Respiratory Emergencies

By Sydorenko O.L.

ObjectivesUpon successful completion of this

program, you should be able to:

• review the signs and symptoms and field interventions for the patient presenting with COPD, and asthma.

• review criteria for the use of CPAP.

• review the SOP for Acute Pulmonary Edema, Asthma/COPD with Wheezing, and Conscious Sedation

Objectives cont’d• review the Whisperflow patient circuit for

CPAP used in the field.

• review the set up of the albuterol nebulizer kit and in-line Albuterol set-up.

CPAP

Continuous

Positive

Airway

PressureA means of providing high flow, low pressure oxygenation

to the patient in pulmonary edema

CPAP• CPAP, if applied early enough, is an effective way to

treat pulmonary edema and a means to prevent the need to intubate the patient

• CPAP increases the airway pressures allowing for better gas diffusion & for reexpansion of collapsed alveoli

• CPAP allows the refilling of collapsed, airless alveoli

• CPAP allows/buys time for administered medications to be able to work

CPAP expands the surface area of the collapsed alveoli allowing more surface area to be in contact with capillaries for gas exchange

With CPAP

Before CPAP

Goal of Therapy With CPAP• Increase the amount of

inspired oxygen

• Decrease the work load of breathing

In turn to: Decrease the need for

intubation Decrease the hospital stay Decrease the mortality rate

Patient Circuit

COPD• Chronic obstructive pulmonary

disease - a progressive and debilitating collection of diseases with airflow obstruction and abnormal ventilation with irreversible components (emphysema & chronic bronchitis)

• Exacerbation of COPD is an increase in symptoms with worsening of the patient’s condition due to hypoxia that deprives tissue of oxygen and hypercapnia (retention of CO2) that causes an acid-base imbalance

Obstructive Lung Disease - COPD & Asthma

• Abnormal ventilation usually from obstruction in the bronchioles

• Common changes noted in the airways– bronchospasm - smooth muscle

contraction– increased mucous production lining

the respiratory tree– destruction of the cilia lining

resulting in poor clearance of excess mucus

– inflammation of bronchial passages resulting in accumulation of fluid and inflammatory cells

Emphysema• Gradual destruction of the alveolar walls distal to the

terminal bronchioles• Less area available for gas exchange• Small bronchiole walls weaken, lungs cannot recoil as

efficiently, air is trapped in number of pulmonary capillaries which

resistance to pulmonary blood flow which leads to pulmonary hypertension– may lead to right heart failure & cor pulmonale (disease of

the heart because of diseased lungs)

Alveolar Sac and Capillaries

Bronchioles

capillary

alveolus

Interior of alveolus

Emphysema in PaO2 leads to in red blood cell production (to carry

more oxygen)

• Develop chronically elevated PaCO2 from retained carbon dioxide

• Loss of elasticity/recoil; alveoli dilated• More common in men; major contributing factor is cigarette

smoking; another contributing factor is environmental exposures

• Patients more susceptible to acute respiratory infections and cardiac dysrhythmias

Chronic Bronchitis• An increase in the number of

mucous-secreting cells in the respiratory tree

• Large production of sputum with productive cough

• Diffusion remains normal because alveoli not severely affected

• Gas exchange decreased due to lowered alveolar ventilation which creates hypoxia and hypercarbia

Asthma• Chronic inflammatory disorder of the airways

• Airflow obstruction and hyperresponsiveness are often reversible with treatment

• Triggers vary from individual environmental allergenscold air; other irritantsexercise; stressfood; certain medications

Asthma’s Two-Phase Reaction• Phase one - within minutes

– Release of chemical mediators (ie: histamine)• contraction of bronchial smooth muscle

(bronchoconstriction)• leakage of fluid from bronchial capillaries (bronchial

edema)

• Phase two - in 6-8 hours– Inflammation of the bronchioles from invasion of the mucosa

of the respiratory tract from the immune system cells• additional swelling & edema of bronchioles

Severe Asthma Attack

• One and two word dyspnea

• Tachycardia

• Decreased oxygen saturation on pulse oximetry

• Agitation & anxiety with increasing hypoxia

Treatment Goals -COPD & Asthma

Relieve and correct hypoxiaReverse any bronchospasm or

bronchoconstriction

Asthma/COPD with Wheezing SOP• Routine medical care• Pulse oximetry (on room air if possible)• Albuterol 2.5 mg / 3ml with oxygen adjusted to 6

l/minute• May repeat Albuterol treatments if needed• May need to consider intubation with in-line

administration of Albuterol based on the patient’s condition

• EMS to contact Medical Control for possible CPAP in patient with COPD

Albuterol Nebulizer Procedure• Medication is added to the chamber which must be kept

upright• The T-piece is assembled over the chamber• The patient needs to be coached to breath slowly and as

deeply as possible– this will take time and several breathes before the patient can

slow down and start breathing deeper; the patient needs a good coach to talk them through the slower/deeper breathing

– the medication needs to be inhaled into the lungs to be effective– the patient should be sitting upright

Add medication to the chamber

Connect the mouthpiece to the T-piece

Connect the corrugated tubing to the T-piece

Kit connected to oxygen and run at 6 l/minute (enough to create a mist)

Encourage slow, deep breathing

Albuterol Nebulizer Mask

For the patient who is unable to keep their lips sealed around the mouthpiece, take the top T-piece off the kit and replace with an adult or pediatric nebulizer mask

Pediatric patient using

nebulizer mask.

Caregiver may assist in holding the mask.

What To Do in Extreme Asthma Attack

• At times, the asthma attack is so severe the patient is at risk of dying

• To relieve the bronchoconstriction, Albuterol needs to be delivered right into the lungs

• To assist with this, the patient may need to be bagged or intubated to deliver the medication

• Abuterol is delivered via in-line technique

Aerosol Medication via BVM or ETT with BVM (In-line)

• Albuterol placed in the chamber as usual

• The chamber is connected to the T-piece

• Adaptor(s) are used to accommodate bagging the patient with in-line Albuterol as soon as possible

– any medication that can be delivered as soon as possible to the target organ (the lungs) will be helpful in promoting bronchodilation

• Mouthpiece removed from T-piece and replaced with BVM

• Nebulizer still connected to oxygen source

• Adaptor placed at distal end of corrugated tubing to connect to BVM mask or ETT

Albuterol Delivered Via BVM

• #1 Disconnect reservoir bag with L valve from mask

• #2 Connect L shaped valve with bag where mouthpiece of albuterol kit would fit

• #3 Place corrugated tubing of albuterol kit to the mask over the patient’s mouth

• #4 Begin to bag to “blow” the drug into the lungs while waiting to complete intubation

#1

#2

#3, #4

To 6lO2

• Adaptor connected to the distal end of the corrugated tubing of Albuterol kit connected to the proximal end of the ETT

• ETT placement confirmed in the usual manner– visualization– chest rise & fall– 5 point auscultation

– ETCO2 detector

Intubatedpatient