© 2011 Seattle / King County EMS CBT425-EMT11: Respiratory Emergencies.

© 2011 Seattle / King County EMS

CBT425-EMT11: Respiratory Emergencies


Introduction

• Patients with lung & heart diseases frequently call 9-1-1 due to breathing difficulty

• This course reviews common disorders that can cause respiratory emergencies & prehospital management of these conditions


Objectives1. Identify the anatomic structures of the respiratory

system

2. Demonstrate an understanding of the physiology of the respiratory system and its relationship to BLS treatment

3. Identify signs and symptoms of respiratory emergencies

4. Identify treatment of respiratory emergencies

5. Distinguish between normal and abnormal breath sounds

6. Identify correct technique for auscultation of breath sounds

7. Identify correct BVM technique and suctioning technique


Termschronic obstructive pulmonary disease (COPD) - A

category of diseases characterized by a slow process of dilation and disruption of pulmonary alveoli.

dyspnea - A term for shortness of breath or breathing

difficulty. embolus - A blood clot or other substance that has formed in

a blood vessel or the heart, that breaks off and travels to another blood vessel, where it may cause blockage.

flail chest - A condition in which three or more ribs are

fractured in two or more places such that a section of the chest wall is detached from the rest of the chest wall.


Terms, continuedgag reflex - A protective contraction of the muscles of the

throat caused especially by stimulation of the pharynx that prevents food and liquids from entering the airway.

hypoxia - A condition in which the body's cells and tissue do not have enough oxygen.

pleuritic chest pain - A sharp, stabbing pain in the chest

that is worsened by a deep breath; often caused by inflammation or irritation of the pleura.

pneumothorax - Condition where air enters the pleural

space and is trapped during expiration. It can occur without trauma as in a spontaneous pneumothorax.


Terms, continuedpulmonary edema - A buildup of fluid in the lungs,

usually as a result of congestive heart failure. rales - Crackling, rattling breath sounds signaling fluid in

the air spaces of the lungs. rhonchi - Coarse breath sounds heard in patients with

mucus in the airways. stridor - A harsh, high-pitched inspiratory sound often

heard in acute laryngeal (upper airway) obstruction.


Terms continuedtension pneumothorax - A life-threatening condition in

which air enters the pleural space and the pressure inside the lung cavity progressively increases and compresses the lung. It may displace the mediastinum and other structures toward the opposite side.

traumatic asphyxia - Condition characterized by

distended neck veins, cyanosis in face and neck and bleeding in the sclera of the eye that is caused by severe compression of the chest.

wheeze - A high-pitched, whistling breath sound,

characteristically heard on expiration in patients with asthma or COPD.


New Termshypoxic drive - A condition in which the body's stimulus

for taking a breath is low oxygen. Occurs in people with COPD.

metabolism - The process by which food molecules are

broken down to provide material and energy for cellular function.

pH (potential of hydrogen) - A measure of the acidity or

alkalinity of a solution, numerically equal to 7 for neutral solutions, increasing with increasing alkalinity and decreasing with increasing acidity. The pH scale ranges from 0 to 14. Numbers from 7 and below represent increasing acidity.


New Terms continuedperfusion - The movement of blood through an

organ or tissue in order to supply nutrients and oxygen.

tidal volume – The volume of gas that is moved

with each breath which is normally 500 ml in an adult.

ventilation – The rate at which gas enters or

leaves the lungs. Generally it is described in terms of good or poor ventilation. Bluish or dusky skin can indicate poor ventilation.


Respiratory Structures

• Airway protection & oxygen administration are perhaps the most important BLS skills you have

• Important to know structures of respiratory system

• Understand basic physiology affected by BLS treatment

Learning Activity for Functions of Respiratory Structureshttp://www.emsonline.net/resp2011/functions.asp

Learning Activity for Functions of Respiratory Structureshttp://www.emsonline.net/resp2011/functions.asp

http://www.emsonline.net/resp2011/functions.asp

http://www.emsonline.net/resp2011/functions.asp


PHYSIOLOGY


Metabolism Produces Carbon Dioxide

• Process by which body breaks down or "burns" stored fuel to create energy• Cells use oxygen to transform stored glucose into energy• Think of glucose as "fuel" & oxygen as "match" that releases energy• Byproduct of metabolism is carbon dioxide (CO2)


Metabolism

• Carbon dioxide produced by cells & carried by circulatory system to lungs where it is expired

• If respirations impaired• Carbon dioxide builds up in blood• Excess carbon dioxide combines with water

in blood to produce acid


pH

• Acidity in solution such as blood measured by potential of Hydrogen

• Body must maintain relatively narrow pH range (neither too acidic nor too basic)

• Respiratory system helps maintain balanced acid level or pH in blood


The pH Balancing Act• Respiratory system – mirror for other changes that happen in the body• Blood pH becomes too low (acidic)

• Respiratory system will attempt to fix by making lungs breathe more deeply & rapidly• Excreting more carbon dioxide

• Homeostasis – body attempts to maintain balance


Hypercarbia • Excessive carbon dioxide in the body• Results in acidosis as carbon dioxide causes chemical reaction producing carbonic acid• Hypercarbia can occur through:

• Metabolic processes that form acids • Muscle exertion • Shivering

• Occurs through decreased elimination of carbon dioxide, for example with:

• Airway obstruction • Inability to exhale fully (e.g., asthma or emphysema) • Depressed respiratory drive (e.g., overdose of sedative drugs)


Hypoxic Drive• Amount of carbon dioxide in blood is

primary stimulus for breathing• Secondary stimulus is hypoxia

• Decrease in oxygen

• Occurs in small percentage of COPD patients• Expirations so inefficient their bodies become

accustomed to higher than normal levels of carbon dioxide

• Decrease in oxygen, rather than increase in carbon dioxide, provides primary stimulus for taking breath


Respiratory Drive

• Act of breathing – autonomic & involuntary function controlled by centers in brain sensitive to blood levels of oxygen & carbon dioxide

• Body’s response to increased carbon dioxide in blood is to "blow off” carbon dioxide by increasing rate & depth of respirations


Metabolic Problems

• Metabolic imbalances affect chemistry of body affecting pH & other measures of body chemistry

• Not a respiratory problem, respiratory system often tries to compensate by changing depth and/or rate of respirations


Metabolic Problems Ketoacidosis – inefficient metabolism of sugars in a

diabetic causes body to turn to other fuel sources for energy (fat & muscle)• Byproducts – acids called ketoacids• Presence of ketoacids & related compounds in blood will

cause lower pH• Respiratory system responds by increasing depth and/or

rate of respirations

Aspirin overdose – an acid (the chemical name is acetylsalicylic acid)• Taken in large quantities, person becomes acidotic• Body compensates by increasing depth and/or rate of

respirations


Metabolic Problems Fever increases metabolic rate, causing production of

more carbon dioxide which leads to more acid in blood• Tissue perfusion fails (as it can in sepsis)

• Excess metabolic acids accumulate causing metabolic acidosis with a low pH

• Body responds by increasing depth and/or rate of respirations

Hyperventilating breathing deeply & rapidly• Efficient way of ridding body of carbon dioxide which in

turn may alter the body’s equilibrium• Causes alkalosis (meaning very "basic")• Symptoms of respiratory alkalosis may include faintness &

tingling in the extremities


CLINICAL SYNDROMES


Airway Obstruction • EMS providers should intervene if choking victim

has signs of severe airway obstruction– Poor air exchange or increased breathing difficulty

(indicated by silent cough) cyanosis or inability to speak or breathe

• Mild obstruction & victim coughing forcefully– Do not interfere with efforts to relieve obstruction– Attempt to relieve obstruction only if it becomes severe

• Use a finger sweep only if you can see solid material obstructing airway of unresponsive patient


Asthma• Chronic, inflammatory disease of airways• Asthma attacks induced by different factors:

– Allergens– Infections– Exercise– Smoke

• During asthma attack:– Muscles around bronchioles tighten– Lining of inside bronchioles swells– Inside of bronchioles fills with thick mucous– Severely restricts expiration of air from lungs


Asthma• Patients often describe history of asthma• Have prescription for metered-dose inhaler• BLS treatment considerations include:

– Calming the patient– Airway management– Oxygen therapy– Assisting with a prescribed inhaler

• Asthma attack – muscles around airways tighten, making airway openings narrower so less air can flow through• Inflammation increases and airways become more swollen and narrow• Cells in airways also produce more mucus than normal

–Extra mucus also narrows the airways.


COPD• Chronic obstructive pulmonary disease

(COPD)• Category of diseases that includes:

– Asthma– Emphysema– Chronic bronchitis

• Slow process of dilation & disruption of airways & alveoli

• Includes several related irreversible conditions that limit ability to exhale


COPD• Patients present with shortness of breath, fever and increased sputum production

– Medical history can include:– Upper-respiratory infection– Chronic bronchitis– Emphysema– History of smoking– Working in hazardous environment (e.g., coal smoke, asbestos)

Common medications include:• Prednisone • Proventil• Ventolin• Atrovent• Azmacort

BLS treatment for a COPD patient with respiratory distress should include high flow

oxygen .

BLS treatment for a COPD patient with respiratory distress should include high flow

oxygen .


Emphysema • Very small airways that join alveoli are

damaged & walls lose elasticity• Chronic irritation of small airways causes

inflammation & swelling – reducing diameter of air passages

• Irritation causes bronchospasms & further decreases the lumen

• On inspiration, expansion of lungs holds airways open

• On exhalation, lungs relax & airways narrow, trapping air


Chronic Bronchitis

• Characterized by structural changes in airways of the lungs

• Enlargement of mucous glands – cause coughing & production of sputum

• Causes shortness of breath • Often accompanied by infection, mucus

production & coughing


Congestive Heart Failure• During acute exacerbation patient will present:

– Sitting up– Short of breath– Diaphoretic– Pale– Cyanotic in color

• Breath sounds can include rales or wheezes

• Medical history can include:

– Increased salt ingestion– Respiratory infection– Non-compliance with medications– Angina– Symptoms of acute coronary syndrome


Congestive Heart Failure • Result of too much fluid in lungs making it difficult to get air in—as opposed to COPD patient who has trouble getting air out • Occurs when ventricles weakened by myocardial infarction, underlying coronary artery disease, hypertension or valve disease • Impairs heart’s ability to contract & empty during systole

– Blood backs up in lungs & tissues of body

• Increased pressure in left ventricle transmitted to lung capillaries

– Fluid forced into alveoli – Interrupts gas exchange & results in shortness of breath

• Increased pressure in right ventricle causes fluid to back up into body’s tissues

– Leading primarily to swelling in lower extremities

• Do not suffer from purely left- or purely right-ventricle heart failure

– Rather present with combination of symptoms


CHF Symptoms


Congestive Heart Failure• Common medications include:

– ACE inhibitors– Furosemide (Lasix)– HCTZ (hydrochlorthiazide)– Beta-blockers– Angiotensin II receptor blockers – Digoxin (Lanoxin)

• Medications can help differentiate this patient's symptoms from those of someone with COPD


Congestive Heart Failure

When treating CHF:• Seat the patient upright• Administer high flow oxygen• Consider positive pressure ventilation

with a BVM if the patient is experiencing severe respiratory difficulty


Inhalation Injuries • Breathing of chemicals, smoke or other

substances• Common chief complaints include:

– Shortness of breath– Coughing– Hoarseness– Chest pain due to bronchial irritation– Nausea

• Individuals with decreased respiratory reserve (e.g., history of COPD or CHF) are likely to experience an exacerbation of the disease


Inhalation Injuries

Patient in respiratory distress:• Treat immediately with high flow

oxygen• Assist breathing with a BVM if the

respiratory effort is insufficient– Indicated by a slow rate & poor air

exchange


Pneumonia • Symptoms include:

– Fever– Chills– Cough (often with yellowish sputum)– Shortness of breath– General discomfort– Fatigue– Loss of appetite– Headache

• Can be chest pain associated with breathing (usually sharp and stabbing in nature) and worsened by coughing or deep inspirations

• Other signs sometimes present are rales, clammy skin, upper abdominal pain & blood-tinged sputum

• Emergency care – may include oxygen therapy.


Pneumothorax • Presence of air in pleural space• Caused when internal or external wound allows air to enter space between pleural tissues

– Causes collapse of lung

• Cause sharp chest pain & shortness of breath

– May be able to feel subcutaneous air & breath sounds will be diminished


Pneumothorax

• Treatment of pneumothorax includes high-flow oxygen

• Be judicious with use of positive-pressure ventilation– Can turn a spontaneous pneumothorax into

a life-threatening tension pneumothorax.

A pneumothorax can cause collapse of the entire lung. The only symptom may be

sudden chest pain.

A pneumothorax can cause collapse of the entire lung. The only symptom may be

sudden chest pain.


Pneumothorax• Under normal conditions no air between these layers of pleura because sealed together• Air or blood can enter space

– Example when hole is punctured in chest wall by gunshot or stab wound

• Can occur spontaneously

– Rupture due to disease or localized weakness of the lung lining– Result of trauma– Forceful coughing

• Chest injury and prior history of pneumothorax possible medical histories• COPD – risk factor


Tension Pneumothorax • Progressively worsening pneumothorax – begins to impinge on function of lungs & circulatory system• Caused when lung injury acts like one-way valve that allows free air to move into pleural space

– Prevents free exit of that air

• Pressure builds inside pleural space & compresses lungs & other organs

Early signs of a tension pneumothorax include:• Increased dyspnea • Cyanosis • Signs of shock • Distended neck veins• Shift in PMI (Point of maximum intensity, where heart is loudest through auscultation)• Tracheal displacement • Tracheal deviation


Pulmonary Embolism • Particle such as blood clot, fat embolus,

amniotic fluid embolus or air bubble gets loose in blood stream

• Travels to the lungs• Embolus lodges in major branch of

pulmonary artery• Circulation through large portion of lung

is interrupted• Blood not able to reach alveoli & it

cannot be oxygenated


Pulmonary Embolism• Causes include:

– Immobility of the lower extremities– Prolonged bed rest– Recent surgery

• Signs of PE:– Sudden-onset of:– Shortness of breath– Tachypnea– Chest pain worsened by breathing– Coughing up blood

• Pulmonary embolism – life-threatening condition

– Treated with high flow oxygen– Rapid transport

• Move patient gently to avoid dislodging additional emboli


PATIENT CARE


Assessment of Respiratory Status • Assess rate & depth of respirations• Normal rate is between 12 & 20

respirations per minute for adult• Depth of respirations more subjective &

varies from shallow, normal, labored or gasping

• Together rate & depth will tell whether tidal volume is adequate.


Assessment of Respiratory StatusOther signs that indicate adequate

oxygen supply to body’s tissues:• Level of consciousness• Breathing effort• Ability to speak in complete sentences• Use of accessory muscles• Skin color• Breath sounds• Body position


Irregular Breathing Patterns • Caused by specific conditions:

– Example: Cheyne-Stokes respirations• May be seen in head injuries & stroke• Characterized by periods of breathing with gradually

increasing & decreasing of tidal volume interspersed with periods of no breathing

• Ataxic respirations – irregular, ineffective respirations with no clear pattern

• Agonal respirations – abnormal pattern of breathing characterized by ineffective, slow inspirations followed by long pauses– Often sound like gasps– Associated with cardiac arrest or severe end-stage

shock


Auscultation of Breath Sounds Proper technique for auscultating chest using a

stethoscope includes: • Listen at six locations on the back• Listen at four locations on the front • Instruct the patient to take a deep breath

through the mouth then exhale • Listen to one or two inspiration/expiration

cycles per location • Avoid listening through clothing

Video demonstration available at EMS Online:

http://www.emsonline.net/resp2011/auscultation.asp


http://www.emsonline.net/resp2011/auscultation.asp


Auscultation of Breath Sounds• Changing airflow patterns inside lungs

produce normal breath sounds• Make a "swishing" sound as one

breathes in or out• Absent breath sounds can indicate

apnea, pneumothorax, hemothorax or lung removal

EMTs must be able to distinguish normal breath sounds from abnormal breath sounds.

EMTs must be able to distinguish normal breath sounds from abnormal breath sounds.


Airway Management • Very important skills for EMS provider• Well versed in the following airway

management techniques:– Head tilt/chin lift– Jaw thrust– Patient positioning– Airway adjuncts– Suction– Oxygen therapy– Assisted ventilation– Relief of foreign body airway obstruction


Suction• Purpose of suction –remove vomit, blood,

excretions & other matter from airway• Guidelines to use for suctioning:

– Measure tip from corner of mouth to earlobe – Oxygenate patient well (if situation permits)– Insert tip into oral cavity without applying

suction– Move suction tip side–to-side– Oxygenate well after suctioning


Tips for Effective Suctioning • Measure tip same as for an oropharyngeal airway—from corner of mouth to ear lobe or from center of mouth to angle of jaw• Insert tip only to base of tongue• If situation permits (e.g., there is no significant airway threat), give at least 30 seconds of oxygen before suctioning• Administer oxygen after suctioning & consider assisting ventilations with a bag-valve mask to help provide extra oxygen• Do not apply suction while inserting tip – can rob airway of oxygen.

• Apply suction for no more than 15 seconds at a time• In rare cases, copious vomiting that threatens airway may require more suctioning• In infants & children, suction for shorter periods of time (e.g., no more than 5 seconds)• If there are secretions or emesis that you cannot easily remove with suction, position patient, (e.g., by using log roll) so gravity & a finger sweep can quickly clear the airway


Assisted Ventilation

• Patients who lack oxygen – must take quick action to improve depth & rate of respirations

• Bag-valve mask (BVM) – useful tool for improving ventilation & acid-base (pH) balance

• Proper technique for assisting ventilation with a BVM is as follows:


Assisted VentilationUnconscious breathing patient:• Consider need for an oropharyngeal airway*• Do not over-ventilate• Keep the airway open• Maintain a good seal• Apply the Sellick maneuver which can help reduce airflow into the stomach*Follow local protocols

Non-breathing patient:• Deliver a ventilation of 1-second duration • Deliver enough volume to make the chest rise • 12 ventilations/min• 8-10 ventilations/min if an advanced airway is in place


http://www.emsonline.net/resp2011/ventilation.asp


http://www.emsonline.net/resp2011/ventilation.asp


Oxygen DeliveryAmount of oxygen administered patient & method of administration depend on many factors including medical history & cause of respiratory problem

Rate Volume (liters/min)

Device

Low Flow 2 - 6 Nasal cannula or blow by

High Flow 10 - 15 Non-rebreathing mask

High flow with ventilation

15 + Bag-valve mask with reservoir


http://www.emsonline.net/resp2011/therapy.asp


http://www.emsonline.net/resp2011/therapy.asp


Case Studies

Video Care Study #1http://www.emsonline.net/resp2011/vcase1.asp

Video Care Study #2http://www.emsonline.net/resp2011/vcase2.asp


SummaryMain structures of the respiratory system are:• Pharynx• Trachea• Epiglottis• Alveoli• Bronchi• Bronchioles• Larynx• Pleura• Diaphragm


Summary• Respiratory system – important mechanism for

regulating pH in body– Respiration impaired, carbon dioxide builds up in

blood (hypercarbia) and produces an acid– BLS providers can help treat this condition by

improving ventilation• Signs of severe airway obstruction include poor

air exchange and increased breathing difficulty• Persons with COPD-related emergency may

present with shortness of breath, fever & increased sputum production

• Signs of congestive heart failure may include an acute onset of breathing difficulty, diaphoresis & cyanosis


Summary• Pneumothorax can cause sharp chest pain &

shortness of breath• Signs of pulmonary embolism include a sudden

onset of shortness of breath, tachypnea, chest pain worsened by breathing & coughing up blood

• Treatment for respiratory emergency can include high flow oxygen and, in case of decreased respiratory drive, assisted ventilations

• CHF patients may require positive-pressure ventilations


SummaryProper technique for auscultating the chest

includes: • Listen at six locations on the back• Listen at four locations on the front • Move from bottom to top in a medical patient • Instruct the patient to take a deep breath

through the mouth then exhale • Listen to one or two inspiration/expiration

cycles per location • Avoid listening through clothing


Summary

Guidelines for use of suction include:• Measure the tip from corner of mouth

to earlobe • Oxygenate the patient well (if the

situation permits)• Insert the tip into the oral cavity

without applying suction• Move the suction tip side to side• Oxygenate well after suctioning


Summary

Key points for ventilating an unconscious breathing patient are:

• Consider oropharyngeal airway• Do not over-ventilate• Keep the airway open• Maintain a good seal• Apply the Sellick maneuver which can

help reduce airflow into the stomach


Questions

Dr. Mickey EisenbergMedical DirectorAsk the Doc: http://www.emsonline.net/doc.asp

EMS OnlineGuidelines and Standing Ordershttp://www.emsonline.net/downloads.asp

Susan KolwitzProgram ManagerEmail support: [email protected]

© 2011 Seattle / King County EMS CBT425-EMT11: Respiratory Emergencies.

Documents

Transcript of © 2011 Seattle / King County EMS CBT425-EMT11: Respiratory Emergencies.