RESPIRATORY EMERGENCY

200,000 People Die Annually From Respiratory Emergencies.

12% of EMS Calls Are For Respiratory Emergencies, 3 Times More Than Heart Attacks.

OVERVIEW

• Differentiate Between Adequate & Inadequate Air Exchange
• Identify & Treat Patients With Breathing Difficulty
• How to Assist a Patient With a Prescribed Rescue Inhaler
• How to Document Findings & Care of a Patient With Breathing Difficulty

RESPIRATORY ANATOMY

• Mouth & Nose
• Pharynx
• Pharynx
• Oropharynx
• Nasopharynx

RESPIRATORY ANATOMY

• Epiglottis
• Leaf-Like Structure
• Protects Airway
• Trachea
• Windpipe

RESPIRATORY ANATOMY

• Larynx
• Voice Box
• Cricoid Cartilage
• Sellick Maneuver

RESPIRATORY ANATOMY

• Lungs
• Bronchi
• Bronchioles
• Alveoli

RESPIRATORY ANATOMY

• Diaphragm
• Dome Shaped
• Separates Thorax & Abdomen

RESPIRATORY ANATOMY

• Inhalation
• Active Process
• Diaphragm & Intercostal Muscles Contract
• Diaphragm Flattens, Moves Downward
• Ribs Move Up & Out
• Increases Size of Thoracic Cavity
• Air Pressure Decreases In Thoracic Cavity
• Air Flows Into Lungs

RESPIRATORY ANATOMY

• Exhalation
• Diaphragm & Intercostal Muscles Relax
• Diaphragm Returns to Dome Shape
• Ribs move Down & In
• Size of Thoracic Cavity Decreases
• Air Pressure In Thoracic Cavity Increases
• Air Flows Out of Lungs

RESPIRATORY PHYSIOLOGY

• Alveolar / Capillary Exchange
• O2 Rich Air Into Alveoli
• O2 Poor Blood In Capillaries
• CO2 From Capillary to Alveoli
• O2 From Alveoli to Capillary

RESPIRATORY PHYSIOLOGY

• Capillary / Cellular Exchange
• Cells Convert O2 to CO2
• Cell Gives CO2 to Capillary
• Capillary Gives O2 to Cell

RESPIRATORY PHYSIOLOGY

• Adequate Breathing
• It is Sufficient to Support Life
• Normal Rate
• Adult 12 – 20 / Minute
• Child 15 – 30 / Minute
• Infant 25 – 50 / Minute
• Rhythm
• Regular
• Irregular

RESPIRATORY PHYSIOLOGY

• Adequate Breathing (cont)
• Quality
• Breath Sounds – Present & Equal
• Chest Expansion – Equal & Adequate
• Effort of Breathing – Use of Accessory Muscles
• Talks in Normal Sentences
• Depth (Tidal Volume)
• Adequate

RESPIRATORY PHYSIOLOGY

• Inadequate Breathing
• Rate – Outside Range
• Rhythm – Irregular
• Quality
• Breath Sounds – Diminished, Absent, Noisy
• Chest Expansion – Unequal, Inadequate
• Effort of Breathing – Increased Accessory Muscles
• Depth (Tidal Volume) – Shallow, Inadequate

RESPIRATORY PHYSIOLOGY

• Inadequate Breathing (cont)
• Skin
• Pale, Cyanotic (Blue)
• Cool, Clammy
• Retractions (Especially Kiddos)
• Clavicles, Ribs
• Nasal Flaring (Especially Kids)
• "Seesaw" Breathing in Infants
• Agonal Breathing – Occasional Gasps

INFANT & CHILD ANATOMY

• Mouth & Nose
• Generally Small
• Easily Obstructed
• Pharynx
• Large Tongue
• Proportionally Take Up More Space Than Adult Mouth

INFANT & CHILD ANATOMY

• Trachea
• Narrow
• Swelling Obstructs
• Soft & Flexible
• Cricoid Cartilage
• Soft, Underdeveloped
• Diaphragm
• Diaphragm Dependent
• Chest Wall Not Strong

INFANTS & CHILDREN

• Leading killer of children
• Children Compensate Very Well
• Rapid deterioration and "crashing" of these patients— rapid treatment & assessment is critical!

• May be result of an acute problem

• Trauma (chest injuries, head injuries)
• Medical condition (heart attack,
  allergic reaction, Pneumonia)
• Other conditions (drowning, vomiting)
• Anxiety, stress

• May be a chronic condition

• COPD
• Asthma

• Frequent chief complaint.
• May also complain of chest tightness, anxiety, or restlessness.
• Do not rely completely on patient’s perception, but rather on full patient assessment.
• May be a chronic problem or an acute onset.

• Includes emphysema, chronic bronchitis, and black lung
• Generally affects older patients
• Affects patient continuously
• Causes include cigarette smoking, chemical exposure, and pollution

• Inflammation of bronchiole lining
• Produces excess mucus
• Damage or destruction of cilia prevents removal of this mucus

CRACKLES & WHEEZING

• Chronic Bronchitis
• Wheezing From Inflammation
• High Pitch Sound
• Crackles From Mucous
• Wet, Sloppy Sound

COPD – Emphysema

• Breakdown of alveoli walls
• Reduces surface area for exchange of oxygen and carbon dioxide
• Reduced elasticity of lungs

ASTHMA

• Episodic disease
• Narrowing of bronchioles & overproduction of mucus
• Typically one directional, allowing air into lungs but requiring forceful exhalation (wheezing)
• Variety of causes

• Allergic reactions
• Pollutants
• Exercise & stress

WHEEZING

• Asthma
• Asthmatic Bronchitis
• Inflammation of the Bronchus and Bronchioles
• Constriction

PNEUMONIA

• Infection of the Lower Airways (Alveoli)
• Sudden Onset of Fever, Chills, Shaking
• Productive Cough w/ Colorful Sputum
• Pain - Aggravated w/ Breathing & Coughing
• Dyspnea w/ Accessory Muscle Use
• Fatigue - Tires Easily
• Lung Sounds - Wheezing, Rales, Rhonchi

MILD CRACKLES - PNEUMONIA

• Expect to Hear the Whole Gamut
• Rales (Fine Crackles)
• Rhonchi (Course Crackles)
• Wheezing

Pulse Oximetry

• If possible, place immediately to obtain "room air" reading.
• Never delay oxygen administration to obtain a reading.
• Normal reading is 95% to 99%
• Below 95% indicates hypoxia
• 91% to 94% = mild hypoxia
• 86% to 90% = moderate hypoxia
• 85% or less = severe hypoxia

General Treatment Considerations

• Ensure open airway.
• Jaw-thrust or head-tilt, chin-lift
• Heimlich maneuver as needed.
• Insert oral/nasal airway as needed.
• Suction secretions and fluids as needed.

Providing Artificial Ventilation

Provided through (in order of preference):

• Pocket face mask with
  supplemental oxygen
• 2 rescuer bag-valve mask with supplemental oxygen
• Flow-restricted, oxygen-powered ventilation device (FROPVD)
• One rescuer bag-valve mask with supplemental oxygen

ARTIFICIAL VENTILATION

• Adequate Artificial Ventilation
• Chest rises & Falls W/ Each Ventilation
• Sufficient Rate
• Adult 12 / Minute
• Infant & Child 20 / Minute
• Heart Rate Returns to Normal
• Skin Color Improves

ARTIFICIAL VENTILATION

• Inadequate Artificial Ventilation
• Chest Does Not Rise & Fall W/ Each Ventilation
• Rate Too Fast / Too Slow
• Heart Rate Does Not Return to Normal
• Skin Color Does Not Improve

BREATHING DIFFICULTY

• Hypoxia – Low Oxygen
• Signs & Symptoms
• Shortness of Breath
• Restlessness
• é Pulse Rate
• é Breathing Rate
• ê Breathing Rate

BREATHING DIFFICULTY

• Skin Color Changes
• Cyanotic (Blue)
• Pale (White/Gray)
• Flushed (Red)

BREATHING DIFFICULTY

• Noisy Breathing
• Crowing
• Wheezing
• Gurgling
• Snoring
• Stridor
• Harsh, High-Pitched Sound
• Upper Airway Obstruction

BREATHING DIFFICULTY

• Inability to Speak - Short Choppy Sentences
• Retractions / Accessory Muscles
• Shallow / Slow Breathing
• Abdominal Breathing - Using Only the Diaphragm
• Coughing
• Irregular Rhythm
• Unusual Anatomy – ie: Barrel Chested
• Patient Position - Tripod

EMERGENCY CARE

• C/C Difficulty Breathing
• Focused History & Physical Exam
• Important Questions
• OPQRST
• Apply O2
• Baseline Vital Signs
• Does the Patient Have a Prescribed Inhaler?
• If No – Continue Focused Assessment

EMERGENCY CARE

• Patient Does Have Prescribed Inhaler
• Be Prepared to Intervene With Artificial Ventilation
• Consult Med Com
• Aid Patient In Use

EMERGENCY CARE

• Medication Names
• Generic Names
• Albuterol, Isoetharine, Metaproteranol
• Trade Names
• Proventil, Ventolin, Bronkosol, Bronkometer, Alupent, Metaprel

EMERGENCY CARE

• Indications (All Must Be Met)
• Exhibits S&S of Respiratory Emergency
• Patient Has His Physician Prescribed Inhaler
• Hand Held Devise
• aka: Rescue Inhaler
• Authorization By Medical Command
• Online Command MD
• Standing Orders

EMERGENCY CARE

• Contraindications
• Inability of Patient to Use Inhaler
• Inhaler Is Not Prescribed to Patient
• No Permission of Medical Command
• Patient Has Already Taken Maximum Dose

ADMINISTRATION of INHALER

• Obtain Command Order
• Assure Right Med for Right Patient, Right Route
• Patient Alert to Use
• Check Expiration Date
• How Many Has Pt Taken
• Assure Room Temp or Warmer
• Shake Inhaler Vigorously
• Remove O2 Adjunct
• Have Pt Exhale Deeply
• Pt’s Lips Around Inhaler
• Pt Depresses Inhaler as He Inhales Deeply
• Instruct Pt to Hold Breath
• Replace O2 Adjunct
• Allow Pt a Few Breaths Between Doses if Ordered

INHALER MEDICATIONS

• Actions
• Bronchodilator – Relaxes the Smooth Muscles of the Lungs, Decreasing Airway Resistance
• Side Effects
• Increased Pulse Rate
• Nervousness
• Tremors

RESPIRATORY EMERGENCY

• Re-Assessment Strategy
• Monitor Vital Signs
• On-Going Assessment
• Respiratory Patients Can Deteriorate Rapidly

PEDIATRIC CONSIDERATIONS

• Inhalers Are Common For Kids
• Use Same Criteria as With Adults
• Retractions Are More Common In Kids
• Children Compensate Very Well to the Point of Death
• Cyanosis Is A Late Sign
• Upper Airway Compromise Due to Illness is Common – Funny Breathing Sounds
• Frequent Coughing Instead of Wheezing ?