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Breathless in America: New Survey Reveals Impact of Chronic Obstructive Pulmonary Disease

This Continuing Education Unit is based on what some are calling “The most comprehensive U.S. survey to date” which highlights the toll of emphysema and chronic bronchitis. The study finds that many patients are not meeting the treatment goals they believe are possible.
It affects twice as many Americans as diabetes1 and is the nation's fourth leading cause of death.2 Yet surprisingly little is known about how chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis that decreases airflow in and out of the lungs, is viewed by patients and their physicians. A new national survey released today helps shed some much-needed light on a disease that is taking a tremendous toll on millions of people in the U.S.

Confronting COPD in America, the most comprehensive U.S. survey ever done on the disease, reveals that millions of Americans are suffering from shortness of breath so severe it interferes with even the most basic daily activities. Of the nearly 600 people with COPD interviewed:

"The survey confirms and quantifies what people living with COPD or caring for someone with COPD know from first-hand experience: It can be a debilitating disease that robs people of their breath and their independence," said Dr. Norman Edelman, spokesperson for the American Lung Association. "We see a growing demand for information about COPD, and a growing awareness that it is actually more common - and has a more profound impact - than other respiratory diseases."

COPD costs the

U.S.

economy an estimated $31.9 billion a year,3 or twice the amount associated with asthma, and in 1998 caused more than 112,000 deaths.2 The disease affects tens of millions of Americans. One estimate is that 16 million patients have been diagnosed with some form of COPD and as many as 16 million more are undiagnosed.1 New government data based on a 1998 prevalence survey suggest that three million Americans have been diagnosed with emphysema and nine million are affected by chronic bronchitis.4

Key Survey Findings
In addition to illuminating the disease burden of COPD, the survey also reveals several issues related to treatment. While the survey finds that patients and physicians are generally optimistic about advances in COPD treatment, it also suggests that patients are not meeting the treatment goals they believe are possible. The survey points to a strong need for better education about how to better manage the condition.

The survey paints a picture of a disease that takes a tremendous toll on patients. Describing their worst three months in the previous year, 58 percent said they had shortness of breath every day and 23 percent of patients said symptoms woke them up every night.

In general, half of all COPD patients (51 percent) say their condition limits their ability to work. Many say it also limits them in normal physical exertion (70 percent), household chores (56 percent), social activities (53 percent), sleeping (50 percent) and family activities (46 percent).
The survey also reveals that COPD symptoms are a cause of great distress for patients:

Optimistic But Suffering: Are Patients Settling for Too Little?
Patients and physicians are generally optimistic about the benefits of proper disease management. Nearly four out of five patients (78 percent) believe that there is better control of the disease than there was five years ago, and 74 percent believe that with proper treatment, it is possible to live a full and active life. Similarly, 76 percent of physicians say that the long-term health outlook for COPD has improved in the past decade, and most of this group (78 percent) credit the improvement to better medications.

Yet the survey also reveals a gap between what patients believe about COPD treatments and the realities of their life with the disease, says Dr. Stephen Rennard, Larson Professor of Medicine at the University of Nebraska Medical Center and one of the nation's top experts on COPD.
"On the one hand, patients believe that treatments are more effective than ever, and can allow them to lead full and active lives," says Dr. Rennard.

"On the other hand, the high levels of breathlessness and activity limitations revealed by the survey would seem to suggest that patients are not living up to their own expectations."

One issue revealed by the survey is that a considerable number of patients underestimate the severity of their COPD and/or overestimate the degree of control they have achieved. More than a third (36 percent) of those whose symptoms fit the criteria for the most severe degree of breathlessness describe their condition as "mild" or "moderate." One in four (25 percent) of those with the most severe degree of breathlessness say their COPD has been "completely controlled" or "well controlled" in the past year.

This disparity may reflect an underestimation of the extent to which COPD can be managed, and a tendency for patients to believe that even a high degree of suffering is the best that can be expected.
"The data suggests that people with COPD are judging their health and quality of life against drastically lowered standards," says Dr. Rennard. "They appear to be accepting the limitations imposed by the disease as normal."

The survey also points to the need for more education about effective COPD management. Although 36 percent of patients say they "completely" understand how best to manage the condition, just one percent of doctors say this about their patients. Still, a majority of patients (76 percent) and doctors (69 percent) agree that there is a "strong need" for better education about COPD.

The findings of Confronting COPD in America are based on interviews with 573 patients and 203 physicians. Interviews covered a wide range of attitudes, beliefs and practices related to COPD.

Confronting COPD in America was conducted by SRBI, a national research firm specializing in health issues. Its findings are supported by several leading respiratory organizations, including the American Lung Association, American College of Chest Physicians, National Lung Health Education Program and American Association of Respiratory Care. The survey was funded by the GlaxoSmithKline group of companies.

Learning Objectives
Upon successful completion of this course, you should be able to:

Chronic obstructive pulmonary disease (COPD) is an umbrella term used to describe airflow obstruction that is associated mainly with emphysema and chronic bronchitis.

COPD has affected tens of millions of Americans. One current estimate is that 6.5 million patients have been diagnosed with some form of COPD and as many as 15.2 million more have been left undiagnosed.1 Government data based on a 1998 prevalence survey suggested that three million Americans have been diagnosed with emphysema and nine million have been affected by chronic bronchitis.2 In 1998, COPD was the fourth leading cause of death in the United States, accounting for more than 112,000 deaths.3

Surprisingly little has been learned about COPD. Studies of the disease burden on patients with COPD have been scarce, and the social and healthcare costs of the disease have not been well quantified. As a result, there have been limited data about COPD symptoms and severity, disability or activity limitations, lifestyle impact, social and psychosocial consequences, healthcare utilization, and patterns of treatment.

Confronting COPD in America was designed to help answer some of these questions and unmask one of the nation's least understood public health problems. It was the largest and most comprehensive US survey to date of patient and provider knowledge, attitudes, and behavior related to COPD. Among the issues it explored were the frequency and severity of symptoms, the burden of illness, healthcare utilization, disease management and treatment, and quality of life issues.

How the Survey Was Conducted
The survey was conducted between August 2 and November 21, 2000. Telephone interviews were completed with a national sample of 573 patients with COPD. The sample was identified by systematically screening a national sample of 26,880 US households to find people aged 45 and older who had been diagnosed with COPD, emphysema, or chronic bronchitis, or whose symptoms matched a strict definition of chronic bronchitis. A national sample of 203 physicians— 100 primary care physicians and 103 respiratory specialists— was also interviewed as part of the survey (Figure 1).

Confronting COPD in America was conducted by Schulman, Ronca, and Bucuvalas, Inc. (SRBI), a national public-opinion research firm. Dr. Stephen Rennard of the University of Nebraska Medical Center served as an advisor. The survey was funded by GlaxoSmithKline, one of the world's leading research-based pharmaceutical and healthcare companies.

Overestimation of Control

A central problem in disease management is that patients with COPD tend to overestimate their degree of symptom control. The survey showed that patients' self-perception of disease control was not in keeping with more objective measures of disease severity. One in four (25%) patients with the most severe degree of breathlessness said that their COPD had been completely or well controlled in the past year, as did 27% of patients with the next most severe level of breathlessness (Figure 29).

In addition (Figure 30):

42% of patients who said that their COPD had been "completely" or "well controlled" over the past year also said there was a three-month period during that time when they had shortness of breath every day.
One in four (24%) of those who said their COPD had been "completely" or "well controlled" over the past year also said their condition restricts them "a lot" in normal physical exertion.
More than a quarter of patients who said their COPD had been "completely" or "well controlled" over the past year also said they get short of breath while getting washed or dressing (28%) or doing light housework (29%).

This underscores the need for better education: if patients underestimate the severity of their condition, or do not realize that it can be better controlled, they may be less likely to seek the care they need.

Need for Better Education

The survey revealed that although patients with COPD in general said they felt relatively informed about their condition, they and their doctors also recognized that there was a significant need for better education — particularly in terms of the best ways to manage COPD.

One important finding was that doctors and patients disagreed about how well patients understood the best ways to manage their condition (Figure 31). Although 71% of patients said that they either completely (36%) or mostly (35%) understood the best ways to manage their condition, only 44% of doctors said that most patients completely (1%) or mostly (43%) understood how to manage their condition.

Yet both doctors and patients agreed that there was a need for better education about the management of the condition (Figure 32):

76% of patients and 69% of doctors agreed there was "strong need" for better patient education about their condition and treatment.

Two other areas where better education might be particularly useful:

Underdiagnosis: There may be a vast number of Americans who are suffering and not getting proper treatment. Educational campaigns may be able to alert undiagnosed patients to COPD symptoms and urge them to seek further information from their healthcare providers.
Treatment Options: Given patient complaints about the inconvenience of medications (Figure 28), it might be useful for patients to talk with their healthcare providers about ways they can simplify their treatment regimen.

Conclusion

In addition to the major findings outlined in the overview, there are several general conclusions that can be drawn from the survey findings:

COPD is a debilitating disease. Shortness of breath and other symptoms took a tremendous toll on the patients interviewed.
There was a significant gap between the level of disease control that patients reported and more objective indicators of the impact and severity of their condition. This disparity may reflect patients' underestimation of the degree to which COPD can be managed and therefore a troublesome tendency to accept their condition as the best that can be expected.
Doctors and patients agreed there is a need for better education about ways to manage the disease. Patients should talk to their healthcare providers about simple treatment options to improve lung function.

EMERGENCY RESPIRATORY CARE

Learning Objectives

Upon completion of this course, you should be able to:

Name three diseases associated with breathing emergencies.
Name three breathing devices and the expected oxygen delivery each provides.
Describe the emergency management of choking and airway obstruction.
Describe the emergency treatment of the drowning and near drowning patient.
Describe the emergency treatment of patients with carbon monoxide poisoning.

Introduction

This course covers the nine steps of the emergency care process. Each step of the process is presented separately in sequential order.

Organized chaos describes the emergency room. The nine steps of the emergency care process outlined in this class are the organized part of the chaos. By using the same care process, all members of the emergency team can anticipate the care of the other and interrelate as a team. A team approach leads to stronger professional practices and improved patient outcomes. During a true emergency, it may be necessary to perform the steps simultaneously or out of sequence. When the care process is known and the same for all team members, the ability to adapt to change during a true emergency is easy.

Part One: Breathing Emergency

The organized systematic care process outlined in this section optimally manages the patient with a breathing emergency. The steps include assessment, problem identification, planning, interventions, ongoing evaluations, and disposition. Detailed information is included for the common medications used for patients with a breathing emergency. The related information section at the end of the course provides an overview of terms, concepts, and pathophysiology related to breathing emergencies.

Topics discussed in this course include:

· ABG critical values · Acid-base imbalances · Acute epiglottitis · Acute and chronic bronchitis · Asthma · Autotransfusion · COPD · Croup · Endotracheal tube placement confirmation technique · Five steps for successful extubation including NIF and FVC · Mechanical ventilation modes · Oxygen delivery devices · Oxygen saturation levels for arterial and venous blood · Petechial rashes · Pneumonia · Post arrest ventilator settings · Pulmonary edema and embolus · Pulse oximetry saturations and corresponding pO2 levels · Ratio of respiratory rate to the pulse · Sodium bicarbonate · Smoke inhalation · Spontaneous pneumothorax

Rapid ABC Assessment

     1. Is the patient’s airway patent?
         a. The airway is patent when speech is clear and no noise is
             associated with breathing.
         b. If the airway is not patent, consider clearing the mouth and
             placing an adjunctive airway.
     2. Is the patient’s breathing effective?
         a. Breathing is effective when the skin color is within normal limits
             and the capillary refill is < 2 seconds.
         b. If breathing is not effective, consider administering oxygen and
             placing an assistive device.
     3. Is the patient’s circulation effective?
         a. Circulation is effective when the radial pulse is present and the
             skin is warm and dry.
         b. If circulation is not effective, consider placing the patient in the              recumbent position, establishing intravenous access, and giving
         a 200 ml fluid bolus.

The patient's identity, chief complaint, and history of present illness are developed by interview. The standard questions are who, what, when, where, why, how, and how much.
Who identifies the patient by demographics, age, sex, and lifestyle.
What develops the chief complaint that prompted the patient to seek medical advice.
When determines the onset of the symptom.
Where identifies the body system or part that is involved and any associated symptoms.
Why identifies precipitating factors or events.
How describes how the symptom affects normal function.
How much describes the severity of the affect

Patient Identification
          1. Who is the patient?
               a. What is the patient’s name?
               b. What is the patient’s age and sex?
               c. What is the name of the patient’s current physician?
               d. Does the patient live alone or with others?

Chief Complaint

     1. In one to three words, what is the main symptom that prompted
         the patient to seek medical attention?
          a. Use direct quotes to document the chief complaint.
          b. Acknowledge the source of the quote, e.g., the patient states;
              John Grimes, the paramedic states; Mary, the granddaughter,
              states.

History of Present Illness
     1. When was the onset of the breathing problem?
     2. Are any other symptoms associated with the breathing problem?
     3. How does the breathing problem affect normal function?
         a. Does the patient have orthopnea (breathing discomfort in all
            positions except upright, sitting, or standing) or dyspnea (air
            hunger)?
         b. Is the patient able to sleep and rest?
         c. Is the patient able to tolerate normal activity?
     4. Was any treatment started before coming to the hospital and has it
         helped?
     5. Has the patient had similar problems before?
         a. When was the problem?
         b. What was the diagnosis and treatment?
     6. Is the patient on oxygen at home?
         a. What is the rate of flow?
         b. How often does the patient use the oxygen?
     7. Has the patient ever been on a breathing machine?
     8. Does the patient have any pertinent past history?
         a. Does the patient have heart problems?
         b. Does the patient have asthma, COPD, or emphysema?
         c. Does the patient smoke tobacco or have a smoking history?
     9. Does the patient take any routine medications?
         a. What is the name, dosage, route, and frequency of the
             medication?
         b. When was the last dose?
     10. Does the patient have allergies to drugs or foods?
         a. What is the name of the allergen?
         b. What was the reaction?
     11. When was the patient’s last tetanus immunization?
     12. If the patient is female and between the ages of 12 to 50 years,
         when was the first day of her last menstrual period?

Caregiver Diagnoses

* Ineffective airway clearance	* Knowledge deficit
* Impaired gas exchange	* Anxiety
* Pain	* Fluid volume deficit
* Altered tissue perfusion	* Activity intolerance

Anticipated Medical Care

Review of the Anticipated Medical Care of Breathing Emergencies

Review of the Anticipated Medical Care of Breathing Emergencies
Exam	Full body
Urine test	None
Blood tests	ABG analysis, CBC, electrolytes, chemistries, drug levels if taking aminophyllin, blood cultures if febrile
Sputum	Culture, gram stain
ECG	ECG for females over 45 years and males over 35 years
X-ray	PA and lateral chest x-ray, portable one view at the bedside for unstable patients
Other	Peak expiratory flow rate (PEFR), ventilation perfusion scan
Diet	NPO
IV	Hydration with NS or Ringer’s solution if patient has COPD without fluid overload. No intravenous infusion if the patient has a fluid overload (CHF or pulmonary edema).
Medications	Diuretics, NTG, and potassium replacements for patients with fluid overload. IV steroids and bronchodilators by hand-held nebulizer for patients with COPD.
Other	Supplemental oxygen by mask, bipap, or endotracheal intubation and mechanical ventilation to keep saturation >94%, an indwelling urinary catheter to monitor urinary output (normal urinary output in a child is 1 to 2 ml/kg per hour and normal adult urinary output is > 30 ml/hr.)
Disposition	Hospital admission may be required if the patient is unable to ventilate effectively (respiratory rate > 30, heart rate >120, PEFR < 120 L/min., FEV < 1000 ml, oxygen sat < 94%).
Worse case scenario	The worse case scenario is an unnoticed pCO₂ build-up to toxic levels causing coma. Management is mechanical ventilation to correct the acid-base problem.

Initial Assessments and Interventions

Ask the patient to undress, remove necklaces and other jewelry that might interfere with the exam, and put on an exam gown. Assist as needed.
Get initial vital signs including oxygen saturation. Consider obtaining a rectal temperature if the patient is mouth breathing.
Place on oxygen to maintain an oxygen saturation of > 94%.
Position the patient to expand lungs and enhance breathing, e.g., sitting with arms supported in an armchair-like position.
Observe for signs of respiratory distress, e.g., flaring nostrils, the use of accessory muscles, learning forward in a tripod position, head bobbing, and decreased level of alertness. Use these indicators as a quick assessment of the patient’s ability to cope with the breathing problem.
Perform a focused patient examination
a. Auscultate the lungs (instruct the patient to take several quick,
    short, deep breaths).
b. Inspect for peripheral edema.
c. Evaluate the level of consciousness to use as a base line. Use the
    mnemonic AVPU. Deterioration of the level of consciousness is
    indicative of hypoxia.

A for alert signifies that the patient is alert, awake, responsive to voice and oriented to person, time, and place.
V for verbal signifies that the patient responds to voice, but is not fully oriented to person, time, or place.
P for pain signifies that the patient does not respond to voice, but does respond to painful stimulus such as a squeeze to the hand.
U for unresponsive signifies that the patient does not respond to painful stimulus.

A for alert signifies that the patient is alert, awake, responsive to voice and oriented to person, time, and place.V for verbal signifies that the patient responds to voice, but is not fully oriented to person, time, or place.P for pain signifies that the patient does not respond to voice, but does respond to painful stimulus such as a squeeze to the hand.U for unresponsive signifies that the patient does not respond to painful stimulus.
Establish and maintain intravenous access for administration of medications and intravenous fluids.
a. Hydrate a COPD patient with normal saline
b. Limit fluids on a CHF or pulmonary edema patient.
If the patient is wheezing, initiate treatment with bronchodilators via nebulizer according to hospital policy.
Consider placing a urinary indwelling catheter if an accurate output is needed or the patient is activity intolerant.
Advise the patient and family if fluids are encouraged or limited. Hydrate a COPD patient and limit fluids on a CHF or pulmonary edema patient.
Elevate the siderails and place the stretcher in the lowest position.
Inform the patient, family, and caregivers of the usual plan of care. Include time involved for each aspect of the stay and the expected overall time in the ER.
Provide the patient with a device to reach someone for assistance and explain how to use it. Ask the patient to call for help before getting off the stretcher.

Ongoing Evaluations and Interventions

Inform the physician of adverse changes noted during ongoing evaluation. Document that the physician was notified of the adverse change and what orders, if any, were received.

Monitor vital signs and effectiveness of breathing and circulation.
Keep oxygen saturation > 94%.
Monitor therapy closely for the patient’s therapeutic response to bronchodilators by nebulizer.
a. Peak flow rates before and after bronchodilator treatments are the
most reliable measure of the effectiveness of the bronchodilator.
b. Onset is rapid. If therapy does not improve the peak flow within 20
minutes, ask the physician for a repeat dose or an alternative.
Monitor intake and output hourly.
Monitor closely for the development of adverse reactions to therapy.
Provide the patient with food at mealtimes.
Keep the patient, family, and caregivers well informed of the plan of care and the remaining time anticipated before disposition.
Monitor the patient’s laboratory and x-ray results. Notify the physician of critical abnormalities. Remedy abnormalities as ordered.
Notify the physician when all diagnostic results are available for review. Ask for establishment of a medical diagnosis and disposition.

Discharge Instructions

Provide the patient with the name of the nurse and doctor in the emergency room.
Inform the patient of their diagnosis or why a definitive diagnosis couldn’t be made. Explain what caused the problem if known.
Instruct the congestive heart failure patient:
a. To weigh daily until seen by the follow-up physician. A daily weight gain of a couple of pounds is a sign of fluid buildup and the follow-up physician should be notified. An increase in the diuretic medication may be needed.
b. Notify the follow-up physician immediately for shortness of breath, swelling, or chest pain. If the physician is not immediately available, return to the ER.
4. Instruct the COPD patient that:
a. The best treatment is prevention, maintaining adequate hydration, using mediations on a regular basis, avoiding smoke, and seeking early treatment.
b. Influenza and pneumonia are the most common causes of respiratory infections. Ask the patient to seek medical advise about vaccines for influenza and pneumonia.
c. Follow-up is essential. Notify the follow-up physician immediately for worsening of symptoms. If the physician is not immediately available, return to the ER.
Instruct the patient with a rib contusion or a minor rib fracture to report fever, dyspnea on exertion, or sputum production to the follow-up physician as they may indicate pneumonia.
Teach the patient how to take the medication as prescribed and how to manage the common side effects. Instruct the patient not to drive or perform any dangerous tasks while taking narcotic pain medications.
Recommend a physician for follow-up care. Provide the name, address, and phone number with a recommendation of when to schedule the care.
Call the follow-up physician immediately or return to the emergency room if the problem worsens or any unusual symptoms develop. Encourage the patient NOT to IGNORE WORSENING OF SYMPTOMS.
Ask for verbal confirmation or demonstration of understanding and reinforce teaching as needed.

Medications

Aminophyllin

Aminophyllin
Indications	Asthma, wheezing, bronchospasm
Adult dose	5 mg/kg IV loading dose over 30 to 45 minutes, maximum loading dose 500 mg 0.7 mg/kg/hr IV maintenance x 12 hours and then 0.5 mg/kg/hr.
Pediatric dose	5.6 mg/kg IV loading dose over ½ hour, maintenance 1 mg/kg/hr
Onset	IV onset immediate, duration 6 to 8 hours
Compatible	Compatible at Y-site with potassium chloride, Bretylium, Dopamine, heparin, Inocor, Lidocaine, Neosynephrine, nitroglycerin, Pronestyl
Adverse reaction	Restlessness, insomnia, muscle twitching, tachycardia, nausea, vomiting
Note	Check Theophylline level if patient is on oral Aminophylline before giving a loading dose. Theophylline 400 mg equals Aminophyllin 500 mg.

Bumex

Bumex (bumetanide)
Indications	Fluid overload
Dose	1 to 2 mg IV, maximum 20 mg/day
Onset	IV onset 5 minutes, peak ½ hour, duration 2 to 3 hours
Side effects	Orthostatic hypotension, hypokalemia, hyperglycemia
Monitor	Urinary output, blood pressure

Lasix

Lasix (furosemide)
Indications	Peripheral edema, congestive heart failure, pulmonary edema
Dose	0.5 to 1 mg/kg over 1 to 2 minutes If no response, double the dose to 2 mg/kg over 1 to 2 minutes
Onset	IV onset 5 minutes, peak ½ hour, duration 2 hours
Side effects	Circulatory collapse, hypokalemia, loss of hearing, nausea
Monitor	Output, blood pressure

Proventil, Albuterol, Ventolin

Proventil, Albuterol, Ventolin
Indications	Bronchospasm, asthma
Adult Dose	2.5 to 5 mg nebulized
Pediatric dose	Nebulized pediatric dose: Age < 1 year .05 to .15 mg/kg Age 1 to 5 years 1.25 to 2.5 mg/dose Age 5 to 12 years 2.5 mg/dose Age > 12 years 2.5 to 5 mg/dose
Onset	Inhaled onset 5 to 15 min., peak 1 to 1 ½ hour, duration 4 to 6 hours
Side effects	Anxiety, tremors, tachycardia
Monitor	Oxygen saturation, heart rate
Other Bronchodilators
Bronkosol	A bronchodilator used for patients with cardiac arrhythmia. Usual adult nebulized dose is 0.5 mg in 2.5 ml NS.
Alupent	Alupent is a long acting bronchodilator. Usual adult nebulized dose is 0.3 ml of a 5% solution of 2.5 ml NS.

Solu-Medrol

Solu-Medrol (methylprednisolone)
Indications	Severe inflammation, shock, contact dermatitis, pruritus
Dose	100 to 250 mg IV
Pediatric dose	117 mcg to 1.66 mg/kg IV in 3 to 4 divided doses
Onset	IV onset rapid, IM onset unknown, duration 1 to 4 weeks
Side effects	Circulatory collapse, thrombophlebitis, embolism, thrombocytopenia
Monitor	Hypokalemia and hyperglycemia are adverse effects of long- term therapy.

Related Information

ABG Critical Values

Review of ABG Critical Values Requiring Interventions
PH	Critical value < 7.25 or > 7.55
pCO₂	Critical value > 55 and > 60 for COPD patients
O₂	Critical value < 55
SpO₂	Critical value < 85 (equals a pO₂ of 46 to 56)

ABG Oxygen Saturation

Review of ABG Oxygen Saturation Levels in Arterial and Venous Blood
Arterial blood	Oxygen saturation is usually >75%.
Venous blood	Oxygen saturation is usually <75%.
Mixed arterial and venous blood	A specimen of mixed arterial and venous blood commonly has an oxygen saturation level in the eighties. Check the patient’s saturation with a pulse oximetry. If oxygen saturation in the ABG result is less than the pulse oximetry saturation, redraw the ABG. The ABG specimen was probably mixed arterial and venous blood.

Acid-Base Imbalance

Review of Acid-Base Imbalance
Respiratory Acidosis	ABG findings of a pH < 7.35 with a CO₂ > 45 are characteristic of respiratory failure. Symptoms may include confusion and lowered level of consciousness. Causes are sedatives, stroke, chronic pulmonary disease, airway obstruction, severe pulmonary edema, and cardiopulmonary arrest. Management is aimed at improvement of ventilation with pulmonary toilet and reversal of bronchospasm. Intubation may be required.
Respiratory Alkalosis	ABG findings of alkalosis are characteristic of excessive ventilation causing a primary reduction in CO2 and an increase in pH. Symptoms may include seizures, tetany, cardiac arrhythmia, or loss of consciousness. Causes include pneumonia, pulmonary edema, interstitial lung disease, and asthma. Pain and psychogenic causes are common. Other causes include fever, hypoxemia, sepsis, delirium tremors, salicylates, hepatic failure, mechanical hyperventilation, and central nervous system lesions. Management is directed at the underlying disorder. Sedation or a rebreathing bag may be used for psychogenic cases.

Acute Epiglottitis
Acute epiglottitis is a rare life-threatening process in children (typically between the ages of 3 and 7 years) associated with a large, cherry-red, edematous epiglottis. The symptoms are drooling, muffled voice sounds or aphonia, dysphagia, and a croaking froglike sound on inspiration. The child may assume the tripod position (sitting forward leaning on both arms) for better air exchange. The child should not be disturbed for fear of worsening the airway obstruction. Vital signs are not taken until the potential of airway obstruction has passed. Parents are asked to stay with the child because separation may increase the child’s anxiety and oxygen needs. Visualization of the epiglottis should not be attempted until intubation and tracheotomy equipment is available. Complete airway obstruction can occur suddenly. Bacteremia is present in 50% of cases.

Airway Obstructions
The most common cause of airway obstruction is a relaxed tongue that falls over the back of the throat obstructing the pharynx and larynx. Because the tongue is attached to the lower jaw, performing a head-tilt-chin-lift maneuver forces the tongue away from the back of the throat and restores spontaneous respirations. When a patient goes into respiratory arrest, the first priority is to open the airway with a head-tilt-chin-lift or a jaw-thrust maneuver.

Asthma

Review of Asthma
Description	The National Asthma Education Program defines asthma as "a disease characterized by airway obstruction that is reversible, airway inflammation, and increased airway responsiveness to a variety of stimuli." Status asthmaticus is obstruction that lasts days or weeks. Extrinsic asthma is asthma due to a known allergen or environmental factor, e.g., pollen, dander, feathers, dust, and foods. Intrinsic asthma is asthma assumed to be due to some endogenous cause because no external cause can be determined.
Symptoms	Symptoms may include bronchospasm with wheezes and a prolonged expiratory phase.
Tests	Chest x-ray may show hilar or basilar infiltrates, or be normal,
Management	Medications may include inhaled nebulized bronchodilators every 20 min. for three doses, then every 2 hours until attack subsides. Peak flow rates are essential before and after each bronchodilator treatment to determine the effectiveness of the therapy. Theophylline and Predisone may be used. Panic and anxiety can be avoided by maintaining a calm reassuring attitude.
Note	An estimated 5% of adults and 10% of children have asthma.

Autotransfusion

Autotransfusion is indicated for a patient with hemothorax and hypotension. A basic autotransfusion device is attached to a chest tube and infused intravenously. Autotransfusion from other sites such as the abdomen places the patient at an increased risk for bacterial contamination. In the emergency setting, sites other than the chest are not used unless the patient is exsanguinating and no blood products are available.

Bradycardia

Bradycardia is the most common arrhythmia in critically ill children and is usually a symptom of hypoxia.

Clinical Assessment of Lungs

Review of Clinical Assessment of Lungs
Auscultation	Bronchial sounds are normally heard over the bronchus and the manubrium of the sternum (the broad upper division of the sternum with which the clavicle and first two ribs articulate), along the sternal border, and over the trachea. Bronchial sounds heard over the lungs indicate abnormal sound transmission and may be due to consolidation such as atelectasis and pneumonia. Bronchial vescicular sounds are normally head over the large bronchi below the clavicles and between the scapulae. They are of moderate amplitude, medium to high pitched, and resemble a mixture of bronchial and vescicular sounds. Bronchial vescicular sounds may indicate consolidation or other abnormalities if heard over the lungs. Vesicular sounds are normally produced by the opening of the alveoli on inspiration, the movement of air through the larynx during expiration, heard over the lungs, of low amplitude, medium to low pitch, and described as swishing or rustling. Decreased breath sounds may indicate disruption of alveolar function, consolidation or compression (pulmonary fibrosis, pleural effusion, or COPD).
Palpation	Palpation for tenderness is used in trauma cases to assess for injured areas. Chest excursion is measured by placing the hands parallel to each other over the lower portion of the rib cage on both sides of the spine. The fingers should be 2 inches apart with thumbs pointing toward the spine with fingers spread laterally. On deep inspiration, observe the movement of the thumbs. Chest excursion should separate the thumbs 1 ½ to 3 inches.
Percussion	Percussion is performed over the intercostal spaces following a systemic pattern to compare both sides. The posterior thorax is normally resonant on percussion and the area over the scapula, ribs, and spine is dull. Areas of consolidation are dull.
Adventitious sounds	Crackles (rales) are the most common in dependent lobes and are caused by fluid. Rhonchi are heard over the trachea and bronchi and are caused by fluid in the larger airways. Wheezes can be heard over all lung fields and are caused by bronchospasm that narrows the airways. Pleural friction rub is heard over the lateral lung fields with the patient upright and is caused by inflamed pleura.

Bronchitis, Acute

Review of Acute Bronchitis
Description	Bronchitis is an acute inflammation of the bronchus most often caused by viral infectious agents. Secondary bacterial infection also occurs.
Signs and symptoms	Signs and symptoms may include a recent upper respiratory infection and a dry nonproductive cough that is worse at night. Taking a deep breath or talking may initiate coughing. Sputum production occurs in a few days. Scattered wheezes and a mild fever may be present.
Tests	Chest x-ray may be normal.
Management	Management may include humidified oxygen, cough suppressant medications, and antibiotics for bacterial infections.
Prognosis	Prognosis is good. The disease is usually self-limiting.

Bronchitis, Chronic

Review of Chronic Bronchitis
Description	Chronic bronchitis occurs frequently in middle-aged men and is uncommon in non-smokers.
Signs and symptoms	Signs and symptoms are excessive mucus production and a cough that occurs for at least 3 consecutive months each year for 2 successive years.
Tests	Chest x-ray may be insignificant. In the late stages, chest x-ray may reveal hyperinflation.
Management	Management may include bronchodilators, nebulized inhalers, and steroids.

Congestive Heart Failure

Review of Congestive Heart Failure
Causes	Congestive heart failure is a fluid overload brought about by an inadequate heart pump. Forward failure causes fluid to accumulate in the lungs and backward failure causes fluid to accumulate in the body. The most common cause of right ventricular failure is left ventricular failure. The increasing pulmonary venous and arterial pressures of the left ventricular failure increase the preload of the right ventricle. Other causes of right ventricular failure are lung disease, valvular disease, and right ventricular infarction.
Symptoms	Forward failure (left ventricular failure): Early signs of respiratory failure may include activity intolerance, tachypnea, orthopnea, shortness of breath, and tachycardia. Cyanosis and production of pink frothy sputum are late signs. Impaired ventilation causes hypoxia and hypercapnia. Backward failure (right ventricular failure): Symptoms may include peripheral edema and hepatosplenomegaly from systemic vascular engorgement (with or without tenderness).
Diagnostic findings	ABG findings may include hypoxia and respiratory acidosis. Electrocardiogram may show left ventricular enlargement. Chest x-ray may have findings of infiltrates (pulmonary fluid overload) and an enlarged heart.
Management	The goal of therapy is to maintain sufficient oxygenation to body tissues by increasing oxygenation, decreasing preload, decreasing afterload, and increasing the contractility of the heart. Medical management may include oxygen to keep oxygen saturation > 94%, fluid restriction, diuretics (Lasix, Bumex) to reduce the fluid preload, inotropic medications (digoxin, dobutamine) to increase the pumping action of the heart, morphine to decrease anxiety and the workload placed on the heart, and blood pressure reducing medications (nitroglycerin, nitroprusside) to decrease afterload.

COPD

Review of COPD
Description	COPD is a group of conditions that include chronic bronchitis, emphysema, and asthma. These conditions cause hyperplasia, inflammation of goblet cells, and increased production of thick mucus.
Facts	Smoking is the most significant factor contributing to the patient’s condition. Cessation of smoking may prevent progression. A patient with severe bronchial abnormalities and mild emphysema is commonly called a blue bloater. Hypoventilation leads to hypoxemia and hypercapnia. The patient with severe emphysema and mild bronchitis is commonly called a pink puffer. Hyperventilation assists in adequate oxygenation and cyanosis is absent. Cor pulmonale (hypertrophy or failure of the right ventricle) is a complication of COPD secondary to decreased intravascular blood volume with arterial congestion. A common sign of COPD is a barrel chest that results from hyperinflation and over distention of alveoli. Elastin and collagen, the supporting structures of the lungs, are destroyed and the bronchiolar walls tend to collapse. Air is trapped in the distal alveoli resulting in hyperinflation and over distention of the alveoli. This trapped air causes the barrel chest.
Management	Medical management may include administration of 30% oxygen via mask and bronchodilators by nebulized therapy, steroids, and hydration. Most COPD patients are dependent on the hypoxic drive to maintain adequate ventilation. Uncontrolled or high-flow oxygen therapy may precipitate severe carbon dioxide narcosis and respiratory arrest. Precise oxygen therapy delivered by mask may allow time for medical intervention, thus avoiding intubation and mechanical ventilation. Placing the patient in a high Fowler’s position or leaning upright over an over-bed table will ensure optimal ventilation. Pursed lip breathing slows expiration, prevents collapse of lung units, and helps the patient control rate and depth of respirations that decreases dyspnea and feelings of panic.

Croup

A low-grade fever and a barking or brassy cough with inspiratory stridor caused by partial upper airway obstruction characterize croup. Croup commonly follows an upper respiratory infection by one to two days. The earliest signs of respiratory failure are hypoxemia, restlessness, tachypnea, and tachycardia. A fever can increase respiratory rate by four breaths per minute for each degree rise above normal. Intermediate signs of respiratory failure are accessory respiratory muscle use, retractions, and nasal flaring. Late signs are cyanosis and lethargy. Treatment is directed towards maintaining the airway and adequate respiratory exchange. Aspirin is avoided as an antipyretic because it has been correlated with Reyes syndrome. Medical management of croup may include a cool high-humidity mist, hydration, oxygen, and intubation for anoxia and airway obstruction. Intravenous hydration is weight based and monitored by skin turgor and urinary output. An initial intravenous fluid bolus of 20 ml/kg can be given based on the child’s hemodynamic response. The 4-2-1 rule for maintenance fluids is 4 ml/kg for the first 10 kg of body weight, 2 ml/kg for the next 10 kg of body weight, and 1 ml/kg for the rest of the weight.

Endotracheal Intubation

Endotracheal intubation is attempted only after other methods of oxygenation have failed. It is not the initial procedure for ventilation in respiratory arrest. Adequate oxygenation is first provided with the use of a bag-valve-mask device. If intubation takes more than 20 to 30 seconds, oxygenation is required with a bag-valve-mask device between attempts. Endotracheal tube placement is confirmed by first listening over the stomach for sounds of rushing air. If nothing is heard, the lungs are then auscultated. If breath sounds are heard, both lungs are auscultated to confirm equality. Final tube placement is confirmed by a portable chest x-ray. The carina is the landmark by which proper depth of endotracheal intubation is measured.

Extubation

Review of Extubation
1	Obtain a negative inspiratory force (NIF) of > -20 cm. (normal < -50 to -100)
2	Obtain a forced vital capacity (FVC) of > 10 ml/kg (normal 40 to 70 ml/kg)
3	Suction the tube, suction the mouth, deflate the balloon, have the patient cough, and pull the tube during the cough.
4	Place the patient on supplemental oxygen at the same FiO2 used prior to extubation.
5	Monitor vital signs including oxygen saturation every 5 to 10 minutes for 30 minutes.

Hypercarbia

Hypercarbia is the first change that occurs in severe airway obstruction in a child.

Mechanical Ventilation Modes

Review of Mechanical Ventilation Modes
PEEP (Positive End Expiration Pressure)	PEEP is an expiratory ventilator maneuver that limits unimpeded expiratory flow at a preset level of system pressure.
CPAP (Continuous Positive Airway Pressure)	CPAP increases oxygenation by increasing positive airway pressure throughout the respiratory cycle and not just on expiration.
CMV (Controlled Mandatory Ventilation)	CMV delivers tidal volume at a preset rate regardless of the patient’s inspiratory efforts.
ACV (Assist Control Ventilation)	ACV augments spontaneous ventilation in patients with normal respiratory drive but weak respiratory musculature.
PSV (Pressure Support Ventilation)	PSV provides positive pressure only in response to a spontaneous breath so the patient determines rate of delivery.
IMV (Intermittent Mandatory Ventilation)	IMV provides positive pressure breaths at a preset volume and rate independent of the patient’s effort.
SIMV (Synchronized Intermittent Mandatory Ventilation)	SIMV synchronizes a mandatory machine delivered breath with the patient’s next spontaneous breath.

Oxygen Delivery Devices

Oxygen Delivery Devices	Oxygen Delivered
Nasal cannula	4% oxygen per liter
Simple Mask	5 to 8 L/m equals 40% to 50% oxygen
Partial non-rebreather	6 to 8 L/m equals 55% to 70% oxygen
Non-rebreather	6 to 10 L/m equals 100% oxygen
Ventura mask	Variable 24% to 50% oxygen
Nebulizer with aerosol mask, face shield, and T-piece at 8 to 12 L/m	30% to 100% oxygen with controlled moisture and temperature

Oxygen, High Flow

High flow oxygen is the first priority when a trauma patient is pale, diaphoretic, and hypoventilating. Long-term high flow oxygen on a COPD patient who is not hypoventilating can decrease the respiratory drive.

Oxygen, Supplemental

Oxygen delivery systems deliver oxygen that is supplemental to room air. The percentage of supplemental oxygen must be added to the 21% oxygen in room air to equal the total amount delivered to the patient.

Peak Expiratory Flow Rates (PEFR)

Peak expiratory flow rates before and after bronchodilator treatments are essential to determine the effectiveness of the bronchodilator therapy. PEFR is how much air is exhaled forcibly from full-lung inflation. Normal range is 400 to 600 L/min. 200 L/min. indicates respiratory fatigue. Oxygen saturation is the indicator for severity.

Petechial Rash

Petechial rash may develop 12 to 96 hours after an injury and is a result of fat globules obstructing the capillaries in the skin and subcutaneous tissue. When a petechial rash is associated with breathing problems, it may be a sign of pulmonary fat embolism.

Pneumonia

Review of Pneumonia
Description	Pneumonia is an acute bacterial, viral, or fungal infection of the pulmonary parenchyma. The most common causal agent is Streptococcus pneumoniae.
Symptoms	Symptoms may include fever, pleuretic chest pain, productive cough, and tachypnea.
Signs	Bronchial breath sounds over the lung area indicate pneumonia.
Tests	Tests may include chest x-ray, hematology, and sputum for gram stain and culture.
Findings	Chest x-ray may show a pattern characteristic of the infecting organism.
Management	Medical management includes identification of the infecting organism and initiation of appropriate antimicrobial therapy.
Note	1% of Americans will have pneumonia during their lifetime.

Respiratory Normal Values

Review of Normal Respiratory Values
Tidal volume	8 to 12 cc/kg
Minute ventilation	Respiratory rate times tidal volume
Vital capacity	60 to 70 cc/kg
Peak expiratory flow rate	400 to 600 liters/min.

Ventilator Settings, Post Arrest

Review of Post Arrest Ventilator Settings
FiO2	100%
Inspiratory: Expiratory Ratio (I:E)	1:2
Mode	AC or SIMV
PEEP	Minus 5
Pressure Limits	10 cm H₂O higher than pressure generated by the delivered tidal volume
Rate	10 to 12 breaths per minute
Sensitivity	-2 cm H2O on assist control, not applicable on IMV
Temperature	97 degrees Fahrenheit (Gabriel Daniel Fahrenheit 1686-1736. German-born physicist who invented the mercury thermometer [1714] and devised the Fahrenheit temperature scale).
Tidal Volume	Ten times the patient’s lean weight in kilograms

Pulse Oximetry Saturation and Corresponding pO2

Pulse Oximetry Saturation and corresponding pO₂
Saturation	Oxygen levels (pO₂)
80% SpO₂	40 to 49 pO₂
85% SpO₂	46 to 56 pO₂
87% SpO₂	49 to 60 pO₂
90% SpO₂	55 to 67 pO₂
93% SpO₂	63 to 78 pO₂
95% SpO₂	72 to 89 pO₂

Pulmonary Edema

Review of Pulmonary Edema
Description	Acute pulmonary edema is a result of an acute event. Inadequate pumping of the left ventricle causes cardiogenic pulmonary edema. Noncardiogenic pulmonary edema or adult respiratory distress syndrome (ARDS) is a result of damage to the alveolar-capillary membrane.
Signs and symptoms	Cardiogenic pulmonary edema may show signs of generalized fluid overload including dyspnea, decreased oxygenation, metabolic acidosis, crackles, wheezes, and productive cough with foamy or pink-tinged sputum.
Tests	Chest x-ray may show bilateral interstitial and alveolar infiltrates.
Management	Medical management may include strict fluid restriction, high-flow oxygen, bronchodilators, bipap, diuretics, dobutamine, nitroglycerin, intravenous morphine, and a urinary catheter to monitor output.
Note	Most patients who require mechanical ventilation have a 50% mortality rate.

Pulmonary Embolus

Review of Pulmonary Embolus
Description	A pulmonary embolus is an embolus that causes obstruction of arterial pulmonary blood flow to the distal lung commonly resulting in ischemia and infarction of the lung
Symptoms	Symptoms may include sudden onset of dyspnea, chest pain, and sinus tachycardia.
Tests	Tests may include blood hematology, ABG studies, chest x-ray, ventilation perfusion scan, and pulmonary arteriogram.
Diagnostic findings	Findings may include decreased oxygen on room air (PaO₂ < 80 mm Hg) and elevated LDH. An elevated LDH is common in many diseases and alone is not diagnostic of pulmonary embolus. A PaO₂of > 80 is inconsistent with pulmonary embolus. The WBC may be elevated or normal.
Management	Medical management may include intravenous heparin. Heparin reduces the risk of secondary thrombi formation.

Respiratory Failure
Respiratory failure is any condition in which the blood oxygen is insufficient to meet the demands of the tissues secondary to decreased lung function. A diagnosis of respiratory failure is based on the patient’s history, clinical appearance, and serial changes in the ABG studies. ABG abnormalities alone do not indicate respiratory failure.

Respiratory Rate Ratio to Pulse
Respiratory rate ratio to pulse is 1:4. An adult with a respiratory rate of 20 will normally have a heart rate of 80.

Sodium Bicarbonate
Although not commonly used for respiratory acidosis, one ampule of sodium bicarbonate can be given for each –5 of base excess to temporarily correct the pH in respiratory and metabolic acidosis. The acidity of the blood must be kept in a near normal range for medications to be effective.

Smoke Inhalation
Smoke inhalation is a combination of carbon monoxide intoxication, upper airway obstruction, and chemical injury to the lower airways and lung parenchyma. Carbon monoxide is a killer. Most people that die in fires succumb from the carbon monoxide poisoning before they are burned. Carbon monoxide links with the hemoglobin replacing the oxygen causing hypoxia and death.

Spontaneous Pneumothorax

Review of Spontaneous Pneumothorax
Description	Pneumothorax is the collapse of a lung and most commonly occurs in patients between the ages of 20 and 40 years.
Symptoms	Symptoms may include sudden sharp chest pain and dyspnea.
Tests	Chest x-ray
Management	Observation may be indicated for a small pneumothorax area and chest tube insertion for large areas. The typical size chest tube (with or without a trocar) for an adult is a #36 or #40 French for hemothorax, and a #28 for a pneumothorax. The chest tube is not clamped for any reason including transport. Clamping does not allow the air or fluid to escape and tension may reoccur.
Complications	Complications include hemothorax or cardiovascular compromise from a tension pneumothorax.
Note	50% of the patients who need chest tubes suffer recurrence. A rupture or laceration of the diaphragm can allow the abdominal contents to enter the chest. The movement of the bowel into the thorax creates excessive pressures that compress and shift the thoracic structures and can mimic a pneumothorax.

Sputum Color

Sputum color is an indicator of the pathological process. Yellow sputum signifies white blood cells that are the major component of pus. Green sputum signifies production of an enzyme produced by stagnant pus cells. Rust, red, and brown sputum signifies red blood cells in the sputum.

Subcutaneous Emphysema

Subcutaneous emphysema results from an increase in intrathoracic pressure that results in alveolar rupture. Air dissects into the tissue and gravitates up to the neck, face, and supraclavicular area. The air can be felt under the skin. A mediastinal air leak can arise from the esophagus or from the lungs. The leak can be heard during auscultation when air is compressed by the contraction of heart (Hamman’s sign).

Venous Carbon Dioxide Levels

Elevated venous carbon dioxide levels are an indicator of acidosis.

Part Two: Chocking and Airway Obstruction

The organized systematic care process outlined in this section optimally manages the patient with an airway obstruction. The steps include assessment, problem identification, planning, interventions, ongoing evaluations, and disposition. Detailed information is included for the common medications used for patients with an obstructed airway. The related information at the end of the section provides an overview of terms, concepts, and pathophysiology related to choking and airway obstruction.

Topics reviewed include:

· Foreign body airway obstruction
· Heimlich maneuver for infants, children, and adults

Rapid ABC Assessment
1. Is the patient’s airway patent?
     a. The airway is patent when speech is clear and no noise is
         associated with breathing.
     b. If the airway is not patent, consider clearing the mouth and placing
         an adjunctive airway.
2. Is the patient’s breathing effective?
     a. Breathing is effective when the skin color is within normal limits and
         the capillary refill is < 2 seconds.
   b. If breathing is not effective, consider administering oxygen and
         placing an assistive device.
3. Is the patient’s circulation effective?
     a. Circulation is effective when the radial pulse is present and the skin
         is warm and dry.
4. If circulation is not effective, consider placing the patient in the
    recumbent position, establishing intravenous access, and giving a 200
    ml fluid bolus.

Be prepared to perform the Heimlich maneuver on a patient that is actively choking. Manual blind finger sweeps are NOT performed in infants and children because of the risk of pushing the foreign body further back into the airway.

The patient’s identity, chief complaint, and history of present illness are developed by interview. The standard questions are who, what, when, where, why, how, and how much.
Who identifies the patient by demographics, age, sex, and lifestyle.
What develops the symptom that prompted the patient to seek medical advice.
When determines the onset of the symptom.
Where identifies the body system or part that is involved and any associated symptoms.
Why identifies precipitating factors or events.
How describes how the symptom affects normal function.
How much describes the severity of the affect.

Patient Identification

1. Who is the patient?
a. What is the patient’s name?
b. What is the patient’s age and sex?
c. What is the name of the patient’s current physician?
d. Does the patient live alone or with others?

Chief Complaint

The chief complaint is a direct quote, from the patient or other, stating the main symptom that prompted the patient to seek medical attention. A symptom is a change from normal body function, sensation, or appearance. A chief complaint is usually three words or less and not necessarily the first words of the patient. Some investigation may be needed to determine the symptom that prompted the patient to come to the ER. When the patient, or other, gives a lengthy monologue, a part of the whole is quoted.
1. In one to three words, what is the main symptom that prompted the patient to seek medical attention?
a. Use direct quotes to document the chief complaint.
b. Acknowledge the source of the quote, e.g., the patient states; John
Grimes, the paramedic states; Mary, the granddaughter, states.

History of Present Illness