HELPFUL TO UNDERGRADUATES

1. RESPIRATORY
EMERGENCIES
DR SOURAB HIREMATH
MD INTERNAL MEDICINE
EMERGENCY MEDICINE

2. PRE TEST QUESTIONS
• Pulsus paradoxus is seen in mild asthma
• Silent chest in asthma is a good prognostic sign
• Unlike short examination of CVS in MI in exacerbation of COPD and Asthma a
detailed respiratory examination with chest measurements is a must

3. • Raised CO2 levels in COPD is more dangerous and life threatening than in
Asthma
• MGSO4 is a very crucial drug in treatment of COPD
• NIV when used early in severe exacerbation OF COPD IS LIFE SAVING
• Avoid injectable steroids in Severe Asthma

4. BREATH OF YOUNG AND OLD

5. CASE 1 CASE 2
64 year old male
c/o dypnea since 1 hour with severe chest tightness
Dyspnea associated with cough and increased mucoid
expectoration
h/o running nose since 3 days with fever
h/o excessive daily early morning cough and attempts
to clear secretions
Past history : repeated breathing difficulty with
previous hospitalisation six months back
Family : Nothing contributory
Personal : smoker since 40 years around one pack per
day
26 year old man
c/o acute onset of dyspnea since 1 hour with
severe chest tightness
Dyspnea was initially associated with wheeze but
now wheeze has disappeared
h/o running nose since 3 days with fever
History is provided by the bystander as the
patient is unable to complete sentences
Past history : repeated breathing difficulty with
one previous hospitalisation a year back
Family : H/o eczema present
Personal : No addictions non smoker

6. CASE 1 CASE 2
• Patient is restless and unable to lie down supine
in bed
• PR : 108/min
• BP: 120/80 mm of hg
• RR : 38/min
• SPO2 : 86%
• Patient is calm and drowsy
• PR : 112/min
• BP : 104/60 mm hg
• RR : 10 /min
• Spo2: 88 %

9. AUSCULTATION
Case 1
No sound from chest
Case 2

10. DIAGNOSIS
Case 1
Acute severe Asthma
(Status Asthmaticus)
Case 2
Acute severe Exacerbation of COPD

11. ACUTE EXACERBATION OF ASTHMA
GINA definition
"Asthma is a heterogeneous disease, usually characterized
by chronic airway inflammation. It is defined by the history
of respiratory symptoms such as wheeze, shortness of
breath, chest tightness, and cough that vary over time and
in intensity, together with variable expiratory airflow
limitation."

12. ASTHMA EXACERBATION
Pulmonary
Cardiac
Respiratory Muscle
Systemic

13. Clinical Features

14. LEVELS OF SEVERITY OF ACUTE ASTHMA
EXACERBATIONS
• MODERATE ASTHMA EXACERBATION
• ACUTE SEVERE ASTHMA
• LIFE THREATENING ASTHMA

15. MODERATE ASTHMA EXACERBATION
• Increasing symptoms
• Fev1/PEFR >50 % of predicted value
• No features of acute severe asthma

16. ACUTE SEVERE ASTHMA
• RR > 25/min
• Heart rate >110 /min
• Inability to complete sentence in one breathe
Spirometry : FEV1/PEFR 30-50% of predicted

17. LIFE THREATENING ASTHMA
• Cyanosis
• Feeble respiratory effort
• Confusion
• Hypotension or bradycardia
• Silent chest
• SPo2 <92 %
• PaO2 < 60 mm hg
• Pa Co2 >45 mmhg

18. INVESTIGATIONS
• CBC
• Chest Xray
• Arterial Blood gas analysis
• Sputum analysis

19. MANAGEMENT
ABC
Oxygen to maintain SPo2 > 92 %

20. INHALED BRONCHODILATORS

21. SALBUTAMOL
• 2.5 – 5 mg every 20 mins for first hours
• Or 4 -8 puffs of MDI
•Should we USE LABA ????

22. ANTICHOLINERGICS
• Ipratropium Bromide 0.5 mg every 20 mins for an
hour

23. CORTICOSTEROIDS
• Inj Methylprednisone 125 mg iv stat
• Prednisolone 40-60 mg
• Inj Hydrocortisone 100 mg every 6th hourly

24. IF NO IMPROVEMENT AFTER 30 MINS
• Continue oxygen
• Steroids
• Nebulisation

25. IF PATIENT DETORIATES AND NO IMPROVEMENT
• Discuss with ICU team
IV MGSO4 2 gm over 20
mins

26. IF STILL WORSENS

27. MECHANICAL VENTILATION

28. ADDITIONAL DRUGS
• Antibiotics
• Montelukast
• Heliox
• Theophyllines

29. ACUTE EXACERBATION OF COPD
Definition of COPD by GOLD
COPD is a common, preventable, and treatable disease that is characterized by persistent
respiratory symptoms and airflow limitation that is due to airway and/or alveolar
abnormalities usually caused by significant exposure to noxious particles or gases. The
chronic airflow limitation that characterizes COPD is caused by a mixture of small airways
disease (eg, obstructive bronchiolitis) and parenchymal destruction (emphysema), the
relative contributions of which vary from person to person. Chronic inflammation causes
structural changes, small airways narrowing, and destruction of lung parenchyma. A loss
of small airways may contribute to airflow limitation and mucociliary dysfunction, a
characteristic feature of the disease.

31. DEFINITION OF EXACERBATION
• Worsening dyspnea
• Increase in sputum purulence
• Increase in sputum volume
TYPE 1 : all three : Severe
Type 2 : two symptoms : Moderate
Type 3 : one symptom : Mild

32. PRECIPITATING FACTORS
• Infection
• Environmental condition
• Host factors

33. Clinical Features

34. INVESTIGATIONS
• CBC
• Chest Xray
• Sputum Analysis
• ECG

35. ARTERIAL BLOOD GAS ANALYSIS

36. TREATMENT
ABC

37. TREATMENT
USE
CAUTIOUSLY
Avoid
respiratory
suppression

38. NEBULISATION
SABA : SALBUTAMOL . DOSE AND FREQUENCY ??????
Anticholinergics : Ipratropium Bromide : DOSE and
Frequency ???????
MODE OF ADMINISTRATION OF DRUG
??????????????

39. STEROIDS
• Hydrocortisone
• Methylprednisone
• Prednisolone

40. ANTIBIOTICS

41. IF PATIENT SERIOUSLY ILL

42. INDICATIONS FOR NIV
• Moderate to severe dyspnea
• Ph<7.35
• Paco2 > 45 mmhg
• RR >25 /min with use of accessory muscles of respirations

43. WHEN NOT TO USE NIV
• Respiratory arrest
• Cardiovascular instability
• Drowsy or comatosed patients
• High aspiration risk
• Craniofacial abnormalities

44. IF NO IMPROVEMENT ON NIV OR
CONTRAINDICATED