that is active exhalation is passive it's relaxation they can't force the air out it's kind of like breathing through a straw i can suck air in and use accessory muscles but when i try to blow out it's constricted and i can't exhale forcefully because my diaphragm is designed to relax and go back into place so as a result of that they can suck air in which means they can get oxygen in but they can't get the co2 out which is why wheezing occurs initially on exhalation which is why in the beginning stages of asthma your pulse ox should be normal too much co2 good or bad so what would you expect the color and temperature of an asthma attack to be red and flushed warm because the co2 is causing vasodilation so i would expect my asthma attack to have a normal pulse ox high co2 to be red in appearance and i would expect wheezing owns only on exhalation because they can suck air in using accessory muscles this patient right here a butyrole is probably going to work as well as astronaut if for some reason it doesn't work heart rate goes up respiratory rate goes up pulse ox goes down and tidal continues to go up what do i try after three treatments of a butyrol two of them with atroven sub qe sub qep or tributalane because what we need to think about it three treatments have failed we're about 20 minutes into this call now we need to emergency rescue them that's where sub-q ep comes in so three treatments have failed no improvement except qfe if i'm staying here i probably don't need to move to the effie but if i'm getting worse i need to move to the up he's solumedrome soluble is not an emergency drug and what i mean by that is it's not going to work in 30 seconds after i get it matter of fact it's probably going to take 15 to 30 minutes before the effects of the saudi medrol ever kick in so an emergency situation it does mean no good right now however the sooner i give saudi medrow on this run the sooner it's going to kick in and help them long term and maybe prevent them having to be innovated at the hospital does that make sense there is no hard fast rule on when you should give solumedral i would say that if you're going to give sodium medrol first of all are we taking the patient to the hospital second of all how many treatments are we going to have to give them and those should be your guiding factors whether we use saudi medical or not so for example let's say that i walk in 20 year old asthma patient he or she says hey i ran out of my butter all this morning i just need a quick treatment and then i'm going to run up to walmart and get a refill i got a good pull socks cabinet is a little high a little bit of sharp pin they're moving good air they're talking in sentences i may go ahead and give them a butter all then maybe another one with that event to give them time to get to the pharmacy i'm not probably not taking that person to the hospital i don't need to be giving themselves versus i walk in and i see this in asthma let's say i got 128 88 and 70. what does that 88 tell me they're not getting oxygen they're not inhaling now so not only do they have expiratory wheezing they also have inspiratory and eventually when they get in toward reason those bronchioles are soaked shut they can't get air in and out this tells me that they've already burned through their four to six minutes of stored oxygen and now their pulse ox is starting to fall is my butter all going to be as effective in this patient no because they can't suck enough air in which is why they're becoming high boxes so i know this person probably needs to go to the hospital and i know i'm going to end up with multiple treatments so let's get the soluble on board quicker because then it's going to work sooner and that's just kind of the general rule there's not like you know respirations are x you have to give solution all just understand that it's going to take a while to work so if i'm going to be transport and given multiple treatments the sooner we give sodium and draw the better off it is for the patient so would you start with sub-q on that patient on this one no not necessarily because of all the tachycardic side effects i got with the appy but now if we if we made it in the low 80s and they've already tried multiple treatments i'd be starting them on cpap right away because then if they're still breathing a little bit you may be able to force air in with that cpap and force the butyrol in it but once again to uc bat they have to be able to suck hard enough to break that five to ten centimeters of water because you can't do that on a cpap right yes you can yeah that's correct so for so far like a registry scenario without they give you and you might have to run through your drone so here here's what they would say 26 year old male status asthmaticus multiple nebulizers have failed what's your next option three treatments it's refractory i'm looking at subcuta they may use turbulene or breathing every once in a while that is basically a sub-q injection like epi specifically designed for bronchodilation can also be used to stop pre-term labor or they give you epi andromeda so here's where we get to mag okay mag is last ditch because of the heart side effects so imagine i have this asthma person i have done a butyrole attribute they were getting worse i gave them soy medrol i put them on cpap they're getting worse i give them some qep and they are locked down what has happened is if you remember back to yesterday all contractions in the body occur from sodium movement into the cell and potassium moving out what has happened in status asthmaticus if i can't relieve it with the muteral atrovent and stub qep sodium has gotten stuck in the cell and potassium's gotten out so it's got stuck in this bronchoconstriction state yesterday how did we make the sodium potassium reset calcium made it start what reset it so mag is a last ditch effort the other problem we have with mag is mag takes 10 to 20 minutes to infuse one gram is 10 minutes 2 grams is 20 minutes so why do we give it that slow even in asthma what's the biggest side effects of matt bradycardia and hypotension so on this person that's having status asthmaticus and everything is failed eventually they're going to start bradying down so i can't go slam and mag in them to reverse the asthma because they're starting to move towards respiratory value and failure so that's why it's a last-ditch effort but i don't want to slam it it's given over the 10 to 20 minutes so if i said you have status asthmaticus all treatments have failed which are the following would you consider valium verstead ativan or mag and that's how that maybe works all right the higher the pulse ox the more likely a buterol is to work on your asthma patients um be aware that we have some old-school medics out there that think pulse ox is end-all be-all and they're like look you're fine your pulse ox is 100 there's nothing wrong with you and you're like yeah but they're breathing 42 times a minute and wheezing and there's at no 70. yes they can currently get oxygen but they can't get that acid and co2 out and remember acid has to be eliminated every exhalation oxygen i got four to six minutes for stuff to go wrong before i run out of oxygen so that co2 is just as important if not more important than oxygen in this patient so my asthma is three treatments no relief epi sodium medrol and cpap anywhere in the middle of that equation all right uh so we good on asthma shark fed bronchospasms look at chronic bronchitis blue bloaters three months out of the year for two consecutive years they're overweight they're always sick they always have bronchitis that's the chronic bronchitis look at your treatment though treatment for chronic bronchitis is the exact same of what we just talked about for asthma correct first treatment of uterus second and third of the butyrol and atrovet no relief consider subcupping use caution if the person has cardiac issues because the tachycardia effects of acne one thing i would add to give to your chronic bronchitis as well as your asthma patients give them a fluid bolus why would i recommend giving fluid bolus to asthma and bronchitis patients huh because everybody's trying to get rid of toxins yeah and what happens if i give you a whole bunch of fluid it helps thin the secretions and the thinner the secretions the easier it is to get out of your nose so think of it like this you've got rock hard crusted boogers in your nose you can't blow it the only thing you can do is try to go up there and pull them out either by picking your nose tweezers whatever all right you gotta suction that stuff out what happens though if i give you a whole bunch of fluid and we change it into a liquid snot that you can blow and help clear out and that's what given fluids to my asthma patients my brochures patients bronchitis patients and pneumonia patients does is it helps then those secretions to where the accurate is more effective and they can move those secretions out of the bronchials if you innovate an asthma patient uh i'm trying to remember if they're still putting this on there or not if you innovate an asthma patient and they are extremely difficult to back and the breath sounds are really diminished give them a fluid bolus and consider squirting 10 to 20 cc's of saline down the et tube because what has happened is they have a giant mucus plug on the alveoli and by squirting saline down the tube it helps moisten that plug and hopefully break it loose to where the air can force it out of the way and that's why they start becoming hard to back because of how tight they are from the mucous and the plug that's built up inside those bronchials and the alveoli so once again fluid can help us in those patients uh one thing to help you determine on the chronic bronchitis we said three months out of the year for two consecutive years or more they chronically have bronchitis uh also there's what's called the 40 rule the 40 rule is packs a day of cigarettes times years so they only smack a smoke one pack a day it would take approximately 40 years for them to develop copd if they smoke two packs a day it would take them 20 years so that's why when you take a patient to the er they say how long you've been spoken and how much do you smoke and if the person has a ratio of packs a day and years above 40 then they're high risk for copd and copd could be pulmonary emphysema or chronic bronchitis chronic bronchitis is blue bloaters pulmonary emphysema is pink puffers pulmonary emphysema is the only patients that actually breathe based on o2 everybody in this room breathes based on co2 here's why if i hold your breath if i tell you to hold your breath and not exhale your oxygen level's spine for a few minutes but what are you stacking up in your body now co2 and so when you stack up co2 that's bad you're going to vasodilate guess what your heart rate's going to do it's going to go up go up it will go up to compensate so the reason why our body breathes off co2 is because it tells us did i have oxygen did i have a heart to pump it did i have blood to transport it did i have pressure to force it into the capillaries and did the capillaries have sugar to convert it to atp and if so is my gas at 35 to 45 where it's supposed to be that's the only way for the body to tell homeostasis if that number changes the body's going to instantly react versus oxygen i could have all the oxygen in the world but if the heart's not moving it it doesn't do me any good i can have all the oxygen in the world but if i'm losing blood it's not going to do me any good i can have all the oxygen in the world but if there's no pressure to force it through the pre-capillary sphincter into the into the capillaries it does me no good that's why we measure carbon dioxide because it's the end result of all body systems working appropriately and if that number changes it stimulates the brain to recognize holy crap my end title is 60 something's gone wrong increased heart rate increased respirations oh my goodness panic let's see if we can figure out why and it happens every three to five seconds every time we exhale that's why our chemoreceptors are set on c on co2 the problem with the emphysema patient is instead of having an alveoli that looks like a balloon sac their abioli has actually collapsed and deflated itself because it's lost its elastase properties so if i handed you a deflated balloon when you inhale or exhale to blow it up exhale so what they do is they partially exhale to reinflate this balloon to create surface area in order to exchange oxygen and carbon dioxide so what are they re-inflating that balloon with carbon dioxide so as a result of that they are going to trap carbon dioxide in their avioli if they were to fully exhale what would happen to their carbon dioxide level and what would happen to their aveolar stack it would collapse so as a result of that they never fully exhale they they puff to prevent complete elimination of co2 well because they're trapping all this co2 to keep their alveolar open their co2 level will start to climb if you and i co2 level gets above 45 that's going to trigger our respirations and heart rate to go up well their co2 is slowly going to start to climb in the beginning their body is going to try to compensate for this increased carbon dioxide so every time i raise my hand i want you to take a breath all right breathe just normal breathe breathe breathe breathe breathe breathe breathe breathe breathe how you feel not too good a little lightheaded now imagine having to breathe that fast you only did that for 15 seconds imagine you have to breathe that fast every minute every hour every day for the rest of your life to try and keep your co2 level normal oh by the way you can't fully exhale because then your lungs will collapse how tired would you be how many calories would you burn how developed would your accessory muscles become you'd be ripped that's why they become thin and barrel chested because they're trying to eliminate that co2 but they never can so as a result of that their chemoreceptors go screw that i cannot get my number down anymore so the chemoreceptors as a backup measure oxygen if the oxygen is 100 does the brain recognize the problem no so what happens is their chemoreceptors adjust to where when they recognize hypoxia it drives them to breathe this is what hypoxic drive is so if i have jace up here his brain sits there and he goes hey man you're 90 take a breath hey you're 90 take a breath hey you're 90 take a breath oh you're 100. you don't need to breathe anymore i just knocked out his what because he no longer recognizes he's hypoxic so the brain has to no longer remind him to breathe that's what hypoxic drive is because of the high levels of co2 too much co2 is bad bad things cause my vessels to vasodilate all that redborn blood goes beneath the skin makes it red in appearance pink puffers purse lips pulmonary emphysema the reason why they breathe through cursed lips we're all going to look dumb together open your mouth stick out your tongue take a deep breath now do it through purse lips which one created pressure first lips so they are essentially seep happening themselves through pursed lips to force air through their constricted alveoli and then they puff because if they fully exhale it would deflate their ravioli because they've lost their elastosome properties this is what true hypoxic drive is pink puffer's personal pulmonary emphysema now how do i know if this is normal for them or not well we put our vital signs back up here 60 to 100 heart rate 12 to 20 respirations but instead of having a pulse ox of 96 to 100 percent they need to be mildly hypoxic 88 to 94 and then we expect their in-title co2 to be greater than 50. now they may or may not need oxygen to keep them in that 88 a lot of times they do need supplemental oxygen it will be on a couple liters of bicannula so let's say that i run 64 year old female history of cp copd she steps off the curb and breaks her ankle all right and they give you this for vital signs 98 18 92 54. that's her vital signs do we need to adjust her cannula from two liters no no no plus why are we there not perfect she broke her ankle and this is normal for a copd patient what if i told you you have a 63 year old female complaining of trouble breathing 112 24 92 percent and 60. she's on 2 liters by cannula is that normal for her or not let me ask you this if it was normal she wouldn't be compensating she wouldn't be to kipnick so even though this 92 percent is in the normal pulse ox range for a copd hypoxic drive this tells me that that's a little low for her so i need to go ahead and give her a what i need to go from 2 liters on a candy lid and maybe 6. i wouldn't want to go straight to an honor breather because if i get her to 100 here's what's going to happen it takes approximately 10 minutes to resupply all of our red blood cells with oxygen it takes another 10 minutes before the chemoreceptors quit activating based on oxygen needs so on average it takes approximately 20 minutes to knock out somebody's hypoxic drive the average transport time according to the rest registry parameters is 15 minutes so on my average call if i put them on an honor breather i'm probably not going to knock out their epoxy drive however if i work in a rural area the roads are snowing i see the ambulance breaks down catches fire on the side of the road which is actually a test question where the bridge is out what does that do to your 20 minutes or the 15 minute transport time makes it longer which puts the patient more at risk for knocking out their what epoxy drives so if i got this person and let's say they're on two liters let's bump them up to 4 liters if 4 liters is working heart rate should what respiratory rate should pulse ox may or may not change capno may change a little bit but this tells me they're compensating or not does that make sense so if heart rate and respiratory rates normal and pulse ox between 88 and 94 and they didn't call you for shortness of breath probably don't need to adjust it if they call you for shortness of breath and heart rate and respiratory rate is compensating probably need to adjust their cannula now we can put a patient on an honor breather so let's say that i have this right here let's say that i run on copd patient respiratory distress they've been taking a butyrole and i get there and they're this 134 28 80 and 90 on the captain believe it or not your cat note can go much higher than your screen shows if they're on two or four liters of cannula is that working no so i put them on not over either if the non-rebreather is working the heart rate should come back to normal respiration should come back to normal pulse ox should come up towards 88 to 94 percent and end title should start to come back down towards 50 correct so let's say 12 minutes go by and i'm now here 116. 100 and 40. you better take them off that can't off that not here because you're starting to relax them so much that if i continue down this path i'm going to knock out their what hypoxic drive and what happens when you knock out their toxic drive is they quit breathing on their own and it takes several weeks to months to get them weaned off the ventilator before they'll breathe get on their own because they have to go from 100 where they're going i don't even got to breathe i just lay here to fighting for every breath and learning how to live in a hypoxic state again that's why we don't want to knock out their hypoxic drive so you can use a non or breather on an emphysema patient the key is when they're at 80 put them on an honor breather when they start getting in the upper 80s to low 90s take the non-rebreather off put them back on a cannula and see how they tolerate they were at 80 i put them on an honor breather i got them to 94. let's take it off and put them back on the candy i put them at four liters and they maintain 94 and their heart rate's less than 100. cool let's stick with it if they fall back down in the 80s put them back on the non-river either we're just using that long enough to get out of the danger zone and then turning around and pulling it back off and going back to a cane if you may if you make them lethargic you're gonna have to ventilate them and then you're gonna have to innovate and then they're gonna have to end up in a skilled nursing facility on a vent for months to be weaned off and they're going to have to slowly get that pulse ox back down to where they live in mild hypoxia of 88 to 94 now because of the excessive carbon dioxide they're going to produce more red blood cells this is called polycythemia the hemoglobin on red blood cells not only carries oxygen but it also carries co2 that's why it's called carboxy hemoglobin what do they have too much of that needs transported what do they have too little of so they end up producing more red blood cells called polycythemia which makes them even redder in appearance they also end up vasodilated as a result of that the back pressure in their chest from always being basically inflated with trapped carbon dioxide puts pressure on the right atrium and right ventricle and makes it pump harder to overcome that chest pressure as a result of that that sa node has a hard time firing which is why a lot of times that sa node will go into what rhythm a5 that's how your copd patients end up in a fed so your copd patients are at risk of 5th and the afib increases the risk of what from yesterday ischemic stroke the clock so that's how they start that cascading effect plus they smoked and did all the years of nicotine and nicotine increases the risk of clots as well so now they've doubled their stroke risk we're good on asthma pneumonia classic pneumonia is what they're going to ask you about you on the test more than likely classic pneumonia occurs in young healthy people that are able to get up and move around so if i get pneumonia and i'm able to move around and walk that pneumonia is probably going to be in only what with one lobe so i'll have a greener yellow productive cough with a fever and one lobe will be congested with wrong time that's classic pneumonia classic pneumonia i give them fluid to help thin the booger snot and swim in the lung and then i give them a butyrole to open it up and then definitively they need antibiotics to take care of the infection the says it is not a good idea to give attribute to pneumonia patients because if you drive that secretion up and you make it rock hard it creates a mucus plug and they can't get that booger stone phlegm out it's the same reason why lasix is contraindicated in pneumonia patients because it drives that crust out and it creates a rock hard film and now they can't move air in and out of their lungs if you give lasix to pneumonia patient you increase your chances of mortality by about 40 now it's easy in a young person because they got a fever they got one side congested they got a yellow or green productive cough give them some fluid give them some of uterol take them to the hospital real world where do we see our pneumonia patients at nursing homes and because their bed confined can't get up and move around they're laying flat in bed that booger snot and flim ends up in both lobes so now i walk in and out here and you're going okay is that booger snot flim or is that rels and chf most ers will not administer lasiks now without a portable chest strike because they have to make sure they're not accidentally given lasiks to pneumonia patients so how can i tell in the field with a nursing owned patient that has a history of chf the chf and constantly having fluid in their lungs become stagnant and bacteria grows and develops bilateral pneumonia so how do i tell the difference is it bilateral pneumonia or is it chf exasperation without a chest x-ray in the nursing home if this new onset pneumonia they should have a fever so if the skin is pink warm and dry the infection will also cause vasodilation and drop their blood pressure a little bit versus yesterday in chf they were cool fell clammy and hypertensive because of the fe release and angiotensin release so if i walk in and i have crappy breast sounds and i have lower than normal blood pressure a 70 year old does not typically have a blood pressure 102. they're probably getting into the 140 to 160 range so i walk in and i got a 70 year old pink worm dry skin fever lower than normal blood pressure fluids in a butyrol i walk in i got a 70 year old and they got crappy breath sounds cool pale clammy tachycardia high blood pressure kidney nitrile opposite treatments skin tip will help you tell the difference between chf and pneumonia all right classic pneumonia what's going to be on the test one low of yellow or green productive cough aspiration and pneumonia occurs after they get a foreign substance in their lungs and their immune system triggers to go fight the infection somebody aspirates on beer they ask for eat on food after choking and near drowning they'll develop pneumonia all right and that will be bilateral foreign body aspiration moving over to the top of the next page top page six foreign body aspiration is a distraction for or actually it's a uh basically a post choking all right if somebody has partial airway obstruction we can assist them with the heimlich or back blows if they have complete airway obstruction to become unconscious we start chest compressions after 30 compressions if we're by ourself we look in see if we can see the object and pull it out all right that's basically that's your aha expect four to eight choking bls aed cpr type questions you're going to see a couple of them on there all right it's just what you're going to say they're going to ask you complete airway obstruction and choking immediately start compressions partial or airway obstruction ask them if they're choking and then do abdominal thrust or heimlich maneuver if they become unconscious they're chest compressions what happens in 44 body aspiration is they clear the object but it scratched their throat so now they have localized swelling and inflammation in the oral fairness so that person needs humidified what oxygen how do you make humidified oxygen put three cc's of saline in the nebulizer and run it in you can run it through a mask whatever that helps uh give the immune humidified oxygen if i have a complete airway obstruction so let's say that you had a person choking you try to do the heimlich they become unresponsive you start chest compressions you open the airway and you see a piece of steak in there and you cannot get that steak out what should you try before going to a surgical or needle cry yeah i tried forceps and i can't get it out and i can't get air in the middle yeah mainstream