Chapter 15: Respiratory Emergencies

4. Demonstrate how to assist a patient with the administration of a metered-dose inhaler. (pp 612-613, Skill Drill 15-1)

Steps: 1. check to make sure that you have the correct med. for the correct pt. Check expiration date. Ensure the inhaler is at room temp or warmer. 2. remove pt's oxygen mask. Hand inhaler to patient. Instruct about breathing and lip seal. 3. Instruct the pt. to press inhaler and inhale one puff. Instruct him or her about breath holding 4. Reapply oxygen. After a few breaths, have the pt. repeat the dose if order or protocol allows.

5. Demonstrate how to assist a patient with the administration of a small-volume nebulizer. (pp 613-615, Skill Drill 15-2)

Steps: 1. check to make sure you have the correct medication for the correct pt. Check expiration date. Confirm correct pt. 2. Insert the medication into the container on the nebulizer. In some cases, sterile saline may be added (about 3mL0 to achieve the optimum volume of fluid for the nebulized application 3. attach med. container to the nebulizer, mouthpiece, and tubing. Attach oxygen to the oxygen tank. Set flowmeter at 6 L/min 4. Instruct the patient on how to breathe

2. Demonstrate how to use the OPQRST assessment to obtain more specific information about a patient's breathing problem. (p 606)

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)?

3. Discuss the pathophysiology of respiration, including examples of the common signs and symptoms a patient with inadequate breathing may present with in an emergency situation. (pp 587-588)

-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.

2. Explain the physiology of respiration; include the signs of normal breathing. (pp 586-587)

-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. -the brain stem constantly senses levels of carbon dioxide in arterial blood -when CO2 is low, person's breathing rate and depth decreases (to conserve CO2 in the body) -Signs of normal breathing (Table 15-1)

The method by which you administer supplemental oxygen to a hypoxemic patient depends MOSTLY on the: A) presence or absence of cyanosis. B) patient's level of consciousness and heart rate. C) suspected underlying cause of the hypoxemia. D) severity of hypoxemia and adequacy of breathing.

All hypoxemic patients, whatever the cause of their condition, should be treated with supplemental oxygen. The method of oxygen delivery depends on the severity of the hypoxemia and the adequacy of the patient's breathing. For example, a hypoxemic patient who is breathing adequately (eg, normal rate, adequate tidal volume) should receive oxygen via nasal cannula or nonrebreathing mask, depending on the severity of the hypoxemia. However, if the patient is breathing inadequately (eg, fast or slow rate, shallow breathing [reduced tidal volume]), he or she may require ventilation assistance with a bag-valve-mask device. The absence of cyanosis does not rule out hypoxia; cyanosis is a later sign and indicates significant hemoglobin desaturation. A patient's level of consciousness and heart rate can give you clues as to the severity of his or her hypoxemia; a decreased level of consciousness and a rapid, weak pulse rate are signs of significant hypoxemia.

10. Describe the primary emergency medical care of a person who is in respiratory distress. (pp 602-605, 609-615)

Assess the airway Breathing Circulation Respiration Provide airway management and ventilation Assess breath sounds Assess circulation

Assuming a dead space volume of 150 mL, which of the following would yield the lowest minute alveolar ventilation? A) Respiratory rate, 10 breaths/min; tidal volume, 500 mL B) Respiratory rate, 16 breaths/min; tidal volume, 300 mL C) Respiratory rate, 12 breaths/min; tidal volume, 400 mL D) Respiratory rate, 14 breaths/min; tidal volume, 350 mL

B) Respiratory rate, 16 breaths/min; tidal volume, 300 mL Minute alveolar ventilation is the amount of air that moves in and out of the alveoli each minute. In calculating minute alveolar ventilation, you must subtract the dead space volume from the tidal volume first, and then multiply that number by the respiratory rate. Of the options listed, a tidal volume of 300 mL and a respiratory rate of 16 breaths/min yields the lowest value (2,400 mL [2.4 L]).

COPD

COPD is an umbrella term used to describe lung diseases including: chronic bronchitis and emphysema (most common form)

5. Describe different respiratory conditions that cause dyspnea, including their causes, assessment findings and symptoms, complications, and specific prehospital management and transport decisions. (pp 589-590, 609-619)

Causes of dyspnea (shortness of breath or difficulty breathing): -hypoxia (tissues and cells not getting enough oxygen) -pulmonary edema -hay fever -pleural effusion -obstruction of the airway -hyperventilation syndrome -environmental/industrial exposure -carbon monoxide poisoning -drug overdose -cardiopulmonary diseases Symptoms: -shortness of breath -chest tightness -air hunger Management options could be: -providing oxygen via nonrebreathing mask at 15 L/min -providing positive-pressure ventilations using a BVM, pocket mask, or a flow restricted oxygen powered ventilation device -airway management techniques such as an oropharyngeal airway, nasopharyngeal airway, suctioning, or airway positioning -noninvasive ventilatory support with CPAP -positioning in a high Fowler or position to facilitate breathing -assist with resp. meds found in a patient-prescribed metered dose inhaler or a small volume nebulizer

6. List the characteristics of infectious diseases that are frequently associated with dyspnea. (pp 590-593)

Croup An inflammatory disease of the upper respiratory system that may cause a partial airway obstruction and is characterized by a barking cough; usually seen in children. Responds well to humidified oxygen Epiglottitis A disease in which the epiglottis becomes inflamed and enlarged and may cause an upper airway obstruction. Caused most often by bacterial infection. Give high flow oxygen. Dont put anything in their mouths. respiratory syncytial virus A virus that causes an infection of the lungs and breathing passages; can lead to other serious illnesses that affect the lungs or heart, such as bronchiolitis and pneumonia; highly contagious and spread through droplets. Bronchiolitis Inflammation of the bronchioles that usually occurs in children younger than 2 years and is often caused by the respiratory syncytial virus (RSV). provide oxygen therapy. Pneumonia An infectious disease of the lung that damages lung tissue; its cause can be bacterial, viral, or fungal. Pneumonia is often a secondary infection and begins after an upper respiratory tract infection such as a cold or sore throat. factors that predispose a patient to pneumonia: -nursing home facility -recent hospitalization -chronic disease processes -immune system compromise -history of COPD Treatment includes airway support and providing supplemental oxygen. Use oxygen with appropriate adjuncts. Pertussis An airborne bacterial infection that affects mostly children younger than 6 years, in which the patient is feverish and exhibits a "whoop" sound on inspiration after a coughing attack; highly contagious through droplet infection. Influenza type A Virus that has crossed the animal/human barrier and has infected humans, recently reaching a pandemic level with the H1N1 strain. Tuberculosis tuberculosis A chronic bacterial disease, caused by Mycobacterium tuberculosis, that usually affects the lungs but can also affect other organs such as the brain and kidneys; it is spread by cough and can lie dormant in a person's lungs for decades and then reactivate. Must wear at least: gloves, eye protection, an N-95 respirator

A 30-year-old woman overdosed on pain pills and is unresponsive. She is breathing at a rate of 6 breaths/min with shallow depth. Left untreated, she will develop: A) hypocarbia and acidosis. B) hypercarbia and alkalosis. C) hypocarbia and alkalosis. D) hypercarbia and acidosis.

D. hypercarbia and acidosis When the respiratory system is depressed, the patient is unable to eliminate adequate amounts of carbon dioxide from the body; as a result, it will accumulate in the blood (hypercarbia). Immediate ventilation is required to help the patient eliminate this excess carbon dioxide. If not treated, the pH of the blood will fall below 7.35 (acidosis). If the patient is breathing too rapidly and/or deeply, too much carbon dioxide would be eliminated from the body (hypocarbia). If this is left untreated, the pH of the blood would rise above 7.45 (alkalosis).

12. State the generic name, medication forms, dose, administration, indications, actions, and contraindications for medications that are administered via metered-dose inhalers (MDI) and small-volume nebulizers. (pp 610-615)

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 Indications The most common use for an MDI is asthma, and a small-volume nebulizer is used in asthma, bronchiolitis, COPD, and anaphylaxis. Contraindications for MDI: -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. -not prescribed to patient -expired -no permission obtained Dose 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.

3. Demonstrate how to use the PASTE assessment to obtain more specific information about a patient's breathing problem. (p 607)

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.

4. Explain the special patient assessment and care considerations that are required for geriatric patients who are experiencing respiratory distress. (pp 589, 592-593, 618-619)

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). -withhold high levels of O2 from these patients bc it can reduce or stop their respiratory drive

pulmonary edema

Pulmonary edema is the collection of fluid buildup in and around the alveoli. Usually a result of congestive heart failure 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.

1. List the structures and functions of the upper and lower airways, lungs, and accessory structures of the respiratory system. (p 585)

Resp. structures include: diaphragm, muscles of chest wall, accessory muscles of breathing, nerves from the brain and spinal cord to those muscles. Upper airway consists of everything above (and including) vocal cords

Skills Objectives 1. Demonstrate the process of history taking to obtain more information related to a patient's chief complaint based on a case scenario. (pp 605-607)

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

You are assessing an elderly man with respiratory distress. He is coughing up bloody sputum and has an oxygen saturation of 85%. You auscultate his breath sounds and hear coarse crackles in all lung fields. This patient MOST likely has: A) congestive heart failure. B) acute-onset emphysema. C) decompensated asthma. D) severe bacterial pneumonia.

This patient's signs and symptoms are classic for left-sided congestive heart failure and pulmonary edema. As the left side of the heart weakens, so that it can no longer effectively pump blood, blood backs up into the lungs, resulting in pulmonary edema. As pulmonary edema gets worse, the patient begins coughing up pink, frothy sputum (hemoptysis). The presence of fluid in the lungs impairs the exchange of oxygen and carbon dioxide, resulting in hypoxemia and a low oxygen saturation (SpO2). Auscultation of the patient's lungs often reveals coarse crackles, which indicates the presence of fluid. Emphysema is a chronic respiratory disease, not an acute one. Furthermore, hemoptysis is not a common finding with emphysema. Likewise, patients with decompensated asthma often have markedly diminished lung sounds owing to severe bronchospasm; hemoptysis and crackles are not common. Bacterial pneumonia can cause respiratory distress; however, it usually presents with fever and diminished breath sounds to a localized area of a lung (eg, the left lower lobe).

7. Discuss some pandemic considerations related to the spread of influenza type A and strategies EMTs should employ to protect themselves from infection during a possible crisis situation. (pp 590, 593)

aall strains of influenza type A are transmitted through direct contact with nasal secretions and aerosolized droplets from coughing and sneezing from infected people. Wear proper PPE.

8. Explain the special patient assessment and care considerations that are required for pediatric patients who are experiencing respiratory distress. (pp 590-593, 597, 615-619)

croup- children 6 months to 3 years. deliver humidified oxygen. epiglottitis- epiglottis can swell 2 to 3 times its size in school age children. put in position of comfort and deliver high flow oxygen. do not make them cry. RSV- deliver humidified oxygen, and treat airway and breathing problems Bronchiolitis- occurs mostly in newborns and toddlers. Treatment is mainly supportive. deliver oxygen. pertussis- affects children 6 and younger. Some children should be treated in a hospital bc pneumonia could occur. May have to suction secretions. Give O2 appropriately. asthma- affects 5-17 y/os mostly.

9. Describe the assessment of a patient who is in respiratory distress and the relationship of the assessment findings to patient management and transport decisions. (pp 602-609)

life threats that constitute rapid transport: -problems with ABCs -poor initial general impression -unresponsiveness -potential hypoperfusion or shock -chest pain associated with a low blood pressure -severe pain anywhere -excessive bleeding

other respiratory emergencies

pneumothorax A partial or complete accumulation of air or gas in the pleural space. 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 Obstruction of the airway pulmonary embolism A blood clot that breaks off from a large vein and travels to the blood vessels of the lung, causing a sudden blockage of the pulmonary artery and an obstruction of blood flow.

11. List five different types of adventitious breath sounds, their signs and symptoms, and the disease process associated with each one. (p 605)

wheezes rhonchi crackles stridor decreased or absent breath sounds