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Chapter 19
Respiratory
Emergencies
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Objectives
• There are no 1985 objectives for this chapter.
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Respiratory Emergencies
• Dyspnea
– Difficulty breathing
– Common chief complaint
• COPD
– Impedes normal functioning
• Learn the signs and symptoms.
• Feeling air-starved is frightening, no matter what the
cause.
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Anatomy and Function of the
Lungs
• Structures that contribute to
breathing
– Upper and lower airways
– Lungs
– Diaphragm
• Path of air travel
• Principle function of the lungs
– Respiration
• Diffusion
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Lung Disorders
• Pulmonary vessels are prevented from absorbing
oxygen, and releasing carbon dioxide.
• Alveoli are damaged.
• Air passages are obstructed.
• Blood flow to the lungs is obstructed.
• Pleural space is filled with air or fluid.
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Normal Respiratory Drive
• Brainstem senses carbon dioxide levels in arterial blood.
• Carbon dioxide level surrounding the brain stem is what
stimulates breathing.
• When the carbon dioxide levels are too low, rate and
depth of breathing decrease, and vice versa.
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Adequate Breathing
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Normal rate and depth
Regular pattern of inhalation and exhalation
Good audible, bilateral breath sounds
Equal, bilateral chest rise and fall
Pink, warm, and dry skin
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Inadequate Breathing
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Rate that falls out of the range of 12-20 breaths/min
Reduced flow of expired air
Muscle retractions or pursed lips
Diminished, noisy, or absent breath sounds
Unequal chest wall movement
Pale, cool, cyanotic skin
Shallow, irregular respirations
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Rising Levels of Carbon Dioxide
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Lung disorders
Excessive carbon dioxide production
Chronic carbon dioxide retention
Hypoxic drive
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Causes of Dyspnea (1 of 2)
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Acute pulmonary edema
Airway obstruction
COPD
Asthma or allergic reaction
Rib fractures
Spontaneous pneumothorax
Upper or lower airway infections
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Causes of Dyspnea (2 of 2)
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Pleural effusion
Pulmonary thromboembolism
Hyperventilation syndrome
Prolonged seizures
Use of CNS depressant drugs
Neuromuscular disease
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Upper or Lower Airway Infection
• Some can cause mild discomfort, whereas others can
be life threatening
• Some form of obstruction
– Flow of air
– Exchange of gases
• Diseases associated with dyspnea
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Acute Pulmonary Edema
• Two categories
– High pressure
– High permeability
• Accumulation of fluids
• Myocardial damage
• Patients can present with:
– Dyspnea/orthopnea
– Fatigue/pulmonary rales
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Management of Cardiogenic
Pulmonary Edema
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Place in position of comfort.
Assess the airway, provide oxygen.
Establish IV access.
Monitor flow rates to avoid fluid excess.
Consider NTG.
Transport to nearest appropriate facility.
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Management of Noncardiogenic
Pulmonary Edema
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Place in position of comfort.
Manage ABCs.
Transport to the nearest appropriate facility.
Remove patient from toxins/underlying problems.
Provide reassurance.
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Obstructive Airway Disease
• Encompasses diseases that affect people worldwide
– COPD
– Asthma
• Exacerbation of underlying conditions
– Internal
– External
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Obstruction
• Occurs in the bronchioles
• May result from smooth muscle spasm or mucous
production
• May be reversible or irreversible
• Caused by air trapping
• Affects 10-20% of the U.S. population
• Many causes; cigarette smoking most common
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COPD
• Chronic bronchitis
– Constant, excess
mucous production
– Productive cough for
at least 3 months/yr
– “Blue bloaters”
• Emphysema
– Surfactant
– Irreversible condition
– “Pink puffers”
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Commonalities of COPD
Patients
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Sputum production
Chronic cough
Difficulty expelling air
Long expiration times
Wheezing
Usually older than 50 years of age
Hx of recurring lung problems
Long-term cigarette smokers
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Abnormal Breath Sounds
• Rales
– Fine, crackling sounds
– Chronic scarring of small airways
• Rhonchi
– Coarse rattling sounds
– Mucous in large airways
• Wheezing
– Whistling sounds
– Heard on expiration
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Common Complaints/Hx/Signs
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Chest tightness
Fatigue
Recent “chest cold”
Normal BP
Rapid, sometimes irregular pulse
Respirations either rapid or slow
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Asthma
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Affects 6 million Americans
Kills 4,000-5,000 people yearly
“Audible wheezing” or no sounds
Reversible condition
Common causes
– Allergic reaction
– Exercise or stress
– Upper respiratory infection
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Assessment Findings
• Signs of respiratory impairment
– Inability to speak freely
• Common chief complaints
– Dyspnea, cough, nocturnal dyspnea
• Obtain thorough history
• Determine possibility of acute exposure
• Other common signs
– Retractions
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Management of Asthma
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Place in position of comfort.
Monitor the airway.
Provide high-flow oxygen.
Initiate IV access.
Assist with MDI.
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Anaphylaxis
• Characterized by:
– Airway swelling
– Dilation of blood vessels
• Can significantly lower BP
• Can be associated with itching and asthma-like
condition
• Most occur within 30 minutes of exposure
• Oxygen, epinephrine, antihistamines
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Hay Fever
• Caused by allergic reaction to substances such as
pollen, molds, and grasses
• Generally does not produce major emergency problems
• Signs are a stuffy/runny nose and sneezing
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Spontaneous Pneumothorax
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Vacuum pressure in the pleural space
Accumulation of air in the pleural space
Caused by medical conditions
Pleuritic chest pain
Subcutaneous emphysema
Some severe findings:
– Altered mental status
– Cyanosis
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Management of Spontaneous
Pneumothorax
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Monitor ABCs.
Provide high-flow oxygen.
Watch for signs of tension pneumothorax.
Initiate IV access.
Place patient in a position of comfort.
Call ALS if needed.
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Pneumonia
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Infection of lung parenchyma
Most commonly bacterial
Fifth leading cause of death in the U.S.
Risk factors
– Cigarette smoking
– Alcoholism
– Exposure to the cold
– Very young or old
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Management of Pneumonia
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ABCs
Ventilatory support PRN
High-flow oxygen
IV fluids
Cool if high fever present
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Pleural Effusion (1 of 2)
• Cause dyspnea.
• Response to irritation, infection, or cancer.
• Should be considered a possibility in lung patients with
SOB.
• Decreased lung sounds where fluid has moved the lung
away from the chest wall.
• Most patients feel better sitting upright.
• Fluid must be removed by a physician.
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Pleural Effusion (2 of 2)
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Mechanical Airway Obstruction
• Semi- and unconscious patients can have an
obstruction as the result of a foreign body or the tongue.
• Always consider upper airway obstruction from a foreign
object first in patients who were just eating.
• Can be the result of trauma, edema, mucous
accumulation, or muscle spasm.
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Pulmonary Thromboembolism
• Embolus – anything that
obstructs distal blood flow
• May occur from damage to the
lining of the vessels, tendency of
blood to clot fast, or blood flow in
a lower extremity
• Some risk factors
– Bedridden patients, prolonged
inactivity, recent surgery, and
oral contraceptives
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Signs and Symptoms
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Acute dyspnea/pleuritic chest pain
Hemoptysis
Cyanosis
Tachypnea
Varying degrees of hypoxia
Tachycardia
Normal breath sounds or wheezing
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Management of Pulmonary
Thromboembolism
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Provide high-flow oxygen.
Assist with ventilations PRN.
Initiate CPR PRN.
Initiate IV access.
Give fluid for hydration based on clinical symptoms.
Transport to nearest appropriate facility.
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Hyperventilation Syndrome
• Defined as overbreathing to the point at which the level
of arterial carbon dioxide falls below normal.
• Most common physical findings:
– Rapid breathing with high minute volume
– Carpopedal spasms
• Diagnosis should occur in hospital.
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Management of Hyperventilation
Syndrome
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Provide psychological support.
Have the patient mime your breathing.
Never withhold oxygen.
Rate of oxygen is based on symptoms and pulse
oximetry readings.
• Never use a paper bag.
• Transport to closest facility.
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Emergency Care of Respiratory
Emergencies
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Pay attention to respirations while gathering vital signs.
Administer oxygen.
Provide reassurance.
Reassess the patient every 5 minutes.
Never withhold oxygen.
Assist breathing via BVM if necessary.
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Scene Size-Up and Initial
Assessment
• Assure safe environment.
• Recognize and treat life threats.
• Some signs of life-threatening respiratory distress
– Altered mental status
– Absent breath sounds
– 1- to 2-word dyspnea
– Tachycardia
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Approach to the Patient in
Respiratory Distress
• Obtain a general impression
• Signs and symptoms
– Determine whether breathing is adequate
• Focused history and physical exam
– C/C
– OPQRST
– Vital signs
– Determine respiratory pattern
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Management
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Provide high-flow oxygen.
Ensure a patent airway.
Provide positive pressure ventilation PRN.
Consider a dual-lumen airway.
Obtain vital signs and a SAMPLE history.
Assist with MDI.
Use IV and cardiac monitor.
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Prescribed Inhalers
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Inhaled beta agonists
Selective beta-2 receptors in the lungs
Albuterol, metaproterenol, terbutaline
Common side effects
– Tachycardia
– Nervousness
– Muscle tremors
• Ensure no contraindications prior to administration
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Administration of MDIs
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Obtain an order.
Check the “6 rights.”
Shake MDI vigorously.
Provide instructions if needed.
Apply spacer if one’s available.
Replace oxygen after administration.
Repeat per protocol.
Reassess during transport.