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Respiratory Emergencies Beyond the Objectives 1 Discussion Points: Respiratory Anatomy & Physiology Pathophysiology Assessment of the Respiratory System Management of Respiratory Disorders Specific Respiratory Diseases 2 Anatomy & Physiology Review • Function • Takes in oxygen • Disposes of wastes • Carbon dioxide • Excess water 3 Anatomy & Physiology Review a) Nose and mouth b) Oropharynx c) Nasopharynx d) Pharynx c) Epiglottis d) Larynx e) Cricoid cartilage 4 Anatomy & Physiology Review Lower Airway a) Trachea b) Lungs c) Bronchi d) Bronchioles e) Alveoli f) Diaphragm g) Intercostal Muscles 5 Anatomy & Physiology Review • Bronchioles • Smallest airways • Walls consist entirely of smooth muscle (no cartilage present) • Constriction increases resistance to airflow • Dilation reduces resistance to airflow 6 Anatomy & Physiology Review • Alveoli • Air sacs • Site of oxygen and carbon dioxide exchange with blood 7 Anatomy & Physiology Review Pleura -Visceral -Parietal 8 Anatomy & Physiology Review • Inhalation • Diaphragm and intercostal muscles contract, increasing the size of the thoracic cavity. • Air flows into the lungs. - Active Process 9 Anatomy & Physiology Review • Exhalation -Diaphragm and intercostal muscles relax decreasing the size of the thoracic cavity. -Air flows out of the lungs. -passive process 10 Anatomy & Physiology Review • Alveolar/capillary exchange • Oxygen-rich air enters the alveoli during each inspiration. • Oxygen-poor blood in the capillaries passes into the alveoli. • Oxygen enters the capillaries as carbon dioxide enters the alveoli. 11 Anatomy & Physiology Review • Capillary/cellular exchange • Cells give up carbon dioxide to the capillaries. • Capillaries give up oxygen to the cells. O2 + Glucose The Cell CO2 + H2O 12 Adequate/Inadequate Breathing Assess….. Rate Rhythm Quality 13 Adequate/Inadequate Breathing • Rate • Normal Rate • Adult – 12-20/minute • Child – 15-30/minute • Infant – 25-50/minute 14 Adequate/Inadequate Breathing • Rhythm • Regular • Irregular 15 Adequate/Inadequate Breathing • Quality • Breath Sounds • Effort of Breathing • Chest Expansion 16 Adequate/Inadequate Breathing • Other indications that your patient is breathing inadequately. • • • • • Cyanosis Cool Clammy Skin Nasal Flaring Agonal Respirations Tripoding 17 Anatomy & Physiology Review • Infant & Child Airway Considerations • • • • • • Smaller airway passages Large tongue Softer pliable structures Cricoid cartilage is narrowest point. Heavily dependant on diaphragm Larger head 18 Discussion Point: In our initial assessment, we find that our lethargic 20y/o patient is breathing 36bpm with shallow respirations and becoming increasingly cyanotic. -What else would you like to know? -What are our treatment options? 19 When you determine that a patient’s breathing is inadequate, provide artificial ventilation with supplemental oxygen. Means of providing Artificial Ventilation: 1- Pocket face mask with supplemental O2. 2- Two-rescuer BVM ventilation with supplemental O2. 3- Flow restricted oxygen-powered ventilation device. (Not appropriate for infant and children.) 4- One-rescuer BVM ventilation with supplemental O2. 20 Oxygen & Artificial Ventilation in Children and Infants • As a general rule in the prehospital setting, apply as much oxygen as the patient will tolerate. • Utilize artificial/positive pressure ventilation when the patient is apneic, gasping, or when there is persistent cyanosis despite oxygen. 21 Assess for Adequate Artificial Ventilation Observe for Chest Rise Sufficient Rate -12bpm for adults (1 breath every 5 sec.) -20bpm for children and infants (1 breath every 3 sec.) Heart rate returns to normal What are other signs of adequate artificial ventilation? 22 Inadequate Artificial Ventilation Chest does not rise and fall with artificial ventilation. Rate is too slow or too fast. Heart rate does not return to normal. 23 Breathing Difficulty (Signs & Symptoms) Shortness of Breath Restlessness Increased Pulse Rate Increased Breathing Rate Skin Color Changes • Cyanotic • Pale • Flushed 24 Breathing Difficulty (Signs & Symptoms) Noisy Breathing Inability to Speak Retractions Shallow or Slow Breathing Abdominal Breathing Coughing Irregular Breathing Rhythms Patient Position 25 Assessment of the Respiratory Emergency Scene Size-up • Threats to Safety • Identify rescue environments having decreased oxygen levels. • Gases and other chemical or biological agents. • Clues to Patient Information 26 Assessment of the Respiratory Emergency • Initial Assessment • General Impression • Position • Color • Ability to speak • Respiratory effort • LOC • AVPU • Chief Complaint/Apparent Life Threats 27 Assessment of the Respiratory Emergency Initial Assessment (cont): Airway -Assure there is no obstruction -Proper ventilation cannot take place without an adequate airway. Breathing -Absent or abnormal breath sounds -Speaking limited to 1–2 words -Use of accessory muscles or presence of retractions Circulation -Tachycardia -Severe central cyanosis, pallor, or diaphoresis 28 Focused History & Physical Exam History SAMPLE History OPQRST History • • • • Paroxysmal nocturnal dyspnea and orthopnea Coughing and hemoptysis Associated chest pain Smoking history or exposure to secondary smoke Similar Past Episodes 29 Focused History & Physical Exam Physical Examination Inspection • Look for asymmetry, increased diameter, or paradoxical motion. Palpation • Feel for subcutaneous emphysema or tracheal deviation. Percussion 30 Focused History & Physical Exam Physical Examination (cont.) Auscultation • Normal Breath Sounds • Clear • Equal • Abnormal Breath Sounds • • • • Stridor Wheezing Rhonchi Rales/crackles 31 Focused History & Physical Exam Physical Examination (cont.) Extremities • Look for peripheral cyanosis. • Look for swelling and redness, indicative of a venous clot. • Look for finger clubbing, which indicates chronic hypoxia. 32 Focused History & Physical Exam Vital Signs Heart Rate • Tachycardia. Blood Pressure • Pulsus paradoxus. Respiratory Rate • Observe for trends. 33 Focused History & Physical Exam • Assume that an elevated respiratory rate in a patient with dyspnea is caused by hypoxia. A persistently slow rate indicates impending respiratory arrest. 34 Focused History & Physical Exam • Diagnostic Testing • Pulse Oximetry • Inaccurate readings 35 Focused History & Physical Exam • Other Diagnostic Testing • Peak Flow • Dextrose Monitoring??? 36 Management of Respiratory Emergencies Basic Principles • Maintain the airway. • Protect the cervical spine if trauma is suspected. • Patients breathing inadequately should be assisted with artificial ventilation. • Any patient with respiratory distress should receive oxygen. • Oxygen should never be withheld from a patient suspected of suffering from hypoxia. 37 Management of Respiratory Emergencies Basic Principles (cont.) All patients in respiratory distress are a priority transport. They have the potential to decline very rapidly. 38 What Kind of Respiratory Emergencies Might I Encounter??? 39 Upper-Airway Obstruction • Common Causes • Tongue, Foreign Matter, Trauma, Burns • Allergic Reaction, Infection • Assessment • Differentiate cause. 40 Upper-Airway Obstruction Management • Conscious Patient • If the patient is able to speak, encourage coughing. • If the patient is unable to speak, perform abdominal thrusts. • Determine if there is a complete obstruction or poor air exchange. • If either one is present, provide up to five abdominal thrusts in rapid succession. • If they fail, repeat until obstruction is relieved or patient becomes unconscious. 41 Upper-Airway Obstruction Management (cont.) • Unconscious Patient • Open the airway. • Attempt to give two ventilations. • If they fail, reposition the head and reattempt. • Administer abdominal thrusts. • Attempt finger sweeps if foreign body is visualized. • If foreign body is removed, resume ventilation. • If unsuccessful, continue abdominal thrusts and sweeps. 42 Adult Respiratory Distress Syndrome • • • • • • • • • Sepsis Aspiration Pneumonia Pulmonary Injury Burns/Inhalation Injury Oxygen Toxicity Drugs High Altitude Hypothermia • • • • • • Near-Drowning Syndrome Head Injury Pulmonary Emboli Tumor Destruction Pancreatitis Invasive Procedures • Bypass, hemodialysis • Hypoxia, Hypotension, or Cardiac Arrest 43 Adult Respiratory Distress Syndrome Pathophysiology • High Mortality • Multiple Organ Failure • Affects Interstitial Fluid • Causes increase in fluid in the interstitial space • Disrupts diffusion and perfusion Assessment • Symptoms Related to Underlying Cause • Abnormal Breath Sounds • Crackles and rales 44 Adult Respiratory Distress Syndrome Management • Manage the underlying condition. • Provide supplemental oxygen. • Support respiratory effort. • Provide positive pressure ventilation if respiratory failure is imminent. • Monitor vital signs. 45 Obstructive Lung Disease Types • Emphysema • Chronic Bronchitis • Asthma Causes • Genetic Disposition • Smoking and Other Risk Factors 46 Emphysema • Pathophysiology • Exposure to Noxious Substances • Exposure results in the destruction of the walls of the alveoli. • Weakens the walls of the small bronchioles and results in increased residual volume. • Cor Pulmonale – hypertrophy of the right ventricle • Polycythemia – an excess of red blood cells • Increased Risk of Infection 47 Emphysema Assessment • History • Recent weight loss, dyspnea with exertion • Cigarette and tobacco usage • Lack of Cough 48 Emphysema Assessment • Physical Exam Barrel chest Prolonged expiration and rapid rest phase Thin Pink skin due to extra red cell production “Pink puffer” Hypertrophy of accessory muscles 49 Chronic Bronchitis Pathophysiology • Results from an increase in mucussecreting cells in the respiratory tree. • Alveoli relatively unaffected. • Decreased alveolar ventilation. Assessment • History • Frequent respiratory infections. • Productive cough. 50 Chronic Bronchitis Assessment (cont.) • Physical Exam • Often overweight • Rhonchi present on auscultation • Jugular vein distention • Ankle edema • Hepatic congestion • “Blue bloater” 51 Bronchitis and Emphysema Management • Establish and maintain airway. • Support breathing. • • • • Find position of comfort. Provide O2 Monitor oxygen saturation. Be prepared to ventilate. • Establish IV access. • Administer medications. 52 Asthma Pathophysiology • Chronic Inflammatory Disorder • Results in widespread but variable air flow obstruction. • The airway becomes hyperresponsive. • Induced by a trigger, which can vary by individual. • Trigger causes release of histamine, causing bronchoconstriction and bronchial edema. • 6–8 hours later, immune system cells invade the bronchial mucosa and cause additional edema. 53 Asthma Assessment • Identify immediate threats. • Obtain history. • SAMPLE & OPQRST history • History of asthma-related hospitalization? • History of respiratory failure/ventilator use? 54 Asthma Assessment (cont.) • Physical Exam • Presenting signs may include dyspnea, wheezing, cough. • Wheezing is not present in all asthmatics. • Speech may be limited to 1–2 consecutive words. • Look for hyperinflation of the chest and accessory muscle use. • Carefully auscultate breath sounds. 55 Asthma Management • Treatment goals: • Correct hypoxia. • Reverse bronchospasm. • Reduce inflammation. • Maintain the airway. • Support breathing. • High-flow oxygen or assisted ventilations as indicated. 56 Asthma Management (cont.) – Establish IV access. • Administer medications. Status Asthmaticus • A severe, prolonged attack that cannot be broken by bronchodilators. • Greatly diminished breath sounds. • Recognize imminent respiratory arrest. 57 Upper Respiratory Infection (URI) Upper Respiratory Infections • Frequent patient complaint. • Common pediatric complaint. • Rarely life threatening. Pathophysiology • Frequently caused by viral and bacterial infections. • Affect multiple parts of the upper airway. • Typically resolve after several days of symptoms. 58 Upper Respiratory Infection (URI) 59 Upper Respiratory Infection (URI) • Assessment • Look for underlying illness. • Evaluate pediatrics for epiglottitis. • Management • Maintain the airway. • Support breathing. • Treat signs and symptoms. 60 Pneumonia Infection of the Lungs • Immune-Suppressed Patients Pathophysiology • Bacterial & Viral Infections • Hospital-acquired vs. community-acquired. • Infection can spread throughout lungs. • Alveoli may collapse, resulting in a ventilation disorder. 61 Pneumonia Assessment • Focused History & Physical Exam • SAMPLE & OPQRST: • Recent fever, chills, weakness, and malaise • Deep, productive cough with associated pleuritic pain • Tachypnea and tachycardia may be present. • Breath sounds: • Presence of rales/crackles in affected lung segments • Decreased air movement in the affected lung 62 Pneumonia Management • Maintain the airway. • Support breathing. • High-flow oxygen or assisted ventilation as indicated. • Monitor vital signs. • Establish IV access. • Avoid fluid overload. 63 Lung Cancer General Pathophysiology • Majority are caused by carcinogens secondary to cigarette smoking or occupational exposure. • May start elsewhere and spread to lungs. • High mortality. Assessment • Focused History & Physical Exam • SAMPLE & OPQRST history • Cancer-related treatments and hospitalizations. • Physical exam • Evaluate for severe respiratory distress. Management • Follow general principles. • Administer oxygen, support ventilation. 64 Toxic Inhalation Pathophysiology • Includes inhalation of heated air, chemical irritants, and steam. • Airway obstruction due to edema and laryngospasm due to thermal and chemical burns. Assessment • Focused History & Physical Exam • SAMPLE & OPQRST history • Determine nature of substance. • Length of exposure and loss of consciousness. 65 Toxic Inhalation Management • Ensure scene safety. • Enter a scene only if properly trained and equipped. • Remove the patient from the toxic environment. • Maintain the airway. • Early, aggressive management may be indicated. • Support breathing & provide O2. • Establish IV access. • Transport promptly. 66 Carbon Monoxide Inhalation Carbon Monoxide • Odorless, Colorless Gas • Results from the incomplete combustion of carbon-containing compounds. • Often builds up to dangerous levels in confined spaces such as mines, autos, and poorly ventilated homes. • Hazardous to Rescuers 67 Carbon Monoxide Inhalation Pathophysiology • Binds to Hemoglobin • Prevents oxygen from binding and creates hypoxia at the cellular level. Assessment • Focused History & Physical Exam • SAMPLE & OPQRST history • Determine source and length of exposure. • Presence of headache, confusion, agitation, lack of coordination, loss of consciousness, and seizures. 68 Carbon Monoxide Inhalation Management • Ensure scene safety. • Enter a scene only if properly trained and equipped. • Remove the patient from the toxic environment. • Maintain the airway. • Support breathing. • High-flow oxygen or assisted ventilations as indicated. • Establish IV access. • Transport promptly. 69 Pulmonary Embolism Pathophysiology • Obstruction of a Pulmonary Artery • Emboli may be of air, thrombus, fat, or amniotic fluid. • Foreign bodies may also cause an embolus. • Risk Factors • Recent surgery, long-bone fractures, pregnancy. • Pregnant or postpartum. • Oral contraceptive use, tobacco use. 70 Pulmonary Embolism Assessment • Focused History & Physical Exam • SAMPLE & OPQRST history • Presence of risk factors • Sudden onset of severe dyspnea and pain • Cough, often blood-tinged • Physical exam • Signs of heart failure, including JVD and hypotension • Warm, swollen extremities 71 Pulmonary Embolism Management • Maintain the airway. • Support breathing. • High-flow oxygen or assist ventilations as indicated. • Establish IV access. • Monitor vital signs closely. • Transport to appropriate facility. 72 Spontaneous Pneumothorax • Pathophysiology • Pneumothorax • Occurs in the absence of blunt or penetrating trauma. • Risk Factors • Assessment • Focused History • • • • • SAMPLE & OPQRST history Presence of risk factors Rapid onset of symptoms Sharp, pleuritic chest or shoulder pain Often precipitated by coughing or lifting 73 Spontaneous Pneumothorax Assessment (cont.) • Physical Exam: • Decreased or absent breath sounds on affected side • Tachypnea, diaphoresis, and pallor Management • Maintain the airway. • Support breathing. • Monitor for tension pneumothorax. • JVD and tracheal deviation away from the affected side. 74 Hyperventilation Syndrome 75 Hyperventilation Syndrome Assessment • Focused History & Physical Exam • SAMPLE & OPQRST history • Fatigue, nervousness, dizziness, dyspnea, chest pain • Numbness and tingling in hands, mouth, and feet • Presence of tachypnea and tachycardia • Spasms of the fingers and feet 76 Hyperventilation Syndrome Management • Maintain the airway. • Support breathing. • Provide high-flow oxygen or assist ventilations as indicated. • Do NOT allow the patient to rebreathe exhaled air. • Reassure the patient. 77 Croup Pathophysiology • Infection of the larynx causing an upper airway obstruction. Assessment • • • • Children < 3 years of age. Low grade fever Slow onset Barky cough 78 Croup • Management • • • • Calm Patient Oxygen Cool Air Prepare for assist ventilations 79 Epiglottitis Pathophysiology • Infection and enflamation of the epiglottis causing an upper airway obstruction. Assessment • • • • Children > 3 years of age. High grade fever Rapid onset Drooling 80 Epiglottitis • Management • Calm Patient • Oxygen • Encourage sitting position • Prepare for assist ventilations 81 Prescribed Inhalers Generic Names: -albuterol -isoetharine -metaproteranol Trade Names: -Proventil -Ventolin -Bronkosol -Alupent -Metaprel 82 QUESTIONS ? 83