Airway DiseasesEMT-Intermediate, W06

P. Andrews

Respiratory Distress Profiles

• Disease and Trauma Profiles

• Management Decisions

Objectives

• Determine the general approach, assessment an management priorities for respiratory distress

• Explain how effective assessment is critical to decisions in airway management of respiratory distress

Objectives• Differentiate between critical life-

threatening, potentially life-threatening and non life-threatening patient presentations

Objectives• Discuss normal and abnormal

assessment findings with airway disease

• Discuss specific observations and specific findings with airway disease

Objectives• Describe the epidemiology,

pathophysiology, assessment and management priorities for respiratory distress

Objectives• Compare airway and ventilation

techniques used to manage airway disease

• Discuss the pharmacological preparations that EMT-Intermediates use for the management of airway disease

Assessment of Respiratory Distress

General Approach to Respiratory Distress

•Scene Size-Up–Environmental causes –Clues to the potential cause and severity of the dyspnea

•General Impression–Level of consciousness–Patient position–Skin color–Effort required for breathing or speaking–Audible lung sounds

General Approach to Respiratory Distress

• Initial Assessment– More focused than the general

impression

• Focused History– Build from the chief complaint

• SAMPLE, OPQRST, etc.

– Include a cardiac assessment as well

General Approach to Respiratory Assessment

• Focused Physical– Start from the chest and move outward

• Chest wall symmetry, signs of trauma or scars• Lung sounds• Accessory muscle use• Productive cough

– “Outward” assessment areas• Vitals• Edema• Quality of peripheral circulation

Respiratory Assessment in Detail

Scene Assessment

•Cigarette packs•Oxygen tubing•Environment

–Chemistry class–Industrial area–Bus of hysterical teens

•# of pillows on bed•Recliner

General Impression•Level of consciousness

–Anxious, restless–lethargic

•Position–Relaxed–Leaning forward–Tripod–Unable to hold position

•Body Type–Obese–Barrel chest

•Effort with breathing and speaking

–Winded after speaking–#-word sentences

•1-3 v. 4-5

–Accessory muscles

•Noises with respirations–Wheezes–Crackles–Stridor

Categorize her level of distress•Life-threatening•Potentially life-threatening•Non life-threatening

The Initial Assessment• Level of consciousness

– Need for ventilatory support• Aggressiveness and methods for support

• Adequacy of airway and breathing– Minute volume– Need to support ventilations or

respiration?

• Adequacy of circulation– Peripheral pulse quality and rate

The Focused History• SAMPLE

– Onset and progression are valuable in pinpointing specific causes for the respiratory distress

• Exploration of dyspnea– Associated with orthopnea or

movement?– Associated with chest pain?

• Sharp or dull chest pain?

The Focused History• Cough history and color of sputum

– Changes: CHF and COPD

• Edema– Presence of pedal edema– Progression of edema

Focused Physical•Inspection

–Skin color –Diaphoresis–Retractions of chest muscles–Accessory muscle use–Nasal flaring–Tracheal tugging–Signs of dehydration

•Palpation–Skin turgor, temperature–Pulse rate and quality–Chest wall pain–Symmetry with respirations–Tracheal deviation

Lung Sounds•Rales•Rhonchi•Wheezes•Stridor•Friction Rub•Nothing… yikes!!!

Test your expertise with lung sounds!

Focused Physical• Always correlate sounds with the

patient’s history!– Wheezes aren’t always caused by a

respiratory problem– Other causes

• Pulmonary edema/CHF, allergies/anaphylaxis

Medication Assessment

Respiratory Meds

• Inhalers– Albuterol, Alupent, metaproterenol– Vanceril, Beclovent, Azmacort

• Pills– Theophylline, aminophylline– Prednisone, methylprednisolone

The “Other” Meds

• Blood pressure meds – ACE Inhibitors, beta blockers, weak diuretics– Hypertension may be a risk factor for a variety of

conditions

• Nitrates + “..olol” drugs + diuretics + digitalis– Chronic history includes CHF– Ask about orthopnea, recent weight gain, chest

pain with activity, pedal edema• Dyspnea/wheezing may be from fluid, not chronic

irritation• Careful with the albuterol!!!

The “Other” Meds• Antibiotics

– Levaquin, Cipro, Keflex, Zithromax, etc.– Not prescribed for COPD itself– Pneumonia may be the cause for the changes

in dyspnea

• Look for other signs– Change in sputum color and productivity– Weakness, less able to tolerate activity– Loss of appetitie

Generalities Regarding Treatment

• “Potentially critical” findings in patients with chronic respiratory conditions may actually be normal for them– Find out more about their baseline

condition– Moderate-flow oxygen and

bronchodilators for initial treatment in a COPD patient

• Reassess for changes in making further treatment decisions

Prehospital Medication Options for Dyspnea

• Albuterol

• Atrovent

• Epinephrine

• Combi-Vent

• Lasix

• Benadryl

Respiratory Disease Profiles•COPD

–Emphysema–Chronic Bronchitis

•Pneumonia•Asthma

•ARDS•Pulmonary edema•Pleural effusion

COPD

COPD Pathophysiology - Review

• Chronic irritation of bronchioles and alveoli– Emphysema: destruction and thickening of

alveoli walls– Chronic bronchitis: chronic secretion of mucus

and thickened bronchiole walls

• Results– Narrowed bronchiole passages– Less surface area for gas exchange in the

alveoli– Thicker alveolar walls make gas exchange

difficult• Alveoli become less elastic and cannot perform

effective recoil

Chronic Signs In Moderate COPD

• Dyspnea

• Increased respiratory rate – Compensates for their inability to

increase tidal volume

• Sputum changes– Increased productivity in the morning– Color change: brown

Chronic Signs in Moderate COPD• Lung sounds:

– Diminished, especially in the bases– Rhonchi in upper lobes– Wheezes

Chronic Signs In Severe COPD• Expiratory wheezes

• HTN/CHF (late emphysema)

• Some difficulty speaking (2 - 5-word sentences)

• Low-dose oxygen therapy

• Increased shortness of breath with any physical exertion

Prehospital Management: Mild-moderate COPD

• Low-flow oxygen if mild distress

• Seated or semi-seated position

• Albuterol, Atrovent

• ECG

• IV, 18-gauge as a standard– Assess for pneumonia

• Watch for signs of decompensation

Clues of Acute COPD Decompensation

•Acute episodes of worsening dyspnea at rest•Pursed-lip breathing•Altered mentation

•1-2 word sentences•Focused on breathing or undistracted•Accessory muscle use or retractions

COPD decompensation typically results from respiratory infections or acute complications from cardiac disease

Tips for Aggressive COPD Management

• BVM just to chest rise– Avoid demand valves

• Medications will ultimately relieve the obstruction

• Signs of improvement:– Change in skin color– Decrease in HR and/or dysrhythmias

Pneumonia

Pathophysiology of Pneumonia

•Commonly caused by bacteria•Irritation of the respiratory system

–Increase mucus production–bronchoconstriction

•Decompensation may occur in patients with later stages of COPD

Pneumonia Presentation

•Fever and chills–May not be as evident in the elderly

•Deep, productive cough•Thick sputum

–Sputum color change to yellow-green

•Pleuritic chest pain•Decreased air movement•Wheezes, rhonchi

Prehospital Care for Pneumonia

• Supplemental oxygen• Pulse oximetry• Bronchodilators for wheezing

– Reassess lung sounds after each treatment

• IV with isotonic fluids– Increase infusion rate with signs of

dehydration

• Position of patient comfort– Semi-seated for COPD and CHF patients

Asthma

Pathophysiology of Asthma

• Exaggerated response to an irritant

• Genetic susceptibility– High sensitivity to irritants– High numbers of inflammatory fighters

present and ready to respond to the irritant

• Result: widespread bronchoconstriction and mucus secretion

Asthma: General Impression

•High work of breathing with low air movement•Pursed-lip breathing•Prolonged expiratory phase•Wheezes•Tachypnea•Tachycardia

•Sitting or leaning forward•Mentation

–Baseline and changes

•#-word sentences–Changes–1-3: severe impairment

Focused History

•Progressive dyspnea•Chest tightness•Cough and/or wheezing•Associated pain

–Location–OPQRST

•Triggers–Stress–Environment–Exercise–Exposure to perfumes, etc.

•Previous attacks–Hospitalization–Intubation

Asthma Medications• “Rescue” inhalers

– Beta agonist: albuterol, Alupent, Bronkosol– Combination: beta agonists and

parasympatholytics

• Long-term inhalers– Steroids: beclovent, Azmacort, AeroBid,

Vanceril– Prevention: Accolate, zafirlukast, cromolyn

• Oral medications– Aminophylline, theophylline

Simple Asthma Management

• Oxygen

• Albuterol– Addition of Atrovent

• IV NS tko

– Fluid challenge if signs of dehydration

• ECG

Status Asthmaticus• At-risk patients

– Prior history or respiratory failure– Steroid-dependent patients– Rapid fluctuations in severity of attacks

• Profile– Unbroken by medications– Cyanosis, decreased lung sounds– Severe anxiety or lethargy

Progression of Respiratory Failure in Asthma and Status Asthmaticus• Early: increased rate, prolonged

expiration• Tiring of diaphragm and large muscles

– Accessory muscle use• Neck muscle use during inspiration =

diaphragm failure

• Impending ventilatory failure– Inward movement of abdominal wall during

inspiration• “see-saw” respirations

Treatment for Status Asthmaticus

• Call for ALS response• Support of ventilation

– Bag-valve mask ventilations with oxygen @15LPM

• Expect poor compliance and little change in patient condition

– Suctioning

• Support of respiration– Adaptation of the nebulizer to the BVM– Epinephrine

• Per standing orders

Respiratory Distress in Congestive Heart Failure

Pathophysiology of Pulmonary Edema

• CHF – Ventricle has difficulty pushing blood out – Blood moves backward

• Right heart failure: back up into feet, JVD, etc• Left heart failure: back up into lung tissue

• Patient has a chronic history of heart problems– “Water retention”– Medications include antihypertensives, nitrates

and diuretics

Pathophysiology of Pulmonary Edema

• Recent History– Orthopnea or “PND” – Paroxysmal

Nocturnal Dyspnea• Fluid in the body reabsorbed and deposited

into the lungs• Occurs 1-2 hours after falling asleep

– Patient begins using extra pillows or the recliner in order to sleep at night

• Precursor to the development of frank pulmonary edema

Signs and Symptoms of Pulmonary Edema

• Sudden Onset– Typically occurs at night

• Audible wheezes or crackles• May have very high blood pressure• Anxiousness, restlessness likely• Lung sounds

– Wheezes, crackles or quiet• Dependent edema

– +1 - +4

Why would a patient with pulmonary edema have

wheezes?

Treatment for Acute Pulmonary Edema

• Goals– Take pressure off of the left ventricle– Move the fluid out of the lungs

• High-flow oxygen• Vasodilators

– Nitroglycerin and Morphine

• Movement of fluid– BVM with PEEP, CPAP, Lasix

Is it COPD or CHF?Quick Assessment Findings to Delineate Them

CHF COPD/Asthma

History HTN, Heart problems

Lung problems

Dyspnea Orthopnea Chronic dyspnea

Recent Hx Acute wt. Gain

Edema in legs

Gradual weight loss

Cough Foamy sputum Productive (bronchitis)

Onset Rapid Gradual

BP High Normal

Meds Digoxin, antiHTN, diuretics

Bronchodilators

Steroids

Treatment High flow O2

NTG, Lasix, MS

Oxygen, Atrovent, albuterol

Miscellaneous Causes of Respiratory Distress: ARDS and Pleural Effusion

Pleural Effusion

• Abnormally large collection of fluid in the pleural cavity

• Compression of lung tissue– Actual cause for the dyspnea

• Causes of Effusion– CHF– Inflammation: pulmonary embolus, high

levels of enzymes from other diseases• Pancreatitis, kidney failure, liver failure

Pleural EffusionPresentation

•Increased RR and HR•Dyspnea•Pleuritic chest pain•Decreased breath sounds

Treatment•Oxygen

–Dependent on the level of hypoxia

•Position of comfort•IV tko•Transport

ARDS: Adult Respiratory Distress Syndrome

• Result of major injury or disease– Burns, aspiration, hypothermia, high

altitude sickness, cardiac arrest, pneumonia or inhalation injury

• Damage to alveoli– Chemical burn to the tissue– Fluid shifts wash away surfactant

• Causes alveolar walls to stick together• Difficulty with ventilation and respiration

ARDS• Accumulation of fluid in the lung

tissue– Similar presentation to pulmonary

edema– Additional signs may be present that

relate to the underlying injury or disease

ARDS

Presentation•Increased RR and HR•Dyspnea•Lung sounds

–Crackles, wheezes

•May appear very ill

Treatment•Oxygen•IV

–Restrict flow of fluid

•BVM use if presence of altered mentation or shock•Transport to a facility capable of critical care

–ICU

Summary

• Increased knowledge of respiratory disease profiles will assist the EMT-I with correct treatment decisions– The increased scope of EMT-I medications

increases the accountability for better patient assessment and treatment

• Initial treatment decisions should focus on the need for improving ventilations v. respirations (or both) in a patient with respiratory distress