Waiting to Exhale

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Waiting to Exhale

• Respiratory Disorders

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A quick review

• Upper airway
• To larynx
• Warms, humidifies, cleans
• Cilia
• Turbinates
• Cribiform plate

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Review, continued

• Lower airway
• Below larynx
• Trachea
• Bronchi
• 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
• Transmitted through phrenic and intercostal
  nerves
• Can be modified by
• Cerebral cortex
• Hypothalamus
• Brainstem (pons)

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What controls our breathing, cont.

• Stretch receptors
• Visceral pleura
• Bronchi and bronchiole walls

• Herring-Breuer reflex

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More stuff

• PCO2 increase increased PCO2 in CSF decreased
  pH
• 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
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Entering the bathroom the EMTs find
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The Patient Is
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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
• Severe cyanosis
• Absent breath sounds
• Audible stridor

• 1-2 word dyspnea
• Tachycardia gt 130/min.
• Pallor and diaphoresis
• Retractions/accessory muscle use

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COPD

• Emphysema
• Chronic Bronchitis
• Asthma

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Case Presentation Two

•  

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You note the following
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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 - pt. exhales with pursed lips
• Almost always associated with cigarette smoking
  or environmental toxins

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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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Pathophys. (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 dyspnea
• Absent 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
• Intubation prn
• Assisted ventilation prn
• High flow oxygen
• 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 nl.
• ? 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
• Oxygen - low flow if possible
• Albuterol inhaler
• Constantly monitor
• Position - seated
• IV TKO

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Case Presentation Three
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You find the following
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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 - intrinsic in children,
  extrinsic 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 contraction,
  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 dyspnea
• 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 - resp. x 30 sec.
• High flow oxygen
• IV with fluids
• ECG
• 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
  tx.
• 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
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Your exam reveals the following 
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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 tx.
• 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
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On physical exam
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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
• 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
• Myalgias
• Fatugue
• Tx
• 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 w/in 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, mailaise

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Tx for Lung CA

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

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Toxic inhalation

• Consider if pt dyspneac
• 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 (very late)

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CO, continued

• Management
• SAFETY
• Maintain airway
• High flow oxygen (NRB vs assist
• 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 enemia
• 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 sx increase, consider needle decompression
• Position of comfort