Transcript Respiratory1 NSC - Hatzalah of Miami-Dade

Pulmonary Diseases &
Disorders: Assessment
Pulmonary Diseases &
Disorders

Epidemiology
 28%
of all EMS Chief Complaints in the US
 >200,000 deaths annually due to respiratory
emergencies
Pulmonary Diseases &
Disorders

Many, many pulmonary diseases
 Difficult
to learn all pathophysiologies
 All can be categorized as affecting:
 Ventilation
 Diffusion
(Respiration)
 Perfusion
 Treatment
can be focused on
identifying and treating source of
ventilatory/respiratory impairment
Sources of Pulmonary
Impairment




Pulmonary Diseases
Disorders of the Pulmonary System
Non-Pulmonary Disorders/Disease
Impairing Ventilation or Respiration
What examples can you list for each of
these?
Sources of Pulmonary
Impairment

Ventilation

Upper Airway
Trauma
 Epiglottitis
 FBAO
 Inflammation
of tonsils


Lower Airway
Trauma
 Obstructive
lung disease
 Mucous
accumulation
 Smooth
muscle spasm
 Airway edema

Sources of Pulmonary
Impairment

Ventilation

Chest Wall
Impairment
Trauma
 Hemothorax
 Pneumothorax
 Empyema
 Pleural
inflammation
 Neuromuscular
diseases


Neurologic Control
Brainstem
dysfunction
 Phrenic or spinal
nerve dysfunction

Sources of Pulmonary
Impairment

Diffusion
Inadequate FiO2
 Diseased alveoli

asbestosis
 COPD
 inhalation injury


Capillary bed
disease

atherosclerosis

Interstitial space
disease
High pressure
pulmonary edema
 High permeability
pulmonary edema

Sources of Pulmonary
Impairment

Perfusion

Inadequate blood  Impaired blood flow
 pulmonary embolus
volume or
hemoblogin
 Capillary wall
 hypovolemia
pathology

anemia

trauma
Risk Factors for Pulmonary
Disease

Intrinsic Risk Factors
 Genetic
predisposition
 asthma
 COPD
 carcinoma
 Cardiac
or Circulatory pathologies
 Source
for pulmonary edema
 Source for pulmonary emboli
 Stress
Risk Factors for Pulmonary
Disease

Extrinsic Factors
 Smoking

prevalence of COPD & carcinomas
  severity of pulmonary disease
 Environmental

Factors
prevalence of COPD & asthma
  severity of all obstructive disorders
Function of the Pulmonary
System

Gas Exchange System
 ~10,000
liters of air are filtered, warmed
and humidified daily
 Oxygen diffused into blood
 Carbon dioxide excreted from the body
Function of the Pulmonary
System

Physiology of Ventilation
 Requires
neurologic initiation (brainstem)
 Nerve conduction pathways between
brainstem and muscles of respiration
 Intact & patent Upper and Lower airways
 Intact & non-collapsed alveoli
Function of the Pulmonary
System

Physiology of Respiration
 Simple
diffusion process at the pulmonarycapillary bed
 Diffusion Requirements
 Intact,
non-thickened alveolar walls
 Minimal interstitial space & without additional
fluid
 Intact, non-thickened capillary walls
Function of the Pulmonary
System

Physiology of Perfusion
 Process
of circulating blood through the
capillary bed
 Perfusion Requirements
 Adequate
blood volume
 Adequate hemoglobin
 Intact, non-occluded pulmonary capillaries
 Functioning Left Heart
Control of Ventilation

Control ventilation in response to
physiologic needs
 Driven
1° by pH of CSF
 influenced
largely by PaCO2
 2°
drive = PaCO2
 3° drive = PaO2 detected by
chemoreceptors
 very
small population with severe COPD
Nervous System Effect on
Ventilation

Medulla
 Stimulation

Phrenic Nerve
 Innervation

of the diaphragm
Spinal Nerves at Thoracic levels
 Innervation

to initiate ventilation
of intercostal muscles
Hering-Breuer reflex
 Prevents
overinflation
General Assessment

Size-Up
 Environment
 Airborne
Hazards
 Number of patients
 Needs
• Specialized rescue equipment
• Protective equipment
 Is
the environment creating or exacerbating
the pulmonary condition?
General Assessment

Initial Goal
 Identify
potentially life-threatening
pulmonary conditions

Perform minimal PE & Hx
 Initiate

immediate & appropriate therapies
Then, continue PE & Hx
 Try
to determine if origin is ventilation,
diffusion, perfusion or combination
General Assessment

Signs of potentially life-threatening
pulmonary condition
 altered
mental status
 absent signs of ventilation
 Audible stridor or wheezing
 Able to speak in short phrases only
 Sustained Tachycardia
 Pallor / Diaphoresis
 Accessory muscle use / Retractions
Assessment: H&P

Present History (focused hx)
 Chief
Complaint
 Dyspnea
• “Subjective sensation that breathing is excessive,
difficult or uncomfortable
 CP
 Cough,
Hemoptysis
 Associated
 Fever,
Symptoms
Chills
  sputum production
 Fatigue
Assessment: H&P

Present History (focused hx)
 Sputum

Findings
amount of sputum  infection
 Thick green or brown  pneumonia or
infection
 Yellow or gray  allergic or inflammatory
response
 Hemoptysis  tuberculosis or carcinoma
 Pink, frothy  severe pulmonary edema
Assessment: H&P

HX of Present Illness
 How
long has dyspnea been present?
 Gradual or sudden onset?
 What aggravates or alleviates?
 Hx
of orthopnea?
 Coughing?
 Productive
cough?
 What does sputum look/smell like?
 Pain?
 What does the pain feel like?
Assessment: H&P

Listen - To Pt. Breathe or Talk
 Noisy
Breathing is Obstructed Breathing
 Not All Obstructed Breathing is Noisy
 Snoring - Tongue Blocking Airway
 Stridor - “Tight” Upper Airway from Partial
Obstruction

Observe Breathing
 Tachypnea
 Bradypnea
Assessment: H&P

Observe
 Body
Positioning
 Tripod
 Legs
in dependent position
 Mental
Status
 Ventilatory Effort
 Accessory
muscle use / retractions
 Abdominal muscle use
 Chest wall expansion
 Nasal flaring, pursed lips
Assessment: H&P

Physical Exam of the Chest
 Increased A-P
 Lung
Diameter
Sounds
 Abnormal:
stridor, wheezing, rhonchi, rales,
pleural rub
 Chest
expansion
 Symmetrical Findings
 Evidence of Trauma
Assessment: H&P

Physical Exam
 Cyanosis?
 Late,
unreliable sign of Hypoxia
 Oxygenate
Immediately! Especially If:
Decreased LOC
 Possible Shock
 Possible Severe Hemorrhage
 Chest Pain
 Chest Trauma
 Respiratory distress or dyspnea
 HX of any Kind of Hypoxia

Assessment: H&P

Physical Exam
 Vital
Signs
 Skin
Color, Temp & Moisture
 Respiratory Rate
• No an accurate lone indicator of respiratory status
unless very slow
 Respiratory
Rhythm/Pattern
 Pulse
• Bradycardia vs Tachycardia
 Blood
Pressure
Assessment: H&P

Physical Exam - Circulatory assessment
 Is
the heart beating?
 Is there major external hemorrhage?
 Is the Pt. Perfusing vital organs?
 Effects of hypoxia:
 Early
in adults - Tachycardia
 Late in adults - Bradycardia
 Children - Bradycardia
Assessment: H&P


Don’t let respiratory failure distract you from
assessing for circulatory failure.
Vascular Access
Assessment: H&P

Physical Exam
 Extremities
 Peripheral
Cyanosis
 Clubbing
 Carpopedal
spasm
 Peripheral edema
Assessment: H&P

Diagnostic Testing

Pulse oximetry
Saturation
 Inaccuracies & Disadvantages


Peak Flow Meter
Baseline measurement for
obstructive lung disease
 Often available from patient


Capnometry
real-time assessment of
endotracheal tube placement
 quantitative vs qualitative

Assessment: H&P

Past History
 Similar
Episodes in Past
 Patient’s
description of acuity
 “What happened last time you had an
episode this bad?”

Chronic Symptoms
 Acute,
Seasonal SOB episodes
 Seasonal Allergies
 Chronic cough
 Recurrent flu, pulmonary infection or SOB
Assessment: H&P

Past History
 Known
diagnosis
 Does
the present H&P correlate with this
past history?
• CHF
• Hypertension
• Renal Failure
 Previous
intubation or hospitalization
 Aggravating Factors (e.g. smoking)
Assessment: H&P

Past History
 Medications
 Class,
Route, Frequency of Use
 Pulmonary
•
•
•
•
Sympathomimetics
Corticosteroids
MAST Cell Stabilizer
Methylxanthines
 Cardiovascular
• Diuretics
• Antihypertensives
• Cardiac glycosides
Assessment: H&P

Disability
 Restlessness,
anxiety, combativeness =
HYPOXIA Until Proven Otherwise
 Drowsiness, lethargy = HYPERCARBIA
When the patient stops fighting, he
is not necessarily getting Better!!
Other Adventitious Sounds

Cough
 Forced
exhalation against partially closed
glottis
 Reflex response to mucosa irritation
 Determine circumstances
At work
 Postural changes
 Lying down

 Productive
vs non-productive
Other Adventitious Sounds

Sneeze
 Forced
exhalation via nasal route
 Clears nasal passages
 Reflex response to mucosa irritation

Sigh
 Slow,
deep inspiration - Prolonged, audible
exhalation
 Reexpands areas of atelectasis
Other Adventitious Sounds

Hiccough
 Hiccups,
singultus
 Spasm of diaphragm followed by glottic
closure
 No useful purpose
 Benign, transient