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Pulmonary Diseases. Pulmonary Diseases & Disorders n Pulmonary Disease & Conditions may result from: –Infectious causes –Non-Infectious causes n Adversely.

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Presentation on theme: "Pulmonary Diseases. Pulmonary Diseases & Disorders n Pulmonary Disease & Conditions may result from: –Infectious causes –Non-Infectious causes n Adversely."— Presentation transcript:

1 Pulmonary Diseases

2 Pulmonary Diseases & Disorders n Pulmonary Disease & Conditions may result from: –Infectious causes –Non-Infectious causes n Adversely affect one or more of the following –Ventilation –Diffusion –Perfusion

3 Pulmonary Diseases & Disorders n The Respiratory Emergency may stem from dysfunction or disease of (examples only): –Control System Hyperventilation Central Respiratory Depression CVA –Thoracic Bellows Chest/Diaphragm Trauma Pickwickian Syndrome Guillian-Barre Syndrome Myasthenia Gravis COPD

4 Pulmonary Diseases & Disorders n The Respiratory Emergency may affect the upper or lower airways n Upper Airway Obstruction –Tongue –Foreign Body Aspiration –Angioneurotic Edema –Maxillofacial, Larnygotracheal Trauma –Croup –Epiglottitis

5 Respiratory Emergencies: Causes n Lower Airway Obstruction –Emphysema –Chronic Bronchitis –Asthma –Cystic Fibrosis

6 Pulmonary Diseases & Disorders n The Respiratory Emergency may stem from Gas Exchange Surface Abnormalities –Cardiogenic Pulmonary Edema –Non-cardiogenic Pulmonary Edema –Pneumonia –Toxic Gas Inhalation –Pulmonary Embolism –Drowning

7 Pulmonary Diseases & Disorders Problems with the Gas Exchange Surface

8 Pulmonary Edema

9 Pulmonary Edema: Pathophysiology n A pathophysiologic condition, not a disease –Fluid in and around alveoli –Interferes with gas exchange –Increases work of breathing n Two Types –Cardiogenic (high pressure) –Non-Cardiogenic (high permeability)

10 Pulmonary Edema n High Pressure (cardiogenic) AMI Chronic HTN Myocarditis n High Permeability (non-cardiogenic) Poor perfusion, Shock, Hypoxemia High Altitude, Drowning Inhalation of pulmonary irritants

11 Cardiogenic Pulmonary Edema: Etiology n Left ventricular failure n Valvular heart disease –Stenosis –Insufficiency n Hypertensive crisis (high afterload) n Volume overload Increased Pressure in Pulmonary Vascular Bed

12 Pulmonary Edema n High Permeability –Disrupted alveolar-capillary membrane –Membrane allows fluid to leak into the interstitial space –Widened interstitial space impairs diffusion

13 Non-Cardiogenic Pulmonary Edema: Etiology n Toxic inhalation n Near drowning n Liver disease n Nutritional deficiencies n Lymphomas n High altitude pulmonary edema n Adult respiratory distress syndrome Increased Permeability of Alveolar-Capillary Walls

14 Pulmonary Edema: Signs &Symptoms n Dyspnea on exertion n Paroxysmal nocturnal dyspnea n Orthopnea n Noisy, labored breathing n Restlessness, anxiety n Productive cough (frothy sputum) n Rales, wheezing n Tachypnea n Tachycardia

15 Management of Non-Cardiogenic Pulmonary Edema n Position n Oxygen n PPV / Intubation –CPAP –PEEP n IV Access; Minimal fluid administration n Treat the underlying cause –Diuretics usually not helpful; May be harmful n Transport

16 Adult Respiratory Distress Syndrome n AKA: Non-cardiogenic pulmonary edema n A complication of: –Severe Trauma / Shock –Severe infection / Sepsis –Bypass Surgery –Multiple blood transfusions –Drug overdose –Aspiration –Decreased compliance –Hypoxemia

17 Pneumonia

18 n Fifth leading cause of death in US/Canada n Group of Specific infections n Risk factors –Cigarette smoking –Exposure to cold –Extremes of age young old

19 Pneumonia n Inflammation of the bronchioles and alveoli –Products of inflammation (secretions, pus) add to respiration difficulty n Gas exchange is impaired n Work of breathing increases n May lead to –Atelectasis –Sepsis –VQ Mismatch –Hypoxemia

20 Pneumonia: Etiology n Viral n Bacterial n Fungi n Protozoa (pneumocystis) n Aspiration

21 Presentation of Pneumonia n Shortness of breath, Dyspnea n Fever, chills n Pleuritic Chest Pain, Tachycardia n Cough –Green/brown sputum n May have crackles, rhonchi or wheezing in peripheral lung fields –Consolidation –Egophony

22 Management of Pneumonia n Treatment mostly based upon symptoms –Oxygen –Rarely is intubation required –IV Access & Rehydration –B 2 agonists may be useful –Antibiotics (e.g. Rocephin) –Antipyretics

23 Pneumonia: Management n MD follow-up for labs, cultures & Rx n Transport considerations –Elderly have significant co-morbidity –Young have difficulty with oral medications –ED vs PMD office/clinic –Transport in position of comfort Would an anticholinergic like Atrovent be useful in managing pneumonia?

24 Pulmonary Embolism

25 n ~ 50,000 deaths / year/ US – ~5% of all sudden deaths –<10% of all PE result in death

26 Pulmonary Embolism: Pathophysiology n Something moving with flow of blood passes through right heart into pulmonary circulation n It reaches an area too narrow to pass through and lodges there n Part of pulmonary circulation is blocked n Blood: –Does not pass alveoli –Does not exchange gases

27 Pulmonary Embolism (PE) n A disorder of perfusion n Combination of factors increase probability of occurrence –Hypercoagulability –Platelet aggregation –Deep vein stasis n Embolus usually originates in lower extremities or pelvis

28 Pulmonary Embolism (PE) n Risk factors –Venostasis or DVT –Recent surgery or trauma Long bone fractures (lower) –Oral contraceptives –Pregnancy –Smoking –Cancer

29 Pulmonary Embolism: Etiology Most Common Cause = Blood Clots Vessel Wall Injury HypercoagulabilityVenous Stasis Virchow’ sTriad

30 n Other causes –Air –Amniotic fluid –Fat particles (long bone fracture) –Particulates from substance abuse –Venous catheter Pulmonary Embolism: Etiology

31 Pulmonary Embolism: Signs & Symptoms n Small Emboli –Rapid Onset –Dyspnea –Tachycardia –Tachypnea –Fever –Episodic = Showers –Evidence or history of thrombophlebitis –Consider early when no other cardiorespiratory diagnosis fits

32 n Larger Emboli –Small Emboli S/S plus: –Pleuritic pain –Pleural rub –Coughing –Wheezing –Hemoptysis (rare) Pulmonary Embolism: Signs & Symptoms

33 n Very Large Emboli –Preceded by S/S of Small & Larger Emboli plus: –Central chest pain –Distended neck veins –Acute right heart failure –Shock –Cardiac arrest Pulmonary Embolism: Signs & Symptoms

34 There are NO assessment findings specific to pulmonary embolism

35 n Management based on severity of Sx/Sx n Airway & Breathing –High concentration O 2 –Consider assisting ventilations –Early Intubation n Circulation –IV, 2 lg bore sites Fluid bolus then TKO; Titrate to BP ~ 90 mm Hg –Monitor ECG n Rapid transport Pulmonary Embolism: Management

36 PE Management n Thrombolytics –Aspirin & Heparin (questionable if any benefit) n Rapid transport to appropriate facility –Embolectomy or thrombolytics at hospital (rarely effective in severe cases due to time delay) –Poor prognosis when cardiac arrest follows

37 Pulmonary Embolism If the patient is alive when you get to them, that embolus isn’t going to kill them. But the next one they throw might!

38 Pleurisy n Inflammation of pleura caused by a friction rub –layers of pleura rubbing together n Commonly associated with other respiratory disease

39 Presentation of Pleurisy n Sharp, sudden and intermittent chest pain with related dyspnea –Possibly referred to shoulder –May  or  with respiration n Pleural “friction rub” may be audible” n May have effusion or be dry

40 Pleurisy n Management –Based upon severity of presentation –Mostly supportive

41 Pulmonary Diseases & Disorders Problems with Airway Obstructions

42 Obstructive Airway Diseases

43 Obstructive Airway Disease n Asthma n Emphysema n Chronic Bronchitis

44 Obstructive Airway Diseases n Asthma experienced by ~ 4 - 5 % of Canadian population –Mortality rate increasing n Factors leading to Obstructive Airway Diseases –Smoking –Exposure to environmental agents –Genetic predisposition n How does this differ from “COPD”?

45 Obstructive Airway Disease n Exacerbation Factors –Intrinsic Stress (especially in adults) URI Exercise –Extrinsic Cigarette Smoke Allergens Drugs Occupational hazards

46 Obstructive Airway Disease n General Pathophysiology –Specific pathophysiology varies by disease –Obstruction in bronchioles Smooth muscle spasm (beta) Mucous accumulation Inflammation –Obstruction may be reversible or irreversible

47 Obstructive Airway Disease n General Pathophysiology –Obstruction results in air trapping Bronchioles usually dilate on inspiration Dilation allows air to enter even in presence of “obstruction” Bronchioles tend to constrict on expiration Air becomes trapped distal to obstruction

48 Lower Airway Disease

49 Chronic Obstructive Pulmonary Disease Emphysema Chronic Bronchitis (Rarely Asthma may result in COPD)

50 COPD: Epidemiology n Most common chronic lung disease n 4th leading cause of death n many deaths annually

51 Emphysema Type A COPD

52 Emphysema: Definition n Destruction of alveolar walls n Distention of pulmonary air spaces n Loss of elastic recoil n Destruction of gas exchange surface

53 Emphysema: Incidence n Male > females n Urban area > rural areas n Age usually > 55

54 Emphysema:Etiology n Smoking –90% of all cases –Smokers 10x more likely to die of COPD than non-smokers n Environmental factors n Alpha – 1 antitrypsin deficiency –hereditary –50,000 to 100,000 cases –mostly people of northern European descent

55 Emphysema: Pathophysiology n Decreased surface area leads to decreased gas exchange with blood n Loss of pulmonary capillaries & hypercapnia lead to –increased resistance to blood flow which leads to pulmonary HTN right heart failure (cor pulmonale)

56 Emphysema: Pathophysiology n Loss of elastic recoil leads to increased residual volume and CO 2 retention –Air Trapping –Hyperinflation –Hypercapnia -> pulmonary vasoconstriction -> V/Q mismatch

57 Emphysema: Signs and Symptoms n Increasing dyspnea on exertion n Non-productive cough n Malaise n Anorexia, Loss of weight n Hypertrophied respiratory accessory muscles

58 Emphysema: Signs and Symptoms n Increased Thoracic AP Diameter (Barrel Chest) n Decreased lung/heart sounds n Hyperresonant chest

59 Emphysema: Signs and Symptoms n Lip pursing on exhalation n Clubbed fingertips n Altered blood gases –Normal or decreased PaO 2 –Elevated CO 2 n Cyanosis occurs LATE in course of disease PINK PUFFER

60 Chronic Bronchitis Type B COPD

61 Chronic Bronchitis: Definition n Increased mucus production for > 3 months for > 2 consecutive years n Recurrent productive cough

62 Chronic Bronchitis: Incidence n Males > females n Urban areas > rural areas n Age usually > 45

63 Chronic Bronchitis: Etiology n Smoking n Environmental irritants

64 Chronic Bronchitis: Pathophysiology n Mucus plugging/inflammatory edema n Increased airflow resistance leads to alveolar hypoventilation n Alveolar hypoventilation leads to –hypercarbia –hypoxemia

65 Chronic Bronchitis: Pathophysiology n Hypoxemia leads to –increased RBC’s w/o oxygen which leads to cyanosis n Hypercarbia leads to –pulmonary vascular constriction which leads to increased right ventricular work which leads to right heart failure which may progress to cor pulmonale

66 Chronic Bronchitis: Signs and Symptoms n Increasing dyspnea on exertion n Frequent colds of increasing duration n Productive cough n Weight gain, edema (right heart failure) n Rales, rhonchi, wheezing n Bluish-red skin color (polycythemia) n Headache, drowsiness (increased CO 2 )

67 Chronic Bronchitis: Signs and Symptoms n Decreased intellectual ability n Personality changes n Abnormal blood gases –Hypercarbia –Hypoxia n Cyanosis EARLY in course of disease BLUE BLOATER

68 COPD Assessment Findings n Chronic condition  acute episode n S&S of  work of breathing and/or hypoxemia –Use of accessory muscles –Increased expiratory effort –Tachycardia, AMS, Cyanosis –Wheezing, Rhonchi,  LS –Thin, red/pink appearance n Saturation usually normal in emphysema

69 COPD: Management n Causes of Decompensation –Respiratory infection (increased mucus production) –Chest trauma (pain discourages coughing or deep breathing) –Sedation (depression of respirations and coughing) –Spontaneous pneumothorax –Dehydration (causes mucus to dry out)

70 COPD: Management n Airway and Breathing –Sitting position or position of comfort –Calm & Reassure –Encourage cough –Avoid exertion n Oxygen –Don’t withhold –Maintain O 2 saturation above 90 % TRUE HYPOXIC DRIVE IS VERY RARE

71 COPD: Management n Ventilation –Avoid intubation unless absolutely necessary near respiratory failure exhaustion n Circulation –IV TKO –Titrate fluid to degree of dehydration 250 cc trial bolus –Excessive fluid may precipitate CHF –Monitor ECG

72 COPD: Management n Drug Therapy –Obtain thorough medication history –Nebulized Beta 2 agonists Albuterol Terbutaline Metaproterenol Isoetharine

73 COPD: Management REMEMBER All bronchodilators are potentially arrhythmogenic

74 COPD: Management n Drug Therapy –Ipratropium (anticholinergic) by SVN –(beta-2 agonist) by MDI, SQ or IV –Corticosteroids (anti-inflammatory agent) by IV

75 COPD: Management n Avoid –Sedatives Restlessness = hypoxia –Antihistamines Dry secretions, decrease LOC –Epinephrine Myocardial ischemia, arrhythmias –Intubation difficult to wean off ventilator

76 Reversible Obstructive Airway Disease Asthma

77 Asthma: Definition n Lower airway hyper-responsiveness to a variety of stimuli n Diffuse reversible airway obstruction or narrowing n Airway inflammation

78 Asthma: Incidence n 50% onset before age 10 n 33% before age 30 n “Asthma” in older patients suggests other obstructive pulmonary diseases n Risk Factors –Family history of asthma –Perinatal exposure to airborne allergens and irritants –Genetic hypersensitivity to environmental allergens (Atopy)

79 Asthma n Diagnosis –H&P, Spirometry –Hx or presence of episodic symptoms of airflow obstruction –airflow obstruction is at least partially reversible –alternative diagnoses are excluded

80 Asthma n Commonly misdiagnosed in children as –Chronic bronchitis –Recurrent croup –Recurrent URI –Recurrent pneumonia

81 Asthma n Often triggered by: –Cold temperature –Respiratory Infections –Vigorous exercise –Emotional Stress –Environmental allergens or irritants n Exacerbation –Extrinsic common in children –Intrinsic common in adults

82 Asthma Pathophysiology n Asthma triggered  n Bronchial smooth muscle contraction n Increased mucus production –Bronchial ‘plugging’ –Relative dehydration n Alveolar hypoventilation  –Ventilation Perfusion Mismatch –CO 2 retention –Air ‘Trapping’

83 Asthma: Pathophysiology Bronchospasm Bronchial EdemaIncreased Mucus Production

84 Asthma: Pathophysiology

85 Cast of airway produced by asthmatic mucus plugs

86 Asthma: Pathophysiology n Difficulty exhaling –chest hyperinflation n Poor gas exchange –hypoxia –hypercarbia n Increased respiratory water loss –dehydration

87 Asthma: Types n Type 1 Extrinsic –Classic allergic asthma –Common in children, young adults –Seasonal in nature –Sudden brief attacks –Major component is bronchospasm –Good bronchodilator response

88 Asthma: Types n Type 2 Extrinsic Asthma –Adults < 35 –Long term exposure to irritants –More inflammation than Type 1 Extrinsic –Does not respond well to bronchodilators –Needs treatment with corticosteroids

89 Asthma: Types n Intrinsic Asthma –Adult > 35 –No immunologic cause –Aspirin sensitivity/nasal polyps –Poor bronchodilator response

90 Asthma: Signs and Symptoms n Onset of attacks associated with “triggers” n Dyspnea n Non-productive cough n Tachypnea n Expiratory wheezing n Accessory muscle use n Retractions

91 Asthma: Signs and Symptoms Absence of wheezing IMPENDING RESPIRATORY ARREST!

92 Asthma: Signs and Symptoms n Tachycardia n Pulsus paradoxus in severe attacks n Anxiety, restlessness (hypoxia) progressing to drowsiness, confusion (hypercarbia)

93 Asthma: Signs and Symptoms Lethargy, confusion, suprasternal retractions RESPIRATORY FAILURE

94 Asthma: Signs and Symptoms n Early Blood Gas Changes –Decreased PaO 2 –Decreased PaCO 2 WHY?

95 Asthma: Signs and Symptoms n Later Blood Gases –Decreased PaO 2 –Normal PaCO 2 IMPENDING RESPIRATORY FAILURE

96 Asthma: Signs and Symptoms n Still Later Blood Gases –Decreased PaO 2 –Increased PaCO 2 RESPIRATORY FAILURE

97 Asthma: Risk Assessment n Prior ICU admissions n Prior intubation n >3 ED visits in past year n >2 hospital admissions in past year n >1 bronchodilator canister used in past month n Use of bronchodilators > every 4 hours n Chronic use of steroids n Progressive symptoms in spite of aggressive Rx

98 Asthma: Management n Airway n Breathing –Sitting position or position of comfort –Humidified O 2 by NRB mask Dry O 2 dries mucus, worsens plugs –Encourage coughing –Consider intubation, assisted ventilation Impending respiratory failure Avoid if at all possible

99 Asthma: Management n Circulation –IV TKO –Assess for dehydration –Titrate fluid administration to severity of dehydration Trial bolus of 250 cc –Monitor ECG, Pulse Oximetry

100 Asthma: Management n Obtain medication history n Consider –Overdose –Dysrhythmias

101 Asthma: Management n Nebulized Beta-2 agents –Salbutamol n Nebulized anticholinergics –Ipratropium –Atropine n IV Corticosteroid –Methylprednisolone n Combination – Flovent/etc

102 Asthma: Management n Rarely used –Questionable efficacy, Potential Complications –Magnesium Sulfate (IV) –Methylxanthines Aminophylline (IV)

103 Asthma: Management n Subcutaneous beta agents –Epinephrine 1:1000 q 30 minutes up to 3 doses Adult – 0.3 mg SQ/IM Pediatric – 0.1 to 0.3 mg SQ/IM POSSIBLE BENEFIT IN PATIENTS WITH VENTILATORY FAILURE

104 Asthma: Management n Use EXTREME caution in giving two sympathomimetics or two doses to same patient n Monitor ECG

105 Asthma: Management n Avoid –Sedatives Depress respiratory drive –Antihistamines Decrease LOC, dry secretions –Aspirin High incidence of allergy

106 Asthma: Management n Continuous Monitoring & Frequent Reassessment n Need for transport? Destination?

107 Asthma: Management n Transport Considerations –How severe is the episode? –Is the patient improving? –How extensive (invasive) were the required therapies? –What does he/she normally do after treatment? –Medical Control or PMD consult

108 Drug Delivery Methods: Review MDI vs. MDI w/ spacer vs. SVN vs. SQ injection

109 Status Asthmaticus Asthma unresponsive to beta-2 adrenergic agents

110 Status Asthmaticus n Oxygen (humidified if possible) n Nebulized beta-2 agents n Nebulized Ipratropium n Corticosteroids n IV or SQ terbutaline or epinephrine n Aminophylline (controversial) n Magnesium sulfate (controversial) n Intubation –Caution with PPV

111 Golden Rule n Pulmonary edema n Pulmonary embolism n Allergic reactions n COPD n Pneumonia n Foreign body aspiration n Cystic fibrosis ALL THAT WHEEZES IS NOT ASTHMA

112 Lower Airway Disease Cystic Fibrosis

113 Cystic Fibrosis: Definition n Inherited metabolic disease of exocrine glands and sweat glands n Primarily affects digestive, respiratory systems Begins in infancy

114 Cystic Fibrosis: Etiology n Autosomal recessive gene n Both parents must be carriers n Incidence –Caucasians--1:2000 –Blacks--1:17,000 –Asians--very rare

115 Cystic Fibrosis: Pathophysiology n Obstruction of pancreatic, intestinal gland, bile ducts n Over-secretion by airway mucus glands –mucous plugs n Excess loss of sodium chloride in sweat

116 Lower Airway Disease Neoplasms of the Lung

117 Hyperventilation Syndrome

118 n Brady Textbook Correction, Vol. 3, p. 57 –Table 1-4: These are NOT Causes of hyperventilation syndrome n A diagnosis of EXCLUSION!!! n An increased ventilatory rate that –DOES NOT have a pathologic origin –Results from anxiety n Remains a real problem for the patient

119 Hyperventilation Syndrome: Pathophysiology Tachypnea or hyperpnea secondary to anxiety Decreased PaCO 2 Respiratory alkalosis VasoconstrictionHypocalcemia Decreased O 2 Release to Tissues

120 Hyperventilation Syndrome: Signs & Symptoms n Symptoms –Light-headedness, giddiness, anxiety –Numbness, paresthesias of: Hands Feet Circumoral area –Cold hands, feet –Carpopedal spasms –Dyspnea –Chest pain

121 Hyperventilation Syndrome: Signs & Symptoms n Signs –Rapid breathing –Cool & possibly pale skin –Carpopedal spasm –Dysrhythmias Sinus Tachycardia SVT Sinus arrhythmia –Loss of consciousness and seizures (late & rare)

122 Hyperventilation Syndrome: Management n Educate patient & family –Consider possible psychopathology especially in “repeat customers” n Transport occasionally required –If loss of consciousness, carpopedal spasm, muscle twitching, or seizures occur: Monitor EKG IV TKO Transport

123 Hyperventilation Syndrome Hyperventilation itself can be serious Serious diseases can mimic hyperventilation

124 Pulmonary Infectious Diseases

125 Laryngotracheobronchitis (Croup) n Common syndrome of infectious upper airway obstruction n Viral infection –parainfluenza virus n Subglottic Edema –larynx, trachea, mainstem bronchi n Usually 3 months to 4 years of age

126 Croup: Signs & Symptoms n Gradual onset (several days) –Often begins with Sx of URI –May begin with only low grade fever n Hoarseness n Cough –“Seal Bark Cough” –“Brassy Cough” n Nocturnal episodes of increased dyspnea and stridor

127 Croup: Signs & Symptoms n Evidence of respiratory distress –Tracheal tugging –Substernal/intercostal retractions –Accessory muscle use n Inspiratory stridor or respiratory distress may develop slowly or acutely

128 Croup: Management n Usually requires little out of home treatment n Calm & Prevent agitation!!! n Moist cool air - mist n Humidified O 2 by mask or blowby n Do Not Examine Upper Airways!!!

129 Croup: Management n If in respiratory distress: –Racemic epinephrine via nebulizer Decreases subglottic edema (temporarily) Necessitates transport for observation for rebound –IV TKO - ONLY if severe respiratory distress –Transport

130 Epiglottitis n Bacterial infection (Hemophilus influenza ) n Edema of epiglottis (supraglottic) –partial upper airway obstruction n Typically affects 3-7 year olds

131 Epiglottitis: Presentation n Age: 3-7 years of age –can occur in adults –can occur in infants n Rapid onset & progression –Fever –Severe sore throat –Dysphagia –Muffled voice –Drooling

132 Epiglottitis: Presentation n Respiratory difficulty –Stridor –Usually in an upright, sitting, tripod position n Child may go to bed asymptomatic and awaken during the night with –sore throat –painful swallowing –respiratory difficulty

133 Epiglottitis: Management n Do NOT attempt to visualize airway n Allow child to assume position of comfort –AVOID agitation of the child!!! –AVOID anxiety of the healthcare providers!!! n O 2 by high concentration mask Immediate life threat (8-12% die from airway obstruction)

134 Epiglottitis: Management n If respiratory failure is eminent: –IV TKO ONLY if eminent or respiratory arrest –Be prepared to take control of airway Intubation equipment with smaller sized tubes Needle cricothyrotomy & jet ventilation equipment n Rapid but calm transport –Appropriate facility

135 Upper Respiratory Infection n Common illness n Rarely life-threatening n Often exacerbates underlying pulmonary conditions n May become more significant in some patients –Immunosuppressed –Elderly –Chronic pulmonary disease

136 Upper Respiratory Infection n Prevention –Avoidance is nearly impossible Too many potential causes Temporarily impaired immune system –Best prevention strategy is handwashing Covering of mouth during sneezing and coughing also helpful

137 Pathophysiology of URI n Wide variety of bacteria and viruses are causes –Normal immune system response results in presentation n 20-30% are Group A streptococci n Most are self-limiting diseases

138 Presentation of URI n Symptoms –Sore throat –Fever –Chills –HA n Signs –Cervical adenopathy –Erythematous pharynx –Positive throat culture (bacterial)

139 Management of URI n Usually requires no intervention n Oxygen if underlying condition has been exacerbated n Rarely, pharmacologic interventions are required –Bronchodilators –Corticosteroid n Occasionally, transport required –Key question: Destination?

140 Central Respiratory Depression

141 Respiratory Depression: Causes n Head trauma n CVA n Depressant drug toxicity –Narcotics –Barbiturates –Benzodiazepines –ETOH

142 Respiratory Depression: Recognition n Decreased respiratory rate (< 12/min) n Decreased tidal volume n Decreased LOC Look, Listen, Feel Use Your Stethoscope If you can’t tell whether a patient is breathing adequately... THEY PROBABLY AREN’T

143 Respiratory Depression: Management n Airway –Open, clear, maintain –Consider endotracheal intubation The need to VENTILATE is not the same as the need to INTUBATE

144 Respiratory Depression: Management n Breathing –Oxygenate, ventilate –Restore normal rate, tidal volume Oxygen alone is INSUFFICIENT if Ventilation is INADEQUATE

145 Respiratory Depression: Management n Circulation –Obtain vascular access –Monitor EKG (Silent MI may present as CVA) n Manage Cause –Check Blood Sugar –Consider Narcan 2mg IV push if S/S suggest narcotic overdose n Intubate if can not find or treat cause

146 Guillian-Barre´ Syndrome n Autoimmune disease –Leads to inflammation and degeneration of sensory and motor nerve roots (de- myelination) n Progressive ascending paralysis –Progressive tingling and weakness –Moves from extremities then proximally –May lead to respiratory paralysis (25%)

147 Guillian-Barre´ Syndrome Management n Treatment based on severity of symptoms –Control airway –Support ventilation –Oxygen –Transport in cases of respiratory depression, distress or arrest

148 Myasthenia Gravis n Autoimmune disease n Causes loss of ACh receptors at neuromuscular junction –Attacks the ACh transport mechanism at the NMJ n Episodes of extreme skeletal muscle weakness n Can cause loss of control of airway, respiratory paralysis

149 Myasthenia Gravis Presentation n Gradual onset of muscle weakness –Face and throat –Extreme muscle weakness n Respiratory weakness -> paralysis n Inability to process mucus

150 Myasthenia Gravis Management n Treat symptomatically n Watch for aspiration n May require assisted ventilations n Assess for Pulmonary infection n Transport based upon severity of presentation

151 Case Studies

152 Case One n It is 1430 hrs. You are called to a business for a “possible stroke.” The patient is a 20-year- old female complaining of dizziness and of numbness around her mouth and fingertips. What would you like to include in your initial differential diagnosis?

153 Case One n Initial Assessment –Airway: Open, maintained by patient –Breathing: Rapid, deep, regular; no accessory muscle use or retractions –Circulation: Radial pulses present, rapid, full; Skin warm, dry; capillary refill < 2 seconds –Disability: Awake, alert, anxious What therapies, if any, would you like to begin?

154 Case One n Vital Signs –P: 126 strong, regular –R: 26 deep, regular –BP: 130/82 n Physical Exam –Chest: BS present, equal bilaterally; no adventitious sounds –Extremities: Equal movement in all extremities; no weakness; hands cool –Oxygen saturation: 98% Would you like to make any Changes to your therapies or Diff Dx?

155 Case One n History –Allergies: NKA –Medications: Birth control pills –Past History: No significant past history; no history of smoking –Last Meal: Lunch 2 hours ago –Events: S/S began suddenly after argument with supervisor

156 Case One n What problem do you now suspect? n How would you manage this patient?

157 Case Two n It is 0530 hours. You are called to a residence to see a child with “a very high fever and difficulty breathing.” The patient is a 6-old-female. Mother says the child woke up crying about 2 hours ago. What would you like to include in your differential diagnosis?

158 Case Two n Initial Assessment –Airway: Inspiratory stridor audible –Breathing: Rapid, shallow, labored –Circulation: Radial pulses present, rapid, weak; skin pale, hot, diaphoretic; capillary refill is 2 seconds –Disability: Awake, alert, obviously frightened and in acute distress What therapies, if any, would you like to begin now?

159 Case Two n Vital Signs –P: 130 weak, regular –R: 32 shallow, regular with stridor –BP: 110/70 n Physical Exam –HEENT: Flaring of nostrils; accessory muscle use on inspiration; drooling present –Chest: BS present, equal bilaterally; no adventitious sounds –Oxygen saturation: 92% Would you like to make any Changes to your therapies or Diff Dx?

160 Case Two n History –Allergies: NKA –Medications: None –Past History: No significant past history –Last Meal: Dinner at about 1800 hours –Events: Awakened with severe sore throat. Has experienced increasing difficulty breathing. Will not eat or drink. Says it hurts to swallow

161 Case Two n What problem do you now suspect? n How would you manage this patient?

162 Case Three n At 2330 hrs you are called to a residence to see a child with “difficulty breathing.” The patient is a 3 year old male. How narrow a Differential Diagnosis can you compile at this point?

163 Case Three n Initial Assessment –Airway: Open, maintained by patient, mild stridor audible –Breathing: Rapid, shallow, labored –Circulation: Radial pulses present, weak, regular; Skin pale, warm, moist; Capillary refill <2 seconds –Disability: Awake, sitting up in bed, looks tired and miserable

164 Case Three n Vital Signs –P: 100 weak, regular –R: 30 shallow, labored with stridor –BP: 90/50 n Physical Exam –HEENT: Use of accessory muscles present; no drooling –Chest: BS present, equal bilaterally with no adventitious sounds. Auscultation difficult because of stridor and barking cough Now you can narrow your Diff Dx? To what?

165 Case Three n History –Allergies: NKA –Medication: Tylenol for fever before bedtime –Past history: No significant past history –Last meal: Dinner around 1800 hours –Events: Patient has had “cold” for about 3 days. Reasonably well during day. Awakens around midnight with high-pitched cough that sounds like a dog barking

166 Case Three n What problem do you suspect? n How would you manage this patient?

167 Case Four n At 1945 hours you are dispatched to a “breathing difficulty” at Long John Silver’s. The patient is a 26-year-old female complaining of strange feeling in her mouth and difficulty swallowing. What is your differential diagnosis?

168 Case Four n Initial Assessment –Airway: Open, maintained by patient, difficulty swallowing, voice is hoarse –Breathing: Rapid, labored –Circulation: Radial pulses present, strong, regular; Skin “flushed”; Capillary refill < 2 seconds –Disability: Awake, alert, very anxious

169 Case Four n Vital Signs –P: 120 strong, regular –R: 26 regular, slightly labored –BP: 118/90 n Physical Exam –HEENT: Puffiness around eyes; Lips appear swollen; Mild accessory muscle use –Chest: BS present, equal bilaterally; No adventitious sounds –Urticaria on upper chest, extremities –Oxygen saturation: 94% What therapies do you want to initiate?

170 Case Four n History –Allergies: No drug allergies; Has experienced itching previously when eating shrimp –Medications: None –Past history: No significant past history; no history of smoking –Last meal: In progress at time of call –Events: Began to experience itching and difficulty swallowing after eating “fish and chips”

171 Case Four n What problem do you suspect? n How would you manage this patient? The patient begins to have increased difficulty swallowing, increased anxiety, and increased difficulty breathing. What do you want to do now?

172 Case Five n At 0130 you are dispatched to an “unconscious person--police on location.” The patient is a 27-year-old male who is apparently unconscious. The police report they found him lying in an alleyway while they were on routine patrol. He is known to live “on the streets”.

173 Case Five n Initial Assessment –Airway: Controllable with manual positioning –Breathing: Very slow, shallow –Circulation: Radial pulses present, weak; Skin pale, cool, moist; Capillary refill 3 seconds –Disability: Unconscious, unresponsive to painful stimuli What therapies would you like to begin?

174 Case Five n Vital Signs –P: 70 regular, weak –R: 4 shallow, regular; alcohol odor on breath –BP: 100/70 n Physical Exam –HEENT: Pupils pinpoint, non-reactive –Chest: BS present, equal bilaterally –Abdomen: Soft, non-tender –Extremities: Needle tracks present –Blood glucose: 40 mg/dl

175 Case Five n What problem or problems do you suspect? n How would you manage this patient?

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