Respiratory Emergencies: CHF, Pulmonary Edema, COPD, Asthma CPAP

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Respiratory Emergencies CHF, Pulmonary Edema,
COPD, Asthma CPAP Albuterol
Nebulizer

• Condell Medical Center EMS System
• September, 2007
• Site Code10-7200E1207
• Prepared by Sharon Hopkins, RN, BSN, EMT-P

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Objectives

• Upon successful completion of this program, the
  EMS provider should be able to
• review the presentation and intervention for the
  patient presenting with CHF, pulmonary edema,
  COPD, and asthma.
• review criteria for the use of CPAP.
• discuss the set-up for CPAP.
• review the SOP for Acute Pulmonary edema,
  Asthma/COPD with Wheezing, and Conscious Sedation

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Objectives contd

• review the Whisperflow patient circuit for CPAP.
• actively participate in return-demonstration of
  the albuterol nebulizer and in-line set-up.
• successfully complete the quiz with a score of
  80 or better.

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Heart Failure

• A clinical syndrome where the hearts mechanical
  performance is compromised and the cardiac output
  cannot meet the demands of the body
• Considered a cardiac problem with great
  implications to the respiratory system
• Heart failure is generally divided into right
  heart failure and left heart failure

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Heart Failure

• Etiologies are varied
• valve problems, coronary disease, heart disease
• dysrhythmias can aggravate heart failure
• Variety of contributing factors to developing
  heart disease
• excess fluid or salt intake, fever (sepsis),
  history of hypertension, pulmonary embolism,
  excessive alcohol or drug usage

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Deoxygenated Blood Flow Through The Heart

• Deoxygenated blood returns to the right heart via
  inferior and superior vena cavas
• Blood flow thru the right side of the heart
• right atrium
• right ventricle
• pulmonary artery to the lungs
• arteries always carry blood away from the heart
• pumped to the lungs to be oxygenated

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Oxygenated Blood Flow Through The Heart

• Oxygenated blood from the lungs returns to the
  heart via the pulmonary veins to the left atrium
• Blood flow thru the left side of the heart
• left atrium
• left ventricle
• thru aortic valve to the aorta
• to aorta for distribution to the body

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Left Side of the Heart

• High pressure system
• Blood needs to be pumped to the entire body
• Left ventricular muscle needs to be significant
  in size to act as a strong pump
• Left sided failure results in backup of blood
  into the lungs

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Right Side of the Heart

• Low pressure system
• Blood needs to be pumped to the lungs right next
  to the heart
• Right ventricle is smaller than the left and does
  not need to be as developed
• Right sided failure results in back pressure of
  blood in the systemic venous system (the
  periphery)

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Left Ventricular Heart Failure

• Causes
• failure of effective forward pump
• back pressure of blood into pulmonary circulation
• heart disease
• MI
• valvular disease
• chronic hypertension
• dysrhythmias

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Left Ventricular Failure

• Pressure in left atrium rises
• increasing pressure is transmitted to the
  pulmonary veins and capillaries
• increasing pressure in the capillaries forces
  blood plasma into alveoli causing pulmonary edema
• increasing fluid in the alveoli decreases the
  lungs oxygenation capacity and increases patient
  hypoxia

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• As MI is a common cause of left ventricular
  failure
• Until proven otherwise, assume all patients
  exhibiting signs and symptoms of pulmonary edema
  are also experiencing an acute MI

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Right Ventricular Heart Failure

• Causes
• failure of the right ventricle to work as an
  effective forward pump
• back pressure of blood into the systemic venous
  circulation causes venous congestion
• most common cause is left ventricular failure
• systemic hypertension
• pulmonary embolism

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Congestive Heart Failure

• A condition where the hearts reduced stroke
  volume causes an overload of fluid in the bodys
  other tissues
• Can present as edema
• pulmonary
• peripheral
• sacral
• ascites (peritoneal edema)

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Compensatory Measures - Starlings Law

• The more the myocardium is stretched, the greater
  the force of contraction and the greater the
  cardiac output
• The greater the preload (amount of blood
  returning to the heart), the farther the
  myocardial muscle stretches, the more forceful
  the cardiac contraction
• After time or with too much resistance the heart
  has to pump against, the compensation methods
  fail to work

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Acute Congestive Heart Failure

• Often presenting in the field as
• Pulmonary edema
• Pulmonary hypertension
• Myocardial infarction

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Chronic Congestive Heart Failure

• Often presenting in the field as
• Cardiomegaly - enlargement of the heart
• Left ventricular failure
• Right ventricular failure

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Patient Assessment

• Scene size-up
• Initial assessment
• airway
• breathing
• circulation
• disability
• AVPU
• GCS
• expose to finish examining

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• Identify priority patients, make transport
  decisions
• Additional assessment
• vital signs, pain scale
• determine weight
• room air pulse ox, if possible, and oxygen PRN
• cardiac monitor 12 lead ECG if applicable
• establish 0.9 NS IV, TKO
• determine blood glucose if indicated
• unconscious, altered level of consciousness,
  known diabetic with diabetic related call
• reassess initial assessment findings and
  interventions started

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Closest Appropriate Hospital

• Hospital of patients choice within the
  departments transport area
• The patient who is alert and oriented has the
  right to request their hospital of choice
• EMS can have the patient sign the release for
  transport to a farther hospital
• If EMS does not feel comfortable transporting
  farther away, you can communicate this to the
  patient to get your point across in a diplomatic
  manner (ie Im very concerned about your
  condition and I would feel more comfortable
  taking you to the closest hospital)

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Refusals

• A conscious and alert patient has the right to
  refuse care and/or transportation
• A refusal, though, with a patient in CHF might
  prove devastating
• worsening of signs and symptoms
• increased and unnecessary myocardial damage
• severe pulmonary edema
• death
• Avoid refusals in these patients at all costs
• Document well the efforts taken to encourage
  transportation

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Signs and Symptoms CHF

• Progressive or acute shortness of breath
• Labored breathing especially during exertion (ie
  standing up, walking a few steps)
• Awakened from sleep with shortness of breath
  (paroxysmal nocturnal dyspnea)
• increasing episodes usually indicate the disease
  is worsening
• Positioning
• tripod - resting arms on thighs, leaning forward
• inability to recline in bed without multiple
  pillows
• using more pillows to be comfortable in bed

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• Changes in skin parameters
• pale, diaphoretic, cyanotic
• mottling present in severe CHF
• Increasing edema or weight gain over a short time
• early edema in most dependent parts of the body
  first (ie feet, presacral area)
• Generalized weakness
• Mild chest pain or pressure
• Elevated blood pressure sometimes
• to compensate for decreased cardiac output

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• Typical home medication profile
• diuretic - to remove excess fluids
• hypertension medications - to treat a typical
  co-morbid factor
• digoxin - to increase the contractile strength of
  the heart
• oxygen
• Worst of the worst complications - pulmonary
  edema

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Progression of Acute CHF

• Left ventricle fails as a forward pump
• Pulmonary venous pressure rises
• Fluid is forced from the pulmonary capillaries
  into the interstitial spaces between the
  capillaries and the alveoli
• Fluid will eventually enter fill the alveoli
• Pulmonary gas exchange is decreased leading to
  hypoxemia (? oxygen in blood) hypercarbia (?
  carbon dioxide in blood)

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Progression of CHF contd

• Hypercarbia (? carbon dioxide retained in the
  blood) can cause CNS depression
• slowing of the respiratory drive
• slowing of the respiratory rate

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• Wheezes heard in any geriatric patient should
  be considered pulmonary edema until proven
  otherwise (especially in the absence of any
  history of COPD or asthma)

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Progression of Pulmonary Edema

• Untreated, leads to respiratory failure
• Oxygen exchange inhibited due to excess serum
  fluid in alveoli? hypoxia ? death
• Presentation
• tachypnea
• abnormal breath sounds
• crackles (rales) at both bases
• rhonchi - fluid in larger airways of the lungs
• wheezing - lungs protective mechanisms
• bronchioles constrict to keep additional fluid
  from entering the airway

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Acute Pulmonary Edema SOP

• Routine medical care
• patient assessment
• IV-O2-monitor
• cautiously monitor IV fluid flow rates
• Place patient in position of comfort
• often patient will choose to sit upright
• dangle the feet off the cart to promote venous
  pooling
• Determine if the patient is stable or unstable
• evaluate mental status, skin parameters, and
  blood pressure

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Stable Acute Pulmonary Edema

• Patient alert
• Skin warm dry
• Systolic B/P 100 mmHg
• Nitroglycerin 0.4 mg sl - maximum 3 doses
• Consider CPAP
• Lasix 40 mg IVP (80 mg if already taking)
• If systolic B/P remains 100 mm Hg give Morphine
  Sulfate 2 mg IVP slowly
• If wheezing, obtain order from Medical Control
  for Albuterol nebulizer

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Pulmonary Edema Medications

• Nitroglycerin
• venodilator reduces cardiac workload and dilates
  coronary vessels
• do not use in the presence of hypotension or if
  Viagra or Viagra-type drug has been taken in the
  past 24 hours
• can repeat the drug (0.4 mg sl) every 5 minutes
  up to 3 doses total if blood pressure remains
  100 mmHg
• onset 1 - 3 minutes sl (mouth needs to be moist
  for the tablet to dissolve be absorbed)

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• Lasix (Furosemide)
• diuretic causes venous dilation which decreases
  venous return to the heart
• avoid in sulfa allergies in the presence of
  hypotension
• dose 40 mg IVP (80 mg IVP if the patient is
  taking the drug at home)
• vascular effect onset within 5 minutes diuretic
  effects within 15 - 20 minutes

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• Morphine sulfate
• narcotic analgesic (opioid)
• causes CNS depression causes euphoria
• increases venous capacity and decreases venous
  return to the heart by dilating blood vessels
• used to decrease anxiety and to decrease venous
  return to the heart in pulmonary edema
• give 2 mg slow IVP titrate to response and vital
  signs and give 2 mg every 2 minutes to a maximum
  of 10 mg IVP
• effects could be increased in the presence of
  other depressant drugs (ie alcohol)

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• Albuterol
• bronchodilator
• reverses bronchospasm associated with COPD
• dose is 2.5 mg in 3 ml solution administered in
  the nebulizer
• the patient may be aware of tachycardia and
  tremors following a dose
• Albuterol must be ordered by Medical Control for
  the acute pulmonary edema patient

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Using CPAP With Medications

• Medications and CPAP are to be administered
  simultaneously
• The use of CPAP buys time for the medications to
  exert their effect
• CPAP and medications used (Nitroglycerin, Lasix,
  and Morphine) can all cause a drop in blood
  pressure
• CPAP and medications must be discontinued if the
  blood pressure falls

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Case Scenario 1

• A 68 year-old female calls 911 due to severe
  respiratory distress which suddenly woke her up
  from sleep. She is unable to speak in complete
  sentences and is using accessory muscles to
  breathe. Lips and nail beds are cyanotic ankles
  are swollen.
• B/P 186/100 P - 124 R - 34 SaO2 - 88
• Crackles are auscultated in the lower half of the
  lung fields.

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Case Scenario 1

• History angina and hypertension smokes 1 pack
  per day for the past 30 years
• Meds Cardizem, nitroglycerin PRN 1 baby aspirin
  daily furosemide, Atrovent inhaler as needed
• Rhythm

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Case Scenario 1

• What is your impression?
• What will be your intervention(s)?
• What is the rationale for your interventions?
• What is this patients rhythm and do you need to
  administer any medications for the rhythm?

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Case Scenario 1

• Impression congestive heart failure with
  pulmonary edema
• paroxysmal nocturnal dyspnea (sudden shortness of
  breath at night)
• bilateral crackles in the lungs
• peripheral edema
• cardiac history - hypertension and angina
• Rhythm - sinus tachycardia
• do not treat this rhythm with medication
• determine and treat the underlying cause

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Case Scenario 1

• Interventions
• Sit the patient upright, have their feet dangle
  off the sides of the cart
• promotes venous pooling of blood and decreases
  the volume of return to the heart
• Oxygen via non-rebreather face mask
• Prepare to assist breathing via BVM
• have BVM reached out and ready for use
• IV-O2-monitor
• Meds NTG, Lasix, Morphine, consider CPAP

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Unstable Acute Pulmonary Edema

• Altered mental status
• Systolic B/P
• Contact Medical Control
• medications given in the stable patient are now
  contraindicated due to a lowered blood pressure
• CPAP on orders of Medical Control
• Consider Cardiogenic Shock protocol
• Treat dysrhythmia as they are presented
• Contact Medical Control for Albuterol if
  wheezing possibly in-line with intubation

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CPAP

• Continuous
• Positive
• Airway
• Pressure
• A means of providing high flow, low pressure
  oxygenation to the patient in pulmonary edema

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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

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• 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
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• CPAP is applied during the entire respiratory
  cycle (inhalation exhalation) via a tight
  fitting mask applied over the nose and mouth
• The patient is assisted into an upright position
• The lowest possible pressure should be used
• the higher the pressure, the risk of barotrauma
  (pneumothorax, pneumomediastinum) rises
• increased pressures in the chest decrease
  ventricular filling worsening cardiac output
  (less coming into the heart, less going out of
  the heart)

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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

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Indications Criteria for CPAP Use

• Patient identified with signs symptoms of
  pulmonary edema or, in consultation with Medical
  Control, exacerbation of COPD with wheezing
• Patient must be alert cooperative
• Systolic B/P 100 mmHg
• No presence of nausea or vomiting absence of
  facial or chest trauma

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Patient Monitoring During CPAP Use

• Patient tolerance mental status
• Respiratory pattern
• rate, depth, subjective feeling of improvement
• B/P, pulse rate quality, SaO2, EKG pattern
• Indications the patient is improving (can be
  noted in as little as 5 minutes after beginning)
• reduced effort work of breathing
• increased ease in speaking
• slowing of respiratory and pulse rates
• increased SaO2

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Discontinuation of CPAP

• Hemodynamic instability
• B/P drops below 100 mmHg
• The positive pressures exerted during the use of
  CPAP can negatively affect the return of blood
  flow to the heart
• Inability of the patient to tolerate the tight
  fitting mask
• Emergent need to intubate the patient

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Patient Circuits

• Complete package includes
• mask tubing
• head strap
• Whisperflow CPAP valve
• corrugated tubing
• air entrapment filter

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Patient Circuit
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Oxygen Tank Duration

• D sized tank - 30 minutes
• typical small portable tank kept on patient cart
• H sized tank - 508 minutes (8 hours)
• typical large tank kept in locker on rig
• Other tank sizes
• E sized tank - 50 minutes
• typically used in hospitals during patient
  transports
• M sized tank - 253 minutes
• Based on 50 psi output approx 30 FIO2

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Case Scenario 2

• You have initiated CPAP and simultaneous
  medication administration (NTG, Lasix and
  Morphine) to a 76 year-old patient who EMS has
  assessed to be in acute pulmonary edema
• The patient begins to lose consciousness and the
  blood pressure has fallen to 86/60.
• What is the appropriate response for EMS to take?

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Case Scenario 2

• This patient is showing signs of deterioration
• The CPAP needs to be discontinued
• No further medications (NTG, Lasix, Morphine) can
  be administered due to the lowered B/P
• Prepare to intubate the patient following the
  Conscious Sedation SOP
• support ventilations with BVM prior to intubation
  attempt

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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 patients condition due to
  hypoxia that deprives tissue of oxygen and
  hypercapnia (retention of CO2) that causes an
  acid-base imbalance

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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

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The Ventilation Process

• Normal inspiration - the working phase
• bronchioles naturally dilate
• Normal exhalation - the relaxation phase
• bronchioles constrict
• Exhalation with obstructive airway disease
• exhalation is a laborous process and not
  efficient or effective
• air trapping occurs due to bronchospasm,
  increased mucous production, and inflammation

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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)

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Alveolar Sac and Capillaries
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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

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Assessment of Emphysema

• Pink puffer - due to excess red blood cells
• Recent weight loss thin bodied
• Increased dyspnea on exertion
• Progressive limitation of physical activity
• Barrel chest (increased chest diameter)
• Prolonged expiratory phase (usually pursed lip
  breathing noted on exhalation)
• Rapid resting respiratory rate
• Clubbing of fingers

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• Diminished breath sounds
• Use of accessory muscles
• One-to-two word dyspnea
• Wheezes and rhonchi depending on amount of
  obstruction to air flow
• May have signs symptoms of right heart failure
• jugular vein distention
• peripheral edema
• liver congestion

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Case Scenario 3

• The patient is a conscious, restless, and anxious
  68 year-old male with respiratory distress that
  has progressively worsened during the past 2
  days.
• The patient has cyanosis of the lips and nail
  beds
• B/P 138/70 P - 116 irregular R - 26 SaO2 82
  
• Rhonchi and rales are auscultated in the lower
  right lung field patient feels warm to the touch
• The patient has had a cold for 1 week with a
  productive cough of yellow-green sputum
• Hx emphysema, angina, osteoarthritis

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Case Scenario
Case Scenario 3
What is this patients rhythm? What
influence would this rhythm have on this
patients health history current condition?
Do you need to intervene?
Atrial fibrillation diminishes the efficiency of
the pumping of the heart which can further
compromise the cardiac output
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Case Scenario 3

• Impression intervention?
• The patient has COPD most likely complicated by
  pneumonia
• a cold over the last week
• productive cough of yellow-green sputum
• warm to the touch (temperature 100.60F)
• rhonchi rales in the right lung field base
• Routine medical care
• supplemental oxygen
• ? heart rate most likely due to pneumonia and
  does not need specific treatment

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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

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Assessment of Chronic Bronchitis

• Blue bloater - tends to be cyanotic
• Tends to be overweight
• Breath sounds reveal rhonchi (course gurgling
  sound) due to blockage of large airways with
  mucous plugs
• Signs symptoms of right heart failure
• jugular vein distention
• ankle edema
• liver congestion

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Drive to Breath COPD

• Normal driving force to breathe
• decreased oxygen (O2) level
• increased carbon dioxide (CO2) level
• Chemoreceptors sense
• too little O2 (? resp rate to improve) or
• too much CO2 (? resp rate to blow off more CO2)
• Patients with COPD have retained excess CO2 for
  so long that their chemoreceptors are no longer
  sensitive to the elevated CO2 levels
• COPD patients breathe to pull in O2

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O2 Administration COPD

• Never withhold oxygen therapy from a patient who
  clinically needs it
• Monitor all patients receiving O2 but especially
  the patient with COPD
• Normal O2 sat for COPD patient is around 90
• If the patient with COPD is supplied all the
  oxygen they need, this might trigger them not to
  work at breathing anymore and may result in
  hypoventilation and/or respiratory arrest

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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

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Asthmas 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

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Assessment of Asthma

• Presentation
• Dyspnea
• Wheezing - initially heard at end of exhalation
• Cough - unproductive, persistent
• may be the only presenting symptom
• Hyperinflation of chest - trapped air
• Tachypnea - an early warning sign of a
  respiratory problem
• Use of accessory muscles

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Severe Asthma Attack

• One and two word dyspnea
• Tachycardia
• Decreased oxygen saturation on pulse oximetry
• Agitation anxiety with increasing hypoxia

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Obtaining a History

• Very helpful in forming an accurate impression
• Will have a history of asthma
• Home medications indicate asthma
• A prior history of hospitalization with
  intubation makes this a high-risk patient for
  significant deterioration
• Note unilateral wheezing is more likely an
  aspirated foreign body or a pneumothorax than an
  asthma attack

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Treatment Goals -COPD Asthma

• Relieve and correct hypoxia
• Reverse any bronchospasm or bronchoconstriction

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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
  patients condition
• Contact Medical Control for possible CPAP in
  patient with COPD

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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

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Add medication to the chamber
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Connect the mouthpiece to the T-piece
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Connect the corrugated tubing to the T-piece
Kit connected to oxygen and run at 6 l/minute
(enough to create a mist)
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Encourage slow, deep breathing
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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

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Pediatric patient using nebulizer mask.Caregiver
may assist in holding the mask.
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Case Scenario 4

• 7 year-old with history of asthma has sudden
  onset of difficulty breathing and wheezing while
  playing outside
• Patient has an increased respiratory rate and is
  using accessory muscles
• B/P - 108/70 P - 90 R - 20 SaO2 - 97
• Upon auscultation, left lung is clear and
  wheezing is present on the right side
• Impression and intervention?

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Case Scenario 4

• Sounds like asthma, looks like asthma, has a
  history of asthma but why should you not suspect
  asthma?
• Asthma is not a selective disease - the patient
  will have widespread, not localized,
  bronchoconstriction and have bilateral wheezing,
  not unilateral
• Dig into the history more - what was the patient
  doing prior to the development of symptoms?

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Case Scenario 4

• This patient was playing with friends, running
  around while eating food
• Possibly aspirated a foreign body
• sudden onset of unilateral wheezing
• Albuterol would not be indicated in this
  situation
• Transport with supplemental oxygen if indicated,
  position of comfort, reassessment watching for
  increase in airway obstruction

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Aerosol Medication via BVM or ETT with BVM
(In-line)

• Place Albuterol in the chamber as usual
• Connect the chamber to the T-piece
• Once the nebulizer kit is assembled and the clear
  adaptor(s) are in place, you may begin to bag the
  patient prior to completion of intubation
• the clear adaptor on the corrugated tubing is
  attached to the BVMs mask
• any medication that can be delivered as soon as
  possible to the target organ (the lungs) will be
  helpful in promoting bronchodilation

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• Nebulizer with white T-piece (CMC pyxis)
• Remove the white mouth piece the BVM will be
  connected to this port
• Add a clear adaptor to the distal end of the
  corrugated tubing
• Intubate the patient as usual and connect the
  clear adaptor on the corrugated tubing to the
  proximal end of the ETT placed in the patient
• Begin to bag the patient
• Supplemental oxygen must be connected to the
  nebulizer and the BVM

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• Nebulizer with blue T-piece
• Remove the mouthpiece from the T-piece and
  connect a clear adaptor in its place
• The BVM will attach to the clear adaptor on the
  T-piece
• Add a second clear adaptor to the distal end of
  the corrugated tubing
• This clear adaptor will be connected to the
  proximal end of the ETT after intubation is
  performed in the usual manner
• Supplemental oxygen must be connected to the
  nebulizer and the BVM

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• Remove mouthpiece from T-piece and replace with
  BVM
• Connect nebulizer to oxygen source
• Place clear adaptor at distal end of corrugated
  tubing (to connect to ETT)

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• Intubate the patient
• Connect the clear adaptor on the distal end of
  the corrugated tubing to the proximal end of the
  ETT
• Confirm placement in the usual manner
• visualization
• chest rise fall
• 5 point auscultation
• ETCO2 detector

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Case Scenario 5

• EMS has responded to a 14 year-old child in
  severe respiratory distress with audible
  wheezing. The complaints have been present for
  the past 3 hours. Inhalers used have not been
  effective.
• B/P - 112/60 P - 120 R - 32 SaO2 - 89
• Patient is very anxious, pale, cool, and
  diaphoretic. The lips and nail beds are cyanotic.
• What is your impression?
• What is your greatest concern?

96
Case Scenario 5

• This patient is experiencing a severe asthma
  attack that is not responding to medication -
  status asthmaticus
• This patient is in danger of going into
  respiratory arrest due to exhaustion
• Begin supportive oxygen therapy
• Set up the albuterol nebulizer kit and
  simultaneously the BVM
• Anticipate intubation with administration of
  Albuterol via the in-line method

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Case Scenario 5

• Patients experiencing an asthma attack are in
  need of bronchodilators (Albuterol) and IV fluids
  (they are usually dry from the rapid respirations
  and inability to have been taking in fluids)
• If the patient is losing consciousness, you may
  need to follow the Conscious Sedation SOP to
  intubate and administer Albuterol via in-line

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Conscious Sedation

• Would Lidocaine bolus be indicated?
• What is the dose of Versed and the purpose of
  Versed?
• What would be the effects of Morphine?
• How do you know if the patient needs Benzocaine
  (Hurricaine, Cetacaine)?

99
Conscious Sedation

• Lidocaine is not indicated
• there is no presence of head injury or insult
• Versed is an amnesic and will relax the patient
• Versed does not take away any pain
• The dose of Versed is 5 mg slow IVP
• If not sedated within 60 seconds, Versed 2 mg
  slow IVP every minutes until sedated
• Following sedation, may give Versed 1 mg IVP
  every 5 minutes for agitation (total dose 15 mg)

100
Conscious Sedation

• Morphine can help increase the effects of Versed
  and assist in improving patient sedation
• Morphine 2 mg slow IVP over 2 minutes
• May repeat Morphine every 3 minutes
• Max dose Morphine 10 mg
• Benzocaine eliminates the gag reflex
• The conscious patient will have a gag reflex
• For the unconscious patient, stroke at the
  eyelashes or tap the space between the eyes
• The gag reflex disappears with the blink reflex
• Minimize the duration of spray (

101
Bibliography

• Bledsoe, B., Porter, R., Cherry, R.
• Essentials of Paramedic Care. Brady.
• 2007.
• Kohlstedt, D. Sales Representative. Tri-Anim.
• Region X SOPs, March 1, 2007.
• Sanders, M. Mosbys Paramedic Textbook,
• Revised Third Edition. 2007.
• Via Google Respiratory Module Part I
• Via Google Respiratory Module Part II