Airway Respiration Ventilation

Anatomy of the Respiratory System Upper airway

Nasopharynx: (nasal cavity)

Oropharynx: (mouth)

Pharynx: (throat)

Laryngopharynx (the lowest part of the throat, sitting just behind the larynx (voice box). It is the critical intersection where the respiratory and digestive tracts meet)

Epiglottis: (flap that prevents from entering respiratory tract)

Esophagus: (food and water routed to the stomach)

Larynx: (vocal cords)

Cricoid cartilage: (only completely circular cartilaginous ring of the upper airway

Anatomy of the Respiratory System Upper airway 1

Nasopharynx: (nasal cavity)

Oropharynx: (mouth)

Pharynx: (throat)

Anatomy of the Respiratory System Upper airway 2

Laryngopharynx (the lowest part of the throat, sitting just behind the larynx (voice box). It is the critical intersection where the respiratory and digestive tracts meet)

Epiglottis: (flap that prevents from entering respiratory tract)

Esophagus: (food and water routed to the stomach)

Anatomy of the Respiratory System Upper airway 3

Larynx: (vocal cords)

Cricoid cartilage: (only completely circular cartilaginous ring of the upper airway

Nasopharynx

(nasal cavity)

Oropharynx

(mouth)

Pharynx

(throat)

Laryngopharynx

(the lowest part of the throat, sitting just behind the larynx (voice box). It is the critical intersection where the respiratory and digestive tracts meet)

Epiglottis

(flap that prevents from entering respiratory tract)

Esophagus

(food and water routed to the stomach)

Larynx

(vocal cords)

Cricoid cartilage

(only completely circular cartilaginous ring of the upper airway

Lower airway

(starts at lower edge of larynx and moves down)

Esophagus: (tube for food)

Trachea: (windpipe)

major bronchi

Right and left mainstem bronchi branch into

bronchioles: composed of smooth muscle and lined with mucous membranes

Bronchioles are made up of millions of tiny air sacs called alveoli (site for gas exchange)

Diaphragm

muscle that separates the chest cavity from the abdominal cavity

Intercostal muscles

muscles between ribs that contract to aid inhalation

Ventilation

It travels through the trachea

physical act of moving air into and out of the lungs

Inhalation

Active muscular part of breathing

Diaphragm and intercostal muscles contract

Dead space

the volume of air that is inhaled that does not take part in the gas exchange

150 Ml~

Alveolar Ventilation

Amount of oxygen that gets to the Alveoli

Tidal volume minus dead space

Tidal volume:

The amount of air (ML) that moves in and out of the lungs in one breath

Minute volume

The amount of air that moves into the lungs in 1 minute

=tidal volume*respiratory rate

Vital capacity

The amount of air that can be forcefully expelled from the lungs after breathing deeply

Residual volume

Air that remains in the lungs after forceful exhalation

Helpful during CPR

Exhalation

Passive process; diaphragm and intercostal muscles relax

Does not normally require muscular effort

Oxygenation

Process of loading oxygen molecules onto hemoglobin molecules in the bloodstream

Respiration

Cells take energy from nutrients through metabolism

oxygen is required for internal respiration to take place

Exchange of oxygen and Carbon dioxide in the alveoli and tissues of the body

Head Tilt/Chin Lift

heel of one hand on patient’s forehead, firm pressure applied to tilt the patient’s head back; fingertips of alternate hand placed under lower jaw and chin lifted upward

can be used on trauma patient IF jaw thrust fails to open airway

avoid if spinal injury is suspected unless there is no alternative way to open airway

Jaw thrust maneuver

(If cervical/spinal trauma suspected (even if no obvious signs)

fingers behind angle of lower jaw, jaw moved upward with index and middle fingers and the thumbs help position the lower jaw

Inadequate breathing

adventitious breath sounds, bradypnea, tachypnea (shortness of breath),

Irregular rhythm

diminished/noisy breath sounds,

unequal shallow chest expansion,

accessory muscle use,

cyanosis, cool moist skin,

skin pulling in around the ribs (retractions)

Inadequate oxygenation:

tachypnea, dyspnea, confusion, lethargy, dizziness, lightheaded, anxiety, irritability, restlessness, headache

Causes for bad Pulse Ox:

1. dark/metallic nail polish, dirty fingers

2. CO poisoning

3. hypovolemia

4. severe peripheral vasoconstriction (hypoxia, smoking, hypothermia)

5. cool proximal extremities reflect poor perfusion and shunting of blood to core

bright ambient light Capillary Refill

good test of circulation in children

color should return to the skin in under 2-3 seconds

It is performed by pressing firmly on the skin or nail bed to force the blood out, and then counting the seconds it takes for the natural pink color to return.

hypovolemia

medical condition characterized by an abnormally low volume of circulating blood or extracellular fluid in the body

Hypoxia symptoms

Early: restless, irritable, apprehensive, tachycardic, anxious, tripod position, retractions

Late: altered mental, weak/thready pulse, cyanosis, hypoxia, bradypnea, bradycardia, altered LOC

Causes for Cyanosis

chronic bronchitis, hypoxia, hypothermia

Anemia

lack of Red blood Cells, appear weak and have pale skin

Stridor

brassy, high-pitched crowing sound heard during inhalation.

It suggests a partially occluded airway; upper airway obstruction

Wheezing

high-pitched whistling sound; exhalation;

bronchi constricted; lower airway constricted

(common in asthma, COPD)

Rhonchi

low-pitched, noisy sounds that are most prominent on exhalation,

suggesting mucus in the lungs,

often accompanied by productive cough (COPD, pneumonia, asthma, bronchitis)

Lower airway

Crackles/Rales, what underlying disease

wet cracking sounds; air passing through fluid in alveoli;

Congestive Heart Failure, pulmonary edema.

Lower airway

Gurgling

Fluid in upper airway- requires suction

Snoring

upper airway obstruction

Vesicular

normal breath sounds

Sniffing position

patient sitting upright with head and chin thrust slightly forward

best for ventilation and intubation

keeps trachea straight and maintains proper spinal alignment

patient on firm surface, small towel under patient’s shoulders and back, stabilize patient forehead to limit rolling during transport

Abdominal Thrust (Heimlich) adult

conscious but has a foreign body obstruction -

to clear airway obstruction (complete, patient unable to speak or cough)

severe obstruction: weak/absent cough, cyanosis, decreasing LOC

stand behind patient, wrap one arm around make fist with one hand, grasp fist with other hand; place thumb side against patient abdomen just above umbilicus and below xiphoid process; press fist into abdomen in quick inward and upward thrust

Abdominal Thrust (Heimlich) other populations

Kids: just above umbilicus and well below tip of sternum

If LOC, start CPR and chest compressions

Infants: back blows + chest thrusts

5 back blows between shoulder blades using heel of hand, 5 chest thrusts on lower part of sternum using 2 fingers

Pregnant/Obese: chest thrusts in instead of abdominal thrust

For mild/partial airway obstructions:

wheezing, stridor, and coughing are common

provide oxygen, place in position of comfort, and rapidly transport

indicated by patient being able to breath and talk

avoid ventilation, manual attempts to remove object, abdominal thrusts

If obstruction is VISIBLE: use gloved index finger to sweep it forward

encourage patient to cough forcefully

Unresponsive: begin chest compressions

oxygen cylinder, how to prepare it

is cracked before attaching regulator to remove dust and other particles -wrench rotates

valve counterclockwise then clockwise

Oxygen cylinders sizes

D: 0.16

E: 0.28

M: 1.56

G: 2.41

H: 3.14

K: 3.14

D-size: 350 L

Jumbo D-size: 500 L

E-size: 625 L

M (MM)-size: 3,000 L

G-size: 5,300 L

H, A (M4), or K-size: 6,900 L

non rebreather mask vs bag valve mask

Non-Rebreather (NRB) mask for patients who are breathing on their own but require high-flow oxygen.

Use a Bag-Valve Mask (BVM) only when a patient's breathing is absent, severely inadequate, or they cannot maintain their own airway

Non Rebreather Mask:

1. up to 90-95% oxygen when reservoir bag is filled

2. bag should be fill before mask is placed on patient (place finger over bag outlet)

3. if oxygen is not flowing, patient exposed to rebreathing exhaled carbon dioxide

4. for patients with adequate breathing with suspected/confirmed hypoxia

5. provide ventilations at same rate as patients and slowly adjust to normal

Bag valve mask: rate of breaths

1. 100% oxygen with filled reservoir bag

2. supplemental oxygen 10-15 lpm

3. 1 breath every 5-6 seconds for adults

4. 1 breath every 3-5 seconds for kids

5. 2 person is best: 1 person maintains mask seal with 2 hands, other ventilates with BVM

6. for patients with signs of inadequate breathing/respiratory distress

7. if gurgling is heard, remove mask, inspect oropharynx, suction as needed

8. 1200-1600 mL volume capacity (500 mL for peds and 240 for infant)

9. 500-600 mL over 1 second is appropriate tidal volume

10. overventilation can cause pneumothorax, gastric distention, vomit aspiration

Bag valve mask 1, oxygen percentage and rate

100% oxygen with filled reservoir bag

supplemental oxygen 10-15 lpm

Bag valve mask breath rate

1 breath every 5-6 seconds for adults

1 breath every 3-5 seconds for kids

Bag valve 2 logistics, when to use it, problems

2 person is best: 1 person maintains mask seal with 2 hands, other ventilates with BVM

for patients with signs of inadequate breathing/respiratory distress

if gurgling is heard, remove mask, inspect oropharynx, suction as needed

Bag valve volume

1200-1600 mL volume capacity (500 mL for peds and 240 for infant)

500-600 mL over 1 second is appropriate tidal volume

Bag valve risks

overventilation can cause:

• pneumothorax

• gastric distention

• vomit aspiration

• Hyper-oxygenation: rare complication

Bag valve common complications

common complications:

• poor mask seal,

• poor head position,

• gastric distention,

• barotrauma

• decreased cardiac output from increased intrathoracic pressure

Hyperventilation

over breathing, reduced arterial CO2

causes: diabetic ketoacidosis, aspirin overdose, severe infection

result: anxiety, dizziness, numbness/tingling, spasms in hands and feet (respiratory alkalosis)

instruct patient to slow breathing, give supplemental oxygen, provide transport

Mouth to mask device:

55% oxygen with supplemental oxygen at 15 lpm

a portable, life-saving barrier tool used to safely deliver rescue breaths during CPR.

Nasal Cannula, what is it, oxygen percentage, lpm, when to use it

a lightweight, flexible medical device used to deliver supplemental oxygen directly into the nostrils of people with respiratory conditions

24-44% oxygen

1-6 lpm

not appropriate is hypoxia is suspected (NRB should be used)

for patients who don’t require high flow oxygen, can’t tolerate a NRB or have a specific illness (COPD, bronchopulmonary dysplasia)

Pocket mask

one way valve prevents backflow of secretions, vomitus, gases

supplemental oxygen can be attached to barrier device

55% oxygen at 15 lpm

a portable device used to safely deliver rescue breaths during CPR or respiratory arrest.

Blow by blow technique

a medical technique where oxygen is gently directed toward a patient's nose and mouth without attaching a device directly to their face. It is typically reserved for infants, young children, or patients with disabilities who panic or become agitated when wearing a standard nasal cannula or face mask

less frightening oxygen for kids

tubing inserted into a small hole into cup or funnel, connected to oxygen source (6 lpm)

cup held 1-2 inches from child’s face

CPAP

• By holding the airway open, CPAP prevents throat muscles from collapsing. This eliminates gasping, improves sleep quality, and reduces the risk of long-term health issues like stroke and heart disease

• provides pressure to keep alveoli open/reverse atelectasis from pulmonary edema

  • Pulmonary edema is a serious condition where excess fluid builds up in the lungs' air sacs (alveoli), causing severe shortness of breath

CPAP used for

indicated for

1. respiratory distress

2. pulmonary edema

3. hypoxia

4. COPD

5. recent submersion incident

6. rapid breathing affecting minute volume

7. pulse ox below 90

CPAP used for 1

1. respiratory distress

2. hypoxia

3. rapid breathing affecting minute volume

4. pulse ox below 90

CPAP used for 2

1. pulmonary edema

2. COPD

3. recent submersion incident

CPAP contradicted for

respiratory arrest,

Hypoventilation,

can’t speak or protect airway,

hypotension (less than 90 systolic BP),

chest trauma,

pneumothorax,

GI bleed or surgery,

can’t sit upright,

can't tolerate mask/seal,

facial trauma

CPAP contradicted for 1

respiratory arrest,

Hypoventilation,

can’t speak or protect airway,

CPAP contradicted for 2

hypotension (less than 90 systolic BP),

chest trauma,

pneumothorax,

GI bleed or surgery,

CPAP contradicted for 3

can’t sit upright,

can't tolerate mask/seal,

facial trauma

CPAP complications

complications: claustrophobia, gastric distention, hypotension, decreased blood return/preload

atelectasis

the partial or complete collapse of a lung or its air sacs (alveoli)

CPAP complications

claustrophobia, gastric distention, hypotension, decreased blood return/preload

Venturi Mask

24, 28, 35, or 40% oxygen depending on adaptor

Oropharyngeal Airway (OPA)

• to keep tongue from blocking upper airway (will not prevent liquids)

• contradicted for intact gag reflex, conscious patients, petroleum ingestion, NPA is an option

• gently remove by following curvature of the mouth

• rough insertion can cause bleeding

• after inserted, reassess airway before assisted ventilation or further intervention

• Peds: measure using length based resuscitation tape (Broselow tape) or place airway next to child’s face with flange at level of central incisors and bite block segment parallel to hard palate, tip should reach angle of the jaw

nasopharyngeal airway (NPA)

• indicated for unconscious or semiconscious with intact gag reflex or won't tolerate OPA

• contradicted for severe head injury, blood draining from nose, fractured nasal bone, basilar skull fracture: CSF draining from ears, ecchymosis under eyes (racoon eyes), or behind one ear (Battle sign) are severe head injury

Carbon monoxide (CO) Poisoning

flu like symptoms, dizziness, fatigue, headache, impaired judgment, confusion, hallucination, syncope, seizure

Cyanide poisoning

dyspnea, respiratory arrest, tachypnea, flushed skin, tachycardia, altered mental, seizures, coma, cardiac arrest

Extended transport for Croup:

indication for humidified oxygen

respiratory rate by population

• Ages 0 to 12 months: 30 to 60 breaths per minute

• Ages 1 to 3 years: 24 to 40 breaths per minute

• Ages 4 to 5 years: 22 to 34 breaths per minute

• Ages 6 to 12 years: 18 to 30 breaths per minute

• Ages 13 to 18 years: 12 to 16 breaths per minute

• Ages 18 and up: 12 to 20 breaths per minute

Children

Pediatric Assessment Triangle: Appearance, Work of Breathing, Circulation

children bradycardia risk

critical hypoxia ischemia

Children Ominous sign of respiratory arrest

(below 20 for kids under 6 and below 12 for older)

Children hypertension

hypertension not a clinical problem; hypotension definitely hypotensive shock, “normal” value is compensated shock

evaluating perfusion in children

• capillary refill more reliable method of evaluating perfusion in children

children anatomy differences

• tongues larger

• trachea smaller, easily obstructed

• narrowest part of airway is cricoid ring: inferior to thyroid cartilage, lowest part of larynx, first and only complete ring of trachea

• diaphragm more relied on for breathing; abdominal breathing is a normal finding (chest cavity can’t optimally contribute to breathing)

signs of increased work:

•  grunting, wheezing 

• accessory muscle use

• retractions (drawing in intercostal or substernal muscles),

•  head bobbing

• nasal flaring

• Tachypnea

• tripod position

Rigid Catheter:

• should be measured from corner of mouth to tip of earlobe

• apply suction only while withdrawing the catheter

• prolonged suction (over 10 s) can cause vagal stimulation, further hypoxia or bradycardia

• insert to depth measured (not to resistance or base of tongue)

• Suctioning: at least 300 mmHg vacuum pressure

• turn head to side if no spine injury

rigid catheter steps

1. assemble unit

2. ensure vacuum of more than 300 mmHg

3. turn patients head (if no c spine)

4. open mouth using cross finger or tongue jaw lift

5. insert catheter only as far as can be visualized

6. apply suction in a circular motion during withdrawal