Pulmonary Diseases & Disorders: Assessment
EMS Professions Temple College
Pulmonary Diseases & Disorders
Epidemiology
28%
of all EMS Chief Complaints in the US >200,000 deaths annually due to respiratory emergencies
Pulmonary Diseases & Disorders
Many, many pulmonary diseases
Difficult
to learn all pathophysiologies All can be categorized as affecting:
Ventilation Diffusion
(Respiration) Perfusion
Treatment
can be focused on identifying and treating source of ventilatory/respiratory impairment
Sources of Pulmonary Impairment
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
Ventilation
Upper Airway
Trauma Epiglottitis FBAO Inflammation of tonsils
Lower Airway
Trauma Obstructive lung disease Mucous accumulation Smooth muscle spasm Airway edema
Sources of Pulmonary Impairment
Ventilation
Chest Wall Impairment
Trauma Hemothorax Pneumothorax Empyema Pleural inflammation Neuromuscular diseases
Neurologic Control
Brainstem dysfunction Phrenic or spinal nerve dysfunction
Sources of Pulmonary Impairment
Diffusion
Inadequate FiO2 Diseased alveoli
Interstitial space disease
High pressure pulmonary edema High permeability pulmonary edema
asbestosis COPD inhalation injury
Capillary bed disease
atherosclerosis
Sources of Pulmonary Impairment
Perfusion
Inadequate blood Impaired blood flow pulmonary embolus volume or hemoblogin Capillary wall hypovolemia pathology
anemia
trauma
Risk Factors for Pulmonary Disease
Intrinsic Risk Factors
Genetic
predisposition
asthma COPD carcinoma
Cardiac
or Circulatory pathologies
for pulmonary edema Source for pulmonary emboli
Stress
Source
Risk Factors for Pulmonary Disease
Extrinsic Factors
Smoking
prevalence of COPD & carcinomas severity of pulmonary disease
Environmental
Factors
prevalence of COPD & asthma severity of all obstructive disorders
Function of the Pulmonary System
Gas Exchange System
~10,000
liters of air are filtered, warmed and humidified daily Oxygen diffused into blood Carbon dioxide excreted from the body
Function of the Pulmonary System
Physiology of Ventilation
Requires
neurologic initiation (brainstem) Nerve conduction pathways between brainstem and muscles of respiration Intact & patent Upper and Lower airways Intact & non-collapsed alveoli
Function of the Pulmonary System
Physiology of Respiration
Simple
diffusion process at the pulmonarycapillary bed Diffusion Requirements
Intact,
non-thickened alveolar walls Minimal interstitial space & without additional fluid Intact, non-thickened capillary walls
Function of the Pulmonary System
Physiology of Perfusion
Process
of circulating blood through the capillary bed Perfusion Requirements
Adequate
blood volume Adequate hemoglobin Intact, non-occluded pulmonary capillaries Functioning Left Heart
Control of Ventilation
Control ventilation in response to physiologic needs
Driven 2°
1° by pH of CSF
largely by PaCO2
influenced
drive = PaCO2 3° drive = PaO2 detected by chemoreceptors
very
small population with severe COPD
Nervous System Effect on Ventilation
Medulla
Stimulation
to initiate ventilation of the diaphragm of intercostal muscles
Phrenic Nerve
Innervation
Spinal Nerves at Thoracic levels
Innervation
Hering-Breuer reflex
Prevents
overinflation
General Assessment
Size-Up
Environment
Airborne
Hazards Number of patients Needs
• Specialized rescue equipment • Protective equipment
Is
the environment creating or exacerbating the pulmonary condition?
General Assessment
Initial Goal
Identify
potentially life-threatening pulmonary conditions
Perform minimal PE & Hx
Initiate
immediate & appropriate therapies
Then, continue PE & Hx
Try
to determine if origin is ventilation, diffusion, perfusion or combination
General Assessment
Signs of potentially life-threatening pulmonary condition
altered
mental status absent signs of ventilation Audible stridor or wheezing Able to speak in short phrases only Sustained Tachycardia Pallor / Diaphoresis Accessory muscle use / Retractions
Assessment: H&P
Present History (focused hx)
Chief
Complaint
Dyspnea
• “Subjective sensation that breathing is excessive, difficult or uncomfortable
CP
Cough,
Hemoptysis
Associated
Fever,
Symptoms
Chills sputum production Fatigue
Assessment: H&P
Present History (focused hx)
Sputum
Findings
amount of sputum infection Thick green or brown pneumonia or infection Yellow or gray allergic or inflammatory response Hemoptysis tuberculosis or carcinoma Pink, frothy severe pulmonary edema
Assessment: H&P
HX of Present Illness
How
long has dyspnea been present? Gradual or sudden onset? What aggravates or alleviates?
Hx
of orthopnea?
Coughing? Productive
cough? What does sputum look/smell like? Pain? What does the pain feel like?
Assessment: H&P
Listen - To Pt. Breathe or Talk
Breathing is Obstructed Breathing Not All Obstructed Breathing is Noisy Snoring - Tongue Blocking Airway Stridor - “Tight” Upper Airway from Partial Obstruction
Noisy
Observe Breathing
Tachypnea Bradypnea
Assessment: H&P
Observe
Body
Positioning
in dependent position
Tripod Legs
Mental
Status Ventilatory Effort
muscle use / retractions Abdominal muscle use Chest wall expansion Nasal flaring, pursed lips
Accessory
Assessment: H&P
Physical Exam of the Chest
Increased
A-P Diameter Lung Sounds
Abnormal:
stridor, wheezing, rhonchi, rales,
pleural rub
expansion Symmetrical Findings Evidence of Trauma
Chest
Assessment: H&P
Physical Exam
Cyanosis?
Late,
unreliable sign of Hypoxia
Oxygenate
Immediately! Especially If:
Decreased LOC Possible Shock Possible Severe Hemorrhage Chest Pain Chest Trauma Respiratory distress or dyspnea HX of any Kind of Hypoxia
Assessment: H&P
Physical Exam
Vital
Signs
Skin
Color, Temp & Moisture Respiratory Rate
• No an accurate lone indicator of respiratory status unless very slow
Respiratory Pulse
Rhythm/Pattern
• Bradycardia vs Tachycardia
Blood
Pressure
Assessment: H&P
Physical Exam - Circulatory assessment
Is
the heart beating? Is there major external hemorrhage? Is the Pt. Perfusing vital organs? Effects of hypoxia:
Early
in adults - Tachycardia Late in adults - Bradycardia Children - Bradycardia
Assessment: H&P
Don’t let respiratory failure distract you from assessing for circulatory failure. Vascular Access
Assessment: H&P
Physical Exam
Extremities
Peripheral Clubbing
Cyanosis
spasm Peripheral edema
Carpopedal
Assessment: H&P
Diagnostic Testing
Pulse oximetry
Saturation Inaccuracies & Disadvantages
Peak Flow Meter
Baseline measurement for obstructive lung disease Often available from patient
Capnometry
real-time assessment of endotracheal tube placement quantitative vs qualitative
Assessment: H&P
Past History
Similar
Episodes in Past
Patient’s
description of acuity “What happened last time you had an episode this bad?”
Chronic Symptoms
Acute,
Seasonal SOB episodes Seasonal Allergies Chronic cough Recurrent flu, pulmonary infection or SOB
Assessment: H&P
Past History
Known
diagnosis
Does
the present H&P correlate with this past history?
• CHF • Hypertension • Renal Failure
intubation or hospitalization Aggravating Factors (e.g. smoking)
Previous
Assessment: H&P
Past History
Medications
Class,
Route, Frequency of Use Pulmonary
• • • • Sympathomimetics Corticosteroids MAST Cell Stabilizer Methylxanthines
Cardiovascular
• Diuretics • Antihypertensives • Cardiac glycosides
Assessment: H&P
Disability
Restlessness,
anxiety, combativeness = HYPOXIA Until Proven Otherwise Drowsiness, lethargy = HYPERCARBIA
When the patient stops fighting, he is not necessarily getting Better!!
Other Adventitious Sounds
Cough
Forced
exhalation against partially closed
glottis Reflex response to mucosa irritation Determine circumstances
At work Postural changes Lying down
Productive
vs non-productive
Other Adventitious Sounds
Sneeze
exhalation via nasal route Clears nasal passages Reflex response to mucosa irritation
Forced
Sigh
Slow,
deep inspiration - Prolonged, audible exhalation Reexpands areas of atelectasis
Other Adventitious Sounds
Hiccough
Hiccups,
singultus Spasm of diaphragm followed by glottic closure No useful purpose Benign, transient