Respiratory Emergencies Study Notes

Respiratory Emergencies

Introduction

• Patients frequently complain of dyspnea, which can stem from various conditions.
• Determining the cause of dyspnea can be challenging.

Anatomy of the Respiratory System

• The respiratory system comprises structures essential for breathing:
  • Diaphragm
  • Chest wall muscles
  • Accessory muscles of breathing
  • Nerves to these muscles
• Upper Airway:
  • Structures above the vocal cords.
    • Nose and mouth
    • Jaw
    • Oral cavity
    • Pharynx
    • Larynx
• Function of Lungs:
  • Primary role is respiration – the exchange of oxygen and carbon dioxide.
  • Air flow:
    • Trachea into the lungs.
    • Bronchi (larger airways).
    • Bronchioles (smaller airways).
    • Alveoli (gas exchange).

Physiology of Respiration

• Respiration Steps:
  • Inspiration (inhaling).
  • Expiration (exhaling).
• Process:
  • Oxygen is delivered to the blood.
  • Carbon dioxide is expelled.
  • Occurs rapidly in the alveoli.
• Alveoli:
  • Oxygen diffuses into capillaries.
  • Carbon dioxide moves into the lungs.
• Brainstem:
  • Monitors carbon dioxide levels in the blood.
  • Adjusts breathing rate and depth accordingly.

Pathophysiology

• Factors Hindering Oxygen Exchange:
  • Airway anatomy conditions.
  • Disease processes.
  • Traumatic conditions.
  • Pulmonary vessel abnormalities.
• Inadequate Breathing:
  • Recognize signs and symptoms.
• Chronic Carbon Dioxide Retention:
  • Some patients rely on low oxygen levels to regulate breathing.
  • Administer oxygen cautiously to avoid suppressing their drive to breathe.

Causes of Dyspnea

• Conditions Associated with Dyspnea/Hypoxia:
  • Pulmonary edema
  • Hay fever
  • Pleural effusion
  • Airway obstruction
  • Hyperventilation syndrome
  • Environmental/industrial exposure
  • Drug overdose
• Dyspneic Patients:
  • Gas exchange obstruction.
  • Damaged alveoli.
  • Obstructed air passages.
  • Obstructed blood flow to the lungs.
  • Excess fluid in the pleural space.
• Other Symptoms:
  • Chest tightness.
  • Air hunger.
• Cardiopulmonary Diseases:
  • These are typically common.
• Pain:
  • Can lead to rapid, shallow breathing.

Upper or Lower Airway Infection

• Airway infections can lead to:
  • Dyspnea.
  • Mucus and secretions obstructing airflow.
  • Swelling of soft tissues in upper airways.
  • Impaired gas exchange in the alveoli.

Specific Conditions

Croup

• Inflammation and swelling of the pharynx, larynx, and trachea.
• Characterized by stridor and a seal-bark cough.
• Responds positively to humidified oxygen.

Epiglottitis

• Bacterial infection causing inflammation of the epiglottis.
• Children often present in a tripod position with drooling.
• Management includes positioning comfortably and administering oxygen.

Respiratory Syncytial Virus (RSV)

• Common in young children.
• Causes lung and passage infections.
• Watch for dehydration.
• Treat airway and breathing issues with humidified oxygen.

Bronchiolitis

• Viral illness, often RSV-related.
• Affects newborns and toddlers.
• Bronchioles become inflamed, swell, and fill with mucus.
• Treat with oxygen therapy and frequent reassessment.

Pneumonia

• Bacterial pneumonia: rapid onset with high fever.
• Viral pneumonia: gradual onset and less severe.
• Affects chronically ill individuals.
• Assess temperature, provide airway support, and administer supplemental oxygen.

Pertussis

• Airborne bacterial infection, primarily affecting children under 6.
• Presents with fever and a "whoop" sound on inspiration after coughing fits.
• Monitor for dehydration and suction as needed.

Influenza Type A

• Pandemic in 2009.
• Symptoms: fever, cough, sore throat, muscle aches, headache, fatigue.
• May lead to pneumonia or dehydration.

COVID-19 (SARS-CoV-2)

• Similar to common cold viruses.
• Affects elderly, those in close quarters, and immunocompromised individuals.
• Transmitted via aerosol droplets and airborne particles.
• Respiratory deterioration can occur rapidly.

Tuberculosis (TB)

• Bacterial infection, primarily affecting the lungs.
• Can remain inactive for years.
• Symptoms: fever, coughing, fatigue, night sweats, weight loss.
• Use PPE, including gloves, eye protection, and an N-95 respirator.

Acute Pulmonary Edema

• Heart muscle dysfunction leads to fluid buildup in alveoli and lung tissue.
• Often results from congestive heart failure.
• Severe cases: frothy pink sputum.

Chronic Obstructive Pulmonary Disease (COPD)

• Progressive airway and alveoli damage.
• Caused by chronic bronchial obstruction, often from tobacco smoke.
• Emphysema: loss of lung elasticity due to inflamed airways or smoking.
• Most COPD patients have both chronic bronchitis and emphysema.
• Pulmonary edema presents with "wet" lung sounds, while COPD presents with "dry" lung sounds; treat the patient, not just the lung sounds.

Asthma, Hay Fever, and Anaphylaxis

• Allergic reactions to inhaled, ingested, or injected substances; allergens sometimes unidentifiable.
• Asthma: acute spasm of bronchioles with excessive mucus and swelling.
• Asthma is most prevalent in children aged 5–17.
• Asthma triggers: allergic reactions, emotional distress, exercise, respiratory infections.
• Hay fever: cold-like symptoms from allergens like pollen, dust mites, pet dander.
• Anaphylaxis: severe airway swelling; treat with epinephrine, oxygen, and antihistamines.

Spontaneous Pneumothorax

• Air accumulation in the pleural space.
• Often caused by trauma but can be spontaneous due to lung infections or weak lungs.
• Leads to dyspnea; breath sounds may be absent on the affected side.

Pleural Effusion

• Fluid collection outside the lung, compressing it and causing dyspnea.
• Stems from irritation, infection, congestive heart failure, or cancer.
• Upright position eases pain.

Obstruction of the Airway

• Mechanical obstruction can cause dyspnea.
• In unconscious patients, it may be caused by aspiration of vomitus or the tongue blocking the airway.
• Consider foreign body obstruction if dyspnea started while eating.

Pulmonary Embolism

• Blood clot circulating through the venous system, cutting off blood flow.
• Can cause sudden death if large enough.
• Symptoms: dyspnea, tachycardia, tachypnea, hypoxia, cyanosis, chest pain, hemoptysis.

Hyperventilation

• Overbreathing leading to abnormally low arterial carbon dioxide levels.
• May indicate a life-threatening illness or compensation for acidosis.
• Can result in alkalosis, causing anxiety, dizziness, numbness, and muscle spasms.

Environmental/Industrial Exposure

• Exposure to pesticides, cleaning solutions, chemicals, chlorine, and carbon monoxide.
  • Carbon Monoxide: Odorless and highly poisonous.
  • Produced by fuel-burning appliances and smoke.
  • Prioritize personal safety.

Patient Assessment

Scene Size-up

• Scene safety: use standard precautions and PPE.
• Consider infectious diseases or toxic substances.
• Mechanism of injury/nature of illness: ask why 9-1-1 was activated.
• Question the patient, family, and bystanders to determine NOI.

Primary Assessment

• Identify immediate life threats.
• Form a general impression, noting age and position.
• Use AVPU scale and ask about chief complaint.
• Airway and breathing: ensure patent and adequate airway; assess rate, rhythm, and quality.
  • Questions: Is air going in? Does the chest rise and fall? Is the rate adequate?
• Assess breath sounds for wheezing, rales, rhonchi, and stridor.
• Circulation: assess pulse rate, rhythm, and quality; evaluate for shock and bleeding; assess perfusion via skin.
• Transport decision: address life threats and transport rapidly if condition is unstable.

History Taking

• Investigate chief complaint and previous treatments.
• Use SAMPLE history, OPQRST assessment (onset, provocation/palliation, quality, radiation/region, severity), and PASTE assessment (progression, associated chest pain, sputum, talking tiredness, exercise tolerance).

Secondary Assessment

• In-depth assessment after addressing life threats.
• Use monitoring devices.
• Look for COPD signs
  • Age over 50 years
  • History of lung problems
  • Smoking History
  • Chest tightness
  • Constant fatigue
  • Barrel Chest
  • Use of Accessory Muscles
  • Abnormal breath sounds

Reassessment

• Repeat primary assessment and assess for changes.
• Implement interventions, including oxygen, ventilation, airway management, positioning, and respiratory medications.

Emergency Medical Care

• Administer supplemental oxygen; consider CPAP or bag-mask device.
• Assist with metered-dose inhaler (MDI) or small-volume nebulizer after consulting medical control and ensuring medication is indicated.
• Ensure no contraindications.
• Most medications relax airway muscles, causing increased pulse rate, nervousness, and muscle tremors.

Treatment of Specific Conditions

• Upper or lower airway infection: administer humidified oxygen, avoid suction or oropharyngeal airway, position comfortably, and transport.
• Acute pulmonary edema: provide 100% oxygen, suction if needed, position comfortably, consider CPAP, and transport.
• Chronic obstructive pulmonary disease: assist with prescribed inhaler, watch for overuse side effects, position comfortably, and transport.
• Asthma: be prepared to suction, assist with inhaler, provide aggressive airway management, oxygen, and transport.
• Hay fever: usually not an emergency.
• Anaphylaxis: remove the cause, maintain the airway, transport rapidly, and administer epinephrine.
• Spontaneous pneumothorax: provide supplemental oxygen, transport promptly, and monitor carefully.
• Pleural effusion: fluid removal in the hospital; provide oxygen and transport.
• Obstruction of the airway: provide oxygen and transport for partial obstruction; clear obstruction and administer oxygen for complete obstruction.
• Pulmonary embolism: administer supplemental oxygen, position comfortably, clear airway if hemoptysis is present, and transport.
• Hyperventilation: complete assessment, avoid paper bag, reassure patient, provide oxygen, and transport.
• Environmental/industrial exposure: ensure decontamination and treat with oxygen, adjuncts, and suction.
• Foreign body aspiration: clear the airway, provide oxygen, and transport.
• Tracheostomy dysfunction: position comfortably, suction to clear the obstruction, and provide oxygen.
• Asthma (For children): Provide blow-by oxygen, use MDIs.
• Cystic fibrosis: suction and oxygenate as needed.

Review Questions and Answers

• Respiration is the process in which oxygen and carbon dioxide are exchanged in the lungs.
• Asthma causes obstruction of the lower airway.
• Tuberculosis may be drug resistant and is transmitted by coughing.
• Emphysema is NOT a cause of acute dyspnea.
• Bronchospasm is most often associated with asthma.
• A sudden onset of difficulty breathing, sharp chest pain, and cyanosis despite supplemental oxygen is most consistent with a pulmonary embolism.
• Albuterol, a beta-2 agonist, is the generic name for Ventolin.
• An acute bacterial infection causing swelling of the epiglottis is called epiglottitis.
• A 70-year-old man with a recent heart attack complaining of severe difficulty breathing, especially when lying flat, and coughing up pink, frothy secretions is most likely experiencing severe left heart failure.
• A 29-year-old woman with respirations of 20 breaths/min, who is conscious and alert is breathing adequately.