Respiratory Respiratory Emergencies Emergencies … … or all that wheezes is NOT or all that wheezes is NOT asthma asthma
Respiratory Respiratory EmergenciesEmergencies……or all that wheezes is NOT or all that wheezes is NOT
asthmaasthma
DefinitionsDefinitionsApneaApnea
DypsneaDypsneaOrthopneaOrthopneaTachypneaTachypneaBradypneaBradypnea
HypercarbiaHypercarbia
AcidosisAcidosisAlkalosisAlkalosis
VentilationVentilationDiffusionDiffusionPerfusionPerfusion
RespirationRespiration
AnatomyAnatomy
Anatomy
PhysiologyPhysiologyTakes in oxygenTakes in oxygenDisposes of wastesDisposes of wastes– Carbon dioxideCarbon dioxide– Excess waterExcess water
O2 + Glucose
CO2 + H2O
The Cell
PhysiologyPhysiology
PhysiologyPhysiology
Inspiration Active process Chest cavity expands Intrathoracic pressure falls Air flows in until pressure
equalizes
Expiration Passive process Chest cavity size decreases Intrathoracic pressure rises Air flows out until pressure
equalizes
PhysiologyPhysiology
Autonomic FunctionAutonomic FunctionPrimary drive: increase in Primary drive: increase in
arterial COarterial CO2 2
Secondary (hypoxic) drive: Secondary (hypoxic) drive: decrease in arterial Odecrease in arterial O22
Adequate BreathingAdequate BreathingNormal rate and depthNormal rate and depth
Regular breathing patternRegular breathing patternGood breath sounds on both sides Good breath sounds on both sides
of lungsof lungsEqual chest rise and fallEqual chest rise and fall
Pink, warm, dry skinPink, warm, dry skin
Inadequate BreathingInadequate BreathingBreathing rate < 12 or > 20*Breathing rate < 12 or > 20*
Shallow or irregular respirationsShallow or irregular respirationsUnequal chest expansionUnequal chest expansion
Decreased or absent lung soundsDecreased or absent lung soundsAccessory muscle usageAccessory muscle usage
Pale or cyanotic skin colorPale or cyanotic skin colorCool, clammy skin appearance Cool, clammy skin appearance
Obstructive PathophysiologyObstructive Pathophysiology• TongueTongue• Foreign body obstructionForeign body obstruction• Anaphylaxis and angiodemaAnaphylaxis and angiodema• Facial trauma and inhalation Facial trauma and inhalation
injuries (burns)injuries (burns)• Epiglottitis and CroupEpiglottitis and Croup• AspirationAspiration
Restrictive PathophysiologyRestrictive Pathophysiology
• AsthmaAsthma• COPDCOPD• EmphysemaEmphysema• Chronic BronchitisChronic Bronchitis
Diffusion PathophysiologyDiffusion Pathophysiology• Pulmonary Edema: Pulmonary Edema:
• Left-sided heart failureLeft-sided heart failure• Toxic inhalationsToxic inhalations• Near drowningNear drowning
• PneumoniaPneumonia• Pulmonary Embolism: Pulmonary Embolism:
• Blood clotsBlood clots• Amniotic fluidAmniotic fluid• Fat embolismFat embolism
Ventilation PathophysiologyVentilation Pathophysiology• Trauma: rib fractures, flail chest, spinal Trauma: rib fractures, flail chest, spinal
cord injuriescord injuries• Pneumothorax, hemothorax, SCWPneumothorax, hemothorax, SCW• Diaphragmatic herniaDiaphragmatic hernia• Pleural effusionPleural effusion• Morbid obesityMorbid obesity• Neurological/muscular diseases: polio, Neurological/muscular diseases: polio,
MD, myasthenia gravisMD, myasthenia gravis
Control System PathophysiologyControl System Pathophysiology
• Head traumaHead trauma• CVACVA• Depressant drug toxicityDepressant drug toxicity
• NarcoticsNarcotics• Sedative-hypnoticsSedative-hypnotics• Ethyl alcoholEthyl alcohol
FBAOFBAO• Obstruction may Obstruction may
result from head result from head position, tongue, position, tongue, aspiration, or foreign aspiration, or foreign body.body.
• Be prepared to treat Be prepared to treat quickly and quickly and aggressively.aggressively.
• Head-tilt/chin-lift to Head-tilt/chin-lift to open airwayopen airway
Upper Airway InfectionsUpper Airway Infections• BronchitisBronchitis• Common coldCommon cold• DiphtheriaDiphtheria• PneumoniaPneumonia• CroupCroup• EpiglottitisEpiglottitis• Severe Acute Respiratory SyndromeSevere Acute Respiratory Syndrome
Upper Airway InfectionsUpper Airway Infections
Signs & SymptomsSigns & Symptoms• Dyspnea or respiratory distressDyspnea or respiratory distress• Seal-bark coughSeal-bark cough• Acute angiodemaAcute angiodema• Excessive salivationExcessive salivation• StridorStridor• Sniff positioningSniff positioning
Acute Pulmonary EdemaAcute Pulmonary Edema• Fluid buildup in lungsFluid buildup in lungs• History of CHFHistory of CHF• High recurrenceHigh recurrence• Signs & symptoms:Signs & symptoms:
• DypsneaDypsnea• Frothy, pink sputumFrothy, pink sputum• Pedal edema, ascitiesPedal edema, ascities• Rales, wheezesRales, wheezes• HypertensionHypertension
..
Pedal EdemaPedal Edema
AscitesAscites
BronchitisBronchitis• Chronic condition similar to emphysemaChronic condition similar to emphysema• Reduction in ventilation due to increased Reduction in ventilation due to increased
mucus production.mucus production.• Productive cough, copious sputumProductive cough, copious sputum• ““Blue bloaters”Blue bloaters”• Treatment goals: relief of hypoxia, reversal Treatment goals: relief of hypoxia, reversal
of bronchoconstrictionof bronchoconstriction
COPDCOPD• Damaged lungs from Damaged lungs from
repeated infections or repeated infections or inhalation of toxic inhalation of toxic agents.agents.
• Signs & symptoms:Signs & symptoms:• Chronic coughChronic cough• Rhonchi, wheezingRhonchi, wheezing• SpO2 88-92%SpO2 88-92%• ClubbingClubbing• Pursed lip breathingPursed lip breathing
ClubbingClubbing
AsthmaAsthma• Common but serious Common but serious
diseasedisease• Acute bronchiole Acute bronchiole
constriction with constriction with increased mucus increased mucus productionproduction
• Signs & symptoms:Signs & symptoms:• WheezingWheezing• Patient looks tiredPatient looks tired• CyanosisCyanosis
PneumothoraxPneumothorax• Spontaneous or Spontaneous or
trauma inducedtrauma induced• Accumulation of air in Accumulation of air in
the pleural spacethe pleural space• Signs & symptoms:Signs & symptoms:
• DypsneaDypsnea• One-sided chest painOne-sided chest pain• Absent or decreased Absent or decreased
breath sounds breath sounds
AnaphylaxisAnaphylaxis• Characterized by Characterized by
respiratory distress respiratory distress and hypotensionand hypotension
• Usually results from Usually results from body response to body response to allergen.allergen.
• Airway obstruction Airway obstruction due to angiodema is due to angiodema is major concern major concern
PneumoniaPneumonia55thth leading cause of death in the U.S. leading cause of death in the U.S.Infection usually caused by bacteria or Infection usually caused by bacteria or virus, rare instances fungalvirus, rare instances fungalPatient will present with sick appearance, Patient will present with sick appearance, febrile, shaking, productive cough, febrile, shaking, productive cough, increased sputum.increased sputum.Patient with increase respiratory Patient with increase respiratory rate/effort, tachycardic, rate/effort, tachycardic, wheezes/rales/consolidated lung soundswheezes/rales/consolidated lung sounds
Pleural EffusionPleural Effusion• Collection of fluid Collection of fluid
outside the lungoutside the lung• Caused by irritation, Caused by irritation,
infection, or cancerinfection, or cancer• Signs & symptoms:Signs & symptoms:
• DypsneaDypsnea• Decreased breath Decreased breath
sounds over effected sounds over effected areaarea
• Positional comfortPositional comfort
Pulmonary EmbolismPulmonary Embolism• Blood clot that breaks Blood clot that breaks
off, circulating through off, circulating through venous system.venous system.
• Signs & symptoms:Signs & symptoms:• Dypsnea/tachypneaDypsnea/tachypnea• CyanosisCyanosis• Acute pleuritic painAcute pleuritic pain• HemoptysisHemoptysis• HypoxiaHypoxia
Pulmonary EmbolismPulmonary Embolism
HyperventilationHyperventilation• Over-breathing resulting in a decrease in Over-breathing resulting in a decrease in
the level of CO2 (alkalosis)the level of CO2 (alkalosis)• Signs and symptoms:Signs and symptoms:
• AnxietyAnxiety• Tingling in hands & feet (carpal-pedal Tingling in hands & feet (carpal-pedal
spasms)spasms)• A sense of dypsnea despite rapid breathingA sense of dypsnea despite rapid breathing• DizzinessDizziness• NumbnessNumbness
ARDSARDS• Pulmonary edema caused by fluid Pulmonary edema caused by fluid
accumulation in the interstitial spaces, accumulation in the interstitial spaces, interfering with diffusion causing hypoxia interfering with diffusion causing hypoxia (fluid balance)(fluid balance)
• Underlying etiology includes sepsis, Underlying etiology includes sepsis, pneumonia, inhalation injuries, emboli, pneumonia, inhalation injuries, emboli, tumors tumors
• Mortality rate >70%Mortality rate >70%• Supportive care at the BLS levelSupportive care at the BLS level
Patient AssessmentPatient AssessmentBSI/Scene SafetyBSI/Scene Safety
Initial Assessment (Sick/Not Sick)Initial Assessment (Sick/Not Sick)Focused ExamFocused ExamDetailed ExamDetailed ExamAssessment Assessment
Treatment and PlanTreatment and Plan
Initial AssessmentInitial Assessment• Initial Impression:Initial Impression:
• Body positionBody position• Skin signs and colorSkin signs and color• Respiratory rate and effortRespiratory rate and effort• Mental statusMental status• Pulse (rate & character) Pulse (rate & character)
• Determine Sick/Not Sick (Oxygen?)Determine Sick/Not Sick (Oxygen?)• Identify and correct immediate life Identify and correct immediate life
threats – threats – ABCS!ABCS!
Focused Exam (S)Focused Exam (S)SSigns and symptomsigns and symptomsAAllergies (med allergies)llergies (med allergies)MMedicationsedicationsPPast medical historyast medical historyLLast meal or intakeast meal or intakeEEvents leading to callvents leading to call
Focused Exam (S)Focused Exam (S)• OOnsetnset• PProvocationrovocation• QQualityuality• RRadiationadiation• SSeverityeverity• TTimeime
Listen to the patient…Listen to the patient…
……they will tell exactly what is they will tell exactly what is wrong!wrong!
Focused Exam (O)Focused Exam (O)• Vital signs:Vital signs:
• Skin (signs of adequate perfusion)Skin (signs of adequate perfusion)• Level of consciousnessLevel of consciousness• Respiratory rate and effortRespiratory rate and effort• Lung sounds (SpO2?)Lung sounds (SpO2?)• Pulse rate and characterPulse rate and character• Blood pressure (bilateral?)Blood pressure (bilateral?)• Pupillary reactionPupillary reaction
Focused Exam (O)Focused Exam (O)
Crackles (Rales)Crackles (Rales)CHFCHFPneumoniaPneumonia
RhonchiRhonchiPneumoniaPneumoniaAspiration Aspiration COPD COPD Sometimes AsthmaSometimes Asthma
StridorStridorFBAO FBAO Croup Croup Anaphylaxis Anaphylaxis EpiglottitisEpiglottitisAirway burnAirway burn
WheezingWheezingAsthmaAsthmaCHFCHFCOPDCOPD
Focused Exam (O)Focused Exam (O)• Based upon Based upon youryour clinical findings. clinical findings.• Observe the patient while they are Observe the patient while they are
talking to you, note any distress.talking to you, note any distress.• Watch for critical signs: JVD, Watch for critical signs: JVD,
tracheal deviation, paradoxial tracheal deviation, paradoxial chest movement. chest movement.
Detailed ExamDetailed Exam• Complete and thorough head, Complete and thorough head,
neck-to-toe exam with non critical neck-to-toe exam with non critical patients.patients.
• Elicit further information and Elicit further information and necessary interventions.necessary interventions.
• Key in on critical signs!Key in on critical signs!
Assessment (A)Assessment (A)This is your best guess (or rule out) as This is your best guess (or rule out) as
to what is going on with the patient.to what is going on with the patient.
It is based upon YOUR Subjective and It is based upon YOUR Subjective and Objective findings and should help Objective findings and should help you develop and implement a Plan.you develop and implement a Plan.
PlanPlanMedics?Medics?
ABC’s/Monitor vitalsABC’s/Monitor vitalsPatient in position of comfort.Patient in position of comfort.
Oxygen via ?Oxygen via ?Assist with medications.Assist with medications.
Maintain body temperature.Maintain body temperature.Calm and reassure.Calm and reassure.
Minimize patient movement.Minimize patient movement.Rapid transport!Rapid transport!
PT Management (P)PT Management (P)Golden Rules:Golden Rules:
• If you are thinking about giving OIf you are thinking about giving O22, , then give it!then give it!
• If you can’t tell whether a patient is breathing If you can’t tell whether a patient is breathing adequately, adequately, then they aren’t!then they aren’t!
• If you’re thinking about assisting a patient’s If you’re thinking about assisting a patient’s breathing, breathing, you probably should be!you probably should be!
• When a patient quits fighting it does not mean When a patient quits fighting it does not mean that they are getting better!that they are getting better!
Tools of the TradeTools of the Trade