Respiratory Emergencies Chapter 17 Respiratory Emergencies

Case History A 30-year-old male walks into your headquarters complaining of severe difficulty in breathing. The patient’s wife tells you that this started about 2 hours ago. He tells you that he has asthma and is carrying a metered-dose inhaler.

Respiratory System

Upper Respiratory Tract

Lower Respiratory Tract

Muscles of Respiration

Inspiration (Active Process) Diaphragm flattens, increases inferior-superior diameter of chest. External intercostals pull ribs up, increase anterior-posterior, lateral dimensions. Chest cavity increases in size – more volume, less gas, decrease in pressure, air rushes in Inspiration continues until pressure between lung and atmosphere equalizes.

Expiration (Passive Process) Elastic recoil of lungs plus muscle relaxation Chest cavity decreases in size – less volume, more gas, air rushes out to atmosphere. Expiration continues until atmosphere and chest pressure are equal.

Inspiration and Expiration

Diffusion of Oxygen and Carbon Dioxide

Pathophysiology – Airway Obstruction Obstruction by the tongue Unconsciousness Relaxed jaw and epiglottis Obstruction of the pharynx Evidenced by snoring Cleared with manual maneuvers and adjuncts

Pathophysiology – Airway Obstruction Swollen epiglottis and other airway structures Epiglottitis and anaphylaxis Obstruction at or above the vocal cords Evidenced by stridor or crowing Surgical airway may be needed Positive-pressure ventilation can be lifesaving.

Pathophysiology – Airway Obstruction Fluid in airway Aspiration, pulmonary edema, or drowning Evidenced by gurgling Immediate suctioning of the airway is critical.

Anatomy Considerations – Infants and Children Smaller airways Tongue is larger in relation to mouth. Trachea Narrower More pliable Cricoid cartilage Smaller and less rigid Narrowest portion of the airway Infants and children depend on diaphragm for breathing.

Problems Associated with Respiratory Patients Difficulty breathing Inadequate breathing (respiratory failure) Respiratory arrest

Adequate Breathing – Rate Adult: 12-20/min Child: 15-30/min Infant: 25-50/min

Adequate Breathing Rhythm Quality Depth (tidal volume) – adequate Regular Irregular Quality Breath sounds – present and equal Chest expansion – adequate and equal Minimum effort of breathing Depth (tidal volume) – adequate

Signs of Inadequate Breathing Very slow respiratory rate Very rapid respiratory rate Shallow breathing Diminished or absent breath sounds

Signs of Inadequate Breathing Altered level of consciousness Seesaw breathing (infants and children) Pale or cyanotic skin color Cool and clammy skin

Increased Work of Breathing Accessory muscle use Retractions Nasal flaring Sitting upright Tripod position

Inadequate Breathing Rate – outside of normal ranges Rhythm – irregular Quality Breath sounds – diminished or absent Chest expansion – unequal or inadequate Increased effort of breathing – use of accessory muscles – predominantly in infants and children Depth (tidal volume) – inadequate/shallow

Adequate Ventilation Chest rises and falls with each artificial ventilation. Rate Adults – 10-12/min Infants and children – 12-20/min Heart rate returns to normal.

Inadequate Ventilation The chest does not rise and fall with artificial ventilation. The rate is too slow or too fast. Heart rate does not return to normal with artificial ventilation.

Assessing the Patient with Difficulty Breathing

Scene Size-up Scene safety If trauma Be alert for toxic environment. Consider mechanism of injury. Provide spinal immobilization. Be alert for toxic environment. Body substance isolation If fluids are present in airway, consider need for eyewear, gowns, gloves, and mask. If TB is possible, consider need for HEPA respirator.

Initial Assessment – General Impression Is there obvious life threat, such as respiratory arrest? In what position is patient found? Bolt upright? Tripod? Sleepy or unresponsive? May require positive-pressure ventilation Does patient speak in complete sentences? Other obvious signs of respiratory distress?

Initial Assessment – Airway Signs of obstruction? Inability to speak Universal choking sign Sounds associated with obstruction Noisy breathing Crowing or stridor (upper airway) Gurgling (fluids) Snoring (tongue) Audible wheezing (lower airway)

Initial Assessment – Airway Management Manual maneuvers Head tilt/ chin lift Jaw thrust Use of adjuncts Nasopharyngeal airway Oropharyngeal airway FBAO maneuvers Suctioning Assistance with MDI medication (bronchiole constriction)

Initial Assessment – Breathing Decrease in tidal volume or rate (minute volume) Tidal volume  rate = minute volume Examples: Normal: 500 mL/breath  12 breaths/min = 6000 mL Hypoventilation: 200 mL/breath  12 breaths/min = 2400 mL Hypoventilation: 500 mL  6 breaths/min = 3000 mL Critical to evaluate Tidal volume (chest rise) Respiratory rate Other signs of hypoxia Mental state Skin color

Signs and Symptoms of Difficulty Breathing Shortness of breath Restlessness Increased pulse rate

Signs and Symptoms of Difficulty Breathing Pale or cyanotic skin Coughing Tripod position

Signs and Symptoms of Difficulty Breathing Shortness of breath Restlessness Increased breathing rate Decreased breathing rate

Skin Color Changes Cyanotic (blue-gray) Pale Flushed (red)

Signs and Symptoms of Difficulty Breathing Inability to speak because of breathing efforts Retractions – use of accessory muscles Shallow or slow breathing May lead to altered mental status with fatigue or obstruction Abdominal breathing (diaphragm only)

Signs and Symptoms of Difficulty Breathing Coughing Irregular breathing pattern Patient position Tripod position (sitting with feet dangling, leaning forward) Unusual anatomy (barrel chest)

Important Questions Onset Provocation Quality Radiation Severity Time Interventions

Primary Management of Respiratory Emergencies Airway management Positive-pressure ventilation Supplemental oxygen Positioning Administration of prescribed inhalers

Breathing Complains of trouble breathing Apply oxygen, if not already done. Assess baseline vital signs. Has a prescribed inhaler available Consult medical direction. Facilitate administration of inhaler.

Breathing Does not have prescribed inhaler Continue with focused assessment. Be prepared to intervene with appropriate oxygen administration. Positive-pressure ventilation (if patient will tolerate)

Prescribed Inhaler Generic name Trade name Albuterol, isoetharine, metaproterenol, etc. Trade name Proventil, Ventolin, Bronkosol, Bronkometer, Alupent, Metaprel, etc.

Prescribed Inhaler – Indications Exhibits signs and symptoms of respiratory emergency Has physician prescribed handheld inhaler? Specific authorization by medical direction

Prescribed Inhaler – Contraindications Inability of patient to use device Inhaler is not prescribed for the patient No permission from medical direction Patient has already met maximum prescribed dose before EMT arrival.

Administration of Inhaler Check the expiration date. Check to see if the patient has already taken any doses. Ensure that the inhaler is at room temperature or warmer. Shake the inhaler vigorously several times. Remove oxygen adjunct from patient. Have the patient exhale deeply.

Administration of Inhaler Replace oxygen adjunct on patient. Allow patient to breathe a few times. Repeat second dose per medical direction. If patient has a spacer device, it should be used for more effective results.

Actions of Inhaler Beta-agonist Dilates bronchioles Reduces airway resistance

Reassessment Strategies Gather vital signs. Perform focused reassessment. Patient’s condition may deteriorate. Consider need for positive-pressure artificial ventilation.

Side Effects of Inhaler Increased pulse rate Tremors Nervousness

Infant and Child Considerations Use of handheld inhalers is very common in children. Retractions are more common in children. Cyanosis is a late finding in children. Coughing rather than wheezing may be present in some children. Use of inhalers is the same if the indications are met by the ill child.

Causes of Respiratory Emergencies Chronic obstructive pulmonary disease Asthma Pneumonia Hyperventilation syndrome Spontaneous pneumothorax

Chronic Obstructive Pulmonary Disease (COPD) Chronic respiratory condition Chronic bronchitis Emphysema Primary complaint – dyspnea Bronchoconstriction

Chronic Bronchitis Chronic productive cough for > 3 mo/yr x 2 yrs Caused by smoking or long-term exposure to environmental pollutants

Chronic Bronchitis Bronchial obstruction = poorly ventilated alveoli = poorly oxygenated blood = cyanosis “Blue bloater”

Chronic Bronchitis Signs Cyanosis Edema – ankles, hips, abdomen Result of right-sided heart failure Jugular venous distention Wheezing, possible crackles

Emphysema Caused by destruction of alveoli Less lung surface for oxygen to diffuse into blood Small bronchioles damaged also Collapse on exhalation = air trapped in lungs Barrel chest Pursed lips Body may increase red blood cells and hemoglobin “Pink puffer”

COPD Signs Can only walk short distances Home oxygen

COPD Normal regulation for breathing – carbon dioxide Patients with COPD retain high levels of carbon dioxide. Regulation for breathing – low oxygen levels Supplemental oxygen may turn hypoxic drive off, resulting in hypoventilation or respiratory arrest. Be alert.

Prepare to assist ventilations. COPD Do not withhold oxygen for COPD patients in shock, with altered mental status, or in severe respiratory arrest. Prepare to assist ventilations.

Asthma Caused by constriction of the lower airways Signs Triggered by stress, infection, or allergy Signs Dyspnea Upright posture Possible accessory muscle use Flushing Forceful breathing Audible wheezing Fatigue Respiratory failure

Pneumonia Inflammation of alveolar spaces Signs and symptoms Interferes with normal exchange of oxygen with blood Signs and symptoms Depend on underlying cause Dyspnea Fever Cough Sputum production Crackles or diminished breath sounds

Hyperventilation Syndrome Increase in rate and depth of breathing = decreased amount of carbon dioxide Result: tingling around mouth and fingers, dizziness, possible nausea Often result of anxiety Check for underlying causes Asthma, COPD If no other known cause, administer oxygen, and calm reassurance.

Spontaneous Pneumothorax Rupture of part of the lung Allows air to exit the lung into the pleural space Lung may partially or totally collapse Frequently seen in thin, muscular men

Spontaneous Pneumothorax Signs Sudden onset of dyspnea and pleuritic chest pain Diminished breath sounds on one side Monitor patient for progression to tension pneumothorax Absent breath sounds on one side Distended neck veins Hypotension Tracheal deviation

Croup and Epiglottitis Usually occurs in children Epiglottitis can occur in adults. Croup – viral infection that causes swelling and narrowing of the upper airway (below thyroid cartilage) Epiglottitis – bacterial infection that causes swelling of the epiglottis

Croup and Epiglottitis Signs Fever Dyspnea Coughing Stridor or crowing Increased work of breathing Tripod position