Pulmonary Diseases

1
Pulmonary Diseases Disorders Assessment
EMS Professions Temple College
2
Pulmonary Diseases Disorders

• Epidemiology
• 28 of all EMS Chief Complaints in the US
• 200,000 deaths annually due to respiratory
  emergencies

3
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

4
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?

5
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

6
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

7
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

8
Sources of Pulmonary Impairment

• Perfusion
• Inadequate blood volume or hemoblogin
• hypovolemia
• anemia

• Impaired blood flow
• pulmonary embolus
• Capillary wall pathology
• trauma

9
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

10
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

11
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

12
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

13
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

14
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

15
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

16
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

17
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?

18
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

19
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

20
Assessment HP

• 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

21
Assessment HP

• 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

22
Assessment HP

• 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?

23
Assessment HP

• 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

24
Assessment HP

• 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

25
Assessment HP

• 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

26
Assessment HP

• 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

27
Assessment HP

• 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

28
Assessment HP

• 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

29
Assessment HP

• Dont let respiratory failure distract you from
  assessing for circulatory failure.
• Vascular Access

30
Assessment HP

• Physical Exam
• Extremities
• Peripheral Cyanosis
• Clubbing
• Carpopedal spasm
• Peripheral edema

31
Assessment HP

• 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

32
Assessment HP

• Past History
• Similar Episodes in Past
• Patients 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

33
Assessment HP

• Past History
• Known diagnosis
• Does the present HP correlate with this past
  history?
• CHF
• Hypertension
• Renal Failure
• Previous intubation or hospitalization
• Aggravating Factors (e.g. smoking)

34
Assessment HP

• Past History
• Medications
• Class, Route, Frequency of Use
• Pulmonary
• Sympathomimetics
• Corticosteroids
• MAST Cell Stabilizer
• Methylxanthines
• Cardiovascular
• Diuretics
• Antihypertensives
• Cardiac glycosides

35
Assessment HP

• Disability
• Restlessness, anxiety, combativeness HYPOXIA
  Until Proven Otherwise
• Drowsiness, lethargy HYPERCARBIA

When the patient stops fighting, he is not
necessarily getting Better!!
36
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

37
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

38
Other Adventitious Sounds

• Hiccough
• Hiccups, singultus
• Spasm of diaphragm followed by glottic closure
• No useful purpose
• Benign, transient