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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