RespEmergencies_eileen1

8/13/2019 RespEmergencies_eileen1

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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 thechest 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 andallow 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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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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Dyspnea

shortness of breath

difficulty breathing


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Apnea

respiratory arrest


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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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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 thebrain


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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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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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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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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 seenjust before resp. arrest. Shallow, gasping

Rhythm-may be regular or irregular


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Quality:

Breath sounds may be diminished or

absent

Depth (tidal volume) will be shallow,

inadequate

Chest expansion-may be unequal orinadequate

Respiratory effort may be increased


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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 ventilationsare 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 exhalebetween breaths

If no air goes in, reposition head

Check pulse frequently to monitor cardiacstatus


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COPD

Chronic obstructed pulmonary disease

Chronic Bronchitis

Emphysema


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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 ofO2 over 24 hours


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Hypoxic Drive

Not normally a problem in prehospital

environments

lw ysgive high flow oxygen to those whoneed 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 attackwhich 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 bodyobstruction

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 theneck 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 forceafter 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

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