Respiration is the exchnge of gases between a living organism and the environment Ventilation is the mechanical movement of air. Many pathologic processes inhhibit respiration and to correct them, you must understnd basic anatomy.
Air filled pockets of the skull that serve several functions Lighten skull, heat and humidify entering air, trap bacteria. Fracturfed sinuses can drain csf to nose
There are three important processes that allow gas exchange to occur 1. Ventilation 2. Diffusion 3. Perfusion
Diffusion – movement of gas from high concentration to low concentration O2 104 mmHg Alveoli to 40 in pulm artery CO2 45 mmHg to 40 Any disorder that damages alveoli will impede gas exchange Ie Alveoli Collapse Fluid accumulation in interstitial space pulm edema or pneumonia Thickening of endothelial lining. O2 admin – increases gradient which provides driving force Also diuretics or antiinflammatory drugs
Perfusion is the circulation of blood through the pulm capillaries bLOOD volume – more specifically hemoglobin which carries 98% O2 Intact pulm cap – example pulmonary embolism
Obstruction – croup epiglottitis, trauma, foreign body aspiration, edema(burns) smooth muscle constriction Any damage to mechanical components such as pneumothorax can disrupt ventilation Neuro – depressents ie etoh, barbiturates, benzodiazepines, stroke etc
Cheyne – brain injury Kussmal – diabetic ketoacidosis Centra – strokes, brain stem injury Ataxic – intracranial pressure Apneustic – stroke, severe central nerv sys disease.
Hypoxia – change in o2 concentration ie high altitude Alveoli – COPD, asbestosis Also fluid – CHF Perfusion – trauma, hemorraghe etc
Why is there a resp problem. Clues o2 tank, nebulizer, cigarettes, aspiration
Color – cyanotic Also – nasal flaring, intercostal mucleretractions,accessory muscle, cyanosis, pursed lips, trachel tugging
Remember that the brain can only survive a couple of minutes in asphysia Noisy breathing, obstructed s not always noisy Must act immediately
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Non cardiac pulm edema resulting from increased vascular permiability.
Cor pulmonale – hypertrophy of left heart from lung disorder Polycythemia – increased red blood cell (pink puffer) body tries to correct hyoxia
Unlike bronchitis, rarely have cough
Frequently elderly, hospital ridden, high rate of mortality
IV for dehydration but be careful of overload Pyretic - fever
Cherry red skin vary late finding
Tx hyperbaric chamber
May cause other clots, prepare for CPR
Risk – tall thin male 20 to 40 years age, COPD
Can be well tolerated if no underlying disease.
Characterized by rapid breathing, chest pains, numbness, other symptoms associated with anxiety But be aware of other diseases that can cause hyperventilation Until proven otherwise
Pulmonology (resp emerg)
Sections Review of Respiratory Anatomy & Physiology Pathophysiology Assessment of the Respiratory System Management of Respiratory Disorders Specific Respiratory Diseases
Pathophysiology Disruption in Ventilation Upper & Lower Respiratory Tracts Obstruction due to trauma or infectious processes Chest Wall & Diaphragm Trauma • Pneumothorax • Hemothorax • Flail chest Neuromuscular disease
Pathophysiolog y Disruption in Ventilation Nervous System Trauma Poisoning or Overdose Disease
Pathophysiology Disruption in Diffusion Hypoxia Damaged Alveoli Disruption in Perfusion Alteration in Blood Flow Changes in Hemoglobin Pulmonary Shunting
Assessment of the Respiratory System Scene Size-up Threats to Safety Identify rescue environments having decreased oxygen levels. Gases and other chemical or biological agents. Clues to Patient Information
Assessment of the Respiratory System Initial Assessment General Impression Position Color Mental status Ability to speak Respiratory effort
Assessment of the Respiratory SystemAirway Proper ventilation cannot take place without an adequate airway.Breathing Signs of life-threatening problems • Alterations in mental status • Severe central cyanosis, pallor, or diaphoresis • Absent or abnormal breath sounds • Speaking limited to 1–2 words • Tachycardia • Use of accessory muscles or presence of retractions
Focused History & Physical Exam History SAMPLE History OPQRST History Paroxysmal nocturnal dyspnea and orthopnea Coughing and hemoptysis Associated chest pain Smoking history or exposure to secondary smoke Similar Past Episodes
Focused History & Physical Exam Physical Examination Inspection Look for asymmetry, increased diameter, or paradoxical motion. Palpation Feel for subcutaneous emphysema or tracheal deviation. Percussion Auscultation
Focused History & Physical ExamAuscultation Normal Breath Sounds • Bronchial, Bronchovesicular, and Vesicular Abnormal Breath Sounds • Snoring • Stridor • Wheezing • Rhonchi • Rales/Crackles • Pleural Friction Rub adventitious lung sounds video
Focused History & Physical ExamExtremities Look for peripheral cyanosis. Look for swelling and redness, indicative of a venous clot. Look for finger clubbing, which indicates chronic hypoxia.
Focused History & Physical ExamPeak Flow PEFR
Focused History & Physical ExamCapnometry Continuous waveform monitoring, or capnography Colorimetric devices
Management of Respiratory Disorders Basic Principles Maintain the airway. Protect the cervical spine if trauma is suspected. Any patient with respiratory distress should receive oxygen. Any patient suspected of being hypoxic should receive oxygen. Oxygen should never be withheld from a patient suspected of suffering from hypoxia.
Upper-Airway Obstruction Common Causes Tongue, Foreign Matter, Trauma, Burns Allergic Reaction, Infection Assessment Differentiate Cause. Management Conscious Patient If the patient is able to speak, encourage coughing. If the patient is unable to speak, perform abdominal thrusts.
Adult Respiratory ARDS Video Link Distress Sepsis Syndrome Syndrome Near-Drowning Aspiration Head Injury Pneumonia Pulmonary Emboli Pulmonary Injury Tumor Destruction Burns/Inhalation Injury Pancreatitis Oxygen Toxicity Invasive Procedures Drugs Bypass, hemodialysis High Altitude Hypoxia, Hypotension, or Hypothermia Cardiac Arrest
Adult Respiratory Distress Syndrome Pathophysiology High Mortality Multiple Organ Failure Affects Interstitial Fluid Causes increase in fluid in the interstitial space, disrupts diffusion and perfusion. Assessment Symptoms Related to Underlying Cause Abnormal Breath Sounds Crackles and Rales
Adult Respiratory Distress Syndrome Management Manage the underlying condition. Provide supplemental oxygen. Support respiratory effort. Provide positive pressure ventilation if respiratory failure is imminent. Monitor cardiac rhythm and vital signs. Consider medications. CorticosteroidsFor more info go towww.ardsusa.org
Emphysema Pathophysiology Exposure to Noxious Substances Exposure results in the destruction of the walls of the alveoli. Weakens the walls of the small bronchioles and results in increase residual volume. Cor Pulmonale Polycythemia Increased Risk of Infection and Dysrhythmia
Emphysema Assessment History Recent weight loss, dyspnea with exertion Cigarette and tobacco usage Lack of Cough
Emphysema Assessment Physical Exam Barrel chest. Prolonged expiration and rapid rest phase. Thin. Pink skin due to extra red cell production. Hypertrophy of accessory muscles. “Pink Puffers.”
Chronic Bronchitis Pathophysiology Results from an increase in mucus-secreting cells in the respiratory tree. Alveoli relatively unaffected. Decreased alveolar ventilation. Assessment History Frequent respiratory infections. Productive cough.
Bronchitis & Emphysema Management Maintain airway. Support breathing. Find position of comfort. Monitor oxygen saturation. Be prepared to ventilate or intubate. Monitor cardiac rhythm. Establish IV access. Administer medications. Bronchodilators & corticosteroids.
Asthma Pathophysiology Chronic Inflammatory Disorder Results in widespread but variable air flow obstruction. The airway becomes hyperresponsive. Induced by a trigger, which can vary by individual. Trigger causes release of histamine, causing bronchoconstriction and bronchial edema. 6–8 hours later, immune system cells invade the bronchial mucosa and cause additional edema.
Asthma Assessment Identify immediate threats. Obtain history. SAMPLE & OPQRST History • History of asthma-related hospitalization? • History of respiratory failure/ventilator use?
AsthmaPhysical Exam Presenting signs may include dyspnea, wheezing, cough. • Wheezing is not present in all asthmatics. • Speech may be limited to 1–2 consecutive words. Look for hyperinflation of the chest and accessory muscle use. Carefully auscultate breath sounds and measure peak expiratory flow rate.
Asthma Management Treatment goals: Correct hypoxia. Reverse bronchospasm. Reduce inflammation. Maintain the airway. Support breathing. High-flow oxygen or assisted ventilations as indicated.
Special Cases of Asthma Status Asthmaticus A severe, prolonged attack that cannot be broken by bronchodilators. Greatly diminished breath sounds. Recognize imminent respiratory arrest. Aggressively manage airway and breathing. Transport immediately. Asthma in Children Pathophysiology and management similar. Adjust medication dosages as needed.
Upper Respiratory Infection (URI) Upper Respiratory Infections Frequent patient complaint Common pediatric complaint Rarely life threatening Pathophysiology Frequently caused by viral and bacterial infections. Affect multiple parts of the upper airway. Typically resolve after several days of symptoms.
Upper Respiratory Infection (URI) Assessment Look for underlying illness. Evaluate pediatrics for epiglottitis. Management Maintain the airway. Support breathing. Treat signs and symptoms.
Pneumonia Infection of the Lungs Immune-Suppressed Patients Pathophysiology Bacterial & Viral Infections Hospital-acquired vs. community-acquired. Infection can spread throughout lungs. Alveoli may collapse, resulting in a ventilation disorder.
Pneumonia Assessment Focused History & Physical Exam SAMPLE & OPQRST • Recent fever, chills, weakness, and malaise • Deep, productive cough with associated pain Tachypnea and tachycardia may be present. Breath sounds: • Presence of rales/crackles in affected lung segments • Decreased air movement in the affected lung
Pneumonia Management Maintain the airway. Support breathing. High-flow oxygen or assisted ventilation as indicated. Monitor vital signs. Establish IV access. Avoid fluid overload. Medications Antibiotics, antipyretics, beta-agonists.
Lung Cancer Pathophysiology General Majority are caused by carcinogens secondary to cigarette smoking or occupational exposure. May start elsewhere and spread to lungs. High mortality. Types Adenocarcinoma. Epidermoid, small-cell, and large-cell carcinomas.
Lung Cancer Assessment Focused History & Physical Exam SAMPLE & OPQRST History • Cancer-related treatments and hospitalizations. Physical Exam • Evaluate for severe respiratory distress. Management Follow general principles. Administer oxygen, support ventilation. Provide emotional support.
Toxic Inhalation Pathophysiology Includes inhalation of heated air, chemical irritants, and steam. Airway obstruction due to edema and laryngospasm due to thermal and chemical burns. Assessment Focused History & Physical Exam SAMPLE & OPQRST History • Determine nature of substance. • Length of exposure and loss of consciousness.
Toxic Inhalation Management Ensure scene safety. Enter a scene only if properly trained and equipped. Remove the patient from the toxic environment. Maintain the airway. Early, aggressive management may be indicated. Support breathing. Establish IV access. Transport promptly.
Carbon Monoxide Inhalation Carbon Monoxide Odorless, Colorless Gas Results from the combustion of carbon-containing compounds. Often builds up to dangerous levels in confined spaces such as mines, autos, and poorly ventilated homes. Hazardous to Rescuers
Carbon Monoxide Inhalation Pathophysiology Binds to Hemoglobin Prevents oxygen from binding and creates hypoxia at the cellular level. Assessment Focused History and Physical Exam SAMPLE & OPQRST History • Determine source and length of exposure. • Presence of headache, confusion, agitation, lack of coordination, loss of consciousness, and seizures.
Carbon Monoxide Inhalation Management Ensure scene safety. Enter a scene only if properly trained and equipped. Remove the patient from the toxic environment. Maintain the airway. Support breathing. High-flow oxygen or assisted ventilations as indicated. Establish IV access. Transport promptly.
Pulmonary Embolism Pathophysiology Obstruction of a pulmonary artery Emboli may be of air, thrombus, fat, or amniotic fluid. Foreign bodies may also cause an embolus. Risk Factors Recent surgery, long-bone fractures, pregnancy. Pregnant or postpartum. Oral contraceptive use, tobacco use.
Pulmonary Embolism Assessment Focused History & Physical Exam SAMPLE & OPQRST History • Presence of risk factors • Sudden onset of severe dyspnea and pain • Cough, often blood-tinged Physical Exam • Signs of heart failure, including JVD and hypotension • Warm, swollen extremities
Pulmonary Embolism Management Maintain the airway. Support breathing. High-flow oxygen or assist ventilations as indicated. Intubation may be indicated. Establish IV access Monitor vital signs closely. Transport to appropriate facility.
Spontaneous Pneumothorax Pathophysiology Pneumothorax Occurs in the absence of blunt or penetrating trauma. Risk factors Assessment Focused history SAMPLE & OPQRST history. Presence of risk factors. Rapid onset of symptoms. Sharp, pleuritic chest or shoulder pain. Often precipitated by coughing or lifting.
Spontaneous Pneumothorax Physical exam: Decreased or absent breath sounds on affected side Tachypnea, diaphoresis, and pallor Management Maintain the airway. Support breathing. Monitor for tension pneumothorax. Pleural decompression may be indicated if patient becomes cyanotic, hypoxic, and difficult to ventilate. JVD and tracheal deviation away from the affected side.
Hyperventilation Syndrome Assessment Focused History & Physical Exam SAMPLE & OPQRST history. • Fatigue, nervousness, dizziness, dyspnea, chest pain. • Numbness and tingling in hands, mouth, and feet. Presence of tachypnea and tachycardia. Spasms of the fingers and feet.
Hyperventilation Syndrome Management Maintain the airway. Support breathing. Provide high-flow oxygen or assist ventilations as indicated. Do NOT allow the patient to rebreathe exhaled air. Reassure the patient.
CNS Dysfunction Pathophysiology Causes can include traumatic/atraumatic brain injury, tumors, and drugs. Assessment Evaluate potentially treatable causes, such as narcotic drug overdose or CNS trauma. Carefully evaluate breathing pattern. Management Follow general management principles. Maintain the airway and support breathing. Use cervical spine precautions if indicated.
Dysfunction of the Spinal Cord,Nerves, or Respiratory Muscles Pathophysiology PNS problems affecting respiratory function may include trauma, polio, myasthenia gravis, viral infections, tumors. Assessment Rule out traumatic injury, and assess for numbness, pain, or signs of PNS dysfunction. Management Follow general management principles. Maintain the airway and support breathing. Use cervical spine precautions if indicated.