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Transcript

  • 1. Pulmonary Diseases & Disorders: Assessment EMS Professions Temple College
  • 2. Pulmonary Diseases & Disorders
    • Epidemiology
      • 28% of all EMS Chief Complaints in the US
      • >200,000 deaths annually due to respiratory emergencies
  • 3. Pulmonary Diseases & Disorders
    • Many, many pulmonary diseases
      • Difficult to learn all pathophysiologies
      • All can be categorized as affecting:
        • Ventilation
        • Diffusion (Respiration)
        • Perfusion
      • Treatment can be focused on identifying and treating source of ventilatory/respiratory impairment
  • 4. Sources of Pulmonary Impairment
    • Pulmonary Diseases
    • Disorders of the Pulmonary System
    • Non-Pulmonary Disorders/Disease Impairing Ventilation or Respiration
    • What examples can you list for each of these?
  • 5. Sources of Pulmonary Impairment
    • Ventilation
      • Upper Airway
        • Trauma
        • Epiglottitis
        • FBAO
        • Inflammation of tonsils
      • Lower Airway
        • Trauma
        • Obstructive lung disease
        • Mucous accumulation
        • Smooth muscle spasm
        • Airway edema
  • 6. Sources of Pulmonary Impairment
    • Ventilation
      • Chest Wall Impairment
        • Trauma
        • Hemothorax
        • Pneumothorax
        • Empyema
        • Pleural inflammation
        • Neuromuscular diseases
      • Neurologic Control
        • Brainstem dysfunction
        • Phrenic or spinal nerve dysfunction
  • 7. Sources of Pulmonary Impairment
    • Diffusion
      • Inadequate FiO2
      • Diseased alveoli
        • asbestosis
        • COPD
        • inhalation injury
      • Capillary bed disease
        • atherosclerosis
      • Interstitial space disease
        • High pressure pulmonary edema
        • High permeability pulmonary edema
  • 8. Sources of Pulmonary Impairment
    • Perfusion
      • Inadequate blood volume or hemoblogin
        • hypovolemia
        • anemia
      • Impaired blood flow
        • pulmonary embolus
      • Capillary wall pathology
        • trauma
  • 9. Risk Factors for Pulmonary Disease
    • Intrinsic Risk Factors
      • Genetic predisposition
        • asthma
        • COPD
        • carcinoma
      • Cardiac or Circulatory pathologies
        • Source for pulmonary edema
        • Source for pulmonary emboli
      • Stress
  • 10. Risk Factors for Pulmonary Disease
    • Extrinsic Factors
      • Smoking
        •  prevalence of COPD & carcinomas
        •  severity of pulmonary disease
      • Environmental Factors
        •  prevalence of COPD & asthma
        •  severity of all obstructive disorders
  • 11. Function of the Pulmonary System
    • Gas Exchange System
      • ~10,000 liters of air are filtered, warmed and humidified daily
      • Oxygen diffused into blood
      • Carbon dioxide excreted from the body
  • 12. Function of the Pulmonary System
    • Physiology of Ventilation
      • Requires neurologic initiation (brainstem)
      • Nerve conduction pathways between brainstem and muscles of respiration
      • Intact & patent Upper and Lower airways
      • Intact & non-collapsed alveoli
  • 13. Function of the Pulmonary System
    • Physiology of Respiration
      • Simple diffusion process at the pulmonary-capillary bed
      • Diffusion Requirements
        • Intact, non-thickened alveolar walls
        • Minimal interstitial space & without additional fluid
        • Intact, non-thickened capillary walls
  • 14. Function of the Pulmonary System
    • Physiology of Perfusion
      • Process of circulating blood through the capillary bed
      • Perfusion Requirements
        • Adequate blood volume
        • Adequate hemoglobin
        • Intact, non-occluded pulmonary capillaries
        • Functioning Left Heart
  • 15. Control of Ventilation
    • Control ventilation in response to physiologic needs
      • Driven 1° by pH of CSF
        • influenced largely by PaCO 2
      • 2° drive = PaCO 2
      • 3° drive = PaO 2 detected by chemoreceptors
        • very small population with severe COPD
  • 16. Nervous System Effect on Ventilation
    • Medulla
      • Stimulation to initiate ventilation
    • Phrenic Nerve
      • Innervation of the diaphragm
    • Spinal Nerves at Thoracic levels
      • Innervation of intercostal muscles
    • Hering-Breuer reflex
      • Prevents overinflation
  • 17. General Assessment
    • Size-Up
      • Environment
        • Airborne Hazards
        • Number of patients
        • Needs
          • Specialized rescue equipment
          • Protective equipment
      • Is the environment creating or exacerbating the pulmonary condition?
  • 18. General Assessment
    • Initial Goal
      • Identify potentially life-threatening pulmonary conditions
    • Perform minimal PE & Hx
      • Initiate immediate & appropriate therapies
    • Then, continue PE & Hx
      • Try to determine if origin is ventilation, diffusion, perfusion or combination
  • 19. General Assessment
    • Signs of potentially life-threatening pulmonary condition
      • altered mental status
      • absent signs of ventilation
      • Audible stridor or wheezing
      • Able to speak in short phrases only
      • Sustained Tachycardia
      • Pallor / Diaphoresis
      • Accessory muscle use / Retractions
  • 20. Assessment: H&P
    • Present History (focused hx)
      • Chief Complaint
        • Dyspnea
          • “ Subjective sensation that breathing is excessive, difficult or uncomfortable
        • CP
        • Cough, Hemoptysis
      • Associated Symptoms
        • Fever, Chills
        •  sputum production
        • Fatigue
  • 21. Assessment: H&P
    • Present History (focused hx)
      • Sputum Findings
        •  amount of sputum  infection
        • Thick green or brown  pneumonia or infection
        • Yellow or gray  allergic or inflammatory response
        • Hemoptysis  tuberculosis or carcinoma
        • Pink, frothy  severe pulmonary edema
  • 22. Assessment: H&P
    • HX of Present Illness
      • How long has dyspnea been present?
      • Gradual or sudden onset?
      • What aggravates or alleviates?
        • Hx of orthopnea?
      • Coughing?
      • Productive cough?
      • What does sputum look/smell like?
      • Pain?
      • What does the pain feel like?
  • 23. Assessment: H&P
    • Listen - To Pt. Breathe or Talk
      • Noisy Breathing is Obstructed Breathing
      • Not All Obstructed Breathing is Noisy
      • Snoring - Tongue Blocking Airway
      • Stridor - “Tight” Upper Airway from Partial Obstruction
    • Observe Breathing
      • Tachypnea
      • Bradypnea
  • 24. Assessment: H&P
    • Observe
      • Body Positioning
        • Tripod
        • Legs in dependent position
      • Mental Status
      • Ventilatory Effort
        • Accessory muscle use / retractions
        • Abdominal muscle use
        • Chest wall expansion
        • Nasal flaring, pursed lips
  • 25. Assessment: H&P
    • Physical Exam of the Chest
      • Increased A-P Diameter
      • Lung Sounds
        • Abnormal: stridor, wheezing, rhonchi, rales, pleural rub
      • Chest expansion
      • Symmetrical Findings
      • Evidence of Trauma
  • 26. Assessment: H&P
    • Physical Exam
      • Cyanosis?
        • Late, unreliable sign of Hypoxia
      • Oxygenate Immediately! Especially If:
        • Decreased LOC
        • Possible Shock
        • Possible Severe Hemorrhage
        • Chest Pain
        • Chest Trauma
        • Respiratory distress or dyspnea
        • HX of any Kind of Hypoxia
  • 27. Assessment: H&P
    • Physical Exam
      • Vital Signs
        • Skin Color, Temp & Moisture
        • Respiratory Rate
          • No an accurate lone indicator of respiratory status unless very slow
        • Respiratory Rhythm/Pattern
        • Pulse
          • Bradycardia vs Tachycardia
        • Blood Pressure
  • 28. Assessment: H&P
    • Physical Exam - Circulatory assessment
      • Is the heart beating?
      • Is there major external hemorrhage?
      • Is the Pt. Perfusing vital organs?
      • Effects of hypoxia:
        • Early in adults - Tachycardia
        • Late in adults - Bradycardia
        • Children - Bradycardia
  • 29. Assessment: H&P
    • Don’t let respiratory failure distract you from assessing for circulatory failure.
    • Vascular Access
  • 30. Assessment: H&P
    • Physical Exam
      • Extremities
        • Peripheral Cyanosis
        • Clubbing
        • Carpopedal spasm
        • Peripheral edema
  • 31. Assessment: H&P
    • Diagnostic Testing
      • Pulse oximetry
        • Saturation
        • Inaccuracies & Disadvantages
      • Peak Flow Meter
        • Baseline measurement for obstructive lung disease
        • Often available from patient
      • Capnometry
        • real-time assessment of endotracheal tube placement
        • quantitative vs qualitative
  • 32. Assessment: H&P
    • Past History
      • Similar Episodes in Past
        • Patient’s description of acuity
        • “What happened last time you had an episode this bad?”
    • Chronic Symptoms
      • Acute, Seasonal SOB episodes
      • Seasonal Allergies
      • Chronic cough
      • Recurrent flu, pulmonary infection or SOB
  • 33. Assessment: H&P
    • Past History
      • Known diagnosis
        • Does the present H&P correlate with this past history?
          • CHF
          • Hypertension
          • Renal Failure
      • Previous intubation or hospitalization
      • Aggravating Factors (e.g. smoking)
  • 34. Assessment: H&P
    • Past History
      • Medications
        • Class, Route, Frequency of Use
        • Pulmonary
          • Sympathomimetics
          • Corticosteroids
          • MAST Cell Stabilizer
          • Methylxanthines
        • Cardiovascular
          • Diuretics
          • Antihypertensives
          • Cardiac glycosides
  • 35. Assessment: H&P
    • Disability
      • Restlessness, anxiety, combativeness = HYPOXIA Until Proven Otherwise
      • Drowsiness, lethargy = HYPERCARBIA
    When the patient stops fighting, he is not necessarily getting Better!!
  • 36. Other Adventitious Sounds
    • Cough
      • Forced exhalation against partially closed glottis
      • Reflex response to mucosa irritation
      • Determine circumstances
        • At work
        • Postural changes
        • Lying down
      • Productive vs non-productive
  • 37. Other Adventitious Sounds
    • Sneeze
      • Forced exhalation via nasal route
      • Clears nasal passages
      • Reflex response to mucosa irritation
    • Sigh
      • Slow, deep inspiration - Prolonged, audible exhalation
      • Reexpands areas of atelectasis
  • 38. Other Adventitious Sounds
    • Hiccough
      • Hiccups, singultus
      • Spasm of diaphragm followed by glottic closure
      • No useful purpose
      • Benign, transient