EMS- Respiratory Emergencies (Again)

Slide 1: Respiratory Emergencies (again) Steve Cole, Paramedic, CCEMT-P

Slide 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.

Slide 3: What we are going to discuss  Respiratory PHYSIOLOGY  5 most common respiratory problems in adults (PEDS will come later)

Slide 4: Basic Concept: Air Goes in and Out Blood Goes Round and Round Any thing infringing on this is a BAD THING!

Slide 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”.

Slide 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.

Slide 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.

Slide 8: Volume  Tidal Volume  Minute Volume – Tidal Volume X Respiratory Rate = Minute Volume

Slide 9: Respiratory Physiology

Slide 10: What do we assess?  Presence or absence?  Rate  Quality

Slide 11: Respiratory Rate  Decreased by: – Depressant Drugs – Sleep  Increased by: – Fever – Fear – Exertion

Slide 12: Respiratory Quality  Irregular: Neuro Insult.  Shallow: – Respiratory Depressants – CNS Depressants – Neuro Insult  Deep: – Hyperglycemia with Acidosis (DKA): “Kussmal Respirations – Electrolyte Imbalances – Neuro Insult

Slide 13: Adult Lung Volumes  5,500 to 6,000mL at end inspiration.  Normal tidal volume: 500mL  Dead space air: 150mL  Alveolar Air: 350mL

Slide 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

Slide 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

Slide 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

Slide 17: Dr. Slovis’s top 5 effects on respiratory drive.  CVA  Trauma to the brain  Drugs  Tumor  Electrolyte Imbalances

Slide 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.”

Slide 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.

Slide 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.

Slide 21: The Mechanical Bellows  Example of a Compromised Bellows  Positional Asphyxia Special Thanks to Charlie Miller for this Graphic.

Slide 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

Slide 23: Diffusion

Slide 24: An O2 friendly RBC with hgb.  Hemoglobin is an Iron Based compound essential to the transport of O2. – Anemia – Cyanide Poisoning – CO Poisoning

Slide 25: An intact circulatory system  Blood Loss  Shock – Pump Problem – Volume Problem » Fluid issue » O2 carrying issue – Vessel Problem

Slide 26: Must have enough of a pressure to promote diffusion.  Conditions like Hypotension cause secondary hypoxia by promoting low perfusion.

Slide 27: Assessing the pt with Respiratory Distress.

Slide 28: First Impressions  Air Hungry  Nasal Flaring  Tripoding  Rocking with respirations  Pursed Lip Breathing  Barrel or Sparrow Chest  Home O2

Slide 29: Skin Signs  Cyanosis – Nail Beds – Lips – Ears  Mottling – Chest – Lower Ext – Abd

Slide 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

Slide 31: Speech Dyspnea  Inability to speak more than a few sylables in a sentence between breaths.

Slide 32: Breath Sounds  Listening by comparison  Listening anterior  Listening posterior  Fremitus

Slide 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

Slide 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

Slide 37: Signs/symptoms of distress  Dyspnea  Restlessness/anxiety  Tachypnea/Bradypnea  Cyanosis (core)  Abnormal sounds  Retractions  Diminished ability to speak

Slide 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

Slide 39: Take another look ….What do you see?

Slide 40: Kewl Haircut Retractions Pursed Lips O2 Sparrow Chest Abd retractions Tripoding Hows this?

Slide 41: Inadequate Breathing: Infants and Children Nasal Flaring Retractions See-Saw Breathing Diaphragmatic Breathing

Slide 42: BREAK?

Slide 43: The Usual Suspects Photo by Linda R. Chen - © 1995 Gramercy Pictures.

Slide 44: Top 6 you need to know  COPD/Reactive Airway Disorders – Emphysema – Asthma – Bronchitis  Pneumonia  CHF  Pulmonary Emboli  Hyperventilation Disorders  Pneumothorax

Slide 45: COPD

Slide 46: Causes of Chronic Obstructive Pulmonary Disease (COPD)  Cigarette smoking  Environmental pollution  Previous pulmonary infections  Chronic asthma

Slide 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

Slide 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..

Slide 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.

Slide 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.

Slide 51: ASTHMA: causes….  Reactive airway event caused by bronchospasm, reversible  Extrinsic: environmental, allergic trigger, temperature  Intrinsic: exertion/ stress, illness  Inflammatory reaction

Slide 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

Slide 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

Slide 54: Status Asthmaticus  Prolonged asthma attack that is not broken by normal treatments  Requires aggressive treatment and transportation  A SILENT CHEST IS BAD!

Slide 55: Treatment  Reassure  High flow humidified oxygen  Assist with medication (per protocol)  Position of comfort  Insure adequate ventilation  BronchoDilators

Slide 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

Slide 57: Metered Dose Inhaler  EMT’s may “assist” a patient with a PRESCRIBED MDI in: – Respiratory Distress – Allergic reactions with wheezing

Slide 58: BASIC USE OF AN MDI

Slide 59: Remember to Obtain orders from medical direction.

Slide 60: Remember the 5 R’s

Slide 61: Remember the 5 R’s  RIGHT PATIENT  RIGHT MEDICATION  RIGHT DOSE  RIGHT ROUTE  RIGHT SITUATION/TIME

Slide 62: Shake vigorously

Slide 63: Depress hand-held inhaler as patient inhales deeply.

Slide 64: Instruct patient to hold/blow out breath.

Slide 65: Allow patient to breathe. Repeat dose if ordered.

Slide 66: Spacer Device

Slide 67: REMEMBER: ALL THAT WHEEZES IS NOT ASTHMA….. AND NOT ALL ASTHMA WHEEZES!

Slide 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

Slide 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

Slide 70: NEVER WITHHOLD OXYGEN FROM A PATIENT WHO NEEDS IT!

Slide 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

Slide 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

Slide 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)

Slide 74: Signs and Symptoms  Anxiety  tachypnea/tachycardia  dyspnea, hemoptysis  abnormal breath sounds (moist, wheezes)  JVD  Elevated blood pressure  orthopnea/paroxysmal nocturnal dyspnea

Slide 75: Treatment:  Reassure  High flow oxygen (positive pressure)  NTG (Medical Control Only)  Position of comfort  Rapid transport

Slide 76: Pneumonia  Definition: infection of respiratory tree, may result in systemic sepsis  Types: – bacterial 90% – viral (from influenza) – mycoplasmal/fungal – aspiration

Slide 77: Signs and symptoms  Patient looks sick/dehydrated  Illness over several days  Fever  Dehydration  Productive cough  tachypnea/ tachycardia  Rales and rhonchi

Slide 78: Treatment:  Oxygen and transport

Slide 79: Pulmonary Embolism  Definition:sudden blocking of pulmonary artery by clot  Causes: – blood clots in legs – prolonged immobilization – birth control pills

Slide 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

Slide 81: Treatment  Recognition  Oxygen  Hospitalization  Suspect PE when there is acute onset of tachycardia or dyspnea of unknown origin

Slide 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

Slide 83: Signs and symptoms  Elevated respiratory rate or increased depth  chest pain  tingling or numbness around mouth, hands, feet  Carpopedal spasm

Slide 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

Slide 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

Slide 86: Signs/ symptoms  Sudden, sharp chest pain  Sudden dyspnea  Diminished breath sounds  Pleuritic chest pain

Slide 87: Treatment  Oxygen and transport

Slide 88: Other problems:  Pickwickian syndrome: patient is VERY obese, related to sleep apnea  Cystic fibrosis  Legionnaires (type of pneumonia)

Slide 89:  Getting a good history will be one of the most important ways to differentiate between respiratory conditions  Look for underlying conditions

Slide 90: Questions?