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My Breath is Barely There!
Eleanor Erwin M.D.Eleanor Erwin M.D.for
James R. WilliamsAAS NRP I/CAAS, NRP, I/C
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ObjectivesObjectives
• Define asthma• Describe pathophysiologyDescribe pathophysiology• Identify asthma “triggers”• Describe the assessment of the asthma patientp
• Describe Signs and Symptoms• Identify appropriate pre‐hospital treatments
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Case 1Case 1
• 32 year old female• Chief complaint of shortness of breathChief complaint of shortness of breath• Assessment : audible expiratory wheezes, HR: 114 28 144/92 SAO2 88%114, RR: 28, BP: 144/92, SAO2: 88%
• How severe an asthma exacerbation is this?• What would be your treatment?
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AsthmaAsthma
• A diffuse airway disease• Result of partial or completely reversibleResult of partial or completely reversible bronchoconstrictionV l di l di i ld id• Very prevalent medical condition worldwide– In US, 20 million reports of symptoms compatible with asthma
– 4000 – 5000 deaths per year4000 5000 deaths per year– Over 300 million people worldwide have asthma
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It’s Not So NewIt s Not So New
• First written description found in the Ebers Papyrus (circa 1500 BC)py ( )– 110 page scroll of Egyptian medicinesListed treatment as inhaling vapors of– Listed treatment as inhaling vapors of Henbane
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It’s Not So NewIt s Not So New
• Maimondies wrote a treatise on asthma• Some of his findings includeSome of his findings include
– No magic cure for asthmaA h f i h ld d i– Asthma often starts with a common cold during the rainy season
– Air pollution in Cairo may in part be responsible
• Written in the 12th Century!
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It’s Not So NewIt s Not So New
h d i i d f• Asthma, as a descriptive word for shortness of breath first appeared in the Iliad of Homer
• Early 1800’s started to be understood• Early 1800’s started to be understood as a medical disease explained through it th lits pathology.– Thank you Paris Hospitals
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PathophysiologyPathophysiology
• Reduction in airway diameter• Three major componentsThree major components
– Airway inflammationI i i fl b i– Intermittent airflow obstruction
– Bronchial hyper responsiveness
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Inflammatory ResponseInflammatory Response
• Inflammatory Cells– Mast Cells– EosinophilsMacrophages– Macrophages
– Activated T lymphocytes• Play an important role in regulation through the release of numerous cytokines
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Intermittent Airflow ObstructionIntermittent Airflow Obstruction
• Bronchi and bronchioles very responsive to irritants– Leads to bronchoconstriction, edema, increased secretion of mucous.secretion of mucous.
• Mucous plugs
• Ma totall or partiall blo k the air a• May totally or partially block the airway
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How Dose this Present?How Dose this Present?
• Pulmonary Function Changes– Increased work of breathingg– Abnormal distribution of pulmonary blood flowBronchospasm/Bronchoconstriction cause– Bronchospasm/Bronchoconstriction cause wheezing
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They must be doing better, I can’t hear anything?
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Air TrappingAir Trapping
h d l h• Air passes into the areas distal to the obstruction
• Exhalation is a passive process– Less force is available to move air outLess force is available to move air out– Forced expiration often collapses the bronchial wallwall
– Residual volume increases– Becomes harder and harder to inhale or cough to– Becomes harder and harder to inhale or cough to remove mucous.
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Proof This Stuff Makes SenseProof This Stuff Makes Sense
• Over time, asthma can damage tissues• Autopsy findings in asthma fatalitiesAutopsy findings in asthma fatalities
– Increased smooth muscle mass in the airwaysI d ll hi k– Increased wall thickness
– Increased inflammation
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Types of AsthmaTypes of Asthma
• Extrinsic– Immune response to inhaled irritants that the ppatient has an allergy to.
– Onset of extrinsic asthma is usually in childhoodOnset of extrinsic asthma is usually in childhood or early adolescence.
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Types of AsthmaTypes of Asthma
• Intrinsic– Response to stimuli other than allergies that initiate the attack
• Infections• Cold air• ExertionM di i• Medications
• Stress• Cigarette smoke• Cigarette smoke• Occupational exposure
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Occupational AsthmaOccupational Asthma
• Asthma as a result of workplace stimuli– Patients will often worsen in the workplacep
O f th t ti l l• One of the most common occupational lung diseases in developed countries
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Asthma TriggersAsthma Triggers
• Viral URI’s• SmokingSmoking• Non‐compliance• Emotional stress• Weather changesWeather changes• Heavy allergen exposure• Air pollution
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Air PollutionAir Pollution
• Remember Maimondies? Bet he was right!
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Case 2Case 2
• 28 year old female– Chief complaint of tightness in chest and difficulty p g ybreathing.
– Assessment: Loud expiratory wheezes audibleAssessment: Loud expiratory wheezes audible without auscultation, speaking single words only , dyspnea pale oxygen saturation is 67% on roomdyspnea, pale, oxygen saturation is 67% on room air, HR – 128, RR – 28, labored
H th b ti i thi ?• How severe an asthma exacerbation is this?• What would be your treatment?y
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Case 2 ContinuedCase 2 Continued
d d % d• Patient administered 100% oxygen and provided albuterol/atrovent svn, x2 20 minutes apart.
• Follow up assessment reveals oxygen p ygsaturation is not improving, increased work of breathing, decreased lung sounds in all fields, g, g ,alterations in mentation
• How severe an asthma exacerbation is this?• How severe an asthma exacerbation is this?• What would be your treatment?
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AssessmentAssessment
• Pretty obvious– Do they have an airway that is maintainable?y y– Is their breathing productive?What is the pulse like?– What is the pulse like?
– Vital signs, to include pulse oximetry and ETCO2.
• ASSESSMENT MUST BE CONTINUOUS• ASSESSMENT MUST BE CONTINUOUS
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HistoryHistory
• You must know the history and medications of asthma patients.p
• Most people with asthma are aware of their condition and can adequately self manage ancondition and can adequately self manage an attack.
• Usually on a regimen of medications to control various stages of an attack.various stages of an attack.
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Home Asthma MedicationsHome Asthma Medications
• Albuterol• AtroventAtrovent• Xopenex• Glucocorticosteroids• AdvairAdvair• Pulmacort• Singular• Theophylline• Theophylline
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Home RemediesHome Remedies
St b th• Steambaths• Honey in a glass of water 3 times per dayG li l b il d i ilk d• Garlic cloves boiled in milk once per day
• Ginger tea with garlic cloves• Mustard oil and camphor rubbed on back• Licorice root tea• Dried grapes, soaked in milk overnight, then chew• Chewing fennel• Pomegranite
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Don’t Forget These!Don t Forget These!
• Allergies– Prescriptionp– OTCHomeopathic– Homeopathic
– Illegal???
• Last oral intake• Events leading up to the crisis• Events leading up to the crisis
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AssesmentAssesment
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Assessment FindingsAssessment Findings
• Generally dyspneic, scared, sweaty– If they are solemn, expect a crash!y , p
• Tripoding• May have a non‐productive cough
– What would we like to see?
• Tachycardic and tachypneicWh• Wheezes– Not all that wheezes is asthma!
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WheezingWheezing
• Are they wheezing on expiration, inspiration, b h?or both?
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Lung Sound AssessmentLung Sound Assessment
f h d d ff l k ll• One of the most important and difficult skills you must master.
• You have to know:– Where to place the stethoscopeWhere to place the stethoscope– Identify various sounds– Know the potential problems the lung sounds– Know the potential problems the lung sounds indicate
– How to properly address their presence in the– How to properly address their presence in the field
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Lung Sound AssessmentLung Sound Assessment
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Lung Sound AssessmentLung Sound Assessment
• Normal•• Wheezes
• StridorStridor•• Rales
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Lung Sound AssessmentLung Sound Assessment
• Normal•• Wheezes
• StridorStridor•• Rales
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Lung Sound AssessmentLung Sound Assessment
• Normal•• Wheezes
• StridorStridor•• Rales
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Lung Sound AssessmentLung Sound Assessment
• Normal•• Wheezes
• StridorStridor•• Rales
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Accessory Muscle UseAccessory Muscle Use
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Accessory Muscle UseAccessory Muscle Use
• May be obviousM b t b i• May be not so obvious– Put a hand on their abdomen
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Pulsus ParadoxusPulsus Paradoxus
• Refers to the loss or diminishing strength of the radial pulses on inhalation.p
• Air trapping will cause an increase in the pressure inside the chestpressure inside the chest.
• Increased pressure on the vena cava reduces blood flow to the heart.
• May note this condition upon assessment of• May note this condition upon assessment of the patients blood pressure.
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CapnographyCapnography
• Excellent assessment tool!– Instantaneous assessment of the patientp
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Capnography in AsthmaCapnography in Asthma
• The expiratory plateau should be flat.• Inflammation ‐ will be squaredInflammation will be squared• Bronchospasm ‐ will be curved
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Capnography in AsthmaCapnography in Asthma
• Valuable triage tool– Can measure severityy– Can be used for trending.
A f d t i di t• A square waveform does not indicate bronchospasm.– Carefully assess the side effects of a bronchodilator.
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Case 3Case 3
ld l• 8 year old male• Chief complaint is severe difficulty breathingp y g• EMS arrives and finds patient face down in the hallway of the residencehallway of the residence
• Patient has a history of asthma and numerous allergies Prescribed several MDI’s and Epiallergies. Prescribed several MDI’s and Epi‐Pen.
• Patient is pulseless, no respirations, peripheral and central cyanosis noted.
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Case 3 continuedCase 3 continued
• Presenting rhythm is V‐fib– 2 minutes of chest compressions performedp p– EMT‐I crew is on call, performed shock with SAED.
• After initial shock patient converts to asystole• After initial shock, patient converts to asystole• Requested Paramedic intercept
Wh t i th d l i ?• What is the underlying cause?• What would you do?y
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Status AsthmaticusStatus Asthmaticus
• Progressive respiratory distress due to asthma where conventional therapy has failed.py
i ll i h i di• Essentially, any patient who is not responding to initial appropriate doses of inhaled bronchodilator agents can be classified.
• Life threat = aggressive treatment
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Acid Base ChangesAcid – Base Changes
• Initial hyperventilation causes increased CO2elimination.
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Extra Hospital StuffExtra Hospital Stuff
• ABG’s– Might helpg p– Supplemental oxygen will generally correct hypoxiahypoxia
– CO2 might be elevated or decreasedA t dil i i P CO i di t i di• A steadily rising PaCO2 can indicate impending respiratory collapse.
Ch i H– Changes in pH
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Extra Hospital StuffExtra Hospital Stuff
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AirwayAirway
• Hopefully they are able to maintain it• These patient may cough up mucusThese patient may cough up mucus
– This is a good thing
• Advise medical control of airway problem ASAP!
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BreathingBreathing
• These patients may already oxygen starved• Don’t hold back?Don t hold back?• Don’t be afraid to assist them
• BUT WAIT!!!!
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Alternative TherapyAlternative Therapy
•ContinuousPositive
AAirway
PressurePressure•
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OxygenOxygen
• All oxygen should be humidified (if possible)
• Humidified oxygen will help to loosen mucous
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Other MedicationsOther Medications
• Albuterol– Bronchodilator– Adult dosage
• 2 5 mg (0 5 ml of a 0 5% solution mixed with 2 5 ml of• 2.5 mg (0.5 ml of a 0.5% solution mixed with 2.5 ml of normal saline) via a SVN.
• May give up to 5 0 mgMay give up to 5.0 mg
– Pediatric dosage• 2 5 mg (0 5 ml of a 0 5% solution mixed with 2 5 ml of• 2.5 mg (0.5 ml of a 0.5% solution mixed with 2.5 ml of normal saline) via a SVN.
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Other MedicationsOther Medications
• Ipratroprium (Atrovent®)– Anticholinergicg– Indicated for bronchial asthma and reversible bronchospasm in COPDbronchospasm in COPD
– DosageAd i i t i j ti ith b t i t th• Administer in conjunction with beta agonist therapy
• 0.25 – 0.5 mg
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CorticosteroidsCorticosteroids
• Emerging trend in pre‐hospital medicine• Solumedrol or Prednisone added to the scopeSolumedrol or Prednisone added to the scope• Not an immediate solution, but will help the
i lpatient later.• 125mg IV solumedrol or 60 mg of Prednisoneg g
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CorticosteroidsCorticosteroids
• Inhibit inflammation of the airway• Blocks leukotriene synthesisBlocks leukotriene synthesis• Inhibit cytokine production• Blocks the late response to inhaled allergens
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PrednisonePrednisone
• Contraindications– Systemic fungal infectionsy g– Hypersensitivity
• Interactions• Interactions– Additive hypokalemia with thiazides and loop diuretics.May increase requirements for insulin or oral– May increase requirements for insulin or oral hypoglycemic agents in diabetics.
– Phenytion phenobarbital and rifampin may decrease– Phenytion, phenobarbital and rifampin may decrease effectiveness.
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CorticosteroidsCorticosteroids
• Why give it?– Early use often aborts exacerbationy– Reduces likelihood of hospital admissionReduces chances of relapse– Reduces chances of relapse
– Improves recovery rate
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Other MedicationsOther Medications
• Epinephrine– Sympathomimeticy p– Indicated for severe bronchospasm, bronchospasms unresponsive to albuterolbronchospasms unresponsive to albuterol
– DosageAd lt 0 3 1 1 000 SQ IM (if fill d d i )• Adults: 0.3 mg 1:1,000 SQ or IM (if pre‐filled device)
• Adults: 0.3 mg 1:1,000 IV or 1 mg if severe or no response to SQ/IMresponse to SQ/IM
• Pediatric: 0.01 mg/kg 1:1,000 SQ (max 0.3 mg/dose)
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MagnesiumMagnesium
• Bronchodilator • Does not replace other medicationsDoes not replace other medications• 1 to 2 grams IV over 30 minutes
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SummarySummary
• Assess• ReassessReassess• Albuterol• Ipratroprium • CorticosteroidsCorticosteroids• Call Medical control for further options on long transport times
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Thank You!Thank You!