Airway Management Case Study 2
- May 15, 2008
Airway Management Case Study 2
You respond to a call, where a 45-year-old woman complains of a sudden onset of shortness of breath. Your assessment reveals that she is conscious and alert. Her skin is warm and moist. She is able to speak in full sentences and tells you that this has happened to her in the past. You can tell that she is in moderate distress with a labored respiratory rate of 28.
- Is this patient breathing adequately or inadequately? Why?
- How will you manage this patient's airway initially?
- With the history of asthma, what will change, if anything, in terms of your management?
- Explain why the pulse oximeter is reading 89%.
- Explain the physiologic process of wheezing and why it is impairing the patient's respirations.
Upon further assessment, the patient tells you that she suffers from asthma and has a prescribed inhaler, from which she has taken no puffs from today. The remainder of her past medical history is unremarkable.
You place the patient on a pulse oximeter and it reads 89%. The patient is still having moderate difficulty breathing. During your focused exam, you note that she has wheezing to all four lung fields upon auscultation.
Case Study 2 Answers
Answer 1: Recall that the most reliable indicator of overall perfusion is the patient's level of consciousness. Not only is this patient conscious and alert, but she is able to speak in full sentences, which indicates that she is moving adequate volumes of air. She is not displaying and signs of inadequate perfusion at this point; therefore, the patient is breathing adequately.
Answer 2: Initial management for a patient with difficulty breathing who is moving adequate volumes of air includes the placement of 100% oxygen with a non-rebreather (15 liters/min). If the patient does not tolerate the non-rebreather, a nasal cannula at 4-6 liters/min. can be applied. Note that this is initial management. The patient must be continuously monitored for signs of impending respiratory failure, such as altered mental status and cyanosis, as she may require assisted ventilation.
Answer 3: With a history of asthma, as well as the sudden onset of difficulty breathing (typical of an asthma attack), you must consider contacting medical control and requesting permission to assist the patient in taking her prescribed inhaler. Note that the medication must be prescribed to the patient. Generally, the EMT in the field administers no more than three puffs from the inhaler.
Answer 4: The pulse oximeter is a device that measure arterial oxygen saturation. Normally, it should read >95%. Since this patient is having a problem that is impairing oxygen-carbon dioxide exchange in the lungs, the blood returning to the left atrium that will ultimately perfuse the body will be relatively lower in oxygen. Remember that the pulse oximeter is an adjunct and, if possible, should be applied prior to the administration supplemental oxygen. This will allow the EMT to determine how the patient is oxygenating on his/her own. Additionally, a pulse oximeter reading >95% does not in itself rule out hypoxia. Any patient with difficulty breathing should receive supplemental oxygen, regardless of what the pulse oximeter reads.
Answer 5: The wheezing that you are auscultating in the lungs indicates constriction of bronchioles in the lungs. Wheezing is a hallmark finding of asthma. As air attempts to pass through the constricted bronchioles, a whistling sound is made. Impairment of respirations is due to decreased amount of inspired oxygen reaching the alveoli.
Case Study 2 Synopsis
This case study presented you with a patient, who although was having difficulty breathing, was breathing adequately. Remember, in determining the adequacy of a patient's respirations, you must note the rate, regularity, and quality. Additionally, you must note the patient's level of consciousness. This patient is breathing at a labored rate of 28 and although this parameter is abnormal, the overall effectiveness of her breathing is adequate. Remember to look at the "big picture" when assessing effectiveness of breathing, not any one single parameter. Signs of adequate breathing include the following:
- The patient is conscious and alert
- The patient is able to speak in full sentences
- The rate is not too fast or too slow
- There is adequate chest wall movement
- Absence of signs of hypoperfusion (shock)
- Diaphoresis
- Cyanosis (late sign)
- Weak, rapid pulse
Remember, continuous monitoring of this patient's airway is critical. Just because she is breathing adequately at present does not indicate how she will be breathing in 10 minutes, or even in 30 seconds for that matter.
