Respiratory Emergencies for   the Emergency Nurse         By Kane Guthrie   ED Graduate Nurse Study Day
Objectives•   Introduction to respiratory emergencies•   Assessing the respiratory patient•   Common presentations•   Case...
Respiratory Emergencies• “Can result from an array of different causes,     from acute exacerbation of a long-term  chroni...
The Respiratory SystemPurpose:• Exchange of gases between the environmental air    and the blood• Oxygenation of blood occ...
The Respiratory System                Structure• Upper and lower tracts  – Upper respiratory tract (upper airways)     • N...
The Upper Airway
The Respiratory Tract
The Ventilatory Structures
Physiology or Respiration
Respiratory Terminology•Dyspnoea                •Difficulty in breathing•Orthopnoea              •Dyspnoea necessitating a...
The Respiratory Exam
Assessing the Respiratory                 PatientA-F approach:• assess Airway and treat if needed• assess Breathing & trea...
The Respiratory ExamGeneral:Level of consciousness:• Agitation/anxiety• Speech  – Sentences/phrases/words/unable to speak ...
The Respiratory ExamHead and neck:• Nasal flaring• Pursed-lip breathing• Mouth vs nose breathing• Evidence of trauma: defo...
The Respiratory ExamThorax:• Symmetry of chest wall movement• Accessory muscle use, recession• Rate, rhythm, pattern of br...
The Respiratory ExamExtremities:• Clubbing• Oedema• Peripheral cyanosis
Breath Sounds1. Crackles            •Caused by opening of collapsed alveoli,                       or from fluid in smalle...
Investigating & Monitoring the          Respiratory Patient• Physical assessment can be further informed by  appropriate u...
The Humble Respiratory Rate•   The neglected vital sign•   Done poorly by nurses•   Pulse oximetry is not a replacement•  ...
Pulse Oximetry        •Pulse oximetry provides non-invasive (almost) real-time                  measurement of oxygen satu...
Capnography• End-tidal carbon dioxide monitoring (EtCO2)• Gold standard for ET placement, and  procedural sedation• Correl...
Capnography
The Blood GasProvides information regarding respiratory  function:• Acid-base balance• Oxygenation• Ventilation• Tissue pe...
Blood Gas ValuesValue                      ABG                          VBGpH                         7.35-7.45           ...
Acid/Base ImbalancesResp Acidosis              •pH<7.35mmol/L                           •PaCO2 > 45mmHgResp Alkalosis     ...
5 steps to interpreting the                     Blood GasStep 1• Look at Pa02 level “does the Pao2 show hypoxaemia?”Step 2...
The CXR
Interpreting the CXRAppearance       •Chest view (AP, lateral, PA), airway, addition                 apparatus- (ETT, trac...
PEFM & Spirometry• Both assess for airway limitations &  obstructionPEFM – used to assess “Peak Expiratory Flow”  – Monito...
Respiratory Failure is the                  Enemy         •Respiratory failure occurs when either function of gas        e...
Causes of Respiratory CompromiseCategory                       DiseaseChest wall disorders           •Chest wall restricti...
Causes of HypoxiaMechanism                                Common clinical causesDecrease in Fi02                         •...
Case Study• 69 male• Presents with 3/7 hx of cough, SOB, and feversPMHx: MI, CVA, COPD, DM TYPE 2Meds: Home O2, spiriva, a...
Blood Gas and CXR• An ABG shows the following:  – pH 7.20mmHg  – PaC02 69mmHg  – Pa02 70mmHg  – HC03 25 mmol/L
The Result’s•   pH is acidotic•   PaC02 is acidotic (High)•   HC03 is normal (no compensation)•   Pa02 is low – hypoxaemic...
COPD   “COPD- pulmonary disease characterised by airflow limitation that is not fully                                 reve...
COPD AssessmentLook for:• Chronic –progressive dyspnea-tachypnoea• Cough• Increased sputum production/colour change• Wheez...
COPD Monitoring & Investigations•   Continuous Sp02•   Blood Gas•   Blood –FBC, U&E, CRP•   CXR
COPD Management•   Oxygen- Keep Sp02 88-92%•   Ventilation- NIV-Mechanical ventilation•   Bronchodialtors- Salbutamol, Ipr...
Non-Invasive Ventilation• Used a lot in ED• NIV= delivery of O2 by positive pressure mask.Two modalities:  – CPAP = fixed ...
Case Study• 19 y.o. male• Playing Basket ball• Sudden onset SOB and R sided inspiratory chest  pain.Vitals: RR 28, SPO2 93...
The X-ray
Pneumothorax      “PTX is a collection of gas in the pleural cavity of the chest      between the lung and chest wall.”• P...
Pneumothorax AssessmentLook for:• Significant dyspnea• Reduced chest expansion• Increased resonance on percussion• Diminis...
Pneumothorax Management• Small <2cm, with no lung disease .D/C home GP F/U. (No  flying 1/52, Never SCUBA dive)Moderate –L...
Case Study• 44 female• P1 from SJA, severe SOB, wheezing, becoming  more agitatedPMHx: Asthma x2 ICU admits, depressionMed...
Asthma      •Asthma characterised by bronchial hyper-responsiveness and       inflammation that cause episodic reversible ...
Asthma AssessmentLook for:• Dyspnea > tachypnoea• Wheezing, chest tightness, cough• Prolonged expiration, ability to speak...
Asthma Investigations“Test’s provide little information over clinical  assessment”• P.E.F.M.• Spirometry• CXR• Blood gas
Asthma ManagementManagement determined by severity.Mild > Moderate:Oxygen: Keep spo2 >95%Bronchodilators: Salbutamol 5mg M...
Asthma Management• Severe:• Goal is to prevent intubation but maximising  therapy.• Ventilation: Trial NIV  – Intubation i...
Case Study• 38 y.o. female• C/O increasing SOB and inspiratory chest pain.PMHx: Recent DVT – post flight from LondonMeds: ...
Pulmonary Embolus        •PE is blockage of the main artery of the lung or one of its       branches by a substance that h...
Pulmonary Embolus Investigation•   CXR•   Blood Gas•   D-Dimmer•   ECG•   V/Q Scan•   CT-PA•   ECHO
CT-PA
Pulmonary Embolus AssessmentLook for:• Dyspnea-tachypnoea• Chest pain• Decreased Pa02Deteriorating:• Hypotensive• Cardioge...
Pulmonary Embolus Management• Prevention – VTE prophylaxis• Start Heparin infusion• Add warfrin• Admit: RespiratoryDeterio...
Case Study• 23 female• C/O SOB, wheezing, productive cough, runny  nose. Currently 20/40.PMHx: Nil.Meds: OCP.O/A: Severe S...
Her CXR
Influenza Like IllnessCharacterised:• Temp >37.8°C• Cough• Sore throat• Absence of a KNOWN cause other than  influenza    ...
H1N1• Influenza A virus is quadruple reassortant  virus – genes from avian strain, 2 swine  strains, 2 human strains.• Ful...
@ Risk Groups for             Critical H1N1• Children <5 y.o.• Adults > 65 y.o• Pregnant women• PT’s with – CHRONIC pulmon...
Influenza Like Illness Assessment• Dyspnoea >tachypnoea• Fever• Sore throat• Productive coughDeteriorating:• Spo2 dropping...
Influenza Like Illness Management•   PPE-Droplet Precautions•   Majority of cases are the humble FLU!•   Swabs – supportiv...
Take Home Points• You will see lots of different respiratory  conditions during your ED period.• Most are chronic.• Assess...
Questions
Thank-you!!!
Basics of Respiratory Emergencies for ED Nurses!
Basics of Respiratory Emergencies for ED Nurses!
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  • Ventilation, the movement of air in and out of lungsDiffusion, the movement of gases between the airspaces in the lungs and the blood stream
  • Hypoxia is the eneemy
  • Basics of Respiratory Emergencies for ED Nurses!

    1. 1. Respiratory Emergencies for the Emergency Nurse By Kane Guthrie ED Graduate Nurse Study Day
    2. 2. Objectives• Introduction to respiratory emergencies• Assessing the respiratory patient• Common presentations• Case studies• Take home points
    3. 3. Respiratory Emergencies• “Can result from an array of different causes, from acute exacerbation of a long-term chronic respiratory disease to acute traumatic injury”
    4. 4. The Respiratory SystemPurpose:• Exchange of gases between the environmental air and the blood• Oxygenation of blood occurs via a two step process – Ventilation – Diffusion
    5. 5. The Respiratory System Structure• Upper and lower tracts – Upper respiratory tract (upper airways) • Nose, mouth, sinuses, pharynx (upper section of the throat), larynx (voice box), trachea (windpipe) – Lower respiratory tract • Lungs, bronchial tubes, and alveoli
    6. 6. The Upper Airway
    7. 7. The Respiratory Tract
    8. 8. The Ventilatory Structures
    9. 9. Physiology or Respiration
    10. 10. Respiratory Terminology•Dyspnoea •Difficulty in breathing•Orthopnoea •Dyspnoea necessitating an upright, sitting position for its relief•Tachypnoea •Abnormally rapid rate of breathing (>20)•Bradypnoea •Abnormally slow rate of breathing (<12)•Hypoxia •Inadequate o2 at cellular level•Hypoxaemia •Low o2 levels in blood•Anoxia •Lack or oxygen, local or systemic
    11. 11. The Respiratory Exam
    12. 12. Assessing the Respiratory PatientA-F approach:• assess Airway and treat if needed• assess Breathing & treat if needed• assess Circulation & treat if needed• assess Disability& treat if needed• Expose & examine patient fully once A.B.C.D are stable.• Full set of vital signs!
    13. 13. The Respiratory ExamGeneral:Level of consciousness:• Agitation/anxiety• Speech – Sentences/phrases/words/unable to speak – Quality (hoarness)Skin colour:• Pallor/cyanosis• Exercise tolernace/bodyposition
    14. 14. The Respiratory ExamHead and neck:• Nasal flaring• Pursed-lip breathing• Mouth vs nose breathing• Evidence of trauma: deformity, bruising, wounds, swelling, burns• Tracheal position• Tracheal plug
    15. 15. The Respiratory ExamThorax:• Symmetry of chest wall movement• Accessory muscle use, recession• Rate, rhythm, pattern of breathing• Evidence of trauma, wounds, deformity, flail, bruising, scars• Anterposterior vs transverse diameter of chest• Alignment of spine, presence of kyphosis, scoliosis
    16. 16. The Respiratory ExamExtremities:• Clubbing• Oedema• Peripheral cyanosis
    17. 17. Breath Sounds1. Crackles •Caused by opening of collapsed alveoli, or from fluid in smaller airways. (pneumonia)2. Wheezes •Air moves through narrowed/tight airways. (FB, bronchoconstriction, sputum). Continuous musical sound.3. Rhonchi •Caused by secretions in large airways.4. Pleural rub •Heard on inspiration, grating or crackling sound.5. Stridor •High-pitched crowing-type noise-louder during inspiration. Indicates obstruction.
    18. 18. Investigating & Monitoring the Respiratory Patient• Physical assessment can be further informed by appropriate use of investigations in the ED such as: • Pulse oximetry • Capnography • Blood Gases • Radiographs • Peak Flow • Spirometry
    19. 19. The Humble Respiratory Rate• The neglected vital sign• Done poorly by nurses• Pulse oximetry is not a replacement• Average adult RR ?10-18• Recent study showed RR >27 was the most important predictor of cardiac arrest in ward patients. • (Cretikos, A. Et al. (2008) Medical Journal Australia)
    20. 20. Pulse Oximetry •Pulse oximetry provides non-invasive (almost) real-time measurement of oxygen saturation.• Amount of oxygenated haemaglobin being transferred• Normal range 95-99%• Accuracy decrease when Spo2 <70%• Poor perfusion and shock states will result inaccurate readings• Finger, ear, forehead devices available.
    21. 21. Capnography• End-tidal carbon dioxide monitoring (EtCO2)• Gold standard for ET placement, and procedural sedation• Correlates similarly to PaC02• Demonstrates adequacy of ventilation• Superior to pulse oximetry (real time)• More accurate than nurse’s at taking RR.• Normal range 35-45mmHg
    22. 22. Capnography
    23. 23. The Blood GasProvides information regarding respiratory function:• Acid-base balance• Oxygenation• Ventilation• Tissue perfusion & compensation
    24. 24. Blood Gas ValuesValue ABG VBGpH 7.35-7.45 7.35-7.38PaCO2 35-45mmHg 44-48mmHgPaO2 80-100mmHg 40mmHgHCO3 22-26mmol/L 21-22mmlol/LBase Excess (-)2-2mmol/L (-)2-2mmol/L • Most info that was traditionally gained from an ABG can now be gained from a VBG!!!
    25. 25. Acid/Base ImbalancesResp Acidosis •pH<7.35mmol/L •PaCO2 > 45mmHgResp Alkalosis •pH>7.45mmol/L •PaC02 <35mmHgMetabolic Acidosis •pH<7.35mmol/L •HCO3<22 •BE<(-)2Metabolic Alkalosis •pH>7.45mmol/L •HCO3 > 26mmol/L
    26. 26. 5 steps to interpreting the Blood GasStep 1• Look at Pa02 level “does the Pao2 show hypoxaemia?”Step 2• Look at the pH level “Is the pH on the acid /alkaline side of 7.40Step 3• Look at PaCO2 level “does it show resp acidosis/alkalosis or normalcy?”Step 4• Look at HC03 level “does it show metabolic acidosis/alkalosis or normalcy?”Step 5• Go back to the pH level does it show a compensated or uncompensated condition?
    27. 27. The CXR
    28. 28. Interpreting the CXRAppearance •Chest view (AP, lateral, PA), airway, addition apparatus- (ETT, trachy, ECG leads, NGT), Lung fieldsBones •FracturesCardiac shadow •Cardiac & costophrenic angles, aortic arch & width of mediastinumDiaphragm •Shape, breadth, depth (8th rib viewed) in lung field.Exposure •Are the posterior spinous process visible?Fine lines •Fine lines (Normal lung markings out to edge of lung field), fat line (congested fluid volume), fuzzy lines (infection).Gastric bubble •Gastric bubbleHylus markings •Hylus markingsIdentification •Named, URM
    29. 29. PEFM & Spirometry• Both assess for airway limitations & obstructionPEFM – used to assess “Peak Expiratory Flow” – Monitors effectiveness of asthma therapySpirometry – More sensitive info gathered – Forced vital capacity – Forced expiratory capacity – (FEV1:FVC) <80% = airflow limitations
    30. 30. Respiratory Failure is the Enemy •Respiratory failure occurs when either function of gas exchange- the exchange of oxygen and of carbon dioxide between the lungs and the atmosphere fails.Occurs when:• Pa02 fall < 60 mmHg (Type 1 – hypoxaemia)• PaC02 rises > 50mmHg (Type 2- hypercapnia) – Can be acute or chronic!
    31. 31. Causes of Respiratory CompromiseCategory DiseaseChest wall disorders •Chest wall restriction •Flail chestPleural abnormalities •Pneumothorax •Haemothorax •Pleural effusion •EmpyemaRestrictive lung disorders •Aspiration •Atelectasis •Bronchiectasis •Bronchiolisis •Pulmonary oedema •ARDSObstructive pulmonary •Asthmadisorders •COPDRespiratory tract infections •Pneumonia •Tuberculosis •Acute bronchitisPulmonary vascular disease •Pulmonary embolus •Pulmonary artery hypertension
    32. 32. Causes of HypoxiaMechanism Common clinical causesDecrease in Fi02 •High altitude •Low O2 concentration of gas mixture •SuffocationHypoventilation of the alveoli •Lack of neurological stimulation of the respiratory centre (medulla) •Defects in chest wall mechanics •Large airway obstruction •Increased work of breathingVentilation-perfusion mismatch •Asthma •Chronic bronchitis •Pneumonia •Atelectasis •Pulmonary embolus •ARDSAlveolocapillary diffusion abnormality •Oedema •Fibrosis •EmphysemaDecreased pulmonary capillary •Intracardic defectsperfusion •Intrapulmonary ateriovenous malformations
    33. 33. Case Study• 69 male• Presents with 3/7 hx of cough, SOB, and feversPMHx: MI, CVA, COPD, DM TYPE 2Meds: Home O2, spiriva, aspirin, ISMN.O/A: Sitting tripod position, pursed lip breathing, mildly agitated.O/E: Audible wheeze, using full accessory muscles, talking in words.Vitals: HR 123, RR44, Spo2 88, BP 179/94, T 38.4An ABG and CXR are done:
    34. 34. Blood Gas and CXR• An ABG shows the following: – pH 7.20mmHg – PaC02 69mmHg – Pa02 70mmHg – HC03 25 mmol/L
    35. 35. The Result’s• pH is acidotic• PaC02 is acidotic (High)• HC03 is normal (no compensation)• Pa02 is low – hypoxaemic – Respiratory acidosis• The chest X-ray shows: – Dynamic hyperinflation – RU Lobe pneumonia
    36. 36. COPD “COPD- pulmonary disease characterised by airflow limitation that is not fully reversible”Combination: – Chronic bronchitis – EmphysemaNarrowing of the airway = decrease airflow (FEV1)Poor gas exchange results hypercapnea & hypoxaemia• Chronic condition with acute exacerbations• Infective Vs Non-infective
    37. 37. COPD AssessmentLook for:• Chronic –progressive dyspnea-tachypnoea• Cough• Increased sputum production/colour change• Wheezing/chest tightnessDeteriorating:• Fatigue, agitation• Decreasing level of consciousness• Check Pc02
    38. 38. COPD Monitoring & Investigations• Continuous Sp02• Blood Gas• Blood –FBC, U&E, CRP• CXR
    39. 39. COPD Management• Oxygen- Keep Sp02 88-92%• Ventilation- NIV-Mechanical ventilation• Bronchodialtors- Salbutamol, Ipratropium• Other – Steriods, Abs-(if infection)• Dispo – admit resp/AAU
    40. 40. Non-Invasive Ventilation• Used a lot in ED• NIV= delivery of O2 by positive pressure mask.Two modalities: – CPAP = fixed pressure through-out. – BiPAP = 2 different pressure IPAP & EPAP through- out cycle.• Most effective in COPD, ACPE, asthma!
    41. 41. Case Study• 19 y.o. male• Playing Basket ball• Sudden onset SOB and R sided inspiratory chest pain.Vitals: RR 28, SPO2 93% RA, BP 105/62, P 110,O/E: Sitting high fowlers, talk in words, moderate use of accessory musclesO/A: Decreased Air Entry R side, ∧resonance on percussion
    42. 42. The X-ray
    43. 43. Pneumothorax “PTX is a collection of gas in the pleural cavity of the chest between the lung and chest wall.”• Primary PTX- occurs in healthy-no lung disease, tall patients.• Secondary PTX- occurs in chronic lung disease, (smokers high risk)• PTX – from blunt & penetrating trauma• Tension PTX – haemodynamic collapse –medical emergency
    44. 44. Pneumothorax AssessmentLook for:• Significant dyspnea• Reduced chest expansion• Increased resonance on percussion• Diminished breath soundsDeteriorating:• JVP distension• Hypotension• More distressed
    45. 45. Pneumothorax Management• Small <2cm, with no lung disease .D/C home GP F/U. (No flying 1/52, Never SCUBA dive)Moderate –Large PTX (2cm or more/50% lung volume lost)1. Needle aspiration2. Intercoastal catheter – ICC – Pigtail• Resp admit, serial CXR, encourage smoking cessation.• Tension = Needle Decompression – (14g canula 2nd intercostal space –midclavicular line)
    46. 46. Case Study• 44 female• P1 from SJA, severe SOB, wheezing, becoming more agitatedPMHx: Asthma x2 ICU admits, depressionMeds: Ventolin, Prednisolone, AvanzaO/A: Nebs insitu, talking in words, wheeze audible,O/E: Using accessory muscles, restless, tremulousVitals: RR36, spo2 97, HR 142, temp 35.9, BP 143/89
    47. 47. Asthma •Asthma characterised by bronchial hyper-responsiveness and inflammation that cause episodic reversible bronchospasm and increased mucus and oedema production.• Leads to widespread but variable airway obstruction that’s reversible either spontaneously or with treatment.• Activated by an allergic/inflammatory cascade.• Long term – develop irreversible lung function impairment.
    48. 48. Asthma AssessmentLook for:• Dyspnea > tachypnoea• Wheezing, chest tightness, cough• Prolonged expiration, ability to speak• Past asthma hxDeteriorating:• Inability to talk• Silent or quiet chest• Agitation, decreased level of consciousness
    49. 49. Asthma Investigations“Test’s provide little information over clinical assessment”• P.E.F.M.• Spirometry• CXR• Blood gas
    50. 50. Asthma ManagementManagement determined by severity.Mild > Moderate:Oxygen: Keep spo2 >95%Bronchodilators: Salbutamol 5mg MDI (prefered) or NebsAntichoinergics: Ipratropium bromide 500mcg MDI or NebSteriods: Prednisolone PO or Hydrocortisone IV• AB’s only if infective process present
    51. 51. Asthma Management• Severe:• Goal is to prevent intubation but maximising therapy.• Ventilation: Trial NIV – Intubation if fails.• Magnesium - causes smooth muscle relaxation > bronchodilation• Adrenaline –Alpha effect > airway oedema, Beta effect > bronchodilation
    52. 52. Case Study• 38 y.o. female• C/O increasing SOB and inspiratory chest pain.PMHx: Recent DVT – post flight from LondonMeds: Warfrin, OCPVitals: RR 24, Spo2 96 2l O2, BP 139/88, Temp 37.3, P 124O/A: Talking in sentences, no accessory muscle use,0/E: Good A:E bilaterally, no adventious sounds
    53. 53. Pulmonary Embolus •PE is blockage of the main artery of the lung or one of its branches by a substance that has traveled elsewhere in the body through the bloodstream.• Usually results from DVT• Risk Factors (Vircow’s Triad) – Hypercoaguability – Venous stasis – Endothelial damage• Impact of PE- dependent on size & blood flow compromise.
    54. 54. Pulmonary Embolus Investigation• CXR• Blood Gas• D-Dimmer• ECG• V/Q Scan• CT-PA• ECHO
    55. 55. CT-PA
    56. 56. Pulmonary Embolus AssessmentLook for:• Dyspnea-tachypnoea• Chest pain• Decreased Pa02Deteriorating:• Hypotensive• Cardiogenic shock• Worsening dyspnea
    57. 57. Pulmonary Embolus Management• Prevention – VTE prophylaxis• Start Heparin infusion• Add warfrin• Admit: RespiratoryDeteriorating:• Give thrombolysis• Consider Embolectomy
    58. 58. Case Study• 23 female• C/O SOB, wheezing, productive cough, runny nose. Currently 20/40.PMHx: Nil.Meds: OCP.O/A: Severe SOB, blue lips,O/E: Agitated, using all accessory muscles, talk in wordsVitals: RR42, SPO2 85%NRBM, BP 90/55, TEMP 37,5, GCS 14
    59. 59. Her CXR
    60. 60. Influenza Like IllnessCharacterised:• Temp >37.8°C• Cough• Sore throat• Absence of a KNOWN cause other than influenza •Generally benign clinical course
    61. 61. H1N1• Influenza A virus is quadruple reassortant virus – genes from avian strain, 2 swine strains, 2 human strains.• Full extent of virus unknown• 2009-10 left huge strain on ICU beds• High mortality in young patients• Relative lack of humoral immunity!!
    62. 62. @ Risk Groups for Critical H1N1• Children <5 y.o.• Adults > 65 y.o• Pregnant women• PT’s with – CHRONIC pulmonary, cardiovascular, hepatic, haematologic, neuro or metabolic disorders.• PT’s with immune defficency– (HIV , CHEMO)• Residents of NH
    63. 63. Influenza Like Illness Assessment• Dyspnoea >tachypnoea• Fever• Sore throat• Productive coughDeteriorating:• Spo2 dropping• Agitation• Respiratory distress
    64. 64. Influenza Like Illness Management• PPE-Droplet Precautions• Majority of cases are the humble FLU!• Swabs – supportive/respiratory care.• Commence antiviral: – Tamiflu 75-150mg BD – RelenzaDeteriorating:• Admit Resp or ICU• Early ventilatory support• ECMO
    65. 65. Take Home Points• You will see lots of different respiratory conditions during your ED period.• Most are chronic.• Assessment is important – reassessment is paramount.• Respiratory rate – do it properly• Enjoy the learning – NIV, mechanical ventilation – “skills for a lifetime”
    66. 66. Questions
    67. 67. Thank-you!!!
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