Emergencies Resulting from Pulmonary Diseases

1
Emergencies Resulting from Pulmonary Diseases
Disorders

• EMS Professions
• Temple College

2
Pulmonary Diseases Disorders

• Pulmonary Disease Conditions may result from
• Infectious causes
• Non-Infectious causes
• Adversely affect one or more of the following
• Ventilation
• Diffusion
• Perfusion

3
Pulmonary Diseases Disorders

• The Respiratory Emergency may stem from
  dysfunction or disease of (examples only)
• Control System
• Hyperventilation
• Central Respiratory Depression
• CVA
• Thoracic Bellows
• Chest/Diaphragm Trauma
• Pickwickian Syndrome
• Guillian-Barre Syndrome
• Myasthenia Gravis
• COPD

4
Pulmonary Diseases Disorders

• The Respiratory Emergency may affect the upper or
  lower airways
• Upper Airway Obstruction
• Tongue
• Foreign Body Aspiration
• Angioneurotic Edema
• Maxillofacial, Larnygotracheal Trauma
• Croup
• Epiglottitis

5
Respiratory Emergencies Causes

• Lower Airway Obstruction
• Emphysema
• Chronic Bronchitis
• Asthma
• Cystic Fibrosis

6
Pulmonary Diseases Disorders

• The Respiratory Emergency may stem from Gas
  Exchange Surface Abnormalities
• Cardiogenic Pulmonary Edema
• Non-cardiogenic Pulmonary Edema
• Pneumonia
• Toxic Gas Inhalation
• Pulmonary Embolism
• Drowning

7
Pulmonary Diseases Disorders

• Problems with the Gas
• Exchange Surface

8
Pulmonary Edema
9
Pulmonary Edema Pathophysiology

• A pathophysiologic condition, not a disease
• Fluid in and around alveoli
• Interferes with gas exchange
• Increases work of breathing
• Two Types
• Cardiogenic (high pressure)
• Non-Cardiogenic (high permeability)

10
Pulmonary Edema

• High Pressure (cardiogenic)
• AMI
• Chronic HTN
• Myocarditis
• High Permeability (non-cardiogenic)
• Poor perfusion, Shock, Hypoxemia
• High Altitude, Drowning
• Inhalation of pulmonary irritants

11
Cardiogenic Pulmonary Edema Etiology

• Left ventricular failure
• Valvular heart disease
• Stenosis
• Insufficiency
• Hypertensive crisis (high afterload)
• Volume overload

Increased Pressure in Pulmonary Vascular Bed
12
Pulmonary Edema

• High Permeability
• Disrupted alveolar-capillary membrane
• Membrane allows fluid to leak into the
  interstitial space
• Widened interstitial space impairs diffusion

13
Non-Cardiogenic Pulmonary Edema Etiology

• Toxic inhalation
• Near drowning
• Liver disease
• Nutritional deficiencies
• Lymphomas
• High altitude pulmonary edema
• Adult respiratory distress syndrome

Increased Permeability of Alveolar-Capillary Walls
14
Pulmonary Edema Signs Symptoms

• Dyspnea on exertion
• Paroxysmal nocturnal dyspnea
• Orthopnea
• Noisy, labored breathing
• Restlessness, anxiety
• Productive cough (frothy sputum)
• Rales, wheezing
• Tachypnea
• Tachycardia

15
Management of Non-Cardiogenic Pulmonary Edema

• Position
• Oxygen
• PPV / Intubation
• CPAP
• PEEP
• IV Access Minimal fluid administration
• Treat the underlying cause
• Diuretics usually not helpful May be harmful
• Transport

16
Adult Respiratory Distress Syndrome

• AKA Non-cardiogenic pulmonary edema
• A complication of
• Severe Trauma / Shock
• Severe infection / Sepsis
• Bypass Surgery
• Multiple blood transfusions
• Drug overdose
• Aspiration
• Decreased compliance
• Hypoxemia

17
ARDS Pathophysiology

• A condition resulting from severe illness or
  injury and associated with a high mortality rate
• Increased permeability
• Pulmonary edema
• Surfactant destruction
• Atelectasis
• Decreased compliance
• Hypoxemia

18
ARDS Presentation

• History
• Recent hx of severe illness or injury
• Often already being treated for underlying cause
• Exam Findings
• Dyspnea
• Evidence of pulmonary edema
• Poor oxygenation
• Decreased lung compliance

19
ARDS Management

• Airway Management
• Endotracheal intubation
• Suction
• Mechanical Ventilation
• PEEP
• ECG Monitoring
• Treat underlying cause
• May require vasopressors for shock

20
Pneumonia
21
Pneumonia

• Fifth leading cause of death in US
• Group of Specific infections
• Risk factors
• Cigarette smoking
• Exposure to cold
• Extremes of age
• young
• old

22
Pneumonia

• Inflammation of the bronchioles and alveoli
• Products of inflammation (secretions, pus) add to
  respiration difficulty
• Gas exchange is impaired
• Work of breathing increases
• May lead to
• Atelectasis
• Sepsis
• VQ Mismatch
• Hypoxemia

23
Pneumonia Etiology

• Viral
• Bacterial
• Fungi
• Protozoa (pneumocystis)
• Aspiration

24
Presentation of Pneumonia

• Shortness of breath, Dyspnea
• Fever, chills
• Pleuritic Chest Pain, Tachycardia
• Cough
• Green/brown sputum
• May have crackles, rhonchi or wheezing in
  peripheral lung fields
• Consolidation
• Egophony

25
Management of Pneumonia

• Treatment mostly based upon symptoms
• Oxygen
• Rarely is intubation required
• IV Access Rehydration
• B2 agonists may be useful
• Antibiotics (e.g. Rocephin)
• Antipyretics

26
Pneumonia Management

• MD follow-up for labs, cultures Rx
• Transport considerations
• Elderly have significant co-morbidity
• Young have difficulty with oral medications
• ED vs PMD office/clinic
• Transport in position of comfort

Would an anticholinergic like Atrovent be useful
in managing pneumonia?
27
Pulmonary Embolism
28
Pulmonary Embolism

• 50,000 deaths / year
• 5 of all sudden deaths
• lt10 of all PE result in death

29
Pulmonary Embolism Pathophysiology

• Something moving with flow of blood passes
  through right heart into pulmonary circulation
• It reaches an area too narrow to pass through and
  lodges there
• Part of pulmonary circulation is blocked
• Blood
• Does not pass alveoli
• Does not exchange gases

30
Pulmonary Embolism (PE)

• A disorder of perfusion
• Combination of factors increase probability of
  occurrence
• Hypercoagulability
• Platelet aggregation
• Deep vein stasis
• Embolus usually originates in lower extremities
  or pelvis

31
Pulmonary Embolism (PE)

• Risk factors
• Venostasis or DVT
• Recent surgery or trauma
• Long bone fractures (lower)
• Oral contraceptives
• Pregnancy
• Smoking
• Cancer

32
Pulmonary Embolism Etiology
Most Common Cause Blood Clots
Vessel Wall Injury
VirchowsTriad
Hypercoagulability
Venous Stasis
33
Pulmonary Embolism Etiology

• Other causes
• Air
• Amniotic fluid
• Fat particles (long bone fracture)
• Particulates from substance abuse
• Venous catheter

34
Pulmonary Embolism Signs Symptoms

• Small Emboli
• Rapid Onset
• Dyspnea
• Tachycardia
• Tachypnea
• Fever
• Episodic Showers
• Evidence or history of thrombophlebitis
• Consider early when no other cardiorespiratory
  diagnosis fits

35
Pulmonary Embolism Signs Symptoms

• Larger Emboli
• Small Emboli S/S plus
• Pleuritic pain
• Pleural rub
• Coughing
• Wheezing
• Hemoptysis (rare)

36
Pulmonary Embolism Signs Symptoms

• Very Large Emboli
• Preceded by S/S of Small Larger Emboli plus
• Central chest pain
• Distended neck veins
• Acute right heart failure
• Shock
• Cardiac arrest

37
Pulmonary Embolism Signs Symptoms
There are NO assessment findings specific to
pulmonary embolism
38
Pulmonary Embolism Management

• Management based on severity of Sx/Sx
• Airway Breathing
• High concentration O2
• Consider assisting ventilations
• Early Intubation
• Circulation
• IV, 2 lg bore sites
• Fluid bolus then TKO Titrate to BP 90 mm Hg
• Monitor ECG
• Rapid transport

39
PE Management

• Thrombolytics
• Aspirin Heparin (questionable if any benefit)
• Rapid transport to appropriate facility
• Embolectomy or thrombolytics at hospital (rarely
  effective in severe cases due to time delay)
• Poor prognosis when cardiac arrest follows

40
Pulmonary Embolism

• If the patient is alive when you get to them,
  that embolus isnt going to kill them.

But the next one they throw might!
41
Pleurisy

• Inflammation of pleura caused by a friction rub
• layers of pleura rubbing together
• Commonly associated with other respiratory disease

42
Presentation of Pleurisy

• Sharp, sudden and intermittent chest pain with
  related dyspnea
• Possibly referred to shoulder
• May ? or ? with respiration
• Pleural friction rub may be audible
• May have effusion or be dry

43
Pleurisy

• Management
• Based upon severity of presentation
• Mostly supportive

44
Pulmonary Diseases Disorders

• Problems with Airway Obstructions

45
Obstructive Airway Diseases
46
Obstructive Airway Disease

• Asthma
• Emphysema
• Chronic Bronchitis

47
Obstructive Airway Diseases

• Asthma experienced by 4 - 5 of US population
• Mortality rate increasing
• Factors leading to Obstructive Airway Diseases
• Smoking
• Exposure to environmental agents
• Genetic predisposition
• How does this differ from COPD?

48
Obstructive Airway Disease

• Exacerbation Factors
• Intrinsic
• Stress (especially in adults)
• URI
• Exercise
• Extrinsic
• Cigarette Smoke
• Allergens
• Drugs
• Occupational hazards

49
Obstructive Airway Disease

• General Pathophysiology
• Specific pathophysiology varies by disease
• Obstruction in bronchioles
• Smooth muscle spasm (beta)
• Mucous accumulation
• Inflammation
• Obstruction may be reversible or irreversible

50
Obstructive Airway Disease

• General Pathophysiology
• Obstruction results in air trapping
• Bronchioles usually dilate on inspiration
• Dilation allows air to enter even in presence of
  obstruction
• Bronchioles tend to constrict on expiration
• Air becomes trapped distal to obstruction

51
Lower Airway Disease
52
Chronic Obstructive Pulmonary Disease

• Emphysema
• Chronic Bronchitis
• (Rarely Asthma may result in COPD)

53
COPD Epidemiology

• Most common chronic lung disease
• 14.8 million cases in U.S.
• 4th leading cause of death
• 110,000 deaths annually

54
Emphysema

• Type A COPD

55
Emphysema Definition

• Destruction of alveolar walls
• Distention of pulmonary air spaces
• Loss of elastic recoil
• Destruction of gas exchange surface

56
Emphysema Incidence

• Male gt females
• Urban area gt rural areas
• Age usually gt 55

57
EmphysemaEtiology

• Smoking
• 90 of all cases
• Smokers 10x more likely to die of COPD than
  non-smokers
• Environmental factors
• Alpha 1 antitrypsin deficiency
• hereditary
• 50,000 to 100,000 cases
• mostly people of northern European descent

58
Emphysema Pathophysiology

• Decreased surface area leads to decreased gas
  exchange with blood
• Loss of pulmonary capillaries hypercapnia lead
  to
• increased resistance to blood flow which leads to
• pulmonary HTN
• right heart failure (cor pulmonale)

59
Emphysema Pathophysiology

• Loss of elastic recoil leads to increased
  residual volume and CO2 retention
• Air Trapping
• Hyperinflation
• Hypercapnia -gt pulmonary vasoconstriction -gt V/Q
  mismatch

60
Emphysema Signs and Symptoms

• Increasing dyspnea on exertion
• Non-productive cough
• Malaise
• Anorexia, Loss of weight
• Hypertrophied respiratory accessory muscles

61
Emphysema Signs and Symptoms

• Increased Thoracic AP Diameter (Barrel Chest)
• Decreased lung/heart sounds
• Hyperresonant chest

62
Emphysema Signs and Symptoms

• Lip pursing on exhalation
• Clubbed fingertips
• Altered blood gases
• Normal or decreased PaO2
• Elevated CO2
• Cyanosis occurs LATE in course of disease

PINK PUFFER
63
Chronic Bronchitis

• Type B COPD

64
Chronic Bronchitis Definition

• Increased mucus production for gt 3 months for gt 2
  consecutive years
• Recurrent productive cough

65
Chronic Bronchitis Incidence

• Males gt females
• Urban areas gt rural areas
• Age usually gt 45

66
Chronic Bronchitis Etiology

• Smoking
• Environmental irritants

67
Chronic Bronchitis Pathophysiology

• Mucus plugging/inflammatory edema
• Increased airflow resistance leads to alveolar
  hypoventilation
• Alveolar hypoventilation leads to
• hypercarbia
• hypoxemia

68
Chronic Bronchitis Pathophysiology

• Hypoxemia leads to
• increased RBCs w/o oxygen which leads to
• cyanosis
• Hypercarbia leads to
• pulmonary vascular constriction which leads to
• increased right ventricular work which leads to
• right heart failure which may progress to
• cor pulmonale

69
Chronic Bronchitis Signs and Symptoms

• Increasing dyspnea on exertion
• Frequent colds of increasing duration
• Productive cough
• Weight gain, edema (right heart failure)
• Rales, rhonchi, wheezing
• Bluish-red skin color (polycythemia)
• Headache, drowsiness (increased CO2)

70
Chronic Bronchitis Signs and Symptoms

• Decreased intellectual ability
• Personality changes
• Abnormal blood gases
• Hypercarbia
• Hypoxia
• Cyanosis EARLY in course of disease

BLUE BLOATER
71
COPD Assessment Findings

• Chronic condition ? acute episode
• SS of ? work of breathing and/or hypoxemia
• Use of accessory muscles
• Increased expiratory effort
• Tachycardia, AMS, Cyanosis
• Wheezing, Rhonchi, ? LS
• Thin, red/pink appearance
• Saturation usually normal in emphysema

72
COPD Management

• Causes of Decompensation
• Respiratory infection (increased mucus
  production)
• Chest trauma (pain discourages coughing or deep
  breathing)
• Sedation (depression of respirations and
  coughing)
• Spontaneous pneumothorax
• Dehydration (causes mucus to dry out)

73
COPD Management

• Airway and Breathing
• Sitting position or position of comfort
• Calm Reassure
• Encourage cough
• Avoid exertion
• Oxygen
• Dont withhold
• Maintain O2 saturation above 90

TRUE HYPOXIC DRIVE IS VERY RARE
74
COPD Management

• Ventilation
• Avoid intubation unless absolutely necessary
• near respiratory failure
• exhaustion
• Circulation
• IV TKO
• Titrate fluid to degree of dehydration
• 250 cc trial bolus
• Excessive fluid may precipitate CHF
• Monitor ECG

75
COPD Management

• Drug Therapy
• Obtain thorough medication history
• Nebulized Beta 2 agonists
• Albuterol
• Terbutaline
• Metaproterenol
• Isoetharine

76
COPD Management

• REMEMBER
• All bronchodilators are potentially arrhythmogenic

77
COPD Management

• Drug Therapy
• Ipratropium (anticholinergic) by SVN
• Terbutaline (beta-2 agonist) by MDI, SQ or IV
• Corticosteroids (anti-inflammatory agent) by IV

78
COPD Management

• Drug Therapy
• Aminophylline (methylxanthine)
• Little evidence of benefit in acute management
• Is arrhythmogenic
• Produces toxicity easily
• 2 to 3 hours to peak effect
• Magnesium sulfate
• Also with little supportive evidence
• Antibiotics

79
COPD Management

• Avoid
• Sedatives
• Restlessness hypoxia
• Antihistamines
• Dry secretions, decrease LOC
• Epinephrine
• Myocardial ischemia, arrhythmias
• Intubation
• difficult to wean off ventilator

80
Reversible Obstructive Airway Disease

• Asthma

81
Asthma Definition

• Lower airway hyper-responsiveness to a variety of
  stimuli
• Diffuse reversible airway obstruction or
  narrowing
• Airway inflammation

82
Asthma Incidence

• 50 onset before age 10
• 33 before age 30
• Asthma in older patients suggests other
  obstructive pulmonary diseases
• Risk Factors
• Family history of asthma
• Perinatal exposure to airborne allergens and
  irritants
• Genetic hypersensitivity to environmental
  allergens (Atopy)

83
Asthma

• Diagnosis
• HP, Spirometry
• Hx or presence of episodic symptoms of airflow
  obstruction
• airflow obstruction is at least partially
  reversible
• alternative diagnoses are excluded

84
Asthma

• Commonly misdiagnosed in children as
• Chronic bronchitis
• Recurrent croup
• Recurrent URI
• Recurrent pneumonia

85
Asthma

• Often triggered by
• Cold temperature
• Respiratory Infections
• Vigorous exercise
• Emotional Stress
• Environmental allergens or irritants
• Exacerbation
• Extrinsic common in children
• Intrinsic common in adults

86
Asthma Pathophysiology

• Asthma triggered ?
• Bronchial smooth muscle contraction
• Increased mucus production
• Bronchial plugging
• Relative dehydration
• Alveolar hypoventilation ?
• Ventilation Perfusion Mismatch
• CO2 retention
• Air Trapping

87
Asthma Pathophysiology
Bronchospasm
Bronchial Edema
Increased Mucus Production
88
Asthma Pathophysiology
89
Asthma Pathophysiology
Cast of airway produced by asthmatic mucus plugs
90
Asthma Pathophysiology

• Difficulty exhaling
• chest hyperinflation
• Poor gas exchange
• hypoxia
• hypercarbia
• Increased respiratory water loss
• dehydration

91
Asthma Types

• Type 1 Extrinsic
• Classic allergic asthma
• Common in children, young adults
• Seasonal in nature
• Sudden brief attacks
• Major component is bronchospasm
• Good bronchodilator response

92
Asthma Types

• Type 2 Extrinsic Asthma
• Adults lt 35
• Long term exposure to irritants
• More inflammation than Type 1 Extrinsic
• Does not respond well to bronchodilators
• Needs treatment with corticosteroids

93
Asthma Types

• Intrinsic Asthma
• Adult gt 35
• No immunologic cause
• Aspirin sensitivity/nasal polyps
• Poor bronchodilator response

94
Asthma Signs and Symptoms

• Onset of attacks associated with triggers
• Dyspnea
• Non-productive cough
• Tachypnea
• Expiratory wheezing
• Accessory muscle use
• Retractions

95
Asthma Signs and Symptoms

• Absence of wheezing
• IMPENDING RESPIRATORY ARREST!

96
Asthma Signs and Symptoms

• Tachycardia
• Pulsus paradoxus in severe attacks
• Anxiety, restlessness (hypoxia) progressing to
  drowsiness, confusion (hypercarbia)

97
Asthma Signs and Symptoms

• Lethargy, confusion, suprasternal retractions
  RESPIRATORY FAILURE

98
Asthma Signs and Symptoms

• Early Blood Gas Changes
• Decreased PaO2
• Decreased PaCO2

WHY?
99
Asthma Signs and Symptoms

• Later Blood Gases
• Decreased PaO2
• Normal PaCO2

IMPENDING RESPIRATORY FAILURE
100
Asthma Signs and Symptoms

• Still Later Blood Gases
• Decreased PaO2
• Increased PaCO2

RESPIRATORY FAILURE
101
Asthma Risk Assessment

• Prior ICU admissions
• Prior intubation
• gt3 ED visits in past year
• gt2 hospital admissions in past year
• gt1 bronchodilator canister used in past month
• Use of bronchodilators gt every 4 hours
• Chronic use of steroids
• Progressive symptoms in spite of aggressive Rx

102
Asthma Management

• Airway
• Breathing
• Sitting position or position of comfort
• Humidified O2 by NRB mask
• Dry O2 dries mucus, worsens plugs
• Encourage coughing
• Consider intubation, assisted ventilation
• Impending respiratory failure
• Avoid if at all possible

103
Asthma Management

• Circulation
• IV TKO
• Assess for dehydration
• Titrate fluid administration to severity of
  dehydration
• Trial bolus of 250 cc
• Monitor ECG, Pulse Oximetry

104
Asthma Management

• Obtain medication history
• Consider
• Overdose
• Dysrhythmias

105
Asthma Management

• Nebulized Beta-2 agents
• Albuterol
• Terbutaline
• Metaproterenol
• Isoetharine
• Nebulized anticholinergics
• Ipratropium
• Atropine
• IV Corticosteroid
• Methylprednisolone

106
Asthma Management

• Rarely used
• Questionable efficacy, Potential Complications
• Magnesium Sulfate (IV)
• Methylxanthines
• Aminophylline (IV)

107
Asthma Management

• Subcutaneous beta agents
• Epinephrine 11000 q 30 minutes up to 3 doses
• Adult 0.3 to 0.5 mg SQ
• Pediatric 0.1 to 0.3 mg SQ
• Terbutaline
• Adult - 0.25 mg SQ q 30 minutes up to 2 doses
• Pediatric -SQ or IV infusion usually begun _at_ 0.17
  mcg/kg/min

POSSIBLE BENEFIT IN PATIENTS WITH VENTILATORY
FAILURE
108
Asthma Management

• Use EXTREME caution in giving two
  sympathomimetics or two doses to same patient
• Monitor ECG

109
Asthma Management

• Avoid
• Sedatives
• Depress respiratory drive
• Antihistamines
• Decrease LOC, dry secretions
• Aspirin
• High incidence of allergy

110
Asthma Management

• Continuous Monitoring Frequent Reassessment
• Need for transport? Destination?

111
Asthma Management

• Transport Considerations
• How severe is the episode?
• Is the patient improving?
• How extensive (invasive) were the required
  therapies?
• What does he/she normally do after treatment?
• Medical Control or PMD consult

112
Drug Delivery Methods Review

• MDI vs. MDI w/ spacer vs. SVNvs. SQ injection

113
Status Asthmaticus

• Asthma unresponsive to beta-2 adrenergic agents

114
Status Asthmaticus

• Oxygen (humidified if possible)
• Nebulized beta-2 agents
• Nebulized Ipratropium
• Corticosteroids
• IV or SQ terbutaline or epinephrine
• Aminophylline (controversial)
• Magnesium sulfate (controversial)
• Intubation
• Caution with PPV

115
Golden Rule
ALL THAT WHEEZES IS NOT ASTHMA

• Pulmonary edema
• Pulmonary embolism
• Allergic reactions
• COPD
• Pneumonia
• Foreign body aspiration
• Cystic fibrosis

116
Lower Airway Disease

• Cystic Fibrosis

117
Cystic Fibrosis Definition

• Inherited metabolic disease of exocrine glands
  and sweat glands
• Primarily affects digestive, respiratory systems
• Begins in infancy

118
Cystic Fibrosis Etiology

• Autosomal recessive gene
• Both parents must be carriers
• Incidence
• Caucasians--12000
• Blacks--117,000
• Asians--very rare

119
Cystic Fibrosis Pathophysiology

• Obstruction of pancreatic, intestinal gland, bile
  ducts
• Over-secretion by airway mucus glands
• mucous plugs
• Excess loss of sodium chloride in sweat

120
Cystic Fibrosis Recognition

• History
• Airway obstruction, chronic cough
• Recurrent respiratory infections
• May be oxygen-dependent
• Diffuse Wheezing
• Frequent, foul-smelling stools
• Salty taste on skin
• Intolerance of hot environments

121
Cystic Fibrosis Management

• Position of comfort
• Oxygen
• Suctioning
• Nebulized Beta agonists
• May not be very helpful but worth attempting if
  absence of contraindications
• Assisted ventilation

122
Lower Airway Disease

• Neoplasms of the Lung

123
Neoplasms of the Lung

• 150,000 cases
• Usually occurs between ages of 55 and 65
• Most die within one year
• 20 only local lung involved
• 25 spread to lymphatic system
• 55 result in distant metastatic cancer

124
Neoplasms of the Lung

• Prevention
• Centered on prevention of smoking in youths
• Then, cessation in current smokers
• Avoid environmental hazards (e.g. asbestos)

125
Neoplasms of the Lung

• Presentation
• Respiratory Difficulty progressing to Distress
• Cough, Hemoptysis
• Hoarseness or voice change
• Dysphagia

126
Management of Neoplasms of the Lung

• Supportive care based upon presentation
• Oxygen
• Consider presence of advance directives or DNR
• Patients wishes
• Family discussions
• MD prognosis
• If appropriate
• Assist ventilations or Intubate
• IV access rehydration
• Bronchodilators
• Analgesia for pain (small, slow doses)

127
Hyperventilation Syndrome
128
Hyperventilation Syndrome

• Brady Textbook Correction, Vol. 3, p. 57
• Table 1-4 These are NOT Causes of
  hyperventilation syndrome
• A diagnosis of EXCLUSION!!!
• An increased ventilatory rate that
• DOES NOT have a pathologic origin
• Results from anxiety
• Remains a real problem for the patient

129
Hyperventilation Syndrome Pathophysiology
Tachypnea or hyperpnea secondary to anxiety
Decreased PaCO2
Respiratory alkalosis
Vasoconstriction
Hypocalcemia
Decreased O2 Release to Tissues
130
Hyperventilation SyndromeSigns Symptoms

• Symptoms
• Light-headedness, giddiness, anxiety
• Numbness, paresthesias of
• Hands
• Feet
• Circumoral area
• Cold hands, feet
• Carpopedal spasms
• Dyspnea
• Chest pain

131
Hyperventilation SyndromeSigns Symptoms

• Signs
• Rapid breathing
• Cool possibly pale skin
• Carpopedal spasm
• Dysrhythmias
• Sinus Tachycardia
• SVT
• Sinus arrhythmia
• Loss of consciousness and seizures (late rare)

132
Hyperventilation Syndrome Management

• Thorough assessment to rule out physiologic
  causes
• Rule out head injury, metabolic acidosis

Metabolic acidosis and increased ICP can cause
rapid breathing that mimics hyperventilation
syndrome!
133
Hyperventilation SyndromeManagement

• Oxygen based upon presentation
• Reassurance Patience
• Coach breathing rate
• CAUTION Rebreathing into bag or NRB
• Monitoring
• ECG
• Pulse oximetry

134
Hyperventilation Syndrome Management

• Educate patient family
• Consider possible psychopathology especially in
  repeat customers
• Transport occasionally required
• If loss of consciousness, carpopedal spasm,
  muscle twitching, or seizures occur
• Monitor EKG
• IV TKO
• Transport

135
Hyperventilation Syndrome
Serious diseases can mimic hyperventilation
Hyperventilation itself can be serious
136
Pulmonary Infectious Diseases
137
Laryngotracheobronchitis (Croup)

• Common syndrome of infectious upper airway
  obstruction
• Viral infection
• parainfluenza virus
• Subglottic Edema
• larynx, trachea, mainstem bronchi
• Usually 3 months to 4 years of age

138
Croup Signs Symptoms

• Gradual onset (several days)
• Often begins with Sx of URI
• May begin with only low grade fever
• Hoarseness
• Cough
• Seal Bark Cough
• Brassy Cough
• Nocturnal episodes of increased dyspnea and
  stridor

139
Croup Signs Symptoms

• Evidence of respiratory distress
• Tracheal tugging
• Substernal/intercostal retractions
• Accessory muscle use
• Inspiratory stridor or respiratory distress may
  develop slowly or acutely

140
Croup Management

• Usually requires little out of home treatment
• Calm Prevent agitation!!!
• Moist cool air - mist
• Humidified O2 by mask or blowby
• Do Not Examine Upper Airways!!!

141
Croup Management

• If in respiratory distress
• Racemic epinephrine via nebulizer
• Decreases subglottic edema (temporarily)
• Necessitates transport for observation for
  rebound
• IV TKO - ONLY if severe respiratory distress
• Transport

142
Bronchiolitis

• Pathophysiology
• Viral Disease resulting in inflammation of the
  lower airways
• Usually caused by RSV
• Typically affects children 6 - 18 months old (15
  of all children lt 2 years old)
• Usually occurs in the winter or early spring

143
Bronchiolitis Presentation

• Usually
• less than 18 months
• during the winter or early spring
• wheezing
• mild to moderate respiratory difficulty
• no asthma history
• associated with other viral symptoms
• runny nose
• sneezing
• cough
• low grade fever

144
Bronchiolitis Management

• Usually require little out of home treatment
• Oxygen, mask or blowby
• Nebulized Bronchodilators if respiratory distress
• May not respond well or at all
• Transport

145
Epiglottitis

• Bacterial infection (Hemophilus influenza )
• Edema of epiglottis (supraglottic)
• partial upper airway obstruction
• Typically affects 3-7 year olds

146
Epiglottitis Presentation

• Age 3-7 years of age
• can occur in adults
• can occur in infants
• Rapid onset progression
• Fever
• Severe sore throat
• Dysphagia
• Muffled voice
• Drooling

147
Epiglottitis Presentation

• Respiratory difficulty
• Stridor
• Usually in an upright, sitting, tripod position
• Child may go to bed asymptomatic and awaken
  during the night with
• sore throat
• painful swallowing
• respiratory difficulty

148
Epiglottitis Management
Immediate life threat (8-12 die from airway
obstruction)

• Do NOT attempt to visualize airway
• Allow child to assume position of comfort
• AVOID agitation of the child!!!
• AVOID anxiety of the healthcare providers!!!
• O2 by high concentration mask

149
Epiglottitis Management

• If respiratory failure is eminent
• IV TKO ONLY if eminent or respiratory arrest
• Be prepared to take control of airway
• Intubation equipment with smaller sized tubes
• Needle cricothyrotomy jet ventilation equipment
• Rapid but calm transport
• Appropriate facility

150
Upper Respiratory Infection

• Common illness
• Rarely life-threatening
• Often exacerbates underlying pulmonary conditions
• May become more significant in some patients
• Immunosuppressed
• Elderly
• Chronic pulmonary disease

151
Upper Respiratory Infection

• Prevention
• Avoidance is nearly impossible
• Too many potential causes
• Temporarily impaired immune system
• Best prevention strategy is handwashing
• Covering of mouth during sneezing and coughing
  also helpful

152
Pathophysiology of URI

• Wide variety of bacteria and viruses are causes
• Normal immune system response results in
  presentation
• 20-30 are Group A streptococci
• Most are self-limiting diseases

153
Presentation of URI

• Symptoms
• Sore throat
• Fever
• Chills
• HA
• Signs
• Cervical adenopathy
• Erythematous pharynx
• Positive throat culture (bacterial)

154
Management of URI

• Usually requires no intervention
• Oxygen if underlying condition has been
  exacerbated
• Rarely, pharmacologic interventions are required
• Bronchodilators
• Corticosteroid
• Occasionally, transport required
• Key question Destination?

155
Central Respiratory Depression
156
Respiratory Depression Causes

• Head trauma
• CVA
• Depressant drug toxicity
• Narcotics
• Barbiturates
• Benzodiazepines
• ETOH

157
Respiratory Depression Recognition

• Decreased respiratory rate (lt 12/min)
• Decreased tidal volume
• Decreased LOC

Use Your Stethoscope
Look, Listen, Feel
THEY PROBABLY ARENT
If you cant tell whether a patient is breathing
adequately...
158
Respiratory Depression Management

• Airway
• Open, clear, maintain
• Consider endotracheal intubation

The need to VENTILATE is not the same as the need
to INTUBATE
159
Respiratory Depression Management

• Breathing
• Oxygenate, ventilate
• Restore normal rate, tidal volume

Oxygen alone is INSUFFICIENT if Ventilation is
INADEQUATE
160
Respiratory Depression Management

• Circulation
• Obtain vascular access
• Monitor EKG (Silent MI may present as CVA)
• Manage Cause
• Check Blood Sugar
• Consider Narcan 2mg IV push if S/S suggest
  narcotic overdose
• Intubate if can not find or treat cause

161
Thoracic Bellows Malfunction

• Pickwickian Syndrome
• Guillian-Barre Syndrome
• Myasthenia Gravis

162
Pickwickian Syndrome

• Results from extreme obesity
• form of sleep apnea
• Decreased excursion of chest wall, diaphragm
  causes
• hypoventilation
• CO2 retention

163
Pickwickian Syndrome

• Signs and Symptoms
• Headache
• Drowsiness
• Inappropriate sleepiness
• Sleep apnea
• Treat symptomatically
• Assist ventilations as needed

164
Guillian-Barre Syndrome

• Autoimmune disease
• Leads to inflammation and degeneration of sensory
  and motor nerve roots (de-myelination)
• Progressive ascending paralysis
• Progressive tingling and weakness
• Moves from extremities then proximally
• May lead to respiratory paralysis (25)

165
Guillian-Barre Syndrome

• Self-Limiting
• Recovery is spontaneous and complete in 95 of
  cases
• In good outcomes, symptoms clear in 15 to 20 days
• Often takes weeks or months

166
Guillian-Barre Syndrome Management

• Treatment based on severity of symptoms
• Control airway
• Support ventilation
• Oxygen
• Transport in cases of respiratory depression,
  distress or arrest

167
Myasthenia Gravis

• Autoimmune disease
• Causes loss of ACh receptors at neuromuscular
  junction
• Attacks the ACh transport mechanism at the NMJ
• Episodes of extreme skeletal muscle weakness
• Can cause loss of control of airway, respiratory
  paralysis

168
Myasthenia Gravis Presentation

• Gradual onset of muscle weakness
• Face and throat
• Extreme muscle weakness
• Respiratory weakness -gt paralysis
• Inability to process mucus

169
Myasthenia Gravis Management

• Treat symptomatically
• Watch for aspiration
• May require assisted ventilations
• Assess for Pulmonary infection
• Transport based upon severity of presentation

170
Pulmonary Diseases Disorders

• Other Causes of Respiratory Emergencies

171
Angioneurotic Edema

• Allergic reaction
• Edema of tongue, pharynx, larynx
• NOT the SAME as anaphylaxis
• Common Causes
• Food (seafood or nuts)
• Drugs (penicillin or sulfa)
• Hymenoptera sting (ants, bees, wasps)

172
Angioneurotic Edema

• Signs and Symptoms
• Itching in palate
• Lump in throat
• Hoarseness
• Stridor
• Coughing
• Dyspnea
• Urticaria (hives)

173
Angioneurotic Edema Management

• Based upon severity of presentation
• Establish airway
• O2 via NRB
• IV lg bore TKO
• Epinephrine
• 11000 0.3 - 0.5mg SQ
• repeat after 20 minutes if needed

174
Angioneurotic Edema Management

• Based upon severity of presentation (cont)
• Diphenhydramine 25 to 50mg IM/IV
• In severe cases, Consider
• Positive pressure ventilation
• Endotracheal intubation
• Surgical airway

175
Spontaneous Pneumothorax

• Low incidence
• Many are well tolerated
• Risk Factors
• Males
• Younger age
• Thin body mass
• Marfans syndrome
• History of Obstructive Airway Disease

176
Presentation of Spontaneous Pneumothorax

• Symptoms
• Sudden SOB
• Sudden pleuritic CP
• Signs
• Mild pallor, tachycardia, tachypnea
• Decreased lung sounds
• usually very localized
• Increasing pneumothorax presents with more severe
  S/S

177
Management of Simple Pneumothorax

• Oxygen based on severity of S/S
• Assisted ventilation and intubation as needed
• May worsen pneumothorax
• Rarely needed
• IV access if severe symptoms are present
• Position of comfort
• Transport

178
Case Studies
179
Case One

• It is 1430 hrs. You are called to a business for
  a possible stroke. The patient is a 20-year-old
  female complaining of dizziness and of numbness
  around her mouth and fingertips.

What would you like to include in your initial
differential diagnosis?
180
Case One

• Initial Assessment
• Airway Open, maintained by patient
• Breathing Rapid, deep, regular no accessory
  muscle use or retractions
• Circulation Radial pulses present, rapid, full
  Skin warm, dry capillary refill lt 2 seconds
• Disability Awake, alert, anxious

What therapies, if any, would you like to begin?
181
Case One

• Vital Signs
• P 126 strong, regular
• R 26 deep, regular
• BP 130/82
• Physical Exam
• Chest BS present, equal bilaterally no
  adventitious sounds
• Extremities Equal movement in all extremities
  no weakness hands cool
• Oxygen saturation 98

Would you like to make any Changes to your
therapies or Diff Dx?
182
Case One

• History
• Allergies NKA
• Medications Birth control pills
• Past History No significant past history no
  history of smoking
• Last Meal Lunch 2 hours ago
• Events S/S began suddenly after argument with
  supervisor

183
Case One

• What problem do you now suspect?
• How would you manage this patient?

184
Case Two

• It is 0530 hours. You are called to a residence
  to see a child with a very high fever and
  difficulty breathing. The patient is a
  6-old-female. Mother says the child woke up
  crying about 2 hours ago.

What would you like to include in your
differential diagnosis?
185
Case Two

• Initial Assessment
• Airway Inspiratory stridor audible
• Breathing Rapid, shallow, labored
• Circulation Radial pulses present, rapid, weak
  skin pale, hot, diaphoretic capillary refill is
  2 seconds
• Disability Awake, alert, obviously frightened
  and in acute distress

What therapies, if any, would you like to begin
now?
186
Case Two

• Vital Signs
• P 130 weak, regular
• R 32 shallow, regular with stridor
• BP 110/70
• Physical Exam
• HEENT Flaring of nostrils accessory muscle use
  on inspiration drooling present
• Chest BS present, equal bilaterally no
  adventitious sounds
• Oxygen saturation 92

Would you like to make any Changes to your
therapies or Diff Dx?
187
Case Two

• History
• Allergies NKA
• Medications None
• Past History No significant past history
• Last Meal Dinner at about 1800 hours
• Events Awakened with severe sore throat. Has
  experienced increasing difficulty breathing. Will
  not eat or drink. Says it hurts to swallow

188
Case Two

• What problem do you now suspect?
• How would you manage this patient?

189
Case Three

• At 2330 hrs you are called to a residence to see
  a child with difficulty breathing. The patient
  is a 3 year old male.

How narrow a Differential Diagnosis can you
compile at this point?
190
Case Three

• Initial Assessment
• Airway Open, maintained by patient, mild stridor
  audible
• Breathing Rapid, shallow, labored
• Circulation Radial pulses present, weak,
  regular Skin pale, warm, moist Capillary refill
  lt2 seconds
• Disability Awake, sitting up in bed, looks tired
  and miserable

191
Case Three

• Vital Signs
• P 100 weak, regular
• R 30 shallow, labored with stridor
• BP 90/50
• Physical Exam
• HEENT Use of accessory muscles present no
  drooling
• Chest BS present, equal bilaterally with no
  adventitious sounds. Auscultation difficult
  because of stridor and barking cough

Now you can narrow your Diff Dx? To what?
192
Case Three

• History
• Allergies NKA
• Medication Tylenol for fever before bedtime
• Past history No significant past history
• Last meal Dinner around 1800 hours
• Events Patient has had cold for about 3 days.
  Reasonably well during day. Awakens around
  midnight with high-pitched cough that sounds like
  a dog barking

193
Case Three

• What problem do you suspect?
• How would you manage this patient?

194
Case Four

• At 1945 hours you are dispatched to a breathing
  difficulty at Long John Silvers. The patient is
  a 26-year-old female complaining of strange
  feeling in her mouth and difficulty swallowing.

What is your differential diagnosis?
195
Case Four

• Initial Assessment
• Airway Open, maintained by patient, difficulty
  swallowing, voice is hoarse
• Breathing Rapid, labored
• Circulation Radial pulses present, strong,
  regular Skin flushed Capillary refill lt 2
  seconds
• Disability Awake, alert, very anxious

196
Case Four

• Vital Signs
• P 120 strong, regular
• R 26 regular, slightly labored
• BP 118/90
• Physical Exam
• HEENT Puffiness around eyes Lips appear
  swollen Mild accessory muscle use
• Chest BS present, equal bilaterally No
  adventitious sounds
• Urticaria on upper chest, extremities
• Oxygen saturation 94

What therapies do you want to initiate?
197
Case Four

• History
• Allergies No drug allergies Has experienced
  itching previously when eating shrimp
• Medications None
• Past history No significant past history no
  history of smoking
• Last meal In progress at time of call
• Events Began to experience itching and
  difficulty swallowing after eating fish and
  chips

198
Case Four

• What problem do you suspect?
• How would you manage this patient?

The patient begins to have increased difficulty
swallowing, increased anxiety, and increased
difficulty breathing. What do you want to do
now?
199
Case Five

• At 0130 you are dispatched to an unconscious
  person--police on location. The patient is a
  27-year-old male who is apparently unconscious.
  The police report they found him lying in an
  alleyway while they were on routine patrol. He
  is known to live on the streets.

200
Case Five

• Initial Assessment
• Airway Controllable with manual positioning
• Breathing Very slow, shallow
• Circulation Radial pulses present, weak Skin
  pale, cool, moist Capillary refill 3 seconds
• Disability Unconscious, unresponsive to painful
  stimuli

What therapies would you like to begin?
201
Case Five

• Vital Signs
• P 70 regular, weak
• R 4 shallow, regular alcohol odor on breath
• BP 100/70
• Physical Exam
• HEENT Pupils pinpoint, non-reactive
• Chest BS present, equal bilaterally
• Abdomen Soft, non-tender
• Extremities Needle tracks present
• Blood glucose 40 mg/dl

202
Case Five

• What problem or problems do you suspect?
• How would you manage this patient?