17)Respiratory Emergencies

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17)Respiratory Emergencies

  1. 1. Respiratory Emergencies
  2. 2. Respiratory Emergencies <ul><li>AIRWAY… </li></ul><ul><li>AIRWAY… </li></ul><ul><li>AIRWAY… </li></ul><ul><ul><li>One of the most life threatening emergencies </li></ul></ul><ul><ul><li>Maintain an open airway!!! </li></ul></ul><ul><ul><li>Ensure oxygenation and ventilation </li></ul></ul><ul><li>Complications </li></ul><ul><ul><li>Must extend uninterrupted from nose/mouth to alveoli </li></ul></ul><ul><ul><li>Muscles of respiration must move air in/out efficiently </li></ul></ul><ul><ul><li>Diffusion of gases must occur over alveoli/capillary membrane </li></ul></ul><ul><ul><li>Also depends on brain stem to monitor and control resp via nerves </li></ul></ul>
  3. 3. Respiratory System <ul><li>Function </li></ul><ul><ul><li>Gas exchange with outside environment </li></ul></ul><ul><ul><li>Filtration/Humidification/Warming/Conduction of air </li></ul></ul><ul><li>Structures </li></ul><ul><ul><li>Nose </li></ul></ul><ul><ul><li>Mouth </li></ul></ul><ul><ul><li>Naso/Oro/Laryngopharynx </li></ul></ul><ul><ul><li>Larynx </li></ul></ul><ul><ul><li>Bronchi </li></ul></ul><ul><ul><ul><li>Bronchioles </li></ul></ul></ul><ul><ul><li>Lungs </li></ul></ul><ul><ul><li>Diaphragm </li></ul></ul><ul><ul><ul><li>Associated muscles </li></ul></ul></ul><ul><ul><li>Alveoli </li></ul></ul>
  4. 4. Upper Airway Nose/Mouth <ul><li>Function </li></ul><ul><ul><li>Filters </li></ul></ul><ul><ul><li>Warms </li></ul></ul><ul><ul><li>Moistens </li></ul></ul>
  5. 5. Upper Airway Pharynx <ul><li>Location </li></ul><ul><ul><li>Posterior to mouth </li></ul></ul><ul><ul><li>Superior to esophagus, larynx, trachea </li></ul></ul><ul><li>Function </li></ul><ul><ul><li>Conducts air to bronchi </li></ul></ul><ul><li>3 Divisions </li></ul><ul><ul><ul><li>Nasopharynx </li></ul></ul></ul><ul><ul><ul><li>Oropharynx </li></ul></ul></ul><ul><ul><ul><li>Laryngopharynx </li></ul></ul></ul>
  6. 6. Upper Airway Epiglottis <ul><li>Location </li></ul><ul><ul><li>Sits posterior to larynx </li></ul></ul><ul><ul><li>Attached to tongue </li></ul></ul><ul><li>Structure </li></ul><ul><ul><li>Leaf shaped cartilage </li></ul></ul><ul><li>Function </li></ul><ul><ul><li>Prevents food/liquid from entering larynx during swallowing </li></ul></ul><ul><ul><li>Guards opening to vocal cords (glottis) </li></ul></ul>
  7. 7. Upper Airway Larynx <ul><li>AKA: “Voice box” </li></ul><ul><li>Location </li></ul><ul><ul><li>Inferior to epiglottis </li></ul></ul><ul><ul><li>Superior to trachea </li></ul></ul><ul><li>Structure </li></ul><ul><ul><li>Cartilaginous rings </li></ul></ul><ul><ul><ul><li>Thyroid Cartilage = “Adam’s Apple” </li></ul></ul></ul><ul><ul><ul><ul><li>Bulk of anterior wall </li></ul></ul></ul></ul><ul><ul><ul><li>Cricoid Cartilage </li></ul></ul></ul><ul><ul><ul><ul><li>Firm rings forming lower aspect/base </li></ul></ul></ul></ul><ul><li>Function </li></ul><ul><ul><li>Stops foreign objects that pass epiglottis </li></ul></ul><ul><ul><ul><li>Laryngospasm </li></ul></ul></ul><ul><ul><li>Voice production </li></ul></ul>
  8. 8. Lower Airway Trachea <ul><li>AKA: “Windpipe” </li></ul><ul><li>Location </li></ul><ul><ul><li>Inferior to Larynx </li></ul></ul><ul><ul><li>Anterior to Esophagus </li></ul></ul><ul><ul><li>Bifurcates into primary bronchi </li></ul></ul><ul><li>Structure </li></ul><ul><ul><li>Cartilaginous rings anterior and lateral </li></ul></ul><ul><ul><ul><li>Approx 15-20 </li></ul></ul></ul><ul><ul><li>Smooth muscle tissue posterior </li></ul></ul><ul><ul><ul><li>Trachealis muscle </li></ul></ul></ul><ul><ul><li>Why???? </li></ul></ul>
  9. 9. Lower Airway Bronchi <ul><li>Location </li></ul><ul><ul><li>Bifurcation of trachea </li></ul></ul><ul><ul><ul><li>2 nd Intercostal space </li></ul></ul></ul><ul><ul><ul><ul><li>Angle of Louis </li></ul></ul></ul></ul><ul><ul><li>Right and Left main stem </li></ul></ul><ul><li>Structure </li></ul><ul><ul><li>Smooth muscle </li></ul></ul><ul><ul><li>Irregular hyaline cartilage rings </li></ul></ul><ul><li>Function </li></ul><ul><ul><li>Conducts air to lungs </li></ul></ul>
  10. 10. Lower Airway Bronchioles <ul><li>Location </li></ul><ul><ul><li>Distal bifurcations of the bronchi </li></ul></ul><ul><ul><li>Terminate at alveoli </li></ul></ul><ul><li>Function </li></ul><ul><ul><li>Conduct air to alveoli </li></ul></ul><ul><li>Structure </li></ul><ul><ul><li>1 st airways with NO cartilage </li></ul></ul><ul><ul><li>ALL muscle </li></ul></ul><ul><ul><ul><li>Bronchoconstriction </li></ul></ul></ul><ul><ul><ul><li>Bronchospasm </li></ul></ul></ul><ul><ul><li>< 1 mm wide =Tiny </li></ul></ul>
  11. 11. Lower Airway Alveoli <ul><li>Location </li></ul><ul><ul><li>Terminal sacs of bronchial tree </li></ul></ul><ul><ul><li>Distal to bronchioles </li></ul></ul><ul><ul><li>Particular to mammalian lungs </li></ul></ul><ul><ul><li>150 million/lung </li></ul></ul><ul><li>Structure </li></ul><ul><ul><li>1 cell thick </li></ul></ul><ul><ul><li>Surface are= 75m 2 (Tennis court) </li></ul></ul><ul><ul><li>Increased SA= Increased 0 2 absorption </li></ul></ul><ul><ul><li>0.2-0.3 mm diameter </li></ul></ul><ul><ul><li>Covered in capillaries (70%) </li></ul></ul><ul><ul><li>Bathed in surfactant </li></ul></ul><ul><li>Function </li></ul><ul><ul><li>Diffusion of gas with capillaries </li></ul></ul>
  12. 13. Lower Airway Lungs <ul><li>Location </li></ul><ul><ul><li>Bilateral of midline </li></ul></ul><ul><li>Structure </li></ul><ul><ul><li>Divided into lobes </li></ul></ul><ul><ul><ul><li>Left= 2 </li></ul></ul></ul><ul><ul><ul><li>Right= 3 </li></ul></ul></ul><ul><li>Function </li></ul><ul><ul><li>Houses structure for gas exchange </li></ul></ul><ul><ul><li>Alteration of pH </li></ul></ul>
  13. 14. Lower Airway Mucociliary Escalator <ul><li>Location </li></ul><ul><ul><li>Along epithelium of primary bronchi </li></ul></ul><ul><ul><li>Beat in rhythm </li></ul></ul><ul><li>Structure </li></ul><ul><ul><li>Cilia projections </li></ul></ul><ul><ul><li>“ Hair like” </li></ul></ul><ul><li>Function </li></ul><ul><ul><li>Move debris up out of lungs </li></ul></ul><ul><ul><ul><li>Cough or swallow </li></ul></ul></ul><ul><ul><ul><ul><li>Smokers… </li></ul></ul></ul></ul><ul><ul><li>Prevent mucous accumulation </li></ul></ul>
  14. 16. Respiratory Physiology How we breathe… <ul><li>Ventilation </li></ul><ul><ul><li>Mechanical movement of air into/out of the body </li></ul></ul><ul><li>Inhalation ( Active ) </li></ul><ul><ul><li>Muscles Used </li></ul></ul><ul><ul><ul><li>Diaphragm & External Intercostals </li></ul></ul></ul><ul><ul><li>Physiology </li></ul></ul><ul><ul><ul><li>Diaphragm contracts downward </li></ul></ul></ul><ul><ul><ul><li>External intercostals pull ribs up and out </li></ul></ul></ul><ul><ul><ul><li>Increases dimension of chest cavity </li></ul></ul></ul><ul><ul><ul><li>Increased diameter of chest drops intra thoracic pressure </li></ul></ul></ul><ul><ul><ul><li>Air rushes in until pressure is equalized </li></ul></ul></ul>
  15. 17. Respiratory Physiology How we breathe… <ul><li>Ventilation </li></ul><ul><ul><li>Mechanical movement of air into/out of the body </li></ul></ul><ul><li>Exhalation ( Passive ) </li></ul><ul><ul><li>Physiology </li></ul></ul><ul><ul><ul><li>Diaphragm relaxes as well as intercostals </li></ul></ul></ul><ul><ul><ul><li>Chest cavity dimension decreases </li></ul></ul></ul><ul><ul><ul><li>Decrease in dimension increases intrathoracic pressure </li></ul></ul></ul><ul><ul><ul><li>Air rushes out </li></ul></ul></ul><ul><ul><ul><li>Lungs recoil </li></ul></ul></ul>
  16. 19. Respiratory Physiology Gas Exchange <ul><li>Respiration </li></ul><ul><ul><li>Process by which the body utilizes oxygen </li></ul></ul><ul><ul><li>Diffusion </li></ul></ul><ul><ul><ul><ul><li>Net movement of molecules from an area of high concentration to an area of low concentration </li></ul></ul></ul></ul>
  17. 21. Respiratory Physiology Gas Exchange <ul><li>Respiration </li></ul><ul><ul><li>Process by which the body utilizes oxygen </li></ul></ul><ul><li>Alveolar/Capillary Exchange </li></ul><ul><ul><li>Physiology </li></ul></ul><ul><ul><ul><li>O 2 rich air enters alveoli </li></ul></ul></ul><ul><ul><ul><li>O 2 poor blood in capillaries pass alveoli </li></ul></ul></ul><ul><ul><ul><li>O 2 diffuses down its concentration gradient into the capillaries </li></ul></ul></ul><ul><ul><ul><li>CO 2 diffuses down its concentration gradient into the alveoli </li></ul></ul></ul><ul><ul><ul><li>CO 2 is exhaled and O 2 transported to tissues </li></ul></ul></ul>
  18. 22. Respiratory Physiology Gas Exchange <ul><li>Respiration </li></ul><ul><ul><li>Process by which the body utilizes oxygen </li></ul></ul><ul><li>Capillary/Cellular Exchange </li></ul><ul><ul><li>Physiology </li></ul></ul><ul><ul><ul><li>O 2 rich blood passes cells </li></ul></ul></ul><ul><ul><ul><li>O 2 diffuses across its concentration gradient into the cells </li></ul></ul></ul><ul><ul><ul><li>CO 2 diffuses across its concentration gradient into the capillary </li></ul></ul></ul><ul><ul><ul><li>CO 2 is transported to the alveoli </li></ul></ul></ul>
  19. 23. Respiratory Evaluation <ul><li>Areas of assessment </li></ul><ul><ul><li>Rate. Rhythm. Depth. Quality. </li></ul></ul><ul><li>Rate </li></ul><ul><ul><li>Adult = 12-20 per minute </li></ul></ul><ul><ul><li>Child = 15-30 per minute </li></ul></ul><ul><ul><li>Infant -= 30-60 per minute </li></ul></ul><ul><li>Rhythm </li></ul><ul><ul><li>Regular or irregular </li></ul></ul><ul><li>Depth </li></ul><ul><ul><li>Tidal volume adequate or inadequate </li></ul></ul><ul><ul><ul><li>Amount of air breathed in/out in one ventilation </li></ul></ul></ul><ul><ul><ul><li>Approx 500 mL </li></ul></ul></ul>
  20. 24. Respiratory Evaluation cont’d. <ul><li>Quality </li></ul><ul><ul><li>Breath sounds </li></ul></ul><ul><ul><ul><li>Midclavicular & Midaxillary lines </li></ul></ul></ul><ul><ul><ul><li>Present or diminished or absent </li></ul></ul></ul><ul><ul><li>Chest expansion </li></ul></ul><ul><ul><ul><li>Unequal or symmetrical </li></ul></ul></ul><ul><ul><li>Increased effort </li></ul></ul><ul><ul><ul><li>Accessory muscles </li></ul></ul></ul><ul><ul><ul><li>“ Seesaw” breathing </li></ul></ul></ul><ul><ul><ul><ul><li>Infants </li></ul></ul></ul></ul><ul><ul><ul><li>Nasal flaring </li></ul></ul></ul><ul><ul><ul><li>Retractions </li></ul></ul></ul><ul><ul><ul><ul><li>Above clavicles, between ribs </li></ul></ul></ul></ul><ul><ul><ul><li>Cyanosis </li></ul></ul></ul><ul><ul><ul><li>Shortness of breath </li></ul></ul></ul><ul><ul><ul><li>Altered mental status </li></ul></ul></ul>
  21. 25. Accessory Muscle Use Nasal Flaring Retractions
  22. 26. Respiratory Evaluation cont’d. <ul><li>Cyanosis </li></ul><ul><ul><li>Blue/pale coloring of skin </li></ul></ul><ul><ul><ul><li>Nail beds </li></ul></ul></ul><ul><ul><ul><li>Lips </li></ul></ul></ul><ul><ul><ul><li>Eyelids </li></ul></ul></ul><ul><ul><li>Why is this seen in these areas first??? </li></ul></ul><ul><ul><li>Indicates poor perfusion </li></ul></ul>
  23. 27. Pediatric Considerations <ul><li>Mouth/Nose </li></ul><ul><ul><li>Smaller and easily obstructed </li></ul></ul><ul><li>Pharynx </li></ul><ul><ul><li>Tongue is BIG </li></ul></ul><ul><li>Trachea </li></ul><ul><ul><li>Narrower </li></ul></ul><ul><ul><li>Softer and more flexible </li></ul></ul><ul><li>Cricoid Cartilage </li></ul><ul><ul><li>Less developed/Less rigid = easily kinked </li></ul></ul><ul><li>Diaphragm </li></ul><ul><ul><li>Chest is soft </li></ul></ul><ul><ul><li>Depend on diaphragm to do most of the work of breathing </li></ul></ul><ul><ul><ul><li>Seesaw Breathing…. </li></ul></ul></ul>
  24. 28. Adequate v Inadequate Artificial Ventilation <ul><li>What is adequate? </li></ul><ul><ul><li>Chest rises/falls with each </li></ul></ul><ul><ul><li>Sufficient rate </li></ul></ul><ul><ul><ul><li>Adults= 12 breaths/min </li></ul></ul></ul><ul><ul><ul><li>Children= 20 breaths/min </li></ul></ul></ul><ul><ul><li>Heart rate returns to normal </li></ul></ul><ul><li>What is inadequate? </li></ul><ul><ul><li>Absent chest rise/fall </li></ul></ul><ul><ul><li>Too fast/slow </li></ul></ul><ul><ul><li>Heart rate continues to be abnormal </li></ul></ul>
  25. 29. Respiratory Emergencies S/S of Breathing Difficulty <ul><ul><li>SOB </li></ul></ul><ul><ul><li>Diff speaking in complete sentences </li></ul></ul><ul><ul><li>Increased resp rate </li></ul></ul><ul><ul><li>Decreased resp rate </li></ul></ul><ul><ul><li>Irregular breathing rhythm </li></ul></ul><ul><ul><li>Accessory muscle use (retractions) </li></ul></ul><ul><ul><li>Abdominal breathing </li></ul></ul><ul><ul><li>Nasal flaring </li></ul></ul><ul><ul><li>AMS </li></ul></ul><ul><ul><li>Agitated/Restless </li></ul></ul><ul><ul><li>Increased pulse rate </li></ul></ul><ul><ul><li>Pt Positioning </li></ul></ul><ul><ul><ul><li>Tripod Position </li></ul></ul></ul><ul><ul><ul><li>Feet dangling, leaning forward </li></ul></ul></ul><ul><ul><li>Unusual Anatomy </li></ul></ul><ul><ul><ul><li>Barrel Chest </li></ul></ul></ul><ul><ul><li>Skin color changes </li></ul></ul><ul><ul><ul><li>Cyanotic – Pale - Flushed </li></ul></ul></ul>
  26. 30. Respiratory Emergencies Pt Assessment <ul><li>Scene Size up </li></ul><ul><ul><li>Scene Safe/BSI </li></ul></ul><ul><ul><ul><li>Possible toxic environment??? </li></ul></ul></ul><ul><ul><ul><li>TB= HEPA mask </li></ul></ul></ul><ul><ul><li>Consider MOI if trauma </li></ul></ul><ul><li>Initial Assessment </li></ul><ul><ul><li>General impression </li></ul></ul><ul><ul><li>Obvious threat to life = Resp Arrest </li></ul></ul><ul><ul><li>Pt positioning – Tripod/Bolt upright </li></ul></ul><ul><ul><li>Mental Status – AVPU </li></ul></ul><ul><ul><ul><li>Any ALOC/AMS, Agitation, etc </li></ul></ul></ul><ul><ul><li>Airway </li></ul></ul><ul><ul><ul><li>Is airway open/patent (Manual techniques, NPA/OPA, Suctioning) </li></ul></ul></ul><ul><ul><ul><li>Is pt breathing noisy </li></ul></ul></ul><ul><ul><li>Breathing </li></ul></ul><ul><ul><ul><li>Apply Supplemental O2 (NRB, NC) </li></ul></ul></ul><ul><ul><ul><li>Does pt need + pressure ventilation </li></ul></ul></ul><ul><ul><ul><ul><li>No breathing = YES </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Slow/irregular breathing, shallow breathing, diminished breath sounds, seesaw breathing, decreased LOC, S/S severe hypoxia = YES </li></ul></ul></ul></ul>
  27. 31. Respiratory Emergencies Pt Assessment <ul><li>Initial assessment continued </li></ul><ul><ul><li>Circulation </li></ul></ul><ul><ul><ul><li>HR increase in early hypoxia </li></ul></ul></ul><ul><ul><ul><ul><li>compensate for low O2 in blood by increasing its flow through the body </li></ul></ul></ul></ul><ul><ul><ul><li>HR decreases </li></ul></ul></ul><ul><ul><ul><ul><li>as heart becomes hypoxic itself = Ominous Sign… </li></ul></ul></ul></ul><ul><ul><ul><li>Cyanosis = ALWAYS a S/S for supplemental O2 </li></ul></ul></ul><ul><li>Focused Hx and Physical Exam </li></ul><ul><ul><li>Hx </li></ul></ul><ul><ul><ul><li>SAMPLE Hx </li></ul></ul></ul><ul><ul><ul><ul><li>Does pt have a prescribed inhaler??? </li></ul></ul></ul></ul><ul><ul><ul><li>OPQRST Hx </li></ul></ul></ul><ul><ul><li>Physical Exam </li></ul></ul><ul><ul><ul><li>Guided by SAMPLE Hx </li></ul></ul></ul><ul><ul><ul><li>Head/Neck/Chest for S/S of Resp distress </li></ul></ul></ul><ul><ul><ul><li>Barrel chest – COPD </li></ul></ul></ul><ul><ul><ul><li>Ausculatate at Midclavicular and Midaxillary lines bilaterally. </li></ul></ul></ul><ul><ul><ul><li>Edema noted in extremities? </li></ul></ul></ul><ul><ul><li>Baseline Vitals </li></ul></ul><ul><ul><ul><li>Particular attention to resp rate/depth/quality and pulse </li></ul></ul></ul>
  28. 32. Respiratory Emergencies Emergency Medical Care <ul><li>Increase O2 concentration early on </li></ul><ul><li>+ Pressure ventilation if required </li></ul><ul><ul><li>When in doubt attempt to administer </li></ul></ul><ul><ul><ul><li>If pt fights then stop </li></ul></ul></ul><ul><ul><ul><li>If pt accepts then continue </li></ul></ul></ul><ul><li>Rapid transport </li></ul><ul><ul><li>ALS??? </li></ul></ul><ul><li>Position of comfort </li></ul><ul><li>Monitor for fatigue </li></ul><ul><li>Medication administration </li></ul>
  29. 33. Oxygen Delivery Devices <ul><li>Nasal Cannula </li></ul><ul><ul><li>22-24% Oxygen </li></ul></ul><ul><ul><li>1-6 Lpm </li></ul></ul><ul><li>Simple Face Mask </li></ul><ul><ul><li>40-60% Oxygen </li></ul></ul><ul><ul><li>8-12 Lpm </li></ul></ul><ul><ul><li>Admin no less than 6 Lpm </li></ul></ul><ul><li>Non Rebreather </li></ul><ul><ul><li>80-100% Oxygen, 15 Lpm </li></ul></ul><ul><ul><li>No less than 8 Lpm </li></ul></ul><ul><li>Venturi Mask </li></ul><ul><ul><li>Used for COPD </li></ul></ul><ul><ul><li>Controlled precise amount of oxygen </li></ul></ul><ul><ul><li>24, 28, 35, 40% Oxygen </li></ul></ul>
  30. 34. Pulse Oximetry <ul><li>“ 5 th Vital Sign” </li></ul><ul><li>Normal SpO2 </li></ul><ul><ul><li>95-100% </li></ul></ul><ul><li>Sp02 Ranges </li></ul><ul><ul><li>91-94% = Mild Hypoxia – Supplemental O2 </li></ul></ul><ul><ul><li>86-91% = Moderate Hypoxia – Supplemental O2 </li></ul></ul><ul><ul><li>85%-< = Severe Hypoxia – IMMEDIATE intervention </li></ul></ul><ul><li>False Readings </li></ul><ul><ul><li>CO poisoning, high intensity lighting, hemoglobin abnormalities, no pulse in extremity, hypovolemia, severe anemia </li></ul></ul>
  31. 35. Metered Dose Inhalers/MDIs <ul><li>Medication Names </li></ul><ul><ul><li>Generic- </li></ul></ul><ul><ul><ul><li>Albuterol, Isoetharine, Metaproteranol </li></ul></ul></ul><ul><ul><li>Trade- </li></ul></ul><ul><ul><ul><li>Proventil, Ventolin, Bronkosol, Bronkometer, Alupet, Metaprel </li></ul></ul></ul><ul><li>Indications </li></ul><ul><ul><li>Exhibits S/S of Resp. Emergency </li></ul></ul><ul><ul><li>Has physician prescribed inhaler </li></ul></ul><ul><ul><li>Orders via med control </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Inability of pt to use device </li></ul></ul><ul><ul><li>No orders from medical control </li></ul></ul><ul><ul><li>Violates any 1 of the 5 Rights </li></ul></ul><ul><ul><li>Maximum number of doses already taken ( RELATIVE CONTRAINDICATION ) </li></ul></ul><ul><li>Dosage </li></ul><ul><ul><li># of inhalations based on MD/Med control </li></ul></ul><ul><li>Form </li></ul><ul><ul><li>Handheld Meted Dose Inhaler </li></ul></ul>
  32. 36. Albuterol (Proventil) <ul><li>Class: Sympathetic agonist </li></ul><ul><li>Description </li></ul><ul><ul><li>Sympathomimetic selective for β 2 </li></ul></ul><ul><li>Mechanism of Action </li></ul><ul><ul><li>Prompt bronchodilation </li></ul></ul><ul><li>Pharmacokinetics </li></ul><ul><ul><li>Onset: 5-15 min </li></ul></ul><ul><ul><li>Peak: 1.0-1.5 hours </li></ul></ul><ul><ul><li>Duration: 3-6 hours </li></ul></ul><ul><ul><li>Half Life: < 3 hours </li></ul></ul><ul><li>Indication </li></ul><ul><ul><li>Bronchial asthma, reversible bronchospams with bronchitis & emphysema </li></ul></ul><ul><li>Contraindication </li></ul><ul><ul><li>Hypersensitivity </li></ul></ul><ul><li>Precautions </li></ul><ul><ul><li>Cardiovascular disease, HTN </li></ul></ul><ul><ul><li>Assess lung sounds before/after </li></ul></ul><ul><li>Side Effects </li></ul><ul><ul><li>Palpitations, anxiety, dizziness, headache, nervousness, N/V </li></ul></ul><ul><li>Interactions </li></ul><ul><ul><li>Other sympathetic agonists </li></ul></ul><ul><ul><li>Blunted by β blockers </li></ul></ul><ul><li>Dosage </li></ul><ul><ul><li>MDI or small dose inhaler </li></ul></ul><ul><ul><li>MDI = 90 µg/spray, 2 sprays </li></ul></ul><ul><ul><li>Nebulizer= 2.5 mg (0.5 mL of 0.5% solution in 2.5 mL NS) over 5-15 min </li></ul></ul>
  33. 37. MDI Administration <ul><li>Administration </li></ul><ul><ul><li>Ask if any doses have already been taken </li></ul></ul><ul><ul><li>Assure 5 Rights and stable pt LOC </li></ul></ul><ul><ul><li>Obtain order from medical direction </li></ul></ul><ul><ul><li>Check to see if MDI is at or above room temp </li></ul></ul><ul><ul><li>Shake vigorously several times </li></ul></ul><ul><ul><li>Remove O2 adjunct from pt </li></ul></ul><ul><ul><li>Have pt exhale deeply </li></ul></ul><ul><ul><li>Have pt put lips around mouthpiece of MDI </li></ul></ul><ul><ul><li>Have pt depress MDI as he begins to breath in deeply </li></ul></ul><ul><ul><li>Have pt hold his breath for as long as he comfortably can </li></ul></ul><ul><ul><li>Replace O2 on pt </li></ul></ul><ul><ul><li>Allow pt to breath a few times and repeat does per med control </li></ul></ul><ul><ul><ul><li>If pt has a spacer device with MDI use spacer device as well </li></ul></ul></ul><ul><ul><ul><li>DOCUMENT time of med administration(s). </li></ul></ul></ul>
  34. 38. MDI’s Infants/Children Concerns <ul><li>MDI use is very common Asthma is common </li></ul><ul><li>Retractions are more commonly seen in children </li></ul><ul><li>Cyanosis is a late finding </li></ul><ul><li>Coughing instead of wheezing may be present </li></ul><ul><li>Emergency care with MDI is same for children as it is for adults </li></ul><ul><ul><li>If spacer device is available use it </li></ul></ul>Spacer
  35. 39. Conditions that Cause Resp Emergencies <ul><li>Emphysema </li></ul><ul><li>Asthma </li></ul><ul><li>Chronic Bronchitis </li></ul><ul><li>Heart Failure </li></ul><ul><li>Croup </li></ul><ul><li>Epiglottitis </li></ul><ul><li>Pneumonia </li></ul><ul><li>Pneumothorax </li></ul><ul><li>Hyperventilation syndrome </li></ul>
  36. 40. Respiratory Emergencies Chronic Obstructive Pulmonary Disease COPD <ul><li>4 th leading COD </li></ul><ul><li>$ 42.6 BILLION yearly </li></ul><ul><li>10-24 million people affected </li></ul><ul><li>Includes: </li></ul><ul><ul><li>Chronic Bronchitis </li></ul></ul><ul><ul><li>Emphysema </li></ul></ul><ul><ul><li>Asthma </li></ul></ul><ul><li>Pathophysiology: </li></ul><ul><ul><ul><li>Loss of elasticity of alveoli </li></ul></ul></ul><ul><ul><ul><li>Collapse of bronchioles </li></ul></ul></ul><ul><ul><ul><li>Decreased inspiratory volume </li></ul></ul></ul><ul><ul><ul><li>“ Trapped” air </li></ul></ul></ul><ul><ul><ul><li>Poor tissue perfusion </li></ul></ul></ul><ul><li>Problem: </li></ul><ul><ul><li>Chronic high CO 2 </li></ul></ul><ul><ul><li>Sensors become desensitized to CO 2 and switches to O 2 </li></ul></ul><ul><ul><li>Resp drive now based on O 2 NOT CO 2 </li></ul></ul><ul><ul><li>Does anyone see the problem???? </li></ul></ul>
  37. 42. Chronic Bronchitis <ul><li>What </li></ul><ul><ul><li>Chronic productive cough present for at least 3 months for at least 2 years </li></ul></ul><ul><li>How </li></ul><ul><ul><li>Smoking, long term exposure to pollutants </li></ul></ul><ul><li>Pathology </li></ul><ul><ul><li>Mucus secreting (goblet) cells become enlarged </li></ul></ul><ul><ul><li>Retained secretions </li></ul></ul><ul><ul><ul><li>Characteristic Productive Cough </li></ul></ul></ul><ul><ul><li>Excessive mucus production blocks bronchioles </li></ul></ul><ul><ul><li>Obstructive bronchioles = poorly ventilated alveoli =poorly oxygenated blood = Cyanosis </li></ul></ul><ul><ul><li>Heart failure occurs on Right side and blood backs up into the?? </li></ul></ul><ul><ul><ul><li>Peripheral edema </li></ul></ul></ul><ul><ul><li>“ Blue Bloaters” </li></ul></ul><ul><ul><li>Upon auscultation lung sounds are wheezy and fluid is noted </li></ul></ul>
  38. 44. Emphysema <ul><li>What </li></ul><ul><ul><li>Destruction of the alveoli </li></ul></ul><ul><li>How </li></ul><ul><ul><li>Smoking </li></ul></ul><ul><li>Pathology </li></ul><ul><ul><li>Bronchiole musculature looses its resistance </li></ul></ul><ul><ul><ul><li>Collapses when intrathoracic pressure rises </li></ul></ul></ul><ul><ul><li>Bronchioles collapse with exhalation </li></ul></ul><ul><ul><li>Air is trapped in alveoli and cannot get out </li></ul></ul><ul><ul><li>Limits amount of air that can be inhaled = “Air Trapping” ---- Barrel Chest </li></ul></ul><ul><li>Compensation </li></ul><ul><ul><li>Pt breathes better when they exhale against a pressure </li></ul></ul><ul><ul><li>Therefore they purse their lips and maintain pressure in their airways </li></ul></ul><ul><ul><li>The body increases RBC count and hemoglobin concentration = Pink coloring </li></ul></ul><ul><ul><li>“ Pink Puffers” </li></ul></ul>
  39. 46. Asthma <ul><li>7.3% (adults) 9.1% (children) of U.S. population, 4,000 deaths/year </li></ul><ul><li>300 Million worldwide </li></ul><ul><li>What </li></ul><ul><ul><li>Constriction of bronchioles </li></ul></ul><ul><li>How </li></ul><ul><ul><li>Stress, infection, allergen </li></ul></ul><ul><li>Pathology </li></ul><ul><ul><li>Muscular constriction of bronchioles narrows air passages </li></ul></ul><ul><ul><ul><li>(Bronchoconstriction) </li></ul></ul></ul><ul><ul><li>Further complicated by mucus secretions </li></ul></ul><ul><ul><li>Further complicated by release of immune cells </li></ul></ul><ul><ul><li>Spasms and mucus reduce air flow = Dyspnea/Hypoxia </li></ul></ul><ul><li>Compensation </li></ul><ul><ul><li>Hyperventilation- Increases O2 content </li></ul></ul><ul><ul><li>Watch for fatigue </li></ul></ul><ul><li>S/S </li></ul><ul><ul><li>Acute: SOB – Accessory muscles – Upright posture – Flushed – Forceful respiration – wheezing – prolonged exhalation – fatigue leading to resp failure </li></ul></ul><ul><ul><li>Severe: Exhaustion – little air flow – no wheezing- diff speaking – decreased breath sounds </li></ul></ul>
  40. 49. The Biology Behind Asthma
  41. 50. Pneumonia <ul><li>What </li></ul><ul><ul><li>Inflammation of alveolar spaces caused be various types of infectious organisms </li></ul></ul><ul><ul><li>Can also occur after aspiration of gastric contents in unresponsive pt </li></ul></ul><ul><li>Pathology </li></ul><ul><ul><li>Fluid interferes with gas exchange </li></ul></ul><ul><ul><li>Damage to lung tissue decreases surface area </li></ul></ul><ul><li>S/S </li></ul><ul><ul><li>Usually follows resp infection </li></ul></ul><ul><ul><li>Fever – Cough – Thick/colored sputum with pus </li></ul></ul><ul><ul><li>Crackles upon auscultation esp at sites of infection </li></ul></ul><ul><ul><li>USE airborne precautions </li></ul></ul>
  42. 51. Normal Alveoli Pneumonia
  43. 52. Streptococcus pneumoniae Staphylococcus aureus Bacillus anthracis Neisseria meningitidis Yersinia pestis Mycobacterium tuberculosis Pneumocystis carinii
  44. 53. Hyperventilation Syndrome <ul><li>What </li></ul><ul><ul><li>Voluntary increase of resp rate and depth </li></ul></ul><ul><li>Why </li></ul><ul><ul><li>Response to anxiety, feeling of SOB, etc. </li></ul></ul><ul><li>Pathology </li></ul><ul><ul><li>Decreases CO2 concentration </li></ul></ul><ul><ul><li>Changes acid base balance in body </li></ul></ul><ul><li>S/S </li></ul><ul><ul><li>Tingling around mouth, fingers </li></ul></ul><ul><ul><li>Dizziness </li></ul></ul><ul><ul><li>Nausea </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Err on side of caution and provide O2 in case there is an underlying medical complication </li></ul></ul>
  45. 54. Spontaneous Pneumothorax <ul><li>What </li></ul><ul><ul><li>Rupture of part of the lung </li></ul></ul><ul><li>Why </li></ul><ul><ul><li>Congenital blebs </li></ul></ul><ul><ul><ul><li>blisters on the lung </li></ul></ul></ul><ul><ul><li>COPD </li></ul></ul><ul><ul><li>Unknown </li></ul></ul><ul><li>Who </li></ul><ul><ul><li>Otherwise healthy, tall, thin, young, men. </li></ul></ul><ul><li>Pathology </li></ul><ul><ul><li>Air enters the pleural space and inhibits expansion of lung </li></ul></ul><ul><ul><li>Can progress to a tension pneumothorax </li></ul></ul><ul><li>S/S </li></ul><ul><ul><li>Sudden onset of dyspnea and pleuritic chest pain </li></ul></ul>

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