Respiratory Emergencies
East Region (Washington) OTEPM-7
Brian Reynolds, MD
Deaconess Medical Center
Spokane, WA
Respiratory Emergencies
We are going to cover material for ALL levels of training
YOU CAN ONLY PRACTICE AT THE LEVEL YOU HAVE BEEN CERTIFIED
Topics
Anatomy and function of the Respiratory System
Patient Assessment
Airway Management
Anatomy of the Upper Airway
Upper Airway
Nasal cavity
Oral cavity
Pharynx
Nasal Cavity
NaresNares
Mucous membranesMucous membranes
SinusesSinuses
Oral Cavity
Cheeks Hard palate Soft palate Tongue Gums Teeth
Nasopharynx
Oropharynx
Laryngopharynx
Pharynx
Larynx
Thyroid cartilage Cricoid cartilage Glottic opening Vocal cords Arytenoid cartilage Pyriform fossae Cricothyroid cartilage
Internal Anatomy of the Upper Airway
Lower Airway Anatomy
Trachea Bronchi Alveoli Lung parenchyma Pleura
Anatomy of the Lower Airway
Definitions
Atelectasis – collapse of small segments of lung
Hypoxia – lack of oxygen
Hypoxemia – lack of oxygen in arterial blood
Ventilation is the mechanical process that brings O2 to the lungs, and clears CO2 from the lungs
Oxygenation is the diffusion of O2 to the blood
Perfusion is the flow of blood through the lungs (thus exchanging oxygen and CO2)
Brain stem is the involuntary regulator of respirations
Introduction
Respiratory Physiology
VentilationBody Structures
Chest Wall Pleura Diaphragm
Tidal Volume: 7ml/kg
(Adult 500ml)
Pathophysiology
Disruption in VentilationUpper & Lower Respiratory Tracts
Obstruction due to trauma or infectious processes
Chest Wall & Diaphragm Trauma
PneumothoraxHemothoraxFlail chest
Neuromuscular disease
Oxygenation
Room air – 21% FiO2
Roughly 3% increase per literNasal cannula – 8L max (40%)Mask – 10L (55%)NRB mask – 15L (80%)
Pulmonary Circulation
Respiratory Physiology
Pulmonary PerfusionRequirements
Adequate blood volume Intact pulmonary capillaries Efficient pumping by the heart
HemoglobinCarbon Dioxide
Pathophysiology
Disruption in PerfusionAlteration in systemic blood flowChanges in hemoglobinPulmonary shuntingDamaged alveoli
Respiratory FactorsFactorFactor EffectEffect
Stimulants
FeverEmotionPainHypoxiaAcidosis
DepressantsSleep
Increases
DecreaseDecreases
IncreasesIncreasesIncreasesIncreasesIncrease
Scene AssessmentThreats to Safety
Make sure you are safe first Identify rescue environments having
decreased oxygen levels Gases and other chemical or biological agents
Clues to Patient Information
Assessment of the Respiratory System
Initial AssessmentGeneral Impression
Position Color Mental status Ability to speak Respiratory effort
Assessment of the Respiratory System
Airway Proper ventilation cannot take place without an
adequate airwayBreathing
Signs of life-threatening problemsAlterations in mental statusSevere central cyanosis, pallor, or diaphoresisAbsent or abnormal breath soundsSpeaking limited to 1–2 wordsTachycardiaUse of accessory muscles or intercostal retractions
Assessment of the Respiratory System
Abnormal Respiratory Patterns
Kussmaul’s respirations:Deep, slow or rapid, gasping; common
in diabetic ketoacidosisCheyne-Stokes respirations:
Progressively deeper, faster breathing alternating gradually with shallow, slower breathing, indication brain stem injury
Abnormal Respiratory Patterns
Agonal respirations:Agonal respirations:Shallow, slow, or infrequent breathing,Shallow, slow, or infrequent breathing,
indicating brain anoxiaindicating brain anoxia
HistorySAMPLE HistoryParoxysmal nocturnal dyspnea and orthopnea
Coughing, fever, hemoptysis Associated chest pain Smoking history or environmental exposures
Similar Past Episodes
Focused History & Physical Exam
Physical ExaminationInspection
Look for asymmetry, increased diameter, or paradoxical motion
Palpation Feel for subcutaneous emphysema or tracheal
deviationPercussionAuscultation
Focused History & Physical Exam
Auscultation Normal Breath Sounds
Bronchial, Bronchovesicular, and Vesicular Abnormal Breath Sounds
SnoringStridorWheezingRhonchiRales/CracklesPleural friction rub
Focused History & Physical Exam
Diagnostic TestingPulse Oximetry
Inaccurate Readings
Focused History & Physical Exam
Listen at the mouth and nose for adequate air movement
Listen with a stethoscope for normal or abnormal air movement
Proper listening positions
Ausculation
Airway Obstruction
The tongue is the most common cause of airway obstruction
Foreign bodies Trauma Laryngeal spasm and edema Aspiration
Congestive Heart Failure
Wet, crackly lung sounds
Lower extremity edema
Must sit and sleep upright
Frothy, pink sputum
Obstructive Lung Disease
TypesEmphysemaChronic BronchitisAsthma
CausesGenetic DispositionSmoking & Other Risk Factors
Emphysema Assessment
Physical Exam Barrel chest Prolonged expiration and
rapid rest phase
Thin Pink skin due to extra red
cell production
Hypertrophy of accessory muscles
“Pink Puffers”
Chronic Bronchitis Physical Exam
Often overweight Rhonchi present on
auscultation Jugular vein distention Ankle edema Hepatic congestion “Blue Bloater”
Asthma
Physical Exam Presenting signs may include dyspnea, wheezing,
coughNo wheezing is severe diseaseSpeech may be limited to 1–2 word sentences
Look for hyperinflation of the chest and accessory muscle use/feel chest wall for crepitus
Carefully auscultate breath sounds and measure peak expiratory flow rate
Pneumonia
Infection of the LungsImmune-Suppressed Patients
PathophysiologyBacterial & Viral Infections
Hospital-acquired vs. community-acquired Alveoli may collapse, resulting in a ventilation
disorder
Lung Cancer
PathophysiologyGeneral
Majority are caused by carcinogens secondary to cigarette smoking or occupational exposure
May start elsewhere and spread to lungs High mortality
Types Adenocarcinoma Epidermoid, small-cell, and large-cell carcinomas
Toxic Inhalation Pathophysiology
Includes inhalation of heated air, chemical irritants, and steam
Airway obstruction due to edema and laryngospasm due to thermal and chemical burns
AssessmentFocused History & Physical Exam
SAMPLE & OPQRST HistoryDetermine nature of substanceLength of exposure and loss of consciousness
PathophysiologyBinds to Hemoglobin
Prevents oxygen from binding to RBC’s Room air half life – 6 hrs., HBO – 23 minutes
AssessmentFocused History and Physical Exam
SAMPLE & OPQRST HistoryDetermine source and length of exposurePresence of headache, confusion, agitation, lack of
coordination, loss of consciousness, and seizures
Carbon Monoxide Inhalation
Pulmonary Embolism Pathophysiology
Obstruction of a pulmonary artery Emboli may be of air, thrombus, fat, or amniotic
fluid Foreign bodies may also cause an embolus
Risk Factors Recent surgery, long-bone fractures Pregnant or postpartum Oral contraceptive use, tobacco use Immobility Blood disorders
Pathophysiology Pneumothorax
Can occur in the absence of blunt or penetrating trauma Risk factors
Assessment Focused history
SAMPLE Presence of risk factors Rapid onset of symptoms Sharp, pleuritic chest or shoulder pain Often precipitated by coughing or lifting
Spontaneous Pneumothorax
AssessmentFocused History & Physical Exam
SAMPLEFatigue, nervousness, dizziness, dyspnea, chest painNumbness and tingling in mouth, feet, and both hands
Presence of tachypnea and tachycardia Spasms of the fingers and feet
Hyperventilation Syndrome
Airway Sounds
Airflow Compromise
Gas Exchange Compromise
Snoring
Stridor
Wheezing
Quiet
Gurgling
Crackles
Rhonchi
Basic Mechanical Airways
Insert oropharyngeal airway with tip facing palate
Rotate airway 180º into position
Nasopharyngeal Airway (Do not use if significant facial trauma)(Do not use if significant facial trauma)
Advanced Airway Management
Advanced Airway Management
Endotracheal intubation
Combitube
CPAP and BiPAP
CO2 monitors – measure exhaled CO2
Normal – 5-6%
Advantages of Endotracheal Intubation
Isolates trachea and permits complete control of airway
Maximizes ventilation and oxygenation Impedes gastric distention Eliminates need to maintain a mask seal Offers direct route for suctioning
Laryngoscope Blades
Placement of Macintosh blade into vallecula
Placement of Miller blade under epiglottis
Endotrol ETT
ETT, stylet, syringe
Combitube
CPAP
Endotracheal Intubation Indicators
Respiratory or cardiac arrest Unconsciousness Risk of aspiration Obstruction due to foreign bodies, trauma,
burns, or anaphylaxis Respiratory extremis due to disease (Pneumothorax), hemothorax,
(hemopneumothorax) with respiratory difficulty
Complications of Endotracheal Intubation
Equipment malfunction Teeth breakage and soft tissue injury Hypoxia Esophageal intubation Endobronchial intubation Tension pneumothorax Extubation
Tracheostomies/Stomas
Use patient’s supplies
Ambu bag attaches easily
Treat as an endotracheal tube
Suction
Questions
1. Which one is lack of oxygen in the blood?a. Hypoxia
b. Hypocarbia
c. Hypoxemia
d. Hypocarbemia
Questions
2. Which one is the best airway?a. Nasal cannula
b. Endotracheal tube
c. Oral airway
d. Combitube
Questions
3. Which one is a contraindication to nasal trumpet use?
a. Seizure
b. Bloody nose
c. DNR patient
d. Significant facial trauma
Questions
4. Which one is the correct tidal volume for a 200 pound patient?
a. 500cc
b. 600cc
c. 700cc
d. 800cc
Questions
5. Which one is not an indication for endotracheal intubation?
a. Respiratory failure
b. Cardiac arrest
c. GCS of 5
d. Hyperventilation syndrome
Now you know everything about respiratory emergencies
Garry Frey
509-242-4263
Questions?
Renee Anderson
509-232-8155
FAX: 509-232-8344