Respiratory Emergencies Flashcards
1
Q
What does the brain depend on a continuous supply of?
A
oxygen
2
Q
What are signs of cerebral hypoxia?
A
Anxiety (early sign), confusion, lethargy, seizure and coma
3
Q
What respiratory symptoms can occur after neurological injury?
A
Irregular respiratory patterns, hypoventilation, nervous impairment of respiratory muscles
4
Q
When respiratory function is impaired, how does the CV system attempt to compensate?
A
with an increased HR and SV
5
Q
Eventually, what will hypoxia lead to?
A
decreased HR and decreased CO (myocardium requires O2 to pump)
6
Q
What are some observable signs of respiratory stress?
A
-Tripod positioning
-Nasal flaring
-Audible wheezes/crackles
-Accessory muscle use
-~1-5-word dyspnea
-Depth/rate (approximate)
-Odor
-Skin color
7
Q
What are some things to look for in a focused respiratory assessment?
A
-Oropharynx - foul odor? possible FBAO?
-Neck - accessory muscle use
-Chest/abdomen -accessory muscle use, diaphragmatic breathing
-Extremities - tingling, cyanosis
-Sputum - color? Change in color?
8
Q
What do the signs and symptoms of respiratory tract infections depend on?
A
-functions of the structure involved
-severity of illness
-patients age/general health status
9
Q
What is the most common cause of respiratory infections?
A
Viruses (can leave the patient open to a secondary bacterial infection as well)
10
Q
What is the common cold?
A
Viral infection of the upper respiratory tract and the most common respiratory tract infection
11
Q
What different viruses are associated with the common cold?
A
rhinoviruses are the primary agent involved
-Others include parainfluenza, respiratory syncytial virus (RSV), coronavirus
12
Q
How long does a cold commonly last?
A
7 days with a 2-day incubation period
13
Q
What are the clinical manifestations of the common cold?
A
-Dry/congested nasopharynx followed by excessive production of nasal secretions and tearing of the eyes (aka - rhinitis)
-Typically, secretions are clear and watery
-Red/swollen mucous membranes of the URT
-Postnasal drip can irritate the pharynx and larynx causing sore throat, hoarseness and cough
-Headache, malaise, chills, fever, fatigue, anorexia
14
Q
What are treatments for the common cold?
A
-A self-limiting illness in normal healthy people
-Treatment of symptoms with rest/antipyretic drugs as needed
-Antihistamine drugs are helpful for drying the nasal secretions but don’t shorten the length of illness
-Decongestant drugs blood vessels in the nasal mucosa (reducing swelling)
-Maintaining fluid/electrolyte intake to avoid dehydration
15
Q
What is rhinosinusitis?
A
Inflammation of the nasal sinuses (cavities lined with mucosa and cilia)
16
Q
What are the causes of rhinosinusitis?
A
-can be acute viral, bacterial or mixed
-usually associated with a viral upper respiratory tract infection first
17
Q
What are the clinical manifestations of rhinosinusitis?
A
Similar to the common cold. Facial/nasal pain or pressure is also common
18
Q
How is rhinosinusitis treated?
A
By treating the cause (antibiotics, rest, symptom management, etc.)
19
Q
What is pneumonia?
A
Inflammation of parenchymal structures of the lung - alveoli and bronchioles
20
Q
What kind of agents can cause pneumonia?
A
-Agents include infectious and non-infectious agents
-Inhalation of irritating fumes or aspiration of gastric contents can cause pneumonia
21
Q
What is aspiration?
A
breathing in a foreign object, usually into the lungs (often stomach contents)
22
Q
How is pneumonia classified?
A
-How it was acquired (hospital acquired, community acquired)
-Areas of airway affected (lobar pneumonia, bronchopneumonia)
-Source of infectious agent (typical - bacterial, atypical - mycoplasma bacteria or viral)
23
Q
What is community acquired pneumonia?
A
An infection that begins outside the hospital or is diagnosed within 48 hours after admission to the hospital in a person who has not resided in a long-term care facility for 14 days or more before admission. May be bacterial or viral
24
Q
What is treatment for community acquired pneumonia?
A
Appropriate antibiotics (if indicated), treatment of symptoms, hospitalization if necessary (usually with elderly and medically fragile
25
What is hospital-acquired pneumonia?
-Lower respiratory tract infection that was not present or incubating on admission to the hospital
-Most often bacterial
26
What is pneumonia in immunocompromised people?
-Pneumonia in the immunocompromised
-Immunocompromised - people with a variety of underlying defects in defense immunodeficiency, bone marrow or organ transplants, corticosteroid or
immunosuppressant drugs
27
How can a URTI make us more susceptible to lower infections like pneumonia?
-Typically our upper airway has defenses that keep our lower airway sterile
-URTI can diminish our innate defenses (damaged/destroy cilia, loss of cough reflex,
preoccupied immune response) opening us up to a lower infection like pneumonia
28
What are some risk factors for lower respiratory infections?
-Patients with critical or chronic illnesses often have epithelial cells in their airway that are more prone to adherence with infectious bacteria
-Other clinical risk factors include: Antibiotic therapy (that alters normal bacterial flora), diabetes, smoking, COPD, viral infections
29
What are the two main types of bacterial pneumonia?
Pneumococcal Pneumonia and Legionnaire’s Disease
30
What is the most common cause of bacterial pneumonia?
Pneumococcal Pneumonia
31
How does pneumococcal pneumonia's structure allow it to spread quickly?
It’s structural make up causes a delay in phagocytic digestion - leading to a more rapid spread/infection
32
What are the signs and symptoms of pneumococcal pneumonia?
Fever, malaise, productive cough (sputum may progress from white, to red, to brown, to purulent), crackles (bilateral or unilateral), pleuritic pain, anorexia
33
How do we treat pneumococcal pneumonia?
-Antibiotics effective against the specific strain
-Manage symptoms
-Immunization (preventative) - recommended for ≥65yrs or medically fragile patients
34
What is pleuritic pain?
chest pain (usually tightness) that worsens with coughing, deep breathing and movements
35
How is legionnaire disease transmitted?
transmitted via aerosolized droplets of water contaminated with the pathogen
36
What are the signs and symptoms of legionnaire disease?
-Malaise, weakness, lethargy, fever, dry cough, fever
-CNS disturbances, GI disturbances, arthralgia (joint pain)
37
What are the treatments for legionnaire disease?
-Antibiotics effective against the specific strain
-Manage symptoms
38
What is primary atypical pneumonia?
-Caused by either a mycoplasma bacteria or viruses
-Characterized by patchy lung involvement
-Patients are predisposed to secondary lung infections due to damaged epithelium
39
What is Severe Acute Respiratory Syndrome (SARS)?
-A respiratory illness caused by a coronavirus
-Spread primarily by person to person contact and respiratory droplets
40
What are the signs and symptoms of SARS?
Fever, chills, malaise, headache, muscle aches, nonproductive cough, dyspnea, and diarrhea
41
What is lung cancer caused by?
-80% is caused by cigarette smoking
-another common cause is exposure to asbestos and other inhaled irritants
42
What are the clinical manifestations of lung cancer?
-Anorexia, weight loss, fatigue
-Chronic cough, shortness of breath, wheezing, hemoptysis
-Pain may present as localized or generalized throughout the pleural tissue depending on the mets
-Pleural effusion resulting in atelectasis
-Decreased SpO2, pallor, cyanosis
43
What are some anatomical considerations for pediatric patients?
-Intercostal muscles are not fully developed as infants, rely mainly on diaphragm
-Lungs and chest are very compliant
-Accessory muscles in peds tire out very quickly - if they are in use, consider the patient to be in severe respiratory distress
-Narrower airways are more prone to obstruction (complete or partial) from foreign bodies or mucous during infection
-Large occiput can create anatomical airway obstruction
44
What are common manifestations of respiratory distress in infants and small children?
grunting, retractions, nasal flaring , stridor, wheezing, lethargy, bobbing head, tripod positioning, drooling, pallor, cyanosis (central or peripheral), tachypnea, dyspnea, orthopnea
45
What is positive end-expiratory pressure (PEEP)?
Pressure that remains in the airways at the end of the respiratory cycle (keeps a/w open)
46
What are retractions?
inward retractions of the accessory respiratory muscles that indicate severe respiratory distress/fatigue (intercostals, supraclavicular, scalene, substernal, tracheal notch, abdomen)
47
What is nasal flaring?
enlargement of the nares as an attempt to decrease airway resistance and maintain airway patency (infants are nasal breathers)
48
What is stridor?
high pitched audible wheeze/squeal sound caused by upper airway obstruction
49
What is croup?
-Acute laryngotracheobronchitis
-A viral infection that affects the larynx, trachea and bronchi (typically 3mo to 5yrs)
-Causes inflammation of the larynx, trachea and bronchi (can lead to swelling and a/w obstruction)
50
What are the clinical manifestations of croup?
-Croup typically manifests initially as a typical URTI (common cold, rhinorrhea, hoarseness, fever, cough) followed by a sudden addition of moderate to severe
respiratory symptoms (stridor, dyspnea)
-“barking cough” that many people describe as “seal-like”
51
What is the treatment for croup?
-Prehospital treatment of severe croup involves nebulized epinephrine and dexamethasone
-Symptom severity also often subsides when the child is exposed to moist or cool air
52
What is spasmodic croup?
-Similar in presentation to viral croup but is thought to be allergic in origin (afebrile)
-Episodes usually occur at night lasting several hours
-High humidification or cold air lessens irritation
53
What is bacterial croup?
Very rare. Similar in presentation to viral croup but can be treated with antibiotics. Symptoms and severity progress more rapid.
54
What is epiglottitis?
-An acute infection of the epiglottis, typically caused by a bacterial infection
-Characterized by inflammatory edema of the supraglottic area (epiglottis and pharynx)
55
What are the symptoms/clinical manifestations of epiglottitis?
-Symptoms arise suddenly and can cause fatal airway obstruction and asphyxia if not treated immediately (within hours)
-Pale, lethargic and distinct position (sitting up, mouth open, chin thrust forward)
-Difficulty swallowing causes drooling and muffled voice
-Moderate to severe dyspnea, febrile
-Stridor, nasal flaring, inspiratory retractions
56
What is acute bronchiolitis?
-Viral infection of the lower airway usually caused by the RSV (respiratory syncytial virus) - usually <2yrs old (3-6mo)
-Produces inflammatory obstruction of the bronchioles and necrosis of the endothelial cells lining the airway
57
What are the clinical manifestations of acute bronchiolitis?
-mild URTI that gradually progresses to respiratory distress, cough, irritability and wheezing
-usually able to inhale air but has difficulty with exhalation (air is trapped in lungs)
-Patient may become hypoxic, hypercapnic, and have hyperinflated lungs - leading to collapsed alveoli
-Shortness of breath, cough, retractions-wheezing/crackles (+/-), cyanosis, pallor, listlessness
58
What is Sudden Infant Death Syndrome (SIDS)?
-The abrupt and unexplained death of an apparently healthy child less than 1 year old
-Exact cause is unknown but may be due to an abnormality in the mechanisms that control respiration or low PaO2
-May also be linked to hypoxia while sleeping prone
59
What are the signs and symptoms of severe distress and impeding respiratory failure (peds)?
-Severe increase in WOB/severe tachypnea
-Retractions, grunting, decreased chest movement
-Cyanosis not relieved by O2 administration
-Bradycardia/severe tachycardia
-Fatigue, extreme anxiety/agitation
60
What is hypoxia?
low levels of oxygen in tissues
61
What is hypoxemia?
low levels of oxygen in arterial blood (PaO2)
62
What are the causes of hypoxemia?
Inadequate ambient O2, respiratory system disorders, dysfunction of the neurological system, alterations in circulatory function
63
What are the clinical manifestations of mild hypoxemia?
ANS compensatory mechanisms - increased HR, peripheral vasoconstriction, diaphoresis, slight increase in BP, slight impairment of mental and visual acuity
64
What are the clinical manifestations of moderate to severe hypoxemia?
Confusion, personality changes, restlessness, agitation, combative behavior, uncoordinated muscle movements, euphoria, impaired judgement, delirium, coma
65
What are the clinical manifestations of chronic hypoxemia?
-People with chronic lung disease may have more subtle manifestations since their body becomes accustomed to it
-Increased RR, pulmonary vasoconstriction, increased erythropoiesis (polycythemia)
-Right shift (decreased O2-HGB affinity —> increased O2 release to tissues)
66
What is cyanosis?
- blueish discoloration of the skin and mucous membranes
-high concentration of reduced or deoxygenated RBCs in capillaries
67
What is central cyanosis?
tongue and lips (deoxygenated HGB in arterial blood)
68
What is peripheral cyanosis?
extremities, nose, ears (cold exposure, shock, heart failure, peripheral vascular disease)
69
What is hypercapnia?
increase in the carbon dioxide content of arterial blood
70
What are the clinical manifestations of hypercapnia?
Acid-base balance, renal/neurologic/CV function
71
What is a pleural effusion?
An abnormal collection of fluid in the pleural cavity that occurs when the fluid formation exceeds the rate of its removal
72
What causes a pleural effusion?
A pleural effusion occurs when one of the 3 locations where fluid enters the pleural space produces too much fluid, or there is a decreased removal from the lymphatic system
73
What are the clinical manifestations of a pleural effusion?
-Manifestations vary with the cause (i.e., may be febrile if its bacterial or viral in origin)
-Decreased lung expansion on the effected side (may be bilateral)
-Decreased lung sounds
-Hypoxemia
-Dyspnea
-Pleuritic pain (only when inflammation is present)
74
What is a hemothorax?
-A type of pleural effusion where blood accumulates in the pleural space
-Usually result of chest trauma. Complications from thoracic surgery, malignancy, or ruptured great vessel.
-Presents the same as a pleural effusion but may have signs of hypovolemia
75
What is a pneumothorax?
The presence of air in the pleural space
76
What is a spontaneous pneumothorax?
-Caused by the spontaneous rupture of an air-filled blister (bleb) on the surface of the lung
-Allows atmospheric air from the lung to enter the pleural cavity (high pressure to low)
-Two categories of patients - tall males (10-30) and pts with lung disease
77
What is a traumatic (open/closed) pneumothorax?
-Fractured ribs that penetrate the pleura are usually the cause of closed traumatic pneumothorax
-Atmospheric air moves from high to low, same as spontaneous
-External penetrating forces cause open
-Air sucks in through penetrating wound and fills the pleural space. If the hole is larger than the diameter of the trachea, the air will go through the hole quicker
78
What is a tension pneumothorax?
Occurs when the intrapleural pressure exceeds the atmospheric pressure and begins compressing the lung and mediastinum away from the affected side
79
What are the clinical manifestations of a pneumothorax?
-Vary depending on the severity of the pneumothorax and integrity of the lung
-SOB, pleuritic pain, hypoxia, decreased lung sounds
-Tension - tracheal deviation, JVD, decreased CO, altered LOA, subcutaneous emphysema, shock
80
What is pleuritis?
Inflammation of the pleura. Common in infectious processes that involve the respiratory system
81
What are the clinical manifestations of pleuritis?
-Most common symptom is pleuritic chest pain
-Sharp, usually isolated to one area (pinpoint), worse during respiratory movement (inhalation, coughing, exaggerated chest movements)
-Due to pleuritic pain, many patients lower their tidal volume and increase their respiratory rate (to compensate)
82
What is atelectasis?
-An incomplete expansion of a lung or portion of a lung
-Numerous causes: Airway obstruction, lung compression (pneumothorax/pleural effusion), loss of
pulmonary surfactant
-May be present at birth (premis) due to underdevelopment or develop later in life
83
What is athsma?
A chronic disorder of the airways that causes episodes of airway obstruction, bronchial hyper-responsiveness, airway inflammation, and occasionally airway remodeling
84
What is the primary antibody involved in creating allergic and immune reactions?
IgE
85
What causes athsma?
-Involves an exaggerated hyper-responsiveness to a variety of stimuli
-Dust, pollen, exercise, inhaled irritants, cold air, etc.
-Airway inflammation manifests from the presence of inflammatory cells (eosinophils, lymphocytes and mast cells) and damage to the bronchial epithelium
86
What are the two types of athsma?
Intrinsic and Extrinsic (most common)
87
What is extrinsic athsma?
-Allergen induced
-IgE coats the membrane of mast cells that line the mucosal surface of the airways, airborne antigen/allergen binds to the IgE and activates the mast cells, stimulates the release a cascade of inflammatory mediators
-triggers a further inflammatory response which leads to major inflammation of the airway: Bronchoconstriction and Increased mucous production
88
What is intrinsic athsma?
-Exercise induced
-Poorly understood
-Thought to involve T1H cells, IgG and IgM
89
What are the clinical manifestations of athsma?
-bronchoconstriction, which presents as audible
and auscultated wheezing
-chest tightness, cough (excess mucous production), moderate to severe shortness of breath, with a prolonged expiratory period
-patient may become diaphoretic, anxious, lightheaded and have a decreased SpO2
-can have a V:Q mismatch, hypoxemia and hyperinflation of the lung
90
What is Chronic Obstructive Pulmonary Disease (COPD)?
-Characterized by chronic and recurrent obstruction of airflow in the airways that is usually progressive in nature
-The most common cause of COPD is smoking
-Other causes include significant/prolonged exposure to chemical irritants or pollutants
91
COPD consists of which two main disease processes?
Emphysema and Chronic Bronchitis
92
What causes emphysema?
-Prolonged airway inflammation causes a loss of lung elasticity (increased compliance), enlargement of the smaller airways and destruction of alveolar walls and capillaries
-can lead to the collapse of smaller airways during exhalation
-Decreased parenchymal lung tissue causes the patient to hyperventilate with short, shallow breaths to maintain blood gas levels - no cyanosis in mild to moderate disease
93
What are the clinical manifestations of emphysema?
-Pronounced “barrel-chest” due to chronic hyperinflation of the lungs (Pink Puffer)
-Typically, very thin (anorexia, increased calorie burn from chronic hyperventilation)
-ETCO2 levels may be normal in the early stages of the disease, but will progress to being chronically high
-hypoxic/hypercapnic
-significant increase in WOB (hyperventilating, accessory muscle use, diaphragm overuse) uses a lot of energy. The patient also has a chronic cough and general malaise
94
What is chronic bronchitis?
-Affects the large and smaller airways as opposed to the alveoli
-Bronchi become damaged by chronic inflammation resulting in hyperproduction and secretion of mucus
-Chronic narrowing of the bronchi
95
What are the clinical manifestations of chronic bronchitis?
-“Blue Bloater” - chronic cyanosis, fluid retention (right sided heart failure)
-Pursed lip breathing, increased RR, chronic productive cough
-Low SpO2 may be normal for them
-Usually have chronically high ETCO2
96
What is hypoxic drive?
-Normal healthy people are stimulated to breath by high levels of CO2 in the blood stream
-Patients with COPD tend to have chronically higher levels of PCO2, so their respiratory system is stimulated more by low levels of PO2
-If we administer high concentration O2 to patients with a strong hypoxic drive (advanced COPD), it may disrupt their stimulation to breath
97
What is cystic fibrosis (CF)?
-A severe genetic respiratory disease involving the exocrine glands in the epithelial lining of the respiratory, GI and reproductive tracts
-The defective gene causes excessive thick mucus that obstructs the lungs, pancreas and the vas deferens (in boys)
98
What are the clinical manifestations of CF?
Lung symptoms:
Chronic cough, shortness of breath, decreased SpO2 (often requiring home O2)
GI Symptoms:
Malabsorption, malnutrition, abdominal discomfort, loose stools
99
What is fibrosis?
fibrous scar tissue
100
What is bronchiectasis?
permanent dilation (loss of elasticity) of the bronchi and bronchioles (resultant fibrosis and loss of function)
101
What is a pulmonary embolism (PE)?
-When a blood-borne substance (embolus) lodges in a branch of the pulmonary artery and obstructs blood flow
-The embolus may be a thrombus (blood clot), air, fat, or amniotic fluid
102
What causes a PE?
-The most common cause is a thrombus originating from a deep vein thrombosis (DVT) that breaks free and migrates until it becomes stuck in a pulmonary artery
-Obstruction of pulmonary blood flow causes reflex bronchoconstriction in the isolated region as well as reflex pulmonary vasoconstriction
103
What are the clinical manifestations of a PE?
Mild to Moderate:
-Pleuritic chest pain (usually pinpoint)
-Dyspnea (worse, or only present on exertion)
-Moderate hypoxemia with normal to high CO2 levels
-Productive cough (blood-soaked sputum)
-Localized wheeze/adventitious sounds
-May vary depending on the size and location of the embolus
Severe:
-All symptoms of mild to moderate but significantly worse
-Minimal exertion causes dramatic exacerbation of symptoms
-Decreased CO (pulmonary HTN and Rt failure)
-JVD (pulmonary HTN and Rt failure)
104
What is Acute Respiratory Distress Syndrome (ARDS)?
-A manifestation of severe respiratory symptoms that may result from a number of conditions
-Aspirated gastric contents, trauma, sepsis, pancreatitis, hematological disorders, metabolic events, drugs/toxins
105
What are the clinical manifestations of ARDS?
-Rapid onset of severe respiratory distress
-Diffuse crackles, cyanosis, dyspnea, tachypnea
-Diaphoresis, pallor, tachycardia
-Marked hypoxemia that is refractory to supplemental oxygen therapy
-May lead to a systemic response of multiple organ failure
106
What are the clinical manifestations of ARDS?
-Rapid onset of severe respiratory distress
-Diffuse crackles, cyanosis, dyspnea, tachypnea
-Diaphoresis, pallor, tachycardia
-Marked hypoxemia that is refractory to supplemental oxygen therapy
-May lead to a systemic response of multiple organ failure
107
What is acute respiratory failure?
-A failure in gas exchange due to either heart failure, lung failure or a combination of both
-Not a specific disease but can occur in the course of several different conditions
108
What are the two types of acute respiratory failure?
Hypoxemic Failure (failure of gas exchange) and Hypercapnic/Hypoxemic failure (ventilators failure)
109
What is hypoxemic respiratory failure?
-Mismatch of Ventilation and Perfusion (V:Q) When an area of the lung is ventilated with decreased perfusion, or when an area is perfused but not ventilated - or both.
-Impaired Pulmonary Diffusion: May produce severe hypoxemia without hypercapnia
110
What is hypercapnic/hypoxemic respiratory failure?
Patients are unable to maintain sufficient alveolar ventilation required to eliminate CO2 and keep PO2 levels normal - hypoventilation
-Decreased PO2 is easily resolved with supplemental O2 while assisted ventilations may be required to decreased the PCO2
111
What occurs due to diaphragmatic injury?
-As the main muscle responsible for breathing, damage to the diaphragm can produce
significant strain on the respiratory system
-Perforations of the diaphragm can allow intestinal contents to protrude into the thoracic cavity leading to increased pressure in the thorax, decreased ventilators space and ultimate decrease in gas exchange
112
What is flail chest?
-When two or more adjacent ribs are fractured in two or more places
-The segment becomes “free floating” and can move paradoxically to the rest of the chest
-Puts increased strain on the intercostal muscles (attempting to hold it in place) and present a significant threat to underlying organs (lungs, vessels, heart)
113
What is a pulmonary contusion?
-Bruising to the lung tissue can cause bleeding and edema into the alveoli which decreases surface area for gas exchange and dilutes surfactant rendering it ineffective
-Alveolar collapse without surfactant
-Pulmonary blood shunting via localized vasoconstriction may occur which can further worsen hypoxemia and develop pulmonary hypertension and right sided heart failure
