Pulmonary Diseases & Disorders: Assessment

1. Pulmonary Diseases & Disorders: Assessment

2. Pulmonary Diseases & Disorders • Epidemiology • 28% of all EMS Chief Complaints in the US • >200,000 deaths annually due to respiratory emergencies

3. Pulmonary Diseases & Disorders • Many, many pulmonary diseases • Difficult to learn all pathophysiologies • All can be categorized as affecting: • Ventilation • Diffusion (Respiration) • Perfusion • Treatment can be focused on identifying and treating source of ventilatory/respiratory impairment

4. Sources of Pulmonary Impairment • Pulmonary Diseases • Disorders of the Pulmonary System • Non-Pulmonary Disorders/Disease Impairing Ventilation or Respiration • What examples can you list for each of these?

5. Ventilation Upper Airway Trauma Epiglottitis FBAO Inflammation of tonsils Lower Airway Trauma Obstructive lung disease Mucous accumulation Smooth muscle spasm Airway edema Sources of Pulmonary Impairment

6. Ventilation Chest Wall Impairment Trauma Hemothorax Pneumothorax Empyema Pleural inflammation Neuromuscular diseases Neurologic Control Brainstem dysfunction Phrenic or spinal nerve dysfunction Sources of Pulmonary Impairment

7. Diffusion Inadequate FiO2 Diseased alveoli asbestosis COPD inhalation injury Capillary bed disease atherosclerosis Interstitial space disease High pressure pulmonary edema High permeability pulmonary edema Sources of Pulmonary Impairment

8. Perfusion Inadequate blood volume or hemoblogin hypovolemia anemia Impaired blood flow pulmonary embolus Capillary wall pathology trauma Sources of Pulmonary Impairment

9. Risk Factors for Pulmonary Disease • Intrinsic Risk Factors • Genetic predisposition • asthma • COPD • carcinoma • Cardiac or Circulatory pathologies • Source for pulmonary edema • Source for pulmonary emboli • Stress

10. Risk Factors for Pulmonary Disease • Extrinsic Factors • Smoking •  prevalence of COPD & carcinomas •  severity of pulmonary disease • Environmental Factors •  prevalence of COPD & asthma •  severity of all obstructive disorders

11. Function of the Pulmonary System • Gas Exchange System • ~10,000 liters of air are filtered, warmed and humidified daily • Oxygen diffused into blood • Carbon dioxide excreted from the body

12. Function of the Pulmonary System • Physiology of Ventilation • Requires neurologic initiation (brainstem) • Nerve conduction pathways between brainstem and muscles of respiration • Intact & patent Upper and Lower airways • Intact & non-collapsed alveoli

13. Function of the Pulmonary System • Physiology of Respiration • Simple diffusion process at the pulmonary-capillary bed • Diffusion Requirements • Intact, non-thickened alveolar walls • Minimal interstitial space & without additional fluid • Intact, non-thickened capillary walls

14. Function of the Pulmonary System • Physiology of Perfusion • Process of circulating blood through the capillary bed • Perfusion Requirements • Adequate blood volume • Adequate hemoglobin • Intact, non-occluded pulmonary capillaries • Functioning Left Heart

15. Control of Ventilation • Control ventilation in response to physiologic needs • Driven 1° by pH of CSF • influenced largely by PaCO2 • 2° drive = PaCO2 • 3° drive = PaO2 detected by chemoreceptors • very small population with severe COPD

16. Nervous System Effect on Ventilation • Medulla • Stimulation to initiate ventilation • Phrenic Nerve • Innervation of the diaphragm • Spinal Nerves at Thoracic levels • Innervation of intercostal muscles • Hering-Breuer reflex • Prevents overinflation

17. General Assessment • Size-Up • Environment • Airborne Hazards • Number of patients • Needs • Specialized rescue equipment • Protective equipment • Is the environment creating or exacerbating the pulmonary condition?

18. General Assessment • Initial Goal • Identify potentially life-threatening pulmonary conditions • Perform minimal PE & Hx • Initiate immediate & appropriate therapies • Then, continue PE & Hx • Try to determine if origin is ventilation, diffusion, perfusion or combination

19. General Assessment • Signs of potentially life-threatening pulmonary condition • altered mental status • absent signs of ventilation • Audible stridor or wheezing • Able to speak in short phrases only • Sustained Tachycardia • Pallor / Diaphoresis • Accessory muscle use / Retractions

20. Assessment: H&P • Present History (focused hx) • Chief Complaint • Dyspnea • “Subjective sensation that breathing is excessive, difficult or uncomfortable • CP • Cough, Hemoptysis • Associated Symptoms • Fever, Chills •  sputum production • Fatigue

21. Assessment: H&P • Present History (focused hx) • Sputum Findings •  amount of sputum  infection • Thick green or brown  pneumonia or infection • Yellow or gray  allergic or inflammatory response • Hemoptysis  tuberculosis or carcinoma • Pink, frothy  severe pulmonary edema

22. Assessment: H&P • HX of Present Illness • How long has dyspnea been present? • Gradual or sudden onset? • What aggravates or alleviates? • Hx of orthopnea? • Coughing? • Productive cough? • What does sputum look/smell like? • Pain? • What does the pain feel like?

23. Assessment: H&P • Listen - To Pt. Breathe or Talk • Noisy Breathing is Obstructed Breathing • Not All Obstructed Breathing is Noisy • Snoring - Tongue Blocking Airway • Stridor - “Tight” Upper Airway from Partial Obstruction • Observe Breathing • Tachypnea • Bradypnea

24. Assessment: H&P • Observe • Body Positioning • Tripod • Legs in dependent position • Mental Status • Ventilatory Effort • Accessory muscle use / retractions • Abdominal muscle use • Chest wall expansion • Nasal flaring, pursed lips

25. Assessment: H&P • Physical Exam of the Chest • Increased A-P Diameter • Lung Sounds • Abnormal: stridor, wheezing, rhonchi, rales, pleural rub • Chest expansion • Symmetrical Findings • Evidence of Trauma

26. Assessment: H&P • Physical Exam • Cyanosis? • Late, unreliable sign of Hypoxia • Oxygenate Immediately! Especially If: • Decreased LOC • Possible Shock • Possible Severe Hemorrhage • Chest Pain • Chest Trauma • Respiratory distress or dyspnea • HX of any Kind of Hypoxia

27. Assessment: H&P • Physical Exam • Vital Signs • Skin Color, Temp & Moisture • Respiratory Rate • No an accurate lone indicator of respiratory status unless very slow • Respiratory Rhythm/Pattern • Pulse • Bradycardia vs Tachycardia • Blood Pressure

28. Assessment: H&P • Physical Exam - Circulatory assessment • Is the heart beating? • Is there major external hemorrhage? • Is the Pt. Perfusing vital organs? • Effects of hypoxia: • Early in adults - Tachycardia • Late in adults - Bradycardia • Children - Bradycardia

29. Assessment: H&P • Don’t let respiratory failure distract you from assessing for circulatory failure. • Vascular Access

30. Assessment: H&P • Physical Exam • Extremities • Peripheral Cyanosis • Clubbing • Carpopedal spasm • Peripheral edema

31. Assessment: H&P • Diagnostic Testing • Pulse oximetry • Saturation • Inaccuracies & Disadvantages • Peak Flow Meter • Baseline measurement for obstructive lung disease • Often available from patient • Capnometry • real-time assessment of endotracheal tube placement • quantitative vs qualitative

32. Assessment: H&P • Past History • Similar Episodes in Past • Patient’s description of acuity • “What happened last time you had an episode this bad?” • Chronic Symptoms • Acute, Seasonal SOB episodes • Seasonal Allergies • Chronic cough • Recurrent flu, pulmonary infection or SOB

33. Assessment: H&P • Past History • Known diagnosis • Does the present H&P correlate with this past history? • CHF • Hypertension • Renal Failure • Previous intubation or hospitalization • Aggravating Factors (e.g. smoking)

34. Assessment: H&P • Past History • Medications • Class, Route, Frequency of Use • Pulmonary • Sympathomimetics • Corticosteroids • MAST Cell Stabilizer • Methylxanthines • Cardiovascular • Diuretics • Antihypertensives • Cardiac glycosides

35. Assessment: H&P • Disability • Restlessness, anxiety, combativeness = HYPOXIA Until Proven Otherwise • Drowsiness, lethargy = HYPERCARBIA When the patient stops fighting, he is not necessarily getting Better!!

36. Other Adventitious Sounds • Cough • Forced exhalation against partially closed glottis • Reflex response to mucosa irritation • Determine circumstances • At work • Postural changes • Lying down • Productive vs non-productive

37. Other Adventitious Sounds • Sneeze • Forced exhalation via nasal route • Clears nasal passages • Reflex response to mucosa irritation • Sigh • Slow, deep inspiration - Prolonged, audible exhalation • Reexpands areas of atelectasis

38. Other Adventitious Sounds • Hiccough • Hiccups, singultus • Spasm of diaphragm followed by glottic closure • No useful purpose • Benign, transient