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Respiratory Emergencies

Eileen Humphreys PA-C, EMT-I

Respiratory Cycle
Inspiration Active process that uses contractions of several muscles to increase the size of the chest cavity Diaphragm lowers and ribs move up and out The expanding size of the chest cavity pulls air in

Respiratory Cycle
Expiration Passive process that uses relaxation of muscles to decrease chest cavity size and allow air to move out Diaphragm moves up and ribs move down and in

Respiratory Cycle
Oxygen and carbon dioxide are exchanged in the alveoli and capillaries of the lungs as well as the capillaries of the body Critical to support life

Respiratory Emergencies
May be a result of head/neck/chest injuries Emotional distress Obstruction to the upper or lower respiratory tract Fluid or collapse of the alveoli Cardiac compromise Allergic reaction

Respiratory Emergencies
Dyspnea
shortness of breath difficulty breathing

Respiratory Emergencies
Apnea
respiratory arrest

Respiratory Emergencies
Hypoxia inadequate supply of oxygen

Bronchoconstriction
Bronchioles of the lower airway are significantly narrowed Also called bronchospasm
Usually results in wheezing

Bronchoconstriction
Can be opened up by use of a bronchodilator such as Albuterol Relaxes the bronchioles Called a Beta 2 agonist

Respiratory Emergencies
Scene size-up may give important clues Look for oxygen tanks,tubing, masks

Initial Assessment
General impression usually in a tripod position patient lying in a supine or reclining position may be in mild distress or in such distress that they have become too exhausted to stay upright

Initial Assessment
Frightened or confused facial expression may indicate severe distress Speech-usually limited or absent
If speech is normal-airway is open and clear with minimal distress

Initial Assessment
Restlessness, agitation, combativeness, confusion, and unresponsiveness can be caused by inadequate oxygenation to the brain

Initial Assessment
Listen for crowing, snoring, stridor, or gurgling Indicates partial airway obstruction
Look for adequate rise and fall of chest, exchange of oxygen, volume exchanged

Initial Assessment
Skin Cyanosis to the neck or chest indicates severe respiratory distress

Respiratory Emergencies
All patients in respiratory distress are priority transport Decline very rapidly

SAMPLE history for responsive patients Use OPQRST to gather information of symptoms

Rapid trauma assessment for unresponsive patients

Physical Exam
Assess the skin for discoloration Assess the neck for tracheal deviation, retractions, JVD (jugular venous distention) Assess the chest for retractions of the intercostal spaces, asymmetrical chest rise, subcutaneous emphysema Auscultate the lungs for equal breath sounds

Wheezing- musical sound caused by bronchospasm or fluid in the lungs Rhonchi-snoring or rattling sounds Crackles-bubbling or crackling noises heard on inhalation. Associated with fluid and heard first at bases

Assessing Adequate Breathing


Patient does not appear to be in distress Can speak in full sentences without stopping to catch their breath Color will be normal Mental status and orientation (person, place, time) will be normal

Assessing Adequate Breathing


Rate: Adult- 12 to 20 per minute-12 Child- 15 to 30 per minute-20 Infant-25 to 50 per minute-20 Rhythm: Regular and even Inspiration and expiration usually last about the same length of time

Assessing Adequate Breathing


Quality: Breath sounds will be present and equal bilaterally Both sides of chest should rise and fall equally and adequately Unlabored-should not require effort

Treatment of Adequate Breathing


If patient is breathing at a slightly abnormal rate but it is adequate: 15 lpm via NRB Monitor closely Be on the lookout for beginnings of inadequate breathing or respiratory arrest Intervene quickly if condition worsens

Assessing Inadequate Breathing


Not adequate to support life and will progress to death unless there is intervention Rate-can be too fast or slow Agonal respirations-dying respirations which are sporadic, irregular breaths seen just before resp. arrest. Shallow, gasping Rhythm-may be regular or irregular

Assessing Inadequate Breathing


Quality: Breath sounds may be diminished or absent Depth (tidal volume) will be shallow, inadequate Chest expansion-may be unequal or inadequate Respiratory effort may be increased

Assessing Inadequate Breathing


Quality: Accessory muscle use seen Skin may be pale or cyanotic Skin may be cool and clammy Snoring or gurgling in unresponsive patients or patients with diminished responsiveness

Treatment of Inadequate Breathing


Inadequate breathing with abnormal rate Begin artificial ventilations with either the pocket mask or BVM Ventilate 12 times per minute for adults Ventilate 20 times per minute for children/infants

Treatment of Inadequate Breathing


You may have to treat a patient with inadequate breathing who is awake enough to fight artificial ventilations In this case contact medical direction and transport immediately

Patient Care for Inadequate Breathing


If properly performed, pulse rate will return to normal (in adults pulse usually increases in resp. distress) If pulse stays high re-evaluate the technique Color will return to normal if ventilations are adequate

Patient Care
If pulse does not return to normal reevaluate airway, ventilations, O2 canister (empty), tubing (kinked) If chest does not rise or pulse does not return to normal, increase ventilation force after assuring proper technique

Respiratory arrest
Confirm unresponsiveness Open airway by jaw thrust or chin-lift Look, listen, feel for 3-5 seconds If not breathing Give 1 full breath lasting 2 seconds and allow patient to exhale

Respiratory arrest
If the air goes in, give breaths every 5 seconds with each breath lasting 2 seconds and allow to passively exhale between breaths If no air goes in, reposition head Check pulse frequently to monitor cardiac status

COPD
Chronic obstructed pulmonary disease Chronic Bronchitis Emphysema

Chronic Bronchitis
Usually has a productive cough for 3 months out of the year for 2 years Edema, inflammation and excessive mucus production of the bronchioles/bronchi Restricted air movement Gas exchange is compromised Retained CO2

Chronic Bronchitis
Overweight Productive cough Rhonchi

Emphysema
Loss of elasticity of the alveolar walls Distention of the sacs causing air trapping Air movement is restricted and patient retains carbon dioxide

Emphysema
Thin, barrel chest Non-productive cough Prolonged exhalation Pursed lip breathing Wheezing and rhonchi

Treatment of COPD
Ensure open airway, adequate breathing, supplemental oxygen, position of comfort

Hypoxic Drive
COPD patients Low levels of oxygen in the body stimulate breathing In theory too much oxygen can cause the body to reduce or stop breathing Usually occurs with high concentrations of O2 over 24 hours

Hypoxic Drive
Not normally a problem in prehospital environments
Always give high flow oxygen to those who need it

Asthma
Reversible narrowing of the lower airways Edema, bronchospasm, and increased mucus production Mucus production block smaller airways and causes air to be trapped in the alveoli

Asthma
Exhalation becomes difficult and patients must force air out past constricted airways This causes wheezing on exhalation Exhalation becomes an active process

Asthma
Lack of wheezing or lung sounds in a patient suffering from an asthma attack is ominous

Status asthmaticus-prolonged attack which does not respond to oxygen or medication

Pneumonia
Viral or bacterial disease infecting the lower respiratory tract Causes lung inflammation Poor gas exchange

Pneumonia

Signs/symptoms fever/chills cough dyspnea chest pain-localized, sharp, worse with breathing rhonchi/crackles

Pulmonary Embolus
Sudden blockage of blood flow through a pulmonary artery or branches Due to blood clot, air bubble, foreign body, fat particle Decrease in gas exchange Hypoxia

Pulmonary Embolus

Risk factors recent surgery prolonged immobilization multiple fractures thrombophlebitis chronic atrial fibrillation medications (OCPs)

Pulmonary Embolus
Suspect if sudden onset of unexplained dyspnea, hypoxia, tachypnea, and stabbing chest pain Will have normal breath sounds and adequate volume

Acute Pulmonary Edema


Excessive amount of fluid between alveoli and capillary space Disturbs gas exchange Causes hypoxia Cardiogenic and non-cardiogenic

Acute Pulmonary Edema


Signs/symptoms dyspnea worse with exertion orthopnea blood tinged sputum tachycardia pale, moist skin swollen lower extremities

Respiratory-Pediatric Patients
Remember the most common cause of cardiac problems in pediatrics is---???
Respiratory intervention must begin quickly and be monitored at all times Know the difference in structures from adults

Inadequate Pediatric Breathing


Early signs accessory muscle use retractions tachypnea tachycardia

Inadequate Pediatric Breathing


nasal flaring coughing cyanosis to the extremities grunting (Bad Bad Sign)-seen in infants during exhalation signaling imminent failure

Pediatric Respiratory Failure


Altered mental status Pulse rises early then drops fast Bradycardia Hypotension Irregular breathing pattern

Pediatric Respiratory Failure


Seesaw pattern-abdomen and chest move in different directions Limp appearance Head bobbing with each breath

Pediatric Problems
Distinguish whether the airway problem is upper or lower

Pediatric Problems
Stridor and crowing indicate upper airway obstruction Usually due to edema or foreign body obstruction Wheezing is sign of lower airway problem

Epiglottis
Inflammation of the epiglottis History of sore throat, fever, stridor Child sits upright leaning forward, sits the neck out, drooling Life-threatening emergency Do not inspect the airway as bronchospasm may completely obstruct the airway

Croup
Swelling of the larynx, trachea, and bronchi Sore throat and fever worse at night Seal-like cough Cool night air usually helps

Patient Care-Pediatrics
Monitor airway and breathing constantly Nothing is more important than adequate airway care Ensure adequate breathing Intervene quickly and appropriately when necessary If in doubt-Treat as inadequate breathing

Patient Care-Pediatrics
If pulse remains low or breathing inadequate re-evaluate airway, ventilations, O2 canister (empty), tubing (kinked) If chest does not rise or pulse does not return to normal, increase ventilation force after ensuring proper technique

Treatment
Oxygen is a drug It must be administered correctly and monitored

MDIs
Metered dose inhalers Delivers a precise dose of medication each time canister is depressed

MDIs

Bronchodilators Albuterol- Proventil, Ventolin Atrovent Serevent Steroids Vanceril Aerobid Azmacort

MDIs
Before using patient must have signs & symptoms of breathing difficulty has a physician prescribed MDI approval from medical control

Contraindications
Not responsive enough to follow directions Medication out of date Not prescribed for the patient Permission not granted by medical control Patient has already taken the maximum allowed dose prior to arrival

Administration
Check name of medicine, date, and name prescribed to Obtain medical control order Shake canister for 30 seconds

Administration
Have patient
exhale fully wrap lips around opening inhale slowly as you depress canister (5 seconds) hold breathe for 10 seconds exhale slowly

MDIs
Side effects include: tachycardia arrhythmia anxiety nervousness