EMS Pulmonary Lecture

Mike MD, MPH

Outline

• Anatomy• Physiology• Airway Management• Medical Management• Trauma Management

Epidemiology

• 25% Infectious• 5% Tb• 28 % Neoplasia• 13 % Multiple or miscellaneous• 28 % Undetermined• Risk Factors – Marlboro Man +/- horse

Functions of Respiratory System

• Moves Air• Communication• Non-specific Immunity• Acid/Base

Respiratory Tract Anatomy

• Conducting– Nose/Mouth– Nasopharynx/Oropharnyx– Laryngopharynx– Trachea

Respiratory Tract Anatomy

• Conducting– Trachea– Bronchus– Bronchiole– Terminal Bronchiole

Respiratory Tract Anatomy

• Respiration– Alveolar ducts– Alveoli

Respiratory Tract Anatomy

Respiratory Mechanics

Pressure and Volume PV=nRTPV=1

As pressure increases, volume decreasesAs volume increases, pressure decreases

Respiratory Mechanics

• Pressure• Volume• Adhesion• Compliance• Surface Tension• Gas Exchange

Respiratory Mechanics

• Adhesion– Parietal– Visceral– Pleural Fluid

Respiratory Mechanics

• Surface Tension

Respiratory Mechanics

• Compliance

Respiratory Mechanics

• Gas Exchange• Oxygen Transport

– Dissolved– Bound

• pH• O2

• Temperature

Airway Resistance

• R=8nL/R 4

• Cross-sectional Area• Dynamic

Respiratory Cycle

Respiratory Control

• Mechanoreceptors– Inflation– Deflation

• Chemoreceptors– pH– PCO2

– PO2

Respiratory Distress

• Dyspnea• Orthopnea• PND• Cyanosis

– Central– Peripheral

• Lung SoundsPT 630 - Breath Sounds

Respiratory Distress

• Airway• Cardiac• Lung• Thoracic Cavity• Vascular• Neuromuscular

Respiratory Distress

• O2– Hypoxia– Hypoxemia– Relative Hypoxemia

• CO2– Acute– Chronic

Infections

• Bronchitis• Pneumonia• Tuberculosis

Hemoptysis

• Dual Blood Supply• Mechanisms

– Intravascular– Inflammatory– Coagulation

Pathophysiology

• Intravascular – LV CHF– Mitral Valve Stenosis– Rheumatic Heart Disease

Pathophysiology

• Inflammatory– Bronchitis– Bronchiectasis– Mycetoma– FB– PE– Pneumonia– Neoplasia– TB– Vasculitidies

Pathophysiology

• Coagulopathies– Hemophilia– Thrombocytopenia– Anticoagulants– Thrombolytics

Clinical Features

• History– Fever– Sputum– Weight loss– Night sweats

• Physical Examination– Vitals– NasalCavity and oropharynx– Murmurs– Clubbing– Rales vs Rhonchi

Diagnostic Approach

• Confirm Location– Pseudo, GI or pulmonary

• Urgent Bronchoscopy• CXR

– Neoplasia– 20-30% normal

• Chest CT– Neoplasia vs bronchiectasis

Treatment

• Identify history of Tb or COPD• Decubitus Position• Intubation with large ETT • Mainstem Bronchus intubation

Asthma in Adults

• Chronic inflammatory disease• Prevalence

– Children– Elderly

• Incidence– < 10– < 40

• Morbidity– > 100% increase

• Mortality– Non uniform increase

Pathophysiology

• Large and Small Airways• Muscular• Vascular • Cellular

– Mast Cells– PMN– Eosinophils– Goblet Cell– Fibroblasts

Pathophysiology

• Acute– Mast– Eosinophils– PMN– Platelets– Lymphocytes

• Subacute– “resident cell activation”

• Chronic– Deposition of Collagen

Pathophysiology

• Allergic– Family history

• Idiosyncratic– Normal IgE

• Triggers– Environmental– Infectious– Behavioral– Medication– Emotional

Pathophysiology

Symptoms

• Dyspnea• Chest Tightness• Wheezing• Cough• Tachypnea• Tachycardia**

** pay attention in pediatrics

Severity Of Exacerbation• Breathlessness

– Walking, talking, rest• Position

– Lying, sitting, upright• Speech

– Sentences, phrases, words• Tachycardia

– 100, 100-120, >120• PEFR

– 80%, 50-80%, < 50%• Pulse Ox

– >95%, 91-95%, <91%• ABG

– You know its severe if you order an ABG

Assessment

• PEFR • Pulse Oximetry• EKG

– Reversible

Treatment

• Adrenergic Agents• IV vs Inhaled• Albuterol• To space or not to space?

Treatment

• Corticosteroids– IV vs PO

• Anticholinergics• Mg• Heliox

Treatment

• Assisted Ventilation– Indications– Risks

• Barotrauma• Hypotension• Mucus Plugging

– Ventilation Rate

Special Circumstances

• Age• Pregnancy

– Incidence– Oxygen– Fetal Risks– Treatment

The Things You Ask if You Have the Time

• Risk Factors for Death– Sudden severe exacerbations– ICU– Intubation– Recent Withdrawl of Steroids– ED visits– Albuterol use

COPD

• Chronic Bronchitis– Clinical definition

• Emphysema– Pathological definition

COPD Epidemiology

• Prevalence• Men vs Women• WHO estimates• Hospitalization mortality

– Floor– ICU– Within 1 year after discharge

Pathophysiology

• Risk Factors– Behavioral– Genetic

• Bronchitis/Emphysema• Expiratory Flow• Inflammation and Elastance

Pathophysiology

• Hypoxemia and hypoventilation• Neurochemical regulation• Pulmonary blood flow• Cardiac risks

Clinical Features - Chronic

• Cough• Crackles• Wheeze • Hyperinflation• Weight Change• Mental Status

Clinical Features –Acute

• Causes– Infectious– Behavioral – Iatrogenic– Cardiac

• Hypoxemia• Hypercapnia• R/O other intrathoracic disease

Treatment - Acute

• Oxygen• Albuterol• Atrovent• Steroids

Treatment - Acute

• Assisted Ventilation– Complications

• Infectious• Cardiac• Traumatic

• BIPAP

Trauma

• Pneumothorax– Blunt– Penetrating

• Hemothorax• Tension Pneumothorax• Assisted Ventilation

– Pros– Cons

Basic Airway Management Saves Lives

• Jaw Thrust• Airway Adjunct• NRB/BVM

Review

• Airway and Lung Anatomy• Respiratory Mechanics and Physiology• Respiratory Infections/Hemoptysis• Asthma• COPD• Trauma• Plug for BLS airway management