slide 1 copyright © 2007, 2004, by mosby, inc., an affiliate of elsevier inc. all rights reserved....

Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Respiratory EmergenciesRespiratory Emergencies

Chapter 17Chapter 17


Case HistoryCase History

A 30-year-old male walks into your A 30-year-old male walks into your headquarters complaining of severe difficulty headquarters complaining of severe difficulty in breathing. The patient’s wife tells you that in breathing. The patient’s wife tells you that this started about 2 hours ago. He tells you this started about 2 hours ago. He tells you that he has asthma and is carrying a that he has asthma and is carrying a metered-dose inhaler.metered-dose inhaler.


Respiratory SystemRespiratory System


Upper Respiratory TractUpper Respiratory Tract


Lower Respiratory TractLower Respiratory Tract


Muscles of RespirationMuscles of Respiration


Inspiration (Active Process)Inspiration (Active Process)

Diaphragm flattens, increases inferior-superior diameter of Diaphragm flattens, increases inferior-superior diameter of chest.chest.

External intercostals pull ribs up, increase anterior-posterior, External intercostals pull ribs up, increase anterior-posterior, lateral dimensions.lateral dimensions.

Chest cavity increases in size – more volume, less gas, Chest cavity increases in size – more volume, less gas, decrease in pressure, air rushes in decrease in pressure, air rushes in

Inspiration continues until pressure between lung and Inspiration continues until pressure between lung and atmosphere equalizes.atmosphere equalizes.


Expiration (Passive Process)Expiration (Passive Process)

Elastic recoil of lungs plus muscle relaxationElastic recoil of lungs plus muscle relaxation

Chest cavity decreases in size – less volume, more Chest cavity decreases in size – less volume, more gas, air rushes out to atmosphere.gas, air rushes out to atmosphere.

Expiration continues until atmosphere and chest Expiration continues until atmosphere and chest pressure are equal.pressure are equal.


Inspiration and ExpirationInspiration and Expiration


Diffusion of Oxygen and Diffusion of Oxygen and Carbon DioxideCarbon Dioxide


Pathophysiology – Pathophysiology – Airway ObstructionAirway Obstruction

Obstruction by the tongueObstruction by the tongue UnconsciousnessUnconsciousness Relaxed jaw and epiglottisRelaxed jaw and epiglottis Obstruction of the pharynxObstruction of the pharynx Evidenced by snoringEvidenced by snoring Cleared with manual Cleared with manual

maneuvers and adjunctsmaneuvers and adjuncts



Swollen epiglottis and other airway structuresSwollen epiglottis and other airway structures Epiglottitis and anaphylaxisEpiglottitis and anaphylaxis Obstruction at or above the vocal cordsObstruction at or above the vocal cords Evidenced by stridor or crowingEvidenced by stridor or crowing Surgical airway may be neededSurgical airway may be needed Positive-pressure ventilation can be lifesaving.Positive-pressure ventilation can be lifesaving.



Fluid in airwayFluid in airway Aspiration, pulmonary edema, or drowningAspiration, pulmonary edema, or drowning Evidenced by gurglingEvidenced by gurgling Immediate suctioning of the airway is critical.Immediate suctioning of the airway is critical.


Anatomy Considerations – Anatomy Considerations – Infants and ChildrenInfants and Children

Smaller airwaysSmaller airways Tongue is larger in relation to mouth.Tongue is larger in relation to mouth. TracheaTrachea

NarrowerNarrower More pliableMore pliable

Cricoid cartilageCricoid cartilage Smaller and less rigidSmaller and less rigid Narrowest portion of the airwayNarrowest portion of the airway

Infants and children depend on diaphragm Infants and children depend on diaphragm for breathing.for breathing.


Problems Associated withProblems Associated with Respiratory PatientsRespiratory Patients

Difficulty breathingDifficulty breathing

Inadequate breathing Inadequate breathing (respiratory failure)(respiratory failure)

Respiratory arrestRespiratory arrest


Adequate Breathing – RateAdequate Breathing – Rate

Adult: 12-20/minAdult: 12-20/min

Child: 15-30/minChild: 15-30/min

Infant: 25-50/minInfant: 25-50/min


Adequate Breathing Adequate Breathing

RhythmRhythm Regular Regular IrregularIrregular

QualityQuality Breath sounds – present and equalBreath sounds – present and equal Chest expansion – adequate and Chest expansion – adequate and

equalequal Minimum effort of breathing Minimum effort of breathing

Depth (tidal volume) – adequateDepth (tidal volume) – adequate


Signs of Inadequate Breathing

Very slow respiratory rate

Very rapid respiratory rate

Shallow breathing

Diminished or absent breath sounds


Signs of Inadequate Breathing

Altered level of consciousnessAltered level of consciousness

Seesaw breathing (infants and Seesaw breathing (infants and children)children)

Pale or cyanotic skin colorPale or cyanotic skin color

Cool and clammy skinCool and clammy skin


Increased Work of Breathing

Accessory muscle use

Retractions

Nasal flaring

Sitting upright

Tripod position


Inadequate BreathingInadequate Breathing

Rate – outside of normal rangesRate – outside of normal ranges

Rhythm – irregularRhythm – irregular

QualityQuality Breath sounds – diminished or absentBreath sounds – diminished or absent Chest expansion – unequal or inadequateChest expansion – unequal or inadequate Increased effort of breathing – use of accessory muscles – predominantly Increased effort of breathing – use of accessory muscles – predominantly

in infants and childrenin infants and children

Depth (tidal volume) – inadequate/shallowDepth (tidal volume) – inadequate/shallow


Adequate VentilationAdequate Ventilation

Chest rises and falls with each Chest rises and falls with each artificial ventilation.artificial ventilation.

RateRate Adults – 10-12/min Adults – 10-12/min Infants and children – 12-20/minInfants and children – 12-20/min

Heart rate returns to normal.Heart rate returns to normal.


Inadequate VentilationInadequate Ventilation

The chest does not rise and The chest does not rise and fall with artificial ventilation.fall with artificial ventilation.

The rate is too slow or too The rate is too slow or too fast.fast.

Heart rate does not return to Heart rate does not return to normal with artificial normal with artificial ventilation.ventilation.


Assessing the Patient with Assessing the Patient with Difficulty BreathingDifficulty Breathing


Scene Size-upScene Size-up Scene safety Scene safety

If traumaIf trauma Consider mechanism of injury.Consider mechanism of injury. Provide spinal immobilization.Provide spinal immobilization.

Be alert for toxic environment.Be alert for toxic environment.

Body substance isolationBody substance isolation If fluids are present in airway, consider need for If fluids are present in airway, consider need for

eyewear, gowns, gloves, and mask.eyewear, gowns, gloves, and mask. If TB is possible, consider need for HEPA If TB is possible, consider need for HEPA

respirator.respirator.


Initial Assessment – Initial Assessment – General ImpressionGeneral Impression

Is there obvious life threat, such as respiratory arrest?Is there obvious life threat, such as respiratory arrest?

In what position is patient found?In what position is patient found? Bolt upright? Tripod?Bolt upright? Tripod? Sleepy or unresponsive?Sleepy or unresponsive?

• May require positive-pressure ventilationMay require positive-pressure ventilation

Does patient speak in complete sentences?Does patient speak in complete sentences?

Other obvious signs of respiratory distress?Other obvious signs of respiratory distress?


Initial Assessment – AirwayInitial Assessment – Airway Signs of obstruction?

Inability to speak Universal choking sign

Sounds associated with obstruction Noisy breathing Crowing or stridor (upper airway) Gurgling (fluids) Snoring (tongue) Audible wheezing (lower airway)


Initial Assessment – Airway Management

Manual maneuvers Head tilt/ chin lift Jaw thrust

Use of adjuncts Nasopharyngeal airway Oropharyngeal airway

FBAO maneuvers Suctioning Assistance with MDI medication

(bronchiole constriction)


Initial Assessment – BreathingInitial Assessment – Breathing

Decrease in tidal volume or rate (minute volume)Decrease in tidal volume or rate (minute volume) Tidal volume Tidal volume rate = minute volume rate = minute volume

• Examples:Examples: Normal: 500 mL/breath 12 breaths/min = 6000 mL Hypoventilation: 200 mL/breath 12 breaths/min = 2400 mL Hypoventilation: 500 mL 6 breaths/min = 3000 mL

Critical to evaluateCritical to evaluate Tidal volume (chest rise)Tidal volume (chest rise) Respiratory rateRespiratory rate Other signs of hypoxiaOther signs of hypoxia

• Mental stateMental state• Skin colorSkin color


Signs and Symptoms of Signs and Symptoms of Difficulty BreathingDifficulty Breathing

Shortness of breathShortness of breath

RestlessnessRestlessness

Increased pulse rateIncreased pulse rate



Pale or cyanotic skin

Coughing

Tripod position



Shortness of breathShortness of breath

RestlessnessRestlessness

Increased breathing rateIncreased breathing rate

Decreased breathing rateDecreased breathing rate


Skin Color ChangesSkin Color Changes

Cyanotic (blue-gray)Cyanotic (blue-gray) Pale Pale Flushed (red)Flushed (red)



Inability to speak because of breathing effortsInability to speak because of breathing efforts

Retractions – use of accessory musclesRetractions – use of accessory muscles

Shallow or slow breathing Shallow or slow breathing May lead to altered mental status with fatigue or obstructionMay lead to altered mental status with fatigue or obstruction

Abdominal breathing (diaphragm only)Abdominal breathing (diaphragm only)



CoughingCoughing

Irregular breathing patternIrregular breathing pattern

Patient positionPatient position Tripod position (sitting with feet dangling, leaning forward)Tripod position (sitting with feet dangling, leaning forward)

Unusual anatomy (barrel chest)Unusual anatomy (barrel chest)


Important QuestionsImportant Questions

OOnsetnset PProvocationrovocation QQualityuality RRadiationadiation SSeverityeverity TTimeime IInterventionsnterventions


Primary Management of Primary Management of Respiratory EmergenciesRespiratory Emergencies

Airway managementAirway management

Positive-pressure ventilationPositive-pressure ventilation

Supplemental oxygenSupplemental oxygen

PositioningPositioning

Administration of prescribed inhalersAdministration of prescribed inhalers


BreathingBreathing

Complains of trouble breathingComplains of trouble breathing Apply oxygen, if not already done. Apply oxygen, if not already done. Assess baseline vital signs.Assess baseline vital signs.

Has a prescribed inhaler availableHas a prescribed inhaler available Consult medical direction.Consult medical direction. Facilitate administration of inhaler.Facilitate administration of inhaler.


BreathingBreathing

Does not have prescribed inhalerDoes not have prescribed inhaler Continue with focused assessment.Continue with focused assessment.

Be prepared to intervene with Be prepared to intervene with appropriate oxygen administration. appropriate oxygen administration. Positive-pressure ventilation (if patient will Positive-pressure ventilation (if patient will

tolerate)tolerate)


Prescribed InhalerPrescribed Inhaler

Generic nameGeneric name Albuterol, isoetharine, Albuterol, isoetharine,

metaproterenol, etc.metaproterenol, etc.

Trade nameTrade name Proventil, Ventolin, Bronkosol, Proventil, Ventolin, Bronkosol,

Bronkometer, Alupent, Metaprel, etc.Bronkometer, Alupent, Metaprel, etc.


Prescribed Inhaler –Prescribed Inhaler – Indications Indications

Exhibits signs and symptoms of respiratory emergencyExhibits signs and symptoms of respiratory emergency

Has physician prescribed handheld inhaler?Has physician prescribed handheld inhaler?

Specific authorization by medical directionSpecific authorization by medical direction


Prescribed Inhaler –Prescribed Inhaler – Contraindications Contraindications

Inability of patient to use deviceInability of patient to use device

Inhaler is not prescribed for the patientInhaler is not prescribed for the patient

No permission from medical directionNo permission from medical direction

Patient has already met maximum prescribed dose Patient has already met maximum prescribed dose before EMT arrival.before EMT arrival.


Administration of InhalerAdministration of Inhaler

Check the expiration date.Check the expiration date. Check to see if the patient has already taken any Check to see if the patient has already taken any

doses.doses. Ensure that the inhaler is at room temperature or Ensure that the inhaler is at room temperature or

warmer.warmer. Shake the inhaler vigorously several times.Shake the inhaler vigorously several times. Remove oxygen adjunct from patient.Remove oxygen adjunct from patient. Have the patient exhale deeply.Have the patient exhale deeply.


Administration of InhalerAdministration of Inhaler

Replace oxygen adjunct on patient.Replace oxygen adjunct on patient.

Allow patient to breathe a few times.Allow patient to breathe a few times. Repeat second dose per medical direction.Repeat second dose per medical direction.

If patient has a spacer device, it should be used for If patient has a spacer device, it should be used for more effective results.more effective results.


Actions of Inhaler Actions of Inhaler

Beta-agonistBeta-agonist

Dilates bronchiolesDilates bronchioles

Reduces airway resistanceReduces airway resistance


Reassessment StrategiesReassessment Strategies

Gather vital signs.Gather vital signs.

Perform focused reassessment.Perform focused reassessment. Patient’s condition may deteriorate.Patient’s condition may deteriorate.

• Consider need for positive-pressure artificial ventilation.Consider need for positive-pressure artificial ventilation.


Side Effects of InhalerSide Effects of Inhaler

Increased pulse rateIncreased pulse rate

TremorsTremors

NervousnessNervousness


Infant and Child Infant and Child ConsiderationsConsiderations

Use of handheld inhalers is very common in children.Use of handheld inhalers is very common in children.

Retractions are more common in children.Retractions are more common in children.

Cyanosis is a late finding in children.Cyanosis is a late finding in children.

Coughing rather than wheezing may be present in some Coughing rather than wheezing may be present in some children.children.

Use of inhalers is the same if the indications are met by the ill Use of inhalers is the same if the indications are met by the ill child.child.


Causes of Causes of Respiratory Emergencies Respiratory Emergencies

Chronic obstructive pulmonary diseaseChronic obstructive pulmonary disease

AsthmaAsthma

PneumoniaPneumonia

Hyperventilation syndromeHyperventilation syndrome

Spontaneous pneumothoraxSpontaneous pneumothorax


Chronic Obstructive Chronic Obstructive Pulmonary Disease (COPD)Pulmonary Disease (COPD)

Chronic respiratory conditionChronic respiratory condition Chronic bronchitisChronic bronchitis EmphysemaEmphysema

Primary complaint – dyspneaPrimary complaint – dyspnea BronchoconstrictionBronchoconstriction


Chronic BronchitisChronic Bronchitis

Chronic productive cough for Chronic productive cough for >> 3 mo/yr x 2 yrs 3 mo/yr x 2 yrs

Caused by smoking or long-term exposure to Caused by smoking or long-term exposure to environmental pollutantsenvironmental pollutants



Bronchial obstruction = poorly ventilated alveoli = Bronchial obstruction = poorly ventilated alveoli = poorly oxygenated blood = cyanosispoorly oxygenated blood = cyanosis

““Blue bloater”Blue bloater”



SignsSigns CyanosisCyanosis Edema – ankles, hips, abdomenEdema – ankles, hips, abdomen

• Result of right-sided heart failureResult of right-sided heart failure Jugular venous distentionJugular venous distention Wheezing, possible cracklesWheezing, possible crackles


EmphysemaEmphysema

Caused by destruction of alveoliCaused by destruction of alveoli

Less lung surface for oxygen to diffuse into bloodLess lung surface for oxygen to diffuse into blood

Small bronchioles damaged alsoSmall bronchioles damaged also Collapse on exhalation = air trapped in lungsCollapse on exhalation = air trapped in lungs

• Barrel chestBarrel chest• Pursed lipsPursed lips

Body may increase red blood cells and hemoglobinBody may increase red blood cells and hemoglobin ““Pink puffer”Pink puffer”


COPDCOPD

SignsSigns Can only walk short distancesCan only walk short distances Home oxygenHome oxygen


COPDCOPD

Normal regulation for breathing – carbon dioxideNormal regulation for breathing – carbon dioxide

Patients with COPD retain high levels of carbon dioxide.Patients with COPD retain high levels of carbon dioxide. Regulation for breathing – low oxygen levelsRegulation for breathing – low oxygen levels

Supplemental oxygen may turn hypoxic drive off, resulting in Supplemental oxygen may turn hypoxic drive off, resulting in hypoventilation or respiratory arrest.hypoventilation or respiratory arrest. Be alert.Be alert.


COPDCOPD

Do not withholdDo not withhold oxygen for COPD patients oxygen for COPD patients in shock, with altered mental status, or in in shock, with altered mental status, or in

severe respiratory arrest.severe respiratory arrest.

Prepare to assist ventilations.Prepare to assist ventilations.


AsthmaAsthma

Caused by constriction of the lower airwaysCaused by constriction of the lower airways Triggered by stress, infection, or allergyTriggered by stress, infection, or allergy

SignsSigns DyspneaDyspnea Upright postureUpright posture Possible accessory muscle usePossible accessory muscle use FlushingFlushing Forceful breathingForceful breathing Audible wheezingAudible wheezing FatigueFatigue Respiratory failureRespiratory failure


PneumoniaPneumonia

Inflammation of alveolar spacesInflammation of alveolar spaces Interferes with normal exchange of oxygen with bloodInterferes with normal exchange of oxygen with blood

Signs and symptomsSigns and symptoms Depend on underlying causeDepend on underlying cause

• DyspneaDyspnea

• FeverFever

• CoughCough

• Sputum productionSputum production

• Crackles or diminished breath soundsCrackles or diminished breath sounds


Hyperventilation SyndromeHyperventilation Syndrome

Increase in rate and depth of breathing = decreased amount of Increase in rate and depth of breathing = decreased amount of carbon dioxidecarbon dioxide Result: tingling around mouth and fingers, dizziness, possible Result: tingling around mouth and fingers, dizziness, possible

nauseanausea Often result of anxietyOften result of anxiety

Check for underlying causesCheck for underlying causes Asthma, COPDAsthma, COPD

If no other known cause, administer oxygen, and calm If no other known cause, administer oxygen, and calm reassurance.reassurance.


Spontaneous PneumothoraxSpontaneous Pneumothorax

Rupture of part of the lungRupture of part of the lung Allows air to exit the lung into the pleural spaceAllows air to exit the lung into the pleural space Lung may partially or totally collapseLung may partially or totally collapse

Frequently seen in thin, muscular menFrequently seen in thin, muscular men


Spontaneous PneumothoraxSpontaneous Pneumothorax

SignsSigns Sudden onset of dyspnea and pleuritic chest painSudden onset of dyspnea and pleuritic chest pain Diminished breath sounds on one sideDiminished breath sounds on one side

Monitor patient for progression to tension pneumothoraxMonitor patient for progression to tension pneumothorax Absent breath sounds on one sideAbsent breath sounds on one side Distended neck veinsDistended neck veins HypotensionHypotension Tracheal deviationTracheal deviation


Croup and EpiglottitisCroup and Epiglottitis

Usually occurs in childrenUsually occurs in children Epiglottitis can occur in adults.Epiglottitis can occur in adults.

Croup – viral infection that causes swelling and Croup – viral infection that causes swelling and narrowing of the upper airway (below thyroid narrowing of the upper airway (below thyroid cartilage)cartilage)

Epiglottitis – bacterial infection that causes swelling of Epiglottitis – bacterial infection that causes swelling of the epiglottisthe epiglottis


Croup and EpiglottitisCroup and Epiglottitis

SignsSigns FeverFever DyspneaDyspnea CoughingCoughing Stridor or crowingStridor or crowing Increased work of breathingIncreased work of breathing Tripod positionTripod position

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