Respiratory Emergencies

East Region (Washington) OTEPM-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

NaresNares

Mucous membranesMucous membranes

SinusesSinuses

Oral Cavity

Cheeks Hard palate Soft palate Tongue Gums Teeth

Nasopharynx

Oropharynx

Laryngopharynx

Pharynx

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

Ventilation is the mechanical process that brings O2 to the lungs, and clears CO2 from the lungs

Oxygenation is the diffusion of O2 to the blood

Perfusion is the flow of blood through the lungs (thus exchanging oxygen and CO2)

Brain stem is the involuntary regulator of respirations

Introduction

Respiratory Physiology

VentilationBody Structures

Chest Wall Pleura Diaphragm

Tidal Volume: 7ml/kg

(Adult 500ml)

Pathophysiology

Disruption in VentilationUpper & Lower Respiratory Tracts

Obstruction due to trauma or infectious processes

Chest Wall & Diaphragm Trauma

PneumothoraxHemothoraxFlail chest

Neuromuscular disease

Oxygenation

Room air – 21% FiO2

Roughly 3% increase per literNasal cannula – 8L max (40%)Mask – 10L (55%)NRB mask – 15L (80%)

Pulmonary Circulation

Respiratory Physiology

Pulmonary PerfusionRequirements

Adequate blood volume Intact pulmonary capillaries Efficient pumping by the heart

HemoglobinCarbon Dioxide

Pathophysiology

Disruption in PerfusionAlteration in systemic blood flowChanges in hemoglobinPulmonary shuntingDamaged alveoli

Respiratory FactorsFactorFactor EffectEffect

Stimulants

FeverEmotionPainHypoxiaAcidosis

DepressantsSleep

Increases

DecreaseDecreases

IncreasesIncreasesIncreasesIncreasesIncrease

Scene AssessmentThreats 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 AssessmentGeneral Impression

Position Color Mental status Ability to speak Respiratory effort

Assessment of the Respiratory System

Airway Proper ventilation cannot take place without an

adequate airwayBreathing

Signs of life-threatening problemsAlterations in mental statusSevere central cyanosis, pallor, or diaphoresisAbsent or abnormal breath soundsSpeaking limited to 1–2 wordsTachycardiaUse of accessory muscles or intercostal retractions

Assessment of the Respiratory System

Abnormal Respiratory Patterns

Kussmaul’s respirations:Deep, slow or rapid, gasping; common

in diabetic ketoacidosisCheyne-Stokes respirations:

Progressively deeper, faster breathing alternating gradually with shallow, slower breathing, indication brain stem injury

Abnormal Respiratory Patterns

Agonal respirations:Agonal respirations:Shallow, slow, or infrequent breathing,Shallow, slow, or infrequent breathing,

indicating brain anoxiaindicating brain anoxia

HistorySAMPLE HistoryParoxysmal nocturnal dyspnea and orthopnea

Coughing, fever, hemoptysis Associated chest pain Smoking history or environmental exposures

Similar Past Episodes

Focused History & Physical Exam

Physical ExaminationInspection

Look for asymmetry, increased diameter, or paradoxical motion

Palpation Feel for subcutaneous emphysema or tracheal

deviationPercussionAuscultation

Focused History & Physical Exam

Auscultation Normal Breath Sounds

Bronchial, Bronchovesicular, and Vesicular Abnormal Breath Sounds

SnoringStridorWheezingRhonchiRales/CracklesPleural friction rub

Focused History & Physical Exam

Diagnostic TestingPulse Oximetry

Inaccurate Readings

Focused History & Physical Exam

Listen at the mouth and nose for adequate air movement

Listen with a stethoscope for normal or abnormal air movement

Proper listening positions

Ausculation

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

TypesEmphysemaChronic BronchitisAsthma

CausesGenetic DispositionSmoking & 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,

coughNo wheezing is severe diseaseSpeech 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 LungsImmune-Suppressed Patients

PathophysiologyBacterial & Viral Infections

Hospital-acquired vs. community-acquired Alveoli may collapse, resulting in a ventilation

disorder

Lung Cancer

PathophysiologyGeneral

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

AssessmentFocused History & Physical Exam

SAMPLE & OPQRST HistoryDetermine nature of substanceLength of exposure and loss of consciousness

PathophysiologyBinds to Hemoglobin

Prevents oxygen from binding to RBC’s Room air half life – 6 hrs., HBO – 23 minutes

AssessmentFocused History and Physical Exam

SAMPLE & OPQRST HistoryDetermine source and length of exposurePresence of headache, confusion, agitation, lack of

coordination, loss of consciousness, and seizures

Carbon Monoxide Inhalation

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

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

Spontaneous Pneumothorax

AssessmentFocused History & Physical Exam

SAMPLEFatigue, nervousness, dizziness, dyspnea, chest painNumbness and tingling in mouth, feet, and both hands

Presence of tachypnea and tachycardia Spasms of the fingers and feet

Hyperventilation Syndrome

Airway Sounds

Airflow Compromise

Gas Exchange Compromise

Snoring

Stridor

Wheezing

Quiet

Gurgling

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)(Do not use if significant facial trauma)

Advanced Airway Management

Advanced Airway Management

Endotracheal intubation

Combitube

CPAP and BiPAP

CO2 monitors – measure exhaled CO2

Normal – 5-6%

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. Hypoxia

b. Hypocarbia

c. Hypoxemia

d. Hypocarbemia

Questions

2. Which one is the best airway?a. Nasal cannula

b. Endotracheal tube

c. Oral airway

d. Combitube

Questions

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

a. Seizure

b. Bloody nose

c. DNR patient

d. Significant facial trauma

Questions

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

a. 500cc

b. 600cc

c. 700cc

d. 800cc

Questions

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

a. Respiratory failure

b. Cardiac arrest

c. GCS of 5

d. Hyperventilation syndrome

Now you know everything about respiratory emergencies

Garry Frey

freyg@inhs.org

509-242-4263

Questions?

Renee Anderson

andersr@inhs.org

509-232-8155

FAX: 509-232-8344