Transcript Airway Diseases - faculty at Chemeketa

Airway Diseases
EMT-Intermediate, W06
P. Andrews
Respiratory Distress Profiles
• Disease and Trauma Profiles
• Management Decisions
Objectives
• Determine the general approach,
assessment an management
priorities for respiratory distress
• Explain how effective assessment is
critical to decisions in airway
management of respiratory distress
Objectives
• Differentiate between critical lifethreatening, potentially lifethreatening and non life-threatening
patient presentations
Objectives
• Discuss normal and abnormal
assessment findings with airway
disease
• Discuss specific observations and
specific findings with airway disease
Objectives
• Describe the epidemiology,
pathophysiology, assessment and
management priorities for respiratory
distress
Objectives
• Compare airway and ventilation
techniques used to manage airway
disease
• Discuss the pharmacological
preparations that EMT-Intermediates
use for the management of airway
disease
Assessment of Respiratory
Distress
General Approach to Respiratory
Distress
•Scene Size-Up
–Environmental
causes
–Clues to the
potential cause and
severity of the
dyspnea
•General Impression
–Level of
consciousness
–Patient position
–Skin color
–Effort required for
breathing or speaking
–Audible lung sounds
General Approach to Respiratory
Distress
• Initial Assessment
– More focused than the general
impression
• Focused History
– Build from the chief complaint
• SAMPLE, OPQRST, etc.
– Include a cardiac assessment as well
General Approach to Respiratory
Assessment
• Focused Physical
– Start from the chest and move outward
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Chest wall symmetry, signs of trauma or scars
Lung sounds
Accessory muscle use
Productive cough
– “Outward” assessment areas
• Vitals
• Edema
• Quality of peripheral circulation
Respiratory Assessment in
Detail
Scene Assessment
•Cigarette packs
•Oxygen tubing
•Environment
–Chemistry class
–Industrial area
–Bus of hysterical teens
•# of pillows on bed
•Recliner
General Impression
•Level of consciousness
–Anxious, restless
–lethargic
•Position
–Relaxed
–Leaning forward
–Tripod
–Unable to hold position
•Body Type
–Obese
–Barrel chest
•Effort with breathing
and speaking
–Winded after speaking
–#-word sentences
•1-3 v. 4-5
–Accessory muscles
•Noises with respirations
–Wheezes
–Crackles
–Stridor
Categorize
her level
of distress
•Life-threatening
•Potentially lifethreatening
•Non lifethreatening
The Initial Assessment
• Level of consciousness
– Need for ventilatory support
• Aggressiveness and methods for support
• Adequacy of airway and breathing
– Minute volume
– Need to support ventilations or
respiration?
• Adequacy of circulation
– Peripheral pulse quality and rate
The Focused History
• SAMPLE
– Onset and progression are valuable in
pinpointing specific causes for the
respiratory distress
• Exploration of dyspnea
– Associated with orthopnea or
movement?
– Associated with chest pain?
• Sharp or dull chest pain?
The Focused History
• Cough history and color of sputum
– Changes: CHF and COPD
• Edema
– Presence of pedal edema
– Progression of edema
Focused Physical
•Inspection
–Skin color
–Diaphoresis
–Retractions of chest
muscles
–Accessory muscle
use
–Nasal flaring
–Tracheal tugging
–Signs of dehydration
•Palpation
–Skin turgor,
temperature
–Pulse rate and
quality
–Chest wall pain
–Symmetry with
respirations
–Tracheal deviation
Lung Sounds
•Rales
•Rhonchi
•Wheezes
•Stridor
•Friction Rub
•Nothing… yikes!!!
Test your expertise with lung
sounds!
Focused Physical
• Always correlate sounds with the
patient’s history!
– Wheezes aren’t always caused by a
respiratory problem
– Other causes
• Pulmonary edema/CHF,
allergies/anaphylaxis
Medication
Assessment
Respiratory Meds
• Inhalers
– Albuterol, Alupent, metaproterenol
– Vanceril, Beclovent, Azmacort
• Pills
– Theophylline, aminophylline
– Prednisone, methylprednisolone
The “Other” Meds
• Blood pressure meds
– ACE Inhibitors, beta blockers, weak diuretics
– Hypertension may be a risk factor for a variety of
conditions
• Nitrates + “..olol” drugs + diuretics + digitalis
– Chronic history includes CHF
– Ask about orthopnea, recent weight gain, chest
pain with activity, pedal edema
• Dyspnea/wheezing may be from fluid, not chronic
irritation
• Careful with the albuterol!!!
The “Other” Meds
• Antibiotics
– Levaquin, Cipro, Keflex, Zithromax, etc.
– Not prescribed for COPD itself
– Pneumonia may be the cause for the changes
in dyspnea
• Look for other signs
– Change in sputum color and productivity
– Weakness, less able to tolerate activity
– Loss of appetitie
Generalities Regarding
Treatment
• “Potentially critical” findings in
patients with chronic respiratory
conditions may actually be normal for
them
– Find out more about their baseline
condition
– Moderate-flow oxygen and
bronchodilators for initial treatment in a
COPD patient
• Reassess for changes in making further
treatment decisions
Prehospital Medication Options
for Dyspnea
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Albuterol
Atrovent
Epinephrine
Combi-Vent
Lasix
Benadryl
Respiratory Disease Profiles
•COPD
–Emphysema
–Chronic Bronchitis
•Pneumonia
•Asthma
•ARDS
•Pulmonary edema
•Pleural effusion
COPD
COPD Pathophysiology - Review
• Chronic irritation of bronchioles and
alveoli
– Emphysema: destruction and thickening of
alveoli walls
– Chronic bronchitis: chronic secretion of mucus
and thickened bronchiole walls
• Results
– Narrowed bronchiole passages
– Less surface area for gas exchange in the
alveoli
– Thicker alveolar walls make gas exchange
difficult
• Alveoli become less elastic and cannot perform
effective recoil
Chronic Signs In Moderate COPD
• Dyspnea
• Increased respiratory rate
– Compensates for their inability to
increase tidal volume
• Sputum changes
– Increased productivity in the morning
– Color change: brown
Chronic Signs in Moderate
COPD
• Lung sounds:
– Diminished, especially in the bases
– Rhonchi in upper lobes
– Wheezes
Chronic Signs In Severe COPD
• Expiratory wheezes
• HTN/CHF (late emphysema)
• Some difficulty speaking (2 - 5-word
sentences)
• Low-dose oxygen therapy
• Increased shortness of breath with
any physical exertion
Prehospital Management: Mildmoderate COPD
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Low-flow oxygen if mild distress
Seated or semi-seated position
Albuterol, Atrovent
ECG
IV, 18-gauge as a standard
– Assess for pneumonia
• Watch for signs of decompensation
Clues of Acute COPD
Decompensation
COPD decompensation typically results
from respiratory infections or acute
complications from cardiac disease
•Acute episodes of
worsening dyspnea
at rest
•Pursed-lip breathing
•Altered mentation
•1-2 word sentences
•Focused on breathing
or undistracted
•Accessory muscle use
or retractions
Tips for Aggressive COPD
Management
• BVM just to chest rise
– Avoid demand valves
• Medications will ultimately relieve the
obstruction
• Signs of improvement:
– Change in skin color
– Decrease in HR and/or dysrhythmias
Pneumonia
Pathophysiology of Pneumonia
•Commonly caused by
bacteria
•Irritation of the
respiratory system
–Increase mucus
production
–bronchoconstriction
•Decompensation may
occur in patients with
later stages of COPD
Pneumonia Presentation
•Fever and chills
–May not be as evident in the elderly
•Deep, productive cough
•Thick sputum
–Sputum color change to yellow-green
•Pleuritic chest pain
•Decreased air movement
•Wheezes, rhonchi
Prehospital Care for Pneumonia
• Supplemental oxygen
• Pulse oximetry
• Bronchodilators for wheezing
– Reassess lung sounds after each treatment
• IV with isotonic fluids
– Increase infusion rate with signs of dehydration
• Position of patient comfort
– Semi-seated for COPD and CHF patients
Asthma
Pathophysiology of Asthma
• Exaggerated response to an irritant
• Genetic susceptibility
– High sensitivity to irritants
– High numbers of inflammatory fighters
present and ready to respond to the
irritant
• Result: widespread
bronchoconstriction and mucus
secretion
Asthma: General Impression
•Sitting or leaning
forward
•Mentation
•High work of
–Baseline and
breathing with low air
changes
movement
•#-word sentences
•Pursed-lip breathing
–Changes
•Prolonged expiratory
–1-3: severe
phase
impairment
•Wheezes
•Tachypnea
•Tachycardia
Focused History
•Progressive
dyspnea
•Chest tightness
•Cough and/or
wheezing
•Associated pain
–Location
–OPQRST
•Triggers
–Stress
–Environment
–Exercise
–Exposure to
perfumes, etc.
•Previous attacks
–Hospitalization
–Intubation
Asthma Medications
• “Rescue” inhalers
– Beta agonist: albuterol, Alupent, Bronkosol
– Combination: beta agonists and
parasympatholytics
• Long-term inhalers
– Steroids: beclovent, Azmacort, AeroBid,
Vanceril
– Prevention: Accolate, zafirlukast, cromolyn
• Oral medications
– Aminophylline, theophylline
Simple Asthma Management
• Oxygen
• Albuterol
– Addition of Atrovent
• IV NS tko
– Fluid challenge if
signs of
dehydration
• ECG
Status Asthmaticus
• At-risk patients
– Prior history or respiratory failure
– Steroid-dependent patients
– Rapid fluctuations in severity of attacks
• Profile
– Unbroken by medications
– Cyanosis, decreased lung sounds
– Severe anxiety or lethargy
Progression of Respiratory
Failure in Asthma and Status
Asthmaticus
• Early: increased rate, prolonged
expiration
• Tiring of diaphragm and large muscles
– Accessory muscle use
• Neck muscle use during inspiration =
diaphragm failure
• Impending ventilatory failure
– Inward movement of abdominal wall during
inspiration
• “see-saw” respirations
Treatment for Status
Asthmaticus
• Call for ALS response
• Support of ventilation
– Bag-valve mask ventilations with oxygen
@15LPM
• Expect poor compliance and little change in patient
condition
– Suctioning
• Support of respiration
– Adaptation of the nebulizer to the BVM
– Epinephrine
• Per standing orders
Respiratory Distress in
Congestive Heart Failure
Pathophysiology of Pulmonary
Edema
• CHF
– Ventricle has difficulty pushing blood out
– Blood moves backward
• Right heart failure: back up into feet, JVD, etc
• Left heart failure: back up into lung tissue
• Patient has a chronic history of heart
problems
– “Water retention”
– Medications include antihypertensives, nitrates
and diuretics
Pathophysiology of Pulmonary
Edema
• Recent History
– Orthopnea or “PND” – Paroxysmal
Nocturnal Dyspnea
• Fluid in the body reabsorbed and deposited
into the lungs
• Occurs 1-2 hours after falling asleep
– Patient begins using extra pillows or the
recliner in order to sleep at night
• Precursor to the development of frank
pulmonary edema
Signs and Symptoms of
Pulmonary Edema
• Sudden Onset
– Typically occurs at night
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Audible wheezes or crackles
May have very high blood pressure
Anxiousness, restlessness likely
Lung sounds
– Wheezes, crackles or quiet
• Dependent edema
– +1 - +4
Why would a patient with
pulmonary edema have wheezes?
Treatment for Acute Pulmonary
Edema
• Goals
– Take pressure off of the left ventricle
– Move the fluid out of the lungs
• High-flow oxygen
• Vasodilators
– Nitroglycerin and Morphine
• Movement of fluid
– BVM with PEEP, CPAP, Lasix
Is it COPD or CHF?
Quick Assessment Findings to
Delineate Them
History
Dyspnea
Recent Hx
Cough
Onset
BP
Meds
Treatment
CHF
HTN, Heart
problems
Orthopnea
Acute wt. Gain
Edema in legs
Foamy sputum
COPD/Asthma
Lung problems
Rapid
High
Digoxin,
antiHTN,
diuretics
High flow O2
NTG, Lasix, MS
Gradual
Normal
Bronchodilators
Steroids
Chronic dyspnea
Gradual weight
loss
Productive
(bronchitis)
Oxygen, Atrovent,
albuterol
Miscellaneous Causes of
Respiratory Distress: ARDS
and Pleural Effusion
Pleural Effusion
• Abnormally large collection of fluid
in the pleural cavity
• Compression of lung tissue
– Actual cause for the dyspnea
• Causes of Effusion
– CHF
– Inflammation: pulmonary embolus, high
levels of enzymes from other diseases
• Pancreatitis, kidney failure, liver failure
Pleural Effusion
Presentation
•Increased RR and
HR
•Dyspnea
•Pleuritic chest pain
•Decreased breath
sounds
Treatment
•Oxygen
–Dependent on the
level of hypoxia
•Position of comfort
•IV tko
•Transport
ARDS: Adult Respiratory
Distress Syndrome
• Result of major injury or disease
– Burns, aspiration, hypothermia, high
altitude sickness, cardiac arrest,
pneumonia or inhalation injury
• Damage to alveoli
– Chemical burn to the tissue
– Fluid shifts wash away surfactant
• Causes alveolar walls to stick together
• Difficulty with ventilation and respiration
ARDS
• Accumulation of fluid in the lung
tissue
– Similar presentation to pulmonary
edema
– Additional signs may be present that
relate to the underlying injury or disease
ARDS
Presentation
•Increased RR and
HR
•Dyspnea
•Lung sounds
–Crackles, wheezes
•May appear very ill
Treatment
•Oxygen
•IV
–Restrict flow of fluid
•BVM use if presence
of altered mentation
or shock
•Transport to a facility
capable of critical care
–ICU
Summary
• Increased knowledge of respiratory
disease profiles will assist the EMT-I with
correct treatment decisions
– The increased scope of EMT-I medications
increases the accountability for better patient
assessment and treatment
• Initial treatment decisions should focus on
the need for improving ventilations v.
respirations (or both) in a patient with
respiratory distress