Transcript Slide 1

Paramedic Care: Principles & Practice
Fourth Edition
Volume 4: Medicine
CHAPTER
1
Pulmonology
Multimedia Directory
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Gas Exchange Animation
Inspiratory Wheezing Animation
Rhonchi Animation
Rales Animation
Stridorous Animation
ARDS Animation
COPD Video
Metered Dose Inhaler Video
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Paramedic Care: Principles & Practice, 4th Ed.
Standard
• Medicine (Respiratory)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Competency
• Integrates assessment findings with
principles of epidemiology and
pathophysiology to formulate a field
impression and implement a
comprehensive treatment/disposition
plan for a patient with a medical
complaint.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Respiratory system: responsible for
providing oxygen to tissues; removing
metabolic waste product, carbon
dioxide.
• Oxygen required for conversion of
essential nutrients into energy; must
be constantly available to all tissues.
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Introduction
• Intrinsic risk factors: influenced by or
are from within patient; genetic
predisposition.
• Certain respiratory conditions increased
in patients who have underlying cardiac
or circulatory problems.
• Patient's level of stress may increase
severity of respiratory complaint.
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Introduction
• Extrinsic risk factors: external to
patient; increase likelihood of
developing respiratory disease.
• Most important risk factor: cigarette
smoking.
• Environmental pollutants another
factor.
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Paramedic Care: Principles & Practice, 4th Ed.
Review of Respiratory Anatomy
and Physiology
• Upper airway responsible for warming
and humidifying incoming air.
– Air enters upper airway through nose.
– Passes through external nares
(nostrils); enters nasal cavity.
– Nasal cavity divided into two chambers
by nasal septum.
– Anterior portion has many hair follicles
that help trap large dust particles.
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Overview of the upper and lower airways.
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Review of Respiratory Anatomy
and Physiology
• Upper Airway
– Between each set of turbinates is
passageway (meatus); leads to
paranasal sinuses.
– Turbinates cause turbulence in
incoming airflow.
– Mucus constantly produced.
– Cilia: thin, fingerlike projections; ability
to contract in single direction.
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Anatomy of the upper airway.
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Review of Respiratory Anatomy
and Physiology
• Upper Airway
– In nose, cilia produce steady posterior
flow of mucus, removing any entrapped
particles.
– Once mucus and entrapped particles
reach nasopharynx, they are swallowed
and removed via digestive tract.
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Review of Respiratory Anatomy
and Physiology
• Upper Airway
– Kiesselbach's plexus, in lower nasal
septum, warms inspired air.
– Paranasal sinuses: air cavities in frontal,
ethmoid, sphenoid, maxillary portions of
skull.
– Superior portion of nose contains nerve
fibers important to sense of smell
(olfactory sense).
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Paranasal sinuses.
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Review of Respiratory Anatomy
and Physiology
• Upper Airway
– Pharynx: funnel-shaped structure that
connects nose and mouth to larynx.
– Three divisions:
 Nasopharynx
 Oropharynx
 Laryngopharynx
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Review of Respiratory Anatomy
and Physiology
• Upper Airway
– In addition to speech, larynx is filtering
device for digestive/respiratory tracts.
– During inspiration, three paired
cartilages remain separated; epiglottis
sits upright so air can enter trachea.
– With swallowing, epiglottis tips
backward; cartilage pairs close,
diverting food to esophagus.
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Review of Respiratory Anatomy
and Physiology
• Lower Airway
– During inspiration, air exits upper
airway; passes through larynx into
trachea.
– Trachea :11 cm in length; composed of
series of C-shaped cartilaginous rings.
– Stimulation by food or other ingested
products triggers coughing response.
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Review of Respiratory Anatomy
and Physiology
• Lower Airway
– At carina, trachea divides into right and
left mainstem bronchi.
– Mainstem bronchi divide into secondary
(lobar) bronchi; ultimately divide into
bronchioles, or small airways.
– Both upper airway and lower airway
must be patent so air may pass through
bronchial system into alveoli.
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Review of Respiratory Anatomy
and Physiology
• Lower Airway
– Bronchioles become terminal
bronchioles.
– Terminal bronchioles divide into
respiratory bronchioles.
– Airway shifts from being conduit for air
to organ of gas exchange.
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Anatomy of the lower airway.
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Review of Respiratory Anatomy
and Physiology
• Lower Airway
– Respiratory bronchioles divide into
alveolar ducts.
– These terminate in alveolar sacs
(alveoli).
– Estimated 300 million alveoli in lungs.
– Most gas exchange (oxygen and carbon
dioxide) takes place in alveoli.
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Gas Exchange Animation
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The alveoli and the pulmonary capillaries.
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Review of Respiratory Anatomy
and Physiology
• Lower Airway
– Pulmonary capillaries: carry carbondioxide-rich blood from heart into lungs
and oxygen-rich blood away from lungs
for return to heart.
– Alveolar lining, supportive tissue, and
capillaries make up respiratory
membrane.
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Review of Respiratory Anatomy
and Physiology
• Lower Airway
– Alveoli moistened and kept open
because of chemical called surfactant.
– Alveolar macrophages part of immune
system; function to digest particles,
bacteria, and other foreign material.
©2013 Pearson Education, Inc.
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Review of Respiratory Anatomy
and Physiology
• Lower Airway
– Lungs main organs of respiration.
– Right lung has three main divisions or
lobes; left lung has only two.
– Covered by connective tissue (pleura).
– Pleural fluid: serves as lubricant for lung
movement during respiration.
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Review of Respiratory Anatomy
and Physiology
• Lower Airway
– Blood supplied to lungs: pulmonary
vessels and bronchial vessels.
– Pulmonary arteries transport
deoxygenated, carbon–dioxide–rich
blood from heart and lungs for
oxygenation.
– Pulmonary veins transport oxygenated
blood from lungs back to heart.
©2013 Pearson Education, Inc.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Major function of respiratory system is
to exchange gases with environment.
– Gas exchange: oxygen taken in; carbon
dioxide eliminated.
– Oxygen diffuses into bloodstream
through lungs.
– In lungs, carbon dioxide exchanged for
oxygen and excreted from lungs.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Ventilation: mechanical process of
moving air in and out of lungs.
– Body structures must be intact: chest
wall, nerve pathways, diaphragm,
pleural cavity, brainstem.
– Chest wall protects heart, lungs, other
organs of thorax; diaphragm separates
thorax and abdomen.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Ventilation has two phases: inspiration
and expiration.
– During inspiration, air drawn into lungs.
– During expiration, air leaves lungs.
– Phases depend on changes in volume of
thoracic cavity.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Inspiration always active process,
requiring energy.
– Inspiration dependent on intact chest wall
and intact pleural cavity.
– During expiration, chest wall and
diaphragm recoil to normal resting state.
– Expiration passive process; does not
require energy.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Amount of airflow into lungs
(ventilation) dependent not only on
difference between pressure in
atmosphere and that inside chest
cavity; also on airway resistance and
lung compliance.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– The more airway resistance (or drag to
flow of air), the less air flowing into
chest cavity.
– Lung compliance: ease with which
chest expands.
 Change in volume of chest cavity; results
from specific change in pressure within
chest cavity.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Volume of air entering lungs varies
based on metabolic needs of patient.
– Factors such as age, sex, physical
conditioning, medical illness will alter
these volumes.
– Tidal volume: during quiet respiration,
500 mL of air move in and out of lungs
of 70-kg adult.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Inspiratory reserve volume: lungs draw
in additional volume of air beyond
volume inspired during quiet respiration.
– Expiratory reserve volume: amount of
air that can be forcibly expired out of
lungs after normal breath.
– Residual volume: air remains in lungs at
all times; maintains patency of alveoli.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Inspiratory capacity: sum of tidal
volume and inspiratory reserve volume.
– Functional residual capacity: sum of
expiratory reserve and residual volume.
– Vital capacity: amount of air measured
from full inspiration to full expiration.
– Total lung capacity: total volume of air
in lungs.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Minute respiratory volume: amount of
air moved in and out of lungs during 1
minute.
– Minute alveolar volume: volume of air
moving through alveoli in 1 minute.
– Forced expiratory volume (FEV): volume
of air exhaled over measured period of
time.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Peak flow: measures maximum rate of
airflow during forced expiration.
– Anatomical dead space: air rests in
trachea, mainstem bronchi, bronchioles;
unavailable for gas exchange.
– Alveolar dead space: some alveoli
unavailable for gas exchange.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Lower portions of brainstem (medulla)
control ventilation; both inspiratory and
expiratory center.
– Medullary signal transmitted through
phrenic and intercostal nerves to
muscles of ventilation; diaphragm and
intercostal muscles.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Stretch receptors provide input to
medulla's respiratory center.
 Prevents overinflation of lungs (HeringBreuer reflex).
– Most important determinant of
ventilatory rate is arterial PCO2.
– Increase in arterial PCO2 results in
decrease in pH of blood.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Chemical receptors in medulla detect
decrease in pH, which produces
increase in ventilatory rate.
– Helps body eliminate excess CO2 and
return pH to normal level.
– In patients with chronic obstructive
pulmonary disease (COPD), body less
responsive to changes in arterial PCO2.
©2013 Pearson Education, Inc.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Diffusion: gases move between alveoli
and pulmonary capillaries.
– Oxygen moves from oxygen-rich alveoli
into oxygen-poor capillaries.
– Carbon dioxide passes out of blood in
response to gradient between
concentration of carbon dioxide in blood
in pulmonary capillaries and in alveoli.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Respiratory membrane must remain
intact for gas exchange to occur.
– Endothelial lining of capillaries must be
intact for exchange of oxygen and
carbon dioxide to occur.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Problems with lung diffusion:
 Provide patient with high concentrations
of oxygen.
 Medications such as diuretic agents or
anti-inflammatory drugs given to reduce
fluid and inflammation.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Lung perfusion: circulation of blood
through lungs or pulmonary capillaries.
– Dependent on three conditions:
 Adequate blood volume
 Intact pulmonary capillaries
 Efficient pumping of blood by heart
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Perfusion: adequate volume of blood in
bloodstream.
– Oxygen transported in bloodstream:
bound to hemoglobin or dissolved in
plasma.
 Oxyhemoglobin: hemoglobin with oxygen
bound.
 Deoxyhemoglobin: hemoglobin without
oxygen.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Hemoglobin: four iron-containing heme
molecules; protein-containing globin.
 Oxygen molecules bind to heme portion.
– Oxygen dissociation curve: fully
oxygen-bound hemoglobin releases
oxygen.
 Changes in body temperature, blood pH,
and PCO2 can alter oxygen dissociation
curve.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Carbon dioxide transported from cells to
lungs:
 As bicarbonate ion (70%)
 Bound to globin portion of hemoglobin
molecule (23%)
 Dissolved in plasma (measured as PCO2)
(7%)
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Majority of carbon dioxide transported
in form of bicarbonate ion; released
from red blood cells (RBCs) and
transported in plasma.
– In lungs, reverse process takes place,
producing water and carbon dioxide.
– Carbon dioxide diffuses into alveoli;
eliminated during exhalation.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– Carbaminohemoglobin: hemoglobin with
carbon dioxide bound.
– Haldane effect: heme portion of
hemoglobin molecule becomes
saturated with oxygen; becomes acidic
and more carbon dioxide released.
– Only fraction of carbon dioxide
transported as gas.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– For perfusion to take place:
 Adequate blood volume.
 Pulmonary capillaries able to transport
blood through lung tissue; vessels must
be open and not occluded, or blocked.
 Heart must pump efficiently to push
blood through pulmonary capillaries to
perfuse lung tissues.
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Review of Respiratory Anatomy
and Physiology
• Physiologic Processes
– To maintain perfusion, ensure patient
has adequate circulating blood volume;
improve pumping action of heart.
– Pulmonary respiration: occurs in lungs.
– Cellular respiration: occurs in peripheral
capillaries.
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Pathophysiology
• Any disease process that impairs
pulmonary system will result in
derangement in ventilation, diffusion,
perfusion, or combination of these
processes.
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Pathophysiology
• Disruption in Ventilation
– Disease states that affect upper
respiratory tract result in obstruction of
airflow to lower structures.
– Chest wall and diaphragm mechanical
components essential for ventilation.
– Traumatic injuries to these areas will
disrupt mechanics, causing loss of
negative pressure within pleural space.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Pathophysiology
• Disruption in Ventilation
– Any disease that impairs regulation of
breathing alters ventilation.
– Abnormal respiratory patterns:
 Cheyne-Stokes respirations
 Kussmaul's respirations
 Central neurogenic hyperventilation
 Ataxic (Biot's) respirations
 Apneustic respiration
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Pathophysiology
• Disruption in Diffusion
– Any change in concentration of oxygen
in alveoli can limit diffusion of oxygen
and produce hypoxia.
– Any disease that alters structure or
patency of alveoli will limit diffusion.
– Diseases alter thickness of respiratory
membrane; fluid and inflammatory cells
in interstitial space.
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Pathophysiology
• Disruption in Diffusion
– Similar effects produced by changes in
permeability (leakiness) of pulmonary
capillaries (noncardiogenic causes).
– Disease states alter pulmonary capillary
endothelial lining.
©2013 Pearson Education, Inc.
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Pathophysiology
• Disruption in Perfusion
– Any disease state that reduces normal
circulating blood volume will limit
normal perfusion of lungs.
– Any reduction in normal circulating
hemoglobin will affect perfusion.
– Pulmonary shunting: area of lung tissue
ventilated, no perfusion occurs; oxygen
not moved to circulatory system.
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Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Scene Size-Up
– Is scene safe to approach patient?
– Are there visual clues that might
provide information regarding patient's
medical complaint?
– Certain gases and toxic products
causing respiratory complaints from
patient may present significant risk to
you; dust particles also a risk.
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Assessment of the Respiratory
System
• Scene Size-Up
– Environments in which concentration of
oxygen significantly reduced: grain
silos, enclosed storage containers, any
enclosed space with active fire.
– Specific protective items: hazardous
materials suits, self-contained breathing
apparatus (SCBA), supplemental
oxygen.
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Assessment of the Respiratory
System
• Scene Size-Up
– HAZMAT teams required; contact
dispatch.
– Using your eyes, ears, nose can lead to
important, useful clues as you assess
patient.
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Assessment of the Respiratory
System
• Primary Assessment
– General Impression
 Consider patient's position.
 Severe cases, patient will assume
“tripod” position.
 Patients with severe respiratory distress
display pallor and diaphoresis.
 Cyanosis late finding; may be absent
even with significant hypoxia.
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Tripod position.
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Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Primary Assessment
– General Impression
 Assess mental status.
 Hypoxic patient: restless and agitated.
 Confusion with hypoxia and hypercarbia.
 Respiratory failure imminent: patient will
appear severely lethargic and somnolent.
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Assessment of the Respiratory
System
• Primary Assessment
– General Impression
 Assess patient's ability to speak in full,
coherent sentences.
 Rambling, incoherent speech indicates
fear, anxiety, hypoxia.
 Respiratory effort: use of accessory
muscles in neck and contractions of
intercostal muscles indicate significant
breathing effort.
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Assessment of the Respiratory
System
• Primary Assessment
– General Impression
 Nasal flaring
 Use of accessory respiratory muscles
 Cyanosis
 Pursed lips
 Tracheal tugging
 Identify life-threatening conditions
resulting from compromise of ABCs.
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Assessment of the Respiratory
System
• Primary Assessment
– Airway
 Any significant abnormality in respiratory
tract potentially life threatening.
 Noisy breathing nearly always means
partial airway obstruction.
 Obstructed breathing not always noisy.
 Brain can survive only few minutes in
asphyxia.
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Assessment of the Respiratory
System
• Primary Assessment
– Airway
 Artificial respiration useless if airway
blocked.
 Patent airway useless if patient apneic.
 If airway obstruction, do not waste time
looking for help or equipment. Act
immediately.
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Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Primary Assessment
– Airway
 If airway compromised, quickly institute
basic airway management techniques.
 Once you have secured patent airway,
ensure patient has adequate ventilation.
 Assessment should be brief and directed.
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Assessment of the Respiratory
System
• Primary Assessment
– Airway/Breathing
 Alterations in mental status
 Severe central cyanosis
 Absent breath sounds
 Audible stridor
 One- to two-word dyspnea
 Tachycardia ≥ 130 beats per minute
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Assessment of the Respiratory
System
• Primary Assessment
– Airway/Breathing
 Pallor and diaphoresis
 Presence of intercostal and
sternocleidomastoid retractions
 Use of accessory muscles
 If any of these signs present,
immediately resuscitate and transport.
©2013 Pearson Education, Inc.
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Assessment of the Respiratory
System
• Secondary Assessment
– History and physical exam determined
by chief complaint or primary problem.
– Obtain SAMPLE history.
– Ask OPQRST questions.
– Obtain past history.
– Question patient or family about prior
hospitalizations for respiratory disease.
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Assessment of the Respiratory
System
• Secondary Assessment
– Consider patients who have been
previously intubated potentially
seriously ill.
– Ask patient if he has known respiratory
disease.
– Determine if disease affecting
ventilation, diffusion, perfusion.
– History of medication use essential.
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Assessment of the Respiratory
System
• Secondary Assessment
– Pay particular attention to medications
that suggest pulmonary disease.
– Ask if patient has home nebulizer unit.
– Ask about drugs for cardiac conditions.
– Inquire about medication allergies.
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Assessment of the Respiratory
System
• Secondary Assessment
– Pursed lips indicate significant
respiratory distress.
– Examine nose, mouth, throat for signs
of swelling or infection.
– Increase in amount of sputum suggests
infection of lungs or bronchial passages.
– Look at jugular veins for evidence of
distention.
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Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Secondary Assessment
– Follow standard steps of patient
assessment: inspection, palpation,
percussion, auscultation.
– Inspection: examine anterior-posterior
dimensions and shape of chest.
– Palpation: palpate chest, front and
back, for abnormalities; tenderness,
crepitus, subcutaneous emphysema.
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Assessment of the Respiratory
System
• Secondary Assessment
– Percussion: limit percussion to
suspected cases of pneumothorax and
pulmonary edema.
– Auscultation: auscultate chest; listen
without stethoscope and from distance;
note loud stridor, wheezing, or cough.
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The chest should be auscultated.
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Assessment of the Respiratory
System
• Secondary Assessment
– Normal Breath Sounds
 Bronchial (or tubular)
– Loud, high-pitched breath sounds heard
over trachea
– Expiratory phase lasts longer than
inspiratory phase
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Assessment of the Respiratory
System
• Secondary Assessment
– Normal Breath Sounds
 Bronchovesicular
– Softer, medium-pitched breath sounds
heard over mainstem bronchi
– Expiratory and inspiratory phase equal
 Vesicular
– Soft, low-pitched breath sounds heard in
lung periphery
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Assessment of the Respiratory
System
• Secondary Assessment
– Abnormal Breath Sounds
 Snoring
 Stridor
 Wheezing
 Rhonchi
 Crackles (rales)
 Pleural friction rub
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Inspiratory Wheezing Animation
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Rhonchi Animation
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Rales Animation
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Stridorous Animation
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©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Secondary Assessment
– Examine extremities.
– Look for peripheral cyanosis (hypoxia).
– Swelling, redness, hard and firm cord
(pulmonary embolism).
– Clubbing of fingers (hypoxemia).
– Carpopedal spasm (hyperventilation).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Characteristics of finger clubbing include large fingertips and a loss of the normal angle at the nail bed.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Characteristics of finger clubbing include large fingertips and a loss of the normal angle at the nail bed.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Secondary Assessment
– Vital Signs
 Tachycardia may indicate hypoxia.
 Pulsus paradoxus associated with COPD
and cardiac tamponade.
 Elevated respiratory rate in patient with
dyspnea caused by hypoxia.
 Persistently slow rate indicates
impending respiratory arrest.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Secondary Assessment
– Vital Signs
 Continually reassess respiratory rate and
pattern.
 Tachypnea: respiratory pattern with rate
that exceeds 20 breaths per minute.
 Bradypnea: respiratory pattern with rate
slower than 12 breaths per minute.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Diagnostic Testing
– Pulse oximetry offers rapid and accurate
means for assessing oxygen saturation.
– Applied to finger or earlobe.
– Pulse rate and oxygen saturation
continuously recorded.
– Concentration of oxyhemoglobin
displayed as percentage (hemoglobin
oxygen saturation).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Sensing unit for pulse oximetry. This device transmits light through a vascular bed, such as in the finger, and can
determine the oxygen saturation of red blood cells. To use the pulse oximeter, it is only necessary to turn the
device on and attach the sensor to a finger. The desired graphic mode on the oximeter should be selected. The
oxygen saturation and pulse rate can be continuously monitored.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Diagnostic Testing
– SpO2 reflects oxygen saturation of
available hemoglobin.
– Pulse oximeters cannot discern between
normal/abnormal levels of hemoglobin.
– Some newer pulse oximeters have
capability of noninvasively measuring
total hemoglobin (SpHb) in addition to
SpO2 and other parameters.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Diagnostic Testing
– Handheld devices available for
determining patient's peak expiratory
flow rate (PEFR).
– Normal expected peak flow rate based
on patient's sex, age, height.
– PEFR obtained using Wright spirometer.
– Peak rate of exhaled gas recorded in
liters per minute.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Diagnostic Testing
– Capnography: noninvasive method of
measuring levels of carbon dioxide
(CO2) in exhaled breath.
– Capnometry: measurement of expired
CO2.
– Capnography: graphic recording or
display of capnometry reading over
time.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Diagnostic Testing
– Capnograph: device that measures
expired CO2 levels.
– Capnogram: visual representation of
expired CO2 waveform.
– End-tidal CO2 (ETCO2): measurement of
CO2 concentration at end of expiration
(maximum CO2).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Diagnostic Testing
– PETCO2: partial pressure of end-tidal
CO2 in mixed gas solution.
– PaCO2: partial pressure of CO2 in
arterial blood.
– CO2 end product of metabolism;
transported by venous system to right
side of heart.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Diagnostic Testing
– CO2 pumped from right ventricle to
pulmonary artery; enters pulmonary
capillaries.
– Diffuses into alveoli; removed from
body through exhalation.
– Decreased CO2 levels: shock, cardiac
arrest, pulmonary embolism,
bronchospasm, airway obstruction.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Diagnostic Testing
– Increased CO2 levels: hypoventilation,
respiratory depression, hyperthermia.
– Capnometry provides noninvasive
measure of CO2 levels.
– Colorimetric device: disposable CO2
detector; pH-sensitive, chemically
impregnated paper encased within
plastic chamber.
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Paramedic Care: Principles & Practice, 4th Ed.
Colorimetric end-tidal CO2 detector. (© Dr. Bryan E. Bledsoe)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Diagnostic Testing
– Colorimetric devices cannot detect
hypercarbia or hypocarbia.
– Electronic capnography detectors:
infrared technique detects CO2 in
exhaled breath; CO2 molecules absorb
infrared light; can then be measured.
– Electronic ETCO2 detectors: qualitative
or quantitative.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Capnography devices provide a digital waveform (capnogram) that reflects the entire respiratory cycle.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Diagnostic Testing
– Capnogram: CO2 concentrations over
time.
 Phase
 Phase
 Phase
 Phase
I: respiratory baseline.
II: respiratory upstroke.
III: respiratory plateau.
IV: inspiratory phase.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Assessment of the Respiratory
System
• Diagnostic Testing
– Continuous waveform capnography:
 Continuous monitoring of airway
placement and ventilation for intubated
patients.
 Utility in monitoring nonintubated
patients.
 CO2 detection useful in cardiopulmonary
resuscitation (CPR).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Respiratory
Disorders
• Management Principles
– Airway always has first priority.
– Any patient with hypoxia should receive
oxygen.
– Any patient whose illness or injury
suggests possibility of hypoxia should
receive oxygen until pulse oximetry
available.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Respiratory
Disorders
• Management Principles
– If question whether oxygen should be
given, administer enough oxygen to
maintain adequate SpO2 level (≥ 96%).
– Strive for normoxia; avoid both hypoxia
and hyperoxia, if possible.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Respiratory
Disorders
• Management Principles
– Administering too much oxygen can
worsen patient outcomes.
– Excess oxygen can result in formation of
toxic chemicals (free radicals).
– These chemicals can damage body cells
and tissues (oxidative stress).
– Provide just enough oxygen to treat
hypoxia without causing hyperoxia.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Excess amounts of oxygen (hyperoxia) have been associated with worsened outcomes in critically ill patients.
Always provide enough oxygen to treat hypoxia but avoid hyperoxia.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Upper Airway Obstruction
– Common causes: relaxed tongue, food,
dentures, other foreign bodies.
– Can be result of facial or neck trauma,
upper airway burns, allergic reactions,
swelling.
– Severe signs: silent cough, cyanosis,
and inability to speak or breathe.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Upper Airway Obstruction
– Unresponsive patient: snoring
respirations, possibly tongue or denture
obstruction.
– Speech indicates obstruction
incomplete.
– If unresponsive and has been eating,
suspect food bolus lodged in trachea.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Upper Airway Obstruction
– If burn present or suspected, assume
laryngeal edema until proven otherwise.
– Watch for urticaria (hives).
– Intercostal muscle retraction and use of
strap muscles of neck for breathing
suggest attempts to ventilate against
partially closed airway.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Upper Airway Obstruction
– Management based on nature of
obstruction
– Blockage by tongue corrected by
opening airway, using head-tilt, chinlift; jaw-thrust; or jaw-thrust without
head extension maneuver.
– Employ nasopharyngeal or
oropharyngeal airway.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Upper Airway Obstruction
– Conscious Adult
 Determine if complete obstruction or
poor air exchange.
 If severe obstruction or poor air
exchange, provide rapid abdominal
thrusts in rapid sequence until
obstruction relieved.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Upper Airway Obstruction
– Unconscious Adult
 Use head-tilt, chin-lift; jaw-thrust; or
jaw-thrust without head extension
maneuver in attempt to open airway.
 Begin CPR.
 If obstruction persists and ventilation
cannot be provided, visualize airway with
laryngoscope.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Upper Airway Obstruction
– Grasp obstruction with Magill forceps
and remove.
– Airway obstruction caused by laryngeal
edema, establish airway by head-tilt,
chin-lift; jaw-thrust; or jaw-thrust
without head extension maneuver.
– Administer supplemental oxygen.
– Attempt bag-valve-mask (BVM)
ventilation.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Upper Airway Obstruction
– Start IV with crystalloid solution.
– Administer intramuscular epinephrine.
– Administer diphenhydramine
(Benadryl).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Adult Respiratory Distress Syndrome
(ARDS)
– Life-threatening condition; adversely
affects gas exchange in lungs.
– Caused by fluid accumulation in
interstitial space within lungs.
– Fluid accumulation result of increased
vascular permeability and decreased
fluid removal from lung tissue.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Adult Respiratory Distress Syndrome
(ARDS)
– Mortality high (70%).
– Death as result of respiratory failure,
failure of organ systems (liver and
kidneys).
– Underlying conditions results in inability
to maintain proper fluid balance in
interstitial space.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Adult Respiratory Distress Syndrome
(ARDS)
– Increases in pulmonary capillary
permeability, destruction of capillary
lining, and increases in osmotic forces
act to draw fluid into interstitial space
and contribute to interstitial edema.
– Increases thickness of respiratory
membrane; limits diffusion of oxygen.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Adult Respiratory Distress Syndrome
(ARDS)
– Specific clinical symptoms related to
underlying cause of ARDS.
– Patients experience gradual decline in
respiratory status.
– Dyspnea, confusion, agitation with
noncardiogenic pulmonary edema.
– Tachypnea and tachycardia.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Adult Respiratory Distress Syndrome
(ARDS)
– Crackles (rales) audible in both lungs.
– Pulse oximetry: low oxygen saturations
with advanced disease.
– Management of patient's underlying
medical condition hallmark of treatment
for this disorder.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Adult Respiratory Distress Syndrome
(ARDS)
– Treatment of gram-negative sepsis with
appropriate antibiotics, removal of
patient from inciting toxin, rapid
descent to lower altitude with HAPE
most important therapies.
– Oxygen supplementation essential.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Adult Respiratory Distress Syndrome
(ARDS)
– Establish intravenous access; provide
fluids only if hypovolemia exists.
– Establish cardiac monitoring.
– Suctioning of lung secretions.
– Use positive pressure ventilation.
– Continuous positive airway pressure
(CPAP) can avoid need for endotracheal
intubation and mechanical ventilation.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Adult Respiratory Distress Syndrome
(ARDS)
– Maintain cardiac monitoring and pulse
oximetry.
– Transport facility capable of advanced
hemodynamic monitoring (Swan-Ganz
catheter) and mechanical ventilation
support.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
ARDS Animation
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©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Obstructive Lung Diseases
– Emphysema
– Chronic bronchitis
– Asthma
 Asthma genetic predisposition.
 COPD directly caused by cigarette
smoking and environmental toxins.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Obstructive Lung Diseases
– Abnormal ventilation common feature.
– Obstruction primarily in bronchioles.
– Bronchospasm occurs.
– Increased mucus production by goblet
cells that line respiratory tree.
– Inflammation of bronchial passages
results in accumulation of fluid and
inflammatory cells.
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Paramedic Care: Principles & Practice, 4th Ed.
COPD Video
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Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Emphysema
– Destruction of alveolar walls distal to
terminal bronchioles.
– More common in men than women.
– Contributing factors: cigarette smoking,
exposure to environmental toxins.
– Decreases alveolar membrane surface
area, lessening area available for gas
exchange.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Emphysema
– Increased ratio of air to lung tissue;
diffusion defects.
– Increases resistance to pulmonary blood
flow.
– Ultimately causes pulmonary
hypertension, leading to right-heart
failure, cor pulmonale, and death.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Emphysema
– Weakening of walls of small bronchioles.
– When destroyed, lungs lose capacity to
recoil; air becomes trapped in lungs.
– Patients breathe through pursed lips;
creates continued positive pressure
similar to positive end-expiratory
pressure (PEEP); prevents alveolar
collapse.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Chronic obstructive pulmonary disease of long duration can cause pulmonary hypertension, which in turn may
lead to cor pulmonale.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Emphysema
– Irreversible airway obstruction.
– Patients susceptible to acute respiratory
infections and cardiac arrhythmias.
– Dependent on bronchodilators,
corticosteroids, supplemental oxygen.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Emphysema
– Weight loss, increased dyspnea on
exertion, limitation of physical activity.
– Rarely associated with cough.
– Barrel chest evidenced by increase in
anterior/posterior chest diameter.
– Tend to be pink in color; polycythemia.
– Hypertrophy of accessory respiratory
muscles.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Emphysema
– Clubbing of fingers common.
– Breath sounds diminished.
– Signs of right-heart failure: jugular vein
distention, peripheral edema, hepatic
congestion.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Chronic Bronchitis
– Increase in number of goblet (mucussecreting) cells in respiratory tree.
– Production of large quantity of sputum.
– Often occurs after prolonged exposure
to cigarette smoke.
– Alveoli not severely affected and
diffusion remains normal.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Chronic mucus production and plugging of the airways occur in chronic bronchitis.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Chronic Bronchitis
– Gas exchange decreased because of
lowered alveolar ventilation; results in
hypoxia and hypercarbia.
– Patient often has history of heavy
cigarette smoking; may occur in
nonsmokers.
– History of frequent respiratory
infections.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Chronic Bronchitis
– Produce considerable quantities of
sputum daily.
– Productive cough for 3 months per year
for 2 or more consecutive years.
– Overweight; can be cyanotic (“blue
bloaters”).
– Rhonchi; occlusion of larger airways
with mucus plugs.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Chronic Bronchitis
– May exhibit signs and symptoms of
right-heart failure.
– Management goal: relieve hypoxia and
reverse bronchoconstriction.
– Supplemental administration of oxygen.
– Establish airway.
– Apply pulse oximeter; determine blood
oxygen saturation (SpO2).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Chronic Bronchitis
– Administer supplemental oxygen at low
flow rate; maintain oxygen saturation
greater than 90 to 95%.
– Support ventilation with BVM
assistance.
– CPAP in COPD.
– Intubation may be required if CPAP fails
and respiratory failure imminent.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Chronic Bronchitis
– Place saline lock.
– Fluid administration if dehydration.
– If ordered by medical direction,
administer bronchodilator medication
(albuterol, levalbuterol,
metaproterenol) through small-volume
nebulizer.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Asthma
– Chronic inflammatory disorder of
airways.
– Airflow obstruction and
hyperresponsiveness often reversible
with treatment.
– Induced by “triggers” or “inducers.”
– Environmental allergens major cause of
inflammation.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Asthma
– Triggers: cold air, exercise, foods,
irritants, stress, certain medications.
– First phase of reaction: release of
chemical mediators such as histamine.
– Contraction of bronchial smooth muscle;
leakage of fluid from peribronchial
capillaries.
– Bronchoconstriction; bronchial edema.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Asthma
– Decreased expiratory airflow, causing
“asthma attack.”
– Often, asthma attacks resolve
spontaneously in 1–2 hours.
– May be aborted by inhaled
bronchodilator medications such as
albuterol.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
(a) Normal bronchiole and (b) an asthmatic bronchiole.
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Paramedic Care: Principles & Practice, 4th Ed.
Metered Dose Inhaler Video
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©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Asthma
– 6–8 hours after exposure to trigger,
second reaction occurs.
– Inflammation of bronchioles as cells of
immune system invade mucosa of
respiratory tract.
– Additional edema; swelling bronchioles;
decrease in expiratory airflow.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Asthma
– Second-phase reaction will not typically
respond to inhaled beta-agonist drugs.
– Anti-inflammatory agents such as
corticosteroids required.
– Consider immediate threats to airway,
breathing, circulation.
– Focused history; physical examination.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Asthma
– Symptoms: dyspnea, wheezing, cough.
– Hyperinflation of chest; tachypnea.
– As hypoxia develops, patient may
become agitated and anxious.
– Patient's medications help confirm
history of asthma.
– Determine when symptoms started;
what attempts to abort attack.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Asthma
– Prior history of intubation and
mechanical ventilation should heighten
index of suspicion.
– Asthmatic on continuous corticosteroid
therapy is high-risk patient.
– Emphasis on exam of chest and neck.
– Note abnormal breath sounds such as
wheezing or rhonchi.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Asthma
– Increase in respiratory rate earliest
symptom of respiratory problem.
– Pulse oximetry adjunct to respiratory
assessment.
– More severe asthma attack, lower PEFR.
– Continuous waveform capnography can
assist in identifying asthma; determine
severity of airflow obstruction.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Asthma
– Acute asthma exacerbation will exhibit
“shark fin” configuration on capnogram.
– Patients tend to hyperventilate to
maintain adequate oxygenation.
– Treatment: correct hypoxia, reverse any
bronchospasm, treat inflammatory
changes associated with disease.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Asthma
– Administer supplemental oxygen to
correct hypoxia.
– Establish intravenous access; place
patient on electrogardiogram (ECG)
monitor.
– Inhaled beta-agonist preparations such
as albuterol (Ventolin, Proventil) or
levalbuterol (Xopenex) in conjunction
with ipratropium bromide (Atrovent).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Asthma
– Drugs administered with small-volume,
oxygen-powered nebulizer.
– The longer the time interval from onset
of asthma attack until treatment, the
less bronchodilator medications will
work.
– Fatigued patient can quickly develop
respiratory failure and require
intubation and mechanical ventilation.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Asthma
– Status asthmaticus: severe, prolonged
asthma attack; cannot be broken by
repeated doses of bronchodilators.
– Serious medical emergency: requires
prompt recognition, treatment,
transport.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Asthma
– Status asthmaticus: greatly distended
chest from continued air trapping.
– Breath sounds (wheezing) absent.
– Patient exhausted, severely acidotic,
dehydrated.
– Recognize respiratory arrest imminent;
prepare for endotracheal intubation.
– Transport immediately.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Asthma
– Common in children.
– Pathophysiology and treatment same as
in adults, with altered medication
dosages.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Upper Respiratory Infection (URI)
– Can make many existing pulmonary
diseases worse or lead to direct
pulmonary infection.
– Best defense against spread is common
practices (good hand washing and
covering mouth during coughing and
sneezing).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Upper Respiratory Infection
– Viruses cause majority of URIs; variety
of bacteria may also produce infection.
– Streptococcus accounts for 30%.
– URIs are self-limiting illnesses; resolve
after several days of symptoms.
– Symptoms: fever, chills, myalgias,
fatigue.
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Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Upper Respiratory Infection
– Diagnosis and treatment based on
history and physical findings.
– No intervention required except in
children with epiglottitis and
complicated infections in which pus may
occlude airway.
– Give oxygen supplementation to treat
hypoxia (avoid hyperoxia).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Upper Respiratory Infection
– Acetaminophen or ibuprofen for fever,
headache, myalgias.
– Drink plenty of fluids.
– Saltwater gargles for throat discomfort.
– Decongestants and antihistamines to
reduce mucus secretion.
– Encourage patients treated with
antibiotics to continue these agents.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Pneumonia
– Infection of lungs; common medical
problem, especially in aged and those
infected with HIV.
– Leading causes of death in both groups;
fifth overall cause of death in U.S.
– Risk factors: history of alcoholism,
cigarette smoking, exposure to cold
temperatures.
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Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Pneumonia
– Collection of related respiratory diseases
caused when variety of infectious
agents invade lungs.
– Defect in mucus production, ciliary
action, or both.
– Bacterial and viral pneumonias most
frequent; fungal and other forms of
pneumonia exist.
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Paramedic Care: Principles & Practice, 4th Ed.
Types of pneumonia: (a) Bronchopneumonia with localized pattern. (b) Lobar pneumonia with diffuse pattern
within the lung lobe. (c) Interstitial pneumonia is typically diffuse and bilateral.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Pneumonia
– Infection begins in one part of lung;
spreads to nearby alveoli.
– Infection may involve entire lung.
– As disease progresses, fluid and
inflammatory cells collect in alveoli;
alveolar collapse may occur.
– Primarily ventilation disorder.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Pneumonia
– Patients appear ill; recent history of
fever and chills (“bed shaking”).
– Weakness; malaise; deep, productive
cough; yellow to brown sputum, often
streaked with blood.
– May be associated pleuritic chest pain.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Pneumonia
– Fever, tachypnea, tachycardia, cough.
– Respiratory distress may be present.
– Auscultation of chest crackles (rales).
– Diagnosed: physical examination, X-ray
findings, laboratory cultures.
– Primary treatment: antibiotics.
– Administer supplemental oxygen to
correct hypoxia.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Pneumonia
– Severe cases: ventilatory assistance;
endotracheal intubation required.
– Establish intravenous access.
– Administering fluids for dehydration
appropriate; overhydration can worsen
respiratory condition.
– Antipyretic agents (acetaminophen or
ibuprofen) to reduce high fever.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Pneumonia
– Patients over age 65: high mortality and
complication rates.
– Transport to facility capable of handling
significant complications associated with
disease for this population.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Severe Acute Respiratory Syndrome
(SARS)
– Viral respiratory illness; first appeared
in southern China in November 2002.
– SARS-associated coronavirus (SARSCoV).
– Spread by close person-to-person
contact; incubation period 2–7 days.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Severe Acute Respiratory Syndrome
(SARS)
– Considered contagious as long as
symptoms.
– All personnel should use appropriate
personal protective equipment (PPE) on
every call or as directed by local health
authorities.
– First address signs of severe respiratory
distress.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Severe acute respiratory syndrome (SARS) is a viral respiratory illness that first appeared in China in November
2002.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Severe Acute Respiratory Syndrome
(SARS)
– Patients with underlying respiratory
disease and chronic illnesses at
increased risk.
– Symptoms: sore throat, rhinorrhea,
chills or rigors, myalgias, headache,
diarrhea; progress to cough, sputum
production, respiratory distress,
eventual respiratory failure.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Severe Acute Respiratory Syndrome
(SARS)
– Management: treat as with suspected
pneumonia or respiratory illness.
– Supplemental oxygen to correct
hypoxia.
– Establish intravenous access.
– Severe cases: ventilatory assistance
and endotracheal intubation required.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Severe Acute Respiratory Syndrome
(SARS)
– If SARS suspected, notify receiving
hospital so that appropriate measures
can be taken for isolation of patient and
protection of health care workers.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Lung Cancer
– Leading cause of cancer-related death in
U.S. in both men and women.
– Between ages of 55 and 65 years.
– Four types based on predominant cell
type.
– 20% cases involve only lung tissue.
– 35% spread to lymphatic system.
– 45% have distant metastases.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Lung Cancer
– Risk factors: cigarette smoking;
environmental exposure to asbestos,
hydrocarbons, radiation, fumes from
metal production; home exposure to
radon.
– Vast majority caused by carcinogens
from cigarette smoking.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Lung Cancer
– Adenocarcinoma: most common type;
glandular-type cells found in lungs and
bronchioles.
– Small-cell carcinoma (“oat cell”
carcinoma): bronchial tissues.
– Epidermoid carcinoma: bronchial
tissues.
– Large-cell carcinoma: bronchial tissues.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Lung Cancer
– Bad prognosis; most patients die within
year of diagnosis.
– Address signs of severe respiratory
distress.
– Severe uncontrolled hemoptysis can be
life-threatening presentation.
– Cough, dyspnea, hoarseness, vague
chest pain, hemoptysis.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Lung Cancer
– Metastatic symptoms: headache,
seizures, bone pain, abdominal pain,
nausea, malaise.
– Profound weight loss, cachexia, crackles
(rales), rhonchi, wheezes, diminished
breath sounds.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Lung Cancer
– Administer supplemental oxygen.
– Be attentive for any do not resuscitate
(DNR) order or advance directive (living
will).
– Follow your local protocol regarding
these legal instruments.
– Consult medical direction if questions
arise.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Lung Cancer
– IV of 0.9% normal saline; provide fluids
if dehydration.
– Follow your local protocol regarding
access of permanent indwelling
catheters in place.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Toxic Inhalation
– Causes pain, inflammation, destruction
of pulmonary tissues.
– Consider in any dyspneic patient.
– Causes: superheated air, toxic products
of combustion, chemical irritants,
inhalation of steam.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Toxic Inhalation
– Severe inhalations; disruption of
alveolar-capillary membranes may
result in life-threatening pulmonary
edema.
– Determine nature of inhalant or
combusted material.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Toxic Inhalation
– Several products result in formation of
corrosive acids or alkalis:
 Ammonia (ammonium hydroxide)
 Nitrogen oxide (nitric acid)
 Sulfur dioxide (sulphurous acid)
 Sulfur trioxide (sulfuric acid)
 Chlorine (hydrochloric acid)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Toxic Inhalation
– Determine duration of exposure,
whether patient was in enclosed area, if
experienced loss of consciousness.
– Pay attention to face, mouth, throat.
– Note burns or particulate matter.
– Wheezing: bronchospasm.
– Crackles: pulmonary edema.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Toxic Inhalation
– After ensuring safety of rescue
personnel, remove patient from
hazardous environment.
– Establish and maintain open airway.
– Administer humidified oxygen to correct
hypoxia.
– Place saline lock for venous access.
– Transport promptly.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Carbon Monoxide Inhalation
– Carbon monoxide: odorless, tasteless,
colorless gas produced from incomplete
burning of fossil fuels and carboncontaining compounds.
– #1 cause of poisoning in industrialized
countries.
– Potentially life threatening because it
binds to hemoglobin molecule.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Carbon Monoxide Inhalation
– Receptor sites on hemoglobin can no
longer transport oxygen to peripheral
tissues.
– Hemoglobin with carbon monoxide
bound is carboxyhemoglobin.
– Result is hypoxia at cellular level;
ultimately, metabolic acidosis.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Carbon Monoxide Inhalation
– Determine source of exposure, length,
location.
– Signs and symptoms: headache, nausea
and vomiting, confusion, agitation, loss
of coordination, chest pain, loss of
consciousness, seizures.
– Skin cyanotic or bright cherry red.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Carbon Monoxide (CO) Inhalation
– Signs of hypoxia (peripheral cyanosis or
confusion).
– Carboxyhemoglobin levels measured
noninvasively in prehospital setting
through CO-oximetry.
– Can detect carboxyhemoglobin,
methemoglobin, oxyhemoglobin,
deoxyhemogobin.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Carbon Monoxide Inhalation
– Ensure safety of rescue personnel.
– Remove patient from site of exposure.
– Ensure and maintain airway.
– Administer supplemental oxygen at
highest possible concentration.
– Apply tight-fitting nonrebreather mask.
– Use of CPAP for moderate to severe
exposures.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Carbon Monoxide Inhalation
– Assist respirations.
– If shock present, treat.
– Prompt transport essential.
– Effectiveness of hyperbaric oxygen
therapy in carbon monoxide poisoning
remains unclear.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Pulmonary Embolism
– Blood clot (thrombus) or other particle
that lodges in pulmonary artery,
blocking blood flow through vessel.
– Condition potentially life threatening;
can significantly decrease pulmonary
blood flow, leading to hypoxemia.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Pulmonary Embolism
– 1 in 5 cases of sudden death caused by
pulmonary emboli.
– Any condition that results in immobility
of extremities can increase risk.
– Risk factors: venous pooling that occurs
during pregnancy, cancer, infections,
thrombophlebitis, atrial fibrillation,
sickle cell anemia.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Pulmonary Embolism
– Sources: air embolism, fat embolism,
amniotic fluid embolism, blood clots.
– Major derangement is perfusion
disorder.
– Involved lung segment still ventilated,
producing ventilation-perfusion
mismatch.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Pulmonary Embolism
– Acute pulmonary embolism: sudden
onset of severe unexplained dyspnea.
– May be recent history of immobilization
(hip fracture, surgery, debilitating
illness).
– Labored breathing, tachypnea,
tachycardia, signs of right-heart failure.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Pulmonary Embolism
– Always examine extremities.
– In up to 50% of cases, deep venous
thrombosis evident.
– Warm, swollen extremity with thick cord
palpated along medial thigh; pain on
palpation or when extending calf.
– Petechiae on arms and chest wall.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Pulmonary Embolism
– First priorities are ABCs.
– Large pulmonary embolism may lead to
cardiac arrest; perform CPR if needed.
– Establish and maintain airway.
– Assist ventilations as required.
– Administer supplemental oxygen at
highest possible concentration.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Pulmonary Embolism
– Endotracheal intubation may be
required.
– Place saline lock.
– Requires high index of suspicion; high
complication rate; significant mortality.
– Monitor patient's vital signs; cardiac
rhythm.
– Quickly transport.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Spontaneous Pneumothorax
– Occurs in absence of blunt or
penetrating trauma.
– 5:1 ratio of male-to-female patients.
– Risk factors: tall, thin stature; history of
cigarette smoking.
– Develops between ages of 20 and 40
years.
– Higher incidence with COPD.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Spontaneous Pneumothorax
– Derangement in ventilation; negative
pressure that normally exists in pleural
space is lost.
– Prevents proper expansion of lung in
concert with chest wall.
– Sudden onset of sharp, pleuritic chest or
shoulder pain.
– Dyspnea commonly reported.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Spontaneous Pneumothorax
– Tachypnea, diaphoresis, pallor; cyanosis
rarely found.
– Symptoms and pulse oximetry readings
are guides to therapy.
– Supplemental oxygen required.
– Patients who require positive pressure
ventilation by mask or endotracheal
tube at risk for tension pneumothorax.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Hyperventilation Syndrome
– Rapid breathing, chest pains,
numbness, other symptoms associated
with anxiety or situational stress.
– Consider indication of serious medical
problem until proven otherwise.
– Carpopedal spasm: cramping of muscles
of feet and hands.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Hyperventilation Syndrome
– History of fatigue, nervousness,
dizziness, dyspnea, chest pain, and
numbness and tingling around mouth,
hands, feet.
– If history of seizure disorder,
hyperventilation episode may precipitate
seizure.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Hyperventilation Syndrome
– Primary treatment is reassurance.
– Instruct patient to voluntarily reduce
respiratory rate and depth of breathing.
– Check oxygen saturation by pulse
oximeter; do not withhold oxygen.
– Pulmonary embolism or acute
myocardial infarction can exhibit similar
symptoms.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Central Nervous System (CNS)
Dysfunction
– Relatively rare; consider possibility in
any dyspneic patient.
– Causes: head trauma, stroke, brain
tumors, various drugs.
– Be alert for nonrespiratory-system
problems such as CNS trauma or drug
ingestion.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Central Nervous System Dysfunction
– Establish and maintain open airway.
– If respiratory depression noted or if
respirations absent, initiate mechanical
ventilation.
– Administer supplemental oxygen.
– Establish saline lock for venous access.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Dysfunction of Spinal Cord, Nerves, or
Respiratory Muscles
– Can lead to hypoventilation and
progressive hypoxemia.
– Spinal cord trauma, polio, amyotrophic
lateral sclerosis (ALS), myasthenia
gravis, viral infections, tumors.
– At risk of developing pneumonia.
– Always question about injuries or falls.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Specific Respiratory Diseases
• Dysfunction of Spinal Cord, Nerves, or
Respiratory Muscles
– If doubt about possible injury,
immobilize cervical spine.
– Numbness, pain, sensory dysfunction.
– Problems with peripheral nervous
system (PNS).
– Protect airway; support ventilation.
– Establish airway; ventilatory support.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Respiratory emergencies commonly
encountered in prehospital care.
• Important to recognize that all
respiratory disorders may produce
derangements in ventilation, perfusion,
or diffusion.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Recognition and treatment must be
prompt.
• Understanding underlying cause of
respiratory disorder can guide therapy.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Primary treatment is to correct
hypoxia.
• Necessary steps include establishing
and maintaining airway, assisting
ventilations as required, administering
supplemental oxygen.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Appropriate pharmacological agents
may be ordered by local protocols.
• Primary responsibility never changes:
Make sure your patient has open airway
and is breathing well enough to
maintain normoxia.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Whenever airway and breathing are
affected, astute paramedic will treat
abnormalities as they are found.
• Oxygen is primary medication of
choice, but remember to use it
sparingly.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Your goal is normoxia, not hyperoxia;
hyperoxia and hypoxia both have
dangerous effects on patient.
• Tools such as capnography, end-tidal
CO2, pulse oximetry, carbon monoxide
detectors available for determining
respiratory patient's status.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Do not become lulled by technology nor
allow technology to replace good oldfashioned assessment and common
sense.
• When combined with thorough physical
assessment and proper judgment,
these tools can be invaluable in guiding
patient care and progress.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.