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BIEMS CEU BIEMS CEU CourseCourse

Acute Respiratory DistressAcute Respiratory Distress

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IntroductionIntroduction

ARD patients are a challenge for BLS technicians.ARD patients are a challenge for BLS technicians.

Many states limit the level of care that a BLS tech Many states limit the level of care that a BLS tech can provide.can provide.

Therefore, it is critical for basic EMS providers to Therefore, it is critical for basic EMS providers to have extremely sharp BLS level skills and to know have extremely sharp BLS level skills and to know when to pass the patient off to an ALS tech.when to pass the patient off to an ALS tech.

Much can still be done at the BLS level to save the Much can still be done at the BLS level to save the patient’s life, as we’ll learn in today’s program.patient’s life, as we’ll learn in today’s program.

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Learning ObjectivesLearning Objectives Identify and treat acute respiratory distress (ARD) Identify and treat acute respiratory distress (ARD)

secondary to congestive heart failure/pulmonary secondary to congestive heart failure/pulmonary edema.edema.

Identify and treat ARD secondary to chronic Identify and treat ARD secondary to chronic obstructive pulmonary disease (emphysema and/or obstructive pulmonary disease (emphysema and/or chronic bronchitis) and asthma.chronic bronchitis) and asthma.

Identify and treat ARD caused by other common Identify and treat ARD caused by other common and not-so-common problems.and not-so-common problems.

Discuss adjuncts of respiratory therapy commonly Discuss adjuncts of respiratory therapy commonly used by EMS provider with the ARD patient. used by EMS provider with the ARD patient.

PULSE ClassroomLearning Objective: Learning Objective: Congestive Heart Failure Congestive Heart Failure (CHF)(CHF) Condition in which the heart cannot pump enough Condition in which the heart cannot pump enough

blood into other organs, causing a backup of fluid into blood into other organs, causing a backup of fluid into the lungsthe lungs

Common cause of ARDCommon cause of ARD RiskRisk factorsfactors

Coronary artery diseaseCoronary artery disease HypertensionHypertension SmokingSmoking Alcohol and drug useAlcohol and drug use

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Signs and Symptoms of Signs and Symptoms of CHFCHF

Tachycardia (rate of over 100 per minute)Tachycardia (rate of over 100 per minute) Shortness of breath (dyspnea)Shortness of breath (dyspnea) Normal or elevated blood pressureNormal or elevated blood pressure CyanosisCyanosis Pulmonary edemaPulmonary edema Anxiety or confusionAnxiety or confusion Pedal edemaPedal edema Engorged pulsating jugular (neck) veinsEngorged pulsating jugular (neck) veins

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Signs and Symptoms of Signs and Symptoms of CHF CHF (cont.)(cont.)

Adventitious lung soundsAdventitious lung sounds Weight gainWeight gain FatigueFatigue Difficulty sleepingDifficulty sleeping CoughCough Decreased urine outputDecreased urine output Chest painChest pain Need for home oxygen therapyNeed for home oxygen therapy

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Pre-hospital Treatment of Pre-hospital Treatment of CHFCHF Scene safetyScene safety ABCsABCs Stable vs. unstable?Stable vs. unstable? Vital signsVital signs History (SAMPLE)History (SAMPLE) Lung soundsLung sounds Pulse oximetry (if available)Pulse oximetry (if available)

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Pre-hospital Treatment of Pre-hospital Treatment of CHF CHF (cont.)(cont.)

Physical exam as appropriatePhysical exam as appropriate Proper patient positioning (i.e., sitting Proper patient positioning (i.e., sitting

upright)upright) Oxygen administration via:Oxygen administration via:

A—nasal cannulaA—nasal cannula B—facemask (simple, partial re-breather or B—facemask (simple, partial re-breather or

non-rebreather)non-rebreather) Re-evaluateRe-evaluate

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Knowledge AssessmentKnowledge Assessment

What are five symptoms of CHF that EMS What are five symptoms of CHF that EMS providers may see in a patient with possible providers may see in a patient with possible CHF?CHF?

PULSE ClassroomLearning Objective: Chronic Learning Objective: Chronic Obstructive Pulmonary Obstructive Pulmonary DiseaseDisease

Chronic obstructive pulmonary disease (COPD) is Chronic obstructive pulmonary disease (COPD) is chronic but may have acute bouts of ARD.chronic but may have acute bouts of ARD.

Types of COPD:Types of COPD:

Emphysema Emphysema Chronic bronchitisChronic bronchitis

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Chronic BronchitisChronic Bronchitis

Inflammation of lung tissueInflammation of lung tissue Long-term diseaseLong-term disease Presentation and treatment similar to emphysemaPresentation and treatment similar to emphysema Caused by:Caused by:

Cigarette, pipe, or cigar smokingCigarette, pipe, or cigar smoking Exposure to toxins or irritants (dust, chemicals, coal dust, etc.)Exposure to toxins or irritants (dust, chemicals, coal dust, etc.) Frequent lung infectionsFrequent lung infections Family history/other genetic factorsFamily history/other genetic factors

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EmphysemaEmphysema

Also known as “black lung”Also known as “black lung” Caused by cigarette smoking, toxic exposure, or repeated Caused by cigarette smoking, toxic exposure, or repeated

infectionsinfections Takes years to be noticedTakes years to be noticed Risk factors:Risk factors:

AgeAge Tobacco use and second-hand smokeTobacco use and second-hand smoke Occupational (toxic fumes, vapors, etc.)Occupational (toxic fumes, vapors, etc.) Pollution (both indoor and outdoor)Pollution (both indoor and outdoor) HeredityHeredity Connective tissue disordersConnective tissue disorders

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Signs and Symptoms of Signs and Symptoms of COPDCOPD

Early signs/symptomsEarly signs/symptoms Trouble breathing especially during activityTrouble breathing especially during activity Morning coughingMorning coughing Colds and respiratory infections more often than previously notedColds and respiratory infections more often than previously noted

Later signsLater signs Skin, lips, nail beds turning blueSkin, lips, nail beds turning blue Pursed lipsPursed lips More SOB with less exertionMore SOB with less exertion WheezingWheezing Faster and more shallow breathingFaster and more shallow breathing Patient losing weightPatient losing weight AnxietyAnxiety Positional breathing (leaning forward)Positional breathing (leaning forward)

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Treatment of COPDTreatment of COPD

Stable patientStable patient

Scene safety is paramount.Scene safety is paramount. Wear personal protective equipment (PPE).Wear personal protective equipment (PPE). Conduct thorough patient exam.Conduct thorough patient exam. Administer oxygen.Administer oxygen. NEVER WITHHOLD OXYGEN FROM A PATIENT WHO NEVER WITHHOLD OXYGEN FROM A PATIENT WHO

NEEDS IT.NEEDS IT.

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Treatment of COPD Treatment of COPD (cont.)(cont.)

Unstable patientUnstable patient

Provide ventilationProvide ventilation Bag valve mask is the “tool of choice”Bag valve mask is the “tool of choice” In COPD patients, avoid PPV (can cause In COPD patients, avoid PPV (can cause

pneumothorax)pneumothorax)

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Patient MedicationsPatient Medications

Patient may already have respiratory nebulizers or Patient may already have respiratory nebulizers or atomizers.atomizers.

EMS providers can usually assist patient with their EMS providers can usually assist patient with their prescribed inhaler.prescribed inhaler. MAKE SURE THIS IS ALLOWED IN YOUR AREA.MAKE SURE THIS IS ALLOWED IN YOUR AREA.

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Recommendations for MDI Recommendations for MDI or Nebulizer Assistanceor Nebulizer Assistance

Examine the medications. Examine the medications. Ensure that the patient is alert enough to use Ensure that the patient is alert enough to use

the inhaler or nebulizer, and of significant the inhaler or nebulizer, and of significant importance is the patient’s tidal volume. importance is the patient’s tidal volume.

Shake the MID vigorously before use. Ensure it Shake the MID vigorously before use. Ensure it is not cold; room temperature is best.is not cold; room temperature is best.

Try and get the patient to exhale deeply before Try and get the patient to exhale deeply before inhaling the medications.inhaling the medications.

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Recommendations for MDI Recommendations for MDI or Nebulizer Assistance or Nebulizer Assistance (cont’d)(cont’d)

After inhalation, see if the patient can hold his After inhalation, see if the patient can hold his or her breath a bit for the medication to be or her breath a bit for the medication to be absorbed. absorbed.

The EMS provider's role is mainly “coaching” The EMS provider's role is mainly “coaching” more than actually administering the more than actually administering the medications.medications.

Follow local protocol and consult medical Follow local protocol and consult medical direction as appropriatedirection as appropriate

REMEMBER: NEVER WITHHOLD OXYGEN!REMEMBER: NEVER WITHHOLD OXYGEN!

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Knowledge AssessmentKnowledge Assessment

What is the “tool of choice” for providing What is the “tool of choice” for providing ventilation to a patient in respiratory ventilation to a patient in respiratory distress?distress?

PULSE ClassroomLearning Objective:Learning Objective:Less Common Causes of Less Common Causes of ARDARD

AnaphylaxisAnaphylaxis

HyperventilationHyperventilation

Spontaneous pneumothoraxSpontaneous pneumothorax

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AnaphylaxisAnaphylaxis

Allergic reaction shock that may be triggered Allergic reaction shock that may be triggered by:by: insect (bee, fire ant, etc.) stings.insect (bee, fire ant, etc.) stings. food allergies (peanuts, etc.).food allergies (peanuts, etc.). drug allergies/reactions.drug allergies/reactions.

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AnaphylaxisAnaphylaxis

Signs/symptoms:Signs/symptoms: Tightness in the throat or chestTightness in the throat or chest CoughCough Labored, noisy breathingLabored, noisy breathing Hoarse, muffled voiceHoarse, muffled voice Wheezing (sometimes audible without a stethoscope)Wheezing (sometimes audible without a stethoscope) Altered mental statusAltered mental status Flushed, dry or pale, or cool and clammy skinFlushed, dry or pale, or cool and clammy skin Nausea or vomitingNausea or vomiting Changes in blood pressure (hypotension)Changes in blood pressure (hypotension)

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Treatment of AnaphylaxisTreatment of Anaphylaxis

IMMEDIATE TREATMENT IS REQUIRED.IMMEDIATE TREATMENT IS REQUIRED. Assess ABCs and maintain an open airway.Assess ABCs and maintain an open airway. Call for an ALS unit to intercept or rendezvous if available.Call for an ALS unit to intercept or rendezvous if available. Start the patient on high-flow oxygen.Start the patient on high-flow oxygen. Evaluate respiratory effectiveness (tidal volume, effort, etc.).Evaluate respiratory effectiveness (tidal volume, effort, etc.). Assess lung sounds.Assess lung sounds. Evaluate blood pressure.Evaluate blood pressure. Patient positioning if the patient is hypotensive.Patient positioning if the patient is hypotensive. Ventilate the patient with BVM or other appropriate pressure Ventilate the patient with BVM or other appropriate pressure

device.device. Monitor oxygen saturation (SaOMonitor oxygen saturation (SaO22).).

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HyperventilationHyperventilation

Rarely life-threatening; often caused by psychological stressorsRarely life-threatening; often caused by psychological stressors

Sometimes referred to as “behavioral breathlessness”Sometimes referred to as “behavioral breathlessness”

Signs and symptoms:Signs and symptoms: Agitation/anxietyAgitation/anxiety Sudden onset of chest painSudden onset of chest pain DyspneaDyspnea DizzinessDizziness WeaknessWeakness PalpitationsPalpitations WheezingWheezing Tetanic cramps (carpopedal spasm)Tetanic cramps (carpopedal spasm) ParesthesiasParesthesias Syncope Syncope

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Treatment of Treatment of HyperventilationHyperventilation

Remove the stressor. Remove the stressor.

Apply a pulse oximeter. Hypoxia can cause hyperventilation, too.Apply a pulse oximeter. Hypoxia can cause hyperventilation, too.

Rebreathing into a paper bag is not recommended in the field. Rebreathing into a paper bag is not recommended in the field.

Treat with supplemental oxygen. Treat with supplemental oxygen.

Try to find the source of the hyperventilation. Transport to the Try to find the source of the hyperventilation. Transport to the closest appropriate facility.closest appropriate facility.

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Spontaneous Spontaneous PneumothoraxPneumothorax

Collection of air or gas in the lung, causing collapseCollection of air or gas in the lung, causing collapse

Occurs in the absence of traumaOccurs in the absence of trauma

Primarily occurs in people without lung disease in tall, thin men Primarily occurs in people without lung disease in tall, thin men between the ages of 20-40 between the ages of 20-40

May also occur in conjunction with:May also occur in conjunction with: tuberculosis.tuberculosis. pneumonia.pneumonia. asthma.asthma. cystic fibrosis.cystic fibrosis. lung cancer.lung cancer. interstitial lung disease.interstitial lung disease.

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Signs and Symptoms of Signs and Symptoms of Spontaneous PneumothoraxSpontaneous Pneumothorax

Sudden chest pain; breathing makes the Sudden chest pain; breathing makes the pain worsepain worse

Shortness of breathShortness of breath TachypneaTachypnea Abnormal breathing movementAbnormal breathing movement CoughingCoughing

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Treatment of Treatment of Spontaneous PneumothoraxSpontaneous Pneumothorax

Ensure adequate respiratory function and tidal Ensure adequate respiratory function and tidal volume.volume.

Use pulse oximetry to monitor oxygen Use pulse oximetry to monitor oxygen saturation.saturation.

General supportive care for stable patients.General supportive care for stable patients. Positive pressure ventilation for unstable Positive pressure ventilation for unstable

patients.patients. Call ALS techs or transport ASAP if patient Call ALS techs or transport ASAP if patient

decompensates.decompensates.

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Knowledge AssessmentKnowledge Assessment

What are the signs and symptoms of What are the signs and symptoms of anaphylactic shock?anaphylactic shock?

PULSE ClassroomLearning Objective: Learning Objective: Adjuncts of Respiratory Adjuncts of Respiratory Care Care

Oxygen delivery equipmentOxygen delivery equipment Come in various sizesCome in various sizes Must be tested every 5 yearsMust be tested every 5 years NEVER USE ANY TYPE OF OIL NEAR ONEVER USE ANY TYPE OF OIL NEAR O22 EQUIPMENT EQUIPMENT

““D” cylinder – about 350 liters of oxygen (most D” cylinder – about 350 liters of oxygen (most commonly used by EMS providers)commonly used by EMS providers)

““E” cylinder – about 625 liters of oxygenE” cylinder – about 625 liters of oxygen ““M” cylinder – about 3,000 liters of oxygenM” cylinder – about 3,000 liters of oxygen

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Patient Care EquipmentPatient Care Equipment

Nasal cannulaNasal cannula Percentage of oxygen delivered is between 24 and 44 percentPercentage of oxygen delivered is between 24 and 44 percent Not to be used on hypoxic patientsNot to be used on hypoxic patients Should be attached by inserting the prongs in the nostrils, Should be attached by inserting the prongs in the nostrils,

around the ears and then under the chin; NOT in the nostrils around the ears and then under the chin; NOT in the nostrils and then back behind the headand then back behind the head

Oxygen flow rates range between 4-6 liters per minute (LPM) Oxygen flow rates range between 4-6 liters per minute (LPM) but 2-3 LPM are not uncommon for patients on home oxygen but 2-3 LPM are not uncommon for patients on home oxygen via nasal cannulavia nasal cannula

Usually well tolerated by patientsUsually well tolerated by patients Patients with inadequate tidal volume should Patients with inadequate tidal volume should NEVERNEVER have a have a

nasal cannula applied for obvious reasonsnasal cannula applied for obvious reasons

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Non-rebreather Oxygen MaskNon-rebreather Oxygen Mask

Excellent 0Excellent 022 delivery tool delivery tool Important points:Important points:

Should only be used in patients with adequate tidal volume.Should only be used in patients with adequate tidal volume. Delivers between 80-90 percent oxygen.Delivers between 80-90 percent oxygen. Oxygen flow rates range around 12-15 LPM.Oxygen flow rates range around 12-15 LPM. Always inflate the reservoir bag before applying to the patient Always inflate the reservoir bag before applying to the patient

by closing off the non-rebreather valve after turning on the by closing off the non-rebreather valve after turning on the oxygen flow.oxygen flow.

Adjust flow rates to not allow bag deflation by more than one-Adjust flow rates to not allow bag deflation by more than one-third.third.

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Venturi Face MaskVenturi Face Mask

Used for long transport situationsUsed for long transport situations

Simple face mask with an adaptorSimple face mask with an adaptor

Adaptor accepts different color-coded Adaptor accepts different color-coded inserts to control the percentage of oxygeninserts to control the percentage of oxygen

Oxygen tubing attaches to the insertOxygen tubing attaches to the insert

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Bag Valve MaskBag Valve Mask

““Tool of choice” in the non-breatherTool of choice” in the non-breather Biggest usage pitfall: improper mask size Biggest usage pitfall: improper mask size

and sealand seal ““E-C” method works well when a single E-C” method works well when a single

rescuer must operate the BVMrescuer must operate the BVM

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CPAPCPAP

Generally used by ALS techs BUT some states Generally used by ALS techs BUT some states are now allowing EMS providers to perform are now allowing EMS providers to perform CPAP under certain conditionsCPAP under certain conditions

Consists of:Consists of: mask.mask. hose.hose. pressure regulator.pressure regulator. PEEP. PEEP.

Indicated in CHF patients but not in other Indicated in CHF patients but not in other COPD patientsCOPD patients

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Pulse Oximetry Devices Pulse Oximetry Devices

Formerly for in-hospital useFormerly for in-hospital use Noninvasively checks the percentage of 0Noninvasively checks the percentage of 022 saturation in saturation in

the blood on the patient’s fingerthe blood on the patient’s finger Normal: 95-99 percent Normal: 95-99 percent COPD patient: 88-92 percentCOPD patient: 88-92 percent Nail polish can cause false readingsNail polish can cause false readings Use different arm for blood pressure readingUse different arm for blood pressure reading Disinfect the probe between patientsDisinfect the probe between patients Get a “room air” reading before 0Get a “room air” reading before 022 administration administration

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Oxygen HumidifiersOxygen Humidifiers

Hook up between the supply and the Hook up between the supply and the patient.patient.

Use sterile water to humidify oxygen.Use sterile water to humidify oxygen. Used primarily for long transport times.Used primarily for long transport times. Used in 0Used in 022 administration for COPD administration for COPD

patientspatients

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Knowledge AssessmentKnowledge Assessment

What are normal SaOWhat are normal SaO22 levels? levels?

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ConclusionConclusion

Acute respiratory distress can be challenging Acute respiratory distress can be challenging to treat in the field.to treat in the field.

Aggressive and appropriate airway and Aggressive and appropriate airway and respiratory management are critical.respiratory management are critical.

EMS providers are encouraged to train and EMS providers are encouraged to train and learn more about ARD emergencies in order to learn more about ARD emergencies in order to improve patient care.improve patient care.

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End of PresentationEnd of Presentation

Good luck with the test!Good luck with the test!