Respiratory ProblemsEmergencies

1
Respiratory Problems/Emergencies
2
Deep Vein Thrombosis

• Risk factors
• Surgery especially orthopedic
• General age, obesity, smoking, contraceptive
• Trauma
• Underlying dx Ca, sepsis, stroke, autoimmune
  disorders
• CV dx heart failure, vascular injury
• Immobility
• Inherited clotting disorders

3
Deep Vein Thrombosis

• About 5 million DVT episodes occur per yr in the
  USabout 10 of these become emboli
• How many emboli per yr would that be?
• Most clinically significant PEs are DVTs from
  the calves that extend above the knees
• DVTs can also occur in the upper extremities,
  but the clots are smaller and less risky
• Clinical features
• Pain
• Heat
• Swelling of the limb
• Erythema

4
Deep Vein Thrombosis

• Diagnosis
• Venography
• Iodine-131 fibrinogen scans
• Doppler ultrasonography
• D-dimer assays
• Prevention
• Weight loss, smoking cessation, withdrawal of
  contraceptives, tx of infection, tx of CHF
• Prophylaxis after surgery
• Early ambulation
• Leg exercises/range of motion
• Compression stockings
• Heparin/Coumadin

5
Deep Vein Thrombosis

• Treatment
• Heparin to prevent clot extension
• Coumadin for at least 6 weeks after DVT is
  diagnosed

6
Pulmonary Embolism

• When a thrombus moves into the lung, the
  pulmonary artery can become occluded
• What actually happens depends on the size of the
  vessel thats occluded the larger the vessel
  involved, the more serious the consequences
• Small emboli, however, can be fatal if the person
  has pre-existing heart or lung dx

7
PE

• Clinical presentation
• Pleuritic pain and hemoptysis (65 of cases)
• Dyspnea (25)
• Circulatory collapse (10)
• Apprehension
• Tachypnea
• Tachycardia
• Sweating
• Syncope
• Hypotension
• JVD
• Atelectasis at site of the PE
• EKG changes RAD, RBBB, S1Q3T3
• ABG hypoxemia, widened A-a gradient, hypocapnia

8
PE

• Diagnosis
• Pulmonary angiography
• V/Q scanning
• A negative perfusion scan rules out PE
• A high probability scan has gt85 probability of
  PE and gt95 if there are symptoms
• Confirmation of DVT with Doppler ultrasound or
  impedence plethysmography
• Spiral CT scan
• MRI
• Echocardiography
• TEE (transesophageal echocardiography)

9
PE

• Treatment
• Similar to that for DVT
• Anticoagulation
• Keeps existing clots from extending
• Heparin for 1 week
• Coumadin for up to 6 months
• Greenfield filter (IVC filter)
• Thrombolytic therapy
• Only if the PE is life-threatening

10
Pneumothorax

• A collection of air between the visceral and
  parietal pleura
• Classification
• Primary spontaneous pneumothorax
• Caused by rupture of blebs
• Rarely cause significant physiological problems
• Usually affects tall young men
• Pleurodesis (bleomycin or talc) is used for
  recurrent ones
• Secondary pneumothorax
• Associated with lung dx (COPD, fibrotic dx, or
  infections)
• More serious that primary b/c the lungs were not
  normal to start with
• May result from mechanical ventilation
• Traumatic (iatrogenic) pneumothorax
• Blunt or penetrating trauma to the chest
• Therapeutic procedures (surgery/line insertions)

11
Pneumothorax

• Tension pneumothorax
• Can occur with any of the classes of pneumo
• Occurs when air accumulates in the pleural space
  faster than it can be evacuated
• Results in mediastinal shift, compression of
  functioning lung, inhibition of venous return,
  and shock from decreased CO
• Treatment is to drain it by inserting a 14 guage
  needle into the 2nd intercostal space in the
  midclavicular line, then insert a chest tube
• Why is the 2nd intercostal space used rather than
  one lower in the thorax?

12
Pneumothorax

• Clinical assessment
• Sudden breathlessness
• Sharp pleuritic pain
• Most primary pneumos are small (lt30) and hard to
  detect clinically
• Large pneumos
• Hyperresonant percussion
• Tachpnea
• Cyanosis
• Tachycardia
• Hypotension
• Desaturation
• Confirmed with CXR and/or CT scan

13
Pneumothorax

• Management
• Supplemental oxygen and analgesia
• Tension pneumo
• Drain immediately

14
Pneumothorax

• Management
• Protective ventilation strategies
• Suction
• Chest drains are removed with CXR confirms that
  the lung has reexpanded AND when theres been no
  air leakage for at least 24 hours through the
  drain
• The chest tube should be pulled out during
  inspiration and the site is then sutured shut

15
Other types of air leaks

• Caused by surgery, barotrauma, trach insertion
• Pneumomediastinum
• Air in the mediastinum
• Pneumopericardium
• Air in the pericardium
• May cause tamponade
• Subcutaneous emphysema
• Air in the tissue space
• Can cause localized neck swelling or can cause
  face and other parts of the body to swell
• Can feel it and may cause a crunch with each
  heart beat

16
Respiratory Emergencies

• Massive hemoptysis
• Expectoration of gt600 ml of blood in 24 hrs
• 80 are caused by infection20 by malignancy
• Death is caused by asphyxia, not blood loss
• Clinical evaluation
• Easily confused with many other problems, such as
  nose bleed or emesis
• Serology, ABGs, clotting profile, CXR, sputum
  analysis, bronchoscopy

17
Respiratory Emergencies

• Causes of massive hemoptysis
• Infection
• TB
• Pneumonia
• Lung abscess
• Bronchiectasis
• Aspergillus
• Malignancy
• Lung cancer
• Metastatis cancer
• Lymphoma
• Other
• Pulmonary infarction
• Adenoma
• Trauma
• Alveolar hemorrhage
• vasculitis

18
Respiratory Emergencies

• Massive hemoptysis
• Management
• Protect the airways
• Place patient on side, with bleeding lung in
  dependent position
• Put in slight Trendelenburg position
• Suppress the cough with narcotics
• Independent lung ventilation
• Determine the site/cause of the bleeding
• Usually done with bronchoscopy
• CT scans identify tumors
• Control the bleeding
• Iced saline or epinephrine lavage
• Topical fibrin
• Balloon tamponade of affected bronchi
• Bronchial artery embolization
• Surgical therapy
• General measures ATB, fluid, bronchodilators

19
Respiratory Emergencies

• Aspiration Syndromes
• Risk factors
• Depressed consciousness
• Laryngeal incompetence
• Critically ill patients
• clinical presentation depends on what was
  aspirated and how much was aspirated
• Partial obstruction stridor, cough, wheeze,
  atelectasis, recurrent pneumonia
• Complete obstruction cyanosis, coma, death
• Solid particulate matter
• Peanuts, coins, teeth
• Most common is partially chewed food
• Heimlich maneuver used for complete obstruction
• Bronchoscopy is done to remove partial
  obstructions

20
Respiratory Emergencies

• Fluid aspiration
• Gastric contents are the most commonly aspirated
  fluid
• Significant volumes lead to lung damage,
  respiratory failure, ARDS
• Usual path is to the right lung with pulmonary
  infiltrates on CXR
• Prevention is the best tx
• NPO before surgery
• HOB 30 degrees
• NG tube placement
• Bronchial hygiene
• Oxygen/bronchodilators

21
Respiratory Emergencies

• Near drowning
• Freshwater
• Causes atelectasis, pulmonary shunt, and
  hypoxemia
• Rapidly absorbed into the bloodstream causing
  hypervolemia, hemolysis, and hyperkalemia
• Salt water
• Pulls fluid into alveoli
• Causes hypovolemia, shunting, and hypoxemia
• Hypothermia (lt30 degrees) is common and
  predisposes the patient to resistant
  arrrhythmias always rewarm the patient before
  stopping resuscitation efforts
• The degree of brain damage determines the outcome

22
Respiratory Emergencies

• Upper airway obstruction
• Causes
• Aspirated particulates
• Inhaled toxic gases
• Burns
• Trauma
• Anaphylaxis
• Laryngeal edema
• Large airway stenosis
• Tongue
• Extubation can cause laryngospasm
• May require re-intubation or may be able to
  handle with racemic epi tx/steroids
• Heliox mixes can be used to improve gas
  distribution

23
Respiratory Emergencies

• Other emergencies
• In undeveloped countries the main causes of resp
  emergencies are polio, tetanus, diptheria, and
  TB
• Lots of other disease processes can predispose or
  lead to a respiratory emergency, mainly due to
  their effect on the CNS or muscle weakness or
  both
• CNS depression
• Neurological diseases
• Infections
• Endocrine disorders