RESPIRATORY EMERGENCYDr Mual B E Parhusip Sp. P

IntroductionIn 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 distressDefinition : air hunger, difficulty of breathing due to inadequate oxigenization and carbonidaoxide removal

Clinical features : dyspnea, hypoxia, wheezing, cyanosis

AsthmaAsthma 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 AsthmaWhat happened in asthma?

Triggers

Acute exacerbations of asthma

Chronic Obstructive Pulmonary DiseaseCOPD 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

PneumothoraxDefinitionThe 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

rupture of an apical pleural bleb in primary spontaneous pneumothorax

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

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

ClassificationPneumothoraces are divided into : SpontaneousIatrogenicTraumatic 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

PneumoniaDefinition: 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 featuresThe 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 pneumoniagray hepatization, gross photograph. The lower lobe is uniformly consolidated

Acute bronchitisAcute 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 featuresSymptoms 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

Inhalational injurySource of inhalation injuryIndustry or occupationHome or communityEnvironmentalWar or chemical weapons

Smoke inhalation, chemical agents, cleaning products etc

Clinical featuresDyspnea, 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

HemoptysisHemoptysis 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, orExpectoration of blood from 250 to 600 mL/day and hemoglobin concentration is less than 10g/dL, orExpectoration 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, lun 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 patients consciousness

Primary suvey :Airway Open and monitor the airwayBreathing Administer oxygen by nasal canule 2-3 L/m or oxygen mask 10-15 L/m and monitor breathing adequacyCirculation 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 hemoptysisIn 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 nebulizerAssemble 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.

ConclusionRespiratory 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