respiratory emergencies by sydorenko o.l.. objectives upon successful completion of this program,...
TRANSCRIPT
Respiratory Emergencies
By Sydorenko O.L.
ObjectivesUpon successful completion of this
program, you should be able to:
• review the signs and symptoms and field interventions for the patient presenting with COPD, and asthma.
• review criteria for the use of CPAP.
• review the SOP for Acute Pulmonary Edema, Asthma/COPD with Wheezing, and Conscious Sedation
Objectives cont’d• review the Whisperflow patient circuit for
CPAP used in the field.
• review the set up of the albuterol nebulizer kit and in-line Albuterol set-up.
CPAP
Continuous
Positive
Airway
PressureA means of providing high flow, low pressure oxygenation
to the patient in pulmonary edema
CPAP• CPAP, if applied early enough, is an effective way to
treat pulmonary edema and a means to prevent the need to intubate the patient
• CPAP increases the airway pressures allowing for better gas diffusion & for reexpansion of collapsed alveoli
• CPAP allows the refilling of collapsed, airless alveoli
• CPAP allows/buys time for administered medications to be able to work
CPAP expands the surface area of the collapsed alveoli allowing more surface area to be in contact with capillaries for gas exchange
With CPAP
Before CPAP
Goal of Therapy With CPAP• Increase the amount of
inspired oxygen
• Decrease the work load of breathing
In turn to: Decrease the need for
intubation Decrease the hospital stay Decrease the mortality rate
Patient Circuit
COPD• Chronic obstructive pulmonary
disease - a progressive and debilitating collection of diseases with airflow obstruction and abnormal ventilation with irreversible components (emphysema & chronic bronchitis)
• Exacerbation of COPD is an increase in symptoms with worsening of the patient’s condition due to hypoxia that deprives tissue of oxygen and hypercapnia (retention of CO2) that causes an acid-base imbalance
Obstructive Lung Disease - COPD & Asthma
• Abnormal ventilation usually from obstruction in the bronchioles
• Common changes noted in the airways– bronchospasm - smooth muscle
contraction– increased mucous production lining
the respiratory tree– destruction of the cilia lining
resulting in poor clearance of excess mucus
– inflammation of bronchial passages resulting in accumulation of fluid and inflammatory cells
Emphysema• Gradual destruction of the alveolar walls distal to the
terminal bronchioles• Less area available for gas exchange• Small bronchiole walls weaken, lungs cannot recoil as
efficiently, air is trapped in number of pulmonary capillaries which
resistance to pulmonary blood flow which leads to pulmonary hypertension– may lead to right heart failure & cor pulmonale (disease of
the heart because of diseased lungs)
Alveolar Sac and Capillaries
Bronchioles
capillary
alveolus
Interior of alveolus
Emphysema in PaO2 leads to in red blood cell production (to carry
more oxygen)
• Develop chronically elevated PaCO2 from retained carbon dioxide
• Loss of elasticity/recoil; alveoli dilated• More common in men; major contributing factor is cigarette
smoking; another contributing factor is environmental exposures
• Patients more susceptible to acute respiratory infections and cardiac dysrhythmias
Chronic Bronchitis• An increase in the number of
mucous-secreting cells in the respiratory tree
• Large production of sputum with productive cough
• Diffusion remains normal because alveoli not severely affected
• Gas exchange decreased due to lowered alveolar ventilation which creates hypoxia and hypercarbia
Asthma• Chronic inflammatory disorder of the airways
• Airflow obstruction and hyperresponsiveness are often reversible with treatment
• Triggers vary from individual environmental allergenscold air; other irritantsexercise; stressfood; certain medications
Asthma’s Two-Phase Reaction• Phase one - within minutes
– Release of chemical mediators (ie: histamine)• contraction of bronchial smooth muscle
(bronchoconstriction)• leakage of fluid from bronchial capillaries (bronchial
edema)
• Phase two - in 6-8 hours– Inflammation of the bronchioles from invasion of the mucosa
of the respiratory tract from the immune system cells• additional swelling & edema of bronchioles
Severe Asthma Attack
• One and two word dyspnea
• Tachycardia
• Decreased oxygen saturation on pulse oximetry
• Agitation & anxiety with increasing hypoxia
Treatment Goals -COPD & Asthma
Relieve and correct hypoxiaReverse any bronchospasm or
bronchoconstriction
Asthma/COPD with Wheezing SOP• Routine medical care• Pulse oximetry (on room air if possible)• Albuterol 2.5 mg / 3ml with oxygen adjusted to 6
l/minute• May repeat Albuterol treatments if needed• May need to consider intubation with in-line
administration of Albuterol based on the patient’s condition
• EMS to contact Medical Control for possible CPAP in patient with COPD
Albuterol Nebulizer Procedure• Medication is added to the chamber which must be kept
upright• The T-piece is assembled over the chamber• The patient needs to be coached to breath slowly and as
deeply as possible– this will take time and several breathes before the patient can
slow down and start breathing deeper; the patient needs a good coach to talk them through the slower/deeper breathing
– the medication needs to be inhaled into the lungs to be effective– the patient should be sitting upright
Add medication to the chamber
Connect the mouthpiece to the T-piece
Connect the corrugated tubing to the T-piece
Kit connected to oxygen and run at 6 l/minute (enough to create a mist)
Encourage slow, deep breathing
Albuterol Nebulizer Mask
For the patient who is unable to keep their lips sealed around the mouthpiece, take the top T-piece off the kit and replace with an adult or pediatric nebulizer mask
Pediatric patient using
nebulizer mask.
Caregiver may assist in holding the mask.
What To Do in Extreme Asthma Attack
• At times, the asthma attack is so severe the patient is at risk of dying
• To relieve the bronchoconstriction, Albuterol needs to be delivered right into the lungs
• To assist with this, the patient may need to be bagged or intubated to deliver the medication
• Abuterol is delivered via in-line technique
Aerosol Medication via BVM or ETT with BVM (In-line)
• Albuterol placed in the chamber as usual
• The chamber is connected to the T-piece
• Adaptor(s) are used to accommodate bagging the patient with in-line Albuterol as soon as possible
– any medication that can be delivered as soon as possible to the target organ (the lungs) will be helpful in promoting bronchodilation
• Mouthpiece removed from T-piece and replaced with BVM
• Nebulizer still connected to oxygen source
• Adaptor placed at distal end of corrugated tubing to connect to BVM mask or ETT
Albuterol Delivered Via BVM
• #1 Disconnect reservoir bag with L valve from mask
• #2 Connect L shaped valve with bag where mouthpiece of albuterol kit would fit
• #3 Place corrugated tubing of albuterol kit to the mask over the patient’s mouth
• #4 Begin to bag to “blow” the drug into the lungs while waiting to complete intubation
#1
#2
#3, #4
To 6lO2
• Adaptor connected to the distal end of the corrugated tubing of Albuterol kit connected to the proximal end of the ETT
• ETT placement confirmed in the usual manner– visualization– chest rise & fall– 5 point auscultation
– ETCO2 detector
Intubatedpatient