Respiratory Distress Assessment

• Study notes on the topic of respiratory emergencies

Learning Objectives

• Review respiratory system physiology.
• Learn about different respiratory emergencies.
• Understand the role of the CCMA in respiratory emergencies.

Respiratory Disease

• The global number of deaths from chronic respiratory diseases has increased in the past 3 decades per the BMJ.
• Health assistants have a key role in educating and caring for patients.
• It's important to understand respiratory emergencies.

Respiratory Review

• A solid understanding of respiratory system anatomy and physiology is needed to understand respiratory emergencies.

Assessment Tools

• The PASTE pneumonic helps assess a patient experiencing a respiratory emergency.
  • Provocation and Progression: What were you doing when it started? How long has this been going on? How has it changed over time?
  • Associated chest pain: Is there pain when you breathe?
  • Sputum/Speech: Color and amount: Indicates a respiratory infection if mucus is yellow or greenish. Pink, frothy sputum suggests a cardiac origin.
  • Talking, Tiredness: Can they carry on a conversation or only speak in 1-2 word sentences? Does talking cause fatigue?
  • Exercise Tolerance: Can you walk across the room? What happens with activity?

Auscultate the Breath Sounds

• Auscultate breath sounds over the bare chest using the stethoscope's diaphragm in firm contact with the skin.
• Check breath sounds on both the right and left sides of the chest.
• Check breath sounds on the patient's back between and below the scapulae.

Common Breath Sounds

• Four common breath sounds are Rales, Rhonchi, Stridor, and Wheezing.
  • Rales: Small clicking, bubbling, or rattling sounds in the lungs when inhaling.
  • Rhonchi: These sounds resemble snoring and are heard when air or airflow is blocked through the large airways
  • Stridor: Wheeze-like sound due to a blockage of airflow in the trachea.
  • Wheezing: High-pitched sounds produced by narrowed airways.

Respiratory Emergencies

• Respiratory emergency symptoms may be associated with another system.
• In an opioid overdose or CNS depression, there is a decreased RR.
• Deep sighing respirations are a compensatory mechanism to eliminate CO2.
• In Diabetic keto-acidosis(DKA), an increased RR is not directly related to the respiratory system but is a compensation mechanism as the body tries to regain homeostasis.

Respiratory Distress

• Use the ABC (Airway, Breathing, Circulation) assessment method for patients with Respiratory Distress.
  • This helps differentiate from an airway obstruction or ineffective respirations.

Signs and Symptoms of Respiratory Distress

• Shortness of breath
• Tachypnea (RR over 30 breaths per minute)
• Altered consciousness and/or confusion
• Agitation
• Use of accessory muscles
• Inability to speak due to difficulty breathing
• Cyanosis
• Exhaustion

Goal for Respiratory Distress Treatment

• The goal is to protect the patient from hypoxia and hypercarbia and return the patient to their baseline respiratory status.
• Complete the standard Respiratory Assessment.
• Obtain initial vital signs and check them often.
• Administer supplemental O2 if applicable.
• If ordered, obtain Arterial Blood Gases (ABGs) and Sputum for culture and sensitivity (C&S).
• Obtain Chest X-Ray and ECG if indicated.
• Place the patient in the Fowler's position.
• Place IV access in the event IV steroids and/or bronchodilators will be needed.
• Provide inhaled therapies as ordered.
• Administer analgesics for pleuritic chest pain.
• Provide psychosocial support using a calm and reassuring manner.

Pneumonia

• Pneumonia refers to a group of syndromes caused by various organisms (Community Acquired Pneumonia, Hospital Acquired Pneumonia, and Ventilator Associated Pneumonia).

Pneumonia: Signs and Symptoms

• Breathlessness
• Cough
• Purulent sputum
• Fever, shivers, aches, and pains
• Pleurisy
• Hemoptysis
• Hypoxia
• Signs of consolidation on CXR or on auscultation and chest percussion

Pneumonia Treatment

• The goal of pneumonia treatment is to cure the infection and prevent complications.
• Complete the standard Respiratory Assessment.
• Obtain and monitor RR, pulse, and pulse oximetry vital signs continuously.
  • RR should be assessed every 30 minutes until the patient stabilizes.
• Place the patient in Fowler's position.
• Provide supplemental oxygen to maintain O2 saturation above 94%.
• If ordered, obtain a sputum C&S, Chest X-Ray, Arterial Blood Gas, WBC, and/or blood cultures.
• Analgesics for pleuritic chest pain
• Administer antibiotics as ordered. (oral or IV depending on severity of pneumonia)
• Administer steroids or bronchodilators to reduce respiratory distress.
• Encourage fluids to ease congestion and prevent dehydration.
• Encourage deep breathing exercises to loosen congestion.

Asthma Exacerbation

• Asthma's pathophysiology is complex, involving airway inflammation, intermittent airflow obstruction, and bronchial hyper-responsiveness.

Asthma Signs and Symptoms

• Wheezing
• Coughing
• Shortness of breath
• Chest tightness/pain
• Young infants may present with:
  • recurrent bronchitis or pneumonia
  • a persistent cough with colds, and/or
  • recurrent croup or chest rattling

Asthma Treatment

• Asthma Exacerbation treatment prevents symptoms and acute episodes, minimizes function declines, and helps foster a healthy lifestyle.
• The primary test to establish a diagnosis is spirometry with post-bronchodilator response.
• Complete the standard respiratory assessment.
• Obtain vital signs and continue to monitor RR, pulse, and pulse oximetry every 30 minutes until the patient stabilizes.
• Place the patient in a Fowler's position.
• Give supplemental O2 to maintain O2 sats above 94%.
• Provide ordered pharmacologic management. This includes short-acting bronchodilators, systemic corticosteroids, and/or ipratropium (Atrovent).
• Provide patient education on environmental exposures, irritants, and smoking cessation.
• Obtain a chest X-Ray if applicable.

COPD Exacerbation

• COPD is an umbrella term for chronic lung diseases.
  • Occurs when airways and air sacs lose stretchiness, the walls between the air sacs are damaged, and the walls of the airways become inflamed and thickened.

COPD Exacerbation: Signs and Symptoms

• Extreme shortness of breath
• Increased mucus
  • May be thicker and darker in color than usual
• Confusion
• Intense fatigue
• Excessive coughing
• Excessive wheezing
• Cyanosis
• Increased heart rate
• Exacerbation occurs due to a sudden blockage in the airways.

Goal of Treatment for COPD Exacerbation

• The goal of COPD Exacerbation treatment is to minimize the impact of the exacerbation, return the patient to baseline, and prevent future episodes.
• Complete the standard Respiratory Assessment.
• Obtain and monitor RR, pulse, and pulse oximetry every 30 minutes until the patient stabilizes.
• Place the patient in a Fowler's position.
• Provide supplemental oxygen to maintain O2 saturation above 92% and to relieve hypoxia.
• Includes CPAP or biphasic positive airway pressure (BiPAP) and Heliox.
  • Altered level of consciousness is a contraindication for BiPAP. *
• Administer short-acting beta2-agonists bronchodilators
• Initiate maintenance therapy with a long-acting bronchodilator once the patient returns to baseline and before they return home.
• Systemic corticosteroids may be ordered to improve lung function and oxygenation
• Antibiotic therapy may be ordered to shorten recovery time and reduce the risk of early relapse and treatment failure.

Pneumothorax

• Pneumothorax occurs when air enters the pleural space via mediastinal tissue planes or direct pleural perforation, causing increased intrapleural pressure and decreased lung volume.

Pneumothorax: Signs and Symptoms

• Sudden or gradual dyspnea
• Pleuritic chest pain
• Decreased breath sounds on the affected side
• Mediastinal shift
  • Pressure causes the mediastinum, which contains the heart, trachea, esophagus, and great vessels, to shift to the unaffected side).
  • This shift causes compression of the lung.
• Hypotension

Goal of Pneumothorax Treatment

• The goal of pneumothorax treatment is to relieve pressure in the lung, reduce air leakage, return the patient to baseline, and prevent recurrences.
• The primary test to establish a diagnosis is an upright inspiratory chest x-ray
• Complete the standard respiratory assessment
• Monitor RR, pulse and pulse oximetry every 30 minutes until the patient stabilizes.
• Place the patient in Fowler's position
• Provide supplemental oxygen to maintain O2 saturations above 94%.
  • This accelerates the pleural reabsorption of air and lung expansion
• Immediate needle decompression for tension pneumothorax
• Observation and follow-up with x-ray for small, asymptomatic, primary spontaneous pneumothorax
• Catheter aspiration for large or symptomatic primary spontaneous pneumothorax
• Tube thoracostomy for secondary and traumatic pneumothoraces

Respiratory distress is indicated by tachypnea. Cyanosis indicates poor oxygenation. Treatment aims to alleviate hypoxia and hypercarbia. Chronic respiratory disease deaths have not increased in the last three decades, according to the BMJ.