Download AEMT Transition - Unit 28 - Respiratory Resistance Disorders

TRANSITION SERIES
Topics for the Advanced EMT
CHAPTER
28
Respiratory Emergencies:
Airway Resistance
Disorders
Objectives
• Review the frequency of airway
resistance disorders in the U.S.
• Identify pathophysiological changes due
to airway resistance disorders.
• Relate pathophysiology with
assessment findings.
• Discuss current treatment standards for
patients with airway resistance
disorders.
Introduction
• Breathing is usually an effortless
procedure under autonomic control.
• Airway resistance disorders are those
that make this process difficult for the
patient.
• Many findings of labored breathing are
actually the body's attempt at
improving breathing adequacy in light
of the disease.
Epidemiology
• 2 million ED visits a year due to
asthma.
• 9.5 million people in the United States
have been diagnosed with bronchitis.
• Bronchiolitis is a highly contagious
disease common to children under 5
years of age.
Pathophysiology
• Asthma
– Most common complaint is respiratory
distress.
– Extrinsic and Intrinsic asthma.
– Basic pathophysiology is narrowing of
the bronchioles, overproduction of
mucus, and edema.
Pathophysiology (cont’d)
• Asthma (continued)
– Collectively, these changes increase the
resistance to airflow as the patient tries
to breathe.
Pathophysiology (cont’d)
• Asthma types
– Intrinsic
– Extrinsic
• Pathophysiologic changes
– Bronchospasm
– Edema
– Mucus production
Pathophysiologic changes in the bronchioles in asthma contribute to higher
airway resistance.
Pathophysiology (cont’d)
• Bronchitis
– Inflammation of bronchial lining
– Thickening of mucosal wall
– Changes resistance to airflow
Mucus plugs and inflammation cause airway restriction in chronic bronchitis.
Mucus plugs and inflammation cause airway restriction in chronic bronchitis.
Pathophysiology (cont’d)
• Types of bronchitis
– Acute bronchitis
 Short duration (<3 weeks)
 Sputum production
– Chronic bronchitis
 COPD disorder
 Productive cough persisting for 3
consecutive months a year, for at least 2
consecutive years
Pathophysiology (cont’d)
• Bronchiolitis
– Diagnosis of younger patients.
– Inflammation that results in mucosal
edema.
– Lumen size of bronchioles decreases.
– Airway resistance increases with
changes in gas diffusion at the alveolar
level.
Assessment Findings
• General assessment findings
– Common to most patients with dyspnea
 Tachypnea, prolonged exhalation,
wheezes
 Accessory muscle use
 Tripod positioning and retractions
 Nasal flaring, mouth breathing
 Changes in pulse oximetry and vitals
 Skin change and mental status changes
Assessment Findings (cont’d)
• Additional findings with asthma
– Progressive dyspnea
– Nonproductive cough
– Wheezing on auscultation
– URI findings
– Chest tightness
– History of asthma
– Prescribed MDI or nebulizer
Assessment Findings (cont’d)
• Additional findings with acute bronchitis
– Productive cough
– Sore throat
– Edematous nasal mucosa
– Malaise, fatigue, muscle aches
– Occasionally fever, nausea/vomiting
Assessment Findings (cont’d)
• Additional findings with chronic
bronchitis
– Typically overweight
– Cyanotic complexion
– Vigorous productive cough
– Coarse rhonchi on auscultation
– Possible wheezing on auscultation
Assessment Findings (cont’d)
• Additional findings with bronchiolitis
– More common to infants and children
– Infants tend to be more “fussy”
– Hx of recent URI
– Onset over 2-5 days
– Nonproductive cough
– Fever
– Possible diffuse wheezing
Findings for Respiratory Airway Disorders
Emergency Medical Care
• Patient positioning.
• Ensure airway adequacy.
• Provide oxygen based on ventilatory
need.
– NRB mask at 15 lpm with adequate
breathing.
– PPV with 15 lpm oxygen with
inadequate breathing.
Emergency Medical Care (cont’d)
• Administer an inhaled beta-2-specific
agonist if warranted
Case Study
• While you are having dinner on shift at
a local restaurant, a female holding a
young child bursts into the restaurant.
She states she saw the ambulance in
the parking lot and stopped. She states
she was rushing her child to the
hospital for trouble breathing. She is
carrying an MDI, but was afraid to use
it.
Case Study (cont’d)
• Scene Size-Up
– You are in a restaurant having dinner,
the scene is safe.
– Patient is 4-5 years old, appears limp.
– Mother is present with patient's newly
prescribed medication.
– NOI appears to be respiratory distress.
– Your partner runs to the ambulance to
grab the “jump bag.”
Case Study (cont’d)
• Primary Assessment Findings
– Patient moans with loud verbal stimuli.
– Airway patent, breathing fast and
labored.
– Peripheral pulse is tachycardic.
– Accessory muscle and nasal flaring
noted.
– Limp muscle tone, ashen skin color.
Case Study (cont’d)
• Is this patient a high or low priority?
Why?
• Why is the pulse tachycardic and
tachypneic?
• What is causing the nasal flaring and
retractions?
Case Study (cont’d)
• Medical History
– Mother states the child was diagnosed
yesterday with “respiratory problem” by
pediatrician.
• Medications
– Physician prescribed MDI (filled today).
• Allergies
– None per the patient's mother.
Case Study (cont’d)
• Pertinent Secondary Assessment
Findings
– Objective respiratory distress noted.
– Coarse inspiratory and expiratory
wheezing.
– Absent alveolar breath sounds.
– Pulse oximeter reads 84% on room air.
Case Study (cont’d)
• Pertinent Secondary Assessment
Findings
– Slight JVD noted.
– Skin ashen, cool, diaphoretic.
– Peripheral pulse present at 138/min,
respirations are 46/min.
Case Study (cont’d)
• What pathologic change is causing the
abnormal breath sounds?
• What respiratory condition does this
patient likely have?
• What would be three assessment
findings that could confirm your
suspicion?
Case Study (cont’d)
• How would you best ascertain if this
patient is breathing adequately?
• Why would this patient be prescribed
this medication by the pediatrician?
• Given this patient’s presentation, would
it be beneficial to give the drug?
Case Study (cont’d)
• Care provided:
– Positioned supine on wheeled cot.
– PPV initiated with high-flow oxygen.
– Administered a beta-2-specific agonist.
– Expeditious transport to the hospital.
Case Study (cont’d)
• If the patient improves, what would be
the expected findings with:
– Vital signs
– Pulse oximeter
– Breath sounds
– Degree of respiratory distress
Case Study (cont’d)
• What would be the likely assessment
findings should the patient continue to
deteriorate despite treatment?
Summary
• Lower airway diseases many times will
present with very similar findings.
• The goal is to match the patient's
history with the summation of clinical
findings to arrive at the correct field
impression.
Summary (cont’d)
• Regardless, though, any patient that is
breathing inadequately needs to be
ventilated no matter what the disease
etiology is.