EMER 112 Respiratory Care Flashcards
Proper ventilation is necessary because
provide adequate oxygen to the blood stream and to remove carbon dioxide increasing the amount of available oxygen ensures that even a patient who is not moving adequate volumes of gas (hypoventilation) can still maintain adequate oxygen saturation
negative pressure vacuum effect
the expansion of the chest and downward movement of the diaphragm create negative pressure in the thorax areas pull through the mouth and the nose and is sucked into the trachea
negative pressure vacuum effect occurs because
the thorax is essentially an airtight box with a flexible diaphragm at the bottom and an open tube at the top which air is sucked into and fills the increasing space inside the thorax
sucking chest wound
holes in the thorax provides a place for air to be sucked in
When multiple ribs are broken in more than one place
causing a flail chest free-floating sections of the thorax get pulled in when you breathe limiting the amount of air that can be sucked into the trachea
Retraction
or in drawing of the intercostals in ribs when airflow is restricted by disease processes exhibited by infants and small children
what happens When you ventilate someone with positive pressure
air is forced into the upper airway and flows into both the trachea and esophagus unless steps are taken to help direct it into the trachea
Exhalation is normally a what kind of process
Exhalation is normally a passive process
exhalation is no longer passive process when
When a patient has trouble exhaling they may need to use a domino muscles to push air out when this occurs exhalation is no longer passive process and indicates obstructive disease
Difficulty in inhalation may indicate
upper airway obstruction
Four parts of the brain responsible for
the smooth rhythmic respirations one area helps control rate, another depth, another inspiratory pause, another rhythmicity Most of these respiratory centres are in and around the brain stem
Apneustic breathing
results from damage to the apneustic center in the brain which regulates inspiratory pause A patient exhibiting apneustic respirations will have a short, brisk inhalation with a long pause before exhalation which is indicative of severe pressure within the cranium or direct trauma to the brain
Biot respirations
are seen when the center that controls breathing rhythm is damaged Grossly irregular sometimes with lengthy apneic periods
Cheyne stroke respirations
are a high brain function Deep sleepers and intoxicated peoplewill exhibit this type of respiratory pattern The depth of breathing gradually increases then decreases followed by an apneic period Exaggerated Cheyne stroke respirations may be seen in patients who have a severe brain injury the apneic period may last 30 to 60 secs
Hering-breuer reflex
limits inspiration and may cause coughing if you take too deep a breath
Agonal respirations
irregular gasps that are a few and far between usually represent strain or logical impulses in the dying patient it’s not unusual for patients who are pulseless to have an occasional agonal gasp
Ataxic respirations
completely irregular respirations that indicates severe brain injury or brainstem herniation
Bradypnea
unusually slow respirations
Central neurogenic hyperventilation
rapid and deep respirations caused by increased intercranial pressure or direct Brain Injury drives CO2 levels down and pH levels up resulting in respiratory alkalosis
Hypernea
unusually deep breathing seen in various neurological or chemical disorders certain drugs may stimulate this type of breathing in patients who have overdosed it does not reflect respiratory rate only respiratory depth
Hypopnea
unusually shallow respirations
Kussmaul respirations
the same pattern as central neurogenic hyperventilation but caused by the body’s response to metabolic acidosis the body is trying to rid itself of blood at the tone via the lungs these are seen in patients who have diabetic keto acidosis and are accompanied by a fruity breath odour the mouth and lips are usually cracked and dry
Respiration
is the process by which oxygen is taken into the body distributed to the cells and used by the cells to make energy it takes place in each cell The primary by product of this process is carbon dioxide the respiratory system is involved in the delivery of the oxygen to the blood stream and the removal of waste carbon dioxide from the body
When the lungs are not working adequately carbon dioxide is not efficiently disposed of and accumulates in the blood
this combines with water to form bicarbonate ions and hydrogen ions also known as acid resulting in acidosis
Hyperventilation
the person breathe faster or deeper than normal and blows off more carbon dioxide than usual resulting in alkalosis
Anxiety
can be an early sign of hypoxia while confusion, lethargy and coma or typically later signs
Dizziness and tingling extremities
could signify hyperventilation
Injury high in the spinal cord
may paralyze the intercostal muscles and even the diaphragm resulting in the inability of respiratory muscles to function normally in response to the respiratory drive
Bodies immediate response to hypoxaemia
is to increase the heart rate to deliver a higher volume of blood to tissues to compensate for lower blood oxygen levels
Severe hypoxia often causes
bradycardia
Orthopnea
shortness of breath
Renal status
Fluid balance, acid base balance and blood pressure are controlled by the kidneys Each of these factors also affects of pulmonary mechanics and hence the delivery of oxygen to tissues patients with severe renal disease often present with a respiratory signs and symptoms so you should always note signs of severe renal disease when evaluating the condition of the patient
The classic presentation of a patient with emphysema
(pink puffer) includes a barrel chest, muscle wasting and pursed lip breathing search patients are often tachypneic and do not typically present with profound hypoxia and cyanosis
Patients who have chronic bronchitis tend to be
more stationary and may be obese these patients are often encountered in a chair or recliner they may be surrounded by cups full of mucus, inhalers, several medication’s
A spontaneous pneumothorax tends to occur in
tall, thin young adults and women who smoke and take birth control pills or predisposed to pulmonary embolus
Tripod position
involves leaning forward and rotating the scapula outward by placing the arms on a table or by placing the hands on my knees the stabilizes the shoulder girdle improves efficiency of accessory breathing muscles and decreases the total with a breathing
Purposeful hyperextension
occurs when a patient maximize airflow through the upper airway
Head tilt chin lift or sniffing position
This position may indicate upper airway swelling but is also commonly seen in patients who are trying to maximize airflow maintaining this position uses a valuable energy
head bobbing
A patient who is severely ill with respiratory disease begins to feel fatigue here she may hold her head up in the sniffing position during inhalation letting it fall during exhalation this head bobbing is very ominous sign signalling potential eminent decompensation
Chest wall retractions
these are most common in infants and small children with a rigid structure of the thorax is still flexible on an elation the child may pull the sternum and ribs into the chest causing a visible deformity with each breath
Soft tissue retractions
in most patients the bones are rigid and do not move but the soft tissue is pulled in around the bones
Tracheal tugging
the thyroid cartilage is pulled upward and the area just above the sternal notch is sucked in word with inhalation
Pyridoxal respiratory movement
the epigastrium is pulled in with inhalation while the abdomen pushes out creating a seesaw appearance as the two move in opposing directions
Pulses paradoxus
profound intrathoracic pressure changes caused the peripheral pulses to weaken on inspiration these pulses are easier to palpate during exhalation
Minute volume
respiratory rate X tidal volume
decline in PAO2
hypoxaemia will manifest initially as restlessness, confusion and in worst case scenario is a combative behaviour
increase in PaCO2
usually has sedative effects making the patient sleepy
Healthy adults have a haemoglobin level of
120 to 140 g/L
healthy persons will begin to exhibit the blue discolouration of cyanosis one about
50 g/L is desaturated meaning their oxygen saturation would be roughly 65%
Chocolate brown skin:
high levels of methemoglobin derive from nitrates in some toxic exposures may turn the mucous membranes brown This transformation is typically more evident in the patient’s venous blood then in the skin and mucous membranes
Hepatojugular reflux
occurs when mild pressure in the patient’s liver causes the jugular vein’s to engorge further this is a specific sign of right heart failure When a patient is in respiratory distress and they’re sitting up in a semi Fowler 45° position it is easy to check for hepatojugular reflux
Tracheal deviation is a classic sign of
tension pneumothorax
Tracheal breath sounds
are not commonly auscultated but know how harsh and tubular they sound
bronchial breath sounds
are also quite loud but no the exhalation predominates
peripheral bronchialvascular sounds
are softer and have equal inspiratory and expiratory sides
Sound moves better through
fluid than air
The breath sounds of a patient who has one sided pathological condition will sound
louder over the side with abnormality then they will over the healthy side
Managing patients with dyspnea
Supportive prehospital care, ensure airy adequacy, administer high concentration supplemental oxygen therapy and provide monitoring and transport for patients Treatment of bronchoconstriction with bronchodilators
Rehydration
is supplemental therapy for patients with respiratory problems who are dehydrated Always assess breath sounds before an after giving a fluid bolus to make certain you do not have volume overload
circulation potential common signs of anaphylaxis
Tachycardia, hypertension and shock
IV access anaphylaxis
IV access is important because the anaphylactic patient will need fluid replacement anaphylaxis causes leakage of fluid into tissues necessitating administration of large amounts of IV fluid
Puritis
itching
what does epinephrine do for anaphylaxis
vasoconstriction, improvement of cardiac contractility, bronchodilation and suspension of the release of histamine
If the patient is on a beta blocker and needs epilepsy
they may not be a good response Epnephrine so give glucagon
Tracheobronchial suctioning
Involves passing a suction catheter into the tracheal tube to remove pulmonary secretionsMonitor patient’s cardiac rhythm and oxygen saturation during the procedure
what can Tracheobronchial suctioning cause
cause cardiac dysrhythmias
Follow these steps for performing tracheobronchial suctioning as an in-line suction device:
Use routine precautions and wear PPE Check prepare and assemble your equipment Connect section to the in-line suction catheter Pre-oxygenate the patient Gently advance the in-line suction catheter down the tracheal tube until resistance is felt Action in a rotating motion while withdrawing the catheter into the side arm of the in-line device. Monitor patient’s cardiac rhythm and oxygen saturation during the procedure Resume ventilation and oxygenation
Causes of airway obstructions
the tongue laryngeal edema, laryngeal spasm, trauma and aspiration
Laryngeal spasm
Results in spasmodic closure of the vocal cords completely including the airway it is often caused by trauma during aggressive intubation relieved by positive pressure ventilation using a bag mask
Laryngeal edema
causes the glottic opening to become extremely narrow or totally close conditions that commonly causes problems include laryngeal trauma, epiglottis, anaphylaxis or inhalation injury relieved by positive pressure ventilation using a bag mask
Laryngeal injury
Airway patency depends on good muscle tone to keep the trachea open Fracture of the larynx increases airway resistance by decreasing airway size secondary to decreased muscle tone, laryngeal oedema and Ventilatory effort
Emergency medical care for foreign body airway obstruction
Manage any unresponsive person as if he or she has a compromised airway open and maintain the airway with appropriate manual maneuver assessed for breathing and provide artificial ventilation if necessary If after opening the airway you are unable to ventilate the patient will you feel resistance when ventilating re-open the airway and attempt to ventilate the patient
lung compliance
is the ability of the alveoli to expand when air is drawn into the lungs either during negative pressure ventilation or positive pressure ventilation poor lung compliance is characterized by increased resistance during ventilation attempts
If the response of patient with a severe airy obstruction becomes unresponsive
carefully position him or her supine on the ground and begin chest compressions perform 30 chest compressions and then open the airway and look in the mouth attempt to remove foreign body if you can see it
Surgical and nonsurgical cricothyrotomy
Two methods of securing a patient’s airway can be used when conventional techniques and methods fail the open surgical cric and Translaryngeal catheter ventilation nonsurgical or needle cric
Open cricothyrotomy
Involves opening the cricothyroid membrane with a scalpel and inserting a tracheal tube directly into the subglottic area of the trachea The open cric involves incising the patients skin and cricthyroid membrane and inserting a tracheal tube
Indications of open cric
Indicated only when you were unable to secure a patient’s airway with a more conventional mean and are unable to oxygenated ventilate the patient it is the last resort indications that may preclude conventional airway management include severe foreign body upper airway obstruction that cannot be extracted and direct laryngoscopy airway, obstruction from swelling, facial trauma and the ability to open the patient’s mouth
contraindications of open cric
the ability to secure a patent airway by less invasive means or lack of familiarity training to perform a cric Other contraindications include in ability to identify the correct anatomical landmarks, crushing injury to the larynx and trachea transection, you’re lying anatomical abnormalities and age younger than eight years
Advantages and disadvantages
Can be performed quickly and is easier than a tracheostomy Be performed without manipulating the cervical spine disdvantages include difficulty in performing the procedure and children and patients with short muscular or fat necks more difficult to perform than a needle cricothyrotomy
open cric complications
Bleeding is usually the result of inadvertent laceration of the external jugular vein After the incision has been made gently insert the tube will minimize the risk of perforating the esophagus or damaging the laryngeal nerves In too long results and hypoxia Expect to miss placement when subcutaneous emphysema is encountered after performing a cric
Subcutaneous emphysema
occurs when air infiltrates the subcutaneous layers of the skin and is characterized by crackling sensation when palpated
Technique for performing open cricothyrotomy
Identify the cricothyroid membrane by palpating the V notch of the thyroid cartilage which feels like a high sharp bump Stabilize the larynx between your thumb and middle finger while you palpate with your index finger slide your index finger down into the depression between the thyroid and cricoid cartilage While stabilizing the larynx with one hand make a 1 to 2 cm vertical incision over the cricothyroid membrane in bariatric patients the vertical incision may need to be longer and deeper Puncture the cricothyroid membrane and make a horizontal incision approximately 1 cm in each direction from the midline insert the scalpel handle into the opening and rotate Insert a tube into the trachea Manually stabilize the trachea tube with your thumb and index finger carefully remove the stylet and inflate the distal cuff Attach the bag mask device in ventilate Confirm correct to placement by attaching ET CO2
Needle Cricothyrotomy
Also uses the cricothyroid membrane as an entry pointed to the airway A 14 to 16 gauge over the needle IV catheter is inserted through the cricothyroid membrane and into the trachea Oxygen is achieved by attaching a high-pressure jet ventilator to help with the catheter Translaryngeal catheter ventilation is commonly used as a temporary measure to oxygenate a patient until more definitive airway can be obtained
needle cric indications
inability to ventilate the patient by less invasive techniques only when you were unable to secure a patent airway with more conventional means complete foreign body airway obstruction that cannot be extracted with forceps and direct laryngoscopy, airway obstruction from swelling, massive facial trauma, inability to open the patient’s mouth uncontrolled oropharyngeal bleeding
needle cric contraindications
in patients who have severe airway obstruction above the site of catheter insertion Only oxygenate the patient do not adequately ventilated as a result patients PaCO2 and ET CO2 levels will rise quickly
what does The high pressure ventilator used with needle cricothyrotomy do
increases intrathoracic pressure possibly resulting in barotrauma and risk for pneumothorax
Barotrauma
can be caused by over inflation of the lungs with the jet ventilator so care must be taken to open the release valve only until the patient’s chest adequately rises
Advantages of neeedle cric
Faster and easier to perform and is associated with lower risk of causing damage to adjacent structures Allows for subsequent intubation attempts because they use a small bore catheter allowing a tracheal tube to easily pass beside it
Disadvantages of needle cric
include using a small bore tube to ventilate the patient does not provide protection from aspiration as a tracheal tube would Requires specialized high-pressure jet ventilator to deliver adequate tidal volume
Complications of needle cric
improper catheter placement can result in severe bleeding secondary to damage of adjacent structures Excessive air leakage around the insertion site can cause subcutaneous emphysema especially if the patient has undetected laryngeal trauma
ventilating a patient with a jet ventilator
Extreme care must be exercise when ventilating a patient with a jet ventilator the release valve should be open just long enough for the adequate chest rise took her over inflation of the lungs can result in barotrauma which carries the risk of pneumothorax conversely opening the release valve for two short period of time can cause hypoventilation resulting in adequate oxygenation and ventilation
Technique for performing needle cricothyrotomy
Draw up approximately 3 mL of sterile water or saline into a 10 mL syringe and attach to the IV catheter Place the patient had in a neutral position and locate the cricothyroid membrane While you are stabilizing the patience lyrics carefully insert the needle into the midline of the membrane at a 45° angle toward the feet you should feel a pop After the pop is felt insert approximately 1 cm further and then aspirate the syringe if the catheter has been correctly place you should be able to easily aspirate air and see bubbling in the syringe if blood is aspirated you should reevaluate Attach one end of the oxygen tubing to the catheter in another end to the jet ventilator begin ventilation and observed adequate chest rise Auscultation of breath and epigastric sounds will confirm correct placement Secure the catheter by placing a folded gods pad under the catheter and taping it in place continue ventilation and reassess
Advanced Airway Management 2 reasons
Not a substitute for basic techniques and maneuvers 1. Failure to maintain a patent airway 2. Failure to adequately oxygenate and ventilate
MOANS
M mask seal: problems getting a good seal with the mask O obese: obese people are difficult to bag mask ventilate because of their increased body weight A aged- older people tend to be difficult to bag mask ventilate due to loss of connective tissue and bony structure on their face N no teeth: forming a good seal with the mask is difficult in edentulous patients S stiff lungs: patients underlying lung disease require higher pressures to ventilate and this may be difficult to do with bag mask ventilation
LEMON
L look: look externally for obvious anatomic deformities E Evaluate the 3-3-2 rule: the width from the front of the chin to the hyoid bone should be at least three fingerbreaths wide, the width of the patients mouth opening should be at least three fingerbreadths wide, and the distance from the mandible to the thyroid bones should be at least two fingerbreaths wide M Mallampati classification: oral access is assessed using the Mallampati classification O obstruction: you can anticipate a difficult intubation if there is obstruction in the airway such as epiglottis, neck injury, tumor N neck mobility: if a patient has limited neck mobility
Cormack- Lehane Classification
Has applicability in an emergent setting because it classifies views obtained by direct laryngoscopy based on the structures seen prior to inbutbation
Tracheal Intubation
passing a tracheal tube through the glottic opening and sealing the tube with a cuff inflated against the tracheal wall
Orotracheal intubation
when the tube is passed into the trachea through the mouth
Nasotracheal intubation
when the tube is passed into the trachea through the nose
indications of tracheal intubation
present or impending respiratory failure, apnea, inability of the patient to protect on airway, control of ventilation
contraindications for tracheal intubation
none in emergency situations however with inexperienced personnel other advanced airways may be easier
advantages/ disadvantages of tracheal intubation
advantages: provides a secure airway, protects against aspiration, provides an alternate route to IV/IO for certain medications disadvantages: special equipment required; physiological functions of the upper airway bypassed
complications of tracheal intubation
bleeding, hypoxia, laryngeal swelling, laryngospasm, vocal cord damage, mucosal necrosis, barotrauma, dental injury, inadvertent tube displacement
The basic structure of tracheal tube
includes the proximal end, the tube, the cuff and pilot balloon and distal tipSizes range from 5 to 9 mm
Murphy eye
the opening of the bevelled tip on the distal end of the tube to facilitate insertion It enables ventilation to occur even if the tip becomes included by blood, mucus, or tracheal wall
A tube that is too small for a patient will lead toa tube that is too large can
A tube that is too small for a patient will lead to an increase resistance to airflow and difficulty in ventilating a tube that is too large can be difficult to insert it may cause trauma
tracheal tube sizes
An adult woman will require a 7-8 mm tube while an adult man will require a 7.5 to 8.5 mm tube
good approximation of the diameter of the glottic opening
The internal diameter of the nostrils
Straight miller blade
Design so that the tip will extend beneath the epiglottis and lift it up particularly useful in infants
Curved macintosh blade
less likely to be levelled against the teeth by an inexperienced paramedic and is usually preferred by beginners the blade follows the outline of the pharynx the tip of the curved blade is placed in the valley Kula rather than beneath the epiglottis It directly lifts the epiglottis to expose the vocal cords
Blade sizes
range from 0 to 4 size 012 are appropriate for infants and children three and four are adult sizes
Stylet
a semi rigid wire that is inserted in the tracheal tube to mound and maintain the shape of the tube enables you to guide the tip of the tube over the arts annoyed cartilage even if you can’t see the entire glottic opening It should be lubricated and the end should be formed like a hockey stick curve
Magill forceps 2 uses
first they are used to remove area obstructions under direct visualization second they are used to guide the tip of the tracheal tube through the glottic opening
Orotracheal intubation by direct laryngoscopy
Involves inserting a tracheal tube through the mouth and into the trachea while visualizing the glottic opening with the laryngoscope
Orotracheal intubation indications
airway control needed as a result of coma, respiratory arrest/cardiac arrest, then territory support, absence of gag reflex, Trumatic brain injury, unresponsiveness or impending airway compromise
Orotracheal intubation contraindications
an intact egg reflects, in ability to open the patient’s mouth because of trauma, dislocation of the jar, inability to see the glottic opening, copious secretions or vomitus blood
Orotracheal intubation advantages and disadvantages
Advantages: Direct visualization of anatomy into placement, ideal method for confirming placement, may be performed in breathing or apnoeic patients Disadvantages: require special equipment
Orotracheal intubation Complications
dental trauma, laryngeal trauma, misplacement
Preoxygenation
Adequate preoxygenation with a bag mask device and 100% oxygen is critical step prior to intubating a patient Deoxygenate and apnoeic or hyper ventilating patient for 2 to 3 minutes monitor the SPO2 and she was closest 100% During the intubation attempt deliver high flow oxygen via nasal canula
Positioning the patient
The airway has three axis is the mouth, the pharynx, and the larynx which must all be aligned to visualize the airway This is most effectively achieved by placing the patient in the sniffing position
A bundle of care:
includes preoxygenation, passive high flow oxygen, the sniffling position and head elevation along with delayed sequence intubation agent
Laryngoscope blade insertion
Hold the laryngoscope cope with your left hand as far down the handles possible if the patient’s mouth is not open use the scissor technique or the tongue jaw lift maneuver insert the blade into the right side of the patient’s mouth and then sweep the tongue gently to the left side while moving the blade into the midline —This is a critical step because if you simply insert the blade in the midline the tongue will hang over both sides and all you’ll see is tongue Placed the little finger of your left hand under the patient’s chin to help lift the jaw and prevent levering against the patient’s teeth Slowly advance the blade while sweeping the tongue to the left exert gentle traction at a 45° angle to the floor as you lift the patient straw continue advancing until the epiglottis comes interview
Visualization of the glottic opening
After you identify the epiglottis placed the tip of the curved blade in the valecullar space which is above the epiglottis or the straight blade directly under the epiglottis and lift until you see the glottic opening You should see the vocal cords in the arytenoid cartilage
Bimanual laryngoscopy
if you’re having difficulty seeing the glottic opening take your right hand and manipulate the larynx directly observing after abuse optimize an assistant to maintain the optimum laryngeal position as you insert the tracheal tube
BURP maneuver
during external laryngeal manipulation the intubator plies backward upward rightward pressure to the lower 1/3 of the thyroid cartilage
Bougie
emi flexible device approximately 1 cm in diameter and 60 cm long it is rigid enough that it could be easily directed to the glottic opening but flexible enough that it does not cause damage to the trachea walls It is inserted through the glottic opening under direct laryngoscopy Enables you to feel the ridges of the trachea wall and becomes a guide for the tracheal tube by simply sliding the tracheal tube over it pass the cords and into the proper position
Tracheal tube insertion
After you visualize the glottic opening pick up the preselected tracheal tube in your right hand insert the tube from the right corner the patient’s mouth as you see the two passing the vocal cords rotate the tube to the right and direct the tip of the tracheal tube downward into the trachea Advance the tracheal tube until the proximal end of the cuff is 1 to 2 cm possible chords you must see the tip of the two past to the vocal cords if you cannot see the vocal cords do not insert the tube Do not try and pass the tube down the barrel of the laryngeal scope blade
Ventilation laraygnoscopy
After you have seen the cup of the tracheal to pass approximately 1.5 cm beyond the vocal cords gently remove the blade hold the tube securely and remove the stylet from the tube Inflate the distal cuff with 5 to 10 mL of air Play some in-line capnography monitor If the tube is properly position you were here quite epigastrium and equal breath sounds bilaterally however epigastric sounds may be transmitted to lungs in patients with obesity leading you to believe you have inadvertently intubated the esopha
Bilaterally absent breath sounds after tube placement
are gurgling over the epigastrium when auscultating during ventilation indicates that you have intubated the esophagus rather than the trachea you must remove the tube and be prepared to suction
If copious vomitus is being admitted from the tracheal tub
do not remove it instead inflate the distal calf turn the tube sideways to allow the bombers to be admitted and continue ventilation with bag mask device if vomitus is not being emitted from the tube you can remove it and resume bag ventilation
Breath sounds are heard only on the right side of the chest after tube insertion
the tube has likely been advance to far and entered the right mainstem bronchi us
Follow these steps to reposition the tube
Loosen or move the tube securing device Deflate the distal cuff Place your stethoscope over the left side of the chest Well ventilation continue slowly retract the tube while simultaneously listening for breath sounds over the left side of the chest Stop as soon as bilaterally equal breath sounds are heard Note the depth of the tube at the patient’s teeth Reinflate the distal cuff Secure the tube Resume ventilations –Increased resistance during ventilation’s may indicate gastric distention, oesophageal intubation or tension pneumothorax
Nasotracheal intubation
Insertion of a tube into the trachea through the nose Blind nasotracheal intubation is an excellent technique for establishing control over the airway and situation where does either difficult or hazardous to perform laryngoscopy
Nasotracheal intubation indications
indicated for patients who are breathing spontaneously but require definitive airway management to prevent further deterioration Responsive patients or patients with an altered mental status and with an intact gag reflects who are in respiratory failure secondary to condition such as COPD asthma or pulmonary oedema
Contraindicated Nasotracheal intubation
apnoea patients because they should receive oral tracheal intubation Contraindicated in patients with head trauma and facial fractures and evidence of cerebral spinal fluid drainage from nose Contraindications include anatomic abnormalities, patients with nasal polyps or patients who frequently use cocaine
Advantages and disadvantages of Nasotracheal intubation
primary advantage is that it can be performed to patients who are awake and breathing Another major advantage of needs a tracheal intubation is that there’s no need for laryngoscope which eliminates the risk of trauma to the teeth or soft tissues of the mouth Does not require the patient to be placed in a sniffing position which makes it ideal for spinal injuries Patient cannot bite tube Disadvantage you cannot use one of the major tube confirmation methods
Technique for nasotracheal intubation
The tube is advance as a patient inhales at which point the vocal cords are open at the widest which facilitates placement of tube into trachea Insert the tube into the nostril with the bevel facing toward the nasal septum In the tip of the tube straight back toward the ear the goal is to follow the floor of the nasal cavity until the tube enters the nasal pharynx As a tube is advanced into the nasal pharynx you will begin to hear air rushing in and out of the tube as the patient breaths As the patient inhales the negative pressure created by inhalation facilitates movement of the tube for the glottic opening If you do not see soft tissue bulge and no air is moving through the tube the tube has been entered into the esophagus When the tube has been properly positioned inflate the distal calf with minimal amount of air necessary to achieve airtight seal
Digital intubation
Involves directly palpating the glottic structures and evaluating the epiglottis with your middle finger while guiding the tracheal tube into the trachea by field does not require laryngoscope Most advantageous in cases of equipment failure
Digital intubation indications and contra
only in patients who are deeply unresponsive and apnoeic and who have a bite block in their mouth This technique is absolutely contra indicated if the patient is breathing, it’s not deeply unresponsive or has an intact gag reflex
Obstructive disease
can’t get air out Occurs when the positive pressure of exhalation causes the small airways to pinch shut trapping gas in the alveoli
Signs of obstructive disease
Pursed lip breathing Increased inspiratory to expiratory ratio Abdominal muscle use Jugular venous distention
Asthma Name from Greek work meaning
panting
Asthma is characterized by
an inflammation in the bronchiole airways due to a variety of stimuli. Is a common chronic inflammatory disease of the airways.
Hallmark of Asthma is
Airway Diameter Reduction
key points of asthma
Reversible Must be triggered
normal levels of C02 in blood
35-45mmhg
CPAP rule
must have neb running
HypoxiaHypoxemia
Hypoxia: area of the body that is short of oxygen Hypoxemia: entire body is short of oxygen
Only way to fix Hypoxemia aka low spo2
02 and PEEP
Bronchospasm/ Bronchoconstriction
Caused by the construction of smooth muscle that surrounds the larger bronchi in the lungs When air is forced through the constricted tubes it causes them to vibrate which creates wheezing
The primary treatment of bronchospasm
is the administration of bronchodilator medication ex: Ventolin
3 main symptoms of asthma
bronchoconstrictionmucous productioninflammation
Signs and Symptoms of asthma
SOB Increase Work of Breathing Accessory Muscle use SPO2 abnormalities Adventitious lung sound, especially wheezing Decreased air entry Pallor or cyanosis ETCO2 reveals signs of bronchoconstriction
treatment for asthma
Ventolin(Salbutimol) Atrovent(Ipratropium Bromide) epinephrine
Potentially Fatal Asthma
Severely compromised ventilation all of the time Be alert for silent chest syndrome
Potentially Fatal Asthma Ask if pt:
Previous intubation for respiratory failure or respiratory arrest 2 or more admissions to hospital despite oral corticosteroid use 2 or more episodes of pneumothorax
Status asthmaticus
severe prolonged asthmatic attack that cannot be broken with conventional treatment Patient physically tired: accessory muscle use, cyanosis, chest hyperinflatedA despite treatment already given
when is epinephrine used for asthma
silent lungs
Mild asthma
Can form sentences Lungs: clear -Expiratory wheezes 2.5-5.0mg Ventolin -Contra: tachy arrythmia 250-500mcg Atrovent *won’t do anything after 2 doses (1000mcg)
moderate asthma
Can speak few words at a time, tripod position Inspiratory and expiratory wheezes through all 4 lobes O2 immediately
Severe asthma
Stridor —Upper airways already 50% closed wheezing upper lobes, silent lower lobes 02 5.0/500 Combivent- Atrovent and Ventolin CPAP: must have neb running 0.5mg EPI when you hear Silent chest —Call ALS
Anaphylaxis
Serious allergic reaction that is rapid in onset and may cause death
Risk factors: Anaphylaxis
Predisposition Substance Route and dosage Time between exposure
AllergenAntibody (immunoglobulin)AntigenHypersensitivity
Allergen: antigen Antibody (immunoglobulin): attach to surface of mast cell and Antigen: proteins found on surface of cells Hypersensitivity: results from immune response to antigens
Allergic Reaction vs Anaphylaxis
Allergic Reaction 1 body system Anaphylaxis 2 body systems EPI!!
Sensitization
over production of IgE (antibodies) First exposure Antibodies attach to MAST cells and basophils –Mast cell: part of immune system and fights off stuff Release of chemical mediators
Anaphylaxis Common causes
Drugs Foods and Additives Hymenoptera Stings
Chemical Mediators cause and result in
Causes inflimation, bronchonstriction and mucous These substances result in bronchoconstriction, peripheral vasodilation and increased capillary permeability.
Mediators that are stored include
*histamine, heparin and chemotactic factors. Other mediators are formed during degranulation such as prostaglandins, leukotriene’s, bradykinins and interleukins.
Histamine Receptors H1
Bronchospasm increased peristalsis Vessel dilation Post capillary venule permeability Increases heart rate
Histamine Receptors H2
Gastric acid secretion
Anaphylaxis Presentation initial response
which occurs within the first 30 minutes after exposure and resolves within one hour consists of vasodilation, vascular leakage, and smooth muscle spasm
Anaphylaxis Presentation delayed response
which can occur hours later and last for days consisting of more intense infiltration of tissues with inflammatory cells and more severe symptoms
Anaphylaxis Presentation skin
Urticaria (Hives) Pruritus(itching) Angioedema (Swelling)
Criteria for anaphylaxiss exist when one of the following are met:
- Acute onset symptoms involving hives, flushing, swelling of the mouth and throat, with at least one of the following: Respiratory concerns or distress, including difficulty breathing or speaking or decrease peak expiratory flow Declining blood pressure Symptoms of end organ disfunction2. Rapid occurrence of two or more of the following after exposure to likely Allergan: Skin and mucosal tissue symptoms including hives itchy and flushed skin and or swelling of the face and body respiratory concerns or distress including difficulty breathing or speaking or decreased peak expiratory flow Declining blood pressure Symptoms of an organ disfunction Severe gastrointestinal symptoms 3. Exposure of known allergin causing a decline in blood pressure
COPD
General term (umbrella term): contains emphysema and chronic bronchitis
copd spo2
Spo2 always lower than normal Goal is 94 but COPD pts goal is 90-92 Do not get COPD pt into 98Too much O2 will lower respiratory rate
copd CO2
CO2 is always higher 50-60 mmhg
Common Pathologies of COPD
Airflow obstruction Bronchospasm/bronchoconstriction Increased mucous production Impaired elasticity of airways
Emphysema
is a long-term, progressive disease of the lungs that primarily causes shortness of breath due to over-inflation of the alveoli. Emphysema patients have damage to lung tissue in alveoli, which causes thickening and delays, or block entirely, the oxygen/carbon dioxide exchange.
Pulmonary Emphysema (Pink Puffers)
Abnormal, permanent enlarged air spaces distal to terminal bronchiole Usually a non-productive cough Increased Anterior/Posterior diameter (barrel chest) due to hyperinflation and increased lung volume
Emphysema Pathologies
Destruction of alveoli walls Weakening and destruction of bronchioles Decreased alveoli surface area Decreased gas exchange
Emphysema – Signs and Symptoms
“pink puffer”- respiratory distress: exhalation Pink color Pursed lip breathing Leaning forward Use of accessory muscles Tachypnea Distended neck veins Barrel chest Tachypneic Thin because they burn calories trying to breath
Chronic Bronchitis
Inflammation, swelling and excessive mucous production in the bronchial tree. Minimal alveoli involvement Decreased ventilation of alveoli due to airflow obstruction
Chronic Bronchitis - Signs and Symptoms
“blue bloater”- respiratory distress: inhalation Cyanotic Sweating Leaning forward Use of accessory muscles Tachypnea Distended neck veins
COPD with right heart failure
Very difficult to push the patients thick blood through lungs destroyed by emphysema and through capillaries squashed by hyperinflated alveoli
COPD with right heart failure Signs and symptoms
Peripheral edema JVD End inspiratory crackles
Hypoxic Drive
Rare phenomenon that affects only a very small percentage Pts whose respiratory drive can be decreased by high levels of oxygen
Bagging someone with COPD
Pts who have severe asthma or copd should be ventilated 4-6 breaths per pin to avoid bagging them to death
Management of COPD
Primary goal is to reverse airflow obstruction through bronchodilation This is accomplished through use of sympathomimetics and anticholinergics. CPAP, if indicated, helps with medication administration PEEP: Positive End Expiratory Pressure
Pleural effusion
is when fluid collects between the visceral and parietal pleura.
Effusions can be caused by
infections, tumors, CHF, trauma
what do pleural Effusions cause
can contain several litres of fluid, which can decrease lung capacity and cause dyspnea. They impair breathing by limiting lungs expansion and can cause partial or complete lung collapse.
where do P effusions happen
Happens in pleural space
what will you hear with a pleural effusionwhat will the spo2 be
When you listen you won’t hear anything SPO2 will be low (hypoxemic)
P effusions Treatment
Prehospital treatment should consist of proper positioning, high fowlers most often, aggressive supplemental oxygen if required.
Bronchitis
Is an inflammation of the mucous membranes of the bronchi
bronchitis Is characterized by
development of cough or small sensation in the back of the throat, with or without production of sputum
bronchitis Divided into two categories:
Acute Chronic
bronchitis treatment
treat symptomatically
Laryngitis
inflammation of voice box due to overuse, irritation or infection
Croup
is the inflammation of the larynx and airwaves just below it it primarily affects children five years or younger it comes on strongest in the night time in the last 3 to 7 days
symptoms and cause of croup
symptoms include loud harsh barking cough, fever, noisy inhalations, hoarse voice and dyspnea caused by a virus
Pneumonia
Is an inflammatory condition of the lung, affecting primarily the alveoli
Viral Pneumonia
In adults, viruses account for approximately a third and in children for about 15% of pneumonia cases Commonly implicated agents include rhinoviruses, coronaviruses, influenza viruses, respiratory syncytial virus (RSV)
Pneumonia signs and symptoms systemic:skin:lungs;muscular:centralvascularheartgastricjoints
Systemic: -High fever -Chills Skin: -Clamminess -Blueness Lungs: -Cough with sputum or phlegm -SOB -Pleuritic chest pain -Hemoptysis Muscular: -Fatigue -Aches Central: -Headaches -Loss of appetite -Mood swings Vascular: -Low bp Heart: -High hr Gastric: -Nausea -Vomiting Joints: -Pain
Pneumonia treatment
treat symptomatically
V:Q normals and normal ratio
Ventilation 4l/min Perfusion 5l/min 0.8 is normal VQ ratio
Pulmonary Embolism
is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream (embolism).
P embolism most commonly results from
deep vein thrombosis (a blood clot in the deep veins of the legs or pelvis) that breaks off and migrates to the lung, a process termed venous thromboembolism (VTE)
Pulmonary embolism Risk Factors
Estrogen-containing hormonal contraception Cancer (due to secretion of pro-coagulants) Alterations in blood flow: immobilization after surgery, injury, pregnancy, obesity (also procoagulant), cancer (also procoagulant) Smoking Travel
Signs and Symptoms of pulmonary embolism
Dyspnea Short of breath but clear and equal lung sounds think pulmonary embolism Pleuritic chest pain on inspiration Pin point chest pain Low oxygen saturation Cyanosis Tachypnea Hemoptysis Usually clear sounding lung sounds About 15% of all cases of sudden death are attributable to PE Severity of symptoms depend on the vessel size and location
pulmonary embolism treatment
symptomaticallyhigh O2
Normal co2 levels
35-45 mmhg
Acute Respiratory Failure
Respiratory failure is inadequate gas exchange by the respiratory system, with the result that levels of arterial oxygen, carbon dioxide, or both cannot be maintained within there normal ranges.
hypoxemia
A drop in blood oxygenation
hypercapnia
a rise in arterial carbon dioxide level
Type 1 Respiratory Failure
Oxygenation Failure hypoxia without hypercapnia, and indeed the PaCO2 may be normal or low
ventilation/perfusion (V/Q) mismatch
; the volume of air flowing in and out of the lungs is not matched with the flow of blood to the lungs
the 5 causes of Type 1 Respiratory Failure
- V:Q mismatch 2. Low inp fiO2= 21% 3. Alveolar wall disease 4. Low resp rate 5. Shunt
Type 1 Respiratory Failure treatment
oxygen
conditions that affect oxygenation
Parenchymal disease (V/Q mismatch) Diseases of vasculature and shunts: right-to-left shunt Pulmonary embolism Interstitial lung diseases: ARDS, pneumonia, emphysema
Type 2 Acute Respiratory Failure
Ventilation CO2 Failure to compensate: hypercapnia They will be breathing like 35 times per minute but their end tidal will still be high
inadequate ventilation defined
the build up of carbon dioxide levels (PaCO2) that has been generated by the body
Type 2 Acute Respiratory Failure underlying causes include
Increased airway resistance( COPD, Asthma, Suffocation) Reduced breathing effort (drug effects, brain stem lesion, extreme obesity) A decrease in the area of the lung available for gas exchange (such as in chronic bronchitis). Neuromuscular problems (GB syndrome., myasthenia gravis, motor neurone disease) Deformed (kyphoscoliosis), rigid (ankylosing spondylitis), or flail chest.
Respiratory failure resulting from hypoventilation
Conditions and impair lung function Conditions that impair mechanisms of breathing Conditions are impaired the neuromuscular apparatus Conditions that reduce respiratory drive
Acute Respiratory Distress Syndrome
Is a life-threatening reaction to injuries or acute infection to the lung.nflammation of the lung parenchyma leads to impaired gas exchange with systemic release of inflammatory mediators, causing inflammation, hypoxemia and frequently multi organ failure
Acute Respiratory Distress Syndrome death rate
This condition has a 90% death rate in untreated patients
Acute Respiratory Distress Syndrome symptoms
People usually present with shortness of breath, tachypnea leading to hypoxia and providing less oxygen to the brain, occasionally causing confusion
Aspiration
Is the inhalation of either oropharyngeal or gastric contents into the lower airways
Aspiration Pneumonia
Migration of fluids and inflammatory cells into the area of irritation Fever, productive cough, radiographic findings Immunocompromised patients may not present the inflammatory response
most common area if aspiration occurs in the sitting position Aspiration in supine position
Right lower lobemay produce infection in any lobe
The severity of the symptoms of Aspiration Pneumonia is related to :
Volume of aspirant Amount of bacterial contamination Oropharyngeal contents with anaerobic bacteria pH of material pH less than 2.0 are associated with a much higher mortality rate
Aspiration Pneumonia Management Acute symptomatic Aspiration
Remove airway obstruction Monitor CO2/SpO2 Correct hypoxia Ventilate as required Bronchodilators –Aspiration-induce bronchospasm Bronchoscopy
Aspiration Pneumonia Treatment
Aggressively reduce the risk of aspiration by avoiding gastric distension when ventilating and by decompressing the stomach with an NG tube whenever appropriate Aggressively monitor the patient’s ability to protect his or her own airway and seek to protect the patient’s airway with an advanced airway if this is impossible Aggressively treat aspiration to suction and airway control if steps one and two fail
BVM: ROMAN
restrictionobesitymask sealage over 55 (loss of muscle tone/ increase risk for disease)no teeth
SGA: RODS
restrictionobesitydeformed anatomystiff neck
nasal O2
1-6lpm24-44%
simple o2
6-12lpm24-50%
nrb o2
10-15lpm90-100%
bvm 02
15lpm100%
o2 consumption constantDEH
D= 0.16E= 0.28H= 3.14
o2 consumption formula
psi in tank x constant—————————— flow rate
fiO2
fraction of inspired oxygen
Hyperventilation
Hyperventilation Syndrome is a respiratory disorder, psychologically or physiologically based, involving breathing too deeply or too rapidly. The hyperventilation is self-promulgating as rapid breathing causes carbon dioxide levels to fall below healthy levels, and respiratory alkalosis (high blood pH) develops.
Hyperventilation Signs and symptoms
Palpation Chest pain Paresthesia hand and muscle Light headed Weak Dizzy Carpo-pedal spasm
One-Person Bag-Valve-Mask Ventilation indication and complications
Indicated for apnoeic patients and for patients who are breathing in adequately Complications associated with the one person bag mask ventilation technique are typically related to in adequate tidal volume delivery which usually occurs secondary to poor technique in adequate mask to face seal or gastric distension
Ventilation rates by age Adult
Apneic with a pulse 10 to 12 breaths per minute with or without an advanced airway in place Apneic and pulseless 10 breaths per minute after an advanced airway has been inserted ventilations can be asynchronous with chest compressions
Ventilation rates by age Infant and child
Apneic with a pulse 12 to 20 breaths per minute with or without an advanced airway in place Apneic and pulseless 10 breaths per minute after advanced airway has been inserted ventilations can be asynchronous with chest compressions
Two person bag mask ventilation indications, contra and complications
Indications for the two apnea, in adequate breathing, inability to ventilate the patient with one paramedic and spinal injury Contra indications include patients who are in tolerant of the device The only major disadvantage of two-person bag mask technique is that it requires additional personnel Complications include hyper inflation of the patient’s lungs and gastric distension
Gastric distention
The pressure in the airway forces open the esophagus and the air flows into the stomach First it promotes regurgitation of stomach contents and vomitus creeping up the back of the throat rapidly finds its way into the patient’s lungs Second a distended stomach pushes to die for an upward into the chest reducing the amount of space in which the lungs can expand
signs of gastric distension
Signs of gastric distension include an increase in diameter of the stomach, an increasingly distended abdomen, and an increased resistance to bag mask ventilation If the signs are noted reassess and reposition the airway as needed, apply Cricoid pressure and observe the chest for adequate rise and fall as you continue ventilating
Artificial ventilation of the pediatric patient
A paediatric bag mask device with a minimum title volume of 450 mL should be used for full term neonate and infants
how to apply cricoid pressure
Locate the cricoid ring by palpating the trachea for prominent horizontal band inferior to the thyroid cartilage Apply gentle downward pressure using one finger tip in infants and thumb and index finger and children
Head tilt chin lift manouver
The preferred technique for opening the airway of a patient who has not sustained trauma
Head tilt chin lift manouver indications and contra
Indications: non-responsive patient, no mechanism for cervical spine injury or patient who is unable to protect his or her own airway Contra indications: a responsive patient or patient with a possible cervical spine injury
Head tilt chin lift manouver advantages and disadvantages
adVadantages: no equipment is required and the technique is simple safe and non-invasive disadvantages: hey is the thought to be a hazardous to patients with spinal injury does not protect from aspiration
jaw thrust manoeuvre
If you suspect that the patient has experienced a cervical spine injury open his or her airway with the jaw thrust maneuver’ Place fingers behind the angle of the jar and left the job forward
jaw thrust manoeuvre indications and contra
Indications: unresponsive patient, a patient with possible cervical spine injury or patient who is unable to protect his or her own airway Contraindications: responsive patient with resistance to opening the mouth the jar thrust maneuver may be needed in the responsive patient who has sustained a jar fracture
jaw thrust manoeuvre advantages and disadvantages
Advantages: maybe used in patients with cervical spine injury Disadvantages: cannot maintain if patient becomes responsive or combative difficult to maintain for an extended period of time
Jaw thrust manouver with head tilt indications and contra
Indications: an unresponsive patient or a patient unable to protect his or her own airway Contraindications: responsive patient or patient with a possible cervical spine injury
Jaw thrust manouver with head tilt advantages and disadvantages
Advantages: it is a non-invasive and does not require special equipment Disadvantages: it is difficult to maintain requires a second paramedic for a bag mask ventilation and does not protect against aspiration
Tongue jaw lift manouver
Used more commonly to open a patient’s airway for the purpose of suctioning or setting an OPA airway It cannot be used to ventilate a patient because it will not allow for adequate mask seal on patient’s face
The king LT Airway
single use single lumen airway device that is blindly inserted to provide positive pressure ventilation to apnoeic patients and to maintain a patent airway and unresponsive patients The king LTSD is more commonly used device it is available in seven sizes that are based on the patient’s height and or weight
Indications for King LT airway
Alternative to bag mask ventilation when a rescue device is required for a failed intubation attempt Indicated for airway management of deeply unresponsive apnoeic patient with no gag reflex and whom tracheal intubation is not possible or has failed
Contraindications for the king LT airway
Does not eliminate the risk of vomiting or aspiration Do not use the king LT airway in patients with an intact gag reflex patients with known oesophageal disease or patients who have ingested a caustic substance
Complications of the king LT airway
Laryngeal spasm, vomiting and possible hyperventilation may occur
The laryngeal mask airway
It’s around the opening of the larynx with an inflatable silicone positioned in the hypopharynx
The laryngeal mask airway Indications and contraindications
Alternative to bag mask ventilation when the patient cannot be intubated ineffective in patients with obesity and should not be used in morbidly obese Ineffective for ventilation of patients requiring high pulmonary pressures
The laryngeal mask airway dvantages and disadvantages
May provide better ventilation than a bag mask and does not require continual maintenance of mask seal Easier and does not require laryngoscopy Provides protection from upper airway secretions Main disadvantage is that it does not provide protection against aspiration but increases the risk of aspiration
Complications of the LMA
The most significant complications associated with use of the LMA involve regurgitation and subsequent aspiration Should only be used in patients who are fasting —Meaning it cannot be used in emergency situations
The I-Gel
Supraglottic airway specifically designed to create non-inflatable anatomical seal of the pharyngeal and laryngeal anatomical structures while avoiding trauma Allows passage of an NG tube to decompress the stomach and prevent regurgitation
Combitube
Multilumen airway device with a long tube that is inserted blindly into the airway it is an alternative to tracheal intubation allows for better ventilation than a bag mask device and simple airway adjunct It can function as a tracheal tube if inserted into the trachea
Combitube Indications and contraindications
Indicated for every management of deeply unresponsive, apnoeic patients with no gag reflex in whom tracheal intubation is not possible or has failed Cannot be used in children younger than 16 years Contraindicated in patients with oesophageal trauma, patients with known pathological conditions of the esophagus, patients who have ingested a caustic substance or patients who have a history of alcoholism
Combitube Advantages and disadvantages
It cannot be improperly placed No mask seals required to ventilate Provides patency to the airway No upper airway positioning is required Does not completely illuminate the risk of aspiration
Combitube complications
Significant complication is unrecognized displacement of the tube into the esophagus Laryngeal spasm, vomiting, impossible hyperventilation may occur
Combitube consist of
a single tube with two lemons, two balloons and two ventilation ports one lumen is open at its distal and the other is closed
Combitube Insertion technique
Forwardly displace the jawinsert deviceInflate the cuff:ventilate the longer blue tube first if there are no breath sounds are epigastric sounds present the chest is not rise and fall during ventilation then switch immediately to the shorter clear tube
Suction Pressures:Premature infants Term infantsChildrenAdults
Premature infants – 60-80 mmHg • Term infants – 80-100 mmHg • Children – 100-220 mmHg • Adults – 120-550 mmHg
Yankauer catherter
(tonsil tip catherter): a good option for suctioning the pharynx in adults and the preferred device for infants and children They have a diameter and a rigid so they do not collapse and are capable of suctioning large volumes of fluid rapidly
Whistler tip catherter
soft plastic, non-rigid catheters can be placed in the oral pharynx or nasal pharynx or down a tracheal tube
adults should be suctioned for a max of — seconds
15 seconds
Mechanical ventilation
Refers to the application of device that provides patience varying degrees of ventilatory support
Negative effects on body
Positive pressure ventilation increases intrathoracic and intraocular pressure which can result in barotrauma (pneumothorax) or volutrauma ( injured alveoli/impaired surfactant function) An increase in interest or acid pressure can result in reduced venous return to the right side of the heart which may result in poor cardiac output and hypertension
Negative pressure ventilation
A negative pressure ventilator operates by a drop in trans airway pressure gradient created by contraction of the diaphragm
Monitoring Tubing
assists in the measurement of flow and pressures by taking information to the ventilator for interpretation and display.
Y–connection
brings the inspiratory limb, expiratory limb, and endotracheal tube together to form a closed circuit.
End-Tidal Carbon Dioxide
The measurement of carbon dioxide in exhaled breath.
Manometer
A sensor within the ventilator permits several respiratory parameters to be measured, such as: Peak pressure, Mean airway pressure, Plateau pressure and lung volumes.
Respirometer:
Measurements of gas exchange can be made with a respirometer located within the ventilator. This is done by measuring the change in the volume of gas surrounding the probe during breathing. A respirometer will measure the rate of oxygen consumption and then calculate the rate of production of carbon dioxide by comparison.
Capnography
measures the concentration of CO2in expired gas
The peak CO2 concentration
occurs at end-exhalation and is regarded as the patient’s “end-tidal CO2” (ET CO2), which approximates the alveolar gas concentration.
D cylinderM cylinder E cylinder
You will often use the D cylinder which contains 350 L of oxygen and is typically carried from the ambulance to the patient The M cylinder which contains 3450 L of oxygen remains on board the ambulance The E cylinder holds 625 L of oxygen
Therapy regulator
attaches to stem of the oxygen cylinder and reduces the high pressure of gas to a safe range approximately 50 psi
Cylander constants
D 0.16 E 0.28 M 1.56 G 2.41 H 3.14 K 3.14
why do we put end tidal on everyone
- Want to see whats going on in the lungs (bronchoconstriction) 2. Want to see the effects of treatments
- Capnography (capnometry)
The measurement of carbon dioxide in exhaled breath
- Capnometer
The numeric measure of CO2
- Capnogram
The wave form produced with inspiration & expiration
- ETCO2 define
the level of partial pressure of carbon
-PaCO2
Partial pressure of CO2 in arterial blood
3 things needed for 02
- Cardiac output - Ventilation: gas exchange at the alveoli wall - Metabolism: what the cells need to use oxygen
- CO2
is the “Gas of Life” produced from “The fire of life” metabolism
ETCO2
- Provides an immediate, real time, picture of the pt.’s condition- Capnography will show immediate apnea- Directly related to the ventilatory status of the pt.
SPO2
- Delayed, SpO2 can show high saturations for several minutes- SPO2 will not show immediate apnea- Directly related to oxygenation of the pt.
What else can ETCO2 tell us?
Not only can ETCO2 measure ventilation but . . . . - It also indirectly measures metabolism & circulation
- An increased metabolism will
increase the production of carbon dioxide & increasing levels on the monitor
- A decreased metabolism will
decrease the amount of CO2 delivered to the lungs & decreases levels on the monitor
Intubated Capnography Patients
- EtCO2 is directly related to the ventilation status & can be used in intubated as well as non-intubated pt.’s
- Capnography in Intubated pt.’s can be used to:
o Verify ETT placement o Monitor ETT position o Assess ventilation and treatments o Evaluate resuscitative efforts during CPR
Non-Intubated Capnography Patients
- Asthma & COPD - CHF/Pulmonary Edema - CPAP pt.’s - Pulmonary Embolus - Head Injury
Capnography Values Hyperventilation / Hypocapnia
- > 45mmHg - Respiratory Acidosis
In-accurate readings may be due to;
- Poor positioning of NC capnofilters - Obstructed nares - Mouth breathers - O2 by mask may lower reading by 10% or more
Increased ETCO2
Due to Increased CO2 Production - Fever - Burns - Hyperthyroidism - Seizure - Bicarbonate Tx - Return Of Spontaneous Circulation - (ROSC) - Release of Tourniquet / Reperfusion - Decreased ETCO2 - Increased CO2 Clearanceo Hyperventilation - Exercise- Sick
Decreased ETCO2
Decreased CO2 production- Hypothermia- Sedation- Paralysis Decreased delivery to the lungs - Decreased cardiac output
Normal Waveform
- Straight boxes are good- Length of wave = Time- Height of wave = CO2 Level
- CO2 is a result of
Metabolism
Hyperventilation Waveform
CO2 goes down - Wave forms start getting lower- Anxiety- Bronchospasm- PE- Increased ventilation - Remember to look at the trend not just the number
Causes for CO2 going down
- Hypothermia- Decreased Metabolism- Decreased Pulmonary perfusion
Hypoventilation Causes
Hypoventilation Causes – CO2 goes up, wave form slows - Wave forms start getting bigger- Decreased ventilation- OD/Intoxication/Sedation - CNS Dysfunction- Tiring respiratory pt. Remember to look at the trend not just the number
High CO2 Waveform
Causes for CO2 going up - Decrease in respiratory rate - Decrease in tidal volume - Increase in metabolic rate - Rapid rise in body temperature (hyperthermia)
Bronchospasm Waveform
- This wave form can occur in Asthma, COPD, Incomplete Airway Obstruction, Tube kinked or obstructed o CO2 that is transferred to the alveoli from the bloodstream may take longer to exhale because of the narrowed bronchi. o This delayed emptying of the alveoli varies in different parts of the lungs. o This results in the sloping plateau on the capnograph trace, CO2 from parts of the lungs with more severe bronchial narrowing is exhaled later than those parts with less severe narrowing.
what type of shape is bronchospasm
o This represents struggling to exhale & un- even emptying of alveoli o The pt. hyperventilates to compensate, CO2 drops to below 35 o Asthma worsens, the C02 levels will rise to normal
Emphysema Waveform
- The slope of phase III can be reversed in patients with emphysema where there is marked destruction of alveolar- capillary membranes and reduced gas exchange
Cardiac Asthma & ETCO2
Decrease in airway diameter caused by pulmonary congestion, not bronchoconstriction. - If the wave form is upright, there is no constriction, the wheezing is caused by the CHF, not the COPD, you might want to withhold the neb treatment.
Pulmonary Embolus
- PE will cause an increase in dead space in the lungs decreasing the alveoli available to off load CO2 - The ETCO2will go down.
- A zero reading from intubated pt
may indicate the ETT is in the esophagus, prolonged down time prior to CPR, or massive PE
Ventilating Pt.’s With ICP
- Finding a Balance - Hyperventilation = Hypocapnea = Cerebral Ischemia - Hypoventilation = Hypercapnia = Dialation bleed & pressure - Keep C02 value of aprox 30 (>35 & not <25 mmHg)
“Bucking” the Tube - “Curare Cleft”
Sedated Intubated Pt.’s - A notch in the wave form indicates the pt. is starting to arouse from sedation, breathing on their own & may need additional medication
Capnography & Cardiac Output
- Increased Cardiac Output = Increased CO2 - Decreased Cardiac Output = Decreased CO2
- CPAP
is a respiratory modality which can assist patients in their breathingdistends alveoli preventing collapse on expirationallows for greater surface area, which improves gas exchangeincreases medication distribution when used for COPD is very effective in reducing the amount of fluid in the alveoli and increase the FiO2 (Fraction of Inspired Oxygen) of the inhaled air up to 100%
- The overall goal of CPAP
CPAP is to increase Functional Residual Capacity(FRC)
- Functional Residual Capacity(FRC
is the volume of air present in the lungs at the end of passive expiration.
How does CPAP work?
- CPAP mask forms a tight seal around patients mouth and nose. - CPAP system pressurizes the patients airway while still allowing them to spontaneously inhale and exhale on their own
What is CPAP?
- CPAP increases pressure in the lungs and holds open collapsed alveoli, pushes more oxygen across the alveolar membrane, and forces interstitial fluid back into the pulmonary vasculature. - This improves oxygenation, ventilation and ease of breathing. - The increased intrathoracic pressure decreases venous return to the heart and reduces the overwhelming preload (pressure in the ventricles at the end of diastole). - This lowers the pressure that the heart must pump against (afterload), both of which improve left ventricular function. - CPAP alters the pressure gradient
protocol criteria for CPAP
- Patient must be alert and able to follow commands (GCS >13) - Be able to maintain an open and patent airway on their own - Patient is over 12 years of age and must be able to fit the CPAP mask - PCP’s may apply CPAP to adult patients with severe respiratory distress - Severe Respiratory distress as per Paramedic Clinical Practice protocols is RR greater than 25,SPO2 less than 92%, use of accessory muscle use. - If the CPAP is on, try to keep it on. Alveoli can collapse again within seconds. - It may take hours to reopen alveoli again
Indications for CPAP
- Hypoxemia secondary to congestive heart failure - Acute cardiogenic shock - Pulmonary edema - Asthma/COPD - Respiratory distress (A respiratory rate >25bpm, SpO2 <92%, accessory muscle use during
CPAP Contraindications
- Pneumothorax or chest trauma - Hemodynamically unstable patients - Altered mental state- Patient has a tracheotomy- Patient is actively vomiting- Patient has an upper GI bleed
