“Sometimes a Wheeze is Not Just a
Wheeze…”
COPD and CHF
Silver Cross EMS System
February 2013 1st Trimester CME
Our Agenda Today
• Review airway anatomy and physiology
• Review the differences between COPD and
CHF.
• Review use of CPAP and nitroglycerin in CHF
and pulmonary edema.
• Take a look at some newer airway techniques
and gadgets on the market.
• (ALS) EKG strip o’ the month: AV blocks/pacing
Quick A & P
Review
Anatomy of the Upper
Airway
Internal Anatomy of the Upper Airway
Anatomy of the Lower Airway
Anatomy of the Pediatric Airway
COPD vs. CHF
•One is respiratory
•One is cardiac
•They may seem the same, but their
treatments are very different!
COPD
– Bronchitis
– Emphysema
– Asthma
– Varying degrees/combination
– Long-term tobacco abuse, exposure to inhaled
toxins
COPD - Bronchitis
– Mucus overproduction
– Cell enlargement in lungs, airways
– Productive cough 3+ months, 2+ years
– Hypoventilation of alveoli, drops O2 level in blood
– Acidosis
– Increased cardiac output, RBC production
Normal Lung
Bronchitis
COPD - Emphysema
–
–
–
–
–
Involves alveoli
Alveolar destruction
Alveolar coalescence
Destruction of elastin fibers surrounding alveoli
Chronic hypoxia, hypercarbia
Emphysema
–Blebs on lung surface, possible
pneumothorax
–Polycythemia
–Muscle wasting, malnourished appearance
–Barrel chest
Emphysema
– Chronic dyspnea
– Little/no cough, little mucus production
– Tripod position
– Mental status changes
– Heart problems, cor pulmonale, ventricular failure
COPD-Asthma
–Bronchiole hyperstimulation, constriction
–Wheezing, dyspnea
–Mucus production
COPD
• Therapeutic interventions
– Transport immediately
» Do all treatment en route if possible
» IV option unless patient is near respiratory failure
– Albuterol (Ventolin) 2.5 mg via nebulizer (repeat x1)
» Can give in-line via ET tube if necessary
– With medical control approval:
» Epinephrine 1:1000 @ 0.01 mg/kg up to 0.3 mg IM (repeat in 15
min)
» CPAP
– Consider Methylprednisolone (solu-medrol) 125 mg IVP.
» No longer just for longer transports
Congestive Heart Failure - CHF
CHF
• Congestive heart failure can involve one side
of the heart, or both.
Left Heart Failure
• Left ventricle fails as an
effective forward pump
• Causes backup of blood
into pulmonary circulation
• Causes
–
–
–
–
MI
Valvular disease
Chronic HTN
Dysrhythmias
• LV dysfunction
–
–
–
–
–
Causes LA pressure rise
Pulmonary HTN
PCP rises
Serum is forced into alveoli
Pulmonary Edema
LHF Signs & Symptoms
• Severe Respiratory Distress
– Orthopnea, dyspnea, spasmodic coughing, pink frothy
sputum
– Paroxysmal Nocturnal Dyspnea (night time SOB)
• Severe Apprehension, Agitation and Confusion
– Smothering feeling
– As hypoxia worsens  agitation
• Cyanosis
• Diaphoresis
Prehospital Management of LHF
• Patients in LHF can decompensate rapidly
• Goals
– Decrease venous return to heart (preload)
– Decrease myocardial oxygen demands
– Improve ventilation and oxygenation
Prehospital management cont.
• CPAP!
– Keeps more fluid from entering the alveoli
– Forces those alveoli to exchange gases
– In Region VII, ALS and BLS crews both can use
CPAP!
• Nitroglycerin!
– Vasodilates
– Forces fluid out of alveoli further
Nitroglycerin
• One tablet or spray sublingual
• Systolic blood pressure higher than 110
• May repeat x2 in 5 minutes.
• If no IV, consider contacting medical control.
• Ask about ED drugs.
Continuous Positive
Airway Pressure (CPAP)
What Is CPAP?
• CPAP is continuous positive airway pressure.
• Designed to apply positive pressure to the
airways of a spontaneously breathing patient
throughout the respiratory cycle.
• Airways are maintained in the open position
during exhalation.
Goal of Therapy With CPAP?
• Goal
– to increase amount of inspired oxygen and
decrease the work load of breathing
– to reduce the need for emergent intubations of
the patient in pulmonary edema
– to increase the oxygenation levels of the
patient
– to reduce mortality and decrease hospital
length of stay
Indications For Use of CPAP
•
•
•
•
•
•
•
•
Patient with acute pulmonary edema/CHF
Alert, cooperative adult patient
Systolic blood pressure >90
No presence of nausea or vomiting
No major trauma
Patent airway
SaO2 <95
Lung sounds - crackles
CPAP And Pulmonary Edema
 Severe pulmonary edema is a frequent cause of
respiratory failure
 CPAP increases functional residual capacity
 CPAP increases transpulmonary pressure
 CPAP improves lung compliance
 CPAP improves arterial blood oxygenation
 CPAP redistributes extravascular lung water
When Not To Use Mask CPAP

Hypercapnia

Pneumothorax

Hypovolemia

Severe facial injuries

Patients at risk of vomiting
Common Complications With CPAP

Pressure sores
 Gastric distension
 Pulmonary barotrauma
 Reduced cardiac output
 Hypoventilation
 Fluid retention
Patient Monitoring During
Use of CPAP
• Patient tolerance, mental status
• Respiratory pattern
– rate, depth, subjective feeling of improvement
• Lung sounds
• B/P, pulse rate and quality, SaO2, EKG
pattern
• Complications to monitor for:
– gastric distention
– nausea & vomiting
Criteria For Discontinuing
Use of CPAP
• Emergent need to intubate the patient
• Inability of the patient to tolerate the tight
fitting mask
– success of tolerance to the treatment increased
with proper coaching by EMS crew
• Hemodynamic instability (B/P drops below 90
systolic)
More treatments if necessary…
• Albuterol if wheezing continues from comorbid COPD
– Make sure it’s wheezing, not crackles/rales
– Albuterol can increase workload of heart
• Lasix/Morphine if medical control approves
– Research showing these may not do what we
thought they always did
Right Heart Failure
• Right Ventricle fails as an effective forward pump
• Results in backpressure of blood into systemic
venous circulation
• Causes
– The most common cause of right heart failure is left
heart failure
– Systemic HTN
• Pulmonary HTN  RV / RA enlargement
– Pulmonary Emboli
• Causes pulmonary HTN
RHF Signs & Symptoms
• Tachycardia
– Attempt to compensate
• Venous Congestion
– Peripheral Edema
• Ankles in ambulatory pts
• Presacral in bedridden
• Severe pitting edema
– JVD
– Fluid accumulation in serous
cavities
• Abdominal (ascites)
• Pleural Space (effusion)
• Pericardium (effusion)
– Liver engorgement
History
Prior MI / Chronic Pump Failure Lasix / Lanoxin
Prehospital Management of RHF
• Not usually emergent, unless accompanied by LHF
• Limit IV fluids
A good time for a saline lock, if you have them.
• IMC
• Treat signs and symptoms of respiratory distress
COPD vs. CHF
• COPD
• Expiratory wheeze
• Skinny w/barrel
chest
• History of
asthma/emphasema
/bronchitis
• Treat w/neb
•CHF
•Crackles/rales
•Retaining fluid
•Blood-tinged sputum
(pink puffers)
•History of afib/heart
failure/edema/
•Treat w/CPAP, nitro
Some New Airway Procedures and Gadgets
• Wave-form capnography
• Quick-trach
• King vision laryngoscope
Using capnography in intubation…
Capnography
• Phase I
– Beginning of exhalation when air from anatomic dead space being
exhaled
– Baseline
Capnography
• Phase II
– CO2 from larger bronchi begins to pass sensor
– Expiratory upslope
– Sharp increase in CO2 concentration passing sensor, rapid departure
of waveform from baseline
– Rapidly departs from Phase I, vertical line
Capnography
• Phase III
– Alveolar plateau
– CO2-rich alveolar air passing sensor
– Flat, straight/slightly angled upward
Capnography
• Phase 0
–
–
–
–
End of exhalation, beginning of inhalation
CO2 levels passing sensor quickly drop to 0
Quick return of waveform to baseline
Straight line, rapidly returns to baseline
Approach to Patient
Normal Capnogram
Important Points
• Capnography is a dynamic monitoring
mechanism.
– The therapeutic range for CO2 levels is 35-45.
– It’s a positive/negative feedback system for how
resuscitation efforts are going.
– Not just an initial tool for intubation
• Can hit record on monitors to chart CO2 levels.
– If tube dislodged during transfer to ER bed, medics
have proof that tube was in trachea during transport.
Inline Capnography
Bottom Line
There are too many esophageal intubations in the field. If
you have access to waveform capnography, use it!
A short video
• http://youtu.be/p4TkeCkBeHw
• This is made by Medtronics but is applicable
information no matter what
capnography/monitor combo you plan to use.
Colorimetric end-tidal CO2 detector.
Quick Trach
Cricothyroidotomy
Indications
• Upper airway obstruction which cannot be
dislodged by back blows or direct larygoscopy
and Magill forceps.
• Inability to insert an ETT past edema
• Destructive facial injury precluding the use of
ALS upper airway adjuncts.
Anatomical Landmarks
for Cricothyroidotomy
Cricothyroid
Membrane
Thyroid
Cartilage
Cricoid
Cartilage
Quicktrach
• More expensive than needle crichs, but really
easy to use!
• Silver Cross EMS only allows the 4mm size, no
pediatric Quicktrachs in this system.
Quicktrach
syringe
hub of
catheter
Picture courtesy Christ
Medical Center
neck
strap
stopper
Quicktrach Procedure
• Patient supine with head slightly extended if no
cervical spine trauma suspected
• Locate the cricothyroid membrane
• Cleanse the overlying skin
Quicktrach Procedure cont’d
•
•
•
•
•
•
Puncture cricothyroid membrane at 90 degree angle
Aspirate air through syringe
Change the angle of insertion to 60 degrees
Slide catheter sheath forward to level of stopper
Remove stopper – may be a bit tight.
Advance plastic cannula while removing needle and
syringe
Quicktrach Procedure cont’d
• Ventilate the patient
• Secure catheter in place using the strap provided
• Confirm placement
– Auscultation, bilateral chest rise and fall
King Vision Video Laryngoscope
From the brochure…
• Durable
•
•
•
•
The King Vision is designed to be your primary tool for intubations
The display comes with a 1-year warranty
The robust, full-color, non-glare display can resist repeated cleaning and normal use wear and tear
The camera and light source are enclosed in the disposable blade, keeping the display free of fragile optics
• Portable
•
•
•
•
The King Vision is light weight, self-contained and battery operated
Assembled, the device is water resistant
Reusable display comes packaged in a protective, foam case
Blades are individually packaged so that the King Vision can be taken anywhere
• Affordable
•
•
•
The disposable blades allow economical use of the King Vision for all of your intubations
Low cost per use procedure
High performance visualization capabilities
In the pyxis now…
• Silver Cross stocks unchanneled #3 King Vision
video laryngoscope blades in the pyxis now.
• Not an endorsement of the product, just an
accommodation for providers who use them.
• Good intubation techniques and practice still
trump gadgets.
EKG Strip O’ the Month
• AV Blocks
Review - AV Junction
• AV Junction = AV Node and Bundle of His
• Pacemaker cells located throughout AV
Junction
62
Review - Functions of AV Node
• Backup pacemaker for SA Node
• Creates delay between atrial and ventricular
depolarizations
• Physiologic block for rapid supraventricular
rhythms
63
Degrees of AV Blocks
• First Degree - Delay in conduction
• Second Degree - Some impulses blocked
• Third Degree - All impulses blocked
64
First Degree AV Block
• An abnormal slowing of AV Junction
conduction
65
First Degree AV Block ECG Criteria
• Rate - Dependent on underlying rhythm
– Interpretation must include underlying rhythm
• Rhythm - Dependent on underlying rhythm
• P-Waves - Normal morphology with one PWave for each QRS
• PRI - > .20 seconds and constant
• QRS - Dependent on underlying rhythm
66
First Degree AV Block Clinical
Significance
• Not usually detrimental and often resolves
when ischemia corrected
• Must consider entire patient
67
Second Degree AV Blocks
• Type I
– Also called “Wenckebach”
– Also called Mobitz I
• Type II
– Also called Mobitz II
68
Second Degree AV Block, Type I
• Intermittent block in which AV conduction
gradually slows until an impulse is blocked
• “Long, longer, longer, drop! Long, longer,
longer, drop!”
69
Second Degree AV Block, Type I
ECG Criteria
 Rate - Atrial rate unaffected but ventricular rate
is less than atrial rate
 Rhythm - Atrial rhythm usually regular.
Ventricular rhythm is irregular with more PWaves than QRS Complexes.
 P-Waves - Unaffected with more P-Waves than
QRS Complexes
 PRI - Progressively increases for consecutively
conducted P-Waves until QRS Complex is
dropped
 QRS - Unaffected
70
Second Degree AV Block, Type I
Etiology
• Often caused by increased parasympathetic
tone or drug effect
• Can be caused by MI
71
Second Degree AV Block, Type I Clinical
Significance
• Usually transient with good prognosis
• Can reduce cardiac output due to bradycardia
72
Second Degree AV Block, Type II
• Intermittent block in which not all P-Waves
are conducted to ventricles but there is no
progressive prolongation of PRI
• “Extra” p-waves.
73
Second Degree AV Block, Type II
Etiology
• Usually due to MI or other organic heart
disease
• Rarely the result of increased parasympathetic
tone or drug effect
74
Second Degree AV Block, Type II
Clinical Significance
• Poorer prognosis than Type I
• Usually requires pacemaker
• Frequently develops into Complete Block
75
Second Degree AV Block, Type II
ECG Criteria
 Rate - Atrial rate is unaffected but ventricular
rate is less than atrial
 Rhythm - Atrial rhythm regular, Ventricular
irregular with more P-waves than QRS
Complexes
 P-Waves - Normal morphology with more PWaves than QRS Complexes
 PRI - Constant for consecutively conducted PWaves
 QRS - Usually wide but may be narrow if block
is at His level or above
76
Second Degree AV Block, Type II
Example
77
Third Degree AV Block
• Complete blockage of impulse conduction
through AV Junction
• Results in “AV dissociation” (very very bad
thing)
• P’s and QRS’s “march to their own drummer”
78
AV Dissociation
• No relationship between P-waves and QRS
complexes
79
Third Degree AV Block Etiology
• MI
• Increased parasympathetic tone
• Drug toxicity
80
Third Degree AV Block ECG Criteria
•
•
•
•
Rate - Atrial > 60, Ventricular based on escape
Rhythm - Atrial and ventricular regular
P-Waves - Normal
PRI - No association between P-Waves and
QRS complexes (P’s and QRS’s are divorced
and do their own thing)
• QRS - Narrow if intranodal, Wide if infranodal
81
Questions?
• Recording of this session will be sent out
shortly.
• Please feel free to type questions in the text
box to the right before we sign off.
• Or email questions to afinkel@silvercross.org
• Thank you!