Medical (ch 16 & 17) - respiratory emergencies & cardiovascular emergencies

16: respiratory emergencies 17: cardiovascular emergencies

the most common symptom of a respiratory emergency is:

shortness of breath

the respiratory system can be divided into three portions:

1. upper airway

2. lower airway

3. lungs and accessory structures (work with first two portions to allow the oxygenation of body cells and the elimination of carbon dioxide from the bloodstream

the upper and lower airway are separated by:

the vocal cords (or glottic opening)

what is the primary purpose of the upper and lower airways?

the conduction of air into and out of the lungs

normal breathing is defined differently for each individual patient group based on:

• age

• preexisting disease

the following findings are consistent with a patient who is breathing adequately:

• an intact (open) airway

• normal respiratory rate

• good rise and fall of the chest

• normal respiratory rhythm

• breath sounds that are present bilaterally

• chest expansion and relaxation that occurs normally

• minimal-to-absent use of accessory muscles to aid in breathing

if no other condition or injury is involved, the following should also occur in a patient who is breathing adequately:

(along with open airway, normal respiratory rate, chest rise/fall, breath sounds, etc.)

• normal mental status

• normal muscle tone

• normal pulse ox reading

• normal skin condition findings

abnormal factors that are present in certain pulmonary (lung) conditions can decrease the efficiency of gas exchange across the alveolar-capillary membrane, including the following:

• increased width of the space between the alveoli and blood vessels

• lack of perfusion of the pulmonary capillaries from the right ventricle of the heart

• filling of the alveoli with fluid, blood, or pus

T/F: the inspiratory and expiratory centers in the medulla and pons in the brainstem are accessory structures that are part of the respiratory system

true - they exert nervous control of breathing

• receive info about the oxygen and carbon dioxide content of the bloodstream from special sensors in the vascular system

• stretch receptors in the walls of the lungs provide information to the brainstem to prevent accidental overexpansion injuries, and irritant receptors in the walls of the bronchioles detect the presence of abnormalities such as excessive fluid, toxic fumes, or smoke, or significant air temperature changes

_____ receptors (near the alveoli) can play a role in the feeling of shortness of breath the patient can experience and can also promote shallow and rapid breathing

juxta-capillary

• detect when the alveolar-capillary beds become abnormally engorged with blood because of heart failure

to achieve the most accurate interpretation of breath sounds, it is important to auscultate in the appropriate fashion:

• whenever feasible, have the patient sit upright and, while using the diaphragm end of your stethoscope over bare skin, instruct the patient to take a deep breath through the mouth and breathe out passively through the mouth

  • (you may need to instruct the patient a few times to make no airway or vocal sounds while he does this)

  • ensure the tubing of the stethoscope does not touch any surface because this can produce extraneous sounds and be mistaken as abnormal breath sounds

• place the head of the stethoscope on the patient’s thorax, and listen through the entire phases of inhalation and exhalation

• if necessary, listen to a few of the pts breaths at each auscultation location to ensure your interpretation of any abnormal breath sound

• finally, listen to sounds on one location of the body and then listen to the exact location on the other side (mirror location)

• before continuing

T/F: never auscultate over clothing

true

three basic types of abnormal breath sounds that are early indicators of impending respiratory distress include:

1. wheezing

2. ronchi

3. crackles

wheezing

• high-pitched, musical, whistling sound that is best heard initially on exhalation but can also be heard during inhalation in more severe cases

• indication of swelling and constriction of the inner lining of the lower airways (primarily the bronchioles

• usually heard in asthma, emphysema, and chronic bronchitis, pneumonia, congestive heart failure, and other conditions when they cause bronchoconstriction

T/F: in wheezing patients with severe obstruction of the lower airways by bronchoconstriction and inflammation, wheezing can be significantly diminished or absent

true - because the velocity of air movement through the bronchioles is no longer sufficient to produce the wheezing sound

ronchi

AKA course crackles

• snoring or rattling noises heard on auscultation

• indicate obstruction of the larger conducting airways of the respiratory tract by thick secretions of mucus

• often heard in chronic bronchitis, emphysema, aspiration, and pneumonia

• a characteristic: quality of sound changes if the person coughs or sometimes even when the person changes position

crackles

AKA rales

• bubbly or crackling sounds heard during inhalation

• associated with fluid that has surrounded or filled the alveoli or small bronchioles

• crackling sound is commonly associated with the alveoli and terminal bronchioles “popping” open with each inhalation

• bases of the lungs posteriorly reveal crackles first because of the natural tendency of fluid to be puled downward by gravity

• can indicate pulmonary edema or pneumonia

• this type of breath sound typically does not change with coughing or movement

T/F: both ronchi and crackles can change in sound quality of the person coughs or when they move/change position

false - only ronchi is has this characteristic while crackles typcally don’t

wheezing can indicate

• asthma

• emphysema

• chronic bronchitis

• pneumonia

• congestive heart failure

• other conditions causing bronchoconstriction

ronchi (course crackles) can indicate

• chronic bronchitis

• emphysema

• aspiration

• pneumonia

crackles (rales) can indicate

• pulmonary edema

• pneumonia

failing to breath adequately, even for short periods of time, can result in hypoxemia

hypoxemia is:

decreased oxygen in the blood stream

failing to breath adequately, even for short periods of time, can result in hypercarbia

hypercarbia is:

increased carbon dioxide in the blood stream

dyspnea

shortness of breath

apnea

complete respiratory arrest (no longer breathing)

hypoxia is:

when the cells of the body are not getting an adequate supply of oxygen in which cellular dysfunction and death occur

indications of hypoxia

• shortness of breath

• abnormal upper airway sounds

• faster/slower breathing rates

• poor chest rise/fall

• other symptoms of respiratory distress

T/F: if adequate breathing and gas exchange are not present, the lack of oxygen causes the body cells to begin to die

true - some cells become irritable when they are hypoxic, causing the cells to function abnormally

• ex: hypoxic cardiac cells become irritable and begin to send out abnormal impulses, leading to cardiac dysrhythmias (abnormal heart rhythms)

the following findings commonly occur in pts with respiratory distress

• subjective complaint of shortness of breath

• restlessness and anxiety

• tachycardia (early finding) or bradycardia (later finding)

• tachypnea

• pale, cool, clammy skin (early finding) or cyanosis (later finding)

• abnormal respiratory pattern

• wheezing, ronchi, or crackles

• difficulty or inability to speak

• muscle contractions

• altered mental status (anxiety and confusion = early finding; aggressive or complacent behavior and sleepiness = later finding)

• abdominal breathing

• excessive coughing

• tripod position

• pulse ox reading <94%

tachycardia is a _______ finding with respiratory distress

early

bradycardia is a ______ finding with respiratory distress

later

pale, cool, and clammy skin are __________ findings with respiratory distress

early

cyanosis is a ______ finding with respiratory distress

later

bronchoconstriction

significant narrowing of the lower airways, which include the bronchi and bronchioles, from inflammation, swelling, or constriction of the muscle layer

AKA bronchospasm

bronchoconstriction - this narrowing causes a drastic increase in:

resistance to airflow in the lower airways

• makes inhalation and particularly exhalation extremely difficult and producing wheezing

beta 2 agonist bronchodilator

• in aerosol form

• can be inhaled during episode of breathing difficulty caused by bronchoconstriction

• designed to relax the bronchi and bronchiole smooth muscle, causing dilation, which results in a decrease in airway resistance and increase in the effectiveness of moving air in and out of the alveoli, better gas exchange and a relief from the S&S

breathing difficulty can also be a symptom of injuries to:

the head. face, neck, spine, chest, or abdomen

(can also be caused by cardiac compromise, hyperventilation, associated with emotional upset, and various abdominal conditions)

cardiac compromise

when the heart isn’t getting enough oxygen

T/F: the sensation of shortness of breath occurs when the metabolic demands of the body are not met

true - this typically results from an inadequate amount of oxygen delivered to the cells to allow for normal aerobic metabolism to continue

the sensation of shortness of breath occurs when the metabolic demands of the body are not met. Dyspnea is usually caused by one of the following:

• mechanical disruption to the airway, lung, or chest wall that prevents effective mechanical ventilation

  • examples of conditions that can cause a disruption in mechanical ventilation include:

    • airway obstruction

    • flail chest

    • chest muscle weakness

    • neuromuscular disease

    • lung collapse

• stimulation of the receptors in the lungs. Such stimulation produces a sensation of shortness of breath.

  • conditions that stimulate the receptors include:

    • asthma

    • pneumonia

    • congestive heart failure

• inadequate gas Exchange at the level of the alveoli and capillaries causing a decrease in the oxygen content in the blood or a rise in the level of carbo dioxide

  • this can occur because of any of the following:

    • ventilation disturbance

    • perfusion disturbance

    • both a ventilation and a perfusion disturbance

    • a gas exchange disturbance

flail chest

2 or more adjacent ribs fractured in two or more places

dyspnea can be caused by inadequate gas exchange at the level of the alveoli and capillaries causing a decrease in the oxygen content in the blood (hypoxemia) or a rise in the level of carbon dioxide in the blood (hypercarbia).

this can occur because of:

• a ventilation disturbance

  • an inadequate amount of oxygen-rich air entering the alveoli and passing across the alveolar membrane to the capillary

• a perfusion disturbance

  • an inadequate amount of blood traveling through the pulmonary capillaries which decreases the number of red blood cells available to pick up the oxygen and transport it to the cells

• both a ventilation and a perfusion disturbance

  • in the lungs, leading to hypoxemia and hypercarbia

• a gas exchange disturbance

  • from an increased amount of interstitial fluid in and around the alveoli

T/F: regardless of the cause, a complaint of breathing difficulty requires your immediate intervention. If severe hypoxia is present, time is critical because of the detrimental effects of severely or prolonged low oxygen levels on all cells and organs.

true

A breathing disturbance in a patient can be categorized in one of three ways:

1. respiratory distress

2. respiratory failure

3. respiratory arrest

it is critical during your primary assessment that you immediately identify in which category the breathing disturbance falls. This is a life-threatening condition, and your assessment must be made decisively and quickly

a patient who has difficulty breathing but has an adequate tidal volume and respiratory rate is said to be in

respiratory distress

• typically, a pt in this condition has a normal minute ventilation compensation in the tidal volume (breathing deeper) and/or the respiratory rate (breathing faster)

• because the tidal volume and respiratory rate are still adequate, the pt is compensating but there are still signs of respiratory distress so you should still administer oxygen

in a patient experiencing respiratory distress, you should administer oxygen via

nasal cannula at 2 lpm to increase or maintain the SpO2 reading at 94% or higher

• oxygenation should be based on the patient’s oxygenation status as measured and primarily guided by the pulse oximeter instead of using predetermined devices and flow rates for all patients

a patient who presents with moderate to severe respiratory distress and who is awake and alert can benefit from

continuous positive pressure ventilation (CPAP)

a patient in respiratory distress presenting with a severely decreased SpO2 reading and obvious signs of severe hypoxia may benefit from

higher concentrations of oxygen delivered by nonrebreather mask at 15 lpm

T/F: the SpO2 in pregnant women should be maintained at the highest level possible

true - to maintain adequate oxygenation of the fetus

• these pts must receive a high concentration of oxygen via a NRB mask regardless of the SpO2 reading

respiratory failure

when the tidal volume or respiratory rate is adequate and no longer can provide an adequate oxygenation of the cells

• inadequate tidal volume

• or an inadequate respiratory rate

• or both

in a pt experiencing respiratory failure, if the tidal volume decreases or the respiratory rate increases or decreases significantly, you must

provide immediate PPV and oxygenation with a BVM device or other ventilation device with supplemental oxygen

• if a pt with inadequate breathing is not treated promptly, it is likely that he will deteriorate to respiratory arrest

respiratory arrest

the complete cessation of breathing effort or the patient experiences agonal breathing

• no tidal volume

• no respiratory rate

• pt may have agonal respirations in which there is a sudden gasping respiratory for a long period of apnea

agonal breathing occurs when

the brainstem reflex causes a gasping breath in an otherwise apneic patient

T/F: respiratory arrest can lead to cardiac arrest in minutes if not properly managed

true - because of a lack of oxygen delivery to the brain and heart

your priority in treating patients with breathing difficulty is to

determine if the pt is in respiratory distress and in need of only oxygen therapy

or

if he is in respiratory failure or respiratory arrest in which he needs immediate ventilatory assistance with a BVM or other ventilation device and supplemental oxygen

T/F: respiratory arrest and failure are treated the same way

true - with positive pressure ventilation and supplemental oxygen (because the tidal volume and/or rate is inadequate - they don’t only need oxygen, they also need help to actively breath)

treat patients in respiratory arrest by

immediately beginning PPV with a BVM and supplemental oxygen connected to the BVM

treat patients in respiratory failure by

immediately beginning PPV with a BVM and supplemental oxygen connected to the BVM

treat patients in respiratory distress by

providing supplemental oxygen to maintain an SpO2 95% or greater

respiratory distress

adequate tidal volume and adequate respiratory rate that produces an adequate minute and alveolar ventilation