CHAPTER 27 Respiratory Emergencies

Judy Selfridge-Thomas, RN, MSN, CEN, FNP K. Sue Hoyt, RN, PhD, FNP, APRN, BC, CEN, FAEN

MAJOR TOPICS

General Strategy

Assessment

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Age-Related Considerations

Specific Respiratory Emergencies

Adult Respiratory Distress Syndrome

Asthma

Acute Bronchitis

Bronchiolitis

Chronic Obstructive Pulmonary Disease

Croup (Laryngotracheobronchitis)

Hyperventilation Syndrome

Pneumothorax (Iatrogenic and Spontaneous) and Pneumomediastinum

Pleural Effusion

Pneumonia

Pulmonary Embolism

I. GENERAL STRATEGIES

A. Assessment

1. Primary and secondary assessment/resuscitation (see Chapter 1)

2. Focused assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Dyspnea, shortness of breath

b) Pain: PQRST (see Chapter 9)

c) Coughing, choking

d) Hemoptysis

e) Sputum production

f) Skin color: pallor, cyanosis, flushed

g) Diaphoresis

h) Hoarseness

i) Dysphagia

j) Hematemesis

k) Abnormal respiratory sounds (e.g., wheezing, rhonchi, crackles)

l) Anxiety/restlessness

m) Time of symptom onset

n) Association with exertion

o) Association with chest pain

p) Fever, chills

q) Nausea, vomiting, diarrhea

r) Anorexia, weight loss

s) Efforts to relieve symptoms

(1) Home remedies

(2) Alternative therapies

(3) Medications

(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history

a) Current or preexisting diseases/illness

(1) Pulmonary disease

(2) Cardiovascular disease

(3) Renal disease

(4) Autoimmune disorders

(5) Postsurgical recovery or immobility

(6) Metabolic disorders

(7) Neuromuscular disorders

(8) Immunodeficiency status: human immunodeficiency virus (HIV) infection, therapeutic immunosuppression, underlying disease impairing pulmonary defense system

(9) History of disseminated intravascular coagulation (DIC)

(10) Respiratory infections: recent respiratory infection may increase susceptibility to other respiratory infections

b) Recent aspiration

c) Smoking history

d) Substance and/or alcohol use/abuse

e) Inhalation of toxic or caustic substances such as gases, animal products, chemicals, metals, wood dust, pharmaceuticals, and other dusts, sprays, and plant substances

f) Recent travel

g) Last normal menstrual period: female patients of childbearing age

h) Current medications

(1) Prescription

(2) Over-the-counter/herbal

i) Allergies to substances or materials, atopy (tendency to experience immediate allergic reactions because of antigen presence)

j) Immunization status

b. Objective data collection

1) General appearance

a) Level of consciousness, behavior, affect

b) Vital signs including pulsus paradoxus

c) Ability to breathe and speak in sentences simultaneously

d) Gait

e) Odors

f) Level of distress/discomfort

2) Inspection

a) Respiratory rhythm, depth, effort

b) Skin and nail bed color

c) Pupillary size and reaction

d) Carpopedal spasms

e) Nasal flaring

f) Tracheal position

g) Neck veins

h) Pharynx

i) Thorax

(1) Shape of chest: deformities, symmetry, anteroposterior diameter; barrel chest may be present in chronic obstructive pulmonary disease (COPD)

(2) Wounds: surgical scars

(3) Use of accessory muscles

(4) Abnormal retraction or bulging of interspaces

3) Palpation/percussion

a) Areas of tenderness, crepitus, deformity

b) Respiratory excursion

c) Fremitus (tremulous vibration of the chest wall)

d) Subcutaneous emphysema

e) Tracheal position, movement

f) Diaphragmatic level and excursion

g) Capillary refill

h) Skin and mucosa: temperature, moisture

i) Location of percussion sounds

4) Auscultation

a) Breath sounds

(1) Presence, equality, or absence

(2) Distribution

b) Adventitious breath sounds

(1) Wheezing: musical sound

(2) Crackles: small popping sounds produced by passage of air through secretions or lightly closed airways

(3) Rhonchi: snoring, low-pitched sounds similar to wheezes, produced by air passing through narrowed air passages

(4) Pleural friction rub: grating heard with inspiration and expiration as a result of inflammation of the pleural surfaces

c) Voice sounds: sound of a spoken word may be increased, decreased, or modified by disease

d) Heart sounds

5) Psychological/social/environmental factors

a) Heredity: tendency to develop certain respiratory diseases (e.g., as asthma) appears to be familial

b) Obesity

c) Environmental pollution

d) Occupational exposure (e.g., firefighters, coal miners, cotton mill workers)

e) Changes in weather: extremes of hot or cold; humidity changes

f) Exercise-induced

g) Stress factors

(1) Emotional distress: may precipitate asthma exacerbation

(2) Possible/actual assault, abuse, or intimate partner violence situations (see Chapter 3)

3. Diagnostic procedures

a. Laboratory studies

1) Complete blood count (CBC) with differential

2) Serum chemistries including glucose, blood urea nitrogen (BUN), and creatinine

3) Arterial blood gases (ABGs) (Tables 27-1 and 27-2); capillary gases, venous gases

4) Urinalysis; pregnancy test in female patients of childbearing age

5) Blood alcohol level (ethanol [ETOH]): elevations may lead to respiratory depression, possible aspiration

6) Serum and urine toxicology levels: may explain cause of increased or decreased respiratory rate or depth

7) Coagulation profile: prothrombin time (PT), partial thromboplastin time (PTT)

8) Thoracentesis fluid analysis

9) D-dimer

10) B-type natriuretic peptide (BNP) level

b. Imaging studies

1) Chest radiograph

2) Computed tomography (CT) scan

3) Magnetic resonance imaging (MRI)

4) Esophagogram

5) Lung scan (ventilation-perfusion [V/Q] scan)

6) Doppler sonography

7) Pulmonary angiography

c. Other

1) 12- to 15-lead electrocardiogram (ECG)

2) Esophagoscopy

3) Bronchoscopy

4) Simple spirometry: to estimate patient’s ability to exhale (significant in asthma)

5) Peak flow rate: measurement of choice in asthma; a decreasing peak flow should raise suspicion of narrowed airways

6) Forced expiratory volume (FEV₁): amount of air that can be forced from lungs in 1 second; FEV₁ of less than 80% of predicted tidal volume is indicative of obstructive lung disease

Table 27-1 BLOOD GAS: NORMAL VALUES

Table 27-2 INTERPRETATION OF ARTERIAL BLOOD GAS VALUES

B. Analysis: Differential Nursing Diagnoses/Collaborative Problems

1. Ineffective airway clearance

2. Ineffective breathing pattern

3. Impaired gas exchange

4. Decreased cardiac output

5. Deficient/excess fluid volume

6. Ineffective tissue perfusion: cardiopulmonary

7. Acute pain

8. Risk for infection

9. Anxiety/fear

10. Deficient knowledge

11. Noncompliance

C. Planning and Implementation/Interventions

1. Determine priorities of care

a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen as indicated

c. Establish intravenous (IV) access for administration of crystalloid fluids/medications as needed

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension

3. Allow significant others to remain with patient if supportive

4. Educate patient and significant others

D. Evaluation and Ongoing Monitoring (see Appendix B)

1. Continuously monitor and treat as indicated

2. Monitor patient response/outcomes and modify nursing care plan as appropriate

3. If positive patient outcomes are not demonstrated, reevaluate assessments and/or plan of care

E. Documentation of Interventions and Patient Response

F. Age-Related Considerations

1. Pediatric

a. Growth or development related

1) Ribs are more compliant; adult-level compliance reached by age 20 years

2) Mediastinum thinner, more mobile

3) Infants are obligate nose breathers; children depend on diaphragm for adequate chest expansion; may exhibit grunting or head bobbing with respiratory distress

4) Airways are small in size and easily obstructed by edema or mucus

5) Children’s metabolic rate and oxygen consumption are much higher than those of adults

b. “Pearls”

1) Airway resistance in infants is 15 times greater than in adults

2) Accessory muscles of inspiration tire quickly because of less reserve of glycogen

3) Greater body surface area and increased respiratory rate lead to rapid heat and water loss with infection and fever

4) Weak intercostal muscle result in observable retractions when respiratory effort is increased

2. Geriatric

a. Aging related

1) Decreased vital capacity, FEV₁, and maximum midexpiratory flow

2) Increased residual volume and functional residual capacity

3) Decreased static muscle strength and elastic lung recoil

4) Increased work of breathing

5) Decreased diffusion capacity and arterial oxygenation

6) Increased V/Q inequality, alveolar-arterial oxygen gradient

b. “Pearls”

1) Pulmonary defense mechanisms are reduced, making older adults more susceptible to infections

2) Diminished ventilatory response to hypoxic and hypercapnic challenge

3) Older adults may report dyspnea as breathlessness

4) Causes of dyspnea in older adults include

a) Functional impairment of pulmonary or cardiopulmonary system

b) Impaired oxygen delivery secondary to hematologic dysfunction

5) ECG is mandatory because acute myocardial infarction can present with dyspnea

6) Aspiration mortality rate of 40% to 70%; significant cause of pulmonary morbidity

7) Pneumonia is leading infectious disease cause of death in older adults; first sign may be deterioration in general health; nonpulmonary complaints, such as malaise and lethargy, are common. Pneumococcal vaccines do not necessarily prevent pneumococcal pneumonia. Older patients with concurrent rheumatoid arthritis, systemic lupus erythematosus (SLE), or alcoholism often remain susceptible to pneumococcal pneumonia because they may not develop an antibody response to the pneumococcal vaccine

8) Normally patients older than 60 years can exhale 75% of vital capacity in 1 second

a) 65% to 75%: mild obstruction

b) 50% to 65%: moderate obstruction

c) Less than 50%: severe obstruction

II. SPECIFIC RESPIRATORY EMERGENCIES

A. Adult Respiratory Distress Syndrome

Adult respiratory distress syndrome (ARDS) is a sudden, progressive, severe pulmonary disorder characterized by dyspnea, hypoxemia, and diffuse bilateral infiltrates. ARDS is also known as adult hyaline membrane disease, wet lung, posttraumatic pulmonary insufficiency, Da Nang lung, shock lung, and acute lung injury (ALI). ARDS is frequently associated with pulmonary contusion. It affects approximately 150,000 adults per year, with a mortality risk of 40% to 70%, although often it occurs in adults in the absence of chronic illness or lung disease. The syndrome may be caused by direct pulmonary injury or may result from systemic illness or trauma. Specific pulmonary insult occurs from pneumonia, embolism, aspiration, inhalation of smoke or toxins, prolonged exposure to oxygen, high-altitude pulmonary edema, and lung contusions. Indirect pulmonary assaults causing ARDS include sepsis, DIC, pancreatitis, uremia, anaphylaxis, drug overdose, eclampsia, radiation therapy, shock, multisystem trauma, and the administration of massive blood transfusions. The lung tissue responds to the assault with a diffuse inflammatory reaction in the microvasculature of the lungs. The release of chemical mediators, alveolar macrophages, and vasoactive substances causes increased permeability of the capillary and alveolar membranes with resultant pulmonary edema. Damage to the alveolar epithelium causes decreased surfactant, and alveolar and interstitial edema contributes to decreased lung compliance. The resultant atelectasis causes severe respiratory distress, leading to respiratory failure. If the patient survives, the lungs are typically scarred. Investigational treatment modalities include pharmacologic therapies to inhibit the destructive activity of chemical mediators and alternative ventilation procedures.

1. Assessment

a. Subjective data collection

1) History of present illness/injury/chief complaint

a) Sudden marked respiratory distress

b) Recent injury

c) Shock

d) Multiple blood transfusions

e) Fluid overload

f) Embolism

g) Drug overdose

h) Drowning incident

i) Inhalation of caustic toxic materials

j) Pulmonary contusion

k) Burns

l) Aspiration

m) Radiation exposure

n) Uremia

o) Pregnancy-related hypertension

p) Sepsis syndrome

q) Multiple fractures

2) Past medical history

a) Current or preexisting diseases/illness

(1) Cardiovascular disease

(2) Pulmonary disease

(3) Pancreatic disease

(4) Central nervous system (CNS) disease

b) Past surgical procedures

c) Smoking history

d) Substance use/abuse

e) Last normal menstrual period: female patients of childbearing age

f) Medications

g) Allergies

b. Objective data collection

1) Physical examination

a) General appearance

(1) Level of consciousness, behavior, affect: restless, anxiety

(2) Tachypnea: usually first sign

(3) Hypoxia, increased respiratory distress

(4) Hypotension, tachycardia

(5) Severe distress, critically ill

b) Inspection

(1) Cyanosis

(2) Retractions

c) Auscultation

(1) Breath sounds: fine to coarse crackles

2) Diagnostic procedures

a) ABGs: hypoxia

(1) Respiratory alkalosis early in disease

(2) Respiratory acidosis and hypercarbia occur as disease progresses

b) CBC with differential

c) Serum chemistries, including BUN, and creatinine

d) Blood cultures in cases of severe ARDS without discernible cause: sepsis is the most common cause

e) Urinalysis; pregnancy test in female patients of childbearing age

f) Chest radiograph

(1) Possible absence of infiltrates early in disease

(2) Bilateral, diffuse, white infiltrates without cardiomegaly

(3) Complete whiteout of lung fields as disease progresses

g) Respiratory function measures (FEV₁, forced vital capacity [FVC])

h) Pulmonary shunting studies

2. Analysis: differential nursing diagnoses/collaborative problems

a. Ineffective airway clearance

b. Impaired gas exchange

c. Ineffective tissue perfusion: cardiopulmonary

d. Decreased cardiac output

e. Excess fluid volume

f. Anxiety/fear

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (see Chapters 1 and 3)

b. Provide supplemental oxygen

1) Rapid-sequence intubation (RSI) and ventilatory support in patients with respiratory compromise

2) High-flow oxygen

c. Establish IV access for administration of crystalloid fluids/medications

d. Prepare for/assist with medical interventions

1) Advanced airway management

a) Nasal or oral intubation

b) Laryngeal mask airway

c) Combitube

d) Surgical airway (e.g., cricothyrotomy)

2) Position patient in high-Fowler’s position when possible

3) Institute cardiac and pulse oximetry monitoring

4) Assist with secretion removal

a) Have patient cough and breathe deeply

b) Use incentive spirometry to help loosen secretions and facilitate coughing; suction as indicated

5) Catheter placement and monitoring of central venous, arterial, and pulmonary pressures (see Chapter 7)

6) Assist with chest tube placement as needed

a) High peak pressures (i.e., greater than 50 cm of water) may indicate pneumothorax

7) Insert indwelling urinary catheter

8) Assist with hospital admission

e. Administer pharmacologic therapy as ordered

1) RSI premedications: sedatives, analgesics, neuromuscular blocking agents

2) Non-narcotic analgesics

3) Corticosteroids: controversial because routine or prophylactic use not found to be beneficial

4) Antibiotics: controversial because routine or prophylactic use may lead to development of multiple drug-resistant infections

4. Evaluation and ongoing monitoring (see Appendix B)

a. Airway patency

b. Level of consciousness

c. Hemodynamic status

d. Breath sounds and pulse oximetry

e. Cardiac rate and rhythm

f. Intake and output

B. Asthma

Asthma is a chronic, reversible obstructive pulmonary disease that is caused by airway inflammation and increased airway responsiveness (bronchospasm) to stimuli. Ten to 15 million persons in the United States have asthma. The disease affects more male than female patients, and it is the most common chronic childhood illness. Asthma affects approximately 5% to 10% of children and is more prevalent among lower-income, inner-city black children, children with low birth weight, children of young mothers, and those with genetic atopic disease. Two thirds of patients with asthma are diagnosed by the age of 40 years. The morbidity and mortality of asthma are increasing, causing approximately 5000 deaths per year in the United States. The death rate for asthma is greater for female patients and for African Americans.

The typical presentation includes dyspnea, wheezing, and a cough. Multiple factors may be involved in an exacerbation, including biochemical, immunologic, endocrine, infectious, autonomic, and psychological precipitators. Typically, environmental factors trigger the response in those individuals with an inherited predisposition to the disease. An allergen or stimulant causes B lymphocytes to produce immunoglobulin E (IgE), which attaches to mast cells and basophils in the bronchial walls. These cells then release their chemical mediators: histamine, prostaglandins, bradykinins, slow-reacting substances of anaphylaxis (SRS-A), and leukotrienes. Steroids may interrupt the release of the chemical mediators that cause mucus secretion, inflammation, and bronchospasm. Chronic inflammation causes hyperresponsiveness of the airways, which can be stimulated by exercise or cold air.

The Global Initiative for Asthma has developed a stepwise therapy model with guidelines for the successful management of long-term outpatient management of asthma. Management involves four strategies: (1) objective measures of lung function, (2) environmental control measures and avoidance of risk factors, (3) comprehensive pharmacologic therapy, and (4) patient education. Other strategies include management of exacerbations and regular follow-up care. Prior to treatment, asthma severity based on symptom prevalence and measurement of lung function needs to be established (Table 27-3).

Table 27-3 CLASSIFICATION OF ASTHMA SEVERITY

Status asthmaticus (acute, severe, and prolonged asthma exacerbation) is a life-threatening emergency. The bronchospasm does not respond to conventional therapy, thus leading to a worsening hypoxemia acid-base balance disturbance and eventual respiratory arrest, if uninterrupted.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Dyspnea, cough, wheezing

b) Restlessness resulting from increased hypoxia

c) Tightness in chest

d) Symptoms of infection: productive cough, fever, general “cold” symptoms such as malaise, sore throat, “stuffy nose”

e) Exposure to known allergens

f) Emotional factors

g) Environmental factors: exposure to extremes of heat/cold, humidity, dust, mold, smoke, pets

h) Time of onset of symptoms

2) Past medical history

a) Current or preexisting diseases/illness

(1) Cardiovascular disease

(2) Pulmonary disease

b) Previous asthma problems, including last emergency department visit, hospital admission, or intubation

c) Hereditary asthma/allergy problems

d) Medications

e) Allergies

f) Immunization status

b. Objective data collection

1) Physical examination

a) General appearance

(1) Level of consciousness, behavior, affect: restlessness; children with significant hypoxemia may demonstrate somnolence

(2) Tachypnea, tachycardia: children with significant hypoxemia may demonstrate decreased respiratory effort, bradycardia, and possible periodic apnea

(3) Inability to speak and breathe simultaneously

(4) Pulsus paradoxus: present in some patients

(5) Orthopneic posturing

(6) Moderate to severe distress/discomfort

b) Inspection

(1) Prolonged expiratory phase of respiratory cycle

(2) Use of accessory muscles

(3) Pallor and/or cyanosis

(4) Diaphoresis

(5) Physical exhaustion

c) Auscultation

(1) Breath sounds: wheezing on exhalation; as disease progresses, wheezing on inspiration; diminishing to absent breath sounds as air movement ceases

d) Percussion

(1) Hyperresonance

2) Diagnostic procedures

a) CBC with differential: leukocytosis, eosinophilia, increased hematocrit (if possible, obtain specimen before bronchodilator therapy and steroids)

b) Serum chemistries: potassium and chloride may be decreased in long-standing respiratory acidosis

c) ABGs: may be normal initially, then reflective of hypoxemia, hypercarbia (an ominous sign), and resulting respiratory acidosis

d) Sputum cultures

e) Medication levels (e.g., theophylline level)

f) Chest radiograph: hyperinflation; findings may help rule out other reactive airway causes (e.g., allergic bronchopulmonary aspergillosis or sarcoidosis)

g) Sinus CT scan: useful in excluding acute or chronic sinusitis as a contributing factor

h) Objective measurement of airflow obstruction: spirometry, peak flow meter

i) ECG in adult patients

2. Analysis: differential nursing diagnoses/collaborative problems

a. Risk for ineffective airway clearance

b. Impaired gas exchange

c. Ineffective breathing pattern

d. Anxiety/fear

e. Deficient knowledge

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen

1) RSI and ventilatory support in patients with respiratory compromise or status asthmaticus

2) High-flow oxygen

c. Establish IV access for administration of crystalloid fluid/medications as needed

d. Prepare for/assist with medical interventions

1) Advanced airway management

a) Nasal or oral intubation

b) Laryngeal mask airway

c) Combitube

d) Surgical airway (e.g. cricothyrotomy)

2) Position patient to facilitate breathing

3) Assist patient in removal of secretions: coughing, deep-breathing exercises, suction as necessary

4) Institute cardiac and pulse oximetry monitoring

5) Assist with possible hospital admission

e. Administer pharmacologic therapy as ordered

1) RSI premedications: sedatives, analgesics, neuromuscular blocking agents

2) Bronchodilators

a) Epinephrine, hand-held nebulizer treatment

b) Magnesium sulfate: inhibits calcium influx into airway smooth muscle cells

3) Rescue medications

a) Short-acting beta-agonists

b) Anticholinergics: used for severe exacerbations

c) Corticosteroids

f. Educate patient and significant others

1) Reduce aggravating allergens and precipitating factors

2) Medications: purpose, route, dose, and side effects

a) Stress that corticosteroid therapy should never be stopped abruptly but should be tapered off as prescribed

b) Use of home medications to prevent exacerbations

3) Importance of hydration

4) Use of home nebulizers and peak flow meters

5) Relaxation techniques and controlled breathing information

6) Importance of providing a smoke-free environment and instituting environmental control measures to reduce allergens, furred animal exposure, molds, dust mites, and other pests

7) Necessity for providing updated records, medications, and physical activity restrictions to child’s school administration and health services

4. Evaluation and ongoing monitoring (see Appendix B)

a. Airway patency

b. Level of consciousness

c. Hemodynamic status

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