Respiratory Emergencies (again) Steve Cole, Paramedic, CCEMT-P Why Again? Respiratory Calls are some of the most Common calls you will see. Respiratory care is as essential as the ABC’s Mishandling a respiratory call can be fatal. Mishandling a respiratory call can be fatal. Mishandling a respiratory call can be fatal. What we are going to discuss Respiratory PHYSIOLOGY 5 most common respiratory problems in adults (PEDS will come later) Basic Concept: Air Goes in and Out Blood Goes Round and Round Any thing infringing on this is a BAD THING! Key Concepts The primary function of the respiratory system is gaseous exchange. – Ventilation and Oxygenation. Air is composed of a mixture of gases. Breathing is largely controlled by the Autonomic Nervous system, in response to changes sensed in all parts of the body. The biggest part of this is the “Hypoxic Drive”. Key Concepts Diffusion of O2 from the lung to the blood is by the binding of O2 to the hemoglobin (Hgb) This is dependant on a pressure gradient. This is a Passive transport system. It is also dependant on available surface area and distance it must travel to cross the threshold. Capillaries are where the real Oxygenation and ventilation take place. Primary Concepts All pt’s with SOB get O2. Lots of O2. Listen to ALL lungs. Beware of the “silent chest”. Noisy Breathing is abnormal breathing Visible Breathing is abnormal breathing. Positional breathing is abnormal breathing. Abnormal Breathing gets O2. Volume Tidal Volume Minute Volume – Tidal Volume X Respiratory Rate = Minute Volume Respiratory Physiology What do we assess? Presence or absence? Rate Quality Respiratory Rate Decreased by: – Depressant Drugs – Sleep Increased by: – – – Fever Fear Exertion Respiratory Quality Irregular: Neuro Insult. Shallow: – – – Respiratory Depressants CNS Depressants Neuro Insult Deep: – Hyperglycemia with Acidosis (DKA): “Kussmal Respirations – Electrolyte Imbalances – Neuro Insult Adult Lung Volumes 5,500 to 6,000mL at end inspiration. Normal tidal volume: 500mL Dead space air: 150mL Alveolar Air: 350mL Key components of an intact respiratory system An appropriate Drive to Breath Airway and respiratory tract Mechanical Bellows A diffusion friendly place for gas exchange to happen. An O2 friendly RBC with hgb. An intact circulatory system to carry the gasses and waste through out the body. – Must have enough of a pressure to promote diffusion. An intact capillary bed Drive to breath Controlled by the CNS through information gathered from receptors in the body. Located in the pons region of the brainstem Detects increases in CO2 or decreases in pH and informs the brain to increase the respiratory rate. Increased respiratory rate reduces CO2 and will increase pH. Other things can effect our drive to breath “Hypoxic Drive” Develops in some patients with Chronic Lung Disease Pons region of brain becomes sensitized to constant increased CO2 state Regulation is now based on O2 level in blood Increased oxygen level states may tell the brain to stop breathing Dr. Slovis’s top 5 effects on respiratory drive. CVA Trauma to the brain Drugs Tumor Electrolyte Imbalances The Airway and Respiratory tract From the tip of the mouth To the “Functional Unit of the Lungs” – Alveoli Functions by negative pressure inspiration. “The means of getting cargo to the loading docks.” The Mechanical Bellows Special Thanks to Charlie Miller for this Graphic. The muscles of the ribs expand the size of the chest, creating a (relative) negative pressure. Air (with O2) moves in to fill the void. Commonly thought of as Oxygenation. Actual oxygenation takes place at the cellular level. The Mechanical Bellows The intercostals muscles relax, allowing the chest to return to its neutral position, expelling air out of the lungs (and CO2 with it.) Commonly thought of as Ventilation. Actual ventilation takes place at the cellular level. Special Thanks to Charlie Miller for this Graphic. The Mechanical Bellows Example of a Compromised Bellows Positional Asphyxia Special Thanks to Charlie Miller for this Graphic. A diffusion friendly place for gas exchange to happen. Diffusion is a passive process. Intact capillary bed. Jimmie Edwards Fart Theory. Things that effect diffusion: – – – – Thickness of Membrane the gas has to cross Surface Area to diffuse across Partial Pressure differences in Gas on each side. Physiologic PEEP Diffusion An O2 friendly RBC with hgb. Hemoglobin is an Iron Based compound essential to the transport of O2. – – – Anemia Cyanide Poisoning CO Poisoning An intact circulatory system Blood Loss Shock – Pump Problem – Volume Problem » Fluid issue » O2 carrying issue – Vessel Problem Must have enough of a pressure to promote diffusion. Conditions like Hypotension cause secondary hypoxia by promoting low perfusion. Assessing the pt with Respiratory Distress. First Impressions Air Hungry Nasal Flaring Tripoding Rocking with respirations Pursed Lip Breathing Barrel or Sparrow Chest Home O2 Skin Signs Cyanosis – – – Nail Beds Lips Ears Mottling – – – Chest Lower Ext Abd Noisy breathing is obstructed breathing Snoring: obstruction by tongue Gurgling: Funky Junk in upper airway Grunting: Physiologic PEEP Stridor: harsh, high pitched sound on inhalation: – Laryngeal edema – Epiglotitis – FBAO Speech Dyspnea Inability to speak more than a few sylables in a sentence between breaths. Breath Sounds Listening by comparison Listening anterior Listening posterior Fremitus Abnormal breath sounds Rales (crackles): fine bubbling sound of fluid in alveoli (“Rice Krispies”: snap, crackle and pop) Alveoli popping open. Rhonchi: fluid in larger airways, obstructing object in the bronchus Wheezes: high pitched whistling, air through narrowed airways SILENCE IS BAD NEWS Causes of respiratory abnormalities Brain damage: trauma, drugs, stroke Spinal cord damage: trauma, polio Upper airways: tongue, swelling, foreign body, trauma Lower airways: asthma, chronic bronchitis Alveoli: atelectasis, obstruction Impaired pulmonary circulation: embolism Signs/symptoms of distress Dyspnea Restlessness/anxiety Tachypnea/Bradypnea Cyanosis (core) Abnormal sounds Retractions Diminished ability to speak More S/S Retractions and/or use of accessory muscles Abdominal breathing Nasal flaring Productive cough – Color? Irregular breathing Tripod position Pursed-lip breathing Take another look ….What do you see? Kewl Haircut Retractions Pursed Lips O2 Sparrow Chest Abd retractions Tripoding Hows this? Inadequate Breathing: Infants and Children Nasal Flaring Retractions See-Saw Breathing Diaphragmatic Breathing BREAK? The Usual Suspects Photo by Linda R. Chen - © 1995 Gramercy Pictures. Top 6 you need to know COPD/Reactive Airway Disorders – – – Emphysema Asthma Bronchitis Pneumonia CHF Pulmonary Emboli Hyperventilation Disorders Pneumothorax COPD Causes of Chronic Obstructive Pulmonary Disease (COPD) Cigarette smoking Environmental pollution Previous pulmonary infections Chronic asthma Common Traits of COPD’ers – “pink puffer” – “air trapping” – destruction of alveoli, loss of elasticity – barrel chest/Sparrow Chest – use of accessory muscles – noisy breath sounds: wheezing prolonged and increasing on exhalation Air Trapping Due to loss of elasticity in the alveoli, these pt’s trap air. They need over double the exhalation period This means inhibited gas exchange and possibly…… They can develop a spontaneous pneumothorax.. EMPHYSEMA In Emphysema the chronic damage to the lungs interferes with gas exchange. A secondary point of exacerbation is the irritation of the broncheols, making them constrict and spasm. Since the alveoli are damaged, this causes them to collapse easily. Chronic Bronchitis “The English Disease” Chronic irritation cause increases mucus production as a defense mechanism. This in turn decreases surface area for gas exchange. The phlegm also irritates the bronchioles, causing bronchio-constriction and spasm. ASTHMA: causes…. Reactive airway event caused by bronchospasm, reversible Extrinsic: environmental, allergic trigger, temperature Intrinsic: exertion/ stress, illness Inflammatory reaction Acute asthmatic attack: Bronchospasm: rapid onset, can be relieved by medications Swelling of mucous membranes in bronchial walls (inflammatory response) Mucus plugging of bronchi Signs and Symptoms Usually patient has history of asthma, may have prescription for meds “Noisy” breath sounds (increased on exhalation) – BEWARE A SILENT CHEST Accessory muscle use Tachycardia and tachypnea Pulsus paradoxus (decrease in systolic BP with inhalation) Exhaustion Status Asthmaticus Prolonged asthma attack that is not broken by normal treatments Requires aggressive treatment and transportation A SILENT CHEST IS BAD! Treatment Reassure High flow humidified oxygen Assist with medication (per protocol) Position of comfort Insure adequate ventilation BronchoDilators Bronchodilators Beta II agonist – Stimulate receptor sites causing bronchiole relaxation – First Line. – Albuterol Parasympatholytic – Inhibit Parasympathetic broncheoconstriction – Second line.Use only once – Atrovent May improve air passage around mucous plugs Many side effects Metered Dose Inhaler EMT’s may “assist” a patient with a PRESCRIBED MDI in: – Respiratory Distress – Allergic reactions with wheezing BASIC USE OF AN MDI Remember to Obtain orders from medical direction. Remember the 5 R’s Remember the 5 R’s RIGHT PATIENT RIGHT MEDICATION RIGHT DOSE RIGHT ROUTE RIGHT SITUATION/TIME Shake vigorously Depress hand-held inhaler as patient inhales deeply. Instruct patient to hold/blow out breath. Allow patient to breathe. Repeat dose if ordered. Spacer Device REMEMBER: ALL THAT WHEEZES IS NOT ASTHMA….. AND NOT ALL ASTHMA WHEEZES! All that wheezes is not asthma: Other causes: – – – – acute left heart failure (“cardiac asthma”) smoke inhalation chronic bronchitis acute pulmonary embolism May be localized: suspect an obstruction The Oxygen Myth and COPD People used to think that if you gave a COPD’er too much O2, they would stop breathing….. This is major BS..purely theoretical at best. In short: If their SOB, they gets lots of O2 – “High Flow” 10-15 LPM NRB NEVER WITHHOLD OXYGEN FROM A PATIENT WHO NEEDS IT! Signs and Symptoms Something has changed from normal Marked respiratory distress Diaphoresis, cyanosis Agitation and confusion (hypoxemia), lethargy (hypercarbia) Tachypnea, tachycardia, irregular heart beat Treatment Ventilate appropriately Expect low pulse oximetry: don’t try to raise to “normal” Base on Mental Status and subjective statements. Try at least above 85-90% Position of comfort (upright, tripod) Rapid transport Monitor ventilations Pulmonary Edema Definition: accumulation of fluid in alveoli, chronic or acute Primary Cause is Cardiac (CHF) Other Causes: – – – exposure to toxic substances damaged tissue Actively Dying (ARDS) Signs and Symptoms Anxiety tachypnea/tachycardia dyspnea, hemoptysis abnormal breath sounds (moist, wheezes) JVD Elevated blood pressure orthopnea/paroxysmal nocturnal dyspnea Treatment: Reassure High flow oxygen (positive pressure) NTG (Medical Control Only) Position of comfort Rapid transport Pneumonia Definition: infection of respiratory tree, may result in systemic sepsis Types: – – – – bacterial 90% viral (from influenza) mycoplasmal/fungal aspiration Signs and symptoms Patient looks sick/dehydrated Illness over several days Fever Dehydration Productive cough tachypnea/ tachycardia Rales and rhonchi Treatment: Oxygen and transport Pulmonary Embolism Definition:sudden blocking of pulmonary artery by clot Causes: – – – blood clots in legs prolonged immobilization birth control pills Signs and symptoms: Sudden onset of severe, unexplained dyspnea other s/s may or may not be present chest pain made worse on coughing Tachycardia/tachypnea JVD Treatment Recognition Oxygen Hospitalization Suspect PE when there is acute onset of tachycardia or dyspnea of unknown origin Hyperventilation Definition: rapid, deep respirations causing imbalance of CO2 in body often caused by emotions or stress May be hard to recognize There may be other causes of pattern Signs and symptoms Elevated respiratory rate or increased depth chest pain tingling or numbness around mouth, hands, feet Carpopedal spasm Treatment: Do NOT use a paper bag Try to calm and reassure Remove patient from environment that may be causing problem Transport if problem can’t be resolved Spontaneous Pneumothorax Definition: sudden leak of air into pleural space; may have no apparent cause Frequently young, tall, thin males May have previous history Signs/ symptoms Sudden, sharp chest pain Sudden dyspnea Diminished breath sounds Pleuritic chest pain Treatment Oxygen and transport Other problems: Pickwickian syndrome: patient is VERY obese, related to sleep apnea Cystic fibrosis Legionnaires (type of pneumonia) Getting a good history will be one of the most important ways to differentiate between respiratory conditions Look for underlying conditions Questions?
