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Respiratory Emergencies East Region (Washington) OTEP M-7

Respiratory Emergencies East Region (Washington) OTEP M-7. Brian Reynolds, MD Deaconess Medical Center Spokane, WA. Respiratory Emergencies. We are going to cover material for ALL levels of training YOU CAN ONLY PRACTICE AT THE LEVEL YOU HAVE BEEN CERTIFIED. Topics.

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Respiratory Emergencies East Region (Washington) OTEP M-7

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  1. Respiratory EmergenciesEast Region (Washington) OTEPM-7 Brian Reynolds, MD Deaconess Medical Center Spokane, WA

  2. Respiratory Emergencies • We are going to cover material for ALL levels of training • YOU CAN ONLY PRACTICE AT THE LEVEL YOU HAVE BEEN CERTIFIED

  3. Topics • Anatomy and function of the Respiratory System • Patient Assessment • Airway Management

  4. Anatomy of the Upper Airway

  5. Upper Airway • Nasal cavity • Oral cavity • Pharynx

  6. Nasal Cavity • Nares • Mucous membranes • Sinuses

  7. Oral Cavity • Cheeks • Hard palate • Soft palate • Tongue • Gums • Teeth

  8. Pharynx • Nasopharynx • Oropharynx • Laryngopharynx

  9. Larynx • Thyroid cartilage • Cricoid cartilage • Glottic opening • Vocal cords • Arytenoid cartilage • Pyriform fossae • Cricothyroid cartilage

  10. Internal Anatomy of the Upper Airway

  11. Lower Airway Anatomy • Trachea • Bronchi • Alveoli • Lung parenchyma • Pleura

  12. Anatomy of the Lower Airway

  13. Definitions • Atelectasis – collapse of small segments of lung • Hypoxia – lack of oxygen • Hypoxemia – lack of oxygen in arterial blood

  14. Introduction • Ventilation is the mechanical process that brings O2 to the lungs, and clears CO2 from the lungs • Oxygenation is the diffusion of O2 to the blood • Perfusion is the flow of blood through the lungs (thus exchanging oxygen and CO2) • Brain stem is the involuntary regulator of respirations

  15. Respiratory Physiology • Ventilation • Body Structures • Chest Wall • Pleura • Diaphragm • Tidal Volume: • 7ml/kg (Adult 500ml)

  16. Pathophysiology • Disruption in Ventilation • Upper & Lower Respiratory Tracts • Obstruction due to trauma or infectious processes • Chest Wall & Diaphragm • Trauma • Pneumothorax • Hemothorax • Flail chest • Neuromuscular disease

  17. Oxygenation • Room air – 21% FiO2 • Roughly 3% increase per liter • Nasal cannula – 8L max (40%) • Mask – 10L (55%) • NRB mask – 15L (80%)

  18. Pulmonary Circulation

  19. Respiratory Physiology • Pulmonary Perfusion • Requirements • Adequate blood volume • Intact pulmonary capillaries • Efficient pumping by the heart • Hemoglobin • Carbon Dioxide

  20. Pathophysiology • Disruption in Perfusion • Alteration in systemic blood flow • Changes in hemoglobin • Pulmonary shunting • Damaged alveoli

  21. Fever Increases Emotion Increases Pain Increases Hypoxia Increases Acidosis Increases Increase Depressants Decrease Sleep Decreases Respiratory Factors Effect Factor Stimulants

  22. Assessment of the Respiratory System • Scene Assessment • Threats to Safety • Make sure you are safe first • Identify rescue environments having decreased oxygen levels • Gases and other chemical or biological agents • Clues to Patient Information

  23. Assessment of the Respiratory System • Initial Assessment • General Impression • Position • Color • Mental status • Ability to speak • Respiratory effort

  24. Assessment of the Respiratory System • Airway • Proper ventilation cannot take place without an adequate airway • Breathing • Signs of life-threatening problems • Alterations in mental status • Severe central cyanosis, pallor, or diaphoresis • Absent or abnormal breath sounds • Speaking limited to 1–2 words • Tachycardia • Use of accessory muscles or intercostal retractions

  25. Abnormal Respiratory Patterns Kussmaul’s respirations: • Deep, slow or rapid, gasping; common in diabetic ketoacidosis Cheyne-Stokes respirations: • Progressively deeper, faster breathing alternating gradually with shallow, slower breathing, indication brain stem injury

  26. Abnormal Respiratory Patterns Agonal respirations: • Shallow, slow, or infrequent breathing,indicating brain anoxia

  27. Focused History & Physical Exam • History • SAMPLE History • Paroxysmal nocturnal dyspnea and orthopnea • Coughing, fever, hemoptysis • Associated chest pain • Smoking history or environmental exposures • Similar Past Episodes

  28. Focused History & Physical Exam • Physical Examination • Inspection • Look for asymmetry, increased diameter, or paradoxical motion • Palpation • Feel for subcutaneous emphysema or tracheal deviation • Percussion • Auscultation

  29. Focused History & Physical Exam • Auscultation • Normal Breath Sounds • Bronchial, Bronchovesicular, and Vesicular • Abnormal Breath Sounds • Snoring • Stridor • Wheezing • Rhonchi • Rales/Crackles • Pleural friction rub

  30. Focused History & Physical Exam • Diagnostic Testing • Pulse Oximetry • Inaccurate Readings

  31. Ausculation • Listen at the mouth and nose for adequate air movement • Listen with a stethoscope for normal or abnormal air movement • Proper listening positions

  32. Airway Obstruction • The tongue is the most common cause of airway obstruction • Foreign bodies • Trauma • Laryngeal spasm and edema • Aspiration

  33. Congestive Heart Failure • Wet, crackly lung sounds • Lower extremity edema • Must sit and sleep upright • Frothy, pink sputum

  34. Obstructive Lung Disease • Types • Emphysema • Chronic Bronchitis • Asthma • Causes • Genetic Disposition • Smoking & Other Risk Factors

  35. Emphysema • Assessment • Physical Exam • Barrel chest • Prolonged expiration and rapid rest phase • Thin • Pink skin due to extra red cell production • Hypertrophy of accessory muscles • “Pink Puffers”

  36. Chronic Bronchitis • Physical Exam • Often overweight • Rhonchi present on auscultation • Jugular vein distention • Ankle edema • Hepatic congestion • “Blue Bloater”

  37. Asthma • Physical Exam • Presenting signs may include dyspnea, wheezing, cough • No wheezing is severe disease • Speech may be limited to 1–2 word sentences • Look for hyperinflation of the chest and accessory muscle use/feel chest wall for crepitus • Carefully auscultate breath sounds and measure peak expiratory flow rate

  38. Pneumonia • Infection of the Lungs • Immune-Suppressed Patients • Pathophysiology • Bacterial & Viral Infections • Hospital-acquired vs. community-acquired • Alveoli may collapse, resulting in a ventilation disorder

  39. Lung Cancer • Pathophysiology • General • Majority are caused by carcinogens secondary to cigarette smoking or occupational exposure • May start elsewhere and spread to lungs • High mortality • Types • Adenocarcinoma • Epidermoid, small-cell, and large-cell carcinomas

  40. Toxic Inhalation • Pathophysiology • Includes inhalation of heated air, chemical irritants, and steam • Airway obstruction due to edema and laryngospasm due to thermal and chemical burns • Assessment • Focused History & Physical Exam • SAMPLE & OPQRST History • Determine nature of substance • Length of exposure and loss of consciousness

  41. Carbon Monoxide Inhalation • Pathophysiology • Binds to Hemoglobin • Prevents oxygen from binding to RBC’s • Room air half life – 6 hrs., HBO – 23 minutes • Assessment • Focused History and Physical Exam • SAMPLE & OPQRST History • Determine source and length of exposure • Presence of headache, confusion, agitation, lack of coordination, loss of consciousness, and seizures

  42. Pulmonary Embolism • Pathophysiology • Obstruction of a pulmonary artery • Emboli may be of air, thrombus, fat, or amniotic fluid • Foreign bodies may also cause an embolus • Risk Factors • Recent surgery, long-bone fractures • Pregnant or postpartum • Oral contraceptive use, tobacco use • Immobility • Blood disorders

  43. Spontaneous Pneumothorax • Pathophysiology • Pneumothorax • Can occur in the absence of blunt or penetrating trauma • Risk factors • Assessment • Focused history • SAMPLE • Presence of risk factors • Rapid onset of symptoms • Sharp, pleuritic chest or shoulder pain • Often precipitated by coughing or lifting

  44. Hyperventilation Syndrome • Assessment • Focused History & Physical Exam • SAMPLE • Fatigue, nervousness, dizziness, dyspnea, chest pain • Numbness and tingling in mouth, feet, and both hands • Presence of tachypnea and tachycardia • Spasms of the fingers and feet

  45. Airflow Compromise Gas Exchange Compromise Snoring Crackles Gurgling Rhonchi Stridor Wheezing Quiet Airway Sounds

  46. Basic Mechanical Airways

  47. Insert oropharyngeal airway with tip facing palate

  48. Rotate airway 180º into position

  49. Nasopharyngeal Airway(Do not use if significant facial trauma)

  50. Advanced Airway Management

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