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Objectives
Upon successful completion of this program, the
ECRN should be able to:
review the signs and symptoms and field
interventions for the patient presenting with CHF,
pulmonary edema, COPD, and asthma.
review criteria for the use of CPAP.
review the SOP for Acute Pulmonary Edema,
Asthma/COPD with Wheezing, and Conscious
Sedation
Objectives contd
review the Whisperflow patient circuit for
CPAP used in the field.
review the set up of the albuterol nebulizer
kit and in-line Albuterol set-up.
successfully complete the quiz with a score
of 80% or better.
Heart Failure
A clinical syndrome where the hearts
mechanical performance is compromised and
the cardiac output cannot meet the demands
of the body
Considered a cardiac problem with great
implications to the respiratory system
Heart failure is generally divided into right
heart failure and left heart failure
Heart Failure
Etiologies are varied
valve problems, coronary disease, heart disease
dysrhythmias can aggravate heart failure
Refusals
A conscious and alert patient has the right to refuse care and/or
transportation
A refusal, though, with a patient in CHF might prove devastating
Positioning
tripod - resting arms on thighs, leaning forward
inability to recline in bed without multiple pillows
using more pillows to be comfortable in bed
pulmonary
Region X SOP
Patient alert
Skin warm & dry
Systolic B/P > 100 mmHg
Nitroglycerin 0.4 mg sl - maximum 3 doses
Consider CPAP
Lasix 40 mg IVP (80 mg if already taking)
If systolic B/P remains >100 mm Hg give Morphine Sulfate 2
mg IVP slowly
If wheezing, obtain order from Medical Control for Albuterol
nebulizer
Lasix (Furosemide)
Morphine sulfate
narcotic analgesic (opioid)
causes CNS depression; causes euphoria
increases venous capacity and decreases venous return to the
heart by dilating blood vessels
used to decrease anxiety and to decrease venous return to the
heart in pulmonary edema
give 2 mg slow IVP; titrate to response and vital signs and give 2
mg every 2 minutes to a maximum of 10 mg IVP
effects could be increased in the presence of other depressant
drugs (ie: alcohol)
Albuterol
bronchodilator
reverses bronchospasm associated with COPD
dose is 2.5 mg in 3 ml solution administered in the
nebulizer
the patient may be aware of tachycardia and tremors
following a dose
Albuterol must be ordered by Medical Control for
the acute pulmonary edema patient
Case Scenario #1
A 68 year-old female calls 911 due to severe
respiratory distress which suddenly woke her up
from sleep. She is unable to speak in complete
sentences and is using accessory muscles to
breathe. Lips and nail beds are cyanotic; ankles are
swollen.
B/P 186/100; P - 124; R - 34; SaO 2 - 88%
Crackles are auscultated in the lower half of the
lung fields.
Case Scenario #1
History: angina and hypertension; smokes 1
pack per day for the past 30 years
Meds: Cardizem, nitroglycerin PRN; 1 baby
aspirin daily; furosemide, Atrovent inhaler
as needed
Rhythm:
Case Scenario #1
What is your impression?
What intervention(s) are appropriate
following Region X SOPs?
What is the rationale for these
interventions?
What is this patients rhythm and do you
need to administer any medications for the
rhythm?
Case Scenario #1
Impression: congestive heart failure with pulmonary
edema
paroxysmal nocturnal dyspnea (sudden shortness of breath at
night)
bilateral crackles in the lungs
peripheral edema
cardiac history - hypertension and angina
Case Scenario #1
Interventions
Sit the patient upright, have their feet dangle off the sides of
the cart
promotes venous pooling of blood and decreases the
volume of return to the heart
Oxygen via non-rebreather face mask
Prepare to assist breathing via BVM
have BVM reached out and ready for use
IV-O2-monitor
Meds: NTG, Lasix, Morphine, consider CPAP
Region x SOP
CPAP
Continuous
Positive
Airway
Pressure
A means of providing high flow, low pressure oxygenation to
the patient in pulmonary edema
CPAP
CPAP, if applied early enough, is an effective way to
treat pulmonary edema and a means to prevent the need
to intubate the patient
CPAP increases the airway pressures allowing for better
gas diffusion & for reexpansion of collapsed alveoli
CPAP allows the refilling of collapsed, airless alveoli
CPAP allows/buys time for administered medications to
be able to work
Before
CPAP
With CPAP
Discontinuation of CPAP
Hemodynamic instability
B/P drops below 100 mmHg
The positive pressures exerted during the use
of CPAP can negatively affect the return of
blood flow to the heart
Patient Circuit
Case Scenario #2
EMS has initiated CPAP and simultaneous
medication administration (NTG, Lasix and
Morphine) to a 76 year-old patient who EMS has
assessed to be in acute pulmonary edema
The patient begins to lose consciousness and the
blood pressure has fallen to 86/60.
What is the appropriate response for EMS to
take?
Case Scenario #2
This patient is showing signs of deterioration
The CPAP needs to be discontinued
No further medications (NTG, Lasix, Morphine)
can be administered due to the lowered B/P
Prepare to intubate the patient following the
Conscious Sedation SOP
support ventilations with BVM prior to
intubation attempt
COPD
Chronic obstructive pulmonary disease - a progressive
and debilitating collection of diseases with airflow
obstruction and abnormal ventilation with irreversible
components (emphysema & chronic bronchitis)
Exacerbation of COPD is an increase in symptoms
with worsening of the patients condition due to
hypoxia that deprives tissue of oxygen and
hypercapnia (retention of CO2) that causes an acidbase imbalance
Emphysema
Gradual destruction of the alveolar walls distal to the
terminal bronchioles
Less area available for gas exchange
Small bronchiole walls weaken, lungs cannot recoil as
efficiently, air is trapped
in number of pulmonary capillaries which resistance
to pulmonary blood flow which leads to pulmonary
hypertension
may lead to right heart failure & cor pulmonale (disease of the
heart because of diseased lungs)
Emphysema
in PaO2 leads to in red blood cell production (to carry
more oxygen)
Develop chronically elevated PaCO 2 from retained carbon
dioxide
Loss of elasticity/recoil; alveoli dilated
More common in men; major contributing factor is cigarette
smoking; another contributing factor is environmental
exposures
Patients more susceptible to acute respiratory infections and
cardiac dysrhythmias
Assessment of Emphysema
Case Scenario #3
The patient is a conscious, restless, and anxious 68 year-old male
with respiratory distress that has progressively worsened during the
past 2 days.
The patient has cyanosis of the lips and nail beds
B/P 138/70; P - 116 & irregular; R - 26; SaO 2 82%
Rhonchi and rales are auscultated in the lower right lung field;
patient feels warm to the touch
The patient has had a cold for 1 week with a productive cough of
yellow-green sputum
Hx: emphysema, angina, osteoarthritis
Case Scenario
Case Scenario #3
What is this patients rhythm?
What influence would this rhythm have on this
patients health history & current condition?
Do you need to intervene?
Case Scenario #3
Impression & intervention?
The patient has COPD most likely complicated by pneumonia
Chronic Bronchitis
An increase in the number of mucous-secreting
cells in the respiratory tree
Large production of sputum with productive
cough
Diffusion remains normal because alveoli not
severely affected
Gas exchange decreased due to lowered alveolar
ventilation which creates hypoxia and hypercarbia
Chemoreceptors sense:
too little O2 ( resp rate to improve) or
too much CO2 ( resp rate to blow off more CO2)
Asthma
Chronic inflammatory disorder of the airways
Airflow obstruction and hyperresponsiveness
are often reversible with treatment
Triggers vary from individual
environmental allergens
cold air; other irritants
exercise; stress
food; certain medications
Assessment of Asthma
Presentation
Dyspnea
Wheezing - initially heard at end of exhalation
Cough - unproductive, persistent
may be the only presenting symptom
Hyperinflation of chest - trapped air
Tachypnea - an early warning sign of a respiratory
problem
Use of accessory muscles
Obtaining a History
Kit connected to
oxygen and run
at 6 l/minute
(enough to
create a mist)
Pediatric
patient
using
nebulizer
mask.
Caregiver
may assist
in holding
the mask.
Case Scenario #4
7 year-old with history of asthma has sudden onset of
difficulty breathing and wheezing while playing
outside
Patient has an increased respiratory rate and is using
accessory muscles
B/P - 108/70; P - 90; R - 24; SaO2 - 97%
Upon auscultation, left lung is clear and wheezing is
present on the right side
Impression and intervention?
Case Scenario #4
Sounds like asthma, looks like asthma, has a
history of asthma but why should you not
suspect asthma?
Asthma is not a selective disease - the patient will
have widespread, not localized, bronchoconstriction
and have bilateral wheezing, not unilateral
Case Scenario #4
This patient was playing with friends, running
around while eating food
Possibly aspirated a foreign body
sudden onset of unilateral wheezing
Albuterol Delivered
Via BVM
#1 Disconnect reservoir
bag with L valve from
mask
#2 Connect L shaped valve
with bag where mouthpiece
of albuterol kit would fit
#3 Place corrugated tubing
of albuterol kit to the mask
over the patients mouth
#4 Begin to bag to blow
the drug into the lungs
while waiting to complete
intubation
#1
#2
#3, #4
To 6l
O2
Intubated
patient
Case Scenario #5
EMS has responded to a 14 year-old child in severe
respiratory distress with audible wheezing. The
complaints have been present for the past 3 hours.
Inhalers used have not been effective.
B/P - 112/60; P - 120; R - 32; SaO2 - 89%
Patient is very anxious, pale, cool, and diaphoretic. The
lips and nail beds are cyanotic.
What is your impression?
What is your greatest concern?
Case Scenario #5
This patient is experiencing a severe asthma attack that
is not responding to medication - status asthmaticus
This patient is in danger of going into respiratory arrest
due to exhaustion
Begin supportive oxygen therapy
Set up the albuterol nebulizer kit and simultaneously the
BVM
Anticipate intubation with administration of Albuterol
via the in-line method
Case Scenario #5
Patients experiencing an asthma attack are in
need of bronchodilators (Albuterol) and IV
fluids (they are usually dry from the rapid
respirations and inability to have been taking
in fluids)
If the patient is losing consciousness, you may
need to follow the Conscious Sedation SOP to
intubate and administer Albuterol via in-line
Bibliography
Bledsoe, B., Porter, R., Cherry, R.
Essentials of Paramedic Care. Brady.
2007.
Kohlstedt, D. Sales Representative. Tri-Anim.
Region X SOPs, March 1, 2007.
Sanders, M. Mosbys Paramedic Textbook,
Revised Third Edition. 2007.
Via Google: Respiratory Module Part I
Via Google: Respiratory Module Part II