Bled PPT Ch27 Part01

Chapter 27, Part
1
Pathophysiology
and Respiratory
Disorders
Copyright 2006 Pearson
27:1-1
Lecture Outline
Introduction
Physiology review
Pathophysiology
Assessment
Management
Specific respiratory diseases
27:1-2
Introduction
More than 20 000 people die each
year due to respiratory complaints
Intrinsic factors
Heredity
Extrinsic factors
Smoking
Environmental pollutants
27:1-3
Physiologic
Processes
Gas exchange
The process by which oxygen is
taken in and carbon dioxide is
eliminated
Ventilation
Diffusion
Perfusion
27:1-4
Ventilation
Mechanical process of moving air
in and out of the lungs
Requires body structures to be
intact
Inspiration
Air drawn into lungs
Expiration
Air leaves the lungs
27:1-5
Body Structures for

Ventilation
27:1-6
Inspiration
27:1-7
Expiration
27:1-8
Diffusion
Process by which gases move
between alveoli and pulmonary
capillaries
Gases flow from areas of high to
low concentration
O2 and CO2
Move across the membrane according to
their concentration gradients
27:1-9
Diffusion
Respiratory membrane must remain
intact
Affected by
Disease process that damage alveoli
Fluid accumulation in interstitial space
Diseases that cause thickening of the endothelial
lining
Oxygen therapy
Improves concentration gradient
Medications
Address inflammation and fluid accumulation
27:1-10
Lung Perfusion
Circulation of blood through the
pulmonary capillaries
Effective perfusion
Adequate lung volume
Adequate concentration of hemoglobin
Oxygen transport
2% in solution
98% bound to hemoglobin
27:1-11
Hemoglobin
Four iron heme and one protein
globin molecules
Oxygen binds to heme molecule
As oxygen binds
More readily accepts additional oxygen
molecules
Relationship described in oxygen
dissociation curve
27:1-12
Oxygen Dissociation
Curve
27:1-13
Oxygen Dissociation
Curve
Alterations
Temperature
Blood pH
Carbon dioxide partial pressure
Allows for oxygen to be released at

tissues and bound at lungs
27:1-14
Carbon Dioxide
Majority transported as bicarbonate
ions
Transported in red blood cells and released at
lungs
Rest transported
Bound to hemoglobin
Dissolved in plasma
Haldane effect
As heme is saturated with O2, more CO2 is
released
27:1-15
Disruption in
Ventilation
Upper and
lower respiratory tracts
Obstruction due to trauma or infectious
processes
Chest wall and diaphragm

Trauma
Neuromuscular disease
Nervous System
Trauma
Poisoning or overdose
Disease
27:1-16
Abnormal Respiratory
Patterns
Cheyne-Stokes respirations
Progressively increasing then declining
respiration, separated by period of apnea
Terminal illness or brain injury
Kussmauls respirations
Deep rapid breaths
Corrective measure for metabolic acidosis
Central neurogenic hyperventilation

Deep, rapid respirations
Stroke or injury to brainstem
27:1-17
Patterns
Ataxic (Biots) respirations
Repeated episodes of gasping separated by
apnea
Increased intracranial pressure
Apneustic respirations
Long deep breaths, stopped during inspiratory
phase
Separated by periods of apnea
Stroke or severe central nervous system disease
27:1-18
Patterns
27:1-19
Pathophysiology
Disruption in diffusion
Hypoxia
Damaged alveoli
Disruption in perfusion
Alteration in blood flow
Alterations in hemoglobin
Pulmonary shunting
27:1-20
Assessment
Scene assessment
Safety
BSI
Identify rescue environments having
decreased oxygen levels
Gases and other chemical or biological agents
Clues to patient information
27:1-21
General Impression of the

Patient
Position
Color
Mental status
Ability to speak
Respiratory effort
27:1-22
Signs of Respiratory
Distress
Nasal flaring
Intercostal retraction
Use of accessory muscles
Cyanosis
Pursed lips
Tracheal tugging
27:1-23
Airway
Noisy breathing means partial airway
obstruction
Obstructed breathing is not always noisy
Brain can only survive minutes in asphyxia
Ventilation is useless if the airway is blocked
A patent airway is useless if the patient is
apneic
Act on airway obstruction
27:1-24
Breathing
Signs of life-threatening problems
Alterations in mental status
Severe central cyanosis, pallor, or
diaphoresis
Absent or abnormal breath sounds
Speaking limited to 12 words
Tachycardia
Use of accessory muscles or presence of
retractions
27:1-25
History
SAMPLE History
OPQRST History
Paroxysmal nocturnal dyspnea and
orthopnea
Coughing and hemoptysis
Associated chest pain
Smoking history or exposure to secondary
smoke
Similar Past Episodes

27:1-26
Neck
Physical
Examination
Swelling
JVD
Inspection
Symmetry/asymmetry
Increased diameter
Paradoxical motion
Scars, lesions, wounds, deformities
Palpation
Tenderness
Subcutaneous emphysema
Tracheal deviation
Tactile fremitus
27:1-27
Auscultation
Normal breath sounds
Bronchial
Bronchovesicular
Vesicular
Abnormal breath sounds
Snoring
Stridor
Wheezing
Rhonchi
Crackles
Pleural friction rub
27:1-28
Extremities
Peripheral cyanosis
Swelling and redness, indicative of a venous clot
Finger clubbing, which indicates chronic
hypoxia.
27:1-29
Vital Signs
Heart Rate
Tachycardia
Blood pressure
Pulsus paradoxus
Respiratory rate
Observe for trends
Assume as elevated rate is caused by hypoxia
Assume a slow rate is impending respiratory
arrest
27:1-30
Pulse Oximetry
Offers rapid and accurate measure
of oxygen saturation
Difficult or inaccurate
Peripheral vasoconstriction
Hypothermia
Sepsis
Carbon monoxide
Hypovolemia
27:1-31
Sensing unit for pulse

oximetry
27:1-32
Peak Flow
Handheld device for
determining patient
peak expiratory flow
rate
27:1-33
Capnometry
Continuous waveform or colorimetric

Detect carbon dioxide at end of expiration
Roughly equal to partial pressure in blood
Reflects adequacy of ventilations
27:1-34
Management
Principles
Maintain the
airway
Protect the cervical spine if trauma is suspected
Any patient with respiratory distress

should receive oxygen
Any patient suspected of being hypoxic
should receive oxygen
Oxygen should never be withheld from
a patient suspected of suffering from
hypoxia.
27:1-35
Upper-Airway
Obstruction
Common
Causes
Tongue, foreign matter, trauma, burns
Allergic reaction, infection
Assessment
Differentiate cause
Conscious patient
If the patient is able to speak, encourage
coughing
If the patient is unable to speak, perform
abdominal thrusts
27:1-36
Upper-Airway
Obstruction
Unconscious Patient
Open the airway

Attempt to give two ventilations
If they fail, reposition the head and reattempt
Administer abdominal thrusts

Attempt finger sweeps if foreign body is
visualized
If foreign body is removed, resume ventilation
If unsuccessful, continue abdominal thrusts and
sweeps
Visualize the airway with the laryngoscope

Remove foreign body with Magill forceps and resume
ventilations
27:1-37
Adult Respiratory
Distress Syndrome
Disorder of lung diffusion
Inability to maintain proper fluid
balance in interstitial space
Disruption of alveolar-capillary
membrane
Non-cardiogenic pulmonary edema
High mortality
27:1-38
Adult Respiratory
Distress Syndrome
Sepsis
Aspiration
Pneumonia
Pulmonary Injury
Burns/Inhalation Injury
Oxygen Toxicity
Drugs
High Altitude
Hypothermia
Near-Drowning Syndrome
Head Injury
Pulmonary Emboli
Tumor Destruction
Pancreatitis
Invasive Procedures
Bypass, hemodialysis
Hypoxia, Hypotension, or
Cardiac Arrest
27:1-39
Adult Respiratory
Distress Syndrome
Manage the underlying condition
Provide supplemental oxygen
Support respiratory effort
Provide positive pressure ventilation if
respiratory failure is imminent
Monitor cardiac rhythm and vital signs

Consider medications
Corticosteroids
27:1-40
Obstructive Lung
Diseases
Widespread in society
Abnormal ventilation
Some elements may be reversible
Asthma
Chronic Obstructive Pulmonary
Disease
Chronic bronchitis
Emphysema
27:1-41
Emphysema
Destruction of alveolar walls distal
to the terminal bronchioles
Contributing factors
Heredity
Cigarette smoking
Environmental factors
27:1-42
Pathophysiology
Destruction of alveolar surfaces
Decreased area for gas exchange
Hypoxia
Cor pulmonale
Decreased number of pulmonary capillaries

Hypoxia constricts pulmonary vessels
Increased resistance to right cardiac output
Right heart failure
27:1-43
Cor Pulmonale
27:1-44
Pathophysiology
Weakening of alveolar walls
Loss of elastic recoil

Air trapping
Pursed lipped breathing
Barrel chest
Unable to expel carbon dioxide

Chronic increased respiratory rate and accessory
muscle use
SOBOE
Polycythemia
27:1-45
27:1-46
Assessment
History
Recent weight loss, dyspnea with exertion
Cigarette and tobacco usage
Lack of cough
Physical Exam
Barrel chest
Prolonged expiration and rapid rest phase
Thin
Pink skin due to extra red cell production
Hypertrophy of accessory muscles
Pink Puffers
27:1-47
Chronic Bronchitis
Increased number of goblet cells in
the respiratory tree
Production of large quantity of
sputum
Often occurs after prolonged
exposure to cigarette smoke
27:1-48
Pathophysiology
Alveoli not severely affected
Gas exchange is compromised
Decreased alveolar ventilation
Hypoxia
Pulmonary vasoconstriction
Cor pulmonale
Vital capacity is decreased

27:1-49
Chronic mucous production

and plugging of the airways
27:1-50
Assessment
History
Frequent respiratory infections
Productive cough
Physical Assessment
Often overweight
Rhonchi present on auscultation
Jugular vein distention
Ankle edema
Hepatic congestion
Blue Bloater.
27:1-51
Management
For both emphysema and chronic
bronchitis
Relieve hypoxia
Maintain airway
Support breathing
Find position of comfort
Monitor oxygen saturation
Be prepared to ventilate or intubate
Reverse bronchoconstriction
Bronchodilators
27:1-52
Asthma
Chronic inflammatory disorder of
the airways
Approximately 20 children and 500
adults die each year
50% die before reaching hospital
Most deaths could be prevented
with education
27:1-53
Pathophysiology
Inflammation causes widespread
variable airflow obstruction
Airways become hyperresponsive
Induced by a trigger (varies by individual)
Release of histamine
Bronchoconstriction and bronchial edema
68 hours later, immune system cells
invade the bronchial mucosa
Additional edema.
27:1-54
Assessment
Identify immediate threats
History
SAMPLE & OPQRST History
History of asthma-related hospitalization
History of respiratory failure/ventilator use
Physical Exam
Presenting signs may include dyspnea, wheezing, cough
Wheezing is not present in all asthmatics
Speech may be limited to 12 consecutive words
Hyperinflation of the chest and accessory muscle use

Carefully auscultate breath sounds and measure peak
expiratory flow rate.
27:1-55
Management
Treatment goals:
Correct hypoxia
Reverse bronchospasm
Reduce inflammation
Maintain the airway

Support breathing
High-flow oxygen or assisted ventilations as indicated
Monitor cardiac rhythm

Establish IV access
Administer medications
Beta-agonists
Ipratropium bromide
Corticosteroids
27:1-56
Special Cases of
Asthma
Status Asthmaticus
A severe, prolonged attack that cannot be
broken by bronchodilators
Greatly diminished breath sounds
Recognize imminent respiratory arrest
Aggressively manage airway and breathing
Transport immediately
Asthma in Children
Pathophysiology and management similar
Adjust medication dosages as needed
27:1-57
Upper Respiratory
Infection
Upper Respiratory
Infections (URIs)
Frequent patient complaint
Common pediatric complaint
Rarely life threatening
Pathophysiology
Frequently caused by viral and bacterial
infections
Affect multiple parts of the upper airway
Typically resolve after several days of symptoms
27:1-58
27:1-59
Upper Respiratory
Infection
Assessment
Look for underlying illness

Evaluate pediatrics for epiglottitis
Management
Maintain the airway
Support breathing
Treat signs and symptoms
27:1-60
Pneumonia
Infection of the lungs
Particularly dangerous in immunesuppressed patients
Usually a bacterial or viral infection
Spreads to other parts of lung

Fluid and inflammatory cells collect
Disorder of ventilation
May spread to entire lung
27:1-61
Assessment
Focused history and physical exam
SAMPLE & OPQRST
Recent fever, chills, weakness, and malaise
Deep, productive cough with associated pain
Tachypnea and tachycardia may be present

Breath sounds
Presence of rales/crackles in affected lung
segments
Decreased air movement in the affected lung
27:1-62
Management
Maintain the airway
Support breathing
High-flow oxygen or assisted ventilation as
indicated
Monitor vital signs

Establish IV access
Avoid fluid overload
Medications
Antibiotics, antipyretics, beta-agonists
27:1-63
Lung Cancer
Leading cause of cancer death
among men and women
Linked to cigarette smoking and
environmental pollutants
Causes:
Spread from somewhere else in the body
Carcinogen
27:1-64
Lung Cancer
Types
Adenocarcinoma
Epidermoid
Small-cell, and large-cell carcinomas
Assessment
Cancer-related treatments and hospitalizations
Physical Exam
Evaluate for severe respiratory distress
27:1-65
Lung Cancer
Management
Administer oxygen
Support ventilation
Be aware of any DNR order
Provide emotional support
27:1-66
Toxic Inhalation
Pathophysiology
Includes inhalation of heated air, chemical
irritants, and steam
Airway obstruction due to edema
Laryngospasm due to thermal and chemical
burns
Assessment
Determine nature of substance.
Length of exposure and loss of consciousness
27:1-67
Toxic Inhalation
Ensure scene safety
Enter a scene only if properly trained and
equipped
Remove the patient from the toxic environment
Maintain the airway

Early, aggressive management may be indicated
Support breathing
Establish IV access
Transport promptly.
27:1-68
Carbon Monoxide
Odorless, colourless gas
Results from the incomplete combustion
Often builds up to dangerous levels in
confined spaces
Hazardous to Rescuers
Pathophysiology
Binds to hemoglobin
Prevents oxygen from binding and creates
hypoxia at the cellular level.
27:1-69
Carbon Monoxide
Assessment
Determine source and length of exposure

Headache
Confusion
Agitation
Lack of coordination,
Loss of consciousness
Seizures
27:1-70
Management
Ensure the safety of rescue personnel
Remove the patient from the exposure
site
Maintain an open airway
Provide high-concentration oxygen
Consider transport to hyperbaric
chamber
27:1-71
Pulmonary
Embolism
Pathophysiology
Obstruction of a pulmonary artery
Emboli may be of air, thrombus, fat, or
amniotic fluid
Foreign bodies may also cause an embolus
Risk Factors
Recent surgery, long-bone fractures,
pregnancy
Pregnant or postpartum
Oral contraceptive use, tobacco use
27:1-72
Assessment
SAMPLE and OPQRST History
Presence of risk factors
Sudden onset of severe dyspnea and pain
Cough, often blood-tinged
Physical Exam
Signs of heart failure, including JVD and
hypotension
Warm, swollen extremities (DVT)
27:1-73
Management
Maintain the airway
Support breathing
High-flow oxygen or assist ventilations as
indicated
Intubation may be indicated
Establish IV access
Monitor vital signs closely
Transport to appropriate facility
27:1-74
Spontaneous
Pneumothorax
Occurs in absence of trauma

Risk factors
Rare but high recurrence rate

More males than females (5:1)
Tall, thin stature
Between 20 and 40 years
COPD (ruptured bleb)
27:1-75
Spontaneous
Pneumothorax
Pathophysiology
Disease of ventilation
Pneumothorax occupying 15-20% of chest
cavity generally well tolerated
Assessment
Presence of risk factors

Rapid onset of symptoms
Sharp, pleuritic chest or shoulder pain
Often precipitated by coughing or lifting
27:1-76
Management
Maintain the airway

Support breathing
Monitor for tension pneumothorax
Pleural decompression
JVD
Tracheal deviation away from the
affected side.
27:1-77
Hyperventilation
Syndrome
Characterized by rapid breathing

Chest pains
Numbness
Other symptoms associated with anxiety
Many serious diseases cause

hyperventilation
Consider it to be an indicator of a serious
medical condition
27:1-78
Hyperventilation
Syndrome
27:1-79
Hyperventilation
Syndrome
Assessment
SAMPLE & OPQRST history

Fatigue, nervousness, dizziness, dyspnea,
chest pain
Numbness and tingling in hands, mouth, and
feet
Presence of tachypnea and tachycardia

Spasms of the fingers and feet.
27:1-80
Hyperventilation
Syndrome
Management
Maintain the airway

Support breathing
Provide high-flow oxygen or assist
ventilations as indicated
Do not allow the patient to rebreathe
exhaled air
Reassure the patient
27:1-81
CNS Dysfunction
Pathophysiology
Traumatic/atraumatic brain injury
Tumours
Drugs
Assessment
Evaluate potentially treatable causes
Narcotic drug overdose
CNS trauma.
Carefully evaluate breathing pattern.
27:1-82
Dysfunction of the
Spinal Cord, Nerves, or
Respiratory Muscles
Pathophysiology
PNS problems affecting respiratory function
Trauma
Polio
Myasthenia gravis
Viral infections
Tumours
Assessment
Rule out traumatic injury, and assess for
numbness, pain, or signs of PNS dysfunction.
27:1-83
Management
Follow general management
principles.
Maintain the airway and support
breathing.
Use cervical spine precautions if
indicated.
27:1-84
Summary
Review of Respiratory Physiology

Pathophysiology
Assessment
Management
Specific Respiratory Diseases
27:1-85

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Chapter 27, Part

Body Structures for

Copyright 2006 Pearson

Copyright 2006 Pearson

Copyright 2006 Pearson

Copyright 2006 Pearson

Copyright 2006 Pearson

Allows for oxygen to be released at

Copyright 2006 Pearson

Chest wall and diaphragm

Central neurogenic hyperventilation

Copyright 2006 Pearson

Copyright 2006 Pearson

Clues to patient information

Copyright 2006 Pearson

General Impression of the

Copyright 2006 Pearson

Copyright 2006 Pearson

Similar Past Episodes

Copyright 2006 Pearson

Abnormal breath sounds

Copyright 2006 Pearson

Sensing unit for pulse

Copyright 2006 Pearson

Copyright 2006 Pearson

Continuous waveform or colorimetric

Copyright 2006 Pearson

Any patient with respiratory distress

Open the airway

Administer abdominal thrusts

Visualize the airway with the laryngoscope

Copyright 2006 Pearson

Copyright 2006 Pearson

Monitor cardiac rhythm and vital signs

Copyright 2006 Pearson

Copyright 2006 Pearson

Decreased number of pulmonary capillaries

Copyright 2006 Pearson

Copyright 2006 Pearson

Loss of elastic recoil

Unable to expel carbon dioxide

Copyright 2006 Pearson

Copyright 2006 Pearson

Vital capacity is decreased

Chronic mucous production

Copyright 2006 Pearson

Copyright 2006 Pearson

Hyperinflation of the chest and accessory muscle use

Copyright 2006 Pearson

Maintain the airway

Monitor cardiac rhythm

Copyright 2006 Pearson

Copyright 2006 Pearson

Look for underlying illness

Usually a bacterial or viral infection

Spreads to other parts of lung

Tachypnea and tachycardia may be present

Monitor vital signs

Copyright 2006 Pearson

Copyright 2006 Pearson

Copyright 2006 Pearson

Maintain the airway

Determine source and length of exposure