RESPIRATORY EMERGENCIES
FLORENCE B. GRAGEDA, MD
Lecturer
RESPIRATORY ASSESSMENT
LUNG VOLUMES and CAPACITIES
PULMONARY EMBOLISM
PULMONARY EMBOLISM
PULMONARY EMBOLISM
• This is a thrombotic or
non-thrombotic embolus
that lodges in the
pulmonary artery system.
• It can damage part of
the lung due to;
•restricted blood flow
•hypoxemia
•affect other organs as
well.
•can be life-threatening
PULMONARY EMBOLISM
• Risk Factors
1.Injury or damage
leading to blood clot
formation
2.Inactivity for prolonged
periods
3.Medical conditions or
treatment procedures
that cause blood to clot
easily
e.g. surgery
DVT
P.E: Causes
PULMONARY EMBOLISM
• Clinical Manifestations :
•Virchow’s triad:
•venous stasis,
•coagulation problems,
•vessel wall injury
•Pleuritic Chest pain
•Friction rub on auscultation
•Tachycardia, tachypnea
•Anxiety, restlessness
•Clammy or bluish skin
PULMONARY EMBOLISM
• Diagnostics:
ü CXR
• Hampton hump
= wedge-
shaped infarct
distal to emboli
PULMONARY EMBOLISM
• Diagnostics:
üCXR
ü ABG analysis
ü D-dimer test
ü detects clot
fragments
from clot
lysis
PULMONARY EMBOLISM
• Diagnostics:
üCXR
ü ABG analysis
ü D-dimer test
ü detects clot fragments
ü from clot lysis
üECG
üV/Q scan / Pulmonary
angiography/ spiral CT
scan
PULMONARY EMBOLISM
• Diagnostics:
üCXR
ü ABG analysis
ü D-dimer test
ü detects clot fragments
ü from clot lysis
üECG
üV/Q scan / Pulmonary angiography/ spiral
CT scan
ü Pulmonary Angiogram
ümost definitive test
PULMONARY EMBOLISM
PULMONARY EMBOLISM
• Treatment:
• Oxygenation
= ET and mechanical
ventilation
•Heparin therapy
•Surgery
= umbrella filter
= pulmonary embolectomy
•Prevention of development of
DVT
= compression stockings
ACUTE RESPIRATORY DISTRESS SYNDROME ( ARDS )
ü This is a
syndrome with;
ü inflammation
ü increased
permeability
of the
alveolocapillary
membrane
Increase permeability of alveolo-
capillary membrane
ACUTE RESPIRATORY DISTRESS SYNDROME
( ARDS )
ü This is a
syndrome with;
ü inflammation
ü increased
permeability
of the
alveolocapillary
membrane
ACUTE RESPIRATORY DISTRESS SYNDROME
( ARDS )
üoccurs as a result of an injury to the lungs.
ü fatal when left undiagnosed or treated for
48hrs.
• Risk Factors
•Critically ill patients
•Age (60y/o and above)
•Malignancy (cancers)
•Cigarette smoking, COPD
{ DIRECT { INDIRECT
CAUSES: ARDS
ACUTE RESPIRATORY DISTRESS SYNDROME
( ARDS )
• Causes:
• Aspiration pneumonia
• Systemic Illness
•Burns
•Sepsis
•Drug overdose
ACUTE RESPIRATORY DISTRESS SYNDROME
( ARDS )
• Clinical Manifestations:
➢ Signs and symptoms are often
exhibited within 24-48 hours after
initial insult to the lungs
1. Restlessness,
2. Hyperventilation,
3. tachycardia,
4. SOB
5. Hypoxemia
4. Severe:
hypotension, cyanosis, decreased UO
RISK FACTORS
DIAGNOSTICS
ACUTE RESPIRATORY DISTRESS SYNDROME
( ARDS )
• Diagnostics:
• Chest x-ray
• “white out lungs"
ACUTE RESPIRATORY DISTRESS SYNDROME
( ARDS )
• Treatment:
• Goal:
à improving and maintaining
ü oxygenation
ü prevent respiratory and metabolic
complications
1. Fluid management
= to maintain tissue perfusion
2. Corticosteroid therapy
= to decrease permeability of the
alveolocapillary
ACUTE RESPIRATORY DISTRESS SYNDROME
( ARDS )
• Treatment:
3. Nutrition
– enteral feeding
4. Supplemental oxygen:
Mechanical Ventilation
– a form of artificial ventilation that
takes over all or part of the work
performed by the respiratory muscles
and organs
ü Modes, Settings, Alarms
ACUTE RESPIRATORY FAILURE
• It is a change in respiratory gas
exchange such that normal cellular
function is jeopardized.
• ARF is defined as a ;
•O2 < 50 mmHg HYPOXEMIA
•pCO2 >50 mmHg HYPERCAPNIA
•pH <7.30 ACIDOSIS
ACUTE RESPIRATORY FAILURE
HYPOXEMIA HYPERCAPNIA
Lung failure, Pump failure,
respiratory insufficiency ventilatory failure
Failure of lungs and heart to Failure of lungs to
provide adequate oxygen eliminate adequate CO2
PaCO2 < 60mmHg with normal PaCO2 > 50mmHg
or decreased PaO2
Alveolar hypoventilation Increase dead space
Associated with acute diseases Drug overdose,
of the lungs (pulmonary NM disease, chest wall
edema, ARDS, pneumonia) deformity, COPD
ACUTE RESPIRATORY FAILURE
{ ARDS {
§ Hypoxia ARF
(hyperventilation &
respiratory acidosis) § Hypoxia
§ Hypercapnia § Hypercapnia
§ Crackles § Crackles / ronchi
§ Cyanosis
§ Hypoxemia § Cyanosis
§ Pulmonary § Retractions
hypertension § Cor pulmonale
§ Tachypnea
§ Hypotension,
q BRONCHODILATORS
q CORTICOSTEROIDS
q (+) INOTROPICS
q VASOPRESSORS
q DIURETICS
q SEDATIVES
q Fluid Management
ü Maintain supplemental
oxygen
ü Positioning (Prone vs.
Supine)
ü Nutrition (enteral)
ü Monitoring:
• LOC
• Respiratory status
• Breath sounds
• Vital signs
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
( COPD )
• It is an umbrella term to describe various
diseases
• chronic bronchitis
• emphysema
• chronic asthma.
• A slowly progressive and irreversible disease,
• usually occurs in people over 50 years of age
• smoking is a major factor in its development
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
( COPD )
• ASSESSMENT :
• Patient’s history:
• Mild
= a ‘smoker’s cough’ is the only abnormal sign.
• Moderate
= breathlessness and/ or wheeze on moderate
exertion, cough, and generalized reduction in
breath sounds.
• Severe
= breathlessness at rest, cyanosis, prominent
wheeze and/ or cough, and lung overinflation
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
( COPD )
• ASSESSMENT :
❖ Consider and record the following, too:
✓ current treatment
— inhalers, nebulizers, antibiotics, steroids, O2,
and theophyllines;
✓ exercise tolerance;
✓ previous admissions
= especially intensive care or treatment with
NIV
= the reason for ED attendance
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
( COPD )
• ASSESSMENT :
• In the ED, assess for the following:
▪ cough; sputum— color and amount;
▪ cyanosis;
▪ tachypnea; wheeze;
▪ accessory muscle usage; lip pursing on expiration
§ chest expansion (which is often poor);
• Fever
• Dehydration
• confusion or reduction in conscious level
• pain
• Consider whether the patient is septic, and treat any
signs of sepsis, severe sepsis, or septic shock
immediately.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
( COPD )
• Diagnostics and Laboratory :
• Continuous monitoring
— HR, RR, and SpO2.
• CXR
• ECG
• ABG analysis as soon as possible
• FBS, U&E, and theophylline level
= if the patient is taking theophylline)
• Sputum for C&S
• = if purulent
• Blood cultures
• = if the patient is pyrexial
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
( COPD )
• Nursing Interventions :
• Reassurance
• Nurse the patient in an upright position
• O2 therapy to keep saturations in the range of 88–
92%
• Nebulizers (may need to be continuous).
• Steroids
• IV theophylline
= for patients who do not respond to nebulizers
• Assessment for NIV
• Mouth care
• IV fluids if the patient is dehydrated
• Analgesia
• AVPU and GCS scores.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
( COPD )
• Management :
• Non-Invasive Ventilation ( NIV )
•
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
( COPD )
• Management :
• Non-Invasive Ventilation ( NIV )
• Increasingly used in ED resuscitation rooms
• NIV should be considered in patients who meet
the following criteria:
• respiratory acidosis (pH <7.35, PaCO2 >6kPa)
that persists despite maximal medical therapy;
• not moribund, GCS score >8
• able to protect the airway;
• cooperative and conscious;
• few co- morbidities;
• hemodynamically stable;
• no excess respiratory secretions;
• potential for recovery to a quality of life
acceptable to the patient.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
( COPD )
• Management :
• Intensive Care
• Patients with exacerbations of COPD should not
be automatically excluded from invasive
ventilation if all other treatments are failing.
• The following will have to be considered:
• quality of life
= ideally involving the family in the discussion
• O2 requirements when stable
• co-morbidities
• forced expiratory volume in 1s (FEV1);
• body mass index (BMI).
PNEUMONIA
• Pneumonia is an inflammation of the lung,
characterized by exudation into the alveoli.
• The terms ‘pneumonia’ and ‘chest infection’
are often used interchangeably.
PNEUMONIA
• Causes :
• Pneumonia can be caused by any of over 100
microorganisms.
• Treatment should be started before the causative
organism has been identified.
• Common microorganisms that can cause Pneumonia
• Streptococcus pneumoniae (90% of cases)
• Haemophilus influenzae
• Staphylococcus aureus
• Legionella species
PNEUMONIA
• Types of Pneumonia :
• Community acquired
– not hospitalized or residing in a long-term
care facility for ≥ 14 days prior to onset of
symptoms.
•Hospital acquired
– more than 48 h between admission and
onset of symptoms.
•Ventilator associated
– more than 48–72 h between intubation and
onset of symptoms.
PNEUMONIA
• Types of Pneumonia :
•Aspiration
– micro-aspiration of bacteria colonizing the;
ü URT,
ü macro-aspiration of gastric contents,
ü indirect transmission from staff,
ü inhaled aerosols.
•Atypical
PNEUMONIA
• Assessment :
ü The clinical findings are often referred to
as consolidation.
ü Expansion is reduced on the affected side.
ü Percussion = dull over the area of
consolidation
üBreath sounds = bronchial
= adventitious crackles.
üTachypnea and central cyanosis.
üFever, sweats, and rigors.
üCough and sputum.
• Diagnostics: PNEUMONIA
• Sputum
microscopy,
culture, and
sensitivity.
• CXR
•consolidation
•ABG
• (if SpO2 is <93%
on room air) and
pulse oximetry
•FBC, U&E, CRP, and
LFTs.
PNEUMONIA
• Management:
• Initial (ED) management:
•Supplemental O2 to maintain saturations
at >93%
•IV fluids (if the patient is dehydrated)
•Medications:
•IV antibiotics
•Analgesic
•Antipyretic
PNEUMONIA
• Management:
•Bronchoalveloar lavage may
be used for patients who are;
•immunocompromised,
•those who do not respond
to antimicrobial therapy,
•those from whom a sputum
sample cannot be obtained.
PNEUMONIA
• Nursing Management:
• Positioning (upright)
• Antimicrobial therapy.
• Monitor hemodynamics
• fluid and electrolytes and imbalances
• Infection prevention and control.
• Ventilator-associated pneumonia ( VAP )
care bundle
VENTILATOR - ASSOCIATED PNEUMONIA
VENTILATOR ASSOCIATED PNEUMONIA
( VAP )
• develops 48 h or later after commencement of
mechanical ventilation via ET or tracheostomy
• colonization of the lower respiratory tract and lung
tissue by pathogens.
• VAP is the most frequent post-admission infection in
critical care patients,
• Risk factors:
• Immunocompromised
• Elderly
• chronic illnesses (e.g. lung disease, malnutrition,
obesity).
VENTILATOR ASSOCIATED PNEUMONIA
( VAP )
• Diagnosis is difficult due to the number of differential
diagnoses that present with the same signs and
symptoms (e.g. sepsis, ARDS, cardiac failure, lung
atelectasis);
• radiological changes = consolidation and
= new or progressive infiltrates
• Clinical signs include;
• pyrexia > 38°C
• raised or reduced white blood cell (WBC) count
• new-onset purulent sputum
• increased respiratory secretions/suctioning
requirements
• worsening gas exchange.
VENTILATOR ASSOCIATED PNEUMONIA (VAP)
• Management:
• CareBundle approach for the prevention of VAP
= demonstrated to be an effective preventive
strategy.
• 6 elements for the prevention ( reviewed daily ):
1. Elevation of the HOB to 30–45°(unless contraindicated)
2. Sedation level assessment
à unless the patient is awake and comfortable
à sedation is reduced or held for assessment at least
daily (unless contraindicated).
3. Oral hygiene
à clean with chlorhexidine gluconate
à q6h
à teeth are brushed q12h with standard toothpaste.
VENTILATOR ASSOCIATED PNEUMONIA ( VAP )
• Management:
• 6 elements for the prevention:
4. Subglottic aspiration
= a tracheal tube (ET or tracheostomy) that has a
subglottic secretion drainage port is used if the
patient is expected to be intubated for > 72 h.
= secretions are aspirated via the subglottic secretion
port 1- to 2-hourly.
5. Tube cuff pressure
= measured q4h
= maintained in the range 20–30 cmH2O (or 2
cmH2O above peak inspiratory pressure)
6. Stress ulcer prophylaxis
•
Severe Acute Respiratory Syndrome – 2 ( SARS-
COV 2) = COVID - 19
= new ( novel ) strain of coronavirus
= Middle East Respiratory Syndrome (MERS-Cov)
à 2012
= Severe Acute Respiratory Syndrome ( SARS-Cov )
à 2003
Origin:
ü bats or pangolins
ü transmitted to humans directly or through an
intermediate host
ü source location:
= large live animal market in Wuhan, Hubei province
ü human – to – human spread
Severe Acute Respiratory Syndrome – 2 ( SARS-
COV 2) = COVID - 19
§ Clinical Manifestations
ü most common symptoms:
§ fever = 83 % - 99 %
§ dry cough = 59 % - 92 %
§ shortness of breath = 31 % - 40 %
ü Less common symptoms:
§ aches and pains
§Sore throat
§Diarrhea
§Conjunctivitis
§Headache
§Anosmia or ageusia
§Rash on skin or discoloration of fingers or toes
Severe Acute Respiratory Syndrome – 2 ( SARS-
COV 2) = COVID - 19
§ Clinical Manifestations
ü Serious symptoms:
§ difficulty of breathing or shortness of
breath
§ chest pain or pressure
§ loss of speech or movement
Severe Acute Respiratory Syndrome – 2 ( SARS-
COV 2) = COVID - 19
§ Diagnostics:
ü C-Xray
= “ ground glass
opacity “
Severe Acute Respiratory Syndrome – 2 ( SARS-
COV 2) = COVID - 19
§ Diagnostics:
ü C-Xray
= “ ground glass
opacity “
ü CT scan
ü ECG
Severe Acute Respiratory Syndrome – 2 ( SARS-
COV 2) = COVID - 19
§ Laboratory test:
ü Inflammatory markers
§ CRP
§ D-dimer
§ Ferritin
Severe Acute Respiratory Syndrome – 2 ( SARS-
COV 2) = COVID - 19
§ Prevention:
ü Keep at least a 1-meter distance from
others
ü Wear a medical mask
ü When possibly exposed, stay in a
separate room
ü Keep room well-ventilated
ü Stay home if you feel unwell
Severe Acute Respiratory Syndrome – 2 ( SARS-
COV 2) = COVID - 19
§ Medical Treatments:
ü Optimal supportive care:
ü O2 for severely ill patients
ü at risk for severe disease and more advanced
respiratory support such as ventilation for px
who are critically ill
ü Dexamethasone
= corticosteroids
= antiinflammatory
Severe Acute Respiratory Syndrome – 2 ( SARS-
COV 2) = COVID - 19
§ Medical Treatments:
ü Remdesivir
ü Tocilizumab
ü Bamlanivimab & Casirivimab
ü Baricitinib in combination with Remdesivir
§ Prevention:
ü Maintain a safe distance from others
ü Wear a mask in public, especially indoors or
when physical distancing is not possible
ü Choose open, well-ventilated spaces over
closed ones.
ü Open a window if indoors
