Pulmonary

Pulmonary Diseases
Diseases

Pulmonary
Pulmonary Diseases
Diseases &
& Disorders
Disorders

Pulmonary Disease & Conditions may result

from:
Infectious causes
Non-Infectious causes

Adversely affect one or more of the following

Ventilation
Diffusion
Perfusion

Pulmonary
Pulmonary Diseases
Diseases &
& Disorders
Disorders

The Respiratory Emergency may stem from

dysfunction or disease of (examples only):
Control System
Hyperventilation
Central Respiratory Depression
CVA

Thoracic Bellows

Chest/Diaphragm Trauma
Pickwickian Syndrome
Guillian-Barre Syndrome
Myasthenia Gravis
COPD

Pulmonary
Pulmonary Diseases
Diseases &
& Disorders
Disorders

The Respiratory Emergency may affect the

upper or lower airways

Upper Airway Obstruction

Tongue
Foreign Body Aspiration
Angioneurotic Edema
Maxillofacial, Larnygotracheal Trauma
Croup
Epiglottitis

Respiratory
Respiratory Emergencies:
Emergencies: Causes
Causes

Lower Airway Obstruction

Emphysema
Chronic Bronchitis
Asthma
Cystic Fibrosis

Pulmonary
Pulmonary Diseases
Diseases &
& Disorders
Disorders

The Respiratory Emergency may stem from

Gas Exchange Surface Abnormalities

Cardiogenic Pulmonary Edema

Non-cardiogenic Pulmonary Edema
Pneumonia
Toxic Gas Inhalation
Pulmonary Embolism
Drowning

Pulmonary
Pulmonary Diseases
Diseases &
& Disorders
Disorders

Problems with the Gas

Exchange Surface

Pulmonary
Pulmonary Edema
Edema

Pulmonary
Pulmonary Edema:
Edema: Pathophysiology
Pathophysiology

A pathophysiologic condition, not a

disease
Fluid in and around alveoli
Interferes with gas exchange
Increases work of breathing

Two Types
Cardiogenic (high pressure)
Non-Cardiogenic (high permeability)

Pulmonary
Pulmonary Edema
Edema

High Pressure (cardiogenic)

AMI
Chronic HTN
Myocarditis

High Permeability (non-cardiogenic)

Poor perfusion, Shock, Hypoxemia
High Altitude, Drowning
Inhalation of pulmonary irritants

Cardiogenic
Cardiogenic Pulmonary
Pulmonary Edema:
Edema:
Etiology
Etiology

Left ventricular failure

Valvular heart disease
Stenosis
Insufficiency

Hypertensive crisis (high afterload)

Volume overload

Increased Pressure in Pulmonary Vascular

Bed

Pulmonary
Pulmonary Edema
Edema

High Permeability
Disrupted alveolar-capillary membrane
Membrane allows fluid to leak into the interstitial
space
Widened interstitial space impairs diffusion

Non-Cardiogenic
Non-Cardiogenic Pulmonary
Pulmonary Edema:
Edema:
Etiology
Etiology

Toxic inhalation
Near drowning
Liver disease
Nutritional deficiencies
Lymphomas
High altitude pulmonary edema
Adult respiratory distress syndrome

Increased Permeability of Alveolar-Capillary

Walls

Pulmonary
Pulmonary Edema:
Edema: Signs
Signs &Symptoms
&Symptoms

Dyspnea on exertion
Paroxysmal nocturnal dyspnea
Orthopnea
Noisy, labored breathing
Restlessness, anxiety
Productive cough (frothy sputum)
Rales, wheezing
Tachypnea
Tachycardia

Management
Management of
of Non-Cardiogenic
Non-Cardiogenic
Pulmonary
Pulmonary Edema
Edema

Position
Oxygen
PPV / Intubation
CPAP
PEEP

IV Access; Minimal fluid administration

Treat the underlying cause
Diuretics usually not helpful; May be harmful

Transport

Adult
Adult Respiratory
Respiratory Distress
Distress Syndrome
Syndrome

AKA: Non-cardiogenic pulmonary edema

A complication of:

Severe Trauma / Shock

Severe infection / Sepsis
Bypass Surgery
Multiple blood transfusions
Drug overdose
Aspiration
Decreased compliance
Hypoxemia

Pneumonia
Pneumonia

Pneumonia
Pneumonia

Fifth leading cause of death in US/Canada

Group of Specific infections
Risk factors
Cigarette smoking
Exposure to cold
Extremes of age
young
old

Pneumonia
Pneumonia

Inflammation of the bronchioles and alveoli

Products of inflammation (secretions, pus) add to
respiration difficulty

Gas exchange is impaired

Work of breathing increases
May lead to

Atelectasis
Sepsis
VQ Mismatch
Hypoxemia

Pneumonia:
Pneumonia: Etiology
Etiology

Viral
Bacterial
Fungi
Protozoa (pneumocystis)
Aspiration

Presentation
Presentation of
of Pneumonia
Pneumonia

Shortness of breath, Dyspnea

Fever, chills
Pleuritic Chest Pain, Tachycardia
Cough
Green/brown sputum

May have crackles, rhonchi or wheezing in

peripheral lung fields
Consolidation
Egophony

Management
Management of
of Pneumonia
Pneumonia

Treatment mostly based upon symptoms

Oxygen
Rarely is intubation required
IV Access & Rehydration
B2 agonists may be useful
Antibiotics (e.g. Rocephin)
Antipyretics

Pneumonia:
Pneumonia: Management
Management

MD follow-up for labs, cultures & Rx

Transport considerations

Elderly have significant co-morbidity

Young have difficulty with oral medications
ED vs PMD office/clinic
Transport in position of comfort

Would an anticholinergic like

Atrovent be useful in managing
pneumonia?

Pulmonary
Pulmonary Embolism
Embolism

Pulmonary
Pulmonary Embolism
Embolism

~ 50,000 deaths / year/ US

~5% of all sudden deaths
<10% of all PE result in death

Pulmonary
Pulmonary Embolism:
Embolism:
Pathophysiology
Pathophysiology

Something moving with flow of blood passes

through right heart into pulmonary circulation
It reaches an area too narrow to pass through
and lodges there
Part of pulmonary circulation is blocked
Blood:
Does not pass alveoli
Does not exchange gases

Pulmonary
Pulmonary Embolism
Embolism (PE)
(PE)

A disorder of perfusion
Combination of factors increase probability of
occurrence
Hypercoagulability
Platelet aggregation
Deep vein stasis

Embolus usually originates in lower

extremities or pelvis

Pulmonary
Pulmonary Embolism
Embolism (PE)
(PE)

Risk factors
Venostasis or DVT
Recent surgery or trauma
Long bone fractures (lower)

Oral contraceptives
Pregnancy
Smoking
Cancer

Pulmonary
Pulmonary Embolism:
Embolism: Etiology
Etiology
Most Common Cause = Blood
Clots
Vessel Wall Injury

Virchow
sTriad
Hypercoagulability

Venous Stasis

Pulmonary
Pulmonary Embolism:
Embolism: Etiology
Etiology

Other causes

Air
Amniotic fluid
Fat particles (long bone fracture)
Particulates from substance abuse
Venous catheter

Pulmonary
Pulmonary Embolism:
Embolism: Signs
Signs &
& Symptoms
Symptoms

Small Emboli

Rapid Onset
Dyspnea
Tachycardia
Tachypnea
Fever
Episodic = Showers
Evidence or history of thrombophlebitis
Consider early when no other cardiorespiratory
diagnosis fits

Pulmonary
Pulmonary Embolism:
Embolism: Signs
Signs &
& Symptoms
Symptoms

Larger Emboli

Small Emboli S/S plus:

Pleuritic pain
Pleural rub
Coughing
Wheezing
Hemoptysis (rare)

Pulmonary
Pulmonary Embolism:
Embolism: Signs
Signs &
& Symptoms
Symptoms

Very Large Emboli

Preceded by S/S of Small & Larger Emboli plus:

Central chest pain
Distended neck veins
Acute right heart failure
Shock
Cardiac arrest

Pulmonary
Pulmonary Embolism:
Embolism: Signs
Signs &
& Symptoms
Symptoms

There are NO
assessment findings
specific to pulmonary
embolism

Pulmonary
Pulmonary Embolism:
Embolism: Management
Management

Management based on severity of Sx/Sx

Airway & Breathing
High concentration O2
Consider assisting ventilations
Early Intubation

Circulation
IV, 2 lg bore sites
Fluid bolus then TKO; Titrate to BP ~ 90 mm Hg

Monitor ECG

Rapid transport

PE
PE Management
Management

Thrombolytics
Aspirin & Heparin (questionable if any benefit)

Rapid transport to appropriate facility

Embolectomy or thrombolytics at hospital (rarely
effective in severe cases due to time delay)
Poor prognosis when cardiac arrest follows

Pulmonary
Pulmonary Embolism
Embolism
If the patient is alive when you get
to them, that embolus isnt going to
kill them.
But the next one they throw
might!

Pleurisy
Pleurisy

Inflammation of pleura caused by a friction

rub
layers of pleura rubbing together

Commonly associated with other respiratory

disease

Presentation
Presentation of
of Pleurisy
Pleurisy

Sharp, sudden and intermittent chest pain

with related dyspnea
Possibly referred to shoulder
May or with respiration

Pleural friction rub may be audible

May have effusion or be dry

Pleurisy
Pleurisy

Management
Based upon severity of presentation
Mostly supportive

Pulmonary
Pulmonary Diseases
Diseases &
& Disorders
Disorders

Problems with Airway

Obstructions

Obstructive Airway Diseases

Obstructive
Obstructive Airway
Airway Disease
Disease

Asthma
Emphysema
Chronic Bronchitis

Obstructive
Obstructive Airway
Airway Diseases
Diseases

Asthma experienced by ~ 4 - 5 % of
Canadian population
Mortality rate increasing

Factors leading to Obstructive Airway

Diseases
Smoking
Exposure to environmental agents
Genetic predisposition

How does this differ from COPD?

Obstructive
Obstructive Airway
Airway Disease
Disease

Exacerbation Factors
Intrinsic
Stress (especially in adults)
URI
Exercise

Extrinsic

Cigarette Smoke
Allergens
Drugs
Occupational hazards

Obstructive
Obstructive Airway
Airway Disease
Disease

General Pathophysiology
Specific pathophysiology varies by disease
Obstruction in bronchioles
Smooth muscle spasm (beta)
Mucous accumulation
Inflammation

Obstruction may be reversible or irreversible

Obstructive
Obstructive Airway
Airway Disease
Disease

General Pathophysiology
Obstruction results in air trapping
Bronchioles usually dilate on inspiration
Dilation allows air to enter even in presence of
obstruction
Bronchioles tend to constrict on expiration
Air becomes trapped distal to obstruction

Lower Airway Disease

Chronic Obstructive Pulmonary

Disease

Emphysema
Chronic Bronchitis
(Rarely Asthma may result in COPD)

COPD:
COPD: Epidemiology
Epidemiology

Most common chronic lung disease

4th leading cause of death
many deaths annually

Emphysema
Type A COPD

Emphysema:
Emphysema: Definition
Definition

Destruction of alveolar
walls
Distention of pulmonary
air spaces
Loss of elastic recoil
Destruction of gas
exchange surface

Emphysema:
Emphysema: Incidence
Incidence

Male > females

Urban area > rural areas
Age usually > 55

Emphysema:Etiology
Emphysema:Etiology

Smoking
90% of all cases
Smokers 10x more likely to die of COPD than
non-smokers

Environmental factors
Alpha 1 antitrypsin deficiency
hereditary
50,000 to 100,000 cases
mostly people of northern European descent

Emphysema:
Emphysema: Pathophysiology
Pathophysiology

Decreased surface area leads to decreased

gas exchange with blood
Loss of pulmonary capillaries & hypercapnia
lead to
increased resistance to blood flow which leads to
pulmonary HTN
right heart failure (cor pulmonale)

Emphysema:
Emphysema: Pathophysiology
Pathophysiology

Loss of elastic recoil leads to increased

residual volume and CO2 retention
Air Trapping
Hyperinflation
Hypercapnia -> pulmonary vasoconstriction ->
V/Q mismatch

Emphysema:
Emphysema: Signs
Signs and
and Symptoms
Symptoms

Increasing dyspnea on exertion

Non-productive cough
Malaise
Anorexia, Loss of weight
Hypertrophied respiratory accessory muscles

Emphysema:
Emphysema: Signs
Signs and
and Symptoms
Symptoms

Increased Thoracic AP
Diameter
(Barrel Chest)
Decreased lung/heart
sounds
Hyperresonant chest

Emphysema:
Emphysema: Signs
Signs and
and Symptoms
Symptoms

Lip pursing on exhalation

Clubbed fingertips
Altered blood gases
Normal or decreased PaO2
Elevated CO2

Cyanosis occurs LATE in course of disease

PINK PUFFER

Chronic Bronchitis
Type B COPD

Chronic
Chronic Bronchitis:
Bronchitis: Definition
Definition

Increased mucus production for > 3 months

for > 2 consecutive years
Recurrent productive cough

Chronic
Chronic Bronchitis:
Bronchitis: Incidence
Incidence

Males > females

Urban areas > rural areas
Age usually > 45

Chronic
Chronic Bronchitis:
Bronchitis: Etiology
Etiology

Smoking
Environmental irritants

Chronic
Chronic Bronchitis:
Bronchitis: Pathophysiology
Pathophysiology

Mucus plugging/inflammatory edema

Increased airflow resistance leads to
alveolar hypoventilation
Alveolar hypoventilation leads to
hypercarbia
hypoxemia

Chronic
Chronic Bronchitis:
Bronchitis: Pathophysiology
Pathophysiology

Hypoxemia leads to
increased RBCs w/o oxygen which leads to
cyanosis

Hypercarbia leads to
pulmonary vascular constriction which leads to
increased right ventricular work which leads to
right heart failure which may progress to
cor pulmonale

Chronic
Chronic Bronchitis:
Bronchitis: Signs
Signs and
and
Symptoms
Symptoms

Increasing dyspnea on exertion

Frequent colds of increasing duration
Productive cough
Weight gain, edema (right heart failure)
Rales, rhonchi, wheezing
Bluish-red skin color (polycythemia)
Headache, drowsiness (increased CO2)

Chronic
Chronic Bronchitis:
Bronchitis: Signs
Signs and
and
Symptoms
Symptoms

Decreased intellectual ability

Personality changes
Abnormal blood gases
Hypercarbia
Hypoxia
Cyanosis EARLY in course of disease
BLUE BLOATER

COPD
COPD Assessment
Assessment Findings
Findings

Chronic condition acute episode

S&S of work of breathing and/or hypoxemia

Use of accessory muscles

Increased expiratory effort
Tachycardia, AMS, Cyanosis
Wheezing, Rhonchi, LS
Thin, red/pink appearance

Saturation usually normal in emphysema

COPD:
COPD: Management
Management

Causes of Decompensation
Respiratory infection (increased mucus
production)
Chest trauma (pain discourages coughing or deep
breathing)
Sedation (depression of respirations and
coughing)
Spontaneous pneumothorax
Dehydration (causes mucus to dry out)

COPD:
COPD: Management
Management

Airway and Breathing

Sitting position or position of comfort

Calm & Reassure
Encourage cough
Avoid exertion

Oxygen
Dont withhold
Maintain O2 saturation above 90 %

TRUE HYPOXIC DRIVE IS VERY RARE

COPD:
COPD: Management
Management

Ventilation
Avoid intubation unless absolutely necessary
near respiratory failure
exhaustion

Circulation
IV TKO
Titrate fluid to degree of dehydration
250 cc trial bolus

Excessive fluid may precipitate CHF

Monitor ECG

COPD:
COPD: Management
Management

Drug Therapy
Obtain thorough medication history
Nebulized Beta 2 agonists
Albuterol
Terbutaline
Metaproterenol
Isoetharine

COPD: Management
REMEMBER
All bronchodilators are
potentially arrhythmogenic

COPD:
COPD: Management
Management

Drug Therapy
Ipratropium (anticholinergic) by SVN
(beta-2 agonist) by MDI, SQ or IV
Corticosteroids (anti-inflammatory agent) by IV

COPD:
COPD: Management
Management

Avoid
Sedatives
Restlessness = hypoxia
Antihistamines
Dry secretions, decrease LOC
Epinephrine
Myocardial ischemia, arrhythmias
Intubation
difficult to wean off ventilator

Reversible Obstructive Airway

Disease

Asthma

Asthma:
Asthma: Definition
Definition

Lower airway hyper-responsiveness to a

variety of stimuli
Diffuse reversible airway obstruction or
narrowing
Airway inflammation

Asthma:
Asthma: Incidence
Incidence

50% onset before age 10

33% before age 30
Asthma in older patients suggests other
obstructive pulmonary diseases
Risk Factors
Family history of asthma
Perinatal exposure to airborne allergens and irritants
Genetic hypersensitivity to environmental allergens
(Atopy)

Asthma
Asthma

Diagnosis
H&P, Spirometry
Hx or presence of episodic symptoms of
airflow obstruction
airflow obstruction is at least partially
reversible
alternative diagnoses are excluded

Asthma
Asthma

Commonly misdiagnosed in children as

Chronic bronchitis
Recurrent croup
Recurrent URI
Recurrent pneumonia

Asthma
Asthma

Often triggered by:

Cold temperature
Respiratory Infections
Vigorous exercise
Emotional Stress
Environmental allergens or irritants

Exacerbation
Extrinsic common in children
Intrinsic common in adults

Asthma
Asthma Pathophysiology
Pathophysiology

Asthma triggered
Bronchial smooth muscle contraction
Increased mucus production
Bronchial plugging
Relative dehydration

Alveolar hypoventilation
Ventilation Perfusion Mismatch
CO2 retention
Air Trapping

Asthma:
Asthma: Pathophysiology
Pathophysiology
Bronchospasm

Bronchial Edema

Increased Mucus
Production

Asthma:
Asthma: Pathophysiology
Pathophysiology

Asthma:
Asthma: Pathophysiology
Pathophysiology
Cast of airway produced by
asthmatic mucus plugs

Asthma:
Asthma: Pathophysiology
Pathophysiology

Difficulty exhaling
chest hyperinflation

Poor gas exchange

hypoxia
hypercarbia

Increased respiratory
water loss
dehydration

Asthma:
Asthma: Types
Types

Type 1 Extrinsic

Classic allergic asthma

Common in children, young adults
Seasonal in nature
Sudden brief attacks
Major component is bronchospasm
Good bronchodilator response

Asthma:
Asthma: Types
Types

Type 2 Extrinsic Asthma

Adults < 35
Long term exposure to irritants
More inflammation than Type 1 Extrinsic
Does not respond well to bronchodilators
Needs treatment with corticosteroids

Asthma:
Asthma: Types
Types

Intrinsic Asthma

Adult > 35
No immunologic cause
Aspirin sensitivity/nasal polyps
Poor bronchodilator response

Asthma:
Asthma: Signs
Signs and
and Symptoms
Symptoms

Onset of attacks associated with triggers

Dyspnea
Non-productive cough
Tachypnea
Expiratory wheezing
Accessory muscle use
Retractions

Asthma: Signs and Symptoms

Absence of wheezing
IMPENDING RESPIRATORY
ARREST!

Asthma:
Asthma: Signs
Signs and
and Symptoms
Symptoms

Tachycardia
Pulsus paradoxus in severe attacks
Anxiety, restlessness (hypoxia) progressing to
drowsiness, confusion (hypercarbia)

Asthma: Signs and Symptoms

Lethargy, confusion,
suprasternal retractions
RESPIRATORY FAILURE

Asthma:
Asthma: Signs
Signs and
and Symptoms
Symptoms

Early Blood Gas Changes

Decreased PaO2
Decreased PaCO2

WHY?

Asthma:
Asthma: Signs
Signs and
and Symptoms
Symptoms

Later Blood Gases

Decreased PaO2
Normal PaCO2

IMPENDING
RESPIRATORY
FAILURE

Asthma:
Asthma: Signs
Signs and
and Symptoms
Symptoms

Still Later Blood Gases

Decreased PaO2
Increased PaCO2

RESPIRATORY
FAILURE

Asthma:
Asthma: Risk
Risk Assessment
Assessment

Prior ICU admissions

Prior intubation
>3 ED visits in past year
>2 hospital admissions in past year
>1 bronchodilator canister used in past month
Use of bronchodilators > every 4 hours
Chronic use of steroids
Progressive symptoms in spite of aggressive Rx

Asthma:
Asthma: Management
Management

Airway
Breathing
Sitting position or position of comfort
Humidified O2 by NRB mask
Dry O2 dries mucus, worsens plugs

Encourage coughing
Consider intubation, assisted ventilation
Impending respiratory failure
Avoid if at all possible

Asthma:
Asthma: Management
Management

Circulation
IV TKO
Assess for dehydration
Titrate fluid administration to severity of
dehydration
Trial bolus of 250 cc

Monitor ECG, Pulse Oximetry

Asthma:
Asthma: Management
Management

Obtain medication history

Consider
Overdose
Dysrhythmias

Asthma:
Asthma: Management
Management

Nebulized Beta-2 agents

Salbutamol

Nebulized anticholinergics
Ipratropium
Atropine

IV Corticosteroid
Methylprednisolone

Combination Flovent/etc

Asthma:
Asthma: Management
Management

Rarely used
Questionable efficacy, Potential Complications

Magnesium Sulfate (IV)

Methylxanthines
Aminophylline (IV)

Asthma:
Asthma: Management
Management

Subcutaneous beta agents

Epinephrine 1:1000 q 30 minutes up to 3 doses
Adult 0.3 mg SQ/IM
Pediatric 0.1 to 0.3 mg SQ/IM

POSSIBLE BENEFIT IN PATIENTS

WITH VENTILATORY FAILURE

Asthma:
Asthma: Management
Management

Use EXTREME caution in giving two

sympathomimetics or two doses to same
patient
Monitor ECG

Asthma:
Asthma: Management
Management

Avoid
Sedatives
Depress respiratory drive
Antihistamines
Decrease LOC, dry secretions
Aspirin
High incidence of allergy

Asthma:
Asthma: Management
Management

Continuous Monitoring & Frequent

Reassessment
Need for transport? Destination?

Asthma:
Asthma: Management
Management

Transport Considerations
How severe is the episode?
Is the patient improving?
How extensive (invasive) were the required
therapies?
What does he/she normally do after treatment?
Medical Control or PMD consult

Drug
Drug Delivery
Delivery Methods:
Methods: Review
Review
MDI vs. MDI w/ spacer vs. SVN
vs. SQ injection

Status Asthmaticus
Asthma unresponsive to beta-2
adrenergic agents

Status
Status Asthmaticus
Asthmaticus

Oxygen (humidified if possible)

Nebulized beta-2 agents
Nebulized Ipratropium
Corticosteroids
IV or SQ terbutaline or epinephrine
Aminophylline (controversial)
Magnesium sulfate (controversial)
Intubation
Caution with PPV

Golden
Golden Rule
Rule
ALL THAT WHEEZES IS NOT
ASTHMA

Pulmonary edema
Pulmonary embolism
Allergic reactions
COPD
Pneumonia
Foreign body aspiration
Cystic fibrosis

Lower Airway Disease

Cystic Fibrosis

Cystic
Cystic Fibrosis:
Fibrosis: Definition
Definition

Inherited metabolic disease of exocrine

glands and sweat glands
Primarily affects digestive, respiratory
systems
Begins in infancy

Cystic
Cystic Fibrosis:
Fibrosis: Etiology
Etiology

Autosomal recessive gene

Both parents must be carriers
Incidence
Caucasians--1:2000
Blacks--1:17,000
Asians--very rare

Cystic
Cystic Fibrosis:
Fibrosis: Pathophysiology
Pathophysiology

Obstruction of pancreatic, intestinal gland,

bile ducts
Over-secretion by airway mucus glands
mucous plugs

Excess loss of sodium chloride in sweat

Lower Airway Disease

Neoplasms of the Lung

Hyperventilation Syndrome

Hyperventilation
Hyperventilation Syndrome
Syndrome

Brady Textbook Correction, Vol. 3, p. 57

Table 1-4: These are NOT Causes of
hyperventilation syndrome

A diagnosis of EXCLUSION!!!
An increased ventilatory rate that
DOES NOT have a pathologic origin
Results from anxiety

Remains a real problem for the patient

Hyperventilation
Hyperventilation Syndrome:
Syndrome:
Pathophysiology
Pathophysiology
Tachypnea or hyperpnea
secondary to anxiety
Decreased PaCO2
Respiratory alkalosis

Vasoconstriction

Hypocalcemia

Decreased O2
Release to
Tissues

Hyperventilation
Hyperventilation Syndrome:
Syndrome:
Signs
Signs &
& Symptoms
Symptoms

Symptoms
Light-headedness, giddiness, anxiety
Numbness, paresthesias of:
Hands
Feet
Circumoral area

Cold hands, feet

Carpopedal spasms
Dyspnea
Chest pain

Hyperventilation
Hyperventilation Syndrome:
Syndrome:
Signs
Signs &
& Symptoms
Symptoms

Signs

Rapid breathing
Cool & possibly pale skin
Carpopedal spasm
Dysrhythmias
Sinus Tachycardia
SVT
Sinus arrhythmia

Loss of consciousness and seizures (late &

rare)

Hyperventilation
Hyperventilation Syndrome:
Syndrome:
Management
Management

Educate patient & family

Consider possible psychopathology especially
in repeat customers

Transport occasionally required

If loss of consciousness, carpopedal spasm,
muscle twitching, or seizures occur:
Monitor EKG
IV TKO
Transport

Hyperventilation Syndrome
Serious diseases can mimic
hyperventilation

Hyperventilation itself can

be serious

Pulmonary Infectious Diseases

Laryngotracheobronchitis
Laryngotracheobronchitis (Croup)
(Croup)

Common syndrome of
infectious upper airway
obstruction
Viral infection
parainfluenza virus

Subglottic Edema
larynx, trachea,
mainstem bronchi

Usually 3 months to 4
years of age

Croup:
Croup: Signs
Signs &
& Symptoms
Symptoms

Gradual onset (several days)

Often begins with Sx of URI
May begin with only low grade fever

Hoarseness
Cough
Seal Bark Cough
Brassy Cough

Nocturnal episodes of increased dyspnea

and stridor

Croup:
Croup: Signs
Signs &
& Symptoms
Symptoms

Evidence of respiratory distress

Tracheal tugging
Substernal/intercostal retractions
Accessory muscle use

Inspiratory stridor or respiratory distress

may develop slowly or acutely

Croup:
Croup: Management
Management

Usually requires little out of home

treatment
Calm & Prevent agitation!!!
Moist cool air - mist
Humidified O2 by mask or blowby

Do Not Examine Upper Airways!!!

Croup:
Croup: Management
Management

If in respiratory distress:
Racemic epinephrine via nebulizer
Decreases subglottic edema (temporarily)
Necessitates transport for observation for rebound

IV TKO - ONLY if severe respiratory distress

Transport

Epiglottitis
Epiglottitis

Bacterial infection
(Hemophilus
influenza )
Edema of epiglottis
(supraglottic)
partial upper airway
obstruction
Typically affects 3-7
year olds

Epiglottitis:
Epiglottitis: Presentation
Presentation

Age: 3-7 years of age

can occur in adults
can occur in infants

Rapid onset & progression

Fever
Severe sore throat
Dysphagia
Muffled voice
Drooling

Epiglottitis:
Epiglottitis: Presentation
Presentation

Respiratory difficulty
Stridor
Usually in an upright, sitting, tripod position

Child may go to bed asymptomatic and

awaken during the night with
sore throat
painful swallowing
respiratory difficulty

Epiglottitis:
Epiglottitis: Management
Management
Immediate life threat (8-12% die
from airway obstruction)

Do NOT attempt to visualize airway

Allow child to assume position of comfort
AVOID agitation of the child!!!
AVOID anxiety of the healthcare providers!!!

O2 by high concentration mask

Epiglottitis:
Epiglottitis: Management
Management

If respiratory failure is eminent:

IV TKO ONLY if eminent or respiratory arrest
Be prepared to take control of airway
Intubation equipment with smaller sized tubes
Needle cricothyrotomy & jet ventilation equipment

Rapid but calm transport

Appropriate facility

Upper
Upper Respiratory
Respiratory Infection
Infection

Common illness
Rarely life-threatening
Often exacerbates underlying pulmonary
conditions
May become more significant in some
patients
Immunosuppressed
Elderly
Chronic pulmonary disease

Upper
Upper Respiratory
Respiratory Infection
Infection

Prevention
Avoidance is nearly impossible
Too many potential causes
Temporarily impaired immune system

Best prevention strategy is handwashing

Covering of mouth during sneezing and coughing also
helpful

Pathophysiology
Pathophysiology of
of URI
URI

Wide variety of bacteria and viruses are

causes
Normal immune system response results in
presentation

20-30% are Group A streptococci

Most are self-limiting diseases

Presentation
Presentation of
of URI
URI

Symptoms

Sore throat
Fever
Chills
HA

Signs
Cervical adenopathy
Erythematous pharynx
Positive throat culture (bacterial)

Management
Management of
of URI
URI

Usually requires no intervention

Oxygen if underlying condition has been
exacerbated
Rarely, pharmacologic interventions are
required
Bronchodilators
Corticosteroid

Occasionally, transport required

Key question: Destination?

Central
Central Respiratory
Respiratory Depression
Depression

Respiratory
Respiratory Depression:
Depression: Causes
Causes

Head trauma
CVA
Depressant drug toxicity

Narcotics
Barbiturates
Benzodiazepines
ETOH

Respiratory
Respiratory Depression:
Depression:
Recognition
Recognition

Decreased respiratory rate (< 12/min)

Decreased tidal volume
Decreased LOC

Look, Listen, Feel

If you cant tell
whether a patient
is breathing
adequately...

Use Your
Stethoscope

THEY
PROBABLY
ARENT

Respiratory
Respiratory Depression:
Depression:
Management
Management

Airway
Open, clear, maintain
Consider endotracheal intubation

The need to VENTILATE is not the

same as the need to INTUBATE

Respiratory
Respiratory Depression:
Depression:
Management
Management

Breathing
Oxygenate, ventilate
Restore normal rate, tidal volume

Oxygen alone is INSUFFICIENT if

Ventilation is INADEQUATE

Respiratory
Respiratory Depression:
Depression:
Management
Management

Circulation
Obtain vascular access
Monitor EKG (Silent MI may present as CVA)

Manage Cause
Check Blood Sugar
Consider Narcan 2mg IV push if S/S suggest
narcotic overdose

Intubate if can not find or treat cause

Guillian-Barre
Guillian-Barre Syndrome
Syndrome

Autoimmune disease
Leads to inflammation and degeneration of
sensory and motor nerve roots (demyelination)

Progressive ascending paralysis

Progressive tingling and weakness
Moves from extremities then proximally
May lead to respiratory paralysis (25%)

Guillian-Barre
Guillian-Barre Syndrome
Syndrome
Management
Management

Treatment based on severity of symptoms

Control airway
Support ventilation
Oxygen
Transport in cases of respiratory depression,
distress or arrest

Myasthenia
Myasthenia Gravis
Gravis

Autoimmune disease
Causes loss of ACh receptors at
neuromuscular junction
Attacks the ACh transport mechanism at the
NMJ

Episodes of extreme skeletal muscle

weakness
Can cause loss of control of airway,
respiratory paralysis

Myasthenia
Myasthenia Gravis
Gravis Presentation
Presentation

Gradual onset of muscle weakness

Face and throat
Extreme muscle weakness

Respiratory weakness -> paralysis

Inability to process mucus

Myasthenia
Myasthenia Gravis
Gravis Management
Management

Treat symptomatically
Watch for aspiration
May require assisted ventilations
Assess for Pulmonary infection
Transport based upon severity of
presentation

Case Studies

Case
Case One
One

It is 1430 hrs. You are called to a business for

a possible stroke. The patient is a 20-yearold female complaining of dizziness and of
numbness around her mouth and fingertips.
What would you like to include in
your initial differential diagnosis?

Case
Case One
One

Initial Assessment
Airway: Open, maintained by patient
Breathing: Rapid, deep, regular; no accessory
muscle use or retractions
Circulation: Radial pulses present, rapid, full; Skin
warm, dry; capillary refill < 2 seconds
Disability: Awake, alert, anxious

What therapies, if any, would you

like to begin?

Case
Case One
One

Vital Signs
P: 126 strong, regular
R: 26 deep, regular
BP: 130/82

Physical Exam
Chest: BS present, equal bilaterally; no
adventitious sounds
Extremities: Equal movement in all
extremities; no weakness; hands cool
Oxygen saturation: 98%

Would you like to make any Changes

to your therapies or Diff Dx?

Case
Case One
One

History
Allergies: NKA
Medications: Birth control pills
Past History: No significant past history; no
history of smoking
Last Meal: Lunch 2 hours ago
Events: S/S began suddenly after argument
with supervisor

Case
Case One
One

What problem do you now suspect?

How would you manage this patient?

Case
Case Two
Two

It is 0530 hours. You are called to a residence

to see a child with a very high fever and
difficulty breathing. The patient is a 6-oldfemale. Mother says the child woke up crying
about 2 hours ago.
What would you like to include in
your differential diagnosis?

Case
Case Two
Two

Initial Assessment
Airway: Inspiratory stridor audible
Breathing: Rapid, shallow, labored
Circulation: Radial pulses present, rapid, weak;
skin pale, hot, diaphoretic; capillary refill is 2
seconds
Disability: Awake, alert, obviously frightened and in
acute distress

What therapies, if any, would you

like to begin now?

Case
Case Two
Two

Vital Signs
P: 130 weak, regular
R: 32 shallow, regular with stridor
BP: 110/70

Physical Exam
HEENT: Flaring of nostrils; accessory muscle
use on inspiration; drooling present
Chest: BS present, equal bilaterally; no
adventitious sounds
Oxygen saturation: 92%

Would you like to make any Changes to

your therapies or Diff Dx?

Case
Case Two
Two

History

Allergies: NKA
Medications: None
Past History: No significant past history
Last Meal: Dinner at about 1800 hours
Events: Awakened with severe sore throat. Has
experienced increasing difficulty breathing. Will
not eat or drink. Says it hurts to swallow

Case
Case Two
Two

What problem do you now suspect?

How would you manage this patient?

Case
Case Three
Three

At 2330 hrs you are called to a residence to

see a child with difficulty breathing. The
patient is a 3 year old male.
How narrow a Differential Diagnosis
can you compile at this point?

Case
Case Three
Three

Initial Assessment
Airway: Open, maintained by patient, mild stridor
audible
Breathing: Rapid, shallow, labored
Circulation: Radial pulses present, weak, regular;
Skin pale, warm, moist; Capillary refill <2 seconds
Disability: Awake, sitting up in bed, looks tired and
miserable

Case
Case Three
Three

Vital Signs
P: 100 weak, regular
R: 30 shallow, labored with stridor
BP: 90/50

Physical Exam
HEENT: Use of accessory muscles present; no
drooling
Chest: BS present, equal bilaterally with no
adventitious sounds. Auscultation difficult
because of stridor and barking cough

Now you can narrow your Diff Dx? To what?

Case
Case Three
Three

History

Allergies: NKA
Medication: Tylenol for fever before bedtime
Past history: No significant past history
Last meal: Dinner around 1800 hours
Events: Patient has had cold for about 3 days.
Reasonably well during day. Awakens around
midnight with high-pitched cough that sounds
like a dog barking

Case
Case Three
Three

What problem do you suspect?

How would you manage this patient?

Case
Case Four
Four

At 1945 hours you are dispatched to a

breathing difficulty at Long John Silvers.
The patient is a 26-year-old female
complaining of strange feeling in her mouth
and difficulty swallowing.
What is your differential diagnosis?

Case
Case Four
Four

Initial Assessment
Airway: Open, maintained by patient, difficulty
swallowing, voice is hoarse
Breathing: Rapid, labored
Circulation: Radial pulses present, strong, regular;
Skin flushed; Capillary refill < 2 seconds
Disability: Awake, alert, very anxious

Case
Case Four
Four

Vital Signs
P: 120 strong, regular
R: 26 regular, slightly labored
BP: 118/90

Physical Exam
HEENT: Puffiness around eyes; Lips appear swollen;
Mild accessory muscle use
Chest: BS present, equal bilaterally; No adventitious
sounds
Urticaria on upper chest, extremities
Oxygen saturation: 94%

What therapies do you want to initiate?

Case
Case Four
Four

History
Allergies: No drug allergies; Has experienced
itching previously when eating shrimp
Medications: None
Past history: No significant past history; no
history of smoking
Last meal: In progress at time of call
Events: Began to experience itching and
difficulty swallowing after eating fish and
chips

Case
Case Four
Four

What problem do you suspect?

How would you manage this patient?

The patient begins to have increased difficulty

swallowing, increased anxiety, and increased
difficulty breathing.
What do you want to do now?

Case
Case Five
Five

At 0130 you are dispatched to an

unconscious person--police on location. The
patient is a 27-year-old male who is
apparently unconscious. The police report
they found him lying in an alleyway while they
were on routine patrol. He is known to live
on the streets.

Case
Case Five
Five

Initial Assessment
Airway: Controllable with manual positioning
Breathing: Very slow, shallow
Circulation: Radial pulses present, weak; Skin
pale, cool, moist; Capillary refill 3 seconds
Disability: Unconscious, unresponsive to painful
stimuli

What therapies would you like to begin?

Case
Case Five
Five

Vital Signs
P: 70 regular, weak
R: 4 shallow, regular; alcohol odor on breath
BP: 100/70

Physical Exam

HEENT: Pupils pinpoint, non-reactive

Chest: BS present, equal bilaterally
Abdomen: Soft, non-tender
Extremities: Needle tracks present
Blood glucose: 40 mg/dl

Case
Case Five
Five

What problem or problems do you

suspect?
How would you manage this patient?