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Our Agenda Today

“Sometimes a Wheeze is Not Just a Wheeze…” COPD and CHF Silver Cross EMS System February 2013 1 st Trimester CME. Our Agenda Today . Review airway anatomy and physiology Review the differences between COPD and CHF. Review use of CPAP and nitroglycerin in CHF and pulmonary edema.

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Our Agenda Today

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  1. “Sometimes a Wheeze is Not Just a Wheeze…” COPD and CHFSilver Cross EMS SystemFebruary 2013 1st Trimester CME

  2. Our Agenda Today • Review airway anatomy and physiology • Review the differences between COPD and CHF. • Review use of CPAP and nitroglycerin in CHF and pulmonary edema. • Take a look at some newer airway techniques and gadgets on the market. • (ALS) EKG strip o’ the month: AV blocks/pacing

  3. Quick A & P Review

  4. Anatomy of the Upper Airway

  5. Internal Anatomy of the Upper Airway

  6. Anatomy of the Lower Airway

  7. Anatomy of the Pediatric Airway

  8. COPD vs. CHF • One is respiratory • One is cardiac • They may seem the same, but their treatments are very different!

  9. COPD • Bronchitis • Emphysema • Asthma • Varying degrees/combination • Long-term tobacco abuse, exposure to inhaled toxins

  10. COPD - Bronchitis • Mucus overproduction • Cell enlargement in lungs, airways • Productive cough 3+ months, 2+ years • Hypoventilation of alveoli, drops O2 level in blood • Acidosis • Increased cardiac output, RBC production

  11. Normal Lung Bronchitis

  12. COPD - Emphysema • Involves alveoli • Alveolar destruction • Alveolar coalescence • Destruction of elastin fibers surrounding alveoli • Chronic hypoxia, hypercarbia

  13. Emphysema • Blebs on lung surface, possible pneumothorax • Polycythemia • Muscle wasting, malnourished appearance • Barrel chest

  14. Emphysema • Chronic dyspnea • Little/no cough, little mucus production • Tripod position • Mental status changes • Heart problems, cor pulmonale, ventricular failure

  15. COPD-Asthma • Bronchiole hyperstimulation, constriction • Wheezing, dyspnea • Mucus production

  16. COPD • Therapeutic interventions • Transport immediately • Do all treatment en route if possible • IV option unless patient is near respiratory failure • Albuterol (Ventolin) 2.5 mg via nebulizer (repeat x1) • Can give in-line via ET tube if necessary • With medical control approval: • Epinephrine 1:1000 @ 0.01 mg/kg up to 0.3 mg IM (repeat in 15 min) • CPAP • Consider Methylprednisolone (solu-medrol) 125 mg IVP. • No longer just for longer transports

  17. Congestive Heart Failure - CHF

  18. CHF • Congestive heart failure can involve one side of the heart, or both.

  19. Left Heart Failure • Left ventricle fails as an effective forward pump • Causes backup of blood into pulmonary circulation • Causes • MI • Valvular disease • Chronic HTN • Dysrhythmias • LV dysfunction • Causes LA pressure rise • Pulmonary HTN • PCP rises • Serum is forced into alveoli • Pulmonary Edema

  20. LHF Signs & Symptoms • Severe Respiratory Distress • Orthopnea, dyspnea, spasmodic coughing, pink frothy sputum • Paroxysmal Nocturnal Dyspnea (night time SOB) • Severe Apprehension, Agitation and Confusion • Smothering feeling • As hypoxia worsens  agitation • Cyanosis • Diaphoresis

  21. Prehospital Management of LHF • Patients in LHF can decompensate rapidly • Goals • Decrease venous return to heart (preload) • Decrease myocardial oxygen demands • Improve ventilation and oxygenation

  22. Prehospital management cont. • CPAP! • Keeps more fluid from entering the alveoli • Forces those alveoli to exchange gases • In Region VII, ALS and BLS crews both can use CPAP! • Nitroglycerin! • Vasodilates • Forces fluid out of alveoli further

  23. Nitroglycerin • One tablet or spray sublingual • Systolic blood pressure higher than 110 • May repeat x2 in 5 minutes. • If no IV, consider contacting medical control. • Ask about ED drugs.

  24. Continuous Positive Airway Pressure (CPAP)

  25. What Is CPAP? • CPAP is continuous positive airway pressure. • Designed to apply positive pressure to the airways of a spontaneously breathing patient throughout the respiratory cycle. • Airways are maintained in the open position during exhalation.

  26. Goal of Therapy With CPAP? • Goal • to increase amount of inspired oxygen and decrease the work load of breathing • to reduce the need for emergent intubations of the patient in pulmonary edema • to increase the oxygenation levels of the patient • to reduce mortality and decrease hospital length of stay

  27. Indications For Use of CPAP • Patient with acute pulmonary edema/CHF • Alert, cooperative adult patient • Systolic blood pressure >90 • No presence of nausea or vomiting • No major trauma • Patent airway • SaO2 <95 • Lung sounds - crackles

  28. CPAP And Pulmonary Edema • Severe pulmonary edema is a frequent cause of respiratory failure • CPAP increases functional residual capacity • CPAP increases transpulmonary pressure • CPAP improves lung compliance • CPAP improves arterial blood oxygenation • CPAP redistributes extravascular lung water

  29. When Not To Use Mask CPAP • Hypercapnia • Pneumothorax • Hypovolemia • Severe facial injuries • Patients at risk of vomiting

  30. Common Complications With CPAP • Pressure sores • Gastric distension • Pulmonary barotrauma • Reduced cardiac output • Hypoventilation • Fluid retention

  31. Patient Monitoring During Use of CPAP • Patient tolerance, mental status • Respiratory pattern • rate, depth, subjective feeling of improvement • Lung sounds • B/P, pulse rate and quality, SaO2, EKG pattern • Complications to monitor for: • gastric distention • nausea & vomiting

  32. Criteria For Discontinuing Use of CPAP • Emergent need to intubate the patient • Inability of the patient to tolerate the tight fitting mask • success of tolerance to the treatment increased with proper coaching by EMS crew • Hemodynamic instability (B/P drops below 90 systolic)

  33. More treatments if necessary… • Albuterol if wheezing continues from co-morbid COPD • Make sure it’s wheezing, not crackles/rales • Albuterol can increase workload of heart • Lasix/Morphine if medical control approves • Research showing these may not do what we thought they always did

  34. Right Heart Failure • Right Ventricle fails as an effective forward pump • Results in backpressure of blood into systemic venous circulation • Causes • The most common cause of right heart failure is left heart failure • Systemic HTN • Pulmonary HTN  RV / RA enlargement • Pulmonary Emboli • Causes pulmonary HTN

  35. RHF Signs & Symptoms • Tachycardia • Attempt to compensate • Venous Congestion • Peripheral Edema • Ankles in ambulatory pts • Presacral in bedridden • Severe pitting edema • JVD • Fluid accumulation in serous cavities • Abdominal (ascites) • Pleural Space (effusion) • Pericardium (effusion) • Liver engorgement History Prior MI / Chronic Pump Failure Lasix / Lanoxin

  36. Prehospital Management of RHF • Not usually emergent, unless accompanied by LHF • Limit IV fluids A good time for a saline lock, if you have them. • IMC • Treat signs and symptoms of respiratory distress

  37. COPD vs. CHF • COPD • Expiratory wheeze • Skinny w/barrel chest • History of asthma/emphasema/bronchitis • Treat w/neb • CHF • Crackles/rales • Retaining fluid • Blood-tinged sputum (pink puffers) • History of afib/heart failure/edema/ • Treat w/CPAP, nitro

  38. Some New Airway Procedures and Gadgets • Wave-form capnography • Quick-trach • King vision laryngoscope

  39. Using capnography in intubation…

  40. Capnography • Phase I • Beginning of exhalation when air from anatomic dead space being exhaled • Baseline

  41. Capnography • Phase II • CO2 from larger bronchi begins to pass sensor • Expiratory upslope • Sharp increase in CO2 concentration passing sensor, rapid departure of waveform from baseline • Rapidly departs from Phase I, vertical line

  42. Capnography • Phase III • Alveolar plateau • CO2-rich alveolar air passing sensor • Flat, straight/slightly angled upward

  43. Capnography • Phase 0 • End of exhalation, beginning of inhalation • CO2 levels passing sensor quickly drop to 0 • Quick return of waveform to baseline • Straight line, rapidly returns to baseline

  44. Approach to Patient Normal Capnogram

  45. Important Points • Capnography is a dynamic monitoring mechanism. • The therapeutic range for CO2 levels is 35-45. • It’s a positive/negative feedback system for how resuscitation efforts are going. • Not just an initial tool for intubation • Can hit record on monitors to chart CO2 levels. • If tube dislodged during transfer to ER bed, medics have proof that tube was in trachea during transport.

  46. Inline Capnography

  47. Bottom Line There are too many esophageal intubations in the field. If you have access to waveform capnography, use it!

  48. A short video • http://youtu.be/p4TkeCkBeHw • This is made by Medtronics but is applicable information no matter what capnography/monitor combo you plan to use.

  49. Colorimetric end-tidal CO2 detector.

  50. Quick Trach

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