Paramedic Resource Manual Flashcards
What is apart of the upper respiratory tract (4)?
- nasal cavity/sinuses
- pharynx
- larynx
- trachea
What is apart of the lower respiratory tract (9)?
- right and left mainstem bronchi
- secondary bronchi
- tertiary bronchi
- bronchioles
- terminal bronchioles
- respiratory bronchioles
- alveolar ducts
- alveolar sacs
- alveoli
What composes the nasal cavity?
- has a septum dividing the anterior nares
- has posterior nares which open to nasopharynx
- each nasal cavity has inferior, middle and superior turbinates
What is the purpose of the turbinates?
- increase surface area
- warming air
- moisture content
What area do nosebleeds impact?
- anterior nasal septum in young people
- posterior nasal structures in elderly
where is woodruff’s plexus?
over middle turbinate - if damaged bleeding will persist (need surgery to fix)
What separates the nasal cavity from the brain? What happens if fracture occurs here?
Cribiform plate
- fracture can lead to CSF fluid leak
What bones make the roof of the nasal cavity?
ethmoid and sphenoid bones
What makes up the hard palate?
palatine and maxillary bones
What are the 4 sinuses?
- frontal
- maxillary
- ethmoid
- sphenoid
Where does the pharynx sit?
base of skull - 6th vertebrae
(nasopharynx, oropharynx, laryngopharynx)
Nasopharynx
- directly behind nose
- air passage only
- when you swallow, soft palate and uvula move up to prevent food from entering nasal cavity
Oropharynx
- posterior to oral cavity
- composed of soft palate, uvula, tonsils
Laryngopharynx
- food and air passage
- runs to larynx where it then separates into your food and air flow
- cricoid cartilage is inferior, esophagus is posterior
What is the Eustachian tube? Where is it located?
Duct going from middle ear - nasopharynx
- allows for pressure control in the ear
- normally closed, opens during things like swallowing, yawning, chewing
Where does the larynx sit?
from hyoid bone to cricoid cartilage in trachea
4 cartilages of the larynx
- thyroid
- cricoid
- arytenoids
- epiglottis
What commonly happens at the larynx level?
airway obstruction - often due to FBO - crich occurs here
What bone is found in larynx?
hyoid bone - directly under the chin which goes to thyroid (adam’s apple)
What is the purpose of thyroid cartilage?
- attachment point
- protects vocal cords
Epiglottis
- behind hyoid cartilage
- during swallowing it covers larynx to prevent food from going down the wrong tube
- swelling at this site can lead to airway obstruction
Vocal cords
go from thyroid to arytenoid cartilages
- can open/close
- controlled by muscles controlled by laryngeal nerves
Where does the trachea sit? What is it made of?
Goes from the cricoid cartilage to the fifth thoracic vertebrae
- 10cm long
- made of incomplete cartilage rings which allow for flexibility to keep airway open
- un-closed part faces esophagus which allows for food to pass
What are accessory parts to the lower respiratory tract?
- pleura
- pleural cavity
- muscles of respiration
The bronchi
- being where trachea ends - divides into left/right mainstem passing through the hilum
- made of cartilage rings like trachea but as it progresses it goes to smooth muscle
- as they go through the lungs they turn to secondary bronchi and than tertiary, going to smaller units until they form bronchial trees (where the bronchioles form)
Difference between right and left main bronchi stem?
Right = shorter, more vertical/ in line with trachea
- often times tube placement goes into this bronchi, or FBO will go here
Respiratory bronchioles
branches of the terminal bronchioles that subdivide into several alveolar ducts
Alveoli
- contained in alveolar sacs (coming off the ducts)
- has respiratory membrane separating capillary blood from the air in alveoli (this is the membrane in which gas exchange occurs)
- things that thicken this membrane lead to less gas exchange (CHF, pneumonia)
Lung anatomy
- takes up most of the thorax, surrounded by pleura sac
- bases end above diaphragm, apex is above collar bone
- each lung has a hilum where things enter/leave lungs
- left lung (2 lobes, oblique fissure divides)
- right lung (3 lobes, has horizontal and oblique fissure)
Pleural cavity
- contains the lungs
- has visceral and parietal layers which have serous fluid between (reduces friction)
The thorax
- chest cavity
- have right/left pleura cavities and mediastinum
- mediastinum contains heart, esophagus, sternum, trachea
- pleural cavity contains lungs
What is atelectasis?
Lung collapse
- can be from cavity compression (fluid, air, diseases) or could be from decreased surfactant
How does air flow? How does that work with us to have inspiration?
- air flows from high to low pressure
- during inspiration, our thoracic cage expands, leading to less overall pressure inside the lungs/cavity (this will now make atmospheric air higher pressure, letting air flow into the alveoli)
How does the diaphragm move during inspiration/expiration?
i - contracts and moves downward
e - relaxes/moves up, sternum moves inward
What are the muscles of inspiration?
diaphragm and external intercostal muscles
How do the intercostal muscles assist respiration?
move ribs upwards/out (increase thoracic cage) as well as contraction of these muscles keep intercostal spaces from being sucked in during inspiration
What can lead to diaphragm paralysis?
transection of spinal cord above C3
What are the muscles of expiration?
internal intercostals and abdominal muscles
Does expiration use energy?
- passive process mostly unless diseases present
- when inspiration occurs, the lung tissue stretch causing potential energy to be stored in them - expiration will occur due to recoil in the lungs
How do abdominal muscles work during expiration?
Contraction moves diaphragm upwards (when it relaxes) and it depresses the ribs leading to less thoracic cage volume
What is pulmonary compliance?
- healthy lungs need to be able to expand (elastic tissue)
- compliance is the amount of pressure needed to expand the lungs
- the more pressure needed to expand them = less complaint
- diseased lungs usually have higher compliance
What is elastance?
ability for lungs to return to normal after they stretch (how well they recoil)
What % of oxygen do we use to breathe?
- respiratory muscles need less than 5% of our oxygen to function
- in patients with respiratory disorder, there system uses around 25% of total oxygen consumption
What structure is more anterior the larynx or the esophagus?
the larynx
What causes the wheezing in asthma?
airway constriction
Why do very sick asthmatic patients often have very little wheezing?
the production of sound is dependent upon adequate ventilation
- decreased ventilation, movement of air results in decreased wheezing
- decreased movement of air results from bronchoconstriction, mucosal edema and increased mucous production which causes obstruction of flow
What are the 3 pathologies involved in COPD?
- asthma
- bronchitis
- emphysema
What is tidal volume?
- the amount of air inhaled and exhaled during a normal breathing cycle at rest
- 400-500ml in healthy adult is normal
What is residual volume?
amount of air remaining in lungs after expiration
Total lung capacity
total amount of air lungs can hold
What controls our bodies ventilation?
- centers in the brainstem
- responds to increasing levels of CO2 (causes us to increase respiratory rate, while it decreases our respiratory rate when CO2 levels are below normal) - hypercapnic drive
How is ventilation controlled in someone with COPD?
- they use thier hypoxic drive
- bases respirations on oxygen levels, not CO2
- due to normally high CO2 levels making them have hypercapnia - body will shift to using oxygen levels as they don’t blow off CO2 normally
Ventilation vs. Perfusion
V = amount of air moving into and out of system
P = flow of blood through tissues
ideally you want V=Q
When does pulmonary shunting occur?
anytime that blood flows through the lungs and does not pick up enough oxygen
What is dead space?
Air going in and out is equal (no gas exchange)
- it is ventilation without perfusion (high V/Q ratio)
What is a shunt?
Perfusion without ventilation (low V/Q)
- when oxygen can not enter, CO2 can not exit (COPD)
- even though area is perfused, not ventilated which leads to shunting of blood to other areas which can be ventilated
Asthma - what is it?
- chronic inflammatory disease of airways
- widespread narrowing of airways - due to smooth muscle contraction, and as it goes on also can be from mucosal edema/mucus production
Symptoms of asthma
wheezing, coughing, SOB, anxiety. tachycardia, nasal flaring, accessory muscle use
- as it goes on and compensation declines, may see confusion, diminished/absent wheezing, become obtunded
Why do lungs become overinflated in COPD/asthma?
air trapping = overinflated
Signs someone is hypoxic? When can it occur?
Combative, confusion, aggressive, visual problems, seizures
- when PAO2 falls below 60 (normal is 80-100)
Hypercapnia
Excessive carbon dioxide in the blood (ventilation not sufficient enough to remove it)
- COPD, overdoses where respiratory drive is declined
What does partial pressure mean?
The pressure of gas in a mixture if it were acting alone
How does diffusion of oxygen work? (blood to tissues)
- in venous blood, PAO2 is 40mmHg
- as blood enters capillaries it comes into contact with alveolar air which is 100mmHg (remember air goes from high to low) so oxygen will diffuse into venous and diffuse until it is equalized (this blood now goes to the heart and into the systemic circulation)
- in tissues the PAO2 is 40mmHg. Once this oxygenated blood reaches tissues (it is now 100) - it will diffuse into the tissues
What 2 factors impact oxygen transportation to the tissues?
- perfusion
- concentration of hemoglobin/it’s affinity for oxygen
Structure of hemoglobin
It is a four sub unit protein containing iron - has 4 irons which can attach to an oxygen (becomes oxyhemoglobin)
What is the oxygen disassociation curve?
The graph of the relationship between the saturation of hemoglobin with oxygen and the partial pressure of oxygen
What 3 factors impact hemoglobins affinity for oxygen?
- pH
- temp
- PCO2
What will cause a downward shift to the right on the curve?
Lowering of pH (increase in H ions), increase in temp
- any shift down/to the right lowers affinity, meaning that oxygen will not bind as easily due to being in acidic state but oxygen will be more readily available for tissues
What will cause a shift upward/to the left?
Increase in pH, decrease in temp
- oxygen can bind more easily (in alkaline state) but does not give up as easy as now hemoglobin has increased affinity for oxygen
How is carbon dioxide transported?
By blood until it can be excreted by kidneys or lungs
- carried in form of bicarbonate (mostly)
- combines with hemoglobin
- dissolves in plasma
What is the BOHR effect?
- when we exhale, it shifts us towards alkaline side (blowing off CO2)
- when we are alkaline, hemoglobin has a greater affinity for oxygen
- when blood reaches tissue level, CO2 will diffuse into blood shifting the scale to be more acidic (which will decrease affinity) making oxygen more available to the tissues
Pons - how does it control breathing?
Pneumotaxic centre - switches inspiration off
Apneustic centre - switches it on
Chemoreceptors
- help to detect changes in CO2 and O2 levels
- helps control breathing
- peripheral chemoreceptors: detect CO2 changes
- central chemoreceptors: detect changes in arterial CO2 and O2
What does pulse oximetry measure? End tidal?
P = amount of oxygen bound to hemoglobin (normal = 92-96%, COPD = 88-92%)
E = amount of exhaled carbon dioxide
3
Non-rebreather mask
- 10-15pm
- uses bodies own reservoir, and the one attached to mask providing 80-95% oxygen