Respiratory distress

CAUSES:
Hyperventilation
Vasodepressor syncope
Asthma
Heart failure
Hypoglycaemia
Overdose reaction
Acute MI
Anaphylaxis
Angioneurotic edema
Cerebrovascular accident
Epilepsy
Hyperglycemic reaction

PATHOPHYSIOLOGY
BRONCHIOLES-primary site of
asthma
HEART FAILURE PTS-respiratory
distress 1
st
symptom
HYPERVENTILATION-Primary site-
brain
ACUTE LOWER AIRWAY
OBSTRUCTION-life threatening-
foreign object impacts in RS tract
MANAGEMENT
Recognize respiratory distress-sounds(wheezing,cough),
abnormal rate or depth of respiration

Terminate dental procedure

P---position patient supine,if unconscious,or
comfortably(upright)if conscious.

A-B-C-assess & provide BLS,as needed


D-monitor vital signs-BP,HR(PULSE),RR.
Manage patient anxiety.
Provide definitive management of RD.







AIRWAY OBSTRUCTION
Instruments & techniques used to
prevent aspiration & swallowing of
objects:
Rubber dam
Oral packing
Chair position
Dental assistant
Suction
Magill intubation forceps
Ligature
SIGNS & SYMPTOMS
Sudden onset of coughing
Choking
Wheezing
Shortness of breath
MANAGEMENT
MANAGEMENT OF VISIBLE
OBJECTS

IF ASSISTANT IS PRESENT:
Place pt in supine or trendelenburg position.

use magill intubation forceps or suction.

IF ASSISTANT IS NOT PRESENT:
Instruct pt to bend over arm of chair with head down.

Encourage pt to cough.
Management of swallowed
objects
Consult radiologist.
Obtain app radiographs
to determine location of
object
Initiate medical
consultation with app
specialist
MANAGEMENT OF
ASPIRATED OBJECTS
Place pt in left lateral decubitus
position.

Encourage pt to cough.


Object is
retrieved
Initiate medical
consult before
discharge
Object is not retrieved
Consult with radiologist
or ER dept
Perform bronchoscopy to
visualize & retrieve object.
AIRWAY OBSTRUCTION
COMPLETE
PARTIAL
SIGNS OF COMPLETE AIRWAY
OBSTRUCTION
INABILITY TO SPEAK
INABILITY TO BREATHE
INABILITY TO COUGH
UNIVERSAL SIGN FOR
CHOKING
PANIC
Signs of partial airway
obstruction
Individual with good airflow
Forceful cough
Wheezing between cough
Ability to breath
Individuals with poor air exchange
Weak ineffectual cough
Crowing sound on inspiration
Paradoxical respiration
Absent or altered voice sounds
Possible
cyanosis,lethargy,disorientation
Establishment of an emergency
airway
Tracheostomy
Cricothyrotomy
Non surgical-abdominal thrust or
heimlich maneuver
Non invasive techniques:
Back blows
Manual thrust
Heimlich maneuver
Chest thrust
Finger sweep
Back blows:
infant: infant is straddled over the
rescuers arm with the head lower than
the trunk & with the head supported by
the rescuers firm hold on the infants
jaw. Using the heel of the hand the
rescuer delivers four back blows
forcefully btw the infants shoulder
blades while resting the other hand on
the thigh.
Manual thrusts
Consists of a series of 6-10 thrusts to
the upper abdomen or to the lower
chest.They produce a rapid increase
in intrathoracic pressure,acting as an
artificial cough that can help dislodge
a foreign body.
Heimlich maneuver
Also known as subdiaphramatic
abdominal thrust or abdominal thrust,
was 1
st
described by Dr. henry J.
heimlich in 1975.
If pt is conscious:
Stand behind the pt and wrap your arms around the
waist and under the arms
Grasp one fist with the other hand placing the
thumb side of the fist against the victims abdomen.
The hand should rest in the midline slightly above
the umbilicus & well above the tip of the xiphoid
process
Perform repeadted inward &upward thrusts until
either the foreign body is expelled or the victim
loses concsiousness
If the victim is unconscious :
1. Place the victim in the supine position.
2. Open the victims airway using the head tilt-chin lift
technique and turn the head up into the neutral
position.yhe head is turned into the neutral position to
avoid airway obstruction,facilitate foreign body to be
visualised.
3. Whenever possible the rescuer should straddle the
victims legs or thighs.
4. Place the heel of one hand against the victims
abdomen,in the midline slightly above the umbilicus and
well above the tip of the xiphoid process.
5. Place the 2
nd
hand directly on top of the 1
st
hand
6. Press into the victims abdomen with a quick inward and
upward thrust.
7. Perform upto 5 abdominal thrusts.
8. Open the victims mouth & perform the finger sweep.
9. Repeat steps 2 -8 till the obstruction is dislodged.
Chest thrust
If victim is conscious:
Stand behind the victim & place the arms directly under
the armpits,encircling the chest.
Grasp one fist with the other hand, placing the thumb
side of the fist on the middle of the sternum,not on the
xiphoid process or the margins of the rib cage.
Perform backwardd thrusts until the foreign body is
expelled or the victim loses consciousness.
If the victim is unconscious:
Place the victim in supine position.
Using the head tilt chin maneuver, open the victims
airway and place the head into the neutral position.
Either straddle or stand astride the victim, as described
in heimlich maneuver.
Place the heel of one hand on the lower half of the
sternum with the 2
nd
hand on top of it, but not on the
xiphoid process.
Perform upto 5 quick ,downward thrusts to compress
the chest cavity.
Open the victims mouth and perform the finger sweep.

Finger sweep
Should be performed in unconscious victims
only.
A magill intubation forceps can aid in the
removal of foreign objects from the airway.
Procedure :
Place the victim in the supine position with the head in
neutral position.
Grasp the tongue & the anterior portionof the mandible.
To perform the finger sweep, place the index finger of the
other hand along the inside of the victims cheek and
advance it deeply into the pharynx at the base of the
tongue. Using a hooking movement try to dislodge the
foreign body & move it into the mouth where either the
suction or magill intubation tube will remov it.
HYPERVENTILATION
DEFINITION:
IS defined as ventilation in excess of that required to
maintain normal blood PaO2 and PaCO2.

OCCURS MOSTLY IN PTS BETWEEN 15 -40 YRS.

Respiratory rate may exceed to 25-30 breaths per
minute.
Clinical manifestations of
hyperventilation
SYSTEM SIGNS & SYMPTOMS
CARDIOVASCULAR Palpitations,tachycardia,precordial
pain
NEUROLOGIC dizziness.,lightheadedness,disturb
ance of consciousness or
vision,numbness & tingling of
extremities,tetany(rare)
RESPIRATORY Shortness of breath,chest
pain,dryness of mouth
GASTROINTESTINAL Globus hystericus,epigastric pain
MUSCULOSKELETAL Muscle pain &
cramps,tremors,stiffness,carpoped
al tetany
PSYCHOLOGIC Tension,anxiety,nightmares
MANAGEMENT
Terminate dental
procedure.
P----position pt
comfortably(upright)
AB---C ---BLS as
needed
D----definitive care:
remove dental materials
from pts mouth.
calm pt.
correct respiratory
alkalosis.
initiate drug treatment,if
necessary.
Perform subsequent dental
treatment.
Discharge pt.
ASTHMA
DEFINTION:
DEFINED BY THE AMERICAN
THORACIC SOCIETY as a disease
characterized by an increased
responsiveness of the trachea & bronchi
to various stimuli and manifested by
widespread narrowing of the airways that
changes in severity either spontaneously
or as a result of therapy.
Causative factors for acute
asthma
Allergy(antigen-antibody reaction
Respiratory infection
Physical exertion
Environmental and air pollution
Occupational stimuli
Pharmacologic stimuli
Psychologic factors
PREDISPOSING FACTORS
PSYCHIC STRESS
ANTIGEN-ANTIBODY
REACTION
BRONCHIAL
INFECTION
NORMAL
BRONCHIAL
REACTIVITY
NORMAL
RESPONSE-no
asthma
DUSTS,FUMES
CLIMATE HEIGHTENED
BRONCHIAL
REACTIVITY
ABNORMAL
RESPONSE--asthma
OTHERS
EXTRINSIC ASTHMA:
Also known as allergic asthma and occurs
more in children amd young adults.
Allergens maybe airborne such as house
dust,feathers,animal dander,furniture
stuffing,fungal spores,plant pollens.foods
such as eggs,milk,fish etcdrugs such as
penicillin,aspirin,sulfites.

INTRINSIC ASTHMA:
Develops usually in adults older than 35 yrs.
Also referred as nonallergic asthma,idiopathic
asthma,infective asthma.
Non allergic factors: respiratory infection,physical
exertion,environmental and air pollution,occupational
stimuli.
MIXED ASTHMA:
Combination of extrinsic and intrinsic asthma
Precipitating factor---presence of infection esp
respiratory tract.



STATUS ASTHMATICUS:
Wheezing,dyspnea,hypoxia,cyanosis,
extreme fatigue,peripheral vascular
shock,dehydration
Most severe form.
ASA CLASSIFICATION OF
ASTHMA
ASA CLASS DESCRIPTION TREATMENT
MODIFICATIONS
II Typical asthmatic-extrinsic or
intrinsic
Infrequent episodes
Easily managed
No need for emergency care of
hospitalization
Reduce stress,as
needed.
Determine triggering
factors.
Avoid triggering
factors.
Keep broncodilator.
III Patient with exercise induced
asthma
Fearful pt.
Pt with prior need for emergency
care or hospitalization
Follow ASA II
modifications.
Administer sedation-
nitrous oxide & O2 or
oral BZD,if indicated.
IV Pt with chronic sign and symptoms
of asthma present at rest.
Obtain medical
consultation.
Provide emergency
care only,in office.
Defer elective care .
SIGNS & SYMPTOMS OF
ACUTE ASTHMA
Feeling of chest congestion
Cough with or without sputum production
Wheezing
Dyspnea
Pt wants to sit or stand up
use of accessory muscles of respiration
Increased anxiety & apprehension
Tachypnea(>20 to>40breaths/min)
Rise in BP
Increase in HR
Diaphoresis
Agitation
Somnolence
Confusion
Cyanosis
Supraclavicular and intercostal retraction
Nasa flaring

CLINICAL SIGNS &
SYMPTOMS OF HYPOXIA &
HYPERCARBIA
HYPOXIA HYPERCARBIA
Restlessness,confusion,anxiety diaphoresis
cyanosis Hypertension(converting to
hypotension if progressive)
diaphoresis Hyperventilation
Tachycardia,cardiac dysrhythmias Headache
Hypertension or hypotension Confusion ,somnolence
coma Cardiac failure
Cardiac or renal failure
MANAGEMENT
Terminate dental procedure

P---position pt comfortably(upright)

A---B---C----assess & perform BLS,as needed

D----initiate definitive care:

administer bronchodilator via inhalation.
(episode terminates) (episode continues)
perform dental care. Administer O2.
discharge pt. Summon emergency
medical services.
administer parenteral drugs

hospitalize or dischrge pt.
HEART FAILURE & ACUTE
PULMONARY EDEMA
HEART FAILURE----Inability of the
heart to supply sufficient oxygenated
blood for the bodys metabolic needs.
ACUTE PULMONARY EDEMA---- life
threatening condition marked by an
excess of serous fluid in the alveolar
spaces or interstitial tissues of the
lungs & is accompanied by extreme
difficulty in breathing.
PREVENTION
MEDICAL HISTORY
QUESTIONNAIRE:
Any history of heart diseases?
When u walk upstairs do u stop becoz of pain
in chest or shortness of breath?
Do ur ankles swell during the day?
Do u use more than 2 pillows to sleep?
Have u lost or gained more than 10 pounds in
the past yr?
Do u ever awaken from sleep short of breath?
Have u ever taken any medicine or drugs
during the past 2 yrs?
DIURETICS used to manage
CHF
THIAZIDES
hydrochlorothiazide,chlorthalidone,met
azolone
LOOP DIURETICS---
furosemide,bumetanide,ethacrynic
acid
POTASSIUM SPARING
DIURETICS
spironolactone,triamterene,amiloride
Inotropic agents to treat CHF:-
digoxin,dopamine,dobutamine,amrino
ne,milrinone,aminophylline.

Vasodilators to treat CHF:-
captopril,analapril,lisinopril,quinapril,ni
troglycerin,isosorbide.
PHYSICAL EVALUATION
VITAL SIGNS:------
BP maybe elevated, with the increase in diastolic
pressure greater than that in systolic pressure.in
some situations BP may b decreased.
Heart pulse & resp rate usually increase
Any recent large unexplained weight gain,ankle
swelling.

PHYSICAL EXAMINATION:------
skin & mucous membrane color---grayish blue
Neck---jugular vein distension
Ankles----edema,pitting
ASA Classification for CHF
ASA I: the pt doesnot experience
dyspnea or undue fatigue with normal
exertion.
ASA II: the pt experiences mild
dyspnea or fatigue during exertion.
ASA III : the pt experiences dyspnes
or undue fatigue with normal activities.
ASA IV: the pt experiences
dyspnes,orthopnea, and undue fatigue
at all times.
Clinical manifestations of HF and
acute pulmonary edema
SIGNS SYMPTOMS
HEART FAILURE
Pallor,cool skin Weakness & undue fatigue
Sweating Dyspnea during exertion
Left ventricular hypertrophy Hyperventilation
Dependent edema Nocturia
Hepatomegaly & splenomegaly PND
Narrow pulse pressure Wheezing(cardiac asthma)
Pulsus alternans
ascites
ACUTE PULMONARY EDEMA
All signs of HF All symptoms of HF
Moist rales at base of lungs Increased anxiety
tachypnea Dyspnea at rest
Cyanosis,frothy pink sputum
Management of HF & acute
pulmonary edema
Terminate dental procedure

Remove dental materials from pts mouth

P----position pt comfortably(upright)

Summon emergency medical services

Calm pt.

A----B----Cassess & perform BLS as needed.

D-----definitive care:
Administer O2
Monitor vital signs
Alleviate symptoms of resp distress
Perform bloodless phlebotomy
Alleviate apprehension.

Discharge pt,

Modify subsequent dental treatment