22nd August 2016 - Surg Lec 02 - Respiratory Emergencies

Respiratory
Emergencies
Elmer S. Jabagat. M.D.,

FPCS, FPSGS
CASE
A 68 year old man en route to the bathroom at night checks on a noise the dog is making
and slips on a staircase falling hard against his right side down several steps.
He complains that "I hurt all over, but it really hurts when I breathe." His
hands guard his right anterolateral chest wall.
You inspect the breathing and think that the chest looks funny; it seems that
the right hemithorax doesnt move as much and that a portion lags behind.
There are abraded contusions with ecchymosis over the ribs, and the area is crepitant
when palpated.
CASE
A "Code Three" paramedic ambulance brings you a 73 year old man with acute shortness
of breath and coughing and a history of emphysema.
He appears severely distressed and barely able to speak.
As he is being moved to a hospital gurney, the oxygen mask is briefly removed, the patient
becomes as cyanotic as "stone-washed blue jeans."
A, B, Cs in the management of
emergency situations
A - Airway
B - Breathing
C - Circulation
Objectives
Anatomy, Physiology and Mechanics of breathing
Signs and Symptoms of respiratory emergencies
Principles in management of respiratory emergencies
including those that affect the
Upper airway
Lower airway
Anatomy and Physiology

Respiratory system structures look like an inverted tree.
Structures of the Upper Airway
Nostrils and nose

Air enters through the nostrils.
Lined with nasal hairs
Quiet breathing allows air to flow through the
nose.

Turbinates
Highly vascular ridges covered with mucus membrane
Traps particulates
Warm and humidify air as it passes
Many blood vesselsswell and bleed easily

Mouth and oropharynx
Contain blood vessels
and mucous membrane
Edema can be extreme.

Ask patient if their
tongue feels thick.
Monitor speech.
E. M. Singletary, M.D. Used with permission.

Hypopharynx
Where the oropharynx and nasopharynx meet
Gag reflex is profound.
Triggering may cause vagal bradycardia, vomiting, and increased
intracranial pressure.
May make airway device use difficult

Larynx and glottis
Dividing line between
upper and lower
airway
Thyroid cartilage:
external landmark

Larynx and glottis (contd)
Several cartilages support the vocal cords.
Arytenoid cartilages: found at the distal end of each vocal cord
Piriform fossae: pockets of tissue found on either side of the glottis
Cricoid cartilage: palpated just below the thyroid cartilage

Larynx and glottis (contd)
Cricothyroid membrane: small space between the thyroid and
cricoid cartilage
Does not contain many blood vessels
Covered only by skin
Potential site for cricothyrotomy

Larynx and glottis
(contd)
Laryngeal swelling or
trauma can create lifethreatening airway
obstruction.
Structures of the Lower Airway

Tracheobronchial tree
Trachea
trunk of tree
Carries air to the lungs
Extends from the larynx to
the mainstem bronchi

Tracheobronchial tree (contd)
Mainstem bronchi branch into:
Lobar bronchi
Segmental bronchi
Subsegmental bronchi
Bronchioles
Bronchi and bronchioles are lined with cilia.
Inset photo: Dr. Kessel &

Dr. Kardon/Tissue &
Organs/Visuals Unlimited.
Dr. Kessel & Dr.
Kardon/Tissue &
Organs/Visuals Unlimited
Inset photo: Dr. Kessel &
Dr. Kardon/Tissue &
Organs/Visuals Unlimited.
Bronchioles
Significant amount of gas exchange

Bronchioles (contd)
Goblet cells produce mucus blanketing.
Gel layer
Sol layer
Smooth muscle surrounds the airway.

Bronchoconstriction: smooth muscle narrows the airway.

Alveoli
Gas exchange interface
Deoxygenated blood releases carbon dioxide and is resupplied with oxygen.
Made up of two types of cells:

Type I: almost empty
Type II: can make new type I cells

Alveoli (contd)
Function best when
kept partially inflated
Collapsed, fluid-filled,
or pus-filled alveoli do
not play a part in gas
exchange.

Alveoli (contd)
Pulmonary capillary bed
Pulmonary circulation starts at the right ventricle.
Pulmonary capillaries are narrow.
Patients with chronic lung disease and chronic hypoxia often have thick
blood (polycythemia).
Strains right side of heart, leads to cor pulmonale

Alveoli (contd)
Interstitial space
Network of gaps between alveoli and capillaries
Filled with interstitial fluid
Conducting airways distributes inspired gas, which does not participate in

ventilation
Wasted ventilation: dead space (1 mL per pound of ideal body weight)

Chest wall
Forms a bellows system with chest muscles
The diaphragm is the primary muscle.
Causes pressure changes to move air in and out
Ribs maintain pressure.

Pleural membranes allow organs to move smoothly.

Chest wall (contd)
Trauma and diseases of the
bones and muscles can
significantly impair air
movement.
Causes restrictive lung diseases

Mediastinum: middle of the chest
Consists of:
Heart
Large blood vessels
The large conducting airways

Other organs
Functions of the Respiratory System

Respirationprocess of oxygen taken into body and distributed
to the cells for energy
Carbon dioxide is returned to the lungs by the circulatory system and
exhaled.

Ventilation
Movement of air in and out of the lungs
Best measured by the carbon dioxide level
Normal breathing removes enough carbon dioxide to keep acid-base
balance.
PACO2 must be 35 to 45 mm Hg for normal ventilation.

Diffusion
For oxygen to go from an alveolus to a red blood cell, it must:
Diffuse into the alveolar cell and out the other side.
Diffuse into the capillary wall and out the other side.

Diffusion (contd)
Some lung diseases make it difficult for oxygen to diffuse into
the blood.
Effective diffusion: higher concentration of oxygen in the

alveoli than in the bloodstream

Perfusion
Circulatory component of respiratory system
Blood must keep flowing through pulmonary vessels.
A large embolus can block blood flow to the lung.
Mechanisms of Respiratory Control

Neurologic control
Centered in the medulla
At least four parts of brainstem responsible for unconscious
breathing
Stretch receptors cause coughing if taking too deep a breath

Hering-Breuer reflex

Neurologic control (contd)
Other neurologic control mechanisms:
Phrenic nerve innervates diaphragm.
Thoracic spinal nerves innervate intercostal muscles.

Cardiovascular regulation
Lungs closely linked to cardiac function
Heart changes have pulmonary consequences.
Left-sided heart failure progresses faster than right-sided heart
failure.

Cardiovascular regulation (contd)
Mild hypoxia causes increase in heart rate
Severe hypoxia causes bradycardia.
Uncorrected hypoxic insults may trigger lethal cardiac
arrhythmia.

Cardiovascular regulation (contd)
Various forms of heart failure from:
Fluid balance changes
Right-sided heart pumping pressure
Left-sided heart pumping pressure

Muscular control
Body takes in air by negative
pressure
Air through mouth and nose,

over turbinates, around
epiglottis and glottis

Muscular control (contd)
Thorax: airtight box with diaphragm at bottom and trachea at
top
Diaphragm flattens during quiet breathing.

Air is sucked in to fill the increasing space.

Minute ventilation can be increased by:
Deep breathing
Rapid breathing
Accessory muscles cause dramatic pressure changes when

greater amounts of air must be moved.

Traumatic opening in thorax
provides route for air to be
sucked in
Sucking chest wound
Exhalation is a passive
process.

Renal status
Kidneys play a part in controlling:
Fluid balance
Acid-base balance
Blood pressure
Factor into pulmonary mechanics and oxygen delivery to body tissues
Assessment of a Patient with Dyspnea

Respiratory assessment includes much more than
listening to the patients lungs.
Many respiratory ailments are life threatening.
Respiratory assessment should be done early.
Scene Size-Up
Observe standard precautions.
Use proper PPE.
Evaluate scene safety for:
Decreased oxygen concentrations
Carbon monoxide
Irritant gasses
Highly contagious respiratory illness
Scene Size-Up
Respiratory diseases can
impair:
Ventilation
Diffusion
Perfusion
Combination of all
three
Rapid-onset dyspnea
may be caused by:
Acute bronchospasm
Anaphylaxis
Pulmonary embolism
Pneumothorax
Primary Assessment
Form a general impression.
Body type may be associated with condition
Emphysema: barrel chest, muscle wasting, pursed-lip breathing,
tachypneic
Chronic bronchitis: sedentary, obese, sleep upright, spit-up secretions
Primary Assessment
Observe condition during typical exertion.
Tachycardia, diaphoresis, and pallor can be triggered by:
Increased work of breathing
Anxiety
Hypoxia
Primary Assessment
Position and degree of distress
Prefer sitting positions, such as
tripod position
Lying flat may be a sign of

sudden deterioration.
Ominous sign: head bobbing
Primary Assessment
Breathing alterations
Can be complex and involve:
Problems with the airway branches

Difficulties at the alveolar level
Problems with the muscles and nerves

Problems with the rigid structure of the thorax
Increased work of
breathing
Patients using accessory
muscles to breathe are in
danger of tiring out.
Infants and small
children are in danger of
collapse of flexible
sternum cartilage.
Courtesy of Health Resources and Services Administration, Maternal and Child Health
Bureau, Emergency Medical Services for Children Program.
Primary Assessment
Primary Assessment
Increased work of breathing
(contd)
Profound intrathoracic
pressure changes can cause

peripheral pulses to weaken
or disappear.
Tension Pneumothorax.
Primary Assessment
Altered rate and depth of respiration
Patient with adequate rate but low volume will have inadequate minute
volume.
Respiratory rate tidal volume = minute volume
Monitor trends in respiratory rates.

Note inspiratory-to-expiratory (I/E) ratio.
Primary Assessment
Abnormal breath
sounds
Auscultate lungs
systematically.
Some conditions are

gravity-dependent and
others diffuse
throughout the lungs.
Primary Assessment
Abnormal breath sounds (contd)
Breath sounds are created by airflow in the large
airways.
Primary Assessment
Primary Assessment
Some conditions cause normal breath sounds to be heard in abnormal
places.
Sounds move better through fluid than in air.

Quality of sounds is dependent on the amount of tissue between
stethoscope and structures.
Primary Assessment
Abnormal breath sounds
(contd)
Continuous: wheezes
Discontinuous: crackles
Rales
Rhonchi
Pleural friction rub
Primary Assessment
Audible sounds include:
Stridorupper airway obstruction
Gruntinglower airway obstruction
Death rattlepatients cant clear secretions
The most ominous sounds are no sounds.
Primary Assessment
Noisy breathing
Snoring: Partial obstruction of the upper airway by the tongue
Gurgling: Fluid in the upper airway

Stridor: Narrowing from swelling
Quiet breathing
Hyperventilation
Shock
Sputum
Primary Assessment
Has color or amount changed from normal?
Primary Assessment
Abnormal breathing patterns
May indicate neurological insults
Brain trauma or any disturbance may depress respiratory control centers in the
medulla.
Brain injuries may damage or deprive blood flow.
Primary Assessment
Primary Assessment
Most respiratory centers are in and around the brainstem.
Primary Assessment
Circulation
Assess skin color.
Note generalized cyanosis.
Pink in healthy patients
Logical Images/Custom Medical Stock Photo
Primary Assessment
Circulation (contd)
Cyanosis
Healthy hemoglobin levels: 12 to 14 g/dL
Cyanosis begins at about 5 g/dL desaturation
Chocolate brown skin

May occur from high levels of methemoglobin
Pale skin
Caused by a blood flow reduction to small vessels
Primary Assessment
Circulation (contd)
Check for dehydration:
Dry, cracked lips
Dry, furrowed tongue
Dry, sunken eyes
History Taking
Investigate chief complaint
Increased cough
Change in amount or color of sputum
Fever
Wheezing
Dyspnea
Chest pain
History Taking
Patient may know exact problem.
Asthma with fever
Failure of a metered-dose inhaler

Travel-related problems
Dyspnea triggers
Seasonal issues
Noncompliance with therapy
Failure of technology or running out of medicine
History Taking
SAMPLE history
Signs and symptoms
Allergies
Medications
Antihistamines
Antitussives
Bronchodilators
Diuretics
Expectorants
Pertinent past medical

history
Last oral intake

Events preceding the onset
of the complaint
Secondary Assessment
Neurologic assessment
Note level of consciousness.
Decline in PaO2: restlessness, confusion, and combative behavior
Increase in PaCO2: sedative effects
If lungs are not functioning correctly, oxygen may not be delivered and
carbon dioxide may not be removed.
Neck exam
Jugular venous distention
Common with asthma or COPD
Rough measure of pressure in

right atrium
ejwhite/ShutterStock, Inc.
Neck exam (contd)
Note trachea for deviation.
Courtesy of Stuart Mirvis, MD
Sign of tension pneumothorax
Chest and abdominal exam
Pressing on the liver when in respiratory distress and semi-Fowlers
position will cause the jugular veins to bulge.
Hepatojugular reflex
Feel for vibrations in the chest as the patient breathes.
Examination of the extremities
Edema
Cyanosis.
Pulse
Jones & Bartlett Learning. Photographed by Kimberly Potvin.
Pulsus paradoxus
Temperature
Distal clubbing
Mediscan/Visuals Unlimited
Vital signs
Patients under stress can be expected to have tachycardia and
hypertension.
Ominous signs:
Bradycardia
Hypotension
Falling respiratory rates
Stethoscope
Diaphragm is for high-pitched sounds.
Bell is for low-pitched sounds.
The longer the tubing, the more extraneous noise that is heard.
Pulse oximeter
Noninvasive way to measure the percentage of hemoglobin with oxygen
attached
Oxygen saturation over 95% = normal
Pulse oximeter (contd)
Oxygen saturation should match patients palpated heart rate.
If hemoglobin level is low, the pulse oximetry result will be high.
Does not differentiate between oxygen or carbon monoxide molecules
Pulse oximeter (contd)
Oxyhemoglobin
dissociation curve
Relationship between
oxygen saturation and
amount of oxygen dissolved
in the plasma (PaO2).
End-tidal carbon dioxide detector
Capnometry: ETCO2 monitoring
Wave capnography: ETCO2 monitoring that measures carbon
dioxide and plots a waveform graph
End-tidal carbon dioxide
detector (contd)
Colorimetric detector
indicates whether carbon
dioxide is present in
reasonable amounts
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
End-tidal carbon dioxide detector (contd)
Special sensor can measure the percentage of carbon dioxide and display a waveform
Waveform capnography
LIFEPAK defibrillator/monitor. Courtesy of Medtronic.
End-tidal carbon dioxide detector (contd)
ETCO2 of less than 10 torr: less-than-optimal CPR compressions
Sudden increase in ETCO2: spontaneous circulation return
Peak expiratory flow
Maximum rate at which a patient can expel air
Normal values: 350 to 700 L/min
Variable by age, sex, and height
Inadequate level: 150 L/min
Reassessment
Interventions
Oxygen (keep saturations above 93%)
IV line
Psychological support
Reassessment
Interventions (contd)
Sympathetic: speeds heart rate
Parasympathetic: slows heart rate
Anticholinergic medications block
the parasympathetic response.
Reassessment
Interventions (contd)
Ipratropium is used today.
Combination of albuterol and ipratropium
Anticholinergics are a central component to manage COPD.
Reassessment
Aerosol therapy
Nebulizers deliver fine mist of liquid medication.
Need gas flow of at least 6 L/min to keep particles optimal
size.
Reassessment
Aerosol therapy (contd)
A nebulizer can be attached to:
A mouthpiece
Face mask
Tracheostomy collar
Can also be held in front of the patients face (blow-by technique)
Reassessment
Aerosol therapy (contd)
Can disperse other drugs through aerosols:
Corticosteroids
Anesthetic agents
Antitussives
Mucolytics
Reassessment
Metered-dose inhalers
Small, easy to carry and
use, convenient
Ambulance metereddose inhalers should

have spacers.
Reassessment
Metered dose inhalers (contd)
To avoid common errors:
Inhale deeply at discharge.
Suck medication out of the bottom.
Flow should be smooth and low-pressure.
Inhale deeply; hold breath for a few seconds.
Make sure the inhaler contains medication.
Keep the spacer and canister holder clean.
After using corticosteroid inhaler, rinse mouth.
Reassessment
Failure of a metered-dose inhaler
Must be properly used.
Contraindicated if patient cannot move enough air into the lungs.
Patient may not realize the inhaler is empty.
Patient may inhale at the wrong time.
Reassessment
Dry powder inhalers
May be dispensed by means of a plastic disk
Patient inhales deeply to suck out the powder.
Other devices require the patient to insert a capsule of powdered

medication.
Emergency Medical Care

Goal is to:
Provide supportive care.
Administer supplemental oxygen.
Provide monitoring.
Identify and Treat primary cause
A. Ensure Adequate Airway

Remove items from mouth.
Suction if necessary.
Keep airway in optimal position.
B. Decrease the Work of Breathing

Muscles work harder during respiratory distress.
Use substantial energy to compensate for respiratory distress.
Requires more oxygen and ventilation
May fatigue to point of decompensation
Decrease the Work of Breathing

To decrease the work of breathing:
Help the patient sit up.

Remove restrictive clothing.
Do not make the patient walk.
Relieve gastric distention.

Do not bind the chest or have the patient lie on the unaffected lung.
C. Provide Supplemental Oxygen

Administer in effective concentrations.
Reassess, then adjust as needed.
Pulse oximetry is a good guide to oxygenation.
Concentrations higher than 50% should be used only with

hypoxia that does not respond to lower concentrations.
D. Administer a Bronchodilator
Many can benefit from bronchodilation.
Those without bronchospasms will benefit only slightly.
Bronchodilators are ineffective in cases of:
Pneumonia
Pulmonary edema
Heart disease
Administer a Bronchodilator
Fast-acting bronchodilators
Most stimulate beta-2 receptors in lung
Provide almost instant relief
Albuterol is the most common beta-2 agonist.
Slow-acting bronchodilators
Do not provide immediate symptom relief
Daily dose reduces frequency/severity of attacks
Common medications include:
Salmeterol
Cromolyn
Methylxanthines
Declining use because of adverse effects
Overdose can cause cardiac dysrhythmias and hypotension.
Carefully monitor level in bloodstream.
Electrolytes
Magnesium may have a role in bronchodilation.
Some physicians use them as a last-ditch effort before
intubation.
Corticosteroids
Reduce bronchial swelling
Adverse effects:
Cushing syndrome
Rapid change in blood glucose levels
Blunts the immune system
Avoid long-term use.
Inhaled corticosteroids
Less adverse effects; becoming standard
Intravenous corticosteroids
Methylprednisolone and hydrocortisone: used for acute asthma attacks or
COPD
E. Administer a Vasodilator
Sequester more fluid in venous circulation and decrease
preload
Nitrates can be used if patient:
Has adequate blood pressure
Does not take a phosphodiesterase inhibitor.
Morphine sulfate is not likely to increase venous capacity.
F. Restore Fluid Balance

Common to give fluid bolus to dehydrated, younger patients.
Elderly patients or patients with cardiac dysfunction could wind up with
pulmonary edema.
Assess breath sounds before and after.
G. Administer a Diuretic
Helps reduce blood pressure and maintain fluid balance in
patients with heart failure
Helps remove excess fluid from circulation, keeping it out of the

lungs of patients with pulmonary edema.
Administer a Diuretic
Many diuretics cause potassium loss.
May lead to cardiac dysrhythmias and chronic muscle cramping
Do not give diuretics to patients with pneumonia or dehydration.
H. Support or Assist Ventilation

Breathing may need more aggressive support if the patient
becomes fatigued.
CPAP and BiPAP may preclude intubation.
May simply require bag-mask ventilation
Support or Assist Ventilation

Continuous positive airway pressure
Used to treat:
Obstructive sleep apnea
Respiratory failure
Patients with obstructive sleep apnea wear a CPAP unit to maintain

airway while they sleep.

CPAP (contd)
CPAP therapy may be
delivered through a mask.
Air is forced into the upper

airway.
Positive pressure is created

in the chest.

CPAP (contd)
Pressure that is too high may
cause:
New guidelines emphasize:

Lower ventilation rates
Tension pneumothorax
Smaller volumes
Subcutaneous air
Lower pressures
Block venous returns

CPAP (contd)
Ensure a seal.
If a patient is unwilling to use
it, do not fight it.
Success is related to
respiratory rate after
application
Courtesy of Respironics, Inc., Murrysville, PA. All rights reserved.

Bi-level positive airway pressure (BiPAP)
One pressure on inspiration and a different pressure during exhalation
More like normal breathing
More complex and expensive

Automated transport ventilators
Flow restricted oxygen-powered
ventilation
Deliver a particular oxygen volume at a set
rate.
Good for patients in cardiac or respiratory

arrest
Not intended to be used without direct

observation
Courtesy of Airon Corporation (www.AironUSA.com)
I. Intubate the Patient

Last option for patients with severe asthma
Ventilate patients before cardiac arrest.
Patients who are severely intoxicated or have had a stroke may have no gag
reflex.
Intubate the Patient

With diabetes or overdose, an ampule of 50% dextrose or naloxone may
change the need for intubation
Use bag-mask ventilation for a few minutes to monitor effects.
J. Inject a Beta-Adrenergic Receptor Agonist

Subcutaneously
Use if inhalation techniques are ineffective.

May cause more tachycardia and hypertension
Be careful using in elderly patients.
Instill Medication Directly Through an

Endotracheal Tube
Option if prompt vascular access is delayed
Epinephrine dose is 2 to 2.5 times the usual
Newer devices mist drug into ET tube
Can be used without interrupting CPR
Anatomic Obstruction
Pathophysiology
The tongue is the most common cause of airway
obstruction if patient is semiconscious or
unconscious.
Assessment:
Risks include:
Decreased level of consciousness
Audible signs include:

Sonorous respirations
Gurgling
Squeaking and bubbling
Management
Obstructive sleep apnea may be caused by excess soft tissue in
airway
Can be manually displaced
Place patient in the recovery position
Inflammation Caused by Infection

Pathophysiology
Infections can cause upper airway swelling.
Can lead to laryngotracheobronchitis
Common cause of croup
Stridor
Hoarseness
Barking cough

Pathophysiology (contd)
Poiseuilles law: as the diameter of a tube decreases, resistance to flow increases.

Assessment
Croup and tonsillitis are common, but other conditions are rare.
Avoid manipulating the airway.

Management
Airway may be entirely obscured.
Laryngoscopy may worsen swelling
Have partner press on the chest while you check for a bubble stream.
If effort fails, cricothyrotomy may be necessary.
Aspiration
Inhalation of anything other than breathable gases
Patients at risk:
Tube-fed patients placed supine after large meal
Geriatric patients with impaired swallowing
Unresponsive patients
Aspiration
Pathophysiology
Aspiration of stomach contents: high mortality
Aspiration of foreign bodies may occur.
Chronic aspiration of food is a common cause of pneumonia in
older patients.
Aspiration
Assessment
Determine scenario of sudden onset dyspnea
Immediately after eating?
Gastric feeding tube?
Aspiration
Management
Avoid gastric distention when ventilating.
Use nasogastric tube to decompress stomach.
Monitor ability to protect airway; use advanced airway when

needed.
Treat with suction and airway control.
Obstructive Lower Airway Diseases

Diseases that cause airflow obstruction to the lungs:
Emphysema and chronic bronchitis (COPD)
Asthma
Obstructive Lower Airway Diseases

Physical findings:
Pursed lip breathing

Increased I/E ratio
Abdominal muscle use
Jugular venous distension
Pathophysiology
Asthma
Increased tracheal
and bronchial
reactivity
Causes
widespread,
reversible airway
narrowing
(bronchospasm)
Scott Rothstein/ShutterStock, Inc.
Asthma
Patients with potentially fatal
asthma often have severely
compromised ventilation all the
time.
Acute bronchospasm or infection
presents risk
Death rates are increasing some

countries
Asthma
Status asthmaticus: severe, prolonged attack that does not stop with
conventional treatment
Struggling to move air through obstructed airways
Prominent use of accessory muscles
Hyperinflated chest
Inaudible breath sounds
Exhausted, severely acidotic, and dehydrated
Asthma
Assessment
Known as reactive airway disease because bronchospasms are caused by
triggers
Also caused by:

Airway edema
Inflammation
Increased mucus production
Asthma
Assessment (contd)
Bronchospasm
Constricting muscle surrounding bronchi
Wheezing: air forced through constricted airways
Primary treatment: nebulized bronchodilator medication
Asthma
Asthma
Assessment (contd)
Bronchial edema
Swelling of the bronchi and bronchioles
Bronchodilator medications do not work.
Increased mucus production

Thick secretions contribute to air trapping.
Dehydration makes secretions thicker.
Asthma
Management
Bronchospasm: aerosol bronchodilators
Bronchial edema: corticosteroids
Excessive mucus secretion: improve hydration, mucolytics
Asthma
Management (contd)
Transport considerations
Infection or continuous exposure to a trigger: consider removing
patient.
No improvement in peak flow: consider corticosteroids.
Asthma
Management (contd)
Transport considerations
Undernourished or dehydrated: consider IV fluids.
Advanced life support more than a few minutes away: consider
transport to nearest ED.
Chronic Obstructive Pulmonary Disease

Pathophysiology
Emphysema damages or destroys terminal bronchiole
structures.
Chronic bronchitis: sputum production most days of the

month for 3 or more months of the year for more than 2 years

Assessment
Emphysema
Barrel chest from chronic lung hyperinflation
Tachypneic
Use muscle mass for energy to breathe

Assessment (contd)
Causes of diffuse wheezing:
Left-sided heart failure (cardiac asthma)
Smoke inhalation
Chronic bronchitis
Acute pulmonary embolism
Cause of localized wheezing: obstruction from foreign body or tumor

COPD with pneumonia
Often have lung infection
Check for:
Fever
Change in sputum
Other infection signs
Breath sounds consistent with pneumonia

COPD with right-sided heart failure
Look for:
Peripheral edema
Jugular venous distention with hepatojugular reflux
End inspiratory crackles
Progressive increase in dyspnea

Greater-than-usual fluid intake
Improper use of diuretics

COPD with left-sided heart failure
Can be caused by any abrupt left ventricular dysfunction

Acute exacerbation of COPD
Sudden decompensation with no copathologic conditions
Often from environmental change or inhalation of trigger substances

End-stage chronic COPD
Lungs no longer support oxygenation, ventilation

Difficult to tell whether situation can be resolved
Secure documentation of patients wishes.
Follow local protocol or contact medical control.

COPD and trauma
Lessens ability to tolerate trauma
Monitor closely.
Oxygen saturation might be less than 90%.
Achieving a saturation of 98% is unrealistic.

Management
Can help improve immediate distress
Determine what caused the situation to worsen enough for the patient to
call for help.
Must understand:
Hypoxic drive
Positive end-expiratory pressure (auto-PEEP)

Hypoxic drive
When breathing stimulus comes from decrease in PaO2 rather
than increase in PaCO2
Affects only a small percentage during end-stage of disease

process
Must decide whether to administer oxygen

Hypoxic drive (contd)
Impossible to tell which patients breathe because of hypoxic
drive.
Encourage breathing.
Skin appearance may remain perfused if patient becomes
apneic.

Hypoxic drive (contd)
Provide artificial ventilation and consider intubation if patient become
apneic.
Intubation may mean the patient remains on the ventilator until the end
of life.
Oxygen saturation values are less useful in patients with COPD.

Auto-PEEP
Allow complete exhalation before the next breath during ventilation.
Otherwise, pressure in the thorax will continue to rise (auto-PEEP).
If possibility, patients should be ventilated 4 to 6 breaths/min.
Pulmonary Infections
Pathophysiology
Infections from:
Bacteria
Viruses
Fungi
Protozoa
Infectious diseases cause:

Swelling of the
respiratory tissues
Increase in mucus
production
Production of pus
Resistance to airflow increases when the airway diameter is narrowed (Poiseuilles law).
Alveoli can become nonfunctional if filled with pus.
At greater risk of pneumonia:
Older people
People with chronic illnesses
People who smoke
Anyone who does not ventilate efficiently
Those with excessive secretions
Those who are immunocompromised
Assessment
Patients usually report:
Several hours to days of weakness
Productive cough
Fever
Chest pains worsened by cough
Assessment (contd)
May start abruptly or gradually
During physical examination, patient:

May look grievously ill
May or may not be coughing
May present with crackles

May have increased tactile fremitus and sputum production
Assessment (contd)
Pneumonia often occurs in the lung bases.
Patients are often dehydrated.

Supportive care includes:
Oxygenation
Secretion management (suctioning)

Transport to the closest facility
Management
Upper airway infections: aggressive airway management
Lower airway infections: supportive care, transport
Atelectasis
Pathophysiology
Disorders of alveoli
Collapse from proximal
airway obstruction or external
pressure
Fill with pus, blood, or fluid

Smoke or toxin damage
Atelectasis
Common for some alveoli to collapse
Sighing, coughing, sneezing, and changing positions help open closed alveoli.
When alveoli do not reopen, entire lung segments eventually collapse.

Increases chance of pneumonia
Atelectasis
Assessment
The affected area can harbor pathogens that result in
pneumonia.
Check if a patient with fever has had recent chest or abdominal
surgery.
Atelectasis
Management
Postsurgical patients
encouraged to:
Get out of bed.
Cough.
Breathe deeply.
Use the incentive spirometer.
T. Bannor/Custom Medical Stock Photo
Cancer
Pathophysiology
Lung cancer is one of most
common forms of cancer.
Cigarette smoking
Exposure to occupational lung hazards
Metastatic from other sites
Cancer
Assessment
First presentation is often hemoptysis.
Frequently accompanied by COPD and impaired lung function
Often metastasizes in the lung from other body sites
Cancer
Assessment (contd)
Other cancers may invade lymph nodes in neck.
Pulmonary complications from radiation and chemotherapy
Treatments may cause pleural effusion.
Cancer
Management
Little prehospital treatment for pleural effusions or hemoptysis
Sometimes called for end-of-life issues
Toxic Inhalations
Pathophysiology
Damage depends on water
solubility of toxic gas.
Toxic Inhalations
Assessment
Highly water-soluble gases react with moist mucous membranes.
Causes upper airway swelling and irritation
Less water-soluble gases get deep in lower airway.

More damage over time
Toxic Inhalations
Assessment (contd)
Moderately water-soluble gases have signs and symptoms
between.
Mixing drain cleaner and chlorine bleach may produce an irritant
chlorine gas.
Industrial settings often use irritant gas-forming chemicals in higher

quantities and concentrations.
Toxic Inhalations
Management
Immediate removal from contact with gas
Provide 100% oxygen or assisted ventilation.
If exposure is to slightly water-soluble gases, patients may have acute
dyspnea hours later.
Consider transport to closest ED for observation.
Pulmonary Edema
Pathophysiology
Fluid buildup in lungs occurring when blood plasma fluid
enters lung parenchyma
Classifications:
High pressure (cardiogenic)
High permeability (noncardiogenic)
Pulmonary Edema
Assessment
By time crackles can be heard, fluid has:
Leaked out of capillaries

Increased diffusion space between capillaries and alveoli
Swollen alveolar walls

Begun to seep into alveoli
Pulmonary Edema
Assessment (contd)
Listen to lower lobes through the back.
Crackles heard higher in the lungs as condition worsens
In severe cases, watery sputum, often with a pink tinged, will
be coughed up.
Acute Respiratory Distress Syndrome

Pathophysiology
Caused by diffuse damage to alveoli from:
Shock
Aspiration of gastric contents
Pulmonary edema
Hypoxic event
Acute Respiratory Distress Syndrome

Assessment
Document oxygen saturation, breath sounds, and any sudden
changes.
Monitor ventilation pressures.
Pneumothorax
Pathophysiology
Air collects
between visceral
and parietal pleura.
Weak spots (blebs)

can predispose a
person.
Pneumothorax
Assessment
Patients may have:
Sharp pain after coughing
Increasing dyspnea in subsequent minutes or hours
Pneumothorax
Management
Most will not require acute intervention.
Except when there is tension penumothorax
They should receive oxygen and close monitoring of their
respiratory status.
Pleural Effusion
Pathophysiology
Blister-like sac of fluid
formed when fluid collects
between visceral and
parietal pleura
Pleural Effusion
Assessment
Hard to hear breath sounds
Position will affect ability to breathe.
Management
Fowlers position likely most comfortable
Supportive care during transport to hospital
Pulmonary Embolism
Pathophysiology
Pulmonary circulation compromised by:
Blood clot
Fat embolism from broken bone
Amniotic fluid embolism during pregnancy
Air embolism from neck laceration or faulty IV
Pulmonary Embolism
Large embolism usually lodges in major pulmonary artery
Prevents blood flow
Venous blood cannot reach alveoli.
Pulmonary Embolism
Assessment
Early presentation: normal breath sounds, good peripheral
aeration
Classic presentation: sudden dyspnea and cyanosis, sharp pain

in chest
Cyanosis does not end with oxygen therapy.
Pulmonary Embolism
Assessment (contd)
Often begin in large leg veins,
then migrate into pulmonary
circulation
Thrombophlebitis: high risk
Pulmonary Embolism
Management
Bedridden patients are often given:
Anticoagulants
Special stockings/other devices to reduce blood clot formation
Greenfield filter: opens to catch clots traveling from the legs in

the main vein
Pulmonary Embolism
Management (contd)
Saddle embolus: exceptionally large embolus lodging at
left/right pulmonary artery bifurcation
May be immediately fatal
Cape cyanosis despite CPR and ventilation
Age-Related Variations
Most common respiratory ailments occur in second half of
patients life.
Asthma often occurs in younger patients but can flare at any time.
Anatomy
Important anatomic differences in children include:
Larger heads relative to body size
Pathophysiology
Infants often expend huge amounts of energy to breath and have a
limited ability to compensate.
Infants and children with respiratory problems may have:

Respiratory distress
Respiratory failure leading to decompensation
Respiratory arrest
Common pediatric respiratory diseases:
Foreign body obstruction of the upper airway
Infections, such as:
Croup
Laryngotracheobronchitis
Epiglottitis
Bacterial tracheitis
Retropharyngeal abscesses
Common pediatric respiratory diseases (contd):
Lower airway disease
Asthma
Bronchiolitis
Pneumonia
Pertussis (whooping cough)
Cystic fibrosis
Bronchopulmonary dysplasia
Common Emergency Surgical Interventions

Endotracheal entubation
Cricothyroicotomy
Closed tube thoracotomy
Summary
Respiratory disease is one of the most common pathologic conditions and
reasons for emergency calls
Impaired ventilation may be caused by upper airway obstruction, lower

airway obstructive disease, chest well impairment, or neuromuscular
impairment.
Summary
Respiratory failure occurs from many pathologic conditions. Care includes
supplemental oxygen.
Hyperventilation syndrome is excessive ventilation; patient may have chest

pain, carpopedal spasm, and alkalosis.
Nasal hairs filter particulates from the air as it flows and is warmed in the
nose, humidified, and filtered.
Summary
The mouth and oropharynxs vascular structures are covered with a mucous
membrane. The hypopharynx is the junction of the oropharynx and
nasopharynx.
The larynx and glottis are the dividing line between upper and lower airways,
with the thyroid cartilage the most obvious external larynx landmark. The
glottis and vocal cords are in the middle of the thyroid cartilage.
Summary
The circoid cartilage forms a complete ring and maintains the trachea in an
open position.
The cricothyroid is between the thyroid and circoid cartilages. It is a

preferred area for inserting large IV catheters or small breathing tubes.
The respiratory system primary components look like an inverted tree.
Summary
The trachea splits into the left and right mainstem bronchi at the carina.
Cilia line the larger airways and help move foreign material out of the
tracheobronchial tree.
Pulmonary circulation begins at the right ventricle.
Summary
The interstitial space can fill with blood, pus, or air, which causes pain, stiff
lungs, and lung collapse.
Ventilation, perfusion, and diffusion are the primary functions of the

respiratory system.
Mechanisms of respiratory control are neurologic, cardiovascular, muscular,

and renal.
Summary
Patients with traumatic brain injuries may exhibit abnormal respiratory
patterns.
Respiratory compromise can cause an altered level of consciousness because

it cannot store the oxygen it needs to function.
Respiratory disease can cause ventilation, diffusion, and perfusion

impairment, or a combination of all three.
Summary
Some respiratory diseases have classic presentations.
It is critical to evaluate how hard a patient is working to breathe.
A patients position of comfort and speaking difficulty level helps determine
degree of distress.
Patients in respiratory distress often use the tripod position.
Summary
Signs of life-threatening respiratory distress:
Bony retractions
Soft tissue retractions

Nasal flaring
Tracheal tugging
Paradoxical respiratory movement
Pursed-lip breathing
Grunting
Summary
Audible abnormal respiratory noises indicate obstructed breathing.
Snoring indicates partial obstruction of the upper airway by the tongue;
stridor indicates narrowing of the upper airway.
Auscultate the lungs to hear adventitious breath sounds, including wheezing

and crackles.
Summary
Crackles: discontinuous noises heard during auscultation.
Wheezes: high-pitched, whistling sounds from air forced through narrowed
airways
If you cant hear breath sounds with a stethoscope, there is not enough
breath to ventilate the lungs.
Summary
The respiratory system delivers oxygen and removes carbon dioxide. If the
lungs do not work, it can lead to hypoxia, cell death, and acidosis.
Patients with dyspnea are usually transported to the nearest facility.

Patients with chronic respiratory disease may have already tried treatment
options.
Summary
Determine if the problem started suddenly or gradually worsened as
indicators to the underlying cause.
If the condition is recurrent, compare the current incident with other

episodes.
If patient cannot speak because of breathing issues, obtain the history from
family members or available clues.
Summary
Assess the mucous membranes for cyanosis, pallor, and moisture.
Assess the level of consciousness in dyspneic patients.
With the patient in a semisitting position, check for jugular venous
distension, which may be caused by cardiac failure.
Summary
Feel the chest for vibrations during breathing, and check for edema of the
ankles and lower back, peripheral cyanosis, and pulse. Check skin
temperature and apply monitors.
A pulse oximeter indicates the percentage of hemoglobin with attached

oxygen; greater than 95% is considered normal.
Summary
Colorimetric end-tidal carbon dioxide devices or wave capnography can
monitor exhaled carbon dioxide.
Peak flow is the maximum flow rate a patient can expel air from the lungs.
Metered-dose inhalers deliver bronchodilators and corticosteroids as an
aerosol treatment; dry powder inhalers use a fine powder to deliver a
measured-dose treatment.
Summary
Aerosol nebulizers deliver a liquid medication in a fine mist.
Emergency care for dyspnea may include:
Decreasing work of breathing

Supplemental oxygen
Bronchodilators
Inhaled corticosteroids, vasodilators, or diuretics
Supporting or assisting ventilation
Intubation
Summary
Ensure an open and maintainable airway. Suction if needed, and keep the
airway optimally positioned. Remove constrictive clothing.
Inhalation drug administration may be ineffective if airway is compromised.

Medications can be given directly into the tracheobronchial tree if patient is
intubated.
Summary
CPAP is a respiratory failure therapy that increases oxygen saturation and
decreases respiratory rate.
BiPAP is CPAP that delivers one pressure during inspiration and a different
one during exhalation.
Automated transport ventilators are flow-restricted oxygen-powered

breathing devices with timers.
Summary
Patients in respiratory failure may need to be intubated.
Anatomic or foreign body obstruction of the upper airway can cause seizures
and death.
Infections can cause upper airway swelling. Croup is one of the most
common causes.
Summary
Emphysema, chronic bronchitis, and asthma are common obstructive airway
diseases, with emphysema and chronic bronchitis collectively classified as
COPD.
Asthma is characterized by significant airway obstruction from:

Widespread, reversible airway narrowing
Airway edema
Increased mucous production
Summary
Primary treatment for bronchospasms is bronchodilatory medicine, while
corticosteroids are the primary treatment for bronchial edema.
Status asthmaticus is a severe, prolonged asthmatic attack that cannot be

stopped with conventional treatment. It is a dire emergency.
Summary
If an asthma attack is recurring, the inhaler may be empty or the medication
ineffective.
Asthma attacks can be triggered by noncompliance with a prescribed

medication regimen.
Emphysema is a chronic weakening and destruction of the terminal

bronchioles and alveoli walls.
Summary
Chronic bronchitis symptoms include:
Excessive mucous production in bronchial tree
Chronic or recurrent productive cough
For patients with COPD, look for cause of a worsened condition.
Summary
Hypoxic drive: High oxygen levels decrease the respiratory drive.
When ventilating, allow the patient to exhale completely before the next
breath is given to avoid auto-PEEP.
Pneumonia may be caused by bacterial, viral, and fungal agents.
Summary
Atelectasis is alveolar collapse from:
Proximal airway obstruction
Pneumothorax
Hemothorax
Toxic inhalation
Lung cancer often presents with hemoptysis and is increasing among women.
Toxic gas inhalation damage depends on the water solubility of the gas.
Summary
Pulmonary edema occurs when fluid migrates into the lungs.
Acute respiratory distress syndrome is caused by diffuse alveolar damage
from aspiration, pulmonary edema, or other alveolar insult.
In a pneumothorax, air collects between the visceral and parietal pleuras.

Administer supplemental oxygen and monitor.
Summary
Pleural effusion will cause dyspnea. Give aggressive oxygen administration
and proper positioning.
A pulmonary embolism occurs when a blood clot travels to the lungs and
blocks blood flow and nutrient exchange.
Summary
Infants are less able than older children to compensate for respiratory insults.
Infants and children may be in:
Respiratory distress
Respiratory failure
Respiratory arrest

22nd August 2016 - Surg Lec 02 - Respiratory Emergencies

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22nd August 2016 - Surg Lec 02 - Respiratory Emergencies

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Respiratory

Elmer S. Jabagat. M.D.,

Anatomy and Physiology

Structures of the Upper Airway

Nostrils and nose

Structures of the Upper Airway

Many blood vesselsswell and bleed easily

Structures of the Upper Airway

Structures of the Upper Airway

Edema can be extreme.

Structures of the Upper Airway

May make airway device use difficult

Structures of the Upper Airway

Structures of the Upper Airway

Structures of the Upper Airway

Structures of the Upper Airway

Structures of the Lower Airway

Structures of the Lower Airway

Structures of the Lower Airway

Bronchi and bronchioles are lined with cilia.

Inset photo: Dr. Kessel &

Structures of the Lower Airway

Significant amount of gas exchange

Structures of the Lower Airway

Smooth muscle surrounds the airway.

Structures of the Lower Airway

Made up of two types of cells:

Structures of the Lower Airway

Structures of the Lower Airway

Structures of the Lower Airway

Structures of the Lower Airway

Conducting airways distributes inspired gas, which does not participate in

Structures of the Lower Airway

Ribs maintain pressure.

Structures of the Lower Airway

Structures of the Lower Airway

The large conducting airways

Functions of the Respiratory System

Functions of the Respiratory System

PACO2 must be 35 to 45 mm Hg for normal ventilation.

Functions of the Respiratory System

Functions of the Respiratory System

Effective diffusion: higher concentration of oxygen in the

Functions of the Respiratory System

Mechanisms of Respiratory Control

Stretch receptors cause coughing if taking too deep a breath

Mechanisms of Respiratory Control

Mechanisms of Respiratory Control

Mechanisms of Respiratory Control

Mechanisms of Respiratory Control

Mechanisms of Respiratory Control

Air through mouth and nose,

Mechanisms of Respiratory Control

Diaphragm flattens during quiet breathing.

Mechanisms of Respiratory Control

Accessory muscles cause dramatic pressure changes when

Mechanisms of Respiratory Control

Mechanisms of Respiratory Control

Factor into pulmonary mechanics and oxygen delivery to body tissues

Assessment of a Patient with Dyspnea

Decreased oxygen concentrations

Chronic bronchitis: sedentary, obese, sleep upright, spit-up secretions

Lying flat may be a sign of

Ominous sign: head bobbing