17)Respiratory Emergencies
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17)Respiratory Emergencies

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    17)Respiratory Emergencies 17)Respiratory Emergencies Presentation Transcript

    • Respiratory Emergencies
    • 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
    • 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
    • Upper Airway Nose/Mouth
      • Function
        • Filters
        • Warms
        • Moistens
    • Upper Airway Pharynx
      • Location
        • Posterior to mouth
        • Superior to esophagus, larynx, trachea
      • Function
        • Conducts air to bronchi
      • 3 Divisions
          • Nasopharynx
          • Oropharynx
          • Laryngopharynx
    • 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)
    • 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
    • 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????
    • 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
    • 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
    • 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
    •  
    • Lower Airway Lungs
      • Location
        • Bilateral of midline
      • Structure
        • Divided into lobes
          • Left= 2
          • Right= 3
      • Function
        • Houses structure for gas exchange
        • Alteration of pH
    • 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
    •  
    • 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
    • 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
    •  
    • 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
    •  
    • 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
    • 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
    • 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
    • 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
    • Accessory Muscle Use Nasal Flaring Retractions
    • 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
    • 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….
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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
    • 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).
    • 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
    • Conditions that Cause Resp Emergencies
      • Emphysema
      • Asthma
      • Chronic Bronchitis
      • Heart Failure
      • Croup
      • Epiglottitis
      • Pneumonia
      • Pneumothorax
      • Hyperventilation syndrome
    • 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????
    •  
    • 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
    •  
    • 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”
    •  
    • 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
    •  
    •  
    • The Biology Behind Asthma
    • 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
    • Normal Alveoli Pneumonia
    • Streptococcus pneumoniae Staphylococcus aureus Bacillus anthracis Neisseria meningitidis Yersinia pestis Mycobacterium tuberculosis Pneumocystis carinii
    • 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
    • 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
    •