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