Pulmonary Emergencies Flashcards
1
Q
upper airway conditions
A
- susceptible to conditions that can obstruct the airway and impair ventilation
- most commonly caused by infections
- also allergic reactions and foreign bodies
- airway obstruction may present with no obvious signs of illness
- some airway diseases can become life threatening
- Airway obstructions may have dysphagia with drooling, abnormal sounds with breathing or speaking (especially stridor on inspiration)
2
Q
upper respiratory tract
A
- nasopharynx
- oropharynx
- laryngopharynx
- nasal cavity
- larynx
3
Q
aspiration
A
- inhalation of anything other than breathable gases
- water, blood, vomitus, food
- patient who receive tube feedings are susceptible
- many geriatric patients have impaired swallowing ability due to stroke, CNS issues
- aspiration of stomach acid may cause pneumonitis in addition to pneumonia
- fluid typically coming from the stomach (acidic) -> pneumonia develops
4
Q
pathophysiology of aspiration
A
- aspiration of stomach contents into lungs with trauma or OD and has high mortality rate
- aspiration of foreign bodies may be seen in intoxicated or traumatized adults
- older adults may have reduced gag reflex from aging or stroke
- chronic aspiration of food in older adults: common cause of pneumonia
5
Q
aspiration treatment
A
- aggressively reduce risk of aspiration when ventilating (and gastric distention) by using nasogastric tube whenever possible (sucks out stomach contents so there is nothing to aspirate)
- aggressively monitor pts ability to protect their own airway and use advanced airway when needed
- aggressively treat aspiration with suction and airway control if previous steps fail
6
Q
aspiration
A
- nasal gastric tube - removes all stomach contents so aspiration risk is low
- pneumonia is your biggest concern
- put them on their side, sit them up -> position appropriate
- use suction to minimize risk of aspiration
7
Q
foreign body obstruction
A
- tongue is the most common cause of airway obstruction in (semi) conscious patients
- can result in death of pt with trauma, insulin shock, seizure, or intoxicated
- increase incidence of FB aspiration in infants/toddlers
- coins and toys most common
8
Q
signs and symptoms of foreign body obstruction
A
- size of object determines partial or total obstruction
- sudden onset of coughing, dyspnea, and signs of choking are hallmarks
- air trapping from partial obstruction of lower airway may lead to pneumothorax
- sudden onset of wheezing (one lung) in child
- Aspirated foreign objects may remain trapped for weeks or months. Chronic blockage may cause bronchial collapse or obstructive pneumonia.
9
Q
foreign body obstruction treatment
A
- determined by ability to breathe or cough
- supplemental oxygen may ease symptoms
- immediate intervention for pt’s w/stridor, ↓O2 saturation, cyanosis, impending respiratory failure
- calm the patient and family members
- conscious patients with partial obstruction: abdominal thrusts may stimulate cough
- if pt loses consciousness -> chest compressions
- prepare meds for RSI (rapid sequence intubation)
10
Q
epiglotitis
A
- lift threatening infection -> swelling of epiglottis can obstruct trachea
- adult men are 3x more likely than women
- most common in children 2-4 years of age
- mortality rate 7% in adults, 1% in children
- pathophysiology- more common before H. influenzae type b (Hib) vaccine
- now more likely caused by streptococcus
11
Q
signs and symptoms of epiglottitis
A
- begins w/sore throat, progresses to pain on swallowing and muffled voice
- moderate or severe respiratory distress (pt may be in tripod position)
- fever, heavy drooling, stridor, pain on palpating larynx, tachycardia, low O2 saturation
12
Q
rapid sequence induction
A
- RSI
- prior to starting RSI, ready endotracheal tube, have forceps handy, prepare suction
- NM-blocking drugs: affect Ach synthesis or block Ach receptors.
- pre-fill patient’s lungs w/high concentration O2
- NRB or BVM attached to 100% oxygen, High flow nasal cannula
- administer neuromuscular-blocking drugs to induce unconsciousness & paralysis
- may see object with laryngoscopy allowing you to grasp the obejct.
- insert endotracheal tube if all clear
13
Q
epiglottitis differential diagnosis
A
- bacterial tracheitis, retropharyngeal abscess, Ludwig’s angina, peritonsillar abscess
- dx. can be confirmed by plain film radiographs (x-rays) of neck & fiber-optic laryngoscopy
14
Q
epiglottitis treatment
A
- administering oxygen
- nebulizers
- ER tx. aimed at oxygenation & ventilation, do not put anything in pt’s mouth, intubate in field only if absolutely necessary, antibiotics & corticosteroids, nebulized epinephrine
- Endotracheal intubation is best achieved surgically w/ENT nearby.
15
Q
ludwigs angina
A
- Potentially life-threatening connective tissue infection (cellulitis) of submandibular space, often after tooth abscess
- Pathophysiology:
- swelling, redness, & warmth between hyoid bone and mandible
- bacterial infection: Streptococcus
16
Q
signs and symptoms of ludwigs angina
A
- severe gingivitis & cellulitis
- submandibular swelling
- drooling
- airway obstruction
- displacement of tongue
17
Q
differential diagnosis lugwigs angina
A
- retropharyngeal/pre-vertebral abscess
- bacterial tracheitis
- epiglottitis
18
Q
ludwigs angina treatment
A
- maintain airway (may require prophylactic intubation in ER)
- humidified oxygen in the field
- antibiotics -> is it viral or bacterial (viral is not antibiotics)
- ENT surgeon
19
Q
emergency surgical airway procedures
A
- cricothyrotomy**- AKA thyrocricotomy, cricothyroidotomy, inferior laryngectomy
- less than 0.6% of intubations require this
- numbers decreasing with increased use of RSI
- last resort procedure for life-threatening cases
- if endotracheal/nasotracheal intubation is impossible or contraindicated
- only temporary
- severe facial trauma, foreign body, anaphylaxis
20
Q
lower airway conditions
A
- more diffuse obstruction to air flow with in lungs
- 20% of adults in US suffer from emphysema, chronic bronchitis, or asthma
- lung conditions usually classified as obstructive or restrictive
21
Q
obstructive lung disease
A
- hard to exhale all the air in the lungs
- air comes out slower than normal and high amount of air stays in lungs after full exhalation
22
Q
emphysema
A
- muscus and puss in the alveoli
- not allowing good gas exchange
23
Q
restrictive lung disease
A
- lungs restricted from fully expanding
- usually conditions affecting stiffness in lungs or chest wall, weal muscles, damaged nerves
- interstitial lung disease, sarcoidosis (autoimmune), obesity, scoliosis, ALS, MD
24
Q
Interstitial lung disease example
A
-idiopathic pulmonary fibrosis. Main symptom of both is shortness of breath with exertion.
25
Q
COPD
A
- emphysema and chronic bronchitis
- obstructive and restrictive
26
Q
asthma
A
- 20-30% of hospital admissions
- high relapse rate
- affects more than 25 million people in the US
- higher prevalence in children
- 90% of asthmatics had first symptoms by age 6
- tachycardia
- wheezing
- obstructive
- can grow out of it
27
Q
pathophysiology: asthma
A
- chronic inflammation and constriction of bronchi results in wheezing
- airway becomes overly sensitive to allergens, viruses, environmental irritants
- inflammation is prime cause of symptoms: dyspnea, wheezing, coughing
- bronchoconstriction**
- Body responds to persistent bronchospasm with edema & mucous secretion, results in bronchial plugging and atelectasis
28
Q
signs and symptoms of asthma
A
- wheezing
- dyspnea
- chest tightness, discomfort, pain
- cough
- signs of recent URI
- signs of exposure to allergens
29
Q
asthma
A
- patient initially hyperventilates -> results in decrease CO2 levels (respiratory alkalosis)
- continued airway narrowing, exhalation more difficult -> increase in CO2
- progressive increase in tachypnea, tachycardia, wheezing and may see retractions
- accessory muscle recruitment
- decrease O2 saturation
30
Q
inhalers
A
- bronchodilation
- steroids coat the throat
- albuterol
- opens the airway
31
Q
asthma summary: severe asthma exacerbation
A
- O2 saturation < 90%
- tachypnea
- frequent or recent hospital visit
- history of intubation
- peak flows < 60% predicted values
- accessory muscle use/retractions
- duration > 2 days
- history frequent corticosteroids
32
Q
asthma: differential diagnosis
A
- many conditions present with wheezing
- asthma usually diagnosed by history of episodes
- bacterial pneumonia, viral respiratory infections, COPD, CHF, foreign object, can all present with wheezing
- asthma vs. COPD asthma airway narrowing is reversible
33
Q
asthma: treatment
A
- inhaled beta-2 agonists: albuterol, levalbuterol (Xopenex) used in early wheezing
- terbutaline or epinephrine: IV or injection added for more severe attacks
- IV corticosteroids reduce inflammation in bronchi, but may take hours to work (long acting)
- even with aggressive pharmacologic therapy, some pt’s may still progress to severe respiratory distress or failure
- Beta 2 agonists: smooth muscle relaxation, bronchodilation,
34
Q
asthma pharmacologic therapy doses
A
- inhaled beta-2 agonists:
- albuterol- 2.5-5 mg every 20 mins for 3 doses or continuously, followed by 2.5-10 mg every 1-4 hours as needed
- parenteral beta-2 agonists:
- terbutaline: 0.25 mg
- 1:1,000 epinephrine: 0.3 mg
35
Q
asthma pharmacological delivery
A
- nebulizer
- inhaler
- spacer
36
Q
COPD
A
- Chronic airflow obstruction caused by chronic bronchitis or alveolar destruction from emphysema
- 4th leading cause of death in U.S.
- 14 million people have COPD: 12.5 million have chronic bronchitis, rest have emphysema
- Rate climbs with age and higher in smokers
- Cigarette smoking is leading cause
- 15% of all smokers will develop clinically significant COPD.
37
Q
characteristics of COPD
A
- characterized by wheezing and airway edema like asthma, but different mechanism
- usually not born with
- rate at which COPD evolves is primarily linked to smoking history: how much and how long
- minor genetic risk
38
Q
pathophysiology: COPD
A
- chronic inflammation from exposure to inhaled particles damages airway
- body’s repair process results in scarring and narrowing
- alveoli become enlarged with thickened has exchange membrane of associated capillaries
- has exchange impaired
- mucus-secreting glands and cells multiply, increasing mucus production
- cilia destroyed
- barrel chest results from airway restriction and air trapping
- chronic cough and shortness of breath
- chronic hypoxia results in chemoreceptors unable to react to fluctuations in blood O2 level
- lung function declines, sputum production increases
- air trapping from lungs’ inability to move air out of airways
- lungs become hyper-inflated w/ limited gas exchange: results in hypoxia and hypercarbia
- chronic hypercarbia effects chemoreceptor sensitivity, hypoxic drive takes over
- body maintains a slightly alkalotic to compensate
- pH affected and patient prone to infections and intolerant of exercise.
39
Q
signs and symptoms of COPD
A
- acute exacerbations
- dyspnea
- cough
- intolerance of exertion
- wheezing
- productive cough
- chest pain
- diaphoresis (sweat)
- orthopnea
- increase RR
- decrease O2 saturation
- accessory muscle use
- peripheral edema
- hyperinflated lungs
- hyperresonance on percussion
- coarse rhonchi
40
Q
COPD: differential diagnosis
A
-asthma, bronchitis, pneumonia, pulmonary fibrosis, pneumothorax, cardiac conditions causing dyspnea (MI, angina, CHF, pulmonary embolus)
41
Q
treatment of COPD exacerbation
A
- mainly maintaining oxygenation & ventilation
- nasal cannula or venturi mask to maintain O2 sat minimum 94%
- if still hypoxic: nonrebeathing mask w/high flow O2, aggressive airway/ventilation mgmt.
- CPAP may be indicated prior to intubation in alert, acutely hypercapnic patient
- severe cases: endotracheal intubation w/RSI or nasotracheal
- once airway is secured, administer beta-2 agonists early and often
- adding anticholinergic agents can provide an additional 20-40% bronchodilation
- systemic corticosteroids (injectible) in moderate or severe cases
- if acute respiratory failure: NPPV required or endotracheal intubation w/invasive ventilation thru a ventilator
- 3 nebulized doses 20 minutes apart or consecutively in severe cases. NPPV: non invasive positive pressure ventilation.
42
Q
pneumonia
A
- lung infection that causes fluid build up in alveoli
- resulting inflammation can cause fever, dyspnea, chills, chest pain, productive cough
- Three broad causes of pneumonia:
- community acquired
- hospital acquired- : nosocomial- begins 48 hours or more after hospitalization.
- Ventilator associated: viral, bacterial, fungal, chemical (stomach contents) -> more susceptible
43
Q
pneumonia stats
A
- > 3 million cases diagnosed annually in US
- if untreated mortality rate of 30%
- increased susceptibility with advanced age
- comorbid conditions- HIV, CHF, diabetes, leukemia, asthma, COPD, bronchitis
- scarring from infection may result in compromised gas exchange
44
Q
signs and symptoms of pneumonia
A
- classic symptoms are cough, fever, and sputum production
- acute onset with rapid progression is usually bacterial, rather than viral
- may also include: chills, malaise, nausea, vomiting, diarrhea, myalgia, chest pain, dyspnea, tachypnea, tachycardia, hypoxia, abnormal breath sounds: rales, rhonci
45
Q
differential diagnosis pneumonia
A
- confirming diagnosis can be made with chest x-ray, clinical presentation and accurate HPI
- asthma, bronchitis, COPD episode, foreign objects, epiglottitis, CHF, MI
46
Q
pneumonia treatment
A
- supplemental oxygen in clinically significant cases (by nasal cannula to maintain sat above 94%)
- more intensive oxygenation: CPAP
- early antibiotic intervention
47
Q
respiratory syncytial virus
A
- RSV- major cause of illness in young children
- infection in lungs and airways
- more serious illness in premature babies and children with suppressed immune systems
- can lead to other more serious illnesses that affect heart and lungs
- RSV infection can cause bronchiolitis and pneumonia
48
Q
respiratory syncytial virus pathophysiology
A
- highly contagious
- spread through droplets from cough
- spread rapidly in schools/child care centers
- virus can survive on surfaces (hands, clothes)
49
Q
signs and symptoms of respiratory syncytial virus
A
- dehydration
- can cause severe upper respiratory infections and asthma symptoms in adults
50
Q
respiratory syncytial virus treatment
A
-treat airway and breathing problems with supplemental oxygen (humidified is better)
51
Q
pleural effusion
A
- collection of fluid outside lung on one or both sides of chest
- lung gets compressed, causes dyspnea
- may occur in response to any irritation, infection, CHF, or cancer
- should be considered as a contributing dx in any patients with lungs cancer and shortness of breath
52
Q
pleural effusion pathophysiology
A
- caused by fluid collecting between visceral and parietal pleura
- sac of fluid similar to a blister
- with each breath, tissues rub against each other causing inflammation and more fluid to accumulate in the space
- some can contain several liters of fluid and can decrease lung capacity and cause dyspnea
53
Q
signs and symptoms of pleural effusion
A
- dyspnea
- also chest pain, cough, orthopnea, dyspnea on exertion
- decreased breath sounds over region where fluid have moved lung away from chest wall
- patient usually feels better sitting upright
- fluid must be removed to completely resolve
54
Q
pleural effusion treatment
A
- if CPAP doesnt work
- fluid can be extracted by needle thoracentesis for dx and symptomatic relief
- in rare cases tube thoracostomy
55
Q
pulmonary embolism
A
- sudden blockage of lung artery with a blood clot
- DVT (deep vein thrombosis) is most common cause- blood clot travels to lungs from leg
56
Q
pulmonary embolism pathophysiology
A
- pulmonary circulation may be compromised by clot, fat embolism from broken bone, or air entering circulation from a laceration in neck or improver IV
- usually lodges in major branch of pulmonary artery
57
Q
signs and symptoms of pulmonary embolism
A
- most challenging diagnosis to make in ED because of vague, general symptoms
- risk post surgery or trauma or with catheters
- chest pain, dyspnea, tachycardia, syncope, hemoptysis (coughing blood), new onset wheezing, new cardiac arrhythmia, thoracic pain
- may evolve quickly and lead to cardiac arrest
58
Q
pulmonary embolism treatment
A
- bedridden patients are often prescribed anticoagulants to reduce risk of clot formation
- patients who have numerous clots can be treated with tPa (tissue plasminogen activator)
- few patients survive cardiac arrest caused by large emobolus
59
Q
velecula ***
A
60
Q
why do we intubate
A
- need a definitive airway
- procedure for a patient that cant maintain their own airway
- basic airway adjuncts and patient positions are unsuccessful
- patient not adequately ventilating on their own
61
Q
when do you intubate
A
- when respiratory compromise suspected
- when all intrinsic mechanisms have failed to alleviate respiratory difficulty
- before they transition to respiratory failure
62
Q
how do you confirm the intubation was successful?
A
- chest rise
- condensation in the endotracheal tube
- direct visualization
- absent epigastric sounds
- waveform capnography
- bilateral lung sounds
63
Q
assessing causes of acute deterioration of intubated patient
A
- if acute deterioration occurs, take patient off ventilator and use bag mask while assessing
- DOPE
- D- displaced tube
- O- obstructed tube- plugged with secretion or patient biting on it
- P- pneumothorax- can occur during positive pressure ventilation
- E- equipment failure- ventilator run out of oxygen
64
Q
intubation: final thoughts
A
- should be last option for asthmatic patients (difficult to ventilate, prone to pneumothorax)
- be proactive- intubate/ventilate before cardiac arrest occurs (conscious patients in respiratory arrest may need sedation/RSI)
- lack of gag reflex in stroke or intoxicated patients makes them prone to vomiting (consider intubation to protect airway)
- if med administered to diabetic or OD patient, use bag mask first and monitor for changes
65
Q
RSI medication
A
- rapid sequence intubation medication
- these medications stop breathing so you can intubate
- sedate
- paralyze
- more sedation
- pain management
66
Q
summary
A
- upper/lower respiratory system- what structures physiologically differentiate them?
- COPD- how is it managed from a ventilation standpoints and what population is most prone
- asthma- signs and symptoms, treatment
- intubation:
- what does the process entail
- what equipment is used to help facilitate this process
- how do you determine whether your intubation is successful
- DOPE and how it relates to intubation
- how do RSI medications works
67
Q
laringiscope
A
attaches to the miller and macintosh blades
68
Q
macintosh and miller blades
A
- miller blades are used for pediatrics -> miller blades are straight
- epiglottis of a child is much bigger (thats why it can become obstructed easier)
- miller blades go under the epiglottis
- macintosh blades are used for adult patients -> curved
- macintosh blades goes into the velicular space
69
Q
stylet
A
-allows tracheal tube to be bent to any shape
70
Q
intubation
A
-
