Respiratory emergencies

Thank You
MANAGEMENT
PRIMARY GOAL
To maintain patent airway

To stabilise haemodynamic status

To localise the site

To control bleeding
Follow up
Chest drains should be managed on wards familiar with chest drains and their management.

Drains should be checked daily for wound infection, fluid drainage volumes and documentation for swinging and/or bubbling.
Don't Do points in ICD
A bubbling chest tube should never be clamped. (C)

A maximum of 1.5 l should be drained in the first hour after insertion of the drain. (C)

Drainage of a large pleural effusion. (C)
BPF
The closed underwater seal bottle is a system in which a tube is placed under water at a depth of approximately 3 cm with a side vent with allows escape of air or may be connected to a suction pump.

This enables the operator to see air bubble out as the lung re-expands in the case of pneumothorax or fluid evacuation rate in empyemas, pleural effusions or haemothorax.

The continuation of bubbling suggests a continued visceral pleural air leak

Acute Exacerbation of IPF
h/o Progressive exertional breathlessness
Bibasilar crackles
Clubbing
Age group- 6th to 7th decade
Males > females
Cigarette smoking
UIP Pattern HRCT diagnosed case of IPF presenting with rapid worsening, severe dyspnea predominantly Type I respiratory failure : Disease progression
Infection
Pulmonary Embolism
LVF
Management strategies
Respiratory Support
High Flow O2 delivery
Ventilatory Support NIV > Mechanical
Arrange for
Fresh CXR-PA view
ECG
ABG
D-dimer
Sputum C& S
Seek Specialist advise at the earliest.





Pathophysiology
Hypoxia
Airway obstruction
Changes in intra thoracicpressure
Ventilation-perfusion mismatches
Hypovolemia
Hypercapnia
Acidosis

Initial Management
ICU setup
Proper positioning
At least 2 large bore IV canula
Volume replacement
Oxygen inhalation
Blood for grouping,cross matching
Blood transfusion
Pulse oximetry,vitals monitoring

ICD Tray
Do not forget
As insertion of a chest drain is a procedure associated with significant risk, consent should be obtained in writing and should include the commonest and most serious complications as outlined below and also the possibility of treatment failure.
Chest Tube drainage
When to stop?
The procedure should be stopped when no more fluid or air can be aspirated, the patient develops symptoms of cough or chest discomfort or 1.5 l has been withdrawn.
Proper positioning
(A) Semi-reclined with hand behind head. (B) Sitting up leaning over a table with padding. (C) Lateral decubitus position.
Procedure
Skin, the pleura and periosteum are the most sensitive areas, this is where most of the anaesthesia should be infiltrated.
Local anaesthetic such as lidocaine (up to 3 mg/kg) is usually infiltrated.
Blunt dissection of the subcutaneous tissue and muscle into the pleural cavity has therefore become universal and is essential.
Tube insertion
For a large chest drain (>24 F), this track should be explored with a finger through into the thoracic cavity to ensure there are no underlying organs that might then be damaged at tube insertion.
A chest drain should be connected to a drainage system that contains a valve mechanism to prevent fluid or air from entering the pleural cavity. This may be an underwater seal, flutter valve or other recognised mechanism.
Rigid bronchoscopy
Advantage
Larger lumen
Better airway control
Better suctioning


Disadvantage
Poor visualisation of segmental lobar
bronchi
General anaesthesia

Therapeutic bronchoscopy
Lavage with iced saline

Suction of blood clots

Topical epinephrine

Balloon catheter tamponade

Laser photocoagulation

Fibrin precursors

RENAL & RESPIRATORY COMPENSATIONS TO ACID-BASE DISTURBANCES
Disorder Compensatory response
Metabolic acidosis PCO2 1.2 mmHg /1.0 meq/L HCO3-
Metabolic alkalosis PCO2 0.7 mmHg/1.meq/L HCO3-
Respiratory acidosis [HCO3-]
Acute 1.0 meq/L per 10 mmHg Pco2
Chronic 3.5 meq/L per 10 mmHg Pco2
Respiratory alkalosis [HCO3-]
Acute 2.0 meq/L per 10 mmHg Pco2
Chronic 4.0 meq/L per 10 mmHg Pco2
Non cardiac Chest pain
Differential
Non-Ischemic Cardiovascular
Aortic Dissection
Myocarditis
Pericarditis
Chest Wall
Cervical disc disease
Costochondritis
Fibrositis
Herpes Zoster( before rash)
Neuropathic pain
Rib fracture
Sternoclavicular arthritis


Pulmonary
Pleuritis
Pneumonia
Pulmonary embolus
Tension pneumothorax

Psychiatric
Affective disorders
Anxiety disorders
Somatoform disorders

>200ml to >600ml over 24 hours

A/c asphyxiation from flooding of airway with
blood

Most common source (90%)- bronchial
arteries
SEVERITY
Mild 200 ml to >600ml/day
100 ml blood loss/day x3 consecutive
days
>150 ml/hr
MASSIVE HAEMOPTYSIS
CAUSES
Tuberculosis

Bronchiectasis

Bronchogenic carcinoma

Lung abscess

Bleeding diathesis






Red flag differentials

Non specific ECG changes and Atypical Chest Pain
Underpinning ACS
Location
Aggravation
Alleviation

Gastrointestinal
Non-esophageal
Biliary
Peptic ulcer disease
pancreatitis
Esophageal
GERD
Esophageal spasm
Esophagitis
HIV-AIDS diseases
Achalasia
Presentation
Burning, squeezing, crushing substernal chest pain
Radiation to the arms, neck, back and jaws
Improves with sublingual nitroglycerin/antacids
Can be accompanied by dyspnea, pleurisy
Essentially, clinical symptoms cannot differentiate cardiac chest pain from NCCP.
3% of initially diagnosed NCCP die of ACS in the next 30 days. Hence requires close follow up.


Rule out PE
A low clinical suspicion for PE (eg, a Wells score 30/minute
Heart rate > 120/minute
Use of accessory muscles of respiration
Pulsus paradoxus > 25 mm Hg
PEF < 60% personal best or < 100L/minute (in adults)
Continuous beta-agonists
Defined as truly continuous aerosol delivery of beta-agonist medication using a large-volume Spacer or sufficiently frequent nebulisations so that medication delivery was effectively continuous

i.e. 1 nebulisation every 15 minutes or 4 / hour in patients with severe acute asthma
Steroids
The use of corticosteroids within 1 hour of presentation to an emergency department significantly reduces the need for hospital admission in patients with acute asthma

No advantage of parenteral over oral glucocorticoids and a maxmum dose of 40-60 mg/day of prednisolone is effective in most
cases
Parenteral bronchodialators
Aminophylline
Loading dose 5mg/kg or 250-500mg by slow IV Injection/infusion over 20-30mts Maintenance dose- 0.5mg/kg/hr
Max:rate- 25mcg/mt
Deriphyllin (Etofylline 169.4mg and theophylline 50.6 mg /2ml/injection)
Theophyllin 5mg/kg 0.4mg/kg/hr
Terbutaline 250- 500mcg QID S/C
IV infusion-3-5mcg /ml at the rate of 0.5-1ml/mt

SABA
MDI- 100-200mcg/puff.
Nebulized solution 2.5-5mg

Nebulized solution 250ug/ml
SAMA
Two hour rule
1st hr (i) Oxygen administration, (ii) hydration (intravenous fluids), (iii)upto four doses of inhaled salbutamol with ipratropium, (iv)intravenous hydrocortisone (100 mg) or oral prednisolone (40-60mg).
Assess patients status

2ndhr (i) Four more doses of inhaled salbutamol with ipratropium, (ii)intravenous aminophylline, (iii) intravenous magnesium sulfate 2 gm, (iv) subcutaneous terbutaline/ adrenaline 0.3-0.5 mg (0.01mg/kg- child) q 3 doses, Preparations: injection 1:1000(1mg/ml)

Patient not responding within 2 hr of treatment or deteriorating
Antibiotics
No role of routine use of antibiotics except if patient has fever,leucocytosis, purulent sputum or radiographic infiltrates suggestive of an infection.
Ac. Major Airway obstruction-causes
Hemorrhage
FB aspiration
Post intubation trauma
Angioneurotic edema
Inhalation injuries
External trauma
Infections
Faulty placement of ET tube
Post intubation trauma
Surgical emphysema
Cervical herniation of lung
Laryngeal dysfunction


Drugs
Adrenaline - 1 : 1000
- 0.3 – 0.5ml s/c or IM adult
- 0.01mg/kg 0.1 –0.3mls/c child
- Repeated at 20mts
- If no response 0.1 – 1ml diluted
in 10ml NS IV
Special syringe kits available
Epipen, Anapen, Anakit , Anaguard, Min I Jet
Adrenalin inhalers with drawn because of stability problems
Effective against all the effect of anaphylaxis
Side effects : tachycardia, VT, Cardiac arrest




Only two things cause death
The 2D rule
Difficult breathing – Swelling in the throat or bronchospasm or both.
Deteriorating consciousness – Once the patient is unconscious life is in danger, give adrenaline to prevent shock and hypoxia.
Priority
The list of real life threatening respiratory emergencies is more or less the same in all adult patients with slight alterations in the priority of the various differential diagnosis.

However elderly being the major bulk of these patients the various causes are enlisted accordingly
Practical Point of View
Commonly encountered Respiratory Emergencies : Recognition & Tackling

Make it as much concise and simple as possible –Problem based approach

Adapt to our setting adhering to standard recommendations based on currently available evidences.









Respiratory Emergencies

Dr.Sunny George
Associate Professor of Pulmonology,
Institute of Chest Diseases,
Government Medical College, Kozhikode.


19/10/2013


Injuries leading to a fatal outcome include blunt cardiac injuries with chamber disruption and injuries to the thoracic aorta

Majority of thoracic injuries can be managed with simple procedures such as clinical observation, thoracentesis, respiratory support, and adequate analgesia.
Symptom based TRIAGE
Severe Dyspnoea

Acute Chest Pain (Non ischaemic)


Massive Haemoptysis
Severe Dyspnea
Severely Dyspnoeic Elderly
Possibilities
Pulmonary edema with Acute coronary syndrome
Stridor with major airway obstruction
Tension Pneumothorax, Rapidly reaccumulating effusion.
Acute Severe Asthma
Acute Exacerbation of COPD
Acute pulmonary Thromboembolism
Acute Exacerbation of Idiopathic Pulmonary Fibrosis
Cor-pulmonale presenting as acute worsening
Rapid Action

Check for vitals including SaO2 and Simultaneously elicit a relevant 3 point history regarding onset & duration, Co-morbid illness and any past similar episodes.


Quick auscultation to pick up any reduction in breath sounds over a particular large area,rhonchi or crepitations.


Patch up
Try & Rectify the deficits in vitals
Secure a proper IV access,
Start Supplemental O2 (SaO2 60 mL/day, hemoptysis,monophonic wheeze).
Other conditions complicating asthma or its diagnosis necessitating additional work-up.
Severe persistent asthma.
Life threatening asthma (cyanosis, mental obtundation).
Acute severe asthma not responding within two hours of intensive therapy.

The decision to intubate an asthma patient should be based on clinical grounds, not on blood gas results


CT picture of ICD



Closed aspiration
Prerequisite
A Directly Observed Practice (DOP) assessment should be completed in support of
this.
Non-urgent pleural aspirations and chest drain insertions should be avoided in anticoagulated patients until international normalised ratio (INR) 90%,
Oral steroids,nebulised SABA/SAMA up to 3 times within 1st hr


Reassess the status
Partial Response
Worsening




O2 to keep Sa O2 > 90%,
Parenteral steroids,nebulised SABA/SAMA up to 1 – 3 hrs


Good Response
Incomplete Response

Hospitalise

Intrapleural pressure > atmospheric pressure throughout expiration.
Medical emergency - A/c severe dyspnea , tachycardia, diaphoresis, cyanosis
O/E – profound hypotension/hypoxemia,distended neck veins
Mediastinal shift, diaphragmatic depression ,unilateral hyperinflation, subcutaneous emphysema
Respiratory acidosis.
Rx – high flow O2 and insert large bore needle.

Tension Pneumothorax
Key Management strategies
Respiratory Support
Controlled O2 delivery
Ventilatory Support NIV > Mechanical
Pharmacological
Bronchodialators SABA > Theophyllines
Corticosteroids oral > Parenteral
Antibiotics
Adjuncts
Markers of COPD severity
Previous h/o mechanical ventilation
Use of accessory muscles of respiration
New onset Central Cyanosis
Peripheral oedema
Deteriorated mental status, older age
Hemodynamic instability,Co morbidities
ABG PaO2 < 60 mm of Hg,PaCo2 > 50 mm of Hg

PaO2 < 40 mm of Hg,pH 30
PaCO2 > 45 mm Hg
RR > 23
Exacerbation -------------medical therapy

Assisted Ventilation

trial of NIPPV ETI & ICU admission

ABG IN 1 HOUR NIPPV IN weaning considered

Adjust settings & Review
Continue NIPPV



Immediate ETI required or C/I to NIPPV



IMPROVEMENT








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Complications are due to lack of diligence to applied anatomy
Not enough anesthesia. Injury to neuromuscular bundle.
Injury to Lung; close by viscera.
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