11: Respiratory Emergencies

Cognitive Objectives (1 of 3) 4-2.1 List the structure and functions of the respiratory system. 4-2.2 State the signs and symptoms of a patient with difficulty breathing. 4-2.3 Describe the emergency medical care of the patient with breathing difficulty. 4-2.4 Recognize the need for medical direction to assist in the emergency medical care of the patient with breathing difficulty.

Cognitive Objectives (2 of 3) 4-2.5 Describe the care of a patient with breathing distress. 4-2.6 Establish the relationship between airway management and breathing difficulty. 4-2.7 List signs of adequate air exchange.

Cognitive Objectives (3 of 3) 4-2.8 State the generic name, forms, dose, administration, actions, indications, and contraindications for the prescribed inhaler. 4-2.9 Distinguish between the emergency medical care of the infant, child, and adult patient with breathing difficulty. 4-2.10 Differentiate between upper airway obstruction and lower airway disease in the infant and child patient.

Affective Objectives 4-2.11 Defend EMT-B treatment regimens for various respiratory emergencies. 4-2.12 Explain the rationale for administering an inhaler.

Psychomotor Objectives 4-2.13 Demonstrate the emergency medical care for breathing difficulty. 4-2.14 Perform the steps in facilitating the use of an inhaler.

Respiratory System

Anatomy and Function of the Lung

Characteristics of Adequate Breathing Normal rate and depth Regular breathing pattern Good breath sounds on both sides of the chest Equal rise and fall of chest Pink, warm, dry skin

Characteristics of Inadequate Breathing Pulmonary vessels become obstructed. Alveoli are damaged. Air passages are obstructed. Blood flow to the lungs is obstructed. Pleural space is filled.

Signs of Inadequate Breathing Slower than 12 breaths/min or faster than 20 breaths/min Unequal chest expansion Decreased breath sounds Muscle retractions Pale or cyanotic skin Cool, damp (clammy) skin Shallow or irregular respirations Pursed lips Nasal flaring

Dyspnea Shortness of breath or difficulty breathing Patient may not be alert enough to complain of shortness of breath.

Upper or Lower Airway Infection Infectious diseases may affect all parts of the airway. The problem is some form of obstruction to the air flow or the exchange of gases.

Acute Pulmonary Edema Fluid build-up in the lungs Signs and symptoms Dyspnea Frothy pink sputum History of chronic congestive heart failure Recurrence high

Chronic Obstructive Pulmonary Disease (COPD) COPD is the result of direct lung and airway damage from repeated infections or inhalation of toxic agents. Bronchitis and emphysema are two common types of COPD. Abnormal breath sounds may be present. Rhonchi and wheezes

Asthma Common but serious disease Asthma is an acute spasm of the bronchioles. Wheezing may be audible without a stethoscope.

Spontaneous Pneumothorax Accumulation of air in the pleural space Caused by trauma or some medical conditions Dyspnea and sharp chest pain on one side Absent or decreased breath sounds on one side

Anaphylactic Reactions An allergen can trigger an asthma attack. Asthma and anaphylactic (allergic) reactions can be similar. Hay fever is a seasonal response to allergens.

Pleural Effusion Collection of fluid outside lung Causes dyspnea Caused by irritation, infection, or cancer Decreased breath sounds over region of the chest where fluid has moved the lung away from the chest wall Eased if patient is sitting up

Mechanical Obstruction of the Airway Be prepared to treat quickly. Obstruction may result from the position of head, the tongue, aspiration of vomitus, or a foreign body. Opening the airway with the head tilt-chin lift maneuver may solve the problem.

Pulmonary Embolism A blood clot that breaks off and circulates through the venous system Signs and symptoms Dyspnea Acute pleuritic pain Hemoptysis Cyanosis Tachypnea Varying degrees of hypoxia

Hyperventilation Overbreathing resulting in a decrease in the level of carbon dioxide Signs and symptoms Anxiety Numbness A sense of dyspnea despite rapid breathing Dizziness Tingling in hands and feet

You are the Provider You and your EMT-B partner are dispatched to 1465 Dalles Military Rd for a 33-year-old woman with difficulty breathing. You arrive at the office building and an upset man identifies himself as the patient’s coworker. He tells you that the patient has had breathing problems before, but he’s never seen it this bad.

You are the Provider (continued) He leads you to a woman who is standing with her arms outstretched on the desk with a metered-dose inhaler in hand. She acknowledges your presence with a nod. When you ask her what is wrong, she answers with a two-word response, “can’t breathe.” You hear audible wheezes.

How significant is the person’s response to your question and why? Scene Size-UP How significant is the person’s response to your question and why? What should you do next? Should you transport this patient or wait for ALS to arrive on scene?

Perform initial assessment. Place the patient on oxygen. If patient is in respiratory distress, ventilate. Check pulse.

Signs and Symptoms (1 of 2) Difficulty breathing Altered mental status Anxiety or restlessness Increased or decreased respirations Increased heart rate Irregular breathing Cyanosis

Signs and Symptoms (2 of 2) Pale conjunctivae Abnormal breath sounds Difficulty speaking Use of accessory muscles Coughing Tripod position Barrel chest

You are the Provider (continued) You arrange to rendezvous with ALS. You apply high-flow oxygen and obtain the following vital signs: Pulse: 42 breaths/min Pulse oximetry: 90% The patient indicates that she has used the inhaler twice already.

You are the Provider (continued) What can you do before you meet ALS? Another pulse oximetry reading reveals a reading of 72%. The patient is using accessory muscles to breathe. What do these signs indicate?

COPD Patients COPD patients cannot handle pulmonary infections well Usually age 50 or older History of recurring lung problems Long-term smokers Tightness in chest/constant fatigue

Focused History and Physical Exam Abnormal breath sounds are symptomatic of COPD Long history of dyspnea with sudden increase in shortness of breath Recent chest cold with fever Vital signs Normal blood pressure Rapid, occasionally irregular pulse Respirations rapid or very slow

Interventions Treat immediate life threats Possible interventions Oxygen via nonrebreathing mask at 15 L/min Positive pressure ventilations Airway adjuncts Positioning Respiratory medications

Detailed Physical Exam Performed only once life threats are addressed. May not be able to do if busy treating airway or breathing problems.

Carefully watch patients for shortness of breath. Ongoing Assessment Carefully watch patients for shortness of breath. Reassess vital signs. Ask patient if treatment has made a difference. Check for accessory muscle use.

Emergency Medical Care Give supplemental oxygen at 10 to 15 L/min via nonrebreathing mask. Patients with longstanding COPD may be started on low-flow oxygen (2 L/min). Assist with inhaler if available. Consult medical control.

Medications in MDI Trade names Proventil Ventolin Alupent Metaprel Brethine Generic names Albuterol Metaproterenol Terbutaline

Prescribed Inhalers Actions Relax the muscles surrounding the bronchioles Enlarge the airways leading to easier passage of air Side effects Increased pulse rate Nervousness Muscle tremors

Prior to Administration Read label carefully. Verify it has been prescribed by a physician for this patient. Consult medical control. Make sure the medication is indicated. Check for contraindications.

Contraindications for MDI Patient unable to help coordinate inhalation Inhaler not prescribed for patient No permission from medical control Maximum dose prescribed has been taken.

Administration of MDI (1 of 3) Obtain order from medical control or local protocol. Check for right medication, right patient, right route. Make sure the patient is alert. Check the expiration date. Check how many doses have been taken.

Administration of MDI (2 of 3) Make sure inhaler is at room temperature or warmer. Shake inhaler. Stop administration of oxygen. Ask the patient to exhale deeply and put lips around opening. If the inhaler has a spacer, use it.

Administration of MDI (3 of 3) Have the patient depress the inhaler and inhale deeply. Instruct the patient to hold his or her breath. Continue administration of oxygen. Allow the patient to breathe a few times then repeat dose according to protocol.

Reassessment Carefully watch for shortness of breath. 5 minutes after administration: Obtain vital signs again. Perform focused reassessment. Transport and continue to assess breathing.

Upper or Lower Airway Infection Administer warm, humidified oxygen. Do not attempt to suction the airway or insert an oropharyngeal airway in a patient with suspected epiglottitis. Transport patient in position of comfort.

Acute Pulmonary Edema Administer 100% oxygen. Suction secretions. Transport in position of comfort.

Chronic Obstructive Pulmonary Disease (COPD) Assist with prescribed inhaler if patient has one. Transport promptly in position of comfort.

Spontaneous Pneumothorax Administer oxygen. Transport in position of comfort. Monitor closely.

Asthma Obtain history. Assess vital signs. Assist with inhaler if patient has one. Administer oxygen. Transport promptly.

Pleural Effusion Definitive treatment is performed in a hospital. Administer oxygen and support measures. Transport promptly.

Obstruction of the Airway Clear airway. Administer oxygen. Transport promptly.

Pulmonary Embolism Administer oxygen. Place patient in comfortable position, usually sitting. Assist breathing as necessary. Keep airway clear. Transport promptly.

Hyperventilation Complete initial assessment and history of the event. Assume underlying problems. Do not have patient breathe into a paper bag. Give oxygen. Reassure patient and transport.