Respiratory Distress

What are the 4 types of respiratory distress?

1. Airway obstruction

2. Hyperventilation

3. Asthma

4. Pulomonary Edema

What is an airway obstruction?

Blocking of the larynx with a foreign object or due to a muscle spasm (laryngospasm)

What blocks the trachea?

epiglottis

What is the opening to thr trachea called?

Glottic opening

What is the size of an airway in a 2 year old?

6.5mm squared

Generally the diameter of the _____ in patients below the age of 11 years old.

pinky

Be ________ in the management of pediatric airway obstruction.

aggressive

Children desaturate quicker of _____

O2

What are some ways to prevent airway obstruction?

1. Rubber dam

2. Oral Packing

3. Chair position

4. Dental assistant

5. Suction

6. Magill forceps

7. Ligature

Managment of the foregin body in the oropharynx:

• Do not allow pt to what?

• Attempts to retrive object with what? (2)

• Patient is placed in _________ position

• Patient is turned to the _____

• If unable to retrive, lean pt head ______ and encourage _________

sit up

high volume suction and magill forceps

trendelenburg

left

down and encourage coughing

Lost foreign object:

• Determine if pt __________ or __________

• How to do that?

aspirated or swalloed

ask the pt and look for airway obstruction signs

If unable to confrim location fo foreign object? (3)

1. patient needs to have radiogrpahs to confirm

2. Patient should be escorted for xrays

3. Aspirated foregin body can be asymptomatic intially

What are the 3 ways to do radiographic evaluation?

1. Abdominal flat plate

2. Lateral chest

3. AP chest

If swallowed:

• What to anticipate?

1. Usally allowed to pass: monitor stools or follow up abdominal film to confirm passage

2. If sharp or concern about GI injury: retrived from stomach or proximal duodenum with endoscopy.

If aspirated…. what to do?

Brochocsope retrival is manditaory and urgent

Coughing, heezing, crowing sound during inspiration

Altered voice

Partial obstruction

Complete obstruction:

• Inablity to _______

• No __________

• Universal ______ sign with ______ struggle

• Loss of _________/____________

speak

breathing

choking, aggressive

consciousness/cyanosis

Partial airway obstruction: with good air exchange

• ________ coughing

• ______ between coughs, _____ minimally affected.

• Not ________ (able to breathe)

foreceful

wheezing, voice

cyanotic

If a patient has good airway echange should you do hymlic?

Do not do hymlic and let pt cough it up

Partial airway obstruction with poor air exchange:

• ______ cough

• _______ sounds

• Significantly altered _______

• ___________

weak

crowing

voice

cyanosis

Emergency complete obstruction:

• Must reestablish ______ as a number one priority prior to any other rescue measures.

• _______ choking sign.

airway

universal

Management of airway obstruction:

• Depends on the degree of __________

• If parital obstruction:

  • If patient is still able to ventilate?

  • If cyanotic?

obstruction

monitor and aid prn

manage as if complete obstruction

Also known as subdiaphragmatic compression technique?

Heimlich maneuver

How to perform heimich maneuever that are conscious? (3 steps)

1. Stand behind patient and wrap arms around the waist/under the arms.

2. Grasp one fist with other hand with clasped hands resting above umbilicus and below xyphoid process.

3. Perfrom repeated inward and upward thrusts to mimic a coughing motion.

For patients with obstruction that are unconscious:

• Instead of ______ _______

• Place patient in the _______ position

• Activate ____ system

• _____/____ thrust

• ____ _____ only if obstruction is observed

• Attempt __________

• Begin ______

abdominal thrust

supine

EMS

Chin lift/jaw

Finger sweep

Ventilation

CPR

Special Circumstances:

• Obese pt?

• Pregant pt?

• Infant less than 1 year?

chest thrust

chest thrust

chest thrust

Similar to other maneuvers but with hands on the middle of the sternum

Chest thrust

With chest thrust be careful in who?

older victums

Infants below the age of 1 year with obstruction?

Back blow with chest thrust

Reserved for absolute emergencies where death is likely unless procedure is attempted.

Emergency Cricothryoidotomy

Emergency Cricothryoidotomy:

• Has significant potential _________

• Ideally, should have done what prior? (3)

• ________ airway for unresolvable complete airway obstruction

morbitity

bag-valve mask, laryngela mask airway, standard intubation

definitve

Emergency Cricothryoidotomy:

• Prepare _____

• Palpate ______

• Stabalize _____

• _______ incision over cricothroid membrane

• Insert scalpel handel into trachea and rotate _____

• Insert _______ ___ into airway

skin

membrane

trachea

transverse

90 degrees

tracheotomy tube

What are the 2 suction devices available?

Are they recommende?

LifeVac, and Dechocker

No

Breathing in excess of that requried for proper ventilation

Hyperventilation

Hyperventilation is commonly the result of what?

anxiety

Hyperventilation pathophysiology:

• Increased _______ _____

• Increased _______ ______

  • Blowing off ______

  • Hypocapnia leads to what?

• __________

sympathetic tone

respiratory rate

CO2

respiratroy alkalosis

palpations

Managment of hyperventilation:

• Aimed at the ________ and reduction in __________

• Position the pt relatively _______

• _______ per standard protocol

• _______ the patient

• Cup hands over mouth or do what?

• Nitrous oxide or other ______ if needed

• _____ or _____ sedation for future appointments

hypocapnia, anxiety

upright

CABs

calm

breath into bag

sedatives

Oral or IV

Asthma:

• _____% of the Us adult population

• Number of cases has been steadily ________

• ___% of US children are affected

• Rarely ________, but can greatly reduce what?

2-3%

increaseing

10%

lethal, greatly reduce quality of life in severe cases

What is extrinsic asthma?

Allergic asthma

What is Intrinsic asthma?

Infection, idiopahtic, psychogenic

Orignins of an asthma atack are ____ fold

two

What causes an acute broncospasm?

Bronchiol smooth muscles

What causes chronic inflammation of asthma?

1. Bronchial mucous membranes

2. Mucous hyperectrion

3. Sputum plugging of small airways

Asthma is typically triggered by what?

Inhaled irritant

What are the 4 steps of asthma?

1. Allergen

2. Allergen binds to IGE of mast cells

3. Mast cells degranulate

4. Edema, bronchoconstriction, and mucus hypersecretion

What are the 5 parts of clinical asthma presentation?

1. Dyspnea with cough and wheezing

2. Sudden onset

3. Expiraratory wheeze

4. Self limiting

5. Status asthmaticus

Symptom only when exposed to a trigger

Symptoms less than 1 hour and twice a week

Mild Asthmatic

More than twice a week

Sleep and activity level is affected

Occasional emergency care

Moderate asthmataic

Ongoing symptoms that limit normal activity

Occasional hospitalization

Severe asthmatic

Medical managment of asthma:

• Avoidance of ______ factors

• Inhaled ______ agonists

• Inhaled _________

• ___________ (theopylline)

• ____________ (mast cell stabilizer)

• Systemic ________

• ________ therapy

• _________ inhibitors (montekukast singulair)

precipiating

beta-2

corticosteroids

methylaxanthines

Cromolyn sodium

steroids

nebulizer

leukotriene

Dental management of asthma:

• Prevetnion of an _______ asthmatic attack

• Having the pt bring their _________

• Reduce anxiety with what?

• Local __________ (sulfites)

• Corticosteroids and ________ suppresion

• __________

acute

medication

nitrous oxide

anesthetics

adrenal

NSAIDs

NSAIDs mechanism of action?

1. Tissue damage releases phospholipids

2. Phospholpiase A2 converts phospholipids ot aradidonic acid

3. Lipoxygenase release leukotrienes and cycoloxygenase release prostaglandins

Managment of asthmatic emergency:

• Having ______ agonist inhaler in your emergency kit (____# of puffs)

• _________

• If unable to use inhaler what to give?

beta 2 agonist, 2-4 puffs immediaately

0.3-0.5 mg (0.30.5 ml 1:1,000) epi IM or under tongue

What are the 3 things you do not manage asthma emergescies with???

1. Steroids

2. Cromolyn Sodium

3. Leukotriene inhibitors

Metaproterenol inhaler:

• What mechanism?

• Indications?

• Contraindications?

• How to use?

beta 2 adrenergic receptor agonist

bronchoconstriction asthma attack

cardiac effects and tachydrsrhytmias

1-2 puffs patients inhales and use until symptoms improve (same as albuterol)

What are the 2 rescuse inhalers and how much do they cost?

1. Metaproterenol (alupent) 30-40 dollars

2. Albuterol (Ventolin) 50-80 dollars

Asthmatic episode that does not respond to the typical beta 2 adrenergic inhaler

Status Asthmaticus

Status Asthmaticus:

• Can become a life threatening event mainly due to what?

• Requires emergency what?

• Can give IM what?

respiratory muscle fatigue

transport and hospital management

Epi (o.3-0.5 1:1,000 mg)

What are the 3 types of COPD?

1. Obstrucitve vs restricitve airway disease

2. Chronic bronchitis

3. Emphysema

COPD:

• ______ leading cause of death in the US

• Etiologic factor?

thrid

Cigarette smoking, dose related

Simple chornic bronchitis:

• Chronic productive cough? (3)

• Result of low grade exposure to what?

Smokers cough, productive cough for 3 months in 2 successive years, and Excessive mucous production

bronchial irritants in pt with hyper reactive airways

What is the pathophysiology of chronic bronchitis?

Hyperplasia and hypertrophy of the mucous secreting cells of the respiratory epithelium

Thickened brochial walls with inflammation

Narrowing and plugging of the small airways

What are the 3 clinical features of chronic bronchitis?

1. Chronic cough with copious sputum production

2. Sedentary, overweight, cyanotic, and SOB

3. Blue bloaters

What is proteolysis antiproteolysis therory of emphysema?

Elastin synthesis and catabolism

Neutrophils produce elastase

Unopposed elastolytic activity leads to destruction of the tissue in the walls of the distal airspaces.

SA is decreased

What are the 5 clinical features of emphysema?

1. Severe exertion dyspnea

2. Minimal non-productive cough

3. Barrel chested with weight loss

4. Minimal cyanosis

5. Pink Puffers

COPD:

• Progressive dyspnea and hypercapnia lead to severe what?

• High risks for pulmonary _______

• Pulmonary _________

• ___________

debiliation

infections

hypertension

irreversible

What does a spriometery test do?

Tests pulmonary function

COPD Lab findings:

• Arterial blood gasses

  • Bronchitis?

  • Emphysema?

• CBC

  • ????

Elevated pCO2 and decrased pO2

Normal pCO2 and decreased pO2

Elevated heatocrit

COPD medical management:

• Is there a cure?

• Treatment aimed at what?

No

preserving quality of life and preventing progression

COPD Medical Management:

• Elimination of _________

• Bronchodilators? (2)

• _______ in acute episodes of respiratory distress

• ________ for severe disease

smoking

beta-2 agonists and methylzanthines

corticosteroids

oxygen

COPD Dental Management:

• _________ in fully supine position

• ________ and airway obstruction considerations

• Care with ________ and __________

• Consider supplemental __________

• Not canidates for what?

orthopenea

rubber dam

narcotics and barbituates

oxygen

sedation techniques

COPD dental management:

• Nitrous oxide? (2)

• Oral _________

• History of systemic __________

• _____________ cancer

• Position more _________

• Avoid __________

• Poor candiates for elective _____ ______

Lower flow and avoid in emphysema pt

sedation

steroids, adrenocoricosuppresion and stress dose steroids

oral-naso-pharyngeal cancer

upright

rubber dams

elective general anesthesia

Dentists role in smoking cessation:

• For some of these pt, the only health care professional they see is who?

• Consoling pt on smoking cessation is a _________ responsibility

• Is it ok for pt to smoke?

dentist

multidisciplinary

NEVER

What 3 things are needed for oxygen in a emergency?

1. E cylinder

2. Know how to turn on

3. Have wrench attached to the tank

Nasal Cannula: great for prophlactic o2

• Well _________

• ____ sedations

• Nasal _______ issues

• For __________ emergencies

• Nasal ________

• Generaly run at what?

tolerated

IV

congestion

non-emergent

drying

4L/min

Non-rebreather mask:

• For ________ _______ pt

• Set oxygen at how much?

• Be sure to fill __________

consioius emergency

10L/min

reservoir

Open Masks (Oxymask)

• Can deliver higher _________ than non-rebreather mask

• More ________ for the pt

concentration

comfortable

Used to deliver oxygen to unconsious patients

Bag-valve mask

% of O2:

• Mouth to mouth?

• Bag-valve-mask+ oxygen?

16%

100%

How to use bag valve air?

1. Open the airway by jaw/chin lift

2. Establish a seal with the mouth with C-clamp tecnhique