Download 03. RespiratoryEmergencies

Respiratory Emergencies
By Sydorenko O.L.
Objectives
Upon successful completion
of this program, you
should be able to:
• review the signs and
symptoms and field
interventions for the
patient presenting with
COPD, and asthma.
• review criteria for the use
of CPAP.
• review the SOP for Acute
Objectives cont’d
• review the Whisperflow patient circuit for
CPAP used in the field.
• review the set up of the albuterol nebulizer
kit and in-line Albuterol set-up.
CPAP
Continuous
Positive
Airway
Pressure
A means of providing high flow, low pressure
oxygenation to the patient in pulmonary edema
CPAP
• CPAP, if applied early enough, is an effective
way to treat pulmonary edema and a means to
prevent the need to intubate the patient
• CPAP increases the airway pressures allowing
for better gas diffusion & for reexpansion of
collapsed alveoli
• CPAP allows the refilling of collapsed, airless
alveoli
• CPAP allows/buys time for administered
medications to be able to work
CPAP expands the surface area of the
collapsed alveoli allowing more surface
area to be in contact with capillaries for gas
exchange
Before
CPAP
With CPAP
Goal of Therapy With CPAP
• Increase the amount of
inspired oxygen
• Decrease the work load of
breathing
In turn to:
 Decrease the need for
intubation
 Decrease the hospital stay
 Decrease the mortality rate
Patient Circuit
COPD
• Chronic obstructive pulmonary
disease - a progressive and
debilitating collection of diseases
with airflow obstruction and
abnormal ventilation with
irreversible components
(emphysema & chronic
bronchitis)
• Exacerbation of COPD is an
increase in symptoms with
worsening of the patient’s
condition due to hypoxia that
deprives tissue of oxygen and
hypercapnia (retention of CO2)
that causes an acid-base
imbalance
Obstructive Lung Disease COPD & Asthma
• Abnormal ventilation usually from
obstruction in the bronchioles
• Common changes noted in the
airways
– bronchospasm - smooth muscle
contraction
– increased mucous production
lining the respiratory tree
– destruction of the cilia lining
resulting in poor clearance of
excess mucus
– inflammation of bronchial
passages resulting in
accumulation of fluid and
inflammatory cells
Emphysema
• Gradual destruction of the alveolar walls
distal to the terminal bronchioles
• Less area available for gas exchange
• Small bronchiole walls weaken, lungs
cannot recoil as efficiently, air is trapped
•  in number of pulmonary capillaries which
 resistance to pulmonary blood flow which
leads to pulmonary hypertension
– may lead to right heart failure & cor pulmonale
(disease of the heart because of diseased lungs)
Alveolar Sac and Capillaries
Bronchioles
capillary
alveolus
Interior
of
alveolus
Emphysema
•  in PaO2 leads to  in red blood cell
production (to carry more oxygen)
• Develop chronically elevated PaCO2 from
retained carbon dioxide
• Loss of elasticity/recoil; alveoli dilated
• More common in men; major contributing
factor is cigarette smoking; another
contributing factor is environmental exposures
• Patients more susceptible to acute respiratory
infections and cardiac dysrhythmias
Chronic Bronchitis
• An increase in the number of
mucous-secreting cells in the
respiratory tree
• Large production of sputum with
productive cough
• Diffusion remains normal
because alveoli not severely
affected
• Gas exchange decreased due to
lowered alveolar ventilation
which creates hypoxia and
hypercarbia
Asthma
• Chronic inflammatory disorder of the
airways
• Airflow obstruction and
hyperresponsiveness are often reversible
with treatment
• Triggers vary from individual
environmental allergens
cold air; other irritants
exercise; stress
food; certain medications
Asthma’s Two-Phase Reaction
• Phase one - within minutes
– Release of chemical mediators (ie: histamine)
• contraction of bronchial smooth muscle
(bronchoconstriction)
• leakage of fluid from bronchial capillaries
(bronchial edema)
• Phase two - in 6-8 hours
– Inflammation of the bronchioles from invasion of
the mucosa of the respiratory tract from the
immune system cells
• additional swelling & edema of bronchioles
Severe Asthma Attack
• One and two word dyspnea
• Tachycardia
• Decreased oxygen saturation on pulse
oximetry
• Agitation & anxiety with increasing
hypoxia
Treatment Goals COPD & Asthma
Relieve and correct hypoxia
Reverse any bronchospasm or
bronchoconstriction
Asthma/COPD with Wheezing SOP
• Routine medical care
• Pulse oximetry (on room air if possible)
• Albuterol 2.5 mg / 3ml with oxygen
adjusted to 6 l/minute
• May repeat Albuterol treatments if needed
• May need to consider intubation with
in-line administration of Albuterol based on
the patient’s condition
• EMS to contact Medical Control for
possible CPAP in patient with COPD
Albuterol Nebulizer Procedure
• Medication is added to the chamber which
must be kept upright
• The T-piece is assembled over the chamber
• The patient needs to be coached to breath
slowly and as deeply as possible
– this will take time and several breathes before the
patient can slow down and start breathing deeper;
the patient needs a good coach to talk them through
the slower/deeper breathing
– the medication needs to be inhaled into the lungs to
be effective
– the patient should be sitting upright
Add medication to the chamber
Connect the mouthpiece to the
T-piece
Connect the corrugated tubing to
the T-piece
Kit connected to
oxygen and run
at 6 l/minute
(enough to
create a mist)
Encourage slow, deep breathing
Albuterol Nebulizer Mask
For the patient
who is unable to
keep their lips
sealed around the
mouthpiece, take
the top T-piece
off the kit and
replace with an
adult or pediatric
nebulizer mask
Pediatric
patient
using
nebulizer
mask.
Caregiver
may assist
in holding
the mask.
What To Do in Extreme Asthma
Attack
• At times, the asthma attack is so severe the
patient is at risk of dying
• To relieve the bronchoconstriction,
Albuterol needs to be delivered right into
the lungs
• To assist with this, the patient may need to
be bagged or intubated to deliver the
medication
• Abuterol is delivered via in-line technique
Aerosol Medication via BVM or ETT
with BVM (In-line)
• Albuterol placed in the chamber as usual
• The chamber is connected to the T-piece
• Adaptor(s) are used to accommodate bagging the
patient with in-line Albuterol as soon as possible
– any medication that can be delivered as soon
as possible to the target organ (the lungs) will
be helpful in promoting bronchodilation
• Mouthpiece
removed from
T-piece and
replaced with
BVM
• Nebulizer still
connected to
oxygen source
• Adaptor placed
at distal end of
corrugated
tubing to
connect to BVM
mask or ETT
Albuterol Delivered
Via BVM
• #1 Disconnect reservoir
bag with L valve from
mask
• #2 Connect L shaped valve
with bag where mouthpiece
of albuterol kit would fit
• #3 Place corrugated tubing
of albuterol kit to the mask
over the patient’s mouth
• #4 Begin to bag to “blow”
the drug into the lungs
while waiting to complete
intubation
#1
#2
#3, #4
To 6l
O2
• Adaptor connected
to the distal end of
the corrugated tubing
of Albuterol kit
connected to the
proximal end of the
ETT
• ETT placement
confirmed in the
usual manner
– visualization
– chest rise & fall
– 5 point
auscultation
– ETCO detector
Intubated
patient