1. 11: Respiratory Emergencies

2. 2 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 (1 of 3)

3. 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 (2 of 3)

4. 4 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. Cognitive Objectives (3 of 3)

5. 5 Affective Objectives 4-2.11 Defend EMT-B treatment regimens for various respiratory emergencies. 4-2.12 Explain the rationale for administering an inhaler.

6. 6 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.

7. 7 Respiratory System

8. 8 Anatomy and Function of the Lung

9. 9 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

10. 10 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.

11. 11 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

12. 12 Dyspnea Shortness of breath or difficulty breathing Patient may not be alert enough to complain of shortness of breath.

13. 13 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.

14. 14 Acute Pulmonary Edema Fluid build-up in the lungs Signs and symptoms –Dyspnea –Frothy pink sputum History of chronic congestive heart failure Recurrence high

15. 15 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

16. 16 Asthma Common but serious disease Asthma is an acute spasm of the bronchioles. Wheezing may be audible without a stethoscope.

17. 17 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

18. 18 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.

19. 19 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

20. 20 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.

21. 21 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

22. 22 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

23. 23 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.

24. 24 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.

25. 25 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?

26. 26 Perform initial assessment. Place the patient on oxygen. If patient is in respiratory distress, ventilate. Check pulse. Initial Assessment

27. 27 Signs and Symptoms (1 of 2) Difficulty breathing Altered mental status Anxiety or restlessness Increased or decreased respirations Increased heart rate Irregular breathing Cyanosis

28. 28 Signs and Symptoms (2 of 2) Pale conjunctivae Abnormal breath sounds Difficulty speaking Use of accessory muscles Coughing Tripod position Barrel chest

29. 29 You are the Provider (continued) You arrange to rendezvous with ALS. You apply high-flow oxygen and obtain the following vital signs: –Respirations: 42 breaths/min –Pulse oximetry: 90% The patient indicates that she has used the inhaler twice already.

30. 30 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?

31. 31 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

32. 32 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

33. 33 Interventions Treat immediate life threats Possible interventions –Oxygen via nonrebreathing mask at 15 L/min –Positive pressure ventilations –Airway adjuncts –Positioning –Respiratory medications

34. 34 Detailed Physical Exam Performed only once life threats are addressed. May not be able to do if busy treating airway or breathing problems.

35. 35 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.

36. 36 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.

37. 37 Medications in MDI Trade names –Proventil –Ventolin –Alupent –Metaprel –Brethine Generic names –Albuterol –Metaproterenol –Terbutaline

38. 38 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

39. 39 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.

40. 40 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.

41. 41 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.

42. 42 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.

43. 43 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.

44. 44 Reassessment Carefully watch for shortness of breath. 5 minutes after administration: –Obtain vital signs again. –Perform focused reassessment. Transport and continue to assess breathing.

45. 45 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.

46. 46 Acute Pulmonary Edema Administer 100% oxygen. Suction secretions. Transport in position of comfort.

47. 47 Chronic Obstructive Pulmonary Disease (COPD) Assist with prescribed inhaler if patient has one. Transport promptly in position of comfort.

48. 48 Spontaneous Pneumothorax Administer oxygen. Transport in position of comfort. Monitor closely.

49. 49 Asthma Obtain history. Assess vital signs. Assist with inhaler if patient has one. Administer oxygen. Transport promptly.

50. 50 Pleural Effusion Definitive treatment is performed in a hospital. Administer oxygen and support measures. Transport promptly.

51. 51 Obstruction of the Airway Clear airway. Administer oxygen. Transport promptly.

52. 52 Pulmonary Embolism Administer oxygen. Place patient in comfortable position, usually sitting. Assist breathing as necessary. Keep airway clear. Transport promptly.

53. 53 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.

54. 54 Review 1.Which of the following patients is breathing adequately? A. 36-year-old man with cyanosis around the lips and irregular respirations B. 29-year old woman with respirations of 20 breaths/min, who is conscious and alert C. 22-year-old man with labored respirations at a rate of 28 breaths/min and pale skin D. 59-year-old woman with difficulty breathing, whose respirations are rapid and shallow

55. 55 Review Answer: B Rationale: Adequate breathing in the adult is characterized by a respiratory rate between 12 and 20 breaths/min; good chest rise (indicates adequate tidal volume); unlabored breathing effort; non-altered mental status; and good perfusion to the skin (eg, pink, warm, dry).

56. 56 Review 1.Which of the following patients is breathing adequately? A.36-year-old man with cyanosis around the lips and irregular respirations Rationale: A patient with irregular respirations is not breathing adequately. Cyanosis is a sign of hypoxia. B. 29-year old woman with respirations of 20 breaths/min, who is conscious and alert Rationale: Correct answer C. 22-year-old man with labored respirations at a rate of 28 breaths/min and pale skin Rationale: The normal adult rate of respirations is 12- 20 breaths/min. D. 59-year-old woman with difficulty breathing, whose respirations are rapid and shallow Rationale: A patient with adequate breathing has a normal rate and an unlabored breathing effort.

57. 57 Review 2. The process in which oxygen and carbon dioxide are exchanged in the lungs is called: A. respiration. B. ventilation. C. metabolism. D. inhalation.

58. 58 Review Answer: A Rationale: Respiration is defined as the exchange of gases between the body and its environment. The exchange of oxygen and carbon dioxide in the lungs is called pulmonary (external) respiration. The exchange of oxygen and carbon dioxide at the cellular level is called cellular (internal) respiration.

59. 59 Review 2. The process in which oxygen and carbon dioxide are exchanged in the lungs is called: A.respiration. Rationale: Correct answer B. ventilation. Rationale: Ventilation is the exchange of air between the lungs and the environment. C. metabolism. Rationale: Metabolism is the series of processes by which food is converted into the energy and products needed to sustain life. D. inhalation. Rationale: Inhalation is the active, muscular part of breathing.

60. 60 Review 3. Which of the following respiratory diseases causes obstruction of the lower airway? A. Croup B. Asthma C. Epiglottitis D. Laryngitis

61. 61 Review Answer: B Rationale: Asthma is a lower airway disease that causes the bronchioles in the lungs to constrict (bronchospasm), resulting in various degrees of obstruction. Croup, epiglottitis, and laryngitis cause swelling, inflammation, and varying degrees of obstruction of the upper airway.

62. 62 Review 3. Which of the following respiratory diseases causes obstruction of the lower airway? A.Croup Rationale: This causes an upper airway obstruction. B. Asthma Rationale: Correct answer C. Epiglottitis Rationale: This causes an upper airway obstruction. D. Laryngitis Rationale: This causes an upper airway obstruction.

63. 63 Review 4. Albuterol, a beta2 agonist, is the generic name for: A. Alupent. B. Metaprel. C. Brethine. D. Ventolin.

64. 64 Review Answer: D Rationale: Albuterol is the generic name for Ventolin (Proventil). Albuterol is a beta-agonist, which dilates the bronchioles, and is commonly used to treat patients with asthma and other reactive airway diseases.

65. 65 Review 4. Albuterol, a beta2 agonist, is the generic name for: A.Alupent. Rationale: This is the trade name for Metaproterenol, also a beta2 agonist. B. Metaprel. Rationale: This is the trade name for Metaproterenol, also a beta2 agonist. C. Brethine. Rationale: This is the trade name for Terbutaline, also a beta2 agonist. D. Ventolin. Rationale: Correct answer

66. 66 Review 5. A 70-year-old man recently had a heart attack and now complains of severe difficulty breathing, especially when lying flat. He is coughing up pink, frothy secretions. This patient is MOST likely experiencing: A. acute right heart failure. B. severe left heart failure. C. an acute onset of bronchitis. D. an acute pulmonary embolism.

67. 67 Review Answer: B Rationale: As a result of his recent heart attack, the left side of this patient's heart has been severely damaged. The left side of the heart is responsible for pumping oxygenated blood to the rest of the body. When it fails to do this, blood backs up into the lungs, resulting in pulmonary edema. Signs of pulmonary edema include dyspnea (especially when lying flat), rapid and shallow respirations, and in severe cases, coughing up of pink, frothy sputum.

68. 68 Review (1 of 2) 5. A 70-year-old man recently had a heart attack and now complains of severe difficulty breathing, especially when lying flat. He is coughing up pink, frothy secretions. This patient is MOST likely experiencing: A.acute right heart failure. Rationale: Acute heart failure causes a backup of blood into the systemic circulatory system and typically causes symptoms of peripheral edema in the hands and feet. B. severe left heart failure. Rationale: Correct answer

69. 69 Review (2 of 2) 5. A 70-year-old man recently had a heart attack and now complains of severe difficulty breathing, especially when lying flat. He is coughing up pink, frothy secretions. This patient is MOST likely experiencing: C. an acute onset of bronchitis. Rationale: This is an acute inflammation of the lungs associated with a cough, increased sputum, fever, and tachypnea. D. an acute pulmonary embolism. Rationale: This is a blood clot in the lungs and seen as dyspnea, acute chest pain, cyanosis, tachypnea, and coughing up blood.

70. 70 Review 6. Which of the following diseases is potentially life threatening and is thought to be transmitted by close person to person contact? A. SARS B. Croup C. Diphtheria D. Epiglottitis

71. 71 Review Answer: A Rationale: Severe Acute Respiratory Syndrome (SARS) is a viral infection that starts with flu-like symptoms, which can progress to pneumonia, respiratory failure, and sometimes death. It is thought to be transmitted via close person to person contact.

72. 72 Review 6. Which of the following diseases is potentially life threatening and is thought to be transmitted by close person to person contact? A.SARS Rationale: Correct answer B. Croup Rationale: Croup is a n inflammatory condition of the larynx and trachea, marked by a cough, hoarseness, and difficulty in breathing. C. Diphtheria Rationale: Diphtheria is c aused by a bacterium that attacks the membranes of the throat. D. Epiglottitis Rationale: Epiglottitis is an acute bacterial infection of the epiglottis.

73. 73 Review 7. A sudden onset of difficulty breathing, sharp chest pain, and cyanosis that persists despite supplemental oxygen is MOST consistent with: A. severe pneumonia. B. myocardial infarction. C. a pulmonary embolism. D. a spontaneous pneumothorax.

74. 74 Review Answer: C Rationale: Signs of an acute pulmonary embolism (PE) include a sudden onset of difficulty breathing, sharp (pleuritic) chest pain, and cyanosis that persists despite the administration of high-flow oxygen. Patients who are immobile for prolonged periods of time (ie, confined to a hospital bed) are prone to a PE.

75. 75 Review 7. A sudden onset of difficulty breathing, sharp chest pain, and cyanosis that persists despite supplemental oxygen is MOST consistent with: A.severe pneumonia. Rationale: This is an acute bacterial or viral infection associated with a fever, cough, and productive sputum. B. myocardial infarction. Rationale: A heart attack is associated with chest pain, sudden onset of weakness, nausea, sweating, and discomfort. C. a pulmonary embolism. Rationale: Correct answer D. a spontaneous pneumothorax. Rationale: This is when air escapes into the pleural cavity.

76. 76 Review 8. All of the following are causes of acute dyspnea, EXCEPT: A. asthma. B. emphysema. C. pneumothorax. D. pulmonary embolism.

77. 77 Review Answer: B Rationale: Emphysema—a form of chronic obstructive pulmonary disease (COPD)—is a chronic respiratory disease; therefore, it presents with progressively worsening dyspnea. Asthma, pulmonary embolism, and pneumothorax are all acute conditions; therefore, they typically present with an acute onset of dyspnea.

78. 78 Review 8. All of the following are causes of acute dyspnea, EXCEPT: A.asthma. Rationale: Asthma is an acute condition with a sudden onset. B. emphysema. Rationale: Correct answer C. pneumothorax. Rationale: Pneumothorax is an acute condition with a sudden onset of dyspnea. D. pulmonary embolism. Rationale: Pulmonary embolism is an acute condition with a sudden onset of dyspnea.

79. 79 Review 9. An acute bacterial infection that results in swelling of the flap that covers the larynx during swallowing is called: A. croup. B. laryngitis. C. epiglottitis. D. diphtheria.

80. 80 Review Answer: C Rationale: Epiglottitis—a potentially life-threatening illness—is an acute bacterial infection that causes swelling of the epiglottis (the flap the covers the larynx during swallowing). It is characterized by a sudden onset of high fever, difficulty breathing, stridor, drooling, and varying degrees of hypoxemia.

81. 81 Review 9. An acute bacterial infection that results in swelling of the flap that covers the larynx during swallowing is called: A.croup. Rationale: This is a n inflammatory condition of the larynx and trachea, marked by a cough, hoarseness, and difficulty in breathing. B. laryngitis. Rationale: This is an i nflammation of the larynx, usually accompanied by hoarseness and coughing. C. epiglottitis. Rationale: Correct answer D. diphtheria. Rationale: This is c aused by a bacterium that attacks the membranes of the throat.

82. 82 Review 10. Bronchospasm is MOST often associated with: A. asthma. B. bronchitis. C. pneumonia. D. pneumothorax.

83. 83 Review Answer: A Rationale: Asthma—a reactive airway disease—is caused by bronchospasm (sustained constriction of the bronchioles). Common triggers to an acute asthma attack include environmental allergens, stress, and temperature changes.

84. 84 Review 10. Bronchospasm is MOST often associated with: A.asthma. Rationale: Correct answer B. bronchitis. Rationale: Bronchitis is the i nflammation of the mucous membrane in the bronchial tubes of the lungs. C. pneumonia. Rationale: Pneumonia is a n inflammation of one or both lungs. D. pneumothorax. Rationale: Pneumothorax is t he presence of air or gas in the pleural cavity surrounding the lungs, causing pain and difficulty in breathing.