Michelle Dawn Mooney: Hello and welcome to the “HealthFirst Talks” podcast. I’m your host, Michelle Dawn Mooney. And today we’re talking about respiratory emergencies, specifically how healthcare teams can recognize the warning signs early and respond appropriately when a patient begins to deteriorate. Respiratory distress can present in a variety of different ways, and knowing what you’re seeing, what steps to take, and then when it’s time to escalate care can make a critical difference in an emergency. So joining me for the conversation today is Dr. Dustin Calhoun. Dr. Calhoun, welcome to the podcast. Good to see you again. Thanks for being here.
Dr. Calhoun: Good to see you again. Yeah, thank you very much for having me on.
Michelle Dawn Mooney: Yeah, so we have a lot to get to today. So let’s start with early recognition when it comes to recognizing respiratory distress. What should dental and medical teams be looking for when a patient begins to experience respiratory distress?
Dr. Calhoun: Sure. There’s, you know, there are the classic teaching, right? We talk about things like accessory muscle use, like you see things like the muscles around the neck starting to work more to try and open up the chest, nasal flaring that you see more in kids than you do in adults, particularly infants. So those are some of the things that you’re going to see in a textbook. I think the thing that is probably one of the more useful things to just put out there to healthcare professionals that maybe don’t see a patient develop respiratory distress in front of them very often, it’s just to listen to the patient. If a patient says that they don’t feel well, that they feel short of breath, or just they feel off, think about it. Think about, is this a respiratory issue? Is there something happening that isn’t just the typical reaction to needles or the typical reaction to a procedure. I find that patients who develop problems in front of us, particularly things like distress scenarios, such as respiratory distress, tend to be harder for us to catch. It’s, you know, that the old thing about what’s the thing with a frog, you put a frog in boiling water, you raise the temperature of the water and the frog just sits there. If you toss a frog into boiling water, it hops out of the boiling water. Same thing. If that patient were put in front of you right now, then you would go, oh, wow, that’s respiratory distress. But if they slowly developed it while you’re working with them, it’s much easier to miss and to attribute little signals to other things. So vigilance, I think, is the biggest part of it. There are obviously some metrics that you can use, end-tidal CO2, pulse oximetry. Those can be used and be very useful things, we have to remember the limitations of those, right? Your end-tidal CO2 is going to be something we don’t have most of our patients in a typical outpatient office on. Even pulse oximetry, they’re probably not going to be getting continuous monitoring. And if we do put that on there, there is a lag. And you can certainly have a patient that has fairly severe respiratory distress without actually becoming truly hypoxic. So there’s no one right answer to figuring out who is that patient that’s in distress, other than just always have that in the back of your mind and recognizing that it can be weird symptoms. I’ve had patients that had fairly significant distress. And the first thing they alerted anyone to was they felt nauseated. And that nausea was from them hyperventilating. They were having a hard time breathing. And this was more than just they were anxious about needles or something like that. They truly were having a respiratory compromise impending.
Michelle Dawn Mooney: Yeah, and it really is easier said than done, as you gave the frog scenario there. So how can providers distinguish relatively mild respiratory distress from a patient whose condition is actively deteriorating? What changes may be in respiratory rate, work of breathing, oxygen saturation, or mental status even should immediately get their attention?
Dr. Calhoun: Sure. I think the one you pointed out there at the end is the easy go-to answer. Altered mental status in a respiratory distress patient is an emergent 911 type of situation. Whether the altered mental status is being caused by the respiratory distress, it doesn’t really matter, right? If they’re altered mental status, that gets you 911. If it happens to be being caused because they’re hypoxic or they’re hypercapnic, then absolutely, it’s the respiratory distress. But even if it’s not, it’s still a reasonable emergency escalation of that patient. But if it is being caused by the respiratory system, that clearly is a severe condition. Other than that, it has to do with your situation and what are your resources. I would say that a dental office probably should have a lower threshold to consider someone in respiratory distress than a medical office because of what they’re set up to be dealing with, what they should be comfortable with. Your typical primary care physician, internal medicine physician, family should be more comfortable dealing with an asthma attack than a dentist should be for very good reason. So I think that plays into it as well. And then what is their response to what you’re doing? If a patient is not responding to what you have, what your resources are, what your knowledge is to attempt to improve them, then that also should be a key. You should be seeing some improvement or at least stabilization. If the patient continues to get worse despite your best efforts, they don’t need to get to a stage of severe compromise before escalating care to somebody else.
Michelle Dawn Mooney: One respiratory emergency that providers may encounter is bronchospasm. What are some of the more common causes or triggers maybe in an office setting, and then what signs and symptoms should teams recognize?
Dr. Calhoun: Bronchospasm is a great way to look at it because we too often use actual diagnoses, which can be great in the long run because that really, the actual diagnosis, whether you have asthma or anaphylaxis or COPD, which is emphysema chronic bronchitis, those have very different long-term treatments. But the emergent treatment, the emergent intervention is very similar between those things. So it’s better to think about what the process is and how I’m going to intervene on it rather than thinking about what is the actual diagnosis and what comes after that. So bronchospasm is a great way to think of that because all those things I mentioned have or can, anaphylaxis doesn’t always have bronchospasm, but they can have that aspect to it. And bronchospasm is what it sounds like. It is the smooth muscle of the airways contracting down. And that is the fundamental problem and the early problem in diseases like asthma. But it also plays a large portion of other diseases, such as severe allergic reaction, anaphylaxis, as well as COPD and a number of other pulmonary diseases out there. The hallmark finding of that is wheezes. Some wheezes you may be able to hear without listening intentionally with the stethoscope. Oftentimes, I find that the noises that sometimes patients or even other providers will attribute to wheezes are really more of a stridor, which is an upper airway noise, which is treated differently, or it’s just a vocalization. Some people, when they are in distress, when they are very anxious, they will make noise as they breathe. So to really be sure that what you’re listening to is wheezes, a stethoscope can be useful and truly listening to the patient’s lungs to see what the air as it moves into their lungs and out of their lungs sounds like. So having a low threshold to look for that can help us because a lot of the treatments that we’re going to throw at the patient are specifically tailored to addressing bronchospasm, to opening up, because that is the low-hanging fruit. That’s the easiest thing to try to reverse.
Michelle Dawn Mooney: I want to take that one step further then. Once bronchospasm is suspected, what should the initial response look like then?
Dr. Calhoun: Some sort of a bronchodilator is typically your first aim or your first tactic that you would take with that. And that’s most often going to be albuterol. So you hear about people carrying a rescue inhaler, a metered dose inhaler, a puffer, some people will refer to. That is sort the baseline first attack at bronchospasm. It directly addresses it. You’re introducing it in through the airway. So it’s getting directly to the airway walls, getting nearly directly to those muscles, relaxing that smooth muscle, opening up the airway, trying to reduce the bronchospasm. So a lot of folks will have those. Many of the HealthFirst kits carry, or I think essentially all of the HealthFirst kits have some sort of an albuterol metered dose inhaler or some other form of bronchodilator in them. There are good and bad ways to use these. Any use of it is probably in the right setting going to be some benefit, but you can get a lot more benefit out of using a bronchodilator if as much of the medicine as possible is getting down in the lungs. And that gets into things like what people refer to as a spacer. There’s a number, an aerochamber is another term for it, but it’s basically a plastic tube that hooks onto the metered dose inhaler and it acts as a holding chamber for that vapor that comes out of the inhaler to allow it to get in and out of the lungs fully, as opposed to just sort of sticking to the back of the throat. But I think that’s a step that’s skipped by the vast majority of patients. And even a lot of providers don’t think to pull that out when they’re giving that metered dose inhaler treatment to their patient.
Michelle Dawn Mooney: In addition to what you just shared there, is there anything else with regard to when and how a rescue bronchodilator should be used?
Dr. Calhoun: It’s somewhat of a judgment call. There is no easy answer as to this trigger is switched, so you should give the patient the albuterol. There’s very little side effect to normal doses of albuterol or other metered dose inhaler that way. Certainly, you can get some tachycardia, some fast heart rate, something like that. But it’s a very rare patient that the side effects from albuterol are actually going to be more detrimental to their health than whatever you’re treating. So it’s certainly better to over-call that than under-call it. It’s also a little bit of a diagnostic test. If the only thing going on is bronchospasm and it’s early in the disease, the bronchodilator usually will have a very impressive impact. Whereas if you’re giving them albuterol, a metered dose inhaler of some sort like that, and you’re not getting a result relatively quickly, then you really should be thinking about, is there something else going on? Especially in younger patients where you may not have gotten the greatest of history from them. There’s certainly been plenty of patients in history that have gotten something up their nose or down their airway, sniffed in and got something down in one of the airways, swallowed wrong and coughed something down in their airway that looked all for the world that they were a bronchospasm and turned out that they had an actual physical airway obstruction. And albuterol is not going to do anything for that. So paying attention to the result is always an important thing when you do an intervention. But I would say have the most important thing, have a low threshold to go ahead and use that albuterol, pull out the MDI, give that to the patient, encourage them to use their own if they know what it is. And then using the spacer, as we mentioned earlier, is going to be an important one. You can, as a healthcare professional, you can certainly use a metered dose inhaler in a different way than the patient is instructed to use it at home. Most of the time, they’re going to be instructed to use two to four puffs at a time. If you look at what we do in the emergency department, we’ll often use nebulized medicines through a little nebulizer machine with an oxygen or air supply. One nebulized treatment, you know, there’s dosages there, but it’s not really important to remember, is kind of equivalent to about eight puffs on a metered dose inhaler. So I think that’s another place that as healthcare professionals, we can advantage and have a benefit to our patient by recognizing that we can go a little beyond what their prescription has and get some additional benefit to the patient.
Michelle Dawn Mooney: You mentioned several options for treatment there, but at what point should supplemental oxygen become part of that response? And then what should the team be aware of knowing that it’s time to activate EMS?
Dr. Calhoun: Those are great questions. Supplemental oxygen is an interesting topic because it’s certainly the easy, oh, they’re in distress, let’s stick some oxygen on them. And rarely are you going to cause a lot of harm that way. There are circumstances, right? We now know that hyperoxia, putting too much oxygen into a patient that’s having acute coronary syndrome or coronary artery blockages is actually detrimental. It can cause a vasospasm of the vessels of the heart and actually worsen problems. So you actually don’t want your heart attack patients on extra oxygen if they don’t need it. So it should be like most things in medicine, which really guided by what your data is showing you. If you do have the ability to put somebody on pulse ox, which most folks in these clinic settings would have because it’s part of the vital signs. So you may not have the usual continuous monitoring, but you should be able to get a spot check periodically. If they have oxygen saturations that are decent, and I’m talking, you know, mid 90s or so or up, you probably don’t need it. In most patients cases, is it going to harm them? No. And sometimes folks either as a placebo effect or just actual benefit, who knows, giving them a little bit of supplemental oxygen may cause some benefit, even in somebody who has a 91, 92 oxygen saturation. I would definitely avoid it in the ACS patient, but that’s not typically the acute coronary syndrome patient. That’s typically not your respiratory distress patient. In a respiratory distress patient, it’s rarely going to cause a problem. But knowing what you’re treating is useful. If I have a respiratory distress patient whose oxygen saturation is in the high 90s, I really need to be thinking about what else is going on here. Is this something more than what just simple oxygen will treat? Because I certainly wouldn’t want to hide another problem and not be addressing other potential causes. As far as when to step this up, when to be activating 911, I really do think that it comes down to your patient’s response. If you have a patient, though, that is requiring supplemental oxygen to maintain a normal oxygen saturation, and that’s not their baseline, they didn’t come in carrying an oxygen tank, then that’s an automatic, right? That is a reasonable activation of 911. Is it possible that you take an asthma attack who is bad enough that they now are slightly hypoxic and you treat them with an albuterol treatment of some nature and you improve them enough to send them home? It’s possible. I doubt very many people are comfortable or should be doing that in a clinic setting. It’s probably best if you’re having to add oxygen for a legitimate indication, add 911 to that process.
Michelle Dawn Mooney: Yeah. I want to talk about another respiratory emergency that may be less familiar to some of our listeners, SCAPE or sympathetic crashing acute pulmonary edema. What exactly is SCAPE and why can it develop so rapidly?
Dr. Calhoun: SCAPE is scary, is the bottom line. And that’s coming from an emergency physician who’s treated a lot of it. A lot of people that are listening may have referenced it or heard it called flash pulmonary edema. That’s certainly the old term for it. SCAPE is just physiologically more descriptive of what it is. But essentially what is happening is you’re getting significantly elevated blood pressures in the pulmonary vessels and you get leakage of fluid into the lung itself. So into what we call the parenchyma or the meat of the lung, the little airways, the alveoli, which is where you’re supposed to be having air exchange, right? You’re supposed to be dumping CO2 out of your blood and putting oxygen into your blood through these membranes in these little tiny balloons. But if the balloons fill up with fluid, they can’t do that gas exchange anymore. And that’s what we’re talking about. That’s a large portion we’re talking about with SCAPE. Usually that is going to come with a very distressed looking patient. They’re often going to be sweaty. And that’s where the sympathetic part of that is your sympathetic nervous system, that fight or flight. So very anxious, tachycardic, fast heart rate, high blood pressure, those sorts of things. So that’s a patient that is in imminent worry of failure. Their respiratory system just completely shutting down and requiring much more advanced airway management than anyone is going to want to do in a clinic. So anyone seen with that presentation is an automatic activation of the 911 system for sure, because they’re going to come with some interventions, including potentially airway management that isn’t typical in most clinics. How you would treat SCAPE is going to vary depending on your clinic capabilities and resources available to you. Some of the most useful treatments for that may be available in some clinics, particularly CPAP or continuous positive airway pressure, or actually any sort of non-invasive positive pressure ventilation, which either BiPAP or BPAP and CPAP. Those are both forms of that. That is probably the simplest and one of the most effective treatments for early SCAPE anyways. Another one of the interventions in addition to CPAP or BPAP that is very useful, particularly in addressing those that have particularly elevated blood pressures, are medications typically in the nitrogen-containing medications such as nitroglycerin. So we’ll often use different forms of nitroglycerin anywhere from the little oral tablets that are dissolving under your tongue that we use for chest pain patients all the way up to actually an IV drip of nitroglycerin to help control that blood pressure and thereby reduce how much more fluid is getting pushed into the lungs. Other treatments, you know, we use things such as medicines that like diuretics that help the patient get rid of fluid. Those are slow reacting. Those are sort of further down the road. Really that mainstay of SCAPE treatment is some sort of non-invasive positive pressure ventilation and some nitroglycerin or some other product similar to that. Many offices may not have those available depending on how prepared someone wants to be. There are very simple CPAP setups out there now that are two figures in cost, you know, $30, $40, $50, because all they do, there’s no electronics to it. It is purely a mechanical device that’s a single-use device that screws onto an oxygen cylinder and can be used to provide up to about 10 centimeters of water of pressure for those patients. And for that SCAPE patient, that may be the life-saving intervention.
Michelle Dawn Mooney: As you said, very scary indeed. So what might providers see in a patient experiencing acute pulmonary edema that could help distinguish it from bronchospasm?
Dr. Calhoun: Some of it is auscultation, meaning listening to the lungs, because those two patients can look identical exteriorly. They can both be hypoxic. They can both be gasping. They can both have elevated end-tidal CO2 if you happen to be getting that. They can both be panicked and sweaty and take on those same like the tripoding position that we’re all taught to look for. But the lungs should sound different. So a patient that has pulmonary edema, you should be able to hear that fluid in their lungs. When I was trained, we called it rales. These days, they call it crackles. And that’s exactly what it sounds like, which is probably why they changed the name. For a bronchospasm patient, you should be hearing wheezes. Now, these are not perfect black and white categories, right? Anything that irritates the lung can cause bronchospasm. So it’s not uncommon for a patient that has some pulmonary edema for that fluid in there to have led to some bronchospasm and have some wheezing additionally. And that’s when we start combining treatments and looking at that patient as sort of an amalgam. Typically, wheezes won’t necessarily cause fluid in lungs, as can happen in reverse. So you will see, though, the mixture. You’ve got to listen. You’ve got to figure it out. But one of the keys to listening is you’ve got to have air movement to hear something. If air is not moving, it won’t make the sound of rales or crackles. If air isn’t moving, it won’t make the whistling of wheezing. And that is a fundamental and very dangerous mistake to make, to listen to someone’s chest and hear no noise and assume that no noise is good news. And that’s not the case, right? When you listen to normal lungs, you hear air movement. It’s just normal air movement. So if you’re not hearing anything, it may be that the lungs are so full of fluid or so bronchospasmed down that they’re not moving any air at that point. And that’s a much worse situation. That’s again a call to 911.
Michelle Dawn Mooney: And once acute pulmonary edema is suspected, what does initial management look like then, particularly when it comes to CPAP, which you mentioned, or other non-invasive positive pressure ventilation?
Dr. Calhoun: Typically, that’s the mainstay, getting that CPAP or BiPAP if that’s what you have available. Most of the time in a pre-hospital setting or clinics, you’re probably more likely to have CPAP because they’re less expensive devices. But that is the, if you can get that quickly, that is going to make a big difference. If you’re not looking at a bronchospasm component to it, then the medicines like albuterol, those sort of things, aren’t going to really play much of a role. Nitroglycerin will play a large role. And this is where you get into a little bit of controversy. There are physicians out there that will push the idea that once you have the CPAP mask on someone, you should never break that seal. And the argument for that is this thing called recruitment, meaning that as I’m putting that air pressure in, it’s just blowing a low level of air pressure into to open the lungs up. I’ve gotten what’s called recruitment, which is I’ve recruited some of those little alveoli, the air sacs that were closed off before. Once I’ve got that, if I break that seal and reduce that pressure, many of them will collapse. And then I’ve lost some ground. So people will argue never break that seal. I argue the other side of this, that if I can get the CPAP mask on them quickly and more quickly than I can get to my nitroglycerin, I put the CPAP mask on. And then when I have nitroglycerin available, if it’s appropriate for that patient, I will very briefly break the seal, put the nitroglycerin in because it’s my opinion. There’s not great evidence to prove this either way, but it’s my opinion that the little bit of lost recruitment I get from that momentary opening of the seal is significantly outweighed by the benefit that nitroglycerin has in a patient with severe hypertension that’s causing part of this pathophysiology. But really those two things, that’s really where it is. But that is more advanced treatment. That is something that certain folks are not comfortable doing and shouldn’t be. And that’s where 911 comes in. Most modern 911 systems are going to provide you with a provider that can do both of those things.
Michelle Dawn Mooney: And I want to ask you about that because it’s easy for us to sit here and you’re saying all the things that people can do, but in the situation, it’s a much different story. So when does that situation warrant immediate escalation to EMS?
Dr. Calhoun: I think the oxygen requirement is usually going to be a pretty, because like we said earlier, it’s unlikely that you’re going to reverse that sufficiently to not have them further evaluated. So that is one. Altered mental status, we talked about earlier, is also a go-to. If you have altered mental status, that’s immediate. Don’t pass go, call 911. In between there, it’s going to be a judgment call of how much distress we’re talking about, how rapidly we’re advancing into that. If there is something else tied to this, right, if you have respiratory distress and it’s associated with something else that would check the 911 box, significant chest pain in the right patient who this could be acute coronary syndrome, if this is respiratory distress brought on by anaphylaxis, that is a patient that needs more monitoring than most folks are going to do in their clinic. And that’s a patient who’s going to get additional treatment, right? Albuterol and his respiratory treatments are insufficient to treat anaphylaxis alone. That patient should get epinephrine, intramuscular epinephrine as quick as possible. So in that gray area, it gets much more difficult in a judgment call. How rapidly the patient is worsening should also play into this. And also you’re judging all of this on a sliding scale of the comfort of the clinician and the resources of the clinic.
Michelle Dawn Mooney: I want to talk a little bit more about CPAP? What is CPAP actually doing physiologically for a patient during a respiratory emergency?
Dr. Calhoun: Sure. It is an amazing tool. It has come to heavy use during my career and has entirely changed the face of these patients. So we intubate, meaning put a plastic tube in the airway, far fewer patients than we did when I was in residency when CPAP was a much less common thing in the pre-hospital setting. So what CPAP does is it provides a small amount of air, just continuous pressure. CPAP stands for continuous positive airway pressure. So it is pushing and the number, it varies in the pre-hospital setting and sort of a starter setting for most folks, even in the ED is about what we call 10 centimeters of water. The easiest way to think of that is if you’re driving down the road and you roll down your window and stick your head out the window, it’s about that much air pressure. And what that does is it helps hold open the airways. So, holding open the airways does several things. That’s one of the more important ones, depending on what the disease process is. Something like COPD, that’s a big part of it, sort of stenting open the airways. Similar for asthma, helping sort of stent open those airways. When you start talking about things like pulmonary edema, SCAPE, in that area of medical problems, it’s doing those things, but it’s also helping to add pressure into that alveolus, the little air sacs, which then helps to minimize how much more fluid is flowing into the air sac. It provides some increased pressure around the heart, which actually can augment the squeeze of the heart a little bit. And through a couple of different mechanisms, it can actually reduce the pressure in the blood vessels that the heart is pumping into, which makes it a little bit easier to pump into those blood vessels. So reducing some of that work on the heart and just makes it easier to breathe, right? If your problem is I’m having a hard time taking a breath in, which is the case in some respiratory distress, then that extra kick of that 10 centimeters of water air pressure can be quite helpful.
Michelle Dawn Mooney: So you talked about the benefits of CPAP, but I want you to break it down if you can. What situations might CPAP be appropriate? And then equally important, who would not be a good candidate for CPAP?
Dr. Calhoun: The way I typically teach CPAP is if the words respiratory distress cross your mind, CPAP is a reasonable thing to use. If you actually think the patient is in true distress from their respiratory situation, you probably will get some benefit. Now, there are situations where we have great evidence for this, right? We know that in CHF, congestive heart failure, pulmonary edema, we know that it does amazing things there. It reduces hospitalization, it reduces intubation, it reduces mortality. Similarly, for chronic obstructive pulmonary disease like chronic bronchitis or emphysema does wonders there. A little bit less evidence in asthma, but fundamentally asthma has a lot of physiologic similarities anyways, and anatomic similarities in some cases to COPD. So we see some benefit there. The evidence just isn’t as strong, even in things like pneumonia, right? So let’s say pneumonia is your cause. Well, that needs antibiotics and a number of other things. But CPAP, if your pneumonia is leading to respiratory distress can have some benefit there. So any sort of cause of respiratory distress is not an unreasonable use of CPAP. As far as when not to use it, it’s a very limited number of patients. And some patients just won’t tolerate it. So your ability to use it versus their ability to tolerate it are two different things. Many patients who have sort of recurrent episodes of COPD or CHF, many of those patients will actually know about CPAP. And when you show up at their house or they show up in your emergency department, they’re reaching for it. They’re asking, where’s the mask? Where’s the CPAP? Where is it? I want to get it on as quick as possible. Patients that have never had it before, particularly if they’re an obstructive lung disease like COPD, where part of the problem is getting air back out. They can get it in, they just can’t get it out. And then you come at them with a mask that has air blowing into them. There’s a logical disconnect there as to why it makes sense to do that. So they can be harder to convince. Little tricks like having the patient actually hold the CPAP rather than the provider coming at them with this mask over their face. Go here. This is going to help. Give this a try. Put this in your hand. Hold it up to your nose and mouth. And then they feel like they have an escape, right? If they put it up and they don’t like the feeling, they can immediately take it away. And that will a lot of times introduce a new patient to that treatment and they’ll see how much benefit there is. There are a few patients. Blood pressure is really one of the big ones. If someone is septic or severely hypovolemic, where their blood pressure is just absolutely terrible, you can, because of some of the physiology of how the plumbing works in your body with your lungs and the low-pressure vessels, CPAP can make that blood pressure worse. You do have to be careful in very low-blood pressure patients. And then there are a few other sort of relative contraindications. If you’ve had recent surgery to your upper airway or upper esophageal area, sometimes folks will shy away from CPAP because that extra pressure can cause some problems on recent surgical sites. But really, most of these are relative contraindications. And if you have a patient in true severe respiratory distress who will tolerate the device, usually it is a reasonable thing to try.
Michelle Dawn Mooney: From a practical standpoint, what type of CPAP equipment could a dental or medical office realistically have available to them?
Dr. Calhoun: There are a number of them out there now. So early on, they were mostly mechanical devices where you had essentially, you think of it as a pump that was producing this pressure. And that’s still essentially what we use in the hospital most of the time. We use an actual device like a ventilator that blows air. But most offices are going to have oxygen on hand, either on the wall or in tanks. And there are plenty of devices, I don’t want to use any brand names, but there are plenty of devices out there that literally hook into that tank. Some of them hook into the quick connect part of that tank, a little screw on device. Some of them actually just plug into what people refer to as the Christmas tree, the same place that your nasal cannula oxygen hooks onto. Some of them will hook into that and then through some really fancy physics in the little device near the part that goes to the patient, it actually ups that pressure to about what we’re talking about here, about that 10 centimeters of water. These are very, very inexpensive devices. It’s like anything else. You can’t just buy it, stick it in a closet and assume that someone’s going to figure out how to use it. It is a little bit of a tinker toy activity when you’re trying to put the pieces together. I mean, particularly if you’re trying to combine that with nebulizers, right? So you can combine a nebulizer, you can combine an MDI, a metered dose inhaler, the albuterol puffer. There are devices that you can plug those into a CPAP device and then you get the advantage of the medicine and the pressure at the same time, which has some synergistic effect. But you have to know how to put those things together. Nothing will make you look dumber than trying to put those two devices together right in front of the patient in an emergency.
Michelle Dawn Mooney: How would you say teams should think about CPAP within the larger emergency response while they’re waiting for EMS to arrive?
Dr. Calhoun: I think you have to have some real significant discussions with if it’s not something you’re doing now, some discussions with your team, because this isn’t a space that everybody wants to get into. It is a more advanced level of therapy that someone needs to be doing some quality assurance on maintaining the equipment. There is some training involved as to who would use it and when. It’s certainly things that most ambulances, most EMS agencies are going to have these days. So if you’re in a high resourced area where you’re going to get a 911 response very quickly, this may not be a necessary expense or complication to your office process. On the other hand, if you have very delayed EMS response times, which is a huge portion of our country, and especially outside of our country, that this may be a cheap thing that really is not that hard to implement that could make a big difference for certain patients.
Michelle Dawn Mooney: I want to dig a little deeper with the difference between bronchospasm versus pulmonary edema. This is an especially important distinction to make because wheezing doesn’t always mean asthma. So what clues can help providers differentiate bronchospasm from pulmonary edema?
Dr. Calhoun: The biggest thing really is that exam. Some of it is history. Most of the time, patients having respiratory distress, not always certainly, but many times they will know their disease, right? And if a patient is in their 50s or 60s and they say, I’ve got asthma, I’ve never had heart failure, then probably what’s going on is asthma. That’s not always the case. You want to, you know, trust but verify kind of a situation. But knowing their history, knowing their meds, is this a patient who has a bunch of inhalers at home? Or is this a patient that’s on a diuretic or some other thing that makes you think they have heart failure, which could lead to pulmonary edema? But then again, it comes back to that exam, listening to their lungs. There are other ways, there are more sensitive ways. Certainly ultrasound is actually proving to be one of the best ways to identify pulmonary edema. So if you have a respiratory distress patient that has a negative ultrasound, then that’s great. But I’m guessing that most clinics are not going to have that capability or training. So the sort of cheap, dirty, poor man’s method of doing this, slap a stethoscope on the back of their lungs and get the best breaths you can and try and decide, are you hearing normal respirations, no respirations, or are you hearing some sort of adventitious lung sounds such as crackles or wheezes?
Michelle Dawn Mooney: Let’s go one step further. When a provider hears wheezing, how can they avoid anchoring on one diagnosis too quickly and make sure they’re looking at the patient’s overall presentation?
Dr. Calhoun: That’s a great question. And it’s certainly reasonable. Once you hear wheezes and you have a patient who is in respiratory distress, it’s certainly reasonable to act on that because there’s a difference between acting on evidence you have and anchoring on that concept. Don’t anchor on that those wheezes are the entirety of their problem, but acting to treat those wheezes since wheezes do, an easy way to think of it is wheezes equal need a bronchodilator. So if a bronchodilator such as albuterol is in your armamentarium, then once you have those wheezes in a respiratory distress patient, very reasonable. Go ahead and initiate treatment there. Just don’t close your mind down to other processes of what else might be going on. Because remember, an asthmatic is going to have wheezes periodically. A COPD patient is almost always going to have at least some amount of wheezing, but that doesn’t mean it’s causing their respiratory distress. They may have a pulmonary embolism, which has absolutely nothing to do with their COPD or their asthma or anything else. And the wheezes you’re hearing may be a problem but they may not be the problem. Addressing them is fine as long as we continue contemplating what else is going on.
Michelle Dawn Mooney: Let’s bring all of this back to preparedness because that’s why we’re here trying to educate the masses on the importance of being proactive. We hope that we never have one of these emergencies but we need to be ready if that does in fact happen. So what medications and equipment should dental and medical teams have immediately accessible if a respiratory emergency occurs?
Dr. Calhoun: I think the biggest keys that are nearly universal, I never want to say because there’s always unusual circumstances, but oxygen is an important one. We talked about some of the limitations there when it is and isn’t the most appropriate thing. Oxygen, some sort of bronchodilator. If you’re going to have a medical emergency kit, having a bronchodilator, albuterol being the most common, and folks that know how to use it, know how to use it properly, and having it associated with something like an aerochamber or knowing how to improvise an aerochamber. There’s a million MacGyver videos on the internet, how to improvise an aerochamber for a patient who’s lost theirs or forgot it or something. So those are two big keys. I think you can step it up into all kinds of other realms with the CPAP stuff we talked about or all kinds of other medicines. Even the concept of using nitroglycerin for the severe pulmonary edema patient, that is definitely a step up in the level of complexity and risk and the care management that you’re doing, which just because you have access to the nitroglycerin doesn’t mean you should be comfortable with implementing it for that purpose. You really need to understand when you’re using it, how to use it, that sort of thing. So I certainly wouldn’t put that in the bare minimum. Nitro might be considered by some to be a bare minimum in an emergency kit. Using it for this particular indication may be a separate thing. But the bronchodilator with the appropriate equipment and the oxygen, those really are your fundamental thing. The most important thing you’re going to have, though, is your ability to recognize respiratory distress and recognize that it needs to be evaluated and catch it before it gets beyond help.
Michelle Dawn Mooney: And an effective response also involves more than one person. So how should team members divide responsibilities so that everyone knows exactly what they need to do during an emergency?
Dr. Calhoun: That’s a great point that we talk about things with CPR. We talk about pit crew CPR, right, where everybody knows what they’re doing, what’s their role, and any sort of emergency can be sort of divided up that same way. The idea of what are your key components of this treatment? Well, some of the treatment is trying to figure out what’s going on with the patient, and some of that may be digging in the chart. I think we all love to think that we know all of our patients super well, and we know all their meds, and we know all their history, but that’s probably not the case. So having someone who is getting as much information as they can, are there meds this patient is on. Someone else specifically designated to get us the emergency kit. That way we have the equipment, we have the albuterol, we have that sort of thing. And then if 911 is activated, sort of your standard 911 steps are important, making sure that someone is making the call, but then someone also facilitating getting 911 into you. Because depending on where your building is, how your office is set up, it may not be as simple as calling 911 and they show up and know where to go. So all of those sort of typical fundamental preparedness steps really do play perfectly into respiratory distress as well.
Michelle Dawn Mooney: I want to end on what I think is a fitting question to wrap things up here. When a patient appears to be deteriorating, what would you want providers to understand about the importance of activating EMS early rather than waiting to see if the situation improves?
Dr. Calhoun: So a lot of respiratory stuff, SCAPE is a great example that we talked about earlier where sometimes patients have sort of this falling off a cliff effect where they’re struggling, they’re struggling, they’re struggling, and then all of a sudden everything just goes very, very, very poorly, very rapidly. So recognizing it earlier, it’s much easier to turn resources around, or for EMS to get there and have the patient have massively improved due to your wizardry in treating what was going on with them, and have the patient go, “You know what, I feel fine now. I don’t really need to go to the hospital. That is a much better scenario than hemming and hawing about how bad is this patient. And then by the time 911 has gotten there, they have deteriorated to the point where they need endotracheal intubation or something like that.
Michelle Dawn Mooney: Dr. Calhoun, thank you so much for your time today, helping us better understand how important it is for healthcare teams to not only recognize, but be able to respond to those respiratory emergencies. And of course, being prepared and the preparedness is so key so that we don’t have to worry about these situations if and when they do happen. So thank you for being here today. I appreciate your time.
Dr. Calhoun: Thanks very much for having me on. I had fun.
Michelle Dawn Mooney: And I want to thank all of you for tuning in and listening to the “HealthFirst Talks” podcast brought to you by HealthFirst. To learn more, you can visit healthfirst.com and be sure to follow the podcast so you don’t miss future conversations like the one you heard today. I’ve been your host, Michelle Dawn Mooney. Thanks again for joining us. We hope to connect with you on another podcast soon.
