a Bronchodilator
• Electrolytes
– Magnesium may have a role in bronchodilation.
– Some physicians use them as a last-ditch effort
before intubation.
Administer a Bronchodilator
• Corticosteroids
– Reduce bronchial swelling
– Adverse effects:
• Cushing syndrome
• Rapid change in blood glucose levels
• Blunts the immune system
– Avoid long-term use.
Administer a Bronchodilator
• Inhaled corticosteroids
– Less adverse effects; becoming standard
• Intravenous corticosteroids
– Methylprednisolone and hydrocortisone: used
for acute asthma attacks or COPD
Administer a Vasodilator
• Sequester more fluid in venous circulation
and decrease preload
– Nitrates can be used if patient:
• Has adequate blood pressure
• Does not take a phosphodiesterase inhibitor.
– Morphine sulfate is not likely to increase venous
capacity.
Restore Fluid Balance
• Common to give fluid bolus to dehydrated,
younger patients.
– Elderly patients or patients with cardiac
dysfunction could wind up with pulmonary
edema.
• Assess breath sounds before and after.
Administer a Diuretic
• Helps reduce blood pressure and maintain
fluid balance in patients with heart failure
• Helps remove excess fluid from circulation,
keeping it out of the lungs of patients with
pulmonary edema.
Administer a Diuretic
• Many diuretics cause potassium loss.
– May lead to cardiac dysrhythmias and chronic
muscle cramping
• Do not give diuretics to patients with
pneumonia or dehydration.
Support or Assist Ventilation
• Breathing may need more aggressive
support if the patient becomes fatigued.
– CPAP and BiPAP may preclude intubation.
– May simply require bag-mask ventilation
Support or Assist Ventilation
• Continuous positive airway pressure
– Used to treat:
• Obstructive sleep apnea
• Respiratory failure
– Patients with obstructive sleep apnea wear a
CPAP unit to maintain airway while they sleep.
Support or Assist Ventilation
• CPAP (cont’d)
– CPAP therapy may
be delivered
through a mask.
• Air is forced into
the upper airway.
• Positive pressure
is created in the
chest.
Support or Assist Ventilation
• CPAP (cont’d)
– Pressure that is too
high may cause:
– New guidelines
emphasize:
• Tension
pneumothorax
• Lower ventilation
rates
• Subcutaneous air
• Block venous
returns
• Smaller volumes
• Lower pressures
Support or Assist Ventilation
• CPAP (cont’d)
– Ensure a seal.
– If a patient is
unwilling to use it,
do not fight it.
– Success is related
to respiratory rate
after application
Courtesy of Respironics, Inc., Murrysville, PA. All rights reserved.
Support or Assist Ventilation
• Bi-level positive airway pressure (BiPAP)
– One pressure on inspiration and a different
pressure during exhalation
• More like normal breathing
• More complex and expensive
Support or Assist Ventilation
• Automated transport ventilators
– Flow restricted oxygen-powered ventilation
• Deliver a particular oxygen volume at a set rate.
• Good for patients in cardiac or respiratory arrest
• Not intended to be used without direct observation
Courtesy of Airon Corporation (www.AironUSA.com)
Intubate the Patient
• Last option for patients with severe asthma
• Ventilate patients before cardiac arrest.
• Patients who are severely intoxicated or
have had a stroke may have no gag reflex.
Intubate the Patient
• With diabetes or overdose, an ampule of
50% dextrose or naloxone may change the
need for intubation
– Use bag-mask ventilation for a few minutes to
monitor effects.
Inject a Beta-Adrenergic Receptor
Agonist Subcutaneously
• Use if inhalation techniques are ineffective.
– May cause more tachycardia and hypertension
– Be careful using in elderly patients.
Instill Medication Directly
Through an Endotracheal Tube
• Option if prompt vascular access is delayed
• Epinephrine dose is 2 to 2.5 times the usual
• Newer devices mist drug into ET tube
– Can be used without interrupting CPR
Anatomic Obstruction
• Pathophysiology
– The tongue is the most common cause of
airway obstruction if patient is semiconscious or
unconscious.
Anatomic Obstruction
• Assessment:
– Risks include:
• Decreased level of consciousness
– Audible signs include:
• Sonorous respirations
• Gurgling
• Squeaking and bubbling
Anatomic Obstruction
• Management
– Obstructive sleep apnea may be caused by
excess soft tissue in airway
• Can be manually displaced
• Place patient in the recovery position
Inflammation Caused by
Infection
• Pathophysiology
– Infections can cause upper airway swelling.
• Can lead to laryngotracheobronchitis
• Common cause of croup
– Stridor
– Hoarseness
– Barking cough
Inflammation Caused by
Infection
• Pathophysiology (cont’d)
– Poiseuille’s law: as the diameter of a tube
decreases, resistance to flow increases.
Inflammation Caused by
Infection
• Assessment
– Croup and tonsillitis are common, but other
conditions are rare.
– Avoid manipulating the airway.
Inflammation Caused by
Infection
Inflammation Caused by
Infection
• Management
– Airway may be entirely obscured.
• Laryngoscopy may worsen swelling
– Have partner press on the chest while you
check for a bubble stream.
• If effort fails, cricothyrotomy may be necessary.
Aspiration
• Inhalation of anything other than breathable
gases
• Patients at risk:
– Tube-fed patients placed supine after large
meal
– Geriatric patients with impaired swallowing
– Unresponsive patients
Aspiration
• Pathophysiology
– Aspiration of stomach contents: high mortality
– Aspiration of foreign bodies may occur.
• Chronic aspiration of food is a common cause of
pneumonia in older patients.
Aspiration
• Assessment
– Determine scenario of sudden onset dyspnea
• Immediately after eating?
• Gastric feeding tube?
Aspiration
• Management
– Avoid gastric distention when ventilating.
• Use nasogastric tube to decompress stomach.
– Monitor ability to protect airway; use advanced
airway when needed.
– Treat with suction and airway control.
Obstructive Lower Airway
Diseases
• Diseases that cause airflow obstruction to
the lungs:
– Emphysema and chronic bronchitis (COPD)
– Asthma
Obstructive Lower Airway
Diseases
• Physical findings:
– Pursed lip breathing
– Increased I/E ratio
– Abdominal muscle use
– Jugular venous distension
Asthma
• Pathophysiology
– Increased tracheal
and bronchial
reactivity
• Causes
widespread,
reversible airway
narrowing
(bronchospasm)
© Scott Rothstein/ShutterStock, Inc.
Asthma
• Pathophysiology (cont’d)
– Patients with potentially fatal asthma often have
severely compromised ventilation all the time.
• Acute bronchospasm or infection presents risk
• Death rates are increasing in the United States.
Asthma
• Pathophysiology (cont’d)
– Status asthmaticus: severe, prolonged attack
that does not stop with conventional treatment
• Struggling to move air through obstructed airways
• Prominent use of accessory muscles
• Hyperinflated chest
• Inaudible breath sounds
• Exhausted, severely acidotic, and dehydrated
Asthma
• Assessment
– Known as reactive airway disease because
bronchospasms are caused by triggers
– Also caused by:
• Airway edema
• Inflammation
• Increased mucus production
Asthma
• Assessment (cont’d)
– Bronchospasm
• Constricting muscle surrounding bronchi
• Wheezing: air forced through constricted airways
• Primary treatment: nebulized bronchodilator
medication
Asthma
Asthma
• Assessment (cont’d)
– Bronchial edema
• Swelling of the bronchi and bronchioles
• Bronchodilator medications do not work.
– Increased mucus production
• Thick secretions contribute to air trapping.
• Dehydration makes secretions thicker.
Asthma
• Management
– Bronchospasm: aerosol bronchodilators
– Bronchial edema: corticosteroids
– Excessive mucus secretion: improve hydration,
mucolytics
Asthma
• Management (cont’d)
– Transport considerations
• Infection or continuous exposure to a trigger:
consider removing patient.
• No improvement in peak flow: consider
corticosteroids.
Asthma
• Management (cont’d)
– Transport considerations
• Undernourished or dehydrated: consider IV fluids.
• Advanced life support more than a few minutes
away: consider transport to nearest ED.
Chronic Obstructive
Pulmonary Disease
• Pathophysiology
– Emphysema damages or destroys terminal
bronchiole structures.
– Chronic bronchitis: sputum production most
days of the month for 3 or more months of the
year for more than 2 years
Chronic Obstructive
Pulmonary Disease
• Assessment
– Emphysema
• Barrel chest from chronic lung hyperinflation
• Tachypneic
• Use muscle mass for energy to breathe
Chronic Obstructive
Pulmonary Disease
• Assessment (cont’d)
– Causes of diffuse wheezing:
• Left-sided heart failure (cardiac asthma)
• Smoke inhalation
• Chronic bronchitis
• Acute pulmonary embolism
– Cause of localized wheezing: obstruction from
foreign body or tumor
Chronic Obstructive
Pulmonary Disease
• COPD with pneumonia
– Often have lung infection
– Check for:
• Fever
• Change in sputum
• Other infection signs
• Breath sounds consistent with pneumonia
Chronic Obstructive
Pulmonary Disease
• COPD with right-sided heart failure
– Look for:
• Peripheral edema
• Jugular venous distention with hepatojugular reflux
• End inspiratory crackles
• Progressive increase in dyspnea
• Greater-than-usual fluid intake
• Improper use of diuretics
Chronic Obstructive
Pulmonary Disease
• COPD with left-sided heart failure
– Can be caused by any abrupt left ventricular
dysfunction
Chronic Obstructive
Pulmonary Disease
• Acute exacerbation of COPD
– Sudden decompensation with no copathologic
conditions
– Often from environmental change or inhalation
of trigger substances
Chronic Obstructive
Pulmonary Disease
• End-stage chronic COPD
– Lungs no longer support oxygenation,
ventilation
– Difficult to tell whether situation can be resolved
– Secure documentation of patient’s wishes.
– Follow local protocol or contact medical control.
Chronic Obstructive
Pulmonary Disease
• COPD and trauma
– Lessens ability to tolerate trauma
– Monitor closely.
– Oxygen saturation might be less than 90%.
• Achieving a saturation of 98% is unrealistic.
Chronic Obstructive
Pulmonary Disease
• Management
– Can help improve immediate distress
– Determine what caused the situation to worsen
enough for the patient to call for help.
– Must understand:
• Hypoxic drive
• Positive end-expiratory pressure (auto-PEEP)
Chronic Obstructive
Pulmonary Disease
• Hypoxic drive
– When breathing stimulus comes from decrease
in PaO2 rather than increase in PaCO2
– Affects only a small percentage during endstage of disease process
– Must decide whether to administer oxygen
Chronic Obstructive
Pulmonary Disease
• Hypoxic drive (cont’d)
– Impossible to tell which patients breathe
because of hypoxic drive.
– Encourage breathing.
– Skin appearance may remain perfused if patient
becomes apneic.
Chronic Obstructive
Pulmonary Disease
• Hypoxic drive (cont’d)
– Provide artificial ventilation and consider
intubation if patient become apneic.
– Intubation may mean the patient remains on the
ventilator until the end of life.
– Oxygen saturation values are less useful in
patients with COPD.
Chronic Obstructive
Pulmonary Disease
• Auto-PEEP
– Allow complete exhalation before the next
breath during ventilation.
• Otherwise, pressure in the thorax will continue to
rise (auto-PEEP).
– If possibility, patients should be ventilated 4 to 6
breaths/min.
Pulmonary Infections
• Pathophysiology
– Infections from:
• Bacteria
• Viruses
• Fungi
• Protozoa
– Infectious diseases
cause:
• Swelling of the
respiratory tissues
• Increase in mucus
production
• Production of pus
Pulmonary Infections
• Pathophysiology (cont’d)
– Resistance to airflow increases when the airway
diameter is narrowed (Poiseuille’s law).
– Alveoli can become nonfunctional if filled with
pus.
Pulmonary Infections
• Pathophysiology (cont’d)
– At greater risk of pneumonia:
• Older people
• People with chronic illnesses
• People who smoke
• Anyone who does not ventilate efficiently
• Those with excessive secretions
• Those who are immunocompromised
Pulmonary Infections
• Assessment
– Patients usually report:
• Several hours to days of weakness
• Productive cough
• Fever
• Chest pains worsened by cough
Pulmonary Infections
• Assessment (cont’d)
– May start abruptly or gradually
– During physical examination, patient:
• May look grievously ill
• May or may not be coughing
• May present with crackles
• May have increased tactile fremitus and sputum
production
Pulmonary Infections
• Assessment (cont’d)
– Pneumonia often occurs in the lung bases.
– Patients are often dehydrated.
– Supportive care includes:
• Oxygenation
• Secretion management (suctioning)
• Transport to the closest facility
Pulmonary Infections
• Management
– Upper airway infections: aggressive airway
management
– Lower airway infections: supportive care,
transport
Atelectasis
• Pathophysiology
– Disorders of alveoli
• Collapse from proximal airway obstruction or
external pressure
• Fill with pus, blood, or fluid
• Smoke or toxin damage
Atelectasis
• Pathophysiology (cont’d)
– Common for some alveoli to collapse
• Sighing, coughing, sneezing, and changing
positions help open closed alveoli.
– When alveoli do not reopen, entire lung
segments eventually collapse.
– Increases chance of pneumonia
Atelectasis
• Assessment
– The affected area can harbor pathogens that
result in pneumonia.
• Check if a patient with fever has had recent chest or
abdominal surgery.
Atelectasis
• Management
– Postsurgical
patients
encouraged to:
• Get out of bed.
• Cough.
• Breathe deeply.
• Use the incentive
spirometer.
© T. Bannor/Custom Medical Stock Photo
Cancer
• Pathophysiology
– Lung cancer is one of most common forms of
cancer.
• Cigarette smoking
• Exposure to occupational lung hazards
Cancer
• Assessment
– First presentation is often hemoptysis.
– Frequently accompanied by COPD and
impaired lung function
– Often metastasizes in the lung from other body
sites
Cancer
• Assessment (cont’d)
– Other cancers may invade lymph nodes in neck.
– Pulmonary complications from radiation and
chemotherapy
– Treatments may cause pleural effusion.
Cancer
• Management
– Little prehospital treatment for pleural effusions
or hemoptysis
– Sometimes called for end-of-life issues
Toxic Inhalations
• Pathophysiology
– Damage depends on water solubility of toxic
gas.
Toxic Inhalations
• Assessment
– Highly water-soluble gases react with moist
mucous membranes.
• Causes upper airway swelling and irritation
– Less water-soluble gases get deep in lower
airway.
• More damage over time
Toxic Inhalations
• Assessment (cont’d)
– Moderately water-soluble gases have signs and
symptoms between.
• Mixing drain cleaner and chlorine bleach may
produce an irritant chlorine gas.
• Industrial settings often use irritant gas-forming
chemicals in higher quantities and concentrations.
Toxic Inhalations
• Management
– Immediate removal from contact with gas
– Provide 100% oxygen or assisted ventilation.
– If exposure is to slightly water-soluble gases,
patients may have acute dyspnea hours later.
• Consider transport to closest ED for observation.
Pulmonary Edema
• Pathophysiology
– Fluid buildup in lungs occurring when blood
plasma fluid enters lung parenchyma
– Classifications:
• High pressure (cardiogenic)
• High permeability (noncardiogenic)
Pulmonary Edema
• Assessment
– By time crackles can be heard, fluid has:
• Leaked out of capillaries
• Increased diffusion space between capillaries and
alveoli
• Swollen alveolar walls
• Begun to seep into alveoli
Pulmonary Edema
• Assessment (cont’d)
– Listen to lower lobes through the back.
– Crackles heard higher in the lungs as condition
worsens
– In severe cases, watery sputum, often with a
pink tinged, will be coughed up.
Acute Respiratory Distress
Syndrome
• Pathophysiology
– Seldom seen in field
– Caused by diffuse damage to alveoli from:
• Shock
• Aspiration of gastric contents
• Pulmonary edema
• Hypoxic event
Acute Respiratory Distress
Syndrome
• Assessment
– Document oxygen saturation, breath sounds,
and any sudden changes.
– Monitor ventilation pressures.
Pneumothorax
• Pathophysiology
– Air collects between visceral and parietal
pleura.
– Weak spots (blebs) can predispose a person.
Pneumothorax
• Assessment
– Patients may have:
• Sharp pain after coughing
• Increasing dyspnea in subsequent minutes or hours
Pneumothorax
• Management
– Most will not require acute intervention.
– They should receive oxygen and close
monitoring of their respiratory status.
Pleural Effusion
• Pathophysiology
– Blister-like sac of
fluid formed when
fluid collects
between visceral
and parietal pleura
Pleural Effusion
• Assessment
– Hard to hear breath sounds
– Position will affect ability to breathe.
• Management
– Fowler’s position likely most comfortable
– Supportive care during transport to hospital
Pulmonary Embolism
• Pathophysiology
– Pulmonary circulation compromised by:
• Blood clot
• Fat embolism from broken bone
• Amniotic fluid embolism during pregnancy
• Air embolism from neck laceration or faulty IV
Pulmonary Embolism
• Pathophysiology (cont’d)
– Large embolism usually lodges in major
pulmonary artery
• Prevents blood flow
– Venous blood cannot reach alveoli.
Pulmonary Embolism
• Assessment
– Early presentation: normal breath sounds, good
peripheral aeration
– Classic presentation: sudden dyspnea and
cyanosis, sharp pain in chest
• Cyanosis does not end with oxygen therapy.
Pulmonary Embolism
• Assessment
(cont’d)
– Often begin in
large leg veins,
then migrate into
pulmonary
circulation
– Thrombophlebitis:
high risk
Pulmonary Embolism
• Management
– Bedridden patients are often given:
• Anticoagulants
• Special stockings/other devices to reduce blood clot
formation
– Greenfield filter: opens to catch clots traveling
from the legs in the main vein
Pulmonary Embolism
• Management (cont’d)
– Saddle embolus: exceptionally large embolus
lodging at left/right pulmonary artery bifurcation
• May be immediately fatal
• Cape cyanosis despite CPR and ventilation
Age-Related Variations
• Most common respiratory ailments occur in
second half of patient’s life.
– Asthma often occurs in younger patients but
can flare at any time.
Age-Related Variations
• Anatomy
– Important anatomic differences in children
include:
• Larger heads relative to body size
Age-Related Variations
• Pathophysiology
– Infants often expend huge amounts of energy to
breath and have a limited ability to compensate.
– Infants and children with respiratory problems
may have:
• Respiratory distress
• Respiratory failure leading to decompensation
• Respiratory arrest
Age-Related Variations
• Common pediatric respiratory diseases:
– Foreign body obstruction of the upper airway
– Infections, such as:
• Croup
• Laryngotracheobronchitis
• Epiglottitis
• Bacterial tracheitis
• Retropharyngeal abscesses
Age-Related Variations
• Common pediatric respiratory diseases (cont’d):
– Lower airway disease
– Asthma
– Bronchiolitis
– Pneumonia
– Pertussis (whooping cough)
– Cystic fibrosis
– Bronchopulmonary dysplasia
Summary
• Respiratory disease is one of the most
common pathologic conditions and reasons
for EMS dispatches.
• Impaired ventilation may be caused by
upper airway obstruction, lower airway
obstructive disease, chest well impairment,
or neuromuscular impairment.
Summary
• Respiratory failure occurs from many
pathologic conditions. Care includes
supplemental oxygen.
• Hyperventilation syndrome is excessive
ventilation; patient may have chest pain,
carpopedal spasm, and alkalosis.
• Nasal hairs filter particulates from the air as
it flows and is warmed in the nose,
humidified, and filtered.
Summary
• The mouth and oropharynx’s vascular
structures are covered with a mucous
membrane. The hypopharynx is the junction
of the oropharynx and nasopharynx.
• The larynx and glottis are the dividing line
between upper and lower airways, with the
thyroid cartilage the most obvious external
larynx landmark. The glottis and vocal cords
are in the middle of the thyroid cartilage.
Summary
• The circoid cartilage forms a complete ring
and maintains the trachea in an open
position.
• The cricothyroid is between the thyroid and
circoid cartilages. It is a preferred area for
inserting large IV catheters or small
breathing tubes.
• The respiratory system primary components
look like an inverted tree.
Summary
• The trachea splits into the left and right
mainstem bronchi at the carina.
• Cilia line the larger airways and help move
foreign material out of the tracheobronchial
tree.
• Pulmonary circulation begins at the right
ventricle.
Summary
• The interstitial space can fill with blood, pus,
or air, which causes pain, stiff lungs, and
lung collapse.
• Ventilation, perfusion, and diffusion are the
primary functions of the respiratory system.
• Mechanisms of respiratory control are
neurologic, cardiovascular, muscular, and
renal.
Summary
• Patients with traumatic brain injuries may
exhibit abnormal respiratory patterns.
• Respiratory compromise can cause an
altered level of consciousness because it
cannot store the oxygen it needs to
function.
• Respiratory disease can cause ventilation,
diffusion, and perfusion impairment, or a
combination of all three.
Summary
• Some respiratory diseases have classic
presentations.
• It is critical to evaluate how hard a patient is
working to breathe.
• A patient’s position of comfort and
speaking difficulty level helps determine
degree of distress.
• Patients in respiratory distress often use the
tripod position.
Summary
• Signs of life-threatening respiratory distress:
– Bony retractions
– Soft tissue retractions
– Nasal flaring
–
–
–
–
Tracheal tugging
Paradoxical respiratory movement
Pursed-lip breathing
Grunting
Summary
• Audible abnormal respiratory noises
indicate obstructed breathing.
• Snoring indicates partial obstruction of the
upper airway by the tongue; stridor
indicates narrowing of the upper airway.
• Auscultate the lungs to hear adventitious
breath sounds, including wheezing and
crackles.
Summary
• Crackles: discontinuous noises heard
during auscultation.
• Wheezes: high-pitched, whistling sounds
from air forced through narrowed airways
• If you can’t hear breath sounds with a
stethoscope, there is not enough breath to
ventilate the lungs.
Summary
• The respiratory system delivers oxygen and
removes carbon dioxide. If the lungs do not
work, it can lead to hypoxia, cell death, and
acidosis.
• Patients with dyspnea are usually
transported to the nearest facility.
• Patients with chronic respiratory disease
may have already tried treatment options.
Summary
• Determine if the problem started suddenly
or gradually worsened as indicators to the
underlying cause.
• If the condition is recurrent, compare the
current incident with other episodes.
• If patient cannot speak because of
breathing issues, obtain the history from
family members or available clues.
Summary
• Assess the mucous membranes for
cyanosis, pallor, and moisture.
• Assess the level of consciousness in
dyspneic patients.
• With the patient in a semisitting position,
check for jugular venous distension, which
may be caused by cardiac failure.
Summary
• Feel the chest for vibrations during
breathing, and check for edema of the
ankles and lower back, peripheral cyanosis,
and pulse. Check skin temperature and
apply monitors.
• A pulse oximeter indicates the percentage
of hemoglobin with attached oxygen;
greater than 95% is considered normal.
Summary
• Colorimetric end-tidal carbon dioxide
devices or wave capnography can monitor
exhaled carbon dioxide.
• Peak flow is the maximum flow rate a
patient can expel air from the lungs.
• Metered-dose inhalers deliver
bronchodilators and corticosteroids as an
aerosol treatment; dry powder inhalers use
a fine powder to deliver a measured-dose
treatment.
Summary
• Aerosol nebulizers deliver a liquid
medication in a fine mist.
• Emergency care for dyspnea may include:
–
–
–
–
–
–
Decreasing work of breathing
Supplemental oxygen
Bronchodilators
Inhaled corticosteroids, vasodilators, or diuretics
Supporting or assisting ventilation
Intubation
Summary
• Ensure an open and maintainable airway.
Suction if needed, and keep the airway
optimally positioned. Remove constrictive
clothing.
• Inhalation drug administration may be
ineffective if airway is compromised.
• Medications can be given directly into the
tracheobronchial tree if patient is intubated.
Summary
• CPAP is a respiratory failure therapy that
increases oxygen saturation and decreases
respiratory rate.
• BiPAP is CPAP that delivers one pressure
during inspiration and a different one during
exhalation.
• Automated transport ventilators are flowrestricted oxygen-powered breathing
devices with timers.
Summary
• Patients in respiratory failure may need to
be intubated.
• Anatomic or foreign body obstruction of the
upper airway can cause seizures and death.
• Infections can cause upper airway swelling.
Croup is one of the most common causes.
Summary
• Emphysema, chronic bronchitis, and
asthma are common obstructive airway
diseases, with emphysema and chronic
bronchitis collectively classified as COPD.
• Asthma is characterized by significant
airway obstruction from:
– Widespread, reversible airway narrowing
– Airway edema
– Increased mucous production
Summary
• Primary treatment for bronchospasms is
bronchodilatory medicine, while
corticosteroids are the primary treatment for
bronchial edema.
• Status asthmaticus is a severe, prolonged
asthmatic attack that cannot be stopped
with conventional treatment. It is a dire
emergency.
Summary
• If an asthma attack is recurring, the inhaler
may be empty or the medication ineffective.
• Asthma attacks can be triggered by
noncompliance with a prescribed
medication regimen.
• Emphysema is a chronic weakening and
destruction of the terminal bronchioles and
alveoli walls.
Summary
• Chronic bronchitis symptoms include:
– Excessive mucous production in bronchial tree
– Chronic or recurrent productive cough
• For patients with COPD, look for cause of a
worsened condition.
Summary
• Hypoxic drive: High oxygen levels decrease
the respiratory drive.
• When ventilating, allow the patient to exhale
completely before the next breath is given
to avoid auto-PEEP.
• Pneumonia may be caused by bacterial,
viral, and fungal agents.
Summary
• Atelectasis is alveolar collapse from:
– Proximal airway obstruction
– Pneumothorax
– Hemothorax
– Toxic inhalation
• Lung cancer often presents with hemoptysis
and is increasing among women.
• Toxic gas inhalation damage depends on
the water solubility of the gas.
Summary
• Pulmonary edema occurs when fluid
migrates into the lungs.
• Acute respiratory distress syndrome is
caused by diffuse alveolar damage from
aspiration, pulmonary edema, or other
alveolar insult.
• In a pneumothorax, air collects between the
visceral and parietal pleuras. Administer
supplemental oxygen and monitor.
Summary
• Pleural effusion will cause dyspnea. Give
aggressive oxygen administration and
proper positioning.
• A pulmonary embolism occurs when a
blood clot travels to the lungs and blocks
blood flow and nutrient exchange.
Summary
• Infants are less able than older children to
compensate for respiratory insults.
• Infants and children may be in:
– Respiratory distress
– Respiratory failure
– Respiratory arrest
Credits
• Chapter opener: © Jones and Bartlett Publishers.
Courtesy of MIEMSS.
• Backgrounds: Blue—Courtesy of Rhonda Beck;
Green—Courtesy of Rhonda Beck; Lime—©
Photodisc; Purple—Courtesy of Rhonda Beck.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for
Emergency Medical Services Systems, or have
been provided by the American Academy of
Orthopaedic Surgeons.