CBT425-EMT11: Respiratory Emergencies

1. CBT425-EMT11: Respiratory Emergencies

2. Introduction • Patients with lung & heart diseases frequently call 9-1-1 due to breathing difficulty • This course reviews common disorders that can cause respiratory emergencies & prehospital management of these conditions

3. Objectives Identify the anatomic structures of the respiratory system Demonstrate an understanding of the physiology of the respiratory system and its relationship to BLS treatment Identify signs and symptoms of respiratory emergencies Identify treatment of respiratory emergencies Distinguish between normal and abnormal breath sounds Identify correct technique for auscultation of breath sounds Identify correct BVM technique and suctioning technique

4. Terms • chronic obstructive pulmonary disease (COPD) - A category of diseases characterized by a slow process of dilation and disruption of pulmonary alveoli. • dyspnea - A term for shortness of breath or breathing difficulty. • embolus - A blood clot or other substance that has formed in a blood vessel or the heart, that breaks off and travels to another blood vessel, where it may cause blockage. • flailchest - A condition in which three or more ribs are fractured in two or more places such that a section of the chest wall is detached from the rest of the chest wall.

5. Terms, continued • gagreflex - A protective contraction of the muscles of the throat caused especially by stimulation of the pharynx that prevents food and liquids from entering the airway. • hypoxia - A condition in which the body's cells and tissue do not have enough oxygen. • pleuriticchestpain - A sharp, stabbing pain in the chest that is worsened by a deep breath; often caused by inflammation or irritation of the pleura. • pneumothorax - Condition where air enters the pleural space and is trapped during expiration. It can occur without trauma as in a spontaneous pneumothorax.

6. Terms, continued • pulmonaryedema - A buildup of fluid in the lungs, usually as a result of congestive heart failure. • rales - Crackling, rattling breath sounds signaling fluid in the air spaces of the lungs. • rhonchi - Coarse breath sounds heard in patients with mucus in the airways. • stridor - A harsh, high-pitched inspiratory sound often heard in acute laryngeal (upper airway) obstruction.

7. Terms continued tensionpneumothorax - A life-threatening condition in which air enters the pleural space and the pressure inside the lung cavity progressively increases and compresses the lung. It may displace the mediastinum and other structures toward the opposite side. traumaticasphyxia - Condition characterized by distended neck veins, cyanosis in face and neck and bleeding in the sclera of the eye that is caused by severe compression of the chest. wheeze - A high-pitched, whistling breath sound, characteristically heard on expiration in patients with asthma or COPD.

8. New Terms • hypoxicdrive - A condition in which the body's stimulus for taking a breath is low oxygen. Occurs in people with COPD. • metabolism - The process by which food molecules are broken down to provide material and energy for cellular function. • pH (potential of hydrogen) - A measure of the acidity or alkalinity of a solution, numerically equal to 7 for neutral solutions, increasing with increasing alkalinity and decreasing with increasing acidity. The pH scale ranges from 0 to 14. Numbers from 7 and below represent increasing acidity.

9. New Terms continued perfusion - The movement of blood through an organ or tissue in order to supply nutrients and oxygen. tidalvolume – The volume of gas that is moved with each breath which is normally 500 ml in an adult. ventilation – The rate at which gas enters or leaves the lungs. Generally it is described in terms of good or poor ventilation. Bluish or dusky skin can indicate poor ventilation.

10. Respiratory Structures • Airway protection & oxygen administration are perhaps the most important BLS skills you have • Important to know structures of respiratory system • Understand basic physiology affected by BLS treatment Learning Activity for Functions of Respiratory Structures http://www.emsonline.net/resp2011/functions.asp

11. PHYSIOLOGY

12. Process by which body breaks down or "burns" stored fuel to create energy Cells use oxygen to transform stored glucose into energy Think of glucose as "fuel" & oxygen as "match" that releases energy Byproduct of metabolism is carbon dioxide (CO2) Metabolism Produces Carbon Dioxide

13. Metabolism • Carbon dioxide produced by cells & carried by circulatory system to lungs where it is expired • If respirations impaired • Carbon dioxide builds up in blood • Excess carbon dioxide combines with water in blood to produce acid

14. pH • Acidity in solution such as blood measured by potentialof Hydrogen • Body must maintain relatively narrow pH range (neither too acidic nor too basic) • Respiratory system helps maintain balanced acid level or pH in blood

15. The pH Balancing Act • Respiratory system – mirror for other changes that happen in the body • Blood pH becomes too low (acidic) • Respiratory system will attempt to fix by making lungs breathe more deeply & rapidly • Excreting more carbon dioxide • Homeostasis – body attempts to maintain balance

16. Hypercarbia • Excessive carbon dioxide in the body • Results in acidosis as carbon dioxide causes chemical reaction producing carbonic acid • Hypercarbia can occur through: • Metabolic processes that form acids • Muscle exertion • Shivering • Occurs through decreased elimination of carbon dioxide, for example with: • Airway obstruction • Inability to exhale fully (e.g., asthma or emphysema) • Depressed respiratory drive (e.g., overdose of sedative drugs)

17. Hypoxic Drive • Amount of carbon dioxide in blood is primary stimulus for breathing • Secondary stimulus is hypoxia • Decrease in oxygen • Occurs in small percentage of COPD patients • Expirations so inefficient their bodies become accustomed to higher than normal levels of carbon dioxide • Decrease in oxygen, rather than increase in carbon dioxide, provides primary stimulus for taking breath

18. Respiratory Drive • Act of breathing – autonomic & involuntary function controlled by centers in brain sensitive to blood levels of oxygen & carbon dioxide • Body’s response to increased carbon dioxide in blood is to "blow off” carbon dioxide by increasing rate & depth of respirations

19. Metabolic Problems • Metabolic imbalances affect chemistry of body affecting pH & other measures of body chemistry • Not a respiratory problem, respiratory system often tries to compensate by changing depth and/or rate of respirations

20. Metabolic Problems • Ketoacidosis – inefficient metabolism of sugars in a diabetic causes body to turn to other fuel sources for energy (fat & muscle) • Byproducts – acids called ketoacids • Presence of ketoacids & related compounds in blood will cause lower pH • Respiratory system responds by increasing depth and/or rate of respirations • Aspirin overdose – an acid (the chemical name is acetylsalicylic acid) • Taken in large quantities, person becomes acidotic • Body compensates by increasing depth and/or rate of respirations

21. Metabolic Problems Fever increases metabolic rate, causing production of more carbon dioxide which leads to more acid in blood • Tissue perfusion fails (as it can in sepsis) • Excess metabolic acids accumulate causing metabolic acidosis with a low pH • Body responds by increasing depth and/or rate of respirations Hyperventilating breathing deeply & rapidly • Efficient way of ridding body of carbon dioxide which in turn may alter the body’s equilibrium • Causes alkalosis (meaning very "basic") • Symptoms of respiratory alkalosis may include faintness & tingling in the extremities

22. CLINICAL SYNDROMES

23. Airway Obstruction EMS providers should intervene if choking victim has signs of severe airway obstruction Poor air exchange or increased breathing difficulty (indicated by silent cough) cyanosis or inability to speak or breathe Mild obstruction & victim coughing forcefully Do not interfere with efforts to relieve obstruction Attempt to relieve obstruction only if it becomes severe Use a finger sweep only if you can see solid material obstructing airway of unresponsive patient

24. Asthma Chronic, inflammatory disease of airways Asthma attacks induced by different factors: Allergens Infections Exercise Smoke During asthma attack: Muscles around bronchioles tighten Lining of inside bronchioles swells Inside of bronchioles fills with thick mucous Severely restricts expiration of air from lungs

26. Asthma Patients often describe history of asthma Have prescription for metered-dose inhaler BLS treatment considerations include: Calming the patient Airway management Oxygen therapy Assisting with a prescribed inhaler Asthma attack – muscles around airways tighten, making airway openings narrower so less air can flow through Inflammation increases and airways become more swollen and narrow Cells in airways also produce more mucus than normal Extra mucus also narrows the airways.

27. COPD Chronic obstructive pulmonary disease (COPD) Category of diseases that includes: Asthma Emphysema Chronic bronchitis Slow process of dilation & disruption of airways & alveoli Includes several related irreversible conditions that limit ability to exhale

29. COPD Patients present with shortness of breath, fever and increased sputum production Medical history can include: Upper-respiratory infection Chronic bronchitis Emphysema History of smoking Working in hazardous environment (e.g., coal smoke, asbestos) Common medications include: Prednisone Proventil Ventolin Atrovent Azmacort BLS treatment for a COPD patient with respiratory distress should include high flow oxygen .

30. Emphysema Very small airways that join alveoli are damaged & walls lose elasticity Chronic irritation of small airways causes inflammation & swelling – reducing diameter of air passages Irritation causes bronchospasms & further decreases the lumen On inspiration, expansion of lungs holds airways open On exhalation, lungs relax & airways narrow, trapping air

31. Chronic Bronchitis Characterized by structural changes in airways of the lungs Enlargement of mucous glands – cause coughing & production of sputum Causes shortness of breath Often accompanied by infection, mucus production & coughing

32. Congestive Heart Failure During acute exacerbation patient will present: Sitting up Short of breath Diaphoretic Pale Cyanotic in color Breath sounds can include rales or wheezes Medical history can include: Increased salt ingestion Respiratory infection Non-compliance with medications Angina Symptoms of acute coronary syndrome

33. Congestive Heart Failure Result of too much fluid in lungs making it difficult to get air in—as opposed to COPD patient who has trouble getting air out Occurs when ventricles weakened by myocardial infarction, underlying coronary artery disease, hypertension or valve disease Impairs heart’s ability to contract & empty during systole Blood backs up in lungs & tissues of body Increased pressure in left ventricle transmitted to lung capillaries Fluid forced into alveoli Interrupts gas exchange & results in shortness of breath Increased pressure in right ventricle causes fluid to back up into body’s tissues Leading primarily to swelling in lower extremities Do not suffer from purely left- or purely right-ventricle heart failure Rather present with combination of symptoms

34. CHF Symptoms

35. Congestive Heart Failure Common medications include: ACE inhibitors Furosemide (Lasix) HCTZ (hydrochlorthiazide) Beta-blockers Angiotensin II receptor blockers Digoxin (Lanoxin) Medications can help differentiate this patient's symptoms from those of someone with COPD

36. Congestive Heart Failure When treating CHF: Seat the patient upright Administer high flow oxygen Consider positive pressure ventilation with a BVM if the patient is experiencing severe respiratory difficulty

37. Inhalation Injuries Breathing of chemicals, smoke or other substances Common chief complaints include: Shortness of breath Coughing Hoarseness Chest pain due to bronchial irritation Nausea Individuals with decreased respiratory reserve (e.g., history of COPD or CHF) are likely to experience an exacerbation of the disease

38. Inhalation Injuries Patient in respiratory distress: Treat immediately with high flow oxygen Assist breathing with a BVM if the respiratory effort is insufficient Indicated by a slow rate & poor air exchange

39. Pneumonia Symptoms include: Fever Chills Cough (often with yellowish sputum) Shortness of breath General discomfort Fatigue Loss of appetite Headache Can be chest pain associated with breathing (usually sharp and stabbing in nature) and worsened by coughing or deep inspirations Other signs sometimes present are rales, clammy skin, upper abdominal pain & blood-tinged sputum Emergency care – may include oxygen therapy.

40. Pneumothorax Presence of air in pleural space Caused when internal or external wound allows air to enter space between pleural tissues Causes collapse of lung Cause sharp chest pain & shortness of breath May be able to feel subcutaneous air & breath sounds will be diminished

41. Pneumothorax Treatment of pneumothorax includes high-flow oxygen Be judicious with use of positive-pressure ventilation Can turn a spontaneous pneumothorax into a life-threatening tension pneumothorax. A pneumothorax can cause collapse of the entire lung. The only symptom may be sudden chest pain.

42. Pneumothorax Under normal conditions no air between these layers of pleura because sealed together Air or blood can enter space Example when hole is punctured in chest wall by gunshot or stab wound Can occur spontaneously Rupture due to disease or localized weakness of the lung lining Result of trauma Forceful coughing Chest injury and prior history of pneumothorax possible medical histories COPD – risk factor

43. Tension Pneumothorax Progressively worsening pneumothorax – begins to impinge on function of lungs & circulatory system Caused when lung injury acts like one-way valve that allows free air to move into pleural space Prevents free exit of that air Pressure builds inside pleural space & compresses lungs & other organs Early signs of a tension pneumothorax include: Increased dyspnea Cyanosis Signs of shock Distended neck veins Shift in PMI (Point of maximum intensity, where heart is loudest through auscultation) Tracheal displacement Tracheal deviation

44. Pulmonary Embolism Particle such as blood clot, fat embolus, amniotic fluid embolus or air bubble gets loose in blood stream Travels to the lungs Embolus lodges in major branch of pulmonary artery Circulation through large portion of lung is interrupted Blood not able to reach alveoli & it cannot be oxygenated

45. Pulmonary Embolism Causes include: Immobility of the lower extremities Prolonged bed rest Recent surgery Signs of PE: Sudden-onset of: Shortness of breath Tachypnea Chest painworsened by breathing Coughing up blood Pulmonary embolism – life-threatening condition Treated with high flow oxygen Rapid transport Move patient gently to avoid dislodging additional emboli

46. PATIENT CARE

47. Assessment of Respiratory Status • Assess rate & depth of respirations • Normal rate is between 12 & 20 respirations per minute for adult • Depth of respirations more subjective & varies from shallow, normal, labored or gasping • Together rate & depth will tell whether tidal volume is adequate.

48. Assessment of Respiratory Status • Other signs that indicate adequate oxygen supply to body’s tissues: • Level of consciousness • Breathing effort • Ability to speak in complete sentences • Use of accessory muscles • Skin color • Breath sounds • Body position

49. Irregular Breathing Patterns • Caused by specific conditions: • Example: Cheyne-Stokes respirations • May be seen in head injuries & stroke • Characterized by periods of breathing with gradually increasing & decreasing of tidal volume interspersed with periods of no breathing • Ataxic respirations – irregular, ineffective respirations with no clear pattern • Agonal respirations – abnormal pattern of breathing characterized by ineffective, slow inspirations followed by long pauses • Often sound like gasps • Associated with cardiac arrest or severe end-stage shock

50. Auscultation of Breath Sounds • Proper technique for auscultating chest using a stethoscope includes: • Listen at six locations on the back • Listen at four locations on the front • Instruct the patient to take a deep breath through the mouth then exhale • Listen to one or two inspiration/expiration cycles per location • Avoid listening through clothing Video demonstration available at EMS Online: http://www.emsonline.net/resp2011/auscultation.asp