Published on March 12, 2014
By Dr. Hossam M. Elsaadany MBB;CH- MSc- MD Lecturer of Internal medicine & Gastroenterology
Respiratory Anatomy • Nose • Pharynx • Larynx • Trachea • Right and Left • Bronchi • Non-Respiratory Bronchi • Respiratory Bronchioles • Alveolar Ducts • Alveoli
Physiology Inspiration Active process Chest cavity expands Intrathoracic pressure falls Air flows in until pressure equalizes Expiration Passive process Chest cavity size decreases Intrathoracic pressure rises Air flows out until pressure equalizes
Adequate Breathing Normal rate and depth Regular breathing pattern Good breath sounds on both sides of lungs Equal chest rise and fall Pink, warm, dry skin
Inadequate Breathing Breathing rate < 12 or > 20* Shallow or irregular respirations Unequal chest expansion Decreased or absent lung sounds Accessory muscle usage Pale or cyanotic skin color Cool, clammy skin appearance
Ventilation is • Definition: The movement of air between the atmosphere and alveoli and the distribution of air within the lungs to maintain appropriate concentrations of oxygen and carbon dioxide in the blood
Perfusion Definition: The movement of blood through though the pulmonary capillaries
Diffusion– process of moving oxygen into blood and carbon dioxide out • Diffusion is movement of particles (gas) from an area of high concentration to an area of low concentration
Exchange of oxygen and carbon dioxide
Causes of Respiratory Emergencies • Failure of: –Ventilation: air in/ air out –Diffusion: movement of gases –Perfusion: movement of blood
Respiratory emergencies • Respiratory emergencies are medical emergencies characterized by difficulty breathing or an inability to breathe at all. Such emergencies can become fatal if they are not treated properly and rapidly. • Acute pulmonary oedema , status asthmaticus, pneumonia, chronic pulmonary obstruction disorder, croup, inflammation of the epiglottis, pulmonary embolism and pneumothorax are all conditions associated with respiratory emergencies. • In a respiratory emergency, a patient may take frequent shallow breaths, irregular breaths, or very slow breaths. In some cases, the patient stops breathing at all. Respiratory emergencies are commonly accompanied with pale, cold, clammy skin, cyanosis and the heart may stop beating or become irregular.
Ventilation defect • Foreign body obstruction • Anaphylaxis and angiodema • Aspiration • Pneumothorax, hemothorax • Asthma • COPD • Emphysema • Chronic Bronchitis
Diffusion defect • Pulmonary Edema: • Left-sided heart failure • Toxic inhalations • Near drowning • Pneumonia
Perfusion defect • Pulmonary Embolism: • Blood clots • Amniotic fluid • Fat embolism
Upper Airway Infections
Upper respiratory tract obstruction • Obstruction may result from tongue, aspiration, or foreign body. • Be prepared to treat quickly and aggressively. • Head-tilt/chin-lift to open airway
Signs & Symptoms • Dyspnea or respiratory distress • Cough • Excessive salivation • Stridor
Acute Pulmonary Edema • Fluid buildup in lungs • History of CHF • High recurrence • Signs & symptoms: • Dypsnea • Frothy, pink sputum • Pedal edema, ascities • Rales, wheezes • Hypertension •.
Asthma • Common but serious disease • Acute bronchiole constriction with increased mucus production • Signs & symptoms: • Wheezing • Patient looks tired • Cyanosis
Pneumothorax • Accumulation of air in the pleural space • Spontaneous or trauma induced • Signs & symptoms: • Dypsnea • One-sided chest pain • Absent or decreased breath sounds
Anaphylaxis • Characterized by respiratory distress and hypotension • Usually results from body response to allergen. • Airway obstruction due to angiodema is major concern
Pneumonia • Infection of the Lungs • Infection usually caused by bacteria or virus, rare instances fungal • Patient will present with sick appearance, febrile, shaking, productive cough, increased sputum. • Patient with increase respiratory rate/effort, tachycardic, wheezes/rales/consolidated lung sounds
Pleural Effusion • Collection of fluid outside the lung • Caused by irritation, infection, or cancer • Signs & symptoms: • Dypsnea • Decreased breath sounds over effected area • Positional comfort
Pulmonary Embolism • Blood clot that breaks off, circulating through venous system. • Signs & symptoms: • Dypsnea/tachypnea • Cyanosis • Acute pleuritic pain • Hemoptysis • Hypoxia
ARDS • Pulmonary edema caused by fluid accumulation in the interstitial spaces, interfering with diffusion causing hypoxia (fluid balance) • Underlying etiology includes sepsis, pneumonia, inhalation injuries, emboli, tumors • Mortality rate >70% • Supportive care at the BLS level
Initial Assessment • Initial Impression: • Past medical history and drug therapy • Body position • Audible breath sound • Skin signs and color • Respiratory rate and effort • Mental status • Pulse (rate & character)
Airway Proper ventilation cannot take place without an adequate airway Breathing Signs of life-threatening problems Alterations in mental status Severe central cyanosis, pallor, or diaphoresis Absent or abnormal breath sounds Speaking limited to 1–2 words Tachycardia Use of accessory muscles or intercostal retractions Immediate management is indicated Assessment of the Respiratory System
Focused Exam (CHEST EX.) Crackles (Rales) • CHF • Pneumonia Rhonchi • Pneumonia • Aspiration • COPD • Sometimes Asthma Stridor • FBAO • Croup • Anaphylaxis • Epiglottitis • Airway burn Wheezing • Asthma • CHF • COPD
Management Plan 1. ABC’s/Monitor vitals 2. Secure airway 3. Patient in position of comfort. 4. Oxygen supply ? 5. Minimize patient movement. 6. IV access 7. Treat underlying cause 8. Rapid transport! 9. Mechanical ventilation
Insert oropharyngeal airway with tip facing palate Rotate airway 180º into position
Advanced Airway Management
By Dr. Hossam M. Elsaadany MBB;CH- MSc- MD Lecturer of Internal medicine & Gastroenterology
Intruduction • Many respiratory disorders can compromise routine dental care and require special treatment for the affected patients. • Patients often visit the dental clinic with respiratory problems already diagnosed by other specialists. The dental professional therefore must provide correct dental care in this condition
Asthma and Chronic obstructive pulmonary disease (COPD) • The dental professional must know how to deal with an asthma attack, and must know the drugs which are to be avoided in such patients e.g morphine and B. blocker. • Chronic obstructive pulmonary disease (COPD) and asthma require special measures, such as working with the patient in the vertical position, since some of these subjects do not tolerate decubitus. On the other hand, patients with COPD can suffer infectious lung diseases secondary to the aspiration of microorganisms in the presence of deficient periodontal conditions.
Drugs to be avoided in asthmatic patients. DRUGS TO BE AVOIDED IN ASTHMATIC PATIENTS Drugs containing aspirin (10-28% of all asthmatics may not tolerate the latter). Nonsteroidal antiinflammatory drugs (patients with intrinsic asthma).acetaminophen e.g paracetamol is analgesic of choice Macrolide antibiotics in patients treated with theophylline. The serum methylxanthines levels (theophylline) may be increased. Opiates: these can cause respiratory depression and histamine release. Local anesthetics: use solutions without adrenalin .
MANAGEMENT OF ASTHMA ATTACKS 1. Suspend the dental procedure and raise the patient to a comfortable position. 2. Establish and keep the airways free, and administer an inhalatory β2 agonist. 3. Administer oxygen with a mask. 4. In life threatening asthma administer subcutaneous epinephrine (1:1000 in solution, 0.01 mg/kg body weight, with a maximum dose of 0.3 mg). 4. Notify the emergency medical service. 5. Maintain adequate oxygen levels until the patient breathes regularly and/or medical help arrives.
Pulmonary tuberculosis • Patients with an established diagnosis of tuberculosis (TB) can also be seen in the dental clinic, and the dental professional in any case must be familiarized with the main signs and symptoms of the disease: productive and persistent cough, blood in sputum, nocturnal perspiration, weight loss, fever or anorexia, or a combination of these manifestations.
• When TB is suspected, it is advisable to postpone all non-emergency dental treatment until the patient has been cured or is no longer infectious • The dental professional must avoid inhaling the infectious droplets by wearing a protective face mask. • Oral manifestation of tuberculosis 1.Tuberculous ulcer 2.Tuberculous gingivitis •Oral tuberculous lesion of the dorsum of the tongue in a patient with TB
FOREIGN BODY ASPIRATION • Many dental materials and elements are of small size, and when exposed to saliva it may be difficult to manipulate them correctly. When the patient is placed in the supine or semi-raised position, such objects might be swallowed or aspirated into the oropharynx. • When a foreign body is aspirated into the oropharynx, the patient should sit up and be instructed to cough forcefully. The immediate priority is to ensure that the airways remain free.
• If breathing is affected, clearly recognizable symptoms quickly develop, such as asphyxia, inspiratory stridor and the need to breathe with accessory muscle support. If vigorous coughing is not effective, the patient in the standing position, we grasp him or her from behind with both arms. In this position we apply pressure with one closed fist and the other hand covering the fist. The fist is positioned with the thumb over the abdomen, and we press firmly towards the center of the stomach, immediately below the ribcage. • If this maneuver likewise proves ineffective, the patient must be moved to the nearest emergency medical center as quickly as possible.
1. What’s means of lung perfusion ,ventilation, diffusion ,pneumonia, pneumothorax, pleural effusion? 2. Respiratory emergency caused by dental procedure? 3. Drugs contraindicated in asthmatic pateints? analgesic ??? 4. Oral manifestation of TB? 5. Manifestations of upper respiratory ob.?
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