Volume 1, Issue 2

September 2010

As the Respiratory System Ages . . .

The respiratory system includes the nose, mouth, throat, larynx, trachea, bronchi, lungs, diaphragm, chest wall muscles and all accessory musclesthe structures that allow us to breathe are susceptible to aging.

(FOR ADULTS ONLY)

SPOTLIGHT ON EMS

N J

O F F I C E
O F
E M E R G E N C Y
M E D I C A L
S E R V I C E S
D E P A R T M E N T
O F
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S E N I O R
S E R V I C E S
P . O .
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As we age, we experience both anatomical and physiological changes.

Our ability to remain healthy and functional becomes more complex. Our attention is drawn to this aging process as the number of people above 65 years of
age has increased significantly over the past two decades. Individuals live
longer, receive better health care and enjoy improved socio-economic conditions.
As we get older, calcification occurs where the ribs meet the sternum
and the spinal column. Osteoporosis of the vertebrae may cause kyphosis
(curvature of the thoracic spine or hunchbacked.) The loss of elasticity from
these conditions limits chest expansion. Respiratory muscles atrophy causing
both a decrease in muscle strength and endurance. The alveoli become
stiffernot able to completely relax and empty. Combined, the total amount of
air allowed into the lungs and the speed with which the air flows are deContinued on page 4

Signs versus Symptoms

We use the term signs and symptoms all the time. Both are something abnormal. They are the diagnostic tools which help us assess each patient. Do you see these words as interchangeable? Or do you really know the
differences between signs and symptoms?
Symptoms are consider the subjective evidence of disease. Symptoms
are experienced by an individual and only that individual can perceive them.
Anxiety, abdominal pain, low back pain and fatigue are all symptoms. They are
those things patients notice and tell us.
Symptoms can be common to a specific diagnosis or illness or they can
be common to a wide range of disease processes. They can affect the entire
body or be specific to one organ or location. They can gradually worsen or become progressively better.
Signs are the objective evidence of disease. Signs are the clinical findings that are observed. They may have no meaning to the affected individual
or even be noticed by them. They can be detected by a person other than the
affected individual. They are evident to the EMT or paramedic. Gross blood in
the stool or a bloody nose are signs. They are the things we can see.
Inside this issue:
Signs versus Symptoms

Special points of interest:

COPDWhat Do These Letters Mean?

Asbestosis

The patients chief complaint can be very

accurate in identifying the problem, even if
the patient is agitated or confused.

Calling for Emergency Services

Other Pulmonary Diseases

Spotlight on OEMSInspections

Approximately 34% of calls (3.4 million

responses) for emergency medical services
in the US involve patients over the age of 60.
The question of how much oxygen to administer to a COPD patient is tricky.

COPDWhat Do These Letters Mean?

by Kathleen Lutz, MSN, CPNP

Chronic obstructive pulmonary disease (or

COPD) is a very common lung disease. According to
Mosbys dictionary, it is a progressive and irreversible
condition characterized by diminished inspiratory and
expiratory capacity of the lungs. This means that it is
hard for a person to breathe, gets worse over time and
has no cure.

smoke and other irritants.

There are numerous complications associated with COPD. These include:
Respiratory infections, including frequent colds,
flu or pneumonia

Less air moves in and out of the airways because the airways and air sacs lose elasticity, the walls
between the air sacs are destroyed, the walls of the
airways become thick and inflamed and the airways
make more mucus, tending to clog the airways.

High blood pressure

Heart problems, including arrhythmias, heart attack, right-sided heart failure or cor pulmonale

Lung cancer

Pneumothorax

COPD is called many different names. They

include chronic obstructive airway disease, chronic obstructive bronchitis, chronic obstructive lung disease
and emphysema.
In the United States, the term COPD actually
combines two diseasesemphysema and chronic bronchitis. One usually accompanies the other. Emphysema changes the anatomy of the lungs causing the
alveoli to become floppy and destroying the walls. This
leads to fewer and larger alveoli instead of many tiny
ones. This destruction of the lungs leads to progressive dyspnea (shortness of breath). In chronic bronchitis, the bronchi are constantly irritated and inflamed.
This leads to a thickening of the lining of the bronchi
and manifests as long-term cough, especially in the
morning with extra mucus. Both disorders make it
hard to breathe.

Weight loss or malnutrition

Signs and symptoms of COPD include:

Cough with mucus (sometimes called smokers
cough)
Shortness of breath that gets worse with even mild
activity

Chest tightness

Fatigue

Frequent respiratory infections

Wheezing
These symptoms usually develop slowly and do not appear until after there has been significant lung damage. The signs and symptoms of COPD will vary depending upon which lung disease is most prominent.
People with COPD will also experience times when their
symptoms suddenly get worse. Some things people
can do to help prevent these exacerbations include
avoiding cold air, making sure no one smokes near
them and reducing air pollution such as fireplace

Page 2

Depression
COPD is almost always caused by cigarette
smoking. The symptoms will usually begin to appear
about 10 years after starting to smoke and will vary
with both the number years a person has smoked
and the number of packs smoked per day. Other
lung irritants, such as air pollution, secondhand
smoke, cigar and pipe smoke, chemical fumes and
dust can also lead to COPD. In rare cases even a
non-smoker will develop COPD as the result of a genetic disorder that causes low levels of a protein
called alpha-1-antitrypsin.

The Diagnosis of COPD

COPD is diagnosed based on a persons
signs and symptoms, medical and family history, a
history of contact with lung irritants and some tests.
These tests might include:
Pulmonary function tests including spirometry to
measure the amount of air the lungs can hold
(the forced vital capacity or FVC) and how fast
that air can be exhaled the forced expiratory
volume in one second or FEV1);
Chest X-ray can show emphysema and can rule
out other lung and heart problems;
Arterial blood gas analysis to measure how well
the lungs are carrying oxygen into the blood and
removing carbon dioxide by measuring the oxygen level in the blood;
Sputum examination can identify some lung
problems and rule out some lung cancers; and
Computerized tomography (CT) scan can produce
more detailed images of the lungs to help detect
emphysema.
Continued on page 5

S P O TL I G H T O N E M S

Asbestosthe Good and the Bad

by Kathleen Lutz, MSN, CPNP

Asbestos is the name of a commonly found

group of minerals with fiber-shaped crystals that are
resistant to chemicals, heat and fire. For these reasons,
it has had many applications aboard ships and submarines, in pipe insulation, roofing, ceiling and floor tiles
and automotive brakes.
In about 2500 B.C. it was added to clay to form
strong utensils and pots. By 300 B.C. the Greeks used
it for lamp wicks and other fireproof items. By the
1800s commercial uses for asbestos were found. By
World War II, ships had asbestos- wrapped pipes, lined
boilers and covered engine parts. At one time auto
brake pads, some textured paints and cement contained asbestos. Surgeons closed incisions with asbestos thread and many Christmas trees were decorated with
asbestos artificial snow. In
homes built before the 1970s
asbestos was in the soundproofing, roofing and siding
shingles and vinyl floor tiles.
But there turned out to
be a dark side to this multi-use product. As asbestos
breaks up into smaller particles, its crystals can become
airborne, get inhaled and lodge in the lungs. The
shorter, wider crystals associated with chrysotile asbestos usually stay in the upper airway, but the long, thin
fibers of its other forms penetrate deep into the lungs
and lower airways. Once imbedded in the respiratory

system, asbestos is usually there for life.

Health problems that seemed to be related
to asbestos exposure began to be noticed by the
early 1900s. By the mid-1960s doctors identified
huge increases in lung diseases, especially among
WW II shipyard workers.
In the 1970s, the Environmental Protection
Agency (EPA) began to restrict some uses of asbestos and although this ban was lifted in 1991, consumer fear remained and many manufacturers have
voluntarily removed asbestos from most products.
It is now generally accepted that inhalation
of the asbestos fibers is associated with three serious and often fatal diseases. Two of these affect
the lungsasbestosis and lung cancer. A third
mesotheliomais a rare form of cancer affected
the lining of the thoracic and abdominal cavities.
Lets begin with asbestosis, a chronic inflammatory disease. The nose and bronchi are
supposed to act as filters, protecting the lungs;
but thin, microscopic and needle-like fibers of asbestos can get past these filters causing an inflammatory reaction. After many such reactions, the
lungs scar. Scarred lung tissue does not expand
and contract normally and limits air exchange.
Most people with asbestosis and other asbestos-related disorders acquired it on the job
Continued on page 6

Adults Are Taught About Calling for Emergency Services

In 2007, Monmouth County emergency dispatchers received almost 170,000 9-1-1 calls. Of these
calls, 27,000 were of a non-emergent nature.

lives and also to save money. They developed

Adults Calling Emergency Services 9-1-1 (ACES
9-1-1) utilizing a video, PowerPoint demonstration,

We teach our children about when and how

to use 9-1-1, but what about todays adults who
grew up without it. Have we every gone back and
taught this group? Non-emergency 9-1-1 calls can
delay response time in real emergencies and can
be costly.

question and answer discussion and a take-home

brochure. Emergency response personnel now
have a standardized approach for the education of
adults on the proper use of the 9-1-1 system.

In Monmouth County, a collaboration between the sheriffs office, the Office on Aging and
the Office on Economic Development and Tourism
recognized a need for an educational program to
teach adults the proper use of 9-1-1 to help save
VOLUME 1, ISSUE 2

Endorsed by the National Sheriffs Association it is available to any sheriffs office. The ACES
9-1-1 program can be downloaded from the 9-1-1
Cell Phone Bank website at www.cellphonebank.org
or the Monmouth County Sheriffs Office website at
www.sheriffgolden.com. For information, contact
Monmouth County Undersheriff Ted Freeman at
(732) 577-5748.
Page 3

As the Respiratory System Ages . . . continued from page 1

creased, air becomes trapped in the alveoli and
there is increased resistance as air moves into and
out of the lungs. This leads to a decreased oxygen/
carbon dioxide exchange and reduced oxygen going
to cells throughout the body. There is also decreased sensitivity to a low oxygen level and decreased cough response. Alterations in pulmonary
circulation are generally mild with little clinical significance.
Besides these changes, sleep is disturbed,
exercise capacity is decreased and sexual activity

alters with age. Aging and the occurrence of disease

can affect the normal functions of the respiratory system and alter our care management strategies both
directly and indirectly.
This aging process is not an overnight occurrence and many of these changes are usually mild.
However, some diseases or risk factors can lead to
significant health problems. This newsletter will explore some of these problems.
Enjoy!

Other Pulmonary Diseases of the Elderly

Pneumonia is a common respiratory infection among elderly people, especially those in nursing and retirement homes. It is probably the most
frequently encountered respiratory infection of old
age.
Pneumococcal pneumonia is the most common form of community-acquired pneumonia. Hospitalized patients will present with Klebsiella and
other Gram negative bacilli or even staphylococci as
the cause of their pneumonias. Both viral and bacterial pneumonias account for increased morbidity
and mortality.
The symptoms of pneumonia in elderly patients are usually different than the symptoms seen
in younger people. These symptoms may take
longer to develop and may not be very noticeable.
The diagnosis of pneumonia should be suspected
with the clinical presentation of fever, feelings of
weakness, the appearance of more fatigue than
normal, and cough with or without sputum or
hemoptysis. Pneumonia in the elderly may also
cause confusion and disorientation and even a loss
of appetite or disinterest in eating.
Treatment includes antibiotics and other
supportive measures as needed. But remember
that older people are more susceptible to stomach
upset associated with medication ingestion and
they are often more sensitive to drug dosages. Plus
medications already being taken for other conditions might interact with any new medications.
Lung cancer is now the leading cause of
death in both men and women throughout the
Page 4

world. Both primary and metastatic (from cancers

elsewhere in the body) lung tumors are common. Metastases may originate from cancers of the breast,
gastrointestinal tract, kidneys and urinary bladder,
prostate and genital tract. Primary lung cancers occur
more commonly during the 6th and 7th decade of life.
Squamous cell is most common type of lung cancer
among smokers and adenocarcinoma among the nonsmokers. Most lung tumors are malignant. Management of lung tumors includes both surgical and nonsurgical treatments which are often poorly tolerated
among the elderly.
Aspiration of gastric contents is common
among semiconscious and unconscious patients due
to their reduced level of consciousness. Pneumonia is
the most common result of this aspiration.
Sleep apnea, although not age specific, tends
to occur more commonly in the elderly, often because
of other medical problems i.e. neuromuscular
changes, micro-infarcts, etc.
Chronic airway obstruction in old age is more
often caused by COPD but can sometimes be attributed to asthma. Asthma in the elderly needs to be differentiated from other causes of wheezing. Left heart
failure, pulmonary thromboembolism and central airway obstruction due to lung tumors are other important causes of wheezing. Eosinophilic syndromes,
bronchial carcinoids and foreign body aspiration may
also present as asthma look-a-likes.
Age-related changes affect not only normal
bodily functions but the occurrence and course of diseases.
S P O TL I G H T O N E M S

COPDWhat Do These Letters Mean? . . . continued from page 2

The diagnosis of COPD includes four stages
based on spirometry results and symptoms. These
include:
Stage 0: At Riskno disease and normal pulmonary function test
Stage I: Mildminimal shortness of breath with
or without cough/sputum. Disease process
usually unrecognized. FEV1 > 80% of predicted
value. Most people are not aware of this reduced air flow.
Stage II: Moderatemoderate or severe shortness of breath with or without cough/sputum.
FEV1 is usually 50-80% of predicted value.
This is the stage at which most people seek
medical attention and are diagnosed.
Stage III: Severemore severe shortness of
breath with or without cough/sputum; repeated
exacerbations; reduced exercise capacity; fatigue. FEV1 is usually 30-50% of predicted
value.
Stage IV: Very Severenoticeably impaired
quality of life due to the shortness of breath;
exacerbations which may be life threatening at
times. FEV1 is less than 30% of predicted
value or less than 50% with chronic respiratory
failure. This individual is often short of breath
even at rest.
COPD is a leading cause of death and disability worldwide. It is the fourth leading cause of
death in the United States. Additionally, as many
as 12 million people are living with the diagnosis
and an additional 12 million probably have the disease but have yet to be diagnosed.
There is no cure for COPD and once lung
damage occurs it is irreversible. However, there
are treatments to control the symptoms and reduce the complications and exacerbations. These
include:
Stop smoking. This is the single most important part of any treatment plan, but one that is
very difficult to achieve.
Medicationssome are used on a regular basis
and some are used only as needed:
Bronchodilatorsusually as inhalersto
relax the airway muscles to relieve
coughing and shortness of breath
Inhaled steroidsto reduce airway inflammation
VOLUME 1, ISSUE 2

Antibioticsto treat respiratory infections

caused by bacteria
Supplemental oxygen for some individuals with hypoxemia. Oxygen therapy might be either used only
during activity, while sleeping or continuously to
improve quality of life, heart function, exercise capacity, depression, mental clarity or to extend life.
Pulmonary rehabilitation program which combines
education, exercise training and nutrition advice
and counseling.
Surgery is an option for some individuals with severe emphysema and might include lung volume
reduction surgery and single-lung transplantation.
Even with good medical follow-up and adherence to an appropriate diet and medical regimen individuals with COPD will experience times when their
symptoms suddenly get worse. These exacerbations
may be due to an infection, air pollution or even a
change in temperature.
Clinical Scenario
Hes 72 years old and a life-long smoker, known COPD,
on long term home oxygen and nebulizer therapy. You
have responded to the familys 9-1-1 call because he is
having increased respiratory distress with wheezing.
Your initial assessment reveals a blood pressure of
120/80mm Hg, pulse of 130 beats/min, respirations
of 28 breaths/min. You hear wheezing and rales on
auscultation.
You should help administer the patients prescribed inhaler, if the patient or family has not already
done this. Oxygenand how much to administeris
always tricky. The potential danger of giving oxygen to
someone with COPD has long been recognized. The
potential benefit is not so well known. Start high flow
oxygen by non-rebreather mask. Transport immediately.
When a COPD patient becomes ill, they almost
always become more hypoxic. Every organ is stressed
because of low oxygen levels throughout the body.
High flow O2 will not kill this patient during transport.
Patients in respiratory distress, whether they have
COPD or not, need oxygen.
Oxygen administration will not be the cause of
a patients apnea and death. Patients in respiratory
failure, whether they have COPD or not, need ventilatory support. Never withhold oxygen from a patient in
respiratory distress!
Page 5

Asbestosthe Good and the Bad. . .continued form page 3

before the federal government began regulating the
use and handling of asbestos-containing products.
Many products now contain only trace amounts of asbestos. However, some developing countries, such as
China and India, have continued to use asbestos. And
the destruction of the Twin Towers on 9/11 is thought
to have released over 1000 tons of asbestos into the
air.
The risk of disease increases as the length
and frequency of exposure increases and is also dependent on the increasing concentration of the asbestos exposure. It can take decades for any symptoms
of asbestos exposure to appear. And not everyone
who is exposed to asbestos will develop disease.
There are often no immediate symptoms with
asbestosis. Late in the course of the disease someone with asbestosis might experience shortness of
breath, a persistent dry cough or chest pain and tightness. Asbestosis is a risk factor for lung cancer.
There is no cure for asbestosis. Treatment focuses on slowing or preventing disease
progression and easing any existing symptoms.
To ease symptoms health care providers often
recommend humidifiers, respiratory therapy or
oxygen.
If a person smokes and has asbestosis,
their chances for developing lung cancer increase greatly. Tobacco smoke and asbestos contribute to each others cancer-causing effects so that the
combination of these risk factors is more dangerous
than either alone.
The mesothelium is the membrane that forms
the lining of several body cavities: the pleura, peritoneum and pericardium. The pleura (lining of the lung)
might thicken and form a plaque or calcifications. Or
the pleural space between the lungs and chest wall
can fill with fluid in a pleural effusion. Mesothelioma,
or cancer of the mesothelium, develops when the cells
of the mesothelium divide without order or control and
even invade nearby tissues and organs. Since the
peritoneum and the pleura are both mesothelial tissue you might see pleural mesothelioma and peritoneal mesothelioma. Approximately 2,000 new cases
of mesothelioma are diagnosed in the U.S. each year.
A history of work-related asbestos exposure is reported in about 70-80 percent of all cases of mesothelioma (but often 30-50 years after the exposure).
Page 6

Symptoms of mesothelioma will vary depending on the primary location of the mesothelioma and may include:

Shortness of breath

Pain in the chest due to an accumulation of

fluid in the pleura

Weight loss

Abdominal pain and swelling due to fluid buildup in the abdomen

Bowel obstruction

Blood clotting abnormalities

Anemia and

Fever

Treatment of mesothelioma includes surgery, radiation therapy and chemotherapy. These

treatments may be used singly or combined. The
National Cancer Institute is
sponsoring clinical trials to find
new treatments and new ways
to use current treatments.
Who gets asbestosis
and other asbestos related
diseases?
Anyone who has
worked at jobs where they encounter asbestos on a regular basis are at highest
risk. Family members of those who have had daily
contact with asbestos have been known to develop
asbestosis through exposure to asbestos particles
brought home on the clothing of that person. Even
individuals living in the vicinity of a factory that
manufactures asbestos or asbestos-containing
products should be concerned.
Reducing asbestos exposure is the best
prevention against asbestosis. Thankfully, bans
and warning on asbestos-containing products over
the past 30 years have made asbestos exposure
less common. Federal law requires employers in
industries working with asbestos products to monitor exposure levels, create regulated areas for asbestos work and provide employees with appropriate training, protective equipment and decontamination areas. Eventually, there will be reports of
fewer and fewer new cases of asbestosis and other
asbestos related diseases .
S P O TL I G H T O N E M S

POST TEST
1-4. Identify each of the following as either:
A.

8.

Health risks associated with asbestos exposure include:

Sign

A.

Mesothelioma

B. Symptom

B.

Lung cancer
COPD

1.

Headache

C.

2.

Rapid pulse

D.

A&B

3.

Jaundice

4.

Nausea

E.

B&C

5.

Many of the symptoms associated with COPD appear early in

the course of the disease before any major lung damage has
occurred.

6.

7.

9. Age-related changes of the respiratory system include all of

the following, EXCEPT . . .
A.

Stiffening of the alveoli

A.

True

B.

Respiratory muscle strength decreases

B.

False

C.

Increased metabolism rate

Medications for the treatment of the symptoms of COPD

include:
A.

Insulin

B.

Inhaled steroids

C.

Chemotherapy

D.

Antihypertensive medications

Cough

B.

Confusion

C.

Loss of appetite

D.

All of the above

Diminished response to hypoxemia

Increased chest wall rigidity

10. Many seniors:

A. Grew up with the 9-1-1 emergency call system
B. Are comfortable with calling 9-1-1 in an emergency

Pneumonia in the elderly might present as:

A.

D.
E.

C.
D.

Are unfamiliar with the proper use of 9-1-1

Will call 9-1-1 before calling a friend or family member
in an emergency

ANSWER SHEET (#100245370) Spotlight on EMS Newsletter, Fall 2010

EMT
Name _______________________________ ID # __________
Address ____________________________________________
Town _______________________________________________
State: _________

1 (One) Professional Development Hour for NJ School

Nurses with a minimum score of 70%

NJ EMT

NJ School Nurse

Zip Code: _____________________

E-mail address: _______________________________________

Completed sheets must be received by March 31, 2011

Answer sheets received after that date will not receive credit.
Complete and return only the answer sheet
via mail, fax or e-maildo not submit multiple copies
OEMS Attention Kathy Lutz
P.O. Box 360, Trenton NJ 08625-0360
Fax (609) 633-7954
E-mail ems@doh.state.nj.us
VOLUME 1, ISSUE 2

1 (One) Elective CEU for NJ EMTs with a minimum score of

70%

Respiratory System (circle correct answer only)

1.

A B

6. A B C D

2.

A B

7. A B C D

3.

A B

8. A B C D E

4.

A B

9. A B C D E

5.

A B

10. A B C D

Page 7

Published by the
STATE OF NEW JERSEY
Chris Christie, Governor
Kim Guadagno, Lt. Governor

OFFICE OF EMERGENCY MEDICAL SERVICES

NJ DEPARTMENT OF HEALTH & SENIOR SERVICES
P.O. BOX 360
TRENTON, NJ 08625-0360

Department of Health &

Senior Services
Dr. Poonam Alaigh
Commissioner
Office of Emergency Medical
Services
Karen Halupke, Director

Spotlight on OEMS INSPECTIONS

Ambulances are supposed to provide safe efficient emergency transportation for the sick, injured and
persons with disabilities. To insure that all of these
vehicles are in good working order the New Jersey Department of Health and Senior Services Office of Emergency Medical Services oversees the provider licensure
of approximately 4,000 vehicles across the state.
Ambulance Licensureevery 2 years
New Jersey requires initial and biennial licensure of all mobility assistance, basic life support and
specialty care transport vehicles (including ALS and air
medical) used to provide prehospital care or medical
transportation to sick, injured or disabled persons while
collecting a fee for the service. Volunteer ambulance
services licensure is optional. The Application for New
Provid ers
is
available
at
www.state.nj.us/health/ems/forms.shtml. as a
MSWord document. Complete the form online. Bring
the printed and signed form with a certified check or
money order. No personal/company checks.
Ambulance Inspectionevery 4 years
All new vehicles must be inspected prior to being
put into service
All currently licensed vehicles (including mobility
assistance, basic life support, ALS & air medical)
must be have a DHSS inspection every 4 years
MAV companies currently working with LogistiCare
get no re-inspectionsonly the initial inspection
2 vehicle inspection sitesschedule all appointments by calling (609)633-7777

Trenton

Jersey City
Prepare for the Inspection
Like any testpreparation counts. During
an inspection isnt the time to identify a problem
with any vehicle.
Do your own pre-inspection on the vehicle
prior to every State inspection. Sample inspection
f o r m s
a r e
a v a i l a b l e
a t
www.state.nj.us/health/ems/forms.shtml.
This
could save you from a failure, a vehicle out of service and another trip to the inspection site.
InspectionsMost Common Mistakes
Triple K-A-1822 Federal Certification sticker
must be on vehicle
Main O2 bottle not properly restrainedneeds 3
brackets/straps
Door openings must not be obstructed
Bench seat must have a positive action latch
Unsecured equipmentinterior items must be
crash-worthy
Suction units dont work
Rips/holes in seat covers/fabric/floor, glass
cracked, door gaskets damaged
Vehicle dirty
Unsure about something? Have a question?
Call (609) 633-7777