Respiratory Emergencies

Chapter 16
Objectives
- List the structure and function of the respiratory system.
- State the signs and symptoms of a patient with breathing difficulty.
- Describe the emergency medical care of the patient with breathing difficulty.
- Recognize the need for medical direction to assist in the emergency medical care of the patient
with breathing difficulty.
- Describe the emergency medical care of the patient with breathing distress.
- Establish the relationship between airway management and the patient with breathing difficulty.
- List signs of adequate air exchange.
- State the generic name medication forms dose administration action indications and
contraindications for the prescribed inhaler.
- Distinguish between the emergency medical care of the infant child and adult patient with
breathing difficulty.
- Differentiate between upper airway obstruction and lower airway disease in the infant and child
patient.
- Defend E!"-#asic treatment regimens for $arious respiratory emergencies.
- Explain the rationale for administering an inhaler.
%. &natomy re$iew
&. Respiratory
'. (ose and mouth
). *harynx
a. +ropharynx
b. (asopharynx
,. Epiglottis - a leaf-shaped structure that pre$ents food and liquid
from entering the trachea during swallowing.
-. "rachea .windpipe/
0. 1ricoid cartilage - firm cartilage ring forming the lower portion of
the larynx.
2. Larynx .$oice box/
3. #ronchi - two ma4or branches of the trachea to the lungs.
#ronchus subdi$ides into smaller air passages ending at the
al$eoli.
5. Lungs
6. Diaphragm
a. %nhalation .acti$e/
.'/ Diaphragm and intercostal muscles contract
increasing the size of the thoracic ca$ity.
.a/ Diaphragm mo$es slightly downward flares
lower portion of rib cage.
.b/ Ribs mo$e upward7outward.
.)/ &ir flows into the lungs.
b. Exhalation
.'/ Diaphragm and intercostal muscles relax
decreasing the size of the thoracic ca$ity.
.a/ Diaphragm mo$es upward.
.b/ Ribs mo$e downward7inward.
.)/ &ir flows out of the lungs.
'8. Respiratory physiology
a. &l$eolar7capillary exchange
.'/ +xygen-rich air enters the al$eoli during each
inspiration.
.)/ +xygen-poor blood in the capillaries passes into
the al$eoli.
.,/ +xygen enters the capillaries as carbon dioxide
enters the al$eoli.
b. 1apillary7cellular exchange
.'/ 1ells gi$e up carbon dioxide to the capillaries.
.)/ 1apillaries gi$e up oxygen to the cells.
c. &dequate breathing
.'/ (ormal Rate
.a/ &dult - ')-)87minute
.b/ 1hild - '0-,87minute
.c/ %nfant - )0-087minute
.)/ Rhythm
.a/ Regular
.b/ %rregular
.,/ 9uality
.a/ #reath sounds - present and equal
.b/ 1hest expansion - adequate and equal
.c/ Effort of breathing - use of accessory
muscles - predominantly in infants and children
.-/ Depth .tidal $olume/ - adequate
d. %nadequate breathing
.'/ Rate - outside of normal ranges.
.)/ Rhythm - irregular
.,/ 9uality
.a/ #reath sounds - diminished or absent
.b/ 1hest expansion - unequal or inadequate
.c/ %ncreased effort of breathing - use of
accessory muscles - predominantly in infants
and children
.-/ Depth .tidal $olume/ - inadequate7shallow
.0/ "he s:in may be pale or cyanotic .blue/ and cool
and clammy.
.2/ "here may be retractions abo$e the cla$icles
between the ribs and below the rib cage especially in
children.
.3/ (asal flaring may be present especially in
children.
.5/ %n infants there may be ;seesaw; breathing where
the abdomen and chest mo$e in opposite directions.
.6/ &gonal breathing .occasional gasping breaths/
may be seen 4ust before death.
''. %nfant and child anatomy considerations
a. !outh and nose - in general< &ll structures are smaller
and more easily obstructed than in adults.
b. *harynx - infants= and children=s tongues ta:e up
proportionally more space in the mouth than adults.
c. "rachea .windpipe/
.'/ %nfants and children ha$e narrower tracheas that
are obstructed more easily by swelling.
.)/ "he trachea is softer and more flexible in infants
and children.
d. 1ricoid cartilage - li:e other cartilage in the infant and
child the cricoid cartilage is less de$eloped and less rigid.
e. Diaphragm - chest wall is softer infants and children tend
to depend more hea$ily on the diaphragm for breathing.
#. &dequate and inadequate artificial $entilation
'. &n E!"-#asic is adequately artificially $entilating a patient when<
a. "he chest rises and falls with each artificial $entilation.
b. "he rate is sufficient approximately ') per minute for
adults and )8 times per minute for children and infants.
c. >eart rate returns to normal with successful artificial
$entilation.
). &rtificial $entilation is inadequate when<
a. "he chest does not rise and fall with artificial $entilation.
b. "he rate is too slow or too fast.
c. >eart rate does not return to normal with artificial
$entilation.
%%. #reathing Difficulty
&. Signs and symptoms
'. Shortness of breath
). Restlessness
,. %ncreased pulse rate
-. %ncreased breathing rate
0. Decreased breathing rate
2. S:in color changes
a. 1yanotic .blue-gray/
b. *ale
c. ?lushed .red/
3. (oisy breathing
a. 1rowing
b. &udible wheezing
c. @urgling
d. Snoring
e. Stridor
.'/ & harsh sound heard during breathing
.)/ Apper airway obstruction
5. %nability to spea: due to breathing efforts.
6. Retractions - use of accessory muscles.
'8. Shallow or slow breathing may lead to altered mental status
.with fatigue or obstruction/.
''. &bdominal breathing .diaphragm only/
'). 1oughing
',. %rregular breathing rhythm
'-. *atient position
a. "ripod position
b. Sitting with feet dangling leaning forward.
'0. Anusual anatomy .barrel chest/
%%%. Emergency !edical 1are - ?ocused >istory and *hysical Exam
&. %mportant questions to as:
'. +nset
). *ro$ocation
,. 9uality
-. Radiation
0. Se$erity
2. "ime
3. %nter$entions
#. #reathing
'. 1omplains of trouble breathing.
a. &pply oxygen if not already done.
b. &ssess baseline $ital signs.
). >as a prescribed inhaler a$ailable.
a. 1onsult medical direction.
b. ?acilitate administration of inhaler
.'/ Repeat as indicated.
.)/ 1ontinue focused assessment.
,. Does not ha$e prescribed inhaler - continue with focused
assessment.
%B. Relationship to &irway !anagement - should be prepared to inter$ene with
appropriate oxygen administration and artificial $entilation support.
B. Lung Disease
&. 1auses of Lung Disease
'. +bstruction of pulmonary $essels by fluid infection or collapsed
air spaces
). Damaged al$eoli
,. +bstructed air passages by muscle spasm mucous or
wea:ened floppy airway walls
-. +bstruction of blood flow by clots
0. Lungs are unable to expand due to fluid7air in the pleural space
#. Respiratory Dri$e
'. (ormal Respiratory Dri$e
a. #rain stem is sensiti$e to 1+) le$els in the arterial
blood
b. %ncreased 1+) causes an increase in respiratory
rate7depth
c. Decreased 1+) causes a decrease in respiratory
rate7depth
). >ypoxic Dri$e
a. #rain stem becomes sensiti$e to +) le$els in the
arterial blood
b. Decreased +) causes an increase in respiratory
rate7depth
c. %ncreased +) causes a decrease in respiratory
rate7depth
d. @i$ing too much +) to these patients may cause
respirations to become depressed or stop
C. NEVER WITHO! O"#$EN %RO& ' ('TIENT TH'T I) H#(O"IC
B%. 1auses of Dyspnea
&. Apper or Lower &irway %nfection
'. !ay cause swelling of tissues which obstructs the air flow into
the lungs .colds epiglottitis croup/
). !ay cause exchange of +) and 1+) at the al$eolar7capillary
le$el to be obstructed due to fluid7mucous7damage .pneumonia/
,. Epiglottitis
a. Se$ere swelling of the epiglottis
b. (ormally seen in children but can occur in adults
c. !ay be sudden in onset
d. Asually accompanied by a high fe$er
e. *atient may ha$e stridor or will be drooling
f. Do not attempt to $isualize or place anything into the
airway
g. "reat with supplemental +) without agitating the patient
h. "ransport in position of comfort .usually sniffing
position/
-. 1roup
a. 1auses swelling of the lining of the larynx
b. (ormally seen in children up to , years old
c. Seal-li:e bar:ing cough
d. "reat with supplemental +) humidified if possible
e. "ransport in position of comfort
0. *neumonia
a. &cute inflammation of the al$eoli
b. "reatment is supporti$e +) as needed
#. &cute *ulmonary Edema
'. 1auses
a. Cea:ened left side of the heart due to heart attac: .!%/
or other illness
). *hysiology
a. >eart cannot pump blood out as fast as it recei$es it
b. ?luid bac:s up into the lungs
c. ?luid separates al$eoli7capillary beds
d. Decreases a$ailable space in lungs for air mo$ement
and blood flow
e. 1an be rapid or delayed in onset
,. &ssessment ?indings
a. Dyspnea
b. (ormal to increased blood pressure
c. "achycardia
d. Lung sounds D Rales
-. "reatment
a. >igh flow +) consider #B!
b. Suction as needed
c. "ransport in position of comfort
0. "raumatic *ulmonary Edema
a. 1auses
.'/ %nhalation of heated air chemicals toxic fumes or
in4ury to the chest
b. *hysiology
.'/ Same as cardiac pulmonary edema except fluid is
caused by response to damaged tissue
c. &ssessment ?inding and "reatment are the same as
cardiac etiology of pulmonary edema
1. 1+*D
'. 1hronic #ronchitis
a. 1auses
.'/ Smo:ing
b. *hysiology
.'/ 1onstant production of excess mucous
.)/ !echanisms that remo$e foreign particles are
paralyzed
.,/ *neumonia de$elops easily
.-/ *atientEs lose the ability to compensate for any
lung insult
c. &ssessment ?indings
.'/ Somewhat obese .blue bloater/
.)/ ?requent producti$e cough
.,/ *ursed lip breathing
.-/ Lung sounds D rhonchi
d. "reatment
.'/ +) as needed
.)/ &ssist patient with home meds .inhalers/
.,/ "ransport in position of comfort .usually sitting
upright/
). Emphysema
a. 1auses
.'/ Smo:ing
b. *hysiology
.'/ Destruction of al$eolar walls
.)/ &l$eoli lose the ability to recoil and expel air
.,/ Large air poc:ets or dead space de$elops in the
lungs
.-/ *atientEs lose the ability to compensate for any
lung insult
c. &ssessment ?indings
.'/ *atientEs will usually be thin with a barrel chest
.)/ Reddish7pin: s:in color .pin: puffer/
.,/ "achypnea
.-/ &ccessory muscle use
.0/ *ursed lip breathing
.2/ Lung sounds D Decreased and7or wheezes
d. "reatment
.'/ +) as needed
.)/ &ssist patient with home meds .inhalers/
.,/ "ransport in position of comfort .usually sitting
upright/
D. Spontaneous *neumothorax
'. 1auses
a. 1hronic lung infections or people with wea: lungs
.asthma emphysema/
b. 1oughing spell
). *hysiology
a. &ir lea:s into pleural space causing lung to partially
collapse
,. &ssessment ?indings
a. Sharp stabbing one sided chest pain which is worse
with inspiration
b. Dyspnea
c. Lung sounds D Decreased or normal
d. 1an be extremely difficult to detect
-. "reatment
a. Reassess often
b. +) as needed
c. "ransport in position of comfort
E. &sthma
'. "riggers
a. &llergies
b. %nfections
c. Stress
d. Exercise
e. 1old air
f. &spiration
). *hysiology
a. #ronchi and bronchiole smooth muscle spasm
b. %ncreased mucous production
c. #ronchiole inflammation
,. &ssessment ?indings
a. Dyspnea .the faster the onset the more serious the
situation/
b. *ersistent cough
c. "achypnea
d. &ccessory muscle use
e. Spea:ing in short sentences
f. Lung sounds D Cheezes with expiration or silent chest
-. "reatment
a. >igh flow +)
b. &ssist patient with medications .inhalers Epi- pen/
c. Feep patient calm
d. *osition of comfort
?. &llergic Reactions .&naphylaxis/
'. 1auses
a. &llergic reaction .bee sting peanuts etc./
). *hysiology
a. #ody o$erreacts to the allergen causing $asodilation
and bronchoconstriction
,. &ssessment ?indings
a. Same as with asthma
b. Decreased blood pressure
c. %tching and hi$es
-. "reatment
a. Same as asthma
b. Rapid "ransport
@. *leural Effusions
'. & collection of fluid outside the lung on one or both sides of the
chest which may compress the lung or lungs
). "reat supporti$e as needed
>. *ulmonary Embolus
'. 1auses
a. Damage to the lining of $essels
b. Slow blood flow in a lower extremity .prolonged bed
rest/
c. Recent surgeries
d. #irth control pills
e. Smo:ing
f. Recent ?ractures
). *hysiology
a. #lood clot tra$els to the lung $ia the $enous system
usually from a lower extremity
b. Decreases or bloc:s blood flow to the lung beyond the
clot
,. &ssessment ?indings
a. Dyspnea
b. 1hest pain .usually sharp/
c. "achypnea
d. "achycardia
e. 1oughing up blood tinged sputum
-. "reatment
a. >igh flow +)
b. *osition of comfort
%. >yper$entilation Syndrome
'. 1auses 7 *atient 1haracteristics
a. Stress7anxiety
b. Goung females
). *hysiology
a. *atient blows off too much 1+)
,. &ssessment ?indings
a. Dyspnea
b. 1hest pain .usually sharp/
c. "achypnea
d. "achycardia
e. (umbness7tingling around mouth7hands
f. *resents the same as pulmonary embolus except for
carpal pedal spasms .muscle spasms of fingers7toes/
-. "reatment
a. 1alm the patient
b. "reat for *.E. if not absolutely sure
c. (e$er place a mas: o$er patients face without +) or
ha$e them breathe into a paper bag
d. Remo$e them from stressful en$ironment
B%%. !edications
&. *rescribed inhaler
'. !edication name
a. @eneric - albuterol isoetharine metaproteranol etc.
b. "rade - *ro$entil Bentolin #ron:osol #ron:ometer
&lupent !etaprel etc.
). %ndications - meets all of the following criteria<
a. Exhibits signs and symptoms of respiratory emergency
b. >as physician prescribed handheld inhaler and
c. Specific authorization by medical direction.
,. 1ontraindications
a. %nability of patient to use de$ice.
b. %nhaler is not prescribed for the patient.
c. (o permission from medical direction.
d. *atient has already met maximum prescribed dose prior
to E!"-#asic arri$al.
-. !edication form - handheld metered dose inhaler
0. Dosage - number of inhalations based upon medical direction=s
order or physician=s order based upon consultation with the patient.
2. &dministration
a. +btain order from medical direction either on-line or off-
line.
b. &ssure right medication right patient right route patient
alert enough to use inhaler.
c. 1hec: the expiration date of the inhaler.
d. 1hec: to see if the patient has already ta:en any doses.
e. &ssure the inhaler is at room temperature or warmer.
f. Sha:e the inhaler $igorously se$eral times.
g. Remo$e oxygen ad4unct from patient.
h. >a$e the patient exhale deeply.
i. >a$e the patient put his lips around the opening of the
inhaler.
4. >a$e the patient depress the handheld inhaler as he
begins to inhale deeply.
:. %nstruct the patient to hold his breath for as long as he
comfortably can .so medication can be absorbed/.
l. Replace oxygen on patient.
m. &llow patient to breathe a few times and repeat second
dose per medical direction.
n. %f patient has a spacer de$ice for use with his inhaler it
should be used. & spacer de$ice is an attachment between
inhaler and patient that allows for more effecti$e use of
medication.
3. &ctions - #eta agonist bronchodilators - dilates bronchioles
reducing airway resistance.
5. Side effects
a. %ncreased pulse rate
b. "remors
c. (er$ousness
6. Re-assessment strategies
a. @ather $ital signs and focused reassessment.
b. *atient may deteriorate and need positi$e pressure
artificial $entilation.
'8. %nfant and child considerations
a. Ase of handheld inhalers is $ery common in children.
b. Retractions are more commonly seen in children than
adults.
c. 1yanosis .blue-gray/ is a late finding in children.
d. Bery frequent coughing may be present rather than
wheezing in some children.
e. Emergency care with usage of handheld inhalers is the
same if the indications for usage of inhalers are met by the ill
child.