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Waiting to Exhale

Waiting to Exhale. Respiratory Disorders. Peggy Andrews, Instructor. The Respiratory System. A quick review. Upper airway To larynx Warms, humidifies, cleans Cilia Turbinates Hard and Soft palates. Lower airway Below larynx Trachea Bronchi Bronchioles Alveoli Surfactant.

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Waiting to Exhale

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  1. Waiting to Exhale Respiratory Disorders Peggy Andrews, Instructor

  2. The Respiratory System

  3. A quick review • Upper airway • To larynx • Warms, humidifies, cleans • Cilia • Turbinates • Hard and Soft palates

  4. Lower airway Below larynx Trachea Bronchi Bronchioles Alveoli Surfactant Review, continued

  5. Lungs Lobes Visceral pleura Parietal pleura Lower airway, cont.

  6. Ventilation Inspiration Expiration Respiration-Tidal Volume 500ml Inspiratory Reserve Volume 3000ml Expiratory reserve volume 1500ml Residual volume 1200ml Dead air space 150ml Minute volume TV x RR Review, continued

  7. What controls our breathing? • Medulla • 12-20/min • Inspiratory and Expiratory areas • Transmitted through • Phrenic nerve • 3rd, 4th, 5th spinal nerves • Intercostal nerves • 11 pair • Can be modified by • Cerebral cortex • Hypothalamus • Pons - on/off switch

  8. What controls our breathing, cont. • Stretch receptors • Visceral pleura • Bronchi and bronchiole walls = • Hering-Breuer reflex • PCO2 increase = increased PCO2 in CSF = decreased pH

  9. Respiratory patterns Cheyne-Stokes Kussmaul’s Central neurogenic hyperventilation Ataxic (Biot’s) Apneustic

  10. Respiratory Disorders • Incidence - 28% of all EMS C/C • Morbidity/Mortality - >200,000 deaths/yr.

  11. Risk Factors • Genetic predisposition • Asthma • COPD • Carcinomas • Stress • Increases severity of respiratory complaints & frequency of exacerbations • Assoc. Cardiac or circulatory pathologies • Pulmonary edema • Pulmonary emboli

  12. Case Presentation One • On a cold Sunday morning in February, a basic amb’lance is dispatched to a trailer park for a “woman down”. When the EMTs arrive, they are met by a young couple who explain that they had arrived about 30 minutes earlier to pick their mother up for church. They found her on the floor of her bathroom, lying on her right side. According to the couple, the mother said that she had fallen just after lunch the previous day, and she had been unable to get up.

  13. Entering the bathroom, the EMTs find: • An elderly woman, CAO PPTE, lying on her side and covered with diarrhea. She says that she feels “fine” but admits to some focal right-sided chest pain and a bruise on her hip where she fell.

  14. She tells the EMTs that she has been experiencing diarrhea for the past two days. Although she feels dizzy, she denies any syncope at the time of her fall, and says that she simply slipped as she was sitting on the toilet.

  15. The Patient Is: • Pale • Mildly cyanotic nailbeds • Skin is warm and dry • Mucous membranes are dry • A productive cough with thick, brown sputum • She states that the coughing is left over from a cold that she had contracted the previous month.

  16. Breath sounds are congested with rhonchi • Blood pressure – 90/50 mmHg • Pulse – 128/min. • Respirations – 40/min. and shallow • Temperature – 101.6 F (oral)

  17. The EMT’s determine that the patient is dehydrated from the diarrhea. They administer oxygen at 4 L/min., and request that an ALS ambulance be dispatched. You arrive to find this 72 year old patient unchanged.

  18. During your transport, her cyanosis progresses to her lips, although she remains alert and oriented and insists she is “OK”. Her medical history reveals that she is a chronic alcoholic, has been Dx with hepatic cirrhosis, and has a 145-pack year smoking history.

  19. Rhonchi and rales are still noted in her right chest • BP – 88/58 mmHg • P – 116/min. • Respirations – 30/min. • Temp 102.5 F (oral)

  20. 1. What is her differential diagnosis? 2. What treatment might you provide for this patient?Why?

  21. Altered mental status 1-2 word speech Tachycardia > 130/min. Absent breath sounds Retractions/ accessory muscle use Audible stridor Pallor and diaphoresis Severe cyanosis Signs of life-threatening respiratory distress in adults

  22. COPD (Chronic Obstructive Pulmonary Disease) • Emphysema • Chronic Bronchitis • Asthma

  23. Case Presentation Two •  You are dispatched as first-in ambulance to a “medical emergency – unknown problem”. • The response time to this rural address is about 12 minutes. • On arrival, you find a first responder who tells you they have a 55-year-old male with difficulty breathing. • She says that oxygen is already being administered.

  24. You enter the house to find the patient seated at the kitchen table, obviously short of breath. • Your initial assessment shows that the patient is moving air, and has a strong pulse. • You replace the nasal cannula with a non-rebreather at 12 Lpm

  25. You note the following: • The patient has diminished breath sounds • Occasional rhonchi • He is using his accessory muscles • He has mild cyanosis around his mouth.

  26. Several years ago, doctors at the VA hospital diagnosed the patient as having emphysema. • Over the last 24 hours, the patient has had progressive dyspnea, and didn’t sleep at all last night.

  27. BP – 140/78 • P - 96 • Resp – 28 • Ecg – SR • SaO2 – 90% with oxygen • Pt is CAO PPTE • Meds – Theophylline and Amoxicillin • Smokes 1 PPD with a 30 pack-yr-hx • He wants to be transported to the VA hospital

  28. What is his differential diagnosis? • What treatment might you provide him? • Why?

  29. Emphysema • Irreversible airway obstruction • Diffusion defect also exists because of blebs - prone to collapse • Patient exhales with pursed lips • Almost always associated with cigarette smoking or environmental toxins

  30. Emphysema Pathophysiology • Destruction of alveolar walls distal to terminal bronchioles. • More common in men • Walls of alveoli gradually distruct, = alveolar membrane surface area. Results in  ratio of air to lung tissue. • Pulmonary capillaries , =  resistance to pulmonary blood flow. • Causes pulmonary hypertension, leads to RHF, then Cor Pulmonale

  31. Emphysema Pathophysiology(cont.) • Bronchiole walls weaken, lungs lose elasticity, air is trapped.  Residual volume, but vital capacity relatively normal. • PaO2 , =  RBC, polycythemia. • PaCO2 is chronically elevated. The body depends on hypoxic drive. • Pt’s are more susceptible to pneumonia, dysrhythmias. • Meds: bronchodilators, corticosteroids, O2.

  32. Assessment • Altered mentation • 1-2 word “sentences” • Absent or decreased breath sounds • c/c Dyspnea, morning cough, nocturnal dyspnea, wheezing

  33. History - • Personal or family hx of allergies/asthma • Acute exposure to pulmonary irritant • Previous similar expisodes • Recent wt. loss, exertional dyspnea • Usually > 20 pack/year/history

  34. Wheezing Retractions and/or accessory muscle use Barrel chest Prolonged expiratory phase Rapid resting respiratory rate Thin Pink puffers Clubbing of fingers Diminished breath sounds JVD, hepatic congestion, peripheral edema Exam

  35. Management • Pulse oximeter (end tidal CO2 detector) • Assisted ventilation prn • High flow oxygen • Intubation prn • IV therapy with fluids • Albuterol, or Albuterol/Atrovent neb • Transport considerations

  36. Chronic Bronchitis • Productive cough for at least 3 months for two or more consecutive years • An increase in mucous-secreting cells • Characterized by large quantity of sputum • Chronic smoker • Alveoli not severely affected - diffusion normal • gas exchange = hypoxia & hypercarbia • May increase RBC = polycythemia • paCO2 = irritability, h/a, personality changes,  intellect. • paCO2 = pulmonary hypertension & eventually cor pulmonale.

  37. Assessment • Hx heavy cigarette smoking • Frequent resp. infections • Productive cough • Overweight, possibly cyanotic - blue bloaters • Rhonchi on auscultation - mucous plugs • S/S RHF; JVD, edema, hepatic congestion

  38. Management • Pulse oximetry (end tidal CO2 detector) • Oxygen - low flow if possible • Nebulized Albuterol/Atrovent • Constantly monitor • Position - seated • IV TKO

  39. Case Presentation Three • It is a hot June afternoon when you are dispatched to the local middle school for a child with difficulty breathing. You are directed to the nurse’s office, and there you find a 10 year-old female.

  40. Wt – 45 kg • Sitting upright on the cot • CAO PPTE • Obviously struggling to breathe. • Anxious

  41. The nurse tells you that the patient is relatively new to the school, and the only medical information she has is that the patient is allergic to many things (dust, pets, plants, as well as peanuts, eggs, shellfish).

  42. The nurse has been unable to contact the parents – they are both out of town, and the custodial aunt is about 30 minutes away, but has left a message to do whatever you think should be done.

  43. The nurse tells you that all she knows is that the patient was out at recess, wandered away from the other children, and when a playground aide went to find her, the patient was sitting down, pale, c/o difficulty breathing and had vomited x 1.

  44. You find the following: • PERL • P – 132 • RR – 32 and shallow • Intercostal retractions, suprasternal notch retractions, nasal flaring, pursed-lip breathing, and sub-costal retractions are all apparent. • Breath sounds are diminished in all lobes, with some wheezing in the bases.

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