Respiratory Emergencies

1. Respiratory Emergencies Chapter 16

2. Objectives • Respiratory Anatomy, Physiology, Pathophysiology – Normal breathing/Abnormal breathing • Respiratory Distress • Pathophysiology of conditions that cause respiratory distress • MDI and SVN • Age Variations – Pediatric and Geriatric • Assessment and Care – Primary and Secondary Assessments

3. Normal Breathing • Respiratory systems can be divided into 3 portions • Upper Airway – works with lower airway to conduct air in and out of the lungs • Lower Airway – Separated from upper airway by the vocal cords • Lungs and accessory structures – allow oxygenation of body cells and elimination of carbon dioxide

4. Patient breathing adequately • Intact (open) airway • Normal respiratory rate • Normal rise/fall of the chest • Normal respiratory rhythm • Breath sounds that present bilaterally • Chest expansion and relaxation occurs normally • Minimal – to – absent use of accessory muscles to aid in breathing You should also expect to find; • Normal mental status • Normal muscle tone • Normal pulse oximetry • Normal skin condition

5. Abnormal Breathing Conditions that can decrease the efficiency of gas exchange across the alveolar/capillary membrane; • Increased width of the space between alveoli and blood vessels • Lack of perfusion of the pulmonary capillaries from the right ventricle of the heart • Filling of the alveoli with fluid, blood or pus Accessory muscles, inspiratory/expiratory centers in the medulla and pone, stretch receptors in the walls of the lungs, irritant receptors in the walls of the bronchioles, and juxta-capillary receptors monitor breathing any can contribute to signs/symptoms of respiratory distress

6. Assessing breath sounds • Have patient sit upright • Use the diaphragm end of stethoscope over bare skin, tell patient to take deep, rhythmic breaths with mouth open • Place stethoscope over bare skin on patient’s thorax, listen all the way through the phases of inhalation/exhalation • Listen to sounds on one location, then listen to the exact location on the other side before moving on

8. Important to Remember! Lungs sounds should be checked on all patients complaining of difficulty breathing or who present in respiratory distress. 8

9. Types of Breath sounds • Wheezing • Rhonchi • Crackles (rales)

10. Respiratory Distress • Failing to breath adequately will result in hypoxemia and cellular death, which leads to all other body systems start to fail • May range from dyspnea to apnea • Hypoxia occurs when cells of the body are not getting adequate supply of oxygen

11. Findings in respiratory distress • Complaint of Shortness of Breath • Restlessness • Increased (early) or decreased (late) pulse rate • Changes to the rate or depth of breathing • Skin color changes • Difficulty or inability to speak • Muscle retractions • Altered mental status • Abdominal breathing • Excessive coughing • Tripod positioning • Decrease in pulse oximetry reading (< 95%)

12. Respiratory Distress Bronchoconstriction or bronchospasm – there is significant narrowing of the bronchioles to the lower airway from inflammation, swelling or constriction of muscle layer. • Look for bronchodilator medication • Watch for injuries to head, face, neck, spine, chest, abdomen, or associated with cardiac compromise, hyperventilation, and various abdominal conditions

13. Common causes • Mechanical disruption • Stimulation of the receptors • Inadequate gas exchange • Ventilation disturbance • Perfusion disturbance • Both ventilation and perfusion disturbances

14. Respiratory Distress – Patient has an adequate tidal volume and respiratory rate but is having difficulty breathing (Oxygen via NRB @ 15 lpm) Respiratory Failure – Patient’s tidal volume or respiratory rate is inadequate (Immediately begin ventilation with bag-valve-mask with supplemental oxygen) Respiratory Arrest – breathing effort ceases completely (can lead to cardiac arrest, expect CPR)

15. COPD

16. Obstructive Pulmonary Disease - Pathophysiology Causes an obstruction of airflow through the respiratory tract, leading to a reduction in gas exchange (hypoxia) • Emphysema • Chronic Obstructive Pulmonary Disease (COPD) • Characterized by destruction of alveolar walls and distention of alveolar sacs • Primary causation – smoking • Lung tissue loses elasticity, alveoli become distended with trapped air, walls of alveoli are destroyed • Drastic reduction in gas exchange = patient becomes hypoxic = retains carbon dioxide • Exhaling becomes active process rather than passive • Barrel-chest appearance is typical

17. Signs/Symptoms • Thin barrel-chest • Coughing, but little sputum • Dimished breath sounds • Wheezing/rhonchi on auscultation • Pursed-lip breathing • Extreme difficulty breathing with minimal exertion • Pink complexion • Tachypnea • Tachycardia • Diaphoresis • Tripod position • May be on home oxygen

18. Chronic bronchitis - Pathophysiology • COPD • Associated with smoking • Characterized by productive cough that persists for 3 consecutive months a year for 2 years • Involves inflammation, swelling, and thickening of lining of bronchi, bronchioles, and excessive mucous production • Recurrent infections leave scar tissue

19. Signs/Symptoms • Typically overweight • Chronic cyanotic complexion • Difficulty in breathing • Vigorous productive chronic cough with sputum • Coarse rhonchi usually heard upon auscultation • Wheezes/crackles at the bases of lungs

20. Emergency Care – Emphysema and bronchitis • Ensure open airway/adequate breathing • Assume position of comfort • Administer supplemental oxygen, MDI, or small-volume nebulizer (SVN) • Respiratory distress is evident, and trauma, shock, cardiac compromise, or any life-threatening conditions exist, administer high concentrations of oxygen via NRB @ 15 lpm • If not in significant distress, patient may just need oxygen via nasal cannula @ 2 – 3 lpm • Never withhold oxygen from any patient that requires it • Oxygen administration takes precedence over concerns of hypoxic drive is lost and cause patient to stop breathing • Consider CPAP or BiPAP

21. Asthma • Patient typically aware of condition and have medication • Characterized by increased sensitivity of lower airways to irritants/allergens • Conditions that can contribute to an attack; • Broncospasm • Edema • Increased mucous secretion that plugs smaller airways

22. Asthma • Patient usually suffers acute, irregular, period attacks, without signs/symptoms between attacks • Status asthmaticus – severe asthma attack that does not respond to oxygen or medication. Requires rapid transport with ALS • Extrinsic asthma (allergic) – results from reaction to dust, pollen, smoke or other irritants • Intrinsic asthma (non-allergic) – most common in adults from infection, emotional stress or strenuous exercise

23. Signs/Symptoms • Dyspnea that may progressively worsen • Non-productive cough • Wheezing on auscultation • Tachypnea • Tachycardia • Anxiety and apprehension • Possible fever • Allergic signs and symptoms • Chest tightness • Inability to sleep • SpO2 < 95% on room air (RA)

24. Signs/Symptoms of severe condition • Begin positive pressure ventilation with supplemental oxygen • Extreme fatigue or exhaustion • Inability to speak • Cyanosis to core of body • Heart rate < 150/min or slow rate • Quiet or absent breath sounds • Tachypnea > 32/min • Excessive diaphoresis • Accessory muscle use • Confusion • SpO2 < 90% on oxygen

25. Emergency Care • Establish/maintain open airway • Apply oxygen or positive pressure ventilation with supplemental oxygen • Assess circulation • Watch for chest rise when assisting ventilation to confirm adequate ventilation • Allow sufficient time for exhalation – avoid increasing pressure inside chest • Calm patient to reduce workload of breathing and oxygen consumption • MDI or SVN to administer beta agonist medication • Transport while continuously reassessing breathing status

26. Other diseases - Pneumonia Pathophysiology • An acute infectious disease caused by bacterium or virus affecting lower respiratory tract, causing lung inflammation and fluid-pus filled alveoli • Can also be caused by toxic irritants or aspiration of vomitus

27. Signs/Symptoms • Malaise and decreased appetite • Fever – might not show up in elderly • Cough • Dyspnea • Tachypnea and Tachycardia • Chest pain • Decreased chest wall movement/shallow respirations • Splinting of thorax with arm • Crackles and rhonchi • Altered mental status • Diaphoresis • Cyanosis • SpO2 < 95% Emergency Care Same as any respiratory distress patient

28. Pulmonary Embolism • Risks- experience long periods of immobility, heart disease, recent surgery, long-bone fracture, venous pooling associated with pregnancy, cancer, deep vein thrombosis, estrogen therapy, smokers

29. Pathophysiology • Sudden blockage of blood flow through pulmonary artery or one of it branches – blood clot, air bubble, fat particle, foreign body, amniotic fluid • Leads to decreased gas exchange with subsequent hypoxia

30. Signs/Symptoms • Sudden onset of dyspnea • Signs of difficulty breathing • Sudden onset of sharp, stabbing pain (most common) • Cough • Tachypnea (common), Tachycardia • Syncope • Cool, moist skin • Restlessness, anxiety, sense of doom • Decrease in blood pressure (late sign) • Cyanosis (late sign) • Distended neck veins (late sign) • Crackles • Fever • SpO2 < 95%

31. Emergency Care • Open airway, initiate positive pressure ventilation with supplemental oxygen or NRB at high concentration • Oxygen therapy must begin early and continuously and watch for signs of respiratory arrest • Transport immediately

32. Acute pulmonary edema • Most common in patient’s with cardiac function leading to CHF • Occurs when excessive amount of fluid collects in spaces between alveoli/capillaries, disturbing gas exchange • Cardiogenic pulmonary edema – an inadequate pumping function of the heart, increasing pressure in pulmonary capillaries and forcing fluid into the space between alveoli/capillaries • Non-cardiogenic pulmonary edema – destruction of capillary bed allowing fluid to leak out. Occurs with severe pneumonia, aspiration of vomit, narcotic overdose, trauma

33. Signs/Symptoms • Dyspnea • Difficulty breathing when lying down • Frothy sputum • Tachycardia • Anxiety, apprehension, combativeness, confusion • Tripod position • Fatigue • Crackles/wheezing, cough • Cyanosis or dusky color • Pale, moist skin • Distended neck veins • Swollen lower extremities • Symptoms of cardiac compromise • SpO2 < 95%

34. Emergency Care • Breathing inadequate – Positive pressure ventilation • Breathing adequate – Oxygen via NRB @ 15 lpm and monitor breathing status • Position patient in sitting position • Transport immediately

35. Spontaneous Pneumothorax • At risk: Males with history of smoking or connective tissue disorder and patients with COPD • Pathophysiology: • Portion of the visceral pleura ruptures without trauma and allows air to enter the pleural cavity, causing lung to collapse • Collapsed lung leads to disturbance in gas exchange/hypoxia

36. Signs/Symptoms • Sudden onset shortness of breath • Sudden onset of sharp chest pain or shoulder pain • Decreased breath sounds on one side of chest • Subcutaneous emphysema • Tachypnea • Diaphoresis • Pallor • Cyanosis (late with large pneumothorax) • SpO2 < 95% Subcutaneous Emphysema

37. Emergency Care • Oxygen via NRB @ 15 lpm if breathing adequate or positive pressure ventilation if inadequate • Suspect tension pneumothorax with cyanosis, hypotension, significant resistance to ventilation, and severe decline in pulse oximeter reading • Call for ALS

38. Hyperventilation Syndrome • Can be caused when patient is emotionally upset or excited or be a sign of serious underlying medical problem • Pathophysiology; • Patient is often anxious and feels unable to breath • Patient “blows off” excessive amounts of carbon dioxide from breathing faster and deeper

39. Signs/Symptoms • Fatigue • Nervousness and anxiety • Dizziness • Shortness of Breath • Chest tightness • Numbness/tingling around mouth, hands and feet • Tachypnea • Tachycardia • Spasms of fingers and feet, causing them to cramp • May precipitate seizures in a patient with a seizure disorder

40. Emergency Care • Calm patient down and slow breathing • Have them close mouth and breathe through nose • Remove patient from anxiety • Do not have patient breathe into a paper bag or oxygen mask not connected to oxygen! • Use only a carbon dioxide rebreathing technique if no other underlying medical problem • Apply pulse oximeter

41. Epiglottis • Most common cause used to be H influenza Type B, not a common anymore with vaccinations • Viruses, fungus, and bacteria is now the most common cause, especially adults • Pathophysiology; • Epiglottis and other structures connected to of surrounding it become inflamed and swollen, leading to compromised airway/respiratory compromise • Untreated, condition eventually leads to death

42. Signs/Symptoms • Dyspnea, with more rapid onset • High fever • Sore throat • Inability to swallow with drooling • Anxiety/apprehension • Tripod position, with jaw jutted forward • Fatigue • High pitched inspiratory stridor • Cyanosis or dusky colored skin • Trouble speaking • SpO2 < 95%

43. Emergency Care • Oxygen via NRB @ 15 lpm • Maintain calm/quiet environment • Keep patient in position of comfort • Ask for ALS • Transport quickly • Do not force inspection of airway if the patient is exchanging air adequately, it can cause the throat to swell more • Airway maneuvers with epiglottis are only warranted in extreme cases of respiratory occlusion • If patient continues to deteriorate, assistance with bag-valve-mask is not helping, ALS will consider intubation

44. Pertussis • Highly contagious disease affecting the respiratory system and is caused by bacteria in the upper airway • Spread by droplets from nose and mouth • Younger the patient, more severe the condition • Pathophysiology; • Starts as a cold or mild respiratory infection • Within 2 weeks, patient develops episodes of rapid coughing, following by “crowing” or “whooping” • Complications include pneumonia, dehydration, seizures, brain injuries, ear infections, and even death

45. Signs/Symptoms • History of upper respiratory infection • Sneezing, runny nose, low grade fever • General malaise • Increase in frequency and severity of coughing • Coughing fits, usually more at night • Vomiting • Inspiratory “whoop” heart at the end of coughting burst • Cyanosis during coughing burst • Diminishing pulse oximetry • Exhaustion from coughing burst • Trouble speaking and breathing during coughing burst

46. Emergency Care • Position of comfort • High-flow, high concentration oxygen (humidified) via NRB @ 15 lpm • Encourage patient to expectorate any mucus that is brought up during coughing burst • Ensure quiet environment • Expedite transport and upgrade to ALS • Prevent cross-contamination (BSI)

47. Cystic fibrosis • Hereditary disease causing patients to die at a young age (20’s – 30’s) from pulmonary failure • Pathophysiology; • Abnormal gene alters the functioning of the mucous glands lining the respiratory system, producing overabundance of very thick and sticky mucus • Mucus block the airway and causes an increase in the incidence of lung infections • Progressive diminishment in the efficiency of respiratory function

48. Signs/Symptoms • Commonly a known disease • Recurrent coughing • General malaise • Expectoration of thick mucus during coughing • Recurrent episodes of history of pneumonia, bronchitis and sinusitis • GI complaints that may include diarrhea and greasy, foul smelling bowel movements • Abdominal pain from intestinal gas • Malnutrition or low weight despite a healthy appetite • Dehydration • Clubbing of the digits • Trouble speaking and breathing with mucus buildup

49. Emergency Care • Care is toward symptomatic relief • Oxygen (humidified) via NRB @ 15 lpm if breathing adequate. Inadequate – positive pressure ventilation with supplemental oxygen • Consider normal saline using SVN to aid in thinning secretions (ALS care) • Allow patient to find position of comfort • Use pulse oximetry • Upgrade to ALS

50. Poisonous Exposures • Label for any type of inhalation injury that occurs secondary to exposure to toxic substances that can cause airway occlusion or pulmonary dysfunction by inhibiting the normal exchange of gasses at the cellular level