Chapter 15: Respiratory Emergencies

a child with Epiglottitis

may be more comfortable sitting up & leaning forward

signs, symptoms & Adventitious Breath sounds Associated with Specific Respiratory Disease

Table 15-5

gas exchange

The alveoli lie against the pulmonary capillary vessels, and as oxygen enters the alveoli from inhalation, it passes freely through tiny passages in the alveolar wall into these capillaries through the process of diffusion. The oxygen is then carried to the heart, which then pumps the oxygen around 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 through the upper airways during exhalation

Environmental/Industrial Exposure

The commonality in these kinds of respiratory problems is the inhalation of a toxic chemical. There are many different types of chemicals, different types of presentations, and certainly different levels of severity. 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.

when is hyperventilation life-threatening?

The decision whether hyperventilation is being caused by a life-threatening illness or a panic attack should not be made outside the hospital. Initially, you can verbally instruct the patient to slow his or her breathing; however, if that does not work, give supplemental oxygen and provide transport to the hospital where physicians will determine the cause of the hyperventilation.

Hyperventilation treatment

When you respond to a patient who is hyperventilating, complete a primary assessment and gather a history of the event. Is the patient having chest pain? Is there a history of cardiac problems or diabetes? You must always assume a serious underlying problem even if you suspect that the underlying problem is stress. Do not have the patient breathe into a paper bag, even though it was once thought to be the technique for managing hyperventilation syndrome. In theory, breathing into a paper bag causes the patient to rebreathe exhaled carbon dioxide, allowing the level of carbon dioxide in the blood to return to normal. In fact, if the patient is hyperventilating because of a serious medical problem, this maneuver could make things worse. A patient with underlying pulmonary disease who breathes into a bag may become severely hypoxic. Treatment should instead consist of reassuring the patient in a calm, professional manner; supplying supplemental oxygen; and providing prompt transport to the ED. Patients who hyperventilate need to be evaluated in the hospital.

orthopnea

ability to breathe only in an upright position

Patients with COPD often use

accessory muscles & pursed lips for breathing The increased work of breathing leads of decreased food intake and muscle wasting patients is also tripods

Diphtheria

an acute bacterial infection of the throat and upper respiratory tract difficulty breathing & swallowing sore throat thick gray buildup in throat or nose Fever

mental status + pulse oximeter

It is important to assess the neurologic system because the level of consciousness can change. Check the patient's mental status, and determine if the patient's activity can be described as anxious or restless. If so, that would be an indicator of hypoxia. Does the patient have clear thought processes? Disorientation may be another indicator of hypoxia. Use monitoring devices if you have them available, including, but not limited to, a pulse oximeter. Pulse oximetry is an effective diagnostic tool when used in conjunction with experience, good assessment skills, and clinical judgment. Pulse oximeters measure the percentage of hemoglobin that is saturated by oxygen. In patients with normal levels of hemoglobin, pulse oximetry can be an important tool in evaluating oxygenation. To use pulse oximetry properly, it is important for you to be able to evaluate the quality of the reading and correlate it with the patient's condition. For example, it is doubtful a patient with congestive heart failure in severe respiratory distress will have a pulse oximetry reading of 98% or that a pulse oximetry reading of 80% is reliable in a conscious, alert, active patient with good skin color. If you get a good reading consistent with your patient's condition, the pulse oximeter can help you determine the severity of the respiratory component of the patient's problem. Also, 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.

Hypoxia

Low oxygen saturation of the body, not enough oxygen in the blood

Crackles

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

carbon monoxide poisoning

-carbon monoxide binds with hemoglobin and reduces oxygen supply to tissues -cannot be seen. smelled, or tasted -s/s include: nausea, vomiting, headache, weakness, and unconsciousness -death may occur with prolonged exposure -prevention by ensuring proper ventilation when using fuel-burning devices -gas-burning devices should be inspected annually -flues and chimneys should be unobstructed -carbon monoxide detectors should be installed and inspected regularly People who are exposed to carbon monoxide may think they have the flu. They initially report headache, dizziness, fatigue, and nausea and vomiting. They may report dyspnea on exertion and chest pain and display nervous system symptoms like 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; therefore, oxygen is not being delivered to the tissues of the body. This can lead to cellular death and organ failure if uncorrected. When you assess the scene, do not put yourself at risk of exposure Figure 15-14 . Consider toxic gas exposure if more than one patient in the same environment is experiencing the same signs and symptoms. The symptoms of patients will start to improve as soon as they are 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.

Scene Size Up: Respiratory Emergencies

As always, first consider standard precautions and use of PPE. The patient may have a respiratory infection that could be passed to you through sputum and/or air droplets. Follow local protocols. Next, consider whether the respiratory emergency may have been caused by a toxic substance that was inhaled, absorbed, or ingested. Once you have determined the scene is safe, determine how many patients there are and whether you need additional or specialized resources. If there are multiple people with dyspnea, consider the possibility of an airborne hazardous material release. If the 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.

Asthma, hay fever, and anaphylaxis

As you assess the patient's vital signs, note that 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. As you care for the patient, be prepared to suction large amounts of mucus from the mouth and to administer oxygen. If you do suction, 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. Even patients who use their inhaler may continue to get worse. Reassess breathing frequently and be prepared to assist ventilations with a BVM in severe cases. If you must assist ventilations in a patient who is having an asthma attack, use slow, gentle breaths. Remember, the problem in asthma is getting the air out of the lungs, not into them. Resist the temptation to squeeze the bag hard and fast. Always assist with ventilations as a last resort, and then provide only about 10 to 12 shallow breaths/min.

concerns with epiglottitis

Deterioration can occur quickly in adults with acute epiglottitis. 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 (adequate) airway, and provide prompt transport to the emergency department (ED).

Chronic Respiratory Conditions

Different respiratory complaints offer different clues and different challenges. Patients with chronic conditions may have long periods in which they are able to live relatively normal lives but then sometimes experience acute worsening of their conditions. That is when you are called, and it is important for you to be able to determine your patient's baseline status; in other words, his or her normal condition (and what is different this time that made the patient call you). For example, patients with COPD do not cope well with pulmonary infections because the existing airway damage makes them unable to cough up the mucus or sputum produced by the infection. The chronic lower airway obstruction makes it difficult for the patient to breathe deeply enough to clear the lungs. Gradually, the arterial oxygen level falls, and the carbon dioxide level rises. If a new infection of the lung occurs in a patient with COPD, the arterial oxygen level may fall rapidly. In a few patients, the carbon dioxide level may become high enough to cause sleepiness. In these cases, patients require respiratory support and careful administration of oxygen. Recall that the patient with COPD usually has a long history of dyspnea with a sudden increase in shortness of breath. There is rarely a history of chest pain. More often, the patient will remember having had a recent "chest cold" with fever and either an inability to cough up mucus or a sudden increase in thick green or yellow sputum. The blood pressure of patients with COPD is often normal; however, the pulse may be rapid and occasionally irregular. Pay particular attention to the respirations. They may be rapid, or they may be very slow. Patients with asthma may have different "triggers," including allergens, cold, exercise, stress, infection, and noncompliance with medication prescriptions. It is important to try to determine what may have triggered the attack so that it can be treated appropriately. For example, an asthma attack that occurred while your patient was jogging in the cold will probably not respond to antihistamines, whereas one brought on by a reaction to pollen might. 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 ("water pills") and blood pressure medications. Obtain a list of all medications and ask about the events leading up to the present problem.

MORE on dyspnea patients

Besides shortness of breath, a patient with dyspnea may also report the sensation of chest tightness and air hunger. Air hunger is when a person reports the feeling of "not getting enough air" and has a strong need to breathe. Chest tightness is described as an uncomfortable feeling in the chest, and it is commonly reported by patients with asthma. Dyspnea is also a common complaint in patients with cardiopulmonary diseases. In some cases, it may be caused by physical exertion that has been made difficult because the patient's heart is damaged. Congestive heart failure is a troublesome 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. Severe pain can cause a patient to experience rapid, shallow breathing without the presence of a primary pulmonary dysfunction. In some patients, breathing deeply causes pain because it causes expansion of the chest wall. When you assess your patient for complaints of dyspnea, ask about chest pain; conversely, when you are evaluating your patient for chest pain, ask about dyspnea.

Side Effects

Common side effects of inhalers used for acute shortness of breath include increased pulse rate, nervousness, and muscle tremors. Often, a patient will begin coughing after administration of an inhaler as the airways are opened and secretions start to loosen and clear. If the patient has a prescribed MDI or small-volume nebulizer, read the label carefully to make sure that the medication is to be used for shortness of breath and that it has, in fact, been prescribed by a physician Figure 15-17 . When in doubt, consult medical control.

in pulmonary edema...

fluid fills the alveoli and separates the capillaries from the alveolar wall, interfering with the exchange of O2 and CO2

With pleural effusion...

fluid may accumulate in large volumes on one or both sides, compressing the lung and causing dyspnea

signs and symptoms of inadequate breathing

patient complains of dyspnea altered mental status with shallow or slow breathing anxious or restless respiratory rate is too fast or too slow breathing rhythm is irregular skin is pale, cool or clammy cyanosis pale conjunctivae respiratory sounds decreased or noisy breath sounds on one or both sides patient cannot speak more than a few words at a time muscle retractions unequal or inadequate chest expansion excessive coughing tripod position barrel shaped chest pursed lips or nasal flaring

signs of normal breathing

rate between 12-20 breaths per min regular pattern of inhalation and exhalation clear and equal lung sounds on both sides of the chest regular and equal chest rise and fall adequate depth/tidal volume

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.

To help a patient self-administer medication from a small-volume nebulizer,

1. Follow standard precautions.2. Obtain an order from medical control or local protocol.3. Check that you have the right medication, right patient, right dose, and right route and that the medication is not expired. Ensure there are no issues with contamination, discoloration, or clarity of the medication Step 1 . 4. Make sure that the patient is alert enough to use the device 5. Check to see whether the patient has already taken any treatments.6. If assisting to assemble the device, maintain aseptic technique.7. Open the medication container on the nebulizer, and insert the medication (generally the whole volume of the medication). In some cases, sterile saline may be added (about 3 mL) to achieve the optimum volume of fluid for the nebulized application Step 2 . 8. Attach the medication container to the nebulizer, mouthpiece, and tubing. Attach oxygen tubing to the oxygen tank. 9. Adjust oxygen flow to 6 L/min to establish misting effect Step 3 . 10. Stop administering supplemental oxygen, and remove nonrebreathing mask from the patient's face.11. Ask the patient to put his or her lips around the mouthpiece of the device, inhale the mist, and hold it for 3 to 5 seconds before exhaling Step 4 .12. When the mist dissipates and the medication has been used or the patient is no longer experiencing shortness of breath, discontinue use of the device.13. Place the nonrebreathing mask back on the patient if the patient continues to report shortness of breath. 14. Reassess vital signs, and document your actions and the patient's response.15. Consult with medical control and/or follow local policy if repeated doses are necessary..

To help a patient self-administer medication from an inhaler, f

1. Follow standard precautions.2. Obtain an order from medical control or local protocol.3. Check that you have the right medication, right patient, right dose, and right route and that the medication is not expired.4. Make sure that the patient is alert enough to use the inhaler.5. Check to see whether the patient has already taken any doses.6. Make sure the inhaler is at room temperature or warmer Step 1 .7. Shake the inhaler vigorously several times.8. Stop administering supplemental oxygen, and remove any mask from the patient's face.9. Ask the patient to exhale deeply and, before inhaling, to put his or her lips around the opening of the inhaler Step 2 . 10. Have the patient depress the hand-held inhaler as he or she begins to inhale deeply. 11.Instructthepatienttoholdhisorherbreathforaslongasiscomfortabletohelpthebodyabsorbthemedication Step 3.12. Continue to administer supplemental oxygen.13. Allow the patient to breathe a few times, then repeat a second dose per direction from medical control or local protocol

Assessing ABCs in Respiratory Patients: What to ask

1. Is the air going in?2. Does the chest rise and fall with each breath? 3. Is the rate adequate for the age of the patient?

hypoxic drive

A "backup system" to control respiration; senses drops in the oxygen level in the blood. 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 for fear that the increased oxygen level in the blood could depress, or completely stop, the patient's respiratory drive. Regardless of the current research, 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. Closely monitor patients who are experiencing respiratory distress, and be prepared to assist with ventilations if needed.

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.

metered-dose inhaler (MDI)

A miniature spray canister used to direct medications through the mouth and into the lungs. albuterol (Proventil, Ventolin), albuterol/ipratropium (Combivent), metaproterenol (Alupent, Metaprel), and terbutaline (Brethine).

pleuritic chest pain

A patient with a spontaneous pneumothorax has dyspnea and might report pleuritic chest pain, a sharp, stabbing pain on one side that is worse during inspiration and expiration or with certain movement of the chest wall. By listening to the chest with a stethoscope, you can sometimes detect that breath sounds are absent or decreased on the affected side. However, altered breath sounds are very difficult to detect in a patient with severe emphysema. Spontaneous pneumothorax may be the cause of sudden dyspnea in a patient with underlying 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

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. In addition, the pulmonary blood vessels themselves may have abnormalities that interfere with blood flow and thus with the transfer of gases.

Secondary Assessment of COPD Versus Congestive Heart Failure

Additional pieces to the assessment and treatment puzzle may be revealed during the physical examination. For example, you are treating a patient in acute respiratory distress who is breathing at a rate of 40 breaths/min and has audible wheezing. On the basis of this information, you may be unsure as to whether the patient is in congestive heart failure or is having an asthma attack. The secondary assessment may provide you with some clues, such as a consistently elevated blood pressure and swollen legs and feet (pedal edema) that would lead you in the direction of congestive heart failure. Assume you are assessing a patient with COPD. What would you notice? Patients with COPD are usually older than 50 years. They will often have a history of recurring lung problems and are almost always long-term active or former cigarette smokers. Patients may report tightness in the chest and constant fatigue. Because air has been gradually and continuously trapped in their lungs in increasing amounts, their chests often have a barrel-like appearance. Patients with COPD often use accessory muscles to breathe Figure 15-16 . If you listen to the patient's chest with a stethoscope, you will hear abnormal breath sounds. Patients with COPD will often exhale through pursed lips as a strategy to keep airways open longer. Digital clubbing (abnormal enlargement of the ends of the fingers) is also a sign of COPD.

A pneumothorax occurs when

Air leaks into the pleural space from an opening in the chest wall or surface of lung. Lung collapses as pleural space fills with air and the two surfaces are no longer in contact.

embolus

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, which can result in a life-threatening condition. 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.

Assessing ABCs in Respiratory Patients

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. If the airway is patent, next evaluate whether the patient's breathing is adequate. 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? What are the color, temperature, and condition of the patient's skin? Are the patient's respirations labored? If the patient can speak only one or two words at a time before gasping for a breath, ventilations are considered labored. If the respiratory effort is inadequate, you must provide the necessary intervention. If the patient is in respiratory distress, place him or her in a position that best facilitates breathing (generally sitting upright in a full or semi-Fowler position) and begin administering 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.

Asthma Treatment

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. Keep in mind that a cough is not always a symptom of a cold; it could signal pneumonia or asthma. 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. However, many small children will not tolerate (or may refuse to wear) a face mask. Rather than fighting with the child, 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 Figure 15-19 . Many children with asthma also will have prescribed hand-held MDIs. Use these inhalers just as you would with an adult. Pediatric patients and some geriatric patients are more likely to use spacers to assist in inhaler use. Treat as in adult asthma. Asthma in an older patient causes bronchospasm, swelling of the lining of the airways, and an accumulation of secretions. Attacks are easily triggered by air pollutants, viral infections, allergens, and sometimes something as simple as exposure to cold air. Asthma, as with any chronic disease, can become life threatening in older people, especially in patients who have problems with airway control. The condition is made worse by anxiety and dehydration, which is typical in older people. Geriatric patients with asthma tend to have both inspiratory and expiratory wheezes.

Wet Lungs Versus Dry Lungs and "Cardiac Asthma"

Be aware that the signs and symptoms of COPD and congestive heart failure significantly overlap. Many patients suffer from both diseases, and it is often difficult to determine which disease is causing the patient's shortness of breath; often these patients are treated for both diseases after arrival to the hospital. Lung sounds (discussed later in the chapter) are one way to help you tell the difference. Patients with pulmonary edema caused most often by congestive heart failure will often have "wet" lung sounds (rhonchi, crackles), and patients with COPD will often have "dry" lung sounds (wheezes). However, do not assume all COPD patients have wheezes and all congestive heart failure patients have crackles. Table 15-4 compares COPD and congestive heart failure. Suppose you are called to assist an 80-year-old man who has had shortness of breath for 45 minutes. Physical examination reveals that his pulse and respirations are elevated, and you observe pedal edema (swollen legs and feet) and jugular vein distention. His lung sound check reveals wheezing. He has a history of hypertension, congestive heart failure, and myocardial infarction; however, he has no history of smoking, asthma, or COPD. What is your initial general impression? This patient's elevated blood pressure, pedal edema, jugular vein distention, and history of congestive heart failure should lead you in the direction of congestive heart failure. Unlike a typical patient with COPD, he has no history of smoking and takes diuretics and medication for hypertension. In this case, the alveoli are so full of fluid that bubbles (the condition that gives the sound of crackles) cannot form. The bronchi also become constricted, which produces wheezing. The wheezing this patient is experiencing is called cardiac asthma, which is not a form of asthma, but rather a type of coughing or wheezing that occurs with left-sided heart failure.

Pulmonary Embolism Treatment

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 any blood that has been coughed up should be cleared from the airway. The patient may have an unusually rapid and possibly irregular heartbeat. Transport the patient to the ED promptly. Be aware that large pulmonary emboli may cause cardiac arrest.

Tracheostomy dysfunction treatment

Children with chronic pulmonary medical conditions may use a home ventilator that is connected by a tracheostomy tube. This tube is placed in an opening in the neck (stoma) and can sometimes become obstructed by secretions, mucus, or foreign bodies. Other tracheostomy tube complications include bleeding, leaking, dislodgement, and infection. Your main goal is to establish a patent airway. 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. As with children, the tube can become obstructed by secretions, foreign bodies, or airway swelling. The stoma itself can become infected. Your immediate goal is to establish airway patency.

Medical Control

Consult medical control (online), or follow standing orders (off-line). Remember to report what the medication is, when the patient last self-administered a treatment, how much medication was used at that time, and what the label states regarding dosage. If medical control or standing orders permit, you may assist the patient to self-administer the medication. Be certain that the inhaler belongs to the patient, it contains the correct medication, the expiration date has not passed, and the correct dose is being administered. There may be times in which the prescribed dose is not explicitly listed on the inhaler. In this situation, 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. The patient may have a tank available, or you will need to use your own tank.

cystic fibrosis Treatment

Cystic fibrosis (CF) is a genetic disorder that affects the lungs and digestive system. CF disrupts the normal function of cells that make up the sweat glands in the skin and that also line the lungs and the digestive and reproductive systems. The disease predisposes the child to repeated lung infections. The disease process in CF disrupts the essential balance of salt and water necessary to maintain a normal coating of fluid and mucus inside the lungs and other organs. The end result is that the mucus becomes thick, sticky, and hard to move. The mucus holds germs, causing the lungs to become infected. In CF, the child's symptoms range from sinus congestion to wheezing and asthma-like complaints. A chronic cough that produces thick, heavy, discolored mucus may develop in the child. As lung function decreases, so does the ability to breathe effectively. The child often has dyspnea; this generally results in the parents or caregivers calling EMS. 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 very 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 CF are predisposed to other medical conditions, including arthritis, osteoporosis, diabetes, and liver problems.

Upper/Lower Airway Infection Treatment

Dyspnea associated with acute infections is common. Except in the patient with pneumonia, acute bronchitis, or epiglottitis, it is rarely serious. The acute congestion and stuffiness of a common cold hardly ever require emergency care. Indeed, most people with colds treat themselves with over-the-counter medications. However, people with a common cold who have underlying problems such as asthma or heart failure may experience a worsening of their condition as a result of the additional stress of the infection. In addition, medications for colds may also have stressful side effects, such as agitation, increased heart rate, and increased blood pressure. 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" Figure 15-18 . To force a patient with epiglottitis to lie supine may cause upper airway obstruction that could result in death

Emphysema

Emphysema is a loss of the elastic material in the lungs that occurs when the alveolar air spaces are chronically stretched due to inflamed airways and obstruction of airflow out of the lungs. Smoking can also directly destroy the elasticity of the lung tissue. Normally, the lungs act like spongy balloons that are inflated; once they are inflated, they will naturally recoil because of their elastic nature, expelling gas rapidly. However, when they are constantly obstructed or when the elasticity is diminished, air is no longer expelled rapidly, and the walls of the alveoli eventually fall apart, leaving large "holes" in the lung that resemble large air pockets or cavities. Most patients with COPD have elements of both chronic bronchitis and emphysema. Some patients will have more elements of one condition than the other; few patients will have only emphysema or bronchitis. Therefore, most patients with COPD will chronically produce sputum, have a chronic cough, and 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.

signs & symptoms of congestive heart failure

However, not all patients with pulmonary edema have heart disease. Poisonings from inhaling large amounts of smoke or toxic chemical fumes can produce pulmonary edema, as can traumatic injuries of the chest and 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 because the heart cannot keep up with the body's need for oxygen. Patients may also report a sudden attack of respiratory distress that wakes them at night when they are in a reclining position. This is caused by fluid accumulation in the lungs. Patients also report coughing, feeling suffocated, cold sweats, and tachycardia. In your primary assessment, you might find the patient has cool, diaphoretic, cyanotic skin and you will hear adventitious breath sounds like crackles or wheezing. The patient's pulse will be tachycardic. The patient may have hypertension early, followed by deterioration to hypotension as a late finding.

Assessing ABCs in Respiratory Patients Continued

If the answer to any of these questions is "no," something is wrong. Try to reposition the patient and insert an oral airway to keep the tongue from blocking the airway. Refer to Chapter 10, Airway Management, for a review of airway management and ventilation techniques. 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. Techniques for this assessment are described at the end of this section. After assessing breath sounds, assess circulation—the pulse rate, quality, and rhythm. If the pulse rate is too fast or too slow, the patient may not be getting enough oxygen. Determine the quality of the pulse. Is it strong, bounding, or weak? Also determine whether the rhythm is regular or irregular. Irregular beats could indicate a cardiac problem. Assessing a patient's circulation includes an evaluation for the presence of shock and bleeding. Respiratory distress in a patient could be caused by an insufficient number of red blood cells to transport the oxygen. Assess capillary refill in infants and children. Normal capillary refill is less than 2 seconds; abnormal capillary refill is greater than 2 seconds. Capillary refill is not considered a reliable assessment tool in the adult patient. Assess the patient's 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

Obstruction of the Airway Treatment

If the patient is a small child or someone who was eating just before dyspnea developed, you may assume that the problem is an inhaled or aspirated foreign body. If the patient is old enough to talk but cannot make any noise, upper airway obstruction is the likely cause. Upper airway obstruction may be either partial or complete. 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. As long as the patient is able to obtain sufficient oxygen, avoid doing anything that might turn a partial airway obstruction into a complete airway obstruction. There is no condition more immediately life threatening than a complete airway obstruction. The obstructing body must be removed before any other actions will be effective. Clear the patient's upper airway according to basic life support guidelines. Opening the airway with the head tilt-chin lift maneuver (or the jaw-thrust maneuver for patients with suspected spinal trauma) may solve the problem. You should perform this maneuver only after you have ruled out a head or neck injury. If simply opening the airway does not correct the breathing problem, you will have to assess the upper airway for the obstruction. Then, whether or not you are successful in clearing the airway, administer supplemental oxygen and transport the patient promptly to the ED.

Upper/Lower Airway Infection

Infectious disease may effect all parts of airway by obstructing air flow or exchange of gases. 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). Infections may also impair exchange of gases between the alveoli and the capillaries (pneumonia). In patients with infectious diseases, you will be in close contact, so be diligent about your personal use of appropriate personal protective equipment (PPE)

Emergency Medical Care

Management of respiratory distress involves continuing awareness of scene safety and the use of standard precautions. Management of ABCs and positioning are primary treatments along with oxygen and suction. You will usually administer oxygen. 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). Depending on the level of distress, some patients may benefit from CPAP (discussed later in the chapter). In addition, 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. Take great care in monitoring 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. In a person with a chronically high carbon dioxide level (eg, certain patients with COPD), this is critical, because the supplemental oxygen may cause a rapid rise in the arterial oxygen level. This, in turn, may depress the patient's hypoxic drive and cause respiratory arrest. In patients who have long-standing COPD and probable carbon dioxide retention, administration of low-flow oxygen (2 L/min) is a good place to start, with adjustments to 3 L/min, then 4 L/min, and so on, until symptoms have improved (for example, the patient's breathing becomes easier or he or she becomes more responsive). Pulse oximetry will help you understand the degree of oxygen deprivation and adjust oxygen therapy accordingly. When in doubt, err on the side of more oxygen, and monitor the patient closely. Remember, do not withhold oxygen for fear of depressing or stopping breathing in a patient with COPD who needs oxygen. A decreased respiratory rate after administration of oxygen does not necessarily mean that the patient no longer needs the oxygen; he or she may need it even more. If respirations slow and the patient becomes unconscious, assist breathing with a BVM. Always provide emotional support to the patient who is anxious. Always speak with assurance and assume a concerned, professional approach to reassure the patient, who is probably very frightened.

Environmental/industrial exposure

Many accidental exposures that cause inhalation injury and dyspnea occur at industrial sites. Pesticides, cleaning solutions, chemicals, chlorine, and other gases can be accidentally released and inhaled by employees. Sometimes chemicals like ammonia and chlorine bleach are mixed and create a hazardous by-product. In many cases, industrial sites have their own medical, fire, and/or hazardous materials (HazMat) teams that are familiar with all the chemicals used at their site and know what to do in case of an exposure. They will begin immediate decontamination and medical care. In these cases, the patient needs to be decontaminated by trained responders before you take responsibility. 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.

Dose/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.

Respiratory Actions

Most respiratory inhalation medications used relax the muscles that surround the air passages in the lungs, leading to enlargement (dilation) of the airways and easier movement of air. See Table 15-6 for a list of 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. The medications for long-term use will provide little relief of acute symptoms.

Assessing Breath Sounds

Obtaining breath sounds, or lung sounds, is an important step when you assess a patient who is experiencing respiratory distress. Listen over the bare chest. Trying to listen over clothing or chest hair may give you inaccurate information. The diaphragm of the stethoscope must be in firm contact with the skin. If your patient is lying down, bring him or her to a sitting position, which is a better position for assessing breath sounds. You need to determine whether your patient's breath sounds are normal (vesicular breath sounds, bronchial breath sounds) or 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 Figure 15-15 . 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. Make sure you 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 you assess for fluid collection, pay special attention to the lower lung fields. Start from the bottom up and determine at which level you start hearing clear breath sounds. You want to hear clear flow of air in both lungs. Not hearing the flow of air is considered an absent lung sound. The lack of air movement in the lung is a significant finding. Listen carefully and do not confuse absent breath sounds with clear breath sounds. See Table 15-5 for examples of breath sounds, the diseases that may be associated with them, and important signs and symptoms.

Reassessment

Once the assessment and treatment have been completed, you need to reassess the patient and closely watch patients with shortness of breath. Repeat the primary assessment, and maintain an open airway. Monitor the patient's breathing, and reassess circulation. Determine if there have been changes in the patient's condition. Confirm the adequacy of interventions and patient status. Is the current treatment improving the patient's condition? Has an already identified problem improved? Has an already identified problem gotten worse? What is the nature of any newly identified problems?If the changes you find are improvements, simply continue the treatments; however, if your patient's condition deteriorates, prepare to modify treatments. 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.

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," then it is another indicator that your patient is in distress. Exercise tolerance will decrease as the breathing problem and hypoxia incease.

chronic obstructive pulmonary disease (COPD) treatment

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

Patients with COPD wheeze because of bronchial constriction and present with....

Patients with COPD wheeze because of bronchial constriction and present with shortness of breath. Their breathing gets progressively worse, and they have the most trouble breathing on exertion. Patients with COPD have chronic coughing and thick sputum. They are usually long-term smokers with a thin, barrel chest appearance. Their medications would include home oxygen, bronchodilators, and corticosteroids. Patients with COPD 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. As you try to discern between COPD and congestive heart failure, keep an open mind so that you do not miss important differences. The best advice is to treat the patient, not the lung sounds.

spontaneous pneumothorax treatment

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 provide prompt transport to the hospital. Like most dyspneic patients, those with spontaneous pneumothorax are usually more comfortable sitting up. Monitor the patient carefully, watching for any sudden deterioration in the respiratory status. Be ready to support the airway, assist respirations, and provide CPR if it becomes necessary.

Primary Assessment: Respiratory Emergencies

Perform a rapid examination to identify immediate life threats, which includes problems with the ABCs: airway, breathing, and circulation (discussed next). If any major problem is identified, treat it immediately. If you find life-threatening issues, provide rapid transport. Note your general impression of the patient. What is his or her age and position? A patient in significant respiratory distress will want to sit up. In a worst-case scenario, you will arrive to see the patient in the tripod position. Does the patient appear calm? Is he or she anxious and restless, or listless and tired? How severe is his or her breathing complaint? This initial impression will help you decide whether the patient's condition is stable or unstable. Use the AVPU scale to check for responsiveness. If the patient is alert or responding to verbal stimuli, you know that the brain is still receiving oxygen. Ask the patient about his or her chief complaint. If the patient is responsive only to painful stimuli or unresponsive, the brain may not be oxygenating well and the potential for an airway or breathing problem is more likely. If there is no gag or cough reflex, you need to immediately assess the patient's airway status. Within seconds you will be able to determine if there are any immediate threats to life.

alkolosis

Similarly, 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. The resulting condition, alkalosis, is 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, and painful spasms of the hands and/or feet (carpopedal spasms). Patients often feel they cannot catch their breath despite the rapid breathing. Although hyperventilation can be the response to illness and a buildup of acids, hyperventilation syndrome is not the same thing. Instead, this syndrome occurs in the absence of other physical problems. It commonly occurs when a person is experiencing psychological stress and affects some 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.

Acute Pulmonary Edema

Sometimes, the heart muscle is so injured after a heart attack or other illness that it cannot circulate blood properly. In these cases, the left side of the heart cannot remove blood from the lung as fast as the right side delivers it. As a result, 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 congestive heart failure. By physically separating the alveoli from the pulmonary capillary vessels, the edema interferes with the exchange of carbon dioxide and oxygen Figure 15-6 . Not enough space is left in the lung to allow for slow, deep breaths. High blood pressure and low cardiac output often trigger this "flash" (sudden) pulmonary edema. These patients are among the most sick, frightened, and worrisome patients you will encounter. They are literally drowning in their own fluid. The patient usually experiences dyspnea with rapid, shallow respirations. In the most severe cases, you will see frothy pink sputum at the nose and mouth.

History Taking: respiratory Emergencies

The next step of your assessment will provide more information specific to the patient's chief complaint (history of present illness) through history taking. The information you obtain during history taking will be subjective (what the patient expresses, or symptoms) and objective (what you observe, or signs). Both sets of information are important in building a general assessment. Rule out any findings that warrant no care or intervention. Report pertinent negatives to health care providers or ED staff members. Recall that a pertinent negative is any sign or symptom that commonly accompanies a particular condition, but is absent. Examples of pertinent negatives would be a patient in respiratory distress who denies chest pain, or a patient with severe chest pain who denies shortness of breath. 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? Be sure to record the name of each device and when it was used.

Pleural effusion treatment

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

Foreign Body Aspiration Treatment

Upper airway obstruction is common in young children, who put objects in their mouths as a way to learn about them. If you have evidence of a partial or complete airway obstruction in a young child, especially a crawling baby, consider that the child may have swallowed and choked on a small object. Perform 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, the normal process of aging creates conditions that contribute to breathing problems. For example, weakening of the airway musculature can cause decreased breathing capacity. Decreased cough and gag reflexes cause a decreased ability to clear secretions. Difficulty in swallowing means the risk 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 pneumoni

What is a pulmonary embolism?

blood clot from a vein that breaks off, circulates through the venous system & moves through the right side of the heart into the pulmonary artery Here it can become lodged and significantly obstruct blood flow Pulmonary emboli may occur as a result of damage to the lining of vessels, a tendency for blood to clot unusually fast, or, most often, slow blood flow in a lower extremity. Slow blood flow in the legs is usually caused by long-term bed rest, which can lead to the collapse of veins. Patients whose legs are immobilized following a fracture or recent surgery are at risk for pulmonary emboli for days or weeks after the incident. Pregnancy, active cancer, and bed rest are other risk factors. Only rarely do pulmonary emboli occur in active, healthy people.

congestive heart failure

dependent edema crackles(pulmonary edema) Orthopnea Paroxysmal nocturnal dyspnea

symptoms of pneumonia vary based on age

depending on the age of the person and the cause of the illness. 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, and 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. You will need to evaluate the patient's history for possible risk factors. If possible, assess temperature to determine the presence of fever. Pulse oximetry readings, if available, may be low. Regardless of the cause, treatment includes airway support and providing supplemental oxygen. Use oxygen with appropriate adjuncts, and provide supportive measures if needed. Evaluate patient treatment through reassessment and prepare for possible deterioration in the patient's condition.

Patient risk factors for congestive heart failure include

hypertension and a history of coronary artery disease and/or atrial fibrillation, a condition in which the atria no longer contract, but instead quiver. However, 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.

repeated episodes of irritation and inflammation in alveoli result

in the obstruction, scarring & some dilation of alveolar sac characteristic COPD

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.

bronchitis

inflammation of the bronchi chronic cough (with sputum production) wheezing Cyanosis Tachypnea(increased breathing rate)

Tuberculosis (TB)

is a bacterial infection caused by Mycobacterium tuberculosis. TB spreads by cough and is dangerous because many strains are resistant to antibiotics. TB most commonly affects the lungs but can also 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 (inactive) for years without causing symptoms or being infectious to other people. However, when the person is in a state of weakened immunity, TB can become active again. The patient may not even be aware he or she has the disease. 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, such as prison inmates, nursing home residents, and people in homeless shelters. TB is also found in people who abuse intravenous drugs or alcohol and people whose immune systems are compromised by an infection such as HIV. Anyone who comes into close contact with people who have active TB, or is in contact with people from countries that have a high prevalence of TB, is at risk for contracting the disease. As an EMT, you are also at risk. If you suspect your patient may have active TB, you need to wear (at a minimum) your gloves, eye protection, and an N- 95 respirator. These respirators are fit-tested to the individual to ensure no contaminated air can pass through.

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 Figure 15-13 . Even though the lung itself can continue the process of inhalation and exhalation, no exchange of oxygen or carbon dioxide takes place in the areas of blocked blood flow because there is no effective circulation. In this circumstance, 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.

pleural effusion

is a collection of fluid outside the lung on one or both sides of the chest. It compresses the lung or lungs and causes dyspnea Figure 15-11 . This 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 effusions 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. Nothing will completely relieve their symptoms, however, except removal of the fluid, which must be done by a physician in the hospital.

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 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. Therefore, 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.

pneumonia

is a general term that 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, meaning it begins after an upper respiratory tract infection such as a cold or sore throat. It can be caused by a virus or bacterium, or by a chemical injury after an accidental ingestion or a direct lung injury from a submersion incident. Interventions such as intubation and tracheostomy can increase the risk of developing pneumonia. Pneumonia commonly affects people who are chronically and terminally ill.

Epiglottitis

is a life-threatening inflammatory disease of the epiglottis, the small flap of tissue at the back of the throat that protects the larynx and trachea during swallowing. Bacterial infection is the most common cause Figure 15-5 . In the past, epiglottitis was most often seen in infants and children. In some cases, it occurs in adults. 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. This puts the airway at risk of complete obstruction. The condition usually develops in otherwise healthy children, and symptoms are sudden in onset. Children with this infection look ill, report a very sore throat, and have a high fever. They will often be found in the tripod position and drooling. Stridor is a late sign in the development of airway obstruction. 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, as this could trigger a complete airway obstruction.

pneumothorax

is a partial or complete accumulation of air in the pleural space. Pneumothorax is most often caused by trauma, but it can also be caused by some medical conditions. In these cases, the condition is called a "spontaneous" pneumothorax. Normally, the "vacuum" pressure in the pleural space keeps the lung inflated. When the surface of the lung is disrupted, however, 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. The accumulation of air in the pleural space may be mild or severe Figure 15-10 . 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. Tall, thin men are also more susceptible than the rest of the population to development of spontaneous pneumothorax, particularly while performing strenuous activities, such as heavy lifting.

Bronchiolitis

is a respiratory illness that often occurs due to respiratory syncytial virus (RSV) infection and results in severe inflammation of the bronchioles. Bronchioles, the tiny airways that lead from the larger airways (bronchi) to the alveoli in the lungs, become inflamed, swell, and fill with mucus. It occurs most frequently in newborns and toddlers, especially boys, whose airways can easily become blocked. Infections are common during the winter and spring. 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. You should provide appropriate oxygen therapy and allow the patient to remain in a position of comfort. Reassess frequently for signs of worsening respiratory distress. Be prepared to provide airway management and positive-pressure ventilation should the patient develop respiratory failure.

anaphylaxis (anaphylactic shock)

is a severe allergic reaction characterized by airway swelling and dilation of blood vessels all over the body, which may significantly lower blood pressure Figure 15-9 . Anaphylaxis may be associated with widespread hives (urticaria), itching, signs of shock, and signs and symptoms similar to asthma. The airway may swell so much that breathing problems can progress to total airway obstruction in a matter of minutes. Most anaphylactic reactions occur within 30 minutes of exposure to the allergen, which can be anything from food (such as peanuts) to medication (such as penicillin). For some patients, the episode of anaphylaxis may be their first; therefore, they may not know what caused the reaction. In other cases, the patient may be aware of what substance he or she is sensitive to but is unaware that an exposure has occurred, such as eating food that was not supposed to contain nuts. 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.

chronic obstructive pulmonary disease (COPD)

is a slow process of dilation and disruption of the airways and alveoli caused by chronic bronchial obstruction. According to the US Department of Health and Human Services, an estimated 12 million people are diagnosed with COPD, and an additional 12 million people may have COPD and not know it. According to the CDC, it is the third leading cause of death in the United States. COPD is an umbrella term used to describe a few lung diseases including emphysema and chronic bronchitis, an ongoing irritation of the trachea and bronchi. COPD may be a result of direct lung and airway damage from repeated infections or inhalation of toxic gases and particles, but most often it results from cigarette smoking. Although it is well known that cigarettes are a direct cause of lung cancer, their role in the development of COPD is far more significant and less publicized. Tobacco smoke is a bronchial irritant and can create chronic bronchitis. With bronchitis, excess mucus is constantly produced, obstructing small airways and alveoli. Protective cells and lung mechanisms that remove foreign particles are destroyed, further weakening the airways. Chronic oxygenation problems can also lead to right-sided heart failure and fluid retention, such as edema in the legs.

Asthma

is an acute spasm of the bronchioles associated with excessive mucus production and with swelling of the mucous lining of the respiratory passages Figure 15-8 . According to the CDC, approximately 25 million Americans have asthma. 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. These same air passages open easily during inspiration. The wheezing may be so loud that you can hear it without a stethoscope. In other cases, the airways are so blocked that no air movement is heard. In severe cases, the actual work of exhaling is tiring, and cyanosis and/or respiratory arrest may quickly develop. Cyanosis is the body's attempt to divert blood to the core to help keep the vital organs functioning. It can be seen first in the lips and mucous membranes. 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. This, 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 and know when an attack is imminent. Typically, they will have appropriate medication with them. Depending on your local protocols, you may be allowed to assist an asthma patient with an inhaler or nebulizer. Listen carefully to what a patient with asthma tells you; they often know exactly what they need.

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. 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. This may frighten the parents or caregivers into calling 9-1-1. Some infants and younger children with pertussis should be treated in a hospital because they are at greater risk for complications like pneumonia, which occurs mostly in children younger than 1 year. 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 that it does in infants and toddlers. However, it can cause a severe upper respiratory infection, which can lead to pneumonia in geriatric patients or people with compromised immune systems. The infection can cause coughing spells that last for weeks and can be so severe that patients find it hard to breathe, eat, or sleep. 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. According to the CDC, the disease has become a serious issue and physicians are becoming more aggressive about immunizing adults with the pertussis vaccine.

influenza type A

is an animal respiratory disease that has mutated to infect humans. In 2009, the H1N1 strain of influenza type A became pandemic (an outbreak that occurred on a global scale). 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. Influenza type A viruses cause fever, cough, sore throat, muscle aches, headache, and fatigue and may lead to pneumonia or dehydration.

Acute Epiglottitis

is caused by a bacterial infection that results in severe swelling of epiglottis, which can obstruct the airway

Croup

is caused by inflammation and swelling of the pharynx, larynx, and trachea Figure 15-4 . 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. Peak seasonal outbreaks of this disease occur in the late fall and during the winter. The disease 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.

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.

Foreign body obstruction

occurs when an object, such as foor is lodged in an airway

mechanical obstruction

occurs when the head is not properly positioned, causing the tongue to fall back on the throat

Secondary Assessment: Respiratory Assessment

ometimes it is not possible to quickly and definitively determine what is causing your patient's respiratory distress. If your patient is a 20-year-old woman at a picnic who rapidly develops difficulty breathing and hives after being stung by a bee, you have a clearcut diagnostic picture. Conversely, if your patient is an older woman in a nursing home who is receiving 12 medications and has a cough and increasing shortness of breath that developed during the past week, this is more perplexing. Keep an open mind, gather as complete a history as possible, and perform a secondary assessment. Conduct an in-depth assessment when a patient reports shortness of breath. In addition to the signs of air hunger present in all patients with respiratory distress, such as the tripod position, rapid breathing, and use of accessory muscles, restriction of the small lower airways in patients with asthma often causes wheezing. Patients may have a prolonged expiratory phase of breathing as they attempt to exhale trapped air from the lungs. In severe cases, you may actually not hear wheezing because of insufficient airflow. Remember that the brain needs a constant, adequate supply of oxygen to function normally. As your patient tires from the effort of breathing and oxygen levels drop, the respiratory and heart rates may drop, and you will notice an altered level of consciousness. This may manifest itself as confusion, lack of coordination, bizarre behavior, or even combativeness. Your patient may seem to relax or fall asleep. A change in affect or level of consciousness 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, and evidence of retractions or accessory muscle use. Are the patient's respirations labored or unlabored? Assess breath sounds, and do a physical assessment if warranted. A secondary assessment of the cardiovascular system, especially when there is associated chest pain, should include checking and comparing distal pulses, reassessing the skin condition, and 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. Blood pressure should be auscultated (by listening) when possible to obtain the systolic and diastolic numbers. If you are in an environment where you cannot hear well enough to auscultate the blood pressure, then palpation (by feeling) is an alternative.

Hay Fever

or allergic rhinitis, causes coldlike symptoms, including a runny nose, sneezing, congestion, and sinus pressure. The symptoms are caused by an allergic response, usually to outdoor airborne allergens such as pollen or sometimes indoor allergens such as dust mites and pet dander. For many people, hay fever is at its worst in the spring and summer, but others may have hay fever symptoms year-round. People do not generally call 9-1-1 or request an ambulance for simple hay fever symptoms, but hay fever is included in this discussion of allergic conditions because it affects so many people. People with hay fever tend to be atopic, meaning that they are more likely to have other allergies, and they may also have a higher incidence of severe reactions, including anaphylaxis.

CPAP (continuous positive airway pressure)

s a noninvasive means of providing ventilatory support for patients experiencing respiratory distress associated with obstructive pulmonary disease and acute pulmonary edema. As discussed in Chapter 10, Airway Management, CPAP increases pressure in the lungs, opens collapsed alveoli, pushes more oxygen across the alveolar membrane, and forces interstitial fluid back into the pulmonary circulation. CPAP systems use oxygen to deliver the positive ventilatory pressure to the patient. Many patients show dramatic improvement with the use of CPAP. CPAP can be used for patients who have moderate to severe respiratory distress from an underlying disease, such as pulmonary edema or obstructive pulmonary disease, are alert and able to follow commands, have tachypnea, or have a pulse oximetry reading of less than 90%. One potential contraindication to the use of CPAP is low blood pressure. Because of the increased pressure inside the chest, blood flow returning to the heart is diminished. CPAP is also not used in patients in respiratory arrest or who have signs and symptoms of a pneumothorax or chest trauma, a tracheostomy, have a decreased level of consciousness, inability to follow commands, or have active gastrointestinal bleeding. If you are authorized to apply CPAP for acute pulmonary edema according to your local protocols, do so. Otherwise, provide prompt transport to the nearest appropriate ED. Continue to reassess patients using CPAP for signs of deterioration and/or respiratory failure.

Hyperventilation

s defined as overbreathing to the point that the level of arterial carbon dioxide falls below normal. This may be an indicator of a life-threatening illness. For example, a patient with diabetes who has a high blood glucose level, a patient who has taken an overdose of aspirin, or a patient with a severe infection is likely to hyperventilate. In these cases, rapid, deep breathing is the body's attempt to stay alive. The body is trying to compensate for acidosis, the buildup of excess acid in the blood or body tissues that results from the primary illness. Because carbon dioxide, mixed with water in the bloodstream, can add to the blood's acidity, lowering the level of carbon dioxide helps to compensate for the other acids.

paroxysmal nocturnal dyspnea

sudden awakening from sleeping with shortness of breath

croup results in

swelling of the whole airway: pharynx, larynx, & trachea Croup often responds well to the administration of humidified oxygen. Note that bronchodilators are not indicated for croup and can worsen a patient's symptoms.

prolonger asthma attack

that is unrelieved may progress into a condition known as status asthmaticus. The patient is likely to be frightened, frantically trying to breathe, and using all the accessory muscles. Status asthmaticus is a true emergency. Give oxygen and promptly transport to the ED. The effort to breathe during an asthma attack is very tiring, and the patient may be exhausted by the time you arrive at the hospital. An exhausted patient may have stopped feeling anxious or even struggling to breathe. This patient is not recovering; he or she is at a very critical stage and is likely to stop breathing. Aggressive airway management, oxygen administration, and prompt transport are essential in this situation. Advanced life support (ALS) should be considered. Follow local protocol. 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. For example, if the patient has a stinger from a bee sting still in place, you may need to remove the stinger. Remember to scrape the stinger off because you can inject more venom into the patient if you pinch or squeeze the stinger. Maintain the airway—the airway is always a priority regardless of the situation. 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. Because epinephrine has immediate action, it can rapidly reverse the effects of anaphylaxis.

brain stem & CO2

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. As a result, less carbon dioxide is expired, allowing carbon dioxide levels in the blood to return to normal. Although considered a waste gas, some level of carbon dioxide in the blood is actually necessary and, in addition to stimulating breathing, helps balance pH. If the level of carbon dioxide in the arterial blood rises above normal, the person breathes more rapidly and more deeply. When more fresh air is brought into the alveoli, more carbon dioxide diffuses out of the bloodstream, thereby lowering the level of carbon dioxide in the blood.

When carbon dioxide levels become elevated,

the respiratory centers in the brain adjust the rate and depth of ventilation accordingly. However, 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 their drive for breathing.

Anatomy of the Respiratory System

these structures include the diaphragm, the muscles of the chest wall, the accessory muscles of breathing, and 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. These include the nose, mouth, jaw, oral cavity, pharynx, and larynx. Air enters the upper airway through the nose and mouth, and it is here that the air is filtered, warmed, and humidified. The upper airway ends at the larynx, which is protected by the epiglottis. This leaf- shaped valve folds over the larynx during swallowing and diverts food and fluid into the esophagus. During normal breathing, the epiglottis returns to an upright position, allowing air to flow freely between the vocal cords into and out of the trachea. Air moves through the trachea into and out of the lungs.

Dyspnea

when a patient reports shortness of breath or has difficulty breathing. It is a symptom of many different conditions, from the common cold or asthma to heart failure and pulmonary embolism. You may not be able to determine what is causing dyspnea in a particular patient

Respiration

which is the exchange of oxygen and carbon dioxide. To reach the lower airways, air travels through the trachea into each lung, first passing through the left and right mainstem bronchus (larger airways), then on to the bronchioles (smaller airways), and finally into the alveoli. The alveoli are microscopic, thin- walled air sacs where the actual exchange of oxygen and carbon dioxide occurs.

small-volume nebulizer

works by providing a means for a fine mist of aerosolized medicine to get deep into the patient's lungs and start to work quickly. The patient inhales the mist through a mouthpiece. When the medicine is breathed in correctly, it goes directly into the lungs.

signs and symptoms of pulmonary embolism

▪ 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.

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.

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

You now know enough to be able to identify any life threats in your patient. They would include 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 If the patient's condition is unstable and there is a possible life threat, address the life threat and proceed with rapid transport. This means you will keep your scene time short, providing only lifesaving interventions. Perform a secondary assessment en route to the hospital. If the patient's condition is stable and there are no life threats, you may decide to perform a thorough secondary assessment on scene, after obtaining the patient history.

Interventions for respiratory problems may include the following:

▪ Providing oxygen via a nonrebreathing mask at 15 L/min▪ Providing positive-pressure ventilations using a BVM, pocket mask, or a flow-restricted oxygen-powered ventilation device▪ Using airway management techniques such as an 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's position or a position of choice to facilitate breathing▪ Assisting with respiratory medications found in a patient-prescribed metered-dose inhaler or a small-volume nebulizer Some of these interventions were performed in the primary assessment to address life threats. Others are used to support breathing problems until definitive care can be provided at the hospital. Some of your interventions may even correct the problem. 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. Be sure to document any changes (and at what time) and any orders given by medical control.

patients often have breathing difficulty and/or hypoxia with the following medical conditions:

▪ Pulmonary edema ▪ Hay fever▪ Pleural effusion Causes of Dyspnea ▪ Obstruction of the airway▪ Hyperventilation syndrome▪ Environmental/industrial exposure ▪ Carbon monoxide poisoning▪ Drug overdose

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.

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? +OPQRST