Respiratory Emergencies

As with any other chapter, it makes sense to start with some definitions.

"Eupnea" describes normal, unlabored breathing.

"Dyspnea" - difficulty breathing

"Tachypnea" - Rapid breathing

"Bradypnea" - Slow breathing

"Apnea" - NO breathing

Some of the conditions that might result in respiratory distress, include infectious disease processes and "mechanical" obstruction to the proper functioning of the system. Some of them we can correct, most of them we can not, all of them will be treated with high concentration oxygen.

1. Congestive Heart Failure. A condition that starts when one side of the heart becomes less effective (usually as a result of a recent infarction) causing a 'back-up'. Let's assume that the MI was left sided, then the left side of the heart would not be able to move blood away from the lungs as quickly as the right side of the heart is supplying blood to the lungs, causing a back-up to occur in the lungs (a condition referred to as 'acute pulmonary edema'). At this point, the patient would present with respiratory distress and a detailed PE would reveal 'rales' upon auscultation of the lungs. The extent of the rales would be dependant upon the progression of the process. In its later stages, the rales would include the upper lobes. Left unattended, 'pulmonary hypertension' would develop, where the blood pressure in the pulmonary artery (carrying blood from the right side of the heart to the lungs) increases ultimately causing the right side of the heart to "fail," and the back-up continues through the right side of the heart into systemic circulation. When that occurs the patient additionally presents with 'dependent edema.' The extent of the edema is again dependant on the progression of the congestive heart failure.Congestive Heart Failure In its later stages the edema may include a portion of the patient's calf. (It's for that reason that we, as Paramedics, sometimes look at the patient's feet, after listening to their lungs, to see if the "pulmonary edema" that we just "heard" in the lungs has developed into "congestive heart failure," which presents as edema in the feet and lower legs.) The Advanced Life Support treatment of this patient will include using drugs to move fluid away from the heart and increase the strength of the heart beat, in order to break the "congestion" in, and around, the heart, and return the blood to 'normal' circulation. At the Basic Life Support level, your job will be to administer as much oxygen as you possible can, immediately after your arrival. Because of the increased pressure in the lungs, it is very possible that, in addition to the rales, this patient may also present with a pink (blood) frothy (air) sputum. The increased blood pressure (in the lungs) can actually force microscopic amounts of blood across the alveoli into the respiratory system. It's that 'fluid' in the lungs that 'causes' the rales, and in the later stages, can mix with, and be coughed up as, pink frothy sputum.

2. Chronic Obstructive Pulmonary Disease (COPD) A classification of diseases, including 'chronic bronchitis' and 'emphysema.' Through the repeated irritation of the airways, as a result of chronic bronchitis, and a narrowing of those airways, as a result of mucus build-up secondary to the irritation, total expiration of air from the lungs is hampered. Because inhalation is an 'active' process, and exhalation a 'passive' one, it is 'easier' for the patient to 'force' air past the partial obstruction of the lower airway during inhalation, but a retention of air in the alveolus results when the patient is unable to "force" the air back out past the same partial obstruction. When the patient "actively" inhales again, the alveolus is inflated, again, and only partial deflated, again. Over a period of time, the alveolus is 'blown up like a balloon' and each subsequent 'breath' becomes less effective in that particular "part" of the lungs. The patient begins retaining carbon dioxide in these "little balloons." That CO2 retention expresses itself as a 'pink' appearance in this patient. The active process of inhalation is accomplished by creating a positive pressure in the upper airway with a diminished pressure at the alveolar level. Patients with chronic bronchitis have "learned" through necessity that by 'maintaining' some positive pressure in the upper airway, during exhalation, more complete exhalation is facilitated. Consequently, they exhale through pursed lips. This creates a condition called, "positive end expiratory pressure" (PEEP.) Due to their practice of "pursed lip breathing," and their "pink" appearance, these patients have been dubbed "Pink Puffers". As time progresses, those little 'balloons' of carbon dioxide, start to burst, giving rise to the second stage of COPD called "emphysema". Emphysema has two effects in the lungs. First, as a result of all the 'stretching' that has occurred in the alveoli, there has been a lose of elasticity in the lung tissue, and second, because of the lose of elasticity, some alveoli actually burst. As the disease process continues and more and more alveoli rupture, the effective surface area of the lung is decreased, and the lung's ability to absorb oxygen is diminished and the patient takes on a cyanotic appearance. Also, as a result of the change in lung 'shape' (because at this point in the process most of the alveoli are hyper inflated,) the 'shape' of the chest has also been altered and the patient has a 'barrel' chest' appearance. Because of their "puffed-up" (barrel) appearance, and their "cyanotic complexion," they are referred to as "Blue Bloaters". It has been suggested that patient's with COPD will stop breathing when administered oxygen because, due to their carbon dioxide retention, their brains initiate a respiratory cycle using the "Hypoxic Drive," and if they are 'flooded' with oxygen the hypoxic drive will remain 'satisfied' and not initiate the next respiratory cycle. Well, it all sound good on paper, but the reality is that it will take quite some time (probably more time than it takes to get to the hospital) for the hypoxic drive to be "completely satisfied." These patient's need OXYGEN, and lots of it. Pneumothorax Do not attempt to titrate the oxygen dosage in the field. FLOOD them with oxygen. If the trip to the hospital is longer than their ability to tolerate the elevated levels of oxygen, and they subsequently stop breathing, BREATH FOR THEM! That's why you have a "Bag-Valve-Mask." COPD patients have a 'chronic' condition. In some cases they have learned to cope with the problems associated with the disease (a process called "compensation") and although it's obvious that the patient is in respiratory distress (tripodding, use of accessory muscles, intercostal retractions, tachypnea, shallow respirations, cyanotic or flushed appearance, conversing in one- or two-word sentences, diminished breath sounds, presence of rales, rhonchi, and/or wheezing,) it's a good possibility that, when questioned, the patient will deny any dyspnea. For them it just another day, a day to "compensate." They still need help, OUR HELP. Because if they "de-compensate" and lose it, they are going to "crash, big-time." (Not on MY shift.)

3. Pneumothorax. The presence of air between the outside of the lung and the inside of the chest wall, in an area called the "pleural cavity." Normally the result of trauma. The amount of air present will determine the severity of the pneumothorax and the amount of lung tissue that has "collapsed," which will, in turn, determine the degree of dyspnea experienced by the patient. The "source" of the air, in the pleural cavity can be external or internal (a hole in the chest wall or a 'hole' in the lungs.) If from a 'hole' in the lungs, the 'hole' may be secondary to some disease process (without trauma) and in such cases the pneumothorax is referred to as a "spontaneous pneumothorax." The "hole" (whether internal or external) may have a "flap" of tissue attached to its perimeter, creating a valve that will permit the movement of air in only one direction. This may lead to a condition called "tension pneumothorax," an immediate life threatening condition. Tension pneumothorax at it's most threatening stage, is indicated by tracheal shift, as the "tension" pushes the lungs to one side or the other and the lungs "drag" the trachea over to the same side. A 'life threat' is created when the mediastinum is also 'dragged' to one side, which shifts the heart and may cause a "crimp" in the aorta and/or the vena cava, disrupting blood flow to or from the heart. If you observe tracheal shift, left or right of center, notify an advanced life support provider. Patients with pneumothorax will complain of mild to severe dyspnea (depending on the amount of collapsed lung tissue) with either a gradual or sudden onset (depending on the "size of the hole.") Breath sounds will either be diminished or absent over the site of the pneumothorax. For any patient with suspect pneumothorax, be alert to any change in tracheal position.

5.	Pulmonary Embolism

4. Pleural Effusion. A collection of fluid in the pleural cavity. It may be the result of irritation, infection, or some other disease process. The presence of the fluid limits the movement of the lungs, and, if the amount of fluid is significant enough, may cause a "collapsed lung" or partial "collapse," in the area of the fluid. Patients will report dyspnea, lung sounds may be 'distant' in the area of the effusion (as if being listened to through fluid, DUH!)

5. Pulmonary Embolism. An embolus is an obstruction in the circulatory system that interrupts blood flow. A pulmonary embolus is an 'obstruction' (interruption) of blood flow to the lungs. "Pulmonary Embolism" is a process where a blood clot (thrombus) breaks loose from it origin (usually the site of a "deep vein thrombosis" [DVT] in the leg) and becomes an "embolus." This 'traveling thrombus' (embolus) makes its way through the vena cava to the right side of the heart, and is immediately 'pumped' out of the heart to the lungs through the pulmonary artery. This artery becomes smaller and smaller until the embolus is eventually lodged 'in place' and interrupts the blood flow to the lungs. The patient reports a very sudden onset of dyspnea and acute pleuritic pain. You may observe cyanosis, and/or tachypnea.

6. Hyperventilation Syndrome. Hyperventilation is a condition resulting in blood chemistry where arterial carbon dioxide levels fall below normal. It can be the result of fast shallow breathing (tachypnea,) as might be the case in aspirin (ASA) overdose, or slow deep breathing (bradypnea) as might be presented in some type of head injury. It is usually caused by some disease process, and as such, is to be considered an indicator of some major, life-threatening illness. "Hyperventilation Syndrome" occurs in the absence of any other associated disease process and is usually the result of some psychological influence. The patient usually presents tachypneic, and reports dyspnea, in spite of the tachypnea. The determination of the underlying cause in NOT one that should be made in the field. This patient should be treated with high-concentration oxygen, as with any other patient in respiratory distress, and the diagnosis left to the professional healthcare providers at the advanced level. If, however, you are "convinced" through a thorough history taking, that this event is psychologically triggered, and would like to try to "talk the patient" through the event, please feel free to do so, WHILE the patient is being treated with high-flow oxygen. By encouraging the patient to breath 'normally' you may be able to 'break' the psychological trigger, and hyper-oxygenated air, inhaled (and exhaled) normally during a hyperventilation syndrome event, will not otherwise exacerbate the 'syndrome' condition. Breathing into paper bags, or using oxygen masks without the oxygen flowing, are inappropriate at this level of care.

There are a several other medical conditions that may present as dyspnea, and they warrant mention here. They include:

1. The Common Cold. A condition that may lead to mild to moderate dyspnea.

The Common Cold

2. Pneumonia. A bacterial or viral infection, usually with an associated fever, where fluid accumulates in the interstitial space between the alveolus and it's capillary, resulting in an ineffective exchange of oxygen and carbon dioxide. This patient will most likely present with moderate dyspnea and tachypnea.

3. Croup. An inflammation of the lining of the larynx, typically seen in children under 3 years of age. It is characterized by a "seal bark" type cough and responds well to the administration of humidified air (oxygen.)

4. Epiglottitis. A bacterial infection of the epiglottis that can produce moderate to severe swelling. When encountered in children (up to 12 years of age) can significantly threaten a patent airway, because of the degree of swelling compared to the size of the adolescent airway anatomy. Patients in this age range need to be approached cautiously because any action (by the provider) perceived as "threatening" by the patient, may exacerbate the condition beyond the ability of the basic life support provider to maintain a patent airway. A thorough history prior to approaching any child, when practical, will help avoid the problem.

As with any disease process, the healthcare provider (at any level) needs to know the origin of the process, and the potential danger to 'self,' presented by the disease. Appropriate PPE needs to be employed with every patient, and when the patient is experiencing some type of respiratory problem, the provider need to be aware that the process may have been transmitted by some airborne pathogen. Act appropriately. The one respiratory emergency for which we, as basic life support providers, may be able to affect some immediate relief, as a result of our intervention, is Asthma. Asthma is a restriction of the smaller passageways of the lower airway (bronchioles). Whether secondary to fluid accumulation as a result of irritation or secondary to loss of patency as a result of spasm, the patient's ability to exhale is compromised. Asthma may be triggered by a disease process, allergen, exertion, or some psychological event. In some cases, the patient may have a prescribed "metered dose inhaler" (MDI,) sometimes referred to as a 'puffer.' The 'puffer' will most likely contain one of two different drug classifications; either a steroid or a bronchodilator, or the patient may be using a combination of both drug classes, depending on the pathophysiology of the asthma.

If the patient has an MDI (or MDIs,) it MAY be appropriate to assist the patient with it's (their) administration., according to the following guidelines:

1. Obtain medical control, either 'on-line' or 'off-line.'

2. Assess the condition (through Hx and PE) as 'asthma.'

3. Question the patient about the use of MDI's.

4. Verify that the Rx is in the name of the patient.

5. Verify that the drug(s) are the prescribed drug(s,) and that the expiration date on the canister(s) is current.

6. If the patient has self-administered the medication prior to your arrival, confirm the time of administration and the number of 'puffs' administered.

7. Consult the prescribed dosage and, if within the maximum allowable dosage, help the patient administer up to the maximum dosage, or until the dyspnea is relieved.

8. Completely, and accurately, document the event. Patients who use an MDI most likely have a 'chronic' problem. They, better than you, probably know what they need to relieve the respiratory distress. Listen to them. In the event, that the MDI treatment does not relieve the problem, or an MDI treatment is not available (No Rx, Out of medication,) the patient needs to be transported, without delay, to the nearest advanced healthcare facility.

During the transport, whether post administration of an MDI or not, whether the dyspnea has been relieved or not, administration of high flow oxygen is indicated. If during that transport the patient is still tachypneic, and the further administration of medication is NOT indicated, you will probably have to "coach" the patient through the respiratory distress. By encouraging the patient to breath normally, updating the patient with information about the estimated arrival time at the hospital, reminding the patient that 'definitive' care for, and relief from, the problem WILL be experienced shortly after arrival at the hospital, and by doing so in an authoritative, confident manner (while maintaining eye contact and expressing genuine concern,) you may just be the 'motivating force' that will help this patient "live" through the experience. Respiratory distress is FRIGHTENING! Feelings of confinement, claustrophobia, restlessness, and anxiety accompany a realization that DEATH may be imminent. All of this, in a patient that is, most likely, normally mentated and aware of what is happening. If you never before had any reason to "dig deep" and draw out true human compassion for a patient, THIS IS THE TIME TO DO IT!!!