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EMS- Respiratory Emergencies (Again)
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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! …

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

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