CEN Review -Respiratory Emergencies – Jeff Solheim Objectives: At the completion of this section, the learner will be able to:  Describe the components of a respiratory assessment  Recognize clinical manifestations associated with common respiratory disorders  List medical and nursing interventions for common respiratory disorders  Evaluate interventions carried out for common respiratory disorders The CEN exam contains 18 questions on respiratory emergencies which involve the following topics: Tasks  Assist with tracheal intubation  Suction airway  Ventilate patient using esophageal-tracheal combitube or laryngeal mask airway (LMA)  Evaluate the patient’s response to oxygen therapy  Interpret end-tidal CO2 results via capnography  Manage patients with surgical airway (e.g., cricothyrotomy, tracheostomy)  Perform a respiratory assessment  Measure peak expiratory flow rate  Assess endotracheal/tracheal tube placement  Initiate oxygen therapy  Care for patient on a mechanical ventilator  Assess need for needle thoracostomy  Perform arterial puncture for arterial blood gas sample  Use BiPAP or CPAP  Manage chest tube and drainage system  Interpret results of arterial blood gas studies  Assist with and/or administer a nebulizer treatment  Assess for pulsus paradoxus  Identify signs and symptoms related to respiratory emergencies  Apply physiologic principles when caring for patients with respiratory emergencies  Administer respiratory pharmacologic agents Primary disease states  Aspiration  Asthma  Bronchiolitis (e.g., RSV)  Bronchitis/upper respiratory infections  Contusion (pulmonary)  COPD (chronic obstructive pulmonary disease)  Flail chest  Hemothorax  Hyperventilation  Inhalation injuries  Obstruction (i.e., of airway)  Pleural effusion  Pneumonia  Pneumothorax (e.g., chest tubes)  Pulmonary edema noncardiac  Pulmonary embolus  Respiratory distress syndrome  Rib fractures  Ruptured diaphragm  Ruptured large airway  Tension pneumothorax (e.g., needle decompression) Page 1 CEN Review -Respiratory Emergencies – Jeff Solheim  Respiratory patterns Pattern Eupnea Tachypnea Hyperventilation Hyperpnea Kussmaul’s respirations Dyspnea Orthopnea Bradypnea Apnea Biot’s respirations Ataxic respirations Central neurogenic hyperventilation Apneustic breathing Cheyne-Stoke respirations  Description Normal rate and depth Used to describe rapid rate regardless of depth. (Depth is variable.) Used to describe increased depth regardless of rate. (rate is variable). Depth exceeds metabolic demands of the body, so patient may have high oxygen and low carbon dioxide content. Both rate and depth are increased but they meet the metabolic demands of the body, therefore oxygen and carbon dioxide levels may be normal. Rapid and deep breathing without pauses. Patient appears to be air hungry, gasping to breath. Usually associated with states of acidosis Subjective sensation of difficult or labored breathing Sensation of dyspnea when laying down Used to describe decreased rate regardless of depth. (Depth is variable) Absence of breathing Fast and deep breathing punctuated by periods of apnea. Related to damage to the medulla oblongata from strokes or trauma. May also be seen in meningitis. Irregular, random pattern of deep and shallow respirations with irregular apneic periods. Usually a poor indicator of prognosis associated with increased intracranial pressure. Very deep and rapid respirations with no apneic periods associated with increased intracranial pressure Prolonged inspiratory and/or expiratory pause of 2 – 3 seconds. This usually signifies the presence of brainstem lesions usually at the level of the pons Rhythmic crescendo and decresendo of rate and depth of respiration, which includes brief periods of apnea. Usually associated with increases of carbon dioxide in the cerebrum. Signs of respiratory distress Nasal Flaring Intercostal muscle retractions Diaphragmatic breathing        Accessory muscle use  Enlargement of the nostrils during inspiration Early finding in infants and small children, later finding in adults Inward movement of the muscles between the ribs as a result or reduced pressure within the chest cavity. Early finding in pediatric patients, later finding in adult patients. Use of the stomach muscles to breath. Normal finding in pediatric patients, early finding of respiratory distress in adults. Use of sternocleidomastoid, scalene, pectoralis major, trapezius, internal intercostals, and abdominal muscles. Early finding of respiratory distress in adults, but not as strongly associated with pediatric patients. Page 2 CEN Review -Respiratory Emergencies – Jeff Solheim  Auscultation Breath sound Wheezing Rhonchi Crackles Pleural fraction rub  Description Significance A whistling or musical sound A snoring, low pitched sound Small popping sounds Grating sound which may be compared to rubbing your hair between your fingers near your ear that is heard with inspiration and expiration. Caused by narrowing of the lower or smaller airways Caused by narrowing of the larger upper airways Produced by the movement of air through secretions or lightly closed airways Caused by inflammation of the pleural surfaces. The inflamed surfaces rub together during the respiratory cycle to produce this sound. Pulmonary Embolism Type of Emboli  Blood Fat Amniotic fluid Air        Notes A blood clot which migrates from another part of the body, typically the right side of the heart, the pelvis or from a deep vein thrombosis in the legs. Blood clots are the most common causative agent of a pulmonary embolus. Risk factors include immobility, pregnancy, and increasing age A fat embolus which can occur 24 to 48 hours after a long bone fracture, such as a fracture of the femur, humerus or pelvis. One symptom that is unique to fat emboli is petechiae of the chest and axilla. Symptoms show up shortly after delivery of an infant. Inadvertent injection through an intravenous line or from intravenous administration of medications. Secondary to diving injuries o Signs and symptoms  Sudden onset of shortness of breath (most common symptom)  Tachypnea and tachycardia  Cough with possible hemoptysis  Diaphoresis  Syncope  Fever  Crackles on auscultation  Accentuated S2 heart sound  Large pulmonary emboli may cause jugular venous distension and hypotension  Elevated erythrocyte sedimentation rate and D-Dimer  New onset right bundle branch block and right axis deviation with peaked P waves in the limb leads as well as depressed T waves in the right precordial leads on the electrocardiogram. Page 3 CEN Review -Respiratory Emergencies – Jeff Solheim o Treatment  Oxygen (nasal cannula to intubation based on presentation)  Anticoagulants and fibrinolytics  Intravenous fluids and vasopressors to treat hypotension  Lung infections Physiology Signs and symptoms Acute bronchitis Viral inflammation of the upper airways    Upper respiratory tract infection (URI) Dry, hacky nonproductive cough that progresses to productive cough. Most troublesome at night triggered by deep breathing, talking and laughing. Chest pain Bronchiolitis Viral infection leading to profuse secretions and a necrotic response producing cellular debris that can occlude the lower airways, more worrisome in infants/young children.  Recent URI with progressive dyspnea and cough.  Poor feeding, irritability, and lethargy  Tachypnea, possibly apnea in infants  Grunting, nasal flaring, intercostal retractions, cyanosis  Wheezing on auscultation  Indications of air trapping on x-ray Diagnosis Clinically evident Nasopharyngeal culture. Chest radiograph may show air trapping and infiltrates. Treatment        Self-limiting Cough preparations Humidification Bronchodilators Corticosteroids  Oxygen Antivirals, anticholinergics, adrenergic stimulants. Admission for signs of respiratory fatigue, oxygen saturations less than 90% despite treatment, respiratory rates above 70 breaths per minute and apneic episodes. Page 4 Pneumonia Multiple causes including bacteria and viruses. Viral infections have a slower onset and are more common in the winter. Bacterial infections have a rapid onset.  Elevated temperature (usually elevates higher and faster in bacterial infections. Infants and the elderly may have subnormal temperatures)  Pleuritic chest pain referred diaphragmatically and may be mistaken for GI disturbances.  Productive cough (purulent with bacterial pathogens)  Tachypnea and tachycardia  Breath sounds decreased over pneumonia  Possible pleural friction rub  Hyporesonance and increased fremitus over affected area.  WBC (higher with bacterial causes.) Chest x-ray may show focal, segmental or lobar infiltrates for bacterial causes, x-ray may be normal for viral causes.  Healthy individuals with mild to moderate symptoms may be discharged home.  Antibiotics administered within four hours of admission for bacterial causes.  CPAP, BiPAP or intubation as required. CEN Review -Respiratory Emergencies – Jeff Solheim o Chronic obstructive pulmonary disease (COPD) o o o o Asthma – airway reaction Chronic Bronchitis – airway inflammation Emphysema – airway collapse Asthma  Common triggers  Allergen inhalation (animal danders, house dust mites, pollens and molds) or air pollutants (exhaust fumes, perfumes, oxidants, sulfur dioxides, cigarette smoke, aerosol sprays.)  Upper respiratory viral infections  Exercise (10 – 20 minutes after vigorous exercise)  Drugs (aspirin, NSAIDs, beta-adrenergic blockers)  Food additives, sulfites (bisulfites and metabisulfites), tartrazine  Menses Definition: Tetrazine – a synthetic lemon  GERD yellow azo dye used as a food coloring.  Cold, dry air  Symptoms  Sensation of tightness in the chest  Cough  Increased work of breathing  Hyperresonance to percussion, crackles on auscultation, prolonged expiratory time on expiration.  Respiratory alkalosis (early)  respiratory and metabolic acidosis (late).  Wheezing on exhalation (early) wheezing on inhalation (late)  Breath sounds decreased in lower lobes first but progress upwards  Signs of hypoxia (restlessness, somnolence, decreased respiratory effort, bradycardia and even periodic apnea.)  Pulsus paradoxus Peak Expiratory Flow Rate (PEFR) – An objective measurement of airflow  Process  Sit upright with legs dangling  Inhale fully, seal circumference of the mouthpiece and exhale fully.  Note position of flowmeter.  Repeat 3 times and base treatment decisions on the best of the three readings.  Findings o Expected values vary depending on a patient’s sex, age and height.  40 – 69% of expected value: moderate exacerbation  < 40 % of expected value: severe exacerbation o PEFR at home  50 – 79% of personal best, use inhalers  < 50% of personal best, seek medical attention Page 5 CEN Review -Respiratory Emergencies – Jeff Solheim  Treatment Classification Action – – – – – Examples Epinephrine (Adrenalin) Racemic epinephrine (Micronefrin, Asthma nefrin) Terbutaline (brethaire, brethine) Albuterol (Proventil, Ventolin) Isoetherine (Bronkosol, Bronkometer) Salmeterol zinaoate (Serevent) Xopenex (Levabuterol) – Ipratropium (Atrovent) – Inhaled – Dexamethasone (Decadron, Respinhaler) – Beclomethasone (Beclovent, Vanceril) – Triamcinolone (Azmacort) – Flunisolide (Aerobid) Oral outpatient treatment – prednisone Intravenous inpatient treatment Methylprednisilone (Solumedrol) – – Sympathomimetics Relax smooth muscles of the bronchioles and produce bronchodilation, also elevate heart rate Parasympatholytics Inhibits contraction of the bronchial smooth muscle and limits the secretions of mucus, but carries side effects such as dry mouth, pupil dilation, increased heart rate, blurred vision. Anti-inflammatory properties and immunosuppressant effects, which reduces airway inflammation, inhibits mucous production, and decreases airway swelling and hyperactivity Corticosteroids  – – Drug delivery methods Method Metered Dose Inhaler Spacer Dry Powder Inhaler Nebulizer Notes The drug is suspended in chlorofluorocarbon liquid propellant (Freon). Patient must be able to hold breath and be coordinated enough to participate. Increase vaporization of particles and increase lung penetration as well as decreasing loss of drug in air or mouth. It takes less coordination to use a spacer and may be an alternative to people who struggle with metered dose inhalers. Another alternative for people who cannot use a metered dose inhaler. Capable of high inspiratory volumes.  This method is preferred for a patient who is unable or too sick to cooperate with metered dose inhalers and spacers.  It will deliver drugs better than other methods to lower airways.  The patient should be upright for the treatment (40 – 90 degrees) to allow deep ventilation and maximal diaphragmatic movement.  If the heart rate increases more than 20 beats per minute, stop the treatment.  Never administer nebulizer treatments to a crying child as crying decreases absorption of the medication. Page 6 CEN Review -Respiratory Emergencies – Jeff Solheim o Instructions for using metered dose inhaler  Shake the inhaler and hold it one to two inches from the face   Discharge Instructions – Asthma  Avoid known allergens  Encase pillows and mattresses in vinyl  Wash bedding every week in water temperature that exceeds 130°F (54.5°C)  Consider carpet removal and antimite treatment  Keep cats and dogs outside the house  Remain inside with air conditioning during the early morning and midday hours  Never stop steroids abruptly. They need to be tapered. Exhale completely Press down on the inhaler as you begin to inhale and continue to inhale as deeply as you can.  Hold your breath as you count to ten slowly.  For beta-two agonists, wait one minute between puffs.  If the patient will be using a spacer, the directions are similar except for third bullet point, the patient should press down on the inhaler and wait five seconds before beginning to inhale. o Chronic Bronchitis (Chronic inflammation of the bronchi) and emphysema (Destruction of the elastic properties of the lungs by enzymes resulting in loss of natural recoil and support of lung tissue) Chronic bronchitis Emphysema “Blue bloater” “Pink puffer” Productive cough Cough uncommon Stocky build Thin Onset 40 – 50 years Onset 50 – 75 years Normal respiratory rate Tachypnea Hypoxemia PaO2 normal or slightly  Increased PaO2 PaCO2 low or normal until the end Cyanosis Barrel chest Polycythemia Accessory muscle use Cor Pulmonale Leans forward while sitting Peripheral edema Pursed-lip breathing Risk for pulmonary embolism Hyporesonance on percussion Enlarged heart on x-ray Lung overinflation and low diaphragm on x-ray Page 7 CEN Review -Respiratory Emergencies – Jeff Solheim  Treatment Continuous positive airway pressure (CPAP) o No cure – symptom control only and Bi-level positive airway pressure (BiPAP) o Patient position: sit upright and  Advantages leaning forward o Rests respiratory muscles o Increases tidal volumes Maintains o Cardiac monitoring PEEP o Pharmacology o Times breaths  Beta-adrenergic agonists o  FiO2  Mucolytic agents  Risks  Steroids o Pneumothorax o Hypotension  Antibiotics for infection o CPAP/BiPAP  Elevate the head of the bed 30º degrees to  leak around the mask.  If pressures exceed 20 cm Hg, consider insertion of gastric tube to decrease gastric distension.  Patient must be able to keep their mouth closed for CPAP/BiPAP to be effective when a nasal Oxygen therapy and COPD patients (Patients with COPD exacerbation are hypoxic and can tolerate oxygen therapy for a period of time without blunting of the respiratory.)  Consider the use of oxygen devices which carefully control oxygen delivery (Venturi masks, low flow oxygen)  Monitor for return to baseline oxygen saturations (will be lower than saturations in non-COPD patients) and decrease in respiratory rates. Oxygen delivery should be reduced or discontinued in these cases. Discharge Instructions – Emphysema and Chronic Bronchitis  Stress the importance of pneumococcal and viral immunizations.  Avoid crowds and situations with high likelihood of exposure to respiratory infections  Eat small, frequent meals to allow maximal excursion of the chest.  Stress the importance of adequate hydration to keep secretions moist.  Stress the importance of exercise to keep the lungs healthy  Stop smoking. mask is used.        Pulmonary edema o Causes Acute Respiratory Cardiogenic Distress Syndrome Inflammatory nonHeart failure cardiogenic MI pulmonary edema Severe Anemia Hyperthyroidism Hypertension Myocarditis Page 8 Neurogenic This relatively rare form of pulmonary edema may occur within hours of a severe neurological insult. High Altitude Occurs 2 – 4 days after ascending above 8000 feet, or people who live above 8000 feet, descend for 2 – 4 weeks, than return home. CEN Review -Respiratory Emergencies – Jeff Solheim Page 9 CEN Review -Respiratory Emergencies – Jeff Solheim o Treatment goals Improve Decrease cardiac oxygenation workload  Administer  Position upright, legs high flow 02 dangling  BiPAP/ CPAP  Vasodilators (Morphine, NTG,  Mechanical Nitroprusside) ventilation  Lasix  Digoxin (inotropy)  Dopamine Treat underlying conditions  Antibiotics for infections  ACE inhibitors for heart failure  Etc. High altitude      Descend below 8000 feet Bed rest High flow oxygen Hyperbaric chamber Acetazolamide may be considered.  Airway Obstruction Area of airway Symptoms  Large obstructions will cause complete airway obstruction with lack of Larynx coughing, airway sounds or air movement.  Smaller obstructions may cause hoarseness and aphonia  Large obstructions will cause complete airway obstruction with lack of Trachea coughing, airway sounds or air movement.  Smaller obstructions will cause wheezing similar to asthma  Cough, unilateral wheezing and unilateral decrease in breath sounds  80 – 90% of aspirated objects lodge in the bronchi. In adults, foreign Bronchi objects are more likely to lodge in the right bronchi. In pediatric patients, there is no difference between obstruction in the right and left bronchi.   Treatment o Complete laryngeal or tracheal obstruction: Heimlich Maneuver o Partial obstruction and bronchial obstruction: Endoscopic removal  Minimize crying in children while awaiting intervention.  Be prepared for alternate airway Thoracic trauma o Rib fractures  Fractures of the first and second ribs associated with injury to the lungs, aortic arch, vertebral column, disruption of the subclavicular artery or vein)  Age Considerations  Kids have cartilaginous ribs which are not easily fractured. o Rib fractures usually indicate significant underlying trauma and lack of rib fractures does not rule out underlying trauma o Always consider abuse with rib fractures  Elderly patients lack the pulmonary reserves necessary to compensate for fractured ribs, may require admission to monitor respiratory status. Key points Page 10 CEN Review -Respiratory Emergencies – Jeff Solheim Definition: Flail Chest – Two or more adjacent ribs are fractured in two or more locations or detachment of the sternum Definition: Paradoxical chest wall movement – A flail chest results in a free floating segment of the chest wall drawn inward during inspiration and outward during expiration o Pulmonary contusion (injury of the lung resulting in edema and blood collection in the lung parenchyma)  Symptoms (Often mild on arrival to ED and progressively worsen)  Dyspnea  Hypoxia  Hemoptysis  Treatment  Rib fractures o Oxygen administration o Pain management (avoid respiratory suppression) o Oral or IV analgesia o Intercostal nerve blocks o Deep breathing/coughing o Incentive spirometry  Flail chest segments o Consider nursing on injured side o Consider mechanical ventilation  Pulmonary contusion o Nurse in semi-Fowler’s position o Consider mechanical ventilation o Absence of hypovolemia - fluid restriction/diuretics o Ruptured diaphragm (abdominal contents herniate into the chest and compress the lungs, heart and mediastinum)  Clinical manifestations  Lower chest, abdominal or epigastric pain that radiates to the left shoulder  Dyspnea  Decreased breath sounds on affected side  Heart sounds shifted to the right side of chest  Signs of obstructive shock  Dysphagia  Bowel sounds in middle to lower chest  Treatment  Trauma care  Surgery Page 11 CEN Review -Respiratory Emergencies – Jeff Solheim  Problems in the pleural space Definition – Fluid in the pleural space - Blood = hemothorax - Chyle = chylothorax - Pus – pyothorax o Pneumonia o Blood-borne infection o Pancreatitis - Serous fluid = hydrothorax o Left ventricular failure o Liver failure o Pulmonary embolism Signs of tension pneumothorax - Respiratory distress - Hyperresonance on the affected side - Tracheal deviation away from the affected side.   Definition - Pneumothorax - Air enters the pleural space, causing a negative intrapleural pressure and collapse of the lung - Causes: Trauma, barotrauma (diving incidents, explosions), spontaneous (common in smokers of tall stature between the ages of 20 and 40), emphysema. Definition - Open Pneumothorax - An opening at least 2/3 the diameter of the trachea from the outside of the body that penetrates the chest wall and allows accumulation of air in the pleural space Definition - Tension Pneumothorax - An accumulation of air in the pleural space that is so great it compresses the contents of the chest cavity to one side or the other Treatment (open pneumothorax: Apply non-occlusive dressing to wound at the height of inspiration, taping to three sides. Treatment (open pneumothorax): Needle thoracentesis  14 or 16 gauge needle is inserted into the second intercostals space, midclavicular line or fifth intercostals space, midaxillary line on the injured side.  Inserted directly over the lower rib of the intercostals space, bevel up.  Should result in an immediate rush of air. o Clinical Manifestations Fluid Accumulation Air Accumulation Breath Sounds Decreased over fluid Decreased over air Fremitus Absent over fluid Decreased over air Percussion Hyporesonance Hyperresonance Pain Dull ache on side of fluid Sharp pain which may radiate to the shoulder on the side of the pneumothorax. Egophany Near top of fluid line Not present over air Page 12 CEN Review -Respiratory Emergencies – Jeff Solheim Definition: Fremitus – Have the patient say “99” while holding hands against the chest. Vibrations will transmit through air, but not fluid Definition: Egophany – Have the patient say “e” while holding a stethoscope near the top of the fluid line. The “e” will sound like an “a” through fluid. o Chest drainage systems  Chest drainage of concern:  Initial output of more than 1500 mL of blood.  Continued blood loss of more than 200 mL/hour. Problem Causes Bubbling or fluctuations in the water seal chamber cease Continuous bubbling in the water seal chamber Considerations for autotransfusion  Considered for significant blood loss (>350 mL)  Blood should be less than 4 – 6 hours old  Never considered if there is risk of enteric contamination (e.g. ruptured diaphragm, injury to lower chest)  Risk of contamination when used with penetrating trauma. Page 13 CEN Review -Respiratory Emergencies – Jeff Solheim Practice Questions A rodeo cowboy is trampled by a bull. He presents to the ED via ambulance with severe abdominal pain and bruising to the upper abdomen where the animal’s foot landed. On assessment, his vital signs BP – 94/72 mm Hg, P – 112 beats per minute, R -32 breaths per minute, T – 96.1°F, and his oxygen saturation is 89% on 100% non-rebreather. His thoracic assessment reveals no surface trauma to the chest, and the ribs are intact, with no crepitus or other structural abnormalities noted. Breath sounds are clear to auscultation on the right and decreased throughout the lung fields on the left. Heart sounds are shifted to the right of the sternum and difficult to auscultate. The abdomen is tender over the bruised area, and bowel sounds are decreased throughout all four abdominal quadrants. Based on this assessment, which of the following diagnosis is most likely suspected? a. b. c. d. Lacerated liver Pancreatic injury Ruptured diaphragm Pericardial tamponade The emergency nurse knows that Triamcinolone (Azmacort) is given to the asthmatic patient for which of the following reasons? a. b. c. d. To inhibit contraction of bronchial smooth muscle To reverse the bronchodilation caused by the inflammatory system To reduce airway inflammation and inhibit pulmonary mucus production To decrease respiratory rate in an effort to improve alveolar gas exchange Hemoptysis is most closely associated with which of the following diagnosis? a. b. c. d. Epiglottits Bronchiolitis Pleural effusion Large pulmonary embolism A needle thoracostomy is performed for the treatment of a tension pneumothorax. Which of the following assessment parameters indicates that the intervention has NOT had its intended effect? a. The patient’s respiratory rate decreases after the procedure is performed. b. The trachea shifts away from the needle after the procedure is performed. c. There is a hissing sound noted from the needle immediately after the procedure is performed. d. The patient’s mean arterial pressure changes from 76 mm Hg to 92 mm Hg after the procedure is performed. Answers: C, C, D, B Page 14