BLS 2014 Respiratory Emergencies

Report
BLS 2014 Respiratory
Emergencies
Objectives
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Name the major anatomic structures of the respiratory
system and understand their function
Demonstrate an understanding of the physiology of the
respiratory system and its relationship to BLS treatment
Identify signs and symptoms of respiratory emergencies in
order to determine whether the patient is Sick or Not Sick
Be able to deploy treatment for a variety of respiratory
emergencies
Demonstrate the correct technique for auscultating breath
sounds and distinguish between normal and abnormal
breath sounds
Demonstrate the correct airway management techniques of
bag-valve-mask ventilation and suctioning
Terms You Should Know

Chronic Obstructive Pulmonary Disease (COPD) - A
category of diseases characterized by a slow process of
dilation and disruption of pulmonary alveoli.
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Dyspnea - A term for shortness of breath or breathing
difficulty.
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Embolus - A blood clot or other substance that has
formed in a blood vessel or the heart, that breaks off and
travels to another blood vessel, where it may cause
blockage.
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Flail chest - A condition in which three or more ribs are
fractured in two or more places such that a section of the
chest wall is detached from the rest of the chest wall.
Terms You Should Know
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Gag reflex - A protective contraction of the muscles of
the throat caused especially by stimulation of the
pharynx that prevents food and liquids from entering the
airway.
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Hypoxia - A condition in which the body's cells and tissue
do not have enough oxygen.
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Hypoxic drive - A condition in which the body's stimulus
for taking a breath is low oxygen. Occurs in people with
COPD.
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Metabolism - The process by which food molecules are
broken down to provide material and energy for cellular
function.
Terms You Should Know
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pH (potential of hydrogen) - A measure of the acidity or
alkalinity of a solution, numerically equal to 7 for neutral
solutions, increasing with increasing alkalinity and decreasing
with increasing acidity. The pH scale ranges from 0 to 14.
Numbers from 7 and below represent increasing acidity.
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Perfusion - The movement of blood through an organ or tissue
in order to supply nutrients and oxygen.
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Pleuritic chest pain - A sharp, stabbing pain in the chest that
is worsened by a deep breath; often caused by inflammation
or irritation of the pleura.
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Pneumothorax - Condition where air enters the pleural space
and is trapped during expiration. It can occur without trauma
as in a spontaneous pneumothorax.
Terms You Should Know
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Pulmonary edema - A buildup of fluid in the lungs, usually as a
result of congestive heart failure.
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Rales - Crackling, rattling breath sounds signaling fluid in the
air spaces of the lungs.
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Rhonchi - Coarse breath sounds heard in patients with mucus
in the airways.
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Stridor - A harsh, high-pitched inspiratory sound often heard in
acute laryngeal (upper airway) obstruction.
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Tension pneumothorax - A life-threatening condition in which
air enters the pleural space and the pressure inside the lung
cavity progressively increases and compresses the lung. It
may displace the mediastinum and other structures toward
the opposite side.
Terms You Should Know
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Tidal volume – The volume of gas that is moved with each
breath which is normally 500 ml in an adult.
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Traumatic asphyxia - Condition characterized by distended
neck veins, cyanosis in face and neck and bleeding in the
sclera of the eye that is caused by severe compression of
the chest.
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Ventilation – The rate at which gas enters or leaves the
lungs. Generally it is described in terms of good or poor
ventilation. Bluish or dusky skin can indicate poor
ventilation.
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Wheeze - A high-pitched, whistling breath sound,
characteristically heard on expiration in patients with
asthma or COPD.
Anatomy and Physiology
Respiratory Structures and Human Physiology
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Airway protection and appropriate oxygen administration
are among the most important BLS skills you have.
Not all respiratory emergencies originate in the airway
and lungs. Disturbances of the human body’s delicate
homeostasis – its acid/base buffer system, gas and
metabolic requirements for cellular respirations, blood
glucose levels, temperature, and many more factors –
can affect the rate, rhythm, and quality of the patient’s
respirations.
A good understanding of the structures of the respiratory
system and the basic physiology involved will help you
take better care of respiratory patients.
Learning Activity for Functions of Respiratory Structures
http://www.emsonline.net/Courses/2011/resp2011/functions.asp
Human Respiratory Structure
Human Physiology
Respiratory Emergencies Anatomy and Physiology
Respiratory Drive
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Respiratory drive is an autonomic and involuntary
function controlled by centers in the brain sensitive to
the blood levels of oxygen and carbon dioxide.
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Specialized cells in the aortic arch and brain constantly
monitor and react to the levels of oxygen and carbon
dioxide in the blood.
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The body’s response to increased carbon dioxide in the
blood is to "blow off” carbon dioxide by increasing the
rate and depth of respirations.
Metabolism Produces Carbon Dioxide
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Metabolism is the process by which the body breaks down or
"burns" stored fuel to create energy. The cells use oxygen to
transform stored glucose into energy.
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You can think of glucose as "fuel" and oxygen as the "match" that
releases the energy. A byproduct of metabolism is carbon dioxide
(CO2).
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Carbon dioxide is produced by the cells and carried by the
circulatory system to the lungs where it is expired. If ventilation is
compromised , carbon dioxide builds up in the blood.
pH
 Acidity in solution such as blood
measured by potential of Hydrogen
 Body must maintain relatively narrow pH
range (neither too acidic nor too basic)
 Respiratory system helps maintain
balanced acid level or pH in blood
The pH Balancing Act
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The Respiratory system is a
mirror for other changes
that happen in the body
When blood pH becomes
too low (acidic) the
respiratory system will
attempt to fix it by making
lungs breathe more deeply
& rapidly, excreting more
carbon dioxide
Homeostasis – The body
attempts to maintain this
delicate balance of gases
and pH.
Hypercarbia
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Excessive carbon dioxide in the body releases H+ ions,
which results in acidosis
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Hypercarbia can occur through:
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Metabolic processes that form acids
Muscle exertion
Shivering
Inability to exhale fully (e.g., asthma or emphysema)
Depressed respiratory drive (e.g., overdose of sedative drugs)
+
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Metabolic Problems
 Metabolic imbalances affect the body’s chemistry,
affecting pH & respirations
 Although this is not a primary respiratory problem, the
respiratory system tries to compensate by changing
depth and/or rate of respirations
 Patients with metabolic problems may present
themselves to EMS with respiratory signs &
symptoms. Usually, by the time respiratory problems
are manifested, these people will be gravely ill with
altered mental status or unconscious
Metabolic Problems
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Ketoacidosis – inefficient metabolism of sugars in a
diabetic causes the body to turn to other fuel sources for
energy (fat & muscle)
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Byproducts – acids called ketoacids
Presence of ketoacids & related compounds in blood will cause
lower pH
Respiratory system responds by increasing depth and/or rate of
respirations
Aspirin overdose – an acid (the chemical name is
acetylsalicylic acid)
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Taken in large quantities, person becomes acidotic
Body compensates by increasing depth and/or rate of
respirations
Metabolic Problems
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Fever increases metabolic rate, causing production of
more carbon dioxide which leads to more acid in blood
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Tissue perfusion fails (as it can in sepsis)
Excess metabolic acids accumulate causing metabolic acidosis
Body responds by increasing depth and/or rate of respirations
Hyperventilating breathing deeply & rapidly
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Efficient way of ridding body of carbon dioxide which, in turn,
may alter the body’s homeostasis
Can cause alkalosis (meaning very "basic")
Symptoms of respiratory alkalosis may include faintness &
tingling or cramping in the extremities
Respiratory Conditions
Respiratory Conditions - Main Categories
Let’s look at some main categories into which we
can group respiratory emergencies.
Obstructive Lung Disease – COPD
exacerbation and Asthma exacerbation
Respiratory Infection – Pneumonia (and
other infections that disrupt airflow)
Cardiovascular and Other Causes – Cardiac
(CHF, MI), Vascular (PE), Metabolic, Anemia,
Trauma, and many more
Obstructive Lung Disease - Asthma
 A chronic, inflammatory disease of the airways
 Asthma exacerbations are caused by different
factors:
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Allergens
Infections
Exercise
Smoke
 During an asthma attack:
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Muscles around bronchioles tighten
Lining of inside bronchioles swells
Insides of bronchioles fill with thick mucous
Ventilation can be severely impaired
Obstructive Lung Disease - Asthma
Obstructive Lung Disease - Asthma
 Common Asthma meds include:
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Albuterol, ProAir
Singulair
Advair
Pulmicort
Symbicort
Obstructive Lung Disease - COPD
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Chronic obstructive pulmonary disease (COPD) is a
category of diseases that includes emphysema, chronic
bronchitis and asthma.
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Emphysema is a process of destruction of alveoli. This
loss of the inter-connected network of aveoli leads to
loss of support for the airways and they close
prematurely during exhalation.
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Chronic bronchitis is defined by the presence of a
mucus-producing cough most days of the month, three
months of a year for two successive years without other
underlying disease to explain the cough. This chronic
mucous production further clogs airways and makes
exhalation difficult.
Obstructive Lung Disease - COPD
 Persons with COPD exacerbation can
present with shortness of breath, fever
and increased sputum production.
 Their medical history can include upperrespiratory infection, chronic bronchitis,
emphysema, a history of smoking or
working in a hazardous environment (e.g.,
coal smoke, asbestos).
Obstructive Lung Disease - COPD
Obstructive Lung Disease - COPD
Patients present with shortness
of breath, fever and increased
sputum production
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Medical history can include:
Upper-respiratory infection
Chronic bronchitis
Emphysema
History of smoking
Working in hazardous
environment (e.g., coal
smoke, asbestos)
Common medications include:
 Prednisone
 Albuterol (Proventil)
 Ventolin
 Inhaled Corticosteroids
(Azmacort, Beclomethasone,
Flovent)
 Ipratroprium (Atrovent,
Combivent)
BLS treatment for a COPD patient with respiratory distress
should include high flow oxygen. Do keep in mind that
these patients may operate on a hypoxia-drive, so look for
signs of respiratory failure due to over-oxygenation (rare).
Obstructive Lung Disease - Emphysema
 The very small airways that join alveoli are
damaged & alveolar walls lose elasticity
 This chronic irritation of small airways causes
inflammation & swelling – reducing diameter of
air passages
 Irritation causes bronchospasms, which further
decreases the lumen
 On inspiration, expansion of the lungs holds
airways open, while on exhalation, the lungs
relax & airways narrow, trapping air
Obstructive Lung Disease - Chronic Bronchitis
 Characterized by structural changes in
airways of the lungs
 Enlargement of mucous glands – cause
coughing & production of sputum
 Causes shortness of breath
 Often accompanied by infection, mucus
production & coughing
Respiratory Infections - Pneumonia
Respiratory Infections cause the disruption of gas exchange
due to congestion of the alveoli with mucus or pus. The
cause of the infection depends on the location: upper
airway (e.g., croup), lower airway (bronchitis), and lungs
(pneumonia and other infections)
Respiratory Infections - Pneumonia
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Symptoms include:
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Fever
Chills
Cough (often with yellowish sputum)
Shortness of breath
General discomfort
Fatigue
Loss of appetite
Headache
Can be chest pain associated with breathing (usually
sharp and stabbing in nature) and worsened by
coughing or deep inspirations
Other signs sometimes present are rales, clammy skin,
upper abdominal pain & blood-tinged sputum
Emergency care – may include oxygen therapy.
Cardiovascular and Other Causes
Congestive Heart Failure
 Congestive heart failure (CHF) is usually a pump
problem such that the heart’s cardiac output is
insufficient to provide forward flow of blood
throughout the body, causing fluid buildup. CHF
patients have weak ventricles from:
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Hypertension
Myocardial infarction
Underlying coronary artery disease
Valve disease
Cardiovascular and Other Causes
Congestive Heart Failure
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The weakened muscle impairs the heart’s ability to
contract and empty during systole
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Left-Sided failure generally causes fluid to back up in
the lungs. This interrupts gas exchange and results in
shortness of breath.
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Right-Sided failure generally causes fluid to back up into
the body’s tissues, leading primarily to swelling in the
lower extremities.
Cardiovascular and Other Causes
Congestive Heart Failure
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During an acute CHF
exacerbation, the
patient will typically
present:
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Sitting up
Short of breath
Diaphoretic
Pale or Cyanotic in color
Breath sounds are often
notable for Rales upon
auscultation.
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Medical history can
include:
 Hypertension
 Heart ailments like MI
 Recent history of increased
salt ingestion
 Non-compliance with
medications or recent
change in medications
(especially diuretics)
Cardiovascular and Other Causes
Congestive Heart Failure
Cardiovascular and Other Causes
Congestive Heart Failure
 Common medications include:
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ACE inhibitors (Lisinopril and other “-Prils”)
Diuretics like Furosemide (Lasix) and
Hydrochlorthiazide
Beta-blockers (Metoprolol, Atenolol, Lopressor)
Angiotensin II receptor blockers (Losartan, Avapro,
Benicar)
Digoxin (Lanoxin)
 Medications can help differentiate this patient's
symptoms from those of someone with
Obstructive Lung Diseases
Cardiovascular and Other Causes
Congestive Heart Failure
 When treating CHF:
 Seat the patient upright
 Administer high flow oxygen
 Consider positive pressure ventilation with a
BVM if the patient is experiencing severe
respiratory difficulty or tiredness
 You can ask the critical patient, “Are you
too tired to keep breathing?”
Cardiovascular and Other Causes
Pulmonary Embolism
 A pulmonary embolism (PE) is a blockage
in an artery of the lungs by a particle that
has traveled there from elsewhere in the
body. Travels to the lungs
 Circulation through that portion of the
lung is compromised because blood is not
able to reach alveoli – air is moving in and
out of the lungs but gas exchange is not
occurring
Cardiovascular and Other Causes
Pulmonary Embolism
 Although they do not occur often in the
pre-hospital setting, patients who call 911
due to Pulmonary Embolism have a high
mortality rate.
 Decompensation can occur rapidly, so it is
imperative to recognize the signs quickly.
Cardiovascular and Other Causes
Pulmonary Embolism
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Causes include:
 Immobility of the lower
extremities (lengthy
travel, sitting, laying)
 Prolonged bed rest
 Recent surgery
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Signs of PE:
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Often sudden-onset of:
Shortness of breath
Tachycardia
Tachypnea
Chest pain
Coughing up frothy /
bloody
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Pulmonary embolism –
life-threatening condition
 Treated with high flow
oxygen
 Rapid transport
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Move patient gently to
avoid dislodging
additional emboli
Cardiovascular and Other Causes
Pneumothorax
 A pneumothorax is the presence of air between the two
layers of the pleura — also called the pleural space.
 Caused when internal or external wound allows air to
enter space between pleural tissues
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Can result in functional collapse of lung
Cardiovascular and Other Causes
Pneumothorax
 A pneumothorax can occur spontaneously (e.g., a rupture
due to disease or localized weakness of the lung lining) or
as a result of trauma.
 Forceful coughing can cause a pneumothorax as well.
Chest injury and prior history of pneumothorax are possible
medical histories. COPD is a risk factor.
Cardiovascular and Other Causes
Pneumothorax
 Symptoms of a pneumothorax can include
sharp chest pain and shortness of breath.
 Signs can include: tachypnea, low SpO2 ,
diminished lung sounds and possibly
feeling subcutaneous air upon palpation
of the patient’s torso.
Cardiovascular and Other Causes
Pneumothorax
 Treatment of pneumothorax includes highflow oxygen
 Be judicious with use of positive-pressure
ventilation
 Can turn a spontaneous pneumothorax into a
life-threatening tension pneumothorax.
 A PLEASE
DELETE:
pneumothorax
can cause collapse of the entire
lung. The only symptom may be sudden chest pain.
Cardiovascular and Other Causes
Tension Pneumothorax
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Caused when lung injury
acts like one-way valve
that allows free air to
move into pleural space
but prevents free exit of
that air
Pressure builds inside
pleural space &
compresses lungs &
other organs
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Early signs of a tension
pneumothorax include:
 Increased Shortness of
Breath
 Tachycardia
 Poor skin signs
 Signs of shock
 Absent breath sounds &
resonance to percussion
 Distended neck veins
 Tracheal deviation (late sign)
Cardiovascular and Other Causes
Tension Pneumothorax
 Consider the situation where you are bagging an
intubated trauma patient who sustained a chest
injury that is being transported by Paramedics.
 You note increasing tachycardia, decreasing BP….
 Now profound bradycardia, perhaps difficulty
bagging…
 And, ultimately, cardiovascular collapse resulting in
PEA….
 Be highly suspicious for a tension pneumothorax.
Cardiovascular and Other Causes
Inhalation Injuries
 Inhalation injuries can be caused by a multitude
of agents, including: heat, chemicals, smoke,
particulate, or other irritants
 Common chief complaints include:
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Shortness of breath
Coughing
Hoarseness
 Individuals with decreased respiratory reserve
(e.g., history of COPD) are likely to experience an
exacerbation of the disease
Cardiovascular and Other Causes
Inhalation Injuries
Patient in respiratory distress:
 These patients typically get worse –
consider early ALS activation
 Treat immediately with high flow oxygen
 Assist breathing with a BVM if the
necessary
Respiratory Emergencies - Assessment
 It is rare to enter a scene and be greeted by a
patient who tells you their diagnosis
 Unfortunately, our job tends to require a little
more digging
 You will also need to quickly determine whether
the patient it Sick or Not Sick
 Your interview and physical exam should narrow
down the list of possible ailments
 Your assessment of the patient’s probable
disease process will steer your treatment
decisions
Respiratory Emergencies - Assessment
 Assess rate & depth of respirations – this
will take 30 – 60 seconds
 Normal respiratory rate is between 12 - 20
respirations per minute for an adult
 The quality of respirations is more
subjective; look for anomalies like
shallow, irregular, inadequate, labored or
gasping types of breathing
Respiratory Emergencies - Assessment
 Other signs that indicate adequate oxygen
supply to body’s tissues:
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Level of consciousness
Breathing effort
Ability to speak in complete sentences
Use of accessory muscles
Skin color
Breath sounds
Body position
Respiratory Emergencies - Assessment
It all comes down to…
Sick
or
Not Sick
Respiratory Emergencies - Assessment
SICK
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Altered Level of
Consciousness
Extreme / unsustainable
Work of Breathing or
respiratory rate
Skin Signs – pale, cool, wet
Vitals – HR >130 or <60, RR
> 30 or < 10
SpO2 – low
NOT SICK
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Normal Level of Consciousness
(baseline)
Normal Work of Breathing or
respiratory rate
Skin Signs – pink, warm, dry
Vitals – HR <130 or >60, RR <
30 or > 10
SpO2 - normal
How does the patient appear from across the room?
Respiratory Emergencies - Assessment
Lung Sounds
 You must put your
stethoscope directly on
the patient’s skin. In most
cases, it is advisable to
listen with the patient
sitting up.
Respiratory Emergencies - Assessment
 The proper technique for auscultating chest
using a stethoscope includes:
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Listen at six locations on the back
Listen at four locations on the front
Instruct the patient to take a deep breath through
the mouth then exhale
Listen to one or two inspiration/expiration cycles per
location
Avoid listening through clothing
Video demonstration available at EMS Online:
http://www.emsonline.net/Courses/2011/resp2
011/auscultation.asp
Respiratory Emergencies - Assessment
 Caused by specific conditions:

Example: Cheyne-Stokes respirations
 May be seen in head injuries & stroke
 Characterized by periods of breathing with gradually
increasing & decreasing tidal volumes interspersed with
periods of no breathing
 Ataxic respirations – irregular, ineffective
respirations with no clear pattern
 Agonal respirations – abnormal pattern of
breathing characterized by ineffective, slow
inspirations followed by long pauses
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Often sound like gasps
Associated with cardiac arrest or severe end-stage
shock
Respiratory Emergencies - Treatment
 Respiratory Patients can be some of the sickest
and most confusing types of patients you will
encounter.
 There are few feelings worse than not being able
to catch your breath.
 Your patients (and their families) will be anxious.
 You may be anxious too!
Respiratory Emergencies - Treatment
 Different types of respiratory emergencies
will need different types of treatment
modalities.
 We presented some ways to take the
hundred possible ailments that a
respiratory patient may be experiencing
and, using the three major categories of
respiratory illness we learned, narrow
them down to a small handful of probable
diseases
Respiratory Emergencies - Treatment
The focus here is immediate BLS interventions that
can help the patient:
O2 Administration
Reassurance
Positioning
Assist with meds (e.g., Inhaler)*
Bag-Valve-Mask ventilator support**
* According to Local Protocols
** If Indicated
Airway Management
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Airway management is one of the most important skills
for an EMS provider
You must be equipped to rapidly deploy the following
airway management techniques:
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Head tilt/chin lift
Jaw thrust
Patient positioning
Airway adjuncts
Suction
Oxygen therapy
Assisted ventilation using a bag valve mask
Relief of foreign body airway obstruction
Respiratory Treatment
Foreign Body Airway Obstruction

EMS providers should intervene if choking victim has
signs of severe / total airway obstruction
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Encourage the conscious patient with mild obstruction
to cough
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Little or no air exchange; high-pitched / squeaking sound
indicating very little air is moving; poor skin signs; inability to
cough
Do not interfere with efforts to relieve obstruction
Attempt to relieve obstruction only if it becomes severe
In the unconscious patient, perform CPR per AHA
guidelines, look for visible foreign body before
performing first rescue breath.
Respiratory Emergencies - Treatment
Tips for Effective Suctioning:

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Measure the Yankuer / Suction Tip 
the same as for an oropharyngeal
airway — from the corner of the

mouth to the ear lobe or from the
center of mouth to the angle of jaw
If situation permits (e.g., there is

no significant airway threat), give
at least 30 seconds of oxygen
before suctioning
Administer oxygen after suctioning
Do not apply suction while
inserting tip

Apply suction for no more than 15
seconds at a time
In rare cases, copious vomiting
that threatens airway may require
more suctioning
In infants & children, suction for
shorter periods of time (no more
than 5 seconds) and be cautious
to not suction too deeply. Some
suction units have a Peds setting
to keep from using too much
suction.
If there are secretions or emesis
that you cannot easily remove with
suction, position patient, (e.g., by
using log roll) so gravity & a finger
sweep can quickly clear the airway
Respiratory Emergencies - Treatment
Assisted Ventilations:
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Patients who are hypoxic and are unable to ventilate
themselves adequately require quick action to be
oxygenated
Some of these patients are conscious enough to find
this procedure uncomfortable, claustrophobic, or
completely intolerable
Your proficiency at this difficult skill and your ability to
explain what you’re doing to the patient in a way that
sets them at ease will help you greatly
Respiratory Emergencies - Treatment
Unconscious breathing patient:
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Consider the need for an
oropharyngeal airway, following
local protocols
Maintain a good seal
Keep the airway open
Do not over-ventilate, just look
for gentle chest rise with each
breath
Deliver breaths at a rate of
approximately 1 breath every 5
seconds
Conscious patient:

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Maintain a good seal
Deliver a ventilation of 1-second
duration
Deliver enough volume to make
the chest rise
Start by trying to match the
patient’s respirations but gradually
try to deliver breaths at a rate of
approximately 1 breath every 5
seconds
Video demonstration available at EMS Online:
http://www.emsonline.net/Courses/2011/res
p2011/ventilation.asp
Oxygen Delivery
The amount of oxygen administered to the patient & the
method of administration depend on many factors including
medical history & cause of respiratory problem
Rate
Volume (liters/min)
Device
Low Flow
2-6
Nasal cannula or blow by
High Flow
10 - 15
Non-rebreathing mask
High flow with
ventilation
15 +
Bag-valve mask with
reservoir
Video demonstration available at EMS Online:
http://www.emsonline.net/Courses/2011/resp2011/therapy.asp
Summary
 Main structures of the respiratory system are:
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Pharynx
Trachea
Epiglottis
Alveoli
Bronchi
Bronchioles
Larynx
Pleura
Diaphragm
Summary
Categories of Respiratory Emergency
Obstructive Lung Disease – COPD
exacerbation and Asthma exacerbation
Respiratory Infection – Pneumonia (and
other infections that disrupt airflow)
Cardiovascular and Other Causes – Cardiac
(CHF, MI), Vascular (PE), Metabolic, Anemia,
Trauma, and many more
Summary
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Pneumothorax can cause sharp chest pain & shortness
of breath with decreased lung sounds
Signs of pulmonary embolism include a sudden onset of
shortness of breath, tachypnea, tachycardia, chest pain
worsened by breathing & coughing up blood
Treatment for respiratory emergency can include sitting
the patient up, opening the airway if necessary,
administering high flow oxygen and, in case of
decreased respiratory drive or DLOC, assisted
ventilations
CHF patients may require positive-pressure ventilations,
they must be sat up if possible
Summary
 Proper technique for auscultating the
chest includes:
Listen at six locations on the back
Listen at four locations on the front
Move from bottom to top in a medical patient
Instruct the patient to take a deep breath
through the mouth then exhale
 Listen to one or two inspiration/expiration
cycles per location
 Avoid listening through clothing
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Questions
EMS Online
Guidelines and Standing Orders
http://www.emsonline.net/downloads.asp
Susan Kolwitz
Program Manager
Email support: [email protected]
Dr. Mickey Eisenberg
Medical Director
Ask the Doc: http://www.emsonline.net/doc.asp

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