Slide  1  

Asthma  and  COPDVS  Heart  Failure

NWC  EMSS  Continuing  EducationApril  2015

Jen  Dyer,  RN,  BS,  EMT-­‐P  EMS  Educator  

 

Slide  2  Objectives

• Generalize  and  differentiate  pathophys  of  chronic  bronchitis,  emphysema,  asthma,    and  HF

• Adopt  comprehensive  assessment  plan  for  pts  w/  resp distress

• Interpret  quantitative capnography readings  as  they  relate  to  COPD/asthma  and  HF  etiologies

• Adopt  capnography as  standard  practice  for  all  pts w/  resp complaints  or  management

• Include  NTG  as  part  of  CPAP  intervention  when  treating  pt  w/  HF

• Review  resources  and  SOP’s• Evaluate  ePCR’s for  assessment  and  management  of  patients  w/  resp distress

 

 

Slide  3  

Respiratory Distress:Differentiate

COPD/Asthma from Heart Failure

 

 

Slide  4  Resp  Distress:    The  Bottom  Line

All  respiratory  problems  can  be  categorized  as  impacting  

Ø OxygenationØVentilationØ Diffusion  Ø Perfusion

Once  identified,  management  is  directed  at  the  source(s)  of  the  problem  

 

 

Slide  5  Assessment:  Respiratory  Distress

LOCBreath  sounds  PositionWOBAccessory  muscles,  retractionsSpeechColor  -­‐ skin,  lips,  mucous  membranesSpO2    &  capnography

 

 

Slide  6  Capnography

– Metabolism:  cellular  “waste”– Perfusion:  adequate  blood  flow  to  transport  CO2  from  the  cells  to  alveoli

– Ventilation:  removal  of  CO2  @  alveoli  via  breathing

Significance  requires  consideration  of  all  3!  

 

 

Slide  7  

Sharkfin Waveform

“Sharkfin”  created  by  ANYTHING  that   interferes  

w/  air  leaving  lungs!

 

 

Slide  8  Capnography Can  Tell  You…

Help  confirm  dx  of  COPD,  asthma,  HFSeverity  of  COPD/asthmaEffect  of  interventionsAccurate,  real  time  resp rateAppropriateness  of  assisted  ventilation  rate,  

depthTREND values  – more  info  than  just  one!

 

 

Slide  9  SAMPLE & PMH

JACKPOT!  

 

Slide  10  

SAMPLE  and  PMHClues  to  etiology  of  eventS&S  Allergies  MedsPMH

 

 

Slide  11  

History:  Present  IllnessWhat’s  normal?    What’s  different?Onset:  time,  duration,  rapidityTrigger  or  eventRecurrencePrior  episodesSeverityCoughAssociated  symptoms

 

 

Slide  12  Assessment  Findings:  COPD

Work  of  breathing:  dypsnea;  accessory  muscles1-­‐2  word  sentences  =  severe  distressProlonged  expiration/pursed  lip  breathing

SpO2:  often  low  (normal  92%)  ETCO2:  usually  incr.  w/  sharkfin  wave  formRt heart  failure  S&S

 

 

Slide  13  Capnography  in  COPD

ETCO2  often  chronically    ↑ TRENDING ETCO2  values  allows  monitoring  of  response  to  treatment    

Falling  numbers  toward  “normal”  =  betterIncreasing  numbers  =  worse

 

 

Slide  14  Asthma:  Assessment  FindingsPosition:  sitting  up  /  leaning  forward

May  be  fatiguedLungs:  clear  →  wheezes  →  diminished  →  absent

SpO2  may  be  WNL  early  in  attackCapnography:  sharkfin

Speech:  fragmented  due  to  resp distressRetractions  – worse  w/  ↑  severity

 

 

Slide  15  

Rapidity  of  onset,  time,  and  durationWhat  provoked  the  attack?Recurrence  (ETI,  ED  visits,  hosp admissions)Meds  used  w/  this  attack  in  past  48  hrsAffecting  sleep,  speech,  exercise  tolerance?Last,  total  doses  of  medsSeverity

Asthma:  Hx of  Present  Illness

 

 

Slide  16  The  High  Risk  Asthma  Patientü RR  ≥  40,  ETCO2  ≥  4ü AMS  ü Speaks  <  3  syllablesü Markedly  diminished  or  absent  lung  soundsü Central  cyanosisü Exhaustion  or  fatigueü VS:  HR  >  120  or  <  60,  RR  >  25-­‐30üCannot  lie  flat

 

 

Slide  17  More  Asthma  Red  Flags

üED  visit  w/in  last  24-­‐48  hrsüMultiple  hosp admissions  w/in  a  yearüPrevious  near  – fatal  attacküAsthma  – related  ETI,  seizure,   resp failureüChronic  steroid  use  or  recent  w/drawlüPsychiatric  or  psychosocial  problemsüAge  >  55

 

 

Slide  18  

Heart  FailureHeart’s  inability  to  pump  sufficient  blood  to  meet   body’s  metabolic  needsRisk  factors:  

§ MI§ Diabetes§ HTN§ Smoking§ Valve  dysfunction

Compensatory  mechanisms  may  actually  harm  pt§ ↑  heart  rate§ Vasoconstriction

 

 

Slide  19  HF  Compensation  Results

Incr demand  for  myocardial  O2Decr ventr filling  time  (  ↓cardiac  output)Decr time  for  coronary  artery  fillingIncr LV  workload  against  constricted  arteries

And  you  see…… ↑HR

↑BP

↓  SpO2

S&S  hypoperfusion

 

 

Slide  20  HF  Assessment  Findings

↑  HR  and  RR  w/  ↑  WOBBP  normal  or  ↑SpO2  <  94%  on  RARestlessness/anxiety/confusionTripod  positionSkin-­‐cool,  pale,  ashen,  cyanotic

 

 

Slide  21  HF  Assessment  Findings

Breath  sounds:  • Crackles  usually  on  insp• Wheezes• Note:  crackles  may  be  obscured  by  wheezes!Orthopnea,  PNDJVD  (RHF)Peripheral  edema  (RHF)Pink,  frothy  sputum

 

 

Slide  22  Capnography  in  Heart  Failure

Square  OR sharkfinExhalation  may    be  restricted    if    bronchioles  narrowed    by    fluid  

accumulation    in  surrounding  tissues  

 

 

Slide  23  Respiratory  Distress  Run  Reviews

Participants  independently  read  first  PCR  and  evaluate  it  

One  participant  will  present  evaluation.  Rest  of  class  adds  comments.

Repeat  w/  remaining  PCRs