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Waiting to Exhale

Waiting to Exhale. Respiratory Disorders. Peggy Andrews, Instructor. Fall, ‘08. A quick review. Upper airway To larynx Warms, humidifies, cleans Cilia Turbinates Cribiform plate. Lower airway Below larynx Trachea Bronchi Alveoli Surfactant. Review, continued. Lungs Lobes

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Waiting to Exhale

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  1. Waiting to Exhale Respiratory Disorders Peggy Andrews, Instructor Fall, ‘08

  2. A quick review • Upper airway • To larynx • Warms, humidifies, cleans • Cilia • Turbinates • Cribiform plate

  3. Lower airway Below larynx Trachea Bronchi Alveoli Surfactant Review, continued

  4. Lungs Lobes Visceral pleura Parietal pleura Lower airway, cont.

  5. Ventilation Inspiration Expiration Respiration-Tidal Volume 500ml Inspiratory Reserve Volume 3000ml Expiratory reserve volume 1500ml Residual volume 1200ml Dead air space 150ml Minute volume TV x RR Review, continued

  6. What controls our breathing? • Medulla • 12-20/min • Transmitted through • phrenic nerves • 3rd, 4th, 5th spinal nerves • and intercostal nerves • 11 pair • Can be modified by • Cerebral cortex • Hypothalamus • Brainstem (pons)

  7. What controls our breathing, cont. • Stretch receptors • Visceral pleura • Bronchi and bronchiole walls • Hering-Breuer reflex Phrenic and intercostal nerves

  8. More stuff • PCO2 increase = increased PCO2 in CSF = decreased pH Respiratory patterns Cheyne-Stokes Kussmaul’s Central neurogenic hyperventilation Ataxic (Biot’s) Apneustic

  9. Cheyne-stokes Central neuro- genic hypervent. Apneustic Ataxic (Biot’s)

  10. Respiratory Disorders • Incidence - 28% of all EMS C/C • Morbidity/Mortality - >200,000 deaths/yr.

  11. Risk Factors • Genetic predisposition • Asthma • COPD • Carcinomas • Stress • Increases severity of respiratory complaints & frequency of exacerbations • Assoc. Cardiac or circulatory pathologies • Pulmonary edema • Pulmonary emboli

  12. Case Presentation One

  13. Entering the bathroom, the EMTs find:

  14. The Patient Is:

  15. 1. What is her differential diagnosis? • 2. What treatment might you provide for this patient?Why?

  16. Altered mental status Severe cyanosis Absent breath sounds Audible stridor 1-2 word dyspnea Tachycardia > 130/min. Pallor and diaphoresis Retractions/accessory muscle use Signs of life-threatening respiratory distress in adults

  17. COPD • Outflow obstructive diseases • Emphysema • Chronic Bronchitis • Asthma

  18. The COPD patient • May have any or all three diseases • Works harder to breath – tires quickly • Be prepared to take over breathing

  19. Case Presentation Two

  20. You note the following:

  21. What is his differential diagnosis? • What treatment might you provide him? • Why?

  22. Emphysema • Irreversible airway obstruction • Diffusion defect also exists because of blebs - prone to collapse - pt. exhales with pursed lips • Almost always associated with cigarette smoking or environmental toxins

  23. Xray of pt With Emphysema

  24. Pathophysiology • Stiffening and enlargement of alveoli – requires higher lung pressures • More common in men • Walls of alveoli gradually destruct, = alveolar membrane surface area. Results in  ratio of air to lung tissue. • Pulmonary capillaries , =  resistance to pulmonary blood flow. • Causes pulmonary hypertension, leads to RHF, then Cor Pulmonale

  25. Pathophys. (Cont.) • Bronchiole walls weaken, lungs lose elasticity, air is trapped.  Residual volume, but vital capacity relatively normal. • PaO2 , =  RBC, polycythemia. • PaCO2 , is chronically elevated. The body depends on hypoxic drive. • Pt’s are more susceptible to pneumonia, dysrhythmias. • Meds; bronchodilators, corticosteroids, O2.

  26. Assessment • Altered mentation • 1-2 word dyspnea • Absent or decreased breath sounds • c/c Dyspnea, morning cough, nocturnal dyspnea, wheezing

  27. History - • Personal or family hx of allergies/asthma • Acute exposure to pulmonary irritant • Previous similar expisodes • Recent wt. loss,  exertional dyspnea • Usually > 20 pack/year/history

  28. Wheezing Retractions and/or accessory muscle use Barrel chest Prolonged expiratory phase Rapid resting respiratory rate Thin Pink puffers Clubbing of fingers Diminished breath sounds JVD, hepatic congestion, peripheral edema Exam

  29. Management • Pulse oximeter • Intubation prn • Assisted ventilation prn • High flow oxygen • IV therapy with fluids • Albuterol, or Albuterol/Atrovent neb • Transport considerations

  30. Chronic Bronchitis • Productive cough for at least 3 months for two or more consecutive years • An increase in mucous-secreting cells • Characterized by large quantity of sputum • Chronic smoker • Alveoli not severely affected - diffusion nl. •  gas exchange = hypoxia & hypercarbia • May increase RBC = polycythemia •  paCO2 = irritability, h/a, personality changes,  intellect. •  paCO2 = pulmonary hypertension & eventually cor pulmonale.

  31. Xray of pt With Chronic Bronchitis

  32. Assessment • Hx heavy cigarette smoking • Frequent resp. infections • Productive cough • Overweight, possibly cyanotic - blue bloaters • Rhonchi on auscultation - mucous plugs • S/S RHF; JVD, edema, hepatic congestion

  33. Management • Pulse oximetry • Oxygen - low flow if possible • Nebulized Albuterol/Atrovent • Constantly monitor • Position - seated • IV TKO

  34. Case Presentation Three

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