Transcript Respiratory Emergencies

Respiratory Emergencies
By
Dr. Liqaa Raffee
Assistant professor of Trauma care and Emergency Medicine
Department of Accident and Emergency Medicine/Faculty of
Medicine/JUST/KAUH
KEY CONCEPTS
The primary function of the respiratory system is gaseous
exchange.
Ventilation and Oxygenation.
Air is composed of a mixture of gases.
Breathing is largely controlled by the Autonomic Nervous
system, in
response to changes sensed in all parts of the body. The
biggest part of this is the “
Hypoxic Drive”.
Diffusion of O2 from the lung to the blood is by the
binding of O2 to
the hemoglobin (Hgb)
This is dependant on a pressure gradient.
This is a Passive transport system.
It is also dependant on available surface area and
distance it must travel to cross the threshold.
Capillaries are where the real Oxygenation and
ventilation take place
 Definition
 Respiratory emergencies are medical emergencies characterized by difficulty in
breathing or inability to breathe.
 In such emergencies :
 Patient take frequent shallow/irregular or slow breaths
 Immediate medical help/hospitalization required
 Patient is extremely agitated
 Can be fatal, if not treated
 Assessment of Respiratory Emergency
A.
Primary(Initial) Assessment

to identify immediate threats to patients life.

Patients of any age who are talking or crying have a patent airway while presence of
snoring or gurgling may indicate potential problems with airway.

Patient who speak only 2-3 words & pause to take breath show sign of respiratory
distress.

Use of accessory muscles of respiration is also sign of respiratory distress.

Altered mental status/asymmetrical movement of chest suggest respiratory problems.
B.
Secondary(Detailed) Assessment

History about recent trauma, food intake & drinking.

Determine whether problem slow or rapid

Ask about allergies and anaphylaxis

Physical Examination
 Inspect patient to note any signs of trauma.
 Assess skin color as indicator of oxygen status
 Note any decrease or increase in respiratory rate
 Look for use of accessory muscles of respiration, intercostal retractions, nasal flaring
and grunting(in children) indicate respiratory distress
 Auscultate patient to listen any harsh sounds and air movement in lungs.
 Palpate lung area for movement of air over lungs with the back of your hand.
What do we assess?
 Presence or absence?
 Rate
 Quality
Respiratory Rate
 Decreased by:
 Depressant Drugs
 Sleep
 Increased by:
 Fever
 Fear
 Exertion
Respiratory Quality
Irregular: Neuro Insult.
Shallow:
Respiratory Depressants
CNS Depressants
Neuro Insult
Deep:
Hyperglycemia with Acidosis (DKA): “Kussmal Respirations
Electrolyte Imbalances
Neuro Insult
Primary concepts
Listen to ALL lungs.
Beware of the “silent chest”.
Noisy Breathing is abnormal breathing
Visible Breathing is abnormal breathing.
Positional breathing is abnormal breathing.
Abnormal Breathing gets O2.
Pulse Oximetry
 “5th Vital Sign”
 Normal SpO2
 95-100%
 Sp02 Ranges
 91-94% = Mild Hypoxia – Supplemental O2
 86-91% = Moderate Hypoxia – Supplemental O2
 85%-< = Severe Hypoxia – IMMEDIATE intervention
 False Readings
 CO poisoning, high intensity lighting, hemoglobin abnormalities, no pulse
in extremity, hypovolemia, severe anemia

Various Respiratory Emergencies are :-
1)
Status Asthmaticus
2)
Acute exacerbation of COPD
3)
Acute Respiratory Distress Syndrome (ARDS)
4)
Acute Pulmonary Edema
5)
Acute Pulmonary Embolism
6)
Pulmonary Hypertension in Newborn and Adults
7)
Acute Mountain Sickness (AMS)
10) Tension Pneumothorax
8)
Decompression Syndrome
11) Respiratory Acidosis
9)
Acute Respiratory Failure
12) Aspiration Pneumonia
 Status Asthmaticus (Severe Acute Asthma):
 Asthma is characterized by paroxysmal and reversible obstruction of the airways.
 Status asthmaticus is severe, prolonged asthma exacerbation not responding to
usual doses of inhaled bronchodilators & associated with symptoms of potential
respiratory failure.
 Sudden onset(resulting from spasm of airways) or may be more insidious.
 Precipitated by viral respiratory infection / prolonged exposure to allergen.
 Requires early recognition and immediate treatment, if not danger of respiratory
failure.
 Levo-Salbutamol 5 mg by nebuliser with oxygen and repeat every 30 mins if necessary
(or give continously in severe asthma).
Anticholinergics – synergistic effect with beta-adrenergic agonists. Anticholinergics relax
smooth muscle whereas B2 agonist increase levels of cAMP to cause bronchodilation.
 Ipratropium bromide 250-500 µg by nebulizer and repeat every 4 hours if necessary.
Corticosteroids – reduce inflammation of airways, effects delayed for at least 4 hours but
important to prevent relapse.
 Hydrocortisone 100-200 mg IV repeat after half hour & then 6-8 hourly.
 Inhaled steroids – Budesonide 1 to 2 inhalations 200 – 400
 mcg twice daily. Max. dose: 2 inhalations (400 mcg) twice daily.


Antibiotics – Amoxicillin 500
Doxycyline/Azithromycin alternatively.
mg
IV
8
hourly
to
control
infections.
If patient is in severe acidosis – shift to ICU and ventilated if needed.

ECG – to know cardiac status and control arrythmias. X-ray & HGT status done along
with 2 D-Echo if patient is in failure.

In severe spasm and respiratory failure, BiPAP given if not controlled then intubate patient.
Acute Exacerbation of COPD (Chronic Obstructive Pulmonary
Disease)
 COPD is common and preventable disease characterized by persistent
airflow limitation that is usually progressive and associated with an
enhanced chronic inflammatory response in airways and lungs to noxious
particles or gases.
 An exacerbation of COPD is an acute event characterized by a worsening
of patient’s respiratory symptoms that is beyond normal day to day
variations.
 Diagnoses of exacerbation relies exclusively on clinical presentation of
patient complaining of an acute change of symptoms (dyspnea, cough,
and/or sputum production) that is beyond day to day variation.
 Occur due to disruption of airways, alveoli and pulmonary blood vessels.
 Refers to group of conditions associated with chronic obstruction of air flow entering or
leaving lungs.
It includes:
1)
Bronchitis
2)
Emphysema
 Causes:
1) Smoking –
2)
Genetic - deficiency of alpha-1 antitrypsin
3)
Age and Gender - >50 years and male more predominant
4)
Air Pollution
5)
Infections – HIV/Tuberculosis and history of severe childhood respiratory infection leading
to reduced lung function.
Take another look ….What do you see?
Retractions
Pursed lips
Barrel Chest
Oxygen
Abdominal
Retraction
Tripoding
Signs/symptoms of distress
Dyspnea
Restlessness/anxiety
Tachypnea/Bradypnea
Cyanosis (core)
Abnormal sounds
Retractions
Diminished ability to speak
More S/S
 Retractions and/or use of accessory muscles
 Abdominal breathing
 Nasal flaring
 Productive cough
 Color?
 Irregular breathing
 Tripod position
 Pursed-lip breathing
 Severity of exacerbation can be assessed by pulse oximetry. Measurement of arterial blood
gas is vital if coexistence of acute or acute on chronic respiratory failure suspected. PaO2 < 8.0
kPa (60 mmHg) with or without PaCO2 > 6.7 kPa (50 mmHg).
 Emergency Care:
 ABG analysis and SpO2 analysis done to find out Oxygen saturation. 84 % FiO2 for 2 ltr O2.

Position patient - sitting and loosen restrictive clothing

Assist ventilation if required and shift to intensive care unit.
 Oxygen therapy (100 %) to be titrated to improve patients hypoxemia with a target saturation
of 88-92 % then low flow oxygen given.
 Bronchodilators

Salbutamol & Ipratropium bromide given in combination via nebulization every 6-8
hourly.
 Corticosteroids

Hydrocortisone 100-200 mg IV stat then 6 hourly and

Antibiotics

repeated every 6-8 hours.
antibiotics should be given when infection is underlying cause
exacerbation.
of
 Amoxycillin 500 mg orally or Ampicillin 500 mg IV every 8 hours OR if penicillin sensitive
 Erythromycin 500 mg orally every 6 hours.
 If patient is having severe pneumonia by atypical bacteria or old age patient then use
antibiotics like Imepenum, Tazobactum or Piperacillin
 Lasix 40 mg IV stat given as single bolus dose improving biventricular failure.
 Advice patient to stop smoking.

Maintenance of hydration is very important in COPD attack. DNS is used and Electrolyte
imbalance restored by giving Cl, Na and K salts.
 ECG done along with 2 D ECHO for cardiac re-modeling if any.


If patient is having CO2 narcosis / Poor consciousness / pH is 7.2 or less intubate patient. If
pH > 7.2 BiPAP can be given. If patient not improved with BiPAP, more secretions & not
tolerating then give mechanical ventilation.
If severe bronchospasm – IV drip of magnesium 4 amp 2 gm
 Acute Pulmonary Edema
It is a condition caused by excess fluid in lungs with collection of fluid in numerous air
sacs making it difficult to breathe.
 A medical emergency requiring immediate care & if 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 – lung’s protective mechanisms
-bronchioles constrict to keep additional fluid from entering the airway.
 Causes may be cardiac or non cardiac

Cardiac include
1.
Coronary artery disease
2.
Cardiomyopathy
3.
Heart valve problems
4.
High blood pressure
 Non Cardiac include
1.
ARDS
2.
High Altitudes
3.
Pulmonary embolism
4.
Near drowning
5.
Lung injury
6.
Exposure to certain toxins – ammonia, chlorine
7.
Adverse drug reaction to certain drugs like heroin or cocaine
8.
Viral Infections
 Treatment
 Immediate hospitalization
 Place patient in position of comfort. Often patient chooses to sit upright posture.
 Oxygen therapy
 Monitor IV fluids and Blood pressure changes.
 Give Continuous Positive Airway Pressure (CPAP) - a means of providing high flow, low
pressure oxygenation. An effective way to treat and prevent intubation of patient. Allows better
gas diffusion and re-expansion of collapsed alveoli. Also buys time for administered
medications to work.
 CPAP expands the surface area of the collapsed alveoli allowing more surface area to be in
contact with capillaries for gas exchange.
 CPAP is applied during entire respiratory cycle (inspiration & expiration) via tight fitting mask
applied over nose & mouth.
 Goals with CPAP are to increase amount of inspired oxygen & decrease work load of
breathing in turn to reduce need for ventilation, hospital stay and mortality.
 Nitroglycerin sublingual 0.4 mg, can repeat every 5 mins up to 3 doses if BP remains ≥
100 mmHg. Its a venodilator, reduce cardiac workload & dilates coronary vessels. Do not
use in presence of Hypotension. Onset in 1-3 mins.
 Lasix 40 mg by IV infusion & repeat dose if needed. Causes venous dilation decreasing
venous return to heart. Vascular effect within 5 mins and diuretic effect in 15-20 mins.
 Morphine sulphate given 2 mg IV, titrate to response and vital signs, repeated every 2
mins to a maximum of 10 mg. Increases venous capacity and decrease venous return to
heart.
 Acute Pulmonary Embolism
 It is a clot that forms in the deep venous system, usually in thigh or pelvis,
breaks off and travels to lungs, where it lodges in pulmonary vasculature.
 Leads to hypoxemia and increase workload on heart.
 Injury to blood vessels, decreased venous blood flow and alterations in
coagulation system all increase risk of pulmonary embolism.
 Signs & symptoms:
• Dyspnea/tachypnea
• Cyanosis
• Acute pleuritic chest pain
• Hemoptysis
• Hypoxia
 Emergency Care
1)
Immediate hospitalization and oxygen therapy (100 %) to all hypoxemic patients to restore
arterial oxygen saturation to over 90%.
2)
Opiates (Morphine) 4 to 10 mg every 4 hours administered IV over 4-5 mins to relieve pain
and distress.
3)
Obtain IV access, monitor closely vital parameters including Blood Pressure. Massive PE
suspected if there systolic BP <90 mmHg or there is a fall of 40 mmHg for 15 mins not due to
other causes.
4)
Anticoagulation – LMW Heparin or Fondaparinux or Unfractioned Heparin is started and
continued for 5 days or until INR ratio is 2 or above for at least 24 hours. UFH continuous IV
Infusion: 5000 units IV one time as a bolus dose followed by 1300 units/hour by continuous IV
infusion.
 Alternatively, a bolus dose of 80 units/kg IV one time followed by 18 units/kg/hour by
continuous IV infusion may be used.
 In massive PE units/hour.
initial dosage may be an IV bolus of 10,000 units followed by 1500
 Heparin effective in reducing mortality in PE by reducing propagation of clot and further risk
of emboli. Administered for at least 5 days and later anticoagulation continued with oral
Warfarin for at least 6 weeks.
5)
Thrombolytic therapy is useful adjunct in patients with severe pulmonary embolism and right
ventricular dysfunction.
6)
Surgical Procedure – Embolectomy in massive PE.
 Tension Pneumothorax
 Tension pneumothorax is a complete collapse of the lung. It occurs when air enters, but does
not leave, the space around the lung (pleural space).
 Treatment
1)
Immediate Hospitalization
2)
Main aim is to remove air from pleural space allowing lung to re-expand.
3)
In emergency, a small needle (IV needle) is placed in 2nd intercostal space , midclavicular
line (Tension Pneumothorax)
4)
Standard treatment is a chest tube, a large plastic tube is inserted through the chest wall
between 4th, 5th or 6th Intercostal space to remove air. The chest tube is attached to a
vacuum bottle that slowly removes air from the chest cavity. This allows the lung to reexpand. As the lung heals and stops leaking air, the vacuum is turned down and then the
chest tube is removed.
 Aspiration Pneumonia
 Aspiration pneumonia is an inflammation of lungs and bronchial tubes. Happens after you inhale foreign matter.
 Also known as anaerobic pneumonia. This condition is caused by inhaling materials such as vomit, food, or
liquid.
 Risk factors

Coma

Drinking large amounts of alcohol

General anesthesia

Poor Gag reflex

Old age
 Symptoms are cyanosis, shortness of breath, chest pain, fever, coughing up foul sputum. Bronchoscopy is
helpful in diagnosing the condition.
 Treatment
1)
Immediate Hospitalization
2)
Oxygen supplementation, cardiac monitoring & pulse oximetry.
3)
Oropharyngeal / tracheal suctioning may be indicated to further remove aspirate.
4)
Reassess the need for intubation on frequent basis depending on patient’s oxygenation,
mental status, signs of increased work of breathing, or impending respiratory failure. IV
fluids & electrolyte replacement.
5)
Bronchoscopy helpful when aspiration of foreign body or food material suspected, also
helpful in guiding antibiotic therapy
6)
Thoracentesis (pleural fluid aspiration) is a diagnostic therapeutic procedure in which
fluid (or air) is removed from between the pleura and chest wall.
7)
Antibiotics to treat respiratory infections & Mechanical ventilation if needed.
Airway obstruction
 Trauma
foreign bodies
inflammation
hematomas
 CNS disease
secretions
 Drug overdose
 Infections
glottitis
 Obstructive sleep apnea
Foreign Body Aspiration
Epidimiology
 Most airway foreign body aspirations occur in children younger than
15 years.
 Children aged 1-3 years are the most susceptible
Etiology
Young children are susceptible because:




They lack molars for proper grinding of food.
They tend to be running or playing at the time of aspiration.
They tend to put objects in their mouth more frequently.
They lack coordination of swallowing and glottic closure.
PATHOPHYSIOLOGY
Food items are aspirated most commonly;
Peanuts are the most frequently aspirated
food
After foreign body aspiration occurs, the
foreign body can settle into 3 anatomic
sites, the larynx, trachea, or bronchus.
HIGH RISK ITEMS
 Hard Food
 Hot Dog
 Peanut
 Grapes
 Beans
 Seeds
STAGES/PHASES OF FOREIGN BODY
ASPIRATION
 Initial phase - Choking and gasping, coughing, or airway
obstruction at the time of aspiration
 Asymptomatic phase - Subsequent lodging of the
object with relaxation of reflexes that often results in a
reduction or cessation of symptoms, lasting hours to
weeks
 Complications phase - Foreign body producing erosion
or obstruction leading to pneumonia, atelectasis, or
abscess
BASIC AIRWAY MANAGEMENT
 Treatment
 Prevention
ADVANCED AIRWAY MANAGEMENT
 Relies on medical equipment
 AIRWAY MANAGEMENT IN SPECIFIC
SITUATION
BASIC AIRWAY MANAGEMENT
 TREATMENT
 Removing foreign bodies from airways
 encouraging the victim to cough, followed by hard
back slaps
 abdominal thrusts (Heimlich maneuver) or chest thrusts
PREVENTION
 focuses on preventing the tongue from falling back
and obstructing the airways
 head-tilt/chin-lift and jaw-thrust maneuvers
 recovery position mainly prevents aspiration of things
like stomach content or blood.
1.REMOVAL OF FOREIGN BODIES
foreign objects are either removed by suction or with e.g.
a Magill forceps under inspection of the airway with
a laryngoscope or bronchoscope.
Hemoptysis
 Hemoptysis is the expectoration of blood or of blood-stained sputum.
 Massive hemoptysis, the amount varies from 200 – 1L / 24 hrs, but is usually
defined as 600 / 24 hrs.
 Any amount that causes respiratory compromise and/or hemodynamic
instability is life threatening and constitutes a medical emergency.
 The mortality ranges 7–30% for non-massive, and up to 80% for massive
hemoptysis
Questions and Answers
Is it Hemoptysis?
What is the Cause?
What is the source?
When massive hemoptysis is the case
Resuscitation + search for the cause + active
treatment are held hand in hand

Hemoptysis
Is it Hemoptysis?
History
Lung disease
Asphyxia is possible
Sputum examination
Frothy, bright red.
Lab
Alkaline pH
Mixed with macrophages and neutrophils
 Hematemesis
 History
Nausea and vomiting
Gastric or hepatic disease
 Sputum examination
Coffee ground, black or brown
 Lab
Acidic pH
Mixed with food particles
What is the cause?
 Neoplastic
Bronchogenic carcinoma
Bronchial adenoma
Pulmonary metastasis
 Infectious
Tuberculosis #
Fungal infections
Necrotising pneumonia
Lung abscess
Hydatid cyst
 Pulmonary
Bronchiectasis #
Cystic fibrosis
LAM
 Vascular
Pulmonary thrombo-embolism
AV malformation
Mitral stenosis
Thoracic aorta aneurysm
 Systemic diseases
Behcet’s disease
Wegener’s granulomatosis
Goodpasture’s syndrome
SLE
 Coagulopathies
DIC, Thrombocytopenia, Haemophilia
Anticoagulant therapy
 Misc.
Catamenial and brocholith
Steps towards diagnosis
History and clinical examinations
Labs
Radiography (CT scan) + contrast.
Bronchoscopy
Bronchial angio
CT pulmonary angio
Echo heart.
Laboratory Tests
CBC
INR and PTT
ESR and Tuberculin test
ABG
Sputum for Gram stain, culture and sensitivity and
cytology.
D- dimer
Initial management steps
1) Resuscitation and airway protection are the first
priority.
2) Localization of the site and establishing the cause of
bleeding is the next step.
3) The final step is directed at specific and definitive
treatments to stop the hemoptysis and to prevent rebleeding
 Resuscitation
 Admit to ICU with full monitoring.
 Position the patient with the bleeding site down.
 Estimate of blood Loss (Hb, Hct and CVP).
 Stable patient are investigated.
 Unstable patients are intubated and ventilated.
Definitive and specific treatments
 Bronchoscopic treatment
 Bronchial embolization
 Surgery
 Disease specific approach
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