30 Respiratory Emergencies: Infectious Disorders

Objectives Review frequency of infectious respiratory disorders. Relate pathophysiology of infectious disorder to presenting signs and symptoms. Discuss current treatment standards for patients with dyspnea from an infectious disorder. Discuss the objectives.

Introduction This topic deals with disorders that alter normal gas diffusion in the lungs due to an infectious pulmonary problem. As in previous topics, the patient will have general dyspnea findings, but the history should help illustrate the cause. Because many findings of respiratory distress actually result from the body's attempt to improve breathing adequacy, not necessarily from the specific pulmonary condition, it is important to remember that pulmonary conditions may present very similarly. As such, many of the Advanced EMT's treatment modalities are similar for these varied conditions. In this topic, the focus will be on infectious disorders that afflict the pulmonary system and lead to respiratory distress. In any instance, however, it is important for the Advanced EMT to recognize the signs and symptoms of respiratory emergencies, complete a thorough patient interview and physical assessment to determine the cause, and provide immediate intervention.

Epidemiology Lower respiratory infections are a leading cause of death worldwide. CDC reports recent outbreaks of pertussis in the United States. VRIs are the most common cause of symptomatic disease among children and adults. Discuss the frequency of these disease processes. The intent being that they are a common emergency that will be seen by the Advanced EMT.

Pathophysiology Pneumonia Bacteria or virus induced Lower respiratory lung infection Can result in fluid- or pus-filled alveoli Diminishes ventilation (V/Q ratio) with resultant dyspnea and blood gas alterations Pneumonia is primarily an acute infectious disease, caused by bacteria or a virus that affects the lower respiratory tract and causes lung inflammation and fluid- or pus-filled alveoli.

Pneumonia causes inflammation of the lungs and causes the alveoli to fill with fluid or pus, leading to poor gas exchange.

Pathophysiology (cont’d) Pertussis Whooping cough Development of heavy mucus from airway Paroxysms of coughing Complications include pneumonia, dehydration, seizures, brain injuries Pertussis typically starts out very similar to a cold or a mild upper respiratory infection. Because of this, the parents of the infant or child (or in the situation of an older patient) may try “waiting it out” before seeking medical care; thus, by the time the patient presents to EMS, the condition may be severe. Within two weeks or so of onset, the patient will develop episodes of numerous rapid coughs (15–24 episodes) as the body attempts to expel thick mucus from the airway, followed by a “crowing” or “whooping” sound made during inhalation as the patient breathes in deeply and rapidly.

Pathophysiology (cont’d) Viral respiratory infections Common VRIs Bronchiolitis, colds, flu Usually mild and self-limiting Can cause upper or lower respiratory infections Cause inflammatory response and mucus production in airway structures In any situation, however, it is nearly impossible (nor is it practical) for the EMT to determine whether the associated findings of respiratory distress from a VRI etiology are in fact viral in nature or not, as there is no specific treatment for viral infections that the Advanced EMT can administer. The mainstay of treatment for respiratory distress secondary to a VRI is supportive in nature and includes: Patient positioning Airway and breathing maintenance Oxygen administration Administer beta-2-specific agonist only if bronchoconstriction is suspected Transport to the hospital for ongoing diagnosis and management

Assessment Findings General assessment findings Common to most patients with dyspnea Changes in respiratory rate and breath sounds Accessory muscle use Tripod positioning and retractions Nasal flaring, mouth breathing Changes in pulse oximetry and vitals Skin change and mental status changes If adequate breathing and gas exchange are not present, the lack of oxygen will cause the body cells to begin to die. Some cells become irritable when they are hypoxic, causing the cells to function abnormally. Oxygen levels decrease, carbon dioxide increases, the blood becomes acidic, and if left unmanaged or improperly managed—there will be a cellular shift from aerobic to anaerobic metabolism. The Advanced EMT must be keenly aware on how to differentiate adequate breathing with inadequate breathing. If the patient is inadequately breathing, there is no way they can oxygenate effectively and the patient will die.

Assessment Findings (cont’d) Additional findings with pneumonia Malaise and decreased appetite Cough (possibly productive) General dyspnea findings Pleuritic chest pain Diaphoresis Possible fever Discuss findings more specific to pneumonia.

Assessment Findings (cont’d) Additional findings with pertussis History of URI Runny nose, low-grade fever Episodes of coughing followed by “whooping” sound Fatigue from coughing Discuss these additional findings that are more specific to pertussis.

Assessment Findings (cont’d) Additional findings with a VRI Nasal congestion Irritated or painful throat Mild dyspnea Fever Malaise, headache, body ache Poor feeding in infants Discuss these additional findings that are more specific to a patient with a VRI.

Emergency Medical Care Ensure airway adequacy. Provide oxygen based on ventilatory need. NRB mask at 15 lpm with adequate breathing PPV with 15 lpm oxygen with inadequate breathing In patients with respiratory distress from infectious disorders, the primary management the Advanced EMT should provide should be geared toward ensuring adequate ventilation while maximizing oxygenation. This is accomplished through the use of high-flow oxygen in the adequately breathing patient, or by the application of positive pressure ventilation with oxygen supplementation in the patient who is breathing inadequately. Treatment may also include administration of a bronchodilator (MDI or small volume nebulizer) if bronchoconstriction is suspected.

Emergency Medical Care (cont’d) Administer inhaled bronchodilator PRN. Keep patient sitting upright if possible. Provide rapid transport to the ED. In patients with respiratory distress from infectious disorders, the primary management the Advanced EMT should provide should be geared toward ensuring adequate ventilation while maximizing oxygenation. This is accomplished through the use of high-flow oxygen in the adequately breathing patient, or by the application of positive pressure ventilation with oxygen supplementation in the patient who is breathing inadequately. Treatment may also include administration of a bronchodilator (MDI or small volume nebulizer) if bronchoconstriction is suspected.

Case Study You are called to an elder care facility for a patient with an altered mental status. Upon your arrival, you are escorted to a patient's room where an elderly male patient lies in bed, seemingly asleep. Discuss the case study.

Case Study (cont’d) Scene Size-Up Scene is safe, standard precautions taken. Patient is 91 years old, about 145 lbs. Entry and egress from room is unobstructed. NOI appears to be altered mental status. No additional resources needed. Discuss the case study.

Case Study (cont’d) Primary Assessment Findings Patient moans to loud verbal stimuli. Airway patent and self-maintained. Breathing adequate but tachypneic. Central and peripheral pulses present. Skin is noted to be diaphoretic. Discuss the case study.

Case Study (cont’d) Medical History Medications Allergies Patient has history of pancreatic cancer Medications Primarily comfort medications Allergies Demerol Discuss the case progression.

Case Study (cont’d) Pertinent Secondary Assessment Findings Pupils equal and reactive, membranes dry. Airway patent, breathing rapid with markedly diminished breath sounds over left lung – some crackles and rhonchi discernible. Peripheral perfusion intact, heart rate fast and regular. Discuss the case progression.

Case Study (cont’d) Pertinent Secondary Assessment Findings (continued) Pulse ox 92% on room air, B/P WNL. Skin diaphoretic and warm. Patient has not eaten for a day and a half. Fever 101.5 F° Discuss the case progression.

Case Study (cont’d) What pathologic change is causing the abnormal breath sounds? What respiratory condition does this patient likely have? What would be three assessment findings that could confirm your suspicion? The diminished breath sounds on the right can only be a few things since it is a unilateral finding. Differentials include: Pneumonia Pneumothorax Lung CA Bronchial obstruction Given the full clinical picture, findings are most consistent with pneumonia. Pneumothorax usually has diminished sounds to the lung apex, lung CA would have appeared in the medical history, and aspiration causing bronchial obstruction is a possibility, but it should have presented shortly after the obstruction, not days later. Although this call came in as an altered mental status, it was actually a change in mental status due to a pulmonary infectious disorder. Breath sounds, elevated temp, change in mental status, geriatric patient, confined in elder care facility, and low pulse ox all help complete the clinical picture.

Case Study (cont’d) Care provided: Patient placed on high-flow oxygen. Placed in a semi-Fowler position on wheeled cot. Transport initiated to ED. Discuss the care provided.

Summary With infectious disorders, many times the presentation will be the same despite a varied etiologic background. Fortunately, treatment of most all infectious diseases is similar enough that if the exact cause is not known, the treatment will still be appropriate. Review as appropriate.