EMS- Respiratory Emergencies (Again)

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Ok, heres the story. I was teaching this otherwise sharp EMT-Basic class that bombed two respiratory emergency tests in a ROW!
So this is the remedial lecture I inflicted on them. I don\'t know if they passed because of this fine work, or just because they were afraid of another lecture fo they failed.

Hope its useful to you.

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  • EMS- Respiratory Emergencies (Again)

    1. 1. Steve Cole, Paramedic, CCEMT-P Respiratory Emergencies (again)
    2. 2. Why Again? <ul><li>Respiratory Calls are some of the most Common calls you will see. </li></ul><ul><li>Respiratory care is as essential as the ABC’s </li></ul><ul><li>Mishandling a respiratory call can be fatal. </li></ul><ul><li>Mishandling a respiratory call can be fatal. </li></ul><ul><li>Mishandling a respiratory call can be fatal. </li></ul>
    3. 3. What we are going to discuss <ul><li>Respiratory PHYSIOLOGY </li></ul><ul><li>5 most common respiratory problems in adults (PEDS will come later) </li></ul>
    4. 4. Basic Concept: Air Goes in and Out Blood Goes Round and Round Any thing infringing on this is a BAD THING !
    5. 5. Key Concepts <ul><li>The primary function of the respiratory system is gaseous exchange. </li></ul><ul><ul><li>Ventilation and Oxygenation. </li></ul></ul><ul><li>Air is composed of a mixture of gases. </li></ul><ul><li>Breathing is largely controlled by the Autonomic Nervous system, in response to changes sensed in all parts of the body. The biggest part of this is the “Hypoxic Drive”. </li></ul>
    6. 6. Key Concepts <ul><li>Diffusion of O2 from the lung to the blood is by the binding of O2 to the hemoglobin (Hgb) </li></ul><ul><li>This is dependant on a pressure gradient. </li></ul><ul><li>This is a Passive transport system. </li></ul><ul><li>It is also dependant on available surface area and distance it must travel to cross the threshold. </li></ul><ul><li>Capillaries are where the real Oxygenation and ventilation take place. </li></ul>
    7. 7. Primary Concepts <ul><li>All pt’s with SOB get O2. Lots of O2. </li></ul><ul><li>Listen to ALL lungs. </li></ul><ul><li>Beware of the “silent chest”. </li></ul><ul><li>Noisy Breathing is abnormal breathing </li></ul><ul><li>Visible Breathing is abnormal breathing. </li></ul><ul><li>Positional breathing is abnormal breathing. </li></ul><ul><li>Abnormal Breathing gets O2. </li></ul>
    8. 8. Volume <ul><li>Tidal Volume </li></ul><ul><li>Minute Volume </li></ul><ul><ul><li>Tidal Volume X Respiratory Rate = Minute Volume </li></ul></ul>
    9. 9. Respiratory Physiology
    10. 10. What do we assess? <ul><li>Presence or absence? </li></ul><ul><li>Rate </li></ul><ul><li>Quality </li></ul>
    11. 11. Respiratory Rate <ul><li>Decreased by: </li></ul><ul><ul><li>Depressant Drugs </li></ul></ul><ul><ul><li>Sleep </li></ul></ul><ul><li>Increased by: </li></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Fear </li></ul></ul><ul><ul><li>Exertion </li></ul></ul>
    12. 12. Respiratory Quality <ul><li>Irregular: Neuro Insult. </li></ul><ul><li>Shallow: </li></ul><ul><ul><li>Respiratory Depressants </li></ul></ul><ul><ul><li>CNS Depressants </li></ul></ul><ul><ul><li>Neuro Insult </li></ul></ul><ul><li>Deep: </li></ul><ul><ul><li>Hyperglycemia with Acidosis (DKA): “Kussmal Respirations </li></ul></ul><ul><ul><li>Electrolyte Imbalances </li></ul></ul><ul><ul><li>Neuro Insult </li></ul></ul>
    13. 13. Adult Lung Volumes <ul><li>5,500 to 6,000mL at end inspiration. </li></ul><ul><li>Normal tidal volume: 500mL </li></ul><ul><li>Dead space air: 150mL </li></ul><ul><li>Alveolar Air: 350mL </li></ul>
    14. 14. Key components of an intact respiratory system <ul><li>An appropriate Drive to Breath </li></ul><ul><li>Airway and respiratory tract </li></ul><ul><li>Mechanical Bellows </li></ul><ul><li>A diffusion friendly place for gas exchange to happen. </li></ul><ul><li>An O2 friendly RBC with hgb. </li></ul><ul><li>An intact circulatory system to carry the gasses and waste through out the body. </li></ul><ul><ul><li>Must have enough of a pressure to promote diffusion. </li></ul></ul><ul><li>An intact capillary bed </li></ul>
    15. 15. Drive to breath <ul><li>Controlled by the CNS through information gathered from receptors in the body. </li></ul><ul><li>Located in the pons region of the brainstem </li></ul><ul><li>Detects increases in CO2 or decreases in pH and informs the brain to increase the respiratory rate. </li></ul><ul><li>Increased respiratory rate reduces CO2 and will increase pH. </li></ul><ul><li>Other things can effect our drive to breath </li></ul>
    16. 16. “ Hypoxic Drive” <ul><li>Develops in some patients with Chronic Lung Disease </li></ul><ul><li>Pons region of brain becomes sensitized to constant increased CO2 state </li></ul><ul><li>Regulation is now based on O2 level in blood </li></ul><ul><li>Increased oxygen level states may tell the brain to stop breathing </li></ul>
    17. 17. Dr. Slovis’s top 5 effects on respiratory drive. <ul><li>CVA </li></ul><ul><li>Trauma to the brain </li></ul><ul><li>Drugs </li></ul><ul><li>Tumor </li></ul><ul><li>Electrolyte Imbalances </li></ul>
    18. 18. The Airway and Respiratory tract <ul><li>From the tip of the mouth </li></ul><ul><li>To the “Functional Unit of the Lungs” </li></ul><ul><ul><li>Alveoli </li></ul></ul><ul><li>Functions by negative pressure inspiration. </li></ul><ul><li>“ The means of getting cargo to the loading docks.” </li></ul>
    19. 19. The Mechanical Bellows <ul><li>The muscles of the ribs expand the size of the chest, creating a (relative) negative pressure. </li></ul><ul><li>Air (with O2) moves in to fill the void. </li></ul><ul><li>Commonly thought of as Oxygenation. </li></ul><ul><li>Actual oxygenation takes place at the cellular level. </li></ul>Special Thanks to Charlie Miller for this Graphic.
    20. 20. The Mechanical Bellows <ul><li>The intercostals muscles relax, allowing the chest to return to its neutral position, expelling air out of the lungs (and CO2 with it.) </li></ul><ul><li>Commonly thought of as Ventilation . </li></ul><ul><li>Actual ventilation takes place at the cellular level. </li></ul>Special Thanks to Charlie Miller for this Graphic.
    21. 21. The Mechanical Bellows <ul><li>Example of a Compromised Bellows </li></ul><ul><li>Positional Asphyxia </li></ul>Special Thanks to Charlie Miller for this Graphic.
    22. 22. A diffusion friendly place for gas exchange to happen. <ul><li>Diffusion is a passive process. </li></ul><ul><li>Intact capillary bed. </li></ul><ul><li>Jimmie Edwards Fart Theory. </li></ul><ul><li>Things that effect diffusion: </li></ul><ul><ul><li>Thickness of Membrane the gas has to cross </li></ul></ul><ul><ul><li>Surface Area to diffuse across </li></ul></ul><ul><ul><li>Partial Pressure differences in Gas on each side. </li></ul></ul><ul><ul><li>Physiologic PEEP </li></ul></ul>
    23. 23. Diffusion
    24. 24. An O2 friendly RBC with hgb. <ul><li>Hemoglobin is an Iron Based compound essential to the transport of O2. </li></ul><ul><ul><li>Anemia </li></ul></ul><ul><ul><li>Cyanide Poisoning </li></ul></ul><ul><ul><li>CO Poisoning </li></ul></ul>
    25. 25. An intact circulatory system <ul><li>Blood Loss </li></ul><ul><li>Shock </li></ul><ul><ul><li>Pump Problem </li></ul></ul><ul><ul><li>Volume Problem </li></ul></ul><ul><ul><ul><li>Fluid issue </li></ul></ul></ul><ul><ul><ul><li>O2 carrying issue </li></ul></ul></ul><ul><ul><li>Vessel Problem </li></ul></ul>
    26. 26. Must have enough of a pressure to promote diffusion. <ul><li>Conditions like Hypotension cause secondary hypoxia by promoting low perfusion. </li></ul>
    27. 27. Assessing the pt with Respiratory Distress.
    28. 28. First Impressions <ul><li>Air Hungry </li></ul><ul><li>Nasal Flaring </li></ul><ul><li>Tripoding </li></ul><ul><li>Rocking with respirations </li></ul><ul><li>Pursed Lip Breathing </li></ul><ul><li>Barrel or Sparrow Chest </li></ul><ul><li>Home O2 </li></ul>
    29. 29. Skin Signs <ul><li>Cyanosis </li></ul><ul><ul><li>Nail Beds </li></ul></ul><ul><ul><li>Lips </li></ul></ul><ul><ul><li>Ears </li></ul></ul><ul><li>Mottling </li></ul><ul><ul><li>Chest </li></ul></ul><ul><ul><li>Lower Ext </li></ul></ul><ul><ul><li>Abd </li></ul></ul>
    30. 30. Noisy breathing is obstructed breathing <ul><li>Snoring: obstruction by tongue </li></ul><ul><li>Gurgling: Funky Junk in upper airway </li></ul><ul><li>Grunting: Physiologic PEEP </li></ul><ul><li>Stridor: harsh, high pitched sound on inhalation: </li></ul><ul><ul><li>Laryngeal edema </li></ul></ul><ul><ul><li>Epiglotitis </li></ul></ul><ul><ul><li>FBAO </li></ul></ul>
    31. 31. Speech Dyspnea <ul><li>Inability to speak more than a few sylables in a sentence between breaths. </li></ul>
    32. 32. Breath Sounds <ul><li>Listening by comparison </li></ul><ul><li>Listening anterior </li></ul><ul><li>Listening posterior </li></ul><ul><li>Fremitus </li></ul>
    33. 35. Abnormal breath sounds <ul><li>Rales (crackles): fine bubbling sound of fluid in alveoli (“Rice Krispies”: snap, crackle and pop) Alveoli popping open. </li></ul><ul><li>Rhonchi: fluid in larger airways, obstructing object in the bronchus </li></ul><ul><li>Wheezes: high pitched whistling, air through narrowed airways </li></ul><ul><li>SILENCE IS BAD NEWS </li></ul>
    34. 36. Causes of respiratory abnormalities <ul><li>Brain damage: trauma, drugs, stroke </li></ul><ul><li>Spinal cord damage: trauma, polio </li></ul><ul><li>Upper airways: tongue, swelling, foreign body, trauma </li></ul><ul><li>Lower airways: asthma, chronic bronchitis </li></ul><ul><li>Alveoli: atelectasis, obstruction </li></ul><ul><li>Impaired pulmonary circulation: embolism </li></ul>
    35. 37. Signs/symptoms of distress <ul><li>Dyspnea </li></ul><ul><li>Restlessness/anxiety </li></ul><ul><li>Tachypnea/Bradypnea </li></ul><ul><li>Cyanosis (core) </li></ul><ul><li>Abnormal sounds </li></ul><ul><li>Retractions </li></ul><ul><li>Diminished ability to speak </li></ul>
    36. 38. More S/S <ul><li>Retractions and/or use of accessory muscles </li></ul><ul><li>Abdominal breathing </li></ul><ul><li>Nasal flaring </li></ul><ul><li>Productive cough </li></ul><ul><ul><li>Color? </li></ul></ul><ul><li>Irregular breathing </li></ul><ul><li>Tripod position </li></ul><ul><li>Pursed-lip breathing </li></ul>
    37. 39. Take another look ….What do you see?
    38. 40. Hows this? Pursed Lips Sparrow Chest Tripoding Retractions Abd retractions Kewl Haircut O2
    39. 41. Inadequate Breathing: Infants and Children Retractions Nasal Flaring See-Saw Breathing Diaphragmatic Breathing
    40. 42. BREAK?
    41. 43. The Usual Suspects Photo by Linda R. Chen - © 1995 Gramercy Pictures.
    42. 44. Top 6 you need to know <ul><li>COPD/Reactive Airway Disorders </li></ul><ul><ul><li>Emphysema </li></ul></ul><ul><ul><li>Asthma </li></ul></ul><ul><ul><li>Bronchitis </li></ul></ul><ul><li>Pneumonia </li></ul><ul><li>CHF </li></ul><ul><li>Pulmonary Emboli </li></ul><ul><li>Hyperventilation Disorders </li></ul><ul><li>Pneumothorax </li></ul>
    43. 45. COPD
    44. 46. Causes of Chronic Obstructive Pulmonary Disease (COPD) <ul><li>Cigarette smoking </li></ul><ul><li>Environmental pollution </li></ul><ul><li>Previous pulmonary infections </li></ul><ul><li>Chronic asthma </li></ul>
    45. 47. Common Traits of COPD’ers <ul><ul><li>“ pink puffer” </li></ul></ul><ul><ul><li>“ air trapping” </li></ul></ul><ul><ul><li>destruction of alveoli, loss of elasticity </li></ul></ul><ul><ul><li>barrel chest/Sparrow Chest </li></ul></ul><ul><ul><li>use of accessory muscles </li></ul></ul><ul><ul><li>noisy breath sounds: wheezing prolonged and increasing on exhalation </li></ul></ul>
    46. 48. Air Trapping <ul><li>Due to loss of elasticity in the alveoli, these pt’s trap air. </li></ul><ul><li>They need over double the exhalation period </li></ul><ul><li>This means inhibited gas exchange and possibly…… </li></ul><ul><li>They can develop a spontaneous pneumothorax.. </li></ul>
    47. 49. EMPHYSEMA <ul><ul><li>In Emphysema the chronic damage to the lungs interferes with gas exchange. </li></ul></ul><ul><ul><li>A secondary point of exacerbation is the irritation of the broncheols, making them constrict and spasm. Since the alveoli are damaged, this causes them to collapse easily. </li></ul></ul>
    48. 50. Chronic Bronchitis <ul><li>“ The English Disease” </li></ul><ul><li>Chronic irritation cause increases mucus production as a defense mechanism. </li></ul><ul><li>This in turn decreases surface area for gas exchange. </li></ul><ul><li>The phlegm also irritates the bronchioles, causing bronchio-constriction and spasm. </li></ul>
    49. 51. ASTHMA: causes…. <ul><li>Reactive airway event caused by bronchospasm, reversible </li></ul><ul><li>Extrinsic: environmental, allergic trigger, temperature </li></ul><ul><li>Intrinsic: exertion/ stress, illness </li></ul><ul><li>Inflammatory reaction </li></ul>
    50. 52. Acute asthmatic attack: <ul><li>Bronchospasm: rapid onset, can be relieved by medications </li></ul><ul><li>Swelling of mucous membranes in bronchial walls (inflammatory response) </li></ul><ul><li>Mucus plugging of bronchi </li></ul>
    51. 53. Signs and Symptoms <ul><li>Usually patient has history of asthma, may have prescription for meds </li></ul><ul><li>“ Noisy” breath sounds (increased on exhalation) </li></ul><ul><ul><li>BEWARE A SILENT CHEST </li></ul></ul><ul><li>Accessory muscle use </li></ul><ul><li>Tachycardia and tachypnea </li></ul><ul><li>Pulsus paradoxus (decrease in systolic BP with inhalation) </li></ul><ul><li>Exhaustion </li></ul>
    52. 54. Status Asthmaticus <ul><li>Prolonged asthma attack that is not broken by normal treatments </li></ul><ul><li>Requires aggressive treatment and transportation </li></ul><ul><li>A SILENT CHEST IS BAD! </li></ul>
    53. 55. Treatment <ul><li>Reassure </li></ul><ul><li>High flow humidified oxygen </li></ul><ul><li>Assist with medication (per protocol) </li></ul><ul><li>Position of comfort </li></ul><ul><li>Insure adequate ventilation </li></ul><ul><li>BronchoDilators </li></ul>
    54. 56. Bronchodilators <ul><li>Beta II agonist </li></ul><ul><ul><li>Stimulate receptor sites causing bronchiole relaxation </li></ul></ul><ul><ul><li>First Line. </li></ul></ul><ul><ul><li>Albuterol </li></ul></ul><ul><li>Parasympatholytic </li></ul><ul><ul><li>Inhibit Parasympathetic broncheoconstriction </li></ul></ul><ul><ul><li>Second line.Use only once </li></ul></ul><ul><ul><li>Atrovent </li></ul></ul><ul><li>May improve air passage around mucous plugs </li></ul><ul><li>Many side effects </li></ul>
    55. 57. Metered Dose Inhaler <ul><li>EMT’s may “assist” a patient with a PRESCRIBED MDI in: </li></ul><ul><ul><li>Respiratory Distress </li></ul></ul><ul><ul><li>Allergic reactions with wheezing </li></ul></ul>
    56. 58. BASIC USE OF AN MDI
    57. 59. Remember to Obtain orders from medical direction.
    58. 60. Remember the 5 R’s
    59. 61. Remember the 5 R’s <ul><li>RIGHT PATIENT </li></ul><ul><li>RIGHT MEDICATION </li></ul><ul><li>RIGHT DOSE </li></ul><ul><li>RIGHT ROUTE </li></ul><ul><li>RIGHT SITUATION/TIME </li></ul>
    60. 62. Shake vigorously
    61. 63. Depress hand-held inhaler as patient inhales deeply.
    62. 64. Instruct patient to hold/blow out breath.
    63. 65. Allow patient to breathe. Repeat dose if ordered.
    64. 66. Spacer Device
    65. 67. REMEMBER: ALL THAT WHEEZES IS NOT ASTHMA….. AND NOT ALL ASTHMA WHEEZES!
    66. 68. All that wheezes is not asthma: <ul><li>Other causes: </li></ul><ul><ul><li>acute left heart failure (“cardiac asthma”) </li></ul></ul><ul><ul><li>smoke inhalation </li></ul></ul><ul><ul><li>chronic bronchitis </li></ul></ul><ul><ul><li>acute pulmonary embolism </li></ul></ul><ul><li>May be localized: suspect an obstruction </li></ul>
    67. 69. The Oxygen Myth and COPD <ul><li>People used to think that if you gave a COPD’er too much O2, they would stop breathing….. </li></ul><ul><li>This is major BS..purely theoretical at best. </li></ul><ul><li>In short: </li></ul><ul><li>If their SOB, they gets lots of O2 </li></ul><ul><ul><li>“ High Flow” 10-15 LPM NRB </li></ul></ul>
    68. 70. NEVER WITHHOLD OXYGEN FROM A PATIENT WHO NEEDS IT!
    69. 71. Signs and Symptoms <ul><li>Something has changed from normal </li></ul><ul><li>Marked respiratory distress </li></ul><ul><li>Diaphoresis, cyanosis </li></ul><ul><li>Agitation and confusion (hypoxemia), lethargy (hypercarbia) </li></ul><ul><li>Tachypnea, tachycardia, irregular heart beat </li></ul>
    70. 72. Treatment <ul><li>Ventilate appropriately </li></ul><ul><li>Expect low pulse oximetry: don’t try to raise to “normal” Base on Mental Status and subjective statements. Try at least above 85-90% </li></ul><ul><li>Position of comfort (upright, tripod) </li></ul><ul><li>Rapid transport </li></ul><ul><li>Monitor ventilations </li></ul>
    71. 73. Pulmonary Edema <ul><li>Definition: accumulation of fluid in alveoli, chronic or acute </li></ul><ul><li>Primary Cause is Cardiac (CHF) </li></ul><ul><li>Other Causes: </li></ul><ul><ul><li>exposure to toxic substances </li></ul></ul><ul><ul><li>damaged tissue </li></ul></ul><ul><ul><li>Actively Dying (ARDS) </li></ul></ul>
    72. 74. Signs and Symptoms <ul><li>Anxiety </li></ul><ul><li>tachypnea/tachycardia </li></ul><ul><li>dyspnea, hemoptysis </li></ul><ul><li>abnormal breath sounds (moist, wheezes) </li></ul><ul><li>JVD </li></ul><ul><li>Elevated blood pressure </li></ul><ul><li>orthopnea/paroxysmal nocturnal dyspnea </li></ul>
    73. 75. Treatment: <ul><li>Reassure </li></ul><ul><li>High flow oxygen (positive pressure) </li></ul><ul><li>NTG (Medical Control Only) </li></ul><ul><li>Position of comfort </li></ul><ul><li>Rapid transport </li></ul>
    74. 76. Pneumonia <ul><li>Definition: infection of respiratory tree, may result in systemic sepsis </li></ul><ul><li>Types: </li></ul><ul><ul><li>bacterial 90% </li></ul></ul><ul><ul><li>viral (from influenza) </li></ul></ul><ul><ul><li>mycoplasmal/fungal </li></ul></ul><ul><ul><li>aspiration </li></ul></ul>
    75. 77. Signs and symptoms <ul><li>Patient looks sick/dehydrated </li></ul><ul><li>Illness over several days </li></ul><ul><li>Fever </li></ul><ul><li>Dehydration </li></ul><ul><li>Productive cough </li></ul><ul><li>tachypnea/ tachycardia </li></ul><ul><li>Rales and rhonchi </li></ul>
    76. 78. Treatment: <ul><li>Oxygen and transport </li></ul>
    77. 79. Pulmonary Embolism <ul><li>Definition: sudden blocking of pulmonary artery by clot </li></ul><ul><li>Causes: </li></ul><ul><ul><li>blood clots in legs </li></ul></ul><ul><ul><li>prolonged immobilization </li></ul></ul><ul><ul><li>birth control pills </li></ul></ul>
    78. 80. Signs and symptoms: <ul><li>Sudden onset of severe, unexplained dyspnea </li></ul><ul><li>other s/s may or may not be present </li></ul><ul><li>chest pain made worse on coughing </li></ul><ul><li>Tachycardia/tachypnea </li></ul><ul><li>JVD </li></ul>
    79. 81. Treatment <ul><li>Recognition </li></ul><ul><li>Oxygen </li></ul><ul><li>Hospitalization </li></ul><ul><li>Suspect PE when there is acute onset of tachycardia or dyspnea of unknown origin </li></ul>
    80. 82. Hyperventilation <ul><li>Definition: rapid, deep respirations causing imbalance of CO2 in body often caused by emotions or stress </li></ul><ul><li>May be hard to recognize </li></ul><ul><li>There may be other causes of pattern </li></ul>
    81. 83. Signs and symptoms <ul><li>Elevated respiratory rate or increased depth </li></ul><ul><li>chest pain </li></ul><ul><li>tingling or numbness around mouth, hands, feet </li></ul><ul><li>Carpopedal spasm </li></ul>
    82. 84. Treatment: <ul><li>Do NOT use a paper bag </li></ul><ul><li>Try to calm and reassure </li></ul><ul><li>Remove patient from environment that may be causing problem </li></ul><ul><li>Transport if problem can’t be resolved </li></ul>
    83. 85. Spontaneous Pneumothorax <ul><li>Definition: sudden leak of air into pleural space; may have no apparent cause </li></ul><ul><li>Frequently young, tall, thin males </li></ul><ul><li>May have previous history </li></ul>
    84. 86. Signs/ symptoms <ul><li>Sudden, sharp chest pain </li></ul><ul><li>Sudden dyspnea </li></ul><ul><li>Diminished breath sounds </li></ul><ul><li>Pleuritic chest pain </li></ul>
    85. 87. Treatment <ul><li>Oxygen and transport </li></ul>
    86. 88. Other problems: <ul><li>Pickwickian syndrome: patient is VERY obese, related to sleep apnea </li></ul><ul><li>Cystic fibrosis </li></ul><ul><li>Legionnaires (type of pneumonia) </li></ul>
    87. 89. <ul><li>Getting a good history will be one of the most important ways to differentiate between respiratory conditions </li></ul><ul><li>Look for underlying conditions </li></ul>
    88. 90. Questions?

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