Management Of Acute Respiratory

Management of Acute Respiratory Problems

Paul Swinton Paramedic Lecturer Practitioner Staffordshire University Foundation Degree – Professional Development In Paramedic Science

Objectives Review the skills associated with management of the acute respiratory emergency Review the drugs associated with the management of the acute respiratory emergency Identity/review the protocols associated with management of the acute respiratory emergency

Definitions Hyperventilating – a fast & deep breathing pattern

Hypoventilating – a fast & shallow breathing pattern (why?) or obviously a slow & shallow breathing pattern Dyspnoea – difficulty with the actual act of breathing

Cheyne Stokes Respiration – Arises from a variety of neurological & metabolic disorders. Periods of rapid irregular breaths becoming deeper then shallow, alternating with periods of apnoea. Cycle repeats every 30 seconds to 2 mins with 5 to 30 second periods of apnoea

Kussmauls Respiration – Term applied to diabetic patient in ketoacidosis. Characterised by hyperpnoea & tachypnoea

Cardinal Signs of Respiratory Distress

• Tachypnoea • Anxiety • Flaring of the Nostrils • Use of accessory muscles in the neck & abdomen •Tugging of the trachea • Retraction of the intercostal muscles and suprasternal species during inhalation • Cyanosis • Change in mental Alertness or Speech (Caroline 2007)

The Airway Oxygen is essential for life; irreversible brain damage will begin to occur 3 to 4 minutes of the brain being deprived of oxygen. Without Oxygen, death will occur very quickly.

It is essential that you quickly assess, establish and maintain the patient’s airway.

Prompt & Regular Assessment

Basic Manoeuvres

Foreign Body Airway Obstruction

An uncommon but potentially treatable cause of death

Commonest cause of FBAO in adults is food, usually fish, meat or poultr

The signs & symptoms vary depending on the degree of airway obstruction (JRCALC 2006)

Foreign Body Airway Obstruction GENERAL SIGNS OF FOREIGN BODY AIRWAY OBSTRUCTION Attack usually occurs while eating Patient may clutch his neck Signs of mild airway obstruction Response to question "Are you choking?" Patient speaks and answers "Yes" Other signs Patient is able to: ● speak ● cough ● breathe

(JRCALC Version4 2006)

Signs of severe airway obstruction Response to question "Are you choking?" Patient unable to speak Patient may respond by nodding Other signs ● Patient unable to breathe ● Breathing sounds wheezy ● Attempts at coughing are silent ● Patient may be unconscious

FBAO

(Resuscitation Council (UK) 2008)

Foreign Body Airway Obstruction

Cough!

(JRCALC 2006; Caroline 2007)

5 Back Slaps

5 Abdominal Thrusts

FBAO – Unconscious Adult Summary Resuscitation

30 to 2

(JRCALC Version4 2006)

• Give 30 chest compressions, then 2 rescue breaths. • Continue giving cycles of 30 compressions to 2 rescue breaths. • Only stop to recheck the patient if they start breathing normally – otherwise do not interrupt resuscitation. • If there is more than one rescuer, change over every 2 minutes to prevent fatigue.

FBAO – Key Points Chest thrusts / compressions generate a higher airway pressure than back blows and finger sweeps Avoid blind finger sweeps. Manually remove solid material that can be seen from the airway Check after each manoeuvre to see if obstruction is relieved

Patients following successful treatment with a persistent cough, difficulty n swallowing or the sensation of an object being suck must be in assessed further Abdominal thrusts can cause serious injury, therefore all patients so treated must be assessed for injury at hospital (JRCALC Version4 2006)

FBAO – Management

If the Airway Remains Obstructed:-

(JRCALC Version4 2006)

Attempt to visualise the cords with a Laryngoscope

Remove any visible foreign material using forceps or suction If this fails or is not possible, consider Needle Cricothyrotom y

Asthma in Adults

Introduction Commonest of all Medical Emergencies

Caused by a chronic inflammation of the bronchi, making them narrower. The muscles around the bronchi become irritated and contract, causing sudden worsening of the symptoms The inflammation can also cause the mucus glands to produce excessive sputum which further blocks the air passages If a patient is suffering a first episode of wheezing – ‘Asthma’ always consider a differential diagnosis e.g. FBAO (JRCALC Version4 ; Caroline 2007)

Introduction The obstruction & subsequent wheezing are caused by three factors within the bronchial tree 1. Increased production of bronchial mucus 2. Swelling of the bronchial tree mucosal lining cells 3. Spasm & constriction of bronchial muscles Because inspiration is an active process involving muscles of respiration, the obstruction of the airways is overcome. Expiration occurs with muscle relaxation and is severely delayed by the narrowing of the airway in asthmatics. This generates the wheezing on expiration

(JRCALC 2006; Caroline2007)

Triggers

In 2002 in the UK 69,000 people were admitted to hospital with asthma. Over 1,400 died from the disease

Asthmatic Patients do not have hypoxic drive and need high concentrations of oxygen

(Caroline 2007)

The amount of cartilage decreases & the amount of smooth muscle increases progressively down the bronchi.

JJR 2007

Smooth Muscle Involuntary muscle in the walls of the bronchi controlled by the action of the sympathetic and parasympathetic nervous systems

Smooth muscle also responds to localised stimuli such as hormones changes in PH, O2, & CO2 levels Temperature or ion concentrations

Para sympathetic control constrict the airways; the sympathetic control relies on the presence of adrenalin produced by the adrenal gland to produce dilation

Assessment

Asthma usually presents to the Ambulance Service in one of two forms

Assess for any LTE features, correct any A & B problems on scene then transfer to nearest hospital continuing with management

Assess A, B, C, D’s (JRCALC Version4 2006)

Management

Reassess to evaluate condition

Assess A, B, C, D’s

Repeat Salbutamol If indicated & consider hydrocortisone

100% Oxygen

IV Access

Commence Transfer

ECG, SP02

Check Peak Flow if practicable

In cases of Hypoventilation Consider in-line Nebulisation / BVM

Administer Salbutamol If indicated

(JRCALC Version4 2006)

Consider Atrovent If Indicated

Life Threatening Asthma

A small minority of cases may not respond to oxygen and nebulised therapy. In these cases the use of intramuscular Epinephrine should be considered where:-

The patient is Suffering from LT Asthma

(JRCALC Version4 2006)

Ventilation Is Failing

Deterioration Continues despite Oxygen and continuous nebulised salbutamol

Drug Therapy

This treatment should be reserved for the most serious cases and is NOT intended to be used as a matter of routine due to its arrhythmogenic properties

Administer Epinephrine

Consider Salbutamol

Consider Atrovent

Hypoxic Drive Normal stimulus to breath is altered levels of CO2 and O2 measured in the central chemosensitive area in the medulla oblongata and the peripheral chemoreceptors in the carotid and aortic bodies.

Patients with chronic respiratory disease other than asthma develop a tolerance for high levels of pCO2 .

The stimulus to breath then becomes reduced levels of oxygen. Hence High levels of oxygenation lessen the stimulus to breath, resulting in hypercarbia

Hypoxia Hypoxia is a reduced level of oxygen availability to the tissues and can be classified as follows... Hypoxic Hypoxia: Caused by Low levels of pO2 in arterial blood. Causes such as airway obstruction, high altitude or fluid in the lungs Anaemic Hypoxia: Caused by too little functioning haemoglobin in the blood stream. Causes such as Haemorrhage, anaemia, failure of haemoglobin to carry O2 Stagnant Hypoxia : Caused by the bloods inability to transport O2 to the tissues fast enough for the tissue requirements. Causes such as heart failure, circulatory shock

Histoxic Hypoxia: Caused by tissues being unable to utilise the oxygen which is delivered to them. Causes such as cyanide poisoning

Group Projects

Projects

Plan & design a booklet covering the following conditions

Chronic Obstructive Airway Disease

Must Contain:• An introduction into the condition (aetiology) • General Signs & Symptoms • Management

Pneumonia

Pulmonar y Embolis m Pulmonar y Oedema

Assessment & Evaluation of Respiratory Function