Chapter 16 - Respiratory Emergencies Flashcards
3 Parts of the Respiratory System
- Upper Airway
- Lower Airway
- Lungs and Accessory Structures
Upper and Lower Airway Seperated By
Vocal Cords (Glottic Opening)
Primary Purpose of the Upper/Lower Airways
Conduction of air into and out of the lungs
Primary Purpose of the Lungs and Accessory Structures
- Oxygenation of body cells
- Elimination of CO2 from bloodstream
Signs of Normal Breathing
- Open airway
- Normal RR
- Good chest rise/fall
- Normal respiratory rhythm
- Bilateral breath sounds
- Normal chest expansion/relaxation
- Minimal/absent use of accessory muscles
The Following Should Occur in a PT with Adequate Breathing if No Other Injury
- Normal Mental Status
- Normal Muscle Tone
- Pulse Ox > or equal to 94%
- Normal Skin Condition Findings
3 Abnormal Factors Present in Certain Pulmonary Conditions that Decrease Gas Exchange Efficiency Across Alv/Cap Membrane
- Increased width of the space between alveoli and blood vessels
- Lack of perfusion of pulmonary capillaries from the RT ventricle of heart
- Filling of alveoli with fluid, blood, or pus
Many Findings Consistent with Respiratory Distress Come from the use of ___
Accessory Muscles
Inspiratory/Expiratory Centers in the Medulla
Receive info about oxygenation and CO2 content of the bloodstream from special sensors in the vascular system
Stretch Receptors
- In walls of the lungs
- Provide info to brainstem to prevent accidental overexpansion injuries
Irritant Receptors
- In walls of bronchioles
- Detect presence of abnormalities such as excess fluid, toxic fumes, smoke, or changes in air temp
Juxta-Capillary Receptors
- Receptors near the alveoli
- Detect when alv/cap beds become abnormally engorged with blood due to heart failure
3 Locations of Auscultate Breath Sounds
- 2nd Intercostal Space, Midclavicular Line
- 3rd Intercostal Space, Anterior Axillary Line
(Or 4th Intercostal Space, Midaxillary Line) - 5th or 6th Intercostal Space, Posterior Midscapular Line
2nd Intercostal Space, Midclavicular Line
- Stridor and Rhonchi
- Sounds represent airflow through larger airways
- Airway structures supported by cartilage
3rd Intercostal Space, Anterior Axillary Line
4th Intercostal Space, Midaxillary Line
- Wheezing
- Airflow through smaller airways (Bronchioles)
- Airflow into air sacs (alveoli)
5th or 6th Intercostal Space, Posterior Midscapular Line
- Crackles (Rales)
- Airflow into alveoli (alveolar airflow)
Wheezing
- High pitched sound heard usually on exhale (inhale in severe cases)
- Swelling/constriction of lower airways (bronchioles)
- Sound will disappear if bronchoconstriction becomes too severe
- Asthma, emphysema, chronic bronchitis
Diffuse Wheezing
- Heard over all lung fields
- Indication to administer Beta-2 Agonist by MDI
Rhonchi (Coarse Crackles)
- Snoring/rattling
- Obstruction of larger airways by mucous
- Sound quality can change with cough of position change
Crackles (Rales)
- Bubbly/cracking on inhalation
- Fluid surrounding or filling alveoli or bronchioles
- Revealed first in posterior base of lungs
- Pulmonary edema or pneumonia
Hypoxemia
Decrease in O2 in bloodstream
Hypercarbia
Increase in CO2 in bloodstream
Dyspnea
Shortness of breath, difficulty breathing
Apnea
Respiratory arrest, no breathing
Hypoxia
Inadequate O2 to cells of body
Bronchoconstriction (Bronchospasm)
Narrowing of lower airways from inflammation/swelling/constriction of muscle layer
Bronchodilator
Beta-2 Agonist that relaxes bronchi/bronchiole smooth muscle, causing dilation
3 Symptoms Causing Dyspnea
- Mechanic disruption of airway/lung/chest wall
(Flail segment, pneumothorax) - Stimulation of lung receptors
(asthma, pneumonia, congestive heart failure) - Inadequate gas exchange at alv/cap level
(Disturbance to ventilation/perfusion)
Assessment and Care: Respiratory Distress
Assessment: Adequate TV/RR producing adequate minute and alveolar ventilation
Care: Supplemental O2 to maintain SpO2 94% or greater (Nasal Cannula)
- Can use CPAP if PT is alert
- Nonrebreather if severe hypoxia
Assessment and Care: Respiratory Failure
Assessment: Inadequate TV and/or RR
Care: +PPV with BVM and supplemental O2
Assessment and Care: Respiratory Arrest
Assessment: No TV/RR (Maybe agonal aspirations)
Care: +PPV with BVM and supplemental O2
3 Most Common Obstructive Pulmonary Diseases
- Emphysema (COPD)
- Chronic Bronchitis (COPD)
- Asthma
Chronic Obstructive Pulmonary Disease (COPD)
- Chronic conditions that continue to progress
- Emphysema and Chronic Bronchitis
- Cause from smoking
- PTs with COPD may have CPAP or BiPAP bedside
- Hypoxic Drive (Respond to low O2 levels)
- 88-92% SpO2
Pathophysiology: Emphysema
- Lung tissue loses elasticity
- Alveoli become distended with trapped air
- Walls of alveoli destroyed, reducing surface area in contact with pulmonary caps
- Disruption in gas exchange leading to Hypoxemia
- Exhaling becomes active instead of passive
- More common in men, 60-70
- Caused by cigarette smoking
- Genetic Emphysema - decrease in Alpha 1 Antitrypsin
- Blood O2 remains normal due to hyperventilation
Signs/Symptoms: Emphysema
- Anxious/Alert/Oriented
- Dyspneic
- Accessory muscle use
- Thin, barrel-chest appearance (air trapped in alveoli expands chest)
- Wheezing/Rhonchi
- Pursed Lip Breathing (PEEP)
Pathophysiology: Chronic Bronchitis
- Swelling/inflammation of bronchi and bronchioles
- Productive cough persisting for 3 consecutive months in 1 year or 2 consecutive years
- Excessive mucous production
- Pulmonary Cap bed unaffected
- Leads to Hypoxemia/Hypercarbia
Signs/Symptoms: Chronic Bronchitis
- Bloating/Cyanotic Appearance
- Vigorous cough
- Peripheral edema and JVD
- Rales (Crackles) and Coarse Rhonchi
- Wheezing at lung base
- Asterixis (Flapping of extended wrists)
Emergency Care: Emphysema and Chronic Bronchitis
- Open airway, adequate breathing, supplemental O2 if needed
- Maintain SpO2 88-92% via nasal cannula (2lpm titrated up to 6lpm)
- CPAP if necessary
2 Indications for CPAP with COPD PT
- Moderate to severe dyspnea with use of accessory muscles and paradoxical chest movement
- RR > 25/minute
- Pressure of 5-10cmH20
- BVM if deterioration
Pathophysiology: Asthma
- Increased airway sensitivity to irritants/allergens
- Bronchospasm (constriction of bronchi/bronchiole smooth muscle)
- Edema (swelling) of inner airway lining
- Increase mucous secretion plugging airways
Acute Severe Asthma (Status Asthmaticus)
- Prolonged, life threatening attack
- Does not respond to O2 or medication therapy with bronchodilators
- Immediate transport to hospital
2 Kinds of Asthma
Extrinsic and Intrinsic
Extrinsic Asthma
- Allergic asthma
- Reaction to dust, pollen, smoke
- Seasonal
- Most common in children
Intrinsic Asthma
- Nonallergic
- Most common in adults
- Result from infection, stress, strenuous activity
Signs/Symptoms: Asthma
- Wheezing on exhale (May disappear in severe case)
- Tachycardia (HR>120bpm severe asthma attack)
- Pulsus Paradoxus (Drop in Systolic BP >10mmHg on inhalation)
- Reduction in peak expiratory flow (PERF)
Slow Onset Asthma
- 80% of cases
- Females
- Triggered by upper respiratory tract infection
- Deteriorates 6 hours to days
Sudden Onset Asthma
- 20% of cases
- Rapid deterioration within 6 hours
- Males
- Triggered by allergens, exercise, stress
Signs/Symptoms: Critically Ill Asthma Attack
- Upright
- Tachypnea (>20/min, often >40/min)
- Tachycardia (>120bpm)
- Pulsus Paradoxus (Drop in systolic >10mmHg on inhale)
- Absent wheezing
- SpO2 <90% on oxygen
- Requires +PPV and supplemental O2
Emergency Care: Asthma
- Nasal Cannula with supplemental O2 for >94%
- Air humidification not necessary
- If severe, administer Short Acting Beta2 Agonist (SABA) through SVN
- CPAP if PT alert/oriented, breathes on own, and GCS>10
Asthma Severity Guide (Mild/Moderate/Severe):
Dyspnea
Mild - When Walking
Moderate - When Talking
Severe - At Rest
Asthma Severity Guide (Mild/Moderate/Severe):
Speaking
Mild - Full Sentences
Moderate - Phrases
Severe - Only Words
Asthma Severity Guide (Mild/Moderate/Severe):
Heart Rate
Mild - 100bpm
Moderate - 100-120bpm
Severe - >120bpm
Asthma Severity Guide (Mild/Moderate/Severe):
Respiratory Rate
Mild - Tachypnea
Moderate - Tachypnea
Severe - >30/minute
Asthma Severity Guide (Mild/Moderate/Severe):
Breath Sounds
Mild - Wheezing at end of exhalation
Moderate - Wheezing throughout exhalation
Severe - Wheezing throughout inhalation and exhalation, absent breath sounds
Asthma Severity Guide (Mild/Moderate/Severe):
Accessory Muscle Use
Mild - Rare
Moderate - Common
Severe - Always
Asthma Severity Guide (Mild/Moderate/Severe):
Mental Status
Mild - Anxious, somewhat agitated
Moderate - Usually agitates
Severe - Agitated to sleepy
Pathophysiology: Pneumonia
- Acute infectious disease caused by bacterium/virus affecting lower respiratory tract
- Causes lung inflammation
- Fluid/pus filled alveoli
- Pneumonitis caused by inhalation of toxic irritants or aspiration of vomit
Signs/Symptoms: Pneumonia
- Malaise
- Decrease appetite
- Splinting of thorax by PT with arm
- Crackles, localized wheezing, rhonchi
- Fever, cough, chest pain on deep inhale
- Decrease chest wall movement
- AMS
- Diaphoresis/cyanosis
Emergency Care: Pneumonia
- Ensure adequate airway, ventilation, oxygenation
- Nasal cannula at 2lpm with supplemental O2
- Consult medical direction for use of any SABA or CPAP
Pathophysiology: Pulmonary Embolism
- Sudden blockage of blood flow through pulmonary artery or one of its branches
- Caused by blood clot/air bubble
- Adequate ventilation but due to decrease blood flow, reduced perfusion
Signs/Symptoms: Pulmonary Embolism
- Sudden dyspnea
- Tachycardia/Tachypnea
- Sudden sharp chest pain
- Fainting
- Deep Vein Thrombosis (DVT) - Swelling/pain to one limb
- Late Signs: Decrease BP, cyanosis, distended neck vein
- Crackles
Emergency Care: Pulmonary Embolism
- Open airway
- +PPV with supplemental O2
- Immediate Transport
Pathophysiology: Acute Pulmonary Edema
- Excessive fluid collects in space between alv and cap
- Disturbs gas exchange, reducing diffusion of O2 and CO2 across alv/cap
- Hypoxia is most significant problem
2 Types of Acute Pulmonary Edema
- Cardiogenic Pulmonary Edema
- Noncardiogenic Pulmonary Edema
Cardiogenic Pulmonary Edema
- Inadequate pumping of LT Ventricle
- Increases pressure in pulmonary caps
- Fluid leaks to space between alv/cap
Noncardiogenic Pulmonary Edema (Acute Respiratory Distress Syndrome ARDS)
- Destruction of cap bed that allows fluid to leak out
- Caused by pneumonia, smoke inhalation
Signs/Symptoms: Acute Pulmonary Edema
- Dyspnea
- Difficulty breathing when flat (Orthopnea)
- Pink/Frothy sputum (cardiogenic only)
- Tripod, dangling legs
- Distended neck veins (Cardio only)
- Swelling of lower extremities (Cardio only)
- Crackles (Rales)
Emergency Care: Acute Pulmonary Edema
- If inadequate breathing, +PPV with O2
- CPAP if alert/oriented, maintain own airway, GSC>10
Pathophysiology: Spontaneous Pneumothorax
- Sudden rupture of portion of visceral lining of lung without trauma
- Air enters pleural cavity causing lung to collapse
2 Types of Spontaneous Pneumothorax
Primary and Secondary
Primary Spontaneous Pneumothorax
- PT has no underlying lung disease
- Teens to early 20s
- Tall and thin
Secondary Spontaneous Pneumothorax
- PT has underlying lung disease
- History of cigarette smoking
- Connective tissue disorder (Marfan Syndrome or Ehlers-Danlos Syndrome)
- PTs with COPD or weakened lung tissue (Blebs or Bullae)
Signs/Symptoms: Spontaneous Pneumothorax
- Sudden shortness of breath without trauma
- Decrease breath sound to one side of chest (most often heard at lung apex)
- Subcutaneous Emphysema
Emergency Care: Spontaneous Pneumothorax
- O2 to maintain 94%
- If needed, +PPV with great care, or could convert it to tension pneumothorax (decrease in Sp02, decrease in breath sounds to 1 side)
- Use minimal TV necessary
- ALS
- CPAP CONTRAINDICATED
Pathophysiology: Hyperventilation
- Feeling of unable to catch breath
- Blowing off excessive amounts of CO2
- PT is excited, anxious, panic attacks
Signs/Symptoms: Hyperventilation
- Fatigue
- Nervous/anxious
- Numbness/tingling around mouth, hands, feet
- Spasms of fingers/feet (carpopedal spasm)
- Dizziness
Emergency Care: Hyperventilation
- Instruct PT to calm down
- Breath through nose
- Remove PT from anxiety scene
- DO NOT breath into bag or use O2 mask not connected to O2
- Pulmonary Embolism/Myocardial Infarction similar to Hyperventilation, rebreathing CO2 could be fatal
Pathophysiology: Epiglottitis
- Most commonly cause in adults is Haemophilus Influenzae Type B
- Epiglottis and surrounding area become inflamed and swollen, leading to compromised airway
Signs/Symptoms: Epiglottitis
- Upper respiratory tract infection (1-2 days prior to onset)
- Rapid onset dyspnea
- Sore throat and pharyngeal pain
- Inability to swallow
- Drooling (late sign)
- Tripod, jaw jetting forward
- High pitched stridor on inhale
Emergency Care: Epiglottitis
- Do not force airway inspection that may further disturb airway
- High O2 at 15lmp
- Maintain calm/quiet environment/comfortable
- BVM if deteriorates
Pathophysiology: Pertussis (Whooping Cough)
- Highly contagious
- Mostly in children
- Starts off as a cold/upper resp tract infection
- PTs may wait it out, tends to be severe by the time EMS is called
- 15-24 coughs in close sequence
Signs/Symptoms: Pertussis
- History of upper resp infections
- General malaise
- Inspiratory “whoop” at end of coughing burst
- Diminished pulse ox
- Coughing fits
Emergency Care: Pertussis
- Tell PT to expectorate any coughing mucous
- Humidify O2 may help expel mucous
- O2 as needed for >94%
3 Stages of Pertussis
- Findings of common cold/upper resp tract infection
- Coughing worsens, EMS called
- Recovery
Pathophysiology: Cystic Fibrosis
- Mucoviscidosis/mucovoidosis
- Hereditary
- Disfunction of mucous glands that line respiratory system (overabundance)
- Thick mucous blocks airway
- No cure of CF, many die young
- Lung transplant if nothing else works
Signs/Symptoms: Cystic Fibrosis
- History of disease
- Recurrent coughing
- Difficulty breathing
- Malnutrition
- Bowel movements, smelly, greasy
- Dehydration
- Clubbing of digits
- Gastro complaints
Emergency Care: Cystic Fibrosis
- Nasal cannula to maintain 94%
- Humidify O2 to allow for expelling mucous
- Normal saline through SVN
Pathophysiology: Viral Respiratory Infections
- Upper Respiratory Infections (URI)
- Most symptoms in nose/throat
- Bronchiolitis, colds, and the flue
- If it reaches lower airways, Croup or pneumonia
- 14 days
Signs/Symptoms: Viral Respiratory Infections
- Nasal congestion
- Sore throat
- Fever (101-102)
Emergency Care: Viral Respiratory Infections
- Nasal cannula until 94%
- EMS not called predominantly
Meter-Dosed Inhaler (MDI)
- Beta2 Specific Bronchodilator
MDI/SVN Actions
Beta2 Agonist that relaxes bronchiole smooth muscle and dilates lower airways reducing airway resistance and improving airflow to alveoli
3 MDI/SVN Indications
- PT exhibits signs of respiratory distress from bronchoconstriction
- PT has prescribed MDI/SVN or EMS has it on hand
- EMT has approval from medical director online or offline
4 MDI/SVN Contraindications
- PT not responsive enough
- Not prescribed to PT or not EMS protocol
- Medical direction not granted
- PT has already taken max amount before EMS arrival
MSI/SVN Side Effects
- Tachycardia
- Tremors
- Nervousness
- Dry Mouth
- Nausea, vomiting
Advair Diskus
- For PTs with uncontrollable asthma
- Long acting beta2 specific drug
- NOT a rescue inhaler
Croup
- Laryngotracheobronchitis
- Common in children
- Swelling of larynx, trachea, bronchi
- Cough like a ‘barking seal’
Respiratory Distress General Impressions
- Position (tripod or laying flat (really good or really bad))
- Face (Agitated or Confused)
- Speech
- AMS (Eyelids droop, sleepy - +PPV)
- Accessory Muscles/Retractions
- Cyanosis/Diaphoresis
- Pallor
- Nasal Flaring/Pursed Lips
