ATS - respiratory compromise

Emergency Medical Technician
8 – Respiratory Compromise
© 2014 Slide 2

© 2014
• The respiratory system
in any patient can
become compromised
with:
– Little warning
– No warning
• Injury and illness can
both compromise
respiration
Slide 3

© 2014
1. Inadequate Breathing
2. Assessing Inadequate Breathing
3. Respiratory Distress Medications
4. Respiratory Distress & Failure
Slide 4

© 2014
• A patient with
respiratory difficulty
can present with
breathing that is:
– Adequate
– Inadequate
• Your ability to rapid
assess and provide
immediate intervention
will be critical in
providing life-saving
care
Slide 6

© 2014
• Inadequate breathing is
breathing that is not
sufficient to support life
due to a lack of oxygen
or an excess of carbon
dioxide
• If untreated, it will lead
to death
Slide 7

© 2014
• The rate of breathing
may be outside the
normal range of 12-20
bpm for an adult
• Breathing that is either
very slow or very rapid
can limit the effective
amount of air entering
or leaving the lungs
Slide 8

© 2014
• The rhythm of breathing
may be irregular
• Regularity can be
difficult to assess, as it
can be difficult to see or
hear the respirations
– Talking can cause
respirations to be
irregular
Slide 9

© 2014
• A patient could exhibit
a regular rate even
though the effort to
breathe is inadequate
Slide 10

© 2014
• The quality of
breathing, or the
effectiveness of the
effort to move adequate
air in and out of the
lungs, will deviate from
normal
• Breath sounds may be:
– Present
– Decreased
– Absent
Slide 11

© 2014
• Respiratory effort may:
– Normal
– Excessively deep
– Shallow
– Absent
• Chest expansion may
be:
– Normal
– Minimal
– Unequal
Slide 12

© 2014
• A patient that has
inadequate breathing is
experiencing respiratory
compromise
• Respiratory compromise:
– Develop slowly over time
– Can come on suddenly
• Any compromise to the
respiratory system is an
emergency that requires
immediate, corrective
action:
– Be alert for respiratory
compromise in every
patient
Slide 13

© 2014
• Respiratory compromise
can involve an
impairment of the
airway, respiration or
ventilation
• If the airway is
impaired, movement of
oxygenated air into and
out of the lungs is
blocked
Slide 14

© 2014
• Possible causes of
airway blockage can
include:
– A foreign body
obstruction
– Blockage from the
tongue
– Fluids such as blood,
secretions or emesis
• The airway can also be
impaired by swelling or
trauma to the neck
Slide 15

© 2014
• Respiration is the exchange of the gases
oxygen and carbon dioxide between the
bloodstream and outside air
• If respiration is impaired, air is breathed
in, but it either lacks adequate oxygen or
the body is unable to use the oxygen
contained in it
Slide 16

© 2014
• Possible causes of impaired
respiration:
– Trauma
– Infection in the lungs
– Narrowing of the airway caused by
illness
– Poor circulation
– Excess fluid in the lungs or between the
lungs an blood vessels
– A low-oxygen environment
– Poison gas
Slide 17

© 2014
• Ventilation is the effectiveness of the
mechanical process by which air is
moved in and out of the lungs
• Ventilation is impaired if an
insufficient volume of air is moving
into and out of the lungs, or the rate
of breathing, depth of breathing or
both are not adequate
Slide 18

© 2014
• Possible causes of
impaired ventilation can
include:
– An altered level of
consciousness
– Injury to the chest
– Poisoning
– Overdose
– Disease
Slide 19

© 2014
• Trauma injuries can
cause severe damage
that can quickly
compromise the
respiratory system
• Some injuries are
obvious when they
involve the chest
• Expect respiratory
compromise in any
trauma case
Slide 20

© 2014
• Common medical
causes of respiratory
compromise can
include:
– Respiratory infections
– Diseases
Slide 21

© 2014
• In the case of
respiratory infections,
the ability of the
respiratory system to
function properly can be
severely limited
• It is not necessary that
you determine the exact
medical cause of the
breathing difficulty:
– Be aware of some
common illnesses
Slide 22

© 2014
• Pneumonia and other chronic
conditions, such as chronic
obstructive pulmonary disease
(COPD) can cause respiratory
compromise
• COPD includes serious conditions
such as:
– Emphysema
– Chronic bronchitis
Slide 23

© 2014
• Asthma is a life-
threatening disease
that presents with
episodic flares
• Can be triggered by:
– Allergies
– Pollutants
– Infections
– Strenuous exercise
– Emotional stress
Slide 24

© 2014
• Asthma patients are
typically able to inhale,
but constricted
bronchioles and
overproduction of
mucus causes stale air
to be trapped in the
lungs
• Forceful exhalation
produces a
characteristic wheezing
sound
Slide 25

© 2014
• Pediatric patients can
have respiratory
compromise due to:
– Asthma
– Allergies
– Drowning
– Choking
– Illness
• In children, respiratory
arrest is the most likely
cause of cardiac arrest
that is not due to
trauma
Slide 26

© 2014
• Croup is a viral illness
often seen in pediatric
patients
• Croup causes
inflammation of the
larynx, trachea and
bronchi that results in
swelling of the upper
airway
Slide 27

© 2014
• A patient with
respiratory difficulty
can present with
breathing that is either
adequate or inadequate
• Your ability to rapid
assess and provide
immediate intervention
is critical
Slide 29

© 2014
• Signs and symptoms for
inadequate breathing
can vary greatly
depending on the
respiratory condition
that is causing the
problem
Slide 30

© 2014
• A common sign of
respiratory distress is
“tripoding”
– The patient may stand
or sit with hands on
the knees, shoulders
arched upward and
head forward
• Tripoding allows for
unrestricted movement
of the muscles used in
respiration and
straightens the airway
to reduce resistance to
airflow
Slide 31

© 2014
• Common signs and
symptoms of
respiratory conditions
associated with
inadequate breathing
can include
• Restlessness:
– Low levels of oxygen to
the brain
• Respiratory distress, or
an increase in the work
of breathing
Slide 32

© 2014
• Dyspnea
• Abnormal breathing sounds
• Changes in respiratory rate or rhythm
• Abdominal breathing
• Accessory muscle use during breathing
Slide 33

© 2014
• Increased pulse
rate
• Altered mental
status
• Skin color changes
• An inability to
speak
Slide 34

© 2014
• Use a modified OPQRST
mnemonic to gather
patient information
• Keep the questioning
short:
– Patient may be in too
much distress to
answer a lot of
questions
Slide 35

© 2014
• Ask what the patient
was doing at the time of
onset:
– Did anything triggered
it ?
– Was gradual or
sudden?
• Inquire and observe
whether changing
position makes
breathing better or
more difficult
Slide 36

© 2014
• Ask if the patient has
more difficulty
breathing in or
breathing out
• Have patient indicate
whether the discomfort
radiates to any other
part of his body
• Have him describe the
severity of his breathing
difficulty on a scale of 1
to 10, with 10 being the
most severe
Slide 37

© 2014
• Ask:
– When the breathing
difficulty began
– How long it lasts
– If it has been a
recurring problem
• Patients with
pneumonia:
– Ask whether he has
been coughing and if
it is productive
Slide 38

© 2014
• Auscultate the patient’s
chest to assess breath
sounds as he inhales
and exhales
• Listen to the anterior
upper lobe just below
the second rib at the
midclavicular line:
– Listen to the lower lobe
just below the 4th rib
Slide 39

© 2014
Slide 40
• Listen to the posterior
upper lobe at the
midscapular line:
– Listen laterally to the
midscapular line for
the lower lobe
• At the mid-axillary line,
listen to the upper lobe

© 2014
• Listening to the lungs in
multiple locations can
help you:
– Localize
– Identify the patient’s
problem
– Detect changes over
time
Slide 41

© 2014
• The quality of breathing
is evaluated by breath
sounds
• The depth of breathing
effort as noted by:
– Chest expansion and
contraction
– Symmetry of the chest
movement
Slide 42

© 2014
• Respiratory effort may be:
– Normal
– Excessively vigorous
– Shallow or absent
• Listen for whether breath
sounds are:
– Present
– Decreased
– Absent
• If present, they may be:
– Normal
– Abnormally noisy
– Diminished
Slide 43

© 2014
• Absent or diminished breath sounds
suggest:
– The presence of air, blood or fluid
outside the lung and in the chest
cavity
– An obstruction of a bronchus
– A problem with the lung tissue such
as fluid, infection or a mass
Slide 44

© 2014
• Compare both sides of
the chest
• Chest expansion may be:
– Normal
– Unequal
• Typically, diminished or
absent breath sounds on
only one side indicates
the presence of:
– An injury
– Collapse lung
– Surrounding air or fluid
between the lung and
the inner chest wall
Slide 45

© 2014
• Note any abnormal sounds
you hear
• Common abnormal breath
sounds include:
– Stridor
– Wheezing
– Rhonchi
– Rales
• Practice listening to breath
sounds:
– Will help you recognize
the difference between
normal and abnormal
breathing
Slide 46

© 2014
• Stridor is a high-pitched
sound
– Is typically be heard on
inspiration, often
without a stethoscope
• Stridor indicates the
presence of a partial
obstruction of the upper
airway caused by an
object, swelling or
spasm
Slide 47

© 2014
•Causes of Stridor include:
– Infection
– Allergic reactions
– Burns
Slide 48

© 2014
• Wheezing is a high-
pitched musical sound
• Typically heard on
expiration:
– In severe cases it is
heard on inhalation
• Wheezing indicates
narrowing of the
bronchioles
Slide 49

© 2014
• Wheezing can be heard with many
conditions
• It is typical in conditions such as:
– Asthma
– Emphysema
Slide 50

© 2014
• Rales, sometimes called
crackles:
– Fine crackling or
bubbling sound on
inhalation
• Crackles indicate that
there is fluid in and
around the alveoli:
– Common in patients
with pneumonia or
heart failure with
congestion
Slide 51

© 2014
• Rhonchi are low-pitched
snoring or rattling sounds:
– Indicates an obstruction
of the larger airway
structures
• Heard in patients with:
– Pneumonia
– Emphysema
– Bronchitis
• Because rhonchi are
caused by thick secretions
of mucus, the quality of
the sound changes if the
patient coughs
Slide 52

© 2014
• Rhonchi are caused by thick secretions
of mucus:
– The quality of the sound changes if the
patient coughs
Slide 53

© 2014
• Whenever the respiratory system is
compromised, expect the patient to be
experiencing some degree of
inadequate oxygenation
• Just because your patient is breathing
does not mean that she is receiving
adequate oxygen to sustain life
• You must determine the adequacy of
the oxygen and act accordingly
Slide 54

© 2014
• A patient with adequate
oxygenation will:
– Exhibit a mental status
considered normal for
the patient
– May or may not have a
skin color that appears
normal for her
Slide 55

© 2014
• A patient with
inadequate oxygenation
will:
– Have a mental status
considered abnormal
or altered
– His skin color may or
may not appear normal
with possible cyanosis,
pallor or mottling
• Inadequate breathing
can lead to hypoxemia
Slide 56

© 2014
• Hypoxemia can
cause hypoxia:
– The cells of the body
lack sufficient
oxygen
– Cells function
abnormally or die
– Can cause organ
failure and,
eventually, death
Slide 57

© 2014
• When you take the
patient’s vital signs, you
may see anomalies in:
– Heart rate
– Breathing rate
– Blood pressure
• The blood pressure may
drop as a result of
pressure inside the
chest
Slide 58

© 2014
• If the needle drops more
than 10 mmHg on
inhalation when obtaining
systolic pressure, pulsus
paradoxus is indicated:
– A severe respiratory
condition
• This caused by pressure in
the chest decreasing the
volume of blood returning
to the heart:
– The pulse strength
returns on exhalation
Slide 59

© 2014
• The heart rate may be
either increased or
decreased
• Bradycardia - a slow
heart rate indicates:
– Poor oxygenation
– Respiratory failure
– Possible impending
cardiac arrest
Slide 60

© 2014
• Expect the breathing
rate to be increased:
– A decrease indicates
severe hypoxia and will
require immediate
ventilation
• Closely monitor the
patient’s respiratory
rate and tidal volume
for adequacy
Slide 61

© 2014
• Get a baseline reading
for comparison later
• Check the pulse
oximeter and make sure
it correlates with the
palpated pulse or a
cardiac monitor:
– This will help you more
accurately identify
changes in the
patient’s oxygen
saturation level
Slide 62

© 2014
• Bronchodilators used to
treat acute and chronic
respiratory conditions:
– These act quickly
– Help to open the airways
• Medications are delivered
via:
– A metered-dose inhaler
– Small-volume nebulizer
• If your patient has a
prescription, you may be
able to assist with
administering the
medication
Slide 64

© 2014
• Contact medical direction for
permission and guidance before
assisting any patient with medication
• An order from medical direction may be
either:
– On-line by direct communication
– Off-line through established protocols or
standing orders
Slide 65

© 2014
• Check the 5 rights of medication
administration
• Confirm the following:
– Right patient
– Right medication
– Right route of administration
– Right dose
– Right time
Slide 66

© 2014
• Inspect the medication to
make sure it is
prescribed for the patient
you are assisting
• Confirm that it is the
correct medication to be
administered under the
circumstances
• Make sure you
understand how to
correctly administer the
medication
• Inhalers and nebulizers
are administered through
the route of inhalation
Slide 67

© 2014
• Follow the manufacturer’s direction
and the guidance of medical control in
administering the proper dose
• Overmedicating can harm the patient
• Ask whether the patient used the
medication before you arrived:
– If so, how much was used?
Slide 68

© 2014
• Assess whether this is
the right time during
your course of
treatment to administer
the medication
Slide 69

© 2014
• Using a metered-dose
inhaler (MDI) make sure
the inhaler is at room
temperature or warmer
• Shake it vigorously for at
least 30 seconds
• Attach a spacer to the
device if one is available:
– This holds aerosolized
medication in a chamber
so it can be inhaled more
directly into the lungs
Slide 70

© 2014
• The patient should be
alert enough to use the
inhaler
• Calm him so that
administration will be
successful
• Direct the patient to
exhale deeply and place
his lips around the
mouthpiece
Slide 71

© 2014
• Remove the patient’s
oxygen source
• Have patient
immediately press down
on the inhaler as he
inhales deeply
• In order to be effective,
the medication must be
mixed with inhaled air
so that it directly
contacts lung tissue
Slide 72

© 2014
Slide 73
• After completing the full
inhalation, direct the
patient to hold his
breath as long as
possible
• Place the patient back
on oxygen

© 2014
Slide 74
• To administer
medication:
– Prepare the nebulizer
by opening chamber
– Put the required
amount of medication
prescribed to the
patient in the device
according to the
manufacturer’s
directions
– Reassemble the
chamber

© 2014
Slide 75
– Attach the chamber
to a delivery device:
 Inhalation tube
 Face mask
– Attach an oxygen
line to the device
and set the flow for
6-8 lpm
– Direct the patient to
put lips around the
mouthpiece and
inhale deeply

© 2014
– Have patient hold
breath for 2 -3
seconds before
exhaling
– Continue to assist
the patient with
nebulizer until all
the medication in the
chamber is used
Slide 76

© 2014
• After administering
any medication,
document the drug,
dose, route and time
of administration
• Reassess the patient
for any changes
• Check vital signs and be
alert for side effects of
the medication
Slide 77

© 2014
• Bronchodilators increase in the heart
rate known as tachycardia
• May also be accompanied by:
– Tremors
– Nervousness
• Expect tachycardia to decrease as the
medication wears off
Slide 78

© 2014
Slide 79
• Check the adequacy of
oxygen being delivered
using a pulse oximeter
• Document any
improvement or
deterioration
• If no improvement:
– Contact medical
direction before
administering another
dose of medication

© 2014
• Any time respiration is
compromised,
immediate action must
be taken:
– To ensure adequate
ventilation
– Provide supplemental
oxygen if needed
• Every patient with
breathing difficulty is
considered a priority
patient
Slide 81

© 2014
Slide 82
• Two common
respiratory conditions
you can expect to
encounter:
– Respiratory distress
– Respiratory failure

© 2014
• Respiratory distress occurs when a
patient must work harder to:
– Move air into the lungs
– Out of the lungs
– Both
• Respiratory distress is an early sign of
respiratory compromise and can progress
in severity
• Be aware that a patient can have
adequate ventilation but still be in
respiratory distress
Slide 83

© 2014
• You must recognize and
treat respiratory distress
as early as possible:
– Helps prevent
respiratory failure
• The signs and symptoms
of respiratory distress can
include:
– Increased rate and
depth of breathing
– Unusual breathing
sounds,
– Normal to pale skin
color
Slide 84

© 2014
Slide 85
• Immediately provide
oxygen according to
protocols:
– 15 lpm often suggested
via NRB:
 Nasal cannula can be
used if NRB is not
tolerated
• Use of supplemental
oxygen will often
restore oxygen levels

© 2014
Slide 86
• Obtain baseline vitals
• Determine if patient has
a prescribed MDI:
– If so, contact medical
control
• Allow patient remain in
a position of comfort
• Perform a secondary
assessment

© 2014
• A patient who is NOT
breathing adequately
will require manually
assisted ventilations,
use:
– A pocket face mask
– Bag mask device
– Other ventilation
equipment
Slide 87

© 2014
• Prepare for transport
• Continue to monitor
vital signs:
– Note any changes
• Reassure the patient to
help reduce stress
Slide 88

© 2014
• Respiratory distress can
lead to respiratory
failure
• Respiratory failure
leads to respiratory
arrest
• Respiratory arrest leads
to cardiac arrest
Slide 89

© 2014
• Respiratory failure occurs when the
respiratory rate or volume is reduced to
the point where the patient does not take
in enough oxygen to support life or retains
too much carbon dioxide
• Common causes include:
– Asthma
– Hyperventilation
– Emphysema
Slide 90

© 2014
• The signs and
symptoms of
respiratory failure are:
– Altered mental
status
– Cyanosis
– An inadequate rate
and depth of
breathing
Slide 91

© 2014
• Assess responsiveness
• Hold your ear next to
the nose and mouth,
listen for:
– Breathing
– Rhythm
– Rate
– Depth
– Effort
Slide 92

© 2014
• If the airway is not
patent, you must
immediately open and
maintain it
• For an unresponsive
medical patient, use the
head-tilt, chin-lift
technique:
– Check again for
breathing and be
prepared to suction if
necessary
Slide 93

© 2014
• If patient is an
unresponsive trauma
patient:
– Open and maintain the
airway using the
modified jaw-thrust
technique
– Maintaining manual
cervical stabilization
Slide 94

© 2014
• Immediately provide
positive pressure
ventilation to force air
into the lungs:
– Always follow local
protocols
• Use a pocket mask or a
bag valve device and
attach it firmly to the
patient’s face to obtain
a firm, leak free seal
Slide 95

© 2014
Slide 96
• Attach an oxygen
supply line to the mask
or bag and adjust the
regulator to a high-flow
rate
• Deliver ventilations by
gently squeezing the
bag with each
inhalation for one
second until you just
see the chest rise

© 2014
• Watch for the chest to rise and fall
with each ventilation
• Adjust the rate of ventilations to
achieve an optimal rate of 10-12
ventilations per minute for an adult,
as noted by the chest rise
Slide 97

© 2014
• For very slow breathing:
– Add ventilations in between the
patient’s own breaths
– Obtain an appropriate rate with
adequate volume
• For rapid breathing, refer to your local
protocols to determine whether
adjustments to the rate and volume
are permitted
Slide 98

© 2014
Slide 99
• Continually reassess
for airway patency:
– Make adjustments as
needed
• Oximetry readings will
help you assess
oxygenation levels
• Prepare and transport
the patient

© 2014
• Inadequate Breathing
• Assessing Inadequate Breathing
• Respiratory Distress Medications
• Respiratory Distress & Failure
Slide 101

© 2014
• Any time a patient experiences a
respiratory emergency, you must be
able to recognize the condition
indicated by the signs and symptoms
and act immediately
• Any patient can develop a respiratory
emergency with little or no warning
• Knowing what to look for and how to
respond will be crucial
Slide 102

ATS - respiratory compromise

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