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Respiratory Emergencies - Helping our patients catch their breath
Julie Antonellis, LVT, VTS (ECC)Technician Supervisor Animal Emergency Critical CareA Life Centre Partner Practice
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Defining terms
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Hypoxia - Hypoxemia
Hypoxia
● Whole body or region of the
body is deprived of adequate
oxygen supply
Hypoxemia
● Decrease in the amount of
oxygen dissolved in the blood
● Think emia = blood
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Hypocapnia - Hypercapnia
Hypocapnia
● Lower than normal levels of
carbon dioxide in the blood
● Hyperventilation
Hypercapnia
● Higher than normal levels of
carbon dioxide in the blood
● Hypoventilation
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SpO2 - PaO2 - SaO2
SpO2
● Non-invasive
measurement of peripheral
capillary oxygen saturation
● How is it measured?○ Pulse oximetry
PaO2
● Partial pressure of oxygen
dissolved in plasma
● Indicates oxygen available
in alveoli that can be
dissolved in the blood
● Does not measure total
body oxygen content
● How is it measured?○ Blood gas
SaO2
● Percent of oxygen bound
to hemoglobin
● How is it measured?
○ Co-oximeter using an
arterial blood sample o
○ Extrapolated from the
measured PaO2
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Do your numbers make sense?
PaO2 should be = FiO2
x 5
● At room air FiO2 is 21%○ 21 x 5 ≈ 100 mmHg (what paO2 should be)
● Under anesthesia FiO2 is 100%
○ 100x5 = 500 mmHg (what paO2 should be)
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Let’s talk cyanosis
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Cyanosis
● Blue to purple color of tissues ● Deoxygenated hemoglobin● Central vs. peripheral● Indicates severe hypoxia● When do we see cyanosis in a patient with a normal PCV?
○ SaO2 of 73-78%
○ PaO2 of 39-44 mm Hg
● Will take much lower SaO2 and PaO2 before cyanosis is seen in anemic patients
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Handling the dyspneic patient
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Living on the edge
● Stress can cause decompensation that could lead to respiratory distress
● Cats can compensate in a non-stressful environment to a point…
● No patient should die in radiology● Diagnostics may have to wait
Diberri, Hemoglobin oxygen dissociation curve, [retrieved from: https://commons.wikimedia.org/wiki/File:Hb_saturation_curve.png}
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Minimize stress
● Toweling techniques for cats● Do not hold mouth closed for auscultation● Consider e-collar for protection if fractious● Sedation for panicked patients
○ Prepare to intubate
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Minimize stress
● Perform treatments/diagnostics in stages if needed● Form a game plan with your support staff
○ What do you want to accomplish?
○ How do you think the patient will respond to treatment?
○ Let them know what signs will tell you the patient has had enough
○ Listen to their concerns
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Oxygen delivery methods
● Flow by● Mask● Oxygen hood● Oxygen cage● Incubator● Oxygen e-collar● Nasal oxygen line● Nasotracheal oxygen line● Intubation
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Initial Stabilization
● Oxygen supplementation● Ensure patent airway● Intravenous catheter● Pain medication if indicated● Sedation for animal who are panicked● Induction and intubation if in severe distress● Prepare for chest tap if pleural effusion or pneumothorax
are suspected
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Breathing patterns
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Breathing patterns
● Normal● Inspiratory effort● Expiratory effort● Paradoxical
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Normal
● Relies almost entirely on the diaphragm● Almost undetectable● Expiration is passive
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Inspiratory effort
Clinical signs
● Noisy● Slow, deep breaths● Open mouth breathing● Neck and head extended● Commissures of the lips extended
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Inspiratory effort
Possible causes
● Usually upper airway disease○ Obstructed nares
○ Elongated soft palate
○ Laryngeal paralysis
○ Pharyngeal or laryngeal edema
○ Airway obstruction
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Expiratory effort
Clinical signs
● Wheezing● Deep breaths with active abdominal component● Normal to slow respiratory rate
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Expiratory effort
Possible causes
● Usually lower airway disease○ Pulmonary parenchymal disease
○ Asthma
○ Bronchial abnormalities or inflammation
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Paradoxical breathing
Clinical signs
● Chest wall moves inward during inhalation rather than expanding outward
● At the same time the abdomen appears to increase in volume○ Due to the displacement of the abdominal components by the
contraction of the caudal ribs
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Paradoxical breathing
Possible causes
● Flail Chest● Pleural space disease
○ Pleural effusion
○ Pneumothorax
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Advanced procedures
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Nasal oxygen catheter
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Nasal oxygen catheter
Benefits
● Allows easy access to the patient without disrupting oxygen delivery
● Effective● Supplies are readily accessible at most clinics● Relatively inexpensive ● Usually well tolerated
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Nasal oxygen catheter
Possible complications
● Nasopharyngeal mucosa trauma from high flow rates● Gastric distention● Epistaxis
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Nasotracheal oxygen catheter
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Nasotracheal oxygen catheter
Benefits
● Effective for patients with upper airway disease or tracheal collapse
● High FiO2 can be achieved with very low flow rate● Relatively inexpensive● Allows easy access to the patient without disrupting
oxygen delivery
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Nasotracheal oxygen catheter
Possible complications
● May not be tolerated as well as nasal oxygen catheter● May irritate the trachea causing the patient to cough● Patient requires sedation for placement● Risk of aspiration
○ Cannot eat or drink
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Nursing Care
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Nursing care
● Stress free environment● Encourage sternal recumbency● Humidify oxygen● Encourage movement for patients with pneumonia● Allow for eliminations
○ Walk on oxygen if able
● Creature comforts
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Nursing care
● Monitor body temperature○ Adjust environmental temperature accordingly
● Frequently reassess patient status● Compare readings from monitor to how the patient looks
clinically● Communicate concerns and changes to clinician no
matter how minor you think they are
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Critical care ventilation
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When should we ventilate?
● Severe hypoxemia despite therapy● Severe hypoventilation despite therapy● Excessive respiratory effort with signs of patient fatigue
and worry of respiratory failure● Severe respiratory distress causing patient panic
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What is the benefit?
● Normalizing oxygenation● Normalizing CO2 levels● Prevention of respiratory failure● Opening up collapsed alveoli● Allowing damaged lungs time to heal without having the
patient struggle to breathe
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Possible complications
Cardiovascular compromise due to impaired venous return due to positive pressure in the chest
● Positive intrathoracic pressures created by the ventilator collapse the caudal vena cava
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Possible complications
Upper airway complications
● Sinusitis● Pharyngitis● Tracheal necrosis● Airway occlusion from mucous or blood
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Possible complications
Lower airway complications
● Pneumothorax from overinflation● Ventilation-acquired pneumonia
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Possible complications
Renal complications
● Decreased glomerular filtration rate● Decrease urine output● Water and sodium retention
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