Ch 15: Respiratory Distress

Stridor

Stridor is the 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 occurs in patients with anatomic or foreign body airway obstruction.

Environmental/industrial exposure

The commonality in these kinds of respiratory problems is the inhalation of a toxic chemical. Ensure that all patients are decontaminated prior to treatment. Treat with oxygen, adjuncts, and suction on the basis of presentation, level of consciousness, and level of distress that is observed in your patient.

Carbon Dioxide Retention and Hypoxic Drive

The exhalation process may be impaired by various types of lung disease. The body may also produce too much carbon dioxide, either temporarily or chronically, depending on the disease or abnormality. 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; thus, 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. Hypoxic drive is frequently found in end-stage chronic obstructive pulmonary disease (COPD). Some experts advocate for withholding high concentrations of oxygen from patients with chronic lung diseases because the increased oxygen level in the blood could depress, or completely stop, the patient's respiratory drive. Use caution when providing high concentrations of oxygen on a long-term basis to patients with chronic lung disease, but never withhold oxygen therapy from a patient who needs it.

Identifying Life 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 Unresponsiveness Potential hypoperfusion or shock Chest pain associated with a low blood pressure Severe pain anywhere Excessive bleeding

Questioning a Patient With Difficulty Breathing When questioning a patient who is having difficulty breathing, use:

-SAMPLE With patients in 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. 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 surgical procedures or hospitalizations? Have there been any traumatic injuries? Look for medications, medical alert bracelets, environmental conditions, and other clues to what may be causing the problem. Each part of the SAMPLE history may give you clues, so be thorough. -OPQRST The OPQRST assessment can be modified to obtain more specific information about the breathing problem. Include the following open-ended questions: 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)? Is the problem continuous or intermittent? If it is intermittent, how frequently does it occur and how long does it last (Timing)? -PASTE An additional assessment for a complaint of shortness of breath or difficulty breathing uses the mnemonic PASTE: P Progression Similar to the O in OPQRST, you want to know if the problem started suddenly or has worsened over time. A Associated chest pain Dyspnea can be a significant symptom of a cardiac problem. 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 a pulmonary embolus may not result in any sputum at all. T Talking tiredness This is an indicator of how much distress the patient is in. Ask the patient to repeat a sentence and see how many words he or she can speak without needing to take a breath. The assessment results would be reported as the patient "speaks in full sentences" or, perhaps, "speaks in two-to-three-word sentences." E Exercise tolerance Ask the patient a question about what he or she was 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," it is another indicator that your patient is in distress. Exercise tolerance will decrease as the breathing problem and hypoxia increase.

Sterile Saline in small-volume nebulizer

3 mL added to achieve best volume of nebulizer

Tuberculosis

A bacterial infection caused by Mycobacterium tuberculosis Tuberculosis (TB) spreads by cough. Many strains are resistant to antibiotics. TB most commonly affects the lungs, but can be found in almost any organ of the body, particularly the kidneys, spine, and lining of the brain and spinal cord (meninges). In some cases, TB can remain dormant for years without causing symptoms or being infectious to other people. 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. TB has a higher prevalence among people who: Live in close contact Abuse intravenous drugs or alcohol Have compromised immune systems If you suspect your patient may have active TB, wear (at a minimum): Gloves Eye protection An N-95 respirator These respirators are fit-tested to the individual to ensure no contaminated air can pass through.

Respiratory syncytial virus

A common cause of illness in young children Respiratory syncytial virus 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. RSV is highly contagious and can be spread through droplets when the patient coughs or sneezes. The virus can also survive on surfaces, including hands and clothing. The infection tends to spread rapidly through schools and child care centers. When you assess a child with suspected RSV, look for signs of dehydration. Infants with RSV often refuse liquids. Treat airway and breathing problems as appropriate. Humidified oxygen is helpful if available.

carbon dioxide retention

A condition characterized by a chronically high blood level of carbon dioxide in which the respiratory center no longer responds to high blood levels of carbon dioxide.

Cystic fibrosis

A 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 line the lungs and the digestive and reproductive systems Predisposes the child to repeated lung infections The disease process disrupts the essential balance of salt and water necessary to maintain a normal coating of fluid and mucus inside the lungs and other organs. Mucus becomes thick, sticky, and hard to move. The mucus holds germs, causing the lungs to become infected. Symptoms range from sinus congestion to wheezing and asthma-like complaints. A chronic cough that produces thick, heavy, discolored mucus may develop. The child often has dyspnea. Treat the child with suction and oxygen using age-appropriate adjuncts. Cystic fibrosis often causes death in childhood because of chronic pneumonia secondary to the thick, pathologic mucus in the airway. It also causes malabsorption of nutrients in the intestines. Because of advances in treatment, the life expectancy for CF patients becomes better each year. Adults with cystic fibrosis are predisposed to other medical conditions, including arthritis, osteoporosis, diabetes, and liver problems.

Epiglottitis

A life-threatening inflammatory disease of the epiglottitis Bacterial infection is the most common cause. In the past, epiglottitis was most often seen in infants and 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. The condition usually develops in otherwise healthy children, and symptoms are sudden in onset. Children look ill, report a very sore throat, and have a high fever. They will often be found in the tripod position and drooling. Treat children with suspected epiglottitis 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 oxygen. Do not put anything in their mouths. You should be concerned if your adult patient presents with stridor or any other sign of airway obstruction without an obvious mechanical cause. Focus your patient management on maintaining a patent airway, and provide prompt transport to the emergency department (ED).

Bronchiolitis

A respiratory illness that often occurs due to respiratory syncytial virus (RSV) infection and results in severe inflammation of the bronchioles Occurs most frequently in newborns and toddlers, especially boys, whose airways can easily become blocked Young children who require hospitalization for bronchiolitis are at increased risk for developing childhood asthma. The treatment for a child suffering from bronchiolitis is mainly supportive. While many of these patients do well, there is still a risk for significant respiratory compromise. Provide appropriate oxygen therapy. 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.

Tracheostomy dysfunction

A tracheostomy tube is placed in a stoma in the neck and can sometimes become obstructed by secretions, mucus, or foreign bodies. Other tracheostomy tube complications include bleeding, leaking, dislodgement, and infection. Place the patient in a position of comfort and provide suctioning to clear the obstruction. If you are unable 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 because of airway obstruction, laryngeal cancer, severe infection, trauma, or the inability to manage secretions. Your immediate goal is to establish airway patency.

adventitious breath sounds

Abnormal breath sounds such as wheezing, stridor, rhonchi, and crackles.

Pathophysiology

Abnormal or pathologic conditions in the anatomy of the airway, disease processes, and traumatic conditions can prevent the proper exchange of oxygen and carbon dioxide. The pulmonary blood vessels themselves may have abnormalities that interfere with blood flow and thus with the transfer of gases.

Pneumonia

According to the World Health Organization, Pneumonia is a significant cause of morbidity worldwide. Pneumonia refers to an infection of the lungs. The infection collects in the surrounding normal lung tissues, impairing the lung's ability to exchange oxygen and carbon dioxide. Pneumonia is often a secondary infection and 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 accidental ingestion or a direct lung injury from a submersion incident. Interventions such as intubation and tracheostomy can increase the risk of developing pneumonia. The factors that predispose patients to pneumonia include: Institutional residence (nursing home or long-term care facilities) Recent hospitalization Chronic disease processes (such as renal failure requiring dialysis) Immune system compromise (patient receiving chemotherapy or diseases such as HIV) History of COPD Symptoms of pneumonia vary. Children often present with unusually rapid or labored breathing or breathing characterized by grunting or wheezing sounds. In severe cases where oxygen exchange at the alveoli is markedly impaired, the lips and fingernails may be blue or gray. If the pneumonia is in the lower part of the lungs near the abdomen, there may be 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. A viral pneumonia presents more gradually and is less severe. Other signs and symptoms include: Dry skin Decreased skin turgor Exertional dyspnea A productive cough Chest discomfort and pain that vary with inspiration and expiration Headache, nausea, and vomiting Musculoskeletal pain Weight loss Confusion The patient may be febrile, tachycardic, or even hypotensive. Assessment of the lungs may reveal diminished breath sounds with sounds of wheezing, crackles, or rhonchi. Evaluate the patient's history for possible risk factors. Assess temperature to determine the presence of fever. Pulse oximetry readings, if available, may be low. Treatment includes airway support and providing supplemental oxygen. Use oxygen with appropriate adjuncts. Evaluate patient treatment through reassessment and prepare for possible deterioration in the patient's condition.

Treatment of Specific Conditions

Acute pulmonary edema Chronic obstructive pulmonary disease Asthma, hay fever, and anaphylaxis Spontaneous pneumothorax Pleural effusion Obstruction of the airway Pulmonary embolism

Crackles

Crackles (formerly called rales) are the sounds of air trying to pass through fluid in the alveoli. A crackling or bubbling sound is typically heard on inspiration. High-pitched sounds are called "fine" crackles. Low-pitched sounds are called "coarse" crackles. These sounds are often a result of congestive heart failure or pulmonary edema.

Asthma, Hay Fever, and Anaphylaxis

Allergens are not the cause of allergic reactions; rather, it is the exaggerated response of the body's immune system to that substance that causes the reaction.

Pertussis

An airborne bacterial infection that primarily affects children younger than 6 years Highly contagious and is passed through droplet infection A patient with pertussis will be feverish and exhibit a "whoop" sound on inspiration after a coughing attack. Symptoms are generally similar to colds, but coughing spells can last for more than a minute during which the child may turn red or purple. In infants younger than 6 months, pertussis can be life threatening. Children with pertussis may vomit or not want to eat or drink. Watch for signs of dehydration. You may have to suction thick secretions to clear the airway. Give oxygen by the most appropriate means. Pertussis in adults does not cause the typical whooping illness but can cause a severe upper respiratory infection, which can lead to pneumonia in geriatric patients or people with compromised immune systems. In the worst cases of infection in geriatric patients, coughing can lead to cracked ribs. For patients who are already weak from other chronic conditions, pertussis can lead to hospitalization.

Influenza type A

An animal respiratory disease that has mutated to infect humans In 2009, the H1N1 strain of influenza Type A became pandemic. Like seasonal flu, it 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 infected people. The viruses cause fever, cough, sore throat, muscle aches, headache, and fatigue and may lead to pneumonia or dehydration.

Scene Size-up

As always, consider standard precautions and use of PPE. Follow local protocols. Consider whether the respiratory emergency may have been caused by a toxic substance that was inhaled, absorbed, or ingested. Once you have determined that 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 nature of illness (NOI) is in question, ask why 9-1-1 was activated. By questioning the patient, family, and/or bystanders, you should be able to determine the NOI.

Primary Assessment Primary assessment for respiratory emergencies involves these steps:

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 nontrauma patients and the jaw-thrust maneuver for patients with suspected spinal trauma Breathing: What are the rate, rhythm, and quality of the respirations? Is the rate within normal limits for the patient's age? Is the patient using accessory muscles to assist the respiratory effort, and can you see retractions? Is there abdominal breathing? What is the depth of breathing, and is the tidal volume adequate? Is there adequate rise and fall of the chest? Circulation:What are the color, temperature, and condition of the patient's skin? Respiration: Are the patient's respirations labored? If respiratory effort is inadequate, 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 oxygen at 15 L/min via nonrebreathing mask, unless contraindicated because of preexisting medical conditions. If the patient's breathing has inadequate depth or the rate is too slow, ventilations may need to be assisted with a BVM. Provide airway management and ventilation: Continue to monitor the airway for fluid, secretions, and other problems as you move on to assess the adequacy of your patient's breathing Assess breath sounds: The next step in assessing breathing in a patient with a respiratory emergency is to assess breath sounds. Techniques for this assessment are described at the end of this section. Assess circulation: Assess pulse rate, quality, and rhythm. If the pulse rate is too fast or too slow, the patient may not be getting enough oxygen. Irregular beats could indicate a cardiac problem. Evaluate for the presence of shock and bleeding. Assess capillary refill in infants and children. Normal capillary refill is less than 2 seconds. Assess perfusion by evaluating skin color, temperature, and condition. A loss of perfusion may be caused by chronic anemia, a wound, internal bleeding, or simply shock overwhelming the body's ability to compensate for the illness.

Airway infections include:

Croup Epiglottitis Respiratory syncytial virus Bronchiolitis Pneumonia Pertussis Influenza type A Tuberculosis

Asthma

Asthma is a common childhood illness. When you assess a pediatric patient, look for retractions of the skin above the sternum and between the ribs. Retractions are typically easier to see in children than in adults. Cyanosis is a late finding in children. Even if you do not hear much wheezing, the presence of a cough can indicate that some degree of reactive airway disease or an acute asthma attack may be taking place. The emergency care of a child with shortness of breath is the same as it is for an adult, including the use of supplemental oxygen. Many small children will not tolerate (or may refuse to wear) a face mask. Provide blow-by oxygen by holding the oxygen mask in front of the child's face or ask the parent or caregiver to hold the mask. Use prescribed MDI inhalers just as you would with an adult. Asthma in an older patient causes bronchospasm, swelling of the lining of the airways, and an accumulation of secretions. Attacks are triggered by air pollutants, viral infections, allergens, and sometimes something as simple as exposure to cold air. Asthma can be life threatening in older people, especially in patients who have problems with airway control. The condition is made worse by anxiety and dehydration. Geriatric patients with asthma tend to have both inspiratory and expiratory wheezes.

Asthma, hay fever, and anaphylaxis

Asthma is often a recurring pathologic condition. Confirm whether the patient is able to breathe normally at other times. Ask family members to describe the patient's asthma. As you assess the patient's vital signs, the pulse rate will be normal or elevated, the blood pressure 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 oxygen. Do not withhold oxygen for more than 15 seconds for adult patients, 10 seconds for a child, and 5 seconds for an infant. Allow some time for oxygenation between suction attempts. If the patient is unconscious, you may have to provide airway management. If the patient has medication, such as an inhaler for an asthma attack, you may help with its administration as directed by local protocol. Reassess breathing frequently and be prepared to assist ventilations with a BVM in severe cases. Use slow, gentle breaths. Always assist with ventilations as a last resort, and then provide only about 10 to 12 shallow breaths/min. A prolonged unrelieved asthma attack may progress into status asthmaticus. Give oxygen and promptly transport to the ED. Aggressive airway management, oxygen administration, and prompt transport are essential if the patient tires. Consider advanced life support (ALS). The patient with hay fever is unlikely to need emergency treatment unless the condition has worsened from generalized cold symptoms. Manage the airway and give oxygen according to the level of distress. An anaphylactic reaction is a life-threatening emergency. The first step should be to remove the offending agent. Maintain the airway. If the patient is still awake, allow him or her to assume a position that does not compromise breathing. Use an appropriate oxygen device for supplemental oxygen administration. Be prepared to assist breathing as needed. Rapid transport and the early administration of epinephrine, if allowed by protocol, should be a priority.

Allergic reactions to inhaled, ingested, or injected substances include:

Asthma:Asthma is an acute spasm of the bronchioles associated with excessive mucus production and with swelling of the mucous lining of the respiratory passages According to the CDC, approximately 25 million Americans have asthma. Affects people of all ages, but the highest prevalence rate is seen in children 5 to 17 years of age Asthma 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. An acute asthma attack may be caused by an allergic response to specific foods or some other allergen. Between attacks, patients may breathe normally. Asthma attacks may also be triggered by severe emotional stress, exercise, and respiratory infections. In its most severe form, an allergic reaction can produce anaphylaxis, which, in turn, may cause respiratory distress that is severe enough to result in coma and death. Most patients with asthma are familiar with their symptoms will have appropriate medication with them. Hay fever: Hay fever causes coldlike symptoms, including a runny nose, sneezing, congestion, and sinus pressure. Symptoms are caused by an allergic response. For many people, hay fever is at its worst in the spring and summer, but others may have hay fever symptoms year-round. People with hay fever tend to be atopic, meaning that they are more likely to have other allergies. They may also have a higher incidence of severe reactions, including anaphylaxis. Anaphylaxis:Anaphylaxis is a severe allergic reaction characterized by airway swelling and dilation of blood vessels all over the body, which may significantly lower blood pressure. May be associated with widespread hives (urticaria), itching, signs of shock, and signs and symptoms similar to asthma Most anaphylactic reactions occur within 30 minutes of exposure to the allergen. In most cases, epinephrine (adrenalin) is the treatment of choice. Patients may have their own prescribed automatic epinephrine injector, or EpiPen. Oxygen and antihistamines are also useful.

Breathing sounds include:

Snoring Wheezing Crackles Rhonchi Stridor

Pulmonary embolism

Because a considerable amount of lung tissue may not be functioning, supplemental oxygen is mandatory in a patient with a pulmonary embolism. Place the patient in a comfortable position, usually sitting, and assist breathing as necessary. Hemoptysis, if present, is usually not severe, but clean up any blood that has been coughed up. The patient may have an unusually rapid and possibly irregular heartbeat. Transport the patient to the ED promptly. Large pulmonary emboli may cause cardiac arrest. It also causes malabsorption of nutrients in the intestines.

Carbon Monoxide Poisoning

Carbon monoxide is a colorless, odorless, tasteless, and highly poisonous gas known as "the silent killer." It is the leading cause of accidental poisoning deaths in the United States. People who survive carbon monoxide poisoning can have permanent brain damage. Sources include: The combined effects of incomplete combustion and a poorly ventilated building Motor vehicle exhaust Initial signs and symptoms include: Headache Dizziness Fatigue Nausea and vomiting Dyspnea on exertion Chest pain Impaired judgment, confusion, or even hallucinations The worst exposures may result in syncope or seizure. Carbon monoxide has a much stronger bond with hemoglobin than does oxygen. Consider toxic gas exposure if more than one patient in the same environment is experiencing the same signs and symptoms. Symptoms will start to improve as soon as the patient is removed from the toxic environment. High-flow oxygen by nonrebreathing mask is the best treatment for conscious patients. Patients who are unconscious or have an altered level of consciousness 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 oxygen therapy.

Croup

Caused by inflammation and swelling of the pharynx, larynx, and trachea Croup 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. Peak seasonal outbreaks occur in the late fall and during the winter. Croup starts with a cold, cough, and a low-grade fever that develops over 2 days. The hallmark signs of croup are stridor and a seal-bark cough, which signal a narrowing of the air passage of the trachea that may progress to significant obstruction. 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 responds well to the administration of humidified oxygen. Bronchodilators are not indicated for croup and can worsen a patient's symptoms.

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, an ongoing irritation of the trachea and bronchi 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. Tobacco smoke is a bronchial irritant and can create chronic bronchitis. Emphysema, 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 The walls of the alveoli eventually fall apart, leaving large "holes" in the lung that resemble large air pockets or cavities. Chronic oxygenation problems can lead to right-sided heart failure and fluid retention, such as edema in the legs. Pneumonia develops easily. Repeated episodes of irritation and pneumonia cause scarring in the lungs and some dilation of the obstructed alveoli, leading to COPD. Most patients with COPD will: Chronically produce sputum Have a chronic cough Have difficulty expelling air from their lungs, with long expiration phases and wheezing Patients may present with adventitious breath sounds such as crackles, rhonchi, and wheezes, or may have severely diminished breath sounds due to poor air movement.

atelectasis

Collapse of the alveolar air spaces of the lungs.

Hyperventilation

Complete a primary assessment and gather a history of the event. 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. A patient with underlying pulmonary disease who breathes into a bag may become severely hypoxic. Treatment should consist of: Reassuring the patient in a calm, professional manner Supplying supplemental oxygen Providing prompt transport to the ED Patients who hyperventilate need to be evaluated in the hospital.

Assessing Breath Sounds

Determine whether your patient's breath sounds are: Normal (vesicular breath sounds, bronchial breath sounds) Decreased, 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 patient's back, place the stethoscope head between and below the scapulae, not over them, or you will have an inaccurate assessment. Listen for a full respiratory cycle so you can detect the adventitious sounds that may be heard at the end of the inspiratory or expiratory phase. When assessing 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. The lack of air movement in the lung is a significant finding.

Acute pulmonary edema

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 sitting up). An unconscious patient may require full ventilatory support, including placement of an airway adjunct, positive-pressure ventilation with oxygen, and suctioning. Continuous positive airway pressure (CPAP) is a 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 oxygen across the alveolar membrane 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 Have a pulse oximetry reading of less than 90% Contraindications to the use of CPAP include: Low blood pressure Respiratory arrest Pneumothorax or chest trauma Tracheostomy A decreased level of consciousness Inability to follow commands Active gastrointestinal bleeding If you are authorized to apply CPAP for acute pulmonary edema according to your local protocols, do so. Otherwise, provide prompt transport to the nearest appropriate ED. Continue to reassess patients using CPAP for signs of deterioration and/or respiratory failure.

dyspnea Shortness of breath or difficulty breathing.

Dyspnea is a symptom of many different conditions, from the common cold or asthma to heart failure and pulmonary embolism.

Treating Upper or Lower Airway Infections

For patients with upper airway infections and dyspnea, administer humidified oxygen (if available). Do not attempt to suction the airway or place an oropharyngeal airway in a patient with suspected epiglottitis. These maneuvers may cause a spasm and complete airway obstruction. Transport the patient promptly to the hospital. Allow the patient to sit in the position that is most comfortable. For someone with epiglottitis, this is usually sitting upright and leaning forward in the "sniffing position." Forcing a patient with epiglottitis to lie supine may cause upper airway obstruction that could result in death.

Treatment of Specific Conditions (continued)

Hyperventilation Environmental/industrial exposure Foreign body aspiration Tracheostomy dysfunction Asthma Cystic fibrosis

Hyperventilation

Hyperventilation is defined as overbreathing to the point that the level of arterial carbon dioxide falls below normal. The body tries to compensate for acidosis, the buildup of excess acid that results from the primary illness. Lowering the level of carbon dioxide helps to compensate for the other acids. In an otherwise healthy person, blood acidity can be diminished by excessive breathing because it "blows off" too much carbon dioxide. The result is a relative lack of acids, known as alkalosis, the 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 and feet Painful spasms of the hands and/or feet (carpopedal spasms) Hyperventilation syndrome occurs in the absence of other physical problems. Commonly occurs when a person is experiencing psychologic stress Affects 10% of the population at one time or another The respirations of an individual who is experiencing hyperventilation syndrome may be as high as 40 shallow breaths/min or as low as only 20 deep breaths/min.

Causes of Dyspnea

Hypoxia is a condition in which the body's cells and tissues do not get enough oxygen. Patients often have breathing difficulty 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 Cardiopulmonary diseases Congestive heart failure is a cause of breathlessness because the heart is not pumping efficiently and, therefore, the body does not have adequate oxygen. Another condition commonly associated with congestive heart failure is pulmonary edema, in which the alveoli are filled with fluid. Pulmonary blood vessels themselves may have abnormalities that interfere with blood flow and thus with the transfer of gases. A patient with dyspnea may report: Shortness of breath Chest tightness Described as an uncomfortable feeling in the chest Commonly reported by patients with asthma Air hunger When a person reports the feeling of "not getting enough air" and has a strong need to breathe As you treat patients with disorders of the lung, be aware that one or more of the following situations most 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.

Metered-Dose Inhaler and Small-Volume Nebulizer

Some of the most common medications used for shortness of breath are inhaled beta-agonists, which dilate breathing passages. Medications that may be administered via a metered-dose inhaler (MDI) include: Albuterol (Proventil, Ventolin) Albuterol/ipratropium (Combivent) Metaproterenol (Alupent, Metaprel) Terbutaline (Brethine) Medications typically administered by small-volume nebulizer include, but are not limited to: Albuterol Metaproterenol Epinephrine

Obstruction of the airway

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. If your patient is able to talk and breathe, the wisest course may be to provide supplemental oxygen and transport carefully in a position of comfort to the hospital. For a complete airway obstruction, remove the obstructing body. Clear the patient's upper airway according to basic life support guidelines. Open the airway with the head tilt-chin lift maneuver (or the jaw-thrust maneuver for patients with suspected spinal trauma). You should perform this maneuver only after you have ruled out a head or neck injury. If opening the airway does not correct the breathing problem, assess the upper airway for the obstruction. Administer supplemental oxygen and transport the patient promptly to the ED.

Foreign body aspiration

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 the appropriate airway clearing technique specific to the age of the child. Another scenario to consider is that an object passed through the airway and has been aspirated (inhaled) into the lung. This problem will not be as obvious as an airway obstruction. Most deaths from foreign body aspiration occur in patients who are younger than 5 years, and most of them are infants. Typical items aspirated include 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 mainstem bronchus. If the bronchus is fully obstructed, the lung could collapse. Aspiration pneumonia may also develop. Provide oxygen, and transport any child with a suspected aspiration. An X-ray will be needed to confirm the aspiration, its location, and the treatment. For an older person, decreased cough and gag reflexes cause a decreased ability to clear secretions. Difficulty in swallowing means the risk for aspiration is markedly increased. Older people can aspirate food or oral secretions that, in many cases, can develop into a potentially life-threatening aspiration pneumonia.

Physiology of Respiration

In healthy lungs, the exchange of gases takes place rapidly at the level of the alveoli. As oxygen enters the alveoli, it passes freely through tiny passages in the alveolar wall into capillaries through the process of diffusion. The oxygen is carried to the heart, which pumps it around the body. Carbon dioxide diffuses back into the alveoli and travels back up the bronchial tree and out through the upper airways during exhalation. Through the process of respiration, the brain stem constantly senses the level of carbon dioxide in the arterial blood. The level of carbon dioxide bathing the brain stem stimulates a healthy person to breathe. If the level of carbon dioxide drops too low, the person automatically breathes at a slower rate and less deeply. Less carbon dioxide is expired, allowing carbon dioxide levels in the blood to return to normal. In addition to stimulating breathing, carbon dioxide helps balance pH.

Upper or Lower Airway Infection

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 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 (epiglottitis, croup) Impair exchange of gases between the alveoli and the capillaries (pneumonia) Be diligent about your use of appropriate PPE. A minimum of gloves, eye protection, and a surgical mask or a high-efficiency air particulate (N-95) respirator should be mandatory. Gowns can be considered in some situations. Place a surgical mask on patients with suspected or confirmed respiratory disease. Completely disinfect your unit prior to returning to service.

Reassessment

Interventions for respiratory problems may include: Providing oxygen via a nonrebreathing mask at 15 L/min Providing positive-pressure ventilations using a BVM, pocket mask, or flow-restricted oxygen-powered ventilation device Using airway management techniques such as an oropharyngeal (oral) airway, a nasopharyngeal (nasal) airway, suctioning, or airway positioning Providing noninvasive ventilatory support with continuous positive airway pressure (CPAP) Positioning the patient in a high-Fowler 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 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, vital signs should be obtained at least every 15 minutes. Contact medical control with any change in level of consciousness or difficulty breathing. Depending on local protocols, contact medical control prior to assisting with any prescribed medications. Document any changes (and at what time) and any orders given by medical control.

When using either of these, consider:

Medical control: Consult medical control (online), or follow standing orders (off-line). Report: What the medication is When the patient last self-administered a treatment How much medication was used 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 that: The inhaler belongs to the patient It contains the correct medication The expiration date has not passed The correct dose is being administered If the prescribed dose is not explicitly listed on the inhaler, ask the patient how many inhalations of the medication he or she takes. Administer repeated doses of the medication if the maximum dose has not been exceeded and the patient is still experiencing shortness of breath. Unlike an MDI, a small-volume nebulizer must be assembled prior to use. An oxygen tank is also required to administer the aerosolized medication. Indications and contraindications: Before helping a patient to self-administer any MDI or small-volume nebulizer medication, make sure that the medication is indicated. The most common use for an MDI is asthma, and a small-volume nebulizer is used in asthma, bronchiolitis, COPD, and anaphylaxis. Check that there are no contraindications for its use, such as 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 has already met the maximum prescribed dose before your arrival. The medication is expired. There are other contraindications specific to the medication. Actions: Most respiratory inhalation medications relax the muscles that surround the air passages in the lungs, leading to dilation of the airways and easier movement of air. The table lists respiratory inhalation medications. The 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 preventive measures or as maintenance doses. Medications for long-term use will provide little relief of acute symptoms. Side effects: Common side effects of inhalers used for acute shortness of breath include: Increased pulse rate Nervousness 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. When in doubt, consult medical control. Dose and route: Medication from 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 medication.

Environmental/Industrial Exposure

Once the patient is decontaminated, gather information 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. The inhaled substance can also cause lung damage. Blood coming from the airway is an ominous sign.

Secondary Assessment of COPD Versus Congestive Heart Failure

Patients with COPD: Are usually older than 50 years Will often have a history of recurring lung problems Are almost always long-term active or former cigarette smokers Often have a barrel-like appearance in the chest Use accessory muscles to breathe Exhale through pursed lips as a strategy to keep airways open longer Patients may report tightness in the chest and constant fatigue. If you listen to the patient's chest with a stethoscope, you will hear abnormal breath sounds. Digital clubbing (abnormal enlargement of the ends of the fingers) is also a sign of COPD.

Chronic obstructive pulmonary disease

Patients with COPD: May have an altered level of consciousness or may be unresponsive from hypoxia or carbon dioxide retention Find breathing difficult when lying down Assist with the patient's prescribed inhaler if there is one. Often times a patient with COPD will overuse an inhaler, so watch for side effects. Promptly transport to the ED, allowing the patient to sit upright if this is most comfortable.

Chronic Respiratory Conditions

Patients with asthma may have different "triggers," including: Allergens Cold Exercise Stress Infection Noncompliance with medication prescriptions It is important to try to determine what may have triggered the attack so that it can be treated appropriately. Patients with congestive heart failure often walk a fine line between compensating for their diminished cardiac capacity and decompensating. Many take several medications, most often including diuretics and blood pressure medications. Obtain a list of all medications and ask about the events leading up to the present problem.

Wet Lungs Versus Dry Lungs and "Cardiac Asthma"

Patients with pulmonary edema caused most often by congestive heart failure will often have "wet" lung sounds (rhonchi, crackles). Patients with COPD will often have "dry" lung sounds (wheezes). Do not assume all COPD patients have wheezes and all congestive heart failure patients have crackles. Patients with COPD: Wheeze because of bronchial constriction Present with shortness of breath Breathing gets progressively worse, and they have the most trouble breathing on exertion. Have chronic coughing and thick sputum Are usually long-term smokers with a thin, barrel-chested appearance Medications include home oxygen, bronchodilators, and corticosteroids. Often have a slower onset of symptoms because 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.

Spontaneous pneumothorax

Patients with spontaneous pneumothorax may have severe respiratory distress, or they may have no distress at all and report only pleuritic chest pain. Provide supplemental oxygen and prompt transport to the hospital. Patients 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 it becomes necessary.

Other Respiratory Emergencies

Spontaneous pneumothorax: Pneumothorax is a partial or complete accumulation of air in the pleural space. Most often caused by trauma When the surface of the lung is disrupted, air escapes into the pleural cavity and results in a loss of negative vacuum pressure. The natural elasticity of the lung tissue causes the lung to collapse. In some medical conditions, the condition is called a "spontaneous" pneumothorax. 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 spontaneous pneumothorax when a weakened portion of lung ruptures, often during severe coughing. A patient with a spontaneous pneumothorax has dyspnea and might report pleuritic chest pain. By listening to the chest with a stethoscope, you can sometimes detect that breath sounds are absent or decreased on the affected side. Altered breath sounds are difficult to detect in a patient with severe emphysema. A spontaneous pneumothorax 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. 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. Though it can build up gradually, over days or even weeks, patients often report that their dyspnea came on suddenly. Pleural effusion 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 fluid has moved the lung away from the chest wall. These patients frequently feel better if they are sitting upright. Obstruction of the airway: A patient with dyspnea may have a mechanical obstruction of the airway. In semiconscious and unconscious patients, the obstruction may be the result of aspiration of vomitus or a foreign object or improper positioning of the head so that the tongue is blocking the airway. Always consider upper airway obstruction from a foreign body first in patients who were eating just before becoming short of breath. 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 significantly 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. A 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. The embolus can also come from the right atrium in a patient with atrial fibrillation. The clot moves through the right side of the heart and into the pulmonary artery, where it becomes lodged, significantly decreasing or blocking blood flow. No exchange of oxygen or carbon dioxide takes place in the areas of blocked blood flow due to ineffective circulation. Oxygen 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. Pulmonary emboli may occur as a result of: Damage to the lining of vessels A tendency for blood to clot unusually fast The most common cause is low blood flow in a lower extremity, due to: Long-term bed rest, which can lead to the collapse of veins Leg immobilization following a fracture or recent surgery Pregnancy Active cancer Pulmonary emboli rarely occur in active, healthy people. Symptoms and signs of pulmonary emboli include: Dyspnea Tachycardia Tachypnea Varying degrees of hypoxia Cyanosis Acute chest pain Hemoptysis (coughing up blood) With a large enough embolus, complete, sudden obstruction of the output of blood flow from the right side of the heart can result in sudden death.

Acute Pulmonary Edema

Pulmonary edema is the collection of fluid buildup in and around the alveoli. Usually a result of congestive heart failure By physically separating the alveoli from the pulmonary capillary vessels, the edema interferes with the exchange of carbon dioxide and oxygen. High blood pressure and low cardiac output often trigger "flash" pulmonary edema. Patients literally drown in their own fluid and experience dyspnea with rapid, shallow respirations. In the most severe cases, you will see frothy pink sputum at the nose and mouth. Patient risk factors for congestive heart failure include: Hypertension A history of coronary artery disease and/or atrial fibrillation Pulmonary edema can result from: Poisonings from inhaling large amounts of smoke or toxic chemical fumes Traumatic injuries of the chest Exposure to high altitudes In these cases, fluid collects in the alveoli and lung tissue in response to damage of the tissues of the lung or the bronchi. Signs and symptoms of congestive heart failure include: Difficulty breathing with exertion Sudden respiratory distress caused by fluid accumulation in the lungs Coughing Feeling suffocated Cold sweats Tachycardia The patient may have hypertension early, followed by deterioration to hypotension as a late finding.

Anatomy of the Respiratory System

Respiratory system structures include: The diaphragm The muscles of the chest wall The accessory muscles of breathing The nerves from the brain and spinal cord to those muscles The upper airway consists of all anatomic airway structures above the level of the vocal cords, including: Nose Mouth Jaw Oral cavity Pharynx Larynx The upper airway ends at the larynx, which is protected by the epiglottis. The principal function of the lungs is respiration. To reach the lower airways, air travels through the trachea into each lung, passing through the left and right mainstem bronchus then on to the bronchioles, and finally into the alveoli.

Secondary Assessment

Restriction of the lower airways in patients with asthma often causes: Air hunger as exemplified by: Tripod position Rapid breathing Use of accessory muscles Wheezing In severe cases, you may actually not hear wheezing because of insufficient airflow. Drops in oxygen levels and respiratory and heart rates lead to an altered level of consciousness. This is one of the early warning signs of respiratory inadequacy, and you must act immediately. When you perform a secondary assessment on the respiratory system, look for: Overall symmetry of the chest Adequate rise and fall of the chest Evidence of retractions or accessory muscle use Assess breath sounds, and do a physical assessment if warranted. A secondary assessment of the cardiovascular system, especially when there is associated chest pain, should include: Checking and comparing distal pulses Reassessing skin condition Being alert for bradycardia and tachycardia Feel for the skin temperature, 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. Auscultate blood pressure to obtain the systolic and diastolic numbers. If you are in an environment where you cannot hear well enough to auscultate blood pressure, palpation is an alternative. Check the patient's mental status. Signs of hypoxia include: Anxiousness or restlessness Disorientation Use monitoring devices if you have them available, including, but not limited to, a pulse oximeter. Can help you determine the severity of the respiratory component of the patient's problem If the reading goes steadily up or down, it can give you an indication of improvement or deterioration of the patient's oxygenation status, often even prior to changes in the patient's appearance or vital signs.

Rhonchi

Rhonchi are low-pitched rattling sounds caused by secretions or mucus in the larger airway. Rhonchi are sometimes referred to as "junky" lung sounds and can be heard with infections such as pneumonia and bronchitis or in cases of aspiration.

History Taking

The information you obtain during history taking will be: Subjective (what the patient expresses, or symptoms) 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. Find out what the patient has done for the breathing problem. Does the patient have home oxygen? 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? Record the name of each device and when it was used.

Pleural effusion

Treatment of pleural effusion consists of removal of fluid collected outside the lung, which must be done by a physician in a hospital setting. Provide oxygen and other routine support measures to these patients.

Wheezing

Wheezing indicates constriction and/or inflammation in the bronchus. Wheezing is generally heard on exhalation as a high-pitched, almost musical or whistling sound. This sound is commonly heard in patients with asthma and sometimes in patients with COPD.

for small-volume nebulizer

attach medication to nebulizer mouthpace to tubing. attach oxygen tubing to O2 tank. Set flowmeter to 6 L/min

Emergency Medical Care

if a patient reports breathing difficulty, administer supplemental oxygen immediately. Adult patients breathing more than 20 breaths/min or fewer than 12 breaths/min should receive high-flow oxygen (defined as 15 L/min). 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 to severe respiratory distress. Monitor the patient's respirations as you provide oxygen. Reevaluate the respirations and the patient's response to oxygen repeatedly, at least every 5 minutes, until you reach the ED. This is critical in a person with a chronically high carbon dioxide level because the supplemental oxygen may cause a rapid rise in the arterial oxygen level, depress the patient's hypoxic drive, and cause respiratory arrest. Use pulse oximetry to get an idea of the degree of oxygen deprivation. Adjust oxygen therapy accordingly. If respirations slow and the patient becomes unconscious, assist breathing with a BVM. When in doubt, err on the side of more oxygen, and monitor the patient closely.

small-volume nebulizer A respiratory device that holds liquid medicine that is turned into a fine mist. The patient inhales the medication into the airways and lungs as a treatment for conditions such as asthma.

metered-dose inhaler (MDI) A miniature spray canister through which droplets or particles of medication may be inhaled through the mouth and into the lungs.

Snoring

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