Transcript Respiratory Emergencies: CHF, Pulmonary Edema, COPD, Asthma

Respiratory Emergencies:
CHF, Pulmonary Edema,
COPD, Asthma
CPAP & Albuterol Nebulizer
Condell Medical Center EMS System
September, 2007
Site Code#10-7200E1207
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Objectives
Upon successful completion of this program,
the EMS provider should be able to:
• review the presentation and intervention for
the patient presenting with CHF, pulmonary
edema, COPD, and asthma.
• review criteria for the use of CPAP.
• discuss the set-up for CPAP.
• review the SOP for Acute Pulmonary
edema, Asthma/COPD with Wheezing, and
Conscious Sedation
Objectives cont’d
• review the Whisperflow patient circuit for
CPAP.
• actively participate in return-demonstration
of the albuterol nebulizer and in-line set-up.
• successfully complete the quiz with a score
of 80% or better.
Heart Failure
• A clinical syndrome where the heart’s
mechanical performance is compromised
and the cardiac output cannot meet the
demands of the body
• Considered a cardiac problem with great
implications to the respiratory system
• Heart failure is generally divided into right
heart failure and left heart failure
Heart Failure
• Etiologies are varied
– valve problems, coronary disease, heart disease
– dysrhythmias can aggravate heart failure
• Variety of contributing factors to developing
heart disease
– excess fluid or salt intake, fever (sepsis),
history of hypertension, pulmonary embolism,
excessive alcohol or drug usage
Deoxygenated Blood Flow
Through The Heart
• Deoxygenated blood returns to the right
heart via inferior and superior vena cavas
• Blood flow thru the right side of the heart
– right atrium
– right ventricle
– pulmonary artery to the lungs
• arteries always carry blood away from
the heart
– pumped to the lungs to be oxygenated
Oxygenated Blood Flow Through
The Heart
• Oxygenated blood from the lungs returns to
the heart via the pulmonary veins to the left
atrium
• Blood flow thru the left side of the heart
– left atrium
– left ventricle
– thru aortic valve to the aorta
– to aorta for distribution to the body
Left Side of the Heart
• High pressure system
• Blood needs to be pumped to the entire
body
• Left ventricular muscle needs to be
significant in size to act as a strong pump
• Left sided failure results in backup of blood
into the lungs
Right Side of the Heart
• Low pressure system
• Blood needs to be pumped to the lungs right
next to the heart
• Right ventricle is smaller than the left and
does not need to be as developed
• Right sided failure results in back pressure
of blood in the systemic venous system (the
periphery)
Left Ventricular Heart Failure
• Causes
failure of effective forward pump
• back pressure of blood into pulmonary
circulation
heart disease
• MI
• valvular disease
• chronic hypertension
• dysrhythmias
Left Ventricular Failure
• Pressure in left atrium rises
increasing pressure is transmitted to the
pulmonary veins and capillaries
increasing pressure in the capillaries
forces blood plasma into alveoli causing
pulmonary edema
increasing fluid in the alveoli decreases
the lungs’ oxygenation capacity and
increases patient hypoxia
As MI is a common cause of left ventricular
failure:
Until proven otherwise,
assume all patients exhibiting
signs and symptoms of
pulmonary edema are also
experiencing an acute MI
Right Ventricular Heart Failure
• Causes
failure of the right ventricle to work as an
effective forward pump
• back pressure of blood into the systemic
venous circulation causes venous congestion
most common cause is left ventricular failure
systemic hypertension
pulmonary embolism
Congestive Heart Failure
• A condition where the heart’s reduced
stroke volume causes an overload of fluid in
the body’s other tissues
• Can present as edema
pulmonary
peripheral
sacral
ascites (peritoneal edema)
Compensatory Measures Starling’s Law
• The more the myocardium is stretched, the
greater the force of contraction and the greater
the cardiac output
• The greater the preload (amount of blood
returning to the heart), the farther the
myocardial muscle stretches, the more
forceful the cardiac contraction
• After time or with too much resistance the
heart has to pump against, the compensation
methods fail to work
Acute Congestive Heart Failure
Often presenting in the field as:
Pulmonary edema
Pulmonary hypertension
Myocardial infarction
Chronic Congestive Heart Failure
Often presenting in the field as:
Cardiomegaly - enlargement of the heart
Left ventricular failure
Right ventricular failure
Patient Assessment
• Scene size-up
• Initial assessment
– airway
– breathing
– circulation
– disability
• AVPU
• GCS
– expose to finish examining
• Identify priority patients, make transport
decisions
• Additional assessment
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vital signs, pain scale
determine weight
room air pulse ox, if possible, and oxygen PRN
cardiac monitor; 12 lead ECG if applicable
establish 0.9 NS IV, TKO
determine blood glucose if indicated
• unconscious, altered level of consciousness, known
diabetic with diabetic related call
– reassess initial assessment findings and
interventions started
Closest Appropriate Hospital
• Hospital of patient’s choice within the department’s
transport area
• The patient who is alert and oriented has the right to
request their hospital of choice
• EMS can have the patient sign the release for
transport to a farther hospital
• If EMS does not feel comfortable transporting farther
away, you can communicate this to the patient to get
your point across in a diplomatic manner (ie: “I’m
very concerned about your condition and I would feel
more comfortable taking you to the closest hospital”)
Refusals
• A conscious and alert patient has the right to
refuse care and/or transportation
• A refusal, though, with a patient in CHF might
prove devastating
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worsening of signs and symptoms
increased and unnecessary myocardial damage
severe pulmonary edema
death
• Avoid refusals in these patients at all costs
• Document well the efforts taken to encourage
transportation
Signs and Symptoms CHF
• Progressive or acute shortness of breath
• Labored breathing especially during exertion
(ie: standing up, walking a few steps)
• Awakened from sleep with shortness of breath
(paroxysmal nocturnal dyspnea)
increasing episodes usually indicate the disease is
worsening
• Positioning
tripod - resting arms on thighs, leaning forward
inability to recline in bed without multiple pillows
using more pillows to be comfortable in bed
• Changes in skin parameters
pale, diaphoretic, cyanotic
mottling present in severe CHF
• Increasing edema or weight gain over a short
time
early edema in most dependent parts of the
body first (ie: feet, presacral area)
• Generalized weakness
• Mild chest pain or pressure
• Elevated blood pressure sometimes
to compensate for decreased cardiac output
• Typical home medication profile
– diuretic - to remove excess fluids
– hypertension medications - to treat a typical
co-morbid factor
– digoxin - to increase the contractile strength of
the heart
– oxygen
• Worst of the worst complications pulmonary edema
Progression of Acute CHF
• Left ventricle fails as a forward pump
• Pulmonary venous pressure rises
• Fluid is forced from the pulmonary
capillaries into the interstitial spaces
between the capillaries and the alveoli
• Fluid will eventually enter & fill the alveoli
• Pulmonary gas exchange is decreased
leading to hypoxemia ( oxygen in blood)
& hypercarbia ( carbon dioxide in blood)
Progression of CHF cont’d
• Hypercarbia ( carbon dioxide retained in
the blood) can cause CNS depression
– slowing of the respiratory drive
– slowing of the respiratory rate
 Wheezes heard in any
geriatric patient should
be considered
pulmonary edema until
proven otherwise
(especially in the
absence of any history
of COPD or asthma)
Progression of Pulmonary Edema
• Untreated, leads to respiratory failure
• Oxygen exchange inhibited due to excess serum
fluid in alveoli hypoxia  death
• Presentation
tachypnea
abnormal breath sounds
• crackles (rales) at both bases
• rhonchi - fluid in larger airways of the lungs
• wheezing - lungs’ protective mechanisms
– bronchioles constrict to keep additional
fluid from entering the airway
Acute Pulmonary Edema SOP
• Routine medical care
– patient assessment
– IV-O2-monitor
• cautiously monitor IV fluid flow rates
• Place patient in position of comfort
– often patient will choose to sit upright
– dangle the feet off the cart to promote venous
pooling
• Determine if the patient is stable or unstable
– evaluate mental status, skin parameters, and
blood pressure
Stable Acute Pulmonary Edema
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Patient alert
Skin warm & dry
Systolic B/P > 100 mmHg
Nitroglycerin 0.4 mg sl - maximum 3 doses
Consider CPAP
Lasix 40 mg IVP (80 mg if already taking)
If systolic B/P remains >100 mm Hg give
Morphine Sulfate 2 mg IVP slowly
• If wheezing, obtain order from Medical
Control for Albuterol nebulizer
Pulmonary Edema Medications
• Nitroglycerin
– venodilator; reduces cardiac workload and
dilates coronary vessels
– do not use in the presence of hypotension or if
Viagra or Viagra-type drug has been taken in
the past 24 hours
– can repeat the drug (0.4 mg sl) every 5 minutes
up to 3 doses total if blood pressure remains
> 100 mmHg
– onset 1 - 3 minutes sl (mouth needs to be moist
for the tablet to dissolve & be absorbed)
• Lasix (Furosemide)
®
– diuretic; causes venous dilation which
decreases venous return to the heart
– avoid in sulfa allergies & in the presence of
hypotension
– dose 40 mg IVP (80 mg IVP if the patient is
taking the drug at home)
– vascular effect onset within 5 minutes; diuretic
effects within 15 - 20 minutes
• Morphine sulfate
– narcotic analgesic (opioid)
– causes CNS depression; causes euphoria
– increases venous capacity and decreases venous
return to the heart by dilating blood vessels
– used to decrease anxiety and to decrease venous
return to the heart in pulmonary edema
– give 2 mg slow IVP; titrate to response and
vital signs and give 2 mg every 2 minutes to a
maximum of 10 mg IVP
– effects could be increased in the presence of
other depressant drugs (ie: alcohol)
• Albuterol
– bronchodilator
– reverses bronchospasm associated with COPD
– dose is 2.5 mg in 3 ml solution administered in
the nebulizer
– the patient may be aware of tachycardia and
tremors following a dose
– Albuterol must be ordered by Medical Control
for the acute pulmonary edema patient
Using CPAP With Medications
• Medications and CPAP are to be administered
simultaneously
• The use of CPAP buys time for the
medications to exert their effect
• CPAP and medications used (Nitroglycerin,
Lasix, and Morphine) can all cause a drop in
blood pressure
– CPAP and medications must be discontinued
if the blood pressure falls
< 100 mmHg
Case Scenario #1
• A 68 year-old female calls 911 due to severe
respiratory distress which suddenly woke
her up from sleep. She is unable to speak in
complete sentences and is using accessory
muscles to breathe. Lips and nail beds are
cyanotic; ankles are swollen.
• B/P 186/100; P - 124; R - 34; SaO2 - 88%
• Crackles are auscultated in the lower half of
the lung fields.
Case Scenario #1
• History: angina and hypertension; smokes 1
pack per day for the past 30 years
• Meds: Cardizem, nitroglycerin PRN; 1 baby
aspirin daily; furosemide, Atrovent inhaler
as needed
• Rhythm:
Case Scenario #1
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What is your impression?
What will be your intervention(s)?
What is the rationale for your interventions?
What is this patient’s rhythm and do you
need to administer any medications for the
rhythm?
Case Scenario #1
• Impression: congestive heart failure with
pulmonary edema
– paroxysmal nocturnal dyspnea (sudden
shortness of breath at night)
– bilateral crackles in the lungs
– peripheral edema
– cardiac history - hypertension and angina
• Rhythm - sinus tachycardia
– do not treat this rhythm with medication
– determine and treat the underlying cause
Case Scenario #1
• Interventions
– Sit the patient upright, have their feet dangle off
the sides of the cart
• promotes venous pooling of blood and
decreases the volume of return to the heart
– Oxygen via non-rebreather face mask
– Prepare to assist breathing via BVM
• have BVM reached out and ready for use
– IV-O2-monitor
– Meds: NTG, Lasix, Morphine, consider CPAP
Unstable Acute Pulmonary Edema
• Altered mental status
• Systolic B/P < 100 mmHg
• Contact Medical Control
– medications given in the stable patient are now
contraindicated due to a lowered blood pressure
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CPAP on orders of Medical Control
Consider Cardiogenic Shock protocol
Treat dysrhythmia as they are presented
Contact Medical Control for Albuterol if
wheezing; possibly in-line with intubation
CPAP
Continuous
Positive
Airway
Pressure
A means of providing high flow, low pressure
oxygenation to the patient in pulmonary edema
CPAP
• CPAP, if applied early enough, is an effective
way to treat pulmonary edema and a means to
prevent the need to intubate the patient
• CPAP increases the airway pressures allowing
for better gas diffusion & for reexpansion of
collapsed alveoli
• CPAP allows the refilling of collapsed, airless
alveoli
• CPAP allows/buys time for administered
medications to be able to work
CPAP expands the surface area of the
collapsed alveoli allowing more surface
area to be in contact with capillaries for gas
exchange
Before
CPAP
With CPAP
• CPAP is applied during the entire
respiratory cycle (inhalation & exhalation)
via a tight fitting mask applied over the
nose and mouth
• The patient is assisted into an upright
position
• The lowest possible pressure should be used
– the higher the pressure, the risk of barotrauma
(pneumothorax, pneumomediastinum) rises
– increased pressures in the chest decrease
ventricular filling worsening cardiac output
(less coming into the heart, less going out of the
heart)
Goal of Therapy With CPAP
• Increase the amount of inspired oxygen
• Decrease the work load of breathing
In turn to:
Decrease the need for intubation
Decrease the hospital stay
Decrease the mortality rate
Indications & Criteria for
Use
CPAP
• Patient identified with signs & symptoms of
pulmonary edema or, in consultation with
Medical Control, exacerbation of COPD
with wheezing
• Patient must be alert & cooperative
• Systolic B/P >100 mmHg
• No presence of nausea or vomiting; absence
of facial or chest trauma
Patient Monitoring During CPAP Use
• Patient tolerance; mental status
• Respiratory pattern
– rate, depth, subjective feeling of improvement
– B/P, pulse rate & quality, SaO2, EKG pattern
• Indications the patient is improving (can be
noted in as little as 5 minutes after beginning)
reduced effort & work of breathing
increased ease in speaking
slowing of respiratory and pulse rates
increased SaO2
Discontinuation of CPAP
• Hemodynamic instability
– B/P drops below 100 mmHg
• The positive pressures exerted during the use
of CPAP can negatively affect the return of
blood flow to the heart
• Inability of the patient to tolerate the tight
fitting mask
• Emergent need to intubate the patient
Patient Circuits
• Complete package includes
mask tubing
head strap
Whisperflow CPAP valve
corrugated tubing
air entrapment filter
Patient Circuit
Oxygen Tank Duration
• D sized tank - 30 minutes*
– typical small portable tank kept on patient cart
• H sized tank - 508 minutes* (8+ hours)
– typical large tank kept in locker on rig
Other tank sizes:
• E sized tank - 50 minutes*
– typically used in hospitals during patient transports
• M sized tank - 253 minutes*
* Based on 50 psi output & approx 30% FIO2
Case Scenario #2
• You have initiated CPAP and simultaneous
medication administration (NTG, Lasix and
Morphine) to a 76 year-old patient who EMS
has assessed to be in acute pulmonary edema
• The patient begins to lose consciousness and the
blood pressure has fallen to 86/60.
• What is the appropriate response for EMS to
take?
Case Scenario #2
• This patient is showing signs of deterioration
• The CPAP needs to be discontinued
• No further medications (NTG, Lasix,
Morphine) can be administered due to the
lowered B/P
• Prepare to intubate the patient following the
Conscious Sedation SOP
– support ventilations with BVM prior to
intubation attempt
COPD
• Chronic obstructive pulmonary disease - a
progressive and debilitating collection of
diseases with airflow obstruction and
abnormal ventilation with irreversible
components (emphysema & chronic
bronchitis)
• Exacerbation of COPD is an increase in
symptoms with worsening of the patient’s
condition due to hypoxia that deprives
tissue of oxygen and hypercapnia (retention
of CO2) that causes an acid-base imbalance
Obstructive Lung Disease COPD & Asthma
• Abnormal ventilation usually from
obstruction in the bronchioles
• Common changes noted in the airways
– bronchospasm - smooth muscle contraction
– increased mucous production lining the
respiratory tree
– destruction of the cilia lining resulting in poor
clearance of excess mucus
– inflammation of bronchial passages resulting in
accumulation of fluid and inflammatory cells
The Ventilation Process
• Normal inspiration - the working phase
– bronchioles naturally dilate
• Normal exhalation - the relaxation phase
– bronchioles constrict
• Exhalation with obstructive airway disease
– exhalation is a laborous process and not
efficient or effective
– air trapping occurs due to bronchospasm,
increased mucous production, and
inflammation
Emphysema
• Gradual destruction of the alveolar walls
distal to the terminal bronchioles
• Less area available for gas exchange
• Small bronchiole walls weaken, lungs
cannot recoil as efficiently, air is trapped
•  in number of pulmonary capillaries which
 resistance to pulmonary blood flow which
leads to pulmonary hypertension
– may lead to right heart failure & cor pulmonale
(disease of the heart because of diseased lungs)
Alveolar Sac and Capillaries
Emphysema
•  in PaO2 leads to  in red blood cell
production (to carry more oxygen)
• Develop chronically elevated PaCO2 from
retained carbon dioxide
• Loss of elasticity/recoil; alveoli dilated
• More common in men; major contributing
factor is cigarette smoking; another
contributing factor is environmental exposures
• Patients more susceptible to acute respiratory
infections and cardiac dysrhythmias
Assessment of Emphysema
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“Pink puffer” - due to excess red blood cells
Recent weight loss; thin bodied
Increased dyspnea on exertion
Progressive limitation of physical activity
Barrel chest (increased chest diameter)
Prolonged expiratory phase (usually pursed lip
breathing noted on exhalation)
• Rapid resting respiratory rate
• Clubbing of fingers
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Diminished breath sounds
Use of accessory muscles
One-to-two word dyspnea
Wheezes and rhonchi depending on amount
of obstruction to air flow
• May have signs & symptoms of right heart
failure
jugular vein distention
peripheral edema
liver congestion
Case Scenario #3
• The patient is a conscious, restless, and anxious
68 year-old male with respiratory distress that has
progressively worsened during the past 2 days.
• The patient has cyanosis of the lips and nail beds
• B/P 138/70; P - 116 & irregular; R - 26; SaO2 82%
• Rhonchi and rales are auscultated in the lower
right lung field; patient feels warm to the touch
• The patient has had a cold for 1 week with a
productive cough of yellow-green sputum
• Hx: emphysema, angina, osteoarthritis
Case Scenario
Case Scenario #3
What is this patient’s rhythm?
What influence would this rhythm have on this
patient’s health history & current condition?
Do you need to intervene?
Atrial fibrillation diminishes the efficiency of
the pumping of the heart which can further
compromise the cardiac output
Case Scenario #3
• Impression & intervention?
• The patient has COPD most likely
complicated by pneumonia
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a “cold” over the last week
productive cough of yellow-green sputum
warm to the touch (temperature 100.60F)
rhonchi & rales in the right lung field base
• Routine medical care
– supplemental oxygen
–  heart rate most likely due to pneumonia and
does not need specific treatment
Chronic Bronchitis
• An increase in the number of mucoussecreting cells in the respiratory tree
• Large production of sputum with productive
cough
• Diffusion remains normal because alveoli
not severely affected
• Gas exchange decreased due to lowered
alveolar ventilation which creates hypoxia
and hypercarbia
Assessment of Chronic Bronchitis
• “Blue bloater” - tends to be cyanotic
• Tends to be overweight
• Breath sounds reveal rhonchi (course gurgling
sound) due to blockage of large airways with
mucous plugs
• Signs & symptoms of right heart failure
jugular vein distention
ankle edema
liver congestion
Drive to Breath & COPD
• Normal driving force to breathe
– decreased oxygen (O2) level
– increased carbon dioxide (CO2) level
• Chemoreceptors sense:
– too little O2 ( resp rate to improve) or
– too much CO2 ( resp rate to blow off more CO2)
• Patients with COPD have retained excess CO2
for so long that their chemoreceptors are no
longer sensitive to the elevated CO2 levels
– COPD patients breathe to pull in O2
O2 Administration & COPD
Never withhold oxygen therapy from a
patient who clinically needs it
• Monitor all patients receiving O2 but especially
the patient with COPD
• Normal O2 sat for COPD patient is around 90%
• If the patient with COPD is supplied all the
oxygen they need, this might trigger them not to
work at breathing anymore and may result in
hypoventilation and/or respiratory arrest
Asthma
• Chronic inflammatory disorder of the
airways
• Airflow obstruction and
hyperresponsiveness are often reversible
with treatment
• Triggers vary from individual
environmental allergens
cold air; other irritants
exercise; stress
food; certain medications
Asthma’s Two-Phase Reaction
• Phase one - within minutes
– Release of chemical mediators (ie: histamine)
• contraction of bronchial smooth muscle
(bronchoconstriction)
• leakage of fluid from bronchial capillaries
(bronchial edema)
• Phase two - in 6-8 hours
– Inflammation of the bronchioles from invasion of
the mucosa of the respiratory tract from the
immune system cells
• additional swelling & edema of bronchioles
Assessment of Asthma
• Presentation
– Dyspnea
– Wheezing - initially heard at end of exhalation
– Cough - unproductive, persistent
• may be the only presenting symptom
– Hyperinflation of chest - trapped air
– Tachypnea - an early warning sign of a
respiratory problem
– Use of accessory muscles
Severe Asthma Attack
• One and two word dyspnea
• Tachycardia
• Decreased oxygen saturation on pulse
oximetry
• Agitation & anxiety with increasing
hypoxia
Obtaining a History
• Very helpful in forming an accurate
impression
• Will have a history of asthma
• Home medications indicate asthma
• A prior history of hospitalization with
intubation makes this a high-risk patient for
significant deterioration
• Note: unilateral wheezing is more likely an
aspirated foreign body or a pneumothorax
than an asthma attack
Treatment Goals COPD & Asthma
Relieve and correct hypoxia
Reverse any bronchospasm or
bronchoconstriction
Asthma/COPD with Wheezing SOP
• Routine medical care
• Pulse oximetry (on room air if possible)
• Albuterol 2.5 mg / 3ml with oxygen
adjusted to 6 l/minute
• May repeat Albuterol treatments if needed
• May need to consider intubation with
in-line administration of Albuterol based on
the patient’s condition
• Contact Medical Control for possible CPAP
in patient with COPD
Albuterol Nebulizer Procedure
• Medication is added to the chamber which
must be kept upright
• The T-piece is assembled over the chamber
• The patient needs to be coached to breath
slowly and as deeply as possible
– this will take time and several breathes before the
patient can slow down and start breathing deeper;
the patient needs a good coach to talk them through
the slower/deeper breathing
– the medication needs to be inhaled into the lungs to
be effective
– the patient should be sitting upright
Add medication to the chamber
Connect the mouthpiece to the
T-piece
Connect the corrugated tubing to
the T-piece
Kit connected to
oxygen and run
at 6 l/minute
(enough to
create a mist)
Encourage slow, deep breathing
Albuterol Nebulizer Mask
For the patient
who is unable to
keep their lips
sealed around the
mouthpiece, take
the top T-piece
off the kit and
replace with an
adult or pediatric
nebulizer mask
Pediatric
patient
using
nebulizer
mask.
Caregiver
may assist
in holding
the mask.
Case Scenario #4
• 7 year-old with history of asthma has
sudden onset of difficulty breathing and
wheezing while playing outside
• Patient has an increased respiratory rate and
is using accessory muscles
• B/P - 108/70; P - 90; R - 20; SaO2 - 97%
• Upon auscultation, left lung is clear and
wheezing is present on the right side
• Impression and intervention?
Case Scenario #4
• Sounds like asthma, looks like asthma, has a
history of asthma but why should you not
suspect asthma?
– Asthma is not a selective disease - the patient
will have widespread, not localized,
bronchoconstriction and have bilateral
wheezing, not unilateral
• Dig into the history more - what was the
patient doing prior to the development of
symptoms?
Case Scenario #4
• This patient was playing with friends,
running around while eating food
• Possibly aspirated a foreign body
– sudden onset of unilateral wheezing
• Albuterol would not be indicated in this
situation
• Transport with supplemental oxygen if
indicated, position of comfort, reassessment
watching for increase in airway obstruction
Aerosol Medication via BVM or ETT
with BVM (In-line)
• Place Albuterol in the chamber as usual
• Connect the chamber to the T-piece
• Once the nebulizer kit is assembled and the clear
adaptor(s) are in place, you may begin to bag the
patient prior to completion of intubation
– the clear adaptor on the corrugated tubing is attached
to the BVM’s mask
– any medication that can be delivered as soon as
possible to the target organ (the lungs) will be helpful
in promoting bronchodilation
• Nebulizer with white T-piece (CMC pyxis)
– Remove the white mouth piece; the BVM will
be connected to this port
– Add a clear adaptor to the distal end of the
corrugated tubing
– Intubate the patient as usual and connect the
clear adaptor on the corrugated tubing to the
proximal end of the ETT placed in the patient
– Begin to bag the patient
– Supplemental oxygen must be connected to the
nebulizer and the BVM
• Nebulizer with blue T-piece
– Remove the mouthpiece from the T-piece and
connect a clear adaptor in it’s place
– The BVM will attach to the clear adaptor on the Tpiece
– Add a second clear adaptor to the distal end of the
corrugated tubing
– This clear adaptor will be connected to the
proximal end of the ETT after intubation is
performed in the usual manner
– Supplemental oxygen must be connected to the
nebulizer and the BVM
• Remove
mouthpiece
from T-piece
and replace with
BVM
• Connect
nebulizer to
oxygen source
• Place clear
adaptor at distal
end of
corrugated
tubing (to
connect to ETT)
• Intubate the patient
• Connect the clear
adaptor on the distal
end of the corrugated
tubing to the
proximal end of the
ETT
• Confirm placement
in the usual manner
– visualization
– chest rise & fall
– 5 point
auscultation
– ETCO2 detector
Case Scenario #5
• EMS has responded to a 14 year-old child in
severe respiratory distress with audible
wheezing. The complaints have been present
for the past 3 hours. Inhalers used have not
been effective.
• B/P - 112/60; P - 120; R - 32; SaO2 - 89%
• Patient is very anxious, pale, cool, and
diaphoretic. The lips and nail beds are
cyanotic.
• What is your impression?
• What is your greatest concern?
Case Scenario #5
• This patient is experiencing a severe asthma
attack that is not responding to medication status asthmaticus
• This patient is in danger of going into
respiratory arrest due to exhaustion
• Begin supportive oxygen therapy
• Set up the albuterol nebulizer kit and
simultaneously the BVM
• Anticipate intubation with administration of
Albuterol via the in-line method
Case Scenario #5
• Patients experiencing an asthma attack are
in need of bronchodilators (Albuterol) and
IV fluids (they are usually dry from the
rapid respirations and inability to have been
taking in fluids)
• If the patient is losing consciousness, you
may need to follow the Conscious Sedation
SOP to intubate and administer Albuterol
via in-line
Conscious Sedation
• Would Lidocaine bolus be indicated?
• What is the dose of Versed and the purpose
of Versed?
• What would be the effects of Morphine?
• How do you know if the patient needs
Benzocaine (Hurricaine, Cetacaine)?
Conscious Sedation
• Lidocaine is not indicated
– there is no presence of head injury or insult
• Versed is an amnesic and will relax the
patient
• Versed does not take away any pain
• The dose of Versed is 5 mg slow IVP
– If not sedated within 60 seconds, Versed 2 mg
slow IVP every minutes until sedated
– Following sedation, may give Versed 1 mg IVP
every 5 minutes for agitation (total dose 15 mg)
Conscious Sedation
• Morphine can help increase the effects of
Versed and assist in improving patient sedation
– Morphine 2 mg slow IVP over 2 minutes
– May repeat Morphine every 3 minutes
– Max dose Morphine 10 mg
• Benzocaine eliminates the gag reflex
– The conscious patient will have a gag reflex
– For the unconscious patient, stroke at the eyelashes
or tap the space between the eyes
• The gag reflex disappears with the blink reflex
– Minimize the duration of spray (<2 seconds)
Bibliography
• Bledsoe, B., Porter, R., Cherry, R.
Essentials of Paramedic Care. Brady.
2007.
• Kohlstedt, D. Sales Representative. Tri-Anim.
• Region X SOP’s, March 1, 2007.
• Sanders, M. Mosby’s Paramedic Textbook,
Revised Third Edition. 2007.
• Via Google: Respiratory Module Part I
• Via Google: Respiratory Module Part II