Pulmonary

Pulmonary Diseases
Diseases
Pulmonary
Pulmonary Diseases
Diseases &
& Disorders
Disorders
Pulmonary Disease & Conditions may result
from:
Infectious causes
Non-Infectious causes
Adversely affect one or more of the following
Ventilation
Diffusion
Perfusion
Pulmonary
Pulmonary Diseases
Diseases &
& Disorders
Disorders
The Respiratory Emergency may stem from
dysfunction or disease of (examples only):
Control System
Hyperventilation
Central Respiratory Depression
CVA
Thoracic Bellows
Chest/Diaphragm Trauma
Pickwickian Syndrome
Guillian-Barre Syndrome
Myasthenia Gravis
COPD
Pulmonary
Pulmonary Diseases
Diseases &
& Disorders
Disorders
The Respiratory Emergency may affect the
upper or lower airways

Upper Airway Obstruction

Tongue
Foreign Body Aspiration
Angioneurotic Edema
Maxillofacial, Larnygotracheal Trauma
Croup
Epiglottitis
Respiratory
Respiratory Emergencies:
Emergencies: Causes
Causes

Lower Airway Obstruction

Emphysema
Chronic Bronchitis
Asthma
Cystic Fibrosis
Pulmonary
Pulmonary Diseases
Diseases &
& Disorders
Disorders
The Respiratory Emergency may stem from
Gas Exchange Surface Abnormalities
Cardiogenic Pulmonary Edema
Non-cardiogenic Pulmonary Edema
Pneumonia
Toxic Gas Inhalation
Pulmonary Embolism
Drowning
Pulmonary
Pulmonary Diseases
Diseases &
& Disorders
Disorders

Problems with the Gas

Exchange Surface
Pulmonary
Pulmonary Edema
Edema
Pulmonary
Pulmonary Edema:
Edema: Pathophysiology
Pathophysiology
A pathophysiologic condition, not a
disease
Fluid in and around alveoli
Interferes with gas exchange
Increases work of breathing
Two Types
Cardiogenic (high pressure)
Non-Cardiogenic (high permeability)
Pulmonary
Pulmonary Edema
Edema
High Pressure (cardiogenic)
AMI
Chronic HTN
Myocarditis
High Permeability (non-cardiogenic)
Poor perfusion, Shock, Hypoxemia
High Altitude, Drowning
Inhalation of pulmonary irritants
Cardiogenic
Cardiogenic Pulmonary
Pulmonary Edema:
Edema:
Etiology
Etiology
Left ventricular failure
Valvular heart disease
Stenosis
Insufficiency
Hypertensive crisis (high afterload)
Volume overload

Increased Pressure in Pulmonary Vascular

Bed
Pulmonary
Pulmonary Edema
Edema
High Permeability
Disrupted alveolar-capillary membrane
Membrane allows fluid to leak into the interstitial
space
Widened interstitial space impairs diffusion
Non-Cardiogenic
Non-Cardiogenic Pulmonary
Pulmonary Edema:
Edema:
Etiology
Etiology
Toxic inhalation
Near drowning
Liver disease
Nutritional deficiencies
Lymphomas
High altitude pulmonary edema
Adult respiratory distress syndrome
Increased Permeability of Alveolar-Capillary
Walls
Pulmonary
Pulmonary Edema:
Edema: Signs
Signs &Symptoms
&Symptoms
Dyspnea on exertion
Paroxysmal nocturnal dyspnea
Orthopnea
Noisy, labored breathing
Restlessness, anxiety
Productive cough (frothy sputum)
Rales, wheezing
Tachypnea
Tachycardia
Management
Management of
of Non-Cardiogenic
Non-Cardiogenic
Pulmonary
Pulmonary Edema
Edema
Position
Oxygen
PPV / Intubation
CPAP
PEEP
IV Access; Minimal fluid administration
Treat the underlying cause
Diuretics usually not helpful; May be harmful
Transport
Adult
Adult Respiratory
Respiratory Distress
Distress Syndrome
Syndrome
AKA: Non-cardiogenic pulmonary edema
A complication of:
Severe Trauma / Shock
Severe infection / Sepsis
Bypass Surgery
Multiple blood transfusions
Drug overdose
Aspiration
Decreased compliance
Hypoxemia
Pneumonia
Pneumonia
Pneumonia
Pneumonia
Fifth leading cause of death in US/Canada
Group of Specific infections
Risk factors
Cigarette smoking
Exposure to cold
Extremes of age
young
old
Pneumonia
Pneumonia
Inflammation of the bronchioles and alveoli
Products of inflammation (secretions, pus) add to
respiration difficulty
Gas exchange is impaired
Work of breathing increases
May lead to
Atelectasis
Sepsis
VQ Mismatch
Hypoxemia
Pneumonia:
Pneumonia: Etiology
Etiology
Viral
Bacterial
Fungi
Protozoa (pneumocystis)
Aspiration
Presentation
Presentation of
of Pneumonia
Pneumonia
Shortness of breath, Dyspnea
Fever, chills
Pleuritic Chest Pain, Tachycardia
Cough
Green/brown sputum
May have crackles, rhonchi or wheezing in
peripheral lung fields
Consolidation
Egophony
Management
Management of
of Pneumonia
Pneumonia
Treatment mostly based upon symptoms
Oxygen
Rarely is intubation required
IV Access & Rehydration
B2 agonists may be useful
Antibiotics (e.g. Rocephin)
Antipyretics
Pneumonia:
Pneumonia: Management
Management
MD follow-up for labs, cultures & Rx
Transport considerations
Elderly have significant co-morbidity
Young have difficulty with oral medications
ED vs PMD office/clinic
Transport in position of comfort

Would an anticholinergic like

Atrovent be useful in managing
pneumonia?
Pulmonary
Pulmonary Embolism
Embolism
Pulmonary
Pulmonary Embolism
Embolism

~ 50,000 deaths / year/ US

~5% of all sudden deaths
<10% of all PE result in death
Pulmonary
Pulmonary Embolism:
Embolism:
Pathophysiology
Pathophysiology
Something moving with flow of blood passes
through right heart into pulmonary circulation
It reaches an area too narrow to pass through
and lodges there
Part of pulmonary circulation is blocked
Blood:
Does not pass alveoli
Does not exchange gases
Pulmonary
Pulmonary Embolism
Embolism (PE)
(PE)
A disorder of perfusion
Combination of factors increase probability of
occurrence
Hypercoagulability
Platelet aggregation
Deep vein stasis
Embolus usually originates in lower
extremities or pelvis
Pulmonary
Pulmonary Embolism
Embolism (PE)
(PE)
Risk factors
Venostasis or DVT
Recent surgery or trauma
Long bone fractures (lower)
Oral contraceptives
Pregnancy
Smoking
Cancer
Pulmonary
Pulmonary Embolism:
Embolism: Etiology
Etiology

Most Common Cause = Blood

Clots

Vessel Wall Injury

Virchow
sTriad

Hypercoagulability Venous Stasis

Pulmonary
Pulmonary Embolism:
Embolism: Etiology
Etiology

Other causes
Air
Amniotic fluid
Fat particles (long bone fracture)
Particulates from substance abuse
Venous catheter
Pulmonary
Pulmonary Embolism:
Embolism: Signs
Signs &
& Symptoms
Symptoms

Small Emboli
Rapid Onset
Dyspnea
Tachycardia
Tachypnea
Fever
Episodic = Showers
Evidence or history of thrombophlebitis
Consider early when no other cardiorespiratory
diagnosis fits
Pulmonary
Pulmonary Embolism:
Embolism: Signs
Signs &
& Symptoms
Symptoms

Larger Emboli
Small Emboli S/S plus:
Pleuritic pain
Pleural rub
Coughing
Wheezing
Hemoptysis (rare)
Pulmonary
Pulmonary Embolism:
Embolism: Signs
Signs &
& Symptoms
Symptoms

Very Large Emboli

Preceded by S/S of Small & Larger Emboli plus:
Central chest pain
Distended neck veins
Acute right heart failure
Shock
Cardiac arrest
Pulmonary
Pulmonary Embolism:
Embolism: Signs
Signs &
& Symptoms
Symptoms

There are NO
assessment findings
specific to pulmonary
embolism
Pulmonary
Pulmonary Embolism:
Embolism: Management
Management

Management based on severity of Sx/Sx

Airway & Breathing
High concentration O2
Consider assisting ventilations
Early Intubation
Circulation
IV, 2 lg bore sites
Fluid bolus then TKO; Titrate to BP ~ 90 mm Hg
Monitor ECG
Rapid transport
PE
PE Management
Management
Thrombolytics
Aspirin & Heparin (questionable if any benefit)
Rapid transport to appropriate facility
Embolectomy or thrombolytics at hospital (rarely
effective in severe cases due to time delay)
Poor prognosis when cardiac arrest follows
Pulmonary
Pulmonary Embolism
Embolism

If the patient is alive when you get

to them, that embolus isnt going to
kill them.

But the next one they throw

might!
Pleurisy
Pleurisy
Inflammation of pleura caused by a friction
rub
layers of pleura rubbing together
Commonly associated with other respiratory
disease
Presentation
Presentation of
of Pleurisy
Pleurisy
Sharp, sudden and intermittent chest pain
with related dyspnea
Possibly referred to shoulder
May or with respiration
Pleural friction rub may be audible
May have effusion or be dry
Pleurisy
Pleurisy

Management
Based upon severity of presentation
Mostly supportive
Pulmonary
Pulmonary Diseases
Diseases &
& Disorders
Disorders

Problems with Airway

Obstructions
Obstructive Airway Diseases
Obstructive
Obstructive Airway
Airway Disease
Disease
Asthma
Emphysema
Chronic Bronchitis
Obstructive
Obstructive Airway
Airway Diseases
Diseases
Asthma experienced by ~ 4 - 5 % of
Canadian population
Mortality rate increasing
Factors leading to Obstructive Airway
Diseases
Smoking
Exposure to environmental agents
Genetic predisposition
How does this differ from COPD?
Obstructive
Obstructive Airway
Airway Disease
Disease
Exacerbation Factors
Intrinsic
Stress (especially in adults)
URI
Exercise
Extrinsic
Cigarette Smoke
Allergens
Drugs
Occupational hazards
Obstructive
Obstructive Airway
Airway Disease
Disease
General Pathophysiology
Specific pathophysiology varies by disease
Obstruction in bronchioles
Smooth muscle spasm (beta)
Mucous accumulation
Inflammation
Obstruction may be reversible or irreversible
Obstructive
Obstructive Airway
Airway Disease
Disease
General Pathophysiology
Obstruction results in air trapping
Bronchioles usually dilate on inspiration
Dilation allows air to enter even in presence of
obstruction
Bronchioles tend to constrict on expiration
Air becomes trapped distal to obstruction
Lower Airway Disease
Chronic Obstructive Pulmonary
Disease

Emphysema
Chronic Bronchitis
(Rarely Asthma may result in COPD)
COPD:
COPD: Epidemiology
Epidemiology

Most common chronic lung disease

4th leading cause of death
many deaths annually
Emphysema

Type A COPD
Emphysema:
Emphysema: Definition
Definition

Destruction of alveolar
walls
Distention of pulmonary
air spaces
Loss of elastic recoil
Destruction of gas
exchange surface
Emphysema:
Emphysema: Incidence
Incidence

Male > females

Urban area > rural areas
Age usually > 55
Emphysema:Etiology
Emphysema:Etiology
Smoking
90% of all cases
Smokers 10x more likely to die of COPD than
non-smokers
Environmental factors
Alpha 1 antitrypsin deficiency
hereditary
50,000 to 100,000 cases
mostly people of northern European descent
Emphysema:
Emphysema: Pathophysiology
Pathophysiology
Decreased surface area leads to decreased
gas exchange with blood
Loss of pulmonary capillaries & hypercapnia
lead to
increased resistance to blood flow which leads to
pulmonary HTN
right heart failure (cor pulmonale)
Emphysema:
Emphysema: Pathophysiology
Pathophysiology
Loss of elastic recoil leads to increased
residual volume and CO2 retention
Air Trapping
Hyperinflation
Hypercapnia -> pulmonary vasoconstriction ->
V/Q mismatch
Emphysema:
Emphysema: Signs
Signs and
and Symptoms
Symptoms

Increasing dyspnea on exertion

Non-productive cough
Malaise
Anorexia, Loss of weight
Hypertrophied respiratory accessory muscles
Emphysema:
Emphysema: Signs
Signs and
and Symptoms
Symptoms
Increased Thoracic AP
Diameter
(Barrel Chest)
Decreased lung/heart
sounds
Hyperresonant chest
Emphysema:
Emphysema: Signs
Signs and
and Symptoms
Symptoms
Lip pursing on exhalation
Clubbed fingertips
Altered blood gases
Normal or decreased PaO2
Elevated CO2
Cyanosis occurs LATE in course of disease

PINK PUFFER
Chronic Bronchitis

Type B COPD
Chronic
Chronic Bronchitis:
Bronchitis: Definition
Definition

Increased mucus production for > 3 months

for > 2 consecutive years
Recurrent productive cough
Chronic
Chronic Bronchitis:
Bronchitis: Incidence
Incidence

Males > females

Urban areas > rural areas
Age usually > 45
Chronic
Chronic Bronchitis:
Bronchitis: Etiology
Etiology

Smoking
Environmental irritants
Chronic
Chronic Bronchitis:
Bronchitis: Pathophysiology
Pathophysiology
Mucus plugging/inflammatory edema
Increased airflow resistance leads to
alveolar hypoventilation
Alveolar hypoventilation leads to
hypercarbia
hypoxemia
Chronic
Chronic Bronchitis:
Bronchitis: Pathophysiology
Pathophysiology
Hypoxemia leads to
increased RBCs w/o oxygen which leads to
cyanosis
Hypercarbia leads to
pulmonary vascular constriction which leads to
increased right ventricular work which leads to
right heart failure which may progress to
cor pulmonale
Chronic
Chronic Bronchitis:
Bronchitis: Signs
Signs and
and
Symptoms
Symptoms
Increasing dyspnea on exertion
Frequent colds of increasing duration
Productive cough
Weight gain, edema (right heart failure)
Rales, rhonchi, wheezing
Bluish-red skin color (polycythemia)
Headache, drowsiness (increased CO2)
Chronic
Chronic Bronchitis:
Bronchitis: Signs
Signs and
and
Symptoms
Symptoms
Decreased intellectual ability
Personality changes
Abnormal blood gases
Hypercarbia
Hypoxia
Cyanosis EARLY in course of disease
BLUE BLOATER
COPD
COPD Assessment
Assessment Findings
Findings
Chronic condition acute episode
S&S of work of breathing and/or hypoxemia
Use of accessory muscles
Increased expiratory effort
Tachycardia, AMS, Cyanosis
Wheezing, Rhonchi, LS
Thin, red/pink appearance
Saturation usually normal in emphysema
COPD:
COPD: Management
Management
Causes of Decompensation
Respiratory infection (increased mucus
production)
Chest trauma (pain discourages coughing or deep
breathing)
Sedation (depression of respirations and
coughing)
Spontaneous pneumothorax
Dehydration (causes mucus to dry out)
COPD:
COPD: Management
Management
Airway and Breathing
Sitting position or position of comfort
Calm & Reassure
Encourage cough
Avoid exertion
Oxygen
Dont withhold
Maintain O2 saturation above 90 %

TRUE HYPOXIC DRIVE IS VERY RARE

COPD:
COPD: Management
Management
Ventilation
Avoid intubation unless absolutely necessary
near respiratory failure
exhaustion
Circulation
IV TKO
Titrate fluid to degree of dehydration
250 cc trial bolus
Excessive fluid may precipitate CHF
Monitor ECG
COPD:
COPD: Management
Management
Drug Therapy
Obtain thorough medication history
Nebulized Beta 2 agonists
Albuterol
Terbutaline
Metaproterenol
Isoetharine
COPD: Management

REMEMBER
All bronchodilators are
potentially arrhythmogenic
COPD:
COPD: Management
Management

Drug Therapy
Ipratropium (anticholinergic) by SVN
(beta-2 agonist) by MDI, SQ or IV
Corticosteroids (anti-inflammatory agent) by IV
COPD:
COPD: Management
Management
Avoid
Sedatives
Restlessness = hypoxia
Antihistamines
Dry secretions, decrease LOC
Epinephrine
Myocardial ischemia, arrhythmias
Intubation
difficult to wean off ventilator
Reversible Obstructive Airway
Disease

Asthma
Asthma:
Asthma: Definition
Definition
Lower airway hyper-responsiveness to a
variety of stimuli
Diffuse reversible airway obstruction or
narrowing
Airway inflammation
Asthma:
Asthma: Incidence
Incidence
50% onset before age 10
33% before age 30
Asthma in older patients suggests other
obstructive pulmonary diseases
Risk Factors
Family history of asthma
Perinatal exposure to airborne allergens and irritants
Genetic hypersensitivity to environmental allergens
(Atopy)
Asthma
Asthma

Diagnosis
H&P, Spirometry
Hx or presence of episodic symptoms of
airflow obstruction
airflow obstruction is at least partially
reversible
alternative diagnoses are excluded
Asthma
Asthma

Commonly misdiagnosed in children as

Chronic bronchitis
Recurrent croup
Recurrent URI
Recurrent pneumonia
Asthma
Asthma
Often triggered by:
Cold temperature
Respiratory Infections
Vigorous exercise
Emotional Stress
Environmental allergens or irritants
Exacerbation
Extrinsic common in children
Intrinsic common in adults
Asthma
Asthma Pathophysiology
Pathophysiology
Asthma triggered
Bronchial smooth muscle contraction
Increased mucus production
Bronchial plugging
Relative dehydration
Alveolar hypoventilation
Ventilation Perfusion Mismatch
CO2 retention
Air Trapping
Asthma:
Asthma: Pathophysiology
Pathophysiology

Bronchospasm

Bronchial Edema Increased Mucus

Production
Asthma:
Asthma: Pathophysiology
Pathophysiology
Asthma:
Asthma: Pathophysiology
Pathophysiology

Cast of airway produced by

asthmatic mucus plugs
Asthma:
Asthma: Pathophysiology
Pathophysiology
Difficulty exhaling
chest hyperinflation
Poor gas exchange
hypoxia
hypercarbia
Increased respiratory
water loss
dehydration
Asthma:
Asthma: Types
Types

Type 1 Extrinsic
Classic allergic asthma
Common in children, young adults
Seasonal in nature
Sudden brief attacks
Major component is bronchospasm
Good bronchodilator response
Asthma:
Asthma: Types
Types

Type 2 Extrinsic Asthma

Adults < 35
Long term exposure to irritants
More inflammation than Type 1 Extrinsic
Does not respond well to bronchodilators
Needs treatment with corticosteroids
Asthma:
Asthma: Types
Types

Intrinsic Asthma
Adult > 35
No immunologic cause
Aspirin sensitivity/nasal polyps
Poor bronchodilator response
Asthma:
Asthma: Signs
Signs and
and Symptoms
Symptoms
Onset of attacks associated with triggers
Dyspnea
Non-productive cough
Tachypnea
Expiratory wheezing
Accessory muscle use
Retractions
Asthma: Signs and Symptoms

Absence of wheezing
IMPENDING RESPIRATORY
ARREST!
Asthma:
Asthma: Signs
Signs and
and Symptoms
Symptoms

Tachycardia
Pulsus paradoxus in severe attacks
Anxiety, restlessness (hypoxia) progressing to
drowsiness, confusion (hypercarbia)
Asthma: Signs and Symptoms

Lethargy, confusion,
suprasternal retractions
RESPIRATORY FAILURE
Asthma:
Asthma: Signs
Signs and
and Symptoms
Symptoms
Early Blood Gas Changes
Decreased PaO2
Decreased PaCO2

WHY?
Asthma:
Asthma: Signs
Signs and
and Symptoms
Symptoms
Later Blood Gases
Decreased PaO2
Normal PaCO2

IMPENDING
RESPIRATORY
FAILURE
Asthma:
Asthma: Signs
Signs and
and Symptoms
Symptoms
Still Later Blood Gases
Decreased PaO2
Increased PaCO2

RESPIRATORY
FAILURE
Asthma:
Asthma: Risk
Risk Assessment
Assessment
Prior ICU admissions
Prior intubation
>3 ED visits in past year
>2 hospital admissions in past year
>1 bronchodilator canister used in past month
Use of bronchodilators > every 4 hours
Chronic use of steroids
Progressive symptoms in spite of aggressive Rx
Asthma:
Asthma: Management
Management
Airway
Breathing
Sitting position or position of comfort
Humidified O2 by NRB mask
Dry O2 dries mucus, worsens plugs
Encourage coughing
Consider intubation, assisted ventilation
Impending respiratory failure
Avoid if at all possible
Asthma:
Asthma: Management
Management

Circulation
IV TKO
Assess for dehydration
Titrate fluid administration to severity of
dehydration
Trial bolus of 250 cc
Monitor ECG, Pulse Oximetry
Asthma:
Asthma: Management
Management

Obtain medication history

Consider
Overdose
Dysrhythmias
Asthma:
Asthma: Management
Management
Nebulized Beta-2 agents
Salbutamol
Nebulized anticholinergics
Ipratropium
Atropine
IV Corticosteroid
Methylprednisolone
Combination Flovent/etc
Asthma:
Asthma: Management
Management
Rarely used
Questionable efficacy, Potential Complications
Magnesium Sulfate (IV)
Methylxanthines
Aminophylline (IV)
Asthma:
Asthma: Management
Management
Subcutaneous beta agents
Epinephrine 1:1000 q 30 minutes up to 3 doses
Adult 0.3 mg SQ/IM
Pediatric 0.1 to 0.3 mg SQ/IM

POSSIBLE BENEFIT IN PATIENTS

WITH VENTILATORY FAILURE
Asthma:
Asthma: Management
Management
Use EXTREME caution in giving two
sympathomimetics or two doses to same
patient
Monitor ECG
Asthma:
Asthma: Management
Management
Avoid
Sedatives
Depress respiratory drive
Antihistamines
Decrease LOC, dry secretions
Aspirin
High incidence of allergy
Asthma:
Asthma: Management
Management
Continuous Monitoring & Frequent
Reassessment
Need for transport? Destination?
Asthma:
Asthma: Management
Management
Transport Considerations
How severe is the episode?
Is the patient improving?
How extensive (invasive) were the required
therapies?
What does he/she normally do after treatment?
Medical Control or PMD consult
Drug
Drug Delivery
Delivery Methods:
Methods: Review
Review

MDI vs. MDI w/ spacer vs. SVN

vs. SQ injection
Status Asthmaticus

Asthma unresponsive to beta-2

adrenergic agents
Status
Status Asthmaticus
Asthmaticus
Oxygen (humidified if possible)
Nebulized beta-2 agents
Nebulized Ipratropium
Corticosteroids
IV or SQ terbutaline or epinephrine
Aminophylline (controversial)
Magnesium sulfate (controversial)
Intubation
Caution with PPV
Golden
Golden Rule
Rule
ALL THAT WHEEZES IS NOT
ASTHMA
Pulmonary edema
Pulmonary embolism
Allergic reactions
COPD
Pneumonia
Foreign body aspiration
Cystic fibrosis
Lower Airway Disease

Cystic Fibrosis
Cystic
Cystic Fibrosis:
Fibrosis: Definition
Definition
Inherited metabolic disease of exocrine
glands and sweat glands
Primarily affects digestive, respiratory
systems
Begins in infancy
Cystic
Cystic Fibrosis:
Fibrosis: Etiology
Etiology
Autosomal recessive gene
Both parents must be carriers
Incidence
Caucasians--1:2000
Blacks--1:17,000
Asians--very rare
Cystic
Cystic Fibrosis:
Fibrosis: Pathophysiology
Pathophysiology

Obstruction of pancreatic, intestinal gland,

bile ducts
Over-secretion by airway mucus glands
mucous plugs
Excess loss of sodium chloride in sweat
Lower Airway Disease

Neoplasms of the Lung

Hyperventilation Syndrome
Hyperventilation
Hyperventilation Syndrome
Syndrome
Brady Textbook Correction, Vol. 3, p. 57
Table 1-4: These are NOT Causes of
hyperventilation syndrome
A diagnosis of EXCLUSION!!!
An increased ventilatory rate that
DOES NOT have a pathologic origin
Results from anxiety
Remains a real problem for the patient
 Hyperventilation
Hyperventilation Syndrome:
Syndrome:
Pathophysiology
Pathophysiology
Tachypnea or hyperpnea
secondary to anxiety

Decreased PaCO2

Respiratory alkalosis

Vasoconstriction Hypocalcemia Decreased O2

Release to
Tissues
Hyperventilation
Hyperventilation Syndrome:
Syndrome:
Signs
Signs &
& Symptoms
Symptoms
Symptoms
Light-headedness, giddiness, anxiety
Numbness, paresthesias of:
Hands
Feet
Circumoral area
Cold hands, feet
Carpopedal spasms
Dyspnea
Chest pain
Hyperventilation
Hyperventilation Syndrome:
Syndrome:
Signs
Signs &
& Symptoms
Symptoms
Signs
Rapid breathing
Cool & possibly pale skin
Carpopedal spasm
Dysrhythmias
Sinus Tachycardia
SVT
Sinus arrhythmia
Loss of consciousness and seizures (late &
rare)
Hyperventilation
Hyperventilation Syndrome:
Syndrome:
Management
Management
Educate patient & family
Consider possible psychopathology especially
in repeat customers
Transport occasionally required
If loss of consciousness, carpopedal spasm,
muscle twitching, or seizures occur:
Monitor EKG
IV TKO
Transport
 Hyperventilation Syndrome

Serious diseases can mimic

hyperventilation

Hyperventilation itself can

be serious
Pulmonary Infectious Diseases
Laryngotracheobronchitis
Laryngotracheobronchitis (Croup)
(Croup)
Common syndrome of
infectious upper airway
obstruction
Viral infection
parainfluenza virus
Subglottic Edema
larynx, trachea,
mainstem bronchi
Usually 3 months to 4
years of age
Croup:
Croup: Signs
Signs &
& Symptoms
Symptoms
Gradual onset (several days)
Often begins with Sx of URI
May begin with only low grade fever
Hoarseness
Cough
Seal Bark Cough
Brassy Cough
Nocturnal episodes of increased dyspnea
and stridor
Croup:
Croup: Signs
Signs &
& Symptoms
Symptoms
Evidence of respiratory distress
Tracheal tugging
Substernal/intercostal retractions
Accessory muscle use
Inspiratory stridor or respiratory distress
may develop slowly or acutely
Croup:
Croup: Management
Management
Usually requires little out of home
treatment
Calm & Prevent agitation!!!
Moist cool air - mist
Humidified O2 by mask or blowby
Do Not Examine Upper Airways!!!
Croup:
Croup: Management
Management
If in respiratory distress:
Racemic epinephrine via nebulizer
Decreases subglottic edema (temporarily)
Necessitates transport for observation for rebound
IV TKO - ONLY if severe respiratory distress
Transport
Epiglottitis
Epiglottitis

Bacterial infection
(Hemophilus
influenza )
Edema of epiglottis
(supraglottic)
partial upper airway
obstruction
Typically affects 3-7
year olds
Epiglottitis:
Epiglottitis: Presentation
Presentation
Age: 3-7 years of age
can occur in adults
can occur in infants
Rapid onset & progression
Fever
Severe sore throat
Dysphagia
Muffled voice
Drooling
Epiglottitis:
Epiglottitis: Presentation
Presentation
Respiratory difficulty
Stridor
Usually in an upright, sitting, tripod position
Child may go to bed asymptomatic and
awaken during the night with
sore throat
painful swallowing
respiratory difficulty
Epiglottitis:
Epiglottitis: Management
Management
Immediate life threat (8-12% die
from airway obstruction)

Do NOT attempt to visualize airway

Allow child to assume position of comfort
AVOID agitation of the child!!!
AVOID anxiety of the healthcare providers!!!
O2 by high concentration mask
Epiglottitis:
Epiglottitis: Management
Management
If respiratory failure is eminent:
IV TKO ONLY if eminent or respiratory arrest
Be prepared to take control of airway
Intubation equipment with smaller sized tubes
Needle cricothyrotomy & jet ventilation equipment
Rapid but calm transport
Appropriate facility
Upper
Upper Respiratory
Respiratory Infection
Infection
Common illness
Rarely life-threatening
Often exacerbates underlying pulmonary
conditions
May become more significant in some
patients
Immunosuppressed
Elderly
Chronic pulmonary disease
Upper
Upper Respiratory
Respiratory Infection
Infection
Prevention
Avoidance is nearly impossible
Too many potential causes
Temporarily impaired immune system
Best prevention strategy is handwashing
Covering of mouth during sneezing and coughing also
helpful
Pathophysiology
Pathophysiology of
of URI
URI
Wide variety of bacteria and viruses are
causes
Normal immune system response results in
presentation
20-30% are Group A streptococci
Most are self-limiting diseases
Presentation
Presentation of
of URI
URI
Symptoms
Sore throat
Fever
Chills
HA
Signs
Cervical adenopathy
Erythematous pharynx
Positive throat culture (bacterial)
Management
Management of
of URI
URI
Usually requires no intervention
Oxygen if underlying condition has been
exacerbated
Rarely, pharmacologic interventions are
required
Bronchodilators
Corticosteroid
Occasionally, transport required
Key question: Destination?
Central
Central Respiratory
Respiratory Depression
Depression
Respiratory
Respiratory Depression:
Depression: Causes
Causes

Head trauma
CVA
Depressant drug toxicity
Narcotics
Barbiturates
Benzodiazepines
ETOH
 Respiratory
Respiratory Depression:
Depression:
Recognition
Recognition
Decreased respiratory rate (< 12/min)
Decreased tidal volume
Decreased LOC

Use Your
Stethoscope
Look, Listen, Feel

If you cant tell THEY

whether a patient PROBABLY
is breathing ARENT
adequately...
Respiratory
Respiratory Depression:
Depression:
Management
Management
Airway
Open, clear, maintain
Consider endotracheal intubation

The need to VENTILATE is not the

same as the need to INTUBATE
 Respiratory
Respiratory Depression:
Depression:
Management
Management
Breathing
Oxygenate, ventilate
Restore normal rate, tidal volume

Oxygen alone is INSUFFICIENT if

Ventilation is INADEQUATE
Respiratory
Respiratory Depression:
Depression:
Management
Management
Circulation
Obtain vascular access
Monitor EKG (Silent MI may present as CVA)
Manage Cause
Check Blood Sugar
Consider Narcan 2mg IV push if S/S suggest
narcotic overdose
Intubate if can not find or treat cause
Guillian-Barre
Guillian-Barre Syndrome
Syndrome
Autoimmune disease
Leads to inflammation and degeneration of
sensory and motor nerve roots (de-
myelination)
Progressive ascending paralysis
Progressive tingling and weakness
Moves from extremities then proximally
May lead to respiratory paralysis (25%)
Guillian-Barre
Guillian-Barre Syndrome
Syndrome
Management
Management
Treatment based on severity of symptoms
Control airway
Support ventilation
Oxygen
Transport in cases of respiratory depression,
distress or arrest
Myasthenia
Myasthenia Gravis
Gravis
Autoimmune disease
Causes loss of ACh receptors at
neuromuscular junction
Attacks the ACh transport mechanism at the
NMJ
Episodes of extreme skeletal muscle
weakness
Can cause loss of control of airway,
respiratory paralysis
Myasthenia
Myasthenia Gravis
Gravis Presentation
Presentation
Gradual onset of muscle weakness
Face and throat
Extreme muscle weakness
Respiratory weakness -> paralysis
Inability to process mucus
Myasthenia
Myasthenia Gravis
Gravis Management
Management
Treat symptomatically
Watch for aspiration
May require assisted ventilations
Assess for Pulmonary infection
Transport based upon severity of
presentation
Case Studies
Case
Case One
One
It is 1430 hrs. You are called to a business for
a possible stroke. The patient is a 20-year-
old female complaining of dizziness and of
numbness around her mouth and fingertips.

What would you like to include in

your initial differential diagnosis?
Case
Case One
One
Initial Assessment
Airway: Open, maintained by patient
Breathing: Rapid, deep, regular; no accessory
muscle use or retractions
Circulation: Radial pulses present, rapid, full; Skin
warm, dry; capillary refill < 2 seconds
Disability: Awake, alert, anxious

What therapies, if any, would you

like to begin?
Case
Case One
One
Vital Signs
P: 126 strong, regular
R: 26 deep, regular
BP: 130/82
Physical Exam
Chest: BS present, equal bilaterally; no
adventitious sounds
Extremities: Equal movement in all
extremities; no weakness; hands cool
Oxygen saturation: 98%
Would you like to make any Changes
to your therapies or Diff Dx?
Case
Case One
One
History
Allergies: NKA
Medications: Birth control pills
Past History: No significant past history; no
history of smoking
Last Meal: Lunch 2 hours ago
Events: S/S began suddenly after argument
with supervisor
Case
Case One
One
What problem do you now suspect?
How would you manage this patient?
Case
Case Two
Two
It is 0530 hours. You are called to a residence
to see a child with a very high fever and
difficulty breathing. The patient is a 6-old-
female. Mother says the child woke up crying
about 2 hours ago.

What would you like to include in

your differential diagnosis?
Case
Case Two
Two
Initial Assessment
Airway: Inspiratory stridor audible
Breathing: Rapid, shallow, labored
Circulation: Radial pulses present, rapid, weak;
skin pale, hot, diaphoretic; capillary refill is 2
seconds
Disability: Awake, alert, obviously frightened and in
acute distress

What therapies, if any, would you

like to begin now?
Case
Case Two
Two
Vital Signs
P: 130 weak, regular
R: 32 shallow, regular with stridor
BP: 110/70
Physical Exam
HEENT: Flaring of nostrils; accessory muscle
use on inspiration; drooling present
Chest: BS present, equal bilaterally; no
adventitious sounds
Oxygen saturation: 92%
Would you like to make any Changes to
your therapies or Diff Dx?
Case
Case Two
Two
History
Allergies: NKA
Medications: None
Past History: No significant past history
Last Meal: Dinner at about 1800 hours
Events: Awakened with severe sore throat. Has
experienced increasing difficulty breathing. Will
not eat or drink. Says it hurts to swallow
Case
Case Two
Two
What problem do you now suspect?
How would you manage this patient?
Case
Case Three
Three
At 2330 hrs you are called to a residence to
see a child with difficulty breathing. The
patient is a 3 year old male.

How narrow a Differential Diagnosis

can you compile at this point?
Case
Case Three
Three
Initial Assessment
Airway: Open, maintained by patient, mild stridor
audible
Breathing: Rapid, shallow, labored
Circulation: Radial pulses present, weak, regular;
Skin pale, warm, moist; Capillary refill <2 seconds
Disability: Awake, sitting up in bed, looks tired and
miserable
Case
Case Three
Three
Vital Signs
P: 100 weak, regular
R: 30 shallow, labored with stridor
BP: 90/50
Physical Exam
HEENT: Use of accessory muscles present; no
drooling
Chest: BS present, equal bilaterally with no
adventitious sounds. Auscultation difficult
because of stridor and barking cough
Now you can narrow your Diff Dx? To what?
Case
Case Three
Three
History
Allergies: NKA
Medication: Tylenol for fever before bedtime
Past history: No significant past history
Last meal: Dinner around 1800 hours
Events: Patient has had cold for about 3 days.
Reasonably well during day. Awakens around
midnight with high-pitched cough that sounds
like a dog barking
Case
Case Three
Three
What problem do you suspect?
How would you manage this patient?
Case
Case Four
Four
At 1945 hours you are dispatched to a
breathing difficulty at Long John Silvers.
The patient is a 26-year-old female
complaining of strange feeling in her mouth
and difficulty swallowing.

What is your differential diagnosis?

Case
Case Four
Four
Initial Assessment
Airway: Open, maintained by patient, difficulty
swallowing, voice is hoarse
Breathing: Rapid, labored
Circulation: Radial pulses present, strong, regular;
Skin flushed; Capillary refill < 2 seconds
Disability: Awake, alert, very anxious
Case
Case Four
Four
Vital Signs
P: 120 strong, regular
R: 26 regular, slightly labored
BP: 118/90
Physical Exam
HEENT: Puffiness around eyes; Lips appear swollen;
Mild accessory muscle use
Chest: BS present, equal bilaterally; No adventitious
sounds
Urticaria on upper chest, extremities
Oxygen saturation: 94%

What therapies do you want to initiate?

Case
Case Four
Four
History
Allergies: No drug allergies; Has experienced
itching previously when eating shrimp
Medications: None
Past history: No significant past history; no
history of smoking
Last meal: In progress at time of call
Events: Began to experience itching and
difficulty swallowing after eating fish and
chips
Case
Case Four
Four
What problem do you suspect?
How would you manage this patient?

The patient begins to have increased difficulty

swallowing, increased anxiety, and increased
difficulty breathing.
What do you want to do now?
Case
Case Five
Five
At 0130 you are dispatched to an
unconscious person--police on location. The
patient is a 27-year-old male who is
apparently unconscious. The police report
they found him lying in an alleyway while they
were on routine patrol. He is known to live
on the streets.
Case
Case Five
Five
Initial Assessment
Airway: Controllable with manual positioning
Breathing: Very slow, shallow
Circulation: Radial pulses present, weak; Skin
pale, cool, moist; Capillary refill 3 seconds
Disability: Unconscious, unresponsive to painful
stimuli

What therapies would you like to begin?

Case
Case Five
Five
Vital Signs
P: 70 regular, weak
R: 4 shallow, regular; alcohol odor on breath
BP: 100/70
Physical Exam
HEENT: Pupils pinpoint, non-reactive
Chest: BS present, equal bilaterally
Abdomen: Soft, non-tender
Extremities: Needle tracks present
Blood glucose: 40 mg/dl
Case
Case Five
Five

What problem or problems do you

suspect?
How would you manage this patient?