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17)Respiratory Emergencies

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  • 1. Respiratory Emergencies
  • 2. Respiratory Emergencies
    • AIRWAY…
    • AIRWAY…
    • AIRWAY…
      • One of the most life threatening emergencies
      • Maintain an open airway!!!
      • Ensure oxygenation and ventilation
    • Complications
      • Must extend uninterrupted from nose/mouth to alveoli
      • Muscles of respiration must move air in/out efficiently
      • Diffusion of gases must occur over alveoli/capillary membrane
      • Also depends on brain stem to monitor and control resp via nerves
  • 3. Respiratory System
    • Function
      • Gas exchange with outside environment
      • Filtration/Humidification/Warming/Conduction of air
    • Structures
      • Nose
      • Mouth
      • Naso/Oro/Laryngopharynx
      • Larynx
      • Bronchi
        • Bronchioles
      • Lungs
      • Diaphragm
        • Associated muscles
      • Alveoli
  • 4. Upper Airway Nose/Mouth
    • Function
      • Filters
      • Warms
      • Moistens
  • 5. Upper Airway Pharynx
    • Location
      • Posterior to mouth
      • Superior to esophagus, larynx, trachea
    • Function
      • Conducts air to bronchi
    • 3 Divisions
        • Nasopharynx
        • Oropharynx
        • Laryngopharynx
  • 6. Upper Airway Epiglottis
    • Location
      • Sits posterior to larynx
      • Attached to tongue
    • Structure
      • Leaf shaped cartilage
    • Function
      • Prevents food/liquid from entering larynx during swallowing
      • Guards opening to vocal cords (glottis)
  • 7. Upper Airway Larynx
    • AKA: “Voice box”
    • Location
      • Inferior to epiglottis
      • Superior to trachea
    • Structure
      • Cartilaginous rings
        • Thyroid Cartilage = “Adam’s Apple”
          • Bulk of anterior wall
        • Cricoid Cartilage
          • Firm rings forming lower aspect/base
    • Function
      • Stops foreign objects that pass epiglottis
        • Laryngospasm
      • Voice production
  • 8. Lower Airway Trachea
    • AKA: “Windpipe”
    • Location
      • Inferior to Larynx
      • Anterior to Esophagus
      • Bifurcates into primary bronchi
    • Structure
      • Cartilaginous rings anterior and lateral
        • Approx 15-20
      • Smooth muscle tissue posterior
        • Trachealis muscle
      • Why????
  • 9. Lower Airway Bronchi
    • Location
      • Bifurcation of trachea
        • 2 nd Intercostal space
          • Angle of Louis
      • Right and Left main stem
    • Structure
      • Smooth muscle
      • Irregular hyaline cartilage rings
    • Function
      • Conducts air to lungs
  • 10. Lower Airway Bronchioles
    • Location
      • Distal bifurcations of the bronchi
      • Terminate at alveoli
    • Function
      • Conduct air to alveoli
    • Structure
      • 1 st airways with NO cartilage
      • ALL muscle
        • Bronchoconstriction
        • Bronchospasm
      • < 1 mm wide =Tiny
  • 11. Lower Airway Alveoli
    • Location
      • Terminal sacs of bronchial tree
      • Distal to bronchioles
      • Particular to mammalian lungs
      • 150 million/lung
    • Structure
      • 1 cell thick
      • Surface are= 75m 2 (Tennis court)
      • Increased SA= Increased 0 2 absorption
      • 0.2-0.3 mm diameter
      • Covered in capillaries (70%)
      • Bathed in surfactant
    • Function
      • Diffusion of gas with capillaries
  • 12.  
  • 13. Lower Airway Lungs
    • Location
      • Bilateral of midline
    • Structure
      • Divided into lobes
        • Left= 2
        • Right= 3
    • Function
      • Houses structure for gas exchange
      • Alteration of pH
  • 14. Lower Airway Mucociliary Escalator
    • Location
      • Along epithelium of primary bronchi
      • Beat in rhythm
    • Structure
      • Cilia projections
      • “ Hair like”
    • Function
      • Move debris up out of lungs
        • Cough or swallow
          • Smokers…
      • Prevent mucous accumulation
  • 15.  
  • 16. Respiratory Physiology How we breathe…
    • Ventilation
      • Mechanical movement of air into/out of the body
    • Inhalation ( Active )
      • Muscles Used
        • Diaphragm & External Intercostals
      • Physiology
        • Diaphragm contracts downward
        • External intercostals pull ribs up and out
        • Increases dimension of chest cavity
        • Increased diameter of chest drops intra thoracic pressure
        • Air rushes in until pressure is equalized
  • 17. Respiratory Physiology How we breathe…
    • Ventilation
      • Mechanical movement of air into/out of the body
    • Exhalation ( Passive )
      • Physiology
        • Diaphragm relaxes as well as intercostals
        • Chest cavity dimension decreases
        • Decrease in dimension increases intrathoracic pressure
        • Air rushes out
        • Lungs recoil
  • 18.  
  • 19. Respiratory Physiology Gas Exchange
    • Respiration
      • Process by which the body utilizes oxygen
      • Diffusion
          • Net movement of molecules from an area of high concentration to an area of low concentration
  • 20.  
  • 21. Respiratory Physiology Gas Exchange
    • Respiration
      • Process by which the body utilizes oxygen
    • Alveolar/Capillary Exchange
      • Physiology
        • O 2 rich air enters alveoli
        • O 2 poor blood in capillaries pass alveoli
        • O 2 diffuses down its concentration gradient into the capillaries
        • CO 2 diffuses down its concentration gradient into the alveoli
        • CO 2 is exhaled and O 2 transported to tissues
  • 22. Respiratory Physiology Gas Exchange
    • Respiration
      • Process by which the body utilizes oxygen
    • Capillary/Cellular Exchange
      • Physiology
        • O 2 rich blood passes cells
        • O 2 diffuses across its concentration gradient into the cells
        • CO 2 diffuses across its concentration gradient into the capillary
        • CO 2 is transported to the alveoli
  • 23. Respiratory Evaluation
    • Areas of assessment
      • Rate. Rhythm. Depth. Quality.
    • Rate
      • Adult = 12-20 per minute
      • Child = 15-30 per minute
      • Infant -= 30-60 per minute
    • Rhythm
      • Regular or irregular
    • Depth
      • Tidal volume adequate or inadequate
        • Amount of air breathed in/out in one ventilation
        • Approx 500 mL
  • 24. Respiratory Evaluation cont’d.
    • Quality
      • Breath sounds
        • Midclavicular & Midaxillary lines
        • Present or diminished or absent
      • Chest expansion
        • Unequal or symmetrical
      • Increased effort
        • Accessory muscles
        • “ Seesaw” breathing
          • Infants
        • Nasal flaring
        • Retractions
          • Above clavicles, between ribs
        • Cyanosis
        • Shortness of breath
        • Altered mental status
  • 25. Accessory Muscle Use Nasal Flaring Retractions
  • 26. Respiratory Evaluation cont’d.
    • Cyanosis
      • Blue/pale coloring of skin
        • Nail beds
        • Lips
        • Eyelids
      • Why is this seen in these areas first???
      • Indicates poor perfusion
  • 27. Pediatric Considerations
    • Mouth/Nose
      • Smaller and easily obstructed
    • Pharynx
      • Tongue is BIG
    • Trachea
      • Narrower
      • Softer and more flexible
    • Cricoid Cartilage
      • Less developed/Less rigid = easily kinked
    • Diaphragm
      • Chest is soft
      • Depend on diaphragm to do most of the work of breathing
        • Seesaw Breathing….
  • 28. Adequate v Inadequate Artificial Ventilation
    • What is adequate?
      • Chest rises/falls with each
      • Sufficient rate
        • Adults= 12 breaths/min
        • Children= 20 breaths/min
      • Heart rate returns to normal
    • What is inadequate?
      • Absent chest rise/fall
      • Too fast/slow
      • Heart rate continues to be abnormal
  • 29. Respiratory Emergencies S/S of Breathing Difficulty
      • SOB
      • Diff speaking in complete sentences
      • Increased resp rate
      • Decreased resp rate
      • Irregular breathing rhythm
      • Accessory muscle use (retractions)
      • Abdominal breathing
      • Nasal flaring
      • AMS
      • Agitated/Restless
      • Increased pulse rate
      • Pt Positioning
        • Tripod Position
        • Feet dangling, leaning forward
      • Unusual Anatomy
        • Barrel Chest
      • Skin color changes
        • Cyanotic – Pale - Flushed
  • 30. Respiratory Emergencies Pt Assessment
    • Scene Size up
      • Scene Safe/BSI
        • Possible toxic environment???
        • TB= HEPA mask
      • Consider MOI if trauma
    • Initial Assessment
      • General impression
      • Obvious threat to life = Resp Arrest
      • Pt positioning – Tripod/Bolt upright
      • Mental Status – AVPU
        • Any ALOC/AMS, Agitation, etc
      • Airway
        • Is airway open/patent (Manual techniques, NPA/OPA, Suctioning)
        • Is pt breathing noisy
      • Breathing
        • Apply Supplemental O2 (NRB, NC)
        • Does pt need + pressure ventilation
          • No breathing = YES
          • Slow/irregular breathing, shallow breathing, diminished breath sounds, seesaw breathing, decreased LOC, S/S severe hypoxia = YES
  • 31. Respiratory Emergencies Pt Assessment
    • Initial assessment continued
      • Circulation
        • HR increase in early hypoxia
          • compensate for low O2 in blood by increasing its flow through the body
        • HR decreases
          • as heart becomes hypoxic itself = Ominous Sign…
        • Cyanosis = ALWAYS a S/S for supplemental O2
    • Focused Hx and Physical Exam
      • Hx
        • SAMPLE Hx
          • Does pt have a prescribed inhaler???
        • OPQRST Hx
      • Physical Exam
        • Guided by SAMPLE Hx
        • Head/Neck/Chest for S/S of Resp distress
        • Barrel chest – COPD
        • Ausculatate at Midclavicular and Midaxillary lines bilaterally.
        • Edema noted in extremities?
      • Baseline Vitals
        • Particular attention to resp rate/depth/quality and pulse
  • 32. Respiratory Emergencies Emergency Medical Care
    • Increase O2 concentration early on
    • + Pressure ventilation if required
      • When in doubt attempt to administer
        • If pt fights then stop
        • If pt accepts then continue
    • Rapid transport
      • ALS???
    • Position of comfort
    • Monitor for fatigue
    • Medication administration
  • 33. Oxygen Delivery Devices
    • Nasal Cannula
      • 22-24% Oxygen
      • 1-6 Lpm
    • Simple Face Mask
      • 40-60% Oxygen
      • 8-12 Lpm
      • Admin no less than 6 Lpm
    • Non Rebreather
      • 80-100% Oxygen, 15 Lpm
      • No less than 8 Lpm
    • Venturi Mask
      • Used for COPD
      • Controlled precise amount of oxygen
      • 24, 28, 35, 40% Oxygen
  • 34. Pulse Oximetry
    • “ 5 th Vital Sign”
    • Normal SpO2
      • 95-100%
    • Sp02 Ranges
      • 91-94% = Mild Hypoxia – Supplemental O2
      • 86-91% = Moderate Hypoxia – Supplemental O2
      • 85%-< = Severe Hypoxia – IMMEDIATE intervention
    • False Readings
      • CO poisoning, high intensity lighting, hemoglobin abnormalities, no pulse in extremity, hypovolemia, severe anemia
  • 35. Metered Dose Inhalers/MDIs
    • Medication Names
      • Generic-
        • Albuterol, Isoetharine, Metaproteranol
      • Trade-
        • Proventil, Ventolin, Bronkosol, Bronkometer, Alupet, Metaprel
    • Indications
      • Exhibits S/S of Resp. Emergency
      • Has physician prescribed inhaler
      • Orders via med control
    • Contraindications
      • Inability of pt to use device
      • No orders from medical control
      • Violates any 1 of the 5 Rights
      • Maximum number of doses already taken ( RELATIVE CONTRAINDICATION )
    • Dosage
      • # of inhalations based on MD/Med control
    • Form
      • Handheld Meted Dose Inhaler
  • 36. Albuterol (Proventil)
    • Class: Sympathetic agonist
    • Description
      • Sympathomimetic selective for β 2
    • Mechanism of Action
      • Prompt bronchodilation
    • Pharmacokinetics
      • Onset: 5-15 min
      • Peak: 1.0-1.5 hours
      • Duration: 3-6 hours
      • Half Life: < 3 hours
    • Indication
      • Bronchial asthma, reversible bronchospams with bronchitis & emphysema
    • Contraindication
      • Hypersensitivity
    • Precautions
      • Cardiovascular disease, HTN
      • Assess lung sounds before/after
    • Side Effects
      • Palpitations, anxiety, dizziness, headache, nervousness, N/V
    • Interactions
      • Other sympathetic agonists
      • Blunted by β blockers
    • Dosage
      • MDI or small dose inhaler
      • MDI = 90 µg/spray, 2 sprays
      • Nebulizer= 2.5 mg (0.5 mL of 0.5% solution in 2.5 mL NS) over 5-15 min
  • 37. MDI Administration
    • Administration
      • Ask if any doses have already been taken
      • Assure 5 Rights and stable pt LOC
      • Obtain order from medical direction
      • Check to see if MDI is at or above room temp
      • Shake vigorously several times
      • Remove O2 adjunct from pt
      • Have pt exhale deeply
      • Have pt put lips around mouthpiece of MDI
      • Have pt depress MDI as he begins to breath in deeply
      • Have pt hold his breath for as long as he comfortably can
      • Replace O2 on pt
      • Allow pt to breath a few times and repeat does per med control
        • If pt has a spacer device with MDI use spacer device as well
        • DOCUMENT time of med administration(s).
  • 38. MDI’s Infants/Children Concerns
    • MDI use is very common Asthma is common
    • Retractions are more commonly seen in children
    • Cyanosis is a late finding
    • Coughing instead of wheezing may be present
    • Emergency care with MDI is same for children as it is for adults
      • If spacer device is available use it
    Spacer
  • 39. Conditions that Cause Resp Emergencies
    • Emphysema
    • Asthma
    • Chronic Bronchitis
    • Heart Failure
    • Croup
    • Epiglottitis
    • Pneumonia
    • Pneumothorax
    • Hyperventilation syndrome
  • 40. Respiratory Emergencies Chronic Obstructive Pulmonary Disease COPD
    • 4 th leading COD
    • $ 42.6 BILLION yearly
    • 10-24 million people affected
    • Includes:
      • Chronic Bronchitis
      • Emphysema
      • Asthma
    • Pathophysiology:
        • Loss of elasticity of alveoli
        • Collapse of bronchioles
        • Decreased inspiratory volume
        • “ Trapped” air
        • Poor tissue perfusion
    • Problem:
      • Chronic high CO 2
      • Sensors become desensitized to CO 2 and switches to O 2
      • Resp drive now based on O 2 NOT CO 2
      • Does anyone see the problem????
  • 41.  
  • 42. Chronic Bronchitis
    • What
      • Chronic productive cough present for at least 3 months for at least 2 years
    • How
      • Smoking, long term exposure to pollutants
    • Pathology
      • Mucus secreting (goblet) cells become enlarged
      • Retained secretions
        • Characteristic Productive Cough
      • Excessive mucus production blocks bronchioles
      • Obstructive bronchioles = poorly ventilated alveoli =poorly oxygenated blood = Cyanosis
      • Heart failure occurs on Right side and blood backs up into the??
        • Peripheral edema
      • “ Blue Bloaters”
      • Upon auscultation lung sounds are wheezy and fluid is noted
  • 43.  
  • 44. Emphysema
    • What
      • Destruction of the alveoli
    • How
      • Smoking
    • Pathology
      • Bronchiole musculature looses its resistance
        • Collapses when intrathoracic pressure rises
      • Bronchioles collapse with exhalation
      • Air is trapped in alveoli and cannot get out
      • Limits amount of air that can be inhaled = “Air Trapping” ---- Barrel Chest
    • Compensation
      • Pt breathes better when they exhale against a pressure
      • Therefore they purse their lips and maintain pressure in their airways
      • The body increases RBC count and hemoglobin concentration = Pink coloring
      • “ Pink Puffers”
  • 45.  
  • 46. Asthma
    • 7.3% (adults) 9.1% (children) of U.S. population, 4,000 deaths/year
    • 300 Million worldwide
    • What
      • Constriction of bronchioles
    • How
      • Stress, infection, allergen
    • Pathology
      • Muscular constriction of bronchioles narrows air passages
        • (Bronchoconstriction)
      • Further complicated by mucus secretions
      • Further complicated by release of immune cells
      • Spasms and mucus reduce air flow = Dyspnea/Hypoxia
    • Compensation
      • Hyperventilation- Increases O2 content
      • Watch for fatigue
    • S/S
      • Acute: SOB – Accessory muscles – Upright posture – Flushed – Forceful respiration – wheezing – prolonged exhalation – fatigue leading to resp failure
      • Severe: Exhaustion – little air flow – no wheezing- diff speaking – decreased breath sounds
  • 47.  
  • 48.  
  • 49. The Biology Behind Asthma
  • 50. Pneumonia
    • What
      • Inflammation of alveolar spaces caused be various types of infectious organisms
      • Can also occur after aspiration of gastric contents in unresponsive pt
    • Pathology
      • Fluid interferes with gas exchange
      • Damage to lung tissue decreases surface area
    • S/S
      • Usually follows resp infection
      • Fever – Cough – Thick/colored sputum with pus
      • Crackles upon auscultation esp at sites of infection
      • USE airborne precautions
  • 51. Normal Alveoli Pneumonia
  • 52. Streptococcus pneumoniae Staphylococcus aureus Bacillus anthracis Neisseria meningitidis Yersinia pestis Mycobacterium tuberculosis Pneumocystis carinii
  • 53. Hyperventilation Syndrome
    • What
      • Voluntary increase of resp rate and depth
    • Why
      • Response to anxiety, feeling of SOB, etc.
    • Pathology
      • Decreases CO2 concentration
      • Changes acid base balance in body
    • S/S
      • Tingling around mouth, fingers
      • Dizziness
      • Nausea
    • Treatment
      • Err on side of caution and provide O2 in case there is an underlying medical complication
  • 54. Spontaneous Pneumothorax
    • What
      • Rupture of part of the lung
    • Why
      • Congenital blebs
        • blisters on the lung
      • COPD
      • Unknown
    • Who
      • Otherwise healthy, tall, thin, young, men.
    • Pathology
      • Air enters the pleural space and inhibits expansion of lung
      • Can progress to a tension pneumothorax
    • S/S
      • Sudden onset of dyspnea and pleuritic chest pain
  • 55.