Respiratory Emergencies

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Respiratory Emergencies

• Eileen Humphreys PA-C, EMT-I

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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

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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

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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

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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

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Respiratory Emergencies

• Dyspnea
• shortness of breath
• difficulty breathing

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Respiratory Emergencies

• Apnea
• respiratory arrest

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Respiratory Emergencies

• Hypoxia
• inadequate supply of oxygen

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Bronchoconstriction

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

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Bronchoconstriction

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

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Respiratory Emergencies

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

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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

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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

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Initial Assessment

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

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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

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Initial Assessment

• Skin
• Cyanosis to the neck or chest indicates severe
  respiratory distress

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Respiratory Emergencies

• All patients in respiratory distress are priority
  transport
• Decline very rapidly

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

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• Rapid trauma assessment for unresponsive patients

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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

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• 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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Patient Care

• If pulse does not return to normal 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
  assuring proper technique

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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

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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

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COPD

• Chronic obstructed pulmonary disease
• Chronic Bronchitis
• Emphysema

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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

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Chronic Bronchitis

• Overweight
• Productive cough
• Rhonchi

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Emphysema

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

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Emphysema

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

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Treatment of COPD

• Ensure open airway, adequate breathing,
  supplemental oxygen, position of comfort

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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

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Hypoxic Drive

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

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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

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Asthma

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

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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

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Pneumonia

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

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Pneumonia

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

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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

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Pulmonary Embolus

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

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Pulmonary Embolus

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

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Acute Pulmonary Edema

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

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Acute Pulmonary Edema

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

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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

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Inadequate Pediatric Breathing

• Early signs
• accessory muscle use
• retractions
• tachypnea
• tachycardia

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Inadequate Pediatric Breathing

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

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Pediatric Respiratory Failure

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

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Pediatric Respiratory Failure

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

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Pediatric Problems

• Distinguish whether the airway problem is upper
  or lower

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Pediatric Problems

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

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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

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Croup

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

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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

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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

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Treatment

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

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MDIs

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

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MDIs

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

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MDIs

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

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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

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Administration

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

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Administration

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

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MDIs

• Side effects include
• tachycardia
• arrhythmia
• anxiety
• nervousness