Respiratory Respiratory System System

AssessmentAssessment

Chemeketa Community Chemeketa Community CollegeCollege

Paramedic ProgramParamedic Program

Peggy Andrews, Instructor

A & P ReviewA & P Review- Upper Airway- Upper Airway

Nasal CavityNasal Cavity Oral CavityOral Cavity

– Hyoid boneHyoid bone Pharynx Pharynx

– NasopharynxNasopharynx– OropharynxOropharynx– HypopharynxHypopharynx

valleculavallecula

Larynx Larynx – Thyroid cartilageThyroid cartilage– Cricoid cartilageCricoid cartilage– Arytenoid cartilageArytenoid cartilage– Glottic openingGlottic opening– Vocal cordsVocal cords– Crithothyroid Crithothyroid

membranemembrane

A & P ReviewA & P Review- Lower Airway- Lower Airway

TracheaTrachea Carina Carina BronchiBronchi

– Left and right Left and right mainstemmainstem

– Secondary & Secondary & tertiary bronchitertiary bronchi

– BronchiolesBronchioles 22 divisions22 divisions

– Respiratory Respiratory bronchiolesbronchioles

Alveoli Alveoli – 1 – 2 cell layers 1 – 2 cell layers

thickthick Lung parenchymaLung parenchyma PleuraPleura

– VisceralVisceral– Parietal Parietal

Respiratory cycleRespiratory cycle

Depends on changes in pressureDepends on changes in pressure Inspiration – active processInspiration – active process Expiration – passive processExpiration – passive process

Pulmonary circulationPulmonary circulation

Exchange of oxygen and carbon Exchange of oxygen and carbon dioxidedioxide

Right side of heartRight side of heart– Pulmonary arteryPulmonary artery– Deoxegynated bloodDeoxegynated blood

Left side of heartLeft side of heart– Pulmonary veinPulmonary vein– Oxygenated bloodOxygenated blood

Measuring oxygen & carbon Measuring oxygen & carbon dioxide levelsdioxide levels

Partial pressure of gasPartial pressure of gas– Percentage of mixture’s total pressurePercentage of mixture’s total pressure

21%21%

DiffusionDiffusion– Movement of gas from higher Movement of gas from higher

concentration – lower concent.concentration – lower concent.

Oxygen concentration in bloodOxygen concentration in blood

Oxygen saturation (SpO2)Oxygen saturation (SpO2)– PaO2PaO2

90 – 100 torr normal90 – 100 torr normal

Hemoglobin moleculeHemoglobin molecule– Carries 4 oxygen moleculesCarries 4 oxygen molecules

Ventilation/perfusion mismatchVentilation/perfusion mismatch Carbon dioxide concent. In bloodCarbon dioxide concent. In blood

What regulates respirations?What regulates respirations?

Nervous impulses from the Nervous impulses from the respiratory centerrespiratory center

Stretch receptorsStretch receptors– Hering-Breuer reflexHering-Breuer reflex

ChemoreceptorsChemoreceptors Hypoxic DriveHypoxic Drive

Respiratory ratesRespiratory rates

Normal - 12 - 20Normal - 12 - 20 Controlled by other factorsControlled by other factors

– Temperature Temperature - Emotion- Emotion– Drugs and medications Drugs and medications - Hypoxia- Hypoxia– Pain Pain - Acidosis- Acidosis– SleepSleep

ObstructionObstruction– Tongue - most commonTongue - most common

Snoring, correct with positioningSnoring, correct with positioning

Foreign bodyForeign body

May cause partial or complete obstructionMay cause partial or complete obstruction– Choking, gaggingChoking, gagging– StridorStridor– DyspneaDyspnea– AphoniaAphonia

SpeechlessSpeechless

– DysphoniaDysphonia Difficulty speakingDifficulty speaking HoarsenessHoarseness

Total Lung CapacityTotal Lung Capacity– ~ 6 L~ 6 L

Tidal VolumeTidal Volume (V (Vtt))– 500 ml (5 – 7 ml/kg)500 ml (5 – 7 ml/kg)

Dead space volumeDead space volume– 150 ml in adult male150 ml in adult male

Minute volumeMinute volume– VVt X RRt X RR

Laryngeal spasm and Laryngeal spasm and edemaedema

SpasmSpasm– Sudden movement/contractionSudden movement/contraction

Most frequently: Most frequently: – Trauma Trauma

Aggressive intubationAggressive intubation– Post-extubation Post-extubation

Especially if patient semi-consciousEspecially if patient semi-conscious

33 year old female rescued 33 year old female rescued from a structure fire. CAO x from a structure fire. CAO x

3, RR38, SaO3, RR38, SaO2 2 64%, harsh 64%, harsh stridor on insp.stridor on insp.

EdemaEdema GlottisGlottis

– Extremely narrowedExtremely narrowed– Totally obstructedTotally obstructed

Most frequently:Most frequently:– EpiglottitisEpiglottitis

Bacterial infectionBacterial infection

– AnaphylaxisAnaphylaxis

Relieved byRelieved by– Aggressive Aggressive

ventilationventilation– Muscle relaxantsMuscle relaxants– Alternative AirwayAlternative Airway

28 year old male, snowmobile 28 year old male, snowmobile intointo

farmers fence, 20 mph.farmers fence, 20 mph.

Fractured larynxFractured larynx– Airway patency dependent on muscle Airway patency dependent on muscle

tonetone– Increased resistance by decreased sizeIncreased resistance by decreased size– Decreased muscle toneDecreased muscle tone– Laryngeal edemaLaryngeal edema– Ventilatory effortVentilatory effort

79 yo male, liquid diet, 79 yo male, liquid diet, hiccup’s during breakfast. hiccup’s during breakfast.

Severely SOBSeverely SOB SaOSaO2 2 72% RA, Upper Resp. fluid 72% RA, Upper Resp. fluid

audibleaudible– AspirationAspiration

Significantly increases mortality - 25% dieSignificantly increases mortality - 25% die Obstructs airwayObstructs airway Destroys delicate bronchiolar tissueDestroys delicate bronchiolar tissue Introduces pathogensIntroduces pathogens Decreases ability to ventilateDecreases ability to ventilate

– Commonly the beginning of the end Commonly the beginning of the end

Airway evaluationAirway evaluation

RateRate– 12-20?12-20?

RegularityRegularity Steady patternSteady pattern Irregular patterns are significant until Irregular patterns are significant until

proven otherwiseproven otherwise

Airway evaluationAirway evaluation

EffortEffort– Should be effortless at restShould be effortless at rest– Changes may be subtle in rate or Changes may be subtle in rate or

regularityregularity– Patients compensate by preferential Patients compensate by preferential

posturingposturing Upright sniffingUpright sniffing Semi-fowlersSemi-fowlers Frequently avoid supineFrequently avoid supine

Some Important PatternsSome Important Patterns

Head injury/ICP

Resp Center Lesions

DKA

Serious Illness/Terminal

Paramedic Students

Recognition of airway Recognition of airway problemsproblems

Respiratory distressRespiratory distress

– Upper and lower obstructionUpper and lower obstruction

– Inadequate ventilationInadequate ventilation

– Impairment of respiratory Impairment of respiratory

musclesmuscles

– Impairment of nervous systemImpairment of nervous system

Dyspnea may be result ofDyspnea may be result of or result in hypoxia or result in hypoxia

HypoxiaHypoxia– Inadequate OInadequate O22 at cells at cells

HypoxemiaHypoxemia– Lack of OLack of O22 in arterial blood in arterial blood

AnoxiaAnoxia– No O’sNo O’s

All therapies All therapies willwill fail if airway inadequate fail if airway inadequate

Visual CluesVisual Clues

Another Sample Pt. Another Sample Pt. What are the clues here?What are the clues here?

Our Lady (continued)Our Lady (continued)

. .

Auscultation techniquesAuscultation techniques

Air movement at mouth and Air movement at mouth and

nosenose

Bilateral lung fields equalBilateral lung fields equal

Palpation techniquesPalpation techniques

Air movement at mouth and Air movement at mouth and

nosenose

Chest wallChest wall

– Paradoxical motionParadoxical motion

– RetractionsRetractions

Bag-valve-maskBag-valve-mask

Resistance/changing compliance Resistance/changing compliance

with BVM ventilationswith BVM ventilations

HistoryHistory

EvolutionEvolution– SuddenSudden– Gradual over timeGradual over time– Known cause or “trigger”Known cause or “trigger”

DurationDuration– ConstantConstant– RecurrentRecurrent

Ease Ease - What makes it better?- What makes it better? Exacerbate Exacerbate – Aggravation of symptoms– Aggravation of symptoms AssociateAssociate - other symptoms (productive - other symptoms (productive

cough, etc)cough, etc)

HistoryHistory

InterventionsInterventions

– Evaluations/admissions to Evaluations/admissions to

hospitalhospital

– Medications (include compliance Medications (include compliance

and dose)and dose)

– Ever intubated???Ever intubated???

HistoryHistory

Modified form of respirationModified form of respiration Protective reflexesProtective reflexes

– Cough - forceful, spastic exhalation; aids in Cough - forceful, spastic exhalation; aids in clearing bronchi and bronchiolesclearing bronchi and bronchioles

– Sneeze - clears nasopharynxSneeze - clears nasopharynx– Gag reflex - spastic pharyngeal and Gag reflex - spastic pharyngeal and

esophageal reflexesophageal reflex SighingSighing

– Increases opening of alveoliIncreases opening of alveoli– Normally sigh @ 1/min.Normally sigh @ 1/min.

HiccoughHiccough– Intermittent spastic closure of glottisIntermittent spastic closure of glottis

Inadequate ventilationInadequate ventilation When body can’t compensate for When body can’t compensate for

increased oxygen demand or maintain increased oxygen demand or maintain O2/CO2 balance.O2/CO2 balance.

Many causesMany causes– InfectionInfection– TraumaTrauma– Brainstem injuryBrainstem injury– Noxious or hypoxic atmosphereNoxious or hypoxic atmosphere– Renal failureRenal failure

Multiple symptomsMultiple symptoms– Altered responseAltered response– Respiratory rate changesRespiratory rate changes

Supplemental oxygen Supplemental oxygen therapytherapy

Supplemental oxygen Supplemental oxygen

therapytherapy

– Increases OIncreases O22 to cells to cells

– OO22 increases patients increases patients

ability to compensateability to compensate

– Delivery method Delivery method

continually reassessedcontinually reassessed

Oxygen sourceOxygen source

Compressed gasCompressed gas

Common sizes Common sizes

and volumesand volumes

– DD 400L400L

– EE 625L625L

– MM 3450L3450L

Calculating Tank LifeCalculating Tank Life

Page 386Page 386

– Tank Size FactorTank Size Factor

0.16 D Tank0.16 D Tank

0.28 E Tank0.28 E Tank

1.56 M Tank1.56 M Tank

)(

)(*))500()((

LPMDesired

FactorSafeLevelTankinPSI

RegulatorsRegulators

High pressure High pressure – Transfer gas from tank to tankTransfer gas from tank to tank

– Cascade SystemCascade System

Therapy regulatorsTherapy regulators– Pressure “stepped down”Pressure “stepped down”

– Delivery via adjustable low pressureDelivery via adjustable low pressure

Delivery DevicesDelivery Devices

Nasal cannulaNasal cannula– Optimal delivery; 40% at 6 LpmOptimal delivery; 40% at 6 Lpm– IndicationsIndications

Low to moderate enrichmentLow to moderate enrichment Long term therapyLong term therapy

– ContraindicationsContraindications Poor respiratory effortPoor respiratory effort Severe hypoxiaSevere hypoxia ApneaApnea Mouth breathingMouth breathing

Delivery DevicesDelivery Devices

Nasal cannulaNasal cannula– AdvantagesAdvantages

Well toleratedWell tolerated Easy to communicateEasy to communicate

– DisadvantagesDisadvantages Doesn’t deliver high volume/high Doesn’t deliver high volume/high

concentrationconcentration % Not guaranteed% Not guaranteed

Delivery DevicesDelivery Devices

Simple face maskSimple face mask– IndicationsIndications

Moderate to high oxygen Moderate to high oxygen concentrationconcentration

40-60% at 10 Lpm40-60% at 10 Lpm– AdvantagesAdvantages

Higher oxygen concentrationsHigher oxygen concentrations– DisadvantagesDisadvantages

Beyond 10 LPM does not enhance Beyond 10 LPM does not enhance oxygen content.oxygen content.

Delivery DevicesDelivery Devices

Partial rebreatherPartial rebreather– IndicationsIndications– ContraindicationsContraindications

ApneaApnea Poor respiratory effortPoor respiratory effort

– AdvantagesAdvantages Higher concentrationsHigher concentrations

– DisadvantagesDisadvantages Beyond 10 LPM does not enhance content.Beyond 10 LPM does not enhance content.

Delivery DevicesDelivery Devices

Non-rebreather maskNon-rebreather mask– Mask side ports Mask side ports

One-way discOne-way disc

– Reservoir bag attachedReservoir bag attached– 80-95% at 15 Lpm80-95% at 15 Lpm– IndicationsIndications

Highest OHighest O22 content (Non PPV) content (Non PPV)

– ContraindicationsContraindications ApneaApnea Poor effortPoor effort

Delivery DevicesDelivery Devices Venturi maskVenturi mask

– Mask with interchangeable adaptersMask with interchangeable adapters Side ports for room airSide ports for room air Highly specific content. OHighly specific content. O22

Oxygen humidifiersOxygen humidifiers– Sterile water reservoir for humidifying oxygenSterile water reservoir for humidifying oxygen– Long term admin.Long term admin.– Desirable for Croup/Epiglottitis/BronchiolitisDesirable for Croup/Epiglottitis/Bronchiolitis

TracheostomyTracheostomy StomaStoma

SummarySummary

Respiratory Assessment conceptsRespiratory Assessment concepts

Scenario’sScenario’s

Oxygen Delivery Method ReviewOxygen Delivery Method Review