Airway/Breathing Flashcards
1
Q
Airway at risk
A
- an airway at risk assumes the rank of your highest clinical priority
- AIRWAY IS NOT BREATHING
- MCC airway obstruction is tongue and submandibular musculature relaxation/collapse
- our job is to:
- recognise an airway in trouble
- anticipate potential airway probs
- protect an airway that is or may be at risk
- act - temporize/manage an airway that is/may be at risk
2
Q
how to open an airway
A
- head tilt, chin lift
- use jaw-thrust alone if C-spine injury known, suspected, or possible
3
Q
Choking
A
- heimlich maneuver
- person should be conscious if you’re standing
- force and location of thrusts pushes air out to dislodge the foreign body
- unconscious? get help, call 911, defibrillator
- search for and remove an object you can see
- begin CPR, ACLS
4
Q
What does an airway in trouble look like?
A
- universal choking sign
- unconscious, deeply sedated
- respiratory distress, position preference
- getting sleepy while working to breathe
- changes in LOC - come in talking, now difficult to arouse
- sedated and vomiting
- head trauma, facial trauma
- infection somewhere along the airway
- burns - smoke inhalation
- face, tongue, neck edema
- severe bleeding from nose or mouth
- cyanosis, shock
5
Q
what does an airway in trouble sound like?
A
- Stridor: high-pitched insp or exp sounds, indicative of airway narrowing; insp at the glottis, exp below the glottis
- Gurgling
- Voice changes
- Drooling
6
Q
Airway options: suction
A
- rapidly clears secretions/blood, allows you to see, helps prevent aspiration
- a must during intubation, any advanced airway intervention or anytime there is a mess
- Yankauer suction tube, collection device, endotracheal tube thumb suction device
7
Q
Nasopharyngeal airway
A
- soft, pliable rubber tube with flange
- for SEMI CONSCIOUS pts with a gag reflex
- fits past tongue into posterior pharynx (bevel to septum, flange flush with nare)
- usually 3 sizes (measure tip of nose to tragus of ear)
- beware - may still vomit - need to keep an eye on them
8
Q
Oropharyngeal airway
A
- rigid, curved plastic tubes
- fit in pharynx behind tongue
- only for UNCONSCIOUS,, UNAROUSABLE pts = conscious or even semi-conscious will gag and vomit
- pre-intub ventilation helps to keep airway open
- post-intub - keeps patient from biting down on tube
- size: flange at corner of mouth to angle of jaw
- open mouth: cross-finger
- insert upside down, curve up, slide along roof of mouth
- rotate 180 degrees, over tongue
- Flange to lips
9
Q
Endotracheal intubation
A
- airway control in ED
- Direct laryngoscopy (DL) vs video lanyngoscopy
- secures airway by placing tube in the airway space
- requires you must now “breathe” for the pt - by hand or ventilator
10
Q
indications for ED intubation
A
- airway indications: cant protect/maintain their own airway d/t ALOC, airway patency threatened d/t edema, secretions, blood, infection, trauma
- breathing indications: failure to ventilate or oxygenate d/t pulmonary probs, cardiac probs, systemic probs, trauma, or preemptive d/t threat to airway patency (consciousness), oxygenation, ventilation, aspiration
11
Q
How to prepare for intubation
A
- O2 by nasal cannula - pre-oxygenate
- bag valve mask - BVM - essential skill - BVM: Not in conscious patient. High risk of vomiting if not paralyzed
- pre-intubation ventilation - 100% O2
- post-intubation first breaths (CO2 detector color change/listen to check tube placement, use while setting up ventilator)
- in between unsuccessful intubation attempts
-SOAP ME checklist - check before you start: Suction, O2, Airway equipment, Pharmacy, Monitoring Equipment
12
Q
Intubation
A
- have plan A, B, and C
- RSI - rapid sequence intubation - pt is paralyzed to gain control; intubation easier, deals with full stomach, prevents aspiration
- The 7 Ps:
- Possibility of success
- prepare
- pre-oxygenation
- pre-treatment
- induction/paralysis
- positioning/protection
- pass it, prove it, post procedure tasks
13
Q
Rapid sequence intubation
A
- Beware of paralyzing a patient!
- Paralyzed patient = no respiratory effort
- You MUST be able to adequately ventilate the patient with bag-valve-mask
- Must anticipate a successful intubation or do not paralyze
- Beware of esophageal intubation
- No color change, low pulse ox, no breath sounds.
- CXR is not reliable to determine if tube is in esophagus – CXR for depth of tube only
14
Q
Adjuncts and alternatives to intubation
A
-Bougie - tube over the wire
- LMA - Laryngeal Mask Airway, King Tube
- Supraglottic airway devices
- Designed for blind insertion - goal is esophagus, not trachea
- LMA for minor surgery common, good Plan B
- LMA, King tube common in EMS
-Nasotracheal intubation and/or fiber optic guided
- All designed to minimize risk of the failed airway
- Cannot intubate but can oxygenate – temporary, not secure
- Cannot intubate, cannot oxygenate – worst case scenario
15
Q
Surgical airway
A
- Cricothyrotomy
- Alternative method of airway control when intubation fails or is not possible
- Bypasses the traditional upper airway
- Plan B or C for failed intubation
- Tracheotomy – placed in OR
- For pt’s needing prolonged airway support
16
Q
Dyspnea: ddx
A
- Extremely common, multiple descriptions
- Perception/evidence that breathing is not normal, comfortable, reflexive.
- Sensation of worsening of baseline
- It is a symptom - not a specific disease
- Airway compromise
- Lung problem
- Cardiac problem
- Metabolic problem
- Blood problem
- Neuromuscular problem
- Shock - anaphalaxis, etc
- Trauma
- Other - GI, anxiety, psych, etc…
17
Q
Causes of Inadequate Ventilation
A
- Increased airway resistance
- Airway collapse, hyper-reactivity, edema
- Small decreases in diameter significant
- COPD, emphysema, asthma
- Decreased airway compliance
- Interstitial edema and alveolar collapse
- Pulmonary edema, effusion, shock, sepsis, aspiration, drowning, smoke inhalation, ARDS, trauma
- Abnormalities of ventilation/perfusion
- Acute left ventricular failure, pneumonia, pulmonary embolus, anemia, ARDS, etc…
- Impaired wall mechanics
- Perfused but under-ventilated alveoli
- Pneumothorax, pneumonia, effusion, neuromuscular problems, rib fx, trauma
- Hypoventilation/hyperventilation
- Poisoning, toxic overdoses, intoxication
- Acidosis
- Endocrine disorders
- CNS lesions
18
Q
outcomes of inadequate ventilation - KNOW WELL
A
- Leads to Hypoxia:
- Low arterial O2 tension - alveoli aren’t transferring O2 from lungs to circulation
- Ventilation-perfusion mismatch
- Leads to Hypercarbia:
- Alveolar hypoventilation
- Increased lung “dead space”
- Acidosis from CO2 retention
- Altered mental status
19
Q
Approach to dyspnec patient
A
- Airway first
- Need one now? Proceed
- Need one soon? Prepare
- Ask yourself: Is this respiratory distress?
- Observation is key
- Vital signs are key
- Sick or not sick?
- What do they need now?
- Is this pulmonary or non-pulmonary?
- What’s on my differential diagnosis list?
- What is most likely from this pt’s Hx/PE?
20
Q
Red flags of respiratory distress
A
- Can they talk?
- How many word sentences?
- Fighting for each breath - anxiety?
- Tachypnec? >30/min?
- Posture - tripod? Won’t lie down?
- Accessory muscles?
- Handling secretions?
- Diaphoretic? Cyanotic?
- Altered? Sleepy?
- Gag reflex?
- Stridor?
21
Q
What to do if the pt is in respiratory distress
A
-Give supplemental O2 now; beta-agonist now if appropriate
-Prepare for definitive airway control
-Vital signs, Pulse Ox
-IV access, cardiac monitor
-Undress
-Pre-hospital hx, PE, interventions
-Rapid assessment: <1 min
Focused history, PE
-Treatment Goals:
-Airway control
- Reverse hypoxemia
- Supplemental O2
- Improve ventilatory effort/status
- Avoid/treat hypercapnea
- Increase effective tidal volume
- Improve alveolar ventilation
-Find and treat the cause
22
Q
Oxygen Therapy
A
-Supplemental oxygen is good
- Nasal cannula - no/slight distress
- Maybe tachypnec but full sentences, no posturing, 2-4L/min
- Face mask
- Moderate distress & O2 deficit, 4-10L/min
- Non-rebreather mask - moderate to serious
- O2 in bag, exhale thru one-way valve
- Significant O2 requirement, 8-15L/min
-Monitor pulse ox changes, humidify
23
Q
Hx: uncovering red flags
A
-Focused Hx. Prolonged = counterproductive
- Have you had this before?
- How long? Onset sudden or gradual?
- Medications? Run out of them?
- Associated symptoms – rash, fever, cough, hemoptysis, DOE, chest pain, orthopnea, edema, trauma, syncope
- Home O2?
- Ever been intubated??
-Focused Past medical history
-Pulmonary, cardiac, renal,
HIV, cancer
-Recent hospitalizations or surgery
-Habits - ETOH, smoking, drugs
- If can’t give hx, can’t talk - get help in the room
- Med list (sometimes better than Hx)
- Paramedic run sheet, family, friends, bystanders, PMD
- Interpreter
- Obtain old record ASAP
- All of this after your focused physical exam
24
Q
Vital signs: red flags
A
- Blood pressure - Often elevated (think cardiac too); Hypotension - ominous sign
- Respiratory rate - tachypnea is sensitive
- Pulse - tachycardia common, beta agonists?
- Pulse – bradycardia – ominous sign
- Temperature - infectious process
- Pulse Oximetry – improvement with O2?
25
Limitations of pulse ox
- Measures % oxygen saturation of hemoglobin in arterial blood (SaO2 measured = SpO2)
- Useful only if arterial O2 above 60%
- Hyperventilation, anemia can give false readings
- Pulse Ox tells us little about adequacy of ventilation
- Pulse Ox tells us nothing about CO2/hypercarbia
26
Physical exam red flags
- Pulmonary exam first - bare the torso
- Accessory muscle use, asymmetrical movements, trauma, surgical scars? Air movement, symmetry?
- Wheezes, rales, rhonchi, rubs, consolidation, I to E ratio
- Cardiac exam, pulses – rhythm, m/r/g
- Check capillary refill time: <2secs normal. >2secs? Think shock!
- Abdomen – distention, ascites
- Eyes (pallor), mouth (tongue, thrush) neck (JVD, masses, swelling)
- Skin – rash, diaphoresis
- Extremities – edema, clubbing? Think CHF, DVT, COPD
- Neuro – mental status, muscle weakness
27
Differential diagnosis for Respiratory distress
- Common PULMONARY causes:
- Asthma or COPD exacerbation
- Pneumonia, infectious
- Pleural effusion
- Pneumothorax
- Pulmonary embolus
- Malignancy
- Trauma
- Rhematologic, connective tissue Dz, Sickle Cell (Pulmonary manifestations)
- Aspiration, foreign body
- Common NON PULMONARY causes:
- Acute coronary syndrome
- Sepsis
- CHF/pulmonary edema (pump problem)
- Pericardial effusion/pericarditis
- Anemia
- Renal and metabolic disturbances
- Environmental, toxic ingestion
- Allergy, anaphylaxis
- Neuromuscular
- Psychiatric
28
ED diagnostics
- Begin with: IV, O2, Monitor
- Bedside ultrasound: lung, cardiac, IVC (triple scan – if available, immediately)
- Chest Xray - portable
- EKG
- Basic labs - CBC, CMP, UPreg, U Tox, lactic acid
- Case specific - consider:
- Cardiac enzymes
- D-Dimer, lower extremity ultrasound
- ABG/VBG, PT/INR
- Aspirin level
- BNP?
- Chest CT
- Non-invasive positive pressure ventilation (NIPPV)
29
NIPPV
- Hypercapnic, hypoxemic respiratory failure
- Useful to Tx and to avoid intubation in:
- COPD exacerbations, severe asthma
- Pulmonary edema/CHF
- Obstructive sleep apnea
- Post-extubation, chest trauma
- CPAP - “continuous positive airway pressure”
- Mask over mouth/nose
- Continuous inspiratory/expiratory pressure (CHF)
- BiPAP - “bilevel positive airway pressure”
- Nasal mask
- Use to vary inspiratory and expiratory pressures (COPD)
30
Positive pressure ventilation
- Reduces the work of breathing
- Maintains alveolar inflation, assists ventilation (O2 in, CO2 out)
- Improves airway compliance
- Reduces preload and afterload
- Contraindications:
- Pt cannot breathe on own if mask falls off
- Must be relatively stable, not agitated or unconscious
- Intact face - avoid subcutaneous air
31
Take home points
- Assure airway, be prepared, anticipate:
- Know signs of airway compromise and respiratory failure
- Give supplemental O2 now to anyone with active dyspnea
- Begin w/u with usual suspects – add bedside ultrasound
- Bronchodilators/epinephrine without delay if needed
- Think - pulmonary or non-pulmonary? Develop a DDx list
- Must explain abnormal vital signs. Get ambulatory pulse ox prior to discharge
- Can’t talk, can’t walk? Can’t go home
