Respiratory Emergencies Flashcards
Respiratory Disease - Clinical Signs
- Increased Respiratory rate
- Increased Respiratory effort
- Open mouth breathing
- Abdominal effort
- Abducted elbows
- Neck extension
- Retraction of lips at the commissures
- Cyanosis
- Blood / foam from the mouth
- Respiratory noise
- Paradoxical breathing
> Chest sucks in during inspiration, belly out & vice versa
Most important basic principle of respiratory emergency
Give O2 & Sedate
basic principles for handling respiratory emergencies
Give O2 & Sedate
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Fragile patients
Minimal reserve function
Minimize handling / stress
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Location:
Quiet
O2 source
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Options (based on degree of distress)
1. Initial survey assessment
2. Sedation & pause > give it 15 minutes to let anxiety of patient pass…
3. Emergency Intervention > unless emergency in which case we need to do something to make it survive
resuscitation for respiratory emergency patient
Provide supplemental O2 Always!!
Minimize restraint & stress
> Sedate!! Wait?
Survey assessment
Point of care thoracic ultrasound
Place IV catheter
> Promptly
> Following sedation
Consider diagnostic thoracocentesis
Emergency intubation +/- ventilation
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Initiate therapeutics & diagnostics
sedation for respiratory emergency patient
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Butorphanol IV, IM, SQ
If additional sedation is required: Benzodiazepines
Diazepam (IV only)
Midazoloam (IV or IM)
<><><><> - Hydromorphone / methadone
If traumatic injuries / Pain appreciated
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Confirm strong pulses
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It’s better to sedate/anesthetize than resuscitate
Emergency Intubation
- wjen to do it, and why?
For severe respiratory distress
Allows airway patency & delivery of 100% O2 Improves oxygenation
decrease Stress
Emergency Intubation
- induction options
- proporfol if IV access
- alfaxalone if no IV access
<><> - Ketamine : valium (1:1 or 1:2) IV to effect
- Ketamine : midazolam (as above) IM
Intubation & Resuscitation for resp emergency patient
- when to ventilate? how?
If not breathing / oxygenating well without
Ambubag / rebreathing bag on anesthetic machine
7 Localizations for Respiratory Distress
- Upper airway
- Lower Airway
- Pulmonary parenchyma
- Pleural space
- chest wall
- pulmonary vasculature
> thromboembolism - abdominal distension
The Cat with Dyspnea
- etiology
38% - cardiogenic
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32% - respiratory
> non-infectious: Asthma (7), laryngeal paralysis (3), tracheal FB / stenosis (2), polyp
> Infectious : FIP (3), pyothorax (4), URTI (2), pneumonia (1)
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20% - neoplastic
> Lymphoma, thymoma, bronchogenic carcinoma, nasal adenocarcinoma
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9% - traumatic
> Diaphragmatic hernia, pneumothorax, tracheal trauma
resp emergency - things to think about moslty for young patients
Infectious disease
FIP, Bot larval migrans, lungworm
resp emergency - things to think about moslty for older patients
Heart disease, Neoplasia
tracheal collapse common in what breeds?
Yorkies, Pomeranians
Laryngeal paralysis more common in what animals?
Older hunting dogs: Labs, Spaniels, Setters
Mitral valve disease more common in what animals?
Older, small breed dogs eg. Shih Tzu, Toy poodles, Cavalier King Charles spaniel
PE for resp energency animal? considerations?
Handle with care!
Abbreviated GPE:
Respiratory rate & character
Thoracic auscultation > heart, lungs
MM – colour & CRT
Cervical evaluation > Jugular distension
Temperature
Blood pressure
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- LIMIT handling!! STERNAL recumbency preferred
- provide O2
Thoracic Auscultation for resp emergency:
- what should we think if we hear:
- Murmur / gallop rhythm / arrhythmia
Cardiac disease
Thoracic Auscultation for resp emergency:
- what should we think if we hear:
- crackles
Pulmonary parenchymal involvement
Edema (cardiogenic or non-cardiogenic)
Pulmonary contusions, pneumonia
Pulmonary fibrosis
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> something in the lung
Thoracic Auscultation for resp emergency:
- what should we think if we hear:
- wheezes
Asthma, Bronchial disease
Thoracic Auscultation for resp emergency:
- what should we think if we hear:
- absent lung sounds
Pleural effusion/ pneumothorax
Intrathoracic masses
Severe (non-aerated) parenchymal disease
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> something in the pleural space?
what parts of our PE should we postpone in a resp emergency?
Abdominal palpation
Lymph node & T4 assessment
Orthopedic examination
Full neurological examination
imaging for resp emergency patients - when should we do it? what can we do and why?
Radiographs
Postpone in patients with significant respiratory distress
Recommended in all trauma patients
> Diaphragmatic hernia, pulmonary contusion
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Point of Care Ultrasound
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Thoracic ultrasound
Pleural effusion
Pneumothorax
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Lung ultrasound
Pulmonary pathology
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Cardiac ultrasound
Point of Care Ultrasound for resp emergency - how do we do it? what are we looking for?
ASSESSMENT from the patient’s RIGHT side
Cross-section (short axis view)
Left atrial (LA) size to aorta (Ao) ratio
LA:Ao ratio (Normal 1:1.5) ; LA : Ao ≥1:2+ Cardiac Dz
Hypoxemia - pulse oximiter values for normal, hypoxic, and severely hypoxic animals
Normal lung function
SpO2%: 98-100
Blood gas PaO2 mmHg: ~100
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Hypoxemia
SpO2%: <95
Blood gas PaO2 mmHg: <80
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Severe Hypoxemia
SpO2%: <90
Blood gas PaO2 mmHg: <60
Urgent Clinical Goal SpO2
SpO2 > 93+%
Fluid Therapy in Respiratory Distress
- considerations based on etiology
Cautious Intravenous Fluids
Etiology:
1. Heart Failure
> Fluids are CONTRAINDICATED
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2. Trauma & shock
> Low volume resuscitation
> Quickly add hypertonic saline, blood products
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3. Other
> Fluids delivered cautiously
CASE:
Chevy, 4-year-old male neutered German Shepherd
HBC, tachypnea & dyspnea
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Auscultation > Quiet lung sounds
Multiple limb fractures
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DDX? therapeutic plan?
DDX:
Pleural space disease
* Pneumothorax
* Hemothorax
Severe pulmonary contusions
Diaphragmatic hernia
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Therapeutic Plan
O2 supplementation
Pain management
> Hydromorphone 0.05 mg/kg IV
Fluid resuscitation (1/2 shock rate)
> 10 ml/kg fluid bolus in 15 min (~40 ml/kg/hr)
> Reassess & repeat if necessary
Thoracocentesis
Chest radiographs
when should we do thoracocentesis in a respiratory emergency?
how?
** Pre radiographs for severe respiratory distress!! **
** Sedation / Local anesthesia**
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Options:
* Butterfly needle
* Over the needle IV catheter
* Needle & extension set
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Sterile technique - prep
7th - 9th intercostal space
> Dorsal 1/3rd – Air
> Ventral 1/3rd – Fluid
Never let go of the needle!
Save sample
> Red top tube: C+S, triglyceride levels
> Purple top tube: PCV, TS, Cytology
Thoracocentesis
Complications
Lung laceration > Pneumothorax
Puncture of vasculature > Bleeding
> usually minor, hemothorax unlikley
> chest wall hematoma
> re-expansion pulmonary edema
Infection
if we perform a thoracocentesis for respiratory distress, in what situations should we insert a chest tube / catheter? where do we put it?
Remains in the thorax for repeat / continuous evacuation
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Indications:
≥2x thoracocentesis ≤ 24 hours
Continuous pneumothorax
Tension pneumothorax
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Placement
Dorsal 1/3rd entry site
Enter thorax (X) at 7-9th ICS
Catheter angled ventrally towards the axilla
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Placed with mild sedation & local analgesia
what do pulmonary contusions look like on U/S?
confluent B-lines = white sheet = pulmonary contusions
Pulmonary Contusions
History
- what is it?
- what we see radiographically?
History - TRAUMA
Hemorrhage into the lung parenchyma
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Pulmonary infiltrates worsen
Radiographic signs worsen
> Over first 12-24 hours
> Be prepared / Forewarn owners
Pulmonary Edema
- types, which is more common?
- cause / distribution?
Non-cardiogenic and cardiogenic edema
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Cardiogenic edema most common:
- Causes:
> Heart failure (myocardial /valvular failure; arrhythmogenic)
- Distribution
> Central / Perihilar (Dogs)
> Anywhere (Cats)
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Non-cardiogenic edema causes:
- post-obstructive
- direct lung injury
- neurogenic
- systemic disease
- near drowning
- blood transfusion
- anaphylaxis
If you can hear it across the room …
where is the airway obstructed?
It’s UPPER airway obstruction!!!
Upper Airway Obstruction – Initial Management
Supplemental O2
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Sedation
> Acepromazine
> Opioid Butorphanol
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Active cooling of core
Wet towels
Fan
Cool IV fluids
Ice – axillas/groin
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Anti-inflammatory
Dexamethasone
Upper airway distress - what do we do if intubation is not possible?
Tracheotomy
Tracheotomy procedure - how to?
Dorsal recumbency
Elevate neck
> Towel under the neck
Clip, shave & prep (as time permits)
Midline incision over trachea
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* Manually isolate trachea
* Incise between ~2nd-3rd or 3rd - 4th tracheal rings
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Horizontal tracheal incision - between 2 rings (>10kg)
* Not more than 50% of tracheal circumference
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Patient ≤ 10 kg
* Vertical tracheal incision - through tracheal ring(s)
* Do not want to transect the trachea!!
respiratory emergecny cases overarching points:
Assess the patient:
Work of breathing
Hypoxia
Primary Goal:
Alleviate distress:
Provide oxygen
Sedate
Gain control of the airway / Intubate / Ventilate
Brachycephalic obstructive airway syndrome (BOAS) history, presentation
Dog collapsed in pool of saliva with severe dyspnea
- increased temperature
- tachycardia
- tachypnea
- cyanotic
- Inspiratory stridor
- noise on auscultation
- bounding pulses
