Respiratory Emergencies

A&E MODULE
MBBS IV 2016-17
Objectives

 Identify and Manage Airway obstruction

 An Approach to a Breathless Patient

 Specific conditions
Pneumonia
Asthma
Pneumothorax
AIRWAY

UPPER
 Nose LOWER
 Nasopharynx  Trachea
 Oropharynx (intra thoracic)
 Larynx
 Supraglottis  Bronchi
 Subglottis
 Trachea  Bronchioles
(extra thoracic)
AIRWAY OBSTRUCTION RECOGNITION

 Talking

 Difficulty breathing, distressed, choking

 Shortness of breath

 Noisy breathing
 Stridor, wheeze, gurgling

 See-saw respiratory pattern, accessory muscles

UPPER AIRWAY OBSTRUCTION
AIRWAY OBSTRUCTION HISTORY

 Precipitating event
Aspiration
Trauma reaction
Systemic illness
 Time course
 Previous intubation or neck trauma
AIRWAY OBSTRUCTION ETIOLOGY

Infectious
Traumatic
 Epiglottitis (more supraglottitis in adults)
 Peritonsillar abscess
 Laryngeal or tracheal fracture
Signs & Systems: sore throat, fever, “hot potato”
 Oropharyngeal laceration voice, drooling, bulging tonsil
Treatment: aspiration vs. I & D Quinsy tonsillectomy
 Edema from injury to head and neck (non-involved side tends to bleed more than usual)
 Deep neck abscess
 Subglottic stenosis or granulation  Paraphayrngeal space
tissue secondary to intubation  Prevertebral space
 Submental space – Ludwig’s angina
AIRWAY OBSTRUCTION ETIOLOGY

 Mechanical  Neoplastic
 Foreign body  Tumors occluding airway
 Blood  Tumors eroding into major vessels with
 Vomitus massive blood loss into airway

 Allergic  CNS depression

 Drug Overdose
 Obstructive Sleep Apnoe
AIRWAY OBSTRUCTION MANAGEMENT

 Patient positioning  Insertion of artificial Airway:

 Simple
 Manual Airway maneuvers:  Advanced
 Chin lift
 Jaw thrust  Surgical Airways
 Crico-thyroidotomy
 Clear secretions/ foreign objects to  tracheostomy
ascertain patent
BREATHING : PROBLEM CAUSES

 Decreased respiratory drive  Lung disorders

 CNS depression  Pneumothorax
 Haemothorax
 Decreased respiratory effort  Infection
 Muscle weakness
 Acute exacerbation COPD
 Nerve damage
 Asthma
 Restrictive chest defect  Pulmonary embolus
 Pain from fractured ribs
 ARDS
BREATHING : PROBLEM CAUSES

OTHERS:
Cardiovascular
Haematological
Metabolic
endocrine
Recognition of breathing problems

 Look
 Respiratory distress, accessory muscles, cyanosis,
respiratory rate, chest deformity, conscious level
 Listen
 Noisy breathing, breath sounds
 Feel
 Expansion, percussion, tracheal position
The Breathless Patient

 Terminology: Dyspnea, Tachypnea, hyperpnea, hypoxia

 Significance: rapid deterioration with the following consequences:

 Altered mental state that can lead to death
 Risk of myocardial ischaemia and arrthymias
 Renal failure
Approach to Breathless Patient

 Reception:
 Appearance: work of breathing, posturing, skin color, sweating

 Triage:
 abnormal vital signs ( RR and O2 saturations)
 Risk stratification : extremes of age, cormobidities
 Categorise as Red or Yellow
 Institute initial managemen
Algorithm for Initial Management of the
breathless Patient
Shortness of Breath

Rapid Triage and categorization with placement in area where oxygen and
airway management can occur

Primary Survey and stabilization

Oxygen therapy with appropriate device ( facemask +/- reservoir), IV access and Blood
specimens, Placement of monitoring devices

Secondary survey: Consider advanced airway device, Assisted ventilation

Treat specific causes eg. Bronchospasms

Treatment of specific condition diagnosed from History, Examination and diagnostic tests
Severe Pneumonia

 Community acquired: Strep pneumoniae

>60% of community acquired.  Severity: CURB-65
 confusion
 urea >7mmol
 Atypicals - mycoplasma, legionella.
 RR ≥30/min
 BP systolic <90, diastolic 60 mm Hg
 Aspiration: unconscious, stroke  Age ≥ 65
 Treatment
 Immunocompromised.  oxygen
 IV antibiotics

 Amoxil / Erythromycin
Asthma

 Wheeze, breathlessness, cough.

 Markers of severity
 Unable to talk in sentences.
 Peak flow < 33% of expected.
 Pulse >120, resp rate >25.
 Systolic BP<100, Pulsus paradoxus.
 Silent chest.

 O2, Steroids, beta agonists, aminophylline, magnesium sulphate

Pneumothorax

 Pleuritic chest pain, breathlessness. Young men, marfanoid.

Underlying pathology.
 Classical signs may not be present.
 CXR
 Observe ?
 Aspirate ?
 Chest Drain ?
Hypoxic Drive ….. note

 Longstanding pulmonary disease results in CO2

retention..Chemoreceptors ‘down regulated’

 Patient relies on hypoxia to drive ventilation

 High concentration of inhaled oxygen results in hypo-

ventilation and further CO2 retention
Reading Assignment:

COPD
Neuromuscular Failure
HeartFailure
Pulmonary embolism
Summary

 Early Recognition and interventions

 airway obstruction
 breathing problems

 Simple things can make the patient improve