breathing and ventilation

Question 1

ribs

Answer 1

• 12 pairs
• 10 pairs attach to sternum and spine
• 2 pairs (floating ribs) attach only in back
• an intercostal nerve, artery, and vein are found along the inferior border of each rib
• IPASSO2- inspect chest (symmetry), palpate, seal on both sides, auscultate in four places

Question 2

mediastinum

Answer 2

• trachea
• esophagus
• main bronchi
• heart
• major arteries- aorta and branches; and pulmonary arteries

Question 3

physiology of life review

Answer 3

• oxygen is transported across the alveolar-capillary membrane
• it then attaches to hemoglobin in RBCs for transport to the rest of the body
• at the same time CO2 moves from the blood plasma into the alveoli
• pH goes down

Question 4

breathing

Answer 4

• the mechanical act of moving air into the lungs and alveoli
• controlled by the respiratory center of the brain
• chemoreceptors located in the aorta and carotid arteries stimulate the respiratory center
• rate and depth of ventilation are continuously adjusted to maintain normal PaCO2 levels

Question 5

breathing assessment

Answer 5

• normal breathing is not a noticeable process
• if the pt breathing draws your attention then there is problem until proven otherwise
• ex.
• breathing you can hear from across the room
• inability to speak in complete sentences
• patient position to ease breathing (tripoding)

Question 6

steps of breathing assessment

Answer 6

• look (observe)
• listen (auscultate)
• feel (palpate)

Question 7

look/observe

Answer 7

• increased respiratory effort
• positioning
• use of accessory muscles
• retractions
• nasal flaring in children
• visible signs of trauma
• contusions
• hematomas
• lacerations
• sucking chest wound
• paradoxical movement of the chest wall- ribs broken and you can see it -> chest moves out during exhalation and inward during inhalation

Question 8

listen (auscultate)

Answer 8

• presence
• equality (symmetry on left and right)
• asymmetry
• decreased on one side
• absent sound on one side
• listen for full cycle- inhale and exhale
• wheezing
• rales
• rhonchi
• crepitus- bony or subcutaneous emphysema

Question 9

feel/palpate

Answer 9

• bony crepitus- broken ribs
• subcutaneous emphysema
• abnormal movement of the chest wall
• bony tenderness
• does it hurt to touch

Question 10

pneumothorax

Answer 10

• simple- collapsed lung
• tension- pressure is building up -> more collapsed
• open- caused by the hole on the chest
• present in up to 20% of severe chest injuries
• a simple pneumothorax may progress to a tension pneumothorax as air continues to accumulate within the affected hemithorax
• tension pneumothorax is life threatening
• needle decompression may be required for tension pneumothorax
• may be associated with hemothorax
• tube can be used to suction out air or blood

Question 11

hemothorax

Answer 11

-blood in the chest

Question 12

rib fractures

Answer 12

• simple

- flail chest

Question 13

simple pneumothorax vs tension pneumothorax

Answer 13

• simple
• blunt or penetrating injury
• breath sounds decreased or absent
• mild to moderate ventilatory distress
• may progress to tension
• tension
• blunt or penetrating injury
• breath sounds decreased or absent
• marked ventilatory distress
• hemodynamic compromise -> prevents blood flow -> obstructive shock

Question 14

open pneumothorax

Answer 14

• penetrating mechanism
• may be sucking or bubbling chest wounds
• respiratory distress- mild to severe
• may be associated with a hemothorax
• optimal method of field management has not been demonstrated
• visceral and parietal pleura -> pressure builds and moves things to the other side

Question 15

hemothorax

Answer 15

• blunt or penetrating mechanism
• bleeding into the pleural cavity
• may be associated with a pneumothorax
• air or blood in the pleural space compromises lung capacity
• could be arterial bleeding under pressure
• chest can handle holding a lot of blood

Question 16

simple rib fractures

Answer 16

• most common thoracic injury
• usually involves ribs 4-8, laterally
• most common cause of hemothorax
• common complaints are chest pain and shortness of breath
• may be associated with injuries to liver and spleen
• hypoventilation bc of pain

Question 17

flail chest

Answer 17

• two or more adjacent ribs fractured in more than one place
• compromises the structural integrity of the chest, causing paradoxical movement while breathing
• segments move inward during inhalation
• and segments move out during exhalation
• positive pressure ventilation helps with moving the segments along with the chest
• associated with underlying injuries:
• pneumothorax, hemothorax, pulmonary contusion

Question 18

treatment of chest injuries

Answer 18

• the goal is to maintain or restore adequate oxygenation and ventilation
• administer supplemental oxygen
• assist ventilation as necessary
• seal open chest wounds
• recognize and decompress tension pneumothorax
• continuous assessment of breathing is essential

Question 19

supplemental oxygen

Answer 19

• can be administered by nonrebreathing mask, a BVM, or an oxygen powered ventilation
• BVM is much better bc it can get a sense of chest compliance -> if its getting harder you can tell pressure is building up
• never withhold oxygen from apt is respiratory distress
• monitor oxygen saturation
• target SpO2 greater than 95%
• increasing the levels of inspired oxygen assists in maintaining aerobic metabolism

Question 20

when to assist ventilations

Answer 20

• ventilatory rate- greater than 30 (and especially shallow) and less than 10
• insufficient spontaneous tidal volume- poor chest rise and use of accessory muscles
• decreased SpO2
• increased ETCO2 -> retaining CO2
• consider the need for airway management

Question 21

ventilatory rates and tidal volume for adults

Answer 21

• 10-12 breaths per minute

- 500-800 ml

Question 22

ventilatory rates and tidal volume for child

Answer 22

• 16-20

- 100 to 500 ml or until good chest rise

Question 23

ventilatory rates and tidal volume for infant

Answer 23

• 25
• 6-8 ml/kg volume
• inadvertent hyperventilation may lead to poor outcomes in patients with a traumatic brain injury

Question 24

tidal volume delivery

Answer 24

-6-7 ml per kg

Question 25

capnometry and capnography

Answer 25

• monitors:
• spontaneously breathing patient
• bag mask device
• endotracheal tube
• supraglottic airways
• maintain between 25 to 45 mm Hg
• may give false reading in hypotension but can be used to monitor trends

Question 26

needle decompression

Answer 26

• used to relieve tension pneumothorax
• appropriate placement is essential
• secondary intercostal space, midclavicular line, over the rib (preferred site)
• fifth intercostal space, midaxillary line, over the rib (alternate site)
• over the rib is always better

Question 27

summary

Answer 27

• Caring for a trauma patient experiencing respiratory difficulty includes:
• Maintaining a patent airway
• Administering supplemental oxygen
• BVM is the best way
• Supporting and monitoring ventilations
• Recognizing and decompressing tension pneumothorax

Question 28

CO2

Answer 28

• CO2 rising-> ventilate more

- monitoring CO2 tells you that your airway management is working and is in the right position