Respiratory Emergencies

Eileen Humphreys PA-C, EMT-I

Respiratory Cycle

• Inspiration• Active process that uses

contractions of several muscles to increase the size of the chest cavity

• Diaphragm lowers and ribs move up and out

• The expanding size of the chest cavity pulls air in

Respiratory Cycle

• Expiration• Passive process that uses

relaxation of muscles to decrease chest cavity size and allow air to move out

• Diaphragm moves up and ribs move down and in

Respiratory Cycle

• Oxygen and carbon dioxide are exchanged in the alveoli and capillaries of the lungs as well as the capillaries of the body

• Critical to support life

Respiratory Emergencies

• May be a result of head/neck/chest injuries

• Emotional distress• Obstruction to the upper or lower

respiratory tract• Fluid or collapse of the alveoli• Cardiac compromise• Allergic reaction

Respiratory Emergencies

• Dyspnea• shortness of breath• difficulty breathing

Respiratory Emergencies

• Apnea• respiratory arrest

Respiratory Emergencies

• Hypoxia• inadequate supply of oxygen

Bronchoconstriction

• Bronchioles of the lower airway are significantly narrowed

• Also called bronchospasm

• Usually results in wheezing

Bronchoconstriction

• Can be opened up by use of a bronchodilator such as Albuterol

• Relaxes the bronchioles• Called a Beta 2 agonist

Respiratory Emergencies

• Scene size-up may give important clues

• Look for oxygen tanks,tubing, masks

Initial Assessment

• General impression• usually in a tripod position• patient lying in a supine or

reclining position may be in mild distress or in such distress that

they have become too exhausted to stay upright

Initial Assessment

• Frightened or confused facial expression may indicate severe distress

• Speech-usually limited or absent

• If speech is normal-airway is open and clear with minimal distress

Initial Assessment

• Restlessness, agitation, combativeness, confusion, and unresponsiveness can be caused by inadequate oxygenation to the brain

Initial Assessment

• Listen for crowing, snoring, stridor, or gurgling

• Indicates partial airway obstruction

• Look for adequate rise and fall of chest, exchange of oxygen, volume exchanged

Initial Assessment

• Skin• Cyanosis to the neck or chest

indicates severe respiratory distress

Respiratory Emergencies

• All patients in respiratory distress are priority transport

• Decline very rapidly

• SAMPLE history for responsive patients

• Use OPQRST to gather information of symptoms

• Rapid trauma assessment for unresponsive patients

Physical Exam

• Assess the skin for discoloration• Assess the neck for tracheal deviation,

retractions, JVD (jugular venous distention)

• Assess the chest for retractions of the intercostal spaces, asymmetrical chest rise, subcutaneous emphysema

• Auscultate the lungs for equal breath sounds

• Wheezing- musical sound caused by bronchospasm or fluid in the lungs

• Rhonchi-snoring or rattling sounds• Crackles-bubbling or crackling

noises heard on inhalation. Associated with fluid and heard first at bases

Assessing Adequate Breathing• Patient does not appear to be in

distress• Can speak in full sentences without

stopping to catch their breath• Color will be normal• Mental status and orientation

(person, place, time) will be normal

Assessing Adequate Breathing

• Rate:• Adult- 12 to 20 per minute-12• Child- 15 to 30 per minute-20• Infant-25 to 50 per minute-20

• Rhythm:• Regular and even• Inspiration and expiration usually last

about the same length of time

Assessing Adequate Breathing

• Quality:• Breath sounds will be present and

equal bilaterally• Both sides of chest should rise and

fall equally and adequately• Unlabored-should not require effort

Treatment of Adequate Breathing• If patient is breathing at a slightly

abnormal rate but it is adequate:• 15 lpm via NRB• Monitor closely • Be on the lookout for beginnings of

inadequate breathing or respiratory arrest

• Intervene quickly if condition worsens

Assessing Inadequate Breathing• Not adequate to support life and will

progress to death unless there is intervention

• Rate-can be too fast or slow• Agonal respirations-dying

respirations which are sporadic, irregular breaths seen just before resp. arrest. Shallow, gasping

• Rhythm-may be regular or irregular

Assessing Inadequate Breathing

• Quality:• Breath sounds may be diminished

or absent• Depth (tidal volume) will be

shallow, inadequate• Chest expansion-may be unequal

or inadequate• Respiratory effort may be

increased

Assessing Inadequate Breathing

• Quality:• Accessory muscle use seen• Skin may be pale or cyanotic• Skin may be cool and clammy• Snoring or gurgling in

unresponsive patients or patients with diminished responsiveness

Treatment of Inadequate Breathing• Inadequate breathing with

abnormal rate• Begin artificial ventilations with

either the pocket mask or BVM• Ventilate 12 times per minute for

adults• Ventilate 20 times per minute for

children/infants

Treatment of Inadequate Breathing• You may have to treat a patient

with inadequate breathing who is awake enough to fight artificial ventilations

• In this case contact medical direction and transport immediately

Patient Care for Inadequate Breathing• If properly performed, pulse rate

will return to normal (in adults pulse usually increases in resp. distress)

• If pulse stays high re-evaluate the technique

• Color will return to normal if ventilations are adequate

Patient Care

• If pulse does not return to normal re-evaluate airway, ventilations, O2 canister (empty), tubing (kinked)

• If chest does not rise or pulse does not return to normal, increase ventilation force after assuring proper technique

Respiratory arrest

• Confirm unresponsiveness• Open airway by jaw thrust or chin-

lift• Look, listen, feel for 3-5 seconds• If not breathing• Give 1 full breath lasting 2 seconds

and allow patient to exhale

Respiratory arrest

• If the air goes in, give breaths every 5 seconds with each breath lasting 2 seconds and allow to passively exhale between breaths

• If no air goes in, reposition head• Check pulse frequently to monitor

cardiac status

COPD

• Chronic obstructed pulmonary disease

• Chronic Bronchitis• Emphysema

Chronic Bronchitis

• Usually has a productive cough for 3 months out of the year for 2 years

• Edema, inflammation and excessive mucus production of the bronchioles/bronchi

• Restricted air movement• Gas exchange is compromised• Retained CO2

Chronic Bronchitis

• Overweight• Productive cough• Rhonchi

Emphysema

• Loss of elasticity of the alveolar walls

• Distention of the sacs causing air trapping

• Air movement is restricted and patient retains carbon dioxide

Emphysema

• Thin, barrel chest• Non-productive cough• Prolonged exhalation• Pursed lip breathing• Wheezing and rhonchi

Treatment of COPD

• Ensure open airway, adequate breathing, supplemental oxygen, position of comfort

Hypoxic Drive

• COPD patients• Low levels of oxygen in the body

stimulate breathing• In theory too much oxygen can

cause the body to reduce or stop breathing

• Usually occurs with high concentrations of O2 over 24 hours

Hypoxic Drive

• Not normally a problem in prehospital environments

• Always give high flow oxygen to those who need it

Asthma

• Reversible narrowing of the lower airways

• Edema, bronchospasm, and increased mucus production

• Mucus production block smaller airways and causes air to be trapped in the alveoli

Asthma

• Exhalation becomes difficult and patients must force air out past constricted airways

• This causes wheezing on exhalation

• Exhalation becomes an active process

Asthma

• Lack of wheezing or lung sounds in a patient suffering from an asthma attack is ominous

• Status asthmaticus-prolonged attack which does not respond to oxygen or medication

Pneumonia

• Viral or bacterial disease infecting the lower respiratory tract

• Causes lung inflammation• Poor gas exchange

Pneumonia

• Signs/symptoms• fever/chills• cough• dyspnea• chest pain-localized, sharp, worse

with breathing• rhonchi/crackles

Pulmonary Embolus

• Sudden blockage of blood flow through a pulmonary artery or branches

• Due to blood clot, air bubble, foreign body, fat particle

• Decrease in gas exchange• Hypoxia

Pulmonary Embolus

• Risk factors• recent surgery• prolonged immobilization• multiple fractures• thrombophlebitis • chronic atrial fibrillation• medications (OCP’s)

Pulmonary Embolus

• Suspect if sudden onset of unexplained dyspnea, hypoxia, tachypnea, and stabbing chest pain

• Will have normal breath sounds and adequate volume

Acute Pulmonary Edema

• Excessive amount of fluid between alveoli and capillary space

• Disturbs gas exchange• Causes hypoxia• Cardiogenic and non-cardiogenic

Acute Pulmonary Edema

• Signs/symptoms• dyspnea worse with exertion• orthopnea• blood tinged sputum• tachycardia• pale, moist skin• swollen lower extremities

Respiratory-Pediatric Patients• Remember the most common cause of

cardiac problems in pediatrics is---???

• Respiratory intervention must begin quickly and be monitored at all times

• Know the difference in structures from adults

Inadequate Pediatric Breathing

• Early signs• accessory muscle use• retractions• tachypnea• tachycardia

Inadequate Pediatric Breathing• nasal flaring• coughing• cyanosis to the extremities• grunting (Bad Bad Sign)-seen in

infants during exhalation signaling imminent failure

Pediatric Respiratory Failure• Altered mental status• Pulse rises early then drops fast• Bradycardia• Hypotension• Irregular breathing pattern

Pediatric Respiratory Failure• Seesaw pattern-abdomen and

chest move in different directions• Limp appearance• Head bobbing with each breath

Pediatric Problems

• Distinguish whether the airway problem is upper or lower

Pediatric Problems

• Stridor and crowing indicate upper airway obstruction

• Usually due to edema or foreign body obstruction

• Wheezing is sign of lower airway problem

Epiglottis

• Inflammation of the epiglottis• History of sore throat, fever, stridor• Child sits upright leaning forward,

sits the neck out, drooling• Life-threatening emergency• Do not inspect the airway as

bronchospasm may completely obstruct the airway

Croup

• Swelling of the larynx, trachea, and bronchi

• Sore throat and fever worse at night

• Seal-like cough• Cool night air usually helps

Patient Care-Pediatrics

• Monitor airway and breathing constantly • Nothing is more important than

adequate airway care• Ensure adequate breathing• Intervene quickly and appropriately

when necessary• If in doubt-Treat as inadequate

breathing

Patient Care-Pediatrics

• If pulse remains low or breathing inadequate re-evaluate airway, ventilations, O2 canister (empty), tubing (kinked)

• If chest does not rise or pulse does not return to normal, increase ventilation force after ensuring proper technique

Treatment

• Oxygen is a drug• It must be administered correctly

and monitored

MDI’s

• Metered dose inhalers• Delivers a precise dose of

medication each time canister is depressed

MDI’s

• Bronchodilators• Albuterol- Proventil, Ventolin• Atrovent• Serevent

• Steroids• Vanceril• Aerobid• Azmacort

MDI’s

• Before using• patient must have signs &

symptoms of breathing difficulty• has a physician prescribed MDI• approval from medical control

Contraindications

• Not responsive enough to follow directions

• Medication out of date• Not prescribed for the patient• Permission not granted by medical

control• Patient has already taken the

maximum allowed dose prior to arrival

Administration

• Check name of medicine, date, and name prescribed to

• Obtain medical control order• Shake canister for 30 seconds

Administration

• Have patient• exhale fully• wrap lips around opening• inhale slowly as you depress

canister (5 seconds)• hold breathe for 10 seconds• exhale slowly

MDI’s

• Side effects include:• tachycardia• arrhythmia

• anxiety• nervousness