Respiratory Distress.pdf

Respiratory Distress General Terms • Anoxia: Absence of oxygen • Apnea: Absence of respiratory movement • Dyspnea: subjective sense of shortness of breath, difficulty breathing • Hyperpnea: Greater than normal ventilation that just meets metabolic demands • Hyperventilation: Ventilation exceeding me...

Respiratory Distress General Terms • Anoxia: Absence of oxygen • Apnea: Absence of respiratory movement • Dyspnea: subjective sense of shortness of breath, difficulty breathing • Hyperpnea: Greater than normal ventilation that just meets metabolic demands • Hyperventilation: Ventilation exceeding metabolic demands (<35 torr) • Hypoventilation: Ventilation that does not meet metabolic demands (>45 torr) • Hypoxia: Deficiency of O2 inspired air • Orthopnea: Inability to breath except in upright position • Respiration: Process of gas exchange whereby the body gains oxygen, loses Co2 • Tachypnea: Greater than normal resp rate • Torr: Unit of pressure = 1mmHg • Ventilation, alveolar: Volume of exchanges air per minute Airway Obstruction • Some degree of obstruction present in med emergencies when pt loses consciousness • A mechanical obstruction: Primary cause of airway obstruction o Tongue falls into hypopharynx as skeletal muscle tone is lost o Airway (A) and Breathing (B) are support steps to manage this Cause Hyperventilation Vasodepressor Syncope Asthma Heart Failure Hypoglycemia Potential Causes of Resp Distress Frequency Most common Most common Common Common Common Text Discussion Resp Distress Unconsciousness Resp Distress Resp Distress Altered consciousness Clinical Manifestations • manifestations vary based on degree of difficulty breathing • most pts stay awake o getting adequate blood/oxygen to brain but can cause acute anxiety • Asthmatic pts: o Wheezing sounds from turbulent airflow thru narrowed bronchioles o Patients suffer from heart failure and pulmonary edema Pathophysiology • Resp distress syndromes can involve different parts of airway • Level of obstruction determines severity of issue and management o Bronchioles are primary site in acute asthma o Hyperventilation more generalized, originating from brain w signs from altered blood chemistry o Acute foreign body (lower) airway obstruction (FBAO), can be life threatening impaction in resp tract Respiratory Distress Management • Sounds = wheeze, cough, crackling, abnormal rate/depth of breathing • Discontinue Tx • Position o Supine (unconscious) o Comfortably (conscious) • Circulation, Airway, Breathing (assess and provide basic life support) • Definitive Care o Monitor vitals, manage anxiety, provide distress management, activate emergency medical services as needed Foreign Body Airway Obstruction • Possibility to drop small objects into posterior oral cavity and into pharynx • FBAO must be managed quickly due to critical nature • More concerning for the elderly, children, and the sedated o Acute airway obstruction is the major cause of nontraumatic cardiac arrest in infants and children • Small objects can be swallowed and successfully pass thru the GI tract, or be aspirated into the lungs (R more common) and cause infection, lung abscess, pneumonia, atelectasis Prevention • Rubber Dam: Not feasible in all procedures • Oral Packing: Pharyngeal curtain of 4x4 gauze to block posterior oral cavity • Other: o patient positioning o dental assistant o suction o Magill intubation forceps o Ligature use: such as floss to secure smaller objects in case of aspiration to use to pull back Foreign Body Airway Obstruction Management • retrieve object if visible, or have pt remove it • If object cannot be seen then radiographs are needed to determine location • CXR (chest x-ray) and KUB (abdominal x-ray) Management of Aspirated Foreign Body • Signs/Symptoms: o Sudden onset of coughing, choking, wheezing, shortness of breath § Most pts who have aspirated something show these signs within 1 hr of aspiration o If in tracheobronchial tree will most likely be in R (more direct route from bifurcation) § Retrieval will involve fiberoptic bronchoscope to visualize and remove § Thoracotomy if unable to remove Recognition of Airway Obstruction • Acute, conscious upper airway obstruction common in pt that is eating • Can be complete or partial obstruction o Partial broken down to “partial w good air exchange, partial w poor air exchange” Complete Airway Obstruction • Phase 1 (1-3 min) o Pt conscious, struggling o paradoxical respirations w/o air movement o Universal choking sign • Phase 2 (2-5 min) o Pt will lose consciousness o Decreased respirations and vital signs • Phase 3 (5+ min) o Pt in cardiovascular arrest, death Partial Airway Obstruction • A forceful cough often may be elicited from a victim with good air exchange o Wheezing may be noted between coughs • The victim with partial obstruction and good air exchange should be allowed to continue coughing and to breathe without any physical intervention by rescuers o Those with poor air exchange exhibit weak, ineffectual cough reflexes and a characteristic “crowing” sound during inspiration Basic Airway Maneuvers • Head tilt-chin lift • Jaw thrust Establishing a new Emergency Airway • Immediate goal of tx • 3 procedures: o Tracheostomy o Cricothyrotomy: Puncture into neck via cricothyroid membrane to open airway o External subdiaphragmatic compressions § Heimlich Hyperventilation • Ventilation in excess of what is required to maintain normal blood PaO2/PaCO2 • Increase in frequency/depth of respiration resulting from anxiety • Symptoms (from change in blood chemistry): o Faintness o Lightheadedness • Predisposing factor: anxiety • Prevention: anxiety management • Vitals: o Increased BP (high systolic) o Increased resp rate w deep/shallow inspiration • Normal Resp rate: 14-18 breaths per min • Hyperventilation: 25-30+ breaths per min Hyperventilation Management • The management of hyperventilation is directed at correcting the respiratory problem and reducing the patient’s anxiety level o Step 1: Remove the presumed cause of anxiety o Step 2: Position the patient in an upright position o Step 3: Remove any foreign materials from the mouth o Step 4: Calm the patient, speak in a relaxed manner and have the patient start taking slower breaths o Step 5: Correct the Respiratory Alkalosis (increased in PaCO2) by having the patient breath in and out of a paper bag or cupped hands Asthma • Extreme sensitivity of the airways characterized by: o Increased contractile response of the respiratory smooth muscle o Abnormal generation and clearance of secretions o Abnormally sensitive cough reflex • 2 types, extrinsic and intrinsic • Extrinsic o Also known as Allergic Asthma affects 50% pf patients with asthma o In children and young adults with an inherited allergic predisposition o Approximately 50% of asthmatic children become asymptomatic before reaching adulthood • Intrinsic o Adults over 35yo o Non-allergic factors are causative o Smoking, Respiratory infection, physical exertion, air pollution, occupational chemical exposure. o Usually without history of allergies o Viral illnesses worsen airway reactivity of asthmatic and non-asthmatic pts o Psychological and physiologic stress can contribute to episodes Predisposing Factors for Asthma • Psychic stress • Antigen-antibody rxn • Bronchial infection • Dusts, fumes • Climate Asthma Classification • Mixed = intrinsic & extrinsic • Major precipitating factor is infection, especially Resp tract infections Classification Symptoms Mild Intermittent Meds: none Mild Persistent Daily meds <_2x per week Asymptomatic, normal btwn exacerbations Exacerbations are brief w varied intensity >2x per week, <1 per day - Anti-inflam (low dose) Inhaled c.steroid - Sustained theophylline - Leukotriene modifier (singulair) Exacerbation may affect activity - Anti-inflam (med dose) Inhaled c.steroid OR - Long acting b2 agonist IF NEEDED: - Long acting bronchodilator Daily symptoms, daily uses of inhaled meds Exacerbation affects activity Moderate Persistent Daily meds Severe Persistent Nighttime Symptoms <_2x a month >2x per week, may lasts days Continual symptoms Limited physical activity Frequent exacerbations >2x a month >1 a week frequent Severe Asthmaticus • Most severe form of asthma • True medical emergency • Can be fatal rapidly • Airway distress that CANNOT be correct w albuterol rescue inhaler Questions for Asthma Patients • DO YOU HAVE OR HAVE YOU HAD ASTHMA, TUBERCULOSIS, EMPHYSEMA, OR OTHER LUNG DISEASES? • DO YOU HAVE OR HAVE YOU HAD ALLERGIES TO DRUGS, FOODS, MEDICATIONS, LATEX? o Common cause of asthma attacks is allergens (extrinsic) o Singular – for severe allergies • ARE YOU TAKING DRUGS, MEDICATIONS, OVER-THE-COUNTER MEDICINES (INCLUDING ASPIRIN), OR NATURAL REMEDIES? o Inhalers: Rescue (Albuterol) vs Daily Questions to Determine Asthma Severity: • What causes you to wheeze? • When was your last asthma attack? • Have you ever had an attack you couldn’t break with your inhaler? • Have you ever been hospitalized for your Asthma? • Do you use your other inhalers every day like you are supposed to? Asthma Meds* • SHORT ACTING BETA-2 AGONISTS (albuterol): 3 doses should break the emergency cycle, if not then call emergency • INHALED CORTICOSTEROIDS (Fluticasone, Mometasone, Budesonide): used daily • Immune Modulators (Cromolyn sodium, Montelukast-Singulair): used preventatively for allergens • LONG ACTING BETA-2 AGONISTS (Salmeterol, Formoterol): for severe asthmatics in combination with other therapy Dental Considerations • Maintain pt’s pulmonary status as close to normal as possible • Prevent acute episodes during tx • Alleviate stress, anxiety, sedation of pt as needed (nitrous oxide, IV) • Asthmatic pts can have an aspirin sensitivity • ASA Classifications: o ASA 2: well controlled o ASA 3 : pts w acute episodes, required medical emergency care/hospitalization o ASA 4: symptoms noted at rest Breathing • Inspiration v Expiration • Diff inflammatory dz and obstructions affect different phases of breathing: o Wheezing: § Sound of pulling air into airways § deals w increased obstruction/infiltrates/narrowing during inspiration o Asthma is obstruction of expiration (air trapped in lungs) • As obstruction continues excess energy spent to exhale trapped air o Resp failure due to muscle fatigue of accessory muscles of breathing How to Recognize Resp Distress • Use accessory muscles to breath/chest flaring • “Tripod” position, leaned forward w hands on knees • Open mouth breathing • Nasal flaring (common in children) Bronchospasm • Stimulation of the vagus nerve causes constriction of bronchial smooth muscle • Sympathetic nerve stimulates bronchial smooth muscle dilation • In asthma there is an exaggerated rxn to protect lungs from stimuli, produces clinical signs and symptoms of resp distress • Bronchial wall edema, hypersecretion of mucus glands also present Management of Asthma attk • Recognize problem • Stop dental tx • Activate office emergency team • Position pt comfortably • Assess and perform basic life support as needed • Provide definitive management o O2 admin o Bronchodilator via inhalation • IF EPISODE STOPS o Dental care can continue o Pt discharged • IF EPISODE CONTINUES o Activate emergency medical services o Administer parenteral drugs