6 Respiratory Emergencies

Francis Feld, DNP, CRNA, LAT, ATC, NRP

CHAPTER KEY WORDS

Asthma
Hemothorax
Pneumothorax
Tension pneumothorax

CHAPTER SCENARIO

During a professional football game, the starting running back presents to the athletic trainer complaining of wheezing and difficulty breathing. The athlete has a known history of asthma, and the team physician is immediately summoned to evaluate him. The physician confirms an acute exacerbation of asthma, and the athlete is assisted from the field to an area out of public view. Paramedics assigned to the team sideline follow the medical staff and provide an albuterol nebulizer and supplemental oxygen. After 2 albuterol treatments, the athlete feels better and wants to return to the game. The team physician performs a quick physical examination and clears the athlete to return to competition. He completes the game without incident and performs well.

SCENARIO RESOLUTION

This athlete had a known history of asthma, and the team medical staff was prepared to deal with an acute attack. Return to competition after treatment was indicated considering the sport level, and the team physician was also the treating physician, so he was aware of the athlete’s medical condition. This may not be the case at other sport levels, so return-to-play decisions must be made at the local level, and caution is always advised.

INTRODUCTION

Air hunger seen with difficult breathing is a terrifying experience for both the patient and the health care professional providing care. Patients who are hypoxic can be combative and difficult to treat and control. Early recognition and management are necessary to prevent a manageable condition from deteriorating into a catastrophic event. Respiratory emergency conditions seen in athletics are either medical- or trauma-related.

The most common medical condition in this population is asthma, whereas blunt force trauma to the thorax can result in pleural injuries. Penetrating trauma to the thorax will usually result in pleural injury, but this type of trauma is rarely seen in athletics. This chapter will briefly examine airway management and recognition, and treatment of medical- and trauma-related respiratory emergencies. Airway management is a technique that requires comprehensive education, and health care professionals working in the athletic arena should avail themselves of additional training in this vital area.

Airway Management

A patient who is conversing normally is said to have a patent airway. Patency refers to the patient’s ability to breathe without obstruction. A patient may experience difficulty breathing and still have a patent airway. Signs of obstruction are snoring, sternal retractions, intercostal retractions, accessory muscle contractions, nasal flaring, and gurgling sounds. Snoring in the unconscious patient is caused by an upper airway obstruction and is managed in the short-term by either a chin lift or jaw thrust maneuver. The jaw thrust is stimulating and may arouse the unconscious patient. Gurgling indicates fluid in the upper airway and is managed by suctioning out the material. Other obstruction signs indicate a more complex pathology and are managed by treating the underlying condition.

Cyanosis, a bluish coloration of the skin and mucous membranes, is an ominous sign of hypoxia. It is a late sign and mandates definitive interventions to improve oxygenation and ventilation. Pulse oximetry is a low-cost, non-invasive monitor that is routinely used to assess the oxygen status of patients and should be readily available in the athletic arena. The pulse oximeter is a clip applied to a finger, and it measures the difference between saturated and desaturated hemoglobin by passing infrared and red light through the finger. Saturated hemoglobin absorbs infrared light at 990 nanometers, whereas desaturated hemoglobin absorbs red light at 660 nanometers. The gradient is an indication of saturated hemoglobin and is expressed as a percentage. Normal ranges for a healthy non-smoker are between 99% and 100%. Values lower than 94% should be treated with supplemental oxygen. Pulse oximetry assumes that the hemoglobin is saturated with oxygen, but other compounds, such as carbon monoxide, will bind to hemoglobin preferentially over oxygen and give false-positive readings.

Although pulse oximetry is a measure of oxygenation, ventilation is measured by carbon dioxide (CO2) exchange at the alveolar level. Capnography monitors end tidal CO₂ with a nasal cannula. Normal CO₂ levels are 35 to 45 mm of mercury as measured by arterial blood gases, while end tidal CO₂ runs slightly lower due to normal physiological dead space. Capnography is expensive, and although normally found in most ambulances in the United States, it is not readily available in the athletic arena. Effective airway management results in a patient who has saturated hemoglobin and is ventilated. This can be accomplished in many ways and is crucial for optimal patient management.

Supplemental Oxygen Administration

The availability of supplemental oxygen at sporting events depends on many factors; although optimal, it is not mandatory. Oxygen tanks require proper storage and management and failure to do so can be dangerous. Oxygen tanks come in different sizes and those most commonly used outside the hospital are E and D tanks. Each tank has a regulator that reduces the tank pressure to a manageable level and a flow meter that supplies the oxygen device used. Tanks must be stored in proper holders and not subjected to extremes of temperature. If the regulator is damaged, the tank can become a deadly missile. Although oxygen is not flammable, it does support combustion, so no open flames or ignition sources should be in close proximity. Clearly labeled signage is required to indicate oxygen is in use. State practice laws may restrict the use of oxygen, so health care professionals must consider all these factors when deciding whether to use supplemental oxygen.

Oxygen tanks are made of aluminum and painted green. A full tank is pressurized to 2000 psi. The D tank holds approximately 360 L of oxygen, whereas the E tank holds approximately 625 L. The size of the D tank makes it convenient for sideline equipment bags, but its utility is suspect because it may be exhausted prior to emergency medical services (EMS) arrival. To estimate how long a D tank will last, multiply the pressure shown on the regulator by 0.2, and then divide by the flow rate. To estimate how long an E tank will last, multiply the pressure shown on the regulator by 0.3, and then divide by the flow rate. Although these are estimates, a full E tank will last twice as long as a full D tank.

Oxygen delivery devices include nasal cannulas, simple facemasks, reservoir facemasks, bag-valve masks (BVMs), supraglottic airways (SGA), and endotracheal tubes. The amount of oxygen delivered to the patient by each device is called the fraction of inspired oxygen (FiO₂) and varies with liter flow and device used. A nasal cannula is oxygen tubing with prongs that fit into the nares, with tubing loops that go around the ears. A simple facemask has vents for expiration and fits over the mouth and nose with an elastic strap that can be tightened for a snug seal around the head. A plastic bag attached to the reservoir facemask fills with oxygen and allows for a higher FiO₂ delivery. This mask also has vents for expiration. The reservoir bag does not have to fill completely for oxygen delivery.

All these devices allow a certain amount of rebreathing of CO₂ that prevents them from delivering an FiO₂ of 100%. A type of reservoir facemask that has valves over the vents is called a non-rebreathing facemask and will deliver up to 90% oxygen, but these are rarely used. Oxygen delivered through a secure airway, such as an SGA or endotracheal tubes with a BVM, will provide the highest FiO₂ possible. The BVM may be used with a facemask and an airway adjunct to ventilate a patient prior to the insertion of an SGA or endotracheal tube. Prior to using any of these tools, all health care professionals must review state practice acts. Endotracheal intubation and SGA insertion are advanced life support skills and are restricted to select health professionals in all states. Table 6-1 shows the flow rates and FiO₂ of each device.

Airway Adjuncts

Although a chin lift or jaw thrust maneuver will often relieve an airway obstruction, these are considered short-term measures, and both require an airway adjunct such as a nasopharyngeal airway (NPA) or oropharyngeal airway (OPA) for definitive management.

The NPA is a soft tube that is lubricated with a water-soluble gel and inserted along the most inferior aspect of the nares, which is the largest passageway. The bevel at the end of the NPA orients toward the septum and is usually inserted into the right nostril. If significant resistance is met upon insertion, the NPA should be withdrawn and inserted into the left nostril. Aligning the bevel with the septum requires rotating the NPA 180 degrees upon insertion, and after approximately half of the airway is inserted, the NPA is rotated into its original alignment and inserted until the flared end is flush with the nares. The diameter of the NPA should approximate the diameter of the patient’s fifth finger, and the length is the distance from the nares to the earlobe. If an NPA is inserted forcefully or without adequate lubrication, a severe nosebleed may result. This bleeding will complicate airway management and must be avoided at all costs.

The OPA is inserted into the mouth over the tongue into the posterior oropharynx. Insertion may be aided with the use of a tongue depressor to retract the tongue upon insertion. Care must be taken to prevent injury to the hard palate of the upper mouth, especially in children. An intact gag reflex is an absolute contraindication for the use of the OPA. The length of the OPA is the distance from the corner of the mouth to the earlobe. An Internet search will easily provide pictures of both devices in place.

Sizes for both the NPA and the OPA are variable based on the manufacturer. The NPA may be 26 to 34 French (8.6-11.3 mm), or it may be small, medium, and large. The NPA is made of silicone and is non-latex. The OPA size may be 60 to 100 mm, or it could be small, medium, and large. The OPA is made of plastic.

Use of both airway adjunct types requires additional education and frequent review. The use of the BVM for mask ventilation is a difficult psychomotor skill to master and requires frequent review and practice.

Medical Respiratory Emergencies

Asthma is a common respiratory condition found in 1 of 13 adults and 1 of 12 children.¹ Triggers such as dust, pollen, chemicals, cold weather, and smoke cause asthma attacks. These triggers cause inflammation and swelling that constrict the bronchial airways. Symptoms include wheezing, coughing, and difficulty breathing. Wheezing is noted when auscultating breath sounds with a stethoscope and may be in one or multiple lung fields. Wheezing that is audible without a stethoscope may indicate a more severe attack. Acute asthma attacks can be fatal, and 10 people in the United States die every day from asthma.¹ There is no cure for asthma, but with proper medication and monitoring, people with asthma can participate in any activity.