Chapter 17: Respiratory Emergencies

Chapter 17 Respiratory Emergencies Unit Summary After students complete this chapter and the related course work, they will understand the significance and characteristics of respiratory emergencies in infant, child, and adult populations. Students should be able to demonstrate a fundamental comprehension of the following topics: respiratory anatomy and physiology, pathophysiology, signs and symptoms of various respiratory etiologies (eg, asthma, chronic obstructive pulmonary disease, pneumonia), and the assessment and management necessary to provide basic and selected advanced care in the prehospital setting. National EMS Education Standard Competencies Applies fundamental knowledge to provide basic and selected advanced emergency care and transportation based on assessment findings for an acutely ill patient. Anatomy, signs, symptoms, and management of respiratory emergencies including those that aspect the Upper airway (pp 882-890, 923-924, 927) Lower airway (pp 887, 904, 923-924) Anatomy, physiology, pathophysiology, assessment, and management of Epiglottitis (pp 903,928) Spontaneous pneumothorax (pp 899,926-927) Pulmonary edema (pp 895-896, 924) Asthma (pp 898, 925-926) Chronic obstructive pulmonary disease (pp 896-898, 924-925) Environmental/industrial exposure (pp 901-902, 927-928) Toxic gas (pp 901-902) Pertussis (pp 903, 928-929) Cystic fibrosis (p902) Pulmonary embolism (pp 900-901, 927) Pneumonia (pp 897, 903, 928) Viral respiratory infections (pp 902-903) Obstructive/restrictive disease (pp 896-898, 905,924-926) Knowledge Objectives Review the structures and functions of the upper and lower airways, lungs, and accessory structures of the respiratory system. (pp 882-885) Explain the physiology of respiration and list the signs of normal breathing. (pp 885-887) Explain the special patient assessment and care considerations that are required for pediatric patients who are experiencing respiratory distress. (pp 906-907) Discuss the pathophysiology of respiration and provide examples of the common signs and symptoms a patient with inadequate breathing may present with in an emergency situation. (pp 887-889) Explain the concept of hypoxic drive. (p 889) Describe the various respiratory conditions that cause dyspnea, including their causes, assessment findings and symptoms, complications, and specific prehospital management and transport decisions. (pp 891-892) List and review the characteristics of infectious diseases that are frequently associated with dyspnea. (pp 892-895) Explain the special patient assessment and care considerations that are required for geriatric patients who are experiencing respiratory distress. (pp 906-907) Describe the assessment of a patient who is in respiratory distress and the relationship of the assessment findings to patient management and transport decisions. (pp 906-907) Describe the primary emergency medical care of a person who is in respiratory distress. (pp 906-907) List and define five different types of adventitious breath sounds, their signs and symptoms, and the disease process associated with each one. (p 909) Summarize the steps in emergency medical care of a patient with dyspnea. (pp 915-916) State the generic name, medication forms, dose, administration, indications, actions, and contraindications for medications that are administered via metered-dose inhalers and small-volume nebulizers. (pp 917-921) Discuss the application of a continuous positive airway pressure/bilevel positive airway pressure unit. (pp 922-923) Discuss some epidemic and pandemic considerations related to the spread of influenza type A and strategies advanced emergency medical technicians should use to protect themselves from infection during a possible crisis situation. (pp 929-931) Skills Objectives Demonstrate the process of history taking to obtain more information related to a patient’s chief complaint based on a case scenario. (pp 909-915) Demonstrate how to use the OPQRST assessment to obtain more specific information about a patient’s breathing problem. (p 910) Demonstrate how to assist a patient with the administration of a small-volume nebulizer. (pp 918-919) Demonstrate how to assist a patient with the administration of a metered-dose inhaler. (pp 920-921) Readings and Preparation Review all instructional materials, including Chapter 17 of Advanced Emergency Care and Transportation of the Sick and Injured, Fourth Edition, and all related presentation support materials. Review local agency protocols for AEMT airway management, particularly those regarding the support and management of respiratory diseases, assistance with administration of oxygen and metered-dose inhalers, and how the AEMT provider will support the ALS provider in the prehospital setting. Provide the student with evidence-based research articles relating to various respiratory topics. This activity helps to validate the effectiveness and necessity of the basic airway management tools that AEMTs are learning to master during their training program. Support Materials: Lecture PowerPoint presentation Case Study PowerPoint presentation Equipment needed to perform the psychomotor skills presented in this chapter Examples of l ung sounds can be found on the Internet. Enhancements Direct students to visit Navigate. Contact the local chapter of the American Lung Association for literature and potential guest speakers on respiratory diseases, prevention, and support groups. Encourage the students to get involved in a community outreach, such as smoking cessation programs (Great American Smokeout). Content connections: Students should be able to implement the skills and objectives learned in Chapter 10, Patient Assessment, and Chapter 11, Airway Management, into their assessment and treatment of respiratory emergencies. Teaching Tips You have presented airway management techniques in Chapter 11, Airway Management. Now, the pathophysiology of airway disease is being introduced. In discussions, demonstrations, and the practical lab associated with this section, integrate clinical insight with appropriate respiratory management interventions. Classroom scenarios are a useful tool to engage the entire classroom, which creates a platform for discussion (Q&A) after the scenario. This valuable tool allows the instructor to solidify the teaching “take home” message/objective in every lecture. If available, the scenario should be videotaped (obtain consent) to review in a group setting, allowing the Unit Activities Writing activities: Provide students with research articles based on respiratory diseases in infant, child, and adult populations. Ask students to put together a brief summary of one of the articles and present it to the class during this topic’s discussion. Group activities: Form groups and assign a particular topic to each group. Ask each group to develop a basic “Jeopardy-style” game about that topic. Templates can be found on the Internet. Using this game, students or groups can present important topics and objectives to their classmates while creating a fun learning activity. Assign activities that encourage collaboration or cooperative learning, such as having students create scenarios for each other to practice assessment and management. Depending on students’ previous experiences, they should be able to role-play patient scenarios while focusing on a learning objective (ie, the importance of administering oxygen to patients). The scenario should be rehearsed and approved by the primary instructor so that time is well spent. Provide students with “hands-on” exposure to a multitude of airway devices (eg, ET tube, Combitube, LMA, King LT), as well as the use of such devices as MDIs (with and without spacers) and tracheostomies. These activities will demonstrate competency and a basic level of knowledge, since the AEMT is permitted to assist the patient with medication administration (MDI) and suctioning of the tracheostomy in a time of need. Medical terminology review: Photocopy Figure 17-1 from the text, omitting the labels. Ask students to label the parts of the upper and lower airway. Visual thinking: Provide handouts of images or project them on a screen, and ask students to explain to the class, or in writing, what the image depicts; or, ask them to write a scenario based on a particular image in the chapter. Pre-Lecture You are the Provider “You are the Provider” is a progressive case study that encourages critical-thinking skills. Instructor Directions Direct students to read the “You are the Provider” scenario found throughout Chapter 17. You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report. You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper. Lecture I. Introduction 1. . Complaint you will often encount 2. . Symptom of many different conditio a.. Several problems occurring at the same time may contribute to a patient’s dyspne 3.. Keep possible medical problems in mind as you obtain a history and perform a physical assessmen II. Anatomy and Physiology Review 1. Upper airway includes all anatomic airway structures above the level of the vocal cords. 2. Gas exchange: Deoxygenated blood from the pulmonary circulation releases carbon dioxide and picks up oxygen a. Occurs at the level of the alveoli 3. Pulmonary circulation begins at right ventricle, where the pulmonary artery branches into increasingly smaller vessels until it reaches the pulmonary capillary bed, which surrounds alveoli and terminal bronchioles. a. More circulation to lung bases than there is to lung apices 1. Two processes occur during respiration: a. Inspiration (inhaling) b. Expiration (exhaling) 2. Ventilation: Process of moving air into and out of the lungs 3. Oxygen entering alveoli passes through tiny passages in the alveolar wall into capillaries. 4. Heart pumps oxygenated blood throughout the body. 5. Carbon dioxide returns to lungs in the blood that circulates through and around alveolar air spaces. 6. Carbon dioxide diffuses back into alveoli and travels out the upper airways during exhalation 7. Carbon dioxide is exchanged for oxygen. 1. Stimulus to breathe comes from the respiratory center in the medulla. a. Involuntary control of breathing originates in brainstem. i. Impulses for automatic breathing can be overridden (to a point) by voluntary control. b. Motor nerves of respiration are the phrenic and intercostal nerves. 2. During inspiration, the diaphragm and intercostal muscles contract. 3. Thorax enlarges and intrapulmonary pressures fall below atmospheric pressure. 4. Air is pulled in fills the lungs 5. When air pressure outside the thorax equals pressure inside the thorax, inhalation stops. 6. Normal inspiratory reserve volume about 3,000 mL in adult male and 2,300 in adult female. 1. As the chest expands, stretch receptors in the chest wall and bronchioles send a signal to the apneustic center via the vagus nerve to inhibit the inspiratory center, and expiration occurs. a. Hering-Breuer reflex b. Prevents overexpansion of lungs 2. Normal expiratory reserve volume about 1,200 mL. 3. Expiration lasts twice as long as inspiration a. Inspiratory/expiratory (I/E) ratio. b. Expiratory phase is prolonged in a patient with asthma. c. Expiratory phase is short in a patient with tachypnea. III. Pathophysiology 1.. Upper airway obstructi a.. Foreign body obstructi b.. Trau c.. Inflammati 2.. Lower airway obstructi a.. Trau b.. Obstructive lung disea c.. Mucus accumulati d.. Smooth-muscle spa e.. Airway ede 3.. Chest wall impairme a.. Trau b.. Hemothor c.. Pneumothor d. Empyema (pleural effusion) e. Pleural inflammation f.. Neuromuscular diseas 4.. Neurologic control problem a.. Brainstem malfuncti b.. Stroke or other medical neurologic conditi c.. Trau d.. Neuromuscular disea 1. Table 17-3 lists key signs and symptoms to help you recognize and differentiate between different respiratory complaints. 1. Alveoli made up of two types of cells. a. Type I b. Type II 2. Alveoli function best when kept partially inflated. 3. Surfactant reduces surface tension of the alveoli, making it easier for them to expand. 4. After foreign material gets into the terminal bronchioles and alveoli, it typically never comes out. 5. Collapsed, fluid-filled, or pus-filled alveoli do not participate in gas exchange. 6. Conditions related to ventilation, perfusion, or both can prevent oxygen from reaching the bloodstream. 7. Pulmonary capillaries are narrow and normally allow red blood cells to pass through only in single file. 8. People with chronic lung disease and chronic hypoxia generate a surplus of red blood cells over time, making blood thicker (polycythemia). a. Places strain on the right side of heart 9. Cor pulmonale: Right-side heart failure because of chronic lung disease 1. Level of carbon dioxide in the arterial blood can rise for many reasons. a. Various types of lung disease may impair exhalation process. b. Body may produce too much carbon dioxide temporarily or chronically. 2. If arterial carbon dioxide levels rise slowly to an abnormally high level and remain there, the respiratory centers may work less efficiently. 3. Failure of those centers to respond normally to a rise in arterial levels of carbon dioxide is a result of chronic carbon dioxide retention. 4. Hypoxic drive b. Stimulus to breathe is detection of low blood oxygen levels. c. If the arterial level of oxygen is increased, there are fewer stimuli to breathe. d. Giving too much oxygen to these patients may actually depress or stop respirations. e. Never withhold oxygen from a patient who needs it. 1. When the lungs fail to work properly carbon dioxide accumulates in the blood. a. Combines with water to form bicarbonate ions and hydrogen ions, also known as carbonic acid, resulting to respiratory acidosis 2.. Acidosis can occur if hypoventilation is not recognize 3.. Impaired ventilation can be attributed to a variety of factor 4.. Carbon dioxide level is directly related to pH (acid-base balance 5.. Respiratory acidos a.. Carbon dioxide level increases and pH level decrease 6.. Causes of hypoventilatio a.. Impaired lung functi b.. Impaired mechanics of breathi i.. Obesity hypoventilation syndrome (Pickwickian syndrome): Respiratory compromise related to morbid obesi c.. Impaired neuromuscular apparat i. Serious injury to the spinal cord ii. Guillain-Barré syndrome iii. Amyotrophic lateral sclerosis (ALS; Lou Gehrig disease) iv. Botulism caused by the bacterium Clostridium botulinum d. Reduced respiratory drive i. Acute opioid narcotic overdose (eg, heroin) ii. Intoxication with alcohol, narcotics, a host of other drugs and toxins iii. Head injury iv. Hypoxic drive v. Asphyxia 1. Arterial carbon dioxide falls below normal. 2. May be an indicator of life-threatening illness a. Body’s attempt to compensate for acidosis b. Buildup of excess acid in the blood or body tissues c. Lowering carbon dioxide helps to compensate for the other acids 3. Tachypnea without physiologic demand for increased oxygen causes respiratory alkalosis. 4. Causes symptoms of hyperventilation syndrome (panic attack): a. Anxiety b. Dizziness c. Numbness d. Tingling of the hands and feet that can lead to carpopedal spasm e. Sense of dyspnea 5. Can be body’s response to illness and a buildup of acids 6. Hyperventilation syndrome a. Occurs in the absence of other physical problems b. Common during psychological stress IV. Causes of Dyspnea 1. Shortness of breath or difficulty breathing 2. If the problem is severe and the brain is deprived of oxygen, the patient may not be alert enough to report shortness of breath. a. Altered mental status is a sign of hypoxia of the brain. 3. Patients often experience breathing difficulty or hypoxia with: a. Pulmonary edema b. Hay fever c. Pleural effusion d. Obstruction of the airway e. Rib fractures (flail segment) f. Cystic fibrosis g. Hyperventilation syndrome h. Prolonged seizures i. Neuromuscular disease (such as multiple sclerosis or muscular dystrophy) j. Environmental or industrial exposure to toxic gases k. Carbon monoxide poisoning l. Drug overdose 4. One or more of these situations most likely exists: a. Gas exchange between the alveoli and pulmonary circulation is obstructed by fluid in the lung, infection, or collapsed alveoli (atelectasis). b. Alveoli are damaged and cannot transport gases properly. c. Air passages are obstructed by muscle spasm, mucus, or weakened airway walls. d. Blood flow to lungs is obstructed by blood clots. e. Pleural space is filled with air or excess fluid 5. Patient with dyspnea may also report: a. Air hunger b. Chest tightness 6. Dyspnea is a common complaint in patients with cardiopulmonary disease. a. Heart failure is a cause of breathlessness. 7. Severe pain can cause a patient to experience rapid, shallow breathing without pulmonary dysfunction. a. Breathing deeply may cause pain because it expands the chest wall. 8. When assessing a patient for complaints of dyspnea, ask about chest pain, and ask about dyspnea when evaluating for chest pain. 1. Infectious diseases may affect all parts of the airway. 2. May cause dyspnea by obstructing air?ow in larger airways 3. May impair exchange of gases between the alveoli and the capillaries (pneumonia) 1. Accumulation of fluid in the lungs 2. Decreased gas exchange 3. Severe dyspnea 4. Severe myocardial damage caused by an acute or chronic problem results in reduced contractile force of the myocardium. a. Left side of the heart cannot remove blood from the lungs as fast as the right side delivers it. 5. Fluid collects in the alveoli and lung tissue. 6. May develop quickly 7. Not all patients with pulmonary edema have heart disease. Other causes: a. Poisonings from smoke or toxic chemical fumes b. Traumatic injuries of the chest c. Exposure to high altitudes 8. Patients with pulmonary edema that is cardiogenic in origin may present with signs and symptoms of a cardiac emergency. 9. Patients with noncardiogenic pulmonary edema tend to have a history of associated factors: a. Hypoxic episode b. Shock c. Chest trauma d. Recent acute inhalation of toxic gases or particles e. Recent ascent to a high altitude without acclimatizing 10. All patients with pulmonary edema may present with: a. Dyspnea b. Orthopnea c. Fatigue d. Reduced exercise capacity e. Pulmonary crackles (formerly known as rales) 1. Common lung condition 2. Slow process of dilation and disruption of the airways and alveoli 3. COPD is an umbrella term used to describe a few lung diseases, including emphysema and chronic bronchitis. 4. Cigarette smoking is most common cause. 5. Obstruction occurs in bronchioles. a. Cilia are unable to remove excess mucus, creating a buildup. 6. Chronic bronchitis a. Results from overgrowth of the airway mucus glands and excess secretion of mucus, blocking the airway b. Patients have a chronic productive cough for at least 3 months per year for 2 or more consecutive years. 7. Pneumonia a. Develops when passages are persistently obstructed b. Repeated episodes can lead to COPD. 8. Emphysema a. Most common form of COPD b. Characterized by destruction of alveolar walls related to destruction of pulmonary surfactant c. Large “holes” are left in the lung that resemble air pockets or cavities. d. Irreversible condition 9. Most patients with COPD: a. Have elements of chronic bronchitis and emphysema b. Have a history of recurring lung problems c. Are long-term smokers d. Consistently produce sputum e. Have a chronic cough f. Have difficulty expelling air from their lungs g. Experience long expiration phases and wheezing 10. Patients with acute COPD will: a. Complain of shortness of breath with gradually increasing symptoms over a period of days b. . Exhale through pursed li c. . Complain of tightness in the chest and constant fatig d. . Have a chest with a barrellike appearan 1. Acute spasm of bronchioles 2. Excess mucus production and bronchiolar muscle spasm 3. Reversible obstruction that is caused by a combination of smooth-muscle spasm (bronchospasm), mucus production, and edema 4. Status asthmaticus is a severe, prolonged attack. a. Cannot be resolved with conventional treatment b. Dire medical emergency 6. Results from: a. Allergic reaction b. Exercise c. Severe emotional stress d. Respiratory infection 1. Severe allergic reaction 2. Characterized by airway swelling 3. Dilation of blood vessels all over the body 4. Sometimes called anaphylactic shock 5. Can cause respiratory distress severe enough to lead to coma and death 6. May be associated with widespread hives (urticaria), itching, signs of shock, and signs and symptoms similar to those of asthma 7. Most reactions occur within 30 minutes of exposure to an allergen. 1. Accumulation of air in the pleural space a. May be partial or complete 2. Trauma is most common cause. 3. May also be caused by medical conditions a. Referred to as spontaneous pneumothorax 4. May occur in patients: a. With certain chronic lung infections b. Who are young and were born with weak areas of the lung c. Who have emphysema d. Who have asthma 5. Tall, thin, athletic males are also at higher risk. 6. Patients become acutely dyspneic and complain of pleuritic chest pain. a. Sharp, stabbing pain on one side b. Worse during breathing or with certain movements of the chest wall 7. Patients may present with subcutaneous emphysema. 8. Breath sounds are absent or decreased on the affected side. 9. Minor problems: a. Pale b. Diaphoretic c. Tachypneic 10. Severe findings: a. Altered mental status b. Cyanosis c. Tachycardia d. Unilaterally decreased breath sounds e. Local hyperresonance to percussion f. Subcutaneous emphysema g. Tracheal deviation (late sign) 1. Collection of fluid outside the lung on one or both sides of chest 2. Fluid may be from irritation, infection, or heart failure, or cancer. 3. Patients often report sudden dyspnea. 4. Should be considered in patients with lung cancer and shortness of breath 5. . Decreased breath sounds over the chest where fluid has moved the lung away from the chest wal 6. . Patients usually feel better when they sit uprigh 7. . Definitive treatment is fluid remova 1. Pulmonary embolism is a blood clot (thrombus). a. Usually formed in a vein in the legs or pelvis; it then breaks off, circulates through venous system, and moves through right side of the heart and into a pulmonary artery 2. Decreases or completely blocks blood flow 3. No exchange of oxygen or carbon dioxide occurs in areas of blocked blood flow. 4. Causes ventilation-perfusion mismatch 5. May also occur as the result of: a. Damage to the lining of vessels b. Hypercoagulability c. Slow blood flow in a lower extremity 6. Risk factors: a. Immobilized legs following surgery or a fracture b. Recent surgery c. Pregnancy d. Previous pulmonary embolism e. First-degree relative who has had pulmonary embolism f. Obesity g. Oral contraceptives h. Smoking i. Infection j. Cancer k. Sickle cell anemia l. Prolonged inactivity m. Being bedridden 7. Signs and symptoms a. Dyspnea b. Tachycardia c. Tachypnea d. Varying degrees of hypoxia e. Cyanosis f. Acute chest pain g. Hemoptysis 1. Patient with dyspnea may have a mechanical obstruction. 2. In an unresponsive patient, this may be the result of: a. Vomitus b. Foreign object c. Improper positioning of the head so tongue is blocking the airway 3. Always consider upper airway obstruction from a foreign body first in patients who were eating just before becoming short of breath. 1. Potentially toxic substances can be inhaled. 2. Chemicals such as ammonia and chlorine bleach can create a hazardous by-product. 3. Type of damage largely depends on the water solubility of the toxic gas a. Highly water-soluble gases such as ammonia will react with moist mucous membranes of the upper airway and cause swelling and irritation. b. Less water-soluble gases such as phosgene and nitrogen dioxide may get deep into lower airway, causing pulmonary edema up to 24 hours later. 1. Genetic disorder that affects the lungs and digestive system 2. Caused by a defective gene that makes it difficult for chloride to move through cells a. Causes unusually high sodium loss and abnormally thick mucus secretions b. Secretions cause breathing difficulties and infections. c. Leads to lung disease 3. Symptoms range from sinus congestion to wheezing and asthmalike complaints. 4. Look for respiratory insufficiency, signs of a respiratory infection, and intestinal blockage. 5. Often causes death in childhood because of chronic pneumonia 1. Bronchiolitis a. Inflammation of bronchioles due to viral infection b. Caused by Metapneumovirus and respiratory syncytial virus (RSV) c. Primarily affects infants and children younger than 2 years d. Signs and symptoms are similar to asthma. i. Asthma is rare in children younger than 1 year. ii. Infant with first-time wheezing episode in late fall or winter likely has bronchiolitis. e. Characteristic findings are mild to moderate retractions, tachypnea, di?use wheezing, di?use crackles, and mild hypoxia 2. Respiratory syncytial virus (RSV) a. Common cause of illness in young children b. Causes an infection in the lungs and breathing passages c. Can cause other serious respiratory illnesses, such as bronchiolitis and pneumonia d. Can also cause serious heart and lung problems in premature infants and children with depressed immune systems e. Highly contagious 3. Croup a. Inflammation and swelling of pharynx, larynx, and trachea b. Secondary to an acute viral infection of upper respiratory tract c. Typically seen in children ages 6 months to 3 years d. Easily passed between children e. Starts with a cold, cough, and low-grade fever that develops over 2 days f. Hallmark signs are stridor and a seal-bark cough g. Peak seasonal outbreaks in late fall and winter h. Rarely seen in adults i. Often responds well to humidified oxygen 4. Epiglottitis a. Inflammation of epiglottis b. Usually caused by a bacterial infection that produces severe swelling of the flap over the larynx c. Predominant in children, but may occur at any age d. Development of a childhood vaccine against Haemophilus in?uenzae has dramatically decreased the incidence of this disease. e. May completely obstruct the airway f. Patients will look very sick. g. Usually has a sudden onset h. Patients will usually be in the tripod position and drooling. i. Symptoms include: i. Sore throat ii. High fever iii. Stridor j. May appear in adults or geriatric patients i. Especially with other issues, such as diabetes ii. Caused by different bacterial or viral organisms iii. Can be potentially life threatening iv. Deterioration can occur quickly. 5. Pneumonia a. Caused by an infection of lung parenchyma b. Eighth leading cause of death in the United States c. Group of specific infections, not a single disease d. At most risk: Young children, the older adults e. Presents as a localized infection in the lungs that may cause atelectasis f. If not treated promptly, can become systemic, leading to sepsis and septic shock. g. Signs and symptoms include: i. Acute onset of fever and chills ii. Productive cough with purulent sputum iii. Pleuritic chest pain iv. Excessive mucus causing pulmonary consolidation 6. Pertussis a. Airborne bacterial infection b. Mostly affects children younger than 6 years c. Highly contagious d. Passed through droplet infection e. Feverish, with a “whoop” sound on inspiration after a coughing attack f. Cold-like symptoms, but coughing spells can last for more than a minute g. Child may turn red or purple. 7. Airway obstruction a. Always consider possibility of a foreign body when a young child becomes short of breath. b. Tonsil inflammation may partially occlude the airway. c. Dysfunction of a tracheostomy may create an upper airway obstruction. d. Obstruction may be in the lower airway, below the vocal cords. i. Tracheal trauma ii. Obstructive lung disease iii. Mucus accumulation iv. Smooth-muscle spasm e. Edema may be present when a patient has been exposed to toxic chemicals or superheated air. 8. Heart failure a. Heart muscles injured by heart attack or illness may not be able to maintain cardiac output that meets the needs of the body. b. Results in pulmonary edema c. Risk factors: i. Hypertension ii. History of coronary artery disease and/or atrial fibrillation d. In most cases, patients have a long-standing history of chronic heart failure that can be controlled with medication. e. Signs and symptoms: i. Difficulty breathing with exertion ii. Sudden attack of respiratory distress iii. Coughing iv. Feeling suffocated v. Cold sweats vi. Tachycardia 1. Wet lungs are associated with pulmonary edema. 2. Dry lungs are associated with COPD. 3. Table 17-6 compares the differences between COPD and heart failure. a. Treat the patient, not the breath sounds. V. Patient Assessment 1. Scene safety a. Use additional PPE if exposure to COVID-19 is a possibility. i. N95 mask, goggles, gloves, and protective covering for clothing b. Ensure a safe environment. c. Determine the number of patients and need for specialized resources. i. Consider possibility of an airborne hazardous material release. 2. Nature of illness 1. Recognition of life threats and initiation of resuscitation take priority 2. Signs of life-threatening respiratory distress in adults: a. Altered mental status b. Severe cyanosis c. Absent or abnormal breath sounds d. Audible stridor e. Two to three-word dyspnea f. Coughing g. Tachycardia of more than 130 beats/min h. Abdominal breathing i. Change in respiratory rate or rhythm j. Pallor and diaphoresis k. The presence of retractions and/or the use of the accessory muscles l. Tripod positioning 3. Note general impression of the patient. 4. Assess airway and breathing a. Determine if airway is open and clear. b. Determine if the patient is breathing c. Provide the appropriate oxygen therapy or positive-pressure ventilations. d. If ventilating, determine if ventilations are effective. a. Assess pulse rate, rhythm, and character. b. Tachycardia or bradycardia indicates patient may not be getting enough oxygen. a. Assess capillary re?ll in infants and children. b. Also assess perfusion by evaluating skin color, temperature, and condition. 7. Identify any life threats: a. Problems with airway, breathing, and circulation (ABCs) b. Poor initial general impression c. An altered mental status d. Potential hypoperfusion or shock e. Chest pain associated with low blood pressure f. Severe pain anywhere g. Excessive bleeding 8. If patient is unstable and there is a possible life threat, address the life threat and proceed with rapid transport. 9. If patient is stable and there are no life threats, you may decide to perform a thorough secondary assessment on scene, after obtaining the patient history. 1. Lung or breath sounds is one of the most important vital signs for your patient in respiratory distress. a. Listen over the bare chest. b. Diaphragm of the stethoscope must be in firm contact with the skin. c. Bring your patient to a sitting position. d. Determine whether breath sounds are normal or abnormal. i. Vesicular breath sounds represent air moving in and out of the alveoli. ii. Bronchial breath sounds represent air moving through the bronchi. iii. Adventitious breath sounds: Decreased, absent, or abnormal 9. Reassess frequently and be prepared to assist ventilation in severe cases. 10. Use the OPQRST-I mnemonic to determine the specifics of pain and obtain specific information about the breathing problem: a. When did the breathing problem begin (Onset)? b. What makes the breathing difficulty worse or better (Provocation or palliation)? c. How does the breathing feel (Quality)? d. Does the discomfort move (Radiation/region)? e. How much of a problem is the patient having (Severity)? On a scale of 1 to 10, with 10 being the worst pain or di?culty the patient has ever had, how bad is it? f. Is the problem continuous or intermittent? If it is intermittent, how frequently does it occur and long does it last (Timing)? g. What has been done to alleviate the problem prior to EMS arrival (Interventions)? Any medications taken? h. Does the patient have a cough? Is it productive or nonproductive? If it is productive, what color is the sputum? Any increased sputum production? i. Is there any hemoptysis? Wheezing? Fever? Chills? j. Has there been any exposure to smoke or does the patient have a history of smoking? 1. Patients with chronic conditions may have long periods in which they are able to live relatively normal lives but then sometimes experience acute worsening of their conditions. 2. Chronic lower airway obstruction makes it dif?cult for patients to breathe deeply enough to clear the lungs. 3. If a new infection of the lung occurs in a patient with COPD, arterial oxygen level may fall rapidly. 4. Patients with COPD usually have a long history of dyspnea with a sudden increase in shortness of breath. 5. Rarely a history of chest pain 6. Pulse is rapid and occasionally irregular. 7. Pay attention to the respirations. 8. Patients with asthma may have different triggers. a. Try to determine what may have triggered the attack. 1. More in-depth assessment of body systems a. Addresses specific chief complaint b. Includes a physical examination and taking vital signs 2. Perform after identifying and treating life threats 3. A change in mental status is one of the early warning signs of respiratory inadequacy and indicates a lack of perfusion to the brain. 4. Look for overall symmetry of the chest, adequate rise and fall of the chest, and evidence of retractions or accessory muscle use. 5. Check respiratory status. a. Slowing respiratory rate with an unimproved condition suggests physical exhaustion and impending respiratory failure. 6. Look for signs of increased work of breathing. 7. Many smokers and people with chronic respiratory diseases cough up sputum every day, so determine if the color or amount of this sputum has changed. a. Note whether the mucus is purulent (puslike). 8. Secondary assessment of the cardiovascular system should include: a. Checking and comparing distal pulses b. Reassessing the skin condition c. Being alert for bradycardia and tachycardia 9. Check for any signs of trauma or retractions in the chest. 10. Numbness, tingling, and carpopedal spasm may be associated with hypocapnia resulting from periods of rapid, deep respiration. 11. Blood pressure should be auscultated when possible. 12. Feel skin temperature, and look for color changes in extremities and in core of the body. 13. Assess the neurologic system frequently. 14. Monitoring devices a. Pulse oximeter b. End-tidal carbon dioxide (etco2) monitor c. Peak flowmeter 1. Do not lay patient supine. 2. Remove constricting clothing. 3. Do not make person walk. 1. Provide supplemental oxygen to any patient who needs it. 2. Administer oxygen in the concentrations necessary to be effective. 3. Patients who are not breathing adequately should receive bag-mask ventilation with supplemental oxygen, or more advanced airway management techniques. 4. Pulse oximetry is a useful guide to oxygenation. 5. Safe to administer oxygen in concentrations less than 50% to almost anyone 6. Oxygen concentrations higher than 50% should be reserved for patients with hypoxia that does not respond to lower concentrations. 7. Use of 100% oxygen should be limited to the shortest period necessary. 8. Never hesitate to administer oxygen aggressively to those patients who need it. 9. Maintain oxygen saturation between 94% and 99%; oxygen saturation of 100% should be avoided. 10. Consider insertion of an advanced airway in unresponsive patients. 11. Call for paramedic backup if needed. 1. Patients who do not have bronchospasm usually bene?t only slightly from aerosol bronchodilators. 2. Bronchodilators are of little value in treating conditions such as pneumonia, pulmonary edema, and heart disease. 3. Respiratory medications a. Most common medications are inhaled beta agonists. b. Typical trade names are Proventil, Ventolin, Alupent, Metaprel, and Brethine. c. Relax the smooth muscles within the bronchioles in the lungs d. Bronchodilators relax the smooth muscle around the larger bronchi. e. Fast-acting bronchodilators provide rapid relief. f. Bronchodilators do not reduce swelling, kill bacteria, push fluid out of the lungs, or open closed alveoli. g. Secondary bronchoconstriction could be reversed with a bronchodilator. h. Table 17-10 lists medications used for acute and chronic respiratory symptoms. i. Common side effects of inhalers: Increased pulse rate, nervousness, and muscle tremors 4. Aerosol therapy a. Aerosol nebulizers deliver liquid medications in a ?ne mist. b. To generate optimal particle size, most nebulizers need to have gas (oxygen) ?ow of at least 6 L/min. c. In the home, can be run off a small air compressor; in the ambulance, it can be run off of tanked oxygen or a wall unit attached to main oxygen supply. d. Can be attached to a mouthpiece (pipe), face mask, tracheostomy collar, or held in front of the patient’s face e. Nebulizers also deliver substantial humidity to the airway. f. Possible to give repeated treatments to patients with bronchospasm 5. Metered-dose inhalers a. Direct medication through the mouth and into the lungs b. Usually the delivery method of choice for bronchodilators and corticosteroids in the home setting c. Document how often the patient has been taking an extra puff. d. Each MDI on the ambulance should ideally be equipped with a spacer. e. Achieving the proper technique when using an MDI requires constant reinforcement. f. Tips on how to avoid common errors when using or administering an MDI: h. About 5 minutes after the patient uses an inhaler, repeat the vital signs and the primary survey. 6. Dry-powder inhalers a. Reasonably convenient and easy to use b. Rarely used during emergency care 7. Consider fluid balance a. Common practice to give a ?uid bolus to younger patients with these conditions b. In any older adult or other patient with cardiac dysfunction, administering too much ?uid could cause pulmonary edema. c. Always assess breath sounds before and after giving a ?uid bolus. d. Almost always want to have an IV line in place 8. Support or assist ventilation a. If the patient becomes fatigued, breathing might need to be supported more aggressively. b. Some patients may simply require bag-mask ventilation for a short period. c. Gastric distention and vomiting can occur from overaggressive ventilation. 9. Continuous positive airway pressure a. Used to treat obstructive sleep apnea and treat respiratory failure b. Many people with obstructive sleep apnea wear a CPAP unit at night to maintain their airways during sleep. c. The CPAP used as therapy for respiratory failure is almost always delivered through a mask secured to the face by some type of strap. d. Be vigilant about monitoring the gas supply. e. Do no struggle with a patient who is unwilling to use the mask. f. The success of CPAP is inversely related to the patient’s respiratory rate soon after its application. i. If this rate increases, the therapy is likely to fail. ii. If this rate decreases, the therapy is likely to succeed. 10. Bilevel positive airway pressure a. One pressure can be delivered during inspiration and a different pressure can be delivered during exhalation. b. More comfortable c. Causes a pressure variation in the chest, which allows for more normal blood flow d. More complex and expensive VII. Assessment and Management of Specific Conditions 1. Patients present with signs of severe respiratory impairment. a. May include one- to two-word dyspnea, diminished or absent breath sounds, altered mental status b. Chief complaint is typically dyspnea, cough, or nocturnal dyspnea. 2. Obtain a thorough history, including personal or family history of asthma and allergies. 3. Determine whether patient has had acute exposure to pulmonary irritant or previous similar episodes. 4. Wheezing may be present. a. Use a peak flowmeter to establish the baseline expiratory airflow. b. Use a pulse oximeter to document the degree of hypoxemia and response to therapy. 5. Place patient in position of comfort. 6. Consider calling early for paramedic backup if patient is in severe distress. 7. Monitor airway, apply high-flow oxygen, and assist ventilation if needed. 8. Use humidified oxygen if available. 9. Establish IV access and provide circulatory support. 10. Assist patient with MDI as needed. 11. Continue monitoring. 12. Transport and contact medical control 13. Provide psychological support. 1. May be associated with cardiac disease or direct lung damage 2. Administer 100% oxygen. 3. If necessary, carefully suction any secretions from airway. 4. Place patient in position of comfort. 5. Provide assisted ventilation. a. Continuous positive airway pressure has proven beneficial. 6. Establish IV access. 7. Monitor flow rates carefully. 8. Consider calling paramedic backup for intubation. 9. Transport promptly. 1. Inhalation of anything other than gases 2. Associated with a high mortality rate 3. When treating patients at risk for aspiration or who have aspirated: a. Avoid gastric distention when ventilating. b. Aggressively monitor the patient’s ability to protect the airway. c. Aggressively treat aspiration with suction and airway control if the previous steps fail. 1. Patients may have an altered level of consciousness. 2. Patients often find breathing difficult while lying down. 3. Assist with prescribed inhaler if there is one. a. Patients with COPD will often overuse an inhaler, so watch for side effects. 4. Transport as promptly as possible to the emergency department, allowing patient to sit upright if that is most comfortable. 5. Auto-PEEP a. Complete exhalation must be allowed before the next breath is delivered. b. Can eventually cause a pneumothorax or cardiac arrest c. Patients in whom auto-PEEP is a concern should be ventilated at a rate of as little as 4 to 6 breaths/min. 1. Assessment of patient is critical. 2. Often a recurring pathologic condition a. If possible, ask family members to describe patient’s asthma. 3. Three components of asthma are bronchospasm, airway edema, and increased mucus production. 4. Pulse rate will be normal or elevated, blood pressure may be slightly elevated, and respirations will be increased. a. Ask questions about how and when the symptoms began. 5. When you are assessing a pediatric patient, look for retractions. 6. Be prepared to suction and administer oxygen. 7. If the patient has medication, help administer inhaler or nebulized medication as directed by local protocol. 8. If you must assist ventilations, use slow, gentle breaths. a. Assist with ventilations as a last resort. 9. Emergency care of a child is the same as for an adult. 10. Status asthmaticus is a dire medical emergency. a. Chest will be maximally hyperinflated. b. Breath sounds and wheezes may be entirely inaudible because air movement is negligible. c. Patient will usually be exhausted, severely acidotic, and dehydrated. d. Aggressive airway management, oxygen administration, and prompt transport are essential. e. Paramedic backup should be considered. 1. Remove the offending agent. 2. Maintain the airway. 3. Administer supplemental oxygen. 4. Assist breathing as needed. 5. Epinephrine is treatment of choice. 1. Management begins with ABCs. 2. Provide airway and ventilatory support. 3. Be alert for signs of tension pneumothorax. 4. Consider IV initiation if severe symptoms are present. 5. Place patient in position of comfort. 6. Transport. 7. Consider calling paramedic unit if patient shows signs of developing a tension pneumothorax. 1. Treatment is removal of fluid collected outside the lung. 2. Provide oxygen and other routine support measures and transport. 1. Manage airway, and provide high-flow oxygen. a. Assist ventilation as needed. 2. Initiate CPR for pulseless and apneic patient. 3. Establish an IV of an isotonic crystalloid solution. 4. Other interventions are supportive. 5. Manage most severe cases as cardiac arrest of unknown origin. 6. Transport. a. Offer reassurance and psychological support. 7. Call for paramedic backup if needed. 1. Can be caused by life-threatening illness or panic attack a. Determination of which it is should not be made outside the hospital. 2. Give supplemental oxygen and transport. 3. Interventions for circulatory support and pharmacologic interventions are rarely required. 4. Provide psychological support for anxiety-related hyperventilation. a. Have patient mimic your respiratory rate and volume. b. Never place paper bag over patient’s mouth and nose. 5. Provide transport. 1. Upper airway obstruction may be partial or complete. 2. If patient can talk and breathe, provide supplemental oxygen and transport in position of comfort. 3. Remove the obstructing body according to basic life support guidelines. 4. Administer supplemental oxygen and transport promptly. 1. Industrial sites often have their own medical/fire/hazardous materials teams. 2. After patient is decontaminated, gather information on substance and cause of dyspnea. 3. Assess patient, paying special attention to lung sounds. a. Blood coming from the airway is an ominous sign. 4. Provide 100% supplemental oxygen or assisted ventilation if necessary. 5. If upper airway is compromised, aggressive airway management may be required. 1. Bronchiolitis a. Treatment is entirely supportive. b. Leave patient in a position of comfort. c. Provide supplemental oxygen and be prepared to assist with bag-mask device. d. Call for paramedic backup for endotracheal intubation if needed. 2. Respiratory syncytial virus a. Look for signs of dehydration. b. Treat airway and breathing problems as appropriate. c. Humidified oxygen is helpful, if available. 3. Croup a. Often responds well to humidified oxygen b. Allow patient to assume position of comfort c. Avoid agitating patient. d. Administer nebulized epinephrine if dictated by local protocol. e. Transport rapidly. 4. Epiglottitis a. Treat children with epiglottitis gently; try not to do anything to make them cry. b. Keep patient in a position of comfort. c. Give high-flow oxygen. d. Do not put anything in patient’s mouth. e. For adult patient, focus on maintaining patent airway. 5. Pneumonia a. Monitor ABCs, provide high-flow oxygen and ventilatory support as needed. b. Administration of IV fluids may help. c. If high fever is present, cool patient. d. Transport and provide psychological support. 6. Pertussis a. Some infants and younger children should be treated in a hospital. i. They are at greater risk of complications like pneumonia. ii. Can sometimes be life threatening b. Children may vomit or not want to eat or drink. i. Watch for signs of dehydration. ii. Suction as necessary. iii. Give oxygen by the most appropriate means. c. In adults or geriatric patients, it does not typically cause whooping illness as seen in young children. i. Can cause severe upper respiratory infection in older patients, which can result in pneumonia ii. Can cause extremely severe coughing spells that last for weeks iii. Coughing can lead to cracked ribs. d. Easily prevented with a vaccine. i. AEMTs should check their immunization status and/or get a booster. 7. Airway obstruction a. Perform most appropriate airway clearing technique. b. Provide oxygen and transport. 8. Heart failure a. High blood pressure and low cardiac output often trigger this flash (sudden) pulmonary edema. b. In addition to the classic signs of respiratory distress, patients may have pink, frothy sputum coming from the mouth. c. The patient’s pulse will be tachycardic. d. The patient may have hypertension early, followed by deterioration to hypotension as a late ?nding. e. Treatment should consist of airway, ventilatory, and circulatory support. f. Consider CPAP. VIII. Tracheostomy Dysfunction 1. Complications include: a. Obstruction by secretions, mucus, or foreign bodies b. Bleeding c. Leaking d. Dislodgement e. Infection 2. Establish a patent airway, place the patient in position of comfort, suction to clear the obstruction. 3. If unable to clear the airway, consider paramedic intervention. 4. After obstruction is clear, oxygenate the patient and treat based on presentation. 1. A pandemic occurs when a new virus emerges for which people have little or no immunity. 2. COVID-19 1. Wear PPE. 2. Viruses can live for several days on surfaces. 3. Frequent handwashing is important. 4. Maintain your vaccinations and stay up to date on the latest CDC recommendations. 5. Place a surgical mask on patients with suspected or confirmed respiratory disease. 6. Wear a HEPA respirator during aerosol-generating procedures (such as suctioning or CPR). 1. A contagious respiratory illness that is easily transmissible from person to person 2. Virus that causes it is a new form of coronavirus (SARS-CoV-2) 3. Spreads through respiratory droplets 4. Symptoms appear 2 to 14 days after exposure 5. Signs and symptoms include, but are not limited to: Post-Lecture This section contains various student-centered end-of-chapter activities designed as enhancements to the instructor’s presentation. As time permits, these activities may be presented in class. They are also designed to be used as homework activities. Assessment in Action This activity is designed to assist the student in gaining a further understanding of issues surrounding the provision of prehospital care. The activity incorporates both critical thinking and application of AEMT knowledge. Instructor Directions 1. Direct students to read the “Assessment in Action” scenario located in the Prep Kit at the end of Chapter 17. 2. Direct students to read and individually answer the quiz questions at the end of the scenario. Allow approximately 10 minutes for this part of the activity. Facilitate a class review and dialogue of the answers, allowing students to correct responses as may be needed. Use the quiz question answers noted below to assist in building this review. Allow approximately 10 minutes for this part of the activity. 3. You may wish to ask students to complete the activity on their own and turn in their answers on a separate piece of paper. Answers to Assessment in Action Questions What is COPD? The end of a slow process that results in disruption of the airways An infectious disease of the lung that damages lung tissue A potentially life-threatening viral infection that usually starts with flulike symptoms A disease of the lungs in which there is extreme dilation of the alveoli Which one of the following is NOT a common cause for exacerbation of COPD? Smoking H1N1 vaccine Air pollution Tuberculosis The clinical definition of chronic bronchitis is a productive cough for at least ___ months per year for ___ or more consecutive years. 2, 2 3, 3 2, 3 3, 2 Which term indicates coarse rattling sounds caused by mucus in the larger lower airways? Stridor Wheezing Rhonchi Crackles The patient is in a tripod position. _____ is severe difficulty breathing experienced when lying down or in a position that is not upright. Apnea Orthopnea Dyspnea Eupnea What is the most common source of bronchiolitis? Prolonged exposure to tobacco smoke Foreign body airway obstruction Respiratory syncytial virus A bacterial upper respiratory infection How does a pleural effusion cause shortness of breath? By compressing one or both lungs By obstructing the airway By causing damage to the alveoli By causing the lungs to fill with fluid _____ is an irreversible condition that makes the alveoli susceptible to atelectasis. Emphysema Asthma Pertussis Bronchiolitis What is the purpose of using a spacer with a metered dose inhaler?