5.Respiratory Distress Dental Lecture

7/27/2019 5.Respiratory Distress Dental Lecture

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RESPIR TORY DISTRESSCAUSES:

HyperventilationVasodepressor syncope

AsthmaHeart failureHypoglycaemiaOverdose reaction

Acute MI Anaphylaxis

Angioneurotic edemaCerebrovascular accidentEpilepsyHyperglycemic reaction


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PATHOPHYSIOLOGYBRONCHIOLES-primary site ofasthmaHEART FAILURE PTS-respiratorydistress 1 st symptomHYPERVENTILATION-Primary site-brain

ACUTE LOWER AIRWAYOBSTRUCTION-life threatening-foreign object impacts in RS tract


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MANAGEMENTRecognize respiratory distress-sounds(wheezing,cough),abnormal rate or depth of respiration

Terminate dental procedure

P---position patient supine,if unconscious,orcomfortably(upright)if conscious.

A-B-C-assess & provide BLS,as needed

D-monitor vital signs-BP,HR(PULSE),RR.Manage patient anxiety.

Provide definitive management of RD.


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AIRWAY OBSTRUCTION

Instruments & techniques used toprevent aspiration & swallowing ofobjects:

Rubber damOral packingChair positionDental assistantSuctionMagill intubation forcepsLigature


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SIGNS & SYMPTOMS

Sudden onset of coughingChokingWheezingShortness of breath


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MANAGEMENT

MANAGEMENT OF VISIBLEOBJECTS

IF ASSISTANT IS PRESENT:Place pt in supine or trendelenburg position.

use magill intubation forceps or suction.

IF ASSISTANT IS NOT PRESENT:Instruct pt to bend over arm of chair with head down.

Encourage pt to cough.


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Management of swallowedobjects

Consult radiologist.

Obtain app radiographsto determine location ofobject

Initiate medicalconsultation with appspecialist


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MANAGEMENT OFASPIRATED OBJECTS

Place pt in left lateral decubitusposition.

Encourage pt to cough .Object isretrieved

Initiate medicalconsult before

discharge

Object is not retrieved

Consult with radiologistor ER dept

Perform bronchoscopy tovisualize & retrieve object.


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AIRWAY OBSTRUCTION

COMPLETE

PARTIAL


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SIGNS OF COMPLETE AIRWAYOBSTRUCTION

INABILITY TO SPEAK

INABILITY TO BREATHE

INABILITY TO COUGH

UNIVERSAL SIGN FOR

CHOKING

PANIC


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Signs of partial airwayobstruction

Individual with good airflow

Forceful cough

Wheezing between cough

Ability to breath

Individuals with poor air exchange

Weak ineffectual cough

Crowing sound on inspiration

Paradoxical respiration

Absent or altered voice sounds

Possiblecyanosis,lethargy,disorientation


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Establishment of an emergencyairway

TracheostomyCricothyrotomyNon surgical-abdominal thrust orheimlich maneuverNon invasive techniques:

Back blows

Manual thrustHeimlich maneuverChest thrustFinger sweep


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Back blows:

infant: infant is straddled over therescuers arm with the head lower thanthe trunk & with the head supported by

the rescuers firm hold on the infants jaw. Using the heel of the hand therescuer delivers four back blows

forcefully btw the infants shoulderblades while resting the other hand onthe thigh.


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Manual thrusts

Consists of a series of 6-10 thrusts tothe upper abdomen or to the lowerchest.They produce a rapid increase

in intrathoracic pressure,acting as anartificial cough that can help dislodgea foreign body.


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Heimlich maneuver

Also known as subdiaphramaticabdominal thrust or abdominal thrust,was 1 st described by Dr. henry J.heimlich in 1975.If pt is conscious:

Stand behind the pt and wrap your arms around thewaist and under the armsGrasp one fist with the other hand placing the

thumb side of the fist against the victims abdomen.The hand should rest in the midline slightly abovethe umbilicus & well above the tip of the xiphoidprocessPerform repeadted inward &upward thrusts until

either the foreign body is expelled or the victimloses concsiousness


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If the victim is unconscious :1. Place the victim in the supine position.2. Open the victims airway using the head tilt -chin lift

technique and turn the head up into the neutralposition.yhe head is turned into the neutral position toavoid airway obstruction,facilitate foreign body to be

visualised.3. Whenever possible the rescuer should straddle thevictims legs or thighs.

4. Place the heel of one hand against the victimsabdomen,in the midline slightly above the umbilicus andwell above the tip of the xiphoid process.

5. Place the 2nd

hand directly on top of the 1st

hand6. Press into the victims abdomen with a quick inward andupward thrust.

7. Perform upto 5 abdominal thrusts.8. Open the victims mouth & perform the finger sweep. 9. Repeat steps 2 -8 till the obstruction is dislodged.


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Chest thrust

If victim is conscious:Stand behind the victim & place the arms directly underthe armpits,encircling the chest.Grasp one fist with the other hand, placing the thumb

side of the fist on the middle of the sternum,not on thexiphoid process or the margins of the rib cage.Perform backwardd thrusts until the foreign body isexpelled or the victim loses consciousness.


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If the victim is unconscious:Place the victim in supine position.Using the head tilt chin maneuver, open the victimsairway and place the head into the neutral position.

Either straddle or stand astride the victim, as describedin heimlich maneuver.Place the heel of one hand on the lower half of thesternum with the 2 nd hand on top of it, but not on thexiphoid process.

Perform upto 5 quick ,downward thrusts to compressthe chest cavity.Open the victims mouth and perform the finger sweep.


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Finger sweep

Should be performed in unconscious victimsonly.

A magill intubation forceps can aid in theremoval of foreign objects from the airway.

Procedure :Place the victim in the supine position with the head inneutral position.Grasp the tongue & the anterior portionof the mandible.To perform the finger sweep, place the index finger of theother hand along the inside of the victims cheek andadvance it deeply into the pharynx at the base of thetongue. Using a hooking movement try to dislodge theforeign body & move it into the mouth where either thesuction or magill intubation tube will remov it.


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HYPERVENTILATION

DEFINITION:IS defined as ventilation in excess of that required tomaintain normal blood PaO2 and PaCO2.

OCCURS MOSTLY IN PTS BETWEEN 15 -40 YRS.

Respiratory rate may exceed to 25-30 breaths perminute.


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Clinical manifestations ofhyperventilationSYSTEM SIGNS & SYMPTOMS

CARDIOVASCULAR Palpitations,tachycardia,precordialpain

NEUROLOGIC dizziness.,lightheadedness,disturbance of consciousness orvision,numbness & tingling ofextremities,tetany(rare)

RESPIRATORY Shortness of breath,chestpain,dryness of mouth

GASTROINTESTINAL Globus hystericus,epigastric pain

MUSCULOSKELETAL Muscle pain &cramps,tremors,stiffness,carpopedal tetany

PSYCHOLOGIC Tension,anxiety,nightmares


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MANAGEMENTTerminate dentalprocedure.P----position pt

comfortably(upright ) AB---C ---BLS as

neededD----definitive care: remove dental materials

from pts mouth. calm pt.

correct respiratoryalkalosis. initiate drug treatment,if

necessary.Perform subsequent dentaltreatment.

Discharge pt.


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ASTHMA

DEFINTION: DEFINED BY THE AMERICAN

THORACIC SOCIETY as a disease

characterized by an increasedresponsiveness of the trachea & bronchito various stimuli and manifested bywidespread narrowing of the airways that

changes in severity either spontaneouslyor as a result of therapy.


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Causative factors for acuteasthma

Allergy(antigen-antibody reactionRespiratory infectionPhysical exertionEnvironmental and air pollutionOccupational stimuliPharmacologic stimuliPsychologic factors


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PREDISPOSING FACTORSPSYCHIC STRESS

ANTIGEN-ANTIBODYREACTION

BRONCHIALINFECTION

NORMALBRONCHIALREACTIVITY

NORMALRESPONSE-noasthma

DUSTS,FUMES

CLIMATE HEIGHTENEDBRONCHIALREACTIVITY

ABNORMALRESPONSE--asthma

OTHERS


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EXTRINSIC ASTHMA: Also known as allergic asthma and occursmore in children amd young adults.

Allergens maybe airborne such as housedust,feathers,animal dander,furniturestuffing,fungal spores,plant pollens.foodssuch as eggs,milk,fish etcdrugs such aspenicillin,aspirin,sulfites.

INTRINSIC ASTHMA:Develops usually in adults older than 35 yrs.

Also referred as nonallergic asthma,idiopathicasthma,infective asthma.Non allergic factors: respiratory infection,physicalexertion,environmental and air pollution,occupationalstimuli.


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MIXED ASTHMA:Combination of extrinsic and intrinsic asthma

Precipitating factor---presence of infection esprespiratory tract.

STATUS ASTHMATICUS:Wheezing,dyspnea,hypoxia,cyanosis,extreme fatigue,peripheral vascularshock,dehydrationMost severe form.


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ASA CLASSIFICATION OF ASTHMA

ASA CLASS DESCRIPTION TREATMENTMODIFICATIONS

II Typical asthmatic-extrinsic orintrinsicInfrequent episodes

Easily managedNo need for emergency care of

hospitalization

Reduce stress,asneeded.Determine triggering

factors. Avoid triggeringfactors.Keep broncodilator.

III Patient with exercise inducedasthmaFearful pt.Pt with prior need for emergencycare or hospitalization

Follow ASA IImodifications.

Administer sedation-nitrous oxide & O2 ororal BZD,if indicated.

IV Pt with chronic sign and symptomsof asthma present at rest.

Obtain medicalconsultation.

Provide emergencycare only,in office.


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SIGNS & SYMPTOMS OF ACUTE ASTHMA

Feeling of chest congestionCough with or without sputum productionWheezingDyspneaPt wants to sit or stand upuse of accessory muscles of respirationIncreased anxiety & apprehensionTachypnea(>20 to>40breaths/min)Rise in BPIncrease in HRDiaphoresis

AgitationSomnolenceConfusionCyanosisSupraclavicular and intercostal retractionNasa flaring

CLINICAL SIGNS &


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CLINICAL SIGNS &SYMPTOMS OF HYPOXIA &

HYPERCARBIAHYPOXIA HYPERCARBIARestlessness,confusion,anxiety diaphoresis

cyanosis Hypertension(converting to

hypotension if progressive)diaphoresis Hyperventilation

Tachycardia,cardiac dysrhythmias Headache

Hypertension or hypotension Confusion ,somnolence

coma Cardiac failure

Cardiac or renal failure


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MANAGEMENTTerminate dental procedure

P---position pt comfortably(upright)

A---B---C----assess & perform BLS,as needed

D----initiate definitive care:

administer bronchodilator via inhalation.(episode terminates) (episode continues)

perform dental care. Administer O2.discharge pt. Summon emergency

medical services.administer parenteral drugs

hospitalize or dischrge pt.


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HEART FAILURE & ACUTEPULMONARY EDEMA

HEART FAILURE----Inability of theheart to supply sufficient oxygenatedblood for the bodys metabolic needs.

ACUTE PULMONARY EDEMA---- lifethreatening condition marked by anexcess of serous fluid in the alveolar

spaces or interstitial tissues of thelungs & is accompanied by extremedifficulty in breathing.


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PREVENTION

MEDICAL HISTORYQUESTIONNAIRE:

Any history of heart diseases?

When u walk upstairs do u stop becoz of painin chest or shortness of breath?Do ur ankles swell during the day?Do u use more than 2 pillows to sleep?

Have u lost or gained more than 10 pounds inthe past yr?Do u ever awaken from sleep short of breath?Have u ever taken any medicine or drugs

during the past 2 yrs?


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DIURETICS used to manageCHF

THIAZIDES hydrochlorothiazide,chlorthalidone,metazolone

LOOP DIURETICS---furosemide,bumetanide,ethacrynicacid

POTASSIUM SPARINGDIURETICS spironolactone,triamterene,amiloride


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Inotropic agents to treat CHF:-digoxin,dopamine,dobutamine,amrinone,milrinone,aminophylline.

Vasodilators to treat CHF:-captopril,analapril,lisinopril,quinapril,ni

troglycerin,isosorbide.


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PHYSICAL EVALUATION

VITAL SIGNS:------BP maybe elevated, with the increase in diastolicpressure greater than that in systolic pressure.insome situations BP may b decreased.

Heart pulse & resp rate usually increase Any recent large unexplained weight gain,ankleswelling.

PHYSICAL EXAMINATION:------skin & mucous membrane color---grayish blueNeck---jugular vein distension

Ankles----edema,pitting


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ASA Classification for CHF

ASA I: the pt doesnot experiencedyspnea or undue fatigue with normalexertion.

ASA II: the pt experiences milddyspnea or fatigue during exertion.

ASA III : the pt experiences dyspnes

or undue fatigue with normal activities. ASA IV: the pt experiencesdyspnes,orthopnea, and undue fatigue

at all times.

Clinical manifestations of HF and


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Clinical manifestations of HF andacute pulmonary edema

SIGNS SYMPTOMS

HEART FAILURE

Pallor,cool skin Weakness & undue fatigue

Sweating Dyspnea during exertion

Left ventricular hypertrophy Hyperventilation

Dependent edema NocturiaHepatomegaly & splenomegaly PND

Narrow pulse pressure Wheezing(cardiac asthma)

Pulsus alternans

ascites

ACUTE PULMONARY EDEMA

All signs of HF All symptoms of HF

Moist rales at base of lungs Increased anxiety

tachypnea Dyspnea at rest

Cyanosis,frothy pink sputum


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Management of HF & acutepulmonary edema

Terminate dental procedure

Remove dental materials from pts mouth

P----position pt comfortably(upright)

Summon emergency medical services

Calm pt.

A----B----C assess & perform BLS as needed.

D-----definitive care: Administer O2Monitor vital signs

Alleviate symptoms of resp distressPerform bloodless phlebotomy

Alleviate apprehension.

Discharge pt,

Modify subsequent dental treatment

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5.Respiratory Distress Dental Lecture