Chapter 15 objectives: respiratory emergencies

respiratory inhalation medications: Metaproterenol sulfate

-generic name: Metaproterenol sulfate -trade name: Alupent, Metaprel -actions: dilates bronchioles -treats: asthma, bronchitis, COPD, and acute disease

respiratory inhalation medications: Montelukast

-generic name: Montelukast -trade name: Singulair -actions: anti inflammatory, reduces swelling -treats: asthma, COPD, and chronic disease

respiratory inhalation medications: Salmeterol

-generic name: Salmeterol -trade name: Servent Diskus -actions: dilates bronchioles -treats: asthma, bronchitis, COPD, and chronic disease

cystic fibrosis: pediatric patients

-genetic disorder that affects the lungs and digestive system. disrupts the normal function of cells that make up the sweat glands in the skin and that also line the lungs and the digestive and reproductive systems. -disease predisposes the child to repeated lung infections. -disease process in CF disrupts the essential balance of salt and water necessary to maintain a normal coating of fluid and mucus inside the lungs and other organs. result is that the mucus becomes thick, sticky, and hard to move. the mucus holds germs, causing the lungs to become infected. -the child's symptoms range from sinus congestion to wheezing and asthma-like complaints. a chronic cough that produces thick, heavy, discolored mucus may develop in the child. -as lung function decreases, so does the ability to breathe effectively. the child often has dyspnea, generally results in the parents or caregivers calling EMS. treat child with suction and O2 using age appropriate adjuncts. -often causes death in childhood b/c of chronic pneumonia secondary to the very thick, pathologic mucus in the airway. also causes malabsorption of nutrients in the intestines. -adults with CF are predisposed to other medical conditions, including arthritis, osteoporosis, diabetes, and liver problems.

Hay fever

-allergic rhinitis -causes cold-like symptoms, including a runny nose, sneezing, congestion, and sinus pressure. -symptoms are caused by an allergic response, usually to an outdoor airborne allergen such as pollen or sometimes indoor allergens such as dust mites and pet dander. -usually worse in spring and summer -people with this tend to be atopic, meaning that they are more likely to have other allergies, and they may also have a higher incidence of severe reactions

interventions for respiratory problems may include

- providing O2 via a nonrebreathing mask at 15 L/min -providing positive pressure ventilations using a BVM, pocket mask, or a flow-restricted oxygen-powered ventilation device. -using airway management techniques such as an oral or nasal airway, suctioning, or airway positioning -providing noninvasive ventilatory support with continuous positive airway pressure (CPAP) -positioning the patient in a high-Fowler's position or a position of choice to facilitate breathing -assisting with respiratory medications found in a patient-prescribed metered-dose inhaler or a small-volume nebulizer. *some of these provided during primary assessment, some are used to support breathing problems until definitive care can be provided.

pleural effusion

-a collection of fluid OUTSIDE the lung on one or both sides of the chest. -compresses the lung or lungs and causes dyspnea. fluid may collect in large volumes in response to any irritation, infection, congestive heart failure, or cancer. -patients often report that their dyspnea came on suddenly -may also contribute to shortness of breath in a patient with lung cancer. -when you listen with a stethoscope to the chest of a patient with dyspnea resulting from pleural effusion, you will hear decreased breath sounds over the region of the chest where the fluid has moved the lung away from the chest wall. -patients feel better if they are sitting upright.

signs of normal breathing

-a normal rate (adult= 12-20, child= 15-30, infant= 25-50) -a regular pattern of inhalation and exhalation -clear and equal breath sounds on both sides of the chest -regular and equal chest rise and fall -adequate depth (tidal volume) -unlabored; without adventitious/ abnormal breath sounds (wheezing, stridor)

bronchiolitis

-a respiratory illness that often occurs due to respiratory syncytial virus (RSV) infection and results in severe inflammation of the bronchioles: tiny airways that lead from the larger airways/ bronchi to the alveoli in the lungs. they become inflamed, swell, and fill with mucus. -occurs most frequently in newborns and toddlers, especially boys, whose airways can easily become blocked. -infections are common during winter and spring -young children who require hospitalization for bronchiolitis are at increased risk for developing childhood asthma. -mainly supportive treatment. provide appropriate O2 therapy and allow the patient to remain in a position of comfort. reassess frequently for signs of worsening respiratory distress. be prepared to provide airway management and positive-pressure ventilation should the patient develop respiratory failure.

pneumonia

-a significant cause of morbidity worldwide. -a general term that refers to an infection of the lungs. infection collects in the surrounding normal lung tissues, impairing the lungs ability to exchange O2 and Co2. -often a secondary infection. it begins after an upper respiratory tract infection such as a cold or sore throat. it can be caused by a virus or bacterium, or by a chemical injury after an accidently ingestion or a direct lung injury from a submersion incident. -interventions such as intubation and tracheostomy can increase the risk of developing this. -commonly affects people who are chronically or terminally ill. -children often have rapid or labored breathing or breathing with grunting or wheezing sounds. -lips and fingers may be blue in serious cases where O2 exchange at the alveoli is seriously impaired. -if the disease is in the lower part of the lungs near the abdomen, there may be a fever, abdominal pain, and vomiting rather than dyspnea. -bacterial pneumonia results in severe symptoms more quickly including high fevers, which put the child at risk for febrile seizures. -viral pneumonia presents more gradually and is less severe. -other signs: dry skin, decreased skin turgor, exertional dyspnea, a productive cough, chest discomfort and pain that vary with inspiration and expiration, headache, nausea, vomiting, musculoskeletal pain, weight loss, and confusion. -patient may be febrile, tachycardic or even hypotensive. assessment of the lungs may reveal diminished breath sounds with sounds of wheezing, crackles, or rhonchi. need to evaluate the patient's history for possible risk factors. assess temp to determine the presence of a fever. pulse oximetry readings may be low. -treatment includes: airway support and providing supplemental O2. use O2 with appropriate adjuncts, and provide supportive measures if needed.

asthma

-acute spasm of the bronchioles associated with excessive mucus production and swelling of the mucous lining of the respiratory passages. bronchiole is spasm= a mucous plug has formed and partially obstructed the bronchiole. -highest prevalence rate is seen in children 5-17. -produces a characteristic wheezing as the patient attempts to exhale through partially obstructed air passages. wheezing is indicative of a partial LOWER airway obstruction. -in other cases, the airways are so blocked that no air movement is heard. in severe cases, the actual work of exhaling is tiring, and cyanosis and/or respiratory arrest may quickly develop. -cyanosis is the body's attempt to divert blood to the core to help the vital organs function. can be seen first in the lips and mucous membranes. -acute asthma attack may be caused by an allergic response to specific food or some other allergen. b/w attacks, patients may breathe normally. attack may also be triggered by severe emotional stress, exercise, and respiratory infections. -in its most serious form, it can produce anaphylaxis. this may cause respiratory distress that is severe enough to result in a coma or death.

respiratory conditions that cause dyspnea

-altered mental status may be a sign that the brain is dysfunctional b/c of severe hypoxia, a condition in which the body's cells and tissues do not get enough O2. -patients often have difficulty breathing and/or hypoxia with the following medical conditions: pulmonary edema, hay fever, pleural effusion, obstruction of the airway, hyperventilation syndrome, environmental/industrial exposure, carbon monoxide poisoning, drug overdose. -dyspnea is a common complaint in patients with cardiopulmonary diseases. may be caused by physical exertion that has been made difficult b/c the patient's heart is damaged. -congestive heart failure is a troublesome cause of breathlessness b/c the heart is not pumping efficiently, and, therefore the body does not have adequate O2.

pulmonary embolism

-an embolus is anything in the circulatory system that moves from its point of origin to a distant site and lodges there, obstructing subsequent blood flow in that area. beyond the point of obstruction, circulation can be decreased or completely blocked. -emboli can be fragments of blood clots in an artery or vein that break off and travel through the bloodstream, or foreign bodies that enter the circulation, such as a bubble of air. -pulmonary embolism is a blood clot formed in a vein, usually in the legs or pelvis, that breaks off and circulates through the venous system. embolus can also come from the RA in a patient with atrial fibrillation. clot moves through the right side of the heart and into the pulmonary artery, where it becomes lodges, decreasing or blocking blood flow. -no exchange of O2 or Co2 takes place in the areas of blocked blood flow b/c there is no effective circulation. O2 levels in the bloodstream may drop enough to cause cyanosis. the severity of cyanosis and dyspnea is directly related to the size of the embolism and the amount of tissue affected. -may occur as a result of damage to the lining of vessels, a tendency for blood to clot unusually fast, or most often, slow blood flow in a lower extremity. -slow blood flow in the legs is usually caused by long-term bed rest, which can lead to the collapse of veins. patients whose legs or immobilized following a recent injury are at risk for pulmonary emboli for days or weeks after the incident. -difficult to diagnose. symptoms: dyspnea, tachycardia, tachypnea, varying degrees of hypoxia, cyanosis, acute chest pain, hemoptysis (coughing up blood)

Anaphylactic Reactions

-anaphylaxis/ anaphylactic shock is a severe allergic reaction characterized by airway swelling and dilation of BV all over the body, which may significantly lower BP. *antigen is introduced into the body, the antigen-antibody reaction at the surface of a mast cell occurs, the release of mast cell chemical mediators occurs, specific antibody reacts with its corresponding antigen, and chemical mediators exert their effect on end organs. (figure 15-9) -may be associated with widespread hives, itching, signs of shock, and signs and symptoms similar to asthma. airway may swell so much that breathing problems can progress to total airway obstruction in minutes. -most anaphylactic reactions occur within 30 mins of exposure to the allergen (can be food to medication). -in most cases epinephrine (adrenalin) is the treatment of choice. patients may have their own EpiPen. O2 and antihistamines are also helpful. medical direction should guide appropriate therapy.

assessing ABCs in Respiratory patients/ primary assessment

-assess the airway; air must flow in and out of the chest easily for the airway to be considered patent. -if there is any question about airway patency, immediately open the airway using the head tilt-chin lift maneuver in non-trauma patients and the jaw-thrust maneuver for patients with suspected spinal trauma. -if the airway is patent, evaluate whether the patient's breathing is adequate. what are the rate, rhythm, and quality of respirations? is the rate within normal limits for their age? is the patient using accessory muscles to assist the respiratory effort, and can you see retractions? is there abnormal breathing? what is the depth of breathing, and is the tidal volume adequate? is there an adequate rise and fall of the chest? what are the color, temp, and condition of the skin? are the patient's respirations labored? -if the patient can speak only one or two words at a time before gasping for a breath, ventilations are considered labored. -if the respiratory effort is inadequate, you must provide the necessary intervention. -if the patient is in respiratory distress, place him or her in a position that best facilitates breathing (generally sitting upright in a full or semi-Fowler position) and begin administering O2 at 15 L/min via a nonrebreathing mask, unless contraindicated b/c of preexisting medical conditions. ask yourself: is the air going in? does the chest rise and fall with each breath? is the rate adequate for the age of the patient? -if the answer is no then something is wrong. try to reposition the patient and insert an oral airway to keep the tongue from blocking the airway. continue to monitor the airway for fluid, secretions, and other problems as you move on to assess the adequacy of your patient's breathing. -next assess the breath sounds. and after that assess circulation: the pulse rate, quality, and rhythm. if the pulse rate is too fast or slow, the patient may not be getting enough O2. determine the quality of the pulse. is it strong, bounding, or weak? determine whether the rhythm is regular or irregular. irregular beats could indicate a cardiac problem. -assessing the patients circulation includes an evaluation for the presence of shock and bleeding. respiratory distress in a patient could be caused by an insufficient number of red blood cells to transport the O2. -normal capillary refill is less than 2 seconds, abnormal is greater than 2 seconds. -assess the perfusion by evaluating skin color, temp, and condition. a loss of perfusion may by caused by chronic anemia, a wound, internal bleeding, or shock overwhelming the body's ability to compensate for the illness.

describe the assessment of a patient who is in respiratory distress and the relationship of assessment findings to patient management and transport decisions: patient assessment

-assessment of patients in respiratory distress should be a calm and systematic process -patients are usually anxious, and they may be some of the most ill and challenging patients you will encounter

asthma, hay fever, anaphylaxis: treatment

-asthma is often a recurring pathologic condition. confirm whether the patient is able to breath normally at other times. if possible, ask family members to describe the patient's asthma. -as you assess the patients vital sings, note that the pulse rate will be normal or elevated, the BP may be slightly elevated, and respirations will be increased. ask questions about how and when the symptoms began. -be prepared to suction large amounts of mucus from the mouth and to administer O2. if you do suction, do not withhold O2 for more than 15 seconds for adult patients, 10 seconds for a child, and 5 seconds for an infant. allow some time for oxygenation b/w suction attempts. if the patient is unconscious, you may have to provide airway management. -if the patient has medication, you may help with its administration, as directed by local protocol. -reassess breathing frequently and be prepared to assist ventilations in a patient who is having as asthma attack, use slow, gentle breaths. the problem in asthma is getting the air out of the lungs, not into them. resist the temptation to squeeze the bag hard and fast. always assist with ventilations as the last resort, and then provide only about 10-12 shallow breaths/min. -a prolonged asthma attack that is unrelieved may progress into a condition: status asthmaticus. patient is likely to be frightened, frantically trying to breathe, and using all the accessory muscles. status asthmaticus is a true emergency. given O2 and promptly transport to the ED. -the effort to breathe during an asthma attack is very tiring and the patient may be exhausted by the time you arrive at the hospital. this patient is not recovering, they are at a very critical stage and are likely to stop breathing. aggressive airway management, oxygen administration, and prompt transport are essential. ALS should be considered. -patient with hay fever is unlikely to need emergency treatment unless the condition has worsened from generalized cold symptoms. manage the airway, and give O2 according to the level of distress. -an anaphylactic reaction is a life threatening emergency. first step should be to remove the offending agent. maintain the airway, always a priority. if the patient is still awake, allow them to assume a position that does not compromise breathing. use an appropriate O2 device for supplemental administration. be prepared to assist breathing as needed. rapid transport and the early administration of epinephrine, if allowed, should be a priority.

respiratory inhalation medications: Fluticasone

-generic name: Fluticasone -trade name: Flovent Diskus -actions: anti inflammatory, reduces swelling -treats: asthma and chronic disease

tuberculosis

-bacterial infection caused by Mycobacterium tuberculosis. TB spread by cough and is dangerous b/w many strains are resistant to antibiotics. most commonly affects the lungs but can be found in any organ in the body, particularly the kidneys, spine, and lining of the brain and spinal cord (meninges). -TB can remain dormant for years w/o causing symptoms or being infectious to others. when the person is in a state of weakened immunity, TB can become active again. -patients with active TB involving the lungs will report fever, coughing, fatigue, night sweats, and weight loss. if the lung infection becomes severe, the patient will experience shortness of breath, coughing, productive sputum, bloody sputum, and chest pain. -higher prevalence among people who live in close contact, such as prison inmates, nursing home residents, and people in homeless shelters. also found in people with IV drugs or alcohol and people whose immune systems are compromised by an infection such as HIV. -anyone who comes into close contact with people who have active TB, or is in contact with people from countries that have a high prevalence of TB, is at risk of contracting the disease. -if you suspect your patient has TB: wear your gloves, eye protection, an N-95 respirator.

obstruction of the airway

-be aware that a patient with dyspnea may have a mechanical obstruction of the airway and be prepared to treat it quickly. -in semiconscious and unconscious patients, the obstruction may be the result of aspiration of vomit or a foreign body object or improper positioning of the head to that the tongue is blocking the airway. -always consider upper airway obstruction from foreign body first in patients who were eating just before becoming short of breath

Acute Pulmonary Edema/ congestive heart failure

-buildup of fluid in the lungs, usually result of congestive heart failure -congestive heart failure is a disease of the heart, characterized by shortness of breath, edema, and weakness. -sometimes the heart muscle is so injured after a heart attack or other illness that it cannot circulate blood properly. the left side of the heart cannot remove blood from the lungs as fast as the right side delivers it. SO fluid builds up within the alveoli and in the lung tissue b/w the alveoli and the pulmonary capillaries. -separates the alveoli from the pulmonary capillary vessels, interfering with the exchange of O2 and Co2. -not enough space is left in the lung to allow for slow, deep breaths. high BP and low cardiac output often trigger this sudden pulmonary edema. -patients are drowning in their own fluid. usually experiences dyspnea with rapid, shallow respirations. in most severe cases you will see frothy pink sputum at the nose and mouth. -patient risk factors for congestive heart failure: hypertension and a history of coronary artery disease and/or atrial fibrillation (condition in which the atria no longer contract, but instead quiver). -patients that have long-standing history of chronic congestive heart failure can be helped with meds. BUT an acute onset may occur if the patient stops taking their meds, eats food that is too salty, or has a stressful illness, a new heart attack, or an abnormal heart rhythm -not all patients with pulmonary edema have heart disease. poisonings from inhaling large amounts of smoke or toxic chemical fumes can produce PE, and traumatic injuries of the chest and exposure to high altitudes can too. fluid collects in the alveoli and lung tissue in response to damage of the tissues of the lung or bronchi.

croup

-caused by inflammation and swelling of the pharynx, larynx, and trachea. -often secondary to an acute viral infection of the upper airway tract and is typically seen in children b/w ages 6 months and 3 years. -peak seasonal outbreaks of this disease occur in the late fall and during the winter. -disease starts with a cold, cough, and low grade fever that develops over 2 days. signs: stridor and seal-bark cough (signal a narrowing of the air passage of the trachea that may progress to significant obstruction. -rarely seen in adults b/c their breathing passages are larger and can accommodate the inflammation and mucus production w/o producing symptoms. airways are wider, and the supporting tissue is firmer than in children. -often responds well to the administration of humidified O2. bronchodilators are not indicated for croup and can worsen a patient's symptoms.

tracheostomy dysfunction: pediatric and geriatric patients

-children with chronic pulmonary medical conditions may use a home ventilator that is connected by a tracheostomy tube. this tube is placed in an opening in the neck (stoma) and can sometimes become obstructed by secretions, mucus, or foreign bodies. -other tracheostomy complication include: bleeding, leaking, dislodgement, and infection. -place the patient in a position of comfort and provide suctioning to clear the obstruction. if you are able to clear the airway, consider ALS intervention. -once the obstruction is clear, oxygenate the patient and treat based on the patient's presentation. -geriatric patients may have a tracheostomy tube in place b/c of airway obstruction, laryngeal cancer, severe infection, trauma, or the inability to manage secretions. tube can become obstructed by secretions, foreign bodies, or airway swelling. -stoma itself can become infected. -immediate goal is to establish airway patency.

carbon monoxide poisoning

-colorless, odorless, tasteless, and high poisonous gas known as the silent killer. -leading cause of accidental poisoning deaths in the US. people who survive can have permanent brain damage. -produced by fuel burning household appliances such as gas water heaters, space heaters, grills, and generators. combined effects of incomplete combustion and a poorly ventilated building can cause a buildup of carbon monoxide. motor vehicle exhaust is another common source. -people who are exposed may think they have the flu. initially report a headache, dizziness, fatigue, and nausea and vomiting. may report dyspnea on exertion and chest pain and display nervous system symptoms like impaired judgement, confusion, or even hallucinations. worst exposures may result in syncope or a seizure. -has a much stronger bond with hemoglobin than O2 does SO oxygen is not being delivered to the tissues of the body. this can lead to cellular death and organ failure. -when you assessing the scene, do not put yourself at risk of exposure. consider toxic gas exposure if more than one patient in the same environment is experiencing the same symptoms and signs. symptoms of a patient will start to improve as soon as they are removed from toxic environment. -high flow O2 by nonrebreathing mask is the best treatment for conscious patients. patients who are unconscious or have an alerted LOC may need full airway control with insertion of an airway adjunct and BVM ventilation. in the worst cases, patients may be treated with hyperbaric or pressurized O2 therapy.

respiratory inhalation medications: Fluticasone, salmeterol

-generic name: Fluticasone, salmeterol -trade name: Advair Diskus -action: decreases secretions -treats: asthma and chronic disease

respiratory inhalation medications: Ipratropium bromide

-generic name: Ipratropium bromide -trade name: Atrovent -actions: dilates bronchioles -treats: asthma, bronchitis, COPD, and acute disease

respiratory syncytial virus (RSV)

-common cause of illness in young children. -causes an infection in the lungs and breathing passages, and can lead to other serious illnesses such as bronchiolitis and pneumonia, as well as serious heart and lung problems in premature infants and in children who have depressed immune systems -highly contagious and can be spread through droplets when a patient coughs or sneezes. can also survive on surfaces, including hands and clothing. infection tends to spread rapidly through schools and child care centers. -when you assess a child with RSV, look for signs of dehydration. infants with RSV often refuse liquids. treat airway and breathing problems as appropriate. humidified O2 is helpful.

asthma: pediatric and geriatric patients/ shortness of breath care

-common childhood illness -when you assess a pediatric patient, look for retractions of the skin above the sternum and b/w the ribs. retractions are typically easier to see in children. cyanosis is a late finding in children. -presence of a cough can indicate that some degree of reactive airway disease or acute asthma attack may be taking place. -emergency care for a child with shortness of breath is the same as for an adult. BUT many small children will not tolerate a face mask for supplemental O2. SO provide blow-by oxygen by holding the O2 mask in front of the child's face or ask the parent or caregiver to hold the mask. -many children with asthma also have prescribed hand-held MDIs. use these inhalers just as you would with an adult. more likely to use spacers to assist in inhaler use. -asthma in older people may cause bronchospasm, swelling of the lining of the airways, and an accumulation of secretions. attacks are easily triggered by air pollutants, viral infections, allergens, and sometimes something as simple as exposure to cold air. asthma can become life threatening in old people, especially in patients who have problems with airway control. condition is made worse with anxiety and dehydration, which is typical in older people. -geriatric patients with asthma tend to have both inspiratory and expiratory wheezes.

side effects: metered-dose inhaler and small-volume nebulizer

-common side effects of inhalers used for acute shortness of breath include: increased pulse rate, nervousness, and muscle tremors. -often a patient will begin coughing after administration of an inhaler as the airways are opened and secretions start to loosen and clear. -if the patient has a described MDI or small-volume nebulizer, read the label carefully to make sure that the medication is to be used for shortness of breath and that it has been prescribed by a physician.

hyperventilation: treatment

-complete a primary assessment and gather a history of the event. is the patient having chest pain? is there a history of cardiac problems or diabetes? -must always assume a serious underlying problem even if you suspect that the underlying problem is stress. -do not have the patient breathe into a paper bag. patient with a serious medical problem, this maneuver could make things worse. a patient with underlying pulmonary disease who breathes into a bag may become severely hypoxic. -treatment should consist of reassuring the patient in a clam, professional manner; supplying supplemental O2; and providing prompt transport to the ED

describe the assessment of a patient who is in respiratory distress and the relationship of assessment findings to patient management and transport decisions: Scene size up

-consider standard precautions and use of PPE -patient may have a respiratory infection that could be passed to you through sputum and or air droplets. follow local protocols -consider whether the respiratory emergency may have been caused by toxic substance that was inhaled, absorbed, or ingested. -once you have determined the scene is safe, determine how many patients there are and whether you need additional or specialized resources. -if there are multiple people with dyspnea, consider the possibility of an airborne hazardous material release -if the NOI is in question, ask why 911 was activated.

pulmonary embolism: treatment

-considerable amount of lung tissue may be not functioning so supplemental oxygen is mandatory in a patient with this condition. -place the patient is a comfortable position, usually sitting, and assist breathing if necessary. -hemoptysis, if present, is usually not severe, but any blood that has been coughed up should be cleared from the airway. -patient may have unusually rapid and possibly irregular heartbeats. -transport the patient to the ED ASAP. be aware that large pulmonary emboli may cause cardiac arrest.

medical control: metered-dose inhaler and small-volume nebulizer

-consult medical control (online) or follow standing orders (offline). -report what the medication is, when the patient last self administered a treatment, how much medication was used at that time, and what the label states regarding dosage. -if medical control or standing orders permit, you may assist the patient to self-administer the medication. -be certain the inhaler belongs to the patient, it contains the correct medication, the expiration date has not passed, and the correct dose is being administered. -prescribed dose may not be listed on the inhaler. ask the patient how many inhalations of the medication they take. administer repeated doses of the medication if the max dose has not been exceeded and the patient is still experiencing shortness of breath. -small volume nebulizer must be assembled prior to use. an O2 tank is required to administer the aerosolized medication.

CPAP treatment

-continuous positive airway pressure -noninvasive means of providing ventilatory support for patients experiencing respiratory distress associated with obstructive pulmonary disease and acute pulmonary edema. -CPAP increases pressure in the lungs, opens collapsed alveoli, pushes more O2 across the alveolar membrane, and forces interstitial fluid back into the pulmonary circulation. -CPAP systems use oxygen to deliver the positive ventilatory pressure to the patient. CPAP can be used for patients who have moderate to severe respiratory distress from an underlying disease, are alert and able to follow commands, have tachypnea, or have a pulse oximetry rate of less than 90%. -contraindication: low blood pressure. b/c of the increased pressure inside the chest, blood flow returning to the heart is diminished. CPAP should also not be used in patients in respiratory arrest or who have signs and symptoms of pneumothorax or chest trauma, a tracheostomy, have a decreased LOC, inability to follow commands, or have active gastrointestinal bleeding. -if you are authorized to apply CPAP for acute pulmonary edema according to your local protocols, do so. if not, provide prompt transport to the nearest ED. -continue to reassess patients using CPAP for signs of deterioration and or respiratory failure.

respiratory inhalation medications: Levalbuterol

-generic name: Levalbuterol -trade name: Xopenex -actions: dilates bronchioles -treats: asthma, bronchitis, COPD, and acute disease

signs and symptoms of congestive heart failure

-difficulty breathing with exertion b/c the heart cannot keep up with the body's need for O2. -patient may report a sudden attack of respiratory distress that wakes them at night when they are in a reclining position (caused by fluid accumulation in the lungs). -may report coughing, feeling suffocated, cold sweats, and tachycardia. -you might find that the patient has cool, diaphoretic, cyanotic skin and you hear adventitious breath sounds like crackles or wheezing. patient may have hypertension early, followed by the deterioration to hypotension as a late finding.

signs, symptoms, and adventitious breath sounds associated with specific respiratory diseases: Rhonchi

-disease: COPD, pneumonia, bronchitis -signs and symptoms: productive cough, fever/ pleuritic chest pain, clear or white sputum

signs, symptoms, and adventitious breath sounds associated with specific respiratory diseases: Wheezes

-disease: asthma, COPD, congestive heart failure/ pulmonary edema, pneumonia, bronchitis, anaphylaxis -signs and symptoms: dyspnea, productive or nonproductive cough, dependent edema/ pink frothy sputum, fever/ pleuritic chest pain, clear or white sputum, hives, facial swelling, stridor.

signs, symptoms, and adventitious breath sounds associated with specific respiratory diseases: decreased or absent breath sounds

-disease: asthma, COPD, pneumonia, hemothorax, pneumothorax, atelectasis -signs and symptoms: nonproductive cough/ dyspnea, productive cough, fever/ pleuritic chest pain, shock/ respiratory distress, dyspnea/ pleuritic chest pain, fever/ decreased O2 saturation

signs, symptoms, and adventitious breath sounds associated with specific respiratory diseases: crackles

-disease: congestive heart failure/ pulmonary edema, pneumonia -signs and symptoms: dependent edema/ pink frothy sputum, fever/ pleuritic chest pain

signs, symptoms, and adventitious breath sounds associated with specific respiratory diseases: stridor

-disease: croup, epiglottis -signs and symptoms: fever/ barking cough, fever/ sour throat/ drooling

upper and lower airway infection (dyspnea too)

-dyspnea associated with acute infections is common. except in patients with pneumonia, acute bronchitis, or epiglottis, it is rarely serious. -people with a common cold who have underlying problems such as asthma or heart failure may experience a worsening of their condition as a result of the additional stress of the infection. medications for colds may have stressful side effects, such as agitation, increased HR, and increased BP. -for patients with upper airway infections and dyspnea, administer humidified O2. do not attempt to suction the airway or place an oral airway in a patient with suspected epiglottis. this can cause a spasm and complete airway obstruction. transport the patient promptly to the hospital. allow the patient to sit in a position that is more comfortable. for someone with epiglottis, this is usually sitting upright and leaning forward in the "sniffing position". -to force a patient with epiglottis to lie supine may cause an upper airway obstruction and could result in death.

acute pulmonary edema (dyspnea too)

-dyspnea caused by acute pulmonary edema may be associated with cardiac disease or direct lung damage. -administer 100% oxygen and if necessary, carefully suction any secretions from the airway. -the best position for a conscious patient who has a myocardial infarction or direct lung injury is the position in which it is easiest to breathe. usually this is sitting up. -an unconscious patient with acute pulmonary edema may require full ventilatory support, including placement of an airway adjunct, positive pressure ventilation with oxygen, and suctioning.

Co2 retention and hypoxic drive

-elevated level of Co2 in their arterial blood. exhalation process may be impaired by various types of lung disease. body may produce too much Co2, either temporarily or chronically, depending on the disease or abnormality. -if over time the arterial Co2 levels rise to an abnormally high level and remain there, the respiratory centers in the brain, which sense the Co2 level and control breathing, may work less efficiently. -failure of these centers to respond normally to a rise in arterial levels of Co2 is due to chronic CARBON DIOXIDE RETENTION. brain senses the level of Co2 based on the pH in the blood and cerebrospinal fluid. when Co2 levels become elevated, the respiratory centers in the brain adjust the rate and depth of ventilation accordingly. BUT patients with chronic lung diseases have difficulty eliminating Co2 through exhalation, SO they always have higher levels of Co2. -this condition potentially alters their drive for breathing. the theory is that the brain gradually accommodates high levels of Co2 and then uses a backup system to control breathing based on low levels of O2, rather than high levels of Co2. this is called HYPOXIC DRIVE. -hypoxic drive is frequently found in end-stag chronic obstructive pulmonary disease (COPD). use caution when providing concentrations of O2 on a long-term basis to patient's with chronic lung disease, but NEVER withhold O2 therapy from a patient who needs it. -closely monitor patients who are experiencing respiratory distress, and be prepared to assist with ventilations if needed.

describe the assessment of a patient who is in respiratory distress and the relationship of assessment findings to patient management and transport decisions: Secondary assessment

-further investigate the specific chief complaint by performing a physical exam and taking vital signs -in respiratory emergencies, only proceed to history taking and the secondary assessment once all life threats have been identified and treated during primary assessment. -sometimes it is not possible to quickly and definitively determine what is causing your patient's respiratory distress. -conduct an in depth assessment when a patient reports shortness of breath. -signs of respiratory distress: air hunger, tripod position, rapid breathing, and use of accessory muscles. -restriction of the small lower airways in patients with asthma often causes wheezing patients may have prolonged expiratory phase of breathing as they attempt to exhale trapped air from the lungs. in severe cases you may not hear wheezing b/c of insufficient airflow. -as your patient tires from the effort of breathing and O2 levels drop, the respiratory and heart rates may drop, and you will notice an altered LOC. may manifest itself as confusion, lack of coordination, bizarre behavior, and even combativeness. patient may seem to relax or fall asleep. a change in affect or LOC is one of the early warning signs of respiratory inadequacy and you must act immediately. -look for overall symmetry of the chest, adequate rise and fall of the chest, and evidence of retractions or accessory muscle use. are the patient's respirations labored or unlabored? assess breath sounds, and do a physical assessment if warranted. -secondary assessment of the cardiovascular system should include checking and comparing distal pulses, reassessing skin condition, and being alert for brady and tachycardia. -feel for the skin temp and look for color changes in the extremities and in the core of the body. cyanosis is an ominous sign that requires immediate, aggressive intervention. -BP should be auscultated when possible. if you cannot hear well then palpating is an other option. -important to assess the neurologic system b/c the LOC can change. check the patient's mental status, and determine if the patients activity can be described as anxious or restless. if so, that would be an indicator of hypoxia. does the patient have clear thought processes? disorientation may be another indicator of hypoxia. -use monitoring devices if you have them. pulse oximetry is an effective diagnostic tool. measure the percentage of hemoglobin that is saturated by O2. can be an important tool in assessing oxygenation in people with normal levels of hemoglobin. can help you determine the severity of the respiratory component of the patient's problem. can give you an indication of improvement or deterioration of the patient's O2 status.

demonstrate how to use the OPQRST assessment to obtain more specific info about a patient's breathing problem

-generally used for determining the specifics of pain, can also be modified to obtain more specific info about the breathing problem. -pay close attention to OPQRST and include the following open-ended questions: 1. when did the breathing problem begin (onset) 2. what makes the breathing difficulty worse (provocation or palliation) 3. how does the breathing feel (quality) 4. how much of a problem is the patient having (severity) 5. is the problem continuous or intermittent? if it is intermittent, how frequently does it occur and how long does it last? (timing)

respiratory inhalation medications: Albuterol

-generic name: Albuterol -trade names: Proventil, Ventolin, Volmax -actions: dilates bronchioles -treats: asthma, bronchitis, COPD, acute disease

respiratory inhalation medications: Beclomethasone

-generic name: Beclomethasone -trade names: Beclovent, Beconase, Qvar, Vanceril -action: anti inflammatory, reduces swelling -treats: asthma and chronic disease

respiratory inhalation medications: Cromolyn

-generic name: Cromolyn -trade names: Intal -action: decreases release of histamines -treats: asthma and chronic disease

special patient assessment and care considerations that are required for geriatric patients who are experiencing respiratory distress

-geriatric patients have greater difficulties with the exchange of O2 and Co2. begin O2 therapy early in the assessment and treatment process in respiratory emergencies. -pertussis: in the worst cases in geriatric patients, coughing can lead to other chronic conditions, pertussis can lead to hospitalization. -for an older person, the normal process of aging creates conditions that contribute to breathing problems. weakening of the airway musculature can cause decreased breathing capacity. decreased cough and gag reflexes cause a decreased ability to clear secretions. difficulty in swallowing means the risk of aspiration is increased. older people can aspirate food or oral secretions that can develop into a life threatening aspiration pneumonia. -most geriatric patients take meds, sometimes many, to treat various ailments that are part of the aging process. some of these meds will blunt the body's normal reactions to stress and the mechanisms the body uses to compensate for respiratory compromise and hypoxia. keep this in mind when you evaluate vital signs in geriatric patients.

obstruction of the airway: treatment

-if the patient is a small child or someone who was eating just before dyspnea developed, you may assume that the problem is an inhaled or aspirated foreign body. if the patient is old enough to talk but cannot make any noise, upper airway obstruction is the likely cause. -upper airway obstruction can be partial or complete. if your patient can talk and breathe, provide supplemental O2 and transport carefully in a position of comfort to the hospital. as long as the patient is able to obtain sufficient O2, avoid doing anything that might turn a partial to a complete obstruction. -complete airway obstruction: the obstructing body must be removed before any other actions will be effective. clear the patients upper airway according to BLS guidelines. opening the airway with the head tilt-chin lift maneuver ,or the jaw-thrust maneuver for patients with spinal trauma, may solve the problem. you will have to assess the upper airway for obstruction if opening it doesn't fix the problem. administer supplemental O2 and transport the patient promptly to the ED

assessing breath sounds

-important to obtain breath sounds when you assess a patient who is experiencing respiratory distress. -listen over the bare chest. the diaphragm of the stethoscope must be in firm contact with the skin. -if your patient is lying down, bring them to a sitting position. -determine whether your patient's breath sounds are normal (vesicular breath sounds, bronchial breath sounds) or decreases, absent, or abnormal (adventitious breath sounds). -with your stethoscope, check breath sounds on the right and left sides of the chest, and compare each side. when listening on the back, place the stethoscope head b/w and below the scapulae, not over them. -listen for a full respiratory cycle so you can detect the adventitious sounds that may be heard at the end of inspiratory or expiratory phase. -when you assess for fluid collection, pay special attention to the lower lung fields. start from the bottom up and determine at which level you start hearing clear breath sounds. -you want to hear a clear flow of air in both lungs. not hearing this is considered an absent lung sound. the lack of air movement in the lungs is a significant finding. -snoring sounds are indicative of a partial UPPER AIRWAY obstruction, usually in the oropharynx. -wheezing indicates constriction and or inflammation in the bronchus. generally heard on exhalation as a high-pitched, almost musical or whistling sound. commonly heard in patients with asthma and sometimes patients with COPD. -crackles are the sounds of air trying to pass through fluid in the alveoli. typically heard on inspiration. high-pitched sounds are "fine crackles" and low-pitched sounds are "coarse" crackles. often a result of a congestive heart failure or pulmonary edema. -rhonchi are low-pitched rattling sounds caused by secretions or mucus in the larger airway. sometimes referred to as "junky" lung sounds and can be heard with infections such as pneumonia and bronchitis or in cases of aspiration. -stridor is the high-pitched sound heard on inspiration as air tries to pass through an obstruction in the UPPER AIRWAY. sound indicates a partial obstruction of the trachea and occurs in patients with anatomic or foreign body airway obstruction.

some pandemic considerations related to the spread of influenza type A and strategies EMTs should employ to protect themselves from infection during a possible crisis situation

-in patients with infectious diseases, you will be in close contact, so wear your PPE. immunizations, protective techniques, and handwashing will minimize your risk. -minimum of gloves, eye protection, and a surgical mask or high-efficiency air particulate (N-95) respirator should be mandatory. gowns can be considered too. -place a surgical mask on patients with suspected or confirmed respiratory disease. completely disinfect your unit prior to returning to service. *INFLUENZA TYPE A -an animal respiratory disease that has mutated to infect humans. pandemic arose in 2009 with the H1N1 strain. may make chronic medical conditions worse. all strains of Influenza type A are transmitted by direct contact with nasal secretions and aerosolized droplets from coughing and sneezing by infections people. -causes fever, cough, sore throat, muscle aches, headache, and fatigue; may led to pneumonia or dehydration.

questioning a patient with difficulty breathing: history taking

-in patients with respiratory distress, many of the SAMPLE questions can be answered by the family or bystanders if they are present. -limit the number of questions to pertinent ones: a patient who is in respiratory distress does not need to be using any additional air to answer questions. -ask the following questions about a patient in respiratory distress: what is the patient's general state of health? has the patient has any childhood or adult diseases? have there been any recent surgical procedures or hospitalizations? have there been any traumatic injuries? -look for meds, medical alert bracelets, environmental conditions, and other clues to what may be causing the problem.

special patient assessment and care considerations that are required for pediatric patients who are experiencing respiratory distress

-in preschool and school-aged children especially, the epiglottis can swell to 2-3 times its normal size. puts the airway at risk of complete obstruction. -treat children with this suspected diseases gently and try not to do anything that will cause them to cry. keep them in a position of comfort, and give them high-flow O2. do not put anything in their mouths, this could trigger a complete airway obstruction. -when you assess a child with RSV, look for signs of dehydration. infants with RSV often refuse liquids. treat airway and breathing problems as appropriate. humidified O2 is helpful. -young children who require hospitalization for bronchiolitis are at increased risk for developing childhood asthma. mainly supportive treatment. provide appropriate O2 therapy and allow the patient to remain in a position of comfort. reassess frequently for signs of worsening respiratory distress. be prepared to provide airway management and positive-pressure ventilation should the patient develop respiratory failure. -bacterial pneumonia results in severe symptoms more quickly including high fevers, which put the child at risk for febrile seizures. -pertussis: some infants and younger children should be treated in a hospital b/c they are at greater risk for complications like pneumonia, which occurs in children younger than 1 year. in infants younger than 6 months, this infection may be life threatening. children may vomit or do not want to eat or drink. watch for signs of dehydration. may have to suction thick secretions to clear the airway. give O2 by the most appropriate means. -asthma: highest prevalence rate is seen in children 5-17. may be allowed to assist patient with an inhaler or nebulizer. listen carefully to what a patient with asthma is telling you, they often know exactly what they need. -upper airway obstruction is common in young children, who put objects into their mouths as a way to learn about them. if you have evidence of a partial or complete airway obstruction in a young child, especially a crawling baby, consider that the child may have swallowed and choked on a small object. perform appropriate airway clearing technique specific to the age of the child. -most deaths from foreign body aspiration occur in patients who are younger than 5 years, and most of them are infants. typical items aspirated: balloons, small balls, and small parts of toys. toddlers may aspirate pieces of food like hot dogs or peanuts. -one sign of aspiration in a child may be an abnormality in the voice. the aspirated object will most likely go down the right mainstream bronchus. if the bronchus is fully obstructed, the lung could collapse. aspiration pneumonia may develop. provide O2, and transport any child with a suspected aspiration. An x-ray will be needed to confirm aspiration, its location, and the treatment.

list the characteristics of infectious diseases that are frequently associated with dyspnea

-infectious diseases causing dyspnea may affect all parts of the airway. some cause mild discomfort; others require aggressive respiratory support. -infections that impair airflow through the airways are problems of respiration. -inadequate O2 delivery to the tissues is a problem of oxygenation -infections may cause dyspnea by obstructing airflow in the larger airways due to production of mucus and secretions (colds, diphtheria) or by causing swelling of soft tissues located in the larger, upper airways (epiglottis, croup). -infections may also impair exchange of gases b/w the alveoli and the capillaries (pneumonia).

demonstrate the process of history taking to obtain more info related to a patient's chief complaint based on a case scenario

-info you obtain during history taking will be subjective (what the patient expresses, or symptoms) and objective (what you observe, or signs). -rule out any findings that warrant no care or intervention. report pertinent negatives to health care providers or ED staff members. pertinent negative is any sign or symptom that commonly accompanies a particular condition, but is absent. examples: patient who denies chest pain, or a patient with severe chest pain that denies shortness of breath. -find out what the patient has done for the breathing problem. does the patient have home O2? does the patient use a prescribed inhaler or a small-volume nebulizer? if so, when was it used last? how many doses have been taken? does the patient use more than one inhaler or treatment? be sure to record the name of each device and when it was used.

environmental/industrial exposure: treatment

-inhalation of a toxic chemical -ensure that all patients are decontaminated prior to treatment. treat with O2, adjuncts, and suction on the basis of presentation, LOC, and level of distress that is observed in the patient.

explain the physiology of respiration

-inspiration and expiration take place -O2 is provided to the blood and Co2 is removed from it. in healthy lungs this takes place rapidly at the level of the alveoli. the alveoli lie against the pulmonary capillary vessels, and as O2 enters the alveoli from inhalation, it passes freely through tiny passages in the alveolar wall into these capillaries through diffusion. -the O2 is carried to the heart, which pumps the O2 around the body. Co2 produced by the body's cells returns to the lungs in the blood that circulates through and around the alveolar air spaces. Co2 diffuses back into the alveoli and travels back up the bronchial tree and out though the upper airways during exhalation. -brain stem constantly senses the level of Co2 in the arterial blood. the level of Co2 bathing the brain stem stimulates a healthy person to breathe. if the level of Co2 drops too low, the person automatically breaths at a slower rate and less deeply. therefore less Co2 is expired, allow Co2 levels in the blood to return to normal. -some level of Co2 is necessary and helps balance pH. -if the level of Co2 in the arterial blood rises above normal, the person breaths more rapidly and deeply. when more fresh air is brought into the alveoli, more Co2 diffuses out of the bloodstream, lowering the level of Co2 in the blood.

factors that predispose patients to pneumonia

-institutional residence (nursing home or long term care facility) -recent hospitalization -chronic disease processes (such as renal failure requiring dialysis) -immune system compromise (patient receiving chemotherapy or diseases such as HIV). -history if COPD.

epiglottis

-life threatening inflammatory disease of the epiglottis, the small flap of tissue at the back of the throat that protects the larynx and trachea during swallowing. -bacterial infection is the most common cause. -most seen in infants and children -in preschool and school-aged children especially, the epiglottis can swell to 2-3 times its normal size. puts the airway at risk of complete obstruction. -condition usually develops in otherwise healthy children, symptoms: look ill, report a sore throat, high fever. often found in a tripod position and drooling. stridor is a late sign in the development of airway obstruction -treat children with this suspected diseases gently and try not to do anything that will cause them to cry. keep them in a position of comfort, and give them high-flow O2. do not put anything in their mouths, this could trigger a complete airway obstruction. -deterioration can occur quickly in adults with acute epiglottis. be concerned if your adult patient presents with stridor or any other sign of airway obstruction without any obvious mechanical cause. -focus on maintaining an adequate airway and provide prompt transport to the ED

indications and contraindications: metered-dose inhaler and small-volume nebulizer

-make sure that the medication is indicated: that the patient has signs and symptoms of shortness of breath. most common use of an MDI is asthma and a small-volume nebulizer is used in asthma, bronchiolitis, COPD, and anaphylaxis. -contraindications for its use: 1. patient is unable to help coordination inhalation with depression of the trigger on an MDI or is too confused to effectively administer medication through a small-volume nebulizer. devices will only be minimally effective when patients are in respiratory failure and have only minimal air movement. 2. the MDI or small-volume nebulizer is not prescribed for the patient 3. you did not obtain permission from medical control and or it is not permissible by local protocol 4. the patient has already met max prescribed dose before your arrival 5. the medication is expired 6. there are other contraindications specific to the medication.

emergency medical care of a person in respiratory distress

-management of respiratory distress involves continuing awareness of scene and the use of standard precautions. management of ABCs and positioning are primary treatments along with O2 and suction. -will usually administer O2. if a patient reports breathing difficulty, administer supplemental O2. adult patients breathing more than 20 breaths/min or fewer than 12 breaths/min should receive high-flow oxygen (15 L/min). -depending on level of distress, some patients may benefit from CPAP. -patients may require ventilatory support with a BVM, particularly if their mental status is declining or if they are in moderate-severe respiratory distress. -monitor respirations as you provide O2. reevaluate the respirations and the patient's response to O2 repeatedly, at least every 5 mins, until you reach the ED. in a person with chronically high Co2 levels, this is critical, b/c the supplemental O2 may cause a rapid rise in the arterial O2 level. this may depress the patient's hypoxic drive and cause respiratory arrest. -in patients who have long-standing COPD and probably carbon dioxide retention, administration of low-flow O2 (2 L/min) is a good place to start, with adjustments to 3 L/min, then 4, and so on, until symptoms have improved. -pulse oximetry will help understand the degree of o2 deprivation and adjust O2 therapy accordingly. -do not withhold O2 for fear of depressing or stopping breathing in a patient with COPD who needs oxygen. -a decreased respiratory rate after administration of O2 doesn't necessarily mean that the patient no longer needs the O2, they may need it even more. -if respirations slow and the patient become unconscious, assist breathing with a BVM. -always provide emotional support to a patient who is anxious. always speak with assurance and assume a concerned, professional approach to reassure the patient.

dose and route: metered-dose inhaler and small-volume nebulizer

-medication for an inhaler is delivered through the respiratory tract to the lung. -the dose is one puff for an MDI and continuation of the small-volume nebulizer until all the medication has been administered or the patient no longer feels the need for the meds.

actions: metered-dose inhaler and small-volume nebulizer

-most respiratory inhalation medications used relax the muscles that surround the air passages in the lungs, leading to enlargement (dilation) of the airways and easier movement of air. -medications used for acute symptoms are designed to give the patient rapid relief from symptoms if the condition is reversible. -medications used for chronic symptoms are administered for preventative measures are as maintenance doses. -medications for long term use will provide little relief of acute symptoms.

hyperventilation

-over breathing to the point that the level of arterial Co2 falls below normal. -response to illness and buildup of acids -patient with diabetes who has a high blood glucose level, a patient who has taken an OD of aspirin, a patient with severe infection, are all likely to hyperventilate. here, rapid, deep breathing is the body's attempt to stay alive. body is trying to compensate for acidosis (buildup of excess acid in the blood or body tissues that results from the primary illness). -Co2 mixed with water in the bloodstream can add to the blood's acidity, so lowering the level of Co2 helps to compensate for the other acids. -in a healthy person, blood acidity can be diminished by excessive breathing b/c it blows off too much CO2. the result is a relative lack of acids, condition called ALKALOSIS (buildup of excess base/ lack of acids in the body fluids). -alkalosis is the cause of many of the symptoms associated with hyperventilation syndrome (panic attack) including: anxiety, dizziness, numbness, tingling of the hands a feet, and painful spasms of the hands and/or feet (carpopedal spasms). patients often feel like they cannot catch their breath. -syndrome occurs in the absence of other physical problems. commonly occurs when a person is experiencing psychological stress. respirators may be as high as 40 shallow breaths/min or as low as only 20 deep breaths/min. -initially you can verbally instruct the patient to slow their breathing. if that does not work, give supplemental O2 and provide transport to the hospital where physicians will determine the cause of the hyperventilation.

examples of the common signs and symptoms of a patient with inadequate breathing may present with an emergency situation

-patient reports difficulty breathing or shortness of breath -patient has an altered mental status associated with shallow or slow breathing -adult patient appears anxious or restless; pediatric patient appears sleepy or listless -RR is too fast or too slow -breathing rhythm is irregular -skin is pale, cool, clammy, or cyanotic -adventitious breath sounds are heard, including wheezing, gurgling, snoring, crowing, or stridor (harsh, high pitched, barking sounds). -decreased or noisy breath sounds are heard on one or both sides of the chest -the patient cannot speak more than few words b/w breaths. ask the patient "how are you doing?" if the patient cannot speak at all, they most likely have a respiratory emergency -observe accessory muscle use, retractions, or labored breathing -patient has unequal or inadequate chest expansion -patent is coughing excessively -patient is sitting up, leaning forward with their palms flat on the bed or the arms of a chair. called the tripod position b/c the patient's back and both arms are working together to support the upper body. -patient has pursed lips (pursed lip breathing) or nasal flaring.

chronic obstructive pulmonary disease (COPD): treatment

-patients have an alerted LOC or may be unresponsive from hypoxia or Co2 retention. -often find breathing difficult when lying down. -assist with the patients prescribed inhaler if there is one. oftentimes a patient with COPD will overuse an inhaler, so watch for side effects. -promptly transport patients to the ED, allowing them to sit upright if this is the most comfortable

spontaneous pneumothorax: treatment

-patients may have respiratory distress, or they may have no distress at all and report only pleuritic chest pain. -provide supplemental O2, and provide quick transport to the hospital. -like most dyspneic patients, those with spontaneous pneumothorax are usually more comfortable sitting up. -monitor the patient carefully, watching for any sudden deterioration in the respiratory status. -be ready to support the airway, assist respirations, and provide CPR if necessary.

chronic respiratory conditions: history taking

-patients with chronic conditions may have long periods in which they are able to live relatively normal lives but then sometimes experience acute worsening of their conditions. -determine your patient's baseline status/ their normal condition, and what is different this time that made the patient call you. -in patients with COPD pay particular attention to the respirations. they may be rapid, or they may be very slow. -in patients with asthma it is important to try to determine what my have triggered the attack so that it can be treated appropriately. -patients with congestive heart failure usually take several meds, most often including diuretics (water pills) and blood pressure medications. obtain a list of all meds and ask about the events leading up to the present problem

Wet lungs vs. dry lungs and "cardiac asthma"

-patients with pulmonary edema caused most often by congestive heart failure will have "wet" lung sounds (rhonchi, crackles) and patients with COPD will often have "dry" lung sounds (wheezes). -cardiac asthma: bronchi are constricted which produced wheezing. the wheezing is not a form of asthma but a type of coughing or wheezing that occurs with left-sided heart failure.

differentiating COPD from congestive heart failure in patients

-patients with pulmonary edema caused most often by congestive heart failure will have "wet" lung sounds (rhonchi, crackles) and patients with COPD will often have "dry" lung sounds (wheezes). -patient's elevated blood pressure, pedal edema, jugular vein distention, and history of congestive heart failure should lead you in the direction of congestive heart failure. -a typical patient with COPD has a history of smoking -patients with COPD wheeze b/c of bronchial constriction and present with shortness of breath. their breathing gets worse and worse, and they have the most trouble breathing on exertion. patients with COPD have chronic coughing and thick sputum. usually long term smokers with thin, barrel chest appearance. meds usually include home O2, bronchodilators, and corticosteroids. -patients with COPD often have a slower onset of symptoms b/c their disease is worsened by infection and other stressors. -patients with congestive heart failure experience a fluid overload in the lung, which may develop quickly from a failing pump. -treat the patient, not the lung sounds.

describe the assessment of a patient who is in respiratory distress and the relationship of assessment findings to patient management and transport decisions: Primary assessment

-perform a rapid examination to identify immediate life threats, which includes problems with the ABCs. if any major problem is identified, treat it. if you find life threatening issues, provide rapid transport. -note your general impression of the patient. what is their age and position? a patient in significant respiratory distress will want to sit up. in a worst-case scenario, you will arrive to see the patient in a TRIPOD position. -does the patient appear to be calm? are they anxious and restless, or listless and tired? how severe is their breathing complaint? initial impression will help you decide whether the patient's condition is stable or not. -use the AVPU scale to check for responsiveness. if the patient is alert or responding to verbal stimuli, you know that the brain is still receiving O2. ask the patient about their chief complaint. if the patient is responsive only to painful stimuli or unresponsive, the brain may not be oxygenating well and the potential for an airway or breathing problem is more likely. -if there is no gag or cough reflex, you need to immediately assess the patient's airway status. within seconds you should be able to determine if there are any immediate threats to life. -if the patient's condition is unstable and there is a possible life threat, address it and proceed with rapid transport. keep scene time short, providing only life saving interventions. perform a secondary assessment en route to the hospital. if the patient's condition is stable and there are no life threats, you may decide to perform a thorough secondary assessment on scene, after obtaining the patient history.

environmental/ industrial exposure

-pesticides, cleaning solutions, chemicals, chlorine, and other gases can be accidently released and inhaled by employees. sometimes chemicals like ammonia and chlorine are mixed and create a hazardous by-product -industrial sites have their own medical, fire, and or hazardous materials teams that are familiar with all the chemicals used on their site and know what to do in case of an exposure. they will begin immediate decontamination and medical care. patients need to be decontaminated by trained responders before you take responsibility -once the patient is decontaminated, gather info from the first responders about the substance and the cause of dyspnea. assess the patient, paying special attention to breath sounds. inhalation injuries can cause aspiration pneumonia that can result in eventual pulmonary edema. inhaled substance can cause lung damage. -blood coming from the airway is an ominous sign.

spontaneous pneumothorax

-pneumothorax is a partial or complete accumulation of air in the pleural space. most often caused by trauma, but it can also be caused by some medical conditions (spontaneous). caused when air leaks into the pleural space from an opening in the chest wall or surface of the lung. the lung collapses as air fills the pleural space and the two pleural spaces are no longer in contact. -normally the vacuum pressure in the pleural space keeps the lungs inflated. when the surface of the lung is disrupted, air escapes into the pleural cavity and results in a loss of negative vacuum pressure. natural elasticity of the lung tissue causes the lung to collapse. accumulation of air in the pleural space may be mild or severe. -spontaneous pneumothorax may occur in patients with certain chronic lung infections or in young people born with weak areas of the lung. patients with emphysema and asthma are at high risk for this when a weakened portion of lung ruptures, often during severe coughing. tall, thin men are also more susceptible than the rest of the population. -patient with this has dyspnea and might report pleuritic chest pain (a sharp, stabbing pain on one side that is worse during inspiration and expiration or with certain movement of the chest wall). can listen with a stethoscope and sometimes hear that breath sounds are absent or decreased on the affected side. -spontaneous pneumothorax may be the cause of sudden dyspnea in a patient with underlying emphysema. -has the potential to evolve into a life threatening pneumothorax. -continually reassess for anxiety, increased dyspnea, hypotension, absent or severely decreased breath sounds on one side, the presence of jugular vein distention, and cyanosis.

list the structures and functions of the lungs

-principal function is the exchange of O2 and Co2.

life threats: signs and symptoms

-problems with the ABCs -poor initial general impression -unresponsiveness -potential hypoperfusion or shock -chest pain associated with a low BP -severe pain anywhere -excessive bleeding

describe the assessment of a patient who is in respiratory distress and the relationship of assessment findings to patient management and transport decisions: Reassessment

-reassess the patient and closely watch patients with shortness of breath. repeat primary assessment and maintain an open airway. monitor the patient's breathing, and reassess circulation. -determine if there have been changes in the patient's condition. confirm the adequacy of interventions and patient status. is the current treatment improving the patients condition? has an already identified problem improved? has an already identified problem gotten worse? what is the nature of any newly identified problems? -if your patient's condition gets worse, prepare to modify treatments. be prepared to assist ventilations with a BVM. monitor the skin color and temp. reassess and record vital signs ever 5 mins for an unstable patient and or after the patient uses an inhaler. -if the patients condition is stable and no life threat exists, vital signs should be obtained at least ever 15 mins. -provide interventions for the problems that are not immediate life threats. interventions may be based on standing orders, or contact the hospital and ask for specific directions. -contact medical control with any change in LOC or difficulty breathing. depending on local protocols, contact medical control prior to assisting with any prescribed meds. be sure to document any changes and what time and any orders given by medical control.

pathophysiology of respiration

-refers to conditions under which body processes are not working as they should and, as a result, interfere with normal respiration -abnormal or pathologic conditions in the anatomy of the airway, disease process, and traumatic conditions can prevent the proper exchange of O2 and Co2. the pulmonary BV themselves may have abnormalities that interfere with blood flow and thus the transfer of gases.

list the structures and functions of the upper and lower airways

-respiratory system consists of the structures of the body that contribute to the breathing process: diaphragm, the muscles of the chest wall, the accessory muscles of breathing, and the nerves from the brain and spinal cord to those muscles. -upper airway includes: nose, mouth, jaw, oral cavity, pharynx, and larynx. all the anatomic ariway structures above the level of the vocal cords. -air enters the upper airway through the nose and mouth where it is filtered, warmed, and humidified. upper airway ends at the larynx which is protected by the epiglottis: leaf shaped valve that folds over the larynx during swallowing and diverts food and fluid into the esophagus. -lower airway includes: trachea, bronchi, bronchioles, and alveoli surrounded by the pulmonary capillaries -during normal breathing, the epiglottis returns to an upright position, allowing air to flow freely b/w the vocal cords into and out of the trachea. air moves through the trachea into and out of the lungs. -to reach the lower airways, air travels through the trachea into each lung, first passing through the left and right mainstream bronchus (larger airway) then onto the bronchioles (smaller airway), and finally into the alveoli.

asthma, hay fever, and anaphylaxis

-result of an allergic reaction to an inhaled, ingested, or injected substance. -substance itself/ allergen is not the cause of the allergic reaction, rather it is an exaggerated response of the body's immune system to that substances that causes it. allergen triggers the body's immune system

secondary assessment of COPD vs Congestive heart failure

-secondary assessment may provide you with some clues -elevated BP, swollen legs and feet, indicate congestive heart failure. -patients with COPD are usually older than 50. often have a history of recurring lung problems and are almost always long-term active or former cigarette smokers. patients may report tightness in the chest and constant fatigue. b/c air has been gradually and continuously trapped in their lungs in increasing amounts, their chests often have a barrel-like appearance. -patients with COPD use accessory muscles to breathe. if you listen to the patient's chest with a stethoscope, you will heart abnormal breath sounds. they often exhale through pursed lips as a strategy to keep airways open longer. digital clubbing is a sign of COPD.

chronic obstructive pulmonary disease (COPD): chronic bronchitis and emphysema too

-slow process of dilation and disruption of the airways and alveoli caused by bronchial obstruction. -3rd leading cause of death in the US -COPD is am umbrella term used to describe a few lung diseases including emphysema and chronic bronchitis (an ongoing irritation of the trachea and bronchi). -COPD may be a result of direct lung and airway damage from repeated infections or inhalation of toxic gases and particles, but most often it results from cigarette smoking. -tobacco smoke is a bronchial irritant and can create chronic bronchitis. excess mucus is constantly produced, obstructing small airways and alveoli. protective cells and lung mechanisms that remove foreign particles are destroyed, further weakening the airways. -pneumonia develops easily when the air passages are persistently obstructed. repeated episodes of irritation and pneumonia cause scarring in the lungs and some dilation of the obstructed alveoli, leading to COPD. -emphysema is a loss of the elastic material in the lungs that occurs when the alveolar air spaces are chronically stretched due to inflamed airways and obstruction of airflow out of the lungs. smoking can also directly destroy the elasticity of the lung tissue. -lungs usually act like spongy balloons that are inflated, once they are inflated they will naturally recoil b/c of their elastic nature, expelling gas rapidly. BUT when they are constantly obstructed/ elasticity diminishes, air is longer expelled rapidly and the walls of the alveoli eventually fall apart, leaving large holes in the lung that resemble large air pockets or cavities. -most patients with COPD have elements of both chronic bronchitis and pneumonia. SO most patients with COPD will chronically produce sputum, have a common cough, and have difficulty expelling air from their lungs, with long expiration phases and wheezing. -patients may present with abnormal breath sounds like crackles, rhonchi, and wheezes, or may have severely diminished breath sound due to poor air movement.

metered-dose inhaler and small-volume nebulizer

-some of the most common meds used for shortness of breath are inhaled beta-agonists, which dilate breathing passages. -following meds may be administered via a MDI, which is a miniature spray canister used to direct such substances through the mouth and into the lungs: albuterol (Proventil, Ventolin), albuterol/ipratropium (Combivent), metaproterenol (Alupent, Metaprel), and terbutaline (Brethine). -meds typically administered by small-volume nebulizer include: albuterol, metaproterenol, and epinephrine. small-volume nebulizer works by providing means for a fine mist of aerosolized medicine to get deep into the patient's lungs and start to work quickly. patient inhales the mist through a mouthpiece. when the medicine is breathed in correctly, it goes directly to the lungs.

pleural effusion: treatment

-treatment consists of removal of fluid collected outside the lung, which must be done by a physician in a hospital. -you should provide oxygen and other routine support measures.

ventilation preacautions

-underventilation and overventilation can cause harmful alterations in the level of Co2 in the blood -avoid hyperventilation when performing BVM ventilation during CPR. can cause serious alterations in the pH, increased intrathoracic pressure, impaired venous return, and hypotension.

foreign body aspiration: treatment

-upper airway obstruction is common in young children, who put objects into their mouths as a way to learn about them. if you have evidence of a partial or complete airway obstruction in a young child, especially a crawling baby, consider that the child may have swallowed and choked on a small object. perform appropriate airway clearing technique specific to the age of the child. -consider that an object passed through the airway and has been aspirated/inhaled into the lung. -most deaths from foreign body aspiration occur in patients who are younger than 5 years, and most of them are infants. typical items aspirated: balloons, small balls, and small parts of toys. toddlers may aspirate pieces of food like hot dogs or peanuts. -one sign of aspiration in a child may be an abnormality in the voice. the aspirated object will most likely go down the right mainstream bronchus. if the bronchus is fully obstructed, the lung could collapse. aspiration pneumonia may develop. -provide O2, and transport any child with a suspected aspiration. An x-ray will be needed to confirm aspiration, its location, and the treatment. -for an older person, the normal process of aging creates conditions that contribute to breathing problems. weakening of the airway musculature can cause decreased breathing capacity. decreased cough and gag reflexes cause a decreased ability to clear secretions. difficulty in swallowing means the risk of aspiration is increased. older people can aspirate food or oral secretions that can develop into a life threatening aspiration pneumonia.

describe the primary emergency medical care of a person who is in respiratory distress: primary assessment

-use the AVPU scale to check for responsiveness. if the patient is alert or responding to verbal stimuli, you know that the brain is still receiving O2. ask the patient about their chief complaint. if the patient is responsive only to painful stimuli or unresponsive, the brain may not be oxygenating well and the potential for an airway or breathing problem is more likely. -if there is no gag or cough reflex, you need to immediately assess the patient's airway status. within seconds you should be able to determine if there are any immediate threats to life. -if the patient is in respiratory distress, place him or her in a position that best facilitates breathing (generally sitting upright in a full or semi-Fowler position) and begin administering O2 at 15 L/min via a nonrebreathing mask, unless contraindicated b/c of preexisting medical conditions. ask yourself: is the air going in? does the chest rise and fall with each breath? is the rate adequate for the age of the patient? -if the answer is no then something is wrong. try to reposition the patient and insert an oral airway to keep the tongue from blocking the airway. continue to monitor the airway for fluid, secretions, and other problems as you move on to assess the adequacy of your patient's breathing. -if the patient's condition is unstable and there is a possible life threat, address it and proceed with rapid transport. keep scene time short, providing only life saving interventions. perform a secondary assessment en route to the hospital. if the patient's condition is stable and there are no life threats, you may decide to perform a thorough secondary assessment on scene, after obtaining the patient history.

dyspnea

-when a patient reports shortness of breath or has difficulty breathing -symptom of many different conditions, from the common cold or asthma to heart failure and pulmonary embolism. -patient with dyspnea may also report the sensation of chest tightness and air hunger. air hunger is when a person reports the feeling of "not getting enough air" and has a strong need to breathe. chest tightness is described as an uncomfortable feeling in the chest, and is commonly reported by patients with asthma.

pertussis

-whooping cough -airborne bacterial infection that primarily affects children younger than 6 years. highly contagious and is passed through droplet infection. -patient will be feverish and exhibit a "whoop" sound on inspiration after a coughing attack. symptoms are similar to colds, but coughing spells can last for more than a minute during which the child may turn red or purple. -some infants and younger children should be treated in a hospital b/c they are at greater risk for complications like pneumonia, which occurs in children younger than 1 year. in infants younger than 6 months, this infection may be life threatening. -children may vomit or do not want to eat or drink. watch for signs of dehydration. may have to suction thick secretions to clear the airway. give O2 by the most appropriate means. -in adults it does not cause the typical whooping illness that it does in younger people. can cause a severe upper respiratory infection, which can lead to pneumonia in geriatric patients or people with compromised immune systems. -infection can cause coughing spells that last for weeks and can be so severe that patents find it hard to breathe, eat, or sleep. -in the worst cases in geriatric patients, coughing can lead to other chronic conditions, pertussis can lead to hospitalization.

demonstrate how to use PASTE assessment to obtain more specific info about a patient's breathing problem

1. P= progression: similar to the O in OPQRST, you want to know if the problem started suddenly or has worsened over time 2. A= associated chest pain: dyspnea can be a significant symptom of cardiac problem 3. S= sputum: has the patient been coughing up sputum? mucus-like sputum could indicate a respiratory infection, pink frothy sputum is indicative of fluid in the lungs, and a problem like pulmonary embolus may not result in any sputum at all. 4. T= talking tiredness: an indicator of how much distress the patient is in. ask the patient to repeat a sentence and see how many words they can speak without needing to take a breath. assessment results would be reported as the patient "speaks in full sentences" or "speaks in two to three word sentences" etc 5. E= exercise tolerance: ask the patient a question about what they were able to do before this problem started, like walk across the room, and then ask if the patient could do it now. if the answer is no, then it is another indicator that your patient is in distress. exercise tolerance will decrease as the breathing problem and hypoxia increase.

how to assist a patient with the administration of a metered-dose inhaler

1. follow standard precautions 2. obtain an order from medical control or local protocol 3. check that you have the right meds, right patient, right dose, and right route and that the medication is not expired 4. make sure that the patient is alert enough to use the inhaler 5. check to see whether the patient has already taken any doses 6. make sure the inhaler is at room temp or warmer 7. shake the inhaler several times 8. stop administering supplemental oxygen, and remove any mask from the patient's face 9. ask the patient to exhale deeply, and before inhaling, to put their lips around the opening of the inhaler 10. have the patient depress the hand-held inhaler as they begin to inhale deeply 11. instruct the patient to hold their breath for as long as is comfortable to help the body absorb the meds 12. continue to administer supplemental O2 13. allow the patient to breathe a few times, then repeat a second dose per direction from medical control or local protocol.

how to assist a patient with the administration of a small-volume nebulizer

1. follow standard precautions 2. obtain an order from medical control or local protocol 3. check that you have the right meds, right patient, right dose, and right route and that the medication is not expired. ensure there are no issues with contamination, discoloration, or clarity of the medication 4. make sure that the patient is alert enough to use the device 5. check to see whether the patient has already taken any treatments 6. if assisting to assemble the device, maintain aseptic technique. 7. open the medication container on the nebulizer, and insert the medication. in some cases, sterile saline may be added (about 3 mL) to achieve the optimum volume of fluid for the nebulized application. 8. attach the medication container to the nebulizer, mouthpiece, and tubing. attach oxygen tubing to the oxygen tank. 9. adjust oxygen flow to 6 L/min to establish misting effect. 10. stop administering supplemental O2 and remove nonrebreathing mask from the patient's face. 11. ask the patient to put their lips around the mouthpiece of the device, inhale the mist, and hold it for 3-5 seconds before exhaling. 12. when the mist dissipates and the medication has been used or the patient is no longer experiencing shortness of breath, discontinue use of the device 13. place the nonrebreathing mask back on the patient if the patient continues to report shortness of breath 14. reassess vital signs, and document your actions and the patient's response 15. consult with medical control and/ or follow local policy if repeated doses are necessary

as you treat patients with disorders of the lung, be aware that one or more of the following situations most likely exists:

1. gas exchange b/w the alveoli and pulmonary circulation is obstructed by fluid in the lung, infection, or collapsed alveoli (atelectasis) 2. the alveoli are damaged and cannot transport gases properly across their own walls 3. the air passages are obstructed by muscle spasm, mucus, or weakened airway walls. 4. blood flow to the lungs is obstructed by blood clots 5. the pleural space is filled with air or excess fluid, so the lungs cannot properly expand. -all of these conditions prevent the proper exchange of O2 and Co2. the pulmonary vessels themselves may have abnormalities that interfere with blood flow and thus the transfer of gases.