Respiratory Emergencies

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• Respiratory Emergencies

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Objectives 1 of 3

• Describe the structure and functions of the
  respiratory system.
• Identify the signs and symptoms of a patient with
  difficulty breathing.
• List signs and symptoms of adequate and
  inadequate air exchange.

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Objectives 2 of 3
Identify the signs and symptoms of the following
causes of dyspnea

• Asthma
• Chronic bronchitis
• Croup
• Pneumonia
• Pulmonary edema
• Chronic obstructive pulmonary disease

• Epiglottitis
• Hyperventilation
• Pulmonary embolism
• Spontaneous Pneumothorax
• Pulmonary embolism

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Objectives 3 of 3

• Describe the care of a patient with breathing
  distress.
• Establish the relationship between airway
  management and breathing difficulty.
• State the generic name, forms, dose,
  administration, actions, indications, and
  contraindications for inhalers.
• Differentiate between upper airway obstruction
  and lower airway disease in infants.

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Respiratory System
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Anatomy and Function of the Lung
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Systemic and Pulmonary Respiration
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Terminology

• Dyspnea Inability to breathe normally.
• Respiratory arrest or apnea cessation of
  spontaneous breathing.
• Hypoxia Cells of the body are not getting enough
  oxygen.
• Hypercapnea Too much carbon dioxide in the
  blood, commonly from the inability to adequately
  ventilate the alveoli.

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Situations Causing Lung Disorders

• Pulmonary vessels become obstructed.
• Alveoli are damaged.
• Air passages are obstructed.
• Pleural space is filled with excess air.

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Normal Breathing

• Normal rate and depth Tidal Volume
• Regular breathing pattern
• Good breath sounds on both sides
• Equal rise and fall of chest
• Movement of the abdomen

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Respiratory Distress

• SOB
• Altered LOC
• Abnormal Rate
• Cyanosis or pallor
• Abnormal airway sounds
• Abnormal breath sounds
• Inability to speak well
• Muscle retractions

• Diaphragmatic breathing
• Shallow breathing
• Productive Cough
• Altered mental status
• Nasal flaring
• Tracheal tugging or indrawing
• Chest trauma
• Pursed lips

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Listen for breath sounds at four points.
MidaxillaryLine
MidclavicularLine
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Abnormal Sounds

• Airway Sounds
• Stridor
• Gurgling
• Snoring

• Breath Sounds
• Wheezes
• Ronchi
• Crackles or Rales

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Wheezing

• High pitched musical whistling sound.
• Bronchioles are constricted from smooth muscle
  contraction.
• Heard usually first during exhalation may
  present during inhalation as well.
• Heard commonly with CHF, COPD, pneumonia, and
  toxic inhalations.

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Ronchi

• Loud snoring or rattling noises heard upon
  auscultation.
• Caused by thick secretions or mucus in the larger
  airways.
• The quality of the sound often changes with
  positioning or coughing.
• Often heard in chronic bronchitis, severe
  pneumonia, and other chronic pulmonary diseases.

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Crackles or Rales

• Inhalatory sound that resembles a bubbly or
  crackling noise.
• Fluid accumulation in the lungs causes the
  alveoli and some small bronchioles to collapse.
• Sounds are caused by the terminal bronchioles and
  alveolar sacs snapping or popping open with
  each inhalation.
• Often heard over the bases of the lungs first,
• These sounds are associated with pulmonary edema
  and pneumonia.

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Agonal respirations
Gasping respirations that are sudden, short
inspirations with long pauses in between.
Often occurs just before death - a grave sign!
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Causes of Dyspnea

• Upper or lower airway infection
• Common Cold
• Excess fluid and drainage from sinus cavities
• May cause some minor upper airway obstruction
• Signs/symptoms
• Nasal congestion
• Mild dyspnea

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Causes of Dyspnea

• Pneumonia
• Bacterial, viral, or fungal
• Fluid buildup in lower airway passages, alveoli
• Signs/symptoms
• Fever
• Productive cough
• Dyspnea

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Causes of Dyspnea

• Epiglottitis
• Not always a childhood infection
• Killed George Washington
• Bacterial infection of epiglottis, causing it to
  swell
• Signs/Symptoms
• High fever (rapid onset)
• Drooling
• Quiet child
• Dyspnea
• Stridor

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Causes of Dyspnea

• Croup
• Children 6 months to 3 years
• Swelling of lining of larynx
• Signs/Symptoms
• Stridor
• Seal bark cough
• Humid air helps

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Causes of Dyspnea

• Acute pulmonary edema
• Fluid build-up in the lungs

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Pulmonary Edema
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Causes of Dyspnea

• Chronic obstructive pulmonary disease (COPD)
• Result of direct lung and airway damage from
  repeated infections or inhalation of toxic agents
• Bronchitis and emphysema are two common types of
  COPD.

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COPD Emphysema
An abnormal condition of the lungs characterized
by overinflation and destructive changes of the
alveoli, resulting in decreased lung elasticity
and impaired gas exchange.
These patients are sometimes referred to as pink
puffers.
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COPD Emphysema
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COPD Chronic bronchitis
A chronic condition characterized by excessive
mucous secretions and inflammatory changes in the
bronchial tree.
These patients are sometimes referred to as blue
bloaters.
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Causes of Dyspnea

• Spontaneous pneumothorax
• Accumulation of air in the pleural space
• Asthma or allergic reactions
• Either can result in acute spasms of the
  bronchioles.
• Pleural effusion
• Collection of fluid outside lung

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Spontaneous Pneumothorax
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Causes of Dyspnea

• Mechanical obstruction of the airway
• Obstruction may result from the tongue,
  aspiration, vomitus, or foreign body.
• Pulmonary embolism
• Blood clot in pulmonary circulation

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Causes of Dyspnea

• Hyperventilation syndrome
• Overbreathing resulting in a decrease in the
  level of carbon dioxide
• Results in anxiety, dizziness, tingling of the
  hands and feet, and even a sense of dyspnea
  despite rapid breathing

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Assessment and Treatment of Respiratory
Emergencies
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Scene Size-up

• Look for clues that indicate chronic breathing
  problems
• O2 tanks
• Concentrators
• Medication nebulizers

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Initial Assessment

• General Impression- Note the following
• Patients position
• Agitated or confused expression
• 2-3 word dyspnea
• Altered mental status
• Accessory muscle use
• Cyanosis
• Diaphoresis
• Pallor
• Nasal flaring
• Pursed lips

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Initial Assessment

• Mental Status/LOC
• Confusion and agitation are common with
  increasing hypoxia.
• Lethargy and a stuporous presentation are common
  with hypercapnea.
• In either instance, alterations in mental status
  in light of dyspnea indicates a patient is in
  severe distress.

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Initial Assessment

• Airway
• Carefully assess for the following
• snoring, stridor, gurgling, or crowing.
• foreign body in the airway.
• Provide manual and mechanical airway maneuvers if
  patient cannot maintain own airway.
• Suction as needed.

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Initial Assessment

• Breathing adequacy or inadequacy
• This determination is probably the most important
  one you will make for this patient.
• Assess rate and quality
• An inadequate rate (too fast or too slow), OR an
  inadequate depth (minimal air exchange) means you
  must provide PPV immediately.

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Initial Assessment

• Breathing adequacy or inadequacy
• If breathing is found to be adequate, provide
  oxygen via NRB at 15 lpm immediately.
• If breathing is found to be inadequate, provide
  PPV with oxygen immediately.

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Initial Assessment

• Circulation
• Inspect the skin and mucous membranes for pallor
  or cyanosis.
• In people with dark skin, inspect the oral cavity
  and conjunctiva for pallor or cyanosis.
• Tachycardia with cool and moist skin are also
  signs of respiratory distress and hypoxia.

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Initial Assessment

• Priority decision making
• If the patient is found to be a priority,
  consider ALS backup and expedite transport.
• Priority patients include
• Altered mental status
• Evidence of inadequate breathing
• Significant cyanosis
• Extremely rapid respiratory rate (tachypnea)
• abnormally slow respiratory rate (bradypnea)

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Focused History and Physical Exam

• History
• Signs/Symptoms
• OPQRST
• Allergies
• Medications
• Pertinent history
• Last oral intake
• Events leading to call

• Physical Exam
• Face
• Neck
• Chest
• Lung Sounds
• Abdomen
• Feet/Ankles
• Vitals

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Scenario

• Scene Size-up
• Dispatch
• You are called to the scene of a 69-year-old male
  complaining of difficulty breathing.
•  While En Route what will you consider?
• Whos going to run the call
• Do you know the area? Is it safe? Police backup
  needed?
• What equipment are you going to carry in?
• Upon arrival
• Scene is safe, residential neighborhood, nice
  house, older woman at the doorway signaling you
  to come in. As you enter the house you note the
  smell of cigarette smoke heavy in the air. You
  see portable oxygen tanks in one corner. There
  are several prescription inhalers on the kitchen
  table.
• You have one patient.
•  (If BLS) Consider ALS backup?

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Initial Assessment

• General Impression
• As you approach the patient, you observe that he
  is sitting in a tripod position and appears to be
  in obvious respiratory distress. He has a nasal
  cannula in place, hooked up to a portable oxygen
  tank. He is pale and breathing with effort. You
  note audible wheezes. Patient is obese.
• LOC
• You identify yourself and ask the patient what is
  going on. He makes eye contact and is able to
  tell you, two to three words between breaths,
  that he cant breathe.

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Initial Assessment (continued)

•  Airway
• Open patient is able to speak and has no upper
  airway obstruction
• Breathing
• Rapid, shallow breathing with audible wheezes and
  a productive, mucousy sounding cough. Shoulders
  heave with each breath.
• Circulation
• You assess carotid and radial pulses and find
  them both rapid and regular. Skin is pale, cool
  and diaphoretic, and lips and nail beds are
  tinged blue.
• Interventions?
• Transport Decision?

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Focused History and Physical Exam

• Signs and Symptoms
• Onset
• Trouble breathing yesterday and last night. Has
  had two breathing treatments and repeated use of
  inhalers without relief. Condition worsened over
  last two hours.
• Provocation
• Nothing he has done has made it easier to
  breathe. When hes lying down its much harder
  to breathe.
• Quality
• Feels like he cant get air in or out. Has pain
  between his shoulders and in posterior ribs
  describes it as sharp pain when he inhales.
• Radiation
• N/A
• Severity
• When it got this bad once six months ago, he
  ended up in the hospital on a vent for 10 days.

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Focused (continued)

• Allergies
• Allergic to PCN, sulfa-based drugs, iodine dye.
• Medications
• Albuterol nebulizer
• Provent inhalers
• Pertinent Hx
• See above. Has chronic bronchitis. Had a fever
  and chills for last several days.
•  Last Oral Intake
• Has not eaten today. Had some chicken soup last
  night at 8 p.m.
•  Events Leading up to call
• See above.

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Physical Exam

• Head
• Cyanosis noted around lips.
• Neck
• No JVD. Trachea midline.
• Chest
• Use of accessory muscles noted. Lung sounds
  Wheezes in both bases. Rhonchi noted in upper
  lungs. Equal chest rise and fall.
• Abdomen
• soft, nontender.
• Pelvis
• skipped.
• Lower extremities
• Pedal edema noted. Patient states this is
  normal.
•  Upper extremities
• normal

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Vital Signs and Treatment

• Vital Signs
• Pulse 110 and regular rate and quality.
• Respirations 28, shallow and labored.
• BP 130/90
• Skin as above.
• Treatment
• BLS
• You continue to provide high-flow oxygen by
  nonrebreather as you load the patient onto your
  cot and place him in a position of comfort. You
  are prepared to ventilate the patient as needed.
  You contact medical control and they give orders
  to assist with additional MDI. You intercept
  with ALS 10 minutes from the hospital.

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Vital Signs and Treatment (continued)

• ILS/ALS
• Initiate albuterol nebulizer, 2.5 mg in 3 ml NS.
• Consider continuous nebulizers.
• Consider terbutaline 0.5 mg SQ consider bagging
  in the nebulizers.
• Establish IV access.
• Monitor shows patient in sinus tach.
• Consider ET intubation if pt shows signs of
  respiratory failure.

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Review Questions (continued)

• Which of the following is a sign of inadequate
  breathing in an adult patient?
• Respiratory rate of 16 breaths per minute.
• Snoring sounds.
• Movement of diaphragm.
• Bilateral chest expansion.
• What is the normal respiratory rate for adults?
• 8-16
• 12-20
• 20-24
• None of the above

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Review Questions (continued)

• Scenario Your patient is a five-year-old female.
  The patient's mother states that her daughter has
  developed a sore throat and rapid-onset fever.
  The mother tells you she became concerned and
  called 9-1-1 because the child was "making funny
  noises" and couldn't breathe. Your physical exam
  reveals a well-developed child sitting upright
  and with high-pitched tracheal noises when she
  tries to breathe.
• Based on the signs and symptoms, what condition
  do you suspect?
• Emphysema
• Pleural effusion
• Epiglottitis
• Croup
• Other signs you would expect to see with this
  patient include
• Drooling
• Seal bark cough
• Wheezing
• High blood pressure

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Review Questions (continued)

• Upon entering the house of a patient complaining
  of dyspnea, you notice that he is an obese male
  with cyanotic skin. You observe an oxygen
  concentrator in the living room and ashtrays
  throughout the house. While examining the
  patient, you find he has a productive cough.
  Which disease is MOST consistent with this
  information?
• Asthma
• Pulmonary embolism
• Emphysema
• Chronic Bronchitis
• After years of heavy smoking, your patient has
  developed a lung disorder. The patient's alveoli
  are distended and have lost their elasticity. As
  a result, the patient is hypoxic and short of
  breath. This disease process is MOST consistent
  with
• Emphysema
• Chronic bronchitis
• Pulmonary edema
• Congestive heart failure

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Review Questions (continued)

• True or False Wheezing is heard only on
  exhalation.
• _________ indicates an obstructed upper airway.
• Stridor
• Snoring
• Wheezing
• All of the above
• True or False Asthma is bronchospasm caused by
  an oversensitivity similar to an allergic
  reaction.
• True or False An appropriate way to stop
  Hyperventilation Syndrome is to have the patient
  breathe into a paper bag.