1. Respiratory Emergencies
Chapter 17
Respiratory Emergencies

2. 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.

3. Respiratory System

4. Upper Respiratory Tract

5. Lower Respiratory Tract

6. Muscles of Respiration

7. 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.

8. 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.

9. Inspiration and Expiration

10. Diffusion of Oxygen and Carbon Dioxide

11. 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

12. 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.

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

14. 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.

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

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

17. 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

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

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

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

21. 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

22. 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.

23. 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.

24. Assessing the Patient with Difficulty Breathing

25. 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.

26. 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?

27. 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)

28. 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)

29. 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

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

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

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

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

34. 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)

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

36. Important Questions Onset Provocation Quality Radiation Severity Time
Interventions

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

38. 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.

39. 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)

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

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

42. 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.

43. 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.

44. 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.

45. Actions of Inhaler Beta-agonist Dilates bronchioles
Reduces airway resistance

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

47. Side Effects of Inhaler
Increased pulse rate
Tremors
Nervousness

48. 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.

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

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

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

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

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

54. 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”

55. COPD
Signs
Can only walk short distances
Home oxygen

56. 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.

57. 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.

58. 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

59. 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

60. 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.

61. 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

62. 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

63. 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

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