Presentation to ED nurse graduate study day.

1. Respiratory Emergencies for
the Emergency Nurse
By Kane Guthrie
ED Graduate Nurse Study Day

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

3. Respiratory Emergencies
• “Can result from an array of different causes,
from acute exacerbation of a long-term
chronic respiratory disease to acute traumatic
injury”

4. 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

5. The Respiratory System
Structure
• 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

6. The Upper Airway

7. The Respiratory Tract

8. The Ventilatory Structures

9. Physiology or Respiration

10. 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

11. The Respiratory Exam

12. 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!

13. 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

14. 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

15. 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

16. The Respiratory Exam
Extremities:
• Clubbing
• Oedema
• Peripheral cyanosis

17. Breath Sounds
1. 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.

18. 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

19. 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)

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

21. 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

22. Capnography

23. The Blood Gas
Provides information regarding respiratory
function:
• Acid-base balance
• Oxygenation
• Ventilation
• Tissue perfusion & compensation

24. 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!!!

25. Acid/Base Imbalances
Resp Acidosis •pH<7.35mmol/L
•PaCO2 > 45mmHg
Resp Alkalosis •pH>7.45mmol/L
•PaC02 <35mmHg
Metabolic Acidosis •pH<7.35mmol/L
•HCO3<22
•BE<(-)2
Metabolic Alkalosis •pH>7.45mmol/L
•HCO3 > 26mmol/L

26. 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 7.40
Step 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?

27. The CXR

28. Interpreting the CXR
Appearance •Chest view (AP, lateral, PA), airway, addition
apparatus- (ETT, trachy, ECG leads, NGT),
Lung fields
Bones •Fractures
Cardiac shadow •Cardiac & costophrenic angles, aortic arch
& width of mediastinum
Diaphragm •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 bubble
Hylus markings •Hylus markings
Identification •Named, URM

29. 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

30. Respiratory Failure is the
Enemy
•Respiratory failure occurs when either function of gas
exchange- the exchange of oxygen and of carbon dioxide
between the lungs and the atmosphere fails.
Occurs when:
• Pa02 fall < 60 mmHg (Type 1 – hypoxaemia)
• PaC02 rises > 50mmHg (Type 2- hypercapnia)
– Can be acute or chronic!

31. Causes of Respiratory Compromise
Category 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 •Asthma
disorders •COPD
Respiratory tract infections •Pneumonia
•Tuberculosis
•Acute bronchitis
Pulmonary vascular disease •Pulmonary embolus
•Pulmonary artery hypertension

32. Causes of Hypoxia
Mechanism 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 •Intracardic defects
perfusion •Intrapulmonary ateriovenous malformations

33. Case Study
• 69 male
• Presents with 3/7 hx of cough, SOB, and fevers
PMHx: MI, CVA, COPD, DM TYPE 2
Meds: 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 38.4
An ABG and CXR are done:

35. Blood Gas and CXR
• An ABG shows the following:
– pH 7.20mmHg
– PaC02 69mmHg
– Pa02 70mmHg
– HC03 25 mmol/L

36. 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

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

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

39. COPD Monitoring & Investigations
• Continuous Sp02
• Blood Gas
• Blood –FBC, U&E, CRP
• CXR

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

41. 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!

42. 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 muscles
O/A: Decreased Air Entry R side, ∧resonance on
percussion

43. The X-ray

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

45. Pneumothorax Assessment
Look for:
• Significant dyspnea
• Reduced chest expansion
• Increased resonance on percussion
• Diminished breath sounds
Deteriorating:
• JVP distension
• Hypotension
• More distressed

46. 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 aspiration
2. Intercoastal catheter
– ICC
– Pigtail
• Resp admit, serial CXR, encourage smoking cessation.
• Tension = Needle Decompression
– (14g canula 2nd intercostal space –midclavicular line)

47. Case Study
• 44 female
• P1 from SJA, severe SOB, wheezing, becoming
more agitated
PMHx: Asthma x2 ICU admits, depression
Meds: Ventolin, Prednisolone, Avanza
O/A: Nebs insitu, talking in words, wheeze audible,
O/E: Using accessory muscles, restless, tremulous
Vitals: RR36, spo2 97, HR 142, temp 35.9, BP
143/89

49. Asthma
•Asthma characterised by bronchial hyper-responsiveness and
inflammation that cause episodic reversible bronchospasm
and increased mucus and oedema production.
• 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.

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

51. Asthma Investigations
“Test’s provide little information over clinical
assessment”
• P.E.F.M.
• Spirometry
• CXR
• Blood gas

52. 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 Neb
Steriods: Prednisolone PO or Hydrocortisone IV
• AB’s only if infective process present

53. 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

54. Case Study
• 38 y.o. female
• C/O increasing SOB and inspiratory chest pain.
PMHx: Recent DVT – post flight from London
Meds: Warfrin, OCP
Vitals: 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

55. Pulmonary Embolus
•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.
• Usually results from DVT
• Risk Factors (Vircow’s Triad)
– Hypercoaguability
– Venous stasis
– Endothelial damage
• Impact of PE- dependent on size & blood flow
compromise.

56. Pulmonary Embolus Investigation
• CXR
• Blood Gas
• D-Dimmer
• ECG
• V/Q Scan
• CT-PA
• ECHO

57. CT-PA

58. Pulmonary Embolus Assessment
Look for:
• Dyspnea-tachypnoea
• Chest pain
• Decreased Pa02
Deteriorating:
• Hypotensive
• Cardiogenic shock
• Worsening dyspnea

59. Pulmonary Embolus Management
• Prevention – VTE prophylaxis
• Start Heparin infusion
• Add warfrin
• Admit: Respiratory
Deteriorating:
• Give thrombolysis
• Consider Embolectomy

60. 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
words
Vitals: RR42, SPO2 85%NRBM, BP 90/55, TEMP
37,5, GCS 14

61. Her CXR

62. Influenza Like Illness
Characterised:
• Temp >37.8°C
• Cough
• Sore throat
• Absence of a KNOWN cause other than
influenza
•Generally benign clinical course

63. 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!!

64. @ Risk Groups for
Critical 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

65. Influenza Like Illness Assessment
• Dyspnoea >tachypnoea
• Fever
• Sore throat
• Productive cough
Deteriorating:
• Spo2 dropping
• Agitation
• Respiratory distress

66. 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

67. 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”

68. Questions

69. Thank-you!!!