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Waiting to ExhaleRespiratory Disorders

Peggy Andrews, Instructor

The Respiratory System

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A quick review

• Upper airway– To larynx– Warms, humidifies,

cleans– Cilia– Turbinates– Hard and Soft palates

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Review, continued• Lower airway

– Below larynx– Trachea– Bronchi– Bronchioles– Alveoli– Surfactant

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Lower airway, cont.

• Lungs– Lobes– Visceral pleura– Parietal pleura

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Review, continued• Ventilation

– Inspiration– Expiration

• Respiration-Tidal Volume– 500ml

• Inspiratory Reserve Volume– 3000ml

• Expiratory reserve volume– 1500ml

• Residual volume– 1200ml

• Dead air space– 150ml

• Minute volume– TV x RR

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What controls our breathing?• Medulla

– 12-20/min– Inspiratory and Expiratory areas

• Transmitted through – Phrenic nerve

• 3rd, 4th, 5th spinal nerves– Intercostal nerves

• 11 pair• Can be modified by

– Cerebral cortex– Hypothalamus– Pons - on/off switch

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What controls our breathing, cont.

Hering-Breuer reflex

• Stretch receptors– Visceral

pleura– Bronchi and

bronchiole walls

=

• PCO2 increase = increased PCO2 in CSF = decreased pH

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Respiratory patternsCheyne-StokesKussmaul’sCentral neurogenic hyperventilationAtaxic (Biot’s) Apneustic

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Respiratory Disorders

• Incidence - 28% of all EMS C/C• Morbidity/Mortality - >200,000

deaths/yr.

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Risk Factors

• Stress– Increases

severity of

respiratory

complaints &

frequency of

exacerbations

Genetic predispositionAsthmaCOPDCarcinomas

Assoc. C

ardiac

or circ

ulatory

pathologies

Pulmonary

edem

a

Pulmonary

emboli

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Case Presentation One

• On a cold Sunday morning in February, a basic amb’lance is dispatched to a trailer park for a “woman down”. When the EMTs arrive, they are met by a young couple who explain that they had arrived about 30 minutes earlier to pick their mother up for church. They found her on the floor of her bathroom, lying on her right side. According to the couple, the mother said that she had fallen just after lunch the previous day, and she had been unable to get up.

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Entering the bathroom, the EMTs find:• An elderly woman, CAO PPTE, lying

on her side and covered with diarrhea. She says that she feels “fine” but admits to some focal right-sided chest pain and a bruise on her hip where she fell.

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• She tells the EMTs that she has been experiencing diarrhea for the past two days. Although she feels dizzy, she denies any syncope at the time of her fall, and says that she simply slipped as she was sitting on the toilet.

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The Patient Is:• Pale• Mildly cyanotic nailbeds• Skin is warm and dry• Mucous membranes are dry• A productive cough with thick, brown

sputum• She states that the coughing is left over

from a cold that she had contracted the previous month.

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• Breath sounds are congested with rhonchi

• Blood pressure – 90/50 mmHg• Pulse – 128/min.• Respirations – 40/min. and shallow• Temperature – 101.6 F (oral)

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• The EMT’s determine that the patient is dehydrated from the diarrhea. They administer oxygen at 4 L/min., and request that an ALS ambulance be dispatched. You arrive to find this 72 year old patient unchanged.

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• During your transport, her cyanosis progresses to her lips, although she remains alert and oriented and insists she is “OK”. Her medical history reveals that she is a chronic alcoholic, has been Dx with hepatic cirrhosis, and has a 145-pack year smoking history.

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• Rhonchi and rales are still noted in her right chest

• BP – 88/58 mmHg• P – 116/min.• Respirations – 30/min.• Temp 102.5 F (oral)

1. What is her differential

diagnosis?

2. What treatment might you

provide for this patient? Why?

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Signs of life-threatening respiratory distress in adults• Altered mental

status• 1-2 word speech• Tachycardia >

130/min.• Absent breath

sounds

• Retractions/ accessory muscle use

• Audible stridor• Pallor and

diaphoresis• Severe cyanosis

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COPD (Chronic Obstructive Pulmonary Disease)

• Emphysema• Chronic Bronchitis• Asthma

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Case Presentation Two

•  You are dispatched as first-in ambulance to a “medical emergency – unknown problem”.

• The response time to this rural address is about 12 minutes.

• On arrival, you find a first responder who tells you they have a 55-year-old male with difficulty breathing.

• She says that oxygen is already being administered.

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• You enter the house to find the patient

seated at the kitchen table, obviously short

of breath.

• Your initial assessment shows that the

patient is moving air, and has a strong

pulse.

• You replace the nasal cannula with a

non-rebreather at 12 Lpm

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You note the following:

• The patient has diminished breath sounds

• Occasional rhonchi• He is using his accessory muscles • He has mild cyanosis around his

mouth.

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• Several years ago, doctors at the VA

hospital diagnosed the patient as having

emphysema.

• Over the last 24 hours, the patient has had

progressive dyspnea, and didn’t sleep at all

last night.

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• BP – 140/78• P - 96• Resp – 28• Ecg – SR• SaO2 – 90% with oxygen• Pt is CAO PPTE• Meds – Theophylline and Amoxicillin• Smokes 1 PPD with a 30 pack-yr-hx• He wants to be transported to the VA

hospital

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• What is his differential

diagnosis?

• What treatment might you

provide him?

• Why?

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Emphysema• Irreversible airway obstruction• Diffusion defect also exists because

of blebs - prone to collapse• Patient exhales with pursed lips• Almost always associated with

cigarette smoking or environmental toxins

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Emphysema Pathophysiology• Destruction of alveolar walls distal to

terminal bronchioles.• More common in men• Walls of alveoli gradually distruct, =

alveolar membrane surface area. Results in ratio of air to lung tissue.

• Pulmonary capillaries , = resistance to pulmonary blood flow.

• Causes pulmonary hypertension, leads to RHF, then Cor Pulmonale

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Emphysema Pathophysiology (cont.)• Bronchiole walls weaken, lungs lose

elasticity, air is trapped. Residual volume, but vital capacity relatively normal.

• PaO2 , = RBC, polycythemia.• PaCO2 is chronically elevated. The body

depends on hypoxic drive.• Pt’s are more susceptible to pneumonia,

dysrhythmias.• Meds: bronchodilators, corticosteroids, O2.

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Assessment

• Altered mentation

• 1-2 word “sentences”

• Absent or decreased breath sounds

• c/c Dyspnea, morning cough, nocturnal dyspnea, wheezing

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• History - – Personal or family hx of allergies/asthma– Acute exposure to pulmonary irritant– Previous similar expisodes– Recent wt. loss, exertional dyspnea– Usually > 20 pack/year/history

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Exam• Wheezing• Retractions

and/or accessory muscle use

• Barrel chest• Prolonged

expiratory phase• Rapid resting

respiratory rate

• Thin• Pink puffers• Clubbing of

fingers• Diminished breath

sounds• JVD, hepatic

congestion, peripheral edema

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Management• Pulse oximeter (end tidal CO2

detector)• Assisted ventilation prn• High flow oxygen• Intubation prn• IV therapy with fluids• Albuterol, or Albuterol/Atrovent neb• Transport considerations

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Chronic Bronchitis• Productive cough for at least 3 months for

two or more consecutive years• An increase in mucous-secreting cells• Characterized by large quantity of sputum• Chronic smoker• Alveoli not severely affected - diffusion

normal gas exchange = hypoxia & hypercarbia• May increase RBC = polycythemia paCO2 = irritability, h/a, personality

changes, intellect. paCO2 = pulmonary hypertension &

eventually cor pulmonale.

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Assessment• Hx heavy cigarette smoking• Frequent resp. infections• Productive cough• Overweight, possibly cyanotic -

blue bloaters• Rhonchi on auscultation - mucous

plugs• S/S RHF; JVD, edema, hepatic

congestion

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Management•Pulse oximetry (end tidal CO2

detector)•Oxygen - low flow if possible•Nebulized Albuterol/Atrovent •Constantly monitor•Position - seated•IV TKO

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Case Presentation Three

• It is a hot June afternoon when you are dispatched to the local middle school for a child with difficulty breathing. You are directed to the nurse’s office, and there you find a 10 year-old female.

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• Wt – 45 kg• Sitting upright on the cot• CAO PPTE• Obviously struggling to breathe.• Anxious

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• The nurse tells you that the patient is relatively new to the school, and the only medical information she has is that the patient is allergic to many things (dust, pets, plants, as well as peanuts, eggs, shellfish).

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• The nurse has been unable to contact the parents – they are both out of town, and the custodial aunt is about 30 minutes away, but has left a message to do whatever you think should be done.

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• The nurse tells you that all she knows is that the patient was out at recess, wandered away from the other children, and when a playground aide went to find her, the patient was sitting down, pale, c/o difficulty breathing and had vomited x 1.

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You find the following:• PERL• P – 132• RR – 32 and shallow• Intercostal retractions, suprasternal notch

retractions, nasal flaring, pursed-lip breathing, and sub-costal retractions are all apparent.

• Breath sounds are diminished in all lobes, with some wheezing in the bases.

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• Skin is pale, cool, dry• Temp is 98.7 F (tympanic)• CBG is 100 mg/dcL• EKG – sinus tachycardia• Patient is able to speak in two or three

word sentences only

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• She tells you that she hasn’t had to use an inhaler for about 4 years, and currently takes no meds except vitamins. She hasn’t been feeling well for a day or so, and ate breakfast, but no lunch. Her urine output is down today as well.

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• What is your differential diagnosis?

• What treatment would you offer this patient and why?

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Asthma• Reversible obstruction caused by

combination of smooth muscle spasm, mucous, edema

• Exacerbating factors - extrinsic in children, intrinsic in adults

• Status asthmaticus - prolonged exacerbation - doesn’t respond to therapy

• Significant increase in deaths in last decade- 45 years or older - black 2x higher

• 50% are prehospital deaths.

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Pathophysiology• A chronic inflammatory airway

disorder.• Triggers vary - allergens, cold air,

exercise, food, irritants, medications.• A two-phase reaction• Phase one

– Histamine release - bronchial constriction, leakage of fluid from peribronchial capillaries = bronchoconstriction, bronchial edema.

– Often resolves in 1 - 2 hours

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Pathophysiology (cont.)

• Phase two– 6-8 hours after exposure, inflammation

of bronchioles - eosinophils, neutrophils, lymphocytes invade respiratory mucosa; = additional edema, swelling.

– Doesn’t typically respond to inhalers; often requires corticosteriods.

• Inflammation usually begins days/weeks before attack.

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Assessment• Dyspnea, 1-2

word sentences• Persistent, non-

productive cough• Wheezing• Hyperinflation of

chest• Tachypnea,

accessory muscle use

• Pulsus paradoxis– 10-15 mm bp drop

during insp vs exp• Agitated, anxious• Decreased

oxygen saturation• Tachycardia• Hx of allergies• Auto PEEP• Potential tensions

(bilateral)

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Management• Check home meds• Determine onset of sx & what pt. has

taken• Check vitals carefully – RR x 30 sec.• High flow oxygen• IV with fluids• EKG• Inhalers• Consider epinephrine 1:1,000 SQ, 0.3-0.5 mg • Consider Solu-Medrol, 1 –2 mg/kg IVP, max

125 mg

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Status Asthmaticus• Severe, prolonged asthma attack

not responsive to treatment• Greatly distended chest• Absent breath sounds• Pt. exhausted, dehydrated, acidotic.• Treat aggressively if obtunded,

profuse diaphoresis, floppy – Intubate (poss. RSI)

• Transport immediately

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Case Presentation Four

• It is 10 pm on a Saturday night in December, and you are dispatched to the mission for a report of a 60 year old male having difficulty breathing. You are met at the door by a worker who tells you that they had just opened the doors to allow the homeless in for the night. Immediately after assigning cots, they noticed the patient sitting on the edge of his cot, blue and gasping for air.

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• You find this 60 y/o, 63 kg male patient, sitting upright with his hands braced on his knees. He has audible wheezing, and is unable to say more than two words without gasping.

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• He tells you he has had a cough for the past couple of months, and that he has been having some chest pain for the past two or three days, has felt nauseated, and has had chills. He says that it got much worse tonight.

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• He hasn’t been seen by a physician. He says that he has a history of alcohol abuse, smokes about ½ pack of cigarettes per day, and has since he was 10 years old.

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Your exam reveals the following: • PERL• Skin cool, dry, pale with cyanosis to

nailbeds, lips, earlobes.• Audible wheezing, diffuse rales in all

lobes, using accessory muscles, has intercostal retractions, and pursed lip breathing.

• Temp is 97.8 F (tympanic)• BP – 126/84• P – 112; RR – 28 and shallow• He is thin, and has clubbing of his fingers.

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• What is his differential diagnosis?

• What treatment would you offer this patient? Why?

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Pneumonia• 5th leading cause of death in US• Risk factors

– Cigarette smoking– Alcoholism– Cold exposure– Extremes of age

• Pathophysiology– A common respiratory disease caused by

infectious agent. bacterial and viral pneumonia most frequent

– May cause atelectasis– May become systemic = sepsis

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Assessment• Typical

– Acute onset of fever and chills– Cough productive with yellow/green sputum (bad breath!)– May have pleuritic chest pain– Pulmonary consolidation on auscultation– Rales – Egophony (strange lung sounds)

• Atypical– Non-productive cough– H/A– Fatigue

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Management• Position• Oxygen• Consider breathing treatment• IV with fluids• Cool if febrile• Elderly, over 65 years

– Significant co-morbidity– Inability to take meds– Support complications

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Case Presentation Five

• You respond to a call for a “shortness of breath”. It is 0930 on a Tuesday. When you arrive, you find a 42 year-old woman. She says that she has had flu-like sx for the past 3 days. This morning, she began breathing rapidly and called 9-1-1. She denies other complaints, but says she has been under some stress. She has just started a new job, and has had to call in sick for the past two days.

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On physical exam:

• Airway is patent• She is tachypneic at 46/min. with deep

respirations and good air exchange• Her pulse is 108 and regular• Skin is warm, dry, with pink mucosa• CAO PPTE, and moderately anxious• The rest of your exam is normal.

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• You cancel the first responders, and spend nearly 40 minutes coaching her to slow her breathing without success. Finally, you transport her to the ED.

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• What is your differential diagnosis?

• What treatment would you offer this patient? Why?

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Hyperventilation Syndrome• Multiple causes

– Hypoxia– High altitude– Pulmonary disease– Pneumonia– Interstitial pneumonitis, fibrosis,

edema– Pulmonary emboli– Bronchial asthma– Congestive heart failure– Hypotension– Metabolic disorder– Acidosis

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Hyperventilation Syndrome (cont)• Causes (cont)

– Hepatic failure– Neurologic disorders– Psychogenic or anxiety hypertension– Central nervous system infection, tumors– Drug-induced– Salicylate– Methylxanthine derivatives– Beta-adrenergic agonists– Progesterone– Fever,sepsis– Pain– Pregnancy

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Assessment

• Chief complaint– Dyspnea– Chest pain– Other sx based on etiology– Carpopedal spasm– Tachypnea with high minute

volume

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Management

• Depends on cause of syndrome• Oxygen based on sx and pulse

oximetry (CO2 waveform)

• Consider coached ventilation

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Upper Respiratory Infection (URI)• One of most common c/c• Usually viral• Bacterial infections

– Group A streptococcus• Strep throat• Sinusitis• Middle ear infections

• Most URI’s self-limiting

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URI continued• S/S

– Fever– Chills– Myalgia– Fatigue

• Treatment– Supportive– Acetaminophen, ibuprofen, liquids

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URI, cont.• If pediatric, beware of possibility of

epiglotitis• If PMH; Asthma or COPD, condition

may worsen– Consider nebulized meds

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Lung CA• Most caused by cigarette smoking• 4 major types

– Adenocarcinoma – most common• Origin; mucus-producing cells

– Small cell carcinoma– Epidermoid carcinoma– Large cell carcinoma

• Origin; bronchial tissues• Most patients die within one year

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Lung CA, continued• General

Assessment;– Altered mentation– 1-2 word

sentences– Cyanosis– Hemoptysis– Hypoxia

• Advanced disease– Profound weight

loss– Cachexia– Malnutrition– Crackles, rhonchi,

wheezes– Diminished breath

sounds– Venous distention

in arms and neck

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• Localized disease– Cough, dyspnea, hoarseness, vague

chest pain, hemoptysis• Local invasion

– Pain on swallowing (dysphagia)– Weakness, numbness in arm– Shoulder pain

• Metastatic spread– Headache, seizures, bone pain,

abdominal pain, nausea, malaise

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Treatment for Lung CA• Oxygen prn• Support ventilations• Intubate prn• IV• Nubulized meds• DNR / Advanced directive?

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Toxic inhalation• Consider if patient dyspneic• Causes

– Superheated air– Products of combustion– Chemical irritants– Steam inhalation

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Inhalation injury, cont.• Medic safety

– Ammonia (ammonium hydroxide)– Nitrogen oxide (nitric acid)– Sulfer dioxide (sulfurous acid)– Sulfur trioxide (sulfuric acid)– Chlorine (hydrochloric acid)

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• Assessment– Enclosed space?– Loss of consciousness?– Mouth, face, throat, nares– Auscultate chest– Laryngeal edema

• Hoarseness, brassy cough, stridor• Management

– Maintain airway– High-flow humidified oxygen– IV

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Carbon Monoxide Inhalation• Incomplete burning of fossel fuels,

other carbon-containing compounds• Automobile exhaust, home-heating

devices most common causes• CO has >200x affinity for hemoglobin

– Cellular hypoxia• Also binds to iron-containing enzymes

– Increased cellular acidosis

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CO, continued• Assessment

– Source, length of exposure? Closed vs open space?

• S/S– H/A, N/V, confusion, agitation, loss of

coordination, chest pain, loss of consciousness, seizures

– Cyanosis– Cherry red skin (very late)

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CO, continued• Management

– SAFETY– Maintain airway– High flow oxygen (NRB vs assisted)– Hyperbaric oxygen therapy

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Pulmonary Embolus• Thrombus• Ventilation perfusion mismatch• 50,000 deaths in US annually • Conditions that predispose to PE

– Recent surgery– Long-bone fracture– Bedridden– Long flights/truck drivers– Pregnancy– Cancer, infections, thrombophlebitis, AF,

sickle cell anemia– BCP

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PE, cont• Assessment

– Sudden onset SOB, Hypoxic– Pleuritic chest pain– Non-productive cough– History– Labored breathing, tachypnea,

tachycardia– RHF– DVT present

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PE, cont• Management• ABC• Airway • High flow oxygen• ET?• IV – flow rate?• Heparin gtt? TPA?

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Spontaneous pneumothorax• Common- high recurrent rate

– 5:1 male to female– Tall, thin– Smoking history– 20-40 years old– COPD = increased risk

• Ventilation perfusion mismatch if > 20%

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Spont. Pneumothorax, cont.• Assessment

– Sudden onset sharp chest or shoulder pain– Coughing/lifting– Dyspnea– Decreased breath sounds at apex– Hyper resonance – Sub-cutaneous emphysema– Tachypnea, diaphoresis, pallor

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Spont. Pneumothorax, cont.• Management

– Supplemental oxygen – If symptoms increase, consider

needle decompression– Position of comfort

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That’s all about breathingfor now, folks!