Respiratory Emergencies Flashcards
Respiratory Anatomy & Physiology
Trachea Bronchus Lungs Thoracic Wall Parietal Pleura Visceral Pleura Mediastinum Diaphragm
Inspiration
• Active process: uses muscle contraction to
increase size of chest cavity
• Intercostal muscles and diaphragm contract
• Diaphragm moves down; ribs move upward and outward
• Air is pulled into lungs
• creates negative pressure
Expiration
- Passive process:
- Muscles and diaphragm relax
- Size of chest cavity decreases
- Air flows out of lungs
Adequate Breathing Rate for an Adult
12-20 breaths/minute
Rhythm regular
Breath sound present & equal
Adequate Breathing Rate for a Child
15-30 breaths/minute
Rhythm regular
Breath sound present & equal
Adequate Breathing Rate for a Child
25-50 breaths/minute infant
Rhythm regular
Breath sound present & equal
Inadequate Breathing Definition & Signs
• Breathing not sufficient to support life • Signs – Rate out of normal range – Irregular rhythm – Diminished or absent lung sounds – Poor tidal volume
Signs of Inadequate Breathing in Infants & Children
• Signs of inadequate breathing in infants and children – Nasal flaring – Grunting – Seesaw breathing – Retractions
How does the structure of a infant & child’s airway differ from that of an adult
– Smaller airway easily obstructed
– Proportionately larger tongues
– Smaller, softer, more flexible trachea
– Less developed, less rigid cricoid cartilage
– Heavy dependence on diaphragm for respiration
Treatment for Pt with Inadequate Breathing
Assisted ventilation with supplemental oxygen
– Pocket face mask with supplemental oxygen
– Two-rescuer/one rescuer BVM with
supplemental oxygen
– Flow-restricted, oxygen-powered ventilation device
Artificial Ventilation Rate for and Adult
12 breaths per minute
Artificial Ventilation Rate for infants & children
20 breaths per minute
How do you check for adequate ventilation
chest rise & fall should be visible with each breath
Signs of inadequate Ventilation
• Increasing pulse rates can indicate
inadequate artificial ventilation in adults
• Decreasing pulse rates can indicate inadequate artificial ventilation in pediatric patients
How can you tell if adequate breathing is becoming inadequate - how might your patient change during this transition
My answer: rate and depth change Pulse ox low increased pulse rate increased blood pressure may be anxious
Breathing Difficulty
- Patient’s subjective perception
- Feeling of labored, or difficult, breathing
- Amount of distress felt may or may not reflect actual severity of condition
OPQRST - what questions do you ask
• Onset—When did it begin?
• Provocation—What were you doing when this came on?
• Quality—Do you have a cough? Are you bringing anything up with it?
• Radiation—Do you have pain or
discomfort anywhere else in your body?
• Severity—On a scale of 1 to 10, how bad is your breathing trouble?
• Time—How long have you had this feeling?
If you have a chest pain questions make sure you ask all the questions - for a respiratory pt may not need to ask about radiation
What things should you look for when assessing a patient with difficulty breathing
• Altered mental status • Unusual anatomy – Barrel chest • Patient’s position – Tripod position – Sitting with feet dangling, leaning forward • Pale, cyanotic, or flushed skin • Pedal edema • Sacral edema • Coughing • Noisy breathing – Audible wheezing (heard without stethoscope) – Gurgling – Snoring – Crowing – Stridor
What are the respiratory signs of a patient with work of breathing
– Retractions
– Use of accessory muscles
– Flared nostrils
– Pursed lips - long term smoker -causes
– Number of words patient can say w/o stopping
What do you assess during Auscultation & what might you hear?
- Lung sounds on both sides during inspiration and expiration
- Wheezes—high-pitched sounds created by air moving through narrowed air passages
- Crackles—fine crackling caused by fluid in alveoli or by opening of closed alveoli
- Rhonchi—low sounds resembling snoring or rattling, caused by secretions in larger airways
- Stridor—high-pitched, upper-airway sounds indicating partial obstruction of trachea or larynx
What Vital signs changes do you see in a person with respiratory distress
- Increased or decreased pulse rate
- Changes in breathing rate
- Changes in breathing rhythm
- Hypertension or hypotension
- Oxygen saturation
How do you treat a patient with difficulty in breathing which is adequate
• If breathing is adequate, non- rebreather mask at 15 Lpm
make sure you stay focused on the airway
How do you treat a patient with difficulty in breathing which is inadequate
• If breathing is inadequate, begin artificial ventilation
CPAP Principles
• Simple principles
– Blowing oxygen or air continuously at low pressure into airway
– Prevents alveoli from collapsing at end of exhalation
– Can prevent fluid shifting into alveoli from surrounding capillaries
Common Uses for CPAP
• Common uses – Pulmonary edema – Drowning – Asthma and COPD – Respiratory failure in general
Contraindication for CPAP
• Contraindications – Severely altered mental status – Lack of normal, spontaneous respiratory rate – Hypotension/shock – Nausea and vomiting – Penetrating chest trauma – Upper GI bleeding – Conditions preventing good mask seal
Potential Side Effects of CPAP
• Side effects – Hypotension – Pneumothorax – Increased risk of aspiration – Drying of corneas
Steps in Using CPAP
- Explain procedure to patient
- Start with low level CPAP
- Reassess mental status, vital signs, and dyspnea level frequently
- Raise CPAP level if no relief within a few minutes
- If patient deteriorates, remove CPAP and ventilate with bag- mask
What is Chronic Obstructive Pulmonary Disease
- Broad classification of chronic lung diseases
- Includes emphysema, chronic bronchitis, and black lung
- Overwhelming majority of cases are caused by cigarette smoking
- Bronchiole lining inflamed
- Excess mucus produced
- Cells in bronchioles that normally clear away mucus accumulations are unable to do so
COPD: Chronic Bronchitis
- Inflamed bronchiole
* Excessive mucus
COPD: Emphysema
• Alveoli walls break down—surface area for
respiratory exchange is greatly reduced
• Lungs lose elasticity
• Results in air being trapped in lungs, reducing effectiveness of normal breathing
Thickened mucosa Bronchospasm Mucus Collapsed bronchiole Trapped air in alveoli Decreased elasticity
Characteristics of Asthma
• Chronic disease with episodic
exacerbations
• During attack, small bronchioles narrow (bronchoconstriction); mucus is overproduced
• Results in small airway passages practically closing down, severely restricting air flow
• Air flow mainly restricted in one direction
• Inhalation—expanding lungs exert outward pull, increasing diameter of airway and allowing air flow into lungs
• Exhalation—opposite occurs and air becomes trapped in lungs
Mucus accumulation
Edema of bronchial lining
Mucous plug
Pulmonary Edema
- Abnormal accumulation of fluid in alveoli
- Congestive heart failure (CHF) patients may experience difficulty breathing because of this
• Pressure builds up in pulmonary
capillaries
• Fluid crosses the thin barrier and accumulates in and around alveoli
• Fluid occupying lower airways makes it difficult for oxygen to reach blood
• Patient experiences dyspnea
Pulmonary Edema
• Pressure builds up in pulmonary
capillaries
• Fluid crosses the thin barrier and accumulates in and around alveoli
• Fluid occupying lower airways makes it difficult for oxygen to reach blood
• Patient experiences dyspnea
Common signs & symptoms of Pulmonary Edema
• Common signs and symptoms – Dyspnea – Anxiety – Pale and sweaty skin – Tachycardia – Hypertension – Low oxygen saturation
– In severe cases, crackles or sometimes wheezes may be audible
– Patients may cough up frothy sputum, usually white, but sometimes pink-tinged
Treatment for Pulmonary Edema
– Assess for and treat inadequate breathing
– High-concentration oxygen
– If possible, keep patient’s legs in dependent position
– CPAP
Think about it
• Might it be possible for a patient to have
multiple respiratory disorders?
• Could a person with an underlying diagnosis of COPD also have pulmonary edema? - yes - open up the lungs fluid could move in
What is Pneumonia
• Infection of one or both lungs caused by
bacteria, viruses, or fungi
• Results from inhalation of certain microbes
• Microbes grow in lungs and cause inflammation
Signs and Symptoms of Pneumonia
• Signs and symptoms – Shortness of breath with or without exertion – Coughing – FEVER AND SEVERE CHILLS – Chest pain (often sharp and pleuritic) – Headache – Pale, sweaty skin – Fatigue – Confusion
Treatment for Pneumonia
• Treatment – Care mostly supportive – Assess for and treat inadequate breathing – Oxygenate – Transport
What is Spontaneous Pneumothorax
• Lung collapses without injury or other
obvious cause
• Tall, thin people, and smokers are at higher risk for this condition
Often in young people - tall skinny basketball player
Signs and Symptoms of Spontaneous Pneumothorax
• Signs and symptoms
– Sharp, pleuritic chest pain
– Decreased or absent lung sounds on side with injured lung
– Shortness of breath/dyspnea on exertion
– Low oxygen saturation, cyanosis
– Tachycardia
Treatment for Spontaneous Pneumothorax
• Treatment
– Transport for definitive care, as patients frequently require chest tube
– Administer oxygen
– CPAP contraindicated
What is Pulmonary Embolism
- Blockage in blood supply to lungs
- Commonly caused by deep vein thrombosis (DVT)
- Increased risk from limb immobility, local trauma, abnormally fast blood clotting
Signs & Symptoms of Pulmonary Embolism
• Signs and symptoms – Chest pain – Shortness of breath – Low oxygen saturation/cyanosis – Tachycardia – Wheezing
these people are panicking
Treatment for Pulmonary Embolism
• Treatment
– Difficult to differentiate in field
– Transport to definitive care
– Oxygenate
What is Epiglottitis
• Infection causing swelling around glottic
opening
• In severe cases, swelling can cause airway obstruction
Signs and Symptoms of Epiglottitis
• Signs and symptoms – Sore throat, drooling, difficult swallowing – Preferred upright or tripod position – Sick appearance – Muffled voice – Fever – Stridor
Treatment for Epiglottitis
Treatment – Keep patient calm and comfortable – Do not inspect throat – Administer high-concentration oxygen if possible without alarming patient – Transport
What is Cystic Fibrosis
• Genetic disease typically appearing in
childhood
• Causes thick, sticky mucus accumulating in the lungs and digestive system
• Mucus can cause life-threatening lung infections and serious digestion problems
Signs & Symptoms of Cystic Fibrosis
• Signs and symptoms – Coughing with large amounts of mucus – Fatigue – Frequent occurrences of pneumonia – Abdominal pain and distention – Coughing up blood – Nausea – Weight loss
Treatment of Cystic Fibrosis
• Treatment
– Caregiver often best resource for baseline assessment of patient
– Caregivers can often guide treatment
– Assess for, and treat, inadequate breathing
– Transport
Viral Respiratory Infections
- Infection of respiratory tract
* Usually minor but can be serious, especially in patients with underlying respiratory diseases like COPD
Signs & Symptoms of Viral Respiratory Infections
• Often starts with sore or scratchy throat
with sneezing, runny nose, and fatigue
• Fever and chills
• Infection can spread into lungs, causing shortness of breath
• Cough can be persistent; may produce yellow or greenish sputum
Characteristics of a Prescribed Inhaler
- Metered-dose inhaler (MDI)
- Provides a metered (exactly measured) inhaled dose of medication
- Most commonly prescribed for conditions causing bronchoconstriction
Steps for administering a Prescribed Inhaler
• Beforeadministering inhaler – Right patient, right medication, right dose, right route – Check expiration date – Shake inhaler vigorously – Patient alert enough to use inhaler – Use spacer device if patient has one
• Toadministerinhaler
– Have patient exhale deeply
– Have patient put lips around opening
– Press inhaler to activate spray as patient inhales deeply
– Make sure patient holds breath as long as possible so medication can be absorbed
What is a Small Volume Nebulizer
learn how to set up a nebulizer
- Medications in metered-dose inhalers can also be administered by a small-volume nebulizer (SVN)
- Nebulizing—running oxygen or air through liquid medication
- Patient breathes vapors created
- Produces continuous flow of aerosolized medication that can be taken in during multiple breaths over several minutes
- Gives patient greater exposure to medication
Chapter Review
- It is important to understand the anatomy, physiology, pathophysiology, assessment and care for patients experiencing respiratory emergencies.
- Patients with respiratory complaints may exhibit inadequate breathing.
- Very slow and shallow respirations are often the end-point of a serious condition and are a precursor to death.
Chapter Review
• The history usually provides significant information about the patient’s condition. In addition to determining a pertinent past history and medications, determine the patient’s signs and symptoms with a detailed description including OPQRST and events leading up to the episode.
Chapter Review
- Important physical examination points include the patient’s work of breathing, accessory muscle use, pulse oximetry readings, assuring adequate and equal lung sounds bilaterally, and examining for excess fluid and vital signs.
- There are several medications which may help a patient’s difficulty breathing.
Remember
• Determine if the patient’s breathing is
adequate, inadequate, or absent.
• Choose the appropriate oxygenation or ventilation therapy.
Remember
• Consider whether to assist a patient with or administer respiratory medications.
– Do I have protocols and medications that may help this patient?
– Does the patient have a presentation and condition that may fit these protocols?
– Are there any contraindications or risks to using medications in my protocols?
Questions to Consider
- What would you expect a patient’s respiratory rate to do when the patient gets hypoxic? Why?
- What would you expect a patient’s pulse rate to do when the patient gets hypoxic? Why?
- List the signs of inadequate breathing.
Questions to Consider
- Would you expect to assist a patient with their prescribed inhaler when they are experiencing congestive heart failure? Why or why not?
- List some differences between adult and infant/child respiratory systems.
Critical Thinking
• A 72-year-old female complains of severe shortness of breath. Her husband notes she is confused. You note respiratory rate of 8 breaths/minute and cyanosis. Patient has a history of COPD and CHF. Discuss the treatment steps to assist this patient.
Inspiration
an active process in which the intercostal (rib) muscles and the diaphragm contract, expanding the size of the chest cavity and causing air flow into the lungs
expiration
a passive process in which the intercostal (rib) muscles and the diaphragm relax, causing the chest cavity to decrease in size and forcing air from the lungs
exhalation
another term for expiration
CPAP - continuous positive airway pressure
a form of noninvasive positive pressure ventilation (NPPV) consisting of a mask and a means of blowing oxygen or air into the mask to prevent airway collapse or to help alleviate difficulty breathing
bronchoconstriction
constriction or blockage of the bronchi that lead from the trachea to the lungs
Key Facts and concepts
Respiratory emergencies are common complaints for EMT’s. It is important to understand the anatomy, physiology, pathophysiology, assessment and care for patients experiencing these emergencies
Key Facts and Concepts
Patients with respiratory complaints (which are closely related to cardiac complaints) may exhibit inadequate breathing. Rapid respiration’s indicate serious conditions including hypoxia, cardiac and reparatory problems, and shock
Key Facts and Concepts
Very slow and shallow respirations are often the endpoint of a serious condition and are a precursor to death
Key Facts and Concepts
The history usually provides significant information about the patients condition. In addition to determining past history and medications, determine the patients signs and symptoms with a detailed description including OQPRST and events leading to the episode.
Key Facts and Concepts
Important physical examination points include checking the patients work of breathing, inspecting accessory muscle use, gathering pulse oximetry readings, assuring adequate and equal lung sounds bilaterally, examining for excess fluid (lungs, ankles and abdomen) and gathering vital signs
Key Facts and Concepts
Several medications are available that may help correct a patients difficulty in breathing
Key Decisions
- Is the patients breathing adequate, inadequate , or absent
- What are the appropriate oxygenation or ventilation therapies
- Should I assist a patient with, or administer, any medications
- Do I have protocols and medications that may help this
Order of preference for providing assisted ventilation are:
- Pocket Face Mask with Supplemental oxygen
- Two Rescuer bag-valve mask with Supplemental oxygen
- Flow-restricted oxygen-powered device
- One-rescuer bag-valve mask with Supplemental Oxygen
Differences in a childs airway:
Airway: All airway structures as small & more easily obstructed
Tongue: proportionally larger & takes up more space
Trachea: smaller, softer & more flexible which may lead to obstruction from swelling or trauma more easily cricoid cartilage is less developed & less rigid
Diaphragm: depend more heavily on diaphragm as the chest wall is softer - may see seesaw breathing, nasal flaring, grunting, retractions
Seesaw breathing
the movement of the diaphragm causes the chest & diaphragm to move in opposite directions
In an infant with respiratory distress what do you need to keep in mind with regard to pulse
In infants & children you may see a small pulse rise to compensate but if you see the pulse drop be prepared for a respiratory emergency
Northing is more important for infants & children than to maintain adequate airway care
What to do if you don’t have signs of adequate artificial ventilation
For any patient, adult, infant or child - if the chest does not reuse and fall with each artificial ventilation, or the pulse does not return to normal increase the force of ventilation
If the chest still does not rise check that you are maintaing an open airway (head tilt / jaw thrust) or airway adjunct
Suction fluids
If you are treating patients who are on steroids for asthma, this should be a good clue that they …..
have recently had a severe attack or their disease has been getting worse
the right side of the lungs has more lobes because you have to leave room for the heart on the left side
.
when assessing breathing respiration you use rate rhythm and quality
.
what indicates adequate ventilation
chest rise and fall
Secondary Assessment with Difficulty Breathing
O P Q R S T
go to web site and listen to lung sounds
.
asthma patients can get air in but they can’t get it out
.
If you have a problem with AB or C you have an ALS call
.
drugs memorized, used for, dose, indication contraindication, route and the action
which ones we carry
asthma
empysema
make sure have them memorized by monday
Adequate Breathing
• Breathing sufficient to support life • Signs – No obvious distress – Ability to speak in full sentences – Normal color, mental status, and orientation
Rate of Breathing Adult
12-20 adult - very slow or very fast may not allow enough air to enter the lungs.
Rhythm of Breathing
The rhythm of inadequate breathing my be irregular. However, rhythm is not an absolute indicator of adequate or inadequate breathing.
Quality of Breathing
When breathing is inadequate, breath sounds may be diminished or absent. The depth of respirations (tidal volume) will be inadequate or shallow. Chest expansion may be inadequate or unequal and respiratory effort increased.
What should the EMT observe in a patient with difficulty in breathing
- altered mental status, including restlessness, anxiety or depressed LOC
- unusual anatomy
- the patient position (trips, feet dangling)
- work of breathing
- pale, cyanotic, or flushed skin color
- pedal edema
- sacral edema
- noisy breathing
Vital sign changes for the patient with difficulty in breathing
- increased pulse rate
- decreasing pulse rate (esp. infants & children)
- changes in breathing rate (above or below normal)
- changes in breathing rhythm
- hyper or hypotension
- O2 sat less than 95
wheezes
high pitched sounds that will seem almost musical in nature. The sound is created by air moving through narrowed passages in the lungs. It can be heard in a variety of diseases but is common in asthma & sometimes in chronic obstructive lung disease such as emphysema and chronic bronchitis. Wheezing is most commonly heard during expiration
Crackles (rales)
as the name indicates, a fine crackling or bubbling sound heard upon inspiration the sound is caused by fluid in the alveoli or by the opening of closed alveoli. Some people refer to crackles as rales.
stridor
a high pitched sound that is heard on inspiration. It is an upper airway sound indicating partial obstruction of the trachea or larynx. Stridor is usually audible without a stethoscope.
Rhonchi
lower pitched sounds that resemble snoring or rattling. They are caused by secretions in larger airways as might be seen with pneumonia or bronchitis or when materials are aspirated (breathed) into the lungs. The difference between crackles and rhonchi is not always obvious and is somewhat subjective. However, rhonchi are generally louder than crackles
Pluera
n human anatomy, the pleural cavity is the potential space between the two pleurae (visceral and parietal) of the lungs. The pleura is a serous membrane which folds back onto itself to form a two-layered membrane structure. The thin space between the two pleural layers is known as the pleural cavity and normally contains a small amount of pleural fluid. The outer pleura (parietal pleura) is attached to the chest wall. The inner pleura (visceral pleura) covers the lungs and adjoining structures, via blood vessels, bronchi and nerves.
