Pulmonary Diseases Disorders Assessment Pulmonary Diseases Disorders n

Pulmonary Diseases & Disorders: Assessment

Pulmonary Diseases & Disorders n Epidemiology u 28% of all EMS Chief Complaints in the US u >200, 000 deaths annually due to respiratory emergencies

Pulmonary Diseases & Disorders n Many, many pulmonary diseases u Difficult to learn all pathophysiologies u All can be categorized as affecting: F Ventilation F Diffusion (Respiration) F Perfusion u Treatment can be focused on identifying and treating source of ventilatory/respiratory impairment

Sources of Pulmonary Impairment n n Pulmonary Diseases Disorders of the Pulmonary System Non-Pulmonary Disorders/Disease Impairing Ventilation or Respiration What examples can you list for each of these?

Sources of Pulmonary Impairment n Ventilation u Upper Airway Trauma F Epiglottitis F FBAO F Inflammation of tonsils F u Lower Airway Trauma F Obstructive lung disease F Mucous accumulation F Smooth muscle spasm F Airway edema F

Sources of Pulmonary Impairment n Ventilation u Chest Wall Impairment Trauma F Hemothorax F Pneumothorax F Empyema F Pleural inflammation F Neuromuscular diseases F u Neurologic Control Brainstem dysfunction F Phrenic or spinal nerve dysfunction F

Sources of Pulmonary Impairment n Diffusion Inadequate Fi. O 2 u Diseased alveoli u asbestosis F COPD F inhalation injury F u Capillary bed disease F atherosclerosis u Interstitial space disease High pressure pulmonary edema F High permeability pulmonary edema F

Sources of Pulmonary Impairment n Perfusion u Inadequate blood u Impaired blood flow F pulmonary embolus volume or hemoblogin u Capillary wall F hypovolemia pathology F anemia F trauma

Risk Factors for Pulmonary Disease n Intrinsic Risk Factors u Genetic predisposition F asthma F COPD F carcinoma u Cardiac or Circulatory pathologies F Source for pulmonary edema F Source for pulmonary emboli u Stress

Risk Factors for Pulmonary Disease n Extrinsic Factors u Smoking prevalence of COPD & carcinomas F severity of pulmonary disease F u Environmental Factors prevalence of COPD & asthma F severity of all obstructive disorders F

Function of the Pulmonary System n Gas Exchange System u ~10, 000 liters of air are filtered, warmed and humidified daily u Oxygen diffused into blood u Carbon dioxide excreted from the body

Function of the Pulmonary System n Physiology of Ventilation u Requires neurologic initiation (brainstem) u Nerve conduction pathways between brainstem and muscles of respiration u Intact & patent Upper and Lower airways u Intact & non-collapsed alveoli

Function of the Pulmonary System n Physiology of Respiration u Simple diffusion process at the pulmonarycapillary bed u Diffusion Requirements F Intact, non-thickened alveolar walls F Minimal interstitial space & without additional fluid F Intact, non-thickened capillary walls

Function of the Pulmonary System n Physiology of Perfusion u Process of circulating blood through the capillary bed u Perfusion Requirements F Adequate blood volume F Adequate hemoglobin F Intact, non-occluded pulmonary capillaries F Functioning Left Heart

Control of Ventilation n Control ventilation in response to physiologic needs u Driven 1° by p. H of CSF F influenced largely by Pa. CO 2 u 2° drive = Pa. CO 2 u 3° drive = Pa. O 2 detected by chemoreceptors F very small population with severe COPD

Nervous System Effect on Ventilation n Medulla u Stimulation n Phrenic Nerve u Innervation n of the diaphragm Spinal Nerves at Thoracic levels u Innervation n to initiate ventilation of intercostal muscles Hering-Breuer reflex u Prevents overinflation

General Assessment n Size-Up u Environment F Airborne Hazards F Number of patients F Needs • Specialized rescue equipment • Protective equipment u Is the environment creating or exacerbating the pulmonary condition?

General Assessment n Initial Goal u Identify potentially life-threatening pulmonary conditions n Perform minimal PE & Hx u Initiate n immediate & appropriate therapies Then, continue PE & Hx u Try to determine if origin is ventilation, diffusion, perfusion or combination

General Assessment n Signs of potentially life-threatening pulmonary condition u altered mental status u absent signs of ventilation u Audible stridor or wheezing u Able to speak in short phrases only u Sustained Tachycardia u Pallor / Diaphoresis u Accessory muscle use / Retractions

Assessment: H&P n Present History (focused hx) u Chief Complaint F Dyspnea • “Subjective sensation that breathing is excessive, difficult or uncomfortable F CP F Cough, Hemoptysis u Associated F Fever, Symptoms Chills F sputum production F Fatigue

Assessment: H&P n Present History (focused hx) u Sputum Findings amount of sputum infection F Thick green or brown pneumonia or infection F Yellow or gray allergic or inflammatory response F Hemoptysis tuberculosis or carcinoma F Pink, frothy severe pulmonary edema F

Assessment: H&P n HX of Present Illness u How long has dyspnea been present? u Gradual or sudden onset? u What aggravates or alleviates? F Hx of orthopnea? u Coughing? u Productive cough? u What does sputum look/smell like? u Pain? u What does the pain feel like?

Assessment: H&P n Listen - To Pt. Breathe or Talk u Noisy Breathing is Obstructed Breathing u Not All Obstructed Breathing is Noisy u Snoring - Tongue Blocking Airway u Stridor - “Tight” Upper Airway from Partial Obstruction n Observe Breathing u Tachypnea u Bradypnea

Assessment: H&P n Observe u Body Positioning F Tripod F Legs in dependent position u Mental Status u Ventilatory Effort F Accessory muscle use / retractions F Abdominal muscle use F Chest wall expansion F Nasal flaring, pursed lips

Assessment: H&P n Physical Exam of the Chest u Increased A-P Diameter u Lung Sounds F Abnormal: stridor, wheezing, rhonchi, rales, pleural rub u Chest expansion u Symmetrical Findings u Evidence of Trauma

Assessment: H&P n Physical Exam u Cyanosis? F Late, unreliable sign of Hypoxia u Oxygenate Immediately! Especially If: Decreased LOC F Possible Shock F Possible Severe Hemorrhage F Chest Pain F Chest Trauma F Respiratory distress or dyspnea F HX of any Kind of Hypoxia F

Assessment: H&P n Physical Exam u Vital Signs F Skin Color, Temp & Moisture F Respiratory Rate • No an accurate lone indicator of respiratory status unless very slow F Respiratory Rhythm/Pattern F Pulse • Bradycardia vs Tachycardia F Blood Pressure

Assessment: H&P n Physical Exam - Circulatory assessment u Is the heart beating? u Is there major external hemorrhage? u Is the Pt. Perfusing vital organs? u Effects of hypoxia: F Early in adults - Tachycardia F Late in adults - Bradycardia F Children - Bradycardia

Assessment: H&P n n Don’t let respiratory failure distract you from assessing for circulatory failure. Vascular Access

Assessment: H&P n Physical Exam u Extremities F Peripheral Cyanosis F Clubbing F Carpopedal spasm F Peripheral edema

Assessment: H&P n Diagnostic Testing u Pulse oximetry Saturation F Inaccuracies & Disadvantages F u Peak Flow Meter Baseline measurement for obstructive lung disease F Often available from patient F u Capnometry real-time assessment of endotracheal tube placement F quantitative vs qualitative F

Assessment: H&P n Past History u Similar Episodes in Past F Patient’s description of acuity F “What happened last time you had an episode this bad? ” n Chronic Symptoms u Acute, Seasonal SOB episodes u Seasonal Allergies u Chronic cough u Recurrent flu, pulmonary infection or SOB

Assessment: H&P n Past History u Known diagnosis F Does the present H&P correlate with this past history? • CHF • Hypertension • Renal Failure u Previous intubation or hospitalization u Aggravating Factors (e. g. smoking)

Assessment: H&P n Past History u Medications F Class, Route, Frequency of Use F Pulmonary • • Sympathomimetics Corticosteroids MAST Cell Stabilizer Methylxanthines F Cardiovascular • Diuretics • Antihypertensives • Cardiac glycosides

Assessment: H&P n Disability u Restlessness, anxiety, combativeness = HYPOXIA Until Proven Otherwise u Drowsiness, lethargy = HYPERCARBIA When the patient stops fighting, he is not necessarily getting Better!!

Other Adventitious Sounds n Cough u Forced exhalation against partially closed glottis u Reflex response to mucosa irritation u Determine circumstances At work F Postural changes F Lying down F u Productive vs non-productive

Other Adventitious Sounds n Sneeze u Forced exhalation via nasal route u Clears nasal passages u Reflex response to mucosa irritation n Sigh u Slow, deep inspiration - Prolonged, audible exhalation u Reexpands areas of atelectasis

Other Adventitious Sounds n Hiccough u Hiccups, singultus u Spasm of diaphragm followed by glottic closure u No useful purpose u Benign, transient