presence regional ems system

Respiratory FailureRespiratory Failure

Presence Regional Presence Regional EMS SystemEMS System

ObjectivesObjectives Review the anatomy and physiology of the Review the anatomy and physiology of the

respiratory system.respiratory system. Describe how carbon dioxide is created in Describe how carbon dioxide is created in

the body.the body. Outline the assessment of patients with Outline the assessment of patients with

respiratory complaintsrespiratory complaints Compare and contrast the signs and Compare and contrast the signs and

symptoms of Respiratory Distress and symptoms of Respiratory Distress and Respiratory Failure.Respiratory Failure.

Outline the use of end tidal capnography Outline the use of end tidal capnography to determine disease specific signs of to determine disease specific signs of Respiratory Distress, Respiratory Failure Respiratory Distress, Respiratory Failure and Respiratory Arrest.and Respiratory Arrest.

Discuss the management of a variety of Discuss the management of a variety of diseases that might result in Respiratory diseases that might result in Respiratory Distress and Respiratory Failure Distress and Respiratory Failure

What we knowWhat we know Air is goodAir is good Pink is goodPink is good Blue is badBlue is bad Air goes in Air goes in Air goes outAir goes out

Ventilation vs RespirationVentilation vs Respiration First: Get the terms straight. What most First: Get the terms straight. What most

people call people call respirationsrespirations are actually are actually ventilationsventilations

VentilationVentilation = Movement of air in and out = Movement of air in and out RespirationRespiration = Exchange = Exchange of oxygen and carbon of oxygen and carbon dioxide (in the lung or dioxide (in the lung or at the cell level)at the cell level)

How does air get in the body?How does air get in the body? Upper airwayUpper airway

• Structures aboveStructures above vocal cordsvocal cords• Breathe in throughBreathe in through nose or mouthnose or mouth

Warms airWarms air Humidifies airHumidifies air Cleans airCleans air

Lower AirwayLower Airway Structures belowStructures below vocal cordsvocal cords Trachea = “C” Trachea = “C” shaped cartilage shaped cartilage rings, posterior rings, posterior wall is muscle wall is muscle (allows for passage of material through (allows for passage of material through

esophagus)esophagus) Cartilage prevents trachea from collapsing Cartilage prevents trachea from collapsing

when coughingwhen coughing Walls lined with mucus producing cellsWalls lined with mucus producing cells

Lower AirwayLower Airway Bronchi: Branch off Bronchi: Branch off tracheatrachea Bronchioles: divide 32Bronchioles: divide 32times, get progressivelytimes, get progressivelysmallersmaller Muscle lined to expand &Muscle lined to expand &contract, inner surface ofcontract, inner surface ofmucus producing cellsmucus producing cells

Alveoli Functional Respiratory Unit Where oxygen/carbon dioxide exchange

occurs One cell thick Muscles and elastic fibersto expand and contract Covered with capillaries Surfactant =chemical that increases surface tension & keeps alveoli open

Alveolar/Capillary/Cell Gas Alveolar/Capillary/Cell Gas ExchangeExchange

RememberRemember No gas exchangeNo gas exchange takes place till the gas takes place till the gas

gets to the alveoli.gets to the alveoli. No gas exchangeNo gas exchange in the upper airway, in the upper airway,

trachea, bronchi or bronchioles.trachea, bronchi or bronchioles. The passage way from the outside to the The passage way from the outside to the

alveoli is alveoli is dead air space.dead air space. Must inhale enough air to get oxygen to Must inhale enough air to get oxygen to

the alveoli = tidal volumethe alveoli = tidal volume

How?How? How do you know if the patient has How do you know if the patient has

an adequate tidal volume?an adequate tidal volume?

Assess for good rise and fall of the Assess for good rise and fall of the chest.chest.

What???What??? What makes oxygen and carbon What makes oxygen and carbon

dioxide exchange across capillaries?dioxide exchange across capillaries?

DiffusionDiffusion Movement of particles (gas) from an area Movement of particles (gas) from an area

of high concentration to an area of low of high concentration to an area of low concentrationconcentration

Oxygen leaves the alveoli and goes into Oxygen leaves the alveoli and goes into the low oxygen area of the pulmonary the low oxygen area of the pulmonary capillarycapillary

Carbon dioxide leaves the capillary and Carbon dioxide leaves the capillary and goes into the low CO2 goes into the low CO2

area of the alveoli.area of the alveoli.

WhatWhat What causes the impulse to take a What causes the impulse to take a

breath?breath?

InspirationInspiration The impulse to begin inspiration is The impulse to begin inspiration is

from the pons of the brain stemfrom the pons of the brain stem Receptor cells sensitive toReceptor cells sensitive tocarbon dioxide levels controlcarbon dioxide levels controlinspiration.inspiration. When CO2 goes up, When CO2 goes up, inspiration is initiated, wheninspiration is initiated, whenCO2 goes down, inspiration is inhibited.CO2 goes down, inspiration is inhibited.

VentilationVentilation Is a mechanical process of gas following Is a mechanical process of gas following

changing pressureschanging pressures Similar to the airSimilar to the airmovement through bellowsmovement through bellows When the ventilationWhen the ventilationprocess begins the process begins the pressure in the alveoli is pressure in the alveoli is equal to the outside equal to the outside atmospheric pressure.atmospheric pressure.

Ventilation As ventilation begins the spaces between

the ribs expand and the diaphragm drops resulting in a vacuum in the chest.

Air rushes in from the atmosphere to fill the space.

VentilationVentilation Once the pressure in the alveoli is equal to Once the pressure in the alveoli is equal to

the atmospheric pressure, air movement the atmospheric pressure, air movement stops.stops.

Then the spaces between the ribs Then the spaces between the ribs contract and the diaphragm moves up contract and the diaphragm moves up increasing the pressure in the alveoli increasing the pressure in the alveoli above the atmospheric pressure, forcing above the atmospheric pressure, forcing air to move from the alveoli into the air to move from the alveoli into the atmosphere.atmosphere.

HemoglobinHemoglobin 98% of inspired oxygen is 98% of inspired oxygen is

transported from the alveoli by the transported from the alveoli by the red blood cells on hemoglobin.red blood cells on hemoglobin.

Carbon dioxide is Carbon dioxide is transported back transported back to the alveoli to the alveoli dissolved in plasma.dissolved in plasma.

PerfusionPerfusion Oxygen in the alveoli does the Oxygen in the alveoli does the

patient no good, until it is patient no good, until it is transported to the cells.transported to the cells.

The purpose of oxygen is to combine The purpose of oxygen is to combine with glucose (sugar) to create carbon with glucose (sugar) to create carbon dioxide, water and lots of energy.dioxide, water and lots of energy.

To Have Perfusion You NeedTo Have Perfusion You Need Two sided pump = heartTwo sided pump = heart System of tubes = circulatory systemSystem of tubes = circulatory system Conduction medium = bloodConduction medium = blood Fuel = glucose (sugar)Fuel = glucose (sugar) Oxygen Source = respiratory systemOxygen Source = respiratory system

PerfusionPerfusion The process of getting oxygen and The process of getting oxygen and

(sugar) glucose to the cells is (sugar) glucose to the cells is perfusion.perfusion.

Oxygen + Sugar Oxygen + Sugar ↔↔(the Cell)(the Cell)

CO2 + H2O + ENERGYCO2 + H2O + ENERGY

Carbon DioxideCarbon Dioxide The only way to get carbon dioxide in The only way to get carbon dioxide in

the body is to break down glucose the body is to break down glucose (sugar) with oxygen.(sugar) with oxygen.

If glucose (sugar) is broken down If glucose (sugar) is broken down without oxygen, the by product is not without oxygen, the by product is not carbon dioxide, but lactic acid.carbon dioxide, but lactic acid.

““CO2 is the smoke from the flames of CO2 is the smoke from the flames of metabolism (sugar breakdown)”metabolism (sugar breakdown)”• Ray Fowler M.D. Dallas: Street Doc’s Ray Fowler M.D. Dallas: Street Doc’s

SocietySociety

HypoxiaHypoxia Hypoxia (poor delivery of oxygen to cells) Hypoxia (poor delivery of oxygen to cells)

can be caused by a variety of problems.can be caused by a variety of problems. Hypoxic – not enough oxygenHypoxic – not enough oxygen Anemic – not enough Anemic – not enough hemoglobinhemoglobin Stagnant – not enough Stagnant – not enough perfusionperfusion Histotoxic – unable to downloadHistotoxic – unable to download

Normal Oxygen TransportNormal Oxygen Transport Plenty of oxygen Plenty of hemoglobin Good perfusion Cells able to take up oxygen and use it

The Physiology Coloring Book Kapit, Macey and Meisami Harpercollins College Publishing 1987

Hypoxic HypoxiaHypoxic Hypoxia Not enough oxygen Plenty of hemoglobin Good perfusion Cells able to take up oxygen and use it

Anemic HypoxiaAnemic Hypoxia Plenty of oxygen Not enough hemoglobin Good perfusion Cells able to take up oxygen and use it

Stagnant HypoxiaStagnant Hypoxia Plenty of oxygen Plenty of hemoglobin Poor perfusion Cells able to take up oxygen and use it

Histotoxic HypoxiaHistotoxic Hypoxia Plenty of oxygen Plenty of hemoglobin Good perfusion Cells unable to take up oxygen and use it

Causes/PathophysiologyCauses/Pathophysiology All Respiratory Distress/Disease is All Respiratory Distress/Disease is

caused by a failure ofcaused by a failure of:: VentilationVentilation: moving air in/ air out: moving air in/ air out

oror DiffusionDiffusion: movement of gases across : movement of gases across

alveolar/capillary membranealveolar/capillary membraneoror

PerfusionPerfusion: movement of blood to: movement of blood to get oxygen to the cellsget oxygen to the cells

Respiratory Distress/Disease can Respiratory Distress/Disease can be:be:•Relieved byRelieved by: Adrenalin based : Adrenalin based

agentsagents•Compounded byCompounded by::

InflammationInflammation Mucus productionMucus production

AssessmentAssessment Scene size upScene size up

• SafetySafety• EnvironmentEnvironment

Living conditionsLiving conditions Presence of oxygenPresence of oxygen delivery devicesdelivery devices Presence of nebulizersPresence of nebulizers

General ImpressionGeneral Impression PositionPosition ColorColor Mental StatusMental Status Ability to SpeakAbility to Speak Respiratory EffortRespiratory Effort

Resting Comfortably: Resting Comfortably: GoodGood

Pursed Lip Breathing: Pursed Lip Breathing: Forcefully Forcefully pushing out CO2: pushing out CO2: (Tolerating)(Tolerating)

Tripod Position: Tripod Position: Helps expand the Helps expand the chest chest (Not good)(Not good)

Altered Level of Consciousness: Altered Level of Consciousness: (Bad)(Bad)

Cyanosis: Cyanosis: Poorly oxygenated Poorly oxygenated hemoglobin close to the surface of the skinhemoglobin close to the surface of the skin

Ability to SpeakAbility to Speak Speaks in complete sentences = Speaks in complete sentences =

GoodGood Speaks only 1 or 2 words between Speaks only 1 or 2 words between

breaths = breaths = Having difficultyHaving difficulty Unable to speak and breath at the Unable to speak and breath at the

same time = same time = BadBad

Respiratory EffortRespiratory Effort EasyEasy: Normal rise and fall of the : Normal rise and fall of the

chest = goodchest = good

LaboredLabored: Using accessory muscles : Using accessory muscles = not good= not good

AbsentAbsent: No respiratory effort = bad: No respiratory effort = bad

Primary Survey: Primary Survey: Fix immediately what can be fixedFix immediately what can be fixed

Airway: able to speakAirway: able to speak Breathing: rise and fall of the chestBreathing: rise and fall of the chest Circulation: radial pulseCirculation: radial pulse Disability – mental statusDisability – mental status Vital SignsVital Signs

Focused HistoryFocused History Signs and symptomsSigns and symptoms AllergiesAllergies MedicationsMedications Past Medical HistoryPast Medical History Last MealLast Meal Events prior to EMS arrivalEvents prior to EMS arrival

PASTE PASTE HistoryHistory ProgressionProgression: Did the respiratory problem start : Did the respiratory problem start

suddenly or did it get worse over time?suddenly or did it get worse over time? Associated Chest PainAssociated Chest Pain?? SputumSputum: What is the patient coughing up? What : What is the patient coughing up? What

is the color? What is the amount?is the color? What is the amount? Talking TirednessTalking Tiredness: Is the patient able to speak : Is the patient able to speak

in sentences, or does he have to take a breath in sentences, or does he have to take a breath between words?between words?

Exercise ToleranceExercise Tolerance: Is the patient able to move : Is the patient able to move around the room without getting more short of around the room without getting more short of breath?breath?

Associated Symptoms/ Associated Symptoms/ Pertinent NegativesPertinent Negatives

Respiratory distress can be associated Respiratory distress can be associated with:with:• Chest painChest pain• Fever/chillsFever/chills• WheezingWheezing• SmokingSmoking• TraumaTraumaAbsence of these associated symptoms is Absence of these associated symptoms is

significant!! (Pertinent Negative)significant!! (Pertinent Negative)

Medications Associated with Medications Associated with Respiratory DistressRespiratory Distress

Is the patient taking:Is the patient taking:• AntibioticsAntibiotics• OxygenOxygen• SteroidsSteroids• Inhalers/nebulizersInhalers/nebulizers• Cardiac drugsCardiac drugs

ExaminationExamination Head and NeckHead and Neck

• Pursed lip breathingPursed lip breathing• CyanosisCyanosis• Distended jugular veinsDistended jugular veins

ExtremitiesExtremities• Edema of the anklesEdema of the ankles

What are you listening to?What are you listening to? Chest SoundsChest Sounds

• Crowing/StridorCrowing/Stridor: swelling : swelling of upper airway/larynxof upper airway/larynx• WheezesWheezes: swollen : swollen muscles in the bronchioles muscles in the bronchioles (constricted airways)(constricted airways)• RhonchiRhonchi: thick fluid in bronchioles and : thick fluid in bronchioles and

bronchibronchi• Rales/cracklesRales/crackles: moisture/stickiness in : moisture/stickiness in

alveolialveoli

Monitoring TechnologyMonitoring Technology Pulse OximetryPulse Oximetry

• Measures oxygen saturation of available Measures oxygen saturation of available hemoglobinhemoglobin

• Measures amount of oxygen delivered to Measures amount of oxygen delivered to cellscells

• Goal > 94%Goal > 94%• 91-94% mild hypoxemia91-94% mild hypoxemia• 85 – 90% moderate 85 – 90% moderate hypoxemiahypoxemia• < 85% severe hypoxemia< 85% severe hypoxemia

Inconsistent Pulse Oximetry Inconsistent Pulse Oximetry ReadingsReadings

Poor perfusionPoor perfusion Cold extremitiesCold extremities Elevated carbon monoxide levelsElevated carbon monoxide levels Low levels of hemoglobinLow levels of hemoglobin Black, blue or green Black, blue or green fingernail polishfingernail polish

CapnographyCapnography End Tidal Carbon dioxide (EtCO2)End Tidal Carbon dioxide (EtCO2)

• Measures level of CO2 in exhaled breathMeasures level of CO2 in exhaled breath• Non invasiveNon invasive• Can give information about:Can give information about:

VentilationVentilation (movement of CO2 out of lungs) (movement of CO2 out of lungs) PerfusionPerfusion (delivering O2 and sugar to cells (delivering O2 and sugar to cells

and carrying away CO2) and carrying away CO2) MetabolismMetabolism (creating CO2 by breaking (creating CO2 by breaking

down sugar with oxygen)down sugar with oxygen)

CapnographyCapnography Normal levels of EtCO2: 35-45Normal levels of EtCO2: 35-45 Capnography can also be expressed Capnography can also be expressed

in a wave formin a wave form• Normal waveformNormal waveform• Measure numerical mmHg of CO2Measure numerical mmHg of CO2• Distinctive plateau (flat top) waveformDistinctive plateau (flat top) waveform

Abnormal CapnographyAbnormal Capnography Low EtCO2Low EtCO2

• Shock (perfusion failure, no creation of Shock (perfusion failure, no creation of CO2)CO2)

• Cardiac Arrest (perfusion failure, no Cardiac Arrest (perfusion failure, no creation of CO2 and/or no ventilation)creation of CO2 and/or no ventilation)

• Pulmonary Embolism (obstructed Pulmonary Embolism (obstructed perfusion to or from the lung)perfusion to or from the lung)

• Complete airway obstruction from mucus Complete airway obstruction from mucus plugging or foreign body (no ventilation)plugging or foreign body (no ventilation)

Abnormal CapnographyAbnormal Capnography High EtCO2High EtCO2

• Hypoventilation (CO2 build up due to Hypoventilation (CO2 build up due to ventilation failure)ventilation failure)

• Respiratory Depression (CO2 build up Respiratory Depression (CO2 build up due to ventilation failure)due to ventilation failure)

• Hyperthermia (accelerated metabolism Hyperthermia (accelerated metabolism with over production of CO2) with over production of CO2)

Abnormal WaveformsAbnormal Waveforms Bronchospasm from asthma, COPD Bronchospasm from asthma, COPD

or airway obstruction can change the or airway obstruction can change the capnography wave form to a “shark capnography wave form to a “shark fin” shapefin” shape

Management of Respiratory Disorders

Open and secure airway Improve ventilation Improve diffusion Improve perfusion

Tools for Management of Tools for Management of Respiratory DisordersRespiratory Disorders

Oxygen delivery devicesOxygen delivery devices• BVM: Bag Valve Mask VentilationBVM: Bag Valve Mask Ventilation• CPAP: Continuous positive airway CPAP: Continuous positive airway

pressurepressure• Nebulizer bronchodilatorsNebulizer bronchodilators• FluidsFluids

Management 1:Oxygen Administration

Delivery Devices• Nasal Cannula: 2-6 liters/minute

Non-rebreather mask: 10-15 liters/minute

REMEMBER!!! Must be able to breathe

spontaneously Must have good rise and fall of the

chest

Management 2: Ventilation Support

Use Bag-Valve-Mask ventilation if patient shows signs of fatigue • Slowing ventilations• Poor rise and fall of the chest• Altered level of consciousness with poor

ventilation • Use supplemental oxygen

Management 3: CPAP: Continuous Positive Airway Pressure

A means of providing high flow, low pressure oxygenation to the patient in severe respiratory distress or respiratory failure

Goals of CPAP

• Increase the amount of inspiredIncrease the amount of inspiredoxygenoxygen• Decrease the work of breathingDecrease the work of breathing

CPAP Increases the airway pressures allowing for better

gas diffusion & for re-expansion of collapsed alveoli

Allows the refilling of collapsed, airless alveoli Expands the surface area of the collapsed alveoli

allowing more surface area to be in contact with capillaries for gas exchange

Without CPAP With CPAP

CPAP CPAP is applied during the entire

respiratory cycle (inhalation & exhalation) via a tight fitting mask applied over the nose and mouth

The patient must be able to maintain an upright sitting position

Indications for CPAP ApplicationIndications for CPAP Application

Patient has severe respiratory distress and/or respiratory failure

To ease significant labored respirations and work of breathing in patients on supplemental oxygen who may otherwise require intubation

Patient exhibiting hypoxemia (O² sat <94% at any time) not responsive to supplemental oxygen therapy

Criteria for CPAP(all must apply) Age ≥ 14 Fully cooperative patient, exhibiting a

reliable respiratory rate and effort, and able to protect their airway.

Medical patient with SBP≥90 mmHg No presence of nausea or vomiting

Patient Monitoring During CPAP Use

Patient tolerance; mental status Respiratory pattern

• rate, depth, subjective feeling of improvement

• B/P, pulse rate & quality, SaO2,EtCO2 EKG pattern

Indications the patient is improving (can be noted in as little as 5 minutes after beginning)reduced effort & work of breathing increased ease in speakingslowing of respiratory and pulse rates increased SaO2

Discontinuation of CPAP Hemodynamic instability

• B/P drops below 90 mmHg The positive pressures exerted

during the use of CPAP can negatively affect the return of blood flow to the heart

Inability of the patient to tolerate the tight fitting mask

Management 4: Nebulized Bronchodilators

For broncho-For broncho-constrictionconstriction

For managementFor management of wheezingof wheezing breath soundsbreath sounds

DuoNebDuoNeb Blended solution of

• Albuterol Sulfate (Albuterol)• Ipratropium Bromide (Atrovent)

Two medications work in different ways to achieve bronchodilation

Albuterol Albuterol-

• Synthetic sympathetic nervous system stimulant

• Beta 2 agonist – bronchodilation• Less cardiac effect ( Beta 1, Alpha 1)

than epinephrine• Reduces mucus secretion, pulmonary

capillary leaking and edema in the lungs in allergic reactions

Ipratropium (Atrovent)Ipratropium (Atrovent) IpratropiumIpratropium

• AnticholinergicAnticholinergic blocks the blocks the acetylcholine receptorsacetylcholine receptors of the of the parasympathetic nervous systemparasympathetic nervous system

• BronchodilationBronchodilation• Drying of respiratory tract secretionsDrying of respiratory tract secretions

DuoNeb DosageDuoNeb Dosage Comes pre-mixedComes pre-mixed

• 0.5 mg Ipratropium0.5 mg Ipratropium• 3 mg Albuterol3 mg Albuterol• In 3 ml solutionIn 3 ml solution

Nebulize withNebulize with 6-8 L Oxygen6-8 L Oxygen

May repeat onceMay repeat once

Management 5: Fluids Patients with respiratory failure are

frequently dehydrated due to • Illness• Mouth breathing

IV fluids• Hydrate the system• Helps thin mucus

How Bad is the Respiratory How Bad is the Respiratory Problem?Problem?

Respiratory Distress Respiratory Distress Respiratory FailureRespiratory Failure

Respiratory DistressRespiratory Distress From “I feel short of breath” to obvious labored breathingFrom “I feel short of breath” to obvious labored breathing Slightly elevated respiratory rate > 16-24/minuteSlightly elevated respiratory rate > 16-24/minute Elevated pulse rate > 100/minuteElevated pulse rate > 100/minute AnxiousAnxious Pale colorPale color Pursed lips breathingPursed lips breathing Use of accessory muscles, tripod positionUse of accessory muscles, tripod position Abnormal respiratory sounds (wheezing, rales, rhonchi) Abnormal respiratory sounds (wheezing, rales, rhonchi) Oxygen saturation slightly low 90-94%Oxygen saturation slightly low 90-94% Able to speak in short sentences (or 1-2 words) between Able to speak in short sentences (or 1-2 words) between

breathsbreaths Able to tolerate some activityAble to tolerate some activity If patient becomes fatigued may lead to respiratory failureIf patient becomes fatigued may lead to respiratory failure

Management of Respiratory Management of Respiratory DistressDistress

Correct the underlying problemCorrect the underlying problem Apply oxygen to keep SaO2 >94%Apply oxygen to keep SaO2 >94% Ventilation assistance Ventilation assistance

• CPAPCPAP• BVM ventilationBVM ventilation

Bronchodilation with nebulized medicationsBronchodilation with nebulized medications PerfusionPerfusion

• Improve circulation Improve circulation

Respiratory FailureRespiratory Failure Inability of the body to meet the Inability of the body to meet the

basic demands for tissue basic demands for tissue oxygenationoxygenation

Early Respiratory FailureEarly Respiratory Failure Respiratory rate > 30/minute Respiratory rate > 30/minute Heart rate > 140/minuteHeart rate > 140/minute Oxygen saturation < 94%Oxygen saturation < 94% Use of multiple accessory muscle groupsUse of multiple accessory muscle groups Inability to lie supineInability to lie supine Altered level of consciousnessAltered level of consciousness Inability to clear airway of secretions/mucusInability to clear airway of secretions/mucus Cyanosis of nail beds and lipsCyanosis of nail beds and lips Unable to speak more than 1 word between breathsUnable to speak more than 1 word between breaths Unable to tolerate physical activityUnable to tolerate physical activity If patient becomes fatigued may lead to end stage If patient becomes fatigued may lead to end stage

respiratory failurerespiratory failure

Late Respiratory FailureLate Respiratory Failure Respiratory rate < 6/minuteRespiratory rate < 6/minute Heart rate < 60/minuteHeart rate < 60/minute Oxygen saturation < 90%Oxygen saturation < 90% Poor rise and fall of the chestPoor rise and fall of the chest Able to lie supineAble to lie supine Stuporus or Unconscious (may respond to pain)Stuporus or Unconscious (may respond to pain) Inability to clear airway of secretions/mucusInability to clear airway of secretions/mucus Gray colorGray color Unable to speak Unable to speak Unable to tolerate any physical activityUnable to tolerate any physical activity If patient becomes fatigued may lead to respiratory arrestIf patient becomes fatigued may lead to respiratory arrest

Respiratory FailureRespiratory Failure Gradual OnsetGradual Onset

• Inadequate oxygen deliveryInadequate oxygen delivery• Inadequate carbon dioxide removalInadequate carbon dioxide removal• Tachycardia (fast heart rate)Tachycardia (fast heart rate)• Tachypnea (fast breathing) with poor Tachypnea (fast breathing) with poor

rise and fall of chestrise and fall of chest

Respiratory FailureRespiratory Failure End Stage Respiratory FailureEnd Stage Respiratory Failure

• Bradycardia (slow heart rate)Bradycardia (slow heart rate)• Bradypnea (slow breathing)Bradypnea (slow breathing)• CyanosisCyanosis• Poor chest wall movementPoor chest wall movement• Profound acid build upProfound acid build up

Respiratory ArrestRespiratory Arrest No spontaneous respirationsNo spontaneous respirations No rise and fall of the chestNo rise and fall of the chest Unconscious; no response to painUnconscious; no response to pain Cold, cyanotic/gray skinCold, cyanotic/gray skin If unresolved will lead to deathIf unresolved will lead to death

Respiratory Failure/Arrest Respiratory Failure/Arrest ManagementManagement

Open airway Open airway Mechanically ventilateMechanically ventilate Work to correct underlying problemWork to correct underlying problem

ReviewReview Answer the following questions as a group.Answer the following questions as a group. If doing this CE individually, please e-mail your If doing this CE individually, please e-mail your

answers to:answers to:[email protected]

Use “January 2016 2015 CE” in subject box.Use “January 2016 2015 CE” in subject box. You will receive an e-mail confirmation. Print You will receive an e-mail confirmation. Print

this confirmation for your records, and this confirmation for your records, and document the CE in your PREMSS CE record document the CE in your PREMSS CE record book.book.

IDPH site code # 067100E1216IDPH site code # 067100E1216

mailto:[email protected]

Scenario ReviewScenario Review Read the assessment for each scenario.Read the assessment for each scenario. Determine:Determine:

• What is wrong with the patient?What is wrong with the patient?• Is the patient in respiratory distress or Is the patient in respiratory distress or

respiratory failure?respiratory failure?• Is the problem one of ventilation, diffusion or Is the problem one of ventilation, diffusion or

perfusion or a mix?perfusion or a mix?• Which of the 5 management tools will be Which of the 5 management tools will be

helpful for this patient?helpful for this patient?

Scenario 1Scenario 1 You are called for a 63 year-old man named Jim.You are called for a 63 year-old man named Jim. Jim has been sick with the “flu” for 3 days. Jim has been sick with the “flu” for 3 days. Jim is alert and oriented X 4 but he is anxious.Jim is alert and oriented X 4 but he is anxious. His airway is open and he can speak in short His airway is open and he can speak in short

sentences between breaths.sentences between breaths. His respiratory rate is 24 with good rise and fall of His respiratory rate is 24 with good rise and fall of

the chest.the chest. He is pale, sweaty and very warm to touch.He is pale, sweaty and very warm to touch.

AssessmentAssessment Jim is sitting upright in tripod position using Jim is sitting upright in tripod position using

accessory muscles.accessory muscles. Jim complains of chest pain on the right side of Jim complains of chest pain on the right side of

his chest. The pain is worse when he coughs or his chest. The pain is worse when he coughs or tries to take a deep breath.tries to take a deep breath.

Breath sounds on the right are diminished with Breath sounds on the right are diminished with rales and rhonchi. Breath sounds on the left are rales and rhonchi. Breath sounds on the left are clear.clear.

Jim states he feels too weak to move.Jim states he feels too weak to move. No other significant findings on head to toe No other significant findings on head to toe

assessmentassessment

SAMPLE HistorySAMPLE History Allergies: PenicillinAllergies: Penicillin Medications: Lisinopril 10 mg daily, Proscar 5 mg Medications: Lisinopril 10 mg daily, Proscar 5 mg

daily daily Past History: hypertension, enlarged prostate Past History: hypertension, enlarged prostate Last Meal: No appetite. Has been drinking fluids Last Meal: No appetite. Has been drinking fluids

mostlymostly Events: Feeling bad and unable to get a deep Events: Feeling bad and unable to get a deep

breathbreath

Vital SignsVital Signs BPBP 140/94140/94 Pulse 98Pulse 98 Respirations 24 SaO2 91% on room airRespirations 24 SaO2 91% on room air EtCO2 46EtCO2 46

Blood sugar: 112Blood sugar: 112

• What is wrong with the patient?What is wrong with the patient?

• Is the patient in respiratory distress or Is the patient in respiratory distress or respiratory failure?respiratory failure?

• Is the problem one of ventilation, diffusion or Is the problem one of ventilation, diffusion or perfusion or a mix?perfusion or a mix?

• Which of the 5 management tools will be Which of the 5 management tools will be helpful for this patient?helpful for this patient?

• What is wrong with the patient? What is wrong with the patient? Probably pneumoniaProbably pneumonia• Is the patient in respiratory distress or respiratory Is the patient in respiratory distress or respiratory

failure? failure? Respiratory distress• Is the problem one of ventilation, diffusion or Is the problem one of ventilation, diffusion or

perfusion or a mix? perfusion or a mix? Mix of ventilation and diffusion (alveoli are full of fluid from pneumonia)

• Which of the 5 management tools will be helpful Which of the 5 management tools will be helpful for this patient? for this patient? Oxygen and/or CPAP and fluids. (No wheezing so no need for nebulized medications)

Scenario 2Scenario 2 You are called to a local long term care facility for You are called to a local long term care facility for

an 86 year-old man.an 86 year-old man. You find Bill in bed lying semi-flat, unresponsive You find Bill in bed lying semi-flat, unresponsive

to touch and voice.to touch and voice. Bill has mucus in his airway.Bill has mucus in his airway. His respirations are irregular, shallow and panting His respirations are irregular, shallow and panting

at a rate of 8. Poor rise and fall of the chestat a rate of 8. Poor rise and fall of the chest Pulses are hard to find at a rate of 60. Skin is Pulses are hard to find at a rate of 60. Skin is

pale, cool and sweaty.pale, cool and sweaty. Staff tells you he has been getting worse since Staff tells you he has been getting worse since

yesterday.yesterday.

Immediately!!Immediately!! Suction airway Suction airway Begin ventilation with BVM at 10-12 Begin ventilation with BVM at 10-12

breaths per minute breaths per minute

AssessmentAssessment Staff reports altered level of consciousness began Staff reports altered level of consciousness began

this morning.this morning. Bill has been ill with a urinary tract infection for 3 Bill has been ill with a urinary tract infection for 3

days.days. Bill is slow to respond to pain only.Bill is slow to respond to pain only. Breath sounds have rales on both sides with no Breath sounds have rales on both sides with no

wheezing and no rhonchi.wheezing and no rhonchi. Edema noted of face, hands and legs. Skin cool Edema noted of face, hands and legs. Skin cool

and diaphoretic to touchand diaphoretic to touch

SAMPLESAMPLE Allergies: morphineAllergies: morphine Medications: Medications: Capoten 25 mg tid, Diabinese 100

mg daily, Pyridium 200 mg tid, Gantrisin 1 gm qid

Past History: hypertension, type II diabetes and Past History: hypertension, type II diabetes and urinary tract infectionurinary tract infection

Last Meal: lunch yesterday, sips of fluid since Last Meal: lunch yesterday, sips of fluid since thenthen

Events: getting more difficult to arouse and Events: getting more difficult to arouse and breathing is getting worse.breathing is getting worse.

Vital SignsVital Signs BP: 84/60BP: 84/60 Pulse: 60 and irregularPulse: 60 and irregular Respirations: < 8 without assistanceRespirations: < 8 without assistance SaO2 on room air: 84%SaO2 on room air: 84% EtCO2: 24EtCO2: 24


• What is wrong with the patient? What is wrong with the patient? Sepsis from Sepsis from urinary tract infection urinary tract infection

• Is the patient in respiratory distress or Is the patient in respiratory distress or respiratory failure? respiratory failure? Respiratory failure

• Is the problem one of ventilation, diffusion or Is the problem one of ventilation, diffusion or perfusion or a mix? perfusion or a mix? Ventilation and perfusion

• Which of the 5 management tools will be Which of the 5 management tools will be helpful for this patient? helpful for this patient? BVM ventilation with oxygen (keep the airway clear of mucus), fluids

Scenario 3Scenario 3 You are called to the high school for a 17 year-old You are called to the high school for a 17 year-old

female, Emily.female, Emily. Emily is in the gym sitting on the bleachers. She Emily is in the gym sitting on the bleachers. She

is in tripod position in obvious distress.is in tripod position in obvious distress. Emily is very anxious and alertEmily is very anxious and alert, , but can only but can only

speak 1-2 words between breaths.speak 1-2 words between breaths. Her airway is clear.Her airway is clear. Respirations are labored at a rate of 32. You can Respirations are labored at a rate of 32. You can

hear wheezing when she breathes.hear wheezing when she breathes. Skin is warm and moist, pulse is 118 and regular.Skin is warm and moist, pulse is 118 and regular.

AssessmentAssessment Emily is using accessory muscles to Emily is using accessory muscles to

breathe. breathe. Lips are blue tingedLips are blue tinged Her lungs have musical wheezing on both Her lungs have musical wheezing on both

sides.sides. She has jugular vein distension.She has jugular vein distension. No edema noted of extremities. No edema noted of extremities. Emily states she is too short of breath to Emily states she is too short of breath to

move.move.

SAMPLESAMPLE Allergies: dust, mold, peanuts and cheese Medications: prednisone 10 mg tid,

terbutaline inhaler 2 puffs every 4 hours Past Medical History: Asthma Last Meal: Lunch 1 hour ago Events: Emily was playing volley ball in PE

class when she suddenly got very short of breath. She feels like her inhaler is not working.

Vital SignsVital Signs BP: 138/74BP: 138/74 Pulse: 118 and regularPulse: 118 and regular Respirations: 32Respirations: 32 SaO2 on room air: 89%SaO2 on room air: 89% EtCO2: 44EtCO2: 44


• What is wrong with the patient? What is wrong with the patient? asthma• Is the patient in respiratory distress or Is the patient in respiratory distress or

respiratory failure? respiratory failure? Respiratory distress• Is the problem one of ventilation, diffusion or Is the problem one of ventilation, diffusion or

perfusion or a mix? perfusion or a mix? ventilation• Which of the 5 management tools will be Which of the 5 management tools will be

helpful for this patient? helpful for this patient? Oxygen (CPAP may help) Nebulized DuoNeb, fluids to break up mucus

Scenario 4Scenario 4 You are called to transfer a 67 year-old woman You are called to transfer a 67 year-old woman

from a local facility to a comprehensive stroke from a local facility to a comprehensive stroke center an hour away.center an hour away.

ED Staff tell you Linda has had a brain stem ED Staff tell you Linda has had a brain stem stroke.stroke.

Linda is lying in the ED unresponsive.Linda is lying in the ED unresponsive. She is intubated on a ventilator with ventilations She is intubated on a ventilator with ventilations

set at 12/minute.set at 12/minute. Her color is good, skin is warm and dry and her Her color is good, skin is warm and dry and her

pulse is slow at a rate of 66.pulse is slow at a rate of 66.

AssessmentAssessment Linda is unresponsive to any stimuli. Pupils are dilated and slow to react. Jugular veins normal. Breath sounds are clear and equal on both

sides with good rise and fall of the chest with the ventilator.

No edema of extremities. Good pulses at all extremities.

SAMPLESAMPLE No allergiesNo allergies Medications: Catapres 0.3 mg bid, diabeta 20 mg Medications: Catapres 0.3 mg bid, diabeta 20 mg

daily, premarin 1 mg dailydaily, premarin 1 mg daily Past Medical History: hypertension, type II Past Medical History: hypertension, type II

diabetes, hormone replacement therapydiabetes, hormone replacement therapy Last Meal: breakfast 5 hours agoLast Meal: breakfast 5 hours ago

Events: The patient, Linda, had complained of Events: The patient, Linda, had complained of feeling weak and dizzy at home approximately 3 feeling weak and dizzy at home approximately 3 hours ago. She was brought to the Emergency hours ago. She was brought to the Emergency Department by her husband. While having a CT Department by her husband. While having a CT scan, she lost consciousness and stopped scan, she lost consciousness and stopped breathing effectively. The neurologist suspects breathing effectively. The neurologist suspects she has had multiple stroke events including a she has had multiple stroke events including a stroke in the pons of her brainstem. She was stroke in the pons of her brainstem. She was immediately intubated and placed on a ventilator.immediately intubated and placed on a ventilator.

Vital SignsVital Signs BPBP 188/110188/110 Pulse 62Pulse 62 Respirations 12 on ventilator Respirations 12 on ventilator SaO2 97% on ventilatorSaO2 97% on ventilator EtCO2 41EtCO2 41


• What is wrong with the patient? What is wrong with the patient? Stroke and brain damage in the respiratory control center of her brain

• Is the patient in respiratory distress or Is the patient in respiratory distress or respiratory failure? respiratory failure? Respiratory failure/arrest

• Is the problem one of ventilation, diffusion or Is the problem one of ventilation, diffusion or perfusion or a mix? perfusion or a mix? Ventilation

• Which of the 5 management tools will be Which of the 5 management tools will be helpful for this patient? helpful for this patient? Oxygen by ventilator, will need continued ventilation during transport either by ventilator or BVM.

presence regional ems system

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