ems pulmonary lecture mike md, mph. outline anatomy physiology airway management medical management...
TRANSCRIPT
EMS Pulmonary Lecture
Mike MD, MPH
Outline
• Anatomy• Physiology• Airway Management• Medical Management• Trauma Management
Epidemiology
• 25% Infectious• 5% Tb• 28 % Neoplasia• 13 % Multiple or miscellaneous• 28 % Undetermined• Risk Factors – Marlboro Man +/- horse
Functions of Respiratory System
• Moves Air• Communication• Non-specific Immunity• Acid/Base
Respiratory Tract Anatomy
• Conducting– Nose/Mouth– Nasopharynx/Oropharnyx– Laryngopharynx– Trachea
Respiratory Tract Anatomy
• Conducting– Trachea– Bronchus– Bronchiole– Terminal Bronchiole
Respiratory Tract Anatomy
• Respiration– Alveolar ducts– Alveoli
Respiratory Tract Anatomy
Respiratory Mechanics
Pressure and Volume PV=nRTPV=1
As pressure increases, volume decreasesAs volume increases, pressure decreases
Respiratory Mechanics
• Pressure• Volume• Adhesion• Compliance• Surface Tension• Gas Exchange
Respiratory Mechanics
• Adhesion– Parietal– Visceral– Pleural Fluid
Respiratory Mechanics
• Surface Tension
Respiratory Mechanics
• Compliance
Respiratory Mechanics
• Gas Exchange• Oxygen Transport
– Dissolved– Bound
• pH• O2
• Temperature
Airway Resistance
• R=8nL/R 4
• Cross-sectional Area• Dynamic
Respiratory Cycle
Respiratory Control
• Mechanoreceptors– Inflation– Deflation
• Chemoreceptors– pH– PCO2
– PO2
Respiratory Distress
• Dyspnea• Orthopnea• PND• Cyanosis
– Central– Peripheral
• Lung SoundsPT 630 - Breath Sounds
Respiratory Distress
• Airway• Cardiac• Lung• Thoracic Cavity• Vascular• Neuromuscular
Respiratory Distress
• O2– Hypoxia– Hypoxemia– Relative Hypoxemia
• CO2– Acute– Chronic
Infections
• Bronchitis• Pneumonia• Tuberculosis
Hemoptysis
• Dual Blood Supply• Mechanisms
– Intravascular– Inflammatory– Coagulation
Pathophysiology
• Intravascular – LV CHF– Mitral Valve Stenosis– Rheumatic Heart Disease
Pathophysiology
• Inflammatory– Bronchitis– Bronchiectasis– Mycetoma– FB– PE– Pneumonia– Neoplasia– TB– Vasculitidies
Pathophysiology
• Coagulopathies– Hemophilia– Thrombocytopenia– Anticoagulants– Thrombolytics
Clinical Features
• History– Fever– Sputum– Weight loss– Night sweats
• Physical Examination– Vitals– NasalCavity and oropharynx– Murmurs– Clubbing– Rales vs Rhonchi
Diagnostic Approach
• Confirm Location– Pseudo, GI or pulmonary
• Urgent Bronchoscopy• CXR
– Neoplasia– 20-30% normal
• Chest CT– Neoplasia vs bronchiectasis
Treatment
• Identify history of Tb or COPD• Decubitus Position• Intubation with large ETT • Mainstem Bronchus intubation
Asthma in Adults
• Chronic inflammatory disease• Prevalence
– Children– Elderly
• Incidence– < 10– < 40
• Morbidity– > 100% increase
• Mortality– Non uniform increase
Pathophysiology
• Large and Small Airways• Muscular• Vascular • Cellular
– Mast Cells– PMN– Eosinophils– Goblet Cell– Fibroblasts
Pathophysiology
• Acute– Mast– Eosinophils– PMN– Platelets– Lymphocytes
• Subacute– “resident cell activation”
• Chronic– Deposition of Collagen
Pathophysiology
• Allergic– Family history
• Idiosyncratic– Normal IgE
• Triggers– Environmental– Infectious– Behavioral– Medication– Emotional
Pathophysiology
Symptoms
• Dyspnea• Chest Tightness• Wheezing• Cough• Tachypnea• Tachycardia**
** pay attention in pediatrics
Severity Of Exacerbation• Breathlessness
– Walking, talking, rest• Position
– Lying, sitting, upright• Speech
– Sentences, phrases, words• Tachycardia
– 100, 100-120, >120• PEFR
– 80%, 50-80%, < 50%• Pulse Ox
– >95%, 91-95%, <91%• ABG
– You know its severe if you order an ABG
Assessment
• PEFR • Pulse Oximetry• EKG
– Reversible
Treatment
• Adrenergic Agents• IV vs Inhaled• Albuterol• To space or not to space?
Treatment
• Corticosteroids– IV vs PO
• Anticholinergics• Mg• Heliox
Treatment
• Assisted Ventilation– Indications– Risks
• Barotrauma• Hypotension• Mucus Plugging
– Ventilation Rate
Special Circumstances
• Age• Pregnancy
– Incidence– Oxygen– Fetal Risks– Treatment
The Things You Ask if You Have the Time
• Risk Factors for Death– Sudden severe exacerbations– ICU– Intubation– Recent Withdrawl of Steroids– ED visits– Albuterol use
COPD
• Chronic Bronchitis– Clinical definition
• Emphysema– Pathological definition
COPD Epidemiology
• Prevalence• Men vs Women• WHO estimates• Hospitalization mortality
– Floor– ICU– Within 1 year after discharge
Pathophysiology
• Risk Factors– Behavioral– Genetic
• Bronchitis/Emphysema• Expiratory Flow• Inflammation and Elastance
Pathophysiology
• Hypoxemia and hypoventilation• Neurochemical regulation• Pulmonary blood flow• Cardiac risks
Clinical Features - Chronic
• Cough• Crackles• Wheeze • Hyperinflation• Weight Change• Mental Status
Clinical Features –Acute
• Causes– Infectious– Behavioral – Iatrogenic– Cardiac
• Hypoxemia• Hypercapnia• R/O other intrathoracic disease
Treatment - Acute
• Oxygen• Albuterol• Atrovent• Steroids
Treatment - Acute
• Assisted Ventilation– Complications
• Infectious• Cardiac• Traumatic
• BIPAP
Trauma
• Pneumothorax– Blunt– Penetrating
• Hemothorax• Tension Pneumothorax• Assisted Ventilation
– Pros– Cons
Basic Airway Management Saves Lives
• Jaw Thrust• Airway Adjunct• NRB/BVM
Review
• Airway and Lung Anatomy• Respiratory Mechanics and Physiology• Respiratory Infections/Hemoptysis• Asthma• COPD• Trauma• Plug for BLS airway management