Respiration & Artificial Ventilation (Ch. 10)

Include definitions for the subtypes of each if there are any.

Ventilation vs Respiration vs Diffusion

Ventilation is defined as breathing in and out.

There is also Alveolar Ventilation, which is the volume of air that reaches the alveoli.

Diffusion refers to the general process of moving molecules from places of higher concentrations to places of lower concentration.

Respiration refers specifically to the diffusion of oxygen and carbon dioxide, there are two subtypes:

1. Pulmonary Respiration

Exchange of oxygen and carbon dioxide that occurs between the pulmonary capillaries and the alveoli.

2. Cellular Respiration

Exchange of oxygen and carbon dioxide between the cells of the body and the circulating blood.

Reductions in tidal volume vs reductions in alveolar ventilation

Alveolar ventilation is the amount of air that reaches the alveoli,

this is determined by the tidal volume minus the dead air space.

Since the dead air space is always the same, let’s say 500, if the normal tidal volume of 1000 is reduced .75x to 750, the alveolar ventilation is reduced by half so the person gets half the oxygen.

So lesser reductions in tidal volume can lead to large reductions in alveolar ventilation

What are the three ways that a breakdown of the cardiopulmonary system can occur?

1. Mechanics of breathing

2. Alveoli gas exchange interrupted

3. Circulation issues

What are the levels of breathing to not breathing and what treatment do we give for each level?

Adequate Breathing: Nonrebreather or Nasal Cannula

Increasing Respiratory Distress: Nonrebreather

Severe Respiratory Distress, Respiratory Failure, Signs of Hypoxia: Bag Valve Mask (BVM) or Pocket Face Mask (PFM)

Respiratory Arrest: BVM or PFM

Difference in children vs adults for a symptom of hypoxia. (not a compensatory symptom)

Children have more sensitive vagal nerves than adults (this is something to watch out for with suctioning as well), and hypoxia can lead to vagal nerve stimulation.

Because of this, bradycardia is a critical sign for children.

Prolonged inspiration vs prolonged expiration

Prolonged inspiration is a sign of upper airway obstruction

Prolonged expiration is a sign of lower airway obstruction.

This is because the negative pressure from inhalation contracts the single upper airway forcing all the force on one.

For lower airway it’s more intuitive hard to explain.

Emphysema

Alveoli become inflated, which decreases pulmonary respiration

What are the negative effects of PPV

1. Decreased cardiac output

Normally the heart relies on the negative pressure generated when breathing, but this positive pressure works opposite to this process.

2. Gastric distention

Air gets pushed into the lungs, self explanatory. Interestingly this can be fixed in part by improving the airway because more pressure needed to push air in puts more pressure on the stomach.

3. Hyperventilation

Having too much carbon dioxide being blown off can lead to vasoconstriction which can limit the blood flow to the brain.

How much volume and frequency to ventilate patients with.

12-20 bpm for pediatrics

10-12 for adults

Until the belly slightly rises.

What are the 3 types of artificial ventilation?

1. Mouth-To-Mask

2. Two-Rescuer Bag-Valve Mask

3. One-Rescuer Bag-Valve Masks

What should be done when giving artificial ventilation to a patient with rapid vs slow ventilations

It’s important to assess the adequacy of the respirations and explain/reassure the patient.

Then you place the mask on the patient.

For rapid you give ventilations with the patient’s breaths and slow over time.

With slow you give ventilations in between the patient’s ventilations as needed.

What two things are needed for the positive pressure ventilations to work? (5 things for one of them)

I’m referring to like the most basic necessary things, not rate or depth or anything.

1. Open airway. Chapter 9 covered this.

2. Sealed Mask.

   1. Should extend from bridge of patient’s nose where the apex of the mask is to the cleft of chin where the lower part o the mask is,

   2. Wide enough to cover whole mouth.

   3. Dentures should be left in

   4. Large beards should be wetted.

   5. Use two handed mouth technique

What’s PFM

Pocket Face Mask

What are the steps for two-rescuer BVM (5 steps)

1. Open airway as appropriate for spine. Place patient in the head-elevated sniffing position if it’s possible to do so without risk to spine. Place airway adjunct.

2. Select the correct sized mask and place apex on nose bridge.

3. One person places thumbs on the mask (fingers pointed inferiorly)

4. Index, middle, and ring fingers on jaw, same as jaw thrust I think.

5. Squeeze bag until the patient’s chest begins to rise every 5-6 seconds for an adult and 3-5 seconds for a child.

I could see 3 and 4 being just one step as well.

One-Rescuer Bag-Valve Mask

How good is it compared to one rescuer pocket mask?

What are the steps?

It’s the worst type of ventilation, worse than one rescuer pocket mask.

The steps are the same as two rescuer except instead of the jaw thrust and thumbs on the mask, you make a ring with your thumb and index finger, and use your other three fingers to do your best holding the jaw.

What are the steps for ventilating a patient with a stoma?

1. Clear stoma of whatever is blocking it

2. Leave patient in the neutral position, as opening the airway is unnecessary for stoma breathers.

3. Use a pediatric sized mask to seal around the stoma

4. Ventilate every 5-6 seconds for children and every 3-5 seconds for adults

5. If that doesn’t work then try the mouth and nose (though sometimes it’s cut off, in that case tough luck ig)

How much do you ventilate adult and children patients.

Every 5-6 seconds for adults, this is 10-12 times per minute.

Every 3-5 seconds for children, this is 12-20 times per minute.

What are automatic transport ventilations

Just a mechanical form of artificial ventilations, which have settings to change volume and rate.

What is the safe residual?

How do you calculate the duration of flow in minutes.

200 psi, the minimum pressure that your oxygen tank can have for it to still be considered safe.

(The gauge pressure minus The safe residual pressure) *cylinder constant/flow rate in minutes

What’s important to make sure of when using gauges, regulators, and tubing?

Make sure that it is made of oxygen use.

What’s important to consider when choosing a wrench to use with oxygen.

Use nonferrous wrenches otherwise they produce a spark

It’s important to make sure ___ is in good condition

Valve Seat Inserts and Gaskets should be in good condition

What type of oxygen do you use, what label, how old?

It’s important to use medical grade oxygen as industrial grade oxygen containers impurities.

It should be labeled OXYGEN U.S.P

Should be no more than 5 years old

What do you have to do whenever you open oxygen

Open the valve fully then close it halfway to prevent people from thinking it’s closed.

Where do you store oxygen

How do you use oxygen

Oxygen must be stored in a cool, ventilated, and secure room.

If it falls it can turn into a missile, so it shouldn’t be put anywhere it can fall

Don’t leave oxygen cylinders standing upright without being secured, even in use.

How often do oxygen cylinders have to be tested and what are they tested for

They are hydrostatically tested every 5 years

What’s never allowed around oxygen equipment use (3 things)

Smoking

Grease, Oil, or Fat (even from hands)

Adhesive Tape

How should oxygen cylinders not be moved

dragging them or rolling them on their side

What is the function of pressure regulators?

What do they connect to?

What are the two connection types?

What do you have to do before connecting the regulators?

What is the safe working pressure?

The function is to maintain a safe pressure for the patient, since the normal pressure of the cylinder itself is very high.

For E and smaller, they use a pin-index safety system which has a yoke assembly.

For larger than E they use a threaded outlet.

Before connecting the regulators you have to “crack the tank”, or slightly open it to clear out dirt and dust.

30-70 psi is considered the safe range.

Humidifiers, what do they connect to and how do they work? What’s their purpose?

Connect to the flowmeter, air goes through water in bubbles humidfying it.

They prevent drying out mucous membranes which can happen on long transports. There is an infection risk, so it’s only used when drying out would be an issue.

What is the flowmeter’s function?

What does it connect to?

What are the types and subtypes of flowmeters

Flowmeters control the amount of oxygen allowed through (the flow rate) in liters per minute.

They are usually permanently attached to the pressure regulator.

1. Low-Pressure Flowmeters. In general use in the field.

   1. Pressure-Compensated Flowmeter. This is the gravity dependent one that floats a ball therefore has to be in an upright position.

   2. Constnat Flow Selector Valve allows you to select the flow at any angle.

2. High-Pressure Flowmeters. Sometimes higher pressure is needed for oxygen-powered devices.

What is the concentration and liters per minute for nonrebreather masks?

80-90% concentrations at 12-15 liters per minute

Bag must be inflated before putting it on a patient’s face, to inflate the bag you cover the exhaust port.

What’s the concentration and liters per minute for nasal cannula

22-44% oxygen at 4-6 liters per minute.

What’s the concentration and liters per minute for partial rebreather mask?

40-60% oxygen at 9-10 liters per minute.

Partial rebreather because 1/3 of the air is breathed back in

What’s the concentration and liters per minute of venturi masks?

Different tips result in different concentrations when used at their own specific liters per minute.

What’s the concentration and liters per minute of tracheostomy masks?

Varying concentrations,

8-10 liters per minute.

What do we do for pediatric patients who are too scared of traditional ventilation?

We do the “blow-by” technique where we hold the oxygen thing 2 inches from their face, there are stuffed animals made just for this and some people use non-styrofoam cups.

Styrofoam can flake off which can be inhaled.

What are the potential jobs of the EMT when assisting in Advanced Airway

1. Preoxygenate the patient

2. Help visualize vocal cords with BURP method,

Bringing Up and to the Right Position (the thyroid cartilage) or by just pressing on the cricoid cartilage.

3. Listen for sounds entering both sides of the lungs and epigastrium. There should be sounds entering the lungs and both sides incase the tube is in a mainstem bronchus, but obviously sounds of air entering the epigastrium is quite bad.

What is the maximum amount of time between the last and next inhalation during intubation

30 seconds is the maximum amount of time between ventilations

Ventilating intubed. What do you do

1. Always make sure

2. During Defibrillation

3. Always look for

4. Look for changes in

5. If the patient gets

If any of these are easy, delete some words.

1. You make sure that the measure of how far the tube is into the patient doesn’t change

2. You remove the bag if defibrillation begins, as the extra weight from the bag can push the tube into the patient.

3. Look for changes in resistance to the air, as this indicates something went wrong.

4. Watch for changes in the patient’s mental status, as if they wake up they will likely take the tube out.

5. If the patient gets gaggy, you might have to pull the bite block out a bit.

Describe the process of assisting with a trauma intubation

The paramedic provides manual stabilization

The EMT applies the cervical collar

EMT maintains this stabilization, and helps push vocal cords into view while paramedic performs intubation

EMT holds tube against teeth until placement is confirmed by Esophageal detector device and auscultation of lungs and epigastrium

Until the patient’s head is taped onto the backboard, provide manual stabilization. Also provide ventilation for the patient.