Respiratory Emergencies

Chapter 11

Respiratory System

Anatomy and Function of the Lung

Characteristics of Adequate Breathing

• Normal rate and depth

• Regular breathing pattern

• Good breath sounds on both sides of the chest

• Equal rise and fall of chest

• Pink, warm, dry skin

Causes of Inadequate Breathing

• Pulmonary vessels become obstructed.

• Alveoli are damaged.

• Air passages are obstructed.

• Blood flow to the lungs is obstructed.

• Pleural space is filled.

Signs of Inadequate Breathing

• Slower than 12 breaths/min or faster than 20 breaths/min

• Unequal chest expansion

• Decreased breath sounds

• Muscle retractions

• Pale or cyanotic skin

• Cool, damp (clammy) skin

• Shallow or irregular respirations

• Pursed lips

• Nasal flaring

Dyspnea

• Shortness of breath or difficulty breathing

• Patient may not be alert enough to complain of shortness of breath.

Upper or Lower Airway Infection

• Infectious diseases may affect all parts of the airway.

• The problem is some form of obstruction to the air flow or the exchange of gases.

Upper or Lower Airway Infection (treatment)

• Administer warm, humidified oxygen.

• Do not attempt to suction the airway or insert an oropharyngeal airway in a patient with suspected epiglottitis.

• Transport patient in position of comfort.

Acute Pulmonary Edema

• Fluid build-up in the lungs

• Signs and symptoms

– Dyspnea

– Frothy pink sputum

• History of chronic congestive heart failure

• Recurrence high

Acute Pulmonary Edema (treatment)

• Administer 100% oxygen.

• Suction secretions.

• Transport in position of comfort.

Chronic Obstructive Pulmonary Disease (COPD)

• COPD is the result of direct lung and airway damage from repeated infections or inhalation of toxic agents.

• Bronchitis and emphysema are two common types of COPD.

• Abnormal breath sounds may be present.

– Rhonchi and wheezes

COPD Patients

• COPD patients cannot handle pulmonary infections well

• Usually age 50 or older

• History of recurring lung problems

• Long-term smokers

• Tightness in chest/constant fatigue

Chronic Obstructive Pulmonary Disease (COPD) (treatment)

• Assist with prescribed inhaler if patient has one.

• Transport promptly in position of comfort.

Asthma

• Common but serious disease

• Asthma is an acute spasm of the bronchioles.

• Wheezing may be audible without a stethoscope.

Asthma (treatment)

• Obtain history.

• Assess vital signs.

• Assist with inhaler if patient has one.

• Administer oxygen.

• Transport promptly.

Spontaneous Pneumothorax

• Accumulation of air in the pleural space

• Caused by trauma or some medical conditions

• Dyspnea and sharp chest pain on one side

• Absent or decreased breath sounds on one side

Spontaneous Pneumothorax (treatment)

• Administer oxygen.

• Transport in position of comfort.

• Monitor closely.

Anaphylactic Reactions

• An allergen can trigger an asthma attack.

• Asthma and anaphylactic (allergic) reactions can be similar.

• Hay fever is a seasonal response to allergens.

Pleural Effusion

• Collection of fluid outside lung

• Causes dyspnea

• Caused by irritation, infection, or cancer

• Decreased breath sounds over region of the chest where fluid has moved the lung away from the chest wall

• Eased if patient is sitting up

Pleural Effusion (treatment)

• Definitive treatment is performed in a hospital.

• Administer oxygen and support measures.

• Transport promptly.

Mechanical Obstruction of the Airway

• Be prepared to treat quickly.

• Obstruction may result from the position of head, the tongue, aspiration of vomitus, or a foreign body.

• Opening the airway with the head tilt-chin lift maneuver may solve the problem.

Obstruction of the Airway (treatment)

• Clear airway.

• Administer oxygen.

• Transport promptly.

Pulmonary Embolism

• A blood clot that breaks off and circulates through the venous system

• Signs and symptoms – Dyspnea – Acute pleuritic pain – Hemoptysis – Cyanosis – Tachypnea – Varying degrees of hypoxia

Pulmonary Embolism (treatment)

• Administer oxygen.

• Place patient in comfortable position, usually sitting.

• Assist breathing as necessary.

• Keep airway clear.

• Transport promptly.

Hyperventilation

• Overbreathing resulting in a decrease in the level of carbon dioxide

• Signs and symptoms

– Anxiety

– Numbness

– A sense of dyspnea despite rapid breathing

– Dizziness

– Tingling in hands and feet

Hyperventilation (treatment)

• Complete initial assessment and history of the event.

• Assume underlying problems.

• Do not have patient breathe into a paper bag.

• Give oxygen.

• Reassure patient and transport.

You are the provider:

• You and your EMT-B partner are dispatched to a 33-year-old woman with difficulty breathing.

• You arrive at the office building and an upset man identifies himself as the patient’s coworker.

• He tells you that the patient has had breathing problems before, but he’s never seen it this bad.

• He leads you to a woman who is standing with her arms outstretched on the desk with a metered-dose inhaler in hand.

• She acknowledges your presence with a nod. When you ask her what is wrong, she answers with a two-word response, “can’t breathe.”

• You hear audible wheezes.

Scene size up

• How significant is the person’s response to your question and why?

• What should you do next? Should you transport this patient or wait for ALS to arrive on scene?

Initial Assessment

• Perform initial assessment.

• Place the patient on oxygen.

• If patient is in respiratory distress, ventilate.

• Check pulse.

Signs and Symptoms

• Difficulty breathing

• Altered mental status

• Anxiety or restlessness

• Increased or decreased respirations

• Increased heart rate

• Irregular breathing

• Cyanosis

• Pale conjunctivae

• Abnormal breath sounds

• Difficulty speaking

• Use of accessory muscles

• Coughing

• Tripod position

• Barrel chest

You are the provider:

• You arrange to rendezvous with ALS. • You apply high-flow oxygen and obtain the following vital

signs: – Respirations: 42 breaths/min – Pulse oximetry: 90%

• The patient indicates that she has used the inhaler twice already.

• What can you do before you meet ALS? • Another pulse oximetry reading reveals a reading of 72%. • The patient is using accessory muscles to breathe. • What do these signs indicate?

Focused History and Physical Exam

• Abnormal breath sounds are symptomatic of COPD

• Long history of dyspnea with sudden increase in shortness of breath

• Recent chest cold with fever

• Vital signs – Normal blood pressure

– Rapid, occasionally irregular pulse

– Respirations rapid or very slow

Interventions

• Treat immediate life threats

• Possible interventions

– Oxygen via nonrebreathing mask at 15 L/min

– Positive pressure ventilations

– Airway adjuncts

– Positioning

– Respiratory medications

Detailed Physical Exam

• Performed only once life threats are addressed.

• May not be able to do if busy treating airway or breathing problems.

Ongoing assessment

• Carefully watch patients for shortness of breath.

• Reassess vital signs.

• Ask patient if treatment has made a difference.

• Check for accessory muscle use.

Emergency Medical Care

• Give supplemental oxygen at 10 to 15 L/min via nonrebreathing mask.

• Patients with longstanding COPD may be started on low-flow oxygen (2 L/min).

• Assist with inhaler if available.

• Consult medical control.

Medications in MDI

• Trade names

– Proventil

– Ventolin

– Alupent

– Metaprel

– Brethine

• Generic names

– Albuterol

– Metaproterenol

– Terbutaline

Prescribed Inhalers

• Actions

– Relax the muscles surrounding the bronchioles

– Enlarge the airways leading to easier passage of air

• Side effects

– Increased pulse rate

– Nervousness

– Muscle tremors

Prior to Administration

• Read label carefully.

• Verify it has been prescribed by a physician for this patient.

• Consult medical control.

• Make sure the medication is indicated.

• Check for contraindications.

Contraindications for MDI

• Patient unable to help coordinate inhalation

• Inhaler not prescribed for patient

• No permission from medical control

• Maximum dose prescribed has been taken.

Administration of MDI

• Obtain order from medical control or local protocol. • Check for right medication, right patient, right route. • Make sure the patient is alert. • Check the expiration date. • Check how many doses have been taken. • Make sure inhaler is at room temperature or warmer. • Shake inhaler. • Stop administration of oxygen. • Ask the patient to exhale deeply and put lips around opening. • If the inhaler has a spacer, use it. • Have the patient depress the inhaler and inhale deeply. • Instruct the patient to hold his or her breath. • Continue administration of oxygen. • Allow the patient to breathe a few times then repeat dose

according to protocol.

Reassessment

• Carefully watch for shortness of breath.

• 5 minutes after administration:

– Obtain vital signs again.

– Perform focused reassessment.

• Transport and continue to assess breathing.