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Objectives:
At the completion of this section, the learner will be able to:
Describe the components of a respiratory assessment
Recognize clinical manifestations associated with common respiratory disorders
List medical and nursing interventions for common respiratory disorders
Evaluate interventions carried out for common respiratory disorders
The CEN exam contains 18 questions on respiratory emergencies which involve the
following topics:
Tasks
Assist with tracheal intubation
Suction airway
Ventilate patient using esophageal-tracheal
combitube or laryngeal mask airway
(LMA)
Evaluate the patients response to oxygen
therapy
Interpret end-tidal CO2 results via
capnography
Manage patients with surgical airway (e.g.,
cricothyrotomy, tracheostomy)
Perform a respiratory assessment
Measure peak expiratory flow rate
Assess endotracheal/tracheal tube
placement
Initiate oxygen therapy
Care for patient on a mechanical ventilator
Assess need for needle thoracostomy
Perform arterial puncture for arterial blood
gas sample
Use BiPAP or CPAP
Manage chest tube and drainage system
Interpret results of arterial blood gas
studies
Assist with and/or administer a nebulizer
treatment
Assess for pulsus paradoxus
Identify signs and symptoms related to
respiratory emergencies
Apply physiologic principles when caring
for patients with respiratory emergencies
Administer respiratory pharmacologic
agents
Page 1
Respiratory patterns
Pattern
Eupnea
Tachypnea
Hyperventilation
Hyperpnea
Kussmauls
respirations
Dyspnea
Orthopnea
Bradypnea
Apnea
Biots
respirations
Ataxic
respirations
Central
neurogenic
hyperventilation
Apneustic
breathing
Cheyne-Stoke
respirations
Description
Normal rate and depth
Used to describe rapid rate regardless of depth. (Depth is variable.)
Used to describe increased depth regardless of rate. (rate is variable). Depth
exceeds metabolic demands of the body, so patient may have high oxygen and
low carbon dioxide content.
Both rate and depth are increased but they meet the metabolic demands of the
body, therefore oxygen and carbon dioxide levels may be normal.
Rapid and deep breathing without pauses. Patient appears to be air hungry,
gasping to breath. Usually associated with states of acidosis
Subjective sensation of difficult or labored breathing
Sensation of dyspnea when laying down
Used to describe decreased rate regardless of depth. (Depth is variable)
Absence of breathing
Fast and deep breathing punctuated by periods of apnea. Related to damage to
the medulla oblongata from strokes or trauma. May also be seen in meningitis.
Irregular, random pattern of deep and shallow respirations with irregular apneic
periods. Usually a poor indicator of prognosis associated with increased
intracranial pressure.
Very deep and rapid respirations with no apneic periods associated with
increased intracranial pressure
Prolonged inspiratory and/or expiratory pause of 2 3 seconds. This usually
signifies the presence of brainstem lesions usually at the level of the pons
Rhythmic crescendo and decresendo of rate and depth of respiration, which
includes brief periods of apnea. Usually associated with increases of carbon
dioxide in the cerebrum.
Nasal Flaring
Intercostal
muscle
retractions
Diaphragmatic
breathing
Accessory
muscle use
Page 2
Auscultation
Breath
sound
Wheezing
Rhonchi
Crackles
Pleural
fraction rub
Description
Significance
Pulmonary Embolism
Type of Emboli
Blood
Fat
Amniotic fluid
Air
Notes
A blood clot which migrates from another part of the body, typically the right side
of the heart, the pelvis or from a deep vein thrombosis in the legs.
Blood clots are the most common causative agent of a pulmonary embolus.
Risk factors include immobility, pregnancy, and increasing age
A fat embolus which can occur 24 to 48 hours after a long bone fracture, such as a
fracture of the femur, humerus or pelvis.
One symptom that is unique to fat emboli is petechiae of the chest and axilla.
Symptoms show up shortly after delivery of an infant.
Inadvertent injection through an intravenous line or from intravenous
administration of medications.
Secondary to diving injuries
Page 3
Lung infections
Physiology
Signs and
symptoms
Acute bronchitis
Viral inflammation of
the upper airways
Upper respiratory
tract infection
(URI)
Dry, hacky
nonproductive
cough that
progresses to
productive cough.
Most troublesome
at night triggered
by deep breathing,
talking and
laughing.
Chest pain
Bronchiolitis
Viral infection leading to
profuse secretions and a
necrotic response
producing cellular debris
that can occlude the lower
airways, more worrisome
in infants/young children.
Recent URI with
progressive dyspnea
and cough.
Poor feeding,
irritability, and
lethargy
Tachypnea, possibly
apnea in infants
Grunting, nasal
flaring, intercostal
retractions, cyanosis
Wheezing on
auscultation
Indications of air
trapping on x-ray
Diagnosis
Clinically evident
Nasopharyngeal culture.
Chest radiograph may
show air trapping and
infiltrates.
Treatment
Self-limiting
Cough preparations
Humidification
Bronchodilators
Corticosteroids
Oxygen
Antivirals,
anticholinergics,
adrenergic stimulants.
Admission for signs of
respiratory fatigue,
oxygen saturations
less than 90% despite
treatment, respiratory
rates above 70 breaths
per minute and apneic
episodes.
Page 4
Pneumonia
Multiple causes including bacteria
and viruses. Viral infections have
a slower onset and are more
common in the winter. Bacterial
infections have a rapid onset.
Antibiotics administered
within four hours of admission
for bacterial causes.
Page 5
Treatment
Classification
Action
Examples
Epinephrine (Adrenalin)
Racemic epinephrine (Micronefrin,
Asthma nefrin)
Terbutaline (brethaire, brethine)
Albuterol (Proventil, Ventolin)
Isoetherine (Bronkosol, Bronkometer)
Salmeterol zinaoate (Serevent)
Xopenex (Levabuterol)
Ipratropium (Atrovent)
Inhaled
Dexamethasone (Decadron,
Respinhaler)
Beclomethasone (Beclovent,
Vanceril)
Triamcinolone (Azmacort)
Flunisolide (Aerobid)
Oral outpatient treatment prednisone
Intravenous inpatient treatment Methylprednisilone (Solumedrol)
Sympathomimetics
Parasympatholytics
Corticosteroids
Method
Metered Dose
Inhaler
Spacer
Dry Powder
Inhaler
Nebulizer
Notes
The drug is suspended in chlorofluorocarbon liquid propellant (Freon). Patient must be
able to hold breath and be coordinated enough to participate.
Increase vaporization of particles and increase lung penetration as well as decreasing
loss of drug in air or mouth. It takes less coordination to use a spacer and may be an
alternative to people who struggle with metered dose inhalers.
Another alternative for people who cannot use a metered dose inhaler. Capable of high
inspiratory volumes.
This method is preferred for a patient who is unable or too sick to cooperate with
metered dose inhalers and spacers.
It will deliver drugs better than other methods to lower airways.
The patient should be upright for the treatment (40 90 degrees) to allow deep
ventilation and maximal diaphragmatic movement.
If the heart rate increases more than 20 beats per minute, stop the treatment.
Never administer nebulizer treatments to a crying child as crying decreases
absorption of the medication.
Page 6
Exhale completely
Press down on the inhaler as you
begin to inhale and continue to
inhale as deeply as you can.
Hold your breath as you count to
ten slowly.
For beta-two agonists, wait one
minute between puffs.
If the patient will be using a spacer,
the directions are similar except for
third bullet point, the patient
should press down on the inhaler
and wait five seconds before
beginning to inhale.
o Chronic Bronchitis (Chronic inflammation of the bronchi) and emphysema
(Destruction of the elastic properties of the lungs by enzymes resulting in loss of
natural recoil and support of lung tissue)
Chronic bronchitis
Emphysema
Blue bloater
Pink puffer
Productive cough
Cough uncommon
Stocky build
Thin
Onset 40 50 years
Onset 50 75 years
Normal respiratory rate
Tachypnea
Hypoxemia
PaO2 normal or slightly
Increased PaO2
PaCO2 low or normal until the end
Cyanosis
Barrel chest
Polycythemia
Accessory muscle use
Cor Pulmonale
Leans forward while sitting
Peripheral edema
Pursed-lip breathing
Risk for pulmonary embolism
Hyporesonance on percussion
Enlarged heart on x-ray
Lung overinflation and low
diaphragm on x-ray
Page 7
Treatment
Continuous positive airway pressure (CPAP)
o No cure symptom control only
and Bi-level positive airway pressure (BiPAP)
o Patient position: sit upright and
Advantages
leaning forward
o Rests respiratory muscles
o Increases tidal volumes Maintains
o Cardiac monitoring
PEEP
o Pharmacology
o Times breaths
Beta-adrenergic agonists
o FiO2
Mucolytic agents
Risks
Steroids
o Pneumothorax
o Hypotension
Antibiotics for infection
o CPAP/BiPAP
Elevate the head of the bed 30 degrees to leak around the mask.
If pressures exceed 20 cm Hg, consider insertion of gastric tube to
decrease gastric distension.
Patient must be able to keep their mouth closed for CPAP/BiPAP to be
effective when a nasal
mask is used.
Pulmonary edema
o Causes
Acute Respiratory
Cardiogenic
Distress Syndrome
Inflammatory nonHeart failure
cardiogenic
MI
pulmonary edema
Severe Anemia
Hyperthyroidism
Hypertension
Myocarditis
Page 8
Neurogenic
This relatively rare
form of pulmonary
edema may occur
within hours of a
severe neurological
insult.
High Altitude
Occurs 2 4 days after
ascending above 8000
feet, or people who live
above 8000 feet, descend
for 2 4 weeks, than
return home.
Page 9
Treat underlying
conditions
Antibiotics for
infections
ACE inhibitors
for heart
failure
Etc.
High altitude
Airway Obstruction
Area of airway
Symptoms
Large obstructions will cause complete airway obstruction with lack of
Larynx
coughing, airway sounds or air movement.
Smaller obstructions may cause hoarseness and aphonia
Large obstructions will cause complete airway obstruction with lack of
Trachea
coughing, airway sounds or air movement.
Smaller obstructions will cause wheezing similar to asthma
Cough, unilateral wheezing and unilateral decrease in breath sounds
80 90% of aspirated objects lodge in the bronchi. In adults, foreign
Bronchi
objects are more likely to lodge in the right bronchi. In pediatric patients,
there is no difference between obstruction in the right and left bronchi.
Treatment
o Complete laryngeal or tracheal obstruction: Heimlich Maneuver
o Partial obstruction and bronchial obstruction: Endoscopic removal
Minimize crying in children while awaiting intervention.
Be prepared for alternate airway
Thoracic trauma
o Rib fractures
Fractures of the first and second ribs associated with injury to the lungs, aortic
arch, vertebral column, disruption of the subclavicular artery or vein)
Age Considerations
Key points
Page
10
Definition:
Paradoxical chest wall movement A
flail chest results in a free floating segment
of the chest wall drawn inward during
inspiration and outward during expiration
o Pulmonary contusion (injury of the lung resulting in edema and blood collection in
the lung parenchyma)
Symptoms (Often mild on arrival to ED and progressively worsen)
Dyspnea
Hypoxia
Hemoptysis
Treatment
Rib fractures
o Oxygen administration
o Pain management (avoid respiratory suppression)
o Oral or IV analgesia
o Intercostal nerve blocks
o Deep breathing/coughing
o Incentive spirometry
Flail chest segments
o Consider nursing on injured side
o Consider mechanical ventilation
Pulmonary contusion
o Nurse in semi-Fowlers position
o Consider mechanical ventilation
o Absence of hypovolemia - fluid
restriction/diuretics
o Ruptured diaphragm (abdominal contents herniate into the chest and compress the
lungs, heart and mediastinum)
Clinical manifestations
Lower chest, abdominal or epigastric pain that radiates to the left
shoulder
Dyspnea
Decreased breath sounds on affected side
Heart sounds shifted to the right side of chest
Signs of obstructive shock
Dysphagia
Bowel sounds in middle to lower chest
Treatment
Trauma care
Surgery
Page
11
Definition - Pneumothorax
- Air enters the pleural space, causing a
negative intrapleural pressure and collapse
of the lung
- Causes: Trauma, barotrauma (diving
incidents, explosions), spontaneous
(common in smokers of tall stature between
the ages of 20 and 40), emphysema.
Definition - Open Pneumothorax
- An opening at least 2/3 the diameter of the
trachea from the outside of the body that
penetrates the chest wall and allows
accumulation of air in the pleural space
Definition - Tension Pneumothorax
- An accumulation of air in the pleural space
that is so great it compresses the contents of
the chest cavity to one side or the other
Air Accumulation
Breath
Sounds
Fremitus
Percussion
Hyporesonance
Hyperresonance
Pain
Egophany
Page
12
Definition:
Egophany Have the patient say e
while holding a stethoscope near the top
of the fluid line. The e will sound like
an a through fluid.
Causes
Bubbling or fluctuations in
the water seal chamber
cease
Continuous bubbling in the
water seal chamber
Page
13
Lacerated liver
Pancreatic injury
Ruptured diaphragm
Pericardial tamponade
The emergency nurse knows that Triamcinolone (Azmacort) is given to the asthmatic patient for
which of the following reasons?
a.
b.
c.
d.
Epiglottits
Bronchiolitis
Pleural effusion
Large pulmonary embolism
A needle thoracostomy is performed for the treatment of a tension pneumothorax. Which of the
following assessment parameters indicates that the intervention has NOT had its intended effect?
a. The patients respiratory rate decreases after the procedure is performed.
b. The trachea shifts away from the needle after the procedure is performed.
c. There is a hissing sound noted from the needle immediately after the procedure is
performed.
d. The patients mean arterial pressure changes from 76 mm Hg to 92 mm Hg after the
procedure is performed.
Answers: C, C, D, B
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