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“I CAN’T BREATH”Respiratory Emergencies

Objectives

•Review of anatomical structures related to heart & lungs•Differentiate differences between adult and pediatric airways•Identify the need for airway assistance & management•Review of patient assessment skills & pearls•Identify interventions with case studies

AIRWAY & HEART ANOTOMY

Normal BreathingWe Must Have:

• Patent airway• Intact System

• Ventilatory • Musculoskeletal

• Pulmonary Blood Flow• Neurological Stimulation

Anatomy of Lungs & Heart

Anatomy of the Upper Airway

• Nasal Cavity• Oral Cavity• Pharynx

– Nasopharynx– Oropharynx– Laryngopharynx

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Anatomy of the Lower Airway

• Carina• Bronchi• Bronchioles• Alveoli

Anatomy of the Heart

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Adult vs. Pediatric Airway

• Difference– Size– Cone Shaped Larynx

• Anterior Position• Epiglottis Rounder and Floppy• Cricoid Ring is the Narrowest Section

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PATIENT ASSESSMENT

Decision Making

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Assessment• General Impression• Mental Status

– AVPU– GCS

• Airway– Patent/Non Patent

• Breathing– Rate– Quality– SpO2 & ETCO2

Assessment• Circulation

– Pulses, Hemorrhage, Skin Color, Temperature & Condition

– Vascular Access– ECG & NIBP

• Disability

• Exposure– Remove clothing to visualize

Respiratory Assessment

Work of Breathing• What you Hear

• Stridor• Snoring• Gurgling• Grunting• Muffled/Hoarse Voice

• What you See• Tripoding• Sniffing Position• Accessory Muscle Use• Pursed Lip Breathing• Nasal Flaring• Head Bobbing• Seesaw Respirations• Prolonged Expiratory• Effortless Tachycardia

Physical Exam

• Inspection• Auscultation• Palpation• Percussion

Focused History

• OPQRST• Signs & Symptoms & Associated Symptoms• Allergies • Medications• Past Medical History• History of Present Illness

Non-Invasive Airway Monitoring• Pulse Oximetry Normal 95-100% <93-95% = Mild Hypoxia 85-90% = Moderate Hypoxia <85% = Severe Hypoxia Variation in Probe Locations

SpO2 reflects oxygenation, NOT ventilation

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Non-Invasive Airway Monitoring

• Capnography (ETCO2)– Quantitative & Waveform– Qualitative

• Normal 35-45 mmHg

Measurement of Ventilation, NOT Oxygenation

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AIRWAY MANAGEMENT

AIRWAYMANAGEMENT

“MOANS” “RODS”

“LEMONS” “SMART”

MOANS

• Difficult Bag-Valve-Mask Ventilations– Mask Seal– Obesity– Age– No Teeth– Stiff

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Rules of 2’sTWO SKILL

Thumbs up technique 1 provider maintains seal1 provider ventilates

Airways NPA & OPA

Inches Raise patient (sniffing position)

Seconds Ventilation slow & gentle

PSI Minimum pressure

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RODS• Difficult Extraglotic Device Placement

– Restricted Mouth Opening– Obstruction/Obesity– Distorted/Disrupted Airway– Stiff

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http://www.jems.com/content/dam/jems/print-articles/2015/08/1508JEMS_BariatricAirway1.jpg

LEMONS & SMART• Difficult Intubation

– Look – Evaluate 3-3-2– Mallampati– Obstruction– Neck Mobility

• Difficult Cricothyrotomy– Surgery – Mallampati– Anatomy– Radiation– Tumor CARDIAC OR

RESPIRTORY

MI (Myocardial Infarction)

• Signs & Symptoms– Chest Discomfort– Dyspnea– Diaphoresis– EKG changes– Nausea & Vomiting– Anxiety– Radiated pain

• Treatment– 12 Lead– Oxygen– ASA– Pain Management

• Nitro• Fentanyl• Morphine

– Rapid Transport to PCI

CHF (Congestive Heart Failure)

• Signs & Symptoms– Non specific fatigue– Dyspnea

• With exertion• While flat (orthopnea)

– Edema– Anxiety– Coughing– Rales, Wheezing BS– S3 Gallop– JVD

• Treatment– Oxygen– NIPPV– Medications

• Nitro• Bronchodilator• Lasix

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PUEMOTHORAX

• Signs & Symptoms– Altered LOC– Severe Dyspnea– Diminished or Absent BS

One Side– Low BP– Tachycardia

• Treatment– Oxygen– Needle Decompression– Chest Tube

BRONCHITIS (acute or chronic)

• Signs & Symptoms– Chest Discomfort– Dyspnea– Productive Cough– Rhinorrhea– BS-Rhonchi; Wheezing– Anxiety– BS reduced

• Treatment– Oxygen– Nebulized Medication

• Duo Neb• Albuterol• Racemic Epi

– Intubation?– Antibiotic– Anti-inflammatory– Corticosteroid

EMPHYSEMA

• Signs & Symptoms– Chest Discomfort– Progressive Dyspnea– SOB worse in AM– Anxiety– Cough worse in AM– Tachypnea– Accessory muscle use– Hyperinflation– Decreased BS

• Treatment– Oxygen– Nebulized Medication

• Duo Neb• Albuterol• Racemic Epi

– Intubation?– Antibiotic– Anti- inflammatory– Corticosteroid

PULMONARY EMBOLISM

• Signs & Symptoms– Shortness of Breath– Anxiety– Agitation– Mild to Sudden

Dyspnea– Chest pain– Hypoxemia– Hyperventilation

• Treatment– Oxygen– Nebulized Medication

• Duo Neb• Albuterol• Racemic Epi

– Epi – Intubation?– Anti-inflammatory– Corticosteroid

PNEUMONIA

• Signs & Symptoms– Shortness of Breath– Dry cough– Increased Temperature– Productive cough

• Green/brown/rust colored

– Tachycardia– Tachypnea

• Treatment– Oxygen– Nebulizer Medication

• Duo Neb• Albuterol• Racemic Epi

– Antibiotics– Intubation?

ASTHMA

• Signs & Symptoms– Shortness of Breath– Wheezing – Cough– Anxiety– Agitation– Speech Dyspnea– Chest Tightness– Pulsus Paradoxus– Tachycardia

• Treatment– Oxygen– Nebulized Medication

• Duo Neb• Albuterol• Racemic Epi

– Epi – Intubation?– Anti-inflammatory

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ANAPHYLAXIS• Signs & Symptoms

– Shortness of Breath/tightness in Throat

– Anxiety– Agitation– Mild to Sudden

Dyspnea– Urtiicaria– Angioedema– Hypoxemia– Hyperventilation

• Treatment– Oxygen– Epi

• More epi

– Nebulizer Medication• Duo Neb• Albuterol• Racemic Epi

– Corticosteroid– Benadryl

Case #1

62 year old MaleProgressive SOB over 18 monthsIncreased over 4-5 daysProductive CoughAccessory Muscle UseHyperinflated

VitalsA- patent,B- 30 bpm; minor wheezing 85% RAC- 120 bpmD- speaks in full sentences; GCS-15E- No Trauma notedSkin- warm and dry but pale

http://4.bp.blogspot.com/_7zQULPNQ7FQ/Sfh8F5-qOQI/AAAAAAAAAB4/f5niTU0epGU/s320/bluebloater.jpg.jpeg

Treatment ?

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Case #222 year old FemaleFour Wheeler AccidentEjected Off WheelerHit Face & Head on Roof of RazorPatient is seated on ground leaning forward

AirwayVitals

A- As seenB- 30 bpm; minor wheezing 85% RAC- 140 bpmD- can answer yes & no GCS-13E- Only facial traumaSkin- pink and dry

Treatment ? Case #3

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85 year old MaleIncreased SOB over 3 hoursNebulizer did not helpAccessory Muscle UseHyperinflated

VitalsA- PatentB- 40 bpm; minor wheezing 80% RAC- 140 bpmD- Speaks in 1-2 word sentence GCS-12E- Barrel chest, ribs visibleSkin- dry and pale

Treatment ?

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiYtenH29TUAhUQz2MKHUqCDCUQjRwIBw&url=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3Dy82dL8QAUF8&psig=AFQjCNFULFv5Kl1XLSSHliXxKRRkCzkGww&ust=1498333009494688

Case #4

35 year old FemaleSudden onset of SOB for last 3 daysProductive cough for 7 daysLeft side chest pain

VitalsA- Green sputumB- 22 bpm; BS-left side cracklesbilateral dullness SpO2 90%C- 120 bpm BP 155/72D- GCS-15E- no noted traumaSkin- hot, flushed

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Treatment ?