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Respiratory EmergenciesChapter 11
Respiratory System:
Anatomy and Function of the Lung:
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
Causes 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.
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
Dyspnea:
• Shortness of breath or difficulty breathing
• Patient may not be alert enough to complain of shortness of breath.
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.
Upper or Lower Airway Infection (treatment):
• 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.
Acute Pulmonary Edema:
• Fluid build-up in the lungs
• Signs and symptoms
• Dyspnea
• Frothy pink sputum
• History of chronic congestive heart failure
• Recurrence high
Acute Pulmonary Edema (treatment):
• Administer 100% oxygen.
• Suction secretions.
• Transport in position of comfort.
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
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
Chronic Obstructive Pulmonary Disease(treatment):
• Assist with prescribed inhaler if patient has one.
• Transport promptly in position of comfort.
Asthma:
• Common but serious disease
• Asthma is an acute spasm of the bronchioles.
• Wheezing may be audible without a stethoscope.
Asthma (treatment):
• Obtain history.
• Assess vital signs.
• Assist with inhaler if patient has one.
• Administer oxygen.
• Transport promptly.
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
Spontaneous Pneumothorax (treatment):
• Administer oxygen.
• Transport in position of comfort.
• Monitor closely.
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.
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
Pleural Effusion (treatment):
• Definitive treatment is performed in a hospital.
• Administer oxygen and support measures.
• Transport promptly.
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.
Obstruction of the Airway (treatment):
• Clear airway.
• Administer oxygen.
• Transport promptly.
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
Pulmonary Embolism (treatment):
• Administer oxygen.
• Place patient in comfortable position, usually sitting.
• Assist breathing as necessary.
• Keep airway clear.
• Transport promptly.
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
Hyperventilation (treatment):
• 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.
You are the provider:
• You and your EMT-B partner are dispatched to 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.
• 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.
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?
Initial Assessment:
• Perform initial assessment.
• Place the patient on oxygen.
• If patient is in respiratory distress, ventilate.
• Check pulse.
Signs and Symptoms:
• Difficulty breathing
• Altered mental status
• Anxiety or restlessness
• Increased or decreased respirations
• Increased heart rate
• Irregular breathing
• Cyanosis
• Pale conjunctivae
• Abnormal breath sounds
• Difficulty speaking
• Use of accessory muscles
• Coughing
• Tripod position
• Barrel chest
You are the provider:
• 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.
• 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?
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
Interventions:
• Treat immediate life threats
• Possible interventions
– Oxygen via nonrebreathing mask at 15 L/min
– Positive pressure ventilations
– Airway adjuncts
– Positioning
– Respiratory medications
Detailed Physical Exam:
• Performed only once life threats are addressed.
• May not be able to do if busy treating airway or breathing problems.
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.
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.
Medications in MDI:
• Trade names
– Proventil
– Ventolin
– Alupent
– Metaprel
– Brethine
• Generic names
– Albuterol
– Metaproterenol
– Terbutaline
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
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.
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.
Administration of MDI:
• 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.
• 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.
• 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.
Reassessment:
• Carefully watch for shortness of breath.
• 5 minutes after administration:
– Obtain vital signs again.
– Perform focused reassessment.
– Transport and continue to assess breathing