Transcript Waiting to Exhale - faculty at Chemeketa

Waiting to Exhale
Respiratory Disorders
Peggy Andrews, Instructor
1
The Respiratory System
A quick review
• Upper airway
– To larynx
– Warms, humidifies,
cleans
– Cilia
– Turbinates
– Hard and Soft palates
3
Review, continued
• Lower airway
– Below larynx
– Trachea
– Bronchi
– Bronchioles
– Alveoli
– Surfactant
4
Lower airway, cont.
• Lungs
– Lobes
– Visceral pleura
– Parietal pleura
5
Review, continued
• Ventilation
– Inspiration
– Expiration
• Respiration-Tidal
Volume
– 500ml
• Inspiratory Reserve
Volume
– 3000ml
• Expiratory reserve
volume
– 1500ml
• Residual volume
– 1200ml
• Dead air space
– 150ml
• Minute volume
– TV x RR
6
What controls our breathing?
• Medulla
– 12-20/min
– Inspiratory and Expiratory areas
• Transmitted through
– Phrenic nerve
• 3rd, 4th, 5th spinal nerves
– Intercostal nerves
• 11 pair
• Can be modified by
– Cerebral cortex
– Hypothalamus
– Pons - on/off switch
7
What controls our breathing, cont.
• Stretch
receptors
– Visceral
pleura
– Bronchi and
bronchiole
walls
=
Hering-Breuer reflex
• PCO2 increase = increased PCO2 in CSF =
decreased pH
8
Respiratory patterns
Cheyne-Stokes
Kussmaul’s
Central neurogenic hyperventilation
Ataxic (Biot’s)
Apneustic
9
11
Respiratory Disorders
• Incidence - 28% of all EMS C/C
• Morbidity/Mortality - >200,000
deaths/yr.
12
Risk Factors
Genetic predisposition
Asthma
COPD
Carcinomas
13
14
15
Case Presentation One
• On a cold Sunday morning in February, a
basic amb’lance is dispatched to a trailer
park for a “woman down”. When the EMTs
arrive, they are met by a young couple who
explain that they had arrived about 30
minutes earlier to pick their mother up for
church. They found her on the floor of her
bathroom, lying on her right side. According
to the couple, the mother said that she had
fallen just after lunch the previous day, and
she had been unable to get up.
16
Entering the bathroom, the EMTs
find:
• An elderly woman, CAO PPTE, lying on
her side and covered with diarrhea. She
says that she feels “fine” but admits to
some focal right-sided chest pain and a
bruise on her hip where she fell.
17
• She tells the EMTs that she has been
experiencing diarrhea for the past two
days. Although she feels dizzy, she
denies any syncope at the time of her
fall, and says that she simply slipped as
she was sitting on the toilet.
18
The Patient Is:
•
•
•
•
•
Pale
Mildly cyanotic nailbeds
Skin is warm and dry
Mucous membranes are dry
A productive cough with thick, brown
sputum
• She states that the coughing is left over
from a cold that she had contracted the
previous month.
19
• Breath sounds are congested with
rhonchi
• Blood pressure – 90/50 mmHg
• Pulse – 128/min.
• Respirations – 40/min. and shallow
• Temperature – 101.6 F (oral)
20
• The EMT’s determine that the
patient is dehydrated from the
diarrhea. They administer oxygen at
4 L/min., and request that an ALS
ambulance be dispatched. You
arrive to find this 72 year old patient
unchanged.
21
• During your transport, her cyanosis
progresses to her lips, although she
remains alert and oriented and
insists she is “OK”. Her medical
history reveals that she is a chronic
alcoholic, has been Dx with hepatic
cirrhosis, and has a 145-pack year
smoking history.
22
• Rhonchi and rales are still noted in
her right chest
• BP – 88/58 mmHg
• P – 116/min.
• Respirations – 30/min.
• Temp 102.5 F (oral)
23
1. What is her differential
diagnosis?
2. What treatment might you
provide for this patient? Why?
Signs of life-threatening respiratory
distress in adults
• Altered mental
status
• 1-2 word speech
• Tachycardia >
130/min.
• Absent breath
sounds
• Retractions/
accessory muscle use
• Audible stridor
• Pallor and
diaphoresis
• Severe cyanosis
25
26
COPD
(Chronic Obstructive Pulmonary Disease)
• Emphysema
• Chronic Bronchitis
• Asthma
27
Case Presentation Two
• You are dispatched as first-in ambulance to
a “medical emergency – unknown problem”.
• The response time to this rural address is
about 12 minutes.
• On arrival, you find a first responder who
tells you they have a 55-year-old male with
difficulty breathing.
• She says that oxygen is already being
administered.
28
• You enter the house to find the patient
seated at the kitchen table, obviously short
of breath.
• Your initial assessment shows that the
patient is moving air, and has a strong pulse.
• You replace the nasal cannula with a
non-rebreather at 12 Lpm
29
You note the following:
• The patient has diminished breath
sounds
• Occasional rhonchi
• He is using his accessory muscles
• He has mild cyanosis around his
mouth.
30
• Several years ago, doctors at the VA
hospital diagnosed the patient as having
emphysema.
• Over the last 24 hours, the patient has had
progressive dyspnea, and didn’t sleep at all
last night.
31
•
•
•
•
•
•
•
•
•
BP – 140/78
P - 96
Resp – 28
Ecg – SR
SaO2 – 90% with oxygen
Pt is CAO PPTE
Meds – Theophylline and Amoxicillin
Smokes 1 PPD with a 30 pack-yr-hx
He wants to be transported to the VA
hospital
32
• What is his differential
diagnosis?
• What treatment might you
provide him?
• Why?
33
Emphysema
• Irreversible airway obstruction
• Diffusion defect also exists because of
blebs - prone to collapse
• Patient exhales with pursed lips
• Almost always associated with cigarette
smoking or environmental toxins
34
Emphysema Pathophysiology
• Destruction of alveolar walls distal to
terminal bronchioles.
• More common in men
• Walls of alveoli gradually distruct, = 
alveolar membrane surface area.
Results in  ratio of air to lung tissue.
•  Pulmonary capillaries , = 
resistance to pulmonary blood flow.
• Causes pulmonary hypertension, leads
to RHF, then Cor Pulmonale
35
Emphysema Pathophysiology (cont.)
• Bronchiole walls weaken, lungs lose elasticity,
air is trapped.  Residual volume, but vital
capacity relatively normal.
• PaO2 , =  RBC, polycythemia.
• PaCO2 is chronically elevated. The body
depends on hypoxic drive.
• Pt’s are more susceptible to pneumonia,
dysrhythmias.
• Meds: bronchodilators, corticosteroids, O2.
36
Assessment
• Altered mentation
• 1-2 word “sentences”
• Absent or decreased breath sounds
• c/c Dyspnea, morning cough, nocturnal
dyspnea, wheezing
37
• History – Personal or family hx of allergies/asthma
– Acute exposure to pulmonary irritant
– Previous similar expisodes
– Recent wt. loss, exertional dyspnea
– Usually > 20 pack/year/history
38
Exam
• Wheezing
• Retractions and/or
accessory muscle
use
• Barrel chest
• Prolonged expiratory
phase
• Rapid resting
respiratory rate
•
•
•
•
Thin
Pink puffers
Clubbing of fingers
Diminished breath
sounds
• JVD, hepatic
congestion,
peripheral edema
39
Management
• Pulse oximeter (end tidal CO2 detector)
• Assisted ventilation prn
• High flow oxygen
• Intubation prn
• IV therapy with fluids
• Albuterol, or Albuterol/Atrovent neb
• Transport considerations
40
Chronic Bronchitis
• Productive cough for at least 3 months for two
or more consecutive years
• An increase in mucous-secreting cells
• Characterized by large quantity of sputum
• Chronic smoker
• Alveoli not severely affected - diffusion normal
• gas exchange = hypoxia & hypercarbia
• May increase RBC = polycythemia
•  paCO2 = irritability, h/a, personality changes,
 intellect.
•  paCO2 = pulmonary hypertension &
eventually cor pulmonale.
41
Assessment
•
•
•
•
Hx heavy cigarette smoking
Frequent resp. infections
Productive cough
Overweight, possibly cyanotic - blue
bloaters
• Rhonchi on auscultation - mucous plugs
• S/S RHF; JVD, edema, hepatic
congestion
42
Management
• Pulse oximetry (end tidal CO2 detector)
• Oxygen - low flow if possible
• Nebulized Albuterol/Atrovent
• Constantly monitor
• Position - seated
• IV TKO
43
44
Case Presentation Three
• It is a hot June afternoon when you
are dispatched to the local middle
school for a child with difficulty
breathing. You are directed to the
nurse’s office, and there you find a 10
year-old female.
45
•
•
•
•
•
Wt – 45 kg
Sitting upright on the cot
CAO PPTE
Obviously struggling to breathe.
Anxious
46
• The nurse tells you that the patient is
relatively new to the school, and the
only medical information she has is
that the patient is allergic to many
things (dust, pets, plants, as well as
peanuts, eggs, shellfish).
47
• The nurse has been unable to contact
the parents – they are both out of
town, and the custodial aunt is about
30 minutes away, but has left a
message to do whatever you think
should be done.
48
• The nurse tells you that all she knows
is that the patient was out at recess,
wandered away from the other
children, and when a playground aide
went to find her, the patient was
sitting down, pale, c/o difficulty
breathing and had vomited x 1.
49
You find the following:
•
•
•
•
PERL
P – 132
RR – 32 and shallow
Intercostal retractions, suprasternal notch
retractions, nasal flaring, pursed-lip
breathing, and sub-costal retractions are all
apparent.
• Breath sounds are diminished in all lobes,
with some wheezing in the bases.
50
• Skin is pale, cool, dry
• Temp is 98.7 F (tympanic)
• CBG is 100 mg/dcL
• EKG – sinus tachycardia
• Patient is able to speak in two or three
word sentences only
51
• She tells you that she hasn’t had to
use an inhaler for about 4 years, and
currently takes no meds except
vitamins. She hasn’t been feeling well
for a day or so, and ate breakfast, but
no lunch. Her urine output is down
today as well.
52
• What is your differential
diagnosis?
• What treatment would you offer
this patient and why?
53
Asthma
• Reversible obstruction caused by combination
of smooth muscle spasm, mucous, edema
• Exacerbating factors - extrinsic in children,
intrinsic in adults
• Status asthmaticus - prolonged exacerbation doesn’t respond to therapy
• Significant increase in deaths in last decade45 years or older - black 2x higher
• 50% are prehospital deaths.
54
Pathophysiology
• A chronic inflammatory airway disorder.
• Triggers vary - allergens, cold air,
exercise, food, irritants, medications.
• A two-phase reaction
• Phase one
– Histamine release - bronchial constriction,
leakage of fluid from peribronchial
capillaries = bronchoconstriction, bronchial
edema.
– Often resolves in 1 - 2 hours
55
Pathophysiology (cont.)
• Phase two
– 6-8 hours after exposure, inflammation of
bronchioles - eosinophils, neutrophils,
lymphocytes invade respiratory mucosa;
= additional edema, swelling.
– Doesn’t typically respond to inhalers; often
requires corticosteriods.
• Inflammation usually begins
days/weeks before attack.
56
Assessment
• Dyspnea, 1-2 word
sentences
• Persistent, nonproductive cough
• Wheezing
• Hyperinflation of
chest
• Tachypnea,
accessory muscle
use
• Pulsus paradoxis
– 10-15 mm bp drop
during insp vs exp
• Agitated, anxious
• Decreased oxygen
saturation
• Tachycardia
• Hx of allergies
• Auto PEEP
• Potential tensions
(bilateral)
57
Management
•
•
•
•
•
•
•
•
•
Check home meds
Determine onset of sx & what pt. has taken
Check vitals carefully – RR x 30 sec.
High flow oxygen
IV with fluids
EKG
Inhalers
Consider epinephrine 1:1,000 SQ, 0.3-0.5 mg
Consider Solu-Medrol, 1 –2 mg/kg IVP, max
125 mg
58
Status Asthmaticus
• Severe, prolonged asthma attack not
responsive to treatment
• Greatly distended chest
• Absent breath sounds
• Pt. exhausted, dehydrated, acidotic.
• Treat aggressively if obtunded, profuse
diaphoresis, floppy – Intubate (poss.
RSI)
• Transport immediately
59
60
Case Presentation Four
• It is 10 pm on a Saturday night in December,
and you are dispatched to the mission for a
report of a 60 year old male having difficulty
breathing. You are met at the door by a
worker who tells you that they had just
opened the doors to allow the homeless in
for the night. Immediately after assigning
cots, they noticed the patient sitting on the
edge of his cot, blue and gasping for air.
61
• You find this 60 y/o, 63 kg male patient,
sitting upright with his hands braced on
his knees. He has audible wheezing,
and is unable to say more than two
words without gasping.
62
• He tells you he has had a cough for the
past couple of months, and that he has
been having some chest pain for the
past two or three days, has felt
nauseated, and has had chills. He says
that it got much worse tonight.
63
• He hasn’t been seen by a physician.
He says that he has a history of alcohol
abuse, smokes about ½ pack of
cigarettes per day, and has since he
was 10 years old.
64
Your exam reveals the following:
• PERL
• Skin cool, dry, pale with cyanosis to nailbeds,
lips, earlobes.
• Audible wheezing, diffuse rales in all lobes,
using accessory muscles, has intercostal
retractions, and pursed lip breathing.
• Temp is 97.8 F (tympanic)
• BP – 126/84
• P – 112; RR – 28 and shallow
• He is thin, and has clubbing of his fingers. 65
• What is his differential
diagnosis?
• What treatment would you offer
this patient? Why?
66
Pneumonia
• 5th leading cause of death in US
• Risk factors
–
–
–
–
Cigarette smoking
Alcoholism
Cold exposure
Extremes of age
• Pathophysiology
– A common respiratory disease caused by
infectious agent. bacterial and viral pneumonia
most frequent
– May cause atelectasis
– May become systemic = sepsis
67
Assessment
• Typical
– Acute onset of fever and chills
– Cough productive with yellow/green
sputum (bad breath!)
– May have pleuritic chest pain
– Pulmonary consolidation on auscultation
– Rales
– Egophony (strange lung sounds)
• Atypical
– Non-productive cough
– H/A
– Fatigue
68
Management
•
•
•
•
•
•
Position
Oxygen
Consider breathing treatment
IV with fluids
Cool if febrile
Elderly, over 65 years
– Significant co-morbidity
– Inability to take meds
– Support complications
69
70
Case Presentation Five
• You respond to a call for a “shortness of
breath”. It is 0930 on a Tuesday. When you
arrive, you find a 42 year-old woman. She
says that she has had flu-like sx for the past
3 days. This morning, she began breathing
rapidly and called 9-1-1. She denies other
complaints, but says she has been under
some stress. She has just started a new job,
and has had to call in sick for the past two
days.
71
On physical exam:
• Airway is patent
• She is tachypneic at 46/min. with deep
respirations and good air exchange
• Her pulse is 108 and regular
• Skin is warm, dry, with pink mucosa
• CAO PPTE, and moderately anxious
• The rest of your exam is normal.
72
• You cancel the first responders,
and spend nearly 40 minutes
coaching her to slow her breathing
without success. Finally, you
transport her to the ED.
73
• What is your differential
diagnosis?
• What treatment would you offer
this patient? Why?
74
Hyperventilation Syndrome
• Multiple causes
– Hypoxia
– High altitude
– Pulmonary disease
– Pneumonia
– Interstitial pneumonitis, fibrosis, edema
– Pulmonary emboli
– Bronchial asthma
– Congestive heart failure
– Hypotension
– Metabolic disorder
– Acidosis
75
Hyperventilation Syndrome
(cont)
• Causes (cont)
– Hepatic failure
– Neurologic disorders
– Psychogenic or anxiety hypertension
– Central nervous system infection, tumors
– Drug-induced
– Salicylate
– Methylxanthine derivatives
– Beta-adrenergic agonists
– Progesterone
– Fever,sepsis
– Pain
– Pregnancy
76
Assessment
• Chief complaint
– Dyspnea
– Chest pain
– Other sx based on etiology
– Carpopedal spasm
– Tachypnea with high minute volume
77
Management
• Depends on cause of syndrome
• Oxygen based on sx and pulse
oximetry (CO2 waveform)
• Consider coached ventilation
78
79
Upper Respiratory Infection (URI)
• One of most common c/c
• Usually viral
• Bacterial infections
– Group A streptococcus
• Strep throat
• Sinusitis
• Middle ear infections
• Most URI’s self-limiting
80
URI continued
• S/S
– Fever
– Chills
– Myalgia
– Fatigue
• Treatment
– Supportive
– Acetaminophen, ibuprofen, liquids
81
URI, cont.
• If pediatric, beware of possibility of
epiglotitis
• If PMH; Asthma or COPD, condition may
worsen
– Consider nebulized meds
82
Lung CA
• Most caused by cigarette smoking
• 4 major types
– Adenocarcinoma – most common
• Origin; mucus-producing cells
– Small cell carcinoma
– Epidermoid carcinoma
– Large cell carcinoma
• Origin; bronchial tissues
• Most patients die within one year
83
Lung CA, continued
• General Assessment; • Advanced disease
–
–
–
–
–
Altered mentation
1-2 word sentences
Cyanosis
Hemoptysis
Hypoxia
–
–
–
–
Profound weight loss
Cachexia
Malnutrition
Crackles, rhonchi,
wheezes
– Diminished breath
sounds
– Venous distention in
arms and neck
84
• Localized disease
– Cough, dyspnea, hoarseness, vague chest
pain, hemoptysis
• Local invasion
– Pain on swallowing (dysphagia)
– Weakness, numbness in arm
– Shoulder pain
• Metastatic spread
– Headache, seizures, bone pain, abdominal
pain, nausea, malaise
85
Treatment for Lung CA
•
•
•
•
•
•
Oxygen prn
Support ventilations
Intubate prn
IV
Nubulized meds
DNR / Advanced directive?
86
Toxic inhalation
• Consider if patient dyspneic
• Causes
– Superheated air
– Products of combustion
– Chemical irritants
– Steam inhalation
87
Inhalation injury, cont.
• Medic safety
– Ammonia (ammonium hydroxide)
– Nitrogen oxide (nitric acid)
– Sulfer dioxide (sulfurous acid)
– Sulfur trioxide (sulfuric acid)
– Chlorine (hydrochloric acid)
88
• Assessment
– Enclosed space?
– Loss of consciousness?
– Mouth, face, throat, nares
– Auscultate chest
– Laryngeal edema
• Hoarseness, brassy cough, stridor
• Management
– Maintain airway
– High-flow humidified oxygen
– IV
89
Carbon Monoxide Inhalation
• Incomplete burning of fossel fuels,
other carbon-containing compounds
• Automobile exhaust, home-heating
devices most common causes
• CO has >200x affinity for hemoglobin
– Cellular hypoxia
• Also binds to iron-containing enzymes
– Increased cellular acidosis
90
CO, continued
• Assessment
– Source, length of exposure? Closed vs
open space?
• S/S
– H/A, N/V, confusion, agitation, loss of
coordination, chest pain, loss of
consciousness, seizures
– Cyanosis
– Cherry red skin (very late)
91
CO, continued
• Management
– SAFETY
– Maintain airway
– High flow oxygen (NRB vs assisted)
– Hyperbaric oxygen therapy
92
Pulmonary Embolus
•
•
•
•
Thrombus
Ventilation perfusion mismatch
50,000 deaths in US annually
Conditions that predispose to PE
–
–
–
–
–
–
Recent surgery
Long-bone fracture
Bedridden
Long flights/truck drivers
Pregnancy
Cancer, infections, thrombophlebitis, AF, sickle cell
anemia
– BCP
93
PE, cont
• Assessment
– Sudden onset SOB, Hypoxic
– Pleuritic chest pain
– Non-productive cough
– History
– Labored breathing, tachypnea, tachycardia
– RHF
– DVT present
94
PE, cont
•
•
•
•
•
•
•
Management
ABC
Airway
High flow oxygen
ET?
IV – flow rate?
Heparin gtt? TPA?
95
Spontaneous pneumothorax
• Common- high recurrent rate
– 5:1 male to female
– Tall, thin
– Smoking history
– 20-40 years old
– COPD = increased risk
• Ventilation perfusion mismatch if > 20%
96
Spont. Pneumothorax, cont.
• Assessment
– Sudden onset sharp chest or shoulder pain
– Coughing/lifting
– Dyspnea
– Decreased breath sounds at apex
– Hyper resonance
– Sub-cutaneous emphysema
– Tachypnea, diaphoresis, pallor
97
Spont. Pneumothorax, cont.
• Management
– Supplemental oxygen
– If symptoms increase, consider needle
decompression
– Position of comfort
98
That’s all about breathing
for now, folks!
99