EMT Crash Course: Chapter 9: Airway, Respiration, and Artificial Ventilation

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Ventilation

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Medicine

130 Terms

1

Ventilation

moving of air in & out of the lungs; required for effective oxygenation & respiration

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Inhalation

active part of ventilation; energy is required

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3

During inhalation

diaphragm & intercostal muscles contract → intrathoracic pressure decreases → vacuum is created → thorax enlarges → air passes through upper airway to lower airway → gets to alveoli

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4

Exhalation

passive part of ventilation; no energy is required

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5

During exhalation

diaphragm & intercostal muscles relax → thorax decreases → air is compressed out of the lungs

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6

Air obstruction

blockage of an airway structure leading to the alveoli; will prevent effective ventilation

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Causes of airway obstruction include

tongue (#1 common cause), fluid (saliva, blood, mucus, vomit), swelling, & foreign bodies

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8

Methods of controlling oxygen delivery

increasing/decreasing rate of breathing & increasing/decreasing the tidal volume of breaths

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9

Hypoxia

inadequate delivery of O2 to the cells

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10

Early indications of hypoxia

restlessness, anxiety, irritability, dyspnea, cyanosis, and tachycardia

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11

Dyspnea

shortness of breath

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Late indications of hypoxia

altered/decreased level consciousness, severe dyspnea, cyanosis, and bradycardia

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Bradycardia

slow heart rate

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14

Carbon dioxide drive

body's primary system for monitoring breathing status; body monitors CO2 leels in the blood & cerebrospinal fluid

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Hypoxic drive

backup system CO2 drive, monitors oxygen levels in plasma, may be used by end-stage chronic obstructive pulmonary disease patients who have high levels of CO2

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Prolonged exposure to high concentrations of oxygen in hypoxic drive patients

may depress spotaneous ventilations

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17

Do not _______ from acutely ill/injured patients

withhold oxygen

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18

Oxygenation

delivery of oxygen to the blood; ventilation is required

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19

Oxygenation is required for respiration BUT

does not ensure respiration

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20

Surrounding air

contains about 21% O2

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21

Expired air

contains about 16% O2

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22

Respiration

exchange oxygen & CO2

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23

Heart and brain become irritable due to

lack of oxygen almost immediately

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24

Brain damage begins within

about 4 minutes

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25

Permanent brain damage likely within

6 minutes

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26

Irrecoverable injury is likely within

10 minutes

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27

Airway/Breathing Assessment

  • Look for chest rise/fall

  • Listen for breathing, ability to speak, & lung sounds

  • Feel for air movement & chest rise/fall (Put ear near patient or hand on patient's chest)

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Adequate Breathing

normal RR & rhythm, nonlabored breathing, adequate tidal volume, & clear bilateral lung sounds

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Inadequate breathing

  • Abnormal RR or breathing pattern

  • Nasal flaring (enlargement of nostrils)

  • Abnormal, diminished, or absent lung sounds

  • Paradoxical motion (flail chest segment moves in opposite direction of the thorax

  • Unequal chest rise/fall

  • Dyspnea, accessory muscle use, retractons

  • Cyanosis

  • Agonal respiration (dying gasps)

  • Apnea (no breathing)

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30

Auscultation

use of stethoscope to listen for lung sounds; left lung field is always compared to right lung field (side to side never top to bottom)

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Anterior auscultation

  • Place the stethoscope at the midclavicular line about the second intercostal space (2 inches below clavicle but above nipple line)

  • Auscultate bilaterally (on both sides of the chest)

  • Place the stethoscope at about the 4th intercostal space at midaxillary line

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Posterior auscultation

Place the stethoscope at about the midclavicular line & below the scapula bilaterally; lung sounds are often easier to access/hear posteriorly

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33

Normal lungs sounds

clear & equal bilaterally

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34

Absent/diminished lung sounds

indicates little or no air exchange

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35

Wheezing lung sounds

high pitched sounds usually heard during exhalation (lower airway)

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36

Rales

"wet" or "crackling" sounds (upper airway) caused by pneumonia. bronchitis. respiratory infections that cause mucus buildup)

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37

Stridor

high-pitched sounds indicating partial upper airway obstruction (auscultated in upper airway/neck)

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38

Rhonchi

low-pitched sounds resemble snoring (upper airway)

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39

Pulse Oximetry

considered the "sixth vital sign."; Monitoring of oxygen saturation (SaO2) is now part of the standard of care for EMS; often a function provided on cardiac monitor/ defibrillators

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SaO2

measures % of hemoglobin (RBC) that are saturated with O2; does not identify definitively how much oxygen is in the blood, but it's an indication of respiratory efficiency

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Normal SaO2

>98%, but <945 indicates the need for supp O2

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Advantages of pulse oximetry

fast, easy, noninvasive assessment tool

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43

Limitations of pulse oximetry

  • Indication of respiratory efficiency, not confirmation

  • Cannot measure the amount of hemoglobin, only the oxygen saturation of the hemoglobin that is present

  • Other clinical assessments must be performed as well

  • Measurement may be difficult to obtain on some patients due to hypovolemia, hypothermia, anemia, nail polish, carbon monoxide poisoning

  • Measures saturation of hemoglobin; it can- not distinguish between oxygen saturation and carbon monoxide saturation.

  • Time delay between patient's pulse oximeter reading & current RR

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44

Head-tilt-chin left

preferred manual method of opening the airway

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45

Indications for Head-tilt-chin lift

altered/decreased LOC, suspected airway obstruction, requiring suctioning

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46

Contraindications for Head-tilt-chin lift

Suspected c-spine injury

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47

Indications for Jaw-thrust maneuver

patients with altered/decreased LOC AND suspected c-spine injury

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48

Contraindications for Jaw-thrust maneuver

conscious patients

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49

Oropharyngeal airway (OPA)

used to prevent the tongue from obstructing the airway; failure to size or insert OPA correctly can cause the tongue to block the airway; remove OPA if patient gags

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50

Indication for OPA

unresponsive patients without a gag reflex

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51

Contraindications for OPA

conscious patients or any patient with intact gag flex

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52

Sizing OPA

measure from the corner of mouth to earlobe

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53

Inserting OPA in Adults

  1. Manually open airway

  2. Suction if needed

  3. Insert OPA upside down with distal end pointing toward roof of mouth

  4. Rotate 180° while advancing OPA until flat

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54

Inserting OPA in Pediatrics

  1. Manually open airway

  2. Suction if needed

  3. Depress tongue with depressing

  4. Insert directly or insert sideways and rotate

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55

Nasopharyngeal Airway (NPA)

used to prevent tongue from obstructing airway in patients that can't protect their own airway

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Indications for NPA

unresponsive patient w/o gag reflex & patients with decreased LOC but with intact gag preventing use the OPA

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Contraindications for NPA

conscious patients with gag reflex that can protect their airway, severe head/facial trauma/injury; resistance to insertion in both nostrils; NPAs are not typically used for patients <1yr

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58

Sizing NPA

measure from tip of nose to earlobe

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Inserting NPA

  1. Lubricate NPA with water-solube lubricant

  2. Always insert NPa with bevel toward septum

  3. Try larger nostril first & switch if needed

  4. Advance gently, rotating as necessary, DO NOT force

  5. Remove immediately if patient gags

  6. Suction if needed

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60

Aspiration

entry of matter into lungs, drastically increases risk of death

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Indications for Suction

secretions (blood, vomit, mucus, oral secretions, etc.) in the airway that could be aspirated, obstruct the airway, or interfere with ventilations or insertion of a mechanical airway adjunct

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Suction should generally be performed

after the airway is opened manually and before insertion of mechanical airway adjunct

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63

Suction units

should be able to generate a vacuum of 300 mmHg when tubing is clamped

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64

Fixed suction

suction unit permanently mounted in a vehicle, hospital

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65

Hand-powered suction

manually powered portable suction unit

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66

Suction catheter

attaches to the suction unit & is inserted into the patient's airway to remove secretions; single-patient use only (tubing & disposable canisters as well)

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67

Rigid suction catheter (tonsil tip or Yankauer)

best suited for suctioning the oral airway

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French catheter (whistle-tip)

flexible catheter that comes in several sizes, best suited for suctioning nose, stoma, or inside of advanced airway device

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69

Suctioning increases the risk of

hypoxia

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70

Adults Max Suction time

15 seconds

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71

Pediatric Max Suction time

10 seconds

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72

Infant Max Suction time

5 seconds

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73

Recovery position (patient on his side)

reduces sick of aspiration; unresponsive patients with adequate breathing and no c-spine should be in this position

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74

Supplemental Oxygen

goal → maintain pulse ox of ≥94%, not needed if no signs or resp. Distress or ≥94% pulse ox

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Indications for Supp O2

  • Cardiac arrest

  • Receiving artificial ventilation

  • Suspected hypoxia

  • Signs of shock (hypoperfusion)

  • Pulse O2 < 94%

  • Altered/decreased LOC

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76

Oxygen cylinders

seamless steal or aluminum cylinder of various sizes, usually green, can never be left standing unattended, amount of O2 measured in psi (full cylinder has about 2000 psi)

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Cylinder should be taken out of service & refilled if below

200 psi

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78

Pin indexing system

safety feature that prevents a CO2 cylinder from being connected to O2 regulator

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79

Flow meters/pressure regulators

Flow meters are connected to pressure regulators. In combination, they re- duce the pressure coming from the tank to safe levels and allow a specific flow rate. The flow rate is measured in liters per minute (lpm or L/ min)

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80

Nonrebreathers (NRB) masks

preferred method O2 admin in prehospital, referred to as "high-flow" O2 admin, available in adult and pediatric sizes

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81

Flow rate of NRB

10-15 LPM

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Oxygen delivered in NRB

up to 90%

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Cautions of NRB

prolonged use can dry & irritate nasal passage if oxygen is not humidified

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84

Simple face mask

similar to nonrebreather, but w/o oxygen reservoir; flow rate → 6-10 lpm, 40-60% oxygen

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85

Venturi mask

mask delivers precise concentration of low-flow oxygen, rarely used in the prehospital environment

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86

Tracheostomy

surgical procedure that creates an opening through the neck & into the trachea

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87

Humidification of oxygen

increases the moisture of supplemental O2 by flowing it through water prior to inhalation by the patient

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88

Oxygen toxicity

alveoli can collapse due to long-term exposure to high concentrations of oxygen; rarely occurs in prehospital environment

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89

Respiratory depression

risk for COPD patients on the hypoxic drive however, it typically requires long- term exposure to high-concentration oxygen; retinal damage can occur in newborns with lon-term exposure to high concent. O2

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90

Assisted Ventilation (also artificial ventilation or positive pressure ventilation (PPV))

includes mouth to mask, flow-restricted, oxygen-powered ventilation device & automatic transport ventilators and BVM; indicated for any patient with inadequate spontaneous breathing leading to severe respiratory distress or failure

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91

Bronchoconstriction

narrowing of the airways

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92

Pulmonary edema

condition caused by too much fluid in the lungs; This fluid collects in the many air sacs in the lungs, making it difficult to breathe

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Apnea

no spontaneous breathing

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94

Agonal breaths

shallow, ineffective gasps

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95

Bradypnea

slow breathing

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Tachypnea

fast breathing

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97

Hypoventilation

breathing too slow or shallow

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Any unresponsive patient receiving artificial ventilations should have an airway adjust in place to

prevent the tongue from obstructing the airway

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99

Complications of PPV

  • Increased intrathoracic pressure, which reduces circulatory efficiency

  • Gastric distention, which increases the risk of vomiting & can compromise ventilatory efficiency

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100

Hyperventilation

common mistake; occurs when ventilations are provided too fast, too deep, or both

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