Volume 1, Issue 2 As the Respiratory System Ages . . .
The respiratory system includes the nose, mouth, throat, larynx, tra-
chea, bronchi, lungs, diaphragm, chest wall muscles and all accessory mus-
cles—the structures that allow us to breathe are susceptible to aging.
As we age, we experience both anatomical and physiological changes.
Our ability to remain healthy and functional becomes more complex. Our atten-
tion is drawn to this aging process as the number of people above 65 years of
age has increased significantly over the past two decades. Individuals live
longer, receive better health care and enjoy improved socio-economic condi-
As we get older, calcification occurs where the ribs meet the sternum
and the spinal column. Osteoporosis of the vertebrae may cause kyphosis
(curvature of the thoracic spine or hunchbacked.) The loss of elasticity from
these conditions limits chest expansion. Respiratory muscles atrophy causing
SPOTLIGHT ON EMS
both a decrease in muscle strength and endurance. The alveoli become
stiffer—not able to completely relax and empty. Combined, the total amount of
air allowed into the lungs and the speed with which the air flows are de-
Continued on page 4
Signs versus Symptoms
We use the term “signs and symptoms” all the time. Both are some-
S E R V I C E S
thing abnormal. They are the diagnostic tools which help us assess each pa-
S E R V I C E S
tient. Do you see these words as interchangeable? Or do you really know the
(FOR ADULTS ONLY)
differences between “signs” and “symptoms?”
Symptoms are consider the subjective evidence of disease. Symptoms
S E N I O R
0 8 6 2 5 - 0 3 6 0
are experienced by an individual and only that individual can perceive them.
M E D I C A L
Anxiety, abdominal pain, low back pain and fatigue are all symptoms. They are
those things patients notice and tell us.
3 6 0
Symptoms can be common to a specific diagnosis or illness or they can
H E A L T H
B O X
be common to a wide range of disease processes. They can affect the entire
E M E R G E N C Y
body or be specific to one organ or location. They can gradually worsen or be-
P . O .
T R E N T O N ,
come progressively better.
Signs are the objective evidence of disease. Signs are the clinical find-
D E P A R T M E N T
ings that are observed. They may have no meaning to the affected individual
or even be noticed by them. They can be detected by a person other than the
O F F I C E
affected individual. They are evident to the EMT or paramedic. Gross blood in
the stool or a bloody nose are signs. They are the things we can see.
Inside this issue:
Signs versus Symptoms 1 Special points of interest:
COPD—What Do These Letters Mean? 2 • The patient’s chief complaint can be very
accurate in identifying the problem, even if
Asbestosis 3 the patient is agitated or confused.
Calling for Emergency Services 3
• Approximately 34% of calls (3.4 million
responses) for emergency medical services
Other Pulmonary Diseases 4 in the US involve patients over the age of 60.
• The question of how much oxygen to admin-
Spotlight on OEMS—Inspections 8
ister to a COPD patient is tricky.
COPD—What Do These Letters Mean?
by Kathleen Lutz, MSN, CPNP
Chronic obstructive pulmonary disease (or smoke and other irritants.
COPD) is a very common lung disease. According to There are numerous complications associ-
Mosby’s dictionary, it is a progressive and irreversible ated with COPD. These include:
condition characterized by diminished inspiratory and
expiratory capacity of the lungs. This means that it is • Respiratory infections, including frequent colds,
hard for a person to breathe, gets worse over time and flu or pneumonia
has no cure. • High blood pressure
Less air moves in and out of the airways be- • Heart problems, including arrhythmias, heart at-
cause the airways and air sacs lose elasticity, the walls tack, right-sided heart failure or cor pulmonale
between the air sacs are destroyed, the walls of the • Lung cancer
airways become thick and inflamed and the airways
make more mucus, tending to clog the airways. • Pneumothorax
COPD is called many different names. They • Weight loss or malnutrition
include chronic obstructive airway disease, chronic ob- • Depression
structive bronchitis, chronic obstructive lung disease
COPD is almost always caused by cigarette
and emphysema. smoking. The symptoms will usually begin to appear
In the United States, the term COPD actually about 10 years after starting to smoke and will vary
combines two diseases—emphysema and chronic bron- with both the number years a person has smoked
chitis. One usually accompanies the other. Emphy- and the number of packs smoked per day. Other
sema changes the anatomy of the lungs causing the lung irritants, such as air pollution, secondhand
alveoli to become floppy and destroying the walls. This smoke, cigar and pipe smoke, chemical fumes and
leads to fewer and larger alveoli instead of many tiny dust can also lead to COPD. In rare cases even a
ones. This destruction of the lungs leads to progres- non-smoker will develop COPD as the result of a ge-
sive dyspnea (shortness of breath). In chronic bronchi- netic disorder that causes low levels of a protein
tis, the bronchi are constantly irritated and inflamed. called alpha-1-antitrypsin.
This leads to a thickening of the lining of the bronchi
The Diagnosis of COPD
and manifests as long-term cough, especially in the
morning with extra mucus. Both disorders make it COPD is diagnosed based on a person’s
hard to breathe. signs and symptoms, medical and family history, a
history of contact with lung irritants and some tests.
Signs and symptoms of COPD include: These tests might include:
• Cough with mucus (sometimes called “smoker’s • Pulmonary function tests including spirometry to
cough”) measure the amount of air the lungs can hold
• Shortness of breath that gets worse with even mild (the “forced vital capacity” or FVC) and how fast
activity that air can be exhaled the “forced expiratory
volume in one second or FEV1);
• Chest tightness
• Chest X-ray can show emphysema and can rule
• Fatigue out other lung and heart problems;
• Frequent respiratory infections • Arterial blood gas analysis to measure how well
• Wheezing the lungs are carrying oxygen into the blood and
removing carbon dioxide by measuring the oxy-
These symptoms usually develop slowly and do not ap- gen level in the blood;
pear until after there has been significant lung dam-
age. The signs and symptoms of COPD will vary de- • Sputum examination can identify some lung
pending upon which lung disease is most prominent. problems and rule out some lung cancers; and
People with COPD will also experience times when their • Computerized tomography (CT) scan can produce
symptoms suddenly get worse. Some things people more detailed images of the lungs to help detect
can do to help prevent these exacerbations include
avoiding cold air, making sure no one smokes near
them and reducing air pollution such as fireplace Continued on page 5
Page 2 S P O TL I G H T O N E M S
Asbestos—the Good and the Bad
by Kathleen Lutz, MSN, CPNP
Asbestos is the name of a commonly found system, asbestos is usually there for life.
group of minerals with fiber-shaped crystals that are
Health problems that seemed to be related
resistant to chemicals, heat and fire. For these reasons,
to asbestos exposure began to be noticed by the
it has had many applications aboard ships and subma-
early 1900s. By the mid-1960s doctors identified
rines, in pipe insulation, roofing, ceiling and floor tiles
huge increases in lung diseases, especially among
and automotive brakes.
WW II shipyard workers.
In about 2500 B.C. it was added to clay to form
In the 1970s, the Environmental Protection
strong utensils and pots. By 300 B.C. the Greeks used
Agency (EPA) began to restrict some uses of asbes-
it for lamp wicks and other fireproof items. By the
tos and although this ban was lifted in 1991, con-
1800s commercial uses for asbestos were found. By
sumer fear remained and many manufacturers have
World War II, ships had asbestos- wrapped pipes, lined
boilers and covered engine parts. At one time auto voluntarily removed asbestos from most products.
brake pads, some textured paints and cement con- It is now generally accepted that inhalation
tained asbestos. Surgeons closed incisions with asbes- of the asbestos fibers is associated with three seri-
tos thread and many Christ- ous and often fatal diseases. Two of these affect
mas trees were decorated with the lungs—asbestosis and lung cancer. A third—
asbestos artificial snow. In mesothelioma—is a rare form of cancer affected
homes built before the 1970s the lining of the thoracic and abdominal cavities.
asbestos was in the sound- Let’s begin with asbestosis, a chronic in-
proofing, roofing and siding flammatory disease. The nose and bronchi are
shingles and vinyl floor tiles. supposed to act as filters, protecting the lungs;
But there turned out to but thin, microscopic and needle-like fibers of as-
be a dark side to this multi-use product. As asbestos bestos can get past these filters causing an inflam-
breaks up into smaller particles, its crystals can become matory reaction. After many such reactions, the
airborne, get inhaled and lodge in the lungs. The lungs scar. Scarred lung tissue does not expand
shorter, wider crystals associated with chrysotile asbes- and contract normally and limits air exchange.
tos usually stay in the upper airway, but the long, thin Most people with asbestosis and other as-
fibers of its other forms penetrate deep into the lungs bestos-related disorders acquired it on the job
and lower airways. Once imbedded in the respiratory Continued on page 6
Adults Are Taught About Calling for Emergency Services
In 2007, Monmouth County emergency dis- lives and also to save money. They developed
patchers received almost 170,000 9-1-1 calls. Of these Adults Calling Emergency Services 9-1-1 (ACES
calls, 27,000 were of a non-emergent nature. 9-1-1) utilizing a video, PowerPoint demonstration,
We teach our children about when and how question and answer discussion and a take-home
to use 9-1-1, but what about today’s adults who brochure. Emergency response personnel now
have a standardized approach for the education of
grew up without it. Have we every gone back and
taught this group? Non-emergency 9-1-1 calls can adults on the proper use of the 9-1-1 system.
delay response time in real emergencies and can Endorsed by the National Sheriffs’ Associa-
be costly. tion it is available to any sheriff’s office. The ACES
9-1-1 program can be downloaded from the 9-1-1
In Monmouth County, a collaboration be- Cell Phone Bank website at www.cellphonebank.org
tween the sheriff’s office, the Office on Aging and or the Monmouth County Sheriff’s Office website at
the Office on Economic Development and Tourism www.sheriffgolden.com. For information, contact
recognized a need for an educational program to Monmouth County Undersheriff Ted Freeman at
teach adults the proper use of 9-1-1 to help save (732) 577-5748.
VOLUME 1, ISSUE 2 Page 3
As the Respiratory System Ages . . . continued from page 1
creased, air becomes trapped in the alveoli and alters with age. Aging and the occurrence of disease
there is increased resistance as air moves into and can affect the normal functions of the respiratory sys-
out of the lungs. This leads to a decreased oxygen/ tem and alter our care management strategies both
carbon dioxide exchange and reduced oxygen going directly and indirectly.
to cells throughout the body. There is also de-
This aging process is not an overnight occur-
creased sensitivity to a low oxygen level and de-
rence and many of these changes are usually mild.
creased cough response. Alterations in pulmonary
However, some diseases or risk factors can lead to
circulation are generally mild with little clinical sig-
significant health problems. This newsletter will ex-
plore some of these problems.
Besides these changes, sleep is disturbed,
exercise capacity is decreased and sexual activity Enjoy!
Other Pulmonary Diseases of the Elderly
Pneumonia is a common respiratory infec- world. Both primary and metastatic (from cancers
tion among elderly people, especially those in nurs- elsewhere in the body) lung tumors are common. Me-
ing and retirement homes. It is probably the most tastases may originate from cancers of the breast,
frequently encountered respiratory infection of old gastrointestinal tract, kidneys and urinary bladder,
age. prostate and genital tract. Primary lung cancers occur
more commonly during the 6th and 7th decade of life.
Pneumococcal pneumonia is the most com-
Squamous cell is most common type of lung cancer
mon form of community-acquired pneumonia. Hos-
among smokers and adenocarcinoma among the non-
pitalized patients will present with Klebsiella and
smokers. Most lung tumors are malignant. Manage-
other Gram negative bacilli or even staphylococci as
ment of lung tumors includes both surgical and non-
the cause of their pneumonias. Both viral and bac-
surgical treatments which are often poorly tolerated
terial pneumonias account for increased morbidity
among the elderly.
Aspiration of gastric contents is common
The symptoms of pneumonia in elderly pa-
among semiconscious and unconscious patients due
tients are usually different than the symptoms seen
to their reduced level of consciousness. Pneumonia is
in younger people. These symptoms may take
longer to develop and may not be very noticeable. the most common result of this aspiration.
The diagnosis of pneumonia should be suspected Sleep apnea, although not age specific, tends
with the clinical presentation of fever, feelings of to occur more commonly in the elderly, often because
weakness, the appearance of more fatigue than of other medical problems i.e. neuromuscular
normal, and cough with or without sputum or changes, micro-infarcts, etc.
hemoptysis. Pneumonia in the elderly may also
Chronic airway obstruction in old age is more
cause confusion and disorientation and even a loss
often caused by COPD but can sometimes be attrib-
of appetite or disinterest in eating. uted to asthma. Asthma in the elderly needs to be dif-
Treatment includes antibiotics and other ferentiated from other causes of wheezing. Left heart
supportive measures as needed. But remember failure, pulmonary thromboembolism and central air-
that older people are more susceptible to stomach way obstruction due to lung tumors are other impor-
upset associated with medication ingestion and tant causes of wheezing. Eosinophilic syndromes,
they are often more sensitive to drug dosages. Plus bronchial carcinoids and foreign body aspiration may
medications already being taken for other condi- also present as asthma look-a-likes.
tions might interact with any new medications. Age-related changes affect not only normal
Lung cancer is now the leading cause of bodily functions but the occurrence and course of dis-
death in both men and women throughout the eases.
Page 4 S P O TL I G H T O N E M S
COPD—What Do These Letters Mean? . . . continued from page 2
The diagnosis of COPD includes four stages • Antibiotics—to treat respiratory infections
based on spirometry results and symptoms. These caused by bacteria
include: • Supplemental oxygen for some individuals with hy-
• Stage 0: At Risk—no disease and normal pul- poxemia. Oxygen therapy might be either used only
monary function test during activity, while sleeping or continuously to
improve quality of life, heart function, exercise ca-
• Stage I: Mild—minimal shortness of breath with
pacity, depression, mental clarity or to extend life.
or without cough/sputum. Disease process
• Pulmonary rehabilitation program which combines
usually unrecognized. FEV1 > 80% of predicted
education, exercise training and nutrition advice
value. Most people are not aware of this re-
duced air flow.
• Surgery is an option for some individuals with se-
• Stage II: Moderate—moderate or severe short-
vere emphysema and might include lung volume
ness of breath with or without cough/sputum.
FEV1 is usually 50-80% of predicted value. reduction surgery and single-lung transplantation.
This is the stage at which most people seek Even with good medical follow-up and adher-
medical attention and are diagnosed. ence to an appropriate diet and medical regimen indi-
viduals with COPD will experience times when their
• Stage III: Severe—more severe shortness of
symptoms suddenly get worse. These exacerbations
breath with or without cough/sputum; repeated
may be due to an infection, air pollution or even a
exacerbations; reduced exercise capacity; fa-
tigue. FEV1 is usually 30-50% of predicted change in temperature.
value. Clinical Scenario
• Stage IV: Very Severe—noticeably impaired He’s 72 years old and a life-long smoker, known COPD,
quality of life due to the shortness of breath; on long term home oxygen and nebulizer therapy. You
exacerbations which may be life threatening at have responded to the family’s 9-1-1 call because he is
times. FEV1 is less than 30% of predicted having increased respiratory distress with wheezing.
value or less than 50% with chronic respiratory Your initial assessment reveals a blood pressure of
failure. This individual is often short of breath
120/80mm Hg, pulse of 130 beats/min, respirations
even at rest.
of 28 breaths/min. You hear wheezing and rales on
COPD is a leading cause of death and dis- auscultation.
ability worldwide. It is the fourth leading cause of
death in the United States. Additionally, as many You should help administer the patient’s pre-
as 12 million people are living with the diagnosis scribed inhaler, if the patient or family has not already
and an additional 12 million probably have the dis- done this. Oxygen—and how much to administer—is
ease but have yet to be diagnosed. always tricky. The potential danger of giving oxygen to
someone with COPD has long been recognized. The
There is no cure for COPD and once lung
damage occurs it is irreversible. However, there potential benefit is not so well known. Start high flow
are treatments to control the symptoms and re- oxygen by non-rebreather mask. Transport immedi-
duce the complications and exacerbations. These ately.
include: When a COPD patient becomes ill, they almost
• Stop smoking. This is the single most impor- always become more hypoxic. Every organ is stressed
tant part of any treatment plan, but one that is because of low oxygen levels throughout the body.
very difficult to achieve. High flow O2 will not kill this patient during transport.
• Medications—some are used on a regular basis Patients in respiratory distress, whether they have
and some are used only as needed: COPD or not, need oxygen.
• Bronchodilators—usually as inhalers—to Oxygen administration will not be the cause of
relax the airway muscles to relieve a patient’s apnea and death. Patients in respiratory
coughing and shortness of breath failure, whether they have COPD or not, need ventila-
tory support. Never withhold oxygen from a patient in
• Inhaled steroids—to reduce airway in-
flammation respiratory distress!
VOLUME 1, ISSUE 2 Page 5
Asbestos—the Good and the Bad. . .continued form page 3
before the federal government began regulating the Symptoms of mesothelioma will vary de-
use and handling of asbestos-containing products. pending on the primary location of the meso-
Many products now contain only trace amounts of as- thelioma and may include:
bestos. However, some developing countries, such as
• Shortness of breath
China and India, have continued to use asbestos. And
the destruction of the Twin Towers on 9/11 is thought • Pain in the chest due to an accumulation of
to have released over 1000 tons of asbestos into the fluid in the pleura
air. • Weight loss
The risk of disease increases as the length • Abdominal pain and swelling due to fluid build-
and frequency of exposure increases and is also de-
up in the abdomen
pendent on the increasing concentration of the asbes-
tos exposure. It can take decades for any symptoms • Bowel obstruction
of asbestos exposure to appear. And not everyone
• Blood clotting abnormalities
who is exposed to asbestos will develop disease.
• Anemia and
There are often no immediate symptoms with
asbestosis. Late in the course of the disease some- • Fever
one with asbestosis might experience shortness of Treatment of mesothelioma includes sur-
breath, a persistent dry cough or chest pain and tight- gery, radiation therapy and chemotherapy. These
ness. Asbestosis is a risk factor for lung cancer. treatments may be used singly or combined. The
There is no cure for asbestosis. Treat- National Cancer Institute is
ment focuses on slowing or preventing disease sponsoring clinical trials to find
progression and easing any existing symptoms. new treatments and new ways
To ease symptoms health care providers often to use current treatments.
recommend humidifiers, respiratory therapy or Who gets asbestosis
oxygen. and other asbestos –related
If a person smokes and has asbestosis, diseases? Anyone who has
their chances for developing lung cancer in- worked at jobs where they en-
crease greatly. Tobacco smoke and asbestos contrib- counter asbestos on a regular basis are at highest
ute to each other’s cancer-causing effects so that the risk. Family members of those who have had daily
combination of these risk factors is more dangerous contact with asbestos have been known to develop
than either alone. asbestosis through exposure to asbestos particles
brought home on the clothing of that person. Even
The mesothelium is the membrane that forms individuals living in the vicinity of a factory that
the lining of several body cavities: the pleura, perito- manufactures asbestos or asbestos-containing
neum and pericardium. The pleura (lining of the lung)
products should be concerned.
might thicken and form a plaque or calcifications. Or
the pleural space between the lungs and chest wall Reducing asbestos exposure is the best
can fill with fluid in a pleural effusion. Mesothelioma, prevention against asbestosis. Thankfully, bans
or cancer of the mesothelium, develops when the cells and warning on asbestos-containing products over
of the mesothelium divide without order or control and the past 30 years have made asbestos exposure
even invade nearby tissues and organs. Since the less common. Federal law requires employers in
peritoneum and the pleura are both mesothelial tis- industries working with asbestos products to moni-
sue you might see pleural mesothelioma and perito- tor exposure levels, create regulated areas for as-
neal mesothelioma. Approximately 2,000 new cases bestos work and provide employees with appropri-
of mesothelioma are diagnosed in the U.S. each year. ate training, protective equipment and decontami-
A history of work-related asbestos exposure is re- nation areas. Eventually, there will be reports of
ported in about 70-80 percent of all cases of meso- fewer and fewer new cases of asbestosis and other
thelioma (but often 30-50 years after the exposure). asbestos related diseases .
Page 6 S P O TL I G H T O N E M S
1-4. Identify each of the following as either: 8. Health risks associated with asbestos exposure include:
A. Sign A. Mesothelioma
B. Symptom B. Lung cancer
1. Headache C. COPD
2. Rapid pulse D. A&B
3. Jaundice E. B&C
9. Age-related changes of the respiratory system include all of
5. Many of the symptoms associated with COPD appear early in the following, EXCEPT . . .
the course of the disease before any major lung damage has
occurred. A. Stiffening of the alveoli
A. True B. Respiratory muscle strength decreases
B. False C. Increased metabolism rate
D. Diminished response to hypoxemia
6. Medications for the treatment of the symptoms of COPD E. Increased chest wall rigidity
B. Inhaled steroids 10. Many seniors:
A. Grew up with the 9-1-1 emergency call system
B. Are comfortable with calling 9-1-1 in an emergency
D. Antihypertensive medications
C. Are unfamiliar with the proper use of 9-1-1
D. Will call 9-1-1 before calling a friend or family member
7. Pneumonia in the elderly might present as: in an emergency
C. Loss of appetite
D. All of the above
ANSWER SHEET (#100245370) Spotlight on EMS Newsletter, Fall 2010
Name _______________________________ ID # __________ 1 (One) Elective CEU for NJ EMTs with a minimum score of
1 (One) Professional Development Hour for NJ School
Nurses with a minimum score of 70%
□ NJ EMT □ NJ School Nurse
State: _________ Zip Code: _____________________
Respiratory System (circle correct answer only)
E-mail address: _______________________________________
1. A B 6. A B C D
Completed sheets must be received by DECEMBER 31, 2010
2. A B 7. A B C D
Answer sheets received after that date will not receive credit.
Complete and return only the answer sheet 3. A B 8. A B C D E
via mail, fax or e-mail—do not submit multiple copies 4. A B 9. A B C D E
OEMS Attention Kathy Lutz 5. A B 10. A B C D
P.O. Box 360, Trenton NJ 08625-0360
Fax (609) 633-7954
VOLUME 1, ISSUE 2 Page 7
Published by the
STATE OF NEW JERSEY
Chris Christie, Governor
OFFICE OF EMERGENCY MEDICAL SERVICES Kim Guadagno, Lt. Governor
NJ DEPARTMENT OF HEALTH & SENIOR SERVICES
P.O. BOX 360
TRENTON, NJ 08625-0360
Department of Health &
Dr. Poonam Alaigh
Office of Emergency Medical
Karen Halupke, Director
Spotlight on OEMS — INSPECTIONS
Ambulances are supposed to provide safe effi- • Trenton
cient emergency transportation for the sick, injured and
persons with disabilities. To insure that all of these • Jersey City
vehicles are in good working order the New Jersey De- Prepare for the Inspection
partment of Health and Senior Services Office of Emer-
gency Medical Services oversees the provider licensure Like any test—preparation counts. During
of approximately 4,000 vehicles across the state. an inspection isn’t the time to identify a problem
with any vehicle.
Do your own pre-inspection on the vehicle
Ambulance Licensure—every 2 years prior to every State inspection. Sample inspection
New Jersey requires initial and biennial licen- f o r m s a r e a v a i l a b l e a t
sure of all mobility assistance, basic life support and www.state.nj.us/health/ems/forms.shtml. This
specialty care transport vehicles (including ALS and air could save you from a failure, a vehicle out of ser-
medical) used to provide prehospital care or medical vice and another trip to the inspection site.
transportation to sick, injured or disabled persons while
collecting a fee for the service. Volunteer ambulance
services licensure is optional. The “Application for New Inspections—Most Common Mistakes
Provid ers” is available at • Triple K-A-1822 Federal Certification sticker
www.state.nj.us/health/ems/forms.shtml. as a must be on vehicle
MSWord document. Complete the form online. Bring
the printed and signed form with a certified check or • Main O2 bottle not properly restrained—needs 3
money order. No personal/company checks. brackets/straps
• Door openings must not be obstructed
Ambulance Inspection—every 4 years • Bench seat must have a positive action latch
• All new vehicles must be inspected prior to being • Unsecured equipment—interior items must be
put into service “crash-worthy”
• All currently licensed vehicles (including mobility • Suction units don’t work
assistance, basic life support, ALS & air medical) • Rips/holes in seat covers/fabric/floor, glass
must be have a DHSS inspection every 4 years cracked, door gaskets damaged
• MAV companies currently working with LogistiCare • Vehicle dirty
get no re-inspections—only the initial inspection
• 2 vehicle inspection sites—schedule all appoint-
ments by calling (609)633-7777 Unsure about something? Have a question?
Call (609) 633-7777