our agenda today

“Sometimes a Wheeze is Not Just a Wheeze…”

COPD and CHF

Silver Cross EMS SystemFebruary 2013 1st 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.• Take a look at some newer airway techniques

and gadgets on the market.• (ALS) EKG strip o’ the month: AV blocks/pacing

Quick A & P Review

Anatomy of the Upper Airway

Internal Anatomy of the Upper Airway

Anatomy of the Lower Airway

Anatomy of the Pediatric Airway

COPD vs. CHF

•One is respiratory•One is cardiac•They may seem the same, but their treatments are very different!

– Bronchitis– Emphysema– Asthma– Varying degrees/combination– Long-term tobacco abuse, exposure to inhaled

toxins

COPD

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

Normal Lung Bronchitis

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

Emphysema

–Blebs on lung surface, possible pneumothorax–Polycythemia–Muscle wasting, malnourished appearance–Barrel chest

Emphysema

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

COPD-Asthma

–Bronchiole hyperstimulation, constriction–Wheezing, dyspnea–Mucus production

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

Congestive Heart Failure - CHF

CHF

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

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

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

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

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

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.

Continuous Positive Airway Pressure (CPAP)

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.

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

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

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

When Not To Use Mask CPAP

Hypercapnia

Pneumothorax

Hypovolemia

Severe facial injuries

Patients at risk of vomiting

Common Complications With CPAP

Pressure sores Gastric distension Pulmonary barotrauma Reduced cardiac output Hypoventilation Fluid retention

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

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)

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

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

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 engorgementHistory Prior MI / Chronic Pump Failure Lasix / Lanoxin

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

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

Some New Airway Procedures and Gadgets

• Wave-form capnography• Quick-trach• King vision laryngoscope

Using capnography in intubation…

Capnography

• Phase I– Beginning of exhalation when air from anatomic dead space being

exhaled– Baseline

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

Capnography

• Phase III– Alveolar plateau– CO2-rich alveolar air passing sensor

– Flat, straight/slightly angled upward

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

Approach to PatientNormal Capnogram

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.

Inline Capnography

Bottom Line

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

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.

Colorimetric end-tidal COColorimetric end-tidal CO22 detector. detector.

Quick Trach

CricothyroidotomyIndications

• Upper airway obstruction which cannot be dislodged by back blows or direct larygoscopy and Magill forceps.

• Inability to insert an ETT past edema• Destructive facial injury precluding the use of

ALS upper airway adjuncts.

Anatomical Landmarksfor Cricothyroidotomy

Thyroid CartilageCricothyroid

Membrane

Cricoid Cartilage

Quicktrach

• More expensive than needle crichs, but really easy to use!

• Silver Cross EMS only allows the 4mm size, no pediatric Quicktrachs in this system.

Quicktrach

neck strap

syringe

stopper

hub of catheter

Picture courtesy Christ Medical Center

Quicktrach Procedure

• Patient supine with head slightly extended if no cervical spine trauma suspected

• Locate the cricothyroid membrane• Cleanse the overlying skin

Quicktrach Procedure cont’d• Puncture cricothyroid membrane at 90 degree angle• Aspirate air through syringe• Change the angle of insertion to 60 degrees• Slide catheter sheath forward to level of stopper• Remove stopper – may be a bit tight.• Advance plastic cannula while removing needle and

syringe

Quicktrach Procedure cont’d

• Ventilate the patient• Secure catheter in place using the strap provided• Confirm placement– Auscultation, bilateral chest rise and fall

King Vision Video Laryngoscope

From the brochure…

• Durable• The King Vision is designed to be your primary tool for intubations• The display comes with a 1-year warranty• The robust, full-color, non-glare display can resist repeated cleaning and normal use wear and tear• The camera and light source are enclosed in the disposable blade, keeping the display free of fragile optics

• Portable• The King Vision is light weight, self-contained and battery operated• Assembled, the device is water resistant• Reusable display comes packaged in a protective, foam case• Blades are individually packaged so that the King Vision can be taken anywhere

• Affordable• The disposable blades allow economical use of the King Vision for all of your intubations• Low cost per use procedure• High performance visualization capabilities

In the pyxis now…

• Silver Cross stocks unchanneled #3 King Vision video laryngoscope blades in the pyxis now.

• Not an endorsement of the product, just an accommodation for providers who use them.

• Good intubation techniques and practice still trump gadgets.

EKG Strip O’ the Month

• AV Blocks

Review - AV Junction

62

• AV Junction = AV Node and Bundle of His• Pacemaker cells located throughout AV

Junction

Review - Functions of AV Node

63

• Backup pacemaker for SA Node• Creates delay between atrial and ventricular

depolarizations• Physiologic block for rapid supraventricular

rhythms

Degrees of AV Blocks

64

• First Degree - Delay in conduction• Second Degree - Some impulses blocked• Third Degree - All impulses blocked

First Degree AV Block

65

• An abnormal slowing of AV Junction conduction

First Degree AV Block ECG Criteria

66

• Rate - Dependent on underlying rhythm– Interpretation must include underlying rhythm

• Rhythm - Dependent on underlying rhythm• P-Waves - Normal morphology with one P-

Wave for each QRS• PRI - > .20 seconds and constant• QRS - Dependent on underlying rhythm

First Degree AV Block Clinical Significance

67

• Not usually detrimental and often resolves when ischemia corrected

• Must consider entire patient

Second Degree AV Blocks

68

• Type I– Also called “Wenckebach”– Also called Mobitz I

• Type II– Also called Mobitz II

Second Degree AV Block, Type I

69

• Intermittent block in which AV conduction gradually slows until an impulse is blocked

• “Long, longer, longer, drop! Long, longer, longer, drop!”

Second Degree AV Block, Type I ECG Criteria

70

Rate - Atrial rate unaffected but ventricular rate is less than atrial rate

Rhythm - Atrial rhythm usually regular. Ventricular rhythm is irregular with more P-Waves than QRS Complexes.

P-Waves - Unaffected with more P-Waves than QRS Complexes

PRI - Progressively increases for consecutively conducted P-Waves until QRS Complex is dropped

QRS - Unaffected

Second Degree AV Block, Type I Etiology

71

• Often caused by increased parasympathetic tone or drug effect

• Can be caused by MI

Second Degree AV Block, Type I Clinical Significance

72

• Usually transient with good prognosis• Can reduce cardiac output due to bradycardia

Second Degree AV Block, Type II

73

• Intermittent block in which not all P-Waves are conducted to ventricles but there is no progressive prolongation of PRI

• “Extra” p-waves.

Second Degree AV Block, Type II Etiology

74

• Usually due to MI or other organic heart disease

• Rarely the result of increased parasympathetic tone or drug effect

Second Degree AV Block, Type II Clinical Significance

75

• Poorer prognosis than Type I• Usually requires pacemaker• Frequently develops into Complete Block

Second Degree AV Block, Type II ECG Criteria

76

Rate - Atrial rate is unaffected but ventricular rate is less than atrial

Rhythm - Atrial rhythm regular, Ventricular irregular with more P-waves than QRS Complexes

P-Waves - Normal morphology with more P-Waves than QRS Complexes

PRI - Constant for consecutively conducted P-Waves

QRS - Usually wide but may be narrow if block is at His level or above

Second Degree AV Block, Type II Example

77

Third Degree AV Block

78

• Complete blockage of impulse conduction through AV Junction

• Results in “AV dissociation” (very very bad thing)

• P’s and QRS’s “march to their own drummer”

AV Dissociation

79

• No relationship between P-waves and QRS complexes

Third Degree AV Block Etiology

80

• MI• Increased parasympathetic tone• Drug toxicity

Third Degree AV Block ECG Criteria

81

• Rate - Atrial > 60, Ventricular based on escape• Rhythm - Atrial and ventricular regular• P-Waves - Normal• PRI - No association between P-Waves and

QRS complexes (P’s and QRS’s are divorced and do their own thing)

• QRS - Narrow if intranodal, Wide if infranodal

Questions?

• Recording of this session will be sent out shortly.

• Please feel free to type questions in the text box to the right before we sign off.

• Or email questions to afinkel@silvercross.org• Thank you!