Standard |
EMS 130 –
Respiratory Function and Management
This unit is designed to help
the Paramedic assess and treat a wide variety of respiratory related illnesses
in the pediatric and adult patient. Topics
include a review of anatomy and physiology, pathophysiology of foreign body
airway obstruction, recognition of respiratory compromise, use of airway
adjunctive equipment and procedures, current therapeutic modalities for
bronchial asthma, chronic bronchitis, emphysema, spontaneous pneumothorax, and
hyperventilation syndromes. This
section also provides expanded information for adult respiratory distress
syndrome, pulmonary thromboembolism, neoplasms of the lung, pneumonia,
emphysema, pulmonary edema, and respiratory infections. This course provides instruction on topics
in Division 2 (Airway), Section 1 (Airway Management and Ventilation) and
Division 5 (Medical), Section 1 (Respiratory) of the USDOT/NHTSA Paramedic
National Standard Curriculum.
Competency Areas
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Hours
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Airway anatomy and physiology |
Class |
4 |
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Pathophysiology of respiratory diseases |
D. Lab |
3 |
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Physiology of ventilation and respiration |
P. Lab/O.B.I. |
0 |
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Pharmacological intervention of respiratory emergencies |
Credit |
5 |
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Integration of assessment findings and management |
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Special considerations |
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Prerequisite: |
EMS
126, EMS 128 , EMS 127, EMS 129 |
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Prerequisite/Corequisite: |
AHS
101 |
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Course Guide |
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Competency |
After completing this
section, the student will: |
Hours |
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Class |
D.Lab |
P.Lab/ O.B.I. |
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AIRWAY ANATOMY AND PHYSIOLOGY
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PATHOPHYSIOLOGY
OF RESPIRATORY DISEASES |
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PHYSIOLOGY
OF VENTILATION AND RESPIRATION |
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PHARMACOLOGICAL
INTERVENTION OF RESPIRATORY EMERGENCIES |
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INTEGRATION
OF ASSESSMENT FINDINGS AND MANAGEMENT |
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SPECIAL
CONSIDERATIONS |
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UNIT TERMINAL OBJECTIVE
2-1 At the completion of this unit, the paramedic student will be able
to establish and/ or maintain a patent airway, oxygenate, and ventilate a
patient.
COGNITIVE OBJECTIVES
At the completion of this unit,
the paramedic student will be able to:
2-1.1 Explain the primary objective of airway maintenance. (C-1)
2-1.2 Identify commonly neglected prehospital skills related to airway.
(C-1)
2-1.3 Identify the anatomy of the upper and lower airway. (C-1)
2-1.4 Describe the functions of the upper and lower airway. (C-1)
2-1.5 Explain the differences between adult and pediatric airway anatomy.
(C-1)
2-1.6 Define gag reflex. (C-1)
2-1.7 Explain the relationship between pulmonary circulation and
respiration. (C-3)
2-1.8 List the concentration of gases that comprise atmospheric air.
(C-1)
2-1.9 Describe the measurement of oxygen in the blood. (C-1)
2-1.10 Describe the measurement of carbon dioxide in the blood.
(C-1)
2-1.11 Describe peak expiratory flow. (C-1)
2-1.12 List factors that cause decreased oxygen concentrations in
the blood. (C-1)
2-1.13 List the factors that increase and decrease carbon dioxide
production in the body. (C-1)
2-1.14 Define atelectasis. (C-1)
2-1.15 Define FiO2. (C-1)
2-1.16 Define and differentiate between hypoxia and hypoxemia.
(C-1)
2-1.17 Describe the voluntary and involuntary regulation of
respiration. (C-1)
2-1.18 Describe the modified forms of respiration. (C-1)
2-1.19 Define normal respiratory rates and tidal volumes for the
adult, child, and infant. (C-1)
2-1.20 List the factors that affect respiratory rate and depth.
(C-1)
2-1.21 Explain the risk of infection to EMS providers associated
with ventilation. (C-3)
2-1.22 Define pulsus paradoxes. (C-1)
2-1.23 Define and explain the implications of partial airway
obstruction with good and poor air exchange. (C-1)
2-1.24 Define complete airway obstruction. (C-1)
2-1.25 Describe causes of upper airway obstruction. (C-1)
2-1.26 Describe causes of respiratory distress. (C-1)
2-1.27 Describe manual airway maneuvers. (C-1)
2-1.28 Describe the Sellick (cricoid pressure) maneuver. (C-1)
2-1.29 Describe complete airway obstruction maneuvers. (C-1)
2-1.30 Explain the purpose for suctioning the upper airway. (C-1)
2-1.31 Identify types of suction equipment. (C-1)
2-1.32 Describe the indications for suctioning the upper airway.
(C-3)
2-1.33 Identify types of suction catheters, including hard or rigid
catheters and soft catheters. (C-1)
2-1.34 Identify techniques of suctioning the upper airway. (C-1)
2-1.35
Identify
special considerations of suctioning the upper airway. (C-1)
2-1.36 Describe the indications, contraindications, advantages,
disadvantages, complications, equipment and technique of tracheobronchial suctioning in the intubated
patient. (C-3)
2-1.37 Describe the use of an oral and nasal airway. (C-1)
2-1.38 Identify special considerations of tracheobronchial
suctioning in the intubated patient. (C-1)
2-1.39 Define gastric distention. (C-1)
2-1.40 Describe the indications, contraindications, advantages,
disadvantages, complications, equipment and technique for inserting a
nasogastric tube and orogastric tube. (C-1)
2-1.41 Identify special considerations of gastric decompression.
(C-1)
2-1.42 Describe the indications, contraindications, advantages,
disadvantages, complications, and technique for inserting an oropharyngeal and
nasopharyngeal airway (C-1)
2-1.43 Describe the indications, contraindications, advantages,
disadvantages, complications, and technique for ventilating a patient by: (C-1)
Mouth-to-mouth
Mouth-to-nose
Mouth-to-mask
One
person bag-valve-mask
Two
person bag-valve-mask
Three
person bag-valve-mask
Flow-restricted,
oxygen-powered ventilation device
2-1.44 Explain the advantage of the two person
method when ventilating with the bag-valve-mask. (C-1)
2-1.45 Compare the ventilation techniques used
for an adult patient to those used for pediatric patients. (C-3)
2-1.46 Describe
indications,
contraindications, advantages, disadvantages, complications, and technique for ventilating
a patient with an automatic transport ventilator (ATV). (C-1)
2-1.47 Explain safety considerations of oxygen storage and
delivery. (C-1)
2-1.48 Identify types of oxygen cylinders and pressure regulators
(including a high-pressure regulator and a therapy regulator). (C-1)
2-1.49 List the steps for delivering oxygen from a cylinder and
regulator. (C-1)
2-1.50 Describe the use, advantages and disadvantages of an oxygen
humidifier. (C-1)
2-1.51 Describe the indications, contraindications, advantages,
disadvantages, complications, liter flow range, and concentration of delivered
oxygen for supplemental oxygen delivery devices. (C-3)
2-1.52 Define, identify and describe a tracheostomy, stoma, and
tracheostomy tube. (C-1)
2-1.53 Define, identify, and describe a laryngectomy. (C-1)
2-1.54 Define how to ventilate with a patient with a stoma,
including mouth-to-stoma and bag-valve-mask-to-stoma ventilation. (C-1)
2-1.55 Describe the special considerations in airway management and
ventilation for patients with facial injuries. (C-1)
2-1.56 Describe the special considerations in airway management and
ventilation for the pediatric patient. (C-1)
2-1.57 Differentiate endotracheal intubation from other methods of
advanced airway management. (C-3)
2-1.58 Describe the indications, contraindications, advantages,
disadvantages and complications of endotracheal intubation. (C-1)
2-1.59
Describe
laryngoscopy for the removal of a foreign body airway obstruction. (C-1)
2-1.60 Describe the indications, contraindications, advantages,
disadvantages, complications, equipment, and technique for direct laryngoscopy.
(C-1)
2-1.61 Describe visual landmarks for direct laryngoscopy. (C-1)
2-1.62 Describe use of cricoid pressure during intubation. (C-1)
2-1.63 Describe indications,
contraindications, advantages, disadvantages, complications, equipment and
technique for digital endotracheal intubation. (C-1)
2-1.64 Describe the indications, contraindications, advantages,
disadvantages, complications, equipment and technique for using a dual lumen
airway. (C-3)
2-1.65 Describe the indications,
contraindications, advantages, disadvantages, complications and equipment for
rapid sequence intubation with neuromuscular blockade. (C-1)
2-1.66 Identify neuromuscular blocking drugs
and other agents used in rapid sequence intubation. (C-1)
2-1.67 Describe the indications,
contraindications, advantages, disadvantages, complications and equipment for
sedation during intubation. (C-1)
2-1.68 Identify sedative agents used in airway
management. (C-1)
2-1.69 Describe the indications, contraindications, advantages,
disadvantages, complications, equipment and technique for nasotracheal
intubation. (C-1)
2-1.70 Describe the indications, contraindications, advantages,
disadvantages and complications for performing an open crichothyrotomy. (C-3)
2-1.71 Describe the equipment and technique
for performing an open cricothyrotomy. (C-1)
2-1.72 Describe the indications, contraindications, advantages,
disadvantages, complications, equipment and technique for transtlaryngeal catheter ventilation (needle
cricothyrotomy). (C-3)
2-1.73 Describe methods of assessment for confirming correct
placement of an endotracheal tube. (C-1)
2-1.74 Describe methods for securing an endotracheal tube. (C-1)
2-1.75 Describe the indications, contraindications, advantages,
disadvantages, complications, equipment and technique for extubation. (C-1)
2-1.76 Describe methods of endotracheal intubation in the pediatric
patient. (C-1)
AFFECTIVE OBJECTIVES
At the completion of this unit,
the paramedic student will be able to:
2-1.77 Defend the need to oxygenate and ventilate a patient. (A-1)
2-1.78 Defend the necessity of establishing and/ or maintaining
patency of a patient’s airway. (A-1)
2-1.79 Comply with standard precautions to defend against
infectious and communicable diseases. (A-1)
PSYCHOMOTOR OBJECTIVES
At the completion of this unit,
the paramedic student will be able to:
2-1.80 Perform body substance isolation (BSI) procedures during
basic airway management, advanced airway management, and ventilation. (P-2)
2-1.81 Perform pulse oximetry. (P-2)
2-1.82 Perform end-tidal CO2 detection. (P-2)
2-1.83 Perform peak expiratory flow testing. (P-2)
2-1.84 Perform manual airway maneuvers, including: (P-2)
a. Opening the mouth
b. Head-tilt/ chin-lift maneuver
c. Jaw-thrust without head-tilt maneuver
d. Modified jaw-thrust maneuver
2-1.85 Perform manual airway maneuvers for pediatric patients,
including: (P-2)
a. Opening the mouth
b. Head-tilt/ chin-lift maneuver
c. Jaw-thrust without head-tilt maneuver
d. Modified jaw-thrust maneuver
2-1.86 Perform the Sellick maneuver (cricoid pressure). (P-2)
2-1.87 Perform complete airway obstruction maneuvers, including:
(P-2)
a. Heimlich maneuver
1.
Finger sweep
2.
Chest thrusts
3.
Removal with Magill forceps
2-1.88 Demonstrate suctioning the upper airway by selecting a
suction device, catheter and technique. (P-2)
2-1.89 Perform
tracheobronchial suctioning in the intubated patient by selecting a
suction device, catheter and technique. (P-2)
2-1.90 Demonstrate insertion of a nasogastric tube. (P-2)
2-1.91 Demonstrate insertion of an orogastric tube. (P-2)
2-1.92 Perform gastric decompression by selecting a suction device,
catheter and technique. (P-2)
2-1.93 Demonstrate insertion of an oropharyngeal airway. (P-2)
2-1.94 Demonstrate insertion of a nasopharyngeal airway. (P-2)
2-1.95 Demonstrate ventilating a patient by the following
techniques: (P-2)
a. Mouth-to-mask ventilation
4.
One person bag-valve-mask
5.
Two person bag-valve-mask
6.
Three person bag-valve-mask
7.
Flow-restricted,
oxygen-powered ventilation device
8.
Automatic transport ventilator
9.
Mouth-to-stoma
10.
Bag-valve-mask-to-stoma ventilation
2-1.96
Ventilate
a pediatric patient using the one and two person techniques. (P-2)
2-1.97 Perform ventilation with a bag-valve-mask with an in-line
small-volume nebulizer. (P-2)
2-1.98 Perform oxygen delivery from a cylinder and regulator with an
oxygen delivery device. (P-2)
2-1.99 Perform oxygen delivery with an oxygen humidifier.
(P-2)
2-1.100 Deliver supplemental oxygen to a breathing patient using the
following devices: nasal cannula,
simple face mask, partial rebreather
mask, non-rebreather mask, and venturi mask (P-2)
2-1.101 Perform stoma suctioning. (P-2)
2-1.102 Perform retrieval of foreign bodies from the upper airway.
(P-2)
2-1.103 Perform assessment to confirm correct placement of the
endotracheal tube. (P-2)
2-1.104 Intubate the trachea by the following methods: (P-2)
a. Orotracheal intubation
b. Nasotracheal intubation
c. Multi-lumen airways
11.
Digital intubation
d. Transillumination
e. Open cricothyrotomy
2-1.105 Adequately secure an endotracheal tube. (P-1)
2-1.106 Perform endotracheal intubation in the pediatric patient.
(P-2)
2-1.107 Perform transtracheal catheter ventilation (needle
cricothyrotomy). (P-2)
2-1.108 Perform extubation. (P-2)
2-1.109 Perform replacement of a tracheostomy tube through a stoma.
(P-2)
DECLARATIVE
I. Introduction
A. The
body’s need for oxygen
B. Primary
objective of emergency care
1. Ensure
optimal ventilation
a. Delivery
of oxygen
b. Elimination
of CO2
C. Brain
death occurs within 6 to 10 minutes
D. Major
prehospital causes of preventable death
1. Early
detection
2. Early
intervention
3. Lay-person
BLS education
E. Most
often neglected of prehospital skills
1. Basics
taken for granted
2. Poor
techniques
a. BVM
seal
b.
Improper positioning
c. Failure
to reassess
II. Anatomy
of upper airway
A. Function
of the upper airway
1. Warm
2. Filter
3. Humidify
B. Pharynx
1. Nasopharynx
a. Formed
by the union of facial bones
b. Orientation
of nasal floor is towards the ear not the eye
c. Separated
by septum
d. Lined
with
(1) Mucous
membranes
(2) Cilia
e. Turbinate
(1) Parallel
to nasal floor
(2) Provide
increased surface area for air
(a) Filtration
(b) Humidifying
(c) Warming
f. Sinuses
(1) Cavities
formed by cranial bones
(2) Appear
to further trap bacteria and act as tributaries for fluid to and from
Eustachian tubes and tear ducts
(a) Commonly
become infected
(b) Fracture
of certain sinus bones may cause cerebrospinal fluid (CSF) leak
g. Tissues
extremely delicate and vascular
(1) Improper
or overly aggressive placement of tubes or airways will cause significant bleeding
which may not be controlled by direct pressure
2. Oropharynx
a. Teeth
(1) 32
adult
(2) Requires
significant force to dislodge
(3) May
fracture or avulse causing obstruction
b. Tongue
(1) Large
muscle attached at the mandible and hyoid bones
(2) Most
common airway obstruction
c. Palate
(1) Roof
of mouth separates oro/ nasopharynx
(a) Anterior
is hard palate
(b) Posterior
(beyond the teeth) is soft palate
d. Adenoids
(1) Lymph
tissue located in the mouth and nose that filters bacteria
(2) Frequently
infected and swollen
e. Posterior
tongue
f. Epiglottis
g. Vallecula
(1) "Pocket"
formed by the base of the tongue and epiglottis
(2) Important
landmark for endotracheal intubation
C. Larynx
1. Attached
to hyoid bone
a. "Horseshoe-shaped”
bone between the chin and mandibular angle
b. Supports
trachea
c. Made
of cartilage
2. Thyroid
cartilage
a. First
tracheal cartilage
b. "Shield-shaped"
(1) Cartilage
anterior
(2) Smooth
muscle posterior
c. Laryngeal
prominence
(1) "Adam's
Apple" anterior prominence of thyroid cartilage
(2) Glottic
opening directly behind
3. Glottic
opening
a. Narrowest
part of adult trachea
b. Patency
heavily dependent on muscle tone
c. Contain
vocal bands
(1) White
bands of cartilage
(2) Produce
voice
4. Arytenoid
cartilage
a. "Pyramid-like"
posterior attachment of vocal bands
b. Important
landmark for endotracheal intubation
5. Pyriform
fossae
a. “Hollow
pockets” along the lateral borders of the larynx
6. Cricoid
ring
a. First
tracheal ring
b. Completely
cartilaginous
c. Compression
occludes esophagus (Sellick maneuver)
7. Cricothyroid
membrane
a. Fibrous
membrane between cricoid and thyroid cartilage
b. Site
for surgical and alternative airway placement
8. Associated
structures
a. Thyroid
gland
(1) Located
below cricoid cartilage
(2) Lies
across trachea and up both sides
b. Carotid
arteries
(1) Branches
cross and lie closely alongside trachea
c. Jugular
veins
(1) Branch
across and lie close to trachea
III. Anatomy
of lower airway
A. Function
of the lower airway
1. Exchange
of O2 and CO2
B. Location
of the lower airway
1. From
fourth cervical vertebrae to xiphoid process
2. From
glottic opening to pulmonary capillary membrane
C. Structures
of the lower airway
1. Trachea
a. Trachea
bifurcates at carina into
(1) Right
and left mainstem bronchi
(2) Right
mainstem has lesser angle
(a) Foreign
bodies, ET tubes commonly displace here
b. Lined
with
(1) Mucous
cells
(2) Beta
2 receptors - dilate bronchioles
2. Bronchi
a. Mainstem
bronchi enter lungs at hilum
b. Branch
into narrowing secondary and tertiary bronchi that branch into bronchioles
3. Bronchioles
a. Branch
into alveolar ducts that end at alveolar sacs
4
Alveoli
a0
"Balloon-like” clusters
b0
Site of gas exchange
c0
Lined with surfactant
(1) Decreases
surface tension of alveoli which facilitates ease of expansion
(2) Alveoli
become thinner as they expand which makes diffusion of O2/ CO2
easier
(3) If
surfactant is decreased or alveoli are not inflated, alveoli collapse
(atelectasis)
5
Lungs
a0
Right lung
(1) 3
lobes
b0 Left lung
(1) 2
lobes
c0
Lobes made of parenchymal tissue
d0 Membranous outer lining called pleura
e0 Lung capacity
IV
Differences
in pediatric airway
A0
Pharynx
1
A proportionately smaller
jaw causes the tongue to encroach upon the airway
2
Omega shaped, floppy
epiglottis
3
Absent or very delicate
dentition
B0
Trachea
1
Airway
is smaller and narrower at all levels
2
Larynx
lies more superior
3
Larynx
is "funnel-shaped" due to narrow, undeveloped cricoid cartilage
4
Narrowest
point is at cricoid ring before 10 years of age
5
Further
narrowing of the airway by tissue swelling of foreign body results in major
increase in airway resistance
C0 Chest wall
1
Ribs and cartilage are
softer
2
Cannot optimally contribute
to lung expansion
3
Infants
and children tend to depend more heavily on the diaphragm for breathing
V
Lung/
respiratory volumes
A0
Total lung volume
1
Adult male, 6 liters
2
Not
all inspired air enters alveoli
3
Minor
diffusion of O2 takes place in alveolar ducts and terminal
bronchioles
B0
Tidal volume
1
Volume
of gas inhaled or exhaled during a single respiratory cycle
2
5-7cc/ kg (500 cc normally)
C0
Dead space air
1
Air
remaining in air passageways, unavailable for gas exchange (approximately
150cc)
2
Anatomic
dead space
a0 Trachea
b0
Bronchi
3
Physiologic
dead space
a0
Dead space formed by factors like
disease or obstruction
(1) COPD
(2) Atelectasis
D0
Minute volume
1
Amount of gas moved in and
out of the respiratory tract per minute
2
Determined by
a0 Tidal volume - dead space volume times
respiratory rate
E0
Functional reserve capacity
1
After
optimal inspiration: optimum amount of air that can be forced from the lungs in
a single exhalation
F0 Residual volume
1
Volume
of air remaining in lungs at the end of maximal expiration
G0
Alveolar air
1
Air
reaching the alveoli for gas exchange (alveolar volume)
2
Approximately
350 cc
H0
Inspiratory reserve
1
Amount
of gas that can be inspired in addition to tidal volume
I0
Expiratory reserve
1
Amount
of gas that can be expired after a passive (relaxed) expiration
J0
FiO2
1
Percentage of oxygen in
inspired air (increases with supplemental oxygen)
a0 Commonly documented as a decimal (e.g.,
FiO2 = .85)
VI
Ventilation
A0
Definition - movement of air into and
out of the lungs
B0
Phases
1
Inspiration
a0
Stimulus to breathe from respiratory
center
b0 Impulse transmitted to diaphragm via
phrenic nerve
(1) Diaphragm
- "muscle of respiration"
(2) Separates
thoracic from abdominal cavity
c0
Diaphragm contracts -
"flattens"
(1) Causes
intrapulmonic pressure to fall slightly below atmospheric pressure
d0
Intercostal muscles contract
e0
Ribs elevate and expand
f0
Air is drawn into lungs like a
vacuum
g0
Alveoli Inflate
h0
O2/ CO2 are
able to diffuse across membrane
2
Expiration
a0
Stretch receptors in lungs signal
respiratory center via vagus nerve to inhibit inspiration (Hering-Breuer
Reflex)
b0 Natural elasticity (recoil) of the lungs
passively expires air
VII
Respiration
A0 Definition
1
Exchange
of gases between a living organism and its environment
2
The
major gases of respiration are oxygen and carbon dioxide
B0
Types
1
External
respiration - exchange of gasses between the lungs and the blood cells
2
Internal
respiration - exchange of gases between the blood cells and tissues
C0
The transportation of oxygen and
carbon dioxide in the human body
1
Diffusion
- passage of solution from area of higher concentration to lower concentration
a0
O2/ CO2
dissolve in water and pass through alveolar membrane by diffusion
2
Oxygen
content of blood
a0
Dissolved O2 crosses
pulmonary capillary membrane and binds to hemoglobin (Hgb) of red blood cell
b0
Oxygen is carried
(1) Bound
to hemoglobin
(2) Dissolved
in plasma
c0
Approximately 97% of total O2
is bound to hemoglobin
d0
O2 saturation
(1) %
of hemoglobin saturated
(2) Normally
greater than 98%
3
Oxygen
in the blood
a0
Bound to hemoglobin
(1) SaO2
b0
Dissolved in plasma
(1) PaO2
4
Carbon
dioxide content of the blood
a0
CO2 is a byproduct of
cellular work (cellular respiration)
b0
CO2 is transported in
blood as bicarbonate ion
c0
About 33% is bound to hemoglobin
d0
As O2 crosses into blood,
CO2 diffuses into alveoli
e0
Carbon dioxide in the blood
(1) PaCO25 Diagnostic
testing
a0 Pulse oximetry
b0 Peak expiratory flow testing
c0 End-tidal CO2 monitoring
d0 Other equipment
VIII
Causes
of decreased oxygen concentrations in the blood
A0
Lower partial pressure of atmospheric
O2
B0
Lower hemoglobin levels in blood
C0
Trauma
1
Less
surface area for gas exchange
a0
Pneumothorax
b0 Hemothorax
c0
Combination of pneumothorax and
hemothorax
2
Decreased
mechanical effort
a0
Pain
b0 Traumatic suffocation
c0
Hypoventilation
D0 Medical
1
Physiological barriers
a0 Pneumonia
b0
Pulmonary edema
c0 COPD
IX
Carbon
dioxide in blood
A0 Increases
1
Hypoventilation
B0
Decreases
1
Hyperventilation
X
The
measurement of gases
A0
Total pressure
1
The combined pressure of all
atmospheric gases
2
100%
or 760 torr at sea level
B0
Partial pressure
1
The
pressure exerted by a specific atmospheric gas
C0
Concentration of gases in the
atmosphere
1
Nitrogen
597.0 torr (78.62%)
2
Oxygen 159.0
torr (20.84%)
3
CO2 0.3
torr ( 0.04%)
4
Water 3.7
torr ( 0.5%)
D0
Water vapor pressure
E0
Alveolar gas concentration
1
Nitrogen 569.0 torr (74.9%)
2
Oxygen 104.0
torr (13.7%)
3
CO2 40.0
torr ( 5.2%)
4
Water 47.0
torr ( 6.2%) XI Respiratory
rate
A0
Definition - the number of times a
person breathes in one minute
B0
Neural control
1
Primary control from the
medulla and pons
2
Medulla
a0
Primary involuntary respiratory
center
b0
Connected to respiratory muscles by
vagus nerve
3
Pons
a0 Apneustic center - secondary control
center if medulla fails to initiate respiration
b0
Pneumotaxic center - controls
expiration
C0
Chemical stimuli
1
Receptors
for O2/ CO2 balance
a0 Cerebrospinal fluid pH
b0 Carotid bodies (sinus)
c0 Aortic arch
2
Hypoxic
drive - respiratory stimulus dependent on O2 rather than CO2
in the blood
D0
Control of respiration by other
factors
1
Body temperature -
respirations increase with fever
2
Drug
and medications - may increase or decrease respirations depending on their
physiologic action
3
Pain
- increases respirations
4
Emotion
- increases respirations
5
Hypoxia - increases respirations
6
Acidosis - respirations
increase as compensatory response to increased CO2 production
7
Sleep
- respirations decrease
XII
Pathophysiology
A0 Obstruction
1
Tongue
a0
Most common airway obstruction
b0
Snoring respirations
c0
Corrected with positioning
2
Foreign
body
a0
May cause partial or full obstruction
b0
Symptoms include
(1) Choking
(2) Gagging
(3) Stridor
(4) Dyspnea
(5) Aphonia
(unable to speak)
(6) Dysphonia
(difficulty speaking)
3
Laryngeal
spasm and edema
a0
Spasm
(1) Spasmotic
closure of vocal cords
(2) Most
frequently caused by
(a) Trauma
from over aggressive technique during intubation
(b) Immediately
upon extubation especially when patient is semiconsciousb0
Edema
(1) Glottic
opening becomes extremely narrow or totally obstructed
(2) Most
frequently caused by
(a) Epiglottitis
(a bacterial infection of the epiglottis)
(b) Anaphylaxis
(severe allergic reaction)
(c) Relieved
by
(3) Aggressive
ventilation
(4) Forceful
upward pull of the jaw
(5) Muscle
relaxants
4
Fractured
larynx
a0
Airway patency dependent upon muscle
tone
b0
Fractured laryngeal tissue
(1) Increases
airway resistance by decreasing airway size through
(a) Decreasing
muscle tone
(b) Laryngeal
edema
(c) Ventilatory
effort
5
Aspiration
a0 Significantly increases mortality
(1) Obstructs
airway
(2) Destroys
delicate bronchiolar tissue
(3) Introduces
pathogens
(4) Decreases
ability to ventilate
XIII
Airway
evaluation
A0
Essential parameters
1
Rate
a0
Normal resting rate in adults - 12-24
2
Regularity
a0
Steady pattern
b0
Irregular respiratory patterns are significant
until proven otherwise
3
Effort
a0
Breathing at rest should be
effortless
b0
Effort changes may be subtle in rate
or regularity
c0
Patients often compensate by
preferential positioning
(a) Upright
sniffing
(b) Semifowlers
(c) Frequently
avoid supine
B0
Recognition of airway problems
1
Respiratory
distress
a0
Upper and lower airway obstruction
b0
Inadequate ventilation
c0
Impairment of the respiratory muscles
d0
Impairment of the nervous system
2
Difficulty
in rate, regularity, or effort is defined as dyspnea
3
Dyspnea
may be result of or result in hypoxia
a0
Hypoxia - lack of oxygen
b0
Hypoxia - lack of oxygen to tissues
c0
Anoxia - total absence of oxygen
4
Recognition and treatment of
dyspnea is crucial to patient survival
a0
Expert assessment and management is
essential
(1) The
brain can survive only a few minutes of anoxia
(2) All
therapies fail if airway is inadequate
5
Visual
techniques
a0 Position
(1) Tripod
positioning
(2) Orthopnea
b0
Rise and fall of chest
c0
Gasping
d0
Color of skin
e0
Flaring of nares
f0
Pursed lips
g0 Retraction
(1) Intercostal
(2) Suprasternal
notch
(3) Supraclavicular
fossa
(4) Subcostal
6
Auscultation
techniques
a0
Air movement at mouth and nose
b0
Bilateral lung fields equal
7
Palpation
Techniques
a0
Air movement at mouth and nose
b0
Chest wall
(1) Paradoxical
motion
(2) Retractions
8
Bag-valve-mask
a0
Resistance or changing compliance
with bag-valve-mask ventilations
9
Pulsus
paradoxus
a0
Systolic blood pressure drops greater
than 10mm Hg with inspiration
(1) Change
in pulse quality maybe detected
(2) Seen
in COPD, pericardial tamponade
(3) Possible
increase in intrathoracic pressure
10
History
a0
Evolution
(1) Sudden
(2) Gradual
over time
(3) Known
cause or "trigger"
b0
Duration
(1) Constant
(2) Recurrent
c0
Ease - what makes it better?
d0
Exacerbate - what makes it worse?
e0
Associate
(1) Other
symptoms (productive cough, chest pain, fever, etc...)
f0
Interventions
(1) Evaluations/
admissions to hospital
(2) Medications
(include compliance)
(3) Ever
intubated
11
Modified
forms of respiration
a0
Protective reflexes
(1) Cough
(a) Forceful,
spastic exhalation
(b) Aids
in clearing bronchi and bronchioles
(2) Sneeze
- clears nasopharynx
(3) Gag
reflex - spastic pharyngeal and esophageal reflex from stimulus of the
posterior pharynx
b0
Sighing
(1) Involuntary
deep breath that increases opening of alveoli
(2) Normally
sigh about once per minute
c0
Hiccough - intermittent spastic
closure of glottis
12
Respiratory
pattern changes
a0
Cheyne-Stokes
(1) Gradually
increasing rate and tidal volume followed by gradual decrease
(2) Associated
with brain stem insult
b0
Kussmaul’s breathing
(1) Deep,
gasping respirations
(2) Common
in diabetic coma
c0
Biot’s respirations
(1) Irregular
pattern, rate, and volume with intermittent periods of apnea
(2) Increased
intracranial pressure
d0
Central neurogenic hyperventilation
(1) Deep
rapid respirations similar to Kussmall's
(2) Increased
intracranial pressure
e0
Agonal
(1) Slow,
shallow, irregular respirations
(2) Resulting
from brain anoxia
13
Inadequate
ventilation
a0
Occurs when body cannot compensate
for increased O2 demand or maintain O2/ CO2
balance
b0
Many causes
(1) Infection
(2) Trauma
(3) Brainstem
insult
(4) Noxious
or hypoxic atmosphere
(5) Renal
failure
c0
Multiple symptoms
(1) Altered
response
(2) Respiratory
rate changes (up or down)
XIV
Supplemental
oxygen therapy
A0
Rationale
1
Enriched
O2 atmosphere increases oxygen to cells
2
Increasing available O2
increases patient's ability to compensate
3
O2 delivery
method must be reassessed to determine adequacy and efficiency
B0 Oxygen source
1
Compressed gas
a0 Oxygen compressed in gas form in an
aluminum or steel tank
b0 Common sizes and volumes
(1) D 400L
(2) E 660L
(3) M 3450L
c0
O2 delivery measured in
liters/ min (LPM)
d0
Calculating tank life
(1) Tank
pressure (psi) x 0.28 = volume
(2) Volume/
LPM = tank life in minutes 2 Liquid
oxygen
a0 O2 cooled to its aqueous state
(1) Converts
to gaseous state when warmed
b0
Advantage
(1) Much
larger volume of gaseous O2 can be stored in aqueous state
c0
Disadvantage
(1) Units
generally require upright storage
(2
Special
requirements for large volume storage and cylinder transfer
C. Regulators
1. High-pressure
a. Attached
to cylinder stem delivers cylinder gas under high pressure
b. Used
to transfer cylinder gas from tank to tank
2. Therapy
regulators
a. Attached
to cylinder stem
b. 50psi
escape pressure is "stepped down" through regulator mechanism
c. Subsequent
delivery to patient is adjustable low pressure
D. Delivery
devices
1. Nasal
cannula
a. Nasally
placed O2 catheter for oxygen enrichment
b. Optimal
delivery: 40% at 6 L/ min
c. Indications
(1
Low
to moderate O2 enrichment
(2
Long
term O2 maintenance therapy
d. Contraindications
(1
Poor
respiratory effort
(2
Severe
hypoxia
(3
Apnea
(4
Mouth
breathing
e. Advantages
(1
Well
tolerated
f. Disadvantages
(1
Does
not deliver high volume/ high concentration
2. Simple
face mask
a. Full
airway enclosure with open side ports
(1
Room
air is drawn through side ports on inspiration
(2
Diluting
O2 concentration
b. Indications
(1
Delivery
of moderate to high O2 concentrations
(2
Range
- 40-60% at 10 L/ min
c. Advantages
(1
Higher
O2 concentrations
d. Disadvantages
(1
Delivery of volumes beyond 10
L/ min does not enhance O2 concentration
e. Special
considerations
(1
Mask
leak around face decreases O2 concentration
3. Partial
rebreather
a. Mask
vent ports covered by one-way disc
(a Residual
expired air mixed in mask and rebreathed
(1
Room
air not entrained with inspiration
b. Indications
c. Contraindications
(1
Apnea
(2
Poor
respiratory effort
d. Advantages
(1
Inspired
gas not mixed with room air
(a
Higher
O2 concentrations attainable
(2
Disadvantages
(a
Delivery
of volumes beyond 10 L/ min does not enhance O2 concentration
(3
Special
considerations
(a
Mask
leak around face decreases O2 concentration
4. Non-rebreather
mask
a. Mask
side ports covered by one-way disc
b. Reservoir
bag attached
c. Range:
80-95+% at 15 L/ min
d. Indications
(1
Delivery
of highest O2 concentration
e. Contraindications
(1
Apnea
(2
Poor
respiratory effort
f. Advantages
(1
Highest
O2 concentration
(2
Delivers
high volume/ high O2 enrichment
(3
Patient
inhales enriched O2 from reservoir bag rather than residual air
g. Disadvantages
5. Venturi
mask
a. Mask
with interchangeable adapters
(1
Adapters
have port holes that entrain room air as O2 passes
(2
Patient
receives a highly specific concentration of O2
(3
Air
is entrained by venturi principle
6. Small
volume nebulizer
a. Delivers
aerosolized medication
b. O2
enters an aerosol chamber containing 3-5 ccs of fluid
c. Pressurized
O2 mists fluid
E. Oxygen
humidifiers
1. Sterile
water reservoir for humidifying O2
2. Good
for long term O2 administration
3. Desirable
for croup/ Epiglottitis/ bronchiolitis
F. Tracheostomy,
stoma, and tracheostomy tubes
1. Tracheostomy
a. Surgical
opening into trachea
(1
Done
in operating room under controlled conditions
(2
A
stoma located just superior to the suprasternal notch
2. Stoma
a. Resultant
orifice connecting trachea to outside air
b. Patient
now breathes through this surgical opening
3. Tracheostomy
tube
a. Plastic
tube placed within tracheostomy site
b. 15
mm connector for ventilator acceptance
A. Mouth-to-mouth
1. Most
basic form of ventilation
2. Indications
a. Apnea
from any mechanism when other ventilation devices are not available
3. Contraindications
a. Awake
patients
b. Communicable
disease risk limitations
4. Advantages
a. No
special equipment required
b. Delivers
excellent tidal volume
c. Delivers
adequate oxygen
5. Disadvantages
a. Psychological
barriers from
(1
Sanitary
issues
(2
Communicable
disease issues
(a
Direct
blood/ body fluid contact
(b
Unknown
communicable disease risks at time of event
6. Complications
a. Hyperinflation
of patient's lungs
b. Gastric
distension
c. Blood/
body fluid contact manifestation
d. Hyperventilation
of rescuer
B. Mouth-to-nose
1. Ventilating
through nose rather than mouth
2. Indications
a. Apnea
from any mechanism
3. Contraindications
a. Awake
patients
4. Advantages
a. No
special equipment required
5. Disadvantages
a. Direct
blood/ body fluid contact
b. Psychological
limitations of rescuer
6. Complications
a. Hyperinflation
of patient's lungs
b. Gastric
distension
c. Blood/
body fluid manifestation
d. Hyperventilation
of rescuer
C. Mouth-to-mask
1. Adjunct
to mouth-to-mouth ventilation
2. Indications
a. Apnea
from any mechanism
3. Contraindications
a. Awake
patients
4. Advantages
a. Physical
barrier between rescuer and patient blood/ body fluids
b. One-way
valve to prevent blood/ body fluid splash to rescuer
c. May
be easier to obtain face seal
5. Disadvantages
a. Useful
only if readily available
6. Complications
a. Hyperinflation
of patient's lungs
b. Hyperventilation
of rescuer
c. Gastric
distention
7. Method
for use
a. Position
head by appropriate method
b. Position
and seal mask over mouth and nose
c. Ventilate
as appropriate
D. One
person bag-valve-mask
1. Fixed
volume self inflating bag can deliver adequate tidal volumes and O2
enrichment
2. Indications
a. Apnea
from any mechanism
b. Unsatisfactory
respiratory effort
3. Contraindications
a. Awake,
intolerant patients
4. Advantages
a. Excellent
blood/ body fluid barrier
b. Good
tidal volumes
c. Oxygen
enrichment
d. Rescuer
can ventilate for extended periods without fatigue
5. Disadvantages
a. Difficult
skill to master
b. Mask
seal may be difficult to obtain and maintain
c. Tidal
volume delivered is dependent on mask seal integrity
6. Complications
a. Inadequate
tidal volume delivery with
(1
Poor
technique
(2
Poor
mask seal
(3
Gastric distention
7. Method
for use
a. Position
appropriately
b. Choose
proper mask size - seats from bridge of nose to chin
c. Position,
spread/ mold/ seal mask
d. Hold
mask in place
e. Squeeze
bag completely over 1.5 to 2 seconds for adults
f. Avoid
overinflation
g. Reinflate
completely over several seconds
8. Special
considerations
a. Medical
(1
Observe
for
(a
Gastric
distension
(b
Changes
in compliance of bag with ventilation
(c
Improvement
or deterioration of ventilation status ( i.e., color change, responsiveness,
air leak around mask)
b. Trauma
(1
Very
difficult to perform with cervical spine immobilization in place
E. Two
person bag-valve-mask ventilation method
1. Most
efficient method
2. Indications
a. Bag-valve-mask
ventilation on any patient
(1
Especially
useful for cervical spine immobilized patients
(2
Difficulty
obtaining or maintaining adequate mask seal
3. Contraindications
a. Awake,
intolerant patients
4. Advantages
a. Superior
mask seal
b. Superior
volume delivery
5. Disadvantages
a. Requires
extra personnel
6. Complications
a. Hyperinflation
of patient's lungs
b. Gastric
distension
7. Method
for use
a. First
rescuer maintains mask seal by appropriate method
b. Second
rescuer squeezes bag
8. Special
considerations
a. Observe
chest movement
b. Avoid
overinflation
c. Monitor
lung compliance with ventilations
F. Three
person bag-valve-mask ventilation
1. Indications
a. Bag-valve-mask
ventilation on any patient
(1
Especially
useful for cervical spine immobilized patients
(2
Difficulty
obtaining or maintaining adequate mask seal
2. Contraindications
a. Awake,
intolerant patients
3. Advantages
a. Superior
mask seal
b. Superior
volume density
4. Disadvantages
a. Requires
extra personnel
b. “Crowded”
around airway
5. Complications
a. Hyperinflation
of patient’s lungs
b. Gastric
distension
6. Method
for use
a. First
rescuer maintains mask seal by appropriate method
b. Second
rescuer holds mask in place
c. Third
rescuer squeezes bag and monitors compliance
7. Special
considerations
a. Avoid
overinflation
b. Monitor
lung compliance with ventilations
G. Flow-restricted,
oxygen-powered ventilation devices
1. The
valve opening pressure at the cardiac sphincter is approx 30 cm H2O
2. These
devices operate at or below 30 cm H2O to prevent gastric distension
3. Indications
a. Delivery
of high volume/ high concentration of O2 (1 L/ sec)
b. Awake
compliant patients
c. Unconscious
patient with caution
4. Contraindications
a. Noncompliant
patients
b. Poor
tidal volume
c. Small
children
5. Advantages
a. Self
administered
b. Delivers
high volume/ high concentration O2
c. O2
delivered in response to inspiratory effort (no O2 wasting)
d. O2
volume delivery is regulated by inspiratory effort minimizing overinflation
risk
e. O2
volume delivery is also restricted to less than 30 cm H2O
6. Disadvantages
a. Cannot
monitor lung compliance
b. Requires
O2 source
7. Complications
a. Gastric
distension
b. Barotrauma
8. Method
a. Mask
is held manually in place
b. Negative
pressure upon inspiration triggers O2 delivery or medic triggers
release button
c. Patient
is monitored for adequate tidal volume and oxygenation
H. Automatic
transport ventilators
1. Volume/
rate controlled
2. Indications
a. Extended
ventilation of intubated patients
b. In
situations in which a BVM is used
c. Can
be used during CPR
3. Contraindications
a. Awake
patients
b. Obstructed
airway
c. Increased
airway resistance
(1
Pneumothorax
(after needle decompression)
(2
Asthma
(3
Pulmonary
edema
4. Advantages
a. Frees
personnel to perform other tasks
b. Lightweight
c. Portable
d. Durable
e. Mechanically
simple
f. Adjustable
tidal volume
g. Adjustable
rate
h. Adapts
to portable O2 tank
5. Disadvantages
a. Cannot
detect tube displacement
b. Does
not detect increasing airway resistance
c. Difficult
to secure
d. Dependent
on O2 tank pressure
I. Cricoid
pressure - Sellick’s maneuver
1. Pressure
on cricoid Ring
2. Occludes
esophagus
3. Facilitates
intubation by moving the larynx posteriorly
4. Helps
to prevent passive emesis
5. Can
help minimize gastric distension during bag-valve-mask ventilation
6. Indications
a. Vomiting
is imminent or occurring
b. Patient
cannot protect own airway
7. Contraindications
a. Use
with caution in cervical spine injury
8. Advantages
a. Noninvasive
b. Protects
from aspiration as long as pressure is maintained
9. Disadvantages
a. May
have extreme emesis if pressure is removed
b. Second
rescuer required for bag-valve-mask ventilation
c. May
further compromise injured cervical spine
10. Complications
a. Laryngeal
trauma with excessive force
b. Esophageal
rupture from unrelieved high gastric pressures
c. Excessive
pressure may obstruct the trachea in small children
11. Method
a. Locate
the anterior aspect of the cricoid ring
b. Apply
firm, posterior pressure