Steve Cole, Paramedic, CCEMT-P Respiratory Emergencies (again)

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.

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.

What we are going to discuss Respiratory PHYSIOLOGY 5 most common respiratory problems in adults (PEDS will come later)

Respiratory PHYSIOLOGY

5 most common respiratory problems in adults (PEDS will come later)

Basic Concept: Air Goes in and Out Blood Goes Round and Round Any thing infringing on this is a BAD THING !

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”.

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”.

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.

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.

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.

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.

Volume Tidal Volume Minute Volume Tidal Volume X Respiratory Rate = Minute Volume

Tidal Volume

Minute Volume

Tidal Volume X Respiratory Rate = Minute Volume

Respiratory Physiology

What do we assess? Presence or absence? Rate Quality

Presence or absence?

Rate

Quality

Respiratory Rate Decreased by: Depressant Drugs Sleep Increased by: Fever Fear Exertion

Decreased by:

Depressant Drugs

Sleep

Increased by:

Fever

Fear

Exertion

Respiratory Quality Irregular: Neuro Insult. Shallow: Respiratory Depressants CNS Depressants Neuro Insult Deep: Hyperglycemia with Acidosis (DKA): “Kussmal Respirations Electrolyte Imbalances Neuro Insult

Irregular: Neuro Insult.

Shallow:

Respiratory Depressants

CNS Depressants

Neuro Insult

Deep:

Hyperglycemia with Acidosis (DKA): “Kussmal Respirations

Electrolyte Imbalances

Neuro Insult

Adult Lung Volumes 5,500 to 6,000mL at end inspiration. Normal tidal volume: 500mL Dead space air: 150mL Alveolar Air: 350mL

5,500 to 6,000mL at end inspiration.

Normal tidal volume: 500mL

Dead space air: 150mL

Alveolar Air: 350mL

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

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

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

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

“ 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

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

Dr. Slovis’s top 5 effects on respiratory drive. CVA Trauma to the brain Drugs Tumor Electrolyte Imbalances

CVA

Trauma to the brain

Drugs

Tumor

Electrolyte Imbalances

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.”

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.”

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.

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.

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.

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.

The Mechanical Bellows Example of a Compromised Bellows Positional Asphyxia Special Thanks to Charlie Miller for this Graphic.

Example of a Compromised Bellows

Positional Asphyxia

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

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

Diffusion

An O2 friendly RBC with hgb. Hemoglobin is an Iron Based compound essential to the transport of O2. Anemia Cyanide Poisoning CO Poisoning

Hemoglobin is an Iron Based compound essential to the transport of O2.

Anemia

Cyanide Poisoning

CO Poisoning

An intact circulatory system Blood Loss Shock Pump Problem Volume Problem Fluid issue O2 carrying issue Vessel Problem

Blood Loss

Shock

Pump Problem

Volume Problem

Fluid issue

O2 carrying issue

Vessel Problem

Must have enough of a pressure to promote diffusion. Conditions like Hypotension cause secondary hypoxia by promoting low perfusion.

Conditions like Hypotension cause secondary hypoxia by promoting low perfusion.

Assessing the pt with Respiratory Distress.

First Impressions Air Hungry Nasal Flaring Tripoding Rocking with respirations Pursed Lip Breathing Barrel or Sparrow Chest Home O2

Air Hungry

Nasal Flaring

Tripoding

Rocking with respirations

Pursed Lip Breathing

Barrel or Sparrow Chest

Home O2

Skin Signs Cyanosis Nail Beds Lips Ears Mottling Chest Lower Ext Abd

Cyanosis

Nail Beds

Lips

Ears

Mottling

Chest

Lower Ext

Abd

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

Snoring: obstruction by tongue

Gurgling: Funky Junk in upper airway

Grunting: Physiologic PEEP

Stridor: harsh, high pitched sound on inhalation:

Laryngeal edema

Epiglotitis

FBAO

Speech Dyspnea Inability to speak more than a few sylables in a sentence between breaths.

Inability to speak more than a few sylables in a sentence between breaths.

Breath Sounds Listening by comparison Listening anterior Listening posterior Fremitus

Listening by comparison

Listening anterior

Listening posterior

Fremitus

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

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

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

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

Signs/symptoms of distress Dyspnea Restlessness/anxiety Tachypnea/Bradypnea Cyanosis (core) Abnormal sounds Retractions Diminished ability to speak

Dyspnea

Restlessness/anxiety

Tachypnea/Bradypnea

Cyanosis (core)

Abnormal sounds

Retractions

Diminished ability to speak

More S/S Retractions and/or use of accessory muscles Abdominal breathing Nasal flaring Productive cough Color? Irregular breathing Tripod position Pursed-lip breathing

Retractions and/or use of accessory muscles

Abdominal breathing

Nasal flaring

Productive cough

Color?

Irregular breathing

Tripod position

Pursed-lip breathing

Take another look ….What do you see?

Hows this? Pursed Lips Sparrow Chest Tripoding Retractions Abd retractions Kewl Haircut O2

Inadequate Breathing: Infants and Children Retractions Nasal Flaring See-Saw Breathing Diaphragmatic Breathing

BREAK?

The Usual Suspects Photo by Linda R. Chen - © 1995 Gramercy Pictures.

Top 6 you need to know COPD/Reactive Airway Disorders Emphysema Asthma Bronchitis Pneumonia CHF Pulmonary Emboli Hyperventilation Disorders Pneumothorax

COPD/Reactive Airway Disorders

Emphysema

Asthma

Bronchitis

Pneumonia

CHF

Pulmonary Emboli

Hyperventilation Disorders

Pneumothorax

COPD

Causes of Chronic Obstructive Pulmonary Disease (COPD) Cigarette smoking Environmental pollution Previous pulmonary infections Chronic asthma

Cigarette smoking

Environmental pollution

Previous pulmonary infections

Chronic asthma

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

“ 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

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..

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..

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.

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.

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.

“ 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.

ASTHMA: causes…. Reactive airway event caused by bronchospasm, reversible Extrinsic: environmental, allergic trigger, temperature Intrinsic: exertion/ stress, illness Inflammatory reaction

Reactive airway event caused by bronchospasm, reversible

Extrinsic: environmental, allergic trigger, temperature

Intrinsic: exertion/ stress, illness

Inflammatory reaction

Acute asthmatic attack: Bronchospasm: rapid onset, can be relieved by medications Swelling of mucous membranes in bronchial walls (inflammatory response) Mucus plugging of bronchi

Bronchospasm: rapid onset, can be relieved by medications

Swelling of mucous membranes in bronchial walls (inflammatory response)

Mucus plugging of bronchi

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

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

Status Asthmaticus Prolonged asthma attack that is not broken by normal treatments Requires aggressive treatment and transportation A SILENT CHEST IS BAD!

Prolonged asthma attack that is not broken by normal treatments

Requires aggressive treatment and transportation

A SILENT CHEST IS BAD!

Treatment Reassure High flow humidified oxygen Assist with medication (per protocol) Position of comfort Insure adequate ventilation BronchoDilators

Reassure

High flow humidified oxygen

Assist with medication (per protocol)

Position of comfort

Insure adequate ventilation

BronchoDilators

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

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

Metered Dose Inhaler EMT’s may “assist” a patient with a PRESCRIBED MDI in: Respiratory Distress Allergic reactions with wheezing

EMT’s may “assist” a patient with a PRESCRIBED MDI in:

Respiratory Distress

Allergic reactions with wheezing

BASIC USE OF AN MDI

Remember to Obtain orders from medical direction.

Remember the 5 R’s

Remember the 5 R’s RIGHT PATIENT RIGHT MEDICATION RIGHT DOSE RIGHT ROUTE RIGHT SITUATION/TIME

RIGHT PATIENT

RIGHT MEDICATION

RIGHT DOSE

RIGHT ROUTE

RIGHT SITUATION/TIME

Shake vigorously

Depress hand-held inhaler as patient inhales deeply.

Instruct patient to hold/blow out breath.

Allow patient to breathe. Repeat dose if ordered.

Spacer Device

REMEMBER: ALL THAT WHEEZES IS NOT ASTHMA….. AND NOT ALL ASTHMA WHEEZES!

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

Other causes:

acute left heart failure (“cardiac asthma”)

smoke inhalation

chronic bronchitis

acute pulmonary embolism

May be localized: suspect an obstruction

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

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

NEVER WITHHOLD OXYGEN FROM A PATIENT WHO NEEDS IT!

Signs and Symptoms Something has changed from normal Marked respiratory distress Diaphoresis, cyanosis Agitation and confusion (hypoxemia), lethargy (hypercarbia) Tachypnea, tachycardia, irregular heart beat

Something has changed from normal

Marked respiratory distress

Diaphoresis, cyanosis

Agitation and confusion (hypoxemia), lethargy (hypercarbia)

Tachypnea, tachycardia, irregular heart beat

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

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

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)

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)

Signs and Symptoms Anxiety tachypnea/tachycardia dyspnea, hemoptysis abnormal breath sounds (moist, wheezes) JVD Elevated blood pressure orthopnea/paroxysmal nocturnal dyspnea

Anxiety

tachypnea/tachycardia

dyspnea, hemoptysis

abnormal breath sounds (moist, wheezes)

JVD

Elevated blood pressure

orthopnea/paroxysmal nocturnal dyspnea

Treatment: Reassure High flow oxygen (positive pressure) NTG (Medical Control Only) Position of comfort Rapid transport

Reassure

High flow oxygen (positive pressure)

NTG (Medical Control Only)

Position of comfort

Rapid transport

Pneumonia Definition: infection of respiratory tree, may result in systemic sepsis Types: bacterial 90% viral (from influenza) mycoplasmal/fungal aspiration

Definition: infection of respiratory tree, may result in systemic sepsis

Types:

bacterial 90%

viral (from influenza)

mycoplasmal/fungal

aspiration

Signs and symptoms Patient looks sick/dehydrated Illness over several days Fever Dehydration Productive cough tachypnea/ tachycardia Rales and rhonchi

Patient looks sick/dehydrated

Illness over several days

Fever

Dehydration

Productive cough

tachypnea/ tachycardia

Rales and rhonchi

Treatment: Oxygen and transport

Oxygen and transport

Pulmonary Embolism Definition: sudden blocking of pulmonary artery by clot Causes: blood clots in legs prolonged immobilization birth control pills

Definition: sudden blocking of pulmonary artery by clot

Causes:

blood clots in legs

prolonged immobilization

birth control pills

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

Sudden onset of severe, unexplained dyspnea

other s/s may or may not be present

chest pain made worse on coughing

Tachycardia/tachypnea

JVD

Treatment Recognition Oxygen Hospitalization Suspect PE when there is acute onset of tachycardia or dyspnea of unknown origin

Recognition

Oxygen

Hospitalization

Suspect PE when there is acute onset of tachycardia or dyspnea of unknown origin

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

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

Signs and symptoms Elevated respiratory rate or increased depth chest pain tingling or numbness around mouth, hands, feet Carpopedal spasm

Elevated respiratory rate or increased depth

chest pain

tingling or numbness around mouth, hands, feet

Carpopedal spasm

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

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

Spontaneous Pneumothorax Definition: sudden leak of air into pleural space; may have no apparent cause Frequently young, tall, thin males May have previous history

Definition: sudden leak of air into pleural space; may have no apparent cause

Frequently young, tall, thin males

May have previous history

Signs/ symptoms Sudden, sharp chest pain Sudden dyspnea Diminished breath sounds Pleuritic chest pain

Sudden, sharp chest pain

Sudden dyspnea

Diminished breath sounds

Pleuritic chest pain

Treatment Oxygen and transport

Oxygen and transport

Other problems: Pickwickian syndrome: patient is VERY obese, related to sleep apnea Cystic fibrosis Legionnaires (type of pneumonia)

Pickwickian syndrome: patient is VERY obese, related to sleep apnea

Cystic fibrosis

Legionnaires (type of pneumonia)

Getting a good history will be one of the most important ways to differentiate between respiratory conditions Look for underlying conditions

Getting a good history will be one of the most important ways to differentiate between respiratory conditions

Look for underlying conditions

Questions?