Respiratory Emergencies

Respiratory Emergencies

• AIRWAY…• AIRWAY…• AIRWAY…

• One of the most life threatening emergencies• Maintain an open airway!!!• Ensure oxygenation and ventilation

• Complications• Must extend uninterrupted from nose/mouth to alveoli• Muscles of respiration must move air in/out efficiently• Diffusion of gases must occur over alveoli/capillary membrane• Also depends on brain stem to monitor and control resp via nerves

Respiratory System

• Function• Gas exchange with outside environment• Filtration/Humidification/Warming/Conduction of air

• Structures• Nose• Mouth• Naso/Oro/Laryngopharynx• Larynx• Bronchi

• Bronchioles• Lungs• Diaphragm

• Associated muscles • Alveoli

Upper Airway Nose/Mouth

• Function• Filters• Warms• Moistens

Upper Airway Pharynx

• Location• Posterior to mouth• Superior to esophagus,

larynx, trachea

• Function• Conducts air to bronchi

• 3 Divisions• Nasopharynx• Oropharynx• Laryngopharynx

Upper Airway Epiglottis

• Location• Sits posterior to larynx• Attached to tongue

• Structure• Leaf shaped cartilage

• Function• Prevents food/liquid from entering

larynx during swallowing • Guards opening to vocal cords

(glottis)

Upper Airway Larynx

• AKA: “Voice box”• Location

• Inferior to epiglottis• Superior to trachea

• Structure • Cartilaginous rings

• Thyroid Cartilage = “Adam’s Apple”

• Bulk of anterior wall• Cricoid Cartilage

• Firm rings forming lower aspect/base

• Function• Stops foreign objects that pass

epiglottis• Laryngospasm

• Voice production

Lower Airway Trachea

• AKA: “Windpipe” • Location

• Inferior to Larynx• Anterior to Esophagus• Bifurcates into primary bronchi

• Structure • Cartilaginous rings anterior

and lateral• Approx 15-20

• Smooth muscle tissue posterior

• Trachealis muscle • Why????

Lower Airway Bronchi

• Location• Bifurcation of trachea

• 2nd Intercostal space• Angle of Louis

• Right and Left main stem

• Structure• Smooth muscle• Irregular hyaline cartilage

rings

• Function• Conducts air to lungs

Lower Airway Bronchioles

• Location• Distal bifurcations of the

bronchi• Terminate at alveoli

• Function• Conduct air to alveoli

• Structure• 1st airways with NO cartilage• ALL muscle

• Bronchoconstriction • Bronchospasm

• < 1 mm wide =Tiny

Lower Airway Alveoli

• Location• Terminal sacs of bronchial tree• Distal to bronchioles• Particular to mammalian lungs• 150 million/lung

• Structure• 1 cell thick• Surface are= 75m2 (Tennis court)• Increased SA= Increased 02 absorption• 0.2-0.3 mm diameter • Covered in capillaries (70%)• Bathed in surfactant

• Function• Diffusion of gas with capillaries

Lower Airway Lungs

• Location• Bilateral of midline

• Structure• Divided into lobes

• Left= 2• Right= 3

• Function• Houses structure for gas exchange• Alteration of pH

Lower AirwayMucociliary Escalator

• Location• Along epithelium of primary

bronchi• Beat in rhythm

• Structure• Cilia projections• “Hair like”

• Function• Move debris up out of lungs

• Cough or swallow• Smokers…

• Prevent mucous accumulation

Respiratory PhysiologyHow we breathe…

• Ventilation• Mechanical movement of air into/out of the body

• Inhalation (Active)• Muscles Used

• Diaphragm & External Intercostals• Physiology

• Diaphragm contracts downward• External intercostals pull ribs up and out• Increases dimension of chest cavity• Increased diameter of chest drops intra thoracic pressure• Air rushes in until pressure is equalized

Respiratory PhysiologyHow we breathe…

• Ventilation• Mechanical movement of air into/out of the body

• Exhalation (Passive)• Physiology

• Diaphragm relaxes as well as intercostals• Chest cavity dimension decreases• Decrease in dimension increases intrathoracic pressure• Air rushes out • Lungs recoil

Respiratory PhysiologyGas Exchange

• Respiration• Process by which the body utilizes oxygen• Diffusion

• Net movement of molecules from an area of high concentration to an area of low concentration

Respiratory PhysiologyGas Exchange

• Respiration• Process by which the body

utilizes oxygen• Alveolar/Capillary Exchange

• Physiology• O2 rich air enters alveoli• O2 poor blood in capillaries

pass alveoli• O2 diffuses down its

concentration gradient into the capillaries

• CO2 diffuses down its concentration gradient into the alveoli

• CO2 is exhaled and O2 transported to tissues

Respiratory PhysiologyGas Exchange

• Respiration• Process by which the body

utilizes oxygen• Capillary/Cellular Exchange

• Physiology• O2 rich blood passes cells• O2 diffuses across its

concentration gradient into the cells

• CO2 diffuses across its concentration gradient into the capillary

• CO2 is transported to the alveoli

Respiratory Evaluation

• Areas of assessment• Rate. Rhythm. Depth. Quality.

• Rate• Adult = 12-20 per minute• Child = 15-30 per minute• Infant -= 30-60 per minute

• Rhythm• Regular or irregular

• Depth• Tidal volume adequate or inadequate

• Amount of air breathed in/out in one ventilation• Approx 500 mL

Respiratory Evaluation cont’d.

• Quality• Breath sounds

• Midclavicular & Midaxillary lines• Present or diminished or absent

• Chest expansion• Unequal or symmetrical

• Increased effort• Accessory muscles • “Seesaw” breathing

• Infants• Nasal flaring • Retractions

• Above clavicles, between ribs• Cyanosis• Shortness of breath• Altered mental status

Accessory Muscle Use

Nasal Flaring

Retractions

Respiratory Evaluation cont’d.

• Cyanosis• Blue/pale coloring of skin

• Nail beds• Lips• Eyelids

• Why is this seen in these areas first???

• Indicates poor perfusion

Pediatric Considerations

• Mouth/Nose• Smaller and easily obstructed

• Pharynx• Tongue is BIG

• Trachea• Narrower• Softer and more flexible

• Cricoid Cartilage• Less developed/Less rigid = easily kinked

• Diaphragm • Chest is soft• Depend on diaphragm to do most of the work of breathing

• Seesaw Breathing….

Adequate v Inadequate Artificial Ventilation

• What is adequate?• Chest rises/falls with each• Sufficient rate

• Adults= 12 breaths/min• Children= 20 breaths/min

• Heart rate returns to normal

• What is inadequate? • Absent chest rise/fall• Too fast/slow• Heart rate continues to be

abnormal

Respiratory EmergenciesS/S of Breathing Difficulty

• SOB• Diff speaking in complete

sentences• Increased resp rate• Decreased resp rate • Irregular breathing rhythm • Accessory muscle use (retractions) • Abdominal breathing • Nasal flaring• AMS• Agitated/Restless• Increased pulse rate • Pt Positioning

• Tripod Position• Feet dangling, leaning forward

• Unusual Anatomy• Barrel Chest

• Skin color changes• Cyanotic – Pale - Flushed

Respiratory EmergenciesPt Assessment

• Scene Size up• Scene Safe/BSI

• Possible toxic environment???• TB= HEPA mask

• Consider MOI if trauma• Initial Assessment

• General impression• Obvious threat to life = Resp Arrest• Pt positioning – Tripod/Bolt upright• Mental Status – AVPU

• Any ALOC/AMS, Agitation, etc• Airway

• Is airway open/patent (Manual techniques, NPA/OPA, Suctioning) • Is pt breathing noisy

• Breathing• Apply Supplemental O2 (NRB, NC) • Does pt need + pressure ventilation

• No breathing = YES• Slow/irregular breathing, shallow breathing, diminished breath sounds,

seesaw breathing, decreased LOC, S/S severe hypoxia = YES

Respiratory EmergenciesPt Assessment

• Initial assessment continued• Circulation

• HR increase in early hypoxia • compensate for low O2 in blood by increasing its flow through the body

• HR decreases • as heart becomes hypoxic itself = Ominous Sign…

• Cyanosis = ALWAYS a S/S for supplemental O2• Focused Hx and Physical Exam

• Hx• SAMPLE Hx

• Does pt have a prescribed inhaler???• OPQRST Hx

• Physical Exam• Guided by SAMPLE Hx• Head/Neck/Chest for S/S of Resp distress• Barrel chest – COPD• Ausculatate at Midclavicular and Midaxillary lines bilaterally. • Edema noted in extremities?

• Baseline Vitals• Particular attention to resp rate/depth/quality and pulse

Respiratory EmergenciesEmergency Medical Care

• Increase O2 concentration early on

• + Pressure ventilation if required

• 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

OxygenDelivery 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

Metered Dose Inhalers/MDIs

• Medication Names• Generic-

• Albuterol, Isoetharine, Metaproteranol

• Trade-• Proventil, Ventolin, Bronkosol,

Bronkometer, Alupet, Metaprel • Indications

• Exhibits S/S of Resp. Emergency• Has physician prescribed inhaler• Orders via med control

• Contraindications• Inability of pt to use device• No orders from medical control• Violates any 1 of the 5 Rights• Maximum number of doses already

taken (RELATIVE CONTRAINDICATION)

• Dosage• # of inhalations based on MD/Med

control• Form

• Handheld Meted Dose Inhaler

Albuterol(Proventil)

Class: Sympathetic agonist Description

– Sympathomimetic selective for β2

Mechanism of Action– Prompt bronchodilation

Pharmacokinetics– Onset: 5-15 min– Peak: 1.0-1.5 hours – Duration: 3-6 hours– Half Life: < 3 hours

Indication– Bronchial asthma, reversible

bronchospams with bronchitis & emphysema

Contraindication– Hypersensitivity

Precautions– Cardiovascular disease, HTN– Assess lung sounds before/after

Side Effects– Palpitations, anxiety, dizziness,

headache, nervousness, N/V Interactions

– Other sympathetic agonists– Blunted by β blockers

Dosage– MDI or small dose inhaler– MDI = 90 µg/spray, 2 sprays– Nebulizer= 2.5 mg (0.5 mL of 0.5%

solution in 2.5 mL NS) over 5-15 min

MDI Administration

• Administration• Ask if any doses have already been taken• Assure 5 Rights and stable pt LOC• Obtain order from medical direction• Check to see if MDI is at or above room temp• Shake vigorously several times• Remove O2 adjunct from pt• Have pt exhale deeply• Have pt put lips around mouthpiece of MDI• Have pt depress MDI as he begins to breath in deeply• Have pt hold his breath for as long as he comfortably can• Replace O2 on pt• Allow pt to breath a few times and repeat does per med control

• If pt has a spacer device with MDI use spacer device as well • DOCUMENT time of med administration(s).

MDI’sInfants/Children Concerns

• MDI use is very common Asthma is common

• Retractions are more commonly seen in children

• Cyanosis is a late finding• Coughing instead of

wheezing may be present• Emergency care with MDI is

same for children as it is for adults

• If spacer device is available use it

Spacer

Conditions that Cause Resp Emergencies

• Emphysema• Asthma• Chronic Bronchitis• Heart Failure• Croup• Epiglottitis• Pneumonia • Pneumothorax• Hyperventilation syndrome

Respiratory EmergenciesChronic Obstructive Pulmonary

Disease COPD

• 4th leading COD• $ 42.6 BILLION yearly • 10-24 million people affected• Includes:

• Chronic Bronchitis• Emphysema • Asthma

• Pathophysiology:• Loss of elasticity of alveoli• Collapse of bronchioles• Decreased inspiratory volume• “Trapped” air• Poor tissue perfusion

• Problem:• Chronic high CO2

• Sensors become desensitized to CO2 and switches to O2

• Resp drive now based on O2 NOT CO2

• Does anyone see the problem????

Chronic Bronchitis

• What• Chronic productive cough present for at least 3 months for at least

2 years • How

• Smoking, long term exposure to pollutants • Pathology

• Mucus secreting (goblet) cells become enlarged • Retained secretions

• Characteristic Productive Cough• Excessive mucus production blocks bronchioles• Obstructive bronchioles = poorly ventilated alveoli =poorly

oxygenated blood = Cyanosis• Heart failure occurs on Right side and blood backs up into the??

• Peripheral edema • “Blue Bloaters” • Upon auscultation lung sounds are wheezy and fluid is noted

Emphysema

• What• Destruction of the alveoli

• How• Smoking

• Pathology• Bronchiole musculature looses its resistance

• Collapses when intrathoracic pressure rises• Bronchioles collapse with exhalation• Air is trapped in alveoli and cannot get out• Limits amount of air that can be inhaled =

“Air Trapping” ---- Barrel Chest • Compensation

• Pt breathes better when they exhale against a pressure• Therefore they purse their lips and maintain pressure in their airways• The body increases RBC count and hemoglobin concentration = Pink coloring• “Pink Puffers”

Asthma

7.3% (adults) 9.1% (children) of U.S. population, 4,000 deaths/year 300 Million worldwide • What

• Constriction of bronchioles • How

• Stress, infection, allergen • Pathology

• Muscular constriction of bronchioles narrows air passages• (Bronchoconstriction)

• Further complicated by mucus secretions• Further complicated by release of immune cells• Spasms and mucus reduce air flow = Dyspnea/Hypoxia

• Compensation• Hyperventilation- Increases O2 content• Watch for fatigue

• S/S• Acute: SOB – Accessory muscles – Upright posture – Flushed – Forceful respiration

– wheezing – prolonged exhalation – fatigue leading to resp failure • Severe: Exhaustion – little air flow – no wheezing- diff speaking – decreased breath

sounds

The Biology Behind Asthma

Pneumonia

• What• Inflammation of alveolar spaces

caused be various types of infectious organisms

• Can also occur after aspiration of gastric contents in unresponsive pt

• Pathology• Fluid interferes with gas exchange• Damage to lung tissue decreases

surface area• S/S

• Usually follows resp infection• Fever – Cough – Thick/colored sputum

with pus• Crackles upon auscultation esp at sites

of infection • USE airborne precautions

Normal Alveoli

Pneumonia

Streptococcus pneumoniae

Staphylococcus aureus

Bacillus anthracis

Neisseria meningitidis

Yersinia pestis

Mycobacterium tuberculosis Pneumocystis

carinii

Hyperventilation Syndrome

• What• Voluntary increase of resp rate and depth

• Why• Response to anxiety, feeling of SOB, etc.

• Pathology• Decreases CO2 concentration• Changes acid base balance in body

• S/S• Tingling around mouth, fingers• Dizziness• Nausea

• Treatment• Err on side of caution and provide O2 in case there is an

underlying medical complication

Spontaneous Pneumothorax

• What• Rupture of part of the lung

• Why• Congenital blebs

• blisters on the lung• COPD• Unknown

• Who• Otherwise healthy, tall, thin,

young, men. • Pathology

• Air enters the pleural space and inhibits expansion of lung

• Can progress to a tension pneumothorax

• S/S• Sudden onset of dyspnea and

pleuritic chest pain