Respiratory Emergencies

December 2003
• All respiratory problems can be categorized
as impacting ventilation, diffusion or
perfusion
• Management can be initiated once this can
be established
 Ventilation
• Upper airway obstruction • Foreign body, epiglottitis

• Lower airway obstruction • Asthma, airway edema

• Chest wall impairment • Trauma, muscular

dystrophy
• Neurogenic dysfunction
• CNS depressant drugs,
stroke
 Diffusion
• Inadequate O2 • Fire, CO poisoning

• Alveolar pathology • Lung disease, inhalation

injury

• Interstitial space • Pulmonary edema,

pathology drowning

• Capillary bed pathology • Severe artherosclerosis

 Perfusion
• Inadequate blood • Shock, anemia
volume/ Hgb

• Impaired circulation • Pulmonary embolus

• Capillary wall • Trauma

pathology
 Ventilation
• Process of air movement in and out of the
lungs
 Interventions
• Ensure that the upper and lower airways are
open and unobstructed
• Provide assisted ventilations
 Ventilation Requirements
• Neurological control to initiate ventilation
• Nerves between the brain stem and the
muscles of respiration
• Functional diaphragm and intercostal
muscles
• Alveoli that are functional and noncollapsed
 Diffusion
• Process of gas exchange between the air-
filled alveoli and the pulmonary capillary
bed
• Gas exchange is driven by simple diffusion
in which gases move from areas of high
concentration of low concentration until
equal
 Interventions
• Provide high flow O2
• Reduce inflammation of interstitial space
 Diffusion Requirements
• Alveolar and capillary walls that are not
thickened
• Interstitial space between the alveoli and
capillary wall that is not enlarged or filled
with fluid
 Perfusion
• Refers to the process of circulating blood
through the pulmonary capillary bed
 Interventions
• Ensure adequate circulating volume and
Hgb levels
• Optimize left sided heart function
 Perfusion Requirements
• Adequate blood volume
• Adequate Hgb in the blood
• Pulmonary capillaries that are not occluded
• Properly function left heart that provides
smooth flow of blood through pulmonary
capillary bed
 Assessment Review
• Scene size up
• Wide variety of toxic environments
resulting in deficient O2
• Initial Assessment
• Recognition of life threats
• Focused history
• Physical exam
 Signs of Life Threats
• Altered LOC
• Severe cyanosis
• Absent BS
• Audible stridor
• One or two word dyspnea
• Tachycardia
• Pallor and diaphoresis
• Retractions/ accessory muscle use
 Focused History
• Dyspnea
• Chest pain
• Productive/ nonproductive cough
• Hemoptysis
• Wheezes
• Infection- fever, sputum
• Previous experience
• Patient’s description of severity
• Medications
 Physical Exam
• Position, respiratory effort, skin color, ability to
speak
• Tachycardia- hypoxemia/ sympathomimetic
medications
• Bradycardia- severe hypoxemia & imminent arrest
• Hypertension- sympathomimetics
• Respiratory rate may not be accurate indicator;
extremely slow- exhaustion
• Pursed lips- helps maintain pressure within airways even
during exhalation to support bronchial walls internally that
have lost their external support as a result of disease
• Accessory muscle use- quickly result in respiratory fatigue
• JVD- right heart failure in severe pulmonary congestion
• Barrel chest- long standing COPD
• Clubbing- enlargement of distal phalanges; long standing
chronic hypoxemia
• Peripheral cyanosis- excess deoxygenated Hgb
• Carpopedal spasm- hypocapnia
 Sputum
• Infection/pneumonia- thick, green, brown
• Allergies/inflammatory- yellow, pale grey
• Pulmonary edema- pink, frothy
 Chronic Obstructive Airway
Disease
• Chronic bronchitis
• Emphysema
• Asthma
 Chronic Bronchitis
• Inflammatory changes and excessive mucus production
in bronchial tree
• Hyperplasia and hypertrophy of mucus producing
glands that result from prolonged exposure to irritants
• Hypoventilation, hypercapnia, hypoxemia, increases
pCO2
• Frequent infections, scarring, irreversible changes
bronchiectasis- bronchi dilation
• “Blue bloaters”- appear cyanotic,decreased
pO2 due to altered ventilation-perfusion
• Polycythemia common secondary to
chronic hypoxemia
• Increased airway resistance during
inspiration and expiration
 Signs and Symptoms
• Typically overweight
• Productive cough with sputum
• Coarse rhonci
• Mild chronic dyspnea
• Resistance on inspiration and expiration
 Emphysema
• Permanent abnormal enlargement of air
spaces beyond terminal bronchioles,
destruction of alveoli, failure of supporting
structures to maintain alveolar integrity
• Reduces alveolar functional surface area,
elasticity resulting in air trapping
• Residual volume increases while vital
capacity remains the same
• Reduced pO2 leads to increased RBC production
and polycythemia- elevated Hct
• “Pink puffer”- increased airway resistance only on
expiration, calorie consumption
• Decrease in alveolar membrane surface area &
number of pulmonary capillaries
• Decrease in area for gas exchange and increased
resistance to pulmonary blood flow
• Air trapping due to loss of elastic recoil
 Signs and Symptoms
• Thin, barrel chested
• Nonproductive cough
• Wheezing, rhonchi
• Pink complexion
• Extreme DOE
• Prolonged expiration
• Pursed lips
 Management
• High flow O2, IV,CM
• Beta agonists- relieve bronchospasms and reduce
constricted airways
• metaproterenol- Alupent
• albuterol- Albuterol
• Corticosteroids- Solumedrol
• Xanthine-bronchodilation and stimulation of respiratory
drive
• Aminophylline
• MgSO4- smooth muscle relaxer
 Asthma
• Reversible airflow obstruction caused by smooth
muscle contraction
• Hypersecretion of mucus resulting in mucus plugging
• Inflammatory changes in bronchial walls
• Increased resistance air flow, alveolar hypoventilation
• Ventilation-perfusion mismatch resulting in hypoxemia
and CO2 retention stimulating hyperventilation

•
• Inspiratory obstruction and marked expiratory obstruction
results in auto-PEEP due to air trapping
• Increased airway resistance, increased respiratory drive,
air trapping results in excessive demand on respiratory
muscles
• Excessive positive thoracic pressure may decrease left
ventricular preload resulting in a transient reduction in CO
and SBP, pulsus paradoxus
• Hypoxemia, hemodynamic alterations, death
 Signs and Symptoms of Severe
Asthma
• Obtundation
• Diaphoresis and pallor
• Retractions
• One, two word sentences
• Poor muscle tone
• HR > 130, RR >30
 Management
• High flow O2, IV-rehydration, CM
• Nebulized Beta agonists
• Albuterol 2.5-5.0mg
• Alupent
• Corticosteroids- solumedrol
• Aminophylline
• MgSO4
• Epinephrine- SQ 0.3-0.5mg
• Ketamine
 Intubation
• Support patient’s failing ventilation efforts-
does not solve problem
• Irritation due to intubation may increase
bronchospasm
• Increased air trapping
• Poor compliance