EMQ practice: Emergency management: respiratory distress

Respiratory distress

• 65 year old male, long standing COPD, severe shortness of breath, Oxygen and nebulised bronchodilators, Hour later: PaO2 6.0 kPa (on max. O2), PaCO2 16.0 kPa, pH 7.2
• Nasal intermittent positive pressure ventilation
• Exacerbation of COPD and Type II respiratory failure
• Responded poorly to medical therapy
• Non-invasive intermittent positive pressure ventilation (NIPPV)
• Reduce need for formal intubation
• Anaesthesia and intubation can be difficult in a patient with respiratory failure
• NIPPV should be tried unless patient is in extremis
• It does need the patient to be conscious and cooperative though
• 17 year old woman, wheeze and marked perioral swelling, Now: PaO2 7.0 kPa (on 28% O2), PaCO2 4.1 kPa
• 100% O2, intramuscular adrenaline, nebulised salbutamol
• Acute anaphylaxis
• Type I IgE-mediated hypersensitivity reaction
• Rash, oedema, tachycardia, hypotension, and wheeze
• Laryngeal oedema giving rise to upper airway obstruction in particularly worrying because it may impede endotracheal intubation
• Initial treatment of choice:
• 0.5ml epinephrine 1:1000 solution (500 micrograms) delivered intramuscularly which can be repeated in the absence of clinical improvement or if deterioration occurs
• Intravenous epinepherine is dangerous and should only be given in dilution of 1:10000 in an immediately life-threatening situation (e.g. frank cardiac arrest)
• 14 year old asthma, acute severe asthma attack, PaO2 10.0 kPa (on 28% O2), PaCO2 8.0kPa
• 100% O2, nebulised salbutamol, intravenous hydrocortisone
• Severe asthma attack features
• Peak expiratory flow rate PEFR < 50%
• Respiratory rate more than or = 25 breaths/min
• Pulse more than or equals to 110 beats/min
• Inability to complete sentence in 1 breath
• Life-threatening asthma attack
• PEFR <33%
• Silent chest
• Cyanosis
• Poor respiratory effort
• Bradycardia
• Arrhythmia
• Hypotension
• Exhaustion
• Confusion
• PaO2 <8kPa
• Acidosis with pH<7.35
• High PaCO2
• Intubation and transfer to ICU if patient does not respond to drug therapy
• 100% O2 should be given since there is no risk of respiratory depression resulting from a hypoxic ventilatory drive
• Between attacks CO2 should be within normal range
• Common mistake to restrict oxygen to patients with asthma dn a high CO2
• 28 year old male, RTA, severe respiratory distress, Examination reveals decreased expansion on right side of chest with mediastinal shift to the left
• Right-sided decompression
• Tension pneumothorax is a medical emergency
• Cannula inserted into second intercostal space in the mid-clavicular line in the affected side until a functioning intercostal tube can be positioned
• Young man, acute onset shortness of breath, decreased expansion on the right, SaO2 95%
• Chest radiograph
• Indicated here to confirm diagnosis of pneumothorax and assess the degree of collapse
• In healthy patients a small penumothorax will often heal without further intervention
• Patient should be observed for 6 hours and, if there is no increase in the size of the pneumothorax, may be discharged with early follow-up and repeated chest radiograph
• Spontaneous pneumothoraces are relatively common in young adults (especially tall thin men) and older patients with emphysema
• In patients with thoracic disease/large pneumothoraces, simple aspiration is recommended
• If not working, then chest drain is required