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124 Cards in this Set

  • Front
  • Back
What is Pulmonary Surfactant?
-Thin film that coats alveoli
-Prevents alveoli from collapsing
What can cause a disruption in ventilation?
=Upper & Lower Respiratory Tracts
-Obstruction due to trauma or infectious processes

= Chest Wall and Diaphragm
-Trauma
• Pneumothorax
• Hemothorax
• Flail chest
-Neuromuscular disease

= Nervous System
-Trauma
-Poisoning or overdose
-Disease
What is it important to do at the scene size up for a respiratory emergency?
Identify threats to safety. Environments with reduced O2 levels, dangerous gases or biological agents.

Look for clues that can give you information about the patient.
What are you looking for with the initial impression?
-Position
-Color
-Mental status
-Ability to speak
-Respiratory effort
What are signs of life threatening breathing problems?
• Alterations in mental status
• Severe central cyanosis, pallor, or diaphoresis
• Absent or abnormal breath sounds
• Speaking limited to 1–2 words
• Inspiration/ expiration ratio
• Tachycardia
• Use of accessory muscles or presence of retractions
Why should neurological status be considered when dealing with respiratory emergencies?
The brain is very sensitive to reduced levels of O2. Any alteration in LOC could represent respiratory compromise.

Brain trauma can disrupt the breathing control centers of the brain.

Injury on the spinal chord can paralyze the intercostals and even the diaphragm.
Why should cardiovascular status be considered with respiratory emergencies?
Changes in the fluid balance and the pumping of the heart can lead to CHF.

Changes in oxygenation can have profound effects on the heart. The heart will reflect changes in the lungs.

A thorough evaluation of the heart in vital when looking at the respiratory system.
How do muscles and mechanics play a role in respiratory emergencies?
People can compensate for respiratory distress by using accessory muscles. This is very tiring and eventually the patient will be unable to maintain this. The rate of breathing will drop and they will enter into respiratory failure.

Positioning of the patient is very important.

Some diseases can cause muscle weakness and can be fatal. Such as Guillian-Barre syndrome.
How does the renal system impact on the respiratory system?
Fluid balance, acid base balance and blood pressure are controlled in part by the kidneys.

If blood cannot be supplied to the lungs effectively then the lungs are unable to supply oxygen to the tissues.
What can be noted about the position of a person in respiratory distress?
The tripod position improves the efficiency of the accessory breathing by stabilizing the shoulder girdle.

A person in respiratory distress wanting to lie flat could be a sign of deterioration.

Patients may also hold their heads up in the sniffing or head lilt position. This opens the airway for better flow. Can be a sign of upper airway swelling.
What is head bobbing?
It is where the person who has respiratory distress is unable to keep the head raised.

This is a very ominous sign signalling the potential for imminent decompression.
Why is it important to note the work of breathing?
Patients using lots of accessory muscle to breath with are in danger or tiring out.
What are chest wall retractions?
Most commonly seen in small infants where the thorax is still flexible. On inhalation the child m may pull the sternum into the chest causing a visible deformity with each breath.
What is nasal flaring?
The nostrils are pulled wide open on inhalation.
What are soft tissue retractions?
In most patients the bones are rigid and not able to move. The soft tissues are pulled in around the bones.

This can be seen during inhalation in the supraclavicular, intercostal and sub-xiphoid areas.
What is tracheal tugging?
Where the thyroid cartilage is pulled upward and the area above the sternal notch is sucked inward with inhalation.
What is paradoxical respiratory movement?
The epigastrium is pulled in with inhalation while the abdomen pushes out creating a see saw appearance as the two move in opposite directions.
What is a general rule with respiratory noises?
Any respiratory noises that are audible without a stethoscope are abnormal noises.
Why is quiet breathing of interest?
A patient with tachypnea who has crystal clear breath sounds may have hyperventilation syndrome.

They may also be breathing fast because of acidosis.

Quiet tachypnea should prompt you to consider shock.
Why is a neurological assessment important?
Enormously important. Any decline in PaO2 will show as restlessness, confusion and in worst case scenarios as combative behaviour.

An increase in PaCO2 usually has sedative effects making the patient sleepy and hard to rouse.
Why is it important to get the reason why the patient called for help?
Many patients will be able to identify their problem and a way for you to treat it without you having to dig for information.

Patients are often knowledgeable about their disease or disorder and may have already tried several treatment options already.
Why is knowing the onset and duration important?
The speed of the onset is important to help determine what the problem may be.

Rapid onset dyspnea may be due to acute brochospasm, anaphylaxis, pulmonary embolism or pneumothorax.

Right sided heart failure may worsen over days. On the other hand left sided failure caused by an AMI may kill in minutes.
Why is paroxysmal nocturnal dyspnea an ominous sign?
It can signal left sided heart failure worsening COPD or both.

It occurs due to accumulation of fluid in the alveoli or pooling of secretions in the bronchi during sleep.
Why is the history of the problem important?
Asthma, CHF, pneumonia in immunocompromised patients even spontaneous pneumothorax are often repeating pathological conditions.

This can serve as a baseline to assess the current condition.

Do you feel better or worse? How often does this happen? What did your doctor say it was?
Why are knowing about attempts at treatment important?
When problems are chronic or re-occurring patients may have strategies to manage their own problem.

Try to determine what the patient has done, any effects and if prescribed medication is being taken correctly.
Why are associated symptoms important?
Respiratory difficulty must always be evaluated in light of the patients cardiovascular and renal status.

Many AMI's present as congestive heart failure as do renal crises.
What can tachynea signal?
Anxiety, diabetes, or shock. The vast majority of chronically ill patients have a respiratory component to their illness.
What is it important to do?
Dig deeper beyond the respiratory distress to determine what may be triggering it.
What are you looking for with the neck?
Look for JVD when a patient is in a semi-sitting position.
What can cause JVD?
Cardiac Tamponade, pneumothorax, heart failure and COPD

It is common to see this all of the time in patients with asthma or COPD (obstructive lung disease)
How should JVD be interpreted?
In light of the patients position and other vital signs.
Why is tracheal deviation important?
It is a classic albeit late sign of a tension pneumothorax. This is very very difficult to see.
What is the hepatojugular reflex?
It is where you gently press on the liver. The blood you squeeze out will back up behind the failing ventricle and the jugular veins will engorge further.
What are things to look for when examining the extremities?
Does the patient have edema of the ankles or lower back?

If so does it pit?

Is their peripheral cyanosis?

Does the patient have an obvious fever or cool and clammy from shock?
How should the lungs be auscultated?
Systematically. We try to compare the left and right sides. The lungs are not symmetrical however.

Be aware of where you need to listen to the lungs. Some conditions are gravity dependent. Pneumonia and CHF will be heard in the bases. Wheezing can be more diffuse and spread throughout the lung fields.
Where should lung sounds be assessed?
The upper lobes are heard by listening to the anterior part of the chest.

The lower lobes are best heard listening to the anterior part of the chest.
What are the breath sounds you will hear?
Tracheal sounds are very harsh and tubular

Bronchial breath sounds are quite loud but exhalation dominates.

Bronchovesicular sounds are softer and have equal inspiratory and expiratory sides.

The most commonly heard breath sounds are the soft breezy vesicular sounds heard in the periphery. They have a much more obvious inspiratory component.
Listen to the saved lung sounds!
Listen to the saved lung sounds!
How can knowledge of the movement of sound help?
Sound moves better through liquid than air.

The more air present in a patients chest as with asthma or COPD the more distant or absent sounds will be in peripheral areas.

The more wet a patients lungs are as in pneumonia, consolidation, or CHF the louder the sounds will be in the periphery.
If you can hear the patient talking through your stethoscope what can this mean?
That you are over a consolidated or fluid filled lobe.
What are adventitious breath sounds?
Extra noises that you hear on top of breath sounds already quizzed about.
What are wheezes?
High pitched whistling sounds made by air being forced through narrowed airways.

Wheezing can be diffuse as in asthma and CHF or localized such as when a foreign body obstructs a bronchus.
What are crackles?
Any discontinuous noises heard when listening to the lungs. They are caused by the popping open of air spaces.

They are usually associated with fluid in the lungs.

They are often referred to as rales or ronchi.
What is the most common upper airway obstruction?
The tongue is the most common obstruction in the semi-conscious or unconscious patient.

If the patient is snoring makes sure that the airway is repositioned.
What can happen with airway infections?
They can cause swelling in the upper airway. The most common is croup.
Why does this more often happen with children?
The pediatric airway is smaller relative to the adults. A small amount of swelling reduces the airway of a pediatric patient by a proportionally greater amount than the same swelling in an adult.
What should not be done with upper airway infections?
The airway should not be manipulated.
What is the difference between croup and epiglotitis?
The presence of a fever hoarse voice and purposeful hyperextension.
What are obstructive airway diseases?
They are characterized by diffuse obstruction to airflow within the lungs.
What are the most common obstructive airway diseases?
Emphysema and chronic bronchitis and asthma.
What are emphysema and chronic bronchitis classified as?
COPD because the changes in pulmonary structure and function are chronic, progressive and irreversible.
What happens with obstructive disease?
The positive pressure of exhalation causes the small airways to pinch shut trapping gas in the alveoli.

Patients end up with large amounts of gas that get trapped in their lungs.
What do patients with obstructive disease learn?
That if they push the air out slowly at a low pressure they can exhale more volume than if they try to push it out hard and fast.
What are some physical findings that patients with obstructive airway disease may demonstrate?
Pursed lip breathing = allows the patient to push breath slowly under controlled pressure.

Increased inspiratory to expiratory ratio. IE longer to breath out than normal.

Abdominal muscle use - patients must work to push every breath out.

JVD - The trapped air creates a higher pressure in the thorax. This can lead to blood backing up in the jugular veins.
What is asthma?
Asthma is characterized by an inflammation of the bronchiole airways due to a variety of stimuli.

The inflammation results in widespread reversible narrowing of the airways or bronchospasm.

Triggers may be things like dust, cold or smoke.
How does asthma occur?
It occurs in acute attacks or variable duration. Between attacks the patient may be relatively asymptomatic.
How is asthma distributed?
3 million Canadians had asthma in 2005. 60% of them do not have adequate control.

500 adults and 20 children die each year in Canada from asthma.

Asthma tends to be more common in males but more severe in females.
What is the bronchospasm?
Caused by the constriction of the smooth muscle that surrounds the larger bronchi in the lungs.
What can cause this?
Stimulation by an allergen or irritant. Also stress or exercise can contribute.
Why do asthmatics wheeze?
Air is forced through the constricted tubes which vibrate causing the wheezing.
What is the primary treatment of bronchospasm?
Beta 2 agonists such as salbutamol.

For life threatening asthma epinephrine is sometimes used.
What is status asthmaticus?
A severe prolonged asthmatic attack what cannot be broken with conventional treatment.

It is reasonably safe to assume that any patient that calls for an ambulance is in status asthmaticus unless proven otherwise.
How do patients in status asthmaticus present?
Fighting to move air through obstructed airways with prominent use of accessory muscles.

The chest is maximally hyperinflated. Breath sounds and wheezes may be entirely inaudible as air movement is negligible.

The patient is usually exhausted, severely acidotic and dehydrated.
What can also cause wheezing?
Chronic bronchitis, acute left sided heart failure, acute pulmonary embolism.
What does localized wheezing signify?
Obstruction by a foreign body or tumour.
What are some history items that signify the patient is at high risk of potentially fatal asthma?
Previous intubation for respiratory failure or respiratory arrest.

Previous ICU admission for asthma

Recent ED visits and patient on maximal therapy.

Altered mental status, hypoxia, silent chest.
What is COPD?
Comprises two distinct clinical entities: emphysema and chronic bronchitis
What is Emphysema?
The destruction of the airway distal to the terminal bronchioles and airway.
What is the most common cause of this disease?
Cigarette smoking
What happens?
The breakdown of the connective tissue structure of the terminal airways results in groups of alveoli merging into large blebs.
What is the consequence of this?
The alveoli are less efficient at exchanging oxygen and collapse far more easily causing obstruction.
What can be associated with emphysema?
Bronchospasm, inflammation, or infections can be treated or relieved.
How do patients with COPD present?
Many patients will have a barrel chest caused by chronic lung hyperinflation. Patients are often tachypneic as they attempt to maintain a normal CO2 level.

They often use extreme amounts of energy breath.
What is chronic bronchitis?
Defined as sputum production most days of the month for 3 months of the year for more than 2 years.
What is the hallmark for chronic bronchitis?
Excessive mucous production in the bronchial tree.

This is almost always accompanied by a chronic or recurrent productive cough.
What is the typical patient for COPD?
A heavy cigarette smoker

Usually somewhat obese

Sometimes has a bluish complexion

Blood gasses tend to be abnormal

Often the patient has right sides heart failure or associated heart disease.
What is the pink puffer and blue bloater?
Pink puffer is Emphysema - patient makes more red blood cells in order to compensate for the lung damage.

Blue bloater - refers to the generally obese nature of the chronic bronchitis patient with the blue caused by hypoxia
What are typical presentations of COPD?
Patients with COPD have no reserves left to help them deal with any additional respiratory insult.

Need to search for what pushed them from a stable state to the insufficiency that caused them to call 911.
What is COPD with pneumonia?
Due to poor secretion clearence and excessive mucous production COPD patients often get infections in their bronchi or lungs.

Do they have a fever?
Are their signs of infection?
Are their localized areas of ronchi consistent with pneumonia?
What is COPD with Right heart failure?
The heart finds in hard to push blood through lungs destroyed by emphysema and through capillaries squashed by hyperinflated alveoli. This commonly causes right heart failure secondary to the patients lung disease.

Do they have peripheral edema?
Is there JVD with hepatojugular reflux?
End inspiratory crackles?
Has the dyspnea progressively increased over several days?
What is COPD with Left Heart Failure?
Patients with COPD are at high risk of of having a sudden cardiac event. Any left ventricular dysfunction such as an AMI or cardiac rhythm disturbance can cause them to have a sudden onset LHF.

Do not allow the initial impression of COPD prevent you from identifying the patient who is also having an AMI
What is an acute exacerbation of COPD?
There is no co-pathalogic condition. The patients condition becomes worse suddenly due to

Environmental change such as weather, humidity, activation of heating or cooling system.

Inhalation of a trigger substance, maybe dust, paint fumes? What is going on near your patient or what did they do today that was different?
What is End stage COPD?
When a patient with severe COPD reaches a point where the lungs are not able to support oxygenation and ventilation any more.

There may be a DNR order. It is important to secure valid documentation of the patients wishes and follow local medical protocol.
What is hypoxic drive?
A very rare phenomenon that affects a very small % of end stage pulmonary disease patients.

It is where the primary stimulus to breath comes from decreased levels of O2 rather than increased levels of CO2
How can patients be managed for hypoxic drive?
It is not possible to identify the patient by looking at them.

The condition presents itself slowly. The respiratory drive will decrease gradually until it is a problem.

You need to keep an eye on respiratory rates. Maybe use waveform capnography.

If the patient becomes apneic provide artificial respiration.
How do patients with tuberculosis present?
Weight Loss
Night sweats
Fever
Cough with blood tinged sputum
What can happen when asthma is present with a fever?
The patients asthma attack will respond to treatment with inhalers for a short while. The symptoms will then return.

The asthma will not go away until the underlying trigger has been treated which could be pneumonia or bronchitis.

Is the patient coughing up colourful sputum or have a fever or chills?
How can failure of a metered dose inhaler cause problems?
Patients do not keep track of how many doses are in their inhalers. Sometimes they can be sucking on nothing but propellant for days.

Medications may be out of date or have been heated.

Patients may not fully understand how to use the device. A spacer can help with this in children and adults who have difficulty.
How can dyspnea triggers cause a problem?
People do not always manage to avoid their triggers. Sometimes a family or important situation will cause a patient to risk the consequences.
How can seasonal issues occur?
Things can grow in heating ducts and air conditioners. When the weather changes and these devices activate there is often an increase in calls from chronically ill or respiratory patients.
How can patients become non-compliant with therapy?
Some patients will rebel against their therapy as a means of seeming to regain some control over their lives.

Sometimes they do not understand the long term nature of their therapy and attempt to wean themselves off medications or support devices.

This often results in them having a crisis.
How can failure of technology or running out of medications cause problems?
Advances in technology have given patients more freedom. These technologies can fail or run out or be left at home.
How can exertion cause problems?
Patients can be stable when they are at rest but any exertion or stress can cause problems as oxygen demands increase.
What are pulmonary infections?
Bacteria, viruses, fungi, mycoplasms and a host of other agents cause infections.
What do these infections do?
They cause swelling of the respiratory tissues and increase in mucous production and the production of pus.

Swelling can be dramatic especially in the upper tissues.

Alveoli can become non-functional if they fill up with pus as occurs in pneumonia.
What happens to lung function?
Pus filled or fluid filled alveoli are not able to contribute to gas exchange causing shunt where O2 does not reach the blood stream.
What causes Pneumonia?
Can be any of a variety of bacterial, viral and fungal agents.
What is bacterial pneumonia responsible for?
10% of hospital admissions in Canada.

Even with antibiotics patients with pneumonia have a 11% in hospital mortality rate and a 26% one-year mortality rate.
Who is at increased risk of developing pneumonia?
Older people, patients with chronic illnesses and smokers.

Anyone who is not moving air well or who has excessive secretions. Anyone who is immunocompromised such as HIV or other illnesses.
What do patients with pneumonia report?
Several hours to days of weakness, productive cough, fever and sometimes chest pain made worse by a cough.
What should you be listening for when getting a history?
Comments like I just got over the flu. Pneumonia is often a secondary illness following a bout of the flu.
How may patients with Pneumonia appear?
The patient often appears very ill (has a toxic appearance).

They may or may not be coughing

Crackles may be heard on auscultation of the chest.

There may be sputum production.

Sputum may be thick or purulent (puslike).
What about dehydration?
Patients with pneumonia are often dehydrated.

IV hydration is often required.
What care is required for pneumonia?
Supportive care
-High flow oxygenation
-Position of comfort - semi fowlers
-Secretion management (suctioning)
-Transport
-bronchodilators will not help the condition but can help if there is an underlying condition such as asthma or COPD
What is lung cancer and how is it caused?
Tumours grow in the lungs impairing function. Cigarette smoke is the primary cause of lung cancer.
What can accompany this disease?
Since lung cancer is often a result of smoking the symptoms may be accompanied by COPD or impaired lung function.
What can tumours and treatment cause?
Pleural effusions which can present with rapidly progressing dyspnea.
What about end of life issues?
Can be called to help with patients in hospice care who have depressed breathing due to narcotic usage for pain control.
What is pulmonary edema?
Swelling of the lungs occurs when fluid from the blood plasma migrates into the lung parenchyma (the tissues that make up the walls of the capillaries and alveoli.
What does his swelling do?
It compromises gas exchange long before the fluid spills into the alveoli and becomes noticeable in the form of pink frothy sputum.
What is one of the most common causes of pulmonary edema?
Heart failure resulting from a left sided AMI.
What else can result in pulmonary edema?
Inhaled toxins can cause damage to alveolar tissue and cause fluid to seep into the lungs.

Infections can damage the pulmonary capillaries to the same effect.

Trauma or altitude changes can lead to ARDS or high altitude pulmonary edema.
How does pulmonary edema develop?
It will start in the bases where you will be able to hear crackles at the end of respiration.

As it worsens you will hear it higher up the patients fields.

When it reaches larger airways and mixes with mucous you can hear coarse crackles on inspiration and exhalation.
What is a classic danger sign of severe pulmonary edema?
Coughing up pink foamy or blood tinged sputum.
What is a pleural effusion?
When fluid collects between the visceral and parietal pleura.
What can cause a pleural effusion?
Infections, tumours, CHF or trauma.
What is the impact of pleural effusions?
Impairs breathing by limiting lung expansion and causing partial or complete lung collapse.
What is pre-hospital treatment for pleural effusion?
Position of comfort
Oxygen therapy
Transport
What might make you think of a pulmonary embolism?
Sudden dyspnea possibly with a sharp pain in the chest.
What can cause hypoventilation?
-Conditions that impair lung function
-Conditions that impair the mechanics of breathing
-Conditions that impair the neuromuscular apparatus
-Conditions that reduce the respiratory drive
What is ARDS?
Acute respiratory distress syndrome.
What causes it?
Diffuse damage to the alveoli as a result of trauma, shock, aspiration of gastric contents, pulmonary edema, toxicity or hypoxic events.
Who does ARDS seem to be worse in?
Trauma patients with severe pulmonary contusions.
What happens?
Alveoli become stiff and non-compliant and difficult to ventilate.

Patients may need mechanical ventilation under high pressure.

The high airway pressure will also cause damage.