Ch. 17: Respiratory Emergencies

Bronchiolitis

-Bronchiolitis is an inflammation of the small airways (bronchioles) in the lower respiratory tract as a result of viral infection. -The most common source of this disease is respiratory syncytial virus (RSV), although a new virus, Metapneumovirus, has also been found to cause this illness. These viruses occur with highest frequency during the late fall and winter months and primarily affect infants and children younger than 2 years. -Severity ranges from mild to moderate respiratory distress with hypoxia and respiratory failure. -The signs and symptoms of bronchiolitis can be difficult to distinguish from those of asthma, but note the child's age. -->Asthma is rare in children younger than 1 year. -->An infant with a first-time wheezing episode occurring in late fall or winter likely has bronchiolitis. -Mild to moderate retractions, tachypnea, diffuse wheezing, diffuse crackles, and mild hypoxia are characteristic findings. -As with asthma, a sleepy or obtunded patient or one with severe retractions, diminished breath sounds, or moderate to severe hypoxia (oxygen saturation 90%) is in danger of respiratory failure and requires immediate ventilatory support and transport.

Bronchodilators

-Bronchodilators relax the smooth muscle around the larger bronchi. -Administered via so-called rescue inhalers, fast-acting bronchodilators provide almost instant relief, a property that sometimes results in their misuse. -Strictly speaking, bronchodilators do not reduce swelling, kill bacteria, push fluid out of the lungs, or open closed alveoli. However, patients with pneumonia, heart failure, or atelectasis may have a small amount of secondary bronchoconstriction that can be reversed with a bronchodilator. -In the past, the strategy was to disperse atropine (the most common parasympathetic blocker) through an aerosol. Currently, a medication specifically designed for aerosol use, ipratropium, is available. It is also available in a metered-dose inhaler (MDI). -The combination of albuterol (a beta-2 agonist) and ipratropium (an anticholinergic) is also available as a so-called premixed cocktail, as an aerosol, or as an MDI.

Carbon Dioxide Retention & Hypoxic Drive

-CO2 levels can rise for several reasons: -->Various types of lung disease may impair the exhalation process. -->The body may also produce too much carbon dioxide, either temporarily or chronically, depending on the disease or abnormality. ----If, over a period of years, arterial carbon dioxide levels rise slowly to an abnormally high level and remain there (as in late COPD), the respiratory centers in the brain, which sense carbon dioxide levels and control breathing, may work less efficiently. -The failure of respiratory centers in the brain to respond normally to a rise in arterial levels of carbon dioxide is due to chronic carbon dioxide retention. -->When carbon dioxide levels become elevated, the respiratory centers in the brain adjust the rate and depth of ventilation accordingly. -Patients with chronic lung diseases have difficulty eliminating carbon dioxide through exhalation, so they always have higher levels of carbon dioxide. -->This condition potentially alters the drive for breathing. -->Hypoxic drive occurs when the brain gradually accommodates high levels of carbon dioxide and uses a "backup system" to control breathing based on low levels of oxygen, rather than high levels of carbon dioxide. -The stimulus to breathe is the detection of low blood oxygen levels. -Giving too much oxygen to these patients may actually depress, or completely stop, the respirations. -Never withhold oxygen from a patient who needs it.

Secondary Assessment (Cont.)

-Check and compare distal pulses. -Reassess the skin condition. -Be alert for bradycardia and tachycardia. -Examine the chest for: -->Obvious signs of trauma -->Retractions -->Symmetry -Examine the extremities for skin color, condition, and temperature. Numbness, tingling, and carpopedal spasm may be associated with hypocapnia. -Auscultate blood pressure. -Feel for the skin temperature and look for color changes in the extremities and in the core of the body. -Assess the neurologic system frequently. -->Anxiousness or restlessness and disorientation are indicators of hypoxia.

Stridor

-A high-pitched sound heard on inspiration as air tries to pass through an obstruction in the upper airway -This sound indicates a partial obstruction of the trachea and is seen in patients with anatomic or foreign body airway obstruction.

Wheezing

-A high-pitched whistling sound typically heard on expiration -It indicates constriction and/ or inflammation in the bronchus. -Wheezing is common in patients with asthma and sometimes in patients with COPD. -Because of large emphysematous air pockets and diminished airflow, sounds of breathing are frequently difficult to hear and may be detected only high up on the posterior portion of the chest.

General Impression

-A patient in substantial respiratory distress will want to sit up. -->In a worst-case scenario, you will see the patient in the tripod position. -Does the patient appear calm? Is he or she anxious or restless? -Is he or she listless and tired? -How severe is his or her breathing complaint? -->This initial impression helps you decide whether the patient's condition is stable or unstable. -Use the AVPU (Awake and alert, responsive to Verbal stimuli, responsive to Pain, Unresponsive) scale to check for responsiveness. -If the patient is alert or responding to verbal stimuli, the brain is still receiving oxygen. -->Ask the patient about his or her chief complaint. -If the patient is responsive only to painful stimuli or unresponsive, the potential for an airway or breathing problem is more likely. -If there is no gag or cough reflex, immediately assess the patient's airway status.

Conditions that Impair the Neuromuscular Apparatus

-A patient who has experienced head trauma, an intracranial infection, or a brain tumor may have sustained damage to the respiratory centers of the brain, which may then compromise ventilation. Other conditions that may impair the neuromuscular apparatus include: -->Serious injury to the spinal cord (above the level of the fourth cervical vertebra [C4]) may block the nerve impulses that stimulate breathing. ->Guillain-Barré syndrome, characterized by progressive muscle weakness and paralysis advancing up the body from the feet, can result in ineffective breathing if the paralysis reaches the diaphragm. -->Amyotrophic lateral sclerosis (ALS; also known as Lou Gehrig disease) also causes progressive muscle weakness. This disease is progressive, with death usually attributable to respiratory failure as the muscles of respiration become unable to maintain adequate ventilation. -->Botulism is caused by the bacterium Clostridium botulinum. This somewhat rare disease is usually caused by food poisoning or by giving infants raw (unpasteurized) honey, which may be contaminated with spores of the bacterium. Botulism can cause muscle paralysis and is usually fatal when it reaches the muscles of respiration.

Obstruction of the Airway

-A patient with dyspnea may have a mechanical obstruction of the airway. -Always consider upper airway obstruction from a foreign body first in patients who were eating just before becoming short of breath.

Pleural Effusion

-A pleural effusion is a collection of fluid outside the lung on one or both sides of the chest. -Patients often report that their dyspnea began suddenly. -Consider pleural effusions a possibility in any patient with lung cancer and shortness of breath. -You will hear decreased breath sounds over the region of the chest where fluid has moved the lung away from the chest wall. -Patients frequently feel better if they are sitting upright.

Recognize & Treat Life Threats

-A variety of pulmonary conditions pose a high risk for death. Recognition of life threats and the initiation of resuscitation take priority over performing a detailed assessment. -Signs of life-threatening respiratory distress in adults, listed from most ominous to least severe, are as follows: -->Altered mental status -->Severe cyanosis -->Absent or abnormal breath sounds -->Audible stridor -->Two- to three-word dyspnea -->Coughing -->Tachycardia of more than 130 beats/min -->Abdominal breathing -->Change in respiratory rate or rhythm -->Pallor and diaphoresis -->The presence of retractions and/or the use of the accessory muscles -->Tripod positioning

Provide Supplemental Oxygen

-Administer oxygen in the concentrations necessary to be effective. -Patients who are not breathing adequately should receive bag-mask ventilation with supplemental oxygen, or more advanced airway management techniques. -Closely reassess the patient's breathing status and adjust treatment accordingly. -Pulse oximetry is a useful guide to oxygenation if it is accurate (the pulse rate on the oximeter matches the palpated pulse) and if the patient's hemoglobin level is relatively normal. It is safe to administer oxygen in concentrations less than 50% to almost anyone, and it is appropriate to do so when there is a reasonable chance the patient would benefit from it. -->Reserve oxygen concentrations higher than 50% for patients with hypoxia that does not respond to lower concentrations. -->Limit the use of 100% oxygen to the shortest period necessary. -After all hemoglobin in the blood has been saturated with oxygen, further exposure to high concentrations of oxygen begins to damage the lung tissue. -Most patients with good oxygen saturation (at least 94%) do not benefit from supplemental oxygen. Even patients with trauma, stroke, and acute coronary syndrome derive no benefit from supplemental oxygen therapy if oxygen saturation is already at or above 94%.It remains common practice to administer low-flow oxygen to such patients but avoid hyperoxia. -Consider the possibility that the pulse oximeter may provide falsely elevated assessment of the patient's overall level of oxygenation, such as in cases of carbon monoxide poisoning or anemia due to acute blood loss or chronic anemia. -->In such cases, providing supplemental oxygen sufficient to achieve an oxygen saturation of 100% may be extremely valuable. -Always consider insertion of an advanced airway in unresponsive patients to protect the airway. Call for paramedic backup if needed.

Aerosol Therapy

-Aerosol nebulizers deliver liquid medications in the form of a fine mist. -To generate the optimal particle size, most nebulizers need to have gas (oxygen) flow of at least 6 L/min. -A nebulizer can be attached to a mouthpiece (pipe), a face mask, or a tracheostomy collar, or it can be held in front of the patient's face (called the blow-by technique). -A quick way to provide a cooling mist to the swollen upper airway of a patient with burns or a child with croup is to give an aerosol treatment of saline solution or sterile water. -Newer aerosol bronchodilators cause less tachycardia, and repeat doses can be given. -Tachycardia is almost always already present in patients with dyspnea, so be sure to consult medical control or local protocols for guidance.

Causes of Dyspnea

-Altered mental status is a sign of hypoxia of the brain. -Patients with the following medical conditions often experience breathing difficulty or hypoxia: -->Pulmonary edema -->Hay fever -->Pleural effusion -->Obstruction of the airway -->Rib fractures (flail segment) -->Cystic fibrosis -->Hyperventilation syndrome -->Prolonged seizures -->Neuromuscular disease (such as multiple sclerosis or muscular dystrophy) -->Environmental or industrial exposure to toxic gases -->Carbon monoxide poisoning -->Drug overdose -As you treat patients with disorders of the lung, one or more of the following situations likely exists: -->Gas exchange between the alveoli and pulmonary circulation is obstructed by fluid in the lung, infection, or collapsed alveoli (atelectasis). -->The alveoli are damaged and cannot transport gases properly across their own walls. -->The air passages are obstructed by muscle spasm, mucus, or weakened airway walls. -->Blood flow to the lungs is obstructed by blood clots. -->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 oxygen and carbon dioxide. In addition, the pulmonary blood vessels may have abnormalities that interfere with blood flow and transfer of gases. -Besides shortness of breath, a patient with dyspnea may also report the sensation of chest tightness and air hunger. -Dyspnea is a common complaint in patients with cardiopulmonary diseases. -->One condition commonly associated with heart failure is pulmonary edema. -Severe pain can cause a patient to experience rapid, shallow breathing without the presence of a primary pulmonary dysfunction.

Gas Exchange Interface

-Alveoli are made up of two types of cells: -->Type I alveolar cells (pneumocytes) are almost empty, allowing for better gas exchange. They lack cellular components that would permit them to reproduce. -->Each alveolus has several type II pneumocytes, which can make new type I cells and produce a substance known as surfactant, which reduces surface tension and helps keep the alveoli expanded. -By reducing the surface tension of the alveoli, surfactant makes it easier for them to expand. -Collapsed, fluid-filled, or pus-filled alveoli do not participate in gas exchange. -->Blood from the right side of the heart bypasses the alveoli and returns to the left side of the heart in an unoxygenated state, resulting in hypoxemia. -People with chronic lung disease and chronic hypoxia often generate a surplus of red blood cells over time, which makes their blood thick (polycythemia). -Right-side heart failure because of chronic lung disease is known as cor pulmonale.

Airway Obstruction

-Always consider upper airway obstruction from a foreign body first when a young child becomes short of breath. This is especially true of crawling babies, who might have swallowed and choked on a small object. -Inflammation of the tonsils may partially occlude the airway, creating an obstruction. -Dysfunction of a tracheostomy may create an upper airway obstruction, especially if plugged with mucus or other secretions. -The obstruction may be in the lower airway, below the vocal cords. -Trauma to the trachea may result in a crushing injury, fractured larynx, or edema that obstructs the lower airway. -Obstruction may also be in the form of obstructive lung disease, mucus accumulation, or smooth muscle spasm. -Edema also may be present when a patient has been exposed to toxic chemicals or superheated air, as in a structural fire.

Metered-Dose Inhalers

-An MDI is a miniature spray canister used to direct medication through the mouth and into the lungs. -Each MDI on the ambulance should ideally be equipped with a spacer.

Pulmonary Embolism

-An embolus is anything in the circulatory system that moves from its point of origin and travels to a distant site where it lodges, obstructing blood flow. -A pulmonary embolism is a blood clot (thrombus) formed in a vein, usually in the legs or pelvis, that breaks off and circulates through the venous system. -As a result of the ventilation-perfusion mismatch, the level of arterial carbon dioxide rises, and the oxygen level may drop substantially.

Anaphylactic reactions

-Anaphylaxis is a severe allergic reaction characterized by airway swelling and dilation of blood vessels all over the body. -->May substantially lower blood pressure -Anaphylactic shock may cause respiratory distress that is severe enough to result in coma and death. -Anaphylaxis is associated with: -->Widespread hives (urticaria) -->Itching -->Signs of shock -->Signs and symptoms similar to those of asthma -->Airway swelling -Most anaphylactic reactions occur within 30 minutes of exposure to the allergen.

Anticholinergics

-Anticholinergics have emerged as a central component in the management of COPD. -Tiotropium (Spiriva), a once-per-day anticholinergic for this indication, is taken via a type of dry-powder inhaler. -Patients taking tiotropium would not typically also use aerosol ipratropium.

Expiration

-As the chest expands, mechanical stretch receptors in the chest wall and bronchioles send a signal to the apneustic center via the vagus nerve to inhibit the inspiratory center, and expiration occurs. -This feedback loop, a combination of mechanical and neural control, is known as the Hering-Breuer reflex and terminates inhalation to prevent overexpansion of the lungs. -The diaphragm and intercostal muscles relax, moving the ribs down and in and the diaphragm back into its dome shape, which increases intrapulmonary pressure. The natural elasticity, or recoil, of the lungs passively removes the air. -Normal expiratory reserve volume, the amount of air that can be exhaled following normal exhalation, is about 1,200 mL. -->Normally, expiration lasts twice as long as inspiration. -->This relationship is expressed by the inspiratory/expiratory (I/E) ratio; a normal I/E ratio is 1:2. -When a patient's lower airway is obstructed and he or she has difficulty getting air out (such as in asthma), the expiratory phase is prolonged and may be four to five times as long as inspiration. -->In the case of a patient with asthma, the I/E ratio would be 1:4 or 1:5. -->In a patient with tachypnea (rapid respiratory rate), the expiratory phase is short and approaches that of inspiration; the I/E ratio may be 1:1.

Evaluate Circulation

-Assess the pulse rate, rhythm, and character. -->Tachycardia or bradycardia indicates the patient may not be getting enough oxygen. -->An increased pulse rate is the body's way of responding to respiratory distress and can be an indicator of shock. -->Tachycardia is also a normal response to pain, fear, excitement, and exertion. -Assess 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 oxygen. -->Assess capillary refill in infants and children. Capillary refill is not considered a reliable assessment tool in the adult patient. -Assess perfusion by evaluating skin color, temperature, and condition.

Asthma

-Asthma is an acute spasm of the bronchioles associated with excessive mucus production and spasm of the bronchiolar muscles. -Asthma is a reversible obstruction that is caused by a combination of: -->Smooth-muscle spasm (bronchospasm) -->Mucus production -->Edema -Status asthmaticus is a severe, prolonged asthma attack that cannot be resolved with conventional treatment. -Asthma produces a characteristic wheezing, indicative of a narrowed lower airway. -->Wheezing is heard only on exhalation. -->Audible wheezing can be heard without a stethoscope. -->Continuous wheezing occurs during inspiration and expiration and is generally diffuse. -->Silent chest occurs when the airways are so blocked that no air movement is heard. -Cyanosis, respiratory arrest, or both may develop. -Most patients with asthma are familiar with their symptoms and know when an attack is imminent.

Assessing Breath Sounds

-Auscultate breath sounds over the bare chest. -Bring the patient to a sitting position. -You need to determine whether your patient's breath sounds are normal or adventitious. -->Normal breath sounds: -----Vesicular breath sounds represent air moving in and out of the alveoli. -----Bronchial breath sounds represent air moving through the bronchi). -->Adventitious breath sounds include decreased, absent, or abnormal sounds. -With your stethoscope, check breath sounds on the right and left sides of the chest and compare each side. -When listening on the patient's back, place the stethoscope head between and below the scapulae. -Listen for a full respiratory cycle. -Pay special attention to the lower lung fields. -Start from the bottom up and determine at which level you start hearing clear breath sounds. -->The lack of air movement in the lung is a substantial finding.

Chronic Obstructive Pulmonary Disease

-Chronic obstructive pulmonary disease (COPD) is a slow process of dilation and disruption of the airways and alveoli caused by chronic bronchial obstruction. -COPD is an umbrella term used to describe lung diseases, including chronic bronchitis. -Obstruction occurs in the bronchioles. -Chronic bronchitis results from overgrowth of the airway mucous glands and excess secretion of mucus -Pneumonia develops when the passages are persistently obstructed. -The patient in an acute COPD episode will: -->Complain of shortness of breath with gradually increasing symptoms over a period of days -->Often exhale through pursed lips -->Complain of tightness in the chest and constant fatigue -->Have a barrel-like chest -->Have abnormal breath sounds

Secondary Assessment

-Conduct an in-depth assessment when a patient reports shortness of breath. -Signs include: -->Air hunger -->Tripod positioning -->Rapid breathing -->Use of accessory muscles -->Wheezing -->Prolonged expiratory phase -A change in mental status is one of the early warning signs of respiratory inadequacy and indicates a lack of perfusion to the brain. -Look for: -->Overall symmetry of the chest -->Adequate rise and fall of the chest -->Evidence of retractions or accessory muscle use -->Increased work of breathing -Assess breath sounds and do a physical assessment, if warranted. -A slowing respiratory rate in the face of an unimproved condition suggests physical exhaustion and impending respiratory failure.

Patient Assessment:

-Consider standard precautions and use of PPE. -Follow local protocols. -Ensure a safe environment for all EMS personnel before making patient contact. -Determine how many patients there are and whether you need additional or specialized resources. -Determine the NOI.

MDI (Cont.)

-Contraindications for the use of an MDI include the following: -->The patient is unable to help coordinate inhalation with depression of the trigger on an MDI or is too confused to effectively administer medication through a small-volume nebulizer. These devices will be only minimally effective when patients are in respiratory failure and have only minimal air movement. -->The MDI or small-volume nebulizer is not prescribed for this patient. -->You did not obtain permission from medical control and/or it is not permissible by local protocol. -->The patient had already met the maximum prescribed dose before your arrival. -->The medication is expired. -->There are other contraindications specific to the medication. -About 5 minutes after the patient uses an inhaler, repeat the vital signs and the primary survey. -Be prepared to assist ventilations with a bag-mask device if the patient's condition deteriorates. -Transport the patient to the closest, most appropriate emergency department. -Using MDIs as well as administering nebulized treatments may be done en route.

Crackles

-Crackles (rales) are sounds of air trying to pass through fluid in the alveoli. -They are usually related to chronic scarring of small airways. -It is a crackling or bubbling sound typically heard on inspiration. -There are high-pitched sounds called fine crackles and low-pitched sounds called coarse crackles. -These sounds are often a result of heart failure, pulmonary edema, or fluid in the lungs caused by heart failure.

Croup

-Croup is caused by inflammation and swelling of the pharynx, larynx, and trachea. -This disease is often secondary to an acute viral infection of the upper respiratory tract and is typically seen in children between ages 6 months and 3 years. It is easily passed between children. -The disease starts with a cold, cough, and low-grade fever that develop over 2 days. -The hallmark signs of croup are stridor and a seal-bark cough, which signal a substantial narrowing of the air passage of the trachea that may progress to marked obstruction. -Peak seasonal outbreaks occur in the late fall and during the winter. -Croup is rarely seen in adults because their breathing passages are larger and can accommodate the inflammation and mucus production without producing symptoms. -->The airways of adults are wider, and the supporting tissue is firmer than in children. -Croup often responds well to the administration of humidified oxygen.

Cystic Fibrosis

-Cystic fibrosis (CF) is a genetic disorder that affects the lungs and digestive system. -A defective gene makes it difficult for chloride to move through cells, causing unusually high sodium loss and abnormally thick mucus secretions. -The patient is highly susceptible to infection. In CF, the child's symptoms range from sinus congestion to wheezing and asthma-like complaints. -The child may: -->Have a chronic cough that produces thick, heavy, discolored mucus -->Present with tachypnea, shortness of breath, barrel chest, clubbed fingers, and cyanosis -->The thick mucus may also collect in the intestines. -->Have dyspnea -Treat the child with suction and oxygen using age-appropriate adjuncts.

COPD (Cont.)

-Emphysema is a degenerative condition characterized by destruction of the alveolar walls related to the destruction of pulmonary surfactant. -When the lungs are constantly obstructed or when the elasticity is diminished, the walls of the alveoli eventually fall apart, leaving large "holes." -Emphysema is an irreversible condition whose progression can be slowed. -Emphysema: -->Makes the alveoli susceptible to collapse (atelectasis) -->Stimulates the production of red blood cells, sometimes in excessive quantity (polycythemia) -Most patients with COPD have elements of both chronic bronchitis and emphysema. -Patients: -->Produce sputum -->Have a chronic cough -->Have difficulty expelling air from their lungs, with long expiration phases and wheezing

End-Tidal Carbon Dioxide Detector

-End-tidal carbon dioxide (ETCO2) monitoring is a method for measuring the amount of exhaled carbon dioxide. -ETCO2 monitoring is accomplished with a device that measures the amount of carbon dioxide exhaled during a specific time (minutes or hours) and plots the resulting values graphically as a waveform, as well as giving numeric readouts. -The exact percentage of carbon dioxide contained in the last few milliliters of the patient's exhaled air can be measured using a special sensor. -Some electronic ETCO2 detectors use a photoelectric sensor that relies on absorption of infrared light by carbon dioxide to provide this measurement. The sensor can evaluate ETCO2 in a spontaneously breathing patient via a specialized nasal cannula-type device, or it can be attached to the end of an endotracheal tube. -->These devices typically display a waveform that can provide additional data about the patient's respiratory status. -->Such monitors serve as alarms that can alert providers to changes in respiratory rate or depth. This kind of monitoring is called waveform capnography. -The ETCO2 value can be dramatically affected by the rate and depth of ventilation. The ultimate value of this parameter depends on a provider's ability to maintain ventilation at recommended levels (8 to 10 breaths/min at 6 to 7 mL/kg in an adult in a state of cardiac arrest).

Epiglottitis

-Epiglottitis is a life-threatening inflammatory disease of the epiglottis. It is usually caused by a bacterial infection that produces severe swelling of the flap over the larynx. -Although epiglottitis may be seen at any age, it is more predominant in children. The development of a childhood vaccine against Haemophilus influenzae has dramatically decreased the incidence of this disease. -In preschool and school-aged children especially, the epiglottis can swell to two to three times its normal size, putting the airway at risk of complete obstruction. -Epiglottitis usually has a sudden onset in an otherwise healthy child; children with this infection look ill, complain of a very sore throat, and have a high fever. They will usually be in the tripod position and drooling. Patients may also have stridor. -Occasionally, the constellation of symptoms can also appear in an adult or a geriatric patient, especially if the patient has other issues such as diabetes. -In adults, epiglottitis, or supraglottitis, can be caused by different bacterial or viral organisms. -->Acute epiglottitis in an adult or geriatric patient can be potentially life threatening and not recognized because it more commonly occurs in pediatric patients. -->Deterioration can occur quickly in adults with acute epiglottitis. -->Be concerned if your patient is an adult presenting with stridor or any other sign of anatomic airway obstruction.

History Taking (Cont.)

-Find out what the patient has already done for the breathing problem. -Pay close attention to the medications the patient is currently taking. -Reassess breathing frequently and be prepared to assist ventilation in severe cases. -Find out whether the patient has any allergies or history of medication reactions. -Use the OPQRST-I mnemonic to determine the specifics of pain and obtain specific information about the breathing problem: -->When did the breathing problem begin (Onset)? -->What makes the breathing difficulty worse or better (Provocation or palliation)? -->How does the breathing feel (Quality)? -->Does the discomfort move (Radiation/region)? -->How much of a problem is the patient having (Severity)? -->On a scale of 1 to 10, with 10 being the worst pain the patient has ever had, how bad is it? -->Is the problem continuous or intermittent? -->If it is intermittent, how frequently does it occur and long does it last (Timing)? -->What has been done to alleviate the problem prior to EMS arrival (Interventions)? -->Any medications taken? -Other questions to ask include the following: -->Does the patient have a cough? Is it productive or nonproductive? If it is productive, what color is the sputum? -->Is there any hemoptysis? Wheezing? Fever? Chills? -->Any increased sputum production? -->Has there been any exposure to smoke or does the patient have a history of smoking?

Gas Exchange

-Gas exchange is the process by which deoxygenated blood from the pulmonary circulation releases carbon dioxide and is resupplied with oxygen before it enters the cardiac circulation. -This process occurs at the level of the alveoli, the tiny air sacs clustered around the terminal bronchioles in the lungs. -->These terminal bronchioles are very thin and have little structure. This is helpful for gas exchange, but it also means that these bronchioles lack cilia, a mucous blanket, smooth muscle, or rigid structures.

Conditions that Impair the Mechanics of Breathing

-Gas flow can be suppressed by a high cervical fracture with chest wall paralysis, flail chest, diaphragmatic rupture, severe retractions, an abdomen full of air or blood, abdominal or chest binding (using a pneumatic antishock garment or immobilization straps), and anything else that restricts the pressure changes that facilitate respiration. -Obesity hypoventilation syndrome (also known as pickwickian syndrome) is respiratory compromise related to morbid obesity.

Hyperventilation

-Hyperventilation is defined as overbreathing to the point that the level of arterial carbon dioxide falls below normal. -->For example, a patient with diabetes who has an extremely high blood glucose level, a patient who has taken an overdose of aspirin, or a patient with a severe infection is likely to hyperventilate. -Rapid, deep breathing is the body's attempt to compensate for acidosis. -Lowering the level of carbon dioxide helps to compensate for the other acids. -Tachypnea without physiologic demand for increased oxygen causes respiratory alkalosis. -Alkalosis is the cause of many of the symptoms associated with hyperventilation syndrome (panic attack), including: -->Anxiety -->Dizziness -->Numbness -->Tingling of the hands and feet (which can progress to carpopedal spasm) -->A sense of dyspnea despite the rapid breathing -Hyperventilation syndrome occurs in the absence of other physical problems. -The respirations of a person experiencing hyperventilation syndrome may be as high as 40 shallow breaths/min or as low as only 20 very deep breaths/min.

Chronic Respiratory Conditions

-If the patient is able to cough up sputum, it will be thick and is often green or yellow. -The blood pressure of patients with COPD is normal. -The pulse is rapid and occasionally irregular. -Pay particular attention to the respirations. -Patients with asthma may have different "triggers," including: -->Allergens -->Cold -->Exercise -->Stress -->Infection -->Noncompliance with medication prescriptions -Try to determine what may have triggered the attack so that it can be treated appropriately. -Obtain a list of all their medications and pay special attention to the events leading up to the current problem.

Upper & Lower Airway Infection

-Infectious diseases causing dyspnea may affect all parts of the airway. -->Infections that impair airflow through the airways are problems of respiration. -->Inadequate oxygen delivery to the tissues is a problem of oxygenation. -Infections may cause dyspnea by the following mechanisms: -->Obstructing airflow in the larger airways as a result of the production of mucus and secretions (colds, diphtheria) -->Causing swelling of soft tissues located in the larger, upper airways (epiglottitis, croup) -->Impairing exchange of gases between the alveoli and the capillaries (pneumonia)

Administer a Bronchodilator

-Many patients with respiratory distress receive some benefit from bronchodilation. -Today's aerosol bronchodilators rarely harm patients, so AEMTs tend to use them aggressively in the field. -Patients who do not have bronchospasm usually benefit only slightly from aerosol bronchodilators, and the oxygen concentration delivered is often reduced during a typical aerosol treatment. -->Under these circumstances, application of a nonrebreathing mask is a better choice than the aerosol treatment. -Follow local protocol, but remember bronchodilators are of little value in treating conditions such as pneumonia, pulmonary edema, and heart disease.

Reassessment

-Monitor the patient's breathing and reassess circulation. -Be prepared to assist ventilations with a BVM. -Monitor the skin color and temperature. Reassess and record vital signs at least every 5 minutes for a patient in unstable condition and/or after the patient uses an inhaler. -->If the patient's condition is stable and no life threat exists, obtain vital signs at least every 15 minutes. -Contact medical control with any change in level of consciousness or difficulty breathing. -Document any changes (and at what time) and any orders given by medical control.

Hypoventilation

-The excess carbon dioxide combines with water to form bicarbonate ions and hydrogen (H+) ions, also known as carbonic acid (HCO). -The result is respiratory acidosis. -->Acidosis can occur if hypoventilation is not recognized. -pH is an inverse expression of how many free hydrogen ions (H+) are in a solution. -->Patients who are hyperventilating usually have respiratory alkalosis with a high pH. -->Patients who are hypoventilating usually have respiratory acidosis.

Decrease the Work of Breathing

-Muscles must work much harder during respiratory distress. The tremendous workload uses large amounts of energy, which requires even more oxygen and ventilation. -At some point, the patient will tire and be unable to continue the necessary work of breathing; he or she will look sleepy, the rate and depth of respirations will slowly decrease, and he or she will experience decompensation (respiratory failure). -The supine position with or without the legs raised, especially for an overweight patient, causes the abdominal organs to compress the diaphragm. With each breath, the patient must move the abdominal contents out of the way to expand the thorax and breathe. Abdominal distention with air or blood compounds the situation. -->Shortness of breath induced by lying flat is called orthopnea. It explains why most people maintain a sitting position when they are short of breath. -To decrease the work of breathing, help the patient sit up if he or she is more comfortable in that position. -Remove constricting clothing, such as belts and tight collars. -Do not make the person walk.

History Taking

-Obtain the SAMPLE history (Signs and symptoms, Allergies, Medications, Pertinent past medical history, Last oral intake, Events leading up to the illness or injury) from the family or bystanders. -Be sure to ask the following questions about a patient in respiratory distress: -->What is the patient's general state of health? -->Has the patient had any childhood or adult diseases? -->Have there been any recent surgeries or hospitalizations? -->Have there been any traumatic injuries? -->Is there any dyspnea or chest pain? -Ask about previous episodes, medication allergies, and current medications. -Try to learn whether the problem is related primarily to ventilation, diffusion, perfusion, or a combination.

Neuromuscular Impairment

-Overdose -Lou Gehrig Disease (amyotrophic lateral sclerosis) -Carbon Dioxide Narcosis

Perform Standard Interventions

-Perform standard interventions -Oxygen to keep the saturation above 94% and an intravenous line are typical interventions for any patient who needs advanced life support. -Psychological support is also an important consideration for a patient with dyspnea. -->Always speak with assurance and assume a calm, professional, and caring demeanor to reassure the patient. Your efforts to reduce the patient's anxiety can help lower the patient's heart rate and blood pressure and allow the patient to maximize breathing effectiveness.

Pertussis

-Pertussis (whooping cough) is an airborne bacterial infection that primarily affects children younger than 6 years. It is highly contagious and is passed through droplet infection. -->In infants younger than 6 months, pertussis can be life threatening. -A patient with pertussis will be feverish and exhibit a "whoop" sound on inspiration after a coughing attack. -Symptoms are generally similar to those of colds, and you should look for signs of dehydration. -The coughing spells can last for more than 1 minute, during which the child may turn red or purple. -Pertussis in adults does not cause the typical whooping illness that it does in infants and toddlers but can cause severe coughing spells that can actually result in fracture of the ribs, and if the patient is already weak, pertussis can result in hospitalization.

Pleural Friction Rub

-Pleural friction rub is a squeaking or grating sound that occurs when the pleural linings rub together. -If this occurs, the pleural layers have lost their lubrication, most commonly because of pleural inflammation. -This condition is usually associated with pain on inspiration. -The sounds may be heard anytime the chest wall moves; therefore, they can be heard on inspiration, expiration, or both.

Pneumonia

-Pneumonia is a ventilation disorder caused by an infection of the lung parenchyma. -It is the eighth leading cause of death in the United States and is not a single disease, but a group of specific infections. -->Young children are at risk for pneumonia because of their immature immune systems. -->Older adults are also at risk because of age-related weakening of the immune system. -Pneumonia presents as a localized infection in the lungs that may cause atelectasis, or alveolar collapse. -If not treated promptly, the infection may become systemic, resulting in sepsis and septic shock. -Typical findings include: -->An acute onset of fever and chills -->Productive cough with purulent (thick) sputum -->Pleuritic chest pain -->Excessive mucus causing pulmonary consolidation that may be detected by auscultation in the form of rales or rhonchi

Chest Wall Impairment

-Pneumothorax -Flail Chest -Pleural Effusion -Restrictive Disease (scoliosis, kyphosis)

Spontaneous Pneumothorax

-Pneumothorax is the partial or complete accumulation of air in the pleural space. -->Most often caused by trauma -Spontaneous pneumothorax can be caused by some medical conditions without any injury. -Patients with emphysema and asthma are at high risk for spontaneous pneumothorax. -A patient with a spontaneous pneumothorax: -->Becomes acutely dyspneic -->Complains of pleuritic chest pain -->Presents with subcutaneous emphysema -->Has breath sounds that are absent or decreased on the affected side -Patients experiencing minor problems may be pale, diaphoretic, and tachypneic. -Severe findings include: -->Altered mental status -->Cyanosis -->Tachycardia -->Unilaterally decreased breath sounds -->Local hyperresonance to percussion -->Subcutaneous emphysema -->Tracheal deviation is a late sign.

Acute Pulmonary Edema

-Pulmonary edema is the collection of fluid in the lungs. -Severe myocardial damage caused by an acute problem (such as acute myocardial infarction) or a chronic problem (such as cardiomyopathy) results in reduced contractile force of the myocardium. -Fluid backs up into the alveoli and in the lung tissue between the alveoli and the pulmonary capillaries. -The patient usually experiences dyspnea with rapid, shallow respirations. -->In the most severe instances, you will see frothy pink sputum at the nose and mouth. -Patients with pulmonary edema that is cardiogenic in origin may present with signs and symptoms of a cardiac emergency. -Patients with non-cardiogenic pulmonary edema tend to have a history of associated factors such as: -->A hypoxic episode -->Shock -->Chest trauma -->Recent acute inhalation of toxic gases or particles -->Recent ascent to a high altitude without acclimatizing -Patients may also present with: -->Orthopnea (severe dyspnea experienced when lying down or in a position that is not upright, and relieved by sitting or standing up) -->Fatigue -->Reduced exercise capacity --.Pulmonary crackles (formerly known as rales)

Pulmonary Embolism (Cont.)

-Pulmonary emboli may occur as a result of damage to the lining of vessels, causing: -->Platelet aggregation -->A tendency for blood to clot unusually fast (hypercoagulability) -->Slow blood flow in a lower extremity -Risk factors include: -->Recent surgery -->Pregnancy -->Oral contraceptives -->Smoking -->Infection -->Cancer -->Sickle cell anemia -->Prolonged inactivity -Signs and symptoms, when they occur, include: -->Dyspnea -->Tachycardia -->Tachypnea -->Varying degrees of hypoxia -->Cyanosis -->Acute chest pain -->Hemoptysis (coughing up blood) -The chief complaint is usually a sudden onset of inspiratory chest pain, dyspnea, and nonproductive cough.

Respiratory Syncytial Virus

-RSV is a common cause of illness in young children. -It causes an infection in the lungs and breathing passages and can result in other serious illnesses such as bronchiolitis and pneumonia, as well as serious heart and lung problems in premature infants and children who have depressed immune systems. -RSV is highly contagious and can be spread through droplets when the patient coughs or sneezes. -The virus can survive on surfaces, including hands and clothing, so the infection tends to spread rapidly through schools and in child care centers. -RSV can cause severe upper respiratory infections and typical asthma symptoms in adults and geriatric patients.

Rhonchi

-Rhonchi are lower-pitched sounds caused by secretions or mucus in the larger airway. -The sound resembles rattling. -This can be heard with infections such as pneumonia, bronchitis, or in cases of aspiration.

Snoring

-Snoring sounds are indicative of a partial upper airway obstruction, usually in the oropharynx.

Inhaled Beta Agonists

-Some of the most common medications used for dyspnea are called inhaled beta agonists, which, through stimulation of selective beta-2 receptors in the lungs, dilate the bronchioles. -Typical trade names are Proventil, Ventolin, Alupent, Metaprel, and Brethine. -->The generic name for Proventil and Ventolin is albuterol; for Alupent and Metaprel, it is metaproterenol; and for Brethine, it is terbutaline. -The action of most of these medications is to relax the smooth muscles within the bronchioles in the lungs, resulting in enlargement (dilation) of the airways and easier passage of air.

Heart Failure

-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 lung as fast as the right side delivers it, so fluid builds up within the alveoli and in the lung tissue between the alveoli and the pulmonary capillaries. This accumulation of fluid is referred to as pulmonary edema, and it is usually a result of heart failure. -Patient risk factors for heart failure include hypertension and a history of coronary artery disease and/or atrial fibrillation. -In most cases, patients have a long-standing history of chronic heart failure that can be controlled with medication. -An acute onset may occur if the patient stops taking the medication; eats food that is too salty; or has a stressful illness, a new heart attack, or an abnormal heart rhythm. -Signs and symptoms include: -->Difficulty breathing with exertion because the heart cannot keep up with the body's need for oxygen -->A sudden attack of respiratory distress that wakes the patient at night when he/she is in a reclining position -->Coughing -->Feeling suffocated -->Cold sweats -->Tachycardia

Peak Flow Meter

-The peak flow meter provides a baseline assessment of expiratory airflow for patients with obstructive lung disease. -The peak flow is the maximum flow rate at which a patient can expel air from the lungs. -->Normal peak flow values vary by age, sex, and height, but generally range from approximately 350 to 700 L/min. -->A peak flow less than 150 L/min is considered inadequate and signals substantial distress. -->Some people with chronic asthma have a peak flow that never exceeds 100 L/min. -Many patients with chronic pulmonary diseases may already use a peak flow meter at home. Encourage these patients to take their records and medications with them to the hospital for evaluation of the progression of their illness.

Respiration

-The principal function of the lungs is respiration, the exchange of oxygen and carbon dioxide. -The two processes that occur during respiration are inspiration (inhaling) and expiration (exhaling). -Ventilation is the mechanical process of moving air into and out of the lungs for gas exchange. -During pulmonary respiration, oxygen entering the alveoli from inhalation passes through tiny passages in the alveolar wall into the capillaries, which carry the oxygen to the heart. The heart, in turn, pumps oxygenated blood throughout the body. -Carbon dioxide produced by the body's cells returns to the lungs in the blood that circulates through and around the alveolar air spaces. -The carbon dioxide diffuses back into the alveoli and travels back up the bronchial tree and out the upper airways during exhalation. -Carbon dioxide is "exchanged" for oxygen, which travels in exactly the opposite direction (during inhalation).

Pulmonary Circulation

-The pulmonary circulation begins at the right ventricle, where the pulmonary artery (the only artery that primarily carries deoxygenated blood) branches into increasingly smaller vessels until the pulmonary capillary bed surrounds the alveoli and terminal bronchioles. -There is substantially more circulation to the lung bases than there is to the lung apices. -Because humans are upright, gravity-dependent creatures, most infections and pathologic conditions occur at the base of the lung.

The Respiratory System

-The respiratory system consists of all the structures of the body that contribute to the breathing process. -The upper airway includes all anatomic airway structures above the level of the vocal cords.

Inspiration

-The stimulus to breathe comes from the respiratory center in the medulla. The involuntary control of breathing originates in the brainstem, specifically in the pons and medulla. -The impulses for automatic breathing descend through the spinal cord and can be overridden (to a point) by voluntary control. -The motor nerves of respiration are the phrenic nerves, which innervate the diaphragm, and the intercostal nerves, which innervate the external intercostal muscles (muscles between the ribs). -During inspiration, the diaphragm and intercostal muscles contract, causing the diaphragm to flatten and the ribs to move up and out. The combined actions of these structures enlarge the thorax in all directions, causing intrapulmonary pressure to fall slightly below atmospheric pressure (the air pressure outside the body). -As the diaphragm and intercostal muscles contract and the thoracic cage expands, air pressure within the thorax decreases, creating a slight vacuum. This pulls air in through the trachea and fills the lungs, inflating the alveoli. -When the air pressure outside the thorax equals the air pressure inside the thorax, air stops moving, and a person stops inhaling. -Oxygen and carbon dioxide are then able to diffuse across the alveolar membrane from an area of higher pressure to an area of lower pressure until the pressures are equal. -Normal inspiratory reserve volume, the amount of air that can be inhaled in addition to normal tidal volume (about 500 mL), is about 3,000 mL in a typical adult male and 2,300 mL in a typical adult female.

Conditions that Reduce Respiratory Drive

-The stimulus to breathe is often called respiratory drive. Anything that interrupts or decreases the involuntary stimulus to breathe can result in hypoventilation or even apnea. -The most common hypoventilation crisis EMS providers see is acute opioid narcotic overdose (heroin, for example). -Intoxication with alcohol, narcotics, and a host of other drugs and toxins can reduce the respiratory drive. -Head injury, hypoxic drive, and asphyxia are all associated with grossly low respiratory rate and volume. -The ultimate expression of hypoventilation is respiratory arrest followed by cardiac arrest.

Environmental/Industrial Exposure

-The type of damage from the substance depends in large part on the water solubility of the toxic gas. -Highly water-soluble gases such as ammonia will react with the moist mucous membranes of the upper airway and cause swelling and irritation. -Less water-soluble gases such as phosgene and nitrogen dioxide may get deep into the lower airway, where they may cause pulmonary edema up to 24 hours later.

Assess Airway & Breathing

-To evaluate airway and breathing, begin with these questions: -->Is the airway open and clear? -->Is the patient breathing? -Provide the appropriate oxygen therapy for a patient with spontaneous breathing, or immediately provide positive pressure ventilations for one who is apneic. -If ventilating, determine if ventilations are effective. Is there equal rise and fall of the chest, and is the heart rate decreasing appropriately? -->If not, try to reposition the airway and insert an airway adjunct 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. -The next step in assessing breathing in a patient with a respiratory emergency is to assess breath sounds.

Lower Airway Obstruction

-Trauma -Obstructive Disease -Increased Mucus Production -Airway Swelling (edema)

Pulse Oximeter

-Under normal circumstances, a pulse oximeter is a noninvasive device that measures the percentage of a patient's hemoglobin that has oxygen attached to it. -Oxygen saturation greater than 94% is considered normal, and most healthy people would feel short of breath at a saturation rate of less than 88%. -Diagnostic testing provides baseline information and indicates the severity of respiratory difficulty. -Pulse oximetry is used to evaluate or confirm the adequacy of oxygen saturation. -Pulse oximetry readings may be inaccurate in the presence of conditions that abnormally bind hemoglobin, including carbon monoxide poisoning, as well as any condition that causes a decrease in perfusion. -->For example, if the patient's hemoglobin level is low (as a result of trauma or hemorrhage, for example), the pulse oximetry result will be correspondingly high. -->If the reading shows only 6 g/dL of hemoglobin (normal level, 12 to 14 g/dL), ideally all hemoglobin will have oxygen attached and the oxygen saturation will be 100%. Such a patient needs more hemoglobin in the form of whole blood or packed red cells. -->A patient with an abnormally high hemoglobin level, as is common in chronic hypoxia such as in cases of COPD, or a patient who lives at a high altitude will have a correspondingly low oxygen saturation.

Wet Lungs VS Dry Lungs

-Wet lungs, found in pulmonary edema, are most often caused by heart failure. -Dry lungs are found in COPD. -Patients with heart failure experience a fluid overload in the lung, which develops quickly from a failing pump. -->Suspect heart failure in a patient with elevated blood pressure, pedal edema, and history of heart failure. -Patients with COPD: -->Wheeze because of bronchial constriction -->Present with shortness of breath -->Have chronic coughing and thick sputum -->Medications include home oxygen, bronchodilators, and corticosteroids. -Do not assume that all COPD patients have wheezing, and all heart failure patients have crackles. -Treat the patient, not the breath sounds.

Conditions that Impair Lung Function

-When a patient is breathing but gas exchange is impaired, the carbon dioxide level in the blood rises. -This situation can occur in patients with severe atelectasis, pneumonia, pulmonary edema, asthma, and COPD.

Identifying Threats

-You now know enough to be able to identify any life threats in your patient, including any of the following signs or symptoms: -->Problems with the ABCs -->Poor initial general impression -->Altered mental status -->Potential hypoperfusion or shock -->Chest pain associated with a low blood pressure -->Severe pain anywhere -->Excessive bleeding

Emphysema

-barrel chest -pursed lip breathing -dyspnea on exertion -cyanosis -wheezing/decreased breath sounds

Bronchitis

-chronic cough (with sputum) -wheezing -cyanosis -tachypnea

Tuberculosis

-cough -fever -fatigue -productive/bloody sputum

Influenza type A (flu)

-cough -fever -sore throat -fatigue

Common Cold

-cough -runny or stuffy nose -sore throat

Respiratory Syncytial Virus (RSV)

-cough -wheezing -fever -dehydration

Pertussis (whooping cough)

-coughing spells -"whooping" sound -fever

Heart Failure

-dependent edema -crackles -orthopnea -paroxysmal nocturnal dyspnea

Diphtheria

-difficulty breathing and swallowing -sore throat -thick, gray buildup in throat or nose -fever

Pneumonia

-dyspnea -chills, fever -cough -green, red, or rust-colored sputum -localized wheezing or crackles

Epiglottitis

-dyspnea -high fever -stridor -drooling -difficulty swallowing -severe sore throat -tripod or sniffing position

Croup

-fever -barking cough -stridor -mostly seen in pediatric patients

Anaphylaxis

-flushed skin or hives (urticaria) -generalized edema -decreased blood pressure (hypotension) -laryngeal edema with dyspnea -wheezing or stridor

Upper Airway Obstruction

-foreign body obstruction -infection -trauma

Tension Pneumothorax

-severe shortness of breath -decreased/altered level of consciousness -neck vein distention -tracheal deviation (late sign) -hypotension, signs of shock

Pulmonary Embolus

-sharp chest pain -sudden onset -dyspnea -tachycardia -clear breath sounds initially

Bronchiolitis

-shortness of breath -wheezing -coughing -fever -dehydration -tachypnea -tachycardia

Pneuomothorax

-sudden chest pain with dyspnea -decreased breath sounds (affected side) -subcutaneous emphysema

Asthma

-wheezing on inspiration/expiration -bronchospasm