Pulmonology (resp emerg)


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  • 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
  • P. 1165 text
  • 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)

    1. 1. Pulmonology
    2. 2. Sections Review of Respiratory Anatomy & Physiology Pathophysiology Assessment of the Respiratory System Management of Respiratory Disorders Specific Respiratory Diseases
    3. 3. Respiratory Anatomy Upper Airway Nasal Cavity Nasopharynx Oropharynx Laryngopharynx Larynx
    4. 4. Respiratory Anatomy Upper Airway The Sinuses
    5. 5. Respiratory Anatomy Lower Airway Trachea Bronchi
    6. 6. Respiratory Anatomy Lower Airway Alveoli Lungs Pulmonary and Bronchial Vessels
    7. 7. Respiratory VentilationPhysiology Body Structures  Chest Wall  Pleura  Diaphragm
    8. 8. Respiratory Ventilation Physiology Inspiration
    9. 9. Respiratory Physiology Ventilation Expiration
    10. 10. Respiratory Physiology Ventilation Airway Resistance & Lung Compliance Lung Volumes
    11. 11. Respiratory Physiology Ventilation Regulation of Ventilation  The Medulla  Stretch Receptors  Changes in PCO2  COPD Patients
    12. 12. Respiratory Physiology Diffusion Interference with Diffusion  Trauma  Fluid accumulation in interstitial spaces  Thickening of the endothelial lining Effect of Oxygen Therapy
    13. 13. Respiratory Physiology Pulmonary Perfusion Requirements  Adequate blood volume  Intact pulmonary capillaries  Efficient pumping action by the heart Hemoglobin Carbon Dioxide
    14. 14. 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
    15. 15. Pathophysiolog y Disruption in Ventilation Nervous System  Trauma  Poisoning or Overdose  Disease
    16. 16. Pathophysiology Disruption in Diffusion Hypoxia Damaged Alveoli Disruption in Perfusion Alteration in Blood Flow Changes in Hemoglobin Pulmonary Shunting
    17. 17. 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
    18. 18. Assessment of the Respiratory System Initial Assessment General Impression  Position  Color  Mental status  Ability to speak  Respiratory effort
    19. 19. Assessment of the Respiratory SystemAirway  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
    20. 20. 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
    21. 21. 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
    22. 22. Focused History & Physical ExamAuscultation  Normal Breath Sounds • Bronchial, Bronchovesicular, and Vesicular  Abnormal Breath Sounds • Snoring • Stridor • Wheezing • Rhonchi • Rales/Crackles • Pleural Friction Rub adventitious lung sounds video
    23. 23. Focused History & Physical ExamExtremities  Look for peripheral cyanosis.  Look for swelling and redness, indicative of a venous clot.  Look for finger clubbing, which indicates chronic hypoxia.
    24. 24. Focused History & Physical Exam Vital Signs Heart Rate  Tachycardia Blood Pressure  Pulsus paradoxus Respiratory Rate  Observe for trends.
    25. 25. Focused History & Physical Exam Diagnostic Testing Pulse Oximetry  Inaccurate Readings
    26. 26. Focused History & Physical ExamPeak Flow  PEFR
    27. 27. Focused History & Physical ExamCapnometry  Continuous waveform monitoring, or capnography  Colorimetric devices
    28. 28. 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.
    29. 29. 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.
    30. 30. Upper-Airway ObstructionUnconscious Patient  Start CPR
    31. 31. 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
    32. 32. 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
    33. 33. 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
    34. 34. Obstructive Lung Disease Types Emphysema Chronic Bronchitis Asthma Causes Genetic Disposition Smoking & Other Risk Factors
    35. 35. 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
    36. 36. Emphysema Assessment History  Recent weight loss, dyspnea with exertion  Cigarette and tobacco usage Lack of Cough
    37. 37. 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.”
    38. 38. 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.
    39. 39. Chronic BronchitisPhysical Exam  Often overweight.  Rhonchi present on auscultation.  Jugular vein distention.  Ankle edema.  Hepatic congestion.  “Blue Bloater.”
    40. 40. 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.
    41. 41. 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.
    42. 42. Asthma Assessment Identify immediate threats. Obtain history.  SAMPLE & OPQRST History • History of asthma-related hospitalization? • History of respiratory failure/ventilator use?
    43. 43. AsthmaPhysical 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.
    44. 44. Asthma Management Treatment goals:  Correct hypoxia.  Reverse bronchospasm.  Reduce inflammation. Maintain the airway. Support breathing.  High-flow oxygen or assisted ventilations as indicated.
    45. 45. AsthmaMonitor cardiac rhythm.Establish IV Access.Administer medications.  Beta-agonists  Ipratropium bromide  Corticosteroids
    46. 46. Administration ofNebulized Medications Complete the initial assessment.
    47. 47. Administration ofNebulized Medications Place the patient on an ECG monitor.
    48. 48. Administration ofNebulized Medications Select the desired medication.
    49. 49. Administration ofNebulized Medications Add medication to the nebulizer.
    50. 50. Administration of Nebulized MedicationsAssemble the nebulizer and determine pre-treatment pulse rate.
    51. 51. Administration ofNebulized Medications Administer the medication.
    52. 52. Administration ofNebulized Medications Determine post-treatment pulse rate.
    53. 53. Administration ofNebulized Medications Reassess breath sounds.
    54. 54. 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.
    55. 55. 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.
    56. 56. Upper Respiratory Infection (URI)
    57. 57. Upper Respiratory Infection (URI) Assessment Look for underlying illness. Evaluate pediatrics for epiglottitis. Management Maintain the airway. Support breathing. Treat signs and symptoms.
    58. 58. 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.
    59. 59. 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
    60. 60. 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.
    61. 61. 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.
    62. 62. 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.
    63. 63. 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.
    64. 64. 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.
    65. 65. 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
    66. 66. 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.
    67. 67. 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.
    68. 68. 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.
    69. 69. 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
    70. 70. 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.
    71. 71. 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.
    72. 72. 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.
    73. 73. Hyperventilation Syndrome
    74. 74. 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.
    75. 75. 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.
    76. 76. 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.
    77. 77. 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.