Respiratory Emergencies

East Region (Washington) OTEP M-7 Brian Reynolds, MD Deaconess Medical Center Spokane, WA

Respiratory Emergencies  We are going to cover material for ALL levels of training  YOU CAN ONLY PRACTICE AT THE LEVEL YOU HAVE BEEN CERTIFIED

Topics

 Anatomy and function of the Respiratory System  Patient Assessment  Airway Management

Anatomy of the Upper Airway

Upper Airway  Nasal cavity  Oral cavity  Pharynx

Nasal Cavity  Nares  Mucous membranes  Sinuses

 Cheeks  Hard palate  Soft palate  Tongue  Gums  Teeth Oral Cavity

Pharynx  Nasopharynx  Oropharynx  Laryngopharynx

Larynx  Thyroid cartilage  Cricoid cartilage  Glottic opening  Vocal cords  Arytenoid cartilage  Pyriform fossae  Cricothyroid cartilage

Internal Anatomy of the Upper Airway

Lower Airway Anatomy  Trachea  Bronchi  Alveoli  Lung parenchyma  Pleura

Anatomy of the Lower Airway

Definitions  Atelectasis – collapse of small segments of lung  Hypoxia – lack of oxygen  Hypoxemia – lack of oxygen in arterial blood

Introduction  Ventilation is the mechanical process that brings O 2 to the lungs, and clears CO 2 lungs from the  Oxygenation is the diffusion of O 2 to the blood  Perfusion is the flow of blood through the lungs (thus exchanging oxygen and CO 2 )  Brain stem is the involuntary regulator of respirations

Respiratory Physiology  Ventilation  Body Structures  Chest Wall  Pleura  Diaphragm  Tidal Volume:  7ml/kg (Adult 500ml)

Pathophysiology  Disruption in Ventilation  Upper & Lower Respiratory Tracts  Obstruction due to trauma or infectious processes  Chest Wall & Diaphragm  Trauma  Pneumothorax  Hemothorax  Flail chest  Neuromuscular disease

Oxygenation  Room air – 21% FiO 2  Roughly 3% increase per liter  Nasal cannula – 8L max (40%)  Mask – 10L (55%)  NRB mask – 15L (80%)

Pulmonary Circulation

Respiratory Physiology  Pulmonary Perfusion  Requirements  Adequate blood volume  Intact pulmonary capillaries  Efficient pumping by the heart  Hemoglobin  Carbon Dioxide

Pathophysiology  Disruption in Perfusion  Alteration in systemic blood flow  Changes in hemoglobin  Pulmonary shunting  Damaged alveoli

Respiratory Factors

Factor

Fever Emotion Pain Hypoxia Acidosis Stimulants Depressants Sleep

Effect

Increases Increases Increases Increases Increases Increase Decrease Decreases

Assessment of the Respiratory System  Scene Assessment  Threats to Safety  Make sure you are safe first  Identify rescue environments having decreased oxygen levels  Gases and other chemical or biological agents  Clues to Patient Information

Assessment of the Respiratory System  Initial Assessment  General Impression  Position  Color  Mental status  Ability to speak  Respiratory effort

Assessment of the Respiratory System  Airway  Proper ventilation cannot take place without an adequate airway  Breathing  Signs of life-threatening problems  Alterations in mental status  Severe central cyanosis, pallor, or diaphoresis  Absent or abnormal breath sounds  Speaking limited to 1–2 words  Tachycardia  Use of accessory muscles or intercostal retractions

Abnormal Respiratory Patterns Kussmaul’s respirations:  Deep, slow or rapid, gasping; common in diabetic ketoacidosis Cheyne-Stokes respirations:  Progressively deeper, faster breathing alternating gradually with shallow, slower breathing, indication brain stem injury

Abnormal Respiratory Patterns Agonal respirations:  Shallow, slow, or infrequent breathing, indicating brain anoxia

Focused History & Physical Exam  History  SAMPLE History  Paroxysmal nocturnal dyspnea and orthopnea  Coughing, fever, hemoptysis  Associated chest pain  Smoking history or environmental exposures  Similar Past Episodes

Focused History & Physical Exam  Physical Examination  Inspection  Look for asymmetry, increased diameter, or paradoxical motion  Palpation  Feel for subcutaneous emphysema or tracheal deviation  Percussion  Auscultation

Focused History & Physical Exam  Auscultation  Normal Breath Sounds  Bronchial, Bronchovesicular, and Vesicular  Abnormal Breath Sounds  Snoring  Stridor  Wheezing  Rhonchi  Rales/Crackles  Pleural friction rub

Focused History & Physical Exam  Diagnostic Testing  Pulse Oximetry  Inaccurate Readings

Ausculation   Listen at the mouth and nose for adequate air movement Listen with a stethoscope for normal or abnormal air movement  Proper listening positions

Airway Obstruction      The tongue is the most common cause of airway obstruction Foreign bodies Trauma Laryngeal spasm and edema Aspiration

Congestive Heart Failure  Wet, crackly lung sounds  Lower extremity edema  Must sit and sleep upright  Frothy, pink sputum

Obstructive Lung Disease  Types  Emphysema  Chronic Bronchitis  Asthma  Causes  Genetic Disposition  Smoking & Other Risk Factors

Emphysema  Assessment  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”

Chronic Bronchitis  Physical Exam  Often overweight  Rhonchi present on auscultation  Jugular vein distention  Ankle edema  Hepatic congestion  “Blue Bloater”

Asthma  Physical Exam  Presenting signs may include dyspnea, wheezing, cough  No wheezing is severe disease  Speech may be limited to 1–2 word sentences  Look for hyperinflation of the chest and accessory muscle use/feel chest wall for crepitus  Carefully auscultate breath sounds and measure peak expiratory flow rate

Pneumonia  Infection of the Lungs  Immune-Suppressed Patients  Pathophysiology  Bacterial & Viral Infections  Hospital-acquired vs. community-acquired  Alveoli may collapse, resulting in a ventilation disorder

Lung Cancer  Pathophysiology  General  Majority are caused by carcinogens secondary to cigarette smoking or occupational exposure  May start elsewhere and spread to lungs  High mortality  Types  Adenocarcinoma  Epidermoid, small-cell, and large-cell carcinomas

Toxic Inhalation  Pathophysiology  Includes inhalation of heated air, chemical irritants, and steam  Airway obstruction due to edema and laryngospasm due to thermal and chemical burns  Assessment  Focused History & Physical Exam  SAMPLE & OPQRST History  Determine nature of substance  Length of exposure and loss of consciousness

Carbon Monoxide Inhalation  Pathophysiology  Binds to Hemoglobin  Prevents oxygen from binding to RBC’s  Room air half life – 6 hrs., HBO – 23 minutes  Assessment  Focused History and Physical Exam  SAMPLE & OPQRST History  Determine source and length of exposure  Presence of headache, confusion, agitation, lack of coordination, loss of consciousness, and seizures

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  Pregnant or postpartum  Oral contraceptive use, tobacco use  Immobility  Blood disorders

Spontaneous Pneumothorax  Pathophysiology  Pneumothorax  Can occur in the absence of blunt or penetrating trauma  Risk factors  Assessment  Focused history  SAMPLE  Presence of risk factors  Rapid onset of symptoms  Sharp, pleuritic chest or shoulder pain  Often precipitated by coughing or lifting

Hyperventilation Syndrome  Assessment  Focused History & Physical Exam  SAMPLE  Fatigue, nervousness, dizziness, dyspnea, chest pain  Numbness and tingling in mouth, feet, and both hands  Presence of tachypnea and tachycardia  Spasms of the fingers and feet

Airway Sounds

Airflow Compromise Gas Exchange Compromise Snoring Gurgling Stridor Wheezing Quiet Crackles Rhonchi

Basic Mechanical Airways

Insert oropharyngeal airway with tip facing palate

Rotate airway 180º into position

Nasopharyngeal Airway (Do not use if significant facial trauma)

Advanced Airway Management

Advanced Airway Management  Endotracheal intubation  Combitube  CPAP and BiPAP  CO 2  monitors – measure exhaled CO Normal – 5-6% 2

Advantages of Endotracheal Intubation      Isolates trachea and permits complete control of airway Maximizes ventilation and oxygenation Impedes gastric distention Eliminates need to maintain a mask seal Offers direct route for suctioning

Laryngoscope Blades

Placement of Macintosh blade into vallecula

Placement of Miller blade under epiglottis

Endotrol ETT

ETT, stylet, syringe

Combitube

CPAP

Endotracheal Intubation Indicators       Respiratory or cardiac arrest Unconsciousness Risk of aspiration Obstruction due to foreign bodies, trauma, burns, or anaphylaxis Respiratory extremis due to disease (Pneumothorax), hemothorax, (hemopneumothorax) with respiratory difficulty

Complications of Endotracheal Intubation        Equipment malfunction Teeth breakage and soft tissue injury Hypoxia Esophageal intubation Endobronchial intubation Tension pneumothorax Extubation

Tracheostomies/Stomas  Use patient’s supplies  Ambu bag attaches easily  Treat as an endotracheal tube  Suction

Questions 1. Which one is lack of oxygen in the blood?

a.

b.

c.

d.

Hypoxia Hypocarbia Hypoxemia Hypocarbemia

Questions 2. Which one is the best airway?

a.

b.

c.

d.

Nasal cannula Endotracheal tube Oral airway Combitube

Questions 3. Which one is a contraindication to nasal trumpet use?

a.

b.

c.

d.

Seizure Bloody nose DNR patient Significant facial trauma

Questions 4. Which one is the correct tidal volume for a 200 pound patient?

a.

b.

c.

d.

500cc 600cc 700cc 800cc

Questions 5. Which one is not an indication for endotracheal intubation?

a.

b.

c.

d.

Respiratory failure Cardiac arrest GCS of 5 Hyperventilation syndrome

Now you know everything about respiratory emergencies

Questions?

Renee Anderson [email protected]

509-232-8155 FAX: 509-232-8344 Garry Frey [email protected]

509-242-4263