RESPIRATORY EMERGENCY(KEGAWATAN PARU)

Dr Mual B E Parhusip Sp. P RSUD Dr. DORIS SYLVANUS

PALANGKA RAYAKALIMANTAN TENGAH

Introduction

• In our daily life, many things can happen

• You may be caught in the situation where you were expected to help someone who is difficulties

• Respiratory emergency is not uncommon to occur.

• As the first responder, you have to know some basic knowledge what you should do before or while contacting further medical assistance / referral to hospital

Respiratory distress

• Definition : air hunger, difficulty of breathing due to inadequate oxigenization and carbonidaoxide removal

• Clinical features : dyspnea, hypoxia, wheezing, cyanosis

Asthma

• Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role.

• The chronic inflammation causes an associated increase in airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning.

• These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment.

Normal airwayMild / Moderate

Persistent AsthmaSevere

Persistent Asthma

What happened in asthma?

Triggers

Acute exacerbations of

asthma

Chronic Obstructive Pulmonary Disease

• COPD is a disease state characterized by airflow limitation that is not fully reversible.

• The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.

• Symptoms, functional abnormalities, and complications of COPD can all be explained on the basis of this underlying inflammation and the resulting pathology

Mechanism of airway limitation in COPD

Pneumothorax

• Definition–The presence of free air between the visceral pleura and the parietal pleura .

• Any air that leaks into this space (pleural space) will cause the lung tissue to collapse in proportion to the amount of air that enters the pleural cavity.

Diagram representing 3 mechanisms of formation of pneumothorax

(A) rupture of an apical pleural bleb in primary spontaneous pneumothorax

(B) visceral pleural tear responsible for the escape of air into the pleural space in secondary spontaneous pneumothorax

(C) one mechanism of traumatic pneumothorax by dissection of air along tracheobronchial tree with proximal rupture.

Classification

Pneumothoraces are divided into : • Spontaneous• Iatrogenic• Traumatic • Artificial

Clinical features

• Symptoms are not always present

• Sometimes a small apical pneumothorax is found on routine chest radiography

• Sudden unilateral chest pain and dyspnea, which is related to the size of the pneumothorax.

• Sometomes dry cough, some cases subcutaneous emphysema may be obvious on inspection of the neck, face, or chest

• In a tension pneumothorax, breathlessness can be severe and there may be hypotension with cardiac tamponade.

• Hypercapnia, hypoxemia

Pneumonia

• Definition: – An acute infection of lung parenchyma including alveolar spaces

and interstitial tissue

• Bacteria are the most common cause of pneumonia in adults > 30 yr.

• Streptococcus pneumoniae is the most common.

• Other pathogens include anaerobic bacteria, gram-negative bacilli, atypical bacteria, mycobacteria including Mycobacterium tuberculosis, fungi.

Clinical features

• The symptoms of pneumonia are not specific

• Generally include fever, possibly chills, and general uneasiness associated with a variety of respiratory and nonrespiratory symptoms such as cough, purulent sputum production, thoracic pain, dyspnea, coryza, pharyngitis, vomiting, myalgia, and headache.

Bronchopneumonia. Gross section of lung showing patches of consolidation (arrows).

Lobar pneumonia—gray hepatization, gross photograph. The lower lobe is uniformly consolidated

Acute bronchitis

• Acute inflammation of the tracheobronchial tree, generally self-limited and with eventual complete healing and return of function.

• Although commonly mild, acute bronchitis may be serious in debilitated patients and in patients with chronic lung or heart disease.

• Airflow obstruction is a common consequence, and pneumonia is a critical complication.

Clinical features• Symptoms of an upper respiratory infection: coryza, malaise,

chilliness, slight fever, back and muscle pain, and sore throat.

• Cough is initially dry and nonproductive, but small amounts of viscid sputum are raised after a few hours or days; later, sputum may be more abundant and mucoid or mucopurulent. Frankly purulent sputum suggests superimposed bacterial infection.

• Some patients have burning substernal chest pain, which is aggravated by coughing. In a severe uncomplicated case, fever of 38.3 to 38.8° C

• Persistent fever suggests complicating pneumonia. Dyspnea may occur secondary to airway obstruction

The normal alveolus (left side) compared with the injured alveolus in the early phase of acute lung injury and acute respiratory distress syndrome. Under the influence of proinflammatory cytokines which contribute to local tissue damage, accumulation of edema fluid in the airspaces, surfactant

inactivation, and hyaline membrane formation. ( N Engl J Med 342:1334, 2000.)

Inhalational injury

• Source of inhalation injury– Industry or occupation– Home or community– Environmental– War or chemical weapons

• Smoke inhalation, chemical agents, cleaning products etc

Clinical features

• Dyspnea, tachypnea, hypoxia by pulse oximetry, altered mental status, and suspected carbon monoxide toxicity

• All indications above are subjects for oxygen administration by nonrebreather mask

• Ask for further medical assistance or refer to hospital

Hemoptysis

• Hemoptysis is coughing blood from the airway.

• It can be ranged from a few ml of blood to massive hemoptysis.

• Massive hemoptysis criterias used in many centers in Indonesia are:– Expectoration of blood over 600 ml/day, or– Expectoration of blood from 250 to 600 mL/day and hemoglobin

concentration is less than 10g/dL, or– Expectoration of blood from 250 to 600 ml/day and hemoglobin

concentration is more than 10g/dL, but bleeding is still going for 48 hours

• The most common causes of hemoptysis in Indonesia are tuberculosis, bronchiectasis, lung cancer, pulmonary abscess, pulmonary mycosis, pneumonia, blood disorders and heart disorders.

• It should be remembered that every hemoptysis is a respiratory emergency because of the potency of asphyxia and respiratory arrest,

What to do in respiratory emergency?

• Secure the scene (in the case of inhalation of toxic gas, bring the patients as far as possible from the scene) and use universal proctection

• Check patient’s consciousness

• Primary suvey :• Airway – Open and monitor the airway• Breathing – Administer oxygen by nasal canule 2-3 L/m or

oxygen mask 10-15 L/m and monitor breathing adequacy• Circulation – Be aware of the signs of shock, if exists, begin

shock management procedures

• DO NOT permit physical activity

• Assist the patient to position in comfort

• Request Advanced Life Support assistance

Special attention in hemoptysis

• In the case of hemoptysis, direct the patient to cough the blood.

• Support the patient to be calm, DO NOT panic.

• Help the patient in sitting position, so the blood will not aspirate and block the airway.

• Bring the patient to the nearest hospital.

• Remember, every hemoptysis is a respiratory emergency

• In the case of asthma exacerbation and acute exacerbation of COPD patients, ask the patient whether they have asthma medication or bronchodilators (inhalers such as metered dose inhaler, turbuhalers, oral medications such as salbutamol, procaterol, theophylline, aminophylline).

• If available, assist them with the self administration of inhalers or take the medication orally.

• Most asthma or bronchodilators drugs for COPD patients are inhaled using various forms of inhalers or nebulizers.

• The basic devices are the metered-dose inhaler (MDI), breath-actuated inhalers, dry powder inhalers, and nebulizers

Inhalers

Spacers

How to use metered dose inhaler (salbutamol/albuterol, fenoterol, terbutalin,

procaterol, ipratropium bromide)

Remove the cap from the mouthpiece; Inspect the inhaler mouthpiece for the presence of foreign objects

before each use, especially if the strap is removed from the actuator and lost or if the cap has not been used to

cover the mouthpiece. Make sure the canister is fully and firmly inserted into the actuator.

Shake the inhaler before each use.

Breath out fully through the mouth, expelling as much air from the lungs as possible. Place the mouthpiece fully

into the mouth, holding the inhaler in the mouthpiece down position and closing the lips around it.

While breathing in deeply and slowly through the mouth, fully depress the top of the metal canister with your index finger .

Immediately after the puff is delivered, release your finger from the canister and remove

the inhaler from your mouth

How to use dry powder inhaler (turbuhaler : terbutalin, formoterol)

• Unscrew the cap and lift off

• Hold the Turbuhaler upright by placing the base on a flat surface and turn the coloured base of the device anticlockwise as far as it will go, then turn it clockwise until you hear a click

• Breathe out a little

• Place the mouthpiece between your lips and breathe in forcefully and deeply through your mouth

• Breathe out gently (but not into the turbuhaler)

Acute exacerbation of COPDHome management

What is a nebulizer?

Nebulizers are used to treat asthma, chronic obstructive pulmonary disease (COPD), and other conditions where inhaled medicines are indicated.

Nebulizers deliver a stream of medicated air to the lungs over a period of time.

How to use nebulizer

Assemble the nebulizer according to its instructions. Connect the hose to an air compressor.

Fill the medicine cup with your prescription, according to the instructions

Attach the hose and mouthpiece to the medicine cup

Place the mouthpiece in your mouth. Breathe through your mouth until all the medicine is used, about 10-15 minutes.

Some people use a nose clip to help them breathe only through the mouth. Some people prefer to use a mask.

Wash the medicine cup and mouthpiece with water, and air-dry until your next treatment.

Conclusion

• Respiratory emergency is not uncommon to be seen in our daily life

• There always a chance that you will be the first responder

• Understanding the basic of the disease and its first management may help others in need