Respiratory I

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Respiratory I

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

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