22nd August 2016 - Surg Lec 02 - Respiratory Emergencies

Respiratory
Emergencie
s
Elmer S. Jabagat. M.D.,
FPCS, FPSGS
CASE
A 68 year old manenroute to the bathroom at night checks on a noise the dog is making
and slips on a staircase falling hard against his right side down several steps.
He complains that "Ihurtallover,butitreallyhurtswhenIbreathe." His
hands guard his right anterolateral chest wall.
You inspect the breathing and think that the chest looks funny; it seems that
the right hemithorax doesnt move as much and that a portion lags behind.
There are abraded contusions with ecchymosis over the ribs, and the area is crepitant
when palpated.
CASE
A"CodeThree"paramedicambulancebringsyoua73yearoldmanwithacuteshortness
ofbreathandcoughingandahistoryofemphysema.
Heappearsseverelydistressedandbarelyabletospeak.
Asheisbeingmovedtoahospitalgurney,theoxygenmaskisbrieflyremoved,thepatient
becomesascyanoticas"stone-washedbluejeans."
A, B, Cs in the management of
emergency situations
A - Airway
B - Breathing
C - Circulation
Objectives
Anatomy, Physiology and Mechanics of
breathing
Signs and Symptoms of respiratory
emergencies
Principles in management of respiratory
emergencies including those that affect the
Upper airway
Lower airway
Anatomy and Physiology

Respiratory system structures look like an inverted tree.
Structures of the Upper Airway
Nostrils and nose

Air enters through the nostrils.
Lined with nasal hairs
Quiet breathing allows air to flow
through the nose.

Turbinates
Highly vascular ridges covered with mucus
membrane
Traps particulates
Warm and humidify air as it passes
Many blood vesselsswell and bleed easily

Mouth and oropharynx
Contain blood vessels
and mucous membrane
Edema can be extreme.
Ask patient if their
tongue feels thick.
Monitor speech.
E. M. Singletary, M.D. Used with permission.

Hypopharynx
Where the oropharynx and nasopharynx meet
Gag reflex is profound.
Triggering may cause vagal bradycardia, vomiting,
and increased intracranial pressure.
May make airway device use difficult

Larynx and
glottis
Dividing line
between upper
and lower airway
Thyroid
cartilage:
external
landmark

Larynx and glottis (contd)
Several cartilages support the vocal cords.
Arytenoid cartilages: found at the distal end of each
vocal cord
Piriform fossae: pockets of tissue found on either side of
the glottis
Cricoid cartilage: palpated just below the thyroid
cartilage

Larynx and glottis (contd)
Cricothyroid membrane: small space between
the thyroid and cricoid cartilage
Does not contain many blood vessels
Covered only by skin
Potential site for cricothyrotomy

Larynx and glottis
(contd)
Laryngeal swelling
or trauma can
create lifethreatening airway
obstruction.
Structures of the Lower Airway

Tracheobronchial tree
Trachea
trunk of tree
Carries air to the lungs
Extends from the larynx
to the mainstem
bronchi

Tracheobronchial tree (contd)
Mainstem bronchi branch into:
Lobar bronchi
Segmental bronchi
Subsegmental bronchi
Bronchioles
Bronchi and bronchioles are lined with cilia.
Inset photo: Dr. Kessel &

Dr. Kardon/Tissue &
Organs/Visuals Unlimited.
Dr. Kessel & Dr.
Kardon/Tissue &
Organs/Visuals Unlimited
Inset photo: Dr. Kessel &
Dr. Kardon/Tissue &
Organs/Visuals Unlimited.

Bronchioles
Significant amount of gas exchange

Bronchioles (contd)
Goblet cells produce mucus blanketing.
Gel layer
Sol layer
Smooth muscle surrounds the airway.
Bronchoconstriction: smooth muscle narrows the airway.

Alveoli
Gas exchange interface
Deoxygenated blood releases carbon dioxide and is resupplied
with oxygen.
Made up of two types of cells:

Type I: almost empty
Type II: can make new type I cells

Alveoli (contd)
Function best
when kept
partially inflated
Collapsed, fluidfilled, or pusfilled alveoli do
not play a part
in gas exchange.

Alveoli (contd)
Pulmonary capillary bed
Pulmonary circulation starts at the right ventricle.

Pulmonary capillaries are narrow.
Patients with chronic lung disease and chronic hypoxia
often have thick blood (polycythemia).
Strains right side of heart, leads to cor pulmonale

Alveoli (contd)
Interstitial space
Network of gaps between alveoli and capillaries

Filled with interstitial fluid
Conducting airways distributes inspired gas, which
does not participate in ventilation
Wasted ventilation: dead space (1 mL per pound of ideal body
weight)

Chest wall
Forms a bellows system with chest muscles
The diaphragm is the primary muscle.
Causes pressure changes to move air in and out
Ribs maintain pressure.
Pleural membranes allow organs to move smoothly.

Chest wall (contd)
Trauma and diseases of
the bones and muscles
can significantly impair
air movement.
Causes restrictive lung
diseases

Mediastinum: middle of the chest
Consists of:
Heart
Large blood vessels
The large conducting airways
Other organs
Functions of the Respiratory

System
Respirationprocess of oxygen taken into body
and distributed to the cells for energy
Carbon dioxide is returned to the lungs by the
circulatory system and exhaled.

System
Ventilation
Movement of air in and out of the lungs
Best measured by the carbon dioxide level
Normal breathing removes enough carbon dioxide to
keep acid-base balance.
PACO2 must be 35 to 45 mm Hg for normal
ventilation.

System
Diffusion
For oxygen to go from an alveolus to a red
blood cell, it must:
Diffuse into the alveolar cell and out the other side.
Diffuse into the capillary wall and out the other side.

System
Diffusion (contd)
Some lung diseases make it difficult for oxygen
to diffuse into the blood.
Effective diffusion: higher concentration of
oxygen in the alveoli than in the bloodstream

System
Perfusion
Circulatory component of respiratory system
Blood must keep flowing through pulmonary
vessels.
A large embolus can block blood flow to the
lung.
Mechanisms of Respiratory
Control
Neurologic control
Centered in the medulla
At least four parts of brainstem responsible for
unconscious breathing
Stretch receptors cause coughing if taking too
deep a breath
Hering-Breuer reflex
Control
Neurologic control (contd)
Other neurologic control mechanisms:
Phrenic nerve innervates diaphragm.
Thoracic spinal nerves innervate intercostal
muscles.
Control
Cardiovascular regulation
Lungs closely linked to cardiac function
Heart changes have pulmonary consequences.
Left-sided heart failure progresses faster than
right-sided heart failure.
Control
Cardiovascular regulation (contd)
Mild hypoxia causes increase in heart rate
Severe hypoxia causes bradycardia.
Uncorrected hypoxic insults may trigger lethal
cardiac arrhythmia.
Control
Cardiovascular regulation (contd)
Various forms of heart failure from:
Fluid balance changes
Right-sided heart pumping pressure
Left-sided heart pumping pressure
Control
Muscular control
Body takes in air by
negative pressure
Air through mouth
and nose, over
turbinates, around
epiglottis and glottis
Control
Muscular control (contd)
Thorax: airtight box with diaphragm at bottom
and trachea at top
Diaphragm flattens during quiet breathing.
Air is sucked in to fill the increasing space.
Control
Muscular control (contd)
Minute ventilation can be increased by:
Deep breathing
Rapid breathing
Accessory muscles cause dramatic pressure
changes when greater amounts of air must be
moved.
Control
Muscular control
(contd)
Traumatic opening in
thorax provides route
for air to be sucked
in
Sucking chest wound
Exhalation is a
passive process.
Control
Renal status
Kidneys play a part in controlling:
Fluid balance
Acid-base balance
Blood pressure
Factor into pulmonary mechanics and oxygen delivery
to body tissues
Assessment of a Patient with

Dyspnea
Respiratory assessment includes much
more than listening to the patients
lungs.
Many respiratory ailments are life
threatening.
Respiratory assessment should be done
early.
Scene Size-Up
Observe standard precautions.
Use proper PPE.
Evaluate scene safety for:
Decreased oxygen concentrations

Carbon monoxide
Irritant gasses
Highly contagious respiratory illness
Scene Size-Up
Respiratory
diseases can
impair:
Ventilation
Diffusion
Perfusion
Combination of all
three
Rapid-onset
dyspnea may be
caused by:
Acute
bronchospasm
Anaphylaxis
Pulmonary
embolism
Pneumothorax
Primary Assessment
Form a general impression.
Body type may be associated with condition
Emphysema: barrel chest, muscle wasting, pursedlip breathing, tachypneic
Chronic bronchitis: sedentary, obese, sleep upright,
spit-up secretions
Primary Assessment
Observe condition during typical exertion.
Tachycardia, diaphoresis, and pallor can be
triggered by:
Increased work of breathing
Anxiety
Hypoxia
Primary Assessment
Position and degree of
distress
Prefer sitting positions,
such as tripod position
Lying flat may be a sign
of sudden deterioration.
Ominous sign: head
bobbing
Primary Assessment
Breathing alterations
Can be complex and involve:
Problems with the airway branches

Difficulties at the alveolar level
Problems with the muscles and nerves
Problems with the rigid structure of the thorax
Increased work of
breathing
Patients using
accessory muscles
to breathe are in
danger of tiring
out.
Infants and small
children are in
danger of collapse
of flexible sternum
Courtesy of Health Resources and Services Administration, Maternal and Child Health
Bureau, Emergency Medical Services for Children Program.
Primary Assessment
Primary Assessment
Increased work of
breathing (contd)
Profound intrathoracic
pressure changes can
cause peripheral pulses
to weaken or disappear.
Tension Pneumothorax.
Primary Assessment
Altered rate and depth of respiration
Patient with adequate rate but low volume will have
inadequate minute volume.
Respiratory rate tidal volume = minute volume
Monitor trends in respiratory rates.
Note inspiratory-to-expiratory (I/E) ratio.
Primary Assessment
Abnormal breath
sounds
Auscultate lungs
systematically.
Some conditions are
gravity-dependent
and others diffuse
throughout the
lungs.
Primary Assessment
Abnormal breath sounds (contd)
Breath sounds are created by airflow in
the large airways.
Primary Assessment
Primary Assessment
Some conditions cause normal breath sounds to be
heard in abnormal places.
Sounds move better through fluid than in air.
Quality of sounds is dependent on the amount of tissue
between stethoscope and structures.
Primary Assessment
Abnormal breath
sounds (contd)
Continuous: wheezes
Discontinuous:
crackles
Rales
Rhonchi
Pleural friction rub
Primary Assessment
Audible sounds include:
Stridorupper airway obstruction
Gruntinglower airway obstruction
Death rattlepatients cant clear secretions
The most ominous sounds are no sounds.
Primary Assessment
Noisy breathing
Snoring: Partial obstruction of the upper airway by the tongue

Gurgling: Fluid in the upper airway
Stridor: Narrowing from swelling
Quiet breathing
Hyperventilation
Shock
Primary Assessment
Sputum
Has color or amount changed from normal?
Primary Assessment
Abnormal breathing patterns
May indicate neurological insults
Brain trauma or any disturbance may depress respiratory
control centers in the medulla.
Brain injuries may damage or deprive blood flow.
Primary Assessment
Primary Assessment
Most respiratory centers are in and around the brainstem.
Primary Assessment
Circulation
Assess skin color.
Note generalized
cyanosis.
Pink in healthy
patients
Logical Images/Custom Medical Stock Photo
Primary Assessment
Circulation (contd)
Cyanosis
Healthy hemoglobin levels: 12 to 14 g/dL

Cyanosis begins at about 5 g/dL desaturation
Chocolate brown skin
May occur from high levels of methemoglobin
Pale skin
Caused by a blood flow reduction to small vessels
Primary Assessment
Circulation (contd)
Check for dehydration:
Dry, cracked lips
Dry, furrowed tongue
Dry, sunken eyes
History Taking
Investigate chief complaint
Increased cough
Change in amount or color of sputum
Fever
Wheezing
Dyspnea
Chest pain
History Taking
Patient may know exact problem.
Asthma with fever

Failure of a metered-dose inhaler
Travel-related problems
Dyspnea triggers
Seasonal issues
Noncompliance with therapy
Failure of technology or running out of medicine
History Taking
SAMPLE history
Signs and symptoms
Allergies
Medications
Antihistamines
Antitussives
Bronchodilators
Diuretics
Expectorants
Pertinent past
medical history
Last oral intake
Events preceding the
onset of the
complaint
Secondary Assessment
Neurologic assessment
Note level of consciousness.
Decline in PaO2: restlessness, confusion, and combative
behavior
Increase in PaCO2: sedative effects
If lungs are not functioning correctly, oxygen may not

be delivered and carbon dioxide may not be removed.
Neck exam
Jugular venous
distention
Common with asthma or
COPD
Rough measure of
pressure in right atrium
ejwhite/ShutterStock, Inc.
Neck exam (contd)
Note trachea for deviation.
Courtesy of Stuart Mirvis, MD
Sign of tension pneumothorax
Chest and abdominal exam
Pressing on the liver when in respiratory distress and
semi-Fowlers position will cause the jugular veins to
bulge.
Hepatojugular reflex
Feel for vibrations in the chest as the patient breathes.
Examination of the
extremities
Edema
Cyanosis.
Pulse
Pulsus paradoxus
Temperature
Distal clubbing
Jones & Bartlett Learning. Photographed by Kimberly Potvin.
Mediscan/Visuals Unlimited
Vital signs
Patients under stress can be expected to have
tachycardia and hypertension.
Ominous signs:
Bradycardia
Hypotension
Falling respiratory rates
Stethoscope
Diaphragm is for high-pitched sounds.
Bell is for low-pitched sounds.
The longer the tubing, the more extraneous noise that
is heard.
Pulse oximeter
Noninvasive way to measure the percentage of
hemoglobin with oxygen attached
Oxygen saturation over 95% = normal
Pulse oximeter (contd)
Oxygen saturation should match patients palpated
heart rate.
If hemoglobin level is low, the pulse oximetry result will
be high.
Does not differentiate between oxygen or carbon
monoxide molecules
Pulse oximeter
(contd)
Oxyhemoglobin
dissociation curve
Relationship between
oxygen saturation
and amount of
oxygen dissolved in
the plasma (PaO2).
End-tidal carbon dioxide detector
Capnometry: ETCO2 monitoring
Wave capnography: ETCO2 monitoring that
measures carbon dioxide and plots a waveform
graph
End-tidal carbon
dioxide detector
(contd)
Colorimetric detector
indicates whether
carbon dioxide is
present in reasonable
amounts
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
End-tidal carbon dioxide detector (contd)
Special sensor can measure the percentage of carbon dioxide and
display a waveform
Waveform capnography
LIFEPAK defibrillator/monitor. Courtesy of Medtronic.
End-tidal carbon dioxide detector (contd)
ETCO2 of less than 10 torr: less-than-optimal CPR
compressions
Sudden increase in ETCO2: spontaneous circulation
return
Peak expiratory flow
Maximum rate at which a patient can expel air
Normal values: 350 to 700 L/min
Variable by age, sex, and height

Inadequate level: 150 L/min
Reassessment
Interventions
Oxygen (keep saturations above 93%)
IV line
Psychological support
Reassessment
Interventions (contd)
Sympathetic: speeds heart
rate
Parasympathetic: slows
heart rate
Anticholinergic medications
block the parasympathetic
response.
Reassessment
Interventions (contd)
Ipratropium is used today.
Combination of albuterol and ipratropium

Anticholinergics are a central component to manage
COPD.
Reassessment
Aerosol therapy
Nebulizers deliver fine mist of liquid
medication.
Need gas flow of at least 6 L/min to keep
particles optimal size.
Reassessment
Aerosol therapy (contd)
A nebulizer can be attached to:
A mouthpiece
Face mask
Tracheostomy collar
Can also be held in front of the patients face (blowby technique)
Reassessment
Aerosol therapy (contd)
Can disperse other drugs through aerosols:
Corticosteroids
Anesthetic agents
Antitussives
Mucolytics
Reassessment
Metered-dose
inhalers
Small, easy to
carry and use,
convenient
Ambulance
metered-dose
inhalers should
have spacers.
Reassessment
Metered dose inhalers (contd)
To avoid common errors:
Inhale deeply at discharge.

Suck medication out of the bottom.
Flow should be smooth and low-pressure.
Inhale deeply; hold breath for a few seconds.
Make sure the inhaler contains medication.
Keep the spacer and canister holder clean.
After using corticosteroid inhaler, rinse mouth.
Reassessment
Failure of a metered-dose inhaler
Must be properly used.
Contraindicated if patient cannot move enough air into the
lungs.
Patient may not realize the inhaler is empty.

Patient may inhale at the wrong time.
Reassessment
Dry powder inhalers
May be dispensed by means of a plastic disk
Patient inhales deeply to suck out the powder.

Other devices require the patient to insert a capsule of
powdered medication.
Emergency Medical Care

Goal is to:
Provide supportive care.
Administer supplemental oxygen.
Provide monitoring.
Identify and Treat primary cause
A. Ensure Adequate Airway

Remove items from mouth.
Suction if necessary.
Keep airway in optimal position.
B. Decrease the Work of

Breathing
Muscles work harder during respiratory
distress.
Use substantial energy to compensate for
respiratory distress.
Requires more oxygen and ventilation
May fatigue to point of decompensation
Decrease the Work of Breathing

To decrease the work of breathing:
Help the patient sit up.

Remove restrictive clothing.
Do not make the patient walk.
Relieve gastric distention.
Do not bind the chest or have the patient lie on the
unaffected lung.
C. Provide Supplemental Oxygen

Administer in effective concentrations.
Reassess, then adjust as needed.
Pulse oximetry is a good guide to oxygenation.
Concentrations higher than 50% should be used
only with hypoxia that does not respond to lower
concentrations.
D. Administer a Bronchodilator
Many can benefit from bronchodilation.
Those without bronchospasms will benefit only slightly.
Bronchodilators are ineffective in cases of:
Pneumonia
Pulmonary edema
Heart disease
Administer a Bronchodilator
Fast-acting bronchodilators
Most stimulate beta-2 receptors in lung
Provide almost instant relief
Albuterol is the most common beta-2 agonist.
Slow-acting bronchodilators
Do not provide immediate symptom relief
Daily dose reduces frequency/severity of attacks
Common medications include:
Salmeterol
Cromolyn
Methylxanthines
Declining use because of adverse effects
Overdose can cause cardiac dysrhythmias and
hypotension.
Carefully monitor level in bloodstream.
Electrolytes
Magnesium may have a role in bronchodilation.
Some physicians use them as a last-ditch effort
before intubation.
Corticosteroids
Reduce bronchial swelling
Adverse effects:
Cushing syndrome
Rapid change in blood glucose levels
Blunts the immune system
Avoid long-term use.
Inhaled corticosteroids
Less adverse effects; becoming standard
Intravenous corticosteroids
Methylprednisolone and hydrocortisone: used for acute
asthma attacks or COPD
E. Administer a Vasodilator
Sequester more fluid in venous circulation
and decrease preload
Nitrates can be used if patient:
Has adequate blood pressure
Does not take a phosphodiesterase inhibitor.
Morphine sulfate is not likely to increase venous
capacity.
F. Restore Fluid Balance

Common to give fluid bolus to dehydrated,
younger patients.
Elderly patients or patients with cardiac dysfunction
could wind up with pulmonary edema.
Assess breath sounds before and after.
G. Administer a Diuretic
Helps reduce blood pressure and maintain fluid
balance in patients with heart failure
Helps remove excess fluid from circulation,
keeping it out of the lungs of patients with
pulmonary edema.
Administer a Diuretic
Many diuretics cause potassium loss.
May lead to cardiac dysrhythmias and chronic muscle
cramping
Do not give diuretics to patients with pneumonia

or dehydration.
H. Support or Assist Ventilation

Breathing may need more aggressive support if
the patient becomes fatigued.
CPAP and BiPAP may preclude intubation.
May simply require bag-mask ventilation
Support or Assist Ventilation

Continuous positive airway pressure
Used to treat:
Obstructive sleep apnea

Respiratory failure
Patients with obstructive sleep apnea wear a CPAP unit
to maintain airway while they sleep.

CPAP (contd)
CPAP therapy may be
delivered through a
mask.
Air is forced into the
upper airway.
Positive pressure is
created in the chest.

CPAP (contd)
Pressure that is too
high may cause:
Tension
pneumothorax
Subcutaneous air
Block venous
returns
New guidelines
emphasize:
Lower ventilation
rates
Smaller volumes
Lower pressures

CPAP (contd)
Ensure a seal.
If a patient is
unwilling to use it, do
not fight it.
Success is related to
respiratory rate after
application
Courtesy of Respironics, Inc., Murrysville, PA. All rights reserved.

Bi-level positive airway pressure (BiPAP)
One pressure on inspiration and a different pressure during
exhalation
More like normal breathing
More complex and expensive

Automated transport
ventilators
Flow restricted oxygenpowered ventilation
Deliver a particular oxygen
volume at a set rate.
Good for patients in cardiac or
respiratory arrest
Not intended to be used without
direct observation
Courtesy of Airon Corporation (www.AironUSA.com)
I. Intubate the Patient

Last option for patients with severe asthma
Ventilate patients before cardiac arrest.
Patients who are severely intoxicated or have had a stroke
may have no gag reflex.
Intubate the Patient

With diabetes or overdose, an ampule of 50% dextrose or
naloxone may change the need for intubation
Use bag-mask ventilation for a few minutes to monitor effects.
J. Inject a Beta-Adrenergic Receptor

Agonist Subcutaneously
Use if inhalation techniques are ineffective.

May cause more tachycardia and hypertension
Be careful using in elderly patients.
Instill Medication Directly Through

an Endotracheal Tube
Option if prompt vascular access is delayed
Epinephrine dose is 2 to 2.5 times the usual
Newer devices mist drug into ET tube
Can be used without interrupting CPR
Anatomic Obstruction
Pathophysiology
The tongue is the most common cause of
airway obstruction if patient is
semiconscious or unconscious.
Assessment:
Risks include:
Decreased level of consciousness

Audible signs include:
Sonorous respirations
Gurgling
Squeaking and bubbling
Management
Obstructive sleep apnea may be caused by
excess soft tissue in airway
Can be manually displaced
Place patient in the recovery position
Inflammation Caused by
Infection
Pathophysiology
Infections can cause upper airway swelling.
Can lead to laryngotracheobronchitis
Common cause of croup
Stridor
Hoarseness
Barking cough
Infection(contd)
Pathophysiology
Poiseuilles law: as the diameter of a tube decreases, resistance to
flow increases.
Infection
Assessment
Croup and tonsillitis are common, but other conditions
are rare.
Avoid manipulating the airway.
Infection
Infection
Management
Airway may be entirely obscured.
Laryngoscopy may worsen swelling

Have partner press on the chest while you check for a
bubble stream.
If effort fails, cricothyrotomy may be necessary.
Aspiration
Inhalation of anything other than breathable
gases
Patients at risk:
Tube-fed patients placed supine after large meal
Geriatric patients with impaired swallowing
Unresponsive patients
Aspiration
Pathophysiology
Aspiration of stomach contents: high mortality
Aspiration of foreign bodies may occur.
Chronic aspiration of food is a common cause of
pneumonia in older patients.
Aspiration
Assessment
Determine scenario of sudden onset dyspnea
Immediately after eating?
Gastric feeding tube?
Aspiration
Management
Avoid gastric distention when ventilating.
Use nasogastric tube to decompress stomach.
Monitor ability to protect airway; use advanced
airway when needed.
Treat with suction and airway control.
Obstructive Lower Airway

Diseases
Diseases that cause airflow obstruction to the
lungs:
Emphysema and chronic bronchitis (COPD)
Asthma
Obstructive Lower Airway

Diseases
Physical findings:
Pursed lip breathing

Increased I/E ratio
Abdominal muscle use
Jugular venous distension
Asthma
Pathophysiolog
y
Increased
tracheal and
bronchial
reactivity
Causes
widespread,
reversible
airway
narrowing
Scott Rothstein/ShutterStock, Inc.
Asthma
Pathophysiology (contd)
Patients with potentially
fatal asthma often have
severely compromised
ventilation all the time.
Acute bronchospasm or
infection presents risk
Death rates are increasing
some countries
Asthma
Status asthmaticus: severe, prolonged attack that does
not stop with conventional treatment
Struggling to move air through obstructed airways
Prominent use of accessory muscles
Hyperinflated chest
Inaudible breath sounds
Exhausted, severely acidotic, and dehydrated
Asthma
Assessment
Known as reactive airway disease because
bronchospasms are caused by triggers
Also caused by:
Airway edema
Inflammation
Increased mucus production
Asthma
Assessment (contd)
Bronchospasm
Constricting muscle surrounding bronchi
Wheezing: air forced through constricted airways
Primary treatment: nebulized bronchodilator
medication
Asthma
Asthma
Assessment (contd)
Bronchial edema
Swelling of the bronchi and bronchioles

Bronchodilator medications do not work.
Increased mucus production
Thick secretions contribute to air trapping.
Dehydration makes secretions thicker.
Asthma
Management
Bronchospasm: aerosol bronchodilators
Bronchial edema: corticosteroids
Excessive mucus secretion: improve hydration,
mucolytics
Asthma
Management (contd)
Transport considerations
Infection or continuous exposure to a trigger:
consider removing patient.
No improvement in peak flow: consider
corticosteroids.
Asthma
Management (contd)
Transport considerations
Undernourished or dehydrated: consider IV fluids.
Advanced life support more than a few minutes
away: consider transport to nearest ED.
Chronic Obstructive Pulmonary

Disease
Pathophysiology
Emphysema damages or destroys terminal
bronchiole structures.
Chronic bronchitis: sputum production most
days of the month for 3 or more months of the
year for more than 2 years

Disease
Assessment
Emphysema
Barrel chest from chronic lung hyperinflation
Tachypneic
Use muscle mass for energy to breathe

Disease
Assessment (contd)
Causes of diffuse wheezing:
Left-sided heart failure (cardiac asthma)

Smoke inhalation
Chronic bronchitis
Acute pulmonary embolism
Cause of localized wheezing: obstruction from foreign
body or tumor

Disease
COPD with pneumonia
Often have lung infection
Check for:
Fever
Change in sputum
Other infection signs
Breath sounds consistent with pneumonia

Disease
COPD with right-sided heart failure
Look for:
Peripheral edema
Jugular venous distention with hepatojugular reflux
End inspiratory crackles
Progressive increase in dyspnea
Greater-than-usual fluid intake
Improper use of diuretics

Disease
COPD with left-sided heart failure
Can be caused by any abrupt left ventricular
dysfunction

Disease
Acute exacerbation of COPD
Sudden decompensation with no copathologic
conditions
Often from environmental change or inhalation of
trigger substances

Disease
End-stage chronic COPD
Lungs no longer support oxygenation, ventilation

Difficult to tell whether situation can be resolved
Secure documentation of patients wishes.
Follow local protocol or contact medical control.

Disease
COPD and trauma
Lessens ability to tolerate trauma
Monitor closely.
Oxygen saturation might be less than 90%.
Achieving a saturation of 98% is unrealistic.

Disease
Management
Can help improve immediate distress
Determine what caused the situation to worsen enough
for the patient to call for help.
Must understand:
Hypoxic drive
Positive end-expiratory pressure (auto-PEEP)

Disease
Hypoxic drive
When breathing stimulus comes from decrease
in PaO2 rather than increase in PaCO2
Affects only a small percentage during endstage of disease process
Must decide whether to administer oxygen

Disease
Hypoxic drive (contd)
Impossible to tell which patients breathe
because of hypoxic drive.
Encourage breathing.
Skin appearance may remain perfused if
patient becomes apneic.

Disease
Hypoxic drive (contd)
Provide artificial ventilation and consider intubation if
patient become apneic.
Intubation may mean the patient remains on the
ventilator until the end of life.
Oxygen saturation values are less useful in patients
with COPD.

Disease
Auto-PEEP
Allow complete exhalation before the next breath
during ventilation.
Otherwise, pressure in the thorax will continue to rise (autoPEEP).
If possibility, patients should be ventilated 4 to 6

breaths/min.
Pulmonary Infections
Pathophysiology
Infections from:
Bacteria
Viruses
Fungi
Protozoa
Infectious diseases
cause:
Swelling of the
respiratory tissues
Increase in mucus
production
Production of pus
Resistance to airflow increases when the airway diameter is
narrowed (Poiseuilles law).
Alveoli can become nonfunctional if filled with pus.
At greater risk of pneumonia:
Older people
People with chronic illnesses
People who smoke
Anyone who does not ventilate efficiently
Those with excessive secretions
Those who are immunocompromised
Assessment
Patients usually report:
Several hours to days of weakness

Productive cough
Fever
Chest pains worsened by cough
Assessment (contd)
May start abruptly or gradually
During physical examination, patient:
May look grievously ill

May or may not be coughing
May present with crackles
May have increased tactile fremitus and sputum production
Assessment (contd)
Pneumonia often occurs in the lung bases.
Patients are often dehydrated.
Supportive care includes:
Oxygenation
Secretion management (suctioning)
Transport to the closest facility
Management
Upper airway infections: aggressive airway
management
Lower airway infections: supportive care,
transport
Atelectasis
Pathophysiology
Disorders of alveoli
Collapse from proximal
airway obstruction or
external pressure
Fill with pus, blood, or
fluid
Smoke or toxin damage
Atelectasis
Common for some alveoli to collapse
Sighing, coughing, sneezing, and changing positions help open
closed alveoli.
When alveoli do not reopen, entire lung segments

eventually collapse.
Increases chance of pneumonia
Atelectasis
Assessment
The affected area can harbor pathogens that
result in pneumonia.
Check if a patient with fever has had recent chest or
abdominal surgery.
Atelectasis
Management
Postsurgical patients
encouraged to:
Get out of bed.
Cough.
Breathe deeply.
Use the incentive
spirometer.
T. Bannor/Custom Medical Stock Photo
Cancer
Pathophysiology
Lung cancer is one of most
common forms of cancer.
Cigarette smoking
Exposure to occupational
lung hazards
Metastatic from other sites
Cancer
Assessment
First presentation is often hemoptysis.
Frequently accompanied by COPD and impaired lung
function
Often metastasizes in the lung from other body sites
Cancer
Assessment (contd)
Other cancers may invade lymph nodes in neck.
Pulmonary complications from radiation and
chemotherapy
Treatments may cause pleural effusion.
Cancer
Management
Little prehospital treatment for pleural
effusions or hemoptysis
Sometimes called for end-of-life issues
Toxic Inhalations
Pathophysiology
Damage depends on
water solubility of toxic
gas.
Toxic Inhalations
Assessment
Highly water-soluble gases react with moist mucous
membranes.
Causes upper airway swelling and irritation
Less water-soluble gases get deep in lower airway.
More damage over time
Toxic Inhalations
Assessment (contd)
Moderately water-soluble gases have signs and
symptoms between.
Mixing drain cleaner and chlorine bleach may
produce an irritant chlorine gas.
Industrial settings often use irritant gas-forming
chemicals in higher quantities and concentrations.
Toxic Inhalations
Management
Immediate removal from contact with gas
Provide 100% oxygen or assisted ventilation.
If exposure is to slightly water-soluble gases, patients
may have acute dyspnea hours later.
Consider transport to closest ED for observation.
Pulmonary Edema
Pathophysiology
Fluid buildup in lungs occurring when blood
plasma fluid enters lung parenchyma
Classifications:
High pressure (cardiogenic)
High permeability (noncardiogenic)
Pulmonary Edema
Assessment
By time crackles can be heard, fluid has:
Leaked out of capillaries
Increased diffusion space between capillaries and
alveoli
Swollen alveolar walls
Begun to seep into alveoli
Pulmonary Edema
Assessment (contd)
Listen to lower lobes through the back.
Crackles heard higher in the lungs as condition
worsens
In severe cases, watery sputum, often with a
pink tinged, will be coughed up.
Acute Respiratory Distress

Syndrome
Pathophysiology
Caused by diffuse damage to alveoli from:
Shock
Aspiration of gastric contents
Pulmonary edema
Hypoxic event
Acute Respiratory Distress

Syndrome
Assessment
Document oxygen saturation, breath sounds,
and any sudden changes.
Monitor ventilation pressures.
Pneumothorax
Pathophysiology
Air collects
between visceral
and parietal
pleura.
Weak spots (blebs)
can predispose a
person.
Pneumothorax
Assessment
Patients may have:
Sharp pain after coughing
Increasing dyspnea in subsequent minutes or hours
Pneumothorax
Management
Most will not require acute intervention.
Except when there is tension penumothorax
They should receive oxygen and close
monitoring of their respiratory status.
Pleural Effusion
Pathophysiology
Blister-like sac of
fluid formed when
fluid collects
between visceral
and parietal pleura
Pleural Effusion
Assessment
Hard to hear breath sounds
Position will affect ability to breathe.
Management
Fowlers position likely most comfortable
Supportive care during transport to hospital
Pulmonary Embolism
Pathophysiology
Pulmonary circulation compromised by:
Blood clot
Fat embolism from broken bone
Amniotic fluid embolism during pregnancy
Air embolism from neck laceration or faulty IV
Pulmonary Embolism
Large embolism usually lodges in major
pulmonary artery
Prevents blood flow
Venous blood cannot reach alveoli.
Pulmonary Embolism
Assessment
Early presentation: normal breath sounds, good
peripheral aeration
Classic presentation: sudden dyspnea and
cyanosis, sharp pain in chest
Cyanosis does not end with oxygen therapy.
Pulmonary Embolism
Assessment (contd)
Often begin in large leg
veins, then migrate
into pulmonary
circulation
Thrombophlebitis: high
risk
Pulmonary Embolism
Management
Bedridden patients are often given:
Anticoagulants
Special stockings/other devices to reduce blood clot
formation
Greenfield filter: opens to catch clots traveling

from the legs in the main vein
Pulmonary Embolism
Management (contd)
Saddle embolus: exceptionally large embolus
lodging at left/right pulmonary artery
bifurcation
May be immediately fatal
Cape cyanosis despite CPR and ventilation
Age-Related Variations
Most common respiratory ailments occur in
second half of patients life.
Asthma often occurs in younger patients but can flare
at any time.
Anatomy
Important anatomic differences in children
include:
Larger heads relative to body size
Pathophysiology
Infants often expend huge amounts of energy to breath
and have a limited ability to compensate.
Infants and children with respiratory problems may
have:
Respiratory distress
Respiratory failure leading to decompensation
Respiratory arrest
Common pediatric respiratory diseases:
Foreign body obstruction of the upper airway
Infections, such as:
Croup
Laryngotracheobronchitis
Epiglottitis
Bacterial tracheitis
Retropharyngeal abscesses
Common pediatric respiratory diseases
(contd):
Lower airway disease
Asthma
Bronchiolitis
Pneumonia
Pertussis (whooping cough)
Cystic fibrosis
Bronchopulmonary dysplasia
Common Emergency Surgical

Interventions
Endotracheal entubation
Cricothyroicotomy
Closed tube thoracotomy
Summary
Respiratory disease is one of the most common pathologic
conditions and reasons for emergency calls
Impaired ventilation may be caused by upper airway
obstruction, lower airway obstructive disease, chest well
impairment, or neuromuscular impairment.
Summary
Respiratory failure occurs from many pathologic
conditions. Care includes supplemental oxygen.
Hyperventilation syndrome is excessive ventilation;
patient may have chest pain, carpopedal spasm, and
alkalosis.
Nasal hairs filter particulates from the air as it flows and
is warmed in the nose, humidified, and filtered.
Summary
The mouth and oropharynxs vascular structures are
covered with a mucous membrane. The hypopharynx is
the junction of the oropharynx and nasopharynx.
The larynx and glottis are the dividing line between upper
and lower airways, with the thyroid cartilage the most
obvious external larynx landmark. The glottis and vocal
cords are in the middle of the thyroid cartilage.
Summary
The circoid cartilage forms a complete ring and maintains
the trachea in an open position.
The cricothyroid is between the thyroid and circoid
cartilages. It is a preferred area for inserting large IV
catheters or small breathing tubes.
The respiratory system primary components look like an
inverted tree.
Summary
The trachea splits into the left and right mainstem bronchi
at the carina.
Cilia line the larger airways and help move foreign
material out of the tracheobronchial tree.
Pulmonary circulation begins at the right ventricle.
Summary
The interstitial space can fill with blood, pus, or air, which
causes pain, stiff lungs, and lung collapse.
Ventilation, perfusion, and diffusion are the primary
functions of the respiratory system.
Mechanisms of respiratory control are neurologic,
cardiovascular, muscular, and renal.
Summary
Patients with traumatic brain injuries may exhibit
abnormal respiratory patterns.
Respiratory compromise can cause an altered level of
consciousness because it cannot store the oxygen it needs
to function.
Respiratory disease can cause ventilation, diffusion, and
perfusion impairment, or a combination of all three.
Summary
Some respiratory diseases have classic presentations.
It is critical to evaluate how hard a patient is working to
breathe.
A patients position of comfort and speaking difficulty
level helps determine degree of distress.
Patients in respiratory distress often use the tripod
position.
Summary
Signs of life-threatening respiratory distress:
Bony retractions
Soft tissue retractions
Nasal flaring
Tracheal tugging
Paradoxical respiratory movement
Pursed-lip breathing
Grunting
Summary
Audible abnormal respiratory noises indicate obstructed
breathing.
Snoring indicates partial obstruction of the upper airway
by the tongue; stridor indicates narrowing of the upper
airway.
Auscultate the lungs to hear adventitious breath sounds,
including wheezing and crackles.
Summary
Crackles: discontinuous noises heard during auscultation.
Wheezes: high-pitched, whistling sounds from air forced
through narrowed airways
If you cant hear breath sounds with a stethoscope, there
is not enough breath to ventilate the lungs.
Summary
The respiratory system delivers oxygen and removes
carbon dioxide. If the lungs do not work, it can lead to
hypoxia, cell death, and acidosis.
Patients with dyspnea are usually transported to the
nearest facility.
Patients with chronic respiratory disease may have
already tried treatment options.
Summary
Determine if the problem started suddenly or gradually
worsened as indicators to the underlying cause.
If the condition is recurrent, compare the current incident
with other episodes.
If patient cannot speak because of breathing issues,
obtain the history from family members or available clues.
Summary
Assess the mucous membranes for cyanosis, pallor, and
moisture.
Assess the level of consciousness in dyspneic patients.
With the patient in a semisitting position, check for
jugular venous distension, which may be caused by
cardiac failure.
Summary
Feel the chest for vibrations during breathing, and check
for edema of the ankles and lower back, peripheral
cyanosis, and pulse. Check skin temperature and apply
monitors.
A pulse oximeter indicates the percentage of hemoglobin
with attached oxygen; greater than 95% is considered
normal.
Summary
Colorimetric end-tidal carbon dioxide devices or wave
capnography can monitor exhaled carbon dioxide.
Peak flow is the maximum flow rate a patient can expel air
from the lungs.
Metered-dose inhalers deliver bronchodilators and
corticosteroids as an aerosol treatment; dry powder
inhalers use a fine powder to deliver a measured-dose
treatment.
Summary
Aerosol nebulizers deliver a liquid medication in a fine mist.
Emergency care for dyspnea may include:
Decreasing work of breathing

Supplemental oxygen
Bronchodilators
Inhaled corticosteroids, vasodilators, or diuretics
Supporting or assisting ventilation
Intubation
Summary
Ensure an open and maintainable airway. Suction if
needed, and keep the airway optimally positioned. Remove
constrictive clothing.
Inhalation drug administration may be ineffective if airway
is compromised.
Medications can be given directly into the
tracheobronchial tree if patient is intubated.
Summary
CPAP is a respiratory failure therapy that increases
oxygen saturation and decreases respiratory rate.
BiPAP is CPAP that delivers one pressure during
inspiration and a different one during exhalation.
Automated transport ventilators are flow-restricted
oxygen-powered breathing devices with timers.
Summary
Patients in respiratory failure may need to be intubated.
Anatomic or foreign body obstruction of the upper airway
can cause seizures and death.
Infections can cause upper airway swelling. Croup is one
of the most common causes.
Summary
Emphysema, chronic bronchitis, and asthma are common
obstructive airway diseases, with emphysema and chronic
bronchitis collectively classified as COPD.
Asthma is characterized by significant airway obstruction
from:
Widespread, reversible airway narrowing
Airway edema
Increased mucous production
Summary
Primary treatment for bronchospasms is bronchodilatory
medicine, while corticosteroids are the primary treatment
for bronchial edema.
Status asthmaticus is a severe, prolonged asthmatic
attack that cannot be stopped with conventional
treatment. It is a dire emergency.
Summary
If an asthma attack is recurring, the inhaler may be empty
or the medication ineffective.
Asthma attacks can be triggered by noncompliance with a
prescribed medication regimen.
Emphysema is a chronic weakening and destruction of the
terminal bronchioles and alveoli walls.
Summary
Chronic bronchitis symptoms include:
Excessive mucous production in bronchial tree

Chronic or recurrent productive cough
For patients with COPD, look for cause of a worsened
condition.
Summary
Hypoxic drive: High oxygen levels decrease the
respiratory drive.
When ventilating, allow the patient to exhale completely
before the next breath is given to avoid auto-PEEP.
Pneumonia may be caused by bacterial, viral, and fungal
agents.
Summary
Atelectasis is alveolar collapse from:
Proximal airway obstruction

Pneumothorax
Hemothorax
Toxic inhalation
Lung cancer often presents with hemoptysis and is
increasing among women.
Toxic gas inhalation damage depends on the water

solubility of the gas.
Summary
Pulmonary edema occurs when fluid migrates into the
lungs.
Acute respiratory distress syndrome is caused by diffuse
alveolar damage from aspiration, pulmonary edema, or
other alveolar insult.
In a pneumothorax, air collects between the visceral and
parietal pleuras. Administer supplemental oxygen and
monitor.
Summary
Pleural effusion will cause dyspnea. Give aggressive
oxygen administration and proper positioning.
A pulmonary embolism occurs when a blood clot travels to
the lungs and blocks blood flow and nutrient exchange.
Summary
Infants are less able than older children to compensate for
respiratory insults.
Infants and children may be in:
Respiratory distress
Respiratory failure
Respiratory arrest

22nd August 2016 - Surg Lec 02 - Respiratory Emergencies

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22nd August 2016 - Surg Lec 02 - Respiratory Emergencies

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Respiratory

Anatomy and Physiology

Structures of the Upper Airway

Nostrils and nose

Structures of the Upper Airway

Structures of the Upper Airway

Structures of the Upper Airway

E. M. Singletary, M.D. Used with permission.

Structures of the Upper Airway

Structures of the Upper Airway

Structures of the Upper Airway

Structures of the Upper Airway

Structures of the Upper Airway

Structures of the Lower Airway

Structures of the Lower Airway

Structures of the Lower Airway

Bronchi and bronchioles are lined with cilia.

Inset photo: Dr. Kessel &

Structures of the Lower Airway

Significant amount of gas exchange

Structures of the Lower Airway

Structures of the Lower Airway

Made up of two types of cells:

Structures of the Lower Airway

Structures of the Lower Airway

Pulmonary circulation starts at the right ventricle.

Structures of the Lower Airway

Structures of the Lower Airway

Network of gaps between alveoli and capillaries

Structures of the Lower Airway

Pleural membranes allow organs to move smoothly.

Structures of the Lower Airway

Structures of the Lower Airway

Functions of the Respiratory

Functions of the Respiratory

Functions of the Respiratory

Functions of the Respiratory

Functions of the Respiratory

Assessment of a Patient with

Decreased oxygen concentrations

Problems with the airway branches

Snoring: Partial obstruction of the upper airway by the tongue

Has color or amount changed from normal?

Brain injuries may damage or deprive blood flow.

Most respiratory centers are in and around the brainstem.

Logical Images/Custom Medical Stock Photo

Healthy hemoglobin levels: 12 to 14 g/dL

Asthma with fever

Increase in PaCO2: sedative effects

If lungs are not functioning correctly, oxygen may not

Note trachea for deviation.

Courtesy of Stuart Mirvis, MD

Sign of tension pneumothorax

Jones & Bartlett Learning. Photographed by Kimberly Potvin.

Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP

LIFEPAK defibrillator/monitor. Courtesy of Medtronic.

Variable by age, sex, and height

Combination of albuterol and ipratropium

Inhale deeply at discharge.

Patient may not realize the inhaler is empty.

Patient inhales deeply to suck out the powder.

Emergency Medical Care

A. Ensure Adequate Airway

B. Decrease the Work of