Respiratory Emergencies:

CHF, Pulmonary Edema,

COPD, Asthma
CPAP & Albuterol Nebulizer

Condell Medical Center EMS System

ECRN CE

Prepared by: Sharon Hopkins, RN, BSN, EMT-P

 Objectives
Upon successful completion of this program, the
ECRN should be able to:
• review the signs and symptoms and field
interventions for the patient presenting with CHF,
pulmonary edema, COPD, and asthma.
• review criteria for the use of CPAP.
• review the SOP for Acute Pulmonary Edema,
Asthma/COPD with Wheezing, and Conscious
Sedation
 Objectives cont’d
• review the Whisperflow patient circuit for
CPAP used in the field.
• review the set up of the albuterol nebulizer
kit and in-line Albuterol set-up.
• successfully complete the quiz with a score
of 80% or better.
 Heart Failure
• A clinical syndrome where the heart’s
mechanical performance is compromised and
the cardiac output cannot meet the demands
of the body
• Considered a cardiac problem with great
implications to the respiratory system
• Heart failure is generally divided into right
heart failure and left heart failure
 Heart Failure
• Etiologies are varied
– valve problems, coronary disease, heart disease
– dysrhythmias can aggravate heart failure
• Variety of contributing factors to
developing heart disease
– excess fluid or salt intake, fever (sepsis),
history of hypertension, pulmonary embolism,
excessive alcohol or drug usage
 Left Side of the Heart
• High pressure system
• Blood needs to be pumped to the entire
body
• Left ventricular muscle needs to be
significant in size to act as a strong pump
• Left sided failure results in backup of blood
into the lungs
 Right Side of the Heart
• Low pressure system
• Blood needs to be pumped to the lungs right
next to the heart
• Right ventricle is smaller than the left and
does not need to be as developed
• Right sided failure results in back pressure of
blood in the systemic venous system (the
periphery)
 Left Ventricular Heart Failure
• Causes
failure of effective forward pump
• back pressure of blood into pulmonary circulation
heart disease
• MI
• valvular disease
• chronic hypertension
• dysrhythmias
 Left Ventricular Failure
• Pressure in left atrium rises
increasing pressure is transmitted to the
pulmonary veins and capillaries
increasing pressure in the capillaries forces blood
plasma into alveoli causing pulmonary edema
increasing fluid in the alveoli decreases the
lungs’ oxygenation capacity and increases patient
hypoxia
 As MI is a common cause of left ventricular failure:

 Until proven otherwise, assume

all patients exhibiting signs and
symptoms of pulmonary edema
are also experiencing an acute MI
 Right Ventricular Heart Failure
• Causes
failure of the right ventricle to work as an
effective forward pump
• back pressure of blood into the systemic
venous circulation causes venous congestion
most common cause is left ventricular failure
systemic hypertension
pulmonary embolism
 Congestive Heart Failure
• A condition where the heart’s reduced stroke
volume causes an overload of fluid in the
body’s other tissues
• Can present as edema
pulmonary
peripheral
sacral
ascites (peritoneal edema)
 Compensatory Measures -
Starling’s Law
• The more the myocardium is stretched, the greater the
force of contraction and the greater the cardiac output
• The greater the preload (amount of blood returning to
the heart), the farther the myocardial muscle stretches,
the more forceful the cardiac contraction
• After time or with too much resistance the heart has
to pump against, the compensation methods fail to
work
 Acute Congestive Heart Failure
Often presents as:
Pulmonary edema
Pulmonary hypertension
Myocardial infarction
Chronic Congestive Heart Failure
Often presents as:
Cardiomegaly - enlargement of the heart
Left ventricular failure
Right ventricular failure
 Patient Assessment Field & ED
• Initial assessment
– airway
– breathing
– circulation
– disability
• AVPU (alert, responds to verbal, responds to pain,
unresponsive)
• GCS
– expose to finish examining
• Priority patients identified
• Additional assessment
– vital signs, pain scale
– determine weight
– room air pulse ox, if possible, and oxygen PRN
– cardiac monitor; 12 lead ECG if applicable
– 0.9 NS IV established TKO
– determine blood glucose if indicated
• unconscious, altered level of consciousness, known diabetic with diabetic
related call
– reassess initial assessment findings and interventions started
 Closest Appropriate Hospital
• Hospital of patient’s choice within the Fire Department’s transport
area
• The patient who is alert and oriented has the right to request their
hospital of choice
• EMS can have the patient sign the release for transport to a farther
hospital
• If EMS does not feel comfortable transporting farther away, EMS
can communicate this to the patient to get the point across in a
diplomatic manner (ie: “I’m very concerned about your condition
and I would feel more comfortable taking you to the closest
hospital”)
 Refusals
• A conscious and alert patient has the right to refuse care and/or
transportation
• A refusal, though, with a patient in CHF might prove devastating
– worsening of signs and symptoms
– increased and unnecessary myocardial damage
– severe pulmonary edema
– death
• Avoid refusals in these patients at all costs
• EMS to thoroughly document the efforts taken to encourage
transportation
 Signs and Symptoms CHF
• Progressive or acute shortness of breath
• Labored breathing especially during exertion (ie: standing up,
walking a few steps)
• Awakened from sleep with shortness of breath (paroxysmal
nocturnal dyspnea)
increasing episodes usually indicate the disease is worsening
• Positioning
tripod - resting arms on thighs, leaning forward
inability to recline in bed without multiple pillows
using more pillows to be comfortable in bed
• Changes in skin parameters
pale, diaphoretic, cyanotic
mottling present in severe CHF
• Increasing edema or weight gain over a short time
early edema in most dependent parts of the body first (ie: feet,
presacral area)
• Generalized weakness
• Mild chest pain or pressure
• Elevated blood pressure sometimes
to compensate for decreased cardiac output
• Typical home medication profile
– diuretic - to remove excess fluids
– hypertension medications - to treat a typical co-
morbid factor
– digoxin - to increase the contractile strength of the
heart
– oxygen
• Worst of the worst complications - pulmonary
edema
 Progression of Acute CHF
• Left ventricle fails as a forward pump
• Pulmonary venous pressure rises
• Fluid is forced from the pulmonary capillaries into
the interstitial spaces between the capillaries and the
alveoli
• Fluid will eventually enter & fill the alveoli
• Pulmonary gas exchange is decreased leading to
hypoxemia ( oxygen in blood) & hypercarbia (
carbon dioxide in blood)
 Progression of CHF cont’d
• Hypercarbia ( carbon dioxide retained in
the blood) can cause CNS depression
– slowing of the respiratory drive
– slowing of the respiratory rate
 Wheezes heard in any
geriatric patient should be
considered pulmonary
edema until proven
otherwise (especially in
the absence of any history
of COPD or asthma)
 Progression of Pulmonary Edema
• Untreated, leads to respiratory failure
• Oxygen exchange inhibited due to excess serum fluid in alveoli
hypoxia  death
• Presentation
tachypnea
abnormal breath sounds
• crackles (rales) at both bases
• rhonchi - fluid in larger airways of the lungs
• wheezing - lungs’ protective mechanisms
– bronchioles constrict to keep additional fluid from entering
the airway
 Acute Pulmonary Edema
Region X SOP
• Routine medical care
– patient assessment
– IV-O2-monitor
• cautiously monitor IV fluid flow rates
• Place patient in position of comfort
– often patient will choose to sit upright
– dangle the feet off the cart to promote venous pooling
• Determine if the patient is stable or unstable
– evaluate mental status, skin parameters, and blood pressure
 Stable Acute Pulmonary Edema
• Patient alert Region X SOP
• Skin warm & dry
• Systolic B/P > 100 mmHg
• Nitroglycerin 0.4 mg sl - maximum 3 doses
• Consider CPAP
• Lasix 40 mg IVP (80 mg if already taking)
• If systolic B/P remains >100 mm Hg give Morphine Sulfate 2
mg IVP slowly
• If wheezing, obtain order from Medical Control for Albuterol
nebulizer
 Pulmonary Edema Medications Used
in Region X SOP
• Nitroglycerin
– venodilator; reduces cardiac workload and dilates coronary
vessels
– do not use in the presence of hypotension or if Viagra or
Viagra-type drug has been taken in the past 24 hours (may
get resistant hypotension)
– can repeat the drug (0.4 mg sl) every 5 minutes up to 3 doses
total if blood pressure remains > 100 mmHg
– onset 1 - 3 minutes sl (mouth needs to be moist for the tablet
to dissolve & be absorbed)
• Lasix (Furosemide)
®

– diuretic; causes venous dilation which decreases

venous return to the heart
– avoid in sulfa allergies & in the presence of
hypotension
– dose 40 mg IVP
• 80 mg IVP if the patient is taking the drug at home
– vascular effect onset within 5 minutes; diuretic
effects within 15 - 20 minutes
• Morphine sulfate
– narcotic analgesic (opioid)
– causes CNS depression; causes euphoria
– increases venous capacity and decreases venous return to the
heart by dilating blood vessels
– used to decrease anxiety and to decrease venous return to the
heart in pulmonary edema
– give 2 mg slow IVP; titrate to response and vital signs and give
2 mg every 2 minutes to a maximum of 10 mg IVP
– effects could be increased in the presence of other depressant
drugs (ie: alcohol)
• Albuterol
– bronchodilator
– reverses bronchospasm associated with COPD
– dose is 2.5 mg in 3 ml solution administered in the
nebulizer
– the patient may be aware of tachycardia and tremors
following a dose
– Albuterol must be ordered by Medical Control for
the acute pulmonary edema patient
 Using CPAP With Medications
• Medications and CPAP are to be administered
simultaneously
• The use of CPAP buys time for the medications to
exert their effect
• CPAP and medications used (Nitroglycerin, Lasix,
and Morphine) can all cause a drop in blood pressure
– CPAP and medications must be discontinued if the
blood pressure falls < 100 mmHg
 Case Scenario #1
• A 68 year-old female calls 911 due to severe
respiratory distress which suddenly woke her up
from sleep. She is unable to speak in complete
sentences and is using accessory muscles to
breathe. Lips and nail beds are cyanotic; ankles are
swollen.
• B/P 186/100; P - 124; R - 34; SaO2 - 88%
• Crackles are auscultated in the lower half of the
lung fields.
 Case Scenario #1
• History: angina and hypertension; smokes 1
pack per day for the past 30 years
• Meds: Cardizem, nitroglycerin PRN; 1 baby
aspirin daily; furosemide, Atrovent inhaler
as needed
• Rhythm:
 Case Scenario #1
• What is your impression?
• What intervention(s) are appropriate
following Region X SOP’s?
• What is the rationale for these
interventions?
• What is this patient’s rhythm and do you
need to administer any medications for the
rhythm?
 Case Scenario #1
• Impression: congestive heart failure with pulmonary
edema
– paroxysmal nocturnal dyspnea (sudden shortness of breath at
night)
– bilateral crackles in the lungs
– peripheral edema
– cardiac history - hypertension and angina
• Rhythm - sinus tachycardia
– do not treat this rhythm with medication
– determine and treat the underlying cause
 Case Scenario #1
• Interventions
– Sit the patient upright, have their feet dangle off the sides of
the cart
• promotes venous pooling of blood and decreases the
volume of return to the heart
– Oxygen via non-rebreather face mask
– Prepare to assist breathing via BVM
• have BVM reached out and ready for use
– IV-O2-monitor
– Meds: NTG, Lasix, Morphine, consider CPAP
Unstable Acute Pulmonary Edema
• Altered mental status
Region x SOP
• Systolic B/P < 100 mmHg
• EMS to contact Medical Control
– medications given in the stable patient are now contraindicated due to a
lowered blood pressure
• CPAP on orders of Medical Control (MD order)
• Consider Cardiogenic Shock protocol
• Treat dysrhythmia as they are presented
• EMS to contact Medical Control for Albuterol if wheezing; possibly
in-line with intubation
 CPAP
Continuous
Positive
Airway
Pressure
A means of providing high flow, low pressure oxygenation to
the patient in pulmonary edema
 CPAP
• CPAP, if applied early enough, is an effective way to
treat pulmonary edema and a means to prevent the need
to intubate the patient
• CPAP increases the airway pressures allowing for better
gas diffusion & for reexpansion of collapsed alveoli
• CPAP allows the refilling of collapsed, airless alveoli
• CPAP allows/buys time for administered medications to
be able to work
CPAP expands the surface area of the
collapsed alveoli allowing more surface area
to be in contact with capillaries for gas
exchange

Before
CPAP
With CPAP
• CPAP is applied during the entire respiratory cycle
(inhalation & exhalation) via a tight fitting mask
applied over the nose and mouth
• The patient is assisted into an upright position
• The lowest possible pressure should be used
– the higher the pressure, the risk of barotrauma
(pneumothorax, pneumomediastinum) rises
– increased pressures in the chest decrease ventricular filling
worsening cardiac output (less coming into the heart, less
going out of the heart)
 Goal of Therapy With CPAP
• Increase the amount of inspired oxygen
• Decrease the work load of breathing

In turn to:
 Decrease the need for intubation
 Decrease the hospital stay
 Decrease the mortality rate
 Region X SOP Indications &
Criteria for CPAP Use
• Patient identified with signs & symptoms of
pulmonary edema or, in consultation with
Medical Control, exacerbation of COPD with
wheezing
• Patient must be alert & cooperative
• Systolic B/P >100 mmHg
• No presence of nausea or vomiting; absence of
facial or chest trauma
Patient Monitoring During CPAP Use
• Patient tolerance; mental status
• Respiratory pattern
– rate, depth, subjective feeling of improvement
– B/P, pulse rate & quality, SaO2, EKG pattern
• Indications the patient is improving (can be noted in as little
as 5 minutes after beginning)
reduced effort & work of breathing
increased ease in speaking
slowing of respiratory and pulse rates
increased SaO2
 Discontinuation of CPAP
• Hemodynamic instability
– B/P drops below 100 mmHg
• The positive pressures exerted during the use
of CPAP can negatively affect the return of
blood flow to the heart
• Inability of the patient to tolerate the tight
fitting mask
• Emergent need to intubate the patient
 CPAP Patient Circuits
• Complete package used in the field (and
similar to in-hospital use) includes
mask tubing
head strap
Whisperflow CPAP valve
corrugated tubing
air entrapment filter
Patient Circuit
 Case Scenario #2
• EMS has initiated CPAP and simultaneous
medication administration (NTG, Lasix and
Morphine) to a 76 year-old patient who EMS has
assessed to be in acute pulmonary edema
• The patient begins to lose consciousness and the
blood pressure has fallen to 86/60.
• What is the appropriate response for EMS to
take?
 Case Scenario #2
• This patient is showing signs of deterioration
• The CPAP needs to be discontinued
• No further medications (NTG, Lasix, Morphine) can
be administered due to the lowered B/P
• Prepare to intubate the patient following the
Conscious Sedation SOP
– support ventilations with BVM prior to intubation
attempt
 COPD
• Chronic obstructive pulmonary disease - a progressive
and debilitating collection of diseases with airflow
obstruction and abnormal ventilation with irreversible
components (emphysema & chronic bronchitis)
• Exacerbation of COPD is an increase in symptoms
with worsening of the patient’s condition due to
hypoxia that deprives tissue of oxygen and
hypercapnia (retention of CO2) that causes an acid-
base imbalance
 Obstructive Lung Disease -
COPD & Asthma
• Abnormal ventilation usually from obstruction in
the bronchioles
• Common changes noted in the airways
– bronchospasm - smooth muscle contraction
– increased mucous production lining the respiratory tree
– destruction of the cilia lining resulting in poor
clearance of excess mucus
– inflammation of bronchial passages resulting in
accumulation of fluid and inflammatory cells
 The Ventilation Process
• Normal inspiration - the working phase
– bronchioles naturally dilate
• Normal exhalation - the relaxation phase
– bronchioles constrict
• Exhalation with obstructive airway disease
– exhalation is a laborous process and not efficient or
effective
– air trapping occurs due to bronchospasm, increased
mucous production, and inflammation
 Emphysema
• Gradual destruction of the alveolar walls distal to the
terminal bronchioles
• Less area available for gas exchange
• Small bronchiole walls weaken, lungs cannot recoil as
efficiently, air is trapped
  in number of pulmonary capillaries which  resistance
to pulmonary blood flow which leads to pulmonary
hypertension
– may lead to right heart failure & cor pulmonale (disease of the
heart because of diseased lungs)
 Alveolar Sac and Capillaries

Bronchioles
capillary

alveolus

Interior
of
alveolus
 Emphysema
  in PaO2 leads to  in red blood cell production (to carry
more oxygen)
• Develop chronically elevated PaCO2 from retained carbon
dioxide
• Loss of elasticity/recoil; alveoli dilated
• More common in men; major contributing factor is cigarette
smoking; another contributing factor is environmental
exposures
• Patients more susceptible to acute respiratory infections and
cardiac dysrhythmias
 Assessment of Emphysema
• “Pink puffer” - due to excess red blood cells
• Recent weight loss; thin bodied
• Increased dyspnea on exertion
• Progressive limitation of physical activity
• Barrel chest (increased chest diameter)
• Prolonged expiratory phase (usually pursed lip breathing
noted on exhalation)
• Rapid resting respiratory rate
• Clubbing of fingers
• Diminished breath sounds
• Use of accessory muscles
• One-to-two word dyspnea
• Wheezes and rhonchi depending on amount of
obstruction to air flow
• May have signs & symptoms of right heart failure
jugular vein distention
peripheral edema
liver congestion
 Case Scenario #3
• The patient is a conscious, restless, and anxious 68 year-old male
with respiratory distress that has progressively worsened during the
past 2 days.
• The patient has cyanosis of the lips and nail beds
• B/P 138/70; P - 116 & irregular; R - 26; SaO2 82%
• Rhonchi and rales are auscultated in the lower right lung field;
patient feels warm to the touch
• The patient has had a cold for 1 week with a productive cough of
yellow-green sputum
• Hx: emphysema, angina, osteoarthritis
 Case Scenario
Case Scenario #3
What is this patient’s rhythm?
What influence would this rhythm have on this
patient’s health history & current condition?
Do you need to intervene?

Atrial fibrillation diminishes the efficiency of

the pumping of the heart which can further
compromise the cardiac output
 Case Scenario #3
• Impression & intervention?
• The patient has COPD most likely complicated by pneumonia
– a “cold” over the last week
– productive cough of yellow-green sputum
– warm to the touch (temperature 100.60F)
– rhonchi & rales in the right lung field base
• Routine medical care for EMS to follow
– supplemental oxygen
  heart rate most likely due to pneumonia and does not need specific
treatment
 Chronic Bronchitis
• An increase in the number of mucous-secreting
cells in the respiratory tree
• Large production of sputum with productive
cough
• Diffusion remains normal because alveoli not
severely affected
• Gas exchange decreased due to lowered alveolar
ventilation which creates hypoxia and hypercarbia
Assessment of Chronic Bronchitis
• “Blue bloater” - tends to be cyanotic
• Tends to be overweight
• Breath sounds reveal rhonchi (course gurgling sound)
due to blockage of large airways with mucous plugs
• Signs & symptoms of right heart failure
jugular vein distention
ankle edema
liver congestion
 Drive to Breath & COPD
• Normal driving force to breathe
– decreased oxygen (O2) level
– increased carbon dioxide (CO2) level
• Chemoreceptors sense:
– too little O2 ( resp rate to improve) or
– too much CO2 ( resp rate to blow off more CO2)
• Patients with COPD have retained excess CO2 for so long that
their chemoreceptors are no longer sensitive to the elevated CO 2
levels
– COPD patients breathe to pull in O2
 O2 Administration & COPD
Never withhold oxygen therapy from a patient who
clinically needs it

• Monitor all patients receiving O2 but especially the patient

with COPD
• Normal O2 sat for COPD patient is around 90%
• If the patient with COPD is supplied all the oxygen they need,
this might trigger them not to work at breathing anymore and
may result in hypoventilation and/or respiratory arrest
 Asthma
• Chronic inflammatory disorder of the airways
• Airflow obstruction and hyperresponsiveness
are often reversible with treatment
• Triggers vary from individual
environmental allergens
cold air; other irritants
exercise; stress
food; certain medications
 Asthma’s Two-Phase Reaction
• Phase one - within minutes
– Release of chemical mediators (ie: histamine)
• contraction of bronchial smooth muscle
(bronchoconstriction)
• leakage of fluid from bronchial capillaries (bronchial edema)
• Phase two - in 6-8 hours
– Inflammation of the bronchioles from invasion of the mucosa of
the respiratory tract from the immune system cells
• additional swelling & edema of bronchioles
 Assessment of Asthma
• Presentation
– Dyspnea
– Wheezing - initially heard at end of exhalation
– Cough - unproductive, persistent
• may be the only presenting symptom
– Hyperinflation of chest - trapped air
– Tachypnea - an early warning sign of a respiratory
problem
– Use of accessory muscles
 Severe Asthma Attack
• One and two word dyspnea
• Tachycardia
• Decreased oxygen saturation on pulse
oximetry
• Agitation & anxiety with increasing
hypoxia
 Obtaining a History
• Very helpful in forming an accurate impression
• Will have a history of asthma
• Home medications indicate asthma
• A prior history of hospitalization with intubation
makes this a high-risk patient for significant
deterioration
• Note: unilateral wheezing is more likely an aspirated
foreign body or a pneumothorax than an asthma
attack
 Treatment Goals -
COPD & Asthma

 Relieve and correct hypoxia

 Reverse any bronchospasm or
bronchoconstriction
Asthma/COPD with Wheezing SOP
• Routine medical care
• Pulse oximetry (on room air if possible)
• Albuterol 2.5 mg / 3ml with oxygen adjusted to 6 l/minute
• May repeat Albuterol treatments if needed
• May need to consider intubation with in-line
administration of Albuterol based on the patient’s
condition
• EMS to contact Medical Control for possible CPAP in
patient with COPD
 Albuterol Nebulizer Procedure
• Medication is added to the chamber which must be kept
upright
• The T-piece is assembled over the chamber
• The patient needs to be coached to breath slowly and as
deeply as possible
– this will take time and several breathes before the patient can slow
down and start breathing deeper; the patient needs a good coach to
talk them through the slower/deeper breathing
– the medication needs to be inhaled into the lungs to be effective
– the patient should be sitting upright
Add medication to the chamber
Connect the mouthpiece to the
T-piece
Connect the corrugated tubing to
the T-piece

Kit connected to
oxygen and run
at 6 l/minute
(enough to
create a mist)
Encourage slow, deep breathing
 Albuterol Nebulizer Mask
For the patient
who is unable to
keep their lips
sealed around the
mouthpiece, take
the top T-piece
off the kit and
replace with an
adult or pediatric
nebulizer mask
 Pediatric
patient
using
nebulizer
mask.
Caregiver
may assist
in holding
the mask.
 Case Scenario #4
• 7 year-old with history of asthma has sudden onset of
difficulty breathing and wheezing while playing
outside
• Patient has an increased respiratory rate and is using
accessory muscles
• B/P - 108/70; P - 90; R - 24; SaO2 - 97%
• Upon auscultation, left lung is clear and wheezing is
present on the right side
• Impression and intervention?
 Case Scenario #4
• Sounds like asthma, looks like asthma, has a
history of asthma but why should you not
suspect asthma?
– Asthma is not a selective disease - the patient will
have widespread, not localized, bronchoconstriction
and have bilateral wheezing, not unilateral
• Dig into the history more - what was the patient
doing prior to the development of symptoms?
 Case Scenario #4
• This patient was playing with friends, running
around while eating food
• Possibly aspirated a foreign body
– sudden onset of unilateral wheezing
• Albuterol would not be indicated in this situation
• Supplemental oxygen if indicated, position of
comfort, reassessment watching for increase in
airway obstruction
 What To Do in Extreme Asthma
Attack
• At times, the asthma attack is so severe the
patient is at risk of dying
• To relieve the bronchoconstriction, Albuterol
needs to be delivered right into the lungs
• To assist with this, the patient may need to be
bagged or intubated to deliver the medication
• Abuterol is delivered via in-line technique
Aerosol Medication via BVM or ETT
with BVM (In-line)
• Albuterol placed in the chamber as usual
• The chamber is connected to the T-piece
• Adaptor(s) are used to accommodate bagging the
patient with in-line Albuterol as soon as possible
– any medication that can be delivered as soon
as possible to the target organ (the lungs) will
be helpful in promoting bronchodilation
• Mouthpiece removed from T-
piece and replaced with BVM
• Nebulizer still connected to
oxygen source
• Adaptor placed at distal end
of corrugated tubing to
connect to BVM mask or ETT
 Albuterol Delivered
Via BVM #1
• #1 Disconnect reservoir
bag with L valve from
mask
#2
• #2 Connect L shaped valve
with bag where mouthpiece
of albuterol kit would fit #3, #4
• #3 Place corrugated tubing
of albuterol kit to the mask
over the patient’s mouth
• #4 Begin to bag to “blow”
the drug into the lungs
while waiting to complete To 6l
intubation
O2
• Adaptor connected to the distal end of the
corrugated tubing of Albuterol kit connected to
the proximal end of the ETT
• ETT placement confirmed in the usual manner
– visualization
– chest rise & fall
– 5 point auscultation
Intubated
– ETCO2 detector patient
 Case Scenario #5
• EMS has responded to a 14 year-old child in severe
respiratory distress with audible wheezing. The
complaints have been present for the past 3 hours.
Inhalers used have not been effective.
• B/P - 112/60; P - 120; R - 32; SaO2 - 89%
• Patient is very anxious, pale, cool, and diaphoretic. The
lips and nail beds are cyanotic.
• What is your impression?
• What is your greatest concern?
 Case Scenario #5
• This patient is experiencing a severe asthma attack that is
not responding to medication - status asthmaticus
• This patient is in danger of going into respiratory arrest
due to exhaustion
• Begin supportive oxygen therapy
• Set up the albuterol nebulizer kit and simultaneously the
BVM
• Anticipate intubation with administration of Albuterol
via the in-line method
 Case Scenario #5
• Patients experiencing an asthma attack are in
need of bronchodilators (Albuterol) and IV
fluids (they are usually dry from the rapid
respirations and inability to have been taking
in fluids)
• If the patient is losing consciousness, you may
need to follow the Conscious Sedation SOP to
intubate and administer Albuterol via in-line
 Region X SOP - Conscious Sedation
• Lidocaine is not indicated
– Lidocaine is used to eliminate the cough reflex that would increase ICP in
head insults/trauma
– There is no presence of head injury or head insult
• Versed is an amnesic and will relax the patient
• Versed does not take away any pain
• Region X SOP dose of Versed is 5 mg slow IVP
– If not sedated within 60 seconds, Versed 2 mg slow IVP every minute until
sedated
– Following sedation, may give Versed 1 mg IVP every 5 minutes for agitation
(total sedation dose is 15 mg)
 Conscious Sedation cont’d
• Morphine can help increase the effects of Versed and assist in
improving patient sedation
– Morphine 2 mg slow IVP over 2 minutes
– May repeat Morphine 2mg IVP every 3 minutes
– Max dose Morphine 10 mg IVP
• Benzocaine eliminates the gag reflex
– The conscious patient will have a gag reflex
– For the unconscious patient, stroke at the eyelashes or tap the space between
the eyes to check for gag
• The gag reflex disappears with the blink reflex
– Minimize the duration of spray (<2 seconds)
 Bibliography
• Bledsoe, B., Porter, R., Cherry, R.
Essentials of Paramedic Care. Brady.
2007.
• Kohlstedt, D. Sales Representative. Tri-Anim.
• Region X SOP’s, March 1, 2007.
• Sanders, M. Mosby’s Paramedic Textbook,
Revised Third Edition. 2007.
• Via Google: Respiratory Module Part I
• Via Google: Respiratory Module Part II