Waiting to Exhale

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Waiting to Exhale

• Respiratory Disorders

Peggy Andrews, Instructor
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The Respiratory System
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A quick review

• Upper airway
• To larynx
• Warms, humidifies, cleans
• Cilia
• Turbinates
• Hard and Soft palates

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Review, continued

• Lower airway
• Below larynx
• Trachea
• Bronchi
• Bronchioles
• Alveoli
• Surfactant

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Lower airway, cont.

• Lungs
• Lobes
• Visceral pleura
• Parietal pleura

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Review, continued

• Ventilation
• Inspiration
• Expiration
• Respiration-Tidal Volume
• 500ml
• Inspiratory Reserve Volume
• 3000ml

• Expiratory reserve volume
• 1500ml
• Residual volume
• 1200ml
• Dead air space
• 150ml
• Minute volume
• TV x RR

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What controls our breathing?

• Medulla
• 12-20/min
• Inspiratory and Expiratory areas
• Transmitted through
• Phrenic nerve
• 3rd, 4th, 5th spinal nerves
• Intercostal nerves
• 11 pair
• Can be modified by
• Cerebral cortex
• Hypothalamus
• Pons - on/off switch

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What controls our breathing, cont.

• Stretch receptors
• Visceral pleura
• Bronchi and bronchiole walls

• Hering-Breuer reflex

• PCO2 increase increased PCO2 in CSF
  decreased pH

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Respiratory patterns

• Cheyne-Stokes
• Kussmauls
• Central neurogenic hyperventilation
• Ataxic (Biots)
• Apneustic

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Respiratory Disorders

• Incidence - 28 of all EMS C/C
• Morbidity/Mortality - gt200,000 deaths/yr.

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Risk Factors

• Genetic predisposition
• Asthma
• COPD
• Carcinomas

• Stress
• Increases severity of respiratory complaints
  frequency of exacerbations

• Assoc. Cardiac or circulatory pathologies
• Pulmonary edema
• Pulmonary emboli

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Case Presentation One

• On a cold Sunday morning in February, a basic
  amblance is dispatched to a trailer park for a
  woman down. When the EMTs arrive, they are met
  by a young couple who explain that they had
  arrived about 30 minutes earlier to pick their
  mother up for church. They found her on the floor
  of her bathroom, lying on her right side.
  According to the couple, the mother said that she
  had fallen just after lunch the previous day, and
  she had been unable to get up.

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Entering the bathroom, the EMTs find

• An elderly woman, CAO PPTE, lying on her side and
  covered with diarrhea. She says that she feels
  fine but admits to some focal right-sided chest
  pain and a bruise on her hip where she fell.

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• She tells the EMTs that she has been experiencing
  diarrhea for the past two days. Although she
  feels dizzy, she denies any syncope at the time
  of her fall, and says that she simply slipped as
  she was sitting on the toilet.

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The Patient Is

• Pale
• Mildly cyanotic nailbeds
• Skin is warm and dry
• Mucous membranes are dry
• A productive cough with thick, brown sputum
• She states that the coughing is left over from a
  cold that she had contracted the previous month.

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• Breath sounds are congested with rhonchi
• Blood pressure 90/50 mmHg
• Pulse 128/min.
• Respirations 40/min. and shallow
• Temperature 101.6 F (oral)

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• The EMTs determine that the patient is
  dehydrated from the diarrhea. They administer
  oxygen at 4 L/min., and request that an ALS
  ambulance be dispatched. You arrive to find this
  72 year old patient unchanged.

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• During your transport, her cyanosis progresses to
  her lips, although she remains alert and oriented
  and insists she is OK. Her medical history
  reveals that she is a chronic alcoholic, has been
  Dx with hepatic cirrhosis, and has a 145-pack
  year smoking history.

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• Rhonchi and rales are still noted in her right
  chest
• BP 88/58 mmHg
• P 116/min.
• Respirations 30/min.
• Temp 102.5 F (oral)

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• 1. What is her differential diagnosis?
• 2. What treatment might you provide for this
  patient? Why?

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Signs of life-threatening respiratory distress in
adults

• Altered mental status
• 1-2 word speech
• Tachycardia gt 130/min.
• Absent breath sounds

• Retractions/ accessory muscle use
• Audible stridor
• Pallor and diaphoresis
• Severe cyanosis

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COPD (Chronic Obstructive Pulmonary Disease)

• Emphysema
• Chronic Bronchitis
• Asthma

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Case Presentation Two

•  You are dispatched as first-in ambulance to a
  medical emergency unknown problem.
• The response time to this rural address is about
  12 minutes.
• On arrival, you find a first responder who tells
  you they have a 55-year-old male with difficulty
  breathing.
• She says that oxygen is already being
  administered.

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• You enter the house to find the patient seated at
  the kitchen table, obviously short of breath.
• Your initial assessment shows that the patient is
  moving air, and has a strong pulse.
• You replace the nasal cannula with a
  non-rebreather at 12 Lpm

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You note the following

• The patient has diminished breath sounds
• Occasional rhonchi
• He is using his accessory muscles
• He has mild cyanosis around his mouth.

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• Several years ago, doctors at the VA hospital
  diagnosed the patient as having emphysema.
• Over the last 24 hours, the patient has had
  progressive dyspnea, and didnt sleep at all last
  night.

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• BP 140/78
• P - 96
• Resp 28
• Ecg SR
• SaO2 90 with oxygen
• Pt is CAO PPTE
• Meds Theophylline and Amoxicillin
• Smokes 1 PPD with a 30 pack-yr-hx
• He wants to be transported to the VA hospital

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• What is his differential diagnosis?
• What treatment might you provide him?
• Why?

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Emphysema

• Irreversible airway obstruction
• Diffusion defect also exists because of blebs -
  prone to collapse
• Patient exhales with pursed lips
• Almost always associated with cigarette smoking
  or environmental toxins

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Emphysema Pathophysiology

• Destruction of alveolar walls distal to terminal
  bronchioles.
• More common in men
• Walls of alveoli gradually distruct, ? alveolar
  membrane surface area. Results in ? ratio of air
  to lung tissue.
• ? Pulmonary capillaries , ? resistance to
  pulmonary blood flow.
• Causes pulmonary hypertension, leads to RHF,
  then Cor Pulmonale

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Emphysema Pathophysiology (cont.)

• Bronchiole walls weaken, lungs lose elasticity,
  air is trapped. ? Residual volume, but vital
  capacity relatively normal.
• PaO2 ?, ? RBC, polycythemia.
• PaCO2 is chronically elevated. The body depends
  on hypoxic drive.
• Pts are more susceptible to pneumonia,
  dysrhythmias.
• Meds bronchodilators, corticosteroids, O2.

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Assessment

• Altered mentation
• 1-2 word sentences
• Absent or decreased breath sounds
• c/c Dyspnea, morning cough, nocturnal dyspnea,
  wheezing

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• History -
• Personal or family hx of allergies/asthma
• Acute exposure to pulmonary irritant
• Previous similar expisodes
• Recent wt. loss, exertional dyspnea
• Usually gt 20 pack/year/history

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Exam

• Wheezing
• Retractions and/or accessory muscle use
• Barrel chest
• Prolonged expiratory phase
• Rapid resting respiratory rate

• Thin
• Pink puffers
• Clubbing of fingers
• Diminished breath sounds
• JVD, hepatic congestion, peripheral edema

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Management

• Pulse oximeter (end tidal CO2 detector)
• Assisted ventilation prn
• High flow oxygen
• Intubation prn
• IV therapy with fluids
• Albuterol, or Albuterol/Atrovent neb
• Transport considerations

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Chronic Bronchitis

• Productive cough for at least 3 months for two or
  more consecutive years
• An increase in mucous-secreting cells
• Characterized by large quantity of sputum
• Chronic smoker
• Alveoli not severely affected - diffusion normal
• ?gas exchange hypoxia hypercarbia
• May increase RBC polycythemia
• ? paCO2 irritability, h/a, personality changes,
  ? intellect.
• ? paCO2 pulmonary hypertension eventually cor
  pulmonale.

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Assessment

• Hx heavy cigarette smoking
• Frequent resp. infections
• Productive cough
• Overweight, possibly cyanotic - blue bloaters
• Rhonchi on auscultation - mucous plugs
• S/S RHF JVD, edema, hepatic congestion

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Management

• Pulse oximetry (end tidal CO2 detector)
• Oxygen - low flow if possible
• Nebulized Albuterol/Atrovent
• Constantly monitor
• Position - seated
• IV TKO

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Case Presentation Three

• It is a hot June afternoon when you are
  dispatched to the local middle school for a child
  with difficulty breathing. You are directed to
  the nurses office, and there you find a 10
  year-old female.

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• Wt 45 kg
• Sitting upright on the cot
• CAO PPTE
• Obviously struggling to breathe.
• Anxious

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• The nurse tells you that the patient is
  relatively new to the school, and the only
  medical information she has is that the patient
  is allergic to many things (dust, pets, plants,
  as well as peanuts, eggs, shellfish).

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• The nurse has been unable to contact the parents
  they are both out of town, and the custodial
  aunt is about 30 minutes away, but has left a
  message to do whatever you think should be done.

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• The nurse tells you that all she knows is that
  the patient was out at recess, wandered away from
  the other children, and when a playground aide
  went to find her, the patient was sitting down,
  pale, c/o difficulty breathing and had vomited x
  1.

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You find the following

• PERL
• P 132
• RR 32 and shallow
• Intercostal retractions, suprasternal notch
  retractions, nasal flaring, pursed-lip breathing,
  and sub-costal retractions are all apparent.
• Breath sounds are diminished in all lobes, with
  some wheezing in the bases.

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• Skin is pale, cool, dry
• Temp is 98.7 F (tympanic)
• CBG is 100 mg/dcL
• EKG sinus tachycardia
• Patient is able to speak in two or three word
  sentences only

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• She tells you that she hasnt had to use an
  inhaler for about 4 years, and currently takes no
  meds except vitamins. She hasnt been feeling
  well for a day or so, and ate breakfast, but no
  lunch. Her urine output is down today as well.

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• What is your differential diagnosis?
• What treatment would you offer this patient and
  why?

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Asthma

• Reversible obstruction caused by combination of
  smooth muscle spasm, mucous, edema
• Exacerbating factors - extrinsic in children,
  intrinsic in adults
• Status asthmaticus - prolonged exacerbation -
  doesnt respond to therapy
• Significant increase in deaths in last decade- 45
  years or older - black 2x higher
• 50 are prehospital deaths.

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Pathophysiology

• A chronic inflammatory airway disorder.
• Triggers vary - allergens, cold air, exercise,
  food, irritants, medications.
• A two-phase reaction
• Phase one
• Histamine release - bronchial constriction,
  leakage of fluid from peribronchial capillaries
  bronchoconstriction, bronchial edema.
• Often resolves in 1 - 2 hours

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Pathophysiology (cont.)

• Phase two
• 6-8 hours after exposure, inflammation of
  bronchioles - eosinophils, neutrophils,
  lymphocytes invade respiratory mucosa
  additional edema, swelling.
• Doesnt typically respond to inhalers often
  requires corticosteriods.
• Inflammation usually begins days/weeks before
  attack.

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Assessment

• Pulsus paradoxis
• 10-15 mm bp drop during insp vs exp
• Agitated, anxious
• Decreased oxygen saturation
• Tachycardia
• Hx of allergies
• Auto PEEP
• Potential tensions (bilateral)

• Dyspnea, 1-2 word sentences
• Persistent, non-productive cough
• Wheezing
• Hyperinflation of chest
• Tachypnea, accessory muscle use

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Management

• Check home meds
• Determine onset of sx what pt. has taken
• Check vitals carefully RR x 30 sec.
• High flow oxygen
• IV with fluids
• EKG
• Inhalers
• Consider epinephrine 11,000 SQ, 0.3-0.5 mg
• Consider Solu-Medrol, 1 2 mg/kg IVP, max 125 mg

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Status Asthmaticus

• Severe, prolonged asthma attack not responsive to
  treatment
• Greatly distended chest
• Absent breath sounds
• Pt. exhausted, dehydrated, acidotic.
• Treat aggressively if obtunded, profuse
  diaphoresis, floppy Intubate (poss. RSI)
• Transport immediately

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Case Presentation Four

• It is 10 pm on a Saturday night in December, and
  you are dispatched to the mission for a report of
  a 60 year old male having difficulty breathing.
  You are met at the door by a worker who tells you
  that they had just opened the doors to allow the
  homeless in for the night. Immediately after
  assigning cots, they noticed the patient sitting
  on the edge of his cot, blue and gasping for air.

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• You find this 60 y/o, 63 kg male patient, sitting
  upright with his hands braced on his knees. He
  has audible wheezing, and is unable to say more
  than two words without gasping.

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• He tells you he has had a cough for the past
  couple of months, and that he has been having
  some chest pain for the past two or three days,
  has felt nauseated, and has had chills. He says
  that it got much worse tonight.

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• He hasnt been seen by a physician. He says that
  he has a history of alcohol abuse, smokes about ½
  pack of cigarettes per day, and has since he was
  10 years old.

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Your exam reveals the following 

• PERL
• Skin cool, dry, pale with cyanosis to nailbeds,
  lips, earlobes.
• Audible wheezing, diffuse rales in all lobes,
  using accessory muscles, has intercostal
  retractions, and pursed lip breathing.
• Temp is 97.8 F (tympanic)
• BP 126/84
• P 112 RR 28 and shallow
• He is thin, and has clubbing of his fingers.

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• What is his differential diagnosis?
• What treatment would you offer this patient? Why?

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Pneumonia

• 5th leading cause of death in US
• Risk factors
• Cigarette smoking
• Alcoholism
• Cold exposure
• Extremes of age
• Pathophysiology
• A common respiratory disease caused by infectious
  agent. bacterial and viral pneumonia most
  frequent
• May cause atelectasis
• May become systemic sepsis

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Assessment

• Typical
• Acute onset of fever and chills
• Cough productive with yellow/green sputum (bad
  breath!)
• May have pleuritic chest pain
• Pulmonary consolidation on auscultation
• Rales
• Egophony (strange lung sounds)
• Atypical
• Non-productive cough
• H/A
• Fatigue

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Management

• Position
• Oxygen
• Consider breathing treatment
• IV with fluids
• Cool if febrile
• Elderly, over 65 years
• Significant co-morbidity
• Inability to take meds
• Support complications

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Case Presentation Five

• You respond to a call for a shortness of
  breath. It is 0930 on a Tuesday. When you
  arrive, you find a 42 year-old woman. She says
  that she has had flu-like sx for the past 3 days.
  This morning, she began breathing rapidly and
  called 9-1-1. She denies other complaints, but
  says she has been under some stress. She has just
  started a new job, and has had to call in sick
  for the past two days.

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On physical exam

• Airway is patent
• She is tachypneic at 46/min. with deep
  respirations and good air exchange
• Her pulse is 108 and regular
• Skin is warm, dry, with pink mucosa
• CAO PPTE, and moderately anxious
• The rest of your exam is normal.

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• You cancel the first responders, and spend nearly
  40 minutes coaching her to slow her breathing
  without success. Finally, you transport her to
  the ED.

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• What is your differential diagnosis?
• What treatment would you offer this patient? Why?

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Hyperventilation Syndrome

• Multiple causes
• Hypoxia
• High altitude
• Pulmonary disease
• Pneumonia
• Interstitial pneumonitis, fibrosis, edema
• Pulmonary emboli
• Bronchial asthma
• Congestive heart failure
• Hypotension
• Metabolic disorder
• Acidosis

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Hyperventilation Syndrome (cont)

• Causes (cont)
• Hepatic failure
• Neurologic disorders
• Psychogenic or anxiety hypertension
• Central nervous system infection, tumors
• Drug-induced
• Salicylate
• Methylxanthine derivatives
• Beta-adrenergic agonists
• Progesterone
• Fever,sepsis
• Pain
• Pregnancy

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Assessment

• Chief complaint
• Dyspnea
• Chest pain
• Other sx based on etiology
• Carpopedal spasm
• Tachypnea with high minute volume

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Management

• Depends on cause of syndrome
• Oxygen based on sx and pulse oximetry (CO2
  waveform)
• Consider coached ventilation

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Upper Respiratory Infection (URI)

• One of most common c/c
• Usually viral
• Bacterial infections
• Group A streptococcus
• Strep throat
• Sinusitis
• Middle ear infections
• Most URIs self-limiting

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URI continued

• S/S
• Fever
• Chills
• Myalgia
• Fatigue
• Treatment
• Supportive
• Acetaminophen, ibuprofen, liquids

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URI, cont.

• If pediatric, beware of possibility of
  epiglotitis
• If PMH Asthma or COPD, condition may worsen
• Consider nebulized meds

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Lung CA

• Most caused by cigarette smoking
• 4 major types
• Adenocarcinoma most common
• Origin mucus-producing cells
• Small cell carcinoma
• Epidermoid carcinoma
• Large cell carcinoma
• Origin bronchial tissues
• Most patients die within one year

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Lung CA, continued

• General Assessment
• Altered mentation
• 1-2 word sentences
• Cyanosis
• Hemoptysis
• Hypoxia

• Advanced disease
• Profound weight loss
• Cachexia
• Malnutrition
• Crackles, rhonchi, wheezes
• Diminished breath sounds
• Venous distention in arms and neck

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• Localized disease
• Cough, dyspnea, hoarseness, vague chest pain,
  hemoptysis
• Local invasion
• Pain on swallowing (dysphagia)
• Weakness, numbness in arm
• Shoulder pain
• Metastatic spread
• Headache, seizures, bone pain, abdominal pain,
  nausea, malaise

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Treatment for Lung CA

• Oxygen prn
• Support ventilations
• Intubate prn
• IV
• Nubulized meds
• DNR / Advanced directive?

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Toxic inhalation

• Consider if patient dyspneic
• Causes
• Superheated air
• Products of combustion
• Chemical irritants
• Steam inhalation

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Inhalation injury, cont.

• Medic safety
• Ammonia (ammonium hydroxide)
• Nitrogen oxide (nitric acid)
• Sulfer dioxide (sulfurous acid)
• Sulfur trioxide (sulfuric acid)
• Chlorine (hydrochloric acid)

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• Assessment
• Enclosed space?
• Loss of consciousness?
• Mouth, face, throat, nares
• Auscultate chest
• Laryngeal edema
• Hoarseness, brassy cough, stridor
• Management
• Maintain airway
• High-flow humidified oxygen
• IV

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Carbon Monoxide Inhalation

• Incomplete burning of fossel fuels, other
  carbon-containing compounds
• Automobile exhaust, home-heating devices most
  common causes
• CO has gt200x affinity for hemoglobin
• Cellular hypoxia
• Also binds to iron-containing enzymes
• Increased cellular acidosis

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CO, continued

• Assessment
• Source, length of exposure? Closed vs open space?
• S/S
• H/A, N/V, confusion, agitation, loss of
  coordination, chest pain, loss of consciousness,
  seizures
• Cyanosis
• Cherry red skin (very late)

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CO, continued

• Management
• SAFETY
• Maintain airway
• High flow oxygen (NRB vs assisted)
• Hyperbaric oxygen therapy

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Pulmonary Embolus

• Thrombus
• Ventilation perfusion mismatch
• 50,000 deaths in US annually
• Conditions that predispose to PE
• Recent surgery
• Long-bone fracture
• Bedridden
• Long flights/truck drivers
• Pregnancy
• Cancer, infections, thrombophlebitis, AF, sickle
  cell anemia
• BCP

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PE, cont

• Assessment
• Sudden onset SOB, Hypoxic
• Pleuritic chest pain
• Non-productive cough
• History
• Labored breathing, tachypnea, tachycardia
• RHF
• DVT present

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PE, cont

• Management
• ABC
• Airway
• High flow oxygen
• ET?
• IV flow rate?
• Heparin gtt? TPA?

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Spontaneous pneumothorax

• Common- high recurrent rate
• 51 male to female
• Tall, thin
• Smoking history
• 20-40 years old
• COPD increased risk
• Ventilation perfusion mismatch if gt 20

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Spont. Pneumothorax, cont.

• Assessment
• Sudden onset sharp chest or shoulder pain
• Coughing/lifting
• Dyspnea
• Decreased breath sounds at apex
• Hyper resonance
• Sub-cutaneous emphysema
• Tachypnea, diaphoresis, pallor

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Spont. Pneumothorax, cont.

• Management
• Supplemental oxygen
• If symptoms increase, consider needle
  decompression
• Position of comfort

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Thats all about breathing for now, folks!