Bronchoconstriction is also treated with medications that inhibit bronchiolar constriction such as: Ipratropium (Atrovent)

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1 Patients with difficulty breathing (dyspnea) may have problems with: Oxygenation due to alveolar problems Ventilation due to bronchiolar problems Oxygenation due to lung perfusion problems Combinations of these problems Other problems (trauma, anxiety / emotional distress) Bronchioles can obstruct from: Constriction of the bronchiole smooth muscle Excess mucous production / mucous plugs Inflammation / swelling Bronchoconstriction is treated with bronchodilators such as: Albuterol (Proventil, Ventolin, Pro-Air) Bronchoconstriction is also treated with medications that inhibit bronchiolar constriction such as: Ipratropium (Atrovent) Some patients and some EMS services use a combination of these two medications in one MDI or a single high-flow nebulizer: Combi-Vent Duo-Neb Patients may have these medications as prescribed medications delivered by: Metered Dose Inhaler (MDI) ( puffer or inhaler ) High-Flow Nebulizer Patients may have High-Flow Nebulizers at home- --typically powered by small air compressors. Not all MDI s are bronchodilators. Many patients take inhaled steroids via MDI. These medications are long-acting and are not for rescue use. EMT s may operate under standing orders within their protocols to assist patients with their bronchodilator MDI s if the patient s condition indicates their use, the medication is not expired and it is prescribed for that specific patient. COPD patients have problems with oxygenation due to alveolar destruction by the disease (usually from smoking) and from bronchiolar obstruction due to the same three mechanisms listed above. Bronchodilators help. CPAP helps (not within EMT scope of practice yet).

2 Asthma patients have problems with ventilation due to bronchiolar obstruction from one or more of the above mechanisms. Bronchodilators via MDI are a common field treatment. Congestive Heart Failure (CHF) patients have problems with oxygenation due to alveolar edema that stems from an accumulation of blood in the pulmonary capillaries caused by the failure of the left ventricle to pump effectively. Treatment is aimed at reducing the amount of blood returning to the heart so that the heart can handle its load. This is called reducing preload and is frequently accomplished with nitroglycerin (NTG). EMT s are not typically authorized by standing orders within protocols to give NTG for preload reduction. However, many of these patients do have NTG prescribed for their chest pain and many CHF patients have chest pain. Following NTG, the patient may benefit from CPAP. CHF is caused by dysfunction of the ventricles and frequent causes of this dysfunction are hypertension and myocardial infarction. Lung sounds reveal rales (crackles) from pulmonary edema for left heart failure. Peripheral edema is a sign of right heart failure including JVD and pedal edema (in ambulatory patients) or pre-sacral edema in those who are sedentary or bed-ridden. The Focused History & Physical exam for patients who have the chief concern of shortness of breath must involve a Look, LIsten and Feel on the chest. Look for equal chest rise and depth of breathing and scars / injuries and barrel chest and use of accessory muscles. Listen for the presence of and for abnormal. Feel for equal chest rise and depth of breathing and for tenderness. Listen for using the diaphragm of the stethoscope. Listen on one side of the chest and then in the identical spot on the opposite side of the chest. Listen anteriorly in the upper chest and then in the mid-axillary line at the nipple line (the bases). Listen when the patient is not talking or making other vocal sounds. Repeat evaluation as part of your ongoing assessment. Lung sound evaluation in the ambulance are more difficult due to vehicle noise and this is compounded by motion of the vehicle. The best way to learn lung sound evaluation is to practice it on many patients----those with normal and those with abnormal lung sounds. Lung sounds evaluation is a key piece of the assessment of patients with difficulty breathing and is a major factor in determining a working field diagnosis. Patients with bronchiolar obstruction (from any of the three causes) will have wheezes. Patients with edema (fluid) in the alveoli will have rales ( crackles ). Patients with diminished or absent may have a pneumothorax (lung has collapsed) or pneumonia (alveoli are filled with infected fluid). CPAP (Continuous Positive Airway Pressure) is a treatment not yet available within the scope of practice for EMTs but is frequently employed by ALS personnel and

3 patients themselves. CPAP delivers PEEP (Positive End-Expiratory Pressure) by the use of a tight-fitting face mask that delivers oxygen under pressure. This continuous pressure helps keep the alveoli from collapsing between breaths (atelectasis) and reduces the energy required to take a breath (example---blowing up a balloon is hardest when the balloon is collapsed compared to when it is partially inflated). CPAP is helpful when the alveoli are obstructed by edema (fluid) or when they are damaged. CHF patients get the most benefit from CPAP. COPD patients do benefit as well. Some (but not all) protocols include CPAP for asthma or pneumonia. A Pulmonary Embolus (PE) is a blood clot that has been wedged into the pulmonary arteries or arterioles after being pumped from the right ventricle. The size of the clot determines how far into the pulmonary vascular tree the clot will be pushed and therefore the amount of lung tissue that won t be perfused. Clots usually form elsewhere in the body (thrombus) and then travel to the lungs. A typical scenario involves a patient who has been sedentary following an illness or a surgery or an injury to their legs. Clots formed in the lower extremities and then broke apart and traveled through the venous system to the heart where they are pumped into the pulmonary vasculature. Also, patients who smoke and take BCP are at increased risk for clot formation and subsequent PE. PE patients may or may not have chest pain and that pain is more likely to be sharp or easily localized compared to cardiac pain. Patients may have a cough and they may have blood-tinged sputum. However, lung sounds are clear and there is not always pain or cough. Patients with significant PE will appear very dyspneic, have signs of hypoxia and yet have clear. Treatment is rapid transport with high flow O2. Hospital treatment is aimed at eliminating the clot. Pneumonia involves infected fluid (pus) in the alveoli. Assessment reveals a variety of including diminished or absent when areas of lung are full of pus as well as wheezes or crackles or rhonchi in areas of lung that are partially filled with pus or where bronchioles are partially obstructed due to inflammation or mucous related to the lung infection. Treatment in the field involves oxygen and transport in the position of comfort for hospital treatment of the infection itself. Bronchodilators may help patients who are wheezing. CPAP is not clearly beneficial and is not indicated in all protocols. These patients may have a fever or chills due to the infection that is causing their lung issue. They may have some chest pain with inspiration or coughing and their chest may be tender to palpation over the effected area. They may have a productive cough with green / yellow / brown sputum. Hyperventilation Syndrome is rapid and deep breathing secondary to some emotional distress which results in abnormally low CO2 blood levels (its not an O2 problem). Patients may experience chest tightness, numbness and tingling in the face and hands, spasm of the hands or feet (carpopedal spasm), dizziness and light headedness. These symptoms may make their anxiety worse and tend to perpetuate the problem. Eventually, patients may simply stop breathing for a period of time and reset. Calming measures with or without O2 are appropriate. Rebreathing into a

4 paper or plastic bag is not indicated. Lung sounds will be normal for the patient---if they have asthma and wheeze normally then they may wheeze when hyperventilating for example. Those who usually have clear will have clear when hyperventilating. These patients may be confused with PE patients and so the history is key. Assessment and Treatment of patients with dyspnea is focused on determining if hypoxia or hypoperfusion is present which then drives O2 therapy and the urgency of transport. Patients are positioned in their position of comfort. Based on focused history and physical, additional treatments for those with bronchodilator MDI s may involve assisted medication administration. ALS treatments for various conditions are more focused on differentiation of the specific condition or conditions. BLS personnel should be aware of this fact and assist the ALS field diagnosis by gathering history and physical exam information to establish trends. Specific tips for assessment and treatment: During the first 30 seconds of contact, evaluate the patient s radial pulse whenever possible. Check for presence, rate, strength and regularity and skin condition. Do this while you make eye contact with the patient and begin your initial assessment of airway & breathing. Look, listen and feel on the chest within the first minute or two of contact and prior to actual measurement of the BP or detailed questioning about SAMPLE or OPQRST. Lung sounds drive your field diagnosis coupled with history. O2 therapy is indicated for patients with difficulty breathing. The device and flow rate are determined by whether or not there are signs of hypoxia. Your initial assessment plus are really all you need for a decision on O2 and transport. Other than hyperventilation syndrome patients, almost any respiratory patient will benefit from transportation and / or ALS intervention. Transport! Ask about history and complete the assessment during transport.

5 Why do we breathe? To bring in O2. Why do we need O2? Cells need it to make energy efficiently and in sufficient amounts. How do we get O2 to cells? The neurological system manages the process where the cardiovascular system delivers O2 (brought into the respiratory system) to the cells in the body. Assuming the neurological system and cardiovascular system are functioning correctly, what issues can arise in the respiratory system that causes decreased O2 in the cells (hypoxia)? The upper airway may not be open. The lower airways may not be open. The gas exchange in the alveoli may not be working correctly. The blood flow to the lungs may be obstructed. The lungs or chest wall may be damaged or not working correctly. How will you know that the patient is experiencing hypoxia? Signs include an altered mental status (anxiety, confusion, decreased responsiveness), tachycardia, tachypnea and maybe skin changes (cool, pale or blue, clammy or moist skin). You assess these in your initial assessment. You may have access to pulse oximetry (perfusion must be adequate to the area of the oximeter sensor and carbon monoxide may give you falsely elevated readings). How will you know where the problem is in the respiratory system? Your focused history and physical will involve looking at the chest for depth and equality of chest rise or damaged chest wall as well as listening for abnormal / diminished / absent and feeling the chest (for adequate depth and equality of chest rise or painful chest wall movement). What will you do about hypoxia? Open upper airways. Seal up holes in the chest wall or splint unstable chest wall areas. Use oxygen therapy with ventilation when indicated (breathing too slow or too fast, breathing that is shallow). O2 therapy for hypoxia is high-flow O2 with a NRBM supplied by at least 10 lpm and always enough to keep the reservoir bag from collapsing more than two-thirds. Patients without clear signs of hypoxia will benefit from low-flow O2 using a nasal cannula at 4 lpm or whatever home O2 the patient is usually using. Use the patient s bronchodilator MDI per protocol when bronchiolar obstruction is assessed (wheezes or absence of lungs sounds and a history that indicates that obstruction of bronchioles is involved). Transport in the position of comfort for ALS intervention. ALS treatments may include CPAP, bronchodilators IV or by high-flow nebulizer, advanced airway management, preload reduction using NTG, support of perfusion using fluids or medications and advanced assessment using pulse oximetry or capnography. What MUST an EMT understand about respiratory patients?

6 Signs of hypoxia. O2 therapy. Patient positioning. Need for transport and ALS interventions. Underlying disease problems, specific assessment clues and treatments. Here is a chart of information that EMTs MUST understand: Condition Problem Assessment Treatment COPD Alveolar destruction; bronchioles obstructed from inflammation / mucous / constriction Wheezes as long as air movement is still bronchodilators via MDI if allowed, CPAP if allowed; Asthma Ventilation is obstructed by bronchioles that are constricted or obstructed by inflammation or mucous Wheezes as long as air movement is still bronchodilators via MDI if allowed, CPAP if allowed; CHF impaired by fluid in alveoli caused by poor ventricular function that has caused blood to back up into the pulmonary capillaries and leak into the avleoli Rales (crackles) as long as air movement is still of risk factors bronchodilators, NTG if allowed, CPAP if allowed; Pulmonary Embolus impaired by lack of perfusion to pulmonary capillaries due to a blood clot in the pulmonary arteries / arterioles Clear lungs or normal lung sound for that patient; history of risk factors comfort; ventilate as needed

7 Pneumonia impaired by infected fluid in alveoli Wheezes or rales or rhonchi as long as air movement is still bronchodilators via MDI if allowed and bronchiolar obstruction is assessed; CPAP if allowed; ventilate as needed Hyperventilation Syndrome Emotional distress has caused a period of abnormally rapid AND deep breathing Normal for that person; history; may have chest tightness / numb and tingling face or extremities and emotional distress calming measures Chest Wall Not Intact Hole in the chest or unstable area of chest due to rib damage Sucking chest wound; unstable chest wall seen or felt; history Seal up holes with an occlusive dressing; attempt to splint chest wall with a bulky dressing or object, Pneumothorax Lung collapsed Diminished or absent ; history ventilate as needed release any occlusive seal that was applied Pulmonary Contusion impaired by blood (bruise) in the lung tissue that has leaked into aveoli after trauma Diminished or absent ; history ventilate as needed