EMS Airway Management - Lungs Sounds

EMS Providers should have a solid understanding of normal lung sounds and be able to recognize those that are adventitious lung, as these can provide crucial information about a patient's respiratory status. 

Here’s an overview of the key points regarding lung sounds:

1. Normal Lung Sounds

• Vesicular Breath Sounds: These are the standard breath sounds heard over most of the lung fields. They are soft, low-pitched, and have a longer inspiratory phase than expiratory phase.
  • Characteristics: "Gentle rustling" sound, more prominent in the bases of the lungs.
  • Cause: Normal airflow through the large and small bronchi and alveoli.

2. Adventitious (Abnormal) Lung Sounds

Adventitious Sounds are additional lung sounds superimposed on normal breath sounds. They indicate an underlying pathology. They include:

Stridor

• Description: A high-pitched, harsh sound heard during inspiration.
• Cause: Caused by a partial obstruction of the upper airway (i.e., larynx).
• Common Conditions:
• Croup: Typically in children, caused by a viral infection that leads to inflammation.
• Epiglottitis: Life-threatening condition caused by bacterial infection.
• Airway Obstruction: Foreign body or severe anaphylaxis.
  
• Sound File: Stridor

Wheezing

• Description: High-pitched, musical sounds, typically heard during expiration (but can be heard on inspiration as well).
• Cause: Narrowing or obstruction of the lower airway (i.e., trachea)
• Common Conditions:
  • Asthma: Due to bronchospasm and inflammation.
  • COPD: From chronic airway obstruction.
  • Bronchiolitis: Inflammation of the small airways, common in infants.
• Sound File: Wheezing

Rhonchi

• Description: Low-pitched, snoring or gurgling sounds, often cleared with coughing.
• Cause: Secretions or mucus in the larger airways (i.e., bronchi; bronchioles)
• Common Conditions:
  • Chronic Bronchitis: Increased mucus production and obstruction.
  • Pneumonia: Accumulation of mucus and fluids.
  • Bronchiectasis: Chronic enlargement and inflammation of bronchi.
• Sound File: Rhonchi

Rales (Crackles)

• Description: Fine or coarse, popping or crackling sounds, more prominent during inspiration.
  • Fine Crackles: High-pitched, short, and intermittent.
  • Coarse Crackles: Low-pitched, bubbling or rattling.
• Cause: Fluid in the small airways (i.e., alveoli)
• Common Conditions:
  • Heart Failure (Pulmonary Edema): Fluid accumulation in the alveoli.
  • Pneumonia: Fluid or pus within alveoli due to infection.
  • Fibrosis: Stiffening of lung tissue.
• Sound File: Fine & Course

Pleural Friction Rub

• Description: Low-pitched, grating sound, like creaking leather, heard during both inspiration and expiration.
• Cause: Inflammation of the pleural layers causing them to rub together.
• Common Conditions:
  • Pleuritis: Inflammation of the pleura, often due to infection or autoimmune disorders.
  • Pulmonary Embolism: Can lead to pleuritic inflammation and pain.
• Sound File: Pleural Friction Rub

3. Other Abnormal Lung Findings

Pleural Effusion

• Description: Presence of fluid in the pleural space, usually causing a decrease in normal lung sounds over the affected area.

• Common Conditions:

  • Heart Failure: Increased hydrostatic pressure causes fluid leakage into the pleural space.
  • Infection (e.g., Pneumonia): Inflammatory fluid accumulation.
  • Cancer: Malignant pleural effusions.

• Physical Exam Findings:

  • Decreased breath sounds over the affected area.
  • Dullness to percussion due to fluid presence.

Key Points for EMS Providers

• Stridor is a red flag indicating upper airway obstruction — immediate airway assessment is critical.

• Wheezing typically suggests lower airway narrowing; listen carefully to both inspiratory and expiratory phases.

• Rhonchi may indicate the need for airway clearance (e.g., suctioning).

• Crackles (rales) suggest fluid in the lungs — think about causes like heart failure or infection.

• Pleural Friction Rub can indicate pleuritic pain and requires assessment for underlying conditions like pleuritis or PE.

• Assess for Patient Symptoms: Correlate lung sounds with symptoms (e.g., shortness of breath, cough, sputum production, chest pain) for a more complete clinical picture.

Recognizing and differentiating these sounds can help EMS providers make critical early decisions about management and transport.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bickley, L. S., & Szilagyi, P. G. (2020) Bates' Guide to Physical Examination & History Taking (13th Ed). Philadelphia, Pennsylvania: Wolters Kluwer.

Bohadana, A., Izbicki, G., & Kraman, S. S. (2014) Fundamentals of Lung Auscultation. New England Journal of Medicine, 370(8): 744-751. Accessed October 8, 2024

Brown, C. A. (2022) Walls Manual of Emergency Airway Management (5th Ed). Philadelphia, Pennsylvania: Lippincott, Williams & Wilkins.

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Sarkar, M., Madabhavi, I., Niranjan, N., & Dogra, M. (2015) Auscultation of The Respiratory System. Annals of Thoracic Medicine 10(3):158-168. Accessed October 8, 2024

EMS Medication Administration - Inhalation Route

EMS Providers need to have a thorough understanding of inhaled medication administration to ensure patient safety and effective treatment. 

Here are some key points they should know:

1. Indications and Contraindications

Indications:

• Respiratory distress due to conditions like asthma, chronic obstructive pulmonary disease (COPD), or anaphylaxis.
• Administration of medications such as bronchodilators (e.g., albuterol), corticosteroids, and emergency medications (e.g., epinephrine via nebulizer for severe allergic reactions).

Contraindications:

• Allergy to the medication.
• Inability of the patient to effectively inhale the medication (e.g., severe respiratory distress, altered mental status).
• Situations where the administration method (e.g., nebulizer, metered-dose inhaler) is not suitable due to specific patient conditions or environmental factors.

2. Types of Inhaled Medications

Metered-Dose Inhalers (MDIs): 

Pressurized canisters that deliver a specific dose of medication in aerosol form.

Dry Powder Inhalers (DPIs): 

• Devices that deliver medication in powder form which the patient inhales.

Nebulizers: 

• Devices that convert liquid medication into a fine mist for inhalation over several minutes.

Breath-Actuated Inhalers: 

• Devices that release medication automatically when the patient inhales.

3. Preparation and Technique

Medication Preparation:

• Verify the “Six Rights” of medication administration: right patient, right medication, right dose, right route, right time and right documentation.
• Ensure the inhaler or nebulizer is properly assembled and medication is correctly loaded.

Patient Preparation:

• Ensure the patient is in an upright position to maximize lung expansion and facilitate proper inhalation.
• Instruct the patient on how to use the inhaler or nebulizer correctly.

4. Administration Techniques

MDIs:

• Shake the inhaler well before use.
• Attach a spacer if recommended, which helps in delivering more medication to the lungs.
• Have the patient exhale fully, place the mouthpiece in their mouth, and inhale slowly and deeply while pressing the canister to release the medication.
• Instruct the patient to hold their breath for about 10 seconds before exhaling slowly.
• Wait about a minute between puffs if a second dose is needed.

DPIs:

• Load the dose according to the inhaler’s instructions.
• Have the patient exhale fully away from the inhaler, place the mouthpiece in their mouth, and inhale quickly and deeply.
• Instruct the patient to hold their breath for about 10 seconds before exhaling slowly.

Nebulizers:

• Assemble the nebulizer and add the prescribed medication to the medication cup.
• Attach the mouthpiece or mask to the nebulizer.
• Turn on the nebulizer and have the patient inhale the mist steadily until the medication is finished (usually 5-10 minutes).

5. Patient Communication and Education

Explain the Medication: 

• Inform the patient about the purpose of the medication, how it will help, and any potential side effects.

Instructions: 

• Provide clear instructions on how to use the inhaler or nebulizer, including breathing techniques and the importance of taking slow, deep breaths.

6. Monitoring and Follow-Up

Observe for Effects: 

• Monitor the patient for the expected therapeutic effects and any adverse reactions.

Reassessment: 

• Regularly reassess the patient’s respiratory status, including breath sounds, respiratory rate, and oxygen saturation, to determine the effectiveness of the medication and any need for additional intervention.

7. Complications and Management

Incorrect Usage: 

• Ensure the patient understands and correctly follows the administration technique to avoid ineffective dosing.

Adverse Reactions: 

• Be prepared to manage potential adverse reactions, such as tachycardia, tremors, or paradoxical bronchospasm.

Device Malfunction: 

• Recognize and troubleshoot any issues with the inhaler or nebulizer.

8. Special Considerations

Pediatric and Geriatric Patients: 

• Adjust instructions and consider additional challenges in administering inhaled medications to these populations, such as the use of spacers for children or coordination issues in the elderly.

Environmental Factors: 

• Ensure the environment is suitable for nebulizer use, especially in situations where power sources may be limited or there is a risk of spreading infectious aerosols.

Patient Condition: 

• Be aware of any conditions that might affect inhaled medication administration, such as severe respiratory distress, altered mental status, or inability to follow instructions.

9. Training and Proficiency

Simulation Training: 

• Regular practice using simulation models to maintain proficiency in inhaled medication administration techniques.

Continuing Education: 

• Stay updated on best practices, new medications, and techniques for inhaled administration.

10. Legal and Ethical Considerations

Scope of Practice: 

• Adhere to the legal scope of practice for their certification level and local regulations.

Informed Consent: 

• Obtain informed consent from the patient or guardian whenever possible.

Documentation: 

• Accurate documentation of medication name, dose, route, time of administration, and any observed effects or adverse reactions.

Conclusion

Effective inhaled medication administration requires EMS providers to combine theoretical knowledge with practical skills. 

Continuous training, adherence to protocols, and understanding the indications, techniques, and potential complications are essential for safe and effective patient care.

Further Reading:

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Bledsoe, B. E. & Clayden, D. (2018) Prehospital Emergency Pharmacology (8th Ed). Boston, Massachusetts: Pearson.

Guy, J. S. (2019) Pharmacology for the Prehospital Professional (2nd Ed) Burlington, Massachusetts: Jones & Bartlett Learning.

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey:  Wiley Blackwell

EMS Medical Emergencies - Asthma Attacks

 

EMS providers should be familiar with key aspects of asthma and associated respiratory emergencies. Here are some important points to consider:

Asthma Overview: Understand that asthma is a chronic inflammatory condition of the airways, characterized by recurrent episodes of wheezing, coughing, chest tightness, and shortness of breath. It can range from mild to severe, and triggers may include allergens, exercise, respiratory infections, or environmental factors.

Signs and Symptoms: Recognize the signs and symptoms of an asthma attack, such as audible wheezing, increased respiratory rate, use of accessory muscles, coughing, cyanosis (bluish discoloration), and difficulty speaking in full sentences.

Assessment: Perform a thorough respiratory assessment, including checking the patient's oxygen saturation levels, lung sounds, and respiratory effort. Assess the severity of the asthma attack using a validated scoring system, such as the Asthma Severity Score.

Treatment: Administer high-flow supplemental oxygen to maintain adequate oxygenation. Consider providing bronchodilator medications, such as albuterol, through a nebulizer or metered-dose inhaler with a spacer. Corticosteroids may also be administered to reduce airway inflammation.

Monitoring: Continuously monitor the patient's vital signs, oxygen saturation, and respiratory status. Reassess the patient's response to treatment periodically and adjust interventions accordingly.

Complications: Be aware of potential complications, including respiratory failure, pneumothorax (collapsed lung), and status asthmaticus (severe, prolonged asthma attack refractory to treatment). Promptly recognize and manage these complications as needed.

Communication: Communicate effectively with the patient and their caregivers, providing reassurance and explaining the actions being taken. Obtain a thorough medical history, including any known asthma triggers or previous exacerbations.

Transport and Referral: Determine the appropriate level of care and transport the patient to the nearest appropriate healthcare facility. Ensure a smooth handoff to the receiving medical team, providing them with a detailed report of the patient's condition, interventions performed, and response to treatment.

Remember, asthma management should be individualized based on the patient's condition and medical history. 

Regular training, updated protocols, and close coordination with medical direction are crucial for providing optimal care to patients experiencing asthma and associated respiratory emergencies.

#Asthma #ChronicInflammatoryDisorder #RespiratoryDistress #RespiratoryFailure 

#Cyanosis #Bronchospasm #StatusAsthmaticus