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.