Ch.11airwaymanagement Flashcards
Is a process in which molecules move from an area of higher concentration to an area of lower concentration
Diffusion
___ cells carry the hemoglobin,with the bound oxygen , through the body,ultimately delivering it to the capillaries to oxygenate the body’s cells
Red blood cells
All the structures of the body that contribute to the process of breathing,consisting of the upper and lower airways and their component parts
Respiratory system
The airway is divided into the upper and the lower airways. Structures that help us breathe include the
diaphragm, the intercostal muscles (muscles in between the ribs) and the nerves from the brain and spinal cord that innervate those muscles
In times of increased distress, muscles that are ordinarily not used during normal breathing, called ___ can be employed
Accessory muscles
Is the simple act of moving air into and out of the lungs
Ventilation
The ___ and ___ are responsible for the regular rise and fall of the chest that accompany normal breathing
Diaphragm
Intercostal muscles
The ___ consists of all anatomic airway structures above the level of the vocal cords
The upper airway
The upper airway consists of all anatomic airway structures above the level of the vocal cords. These include the
Nose,jaw,oral cavity,pharynx,and larynx
The ___ is a muscular tube that extends from the nose and mouth to the level of the esophagus and trachea
The pharynx (throat)
The pharynx is composed of the _
Nasopharynx,Oropharynx,and the Laryngopharynx (also called the hypopharynx)
The __ is the lowest portion of the pharynx. At the base, it splits into two lumens, the larynx(and ultimately,the trachea) anteriorly and the esophagus posteriorly
Laryngopharynx
During inhalation, air typically enters the body through the nose and passes into the___
Nasopharynx
The _ is lined with a ciliated mucous membrane that keeps contaminants such as dust and other small particles
Nasopharynx
The ___ forms the posterior portion of the oral cavity, which is bordered superiorly by the hard and soft palates, laterally by the cheeks , and inferiorly by the tongue
Oropharynx
Superior to the larynx, the __ helps separate the digestive system from the respiratory system. Its function is to prevent food and liquid from entering the larynx during swallowing.
Epiglottis
When swallowing occurs, the larynx is elevated and the epiglottis folds over the glottis to prevent ___ of contents into the trachea
Aspiration
The ___ is a complex structure formed by many independent cartilaginous structures . It marks where the upper airway ends and the lower airway begins.
Larynx
The __ is a shield shaped structure formed by two plates that join in a V shape anteriorly to form the laryngeal prominence known as the Adams Apple
Thyroid cartilage
The____, or cricoid ring, lies inferiorly to the thyroid cartilage; it forms the lowest portion of the larynx. The___ is the first ring of the trachea and the only lower airway structure that forms a complete ring.
cricoid cartilage
The_ is the elastic tissue that connects the thyroid cartilage superiorly to the cricoid ring inferiorly.
cricothyroid membrane
The lateral borders of the glottis are the__. These white bands of thin muscle tissue are partially separated at rest and serve as the primary center for speech production. In addition, the ___contain defense reflexes that protect the lower airway, causing a spasmodic closure to the lower airway to prevent substances from entering the trachea (eg, water, vomitus).
vocal cords
The __ or windpipe is the conduit for air entry into the lungs
The__, also called the glottic opening, is the space between the vocal cords and the narrowest portion of the adults airway.
glottis
The trachea begins directly below the __ and descends anteriorly down the midline of the neck into the thoracic cavity.
Cricoid cartilage
Once in the thoracic cavity, the trachea divides at the level of the __ into two main steam bronchi . The hollow bronchi are supported by cartilage and distribute air into the right and left lungs
Carina
Generally, the maneuvers, techniques, and indications for airway management are the same in children as they are in adults. However, several anatomic differences in the child require modification of certain techniques.
Infants and small children have a proportionately larger __which causes the neck to flex,
moving the head forward and backward, when the child lies supine, this position itself can cause an airway obstruction. When positioning the airway of an infant or child, place a folded towel under the child’s shoulders to maintain a neutral position of the head.
Compared with adults, children have a proportionately smaller mandible and a proportionately larger tongue (FIGURE 11-4). Both
factors increase the incidence of airway obstruction in children.
occiput (posterior portion of the cranium),
Children rely heavily on their __ for breathing
Diaphragm
general, the infant’s and the child’s airway is smaller and narrower at all levels. The larynx lies more superior and anterior than that of an adult. The larynx is also funnel-shaped due to the narrow, underdeveloped___. In children younger than & years, the narrowest portion of the airway is at the cricoid ring. Further narrowing of the child’s inherently narrow airway, such as that caused by soft-tissue swelling or foreign body aspiration, can significantly increase airway resistance and cause breathing inadequacy.
Cricoid cartilage
The lungs consist of the entire mass of tissue that includes the smaller bronchi, bronchioles, and alveoli (FIGURE 11-7).
The pleurae are thin serous membranes that cover the lungs and line the thoracic cavity. The___ covers the outer surface of the lung tissue, and the __lines the inside of the thoracic cavity. A small amount of fluid is found between these two pleural layers and serves as a lubricant to prevent friction during breathing.
visceral pleura
parietal pleura
On entering the lungs, each bronchus divides into increasingly smaller bronchi, which in turn subdivide into bronchioles The bronchioles are thin, hollow tubes made of__. The tone of these _____allows the bronchioles to dilate or constrict in response to various stimuli. The smaller bronchioles branch into alveolar ducts that end at the alveolar sacs
Smooth muscle
The alveoli, located at the end of the airway, are millions of thin-walled, balloonlike sacs that serve as the functional site for the exchange of oxygen and carbon dioxide. Surrounding each of these sacs is an intricate bed of blood vessels, known as___. Oxygen diffuses through the lining of the alveoli into the___ where, depending on adequate blood volume and pressure, it is carried back to the heart for distribution to the rest of the body. At the same time, carbon dioxide (waste) diffuses from the____ into the alveoli, where it is xhaled and removed from the body
Pulmonary capillaries
The chest cage (thoracic cavity) contains the lungs, one on each side (FIGURE 11-8). The boundaries of the thorax are the rib cage anteriorly, superiorly, and posteriorly and the diaphragm inferiorly. Each individual rib plays a part in the overall protection of the thorax. In between each rib are intercostal muscles that, in conjunction with the diaphragm, facilitate normal breathing. Within the chest cage, you will find the lungs, which hang freely within the chest cavity. Between the lungs is a space called the___, which is surrounded by tough connective tissue. This space contains the heart, the great vessels, the esophagus, the trachea, the major bronchi, and many nerves. The____ effectively separates the right lung space from the left lung space. In addition to the respiratory and circulatory structures found in the thoracic cavity, important structures of the nervous system are also found in the thorax— the phrenic nerves. The phrenic nerves, which originate from the third, fourth, and fifth cervical nerves, innervate the diaphragm muscle, allowing it to contract. Contraction of the diaphragm occurs in a downward direction and is necessary for adequate breathing to occur.
mediastinum
The two nerves that innervate the diaphragm; necessary for adequate breathing to occur
Phrenic nerves
As described earlier, air enters the body through the oral and nasal cavities and travels into the lungs. This occurs because a___ is created in the chest when the thoracic cavity enlarges due to contraction of the diaphragm and intercostal muscles.
negative pressure
Eventually the air reaches the alveolar sacs, where oxygen diffuses across the alveolar membrane and binds to___ in the bloodstream. At the same time, carbon dioxide diffuses from the bloodstream into the alveoli The carbon dioxide is exhaled from the lungs, and the oxygen is transported back to the heart, where it is distributed to the rest of the body.
hemoglobin
The heart pumps blood to the tissues of the body through a series of arteries and veins. Arteries carry blood away from the heart and eventually branch into___.
capillaries
the exchange of nutrients and waste products takes place.
Oxygen and nutrients leave the capillaries and enter the___. At the same time, waste products, such as carbon dioxide, diffuse from the___ back into the blood of the capillaries.
Cells
From here, the deoxygenated blood travels back to the heart. The deoxygenated blood enters the right side of the heart through the___. The right ventricle pumps the blood to the lungs for oxygenation and removal of carbon dioxide. The oxygenated blood then travels back to the heart and into the left atrium. The left ventricle then pumps the oxygenated blood to the rest of the body. Refer back to Chapter 6, The Human Body, for an illustration of this process.
right atrium
The physical act of moving air into and out of the lungs
Ventilation
The process of loading oxygen molecules onto hemoglobin molecules in the bloodstream
Oxygenation
The actual exchange of oxygen and carbon dioxide in the alveoli as well as the tissues of the body
Respiration
Examples of injuries or conditions that can impair ventilation include flat chest,foreign body airway obstruction,and an injury to the spinal cord that disrupts the ___,which inner ate the diaphragm
Phrenic nerves
The active , muscular part of breathing is called
Inhalation
When a person inhales , the diaphragm and ___ muscles contract,allowing air to enter the body and travel to the lungs. When it contracts, the diaphragm moves down slightly, enlarging the ___ from top to bottom.
Intercostal muscles
Thoracic cage
The lungs have no muscle tissue; therefore, they cannot move on their own. They need the help of other structures to be able to expand and contract during inhalation and exhalation. Therefore, the ability of the lungs to function properly is dependent on the movement of the chest and supporting structures. These structures include the__. Accessory muscles are secondary muscles of respiration
thorax, the thoracic cage (chest), the diaphragm, the intercostal muscles, and the accessory muscles of breathing
Is the term used to describe the amount of gas in air or dissolved in fluid such as blood.
Partial pressure
The partial pressure of oxygen in air (Pao2) within the alveoli is ___ mm Hg. The carbo dioxide (CO2) enters the alveoli from the blood and causes a partial pressure of __mm Hg
104
40
The air pressure outside the body, called the ___ is normally higher than the air pressure within the thorax
Atmospheric pressure
The entire process of inspiration is focused on delivering oxygen to the alveoli. However, not all of the air you breathe actually reaches the alveoli.
The average__, the amount of air in milliters (mL) moved into or out of the lung during a single breath, for an average adult man is approximately 500 mL Breathing becomes deeper as the ___responds to the increased metabolic demand for oxygen. However, as noted previously, not all inspired air reaches the alveoli for gas exchange. Dead space is described as the portion of inspired air that fails to reach the alveoli and deliver oxygen
Tidal volume
The amount of air (in ML) that is moved into or out of the lungs during one breath
Tidal volume
The air that remains in the lungs after maximal expiration
Residual volume
The volume of air moved through the lungs in 1 minute minus the dead space;calculated by multiplying tidal volume (minus dead space) and respiratory rate
Alveolar minute volume
The amount of air that can be forcibly expelled from the lungs after breathing in as deeply as possible
Vital capacity
The portion of the tidal volume that does not reach alveoli and thus does not participate in gas exchange
Dead space
Unlike inhalation, exhalation does not normally require muscular effort; therefore, it is a ___ process
Passive
When the size of the thoracic cage decreases, air in the lungs is compressed into a smaller space. The air pressure within the thorax then becomes ___ than the outside pressure, and the air is pushed out through the trachea
Outside
The body’s need for oxygen is constantly changing. The respiratory system must be able to accommodate the changes in oxygen demand by altering the rate and depth of ventilation. The regulation of ventilation involves a complex series of receptors and feedback loops that sense gas concentrations in the body fluids and send messages to the respiratory centers in the brain to adjust the rate and depth of ventilation accordingly. Failure to meet the body’s needs for oxygen may result in____.____ is an extremely dangerous condition in which the tissues and cells of the body do not get enough oxygen ____ can be fatal if not promptly recognized and corrected
Hypoxia
For most people, the drive to breathe is based on pH changes (related to carbon dioxide levels) in the blood and___. When carbon dioxide levels in the blood increase, the pH of the___ decreases. When this occurs, a message is sent to the respiratory centers in the brain, which stimulates breathing.
cerebrospinal fluid (CSF)
However, patients with a chronic obstructive pulmonary disease (COPD), such as emphysema or chronic bronchitis, have difficulty eliminating carbon dioxide through exhalation; thus, they always have higher levels of carbon dioxide. This condition potentially alters their respiratory drive. The theory is that the respiratory centers in the brain gradually adjust to accommodate high levels of carbon dioxide. In patients with COPD, the body uses a backup system to control breathing. This theory of secondary control of breathing, called___, is based on levels of oxygen dissolved in plasma. This method is different from the primary control of breathing that uses carbon dioxide as the driving force. __is typically found in end stage COPD. Providing high concentrations of oxygen over time will increase the amount of oxygen dissolved in plasma. Some believe this could potentially negatively affect the body’s drive to breathe.
hypoxic drive
Early signs of hypoxia include
Restlessness,irritability,apprehension,fast heart rate (tachycardia),and anxiety.
Late signs of hypoxia
Mental status changes, a weak(thready) pulse, and cyanosis.
Although the terms hypoxemia and hypoxia are often used interchangeably, they are, in fact, separate processes.___ is a low level of oxygen in arterial blood, whereas ___ is a low level of oxygen at the cellular level. Uncorrected hypoxemia will lead to hypoxia
Hypoxemia
Hypoxia
Adequate ___ is required for internal respiration to occur; however it does not guarantee___ is taking place.
internal respiration
Ventilation without adequate oxygenation also occurs in climbers who ascend too quickly to an altitude of lower___. At high altitudes, the percentage of oxygen remains the same, but the lower___ makes it difficult to adequately bring sufficient amounts of oxygen into the body.
atmospheric pressure
Oxygenation can be disrupted through carbon monoxide poisoning. Carbon monoxide has a much greater affinity for hemoglobin than oxygen (____times more); in other words, carbon monoxide binds to hemoglobin more readily than oxygen. If oxygen cannot bind to hemoglobin, it cannot be transported to the tissues and cells as efficiently.
250 times more
Cells take energy from nutrients through a series of chemical processes. The name given to these processes is __ or cellular respiration
Metabolism
During metabolism, each cell combines nutrients (such as sugar) and oxygen and produces energy (in the form of___) and waste products, primarily water and carbon dioxide. Each cell in the body requires a continuous supply of oxygen and a regular means of disposing of waste (carbon dioxide). The body provides for these requirements through respiration.
adenosine triphosphate
___is the process of exchanging oxygen and carbon dioxide. This exchange occurs by diffusion, a process in which a gas moves from an area of greater concentration to an area of lower concentration. In the body, gases diffuse rapidly across a distance of micrometers.
Respiration
____(pulmonary respiration) is the process of breathing fresh air into the respiratory system and exchanging oxygen and carbon dioxide between the alveoli and the blood in the pulmonary capillaries
External respiration
Fresh air that is inspired into the lungs contains approximately 21% oxygen, 78% nitrogen, and 0.3% carbon dioxide. As this air reaches the alveoli, it comes in contact with a fluid called__. ___ reduces surface tension within the alveoli and keeps them expanded, making it easier for the gas exchange between oxygen and carbon dioxide to occur. It is important to remember that although adequate ventilation is necessary for external respiration to occur, it does not guarantee that external respiration is being achieved.
surfactant
The exchange of oxygen and carbon dioxide between the systemic circulatory system and the cells of the body is called____. As blood travels through the body, it supplies oxygen and nutrients to tissues and cells. Oxygen passes from the blood in the capillaries to the cells in the body’s tissues. At the same time, carbon dioxide and cell waste pass from the cells into the capillaries, where they are transported in the venous system back to the lungs
internal respiration
Cells need a constant supply of oxygen to survive. Some cells may be severely or permanently damaged after to without oxygen
4 to 6 minutes
Cells after _ minutes without oxygen is irreversible brain damage
10 minutes
Chemical factors are commonly involved in respiratory control issues because of the level of complexity of the human body.
A complex series of chemical reactions are constantly taking place. For example,____ monitor the levels of oxygen, carbon dioxide, hydrogen ion concentration, and the pH of the CSF and then provide feedback to the respiratory centers to modify the rate and depth of breathing based on the body’s needs at any given time.
chemoreceptors
___in the medulla respond quickly to slight elevations in carbon dioxide level or a decrease in the pH of the CSF. The___, located in the carotid arteries and the aortic arch, are sensitive to decreased levels of oxygen in arterial blood as well as to low pH levels.
Central chemoreceptors
peripheral chemoreceptors
When serum carbon dioxide or hydrogen ion levels increase because of medical or traumatic conditions involving the respiratory system.___ stimulate the medulla to increase the respiratory rate, thus removing more carbon dioxide or acid from the body. One area in the medulla is responsible for initiating inspiration based on the information received from the____. Another area in the medulla is primarily responsible for motor control of the inspiratory and expiratory muscles
In addition, stimulation from the pons affects the rate and depth of respirations. If one item in this process is disrupted,
then the respiratory process will be affected
chemoreceptors
The lung has a functional role of placing ambient air in proximity to circulating blood to permit gas exchange by simple diffusion. To accomplish this action, air and blood flow must be directed to the same place at the same time. In other words,___ (air flow. V) and____ (blood flow, Q) must be matched. A failure to match ventilation and perfusion lies behind most abnormalities in oxygen and carbon dioxide exchange.
ventilation and perfusion
Medications that depress the central nervous system lower the respiratory rate and tidal volume. This lower rate and volume will decrease minute volume as well as alveolar volume. As a result, the amount of oxygen in the blood decreases and the amount of carbon dioxide in the bloodstream increases, a condition called____.
Hypercarbia
You should be aware that a patient may appear to be breathing after his or her heart has stopped. These occasional gasping breaths are called
Agonal gasps
__are an irregular respiratory pattern in which the patient breathes with an increasing rate and depth of respirations that is followed by a period of apnea, or lack of spontaneous breathing, followed again by a pattern of increasing rate and depth of respiration. Serious head injuries may also cause changes in the normal respiratory rate and pattern of breathing. The result may be irregular, ineffective respirations that may or may not have an identifiable pattern (ataxic respirations).
Cheyne-Stokes respirations
Patients experiencing a metabolic or toxic disorder may display other abnormal respiratory patterns such as___.___ are characterized as deep, rapid respirations commonly seen in patients with metabolic acidosis.
Kussmaul respirations
__is the measure of the maximal concentration of coz at the end of an exhaled breath. A low co2 level could indicate a number of conditions. If the patient is hyperventilating, he or she is eliminating carbon dioxide faster than the body is making it; this would cause a low co2 level. A low co2 level could also indicate decreased co2 return to the lungs because of reduced co2 production at the cellular level secondary to conditions such as shock and cardiac arrest. When cardiac output increases,____ levels generally increase— a reflection of improved oxygen delivery. By contrast, a high co2 level may indicate that the patient is retaining co2 secondary to ventilation inadequacy. An absence of co2 can indicate that the patient is not breathing at all.
End-tidal co2
End-tidal cop is measured by using capnometry and capnography devices.___ typically refers to use of a device that provides a digital numeric reading of the end-tidal coz level.___ provides both a numeric reading and a graph, or real-time image, of the end-tidal coz levels from breath to breath.
Capnometry
capnography
The digital display of end-tidal coz is expressed in millimeters of mercury (mm Hg) (FIGURE 11-17). The normal range is
35 to 45 mm Hg
Without adequate oxygen the cells do not completely convert glucose into energy, and lactic acid and other toxins accumulate in the cell. This process__, cannot meet the metabolic demands of the cell
Anaerobic metabolism
Waveform capnography can be monitored in spontaneously breathing patients with an adequate airway by applying a special___ device to the patient and connecting the sampling line to the cardiac monitor (FIGURE 11-18). If an advanced airway device is in place (ie, endotracheal tube, supraglottic airway), an inline adapter is placed between the advanced airway device and the ventilation device. The sampling line is then connected to the cardiac monitor
nasal cannula
A fixed suctioning unit should generate a vacuum of more than __ when the tubing is clamped
300 mm hg
A __ is a hollow cylindrical device that is used to remove fluids from the patients airway. A tonsil tip catheter is the best type of catheter for infants and children
Suction catheter
Nonrigid plastic catheters, sometimes called__ or whistle-tip catheters, are used to suction the nose and thin secretions in the back of the mouth and in situations in which you cannot use a rigid catheter, such as for a patient with a stoma (FIGURE 11-29). A stoma is an opening through the skin that goes into an organ or other structure.
French
An oropharyngeal (oral) airway has two principal purposes. The first is to keep the tongue from blocking the upper airway. The second is to make it easier to__ the oropharynx if necessary.___ is possible through an opening down the center or along either side of the oropharyngeal airway
Suctioning
Indications for the oral airway include the following:
• Unresponsive patients without a gag reflex (breathing or apneic)
• Any apneic patient being ventilated with a bag-mask device Contraindications for the oral airway include the following:
• Conscious patients
• Any patient (conscious or unconscious) who has an intact gag reflex
Is a protective reflex mechanism that prevents food and other particles from entering the airway
Gag reflex
You must clearly understand when and how this device is used. If the oropharyngeal airway is too large, it could actually push the tongue back into the__, blocking the airway. Conversely, an oral airway that is too small could block the airway directly, just like any foreign body obstruction. The following steps should be used when inserting an oropharyngeal airway
pharynx
A___ airway is usually used with an unresponsive patient or a patient with an altered level of consciousness who has an intact gag reflex and is not able to maintain his or her airway spontaneously
nasopharyngeal (nasal)
Indications for the nasopharyngeal airway include the following:
• Semiconscious or unconscious patients with an intact gag reflex
• Patients who otherwise will not tolerate an oropharyngeal airway
Contraindications for the nasopharyngeal airway include the following:
• Severe head injury with blood draining from the nose
• History of fractured nasal bone
The____ is used to help maintain a clear airway in an unconscious patient who is not injured and is breathing on his or her own with a normal respiratory rate and adequate tidal volume (depth of breathing)
recovery position
For patients who have resumed spontaneous breathing after being resuscitated, the___ position will prevent the aspiration of vomitus. However, this position is not appropriate for patients with suspected spinal, hip, or pelvic injuries or for patients who are unconscious and require ventilatory assistance.
recovery
Always give supplemental oxygen to patients who are___ because not enough oxygen is being supplied to the tissues and cells of the body. Some tissues and organs, such as the heart, central nervous system, lungs, kidneys, and liver, need a constant supply of oxygen to function normally. Never withhold oxygen from any patient who might benefit from it, especially if you must assist ventilations. When ventilating any patient in cardiac or respiratory arrest, use high-concentration supplemental oxygen.
hypoxic
Generally,aluminum cylinders are tested every _years; composite cylinders are tested every _years
5years
3years
Oxygen cylinders are available in several sizes. The two sizes that you will most often use__ (FIGURE 11-34).
the D (or jumbo D) and M cylinders
___cylinder can be carried from your unit to the patient.
The D (or jumbo D)
remains on board your unit as a main supply tank. Other sizes that you will see are A, E, G, H, and K (TABLE 11-4).
Another naming system for identifying the size of the oxygen cylinder has been introduced. Per this naming convention, cylinders are labeled with M (for medical), followed by a number.
The M tank
Oxygen cylinder sizes carried in the ambulance
D
Jumbo D
E
M(MM)
G
H,A(M4),K
Volume ,Liters
350
500
625
3,000
5,300
6,900
The compressed gas industry has established a __for portable cylinders to prevent an oxygen regulator from being connected to a carbon dioxide cylinder, a carbon dioxide regulator from being connected to an oxygen cylinder, and so on. In preparing to administer oxygen, always check to be sure that the pinholes on the cylinder exactly match the corresponding pins on the regulator.
pin-indexing system
The ___features a series of pins on a yoke that must be matched with the holes on the valve stem of the gas cylinder. The arrangement of the pins and holes varies for different gases according to accepted national standards (FIGURE 11-35). Other gases that are supplied in portable cylinders, such as acetylene, carbon dioxide, and nitrogen, use regulators and flowmeters that are similar to those used with oxygen. Each cylinder of a specific gas type has a given pattern and a given number of pins. These safety measures make it impossible for you to attach a cylinder of nitrous oxide to an oxygen regulator. The oxygen regulator will not fit.
pin-indexing system
The pressure of the gas in a full oxygen cylinder is approximately___. This is far too much pressure to be safe for patient use. Pressure regulators reduce the pressure to a more useful range, usually 40 to 70 psi. Most pressure regulators currently in use reduce the pressure in a single stage, although multistage regulators exist. A two-stage regulator will reduce the pressure first to 700 psi and then to 40 to 70 psi.
2,000 psi
Recent research has shown that although the administration of oxygen benefits many patients and is rarely problematic,high concentrations of oxygen are potentially harmful for a select population. __ refers to damage to cellular tissue due to excessive oxygen levels in the blood
Oxygen toxicity
What is the flow rate and oxygen delivered for a nasal cannula
1 to 6L/min
24% to 44%
What is the flow rate and oxygen delivered for a nonrebreathing mask with reservoir
10 to 15L/min
Up to 90%
What is the flow rate and oxygen delivered for a bag mask device with reservoir
15L/min
Nearly 100%
The___ is used to administer high concentrations of oxygen to significantly hypoxemic patients who are otherwise breathing adequately. With a good mask-to-face seal and a flow rate of 15 L/min, the___ is capable of providing up to 90% inspired oxygen.
The____ is a combination mask and reservoir bag system. Oxygen fills a reservoir bag that is attached to the mask by a one-way valve. The system is called a __ because the exhaled gas escapes through flapper valve ports at the cheek areas of the mask (FIGURE 11-39). These valves prevent the patient from rebreathing exhaled gases, namely carbon dioxide.
nonrebreathing mask
A ___ delivers oxygen through two small, tubelike prongs that fit into the patient’s nostrils (FIGURE 11-40). This device can provide 24% to 44% inspired oxygen when the flowmeter is set at 1 to 6 L/min. For the comfort of your patient, flow rates above 6 L/min are not recommended with the nasal cannula, Typically, the__ is used in patients with mild hypoxemia.
nasal cannula
The__ delivers dry oxygen directly into the nostrils, which, over prolonged periods, can cause dryness or irritate the mucous membrane lining of the nose. Therefore, when you anticipate a long transport time, consider the use of humidification. Remember that humidification may be associated with an increased generation of aerosolized droplets of fluid that may increase the degree to which the patient can transmit disease to other people in the same ambulance compartment.
nasal cannula
Use a nonrebreathing mask if the patient is significantly
Hypoxemic
The____ mask is similar to a nonrebreathing mask except that there is no one-way valve between the mask and the reservoir. Consequently, patients rebreathe a small amount of their exhaled air. This has some benefit when you want to increase the patient’s Paco, which makes this the ideal mask for patients whom you think are experiencing hyperventilation syndrome. The oxygen enriches the air mixture and delivers a gas mix of approximately 80% to 90% oxygen. You can easily convert a nonrebreathing mask to a __mask by removing the one-way valve between the mask and the reservoir bag
partial rebreathing
A _has a number of attachments that enable you to vary the percentage of oxygen delivered to the patient while a constant flow is maintained from the regulator (FIGURE 11-41). This is accomplished by the Venturi principle, which causes air to be drawn into the flow of oxygen as it passes a hole in the line. The__ is a medium-flow device that delivers 24% to 40% oxygen. depending on the manufacturer.
Venturi mask
The main advantage of the ___ mask is the use of its fine adjustment capabilities in the long term management of physiologically stable patients
Venturi mask
Patients with__ do not breathe through their mouth and nose. A face mask or nasal cannula therefore cannot be used to treat them. Masks designed specifically for these patients cover the tracheostomy hole and have a strap that goes around the neck. These masks are usually available in intensive care units, where many patients have___, and may not be available in an emergency setting If you do not have a tracheostomy mask, you can improvise by placing a face mask over the stoma. Even though the mask is shaped to fit the face, you can usually get an adequate fit over the patient’s neck by adjusting the strap
tracheostomies
Giving__ is preferred with long transport times although it increases the aerosolization of droplets and may increase the risk of disease transmission to others in the same ambulance compartment as the patient.
humidified oxygen
___ oxygen is usually indicated only for long term oxygen therapy.
Humidified oxygen
Keep in mind that fast, shallow breathing can be just as dangerous as very slow breathing. Fast, shallow breathing moves air primarily in the larger__ and does not allow for adequate exchange of air and carbon dioxide in the alveoli. Patients with inadequate breathing require assisted ventilations with some form of __ventilation. Remember to follow standard precautions as needed when managing the patient’s airway.
airway passages (dead air space)
positive-pressure ventilation
However, when positive-pressure ventilation is initiated, more air is needed to achieve the same oxygenation and ventilatory effects of normal breathing. This increase in airway wall pressure causes the walls of the chest cavity to push out of their normal anatomic shape. As a result, there is an increase in the overall intrathoracic pressure. This pressure increase affects the return of venous blood to the heart. Considering that the left side of the heart receives only what the right side gives it, reduced venous return would result in reduced___. Therefore, it is imperative that you regulate the rate and volume of artificial ventilations to help prevent this drop in ___.___ is a function of stroke volume and heart rate, such that____ = stroke volume × heart rate. Stroke volume is the amount of blood ejected by the ventricle in one cardiac cycle. The heart rate is assessed by taking the pulse for 1 minute. The___ is the amount of blood ejected by the left ventricle in 1 minute.
cardiac output
Ventilation rates “for apneic patients with a pulse”
Adult
Child
Infant
1 breath every 6 seconds
1 breath every 2 to 3 seconds
1 breath every 2 to 3 seconds
The __ device provides less tidal volume than mouth to mask ventilation;however , it delivers a higher concentration of oxygen
Bag mask device
The total volume in the bag of an
Adult
Pediatric
Infant
1,200 to 1,600 ml
500 to 700 ml
150 to 240 ml
A condition in which air fills the stomach,often as a result of high volume and pressure during artificial ventilation
Gastric distention
During cardiac arrest, you are responsible for providing high-quality chest compressions to circulate blood and artificial ventilations to oxygenate the hemoglobin. Because movement of the chest wall has been shown to assist in the ventilation process, patients receiving chest compressions benefit from a process known as__
passive ventilation.
This is sometimes also called passive oxygenation or apneic oxygenation. In___, air movement into and out of the chest cavity occurs passively as a result of compressing the chest. When the chest is compressed, air is forced out of the thorax. As the chest recoils following compression, a negative pressure is created within the chest, which results in a vacuum. This leads to air being sucked into the chest cavity, similar to what occurs with muscle contraction
passive ventilation
Prior to and during placement of an endotracheal tube (a procedure performed by ALS providers), consider applying a nasal cannula and setting the flow rate at 15 L/min. This initiates the processes of preoxygenation and___.___ attempts to replace alveolar nitrogen with oxygen; the goal is to increase oxygen reserve in the lungs,
Denitrogenation
Indications that artificial ventilation is adequate with ventilations delivered at the appropriate rate
10 breaths/min for adults **
20 to 30 breaths/min for infants **and children
In patients with ongoing cpr with an advanced airway in place (intubation) , 1 breath every 6 seconds
***in apneic patients with a pulse
__is the ability of the alveoli to expand when air is drawn in during inhalation. Poor lung__ is the inability of the alveoli to fully expand during inhalation. When ventilating a patient, you would recognize this by noting an increase in resistance when you attempt to ventilate.
Compliance
A ventilation device attached to a control
box that allows the variables of ventilation
to be set. It frees the EMT to perform other tasks while the patient is being ventilated.
Automatic transport ventilator
__ increases pressure in the lungs, opens collapsed alveoli and prevents further alveolar collapse (atelectasis), pushes more oxygen across the alveolar membrane, and forces interstitial fluid back into the pulmonary circulation.
The desired effect of__ is to improve pulmonary compliance and make spontaneous ventilation easier for the patient.
CPAP
some __ units can empty a D cylinder in as little as 5 to 10 minutes.
CPAP
The CPAP device is fitted with a pressure relief valve that determines the amount of pressure the patient must breathe against and overcome, referred to as___. The __ setting typically ranges between 5 and 20 cm H20. As the patient breathes against this pressure, positive pressure is redirected to the lower airway. Therefore, patients benefit the most from CPAP during exhalation rather than inhalation. The effect of CPAP is similar to hanging your head out the window while driving on the highway. In order to exhale, you must first overcome the high inspiratory flow created by the fast-moving air. Although this may appear to require a great deal of effort on the part of a patient who is already in distress, many patients improve dramatically when CAP is applied.
expiratory positive airway pressure (EPAP)
Because__ increases pressure inside the chest, it reduces the amount of blood flow returning to the heart. As the pressure in the thorax increases, the venous flow of blood returning to the heart meets the resistance of the increased pressure in the chest. The result is a decrease in the workload of the heart and a drop in cardiac output.
This is not common with lower levels of __; however, caution should be used when considering ___ in patients with low blood pressure. Continually monitor blood pressure in patients receiving __ treatment.
CPAP
The following are general indications for using CPAP:
• Patient is alert and able to follow commands.
• Patient is displaying obvious signs of moderate to severe respiratory distress (eg, accessory muscle use, tripod position, retractions) from an underlying pathology, such as pulmonary edema or obstructive pulmonary disease (ie, COPD), or bronchospasm.
• Respiratory distress occurs after a submersion incident.
• Patient is breathing so rapidly that it affects overall minute volume.
• Pulse oximetry reading is less than 90%.
CPAP has proven to be immensely beneficial to patients experiencing respirátory distress from acute pulmonary edema or COPD; however, there are times when CAP is not appropriate for the patient.
The following are general contraindications for CPAP use:
Patient is in respiratory arrest or has agonal respirations.
• Patient is hypoventilating (slow respiratory rate and/or reduced tidal volume).
• Patient cannot speak.
• Patient is unresponsive or otherwise unable to follow verbal commands.
• Patient cannot protect his or her own airway.
• Patient has hypotension (systolic blood pressure less than 90 mm Hg).
• Signs and symptoms of a pneumothorax or chest trauma are present.
• Patient has a tracheostomy.
• Active gastrointestinal bleeding, nausea, or vomiting is present.
• Patient has experienced facial trauma.
Patient is in cardiogenic shock.
Patient cannot sit upright.
CPAP system mask and strap cannot be properly fit.
Excessive facial hair or dysmorphic facial features can impede your ability to ensure a properly fitting mask.
• Various mask sizes are available for smaller patients.
• Patient cannot tolerate the mask.
A pressure of__ is generally an acceptable therapeutic range for a patient on CPAP.
7.0 to 10.0 cm H20
A TYPICAL(not as little as!,5to10mins), CPAP unit will deplete a full D cylinder of oxygen in__, depending on the fraction of inspired oxygen (FIo2) setting
15 to 30 minutes
Bag mask ventilation may also need to be used for patients who have had a __(surgical removal of the larynx). These patients have a permanent tracheal stoma (an opening in the neck that connects the trachea directly to the skin)
Laryngectomy
A surgical procedure to create an opening (stoma) into the trachea;stoma in the neck connects the trachea directly to the skin
Tracheostomy
Neither the head tilt chin lift nor the jaw thrust maneuver is required for ventilating a patient with a
Stoma
__is the insertion of a tube into the trachea to maintain and protect the airway. The__ can be inserted through the mouth or through the nose. In either case, the __passes directly through the larynx between the vocal cords and then into the trachea. You may also be asked to assist with the placement of other advanced airway. devices.
Endotracheal (ET) intubation
The first step in preparing a patient for El intubation is oxygenation. Good oxygenation often includes bag-mask ventilation (including the use of an oral or nasal airway) and ensuring a proper seal, ventilation rate, volume of ventilation, and time for patient exhalation. Oxygen enters the bloodstream through the process of diffusion. The more oxygen that is available in the alveoli, the longer the patient can maintain adequate gas exchange in the lungs while the intubation procedure is being performed (FIGURE 11-53). This critical phase of the intubation procedure is called___.
preoxygenation
Maintain a high-flow nasal cannula on the patient during the preoxygenation phase and leave the nasal cannula in place during the intubation attempt, during which bag-mask ventilation and chest rise and fall are not possible. This technique, called__, allows for continuous oxygen delivery down the airways during all phases of the intubation procedure.
apheic oxygenation
Equipment sets vary depending on local protocols, provider preference, and whether direct laryngoscopy or video laryngoscopy Will be used. (___is visualization of the vocal cords with a laryngoscope, while__ is visualization of the vocal cords using a video camera and monitor.) These differences emphasize why it is important for team members to train and practice together.
Direct laryngoscopy
video laryngoscopy
While the details of endotracheal intubation may vary depending on available equipment, difficulties encountered, and provider preference, you can remember the six typical steps by using the BE MAGIC mnemonic:
• B Perform Bag-mask preoxygenation.
• E Evaluate for airway difficulties
• M Manipulate the patient.
• A Attempt first-pass intubation,
• GI Use a supraGlottic airway if unable to intubate.
• C Confirm successful intubation/Correct any issues.
