Respiratory Emergencies forthe Emergency Nurse

By Kane Guthrie

ED Graduate Nurse Study Day

Objectives

• Introduction to respiratory emergencies• Assessing the respiratory patient• Common presentations• Case studies• Take home points

Respiratory Emergencies• “Can result from an array of different causes,

from acute exacerbation of a long-term chronic respiratory disease to acute traumatic

injury”

The Respiratory System

Purpose:• Exchange of gases between the environmental air

and the blood• Oxygenation of blood occurs via a two step process– Ventilation– Diffusion

The Respiratory SystemStructure

• Upper and lower tracts

– Upper respiratory tract (upper airways)• Nose, mouth, sinuses, pharynx (upper section of the

throat), larynx (voice box), trachea (windpipe)

– Lower respiratory tract • Lungs, bronchial tubes, and alveoli

The Upper Airway

The Respiratory Tract

The Ventilatory Structures

Physiology or Respiration

Respiratory Terminology• Dyspnoea •Difficulty in breathing

•Orthopnoea •Dyspnoea necessitating an upright, sitting position for its relief

•Tachypnoea •Abnormally rapid rate of breathing (>20)

•Bradypnoea •Abnormally slow rate of breathing (<12)

•Hypoxia •Inadequate o2 at cellular level

•Hypoxaemia •Low o2 levels in blood

•Anoxia •Lack or oxygen, local or systemic

The Respiratory Exam

Assessing the Respiratory Patient

A-F approach:• assess Airway and treat if needed• assess Breathing & treat if needed• assess Circulation & treat if needed• assess Disability & treat if needed• Expose & examine patient fully once A.B.C.D

are stable.• Full set of vital signs!

The Respiratory Exam

General:Level of consciousness:• Agitation/anxiety• Speech– Sentences/phrases/words/unable to speak

– Quality (hoarness)

Skin colour:

• Pallor/cyanosis

• Exercise tolernace/bodyposition

The Respiratory Exam

Head and neck:• Nasal flaring• Pursed-lip breathing• Mouth vs nose breathing• Evidence of trauma: deformity, bruising,

wounds, swelling, burns• Tracheal position• Tracheal plug

The Respiratory Exam

Thorax:• Symmetry of chest wall movement• Accessory muscle use, recession• Rate, rhythm, pattern of breathing• Evidence of trauma, wounds, deformity, flail,

bruising, scars• Anterposterior vs transverse diameter of chest• Alignment of spine, presence of kyphosis,

scoliosis

The Respiratory Exam

Extremities:• Clubbing• Oedema• Peripheral cyanosis

Breath Sounds1. Crackles •Caused by opening of collapsed alveoli,

or from fluid in smaller airways. (pneumonia)

2. Wheezes •Air moves through narrowed/tight airways. (FB, bronchoconstriction, sputum). Continuous musical sound.

3. Rhonchi •Caused by secretions in large airways.

4. Pleural rub •Heard on inspiration, grating or crackling sound.

5. Stridor •High-pitched crowing-type noise-louder during inspiration. Indicates obstruction.

Investigating & Monitoring the Respiratory Patient

• Physical assessment can be further informed by appropriate use of investigations in the ED such

as:• Pulse oximetry• Capnography• Blood Gases• Radiographs• Peak Flow • Spirometry

The Humble Respiratory Rate

• The neglected vital sign• Done poorly by nurses• Pulse oximetry is not a replacement• Average adult RR ?10-18• Recent study showed RR >27 was the most

important predictor of cardiac arrest in ward patients.

• (Cretikos, A. Et al. (2008) Medical Journal Australia)

Pulse Oximetry

• Amount of oxygenated haemaglobin being transferred

• Normal range 95-99%• Accuracy decrease when Spo2 <70%• Poor perfusion and shock states will result

inaccurate readings• Finger, ear, forehead devices available.

•Pulse oximetry provides non-invasive (almost) real-time measurement of oxygen saturation.

Capnography

• End-tidal carbon dioxide monitoring (EtCO2)• Gold standard for ET placement, and

procedural sedation• Correlates similarly to PaC02• Demonstrates adequacy of ventilation• Superior to pulse oximetry (real time)• More accurate than nurse’s at taking RR.• Normal range 35-45mmHg

Capnography

The Blood Gas

Provides information regarding respiratory function:

• Acid-base balance• Oxygenation• Ventilation• Tissue perfusion & compensation

Blood Gas Values

Value ABG VBG

pH 7.35-7.45 7.35-7.38

PaCO2 35-45mmHg 44-48mmHg

PaO2 80-100mmHg 40mmHg

HCO3 22-26mmol/L 21-22mmlol/L

Base Excess (-)2-2mmol/L (-)2-2mmol/L

• Most info that was traditionally gained from an ABG can now be gained from a VBG!!!

Acid/Base ImbalancesResp Acidosis •pH <7.35mmol/L

•PaCO2 > 45mmHgResp Alkalosis •pH>7.45mmol/L

•PaC02 <35mmHgMetabolic Acidosis •pH<7.35mmol/L

•HCO3 <22•BE<(-)2

Metabolic Alkalosis •pH >7.45mmol/L•HCO3 > 26mmol/L

5 steps to interpreting the Blood Gas

Step 1• Look at Pa02 level “does the Pao2 show hypoxaemia?”Step 2• Look at the pH level “Is the pH on the acid /alkaline side of 7.40Step 3• Look at PaCO2 level “does it show resp acidosis/alkalosis or normalcy?”Step 4• Look at HC03 level “does it show metabolic acidosis/alkalosis or

normalcy?”Step 5• Go back to the pH level does it show a compensated or uncompensated

condition?

The CXR

Interpreting the CXR

Appearance •Chest view (AP, lateral, PA), airway, addition

apparatus- (ETT, trachy, ECG leads, NGT), Lung fields

Bones •FracturesCardiac shadow •Cardiac & costophrenic angles, aortic arch

& width of mediastinumDiaphragm •Shape, breadth, depth (8th rib viewed) in

lung field. Exposure •Are the posterior spinous process visible?Fine lines •Fine lines (Normal lung markings out to

edge of lung field), fat line (congested fluid volume), fuzzy lines (infection).

Gastric bubble •Gastric bubbleHylus markings •Hylus markingsIdentification •Named, URM

PEFM & Spirometry

• Both assess for airway limitations & obstruction

PEFM – used to assess “Peak Expiratory Flow”– Monitors effectiveness of asthma therapy

Spirometry – More sensitive info gathered– Forced vital capacity– Forced expiratory capacity– (FEV1:FVC) <80% = airflow limitations

Respiratory Failure is theEnemy

Occurs when:• Pa02 fall < 60 mmHg (Type 1 – hypoxaemia)• PaC02 rises > 50mmHg (Type 2- hypercapnia)– Can be acute or chronic!

•Respiratory failure occurs when either function of gas exchange- the exchange of oxygen and of carbon dioxide

between the lungs and the atmosphere fails.

Causes of Respiratory CompromiseCategory Disease

Chest wall disorders •Chest wall restriction•Flail chest

Pleural abnormalities •Pneumothorax•Haemothorax•Pleural effusion•Empyema

Restrictive lung disorders •Aspiration•Atelectasis•Bronchiectasis•Bronchiolisis•Pulmonary oedema•ARDS

Obstructive pulmonary disorders

•Asthma•COPD

Respiratory tract infections •Pneumonia•Tuberculosis•Acute bronchitis

Pulmonary vascular disease •Pulmonary embolus•Pulmonary artery hypertension

Causes of HypoxiaMechanism Common clinical causes

Decrease in Fi02 •High altitude•Low O2 concentration of gas mixture•Suffocation

Hypoventilation of the alveoli •Lack of neurological stimulation of the respiratory centre (medulla)•Defects in chest wall mechanics•Large airway obstruction•Increased work of breathing

Ventilation-perfusion mismatch •Asthma•Chronic bronchitis•Pneumonia•Atelectasis•Pulmonary embolus•ARDS

Alveolocapillary diffusion abnormality •Oedema•Fibrosis•Emphysema

Decreased pulmonary capillary perfusion

•Intracardic defects•Intrapulmonary ateriovenous malformations

Case Study

• 69 male• Presents with 3/7 hx of cough, SOB, and feversPMHx: MI, CVA, COPD, DM TYPE 2Meds: Home O2, spiriva, aspirin, ISMN.O/A: Sitting tripod position, pursed lip breathing, mildly

agitated. O/E: Audible wheeze, using full accessory muscles, talking

in words. Vitals: HR 123, RR44, Spo2 88, BP 179/94, T 38.4An ABG and CXR are done:

Blood Gas and CXR

• An ABG shows the following:– pH 7.20mmHg– PaC02 69mmHg– Pa02 70mmHg– HC03 25 mmol/L

The Result’s

• pH is acidotic• PaC02 is acidotic (High)• HC03 is normal (no compensation)• Pa02 is low – hypoxaemic– Respiratory acidosis

• The chest X-ray shows:– Dynamic hyperinflation– RU Lobe pneumonia

COPD

Combination:– Chronic bronchitis – Emphysema

Narrowing of the airway = decrease airflow (FEV1)Poor gas exchange results hypercapnea &

hypoxaemia• Chronic condition with acute exacerbations• Infective Vs Non-infective

“COPD- pulmonary disease characterised by airflow limitation that is not fully reversible”

COPD Assessment

Look for:• Chronic –progressive dyspnea-tachypnoea• Cough• Increased sputum production/colour change• Wheezing/chest tightnessDeteriorating:• Fatigue, agitation• Decreasing level of consciousness • Check Pc02

COPD Monitoring & Investigations

• Continuous Sp02• Blood Gas• Blood –FBC, U&E, CRP• CXR

COPD Management

• Oxygen- Keep Sp02 88-92%• Ventilation- NIV-Mechanical ventilation• Bronchodialtors- Salbutamol, Ipratropium • Other – Steriods, Abs-(if infection)• Dispo – admit resp/AAU

Non-Invasive Ventilation

• Used a lot in ED• NIV= delivery of O2 by positive pressure mask.Two modalities:– CPAP = fixed pressure through-out.– BiPAP = 2 different pressure IPAP & EPAP through-

out cycle.• Most effective in COPD, ACPE, asthma!

Case Study

• 19 y.o. male• Playing Basket ball• Sudden onset SOB and R sided inspiratory chest

pain.Vitals: RR 28, SPO2 93% RA, BP 105/62, P 110, O/E: Sitting high fowlers, talk in words, moderate

use of accessory musclesO/A: Decreased Air Entry R side, ∧resonance

on percussion

The X-ray

Pneumothorax

• Primary PTX- occurs in healthy-no lung disease, tall patients.

• Secondary PTX- occurs in chronic lung disease, (smokers high risk)

• PTX – from blunt & penetrating trauma• Tension PTX – haemodynamic collapse –medical

emergency

“PTX is a collection of gas in the pleural cavity of the chest between the lung and chest wall.”

Pneumothorax Assessment

Look for:• Significant dyspnea• Reduced chest expansion• Increased resonance on percussion• Diminished breath soundsDeteriorating:• JVP distension• Hypotension• More distressed

Pneumothorax Management

• Small <2cm, with no lung disease .D/C home GP F/U. (No flying 1/52, Never SCUBA dive)

Moderate –Large PTX (2cm or more/50% lung volume lost)1. Needle aspiration2. Intercoastal catheter– ICC

– Pigtail

• Resp admit, serial CXR, encourage smoking cessation.

• Tension = Needle Decompression

– (14g canula 2nd intercostal space –midclavicular line)

Case Study

• 44 female• P1 from SJA, severe SOB, wheezing, becoming

more agitatedPMHx: Asthma x2 ICU admits, depressionMeds: Ventolin, Prednisolone, AvanzaO/A: Nebs insitu, talking in words, wheeze audible,O/E: Using accessory muscles, restless, tremulousVitals: RR36, spo2 97, HR 142, temp 35.9, BP

143/89

Asthma

• Leads to widespread but variable airway obstruction that’s reversible either spontaneously or with treatment.

• Activated by an allergic/inflammatory cascade.• Long term – develop irreversible lung function

impairment.

•Asthma characterised by bronchial hyper-responsiveness and inflammation that cause episodic reversible bronchospasm

and increased mucus and oedema production.

Asthma Assessment

Look for:• Dyspnea > tachypnoea• Wheezing, chest tightness, cough• Prolonged expiration, ability to speak• Past asthma hxDeteriorating: • Inability to talk• Silent or quiet chest • Agitation, decreased level of consciousness

Asthma Investigations

“Test’s provide little information over clinical assessment”

• P.E.F.M. • Spirometry• CXR• Blood gas

Asthma Management

Management determined by severity.Mild > Moderate: Oxygen: Keep spo2 >95%Bronchodilators: Salbutamol 5mg MDI (prefered) or

Nebs Antichoinergics: Ipratropium bromide 500mcg MDI

or NebSteriods: Prednisolone PO or Hydrocortisone IV• AB’s only if infective process present

Asthma Management

• Severe:• Goal is to prevent intubation but maximising

therapy.• Ventilation: Trial NIV – Intubation if fails.

• Magnesium - causes smooth muscle relaxation > bronchodilation

• Adrenaline –Alpha effect > airway oedema, Beta effect > bronchodilation

Case Study

• 38 y.o. female• C/O increasing SOB and inspiratory chest pain.PMHx: Recent DVT – post flight from LondonMeds: Warfrin, OCPVitals: RR 24, Spo2 96 2l O2, BP 139/88, Temp 37.3,

P 124 O/A: Talking in sentences, no accessory muscle use, 0/E: Good A:E bilaterally, no adventious sounds

Pulmonary Embolus

• Usually results from DVT• Risk Factors (Vircow’s Triad)– Hypercoaguability– Venous stasis– Endothelial damage

• Impact of PE- dependent on size & blood flow compromise.

• PE is blockage of the main artery of the lung or one of its branches by a substance that has traveled elsewhere in the

body through the bloodstream.

Pulmonary Embolus Investigation

• CXR• Blood Gas• D-Dimmer• ECG• V/Q Scan• CT-PA• ECHO

CT-PA

Pulmonary Embolus Assessment

Look for:• Dyspnea-tachypnoea• Chest pain• Decreased Pa02Deteriorating:• Hypotensive• Cardiogenic shock• Worsening dyspnea

Pulmonary Embolus Management

• Prevention – VTE prophylaxis • Start Heparin infusion• Add warfrin• Admit: RespiratoryDeteriorating:• Give thrombolysis• Consider Embolectomy

Case Study

• 23 female• C/O SOB, wheezing, productive cough, runny nose.

Currently 20/40.PMHx: Nil.Meds: OCP.O/A: Severe SOB, blue lips, O/E: Agitated, using all accessory muscles, talk in wordsVitals: RR42, SPO2 85%NRBM, BP 90/55, TEMP 37,5,

GCS 14

Her CXR

Influenza Like Illness

Characterised:• Temp >37.8°C• Cough• Sore throat• Absence of a KNOWN cause other than

influenza

• Generally benign clinical course

H1N1

• Influenza A virus is quadruple reassortant virus – genes from avian strain, 2 swine strains, 2 human strains.

• Full extent of virus unknown• 2009-10 left huge strain on ICU beds• High mortality in young patients• Relative lack of humoral immunity!!

@ Risk Groups forCritical H1N1

• Children <5 y.o.• Adults > 65 y.o• Pregnant women• PT’s with – CHRONIC pulmonary,

cardiovascular, hepatic, haematologic, neuro or metabolic disorders.

• PT’s with immune defficency – (HIV , CHEMO)• Residents of NH

Influenza Like Illness Assessment

• Dyspnoea >tachypnoea• Fever• Sore throat• Productive coughDeteriorating:• Spo2 dropping• Agitation• Respiratory distress

Influenza Like Illness Management

• PPE-Droplet Precautions• Majority of cases are the humble FLU!• Swabs – supportive/respiratory care.• Commence antiviral:– Tamiflu 75-150mg BD– Relenza

Deteriorating:• Admit Resp or ICU• Early ventilatory support• ECMO

Take Home Points

• You will see lots of different respiratory conditions during your ED period.

• Most are chronic.• Assessment is important – reassessment is

paramount.• Respiratory rate – do it properly• Enjoy the learning – NIV, mechanical

ventilation – “skills for a lifetime”

Questions

Thank-you!!!