Respiratory Emergencies

What we are going to discuss

5 most common respiratory problems in adults

Basic Concept:

Air Goes in and Out

Blood Goes Round and Round

Any thing infringing on this is a BAD THING!

Key Concepts
The primary function of the respiratory system is gaseous exchange.
Ventilation and Oxygenation.
Air is composed of a mixture of gases.
Breathing is largely controlled by the Autonomic Nervous system, in response to changes
sensed in all parts of the body. The biggest part of this is the Hypoxic Drive.
Key Concepts
Diffusion of O2 from the lung to the blood is by the binding of O2 to the hemoglobin
(Hgb)
This is dependant on a pressure gradient.
This is a Passive transport system.
It is also dependant on available surface area and distance it must travel to cross the
threshold.
Capillaries are where the real Oxygenation and ventilation take place.
Primary Concepts
All pts with SOB get O2. Lots of O2.
Listen to ALL lungs.
Beware of the silent chest.
Noisy Breathing is abnormal breathing
Visible Breathing is abnormal breathing.
Positional breathing is abnormal breathing.
Abnormal Breathing gets O2.
Volume
Tidal Volume
Minute Volume
Tidal Volume X Respiratory Rate = Minute Volume

Respiratory Emergencies
Emergency Medical Care
Increase O2 concentration early on
+ Pressure ventilation if required
o When in doubt attempt to administer
If pt fights then stop
 If pt accepts then continue
Rapid transport
ALS???
Position of comfort
Monitor for fatigue
Medication administration
Oxygen Delivery Devices
Nasal Cannula
22-24% Oxygen
1-6 Lpm
Simple Face Mask
40-60% Oxygen
8-12 Lpm
Admin no less than 6 Lpm
Non Rebreather
80-100% Oxygen, 15 Lpm
No less than 8 Lpm
Venturi Mask
Used for COPD
Controlled precise amount of oxygen
24, 28, 35, 40% Oxygen
Pulse Oximetry
5th Vital Sign
Normal SpO2
95-100%
Sp02 Ranges
91-94% = Mild Hypoxia Supplemental O2
86-91% = Moderate Hypoxia Supplemental O2
85%-< = Severe Hypoxia IMMEDIATE intervention
False Readings
CO poisoning, high intensity lighting, hemoglobin abnormalities, no pulse in extremity,
hypovolemia, severe anemia
Respiratory Physiology
What do we assess?
Presence or absence?
Rate
Quality
Respiratory Rate
Decreased by:
Depressant Drugs
Sleep
Increased by:
o Fever
 o Fear
o Exertion
Respiratory Quality
Irregular: Neuro Insult.
Shallow:
Respiratory Depressants
CNS Depressants
Neuro Insult
Deep:
o Hyperglycemia with Acidosis (DKA): Kussmal Respirations
o Electrolyte Imbalances
o Neuro Insult
Adult Lung Volumes
5,500 to 6,000mL at end inspiration.
Normal tidal volume: 500mL
Dead space air: 150mL
Alveolar Air: 350mL
Key components of an intact respiratory system
An appropriate Drive to Breath
Airway and respiratory tract
Mechanical Bellows
A diffusion friendly place for gas exchange to happen.
An O2 friendly RBC with hgb.
An intact circulatory system to carry the gasses and waste through out the body.
Must have enough of a pressure to promote diffusion.
An intact capillary bed
Drive to breath
Controlled by the CNS through information gathered from receptors in the body.
Located in the pons region of the brainstem
Detects increases in CO2 or decreases in pH and informs the brain to increase the
respiratory rate.
Increased respiratory rate reduces CO2 and will increase pH.
Other things can effect our drive to breath
Hypoxic Drive
Develops in some patients with Chronic Lung Disease
Pons region of brain becomes sensitized to constant increased CO2 state
Regulation is now based on O2 level in blood
Increased oxygen level states may tell the brain to stop breathing
5 effects on respiratory drive.
CVA
Trauma to the brain
Drugs
 Tumor
Electrolyte Imbalances
Assessing the pt with Respiratory Distress.
First Impressions
Air Hungry
Nasal Flaring
Tripoding
Rocking with respirations
Pursed Lip Breathing
Barrel or Sparrow Chest
Home O2
Skin Signs
Cyanosis
Nail Beds
Lips
Ears
n Mottling
Chest
Lower Ext
Abd
Noisy breathing is obstructed breathing
Snoring: obstruction by tongue
Gurgling: Funky Junk in upper airway
Grunting: Physiologic PEEP
Stridor: harsh, high pitched sound on inhalation:
Laryngeal edema
Epiglotitis
FBAO
Speech Dyspnea
Inability to speak more than a few sylables in a sentence between breaths.
Breath Sounds
Listening by comparison
Listening anterior
Listening posterior
Fremitus
Abnormal breath sounds
Rales (crackles): fine bubbling sound of fluid in alveoli (Rice Krispies: snap, crackle
and pop) Alveoli popping open.
Rhonchi: fluid in larger airways, obstructing object in the bronchus
Wheezes: high pitched whistling, air through narrowed airways
SILENCE IS BAD NEWS
Causes of respiratory abnormalities
Brain damage: trauma, drugs, stroke
 Spinal cord damage: trauma, polio
Upper airways: tongue, swelling, foreign body, trauma
Lower airways: asthma, chronic bronchitis
Alveoli: atelectasis, obstruction
Impaired pulmonary circulation: embolism
Signs/symptoms of distress
Dyspnea
Restlessness/anxiety
Tachypnea/Bradypnea
Cyanosis (core)
Abnormal sounds
Retractions
Diminished ability to speak
More S/S
Retractions and/or use of accessory muscles
Abdominal breathing
Nasal flaring
Productive cough
Color?
Irregular breathing
Tripod position
Pursed-lip breathing
The Usual Suspects
Top 6 you need to know
COPD/Reactive Airway Disorders
o Emphysema
o Asthma
o Bronchitis
o Pneumonia
o CHF
o Pulmonary Emboli
o Hyperventilation Disorders
o Pneumothorax
COPD
Causes of Chronic Obstructive Pulmonary Disease (COPD)
o Cigarette smoking
o Environmental pollution
o Previous pulmonary infections
o Chronic asthma
Common Traits of COPDers
pink puffer
air trapping
 destruction of alveoli, loss of elasticity
barrel chest/Sparrow Chest
use of accessory muscles
noisy breath sounds: wheezing prolonged and increasing on exhalation
Air Trapping
Due to loss of elasticity in the alveoli, these pts trap air.
They need over double the exhalation period
This means inhibited gas exchange and possibly
They can develop a spontaneous pneumothorax..
EMPHYSEMA
In Emphysema the chronic damage to the lungs interferes with gas exchange.
A secondary point of exacerbation is the irritation of the broncheols, making them constrict and
spasm. Since the alveoli are damaged, this causes them to collapse easily.
Chronic Bronchitis
The English Disease
Chronic irritation cause increases mucus production as a defense mechanism.
This in turn decreases surface area for gas exchange.
The phlegm also irritates the bronchioles, causing bronchio-constriction and spasm.
ASTHMA: causes.
Reactive airway event caused by bronchospasm, reversible
Extrinsic: environmental, allergic trigger, temperature
Intrinsic: exertion/ stress, illness
Inflammatory reaction
Acute asthmatic attack:
Bronchospasm: rapid onset, can be relieved by medications
Swelling of mucous membranes in bronchial walls (inflammatory response)
Mucus plugging of bronchi
Signs and Symptoms
Usually patient has history of asthma, may have prescription for meds
Noisy breath sounds (increased on exhalation)
BEWARE A SILENT CHEST
Accessory muscle use
Tachycardia and tachypnea
Pulsus paradoxus (decrease in systolic BP with inhalation)
Exhaustion
Status Asthmaticus
Prolonged asthma attack that is not broken by normal treatments
Requires aggressive treatment and transportation
A SILENT CHEST IS BAD!
Treatment
Reassure
High flow humidified oxygen
 Assist with medication (per protocol)
Position of comfort
Insure adequate ventilation
BronchoDilators
Bronchodilators
Beta II agonist
Stimulate receptor sites causing bronchiole relaxation
First Line.
Albuterol
Parasympatholytic
o Inhibit Parasympathetic broncheoconstriction
o Second line.Use only once
Atrovent
May improve air passage around mucous plugs
Many side effects

REMEMBER:
ALL THAT WHEEZES IS NOT ASTHMA..
AND NOT ALL ASTHMA WHEEZES!
All that wheezes is not asthma:
n Other causes:
acute left heart failure (cardiac asthma)
smoke inhalation
chronic bronchitis
acute pulmonary embolism
n May be localized: suspect an obstruction
High Flow 10-15 LPM NRB
NEVER WITHHOLD OXYGEN FROM A PATIENT WHO NEEDS IT!
Signs and Symptoms
Something has changed from normal
Marked respiratory distress
Diaphoresis, cyanosis
Agitation and confusion (hypoxemia), lethargy (hypercarbia)
Tachypnea, tachycardia, irregular heart beat
Treatment
Ventilate appropriately
Expect low pulse oximetry: dont try to raise to normal Base on Mental Status and
subjective statements. Try at least above 85-90%
Position of comfort (upright, tripod)
Rapid transport
Monitor ventilations
Pulmonary Edema
Definition: accumulation of fluid in alveoli, chronic or acute
 Primary Cause is Cardiac (CHF)
Other Causes:
exposure to toxic substances
damaged tissue
Actively Dying (ARDS)
Signs and Symptoms
Anxiety
tachypnea/tachycardia
dyspnea, hemoptysis
abnormal breath sounds (moist, wheezes)
JVD
Elevated blood pressure
orthopnea/paroxysmal nocturnal dyspnea
Treatment:
Reassure
High flow oxygen (positive pressure)
NTG (Medical Control Only)
Position of comfort
Rapid transport
Pneumonia
Definition: infection of respiratory tree, may result in systemic sepsis
Types:
bacterial 90%
viral (from influenza)
mycoplasmal/fungal
aspiration
Signs and symptoms
Patient looks sick/dehydrated
Illness over several days
Fever
Dehydration
Productive cough
tachypnea/ tachycardia
Rales and rhonchi
Treatment:
Oxygen and transport
Pulmonary Embolism
Definition:sudden blocking of pulmonary artery by clot
Causes:
blood clots in legs
prolonged immobilization
birth control pills
Signs and symptoms:
Sudden onset of severe, unexplained dyspnea
other s/s may or may not be present
chest pain made worse on coughing
Tachycardia/tachypnea
JVD
Treatment
Recognition
Oxygen
Hospitalization
Suspect PE when there is acute onset of tachycardia or dyspnea of unknown origin
Hyperventilation
Definition: rapid, deep respirations causing imbalance of CO2 in body often caused by
emotions or stress
May be hard to recognize
There may be other causes of pattern
Signs and symptoms
Elevated respiratory rate or increased depth
chest pain
tingling or numbness around mouth, hands, feet
Carpopedal spasm
Treatment:
Do NOT use a paper bag
Try to calm and reassure
Remove patient from environment that may be causing problem
Transport if problem cant be resolved
Spontaneous Pneumothorax
Definition: sudden leak of air into pleural space; may have no apparent cause
Frequently young, tall, thin males
May have previous history
Signs/ symptoms
Sudden, sharp chest pain
Sudden dyspnea
Diminished breath sounds
Pleuritic chest pain
Treatment
Oxygen and transport
Other problems:
Pickwickian syndrome: patient is VERY obese, related to sleep apnea
Cystic fibrosis
Legionnaires (type of pneumonia)
 Getting a good history will be one of the most important ways to differentiate between
respiratory conditions
Look for underlying conditions