11: Respiratory Emergencies

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11 Respiratory Emergencies
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Cognitive Objectives (1 of 3)

• 4-2.1 List the structure and functions of the
  respiratory system.
• 4-2.2 State the signs and symptoms of a patient
  with difficulty breathing.
• 4-2.3 Describe the emergency medical care of the
  patient with breathing difficulty.
• 4-2.4 Recognize the need for medical direction to
  assist in the emergency medical care of the
  patient with breathing difficulty.

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Cognitive Objectives (2 of 3)

• 4-2.5 Describe the care of a patient with
  breathing distress.
• 4-2.6 Establish the relationship between airway
  management and breathing difficulty.
• 4-2.7 List signs of adequate air exchange.

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Cognitive Objectives (3 of 3)

• 4-2.8 State the generic name, forms, dose,
  administration, actions, indications, and
  contraindications for the prescribed inhaler.
• 4-2.9 Distinguish between the emergency medical
  care of the infant, child, and adult patient with
  breathing difficulty.
• 4-2.10 Differentiate between upper airway
  obstruction and lower airway disease in the
  infant and child patient.

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Affective Objectives

• 4-2.11 Defend EMT-B treatment regimens for
  various respiratory emergencies.
• 4-2.12 Explain the rationale for administering an
  inhaler.

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Psychomotor Objectives

• 4-2.13 Demonstrate the emergency medical care for
  breathing difficulty.
• 4-2.14 Perform the steps in facilitating the use
  of an inhaler.

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Respiratory System
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Anatomy and Functionof the Lung
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Characteristics of Adequate Breathing

• Normal rate and depth
• Regular breathing pattern
• Good breath sounds on both sides of the chest
• Equal rise and fall of chest
• Pink, warm, dry skin

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Characteristics ofInadequate Breathing

• Pulmonary vessels become obstructed.
• Alveoli are damaged.
• Air passages are obstructed.
• Blood flow to the lungs is obstructed.
• Pleural space is filled.

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Signs ofInadequate Breathing

• Slower than 12 breaths/min or faster than 20
  breaths/min
• Unequal chest expansion
• Decreased breath sounds
• Muscle retractions

• Pale or cyanotic skin
• Cool, damp (clammy) skin
• Shallow or irregular respirations
• Pursed lips
• Nasal flaring

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Dyspnea

• Shortness of breath or difficulty breathing
• Patient may not be alert enough to complain of
  shortness of breath.

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Upper or Lower Airway Infection

• Infectious diseases may affect all parts of the
  airway.
• The problem is some form of obstruction to the
  air flow or the exchange of gases.

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Acute Pulmonary Edema

• Fluid build-up in the lungs
• Signs and symptoms
• Dyspnea
• Frothy pink sputum
• History of chronic congestive heart failure
• Recurrence high

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Chronic Obstructive Pulmonary Disease (COPD)

• COPD is the result of direct lung and airway
  damage from repeated infections or inhalation of
  toxic agents.
• Bronchitis and emphysema are two common types of
  COPD.
• Abnormal breath sounds may be present.
• Rhonchi and wheezes

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Asthma

• Common but serious disease
• Asthma is an acute spasm of the bronchioles.
• Wheezing may be audible without a stethoscope.

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Spontaneous Pneumothorax

• Accumulation of air in the pleural space
• Caused by trauma or some medical conditions
• Dyspnea and sharp chest pain on one side
• Absent or decreased breath sounds on one side

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Anaphylactic Reactions

• An allergen can trigger an asthma attack.
• Asthma and anaphylactic (allergic) reactions can
  be similar.
• Hay fever is a seasonal response to allergens.

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Pleural Effusion

• Collection of fluid outside lung
• Causes dyspnea
• Caused by irritation, infection, or cancer
• Decreased breath sounds over region of the chest
  where fluid has moved the lung away from the
  chest wall
• Eased if patient is sitting up

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Mechanical Obstruction of the Airway

• Be prepared to treat quickly.
• Obstruction may result from the position of head,
  the tongue, aspiration of vomitus, or a foreign
  body.
• Opening the airway with the head tilt-chin lift
  maneuver may solve the problem.

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Pulmonary Embolism

• A blood clot that breaks off and circulates
  through the venous system
• Signs and symptoms
• Dyspnea
• Acute pleuritic pain
• Hemoptysis
• Cyanosis
• Tachypnea
• Varying degrees of hypoxia

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Hyperventilation

• Overbreathing resulting in a decrease in the
  level of carbon dioxide
• Signs and symptoms
• Anxiety
• Numbness
• A sense of dyspnea despite rapid breathing
• Dizziness
• Tingling in hands and feet

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You are the Provider

• You and your EMT-B partner are dispatched to 1465
  Dalles Military Rd for a 33-year-old woman with
  difficulty breathing.
• You arrive at the office building and an upset
  man identifies himself as the patients coworker.
  
• He tells you that the patient has had breathing
  problems before, but hes never seen it this bad.

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You are the Provider (continued)

• He leads you to a woman who is standing with her
  arms outstretched on the desk with a metered-dose
  inhaler in hand.
• She acknowledges your presence with a nod. When
  you ask her what is wrong, she answers with a
  two-word response, cant breathe.
• You hear audible wheezes.

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Scene Size-UP

• How significant is the persons response to your
  question and why?
• What should you do next? Should you transport
  this patient or wait for ALS to arrive on scene?

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Initial Assessment

• Perform initial assessment.
• Place the patient on oxygen.
• If patient is in respiratory distress, ventilate.
• Check pulse.

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Signs and Symptoms (1 of 2)

• Difficulty breathing
• Altered mental status
• Anxiety or restlessness
• Increased or decreased respirations
• Increased heart rate
• Irregular breathing
• Cyanosis

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Signs and Symptoms (2 of 2)

• Pale conjunctivae
• Abnormal breath sounds
• Difficulty speaking
• Use of accessory muscles
• Coughing
• Tripod position
• Barrel chest

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You are the Provider (continued)

• You arrange to rendezvous with ALS.
• You apply high-flow oxygen and obtain the
  following vital signs
• Pulse 42 breaths/min
• Pulse oximetry 90
• The patient indicates that she has used the
  inhaler twice already.

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You are the Provider (continued)

• What can you do before you meet ALS?
• Another pulse oximetry reading reveals a reading
  of 72.
• The patient is using accessory muscles to
  breathe.
• What do these signs indicate?

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COPD Patients

• COPD patients cannot handle pulmonary infections
  well
• Usually age 50 or older
• History of recurring lung problems
• Long-term smokers
• Tightness in chest/constant fatigue

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Focused History and Physical Exam

• Abnormal breath sounds are symptomatic of COPD
• Long history of dyspnea with sudden increase in
  shortness of breath
• Recent chest cold with fever
• Vital signs
• Normal blood pressure
• Rapid, occasionally irregular pulse
• Respirations rapid or very slow

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Interventions

• Treat immediate life threats
• Possible interventions
• Oxygen via nonrebreathing mask at 15 L/min
• Positive pressure ventilations
• Airway adjuncts
• Positioning
• Respiratory medications

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Detailed Physical Exam

• Performed only once life threats are addressed.
• May not be able to do if busy treating airway or
  breathing problems.

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Ongoing Assessment

• Carefully watch patients for shortness of breath.
• Reassess vital signs.
• Ask patient if treatment has made a difference.
• Check for accessory muscle use.

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Emergency Medical Care

• Give supplemental oxygen at 10 to 15 L/min via
  nonrebreathing mask.
• Patients with longstanding COPD may be started on
  low-flow oxygen (2 L/min).
• Assist with inhaler if available.
• Consult medical control.

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Medications in MDI

• Trade names
• Proventil
• Ventolin
• Alupent
• Metaprel
• Brethine

• Generic names
• Albuterol
• Metaproterenol
• Terbutaline

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Prescribed Inhalers

• Actions
• Relax the muscles surrounding the bronchioles
• Enlarge the airways leading to easier passage of
  air
• Side effects
• Increased pulse rate
• Nervousness
• Muscle tremors

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Prior to Administration

• Read label carefully.
• Verify it has been prescribed by a physician for
  this patient.
• Consult medical control.
• Make sure the medication is indicated.
• Check for contraindications.

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Contraindications for MDI

• Patient unable to help coordinate inhalation
• Inhaler not prescribed for patient
• No permission from medical control
• Maximum dose prescribed has been taken.

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Administration of MDI (1 of 3)

• Obtain order from medical control or local
  protocol.
• Check for right medication, right patient, right
  route.
• Make sure the patient is alert.
• Check the expiration date.
• Check how many doses have been taken.

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Administration of MDI (2 of 3)

• Make sure inhaler is at room temperature or
  warmer.
• Shake inhaler.
• Stop administration of oxygen.
• Ask the patient to exhale deeply and put lips
  around opening.
• If the inhaler has a spacer, use it.

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Administration of MDI (3 of 3)

• Have the patient depress the inhaler and inhale
  deeply.
• Instruct the patient to hold his or her breath.
• Continue administration of oxygen.
• Allow the patient to breathe a few times then
  repeat dose according to protocol.

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Reassessment

• Carefully watch for shortness of breath.
• 5 minutes after administration
• Obtain vital signs again.
• Perform focused reassessment.
• Transport and continue to assess breathing.

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Upper or Lower Airway Infection

• Administer warm, humidified oxygen.
• Do not attempt to suction the airway or insert an
  oropharyngeal airway in a patient with suspected
  epiglottitis.
• Transport patient in position of comfort.

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Acute Pulmonary Edema

• Administer 100 oxygen.
• Suction secretions.
• Transport in position of comfort.

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Chronic Obstructive Pulmonary Disease (COPD)

• Assist with prescribed inhaler if patient has
  one.
• Transport promptly in position of comfort.

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Spontaneous Pneumothorax

• Administer oxygen.
• Transport in position of comfort.
• Monitor closely.

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Asthma

• Obtain history.
• Assess vital signs.
• Assist with inhaler if patient has one.
• Administer oxygen.
• Transport promptly.

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Pleural Effusion

• Definitive treatment is performed in a hospital.
• Administer oxygen and support measures.
• Transport promptly.

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Obstruction of the Airway

• Clear airway.
• Administer oxygen.
• Transport promptly.

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Pulmonary Embolism

• Administer oxygen.
• Place patient in comfortable position, usually
  sitting.
• Assist breathing as necessary.
• Keep airway clear.
• Transport promptly.

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Hyperventilation

• Complete initial assessment and history of the
  event.
• Assume underlying problems.
• Do not have patient breathe into a paper bag.
• Give oxygen.
• Reassure patient and transport.