BLS 2014 Respiratory Emergencies. Objectives Name the major anatomic structures of the respiratory system and understand their function Demonstrate

© 2013 Seattle / King County EMS

BLS 2014 Respiratory

Emergencies


Objectives Name the major anatomic structures of the

respiratory system and understand their function Demonstrate an understanding of the physiology

of the respiratory system and its relationship to BLS treatment

Identify signs and symptoms of respiratory emergencies in order to determine whether the patient is Sick or Not Sick

Be able to deploy treatment for a variety of respiratory emergencies

Demonstrate the correct technique for auscultating breath sounds and distinguish between normal and abnormal breath sounds

Demonstrate the correct airway management techniques of bag-valve-mask ventilation and suctioning


Terms You Should Know Chronic Obstructive Pulmonary Disease (COPD)

- A category of diseases characterized by a slow process of dilation and disruption of pulmonary alveoli.

Dyspnea - A term for shortness of breath or breathing difficulty.

Embolus - A blood clot or other substance that has formed in a blood vessel or the heart, that breaks off and travels to another blood vessel, where it may cause blockage.

Flail chest - A condition in which three or more ribs are fractured in two or more places such that a section of the chest wall is detached from the rest of the chest wall.


Terms You Should Know Gag reflex - A protective contraction of the

muscles of the throat caused especially by stimulation of the pharynx that prevents food and liquids from entering the airway.

Hypoxia - A condition in which the body's cells and tissue do not have enough oxygen.

Hypoxic drive - A condition in which the body's stimulus for taking a breath is low oxygen. Occurs in people with COPD.

Metabolism - The process by which food molecules are broken down to provide material and energy for cellular function.


Terms You Should Know pH (potential of hydrogen) - A measure of the

acidity or alkalinity of a solution, numerically equal to 7 for neutral solutions, increasing with increasing alkalinity and decreasing with increasing acidity. The pH scale ranges from 0 to 14. Numbers from 7 and below represent increasing acidity.

Perfusion - The movement of blood through an organ or tissue in order to supply nutrients and oxygen.

Pleuritic chest pain - A sharp, stabbing pain in the chest that is worsened by a deep breath; often caused by inflammation or irritation of the pleura.

Pneumothorax - Condition where air enters the pleural space and is trapped during expiration. It can occur without trauma as in a spontaneous pneumothorax.


Terms You Should Know Pulmonary edema - A buildup of fluid in the lungs,

usually as a result of congestive heart failure.

Rales - Crackling, rattling breath sounds signaling fluid in the air spaces of the lungs.

Rhonchi - Coarse breath sounds heard in patients with mucus in the airways.

Stridor - A harsh, high-pitched inspiratory sound often heard in acute laryngeal (upper airway) obstruction.

Tension pneumothorax - A life-threatening condition in which air enters the pleural space and the pressure inside the lung cavity progressively increases and compresses the lung. It may displace the mediastinum and other structures toward the opposite side.


Terms You Should Know Tidal volume – The volume of gas that is moved

with each breath which is normally 500 ml in an adult.

Traumatic asphyxia - Condition characterized by distended neck veins, cyanosis in face and neck and bleeding in the sclera of the eye that is caused by severe compression of the chest.

Ventilation – The rate at which gas enters or leaves the lungs. Generally it is described in terms of good or poor ventilation. Bluish or dusky skin can indicate poor ventilation.

Wheeze - A high-pitched, whistling breath sound, characteristically heard on expiration in patients with asthma or COPD.


Anatomy and Physiology


Respiratory Structures and Human Physiology Airway protection and appropriate oxygen

administration are among the most important BLS skills you have.

Not all respiratory emergencies originate in the airway and lungs. Disturbances of the human body’s delicate homeostasis – its acid/base buffer system, gas and metabolic requirements for cellular respirations, blood glucose levels, temperature, and many more factors – can affect the rate, rhythm, and quality of the patient’s respirations.

A good understanding of the structures of the respiratory system and the basic physiology involved will help you take better care of respiratory patients.

Learning Activity for Functions of Respiratory Structureshttp://www.emsonline.net/Courses/2011/resp2011/functions.asp

http://www.emsonline.net/resp2011/functions.asp

http://www.emsonline.net/resp2011/functions.asp


Human Respiratory Structure


Human Physiology


Respiratory Emergencies - Anatomy and Physiology

Respiratory Drive

Respiratory drive is an autonomic and involuntary function controlled by centers in the brain sensitive to the blood levels of oxygen and carbon dioxide.

Specialized cells in the aortic arch and brain constantly monitor and react to the levels of oxygen and carbon dioxide in the blood.

The body’s response to increased carbon dioxide in the blood is to "blow off” carbon dioxide by increasing the rate and depth of respirations.


Metabolism Produces Carbon Dioxide

Metabolism is the process by which the body breaks down or "burns" stored fuel to create energy. The cells use oxygen to transform stored glucose into energy.

You can think of glucose as "fuel" and oxygen as the "match" that releases the energy. A byproduct of metabolism is carbon dioxide (CO2).

Carbon dioxide is produced by the cells and carried by

the circulatory system to the lungs where it is expired. If ventilation is compromised , carbon dioxide builds up in the blood.


pH

Acidity in solution such as blood measured by potential of Hydrogen

Body must maintain relatively narrow pH range (neither too acidic nor too basic)

Respiratory system helps maintain balanced acid level or pH in blood


The pH Balancing Act The Respiratory

system is a mirror for other changes that happen in the body

When blood pH becomes too low (acidic) the respiratory system will attempt to fix it by making lungs breathe more deeply & rapidly, excreting more carbon dioxide

Homeostasis – The body attempts to maintain this delicate balance of gases and pH.


Hypercarbia Excessive carbon dioxide in the body releases

H+ ions, which results in acidosis

Hypercarbia can occur through: Metabolic processes that form acids Muscle exertion Shivering Inability to exhale fully (e.g., asthma or emphysema) Depressed respiratory drive (e.g., overdose of

sedative drugs)

+ -


Metabolic Problems Metabolic imbalances affect the body’s

chemistry, affecting pH & respirations

Although this is not a primary respiratory problem, the respiratory system tries to compensate by changing depth and/or rate of respirations

Patients with metabolic problems may present themselves to EMS with respiratory signs & symptoms. Usually, by the time respiratory problems are manifested, these people will be gravely ill with altered mental status or unconscious


Metabolic Problems Ketoacidosis – inefficient metabolism of

sugars in a diabetic causes the body to turn to other fuel sources for energy (fat & muscle) Byproducts – acids called ketoacids Presence of ketoacids & related compounds in blood

will cause lower pH Respiratory system responds by increasing depth

and/or rate of respirations

Aspirin overdose – an acid (the chemical name is acetylsalicylic acid) Taken in large quantities, person becomes acidotic Body compensates by increasing depth and/or rate

of respirations


Metabolic Problems Fever increases metabolic rate, causing

production of more carbon dioxide which leads to more acid in blood Tissue perfusion fails (as it can in sepsis) Excess metabolic acids accumulate causing

metabolic acidosis Body responds by increasing depth and/or rate of

respirations

Hyperventilating breathing deeply & rapidly Efficient way of ridding body of carbon dioxide which,

in turn, may alter the body’s homeostasis Can cause alkalosis (meaning very "basic") Symptoms of respiratory alkalosis may include

faintness & tingling or cramping in the extremities


Respiratory Conditions


Respiratory Conditions - Main CategoriesLet’s look at some main categories into which we can group respiratory emergencies.

Obstructive Lung Disease – COPD exacerbation and Asthma exacerbation

Respiratory Infection – Pneumonia (and other infections that disrupt airflow)

Cardiovascular and Other Causes – Cardiac (CHF, MI), Vascular (PE), Metabolic, Anemia, Trauma, and many more


Obstructive Lung Disease - Asthma

A chronic, inflammatory disease of the airways

Asthma exacerbations are caused by different factors: Allergens Infections Exercise Smoke

During an asthma attack: Muscles around bronchioles tighten Lining of inside bronchioles swells Insides of bronchioles fill with thick mucous Ventilation can be severely impaired





Common Asthma meds include: Albuterol, ProAir Singulair Advair Pulmicort Symbicort


Obstructive Lung Disease - COPD

Chronic obstructive pulmonary disease (COPD) is a category of diseases that includes emphysema, chronic bronchitis and asthma.

Emphysema is a process of destruction of alveoli. This loss of the inter-connected network of aveoli leads to loss of support for the airways and they close prematurely during exhalation.

Chronic bronchitis is defined by the presence of a mucus-producing cough most days of the month, three months of a year for two successive years without other underlying disease to explain the cough. This chronic mucous production further clogs airways and makes exhalation difficult.



Persons with COPD exacerbation can present with shortness of breath, fever and increased sputum production.

Their medical history can include upper-respiratory infection, chronic bronchitis, emphysema, a history of smoking or working in a hazardous environment (e.g., coal smoke, asbestos).





Patients present with shortness of breath, fever and increased sputum production

Medical history can include:

Upper-respiratory infection

Chronic bronchitis Emphysema History of smoking Working in hazardous

environment (e.g., coal smoke, asbestos)

Common medications include: Prednisone Albuterol (Proventil) Ventolin Inhaled Corticosteroids

(Azmacort, Beclomethasone, Flovent)

Ipratroprium (Atrovent, Combivent)

BLS treatment for a COPD patient with respiratory distress should include high flow oxygen. Do keep

in mind that these patients may operate on a hypoxia-drive, so look for signs of respiratory

failure due to over-oxygenation (rare).


Obstructive Lung Disease - Emphysema The very small airways that join alveoli

are damaged & alveolar walls lose elasticity

This chronic irritation of small airways causes inflammation & swelling – reducing diameter of air passages

Irritation causes bronchospasms, which further decreases the lumen

On inspiration, expansion of the lungs holds airways open, while on exhalation, the lungs relax & airways narrow, trapping air


Obstructive Lung Disease - Chronic Bronchitis Characterized by structural

changes in airways of the lungs Enlargement of mucous glands –

cause coughing & production of sputum

Causes shortness of breath Often accompanied by infection,

mucus production & coughing


Respiratory Infections - Pneumonia Respiratory Infections cause the disruption of gas exchange due to congestion of the alveoli with mucus or pus. The cause of the infection depends on the location: upper airway (e.g., croup), lower airway (bronchitis), and lungs (pneumonia and other infections)


Respiratory Infections - Pneumonia

Symptoms include: Fever Chills Cough (often with yellowish sputum) Shortness of breath General discomfort Fatigue Loss of appetite Headache

Can be chest pain associated with breathing (usually sharp and stabbing in nature) and worsened by coughing or deep inspirations

Other signs sometimes present are rales, clammy skin, upper abdominal pain & blood-tinged sputum

Emergency care – may include oxygen therapy.


Cardiovascular and Other CausesCongestive Heart Failure

Congestive heart failure (CHF) is usually a pump problem such that the heart’s cardiac output is insufficient to provide forward flow of blood throughout the body, causing fluid buildup. CHF patients have weak ventricles from: Hypertension Myocardial infarction Underlying coronary artery disease Valve disease



The weakened muscle impairs the heart’s ability to contract and empty during systole

Left-Sided failure generally causes fluid to back up in the lungs. This interrupts gas exchange and results in shortness of breath.

Right-Sided failure generally causes fluid to back up into the body’s tissues, leading primarily to swelling in the lower extremities.


Cardiovascular and Other CausesCongestive Heart Failure During an acute

CHF exacerbation, the patient will typically present: Sitting up Short of breath Diaphoretic Pale or Cyanotic in

color

Breath sounds are often notable for Rales upon auscultation.

Medical history can include: Hypertension Heart ailments like MI Recent history of

increased salt ingestion Non-compliance with

medications or recent change in medications (especially diuretics)




Cardiovascular and Other CausesCongestive Heart Failure Common medications include:

ACE inhibitors (Lisinopril and other “-Prils”) Diuretics like Furosemide (Lasix) and

Hydrochlorthiazide Beta-blockers (Metoprolol, Atenolol,

Lopressor) Angiotensin II receptor blockers (Losartan,

Avapro, Benicar) Digoxin (Lanoxin)

Medications can help differentiate this patient's symptoms from those of someone with Obstructive Lung Diseases



When treating CHF: Seat the patient upright Administer high flow oxygen Consider positive pressure ventilation

with a BVM if the patient is experiencing severe respiratory difficulty or tiredness

You can ask the critical patient, “Are you too tired to keep breathing?”


Cardiovascular and Other Causes Pulmonary Embolism

A pulmonary embolism (PE) is a blockage in an artery of the lungs by a particle that has traveled there from elsewhere in the body. Travels to the lungs

Circulation through that portion of the lung is compromised because blood is not able to reach alveoli – air is moving in and out of the lungs but gas exchange is not occurring



Although they do not occur often in the pre-hospital setting, patients who call 911 due to Pulmonary Embolism have a high mortality rate.

Decompensation can occur rapidly, so it is imperative to recognize the signs quickly.



Causes include: Immobility of the

lower extremities (lengthy travel, sitting, laying)

Prolonged bed rest Recent surgery

Signs of PE: Often sudden-onset

of: Shortness of breath Tachycardia Tachypnea Chest pain Coughing up frothy /

bloody

Pulmonary embolism – life-threatening condition Treated with high flow

oxygen Rapid transport

Move patient gently to avoid dislodging additional emboli


Cardiovascular and Other Causes Pneumothorax

A pneumothorax is the presence of air between the two layers of the pleura — also called the pleural space.

Caused when internal or external wound allows air to enter space between pleural tissues Can result in functional collapse of lung



A pneumothorax can occur spontaneously (e.g., a rupture due to disease or localized weakness of the lung lining) or as a result of trauma.

Forceful coughing can cause a pneumothorax as well. Chest injury and prior history of pneumothorax are possible medical histories. COPD is a risk factor.



Symptoms of a pneumothorax can include sharp chest pain and shortness of breath.

Signs can include: tachypnea, low SpO2 , diminished lung sounds and possibly feeling subcutaneous air upon palpation of the patient’s torso.



Treatment of pneumothorax includes high-flow oxygen

Be judicious with use of positive-pressure ventilation Can turn a spontaneous

pneumothorax into a life-threatening tension pneumothorax.

PLEASE DELETE:A pneumothorax can cause collapse of the

entire lung. The only symptom may be sudden chest pain.


Cardiovascular and Other Causes Tension Pneumothorax Caused when lung

injury acts like one-way valve that allows free air to move into pleural space but prevents free exit of that air

Pressure builds inside pleural space & compresses lungs & other organs

Early signs of a tension pneumothorax include: Increased Shortness of

Breath Tachycardia Poor skin signs Signs of shock Absent breath sounds &

resonance to percussion Distended neck veins Tracheal deviation (late

sign)


Cardiovascular and Other Causes Tension Pneumothorax

Consider the situation where you are bagging an intubated trauma patient who sustained a chest injury that is being transported by Paramedics.

You note increasing tachycardia, decreasing BP….

Now profound bradycardia, perhaps difficulty bagging…

And, ultimately, cardiovascular collapse resulting in PEA….

Be highly suspicious for a tension pneumothorax.


Cardiovascular and Other Causes Inhalation Injuries

Inhalation injuries can be caused by a multitude of agents, including: heat, chemicals, smoke, particulate, or other irritants

Common chief complaints include: Shortness of breath Coughing Hoarseness

Individuals with decreased respiratory reserve (e.g., history of COPD) are likely to experience an exacerbation of the disease


Cardiovascular and Other Causes Inhalation Injuries

Patient in respiratory distress: These patients typically get worse

– consider early ALS activation Treat immediately with high flow

oxygen Assist breathing with a BVM if the

necessary


Respiratory Emergencies - Assessment It is rare to enter a scene and be

greeted by a patient who tells you their diagnosis

Unfortunately, our job tends to require a little more digging

You will also need to quickly determine whether the patient it Sick or Not Sick

Your interview and physical exam should narrow down the list of possible ailments

Your assessment of the patient’s probable disease process will steer your treatment decisions


Respiratory Emergencies - Assessment Assess rate & depth of respirations

– this will take 30 – 60 seconds Normal respiratory rate is between

12 - 20 respirations per minute for an adult

The quality of respirations is more subjective; look for anomalies like shallow, irregular, inadequate, labored or gasping types of breathing


Respiratory Emergencies - Assessment Other signs that indicate adequate

oxygen supply to body’s tissues: Level of consciousness Breathing effort Ability to speak in complete

sentences Use of accessory muscles Skin color Breath sounds Body position


Respiratory Emergencies - AssessmentIt all comes down to…

Sick or

Not Sick


Respiratory Emergencies - Assessment

SICK

Altered Level of Consciousness

Extreme / unsustainable Work of Breathing or respiratory rate

Skin Signs – pale, cool, wet

Vitals – HR >130 or <60, RR > 30 or < 10

SpO2 – low

NOT SICK

Normal Level of Consciousness (baseline)

Normal Work of Breathing or respiratory rate

Skin Signs – pink, warm, dry

Vitals – HR <130 or >60, RR < 30 or > 10

SpO2 - normal

How does the patient appear from across the room?


Respiratory Emergencies - AssessmentLung Sounds You must put your

stethoscope directly on the patient’s skin. In most cases, it is advisable to listen with the patient sitting up.


Respiratory Emergencies - Assessment The proper technique for auscultating

chest using a stethoscope includes: Listen at six locations on the back Listen at four locations on the front Instruct the patient to take a deep breath

through the mouth then exhale Listen to one or two inspiration/expiration

cycles per location Avoid listening through clothing

Video demonstration available at EMS Online: http://

www.emsonline.net/Courses/2011/resp2011/auscultation.asp

http://www.emsonline.net/Courses/2011/resp2011/auscultation.asp




Respiratory Emergencies - Assessment Caused by specific conditions:

Example: Cheyne-Stokes respirations May be seen in head injuries & stroke Characterized by periods of breathing with

gradually increasing & decreasing tidal volumes interspersed with periods of no breathing

Ataxic respirations – irregular, ineffective respirations with no clear pattern

Agonal respirations – abnormal pattern of breathing characterized by ineffective, slow inspirations followed by long pauses Often sound like gasps Associated with cardiac arrest or severe

end-stage shock


Respiratory Emergencies - Treatment

Respiratory Patients can be some of the sickest and most confusing types of patients you will encounter.

There are few feelings worse than not being able to catch your breath.

Your patients (and their families) will be anxious.

You may be anxious too!



Different types of respiratory emergencies will need different types of treatment modalities.

We presented some ways to take the hundred possible ailments that a respiratory patient may be experiencing and, using the three major categories of respiratory illness we learned, narrow them down to a small handful of probable diseases


Respiratory Emergencies - TreatmentThe focus here is immediate BLS interventions that can help the patient:

Positioning

O2 Administration

Assist with meds (e.g., Inhaler)*

Reassurance

Bag-Valve-Mask ventilator support**

* According to Local Protocols ** If Indicated


Airway Management Airway management is one of the most

important skills for an EMS provider You must be equipped to rapidly deploy the

following airway management techniques: Head tilt/chin lift Jaw thrust Patient positioning Airway adjuncts Suction Oxygen therapy Assisted ventilation using a bag valve mask Relief of foreign body airway obstruction


Respiratory TreatmentForeign Body Airway Obstruction

EMS providers should intervene if choking victim has signs of severe / total airway obstruction Little or no air exchange; high-pitched / squeaking

sound indicating very little air is moving; poor skin signs; inability to cough

Encourage the conscious patient with mild obstruction to cough Do not interfere with efforts to relieve obstruction Attempt to relieve obstruction only if it becomes

severe

In the unconscious patient, perform CPR per AHA guidelines, look for visible foreign body before performing first rescue breath.



Measure the Yankuer / Suction Tip the same as for an oropharyngeal airway — from the corner of the mouth to the ear lobe or from the center of mouth to the angle of jaw

If situation permits (e.g., there is no significant airway threat), give at least 30 seconds of oxygen before suctioning

Administer oxygen after suctioning

Do not apply suction while inserting tip

Apply suction for no more than 15 seconds at a time

In rare cases, copious vomiting that threatens airway may require more suctioning

In infants & children, suction for shorter periods of time (no more than 5 seconds) and be cautious to not suction too deeply. Some suction units have a Peds setting to keep from using too much suction.

If there are secretions or emesis that you cannot easily remove with suction, position patient, (e.g., by using log roll) so gravity & a finger sweep can quickly clear the airway

Tips for Effective Suctioning:



Assisted Ventilations:

Patients who are hypoxic and are unable to ventilate themselves adequately require quick action to be oxygenated

Some of these patients are conscious enough to find this procedure uncomfortable, claustrophobic, or completely intolerable

Your proficiency at this difficult skill and your ability to explain what you’re doing to the patient in a way that sets them at ease will help you greatly



Unconscious breathing patient:

Consider the need for an oropharyngeal airway, following local protocols

Maintain a good seal Keep the airway open Do not over-ventilate, just

look for gentle chest rise with each breath

Deliver breaths at a rate of approximately 1 breath every 5 seconds

Conscious patient:

Maintain a good seal Deliver a ventilation of 1-

second duration Deliver enough volume to

make the chest rise Start by trying to match the

patient’s respirations but gradually try to deliver breaths at a rate of approximately 1 breath every 5 seconds


www.emsonline.net/Courses/2011/resp2011/ventilation.asp

http://www.emsonline.net/resp2011/ventilation.asp





Oxygen Delivery


www.emsonline.net/Courses/2011/resp2011/therapy.asp

The amount of oxygen administered to the patient & the method of administration depend on many factors including medical history & cause of respiratory problemRate Volume

(liters/min)Device

Low Flow 2 - 6 Nasal cannula or blow by

High Flow 10 - 15 Non-rebreathing mask

High flow with ventilation

15 + Bag-valve mask with reservoir

http://www.emsonline.net/resp2011/therapy.asp




Summary Main structures of the respiratory

system are: Pharynx Trachea Epiglottis Alveoli Bronchi Bronchioles Larynx Pleura Diaphragm


Summary

Categories of Respiratory Emergency

Obstructive Lung Disease – COPD exacerbation and Asthma exacerbation

Respiratory Infection – Pneumonia (and other infections that disrupt airflow)

Cardiovascular and Other Causes – Cardiac (CHF, MI), Vascular (PE), Metabolic, Anemia, Trauma, and many more


Summary Pneumothorax can cause sharp chest pain &

shortness of breath with decreased lung sounds

Signs of pulmonary embolism include a sudden onset of shortness of breath, tachypnea, tachycardia, chest pain worsened by breathing & coughing up blood

Treatment for respiratory emergency can include sitting the patient up, opening the airway if necessary, administering high flow oxygen and, in case of decreased respiratory drive or DLOC, assisted ventilations

CHF patients may require positive-pressure ventilations, they must be sat up if possible


Summary

Proper technique for auscultating the chest includes: Listen at six locations on the back Listen at four locations on the front Move from bottom to top in a medical

patient Instruct the patient to take a deep

breath through the mouth then exhale

Listen to one or two inspiration/expiration cycles per location

Avoid listening through clothing


Questions

Dr. Mickey EisenbergMedical DirectorAsk the Doc: http://www.emsonline.net/doc.asp

EMS OnlineGuidelines and Standing Ordershttp://www.emsonline.net/downloads.asp

Susan KolwitzProgram ManagerEmail support: [email protected]

http://www.emsonline.net/doc.asp

http://www.emsonline.net/downloads.asp

http://www.emsonline.net/downloads.asp

http://www.emsonline.net/

Documents

BLS 2014 Respiratory Emergencies. Objectives Name the major anatomic structures of the respiratory system and understand their function Demonstrate