Respiratory Emergencies
Since the human body has a constant need for oxygen, there are not many things as upsetting as hearing someone trying desperately to get a breath of air or it seems as though the next breath will never come. It is without doubt even more frightening to be the one gasping for that breath. Some people have conditions such as asthma, emphysema or bronchitis that are a constant threat. However, respiratory difficulties can be triggered by a number of medical problems that are exacerbated by physiological or psychological stress, and even healthy patients can find themselves gasping from hyperventilation brought on by psychological stress.
Recognition of a person at risk, or an extremely anxious healthy person, is very important. Once again, the medical history and attempt to reduce stress as much as possible are the keys to preventing episodes of respiratory distress.
Recognizing of the signs and symptoms of respiratory distress allows prompt action that can help solve or alleviate the problem and prevent other emergencies. Besides the obvious unusual noises, such as gasping or wheezing, the person may breathe much faster or more slowly than normal, or breathing may be deeper or more shallow. Skin appearance and temperature are other indications of respiratory difficulty; initially, the skin may be moist and flushed; later, it may be pale, ashen, or cyanotic and feel cool to the touch. The person may verbally express lightheadedness, pain and tightness in the chest, paresthesia (numbness and tingling) of the hands, feet and/or lips. The difficulty being experienced, along with feelings of suffocation, may quite understandably cause fear and apprehension - stress - that can in turn cause the problem to worsen.
The two most common causes of respiratory difficulty are hyperventilation and airway obstruction that may occur with vasodepressor syncope. Breathing emergencies can result from other causes such as obstructed airway, asthma, heart failure, myocardial infarction, allergic reactions, inhaling or ingesting toxic substances, cerebrovascular accident (CVA, stroke) and less commonly, drug overdose reaction. Croup, a childhood viral infection and epiglottitis, another childhood illness of bacterial origin, also may cause respiratory distress in children.
The most common respiratory medical emergency in the dental office is Hyperventilation, which is almost always caused by unexpressed extreme anxiety. Hyperventilation occurs when respiration is increased in depth or frequency, most commonly occurring in individuals 15 - 40 years of age who are especially tense and nervous. There are conditions other than stress that can induce hyperventilation, such as head injury, severe bleeding, and hyperglycemia associated with diabetes mellitus. Regardless of the cause, hyperventilation is one of the easiest medical emergencies to correct.
The patient is usually unaware of overbreathing, but may feel unable to take in enough air, or that he or she is suffocating. The person also may experience the subjective feeling of tightness in the chest, globus hystericus (a "lump" in the throat), and lightheadedness or giddiness that in turn can cause even more apprehension. Increased apprehension causes more overbreathing, which then increases symptoms by exacerbating chemical changes, causing more apprehension, and a vicious circle is established.
The goal for treatment of hyperventilation is to break that circle before later clinical manifestations occur such as tingling and paresthesia of hands, feet and perioral area; muscular twitching; carpopedal tetany (a syndrome characterized by flexion of ankle joints, muscular twitching, muscular cramps, and convulsions); and unconsciousness.
Management of this emergency includes positioning the patient in an upright position for comfort; removing any materials from the mouth; and loosening binding clothing, such as a tight collar, belt, or tie. One may calm the patient by offering reassurance of regaining control of breathing. The person should be asked to breathe slowly, only at about four to six breaths per minute. Often, this alone will correct the problem. If this does not work, or if the victim is unable to slow the breathing, rebreathing exhaled air slowly into the cupped hands, into a small paper bag, or into a full face mask from the oxygen delivery unit may help. When the person rebreathes exhaled air the carbon dioxide necessary to control breathing is replenished. If all these efforts fail, EMS should be called immediately. The airway should be kept open and breathing monitored until EMS personnel arrive and take over. Under no circumstances should oxygen be administered.
Asthma is a disease caused by increased responsiveness of the tracheobronchial tree to various stimuli, which results in bronchospasm, bronchial wall edema, and hypersecretion of mucous glands. Asthma is most frequently seen in children and in twice as many boys as girls. It affects six to eight million Americans, and the frequency and severity of the disease seems to be increasing. Asthma is a killer, with a 100% increase in asthma deaths for children between the ages of 10 and 14.3
A characteristic sign of asthma is wheezing, described as hoarse, whistling sounds on exhalation due to air trapped in the lungs. The typical patient is generally free of symptoms except during acute episodes. Individuals diagnosed with asthma control the frequency of attacks with medications that stop the muscle spasm and open the airway, making breathing easier.
Status asthmaticus, defined as persistent exacerbation of asthma, is the life-threatening condition that occurs when an asthmatic attack does not respond to therapy. Status asthmaticus manifests the same symptoms as any acute asthmatic episode and may occur in any asthmatic patient, but manifestations of the episode continue for a prolonged time, even with treatment. As a result of continuing effects of the acute episode, the person experiences extreme fatigue, dehydration, severe hypoxia (oxygen deprivation) which in turn causes cyanosis, peripheral vascular shock, and drug intoxication from intensive therapy.
Prevention of asthma attack includes using information from the health history to determine factors that may trigger an episode so that steps can be taken to minimize risk. Reduction of stress is important since psychological and physiological stress may precipitate an acute attack in susceptible individuals.
Management of an acute asthmatic episode includes positioning the patient in the most comfortable position, which is usually sitting with arms thrown forward, and administering a bronchodilator. Most asthmatic patients carry their own bronchodilator. Often taking these two steps is the only treatment necessary to terminate the episode. Dental therapy should be discontinued for the day and rescheduled. The patient may be discharged when fully recovered. However, if the episode continues, oxygen should be administered and EMS called immediately. Heart failure and acute pulmonary edema also can cause respiratory distress. Heart failure is a pathologic state in which abnormal cardiac function is responsible for failure of the heart to pump the volume of blood necessary to meet requirements of tissue metabolism. Heart failure can develop in pulmonary circulation (left heart failure), systemic circulation (right heart failure), or both (congestive heart failure). All pose a significant risk during dental therapy, especially in both psychologically and physiologically stressful situations, which can provoke an acute episode.
A person with left heart failure may exhibit weakness and undue fatigue; dyspnea and tachypnea (abnormally rapid respiration); cough with expectoration; and orthopnea, a condition in which the person can only breath in an upright or seated position. Such a person could not tolerate reclining during dental treatment. Right heart failure is characterized by systemic venous congestion evidenced first by signs of peripheral edema. Right heart failure is usually caused by left heart failure, so symptoms are similar, with the addition of cyanosis and cold skin, especially in extremities, due to decreased blood flow.
The patient with right heart failure also may exhibit anorexia, nausea and vomiting, headache, and irritability.
The patient with heart failure is at risk for acute pulmonary edema, a sudden, rapid passage of fluid through membranes from the pulmonary capillary bed into the alveolar spaces of the lungs, usually precipitated by psychological or physiological stress. Signs and symptoms include a rapid onset of severe orthopnea (feelings of suffocation and anxiety) which further increase breathing rate and difficulty. The person may notice a sense of heaviness in the chest, and may exhibit tachypnea, pallor, sweating, cyanosis, and frothy pink sputum (blood tinged saliva and mucous filled with air bubbles).
Management of acute pulmonary edema includes positioning the conscious person in an upright position, and the unconscious person in the supine position. EMS should be activated immediately, the patient calmed as much as possible, vital signs monitored, and basic life support provided. High concentrated oxygen should be administered via nasal cannula, if available. Malamed notes that since the sufferer feels like he is suffocating, a facemask would be uncomfortable. A vasodilator may also be administered until EMS arrives.
A "bloodless phlebotomy" to remove blood from circulation and alleviate symptoms of respiratory distress is a further step that can be taken especially if the patient is in extreme distress and EMS is not immediately present. A tourniquet and/or blood pressure cuff is firmly applied to three extremities, about six inches below the groin and four inches below the shoulder. The constricting strap should be tight enough to be less than systolic blood pressure, but greater than diastolic pressure. For example, if one's blood pressure were 120/80, then 100 would be less than the systolic pressure, but more than diastolic. The purpose of this degree of pressure is for the blood flow to be reduced, but loose enough for the arterial pulse to still be palpable distal to the tourniquet. Every 15 to 20 minutes one tourniquet is removed and placed on the free extremity.
The person who has experienced acute pulmonary edema must be hospitalized. Later dental treatment with appropriate stress reduction should be carried out after consultation with the person's physician.
