3. *
*Upper Respiratory Tract
*Nose: The nose draws in air
through the nostrils and into
the nasal cavity. The nasal
cavity opens into the
pharynx (throat) at the
nasopharynx.
*Mouth: The mouth also
draws in air, especially
during times of physical
exertion or when the nose is
“stuffy.” The oral cavity
opens into the pharynx at
the oropharynx.
*Laryngopharynx: Air passes
through the nasopharynx and
oropharynx toward the
laryngopharynx, which is the
opening to the larynx (or
voice box).
*Lower Respiratory Tract
*Trachea: The trachea (or
windpipe) continues from the
larynx.
*Bronchi: The trachea splits into
two bronchi that each lead to a
lung.
*Lungs: Each lung is divided into
lobes. The right lung has three
lobes and the left lung has two.
*Alveoli: The bronchi branch into
smaller bronchioles that lead to
the alveoli, which are small air
sacs surrounded by capillaries.
Gas exchange between the air and
blood occurs across the alveolar
and capillary walls.
4. *Dyspnea-Difficult or
labored breathing.
*Hemoptysis- Coughing up
blood.
*Hypoxia- Deficiency in the
amount of oxygen reaching
tissues.
*Anoxia- Absence of
oxygen.
*Orthopnea- Dyspnea while
lying flat.
*Tactile Fremitus- A
vibration perceptible on
palpation or auscultation.
*Atelectasis- Lack of
surfactant causing
collapse of the alveoli.
5. *Arterial Blood Gases
Q: “WHY do I need to know this”?
Capnography, as we all should know is the measurement of
carbon dioxide (CO2) in each exhaled breath. While
Capnography is a direct measurement of ventilation in the
lungs, it also indirectly measures metabolism and
circulation. For example, an increased metabolism will
increase the production of CO2 increasing the ETCO2. A
decrease in cardiac output will lower the delivery of CO2
to the lungs decreasing the ETCO2.
A: Because we use it on the truck every day!
9. 2.2.2 Asthma/Bronchospasm
Adult Medical Protocol
Purpose: This protocol is used for patients who are
complaining of dyspnea and who are wheezing.
Whenever possible, allow these patients to assume
whatever position is comfortable (they may not
tolerate laying flat). A patient with a history of CHF
that has wheezing on auscultation of lung sounds
should not be automatically classified as an “asthma
patient”. If the CHF patient does not have a history of
asthma or allergic reaction, the more prudent
assessment would be that of CHF (cardiac asthma) (See
CHF/Pulmonary Edema protocol)
10. *True asthma is a chronic
condition caused by
inflammation of the
airways, which can
narrow them, leading to
breathing difficulties.
True asthma has nothing
to do with fluid in the
lungs or heart disease.
*Heart failure can cause
fluid to build up in your
lungs (pulmonary edema)
and in and around your
airways. The latter
causes signs and
symptoms — such as
shortness of breath,
coughing and wheezing —
that may mimic asthma.
*
The distinction is important because treatments for asthma and heart
failure are different. Treatments for heart failure can help improve your
symptoms for both the heart failure and the cardiac asthma. Overusing
treatments for true asthma, such as rescue inhalers, may actually
worsen cardiac asthma and could cause dangerous heart rhythms.
11. Treating The Asthma
Patient
1. Initial Patient Assessment Protocol 2.1.1
2. Airway Assessment/Management Protocol 2.1.2 Oxygen
via nasal cannula @2 - 4 LPM to maintain pulse ox at ≥
94% (non-rebreather @15 LPM if SpO2 < 90%).
3. Attach cardiac monitor and pulse oximeter.
4. Transport to designated hospital.
12. ALS LEVEL 1: PARAMEDIC ONLY
1. If severe distress consider CPAP with in-line nebulized medication may
or may not help (keep in mind, it is the medications that will work best
to break the bronchospasm)
2. Administer Albuterol (Ventolin) 2.5mg (in 2.5cc normal saline) by
nebulizer. May repeat twice PRN. DO NOT GIVE ALBUTEROL OR
IPRATROPIUM BROMIDE IF THE HEART RATE IS > 140
3. May add Ipratropium Bromide (Atrovent) 0.5 mg (0.5ml) to the first
Albuterol neb only.
4. If indicated, start IV of Lactated Ringer’s or Normal Saline at TKO
5. For persistent respiratory distress, give Methylprednisolone Sodium
Succinate (Solu-Medrol) 80mg IV/IO/IM.
6. For severe dyspnea, Epinephrine (1:1000) 0.4 ml IM Adult
(Peds: 0.01 ml/kg.) Caution should be used with administration of
Epinephrine when the patient has a history of hypertension or heart
disease (call med control if you have any concerns)
7. Consider need for endotracheal intubation
13. ALS LEVEL 2: MEDICAL CONTROL
1. Repeat Epinephrine (1:1000) 0.4 mg IM
2. If patient still has dyspnea after SubQ Epi, 3 Albuterol
nebs (first with Atrovent), and Solu-Medrol, Medical
Control may order Magnesium Sulfate
2 gms IV (mixed with 50ml of D5W given over 10 – 15
minutes)
Remember to avoid positioning patient FLAT
19. This protocol is used for patients with a history of
emphysema and/or chronic
bronchitis that complain of dyspnea.
If at any point, the patient’s respiratory status
deteriorates, consider CPAP or endotracheal
intubation and administration of Albuterol via the
ET tube as a mist, and transport immediately. See
Oxygen Tolerance in COPD in Appendix.
20. BASIC LEVEL: EMT and PARAMEDIC
1. Initial Patient Assessment 2.1.1
2. Airway Assessment/Management Protocol 2.1.2. Oxygen
via nasal cannula @2 - 4 LPM to maintain pulse ox at ≥ 94%
(non-rebreather @15 LPM if SpO2 < 90%).
3. Attach cardiac monitor and pulse oximeter.
Treatment
21. ALS LEVEL 1: PARAMEDIC ONLY
1. If patient is in moderate to severe distress and is still alert and
cooperative, consider CPAP (with in-line nebulized medication) per
CPAP Protocol .
2. Administer Albuterol 2.5 mg in 2.5ml of normal saline and Atrovent
(Ipratropium) 0.5mg via nebulized breathing treatment.
3. Repeat Albuterol (only) every 15 minutes as needed x 3 doses total.
Discontinue therapy if patient develops marked tachycardia (HR >
140) or chest pain.
4. If signs of severe hypoventilation despite CPAP and/or Nebulized
bronchodilators: (See Airway Assessment Protocol, 2.1.2)
a. Assist ventilations with BVM with 100% oxygen.
b. Consider endotracheal intubation
5. Initiate IV lactated Ringer's or normal saline TKO.
6. For persistent respiratory distress, give Methylpredisolone Sodium
Succinate (Solu-Medrol) 80 mg IV.
22. ALS LEVEL 2: MEDICAL CONTROL
1. Contact medical control or medical director for any
questions or problems.
2. Consider (per med control) Valium 2-5 mg or Versed
2-4 mg IVP for anxiety, however patient may then need
to be intubated.
25. *In most cases, heart problems cause pulmonary edema.
However, fluid can accumulate for other reasons including;
Pneumonia, exposure to certain toxins or medications,
trauma to the chest wall and exercising or living at high
elevations.
* Pulmonary edema can be fatal. However, the outlook
improves with prompt treatment along with treatment of
the underlying problem.
*BNP- B-type Natriuretic Peptide blood test.
BNP is an amino acid polypeptide released by the ventricles
of the heart in response to excessive stretching of heart
muscle cells, used to diagnosis CHF normal is less than
100pg/mL.
26. This protocol is used for patients who are exhibiting
signs/symptoms of pulmonary edema – CHF including:
tachypnea, orthopnea, JVD, edema, dyspnea with rales
and/or wheezing (cardiac asthma). The patient may also
have diminished air exchange. In severe case, patient may
be pursed lip breathing. Other treatment for the causes of
pulmonary edema-CHF should be considered (e.g.
supraventricular tachycardia, myocardial infarction and
cardiogenic shock).
Protocol 2.2.4
27. BASIC LEVEL: EMT and PARAMEDIC
1. Initial Patient Assessment Protocol. 2.1.1
2. Airway Assessment/Management Protocol.2.1.2. Put patient in
position of comfort. Oxygen via nasal cannula @2 - 4 LPM to
maintain pulse ox at ≥ 94% (non-rebreather @15 LPM if SpO2 < 90%).
3. Attach cardiac monitor and pulse oximeter.
28. ALS LEVEL 1: PARAMEDIC ONLY
1. Administer CPAP (if available). Titrate to 10cm of pressure (see
CPAP Protocol)
2. If patient’s respiratory status deteriorates (fatigues, does not respond to
CPAP, obvious persistent distress), assist ventilations with BVM with
100% oxygen and consider endotracheal intubation. If patient has end-stage
disease and has previously expressed to family (verbally or in
writing) he/she does not want to be intubated, and then continue
assisting with BVM or CPAP.
3. Initiate IV lactated Ringer’s or Normal Saline TKO.
4. If systolic BP > 100 mm Hg; give Nitroglycerine 0.4mg sublingual
(spray or tablet) followed by Nitroglycerin paste 1 inch to chest wall
Avoid if patient used Viagra, Cialis, Levitra or other ED drugs. (May
repeat sublingual Nitro every 3 minutes up to 3 doses total if patient is
hypertensive or has chest pain).
5. Do 12 Lead EKG. Transmit if abnormal and time permits
29. ALS LEVEL 2: MEDICAL CONTROL
1. Lasix 40-80 mg IV.
2. Contact medical control or medical director
for any concerns or
questions.
31. Protocol 2.2.5
Patients complaining of dyspnea should be suspected of
having pneumonia when they present with fever,
productive cough, and possible pleuritic chest pain,
history of being bedridden, known immune-compromise,
diabetes, elderly and lung sounds indicative of
consolidation (rales and/or rhonchi with egophony over
area of consolidation).
32. BASIC LEVEL: EMT and PARAMEDIC
1. Initial Patient Assessment Protocol 2.1.1
2. Airway Assessment/Management Protocol 2.1.2.
Oxygen via nasal
cannula @2 - 4 LPM to maintain pulse ox at ≥ 94%
(non-rebreather @15
LPM if SpO2 < 90%).
3. Attach cardiac monitor and pulse oximeter
4. Check temperature if able
33. ALS LEVEL 1: PARAMEDIC ONLY
1. Consider CPAP (per CPAP protocol) for severe dyspnea/air hunger. It
may or may not help but will not harm.
2. Initiate IV lactated Ringer’s or Normal Saline at 125ml/hr. If patient
hypotensive (systolic < 90 mm Hg) and/or tachycardic (HR > 110) bolus
with 1- 2 liters of IV fluid in 250ml increments until systolic BP > 90 mm
Hg (20 ml/kg for children). Recheck vital signs and lung exam inbetween
each increment. Discontinue bolus if signs of pulmonary edema
or development of respiratory distress.
3. If dyspnea noted, administer Albuterol 2.5 mg in 2.5ml of normal saline
and Atrovent (Ipratropium) 0.5mg via nebulized breathing treatment.
Do not give if HR ≥ 140
4. Repeat Albuterol (only) every 15 minutes as needed x 3 doses total.
Discontinue therapy if patient develops marked tachycardia (HR > 140)
or chest pain.
5. If signs of severe hypoventilation despite CPAP and/or Nebulized
bronchodilators: (See Airway Assessment Protocol 2.1.2)
a. Assist ventilations with BVM with 100% oxygen.
b. Consider endotracheal intubation
6. AVOID USE OF DIURETICS!!
34. ALS LEVEL 2: MEDICAL CONTROL
1. Notify medical control or medical director for any problems
or concerns.
35. *Pneumonia can range from mild to life-
threatening. Can be a serious problem for infants,
young children, geriatrics and people with
compromised immune systems (HIV, autoimmune
disease, cancer and chemo
*Usually bacterial. Streptococcus is most common
type of Pneumonia.
36. *
*Pulmonary Embolus- sudden on-set, shock, respiratory
distress, pleuritic chest pain-more on inspiration, JVD.
Predisposed to Pulmonary Embolus- Females, birth control
pills, post surgery patients, patients with hx of deep vein
thrombosis, patents with hx of cellulitis of the leg, bed
ridden patients, during or post delivery females, patients
with recent or current long bone fractures. GET A GOOD
HISTORY!
37. *HYPERVENTILATION-
Do not assume that all patients hyperventilating are
having panic attacks. If it is due to an emotional event
assist patient in slowing their breathing and provide
emotional support.
Hyperventilation can cause carpal/pedal spasms due to
hypocarbia or reduced carbon dioxide in the blood.
Respiratory alklosis which is associated with many
critically ill patients can present as hyperventilation.
ONCE AGAIN OBTAIN A GOOD HISTORY!
