Respiratory & Airway

Respiratory & Airway

Ventilation

The process of air movement into and out of the lungs

Perfusion

The circulation of blood through the lung tissues (alveoli)

Diffusion

The process of gas exchange (carbon dioxide and oxygen)

Where is the respiratory center housed in the brain?

brainstem, more specifically the medulla oblongata

Crackles (rales)

fine, bubbling sound heard on auscultation of the lung. Produced by air entering the distal airways and alveoli that contain serous secretions.

Rhonchi

abnormal, coarse, rattling respiratory sounds, usually caused by secretions in the bronchial airways.

Stridor

abnormal, high-pitched, musical sound caused by an upper airway obstruction (subglottic).

Wheezing

form of rhonchi, characterized by a high pitched, musical quality. Produced in the lower airways (bronchioles).

Eupnea

normal respirations

Tachypnea

increased (fast) respirations

Bradypnea

decreased (slow) respirations

Apnea

no respirations (not breathing)

Cheyne Stokes

abnormal respirations with regular, periodic breathing with intervals of apnea and a crescendo-decrescendo pattern of respirations.

Biot’s

abnormal respirations characterized by regular deep inspirations followed by regular or irregular periods of apnea.

Apneustic

abnormal rapid respirations associated with deep, gasping inspirations – most often associated with stroke or trauma.

Kussmaul’s

rapid and deep respirations – most often associated with diabetic ketoacidosis (DKA) as a compensatory mechanism in an attempt to correct the body’s metabolic acidosis

OROPHARYNGEAL AIRWAY

Used on patients without gag reflex, moves tongue forward as it curves back to pharynx

Measured from center of mouth to angle of jaw

Insert device along roof of mouth, rotate 180 degrees to sit anatomically (can insert in “normal” position in pediatrics)

NASOPHARYNGEAL AIRWAY

Used in patients with intact gag reflex, moves tongue and soft tissue forward to provide channel for air.

Measured from patient’s nostril to the tip of the earlobe or to the angle of the jaw

Bevel always goes towards the nasal septum

NASAL CANNULA

Liters/Minute: 1 – 6
Oxygen Concentration: 24 – 44%

NEBULIZER

Nebulized albuterol, ipratropium, and epinephrine Liters/Minute: 4 – 6 (hand-held); 6 – 8 (mask)

NON-REBREATHER MASK

Liters/Minute: 12 – 15
Oxygen Concentration: 80 – 100%

BAG VALVE MASK

Liters/Minute: at least 15
Use two rescuers when possible to deliver ventilations

Deliver breath over 1 second of time, allow for adequate exhalation

Squeeze bag until you see chest rise, release bag Average tidal volume in adult patient is 500mL Average dead space in adult patient is 150mL

12 breaths per minute in adults
20 breaths per minute in pediatrics

CPAP (CONTINUOUS POSITIVE AIRWAY PRESSURE)

Tight fitting mask, not a leak tolerant system Centimeters of water pressure (cmH2O): 4 – 20

Most protocols do not exceed 10cmH2O Indications for CPAP:

F: Flail Chest
N: Near Drowning
C: COPD
P: Pulmonary Edema, Pulmonary Embolism A: Asthma, ARDS
P: Pneumonia

“Go get the F’n CPAP!”

Typically not used in pediatrics (< 12 years of age), however, pediatric CPAP is gaining traction in prehospital setting.

In pediatric CPAP, all settings are the same, it’s simply a smaller mask.

i-GEL

Non-inflatable cuff
Designed to rest over the larynx
Insertion is same as LMA, but without inflation Takes less than 5 seconds to insert, faster than LMA

KING LT-D AIRWAY

Similar to i-gel and LMA

Single tube with two cuffs, that is placed into the esophagus, large balloon is inflated in the esophagus

Holes between the two cuffs allow for ventilations to be delivered near the glottis

MILLER BLADE

Straight blade, sizes 1 – 4

Tip of blade is applied directly to the epiglottis to expose vocal cords

Typically recommends for infant intubation → provides greater displacement of the tongue

May be better for anterior airways

MACINTOSH BLADE

Curved blade, sizes 1 – 4

Tip of blade is inserted into the vallecula → displaces tongue to the left to lift the epiglottis without touching it

My reduce chance of dental trauma

STYLET

May be inserted through ET tube before intubation, adds rigidity and shape to tube

Must be recessed 1 - 2” into the tube, should not pass the “Murphy’s Eye”

BOUGIE

60 – 70cm in length

Can be used in place of stylet, performs very well in difficult and anterior airways

Patient can be “intubated” with the bougie, then ET tube is slid over bougie into the airway (remove bougie after tube is in place)

ENDOTRACHEAL TUBE

Sizes: 0.5 – 10

Average Adult Male: 7.5

Average Adult Female: 7

Direct placement through glottis opening into trachea

Confirm placement with traditional methods – capnography is the gold standard!

What must be present in the pt in order to conduct a nasotracheal intubation?

respirations

ENDOTROL

Same sizes as endotracheal tubes, performs same way as endotracheal tube

Often used for nasotracheal intubation due to ring at top of tube that allows for distal manipulation/movement of the tube

BAAM DEVICE

Placed on end of endotracheal tube (or Endotrol) to help identify proximity of glottis opening and when patient is inhaling/exhaling during nasotracheal intubation. Device will produce loud whistling noise.

Glottis is largest during inspiration, which is when tube should be advanced into glottic opening.

Pediatric Tube Size Formula

(16 + age*) / 4 *age in years

“DOPE” (diagnosing tube problems)

Displacement or dislodgement

Obstruction

Pneumothorax

Equipment failure

What are the 3 values relevant to ABG interpretations?

pH, CO2, HCO3

A pH that is low is considered:

Acidic, below 7.35

A pH that is high is considered:

Alkalotic, above 7.45

Normal pH level for blood:

7.35-7.45

Normal carbon dioxide (CO2) levels:

35-45

Normal bicarb (HCO3) levels:

22-26

In respiratory acidosis, the pH, CO2 and HCO3 levels would present as such:

pH - decreased

CO2 - increased

HCO3 - normal

In respiratory alkalosis, the pH, CO2 and HCO3 levels would present as such:

pH - increased

CO2 - decreased

HCO3 - normal

In metabolic acidosis, the pH, CO2 and HCO3 levels would present as such:

pH - decreased

CO2 - normal

HCO3 - decreased

In metabolic alkalosis, the pH, CO2 and HCO3 levels would present as such:

pH - increased

CO2 - normal

HCO3 - increased

What does the acronym “ROME” stand for and what does it mean?

“Respiratory Opposite, Metabolic Equal”

ROME refers to the directions that the pH and CO2 or HCO3 move in correlation with one another.

In respiratory-caused conditions, when the pH decreases (< 7.35, acidic) the CO2 ———— (> 45, acidosis). Conversely, when the pH increases (> 7.45, alkalosis) the CO2 ———— (< 35, alkalosis)

increases, decreases

In metabolic-caused conditions, when the pH decreases (< 7.35, acidic) the HCO3 ———— (< 22, acidosis). Conversely, when the pH increases (> 7.45, alkalosis) the HCO3 ———— (> 26, alkalosis)

decreases, increases

What’s happening when a pt is in respiratory acidosis and what is the treatment?

Hypoventilation (retaining too much CO2)

Treatment: increase ventilatory rate

What’s happening when a pt is in respiratory alkalosis and what is the treatment?

Hyperventilation (blowing off too much CO2)

Treatment: decrease ventilatory rate

What’s happening when a pt is in metabolic acidosis and what is the treatment?

Build up of lactic acid – lactic acidosis, diabetic ketoacidosis, renal failure, sepsis, toxic ingestion

Treatment: controlling respiratory rate, IV fluids, sodium bicarbonate

What’s happening when a pt is in metabolic alkalosis and what is the treatment?

Rare, loss of hydrogen ions (vomiting or gastric suction) – consumption of large amounts of baking soda or antacids

Treatment: correct underlying condition

EXAMPLE

pH 7.28 CO2: 54 HCO3: 24

What is happening?

What is the pH doing? It’s below 7.35 therefore it’s acidic.
Now, which of the other values are also acidic?
CO2! A normal CO2 is 35 – 45, the given value is 54 which is higher than normal and is acidic. The HCO3 is within a normal range.
Interpretation: Respiratory Acidosis

What is the GOLD standard in endotracheal tube intubation and confirmation!”?

Capnography

Study this capnography graph

Study this capnography graph

Normal capno characteristics

Square box waveform

ETCO2 = 35 – 45mmHg

DISLODGED ENDOTRACHEAL TUBE (ETT) capno characteristics

Loss of waveform

Loss of ETCO2 reading

Management: Replace ETT

ESOPHAGEAL INTUBATION (OR APNEA) capno characteristics

Absence of waveform

Absence of ETCO2 reading

Management: Ventilate or intubate

CPR capno characteristics

Square box waveform

ETCO2 = 10 – 15mmHg

Management: Change rescuers if ETCO2 falls below 10mmHg

OBSTRUCTIVE AIRWAY capno characteristics

“Shark fin” waveform
With or without prolonged expiratory phase Can be seen before actual “attack” or “exacerbation”Bronchospasm→asthma, COPD, anaphylaxis, FBAO

Management: Bronchodilators & treat underlying cause
(albuterol, atrovent, racemic epinephrine, epinephrine)

ROSC capno characteristics

During CPR, sudden increase of ETCO2 above 10 – 15mmHg

Management: Check femoral or carotid pulse

RISING BASELINE capno characteristics

Patient is rebreathing CO2

Management: Check equipment for adequate oxygen flow, allow more time for exhalation, ensure cuff has good seal

Hypoventilation capno characteristics

Prolonged waveform ECTO2 > 45mmHg

Management: Assist ventilations, increase respiratory/ventilatory rate

Hyperventilation capno characterisitics

Shortened waveform ECTO2 < 35mmHg

Management: Slow respirations/ventilatory rate

Consider other causes: DKA, sepsis, TCA overdose, methanol ingestion

BREATHING AROUND ETT capno characteristics

Angled, sloping down stroke on waveform Ruptured cuff or ETT too small

Management: Check cuff and tube size, possible re-intubation

CURARE CLEFT capno characteristics

Neuromuscular blockade is wearing off Patient takes small breath that causes the cleft

Management: Consider re-administration of neuromuscular blockade medication

Two diseases covered by COPD

1. Chronic bronchitis

2. Emphysema

Aspects of Chronic Bronchitis

1. overweight

2. productive cough with sputum

3. course rhonchi

4. chronic cyanosis

5. mild, chronic dyspnea

6. resistance on inspiration and expiration

7. “Blue Bloater”

Aspects of Emphysema

1. thin, barrel chest appearance

2. non productive cough

3. wheezing and rhonchi

4. pink complextion

5. extreme dyspnea on exertion

6. prolonged inspiration (pursed-lip breathing)

7. clubbing of fingers

8. “Pink Puffers”

Treatment for COPD

Oxygen and bronchodilators

DuoNeb: Albuterol: 2.5mg in 3mL / Ipratropium: .5mg Consider steroids for inflammation

Consider CPAP

Two main issues of asthma

bronchoconstriction and inflammation

Two main goals of asthma treatment

bronchodilation (albuterol) and reducing inflammation (steroids)

For extreme asthma, what treatments are considered?

epinephrine is considered for additional bronchodilatory effects along with nebulized magnesium sulfate to act as smooth muscle relaxer

Characteristics of Asthma

1. bronchoconsrtiction

2. inflammation

3. dyspnea

4. intercostal retractions

5. decreased LOC

6. inability to speak in complete sentences

7. tachycardia

8. tachypnea

9. ETCO2 >45mmHg

Define status asthmatics

severe, prolonged asthma attack that has not been stopped with repeated doses of bronchodilators

Asthma treatment

Oxygen and bronchodilators

DuoNeb: Albuterol: 2.5mg in 3mL / Ipratropium: .5mg Nebulized Magnesium Sulfate

Consider steroids for inflammation

IV fluids

Epinephrine IM

Consider CPAP

Characteristics of pneumonia

1. infection that causes an acute inflammatory response

2. bacterial, viral, or fungal

3. productive cough

4. pleuritic chest pain

5. tachypnea

6. wheezing, crackles, or rhonchi

7. fever

8. fatigues

characteristics of ARDS

1. acute respiratory distress syndrome

2. form of hypoxemia respiratory failure

3. results from non-cariogenic pulmonary edema

   1. significant pulmonary edema leads to severe hypoxemia, intrapulmonary shunting, reduced lung compliance, and irreversible lung damage

4. 65% mortality rate

Define intrapulmonary shunting

blood passes through the lungs but fails to take part in gas exchange. Problems like alveolar filling (with blood, tumor, edema, and pus) can all lead to shunting. Take pneumonia, for example. Pus starts to fill up the alveoli, which hinders gas exchange

#1 indicator of pulmonary embolism

Rapid onset of difficulty breathing and chest pain – especially high suspicion in the patient without a significant cardiac or respiratory history

Pt susceptible to a PE

Bedridden (chronically or after surgery)
Long flights
History of deep vein thrombosis (DVT) Female patient (teens – 40’s) on birth control

(birth control produces increased levels of estrogen and progesterone which have been proven to increase blood clots)
History of smoking

S&S of PE

Rapid onset of dyspnea Cough
Pain
Anxiety

Hypertension
Tachypnea
Tachycardia
Crackles, wheezes, rhonchi

Treatment for PE

Identification and Rapid Transport!

EKG findings for pt with PE

Right Axis Deviation

S1 Q3 T3

S-wave in lead I, Q-wave in lead III, inverted T-wave in lead III

Describes relation between PE and Obstructive shock

• PE will develop into Obstructive Shock

• Once patient has entered shock state, administer 20mL/kg fluid boluses, repeating as needed to support BP

What’s a weird sign that someone is experiencing hyperventilation syndrome (panic attack)?

Carpopedal spasms

characteristics of simple pneumothorax

1. presence of air in pleural space

2. caused spontaneously or by trauma

3. breathing sounds diminished or absent on the affected side

4. pt is dyspneic and restless

5. tachypnea

characteristics of tension pneumothorax

1. accumulation of air in the pleural space that causes “tension” (obstruction)

2. JVD

3. Hyperresonance on percussion

4. subcutaneous emphysema

5. pts will become hypotensive in late stages (obstructive shock)

Define subcutaneous emphysema

Subcutaneous (under the skin) emphysema occurs when air gets into tissues under the skin. This most often occurs in the skin covering the chest or neck, but can also occur in other parts of the body.

characteristics of acute mountain sickness

• very common

• person ascends rapidly to altitude > 5000-7000ft

• headache, nausea, vomiting, weakness, dizziness, fatigue, difficulty sleeping, tachycardia, bradycardia, postural hypotension, ataxia

• ataxia is a key sign of development to high altitude cerebral edema (HACE)

Define ataxia

the loss of full control of bodily movements

Define postural hypotension (orthostatic hypotension)

a form of low blood pressure that happens when standing after sitting or lying down. Orthostatic hypotension can cause dizziness or lightheadedness and possibly fainting.

characteristics of high altitude pulmonary edema (HAPE)

1. caused by increased pulmonary artery pressure

2. symptoms begin 24-72hrs after exposure to high altitudes

3. most lethal of all altitude illnesses

4. progressive cough, hypoxia, tachypnea, weakness at altitude >8000ft

5. may develop crackles, wheezes, rhonchi, tachycardia, cyanosis

6. O2 administration and decent to altitude < 500ft is essential

In the adult patient, the average tidal volume is: _________mL.

500mL

Most commonly, the maximum cmH2O we should administer through CPAP is: ______cmH2O.

10

When using the Miller blade, the tip of the blade is applied directly to the ________ to expose the cords.

epiglottis

When using the Macintosh blade, the tip of the blade is inserted into the:

vallecula → displaces tongue to the left to lift the epiglottis without touching it

True or False: When nasotracheally intubating a patient, he or she must be breathing.

TRUE

Which mnemonic should be used to assist in diagnosing endotracheal tube problems?

“DOPE” (diagnosing tube problems)

Displacement or dislodgement

Obstruction

Pneumothorax

Equipment failure

A normal ETCO2 level is: ____ to ____.

35mmHg to 45mmHg