Pulmonary Diseases & Disorders: Assessment

Pulmonary Diseases & Disorders Epidemiology

28% of all EMS Chief Complaints in the US >200,000 deaths annually due to

respiratory emergencies

Pulmonary Diseases & Disorders

Many, many pulmonary diseases Difficult to learn all pathophysiologies All can be categorized as affecting:

Ventilation Diffusion (Respiration) Perfusion

Treatment can be focused on identifying and treating source of ventilatory/respiratory impairment

Sources of Pulmonary Impairment Pulmonary Diseases Disorders of the Pulmonary System Non-Pulmonary Disorders/Disease

Impairing Ventilation or Respiration

What examples can you list for each of these?

Sources of Pulmonary Impairment

Ventilation Upper Airway

Trauma Epiglottitis FBAO Inflammation

of tonsils

Lower Airway Trauma Obstructive

lung disease Mucous

accumulation Smooth

muscle spasm Airway edema

Sources of Pulmonary Impairment

Ventilation Chest Wall

Impairment Trauma Hemothorax Pneumothorax Empyema Pleural

inflammation Neuromuscular

diseases

Neurologic Control Brainstem

dysfunction Phrenic or spinal

nerve dysfunction

Sources of Pulmonary Impairment

Diffusion Inadequate FiO2 Diseased alveoli

asbestosis COPD inhalation injury

Capillary bed disease atherosclerosis

Interstitial space disease High pressure

pulmonary edema High permeability

pulmonary edema

Sources of Pulmonary Impairment

Perfusion Inadequate blood

volume or hemoblogin hypovolemia anemia

Impaired blood flow pulmonary embolus

Capillary wall pathology trauma

Risk Factors for Pulmonary Disease Intrinsic Risk Factors

Genetic predisposition asthma COPD carcinoma

Cardiac or Circulatory pathologies Source for pulmonary edema Source for pulmonary emboli

Stress

Risk Factors for Pulmonary Disease Extrinsic Factors

Smoking prevalence of COPD & carcinomas severity of pulmonary disease

Environmental Factors prevalence of COPD & asthma severity of all obstructive disorders

Function of the Pulmonary System Gas Exchange System

~10,000 liters of air are filtered, warmed and humidified daily

Oxygen diffused into blood Carbon dioxide excreted from the body

Function of the Pulmonary System Physiology of Ventilation

Requires neurologic initiation (brainstem) Nerve conduction pathways between

brainstem and muscles of respiration Intact & patent Upper and Lower airways Intact & non-collapsed alveoli

Function of the Pulmonary System Physiology of Respiration

Simple diffusion process at the pulmonary-capillary bed

Diffusion Requirements Intact, non-thickened alveolar walls Minimal interstitial space & without additional

fluid Intact, non-thickened capillary walls

Function of the Pulmonary System Physiology of Perfusion

Process of circulating blood through the capillary bed

Perfusion Requirements Adequate blood volume Adequate hemoglobin Intact, non-occluded pulmonary capillaries Functioning Left Heart

Control of Ventilation

Control ventilation in response to physiologic needs Driven 1° by pH of CSF

influenced largely by PaCO2

2° drive = PaCO2

3° drive = PaO2 detected by chemoreceptors very small population with severe COPD

Nervous System Effect on Ventilation Medulla

Stimulation to initiate ventilation Phrenic Nerve

Innervation of the diaphragm Spinal Nerves at Thoracic levels

Innervation of intercostal muscles Hering-Breuer reflex

Prevents overinflation

General Assessment Size-Up

Environment Airborne Hazards Number of patients Needs

• Specialized rescue equipment• Protective equipment

Is the environment creating or exacerbating the pulmonary condition?

General Assessment

Initial Goal Identify potentially life-threatening

pulmonary conditions Perform minimal PE & Hx

Initiate immediate & appropriate therapies Then, continue PE & Hx

Try to determine if origin is ventilation, diffusion, perfusion or combination

General Assessment Signs of potentially life-threatening

pulmonary condition altered mental status absent signs of ventilation Audible stridor or wheezing Able to speak in short phrases only Sustained Tachycardia Pallor / Diaphoresis Accessory muscle use / Retractions

Assessment: H&P Present History (focused hx)

Chief Complaint Dyspnea

• “Subjective sensation that breathing is excessive, difficult or uncomfortable

CP Cough, Hemoptysis

Associated Symptoms Fever, Chills sputum production Fatigue

Assessment: H&P Present History (focused hx)

Sputum Findings amount of sputum infection Thick green or brown pneumonia or

infection Yellow or gray allergic or inflammatory

response Hemoptysis tuberculosis or carcinoma Pink, frothy severe pulmonary edema

Assessment: H&P HX of Present Illness

How long has dyspnea been present? Gradual or sudden onset? What aggravates or alleviates?

Hx of orthopnea? Coughing? Productive cough? What does sputum look/smell like? Pain? What does the pain feel like?

Assessment: H&P Listen - To Pt. Breathe or Talk

Noisy Breathing is Obstructed Breathing Not All Obstructed Breathing is Noisy Snoring - Tongue Blocking Airway Stridor - “Tight” Upper Airway from Partial

Obstruction Observe Breathing

Tachypnea Bradypnea

Assessment: H&P Observe

Body Positioning Tripod Legs in dependent position

Mental Status Ventilatory Effort

Accessory muscle use / retractions Abdominal muscle use Chest wall expansion Nasal flaring, pursed lips

Assessment: H&P Physical Exam of the Chest

Increased A-P Diameter Lung Sounds

Abnormal: stridor, wheezing, rhonchi, rales, pleural rub

Chest expansion Symmetrical Findings Evidence of Trauma

Assessment: H&P Physical Exam

Cyanosis? Late, unreliable sign of Hypoxia

Oxygenate Immediately! Especially If: Decreased LOC Possible Shock Possible Severe Hemorrhage Chest Pain Chest Trauma Respiratory distress or dyspnea HX of any Kind of Hypoxia

Assessment: H&P Physical Exam

Vital Signs Skin Color, Temp & Moisture Respiratory Rate

• No an accurate lone indicator of respiratory status unless very slow

Respiratory Rhythm/Pattern Pulse

• Bradycardia vs Tachycardia

Blood Pressure

Assessment: H&P

Physical Exam - Circulatory assessment Is the heart beating? Is there major external hemorrhage? Is the Pt. Perfusing vital organs? Effects of hypoxia:

Early in adults - Tachycardia Late in adults - Bradycardia Children - Bradycardia

Assessment: H&P

Don’t let respiratory failure distract you from assessing for circulatory failure.

Vascular Access

Assessment: H&P

Physical Exam Extremities

Peripheral Cyanosis Clubbing Carpopedal spasm Peripheral edema

Assessment: H&P Diagnostic Testing

Pulse oximetry Saturation Inaccuracies & Disadvantages

Peak Flow Meter Baseline measurement for

obstructive lung disease Often available from patient

Capnometry real-time assessment of

endotracheal tube placement quantitative vs qualitative

Assessment: H&P Past History

Similar Episodes in Past Patient’s description of acuity “What happened last time you had an

episode this bad?” Chronic Symptoms

Acute, Seasonal SOB episodes Seasonal Allergies Chronic cough Recurrent flu, pulmonary infection or SOB

Assessment: H&P Past History

Known diagnosis Does the present H&P correlate with this

past history?• CHF• Hypertension• Renal Failure

Previous intubation or hospitalization Aggravating Factors (e.g. smoking)

Assessment: H&P Past History

Medications Class, Route, Frequency of Use Pulmonary

• Sympathomimetics• Corticosteroids• MAST Cell Stabilizer

• Methylxanthines

Cardiovascular• Diuretics

• Antihypertensives• Cardiac glycosides

Assessment: H&P

Disability Restlessness, anxiety, combativeness =

HYPOXIA Until Proven Otherwise Drowsiness, lethargy = HYPERCARBIA

When the patient stops fighting, he is not necessarily getting Better!!

Other Adventitious Sounds Cough

Forced exhalation against partially closed glottis

Reflex response to mucosa irritation Determine circumstances

At work Postural changes Lying down

Productive vs non-productive

Other Adventitious Sounds

Sneeze Forced exhalation via nasal route Clears nasal passages Reflex response to mucosa irritation

Sigh Slow, deep inspiration - Prolonged, audible

exhalation Reexpands areas of atelectasis

Other Adventitious Sounds

Hiccough Hiccups, singultus Spasm of diaphragm followed by glottic

closure No useful purpose Benign, transient