ChapterChapter

RespiratoryRespiratory

EmergenciesEmergencies

ThirteenThirteen

ChapterChapter

How to recognize adequate and inadequate breathing How to assist a patient with breathing difficulty in using a prescribed inhaler

ThirteenThirteenCORE CONCEPTSCORE CONCEPTS

RRESPIRATORYESPIRATORYSYSTEMSYSTEM

Respiratory SystemRespiratory System

Airway structures are smallerAirway structures are smaller(more easily obstructed).(more easily obstructed).

Tongue is proportionatelyTongue is proportionately larger than an adult’s. larger than an adult’s. Trachea is more narrowTrachea is more narrow

(more easily obstructed).(more easily obstructed).

(Continued)(Continued)

Pediatric Airway AnatomyPediatric Airway Anatomy

Cricoid is not well developedCricoid is not well developed(less rigid)(less rigid)..

Trachea is softer, more flexible Trachea is softer, more flexible than an adult’s. than an adult’s. Chest wall is softer.Chest wall is softer.

Pediatric Airway AnatomyPediatric Airway Anatomy

Process of RespirationProcess of Respiration

Oxygen-rich air enters alveoli.Oxygen-rich air enters alveoli. Oxygen-poor blood passes Oxygen-poor blood passes

around alveoli. around alveoli. Oxygen enters capillaries; Oxygen enters capillaries; carbon dioxide enters alveoli. carbon dioxide enters alveoli.

Gas Exchange:Gas Exchange:Alveolar CapillaryAlveolar Capillary

Cells give off carbon dioxide Cells give off carbon dioxide to capillaries. to capillaries. Capillaries give off oxygen Capillaries give off oxygen to cells. to cells.

Gas Exchange:Gas Exchange:Capillary CellularCapillary Cellular

AdultsAdults ChildrenChildren InfantInfant

12-20/min.12-20/min.15-30/min.15-30/min.25-50/min.25-50/min.

Adequate Breathing: Adequate Breathing: Normal RatesNormal Rates

(Continued)(Continued)

Usually regularUsually regular

May be slightly irregularMay be slightly irregular and influenced by talking and influenced by talking

(Continued)(Continued)

Adequate Breathing: RhythmAdequate Breathing: Rhythm

Breath sounds:Breath sounds: Present, equal Present, equal

Chest expansion: Adequate, equalChest expansion: Adequate, equal

EffortEffort : : Minimal or no Minimal or nouse of accessory use of accessory musclesmuscles

Depth:Depth:

Adequate Breathing: QualityAdequate Breathing: Quality

Adequate tidalAdequate tidalvolumevolume

Rate:Rate: Outside normal rangesOutside normal ranges Rhythm:Rhythm: May be irregularMay be irregular Depth:Depth: Inadequate or shallowInadequate or shallow

(Continued)(Continued)

Inadequate BreathingInadequate Breathing

volumevolume

Breath sounds:Breath sounds: Diminished or Diminished or absent absent

Chest expansion:Chest expansion: Unequal or Unequal or

inadequateinadequate

(Continued)(Continued)

Inadequate BreathingInadequate Breathing

EffortEffort

(Continued)(Continued)

Inadequate BreathingInadequate Breathing

Increased use of Increased use of accessory muscles, accessory muscles, especially in infantsespecially in infantsand children and children

Pale or cyanotic (blue) skinPale or cyanotic (blue) skin

Cool, clammy skinCool, clammy skin

Agonal (occasional) gasp Agonal (occasional) gasp

(seen just before death)(seen just before death)

Inadequate BreathingInadequate Breathing

Retractions

Nasal Flaring

See-Saw Breathing

Diaphragmatic Breathing

Inadequate Breathing: Infants and ChildrenInadequate Breathing: Infants and Children

Artificial VentilationArtificial Ventilation Performed with a pocket Performed with a pocket

mask or bag-mask device.mask or bag-mask device.

Must be performed Must be performed ADEQUATELY.ADEQUATELY.

Chest rises and falls.Chest rises and falls. Rate:Rate: 10–12/min. for adults10–12/min. for adults

12–20/min. for infants/children12–20/min. for infants/children

Heart rate returns to normal.Heart rate returns to normal.

Artificial Ventilation — Artificial Ventilation — AdequateAdequate

Chest does not rise and fall.Chest does not rise and fall.

Rate is too slow or too fast.Rate is too slow or too fast.

Heart rate does not return Heart rate does not return to normal.to normal.

Artificial Ventilation Artificial Ventilation InadequateInadequate

The concept of adequate vs. inadequate breathing is one that must be stressed to new EMT-Bs. The mere thought of providing artificial ventilation to a person who has some respiratory effort is confusing. Ventilating a nonbreathing patient is difficult, let alone one who is breathing. Explain to new EMT-Bs that they should work with the patient’s respiratory effort and coach the patient when appropriate.

PPRECEPTOR RECEPTOR PPEARLEARL

Breathing DifficultyBreathing Difficulty

A chief complaint representing a A chief complaint representing a patient’s feeling of labored or patient’s feeling of labored or difficult breathingdifficult breathing

KKEY TERMEY TERM

Patient Patient ASSESSMENTASSESSMENT

Breathing DifficultyBreathing Difficulty

Signs and SymptomsSigns and Symptoms

Shortness of breathShortness of breath RestlessnessRestlessness Increased pulse rateIncreased pulse rate Breathing rate increased or Breathing rate increased or

decreaseddecreased

(Continued)(Continued)

Patient Patient ASSESSMENTASSESSMENT

Breathing DifficultyBreathing Difficulty

Signs and SymptomsSigns and Symptoms

Skin color changesSkin color changes• CyanoticCyanotic• PalePale• FlushedFlushed

(Continued)(Continued)

Patient Patient ASSESSMENTASSESSMENT

Breathing DifficultyBreathing Difficulty

Signs and SymptomsSigns and Symptoms

Noisy breathingNoisy breathing• CrowingCrowing• Audible wheezingAudible wheezing• GurglingGurgling• SnoringSnoring• StridorStridor

(Continued)(Continued)

Patient Patient ASSESSMENTASSESSMENT

Breathing DifficultyBreathing Difficulty

Signs and SymptomsSigns and Symptoms

Inability to speakInability to speak Retractions/accessory muscle useRetractions/accessory muscle use Abdominal breathingAbdominal breathing Irregular breathing patternIrregular breathing pattern

Signs of Breathing DifficultySigns of Breathing Difficulty

Sign of Breathing Difficulty Sign of Breathing Difficulty Tripod PositionTripod Position

Patient Patient CARECARE

Breathing DifficultyBreathing Difficulty

Emergency Care StepsEmergency Care Steps

Focused History and Physical Focused History and Physical ExamExam OnsetOnset

ProvocationProvocation QualityQuality RadiationRadiation SeveritySeverity TimeTime

============

OOPPQQRRSST T (Continued)(Continued)

Patient Patient CARECARE

Breathing DifficultyBreathing Difficulty

Emergency Care StepsEmergency Care Steps

Focused History and Physical ExamFocused History and Physical Exam• Apply oxygen.Apply oxygen.• Assess baseline vital signs.Assess baseline vital signs.

(Continued)(Continued)

Patient Patient CARECARE

Breathing DifficultyBreathing Difficulty

Emergency Care StepsEmergency Care Steps

Determine what interventions theDetermine what interventions thepatient has used.patient has used.

Determine what medications patientDetermine what medications patient takes takes (types, doses, times used). (types, doses, times used).

If medical direction approves,If medical direction approves,facilitate use of prescribed inhaler.facilitate use of prescribed inhaler.

Prescribed InhalerPrescribed Inhaler

MedicationMedication

NameName

Generic (albuterol(albuterol,, isoetharine, etc.)isoetharine, etc.)

Trade (Proventil,(Proventil,Ventolin, Alupent, etc.)Ventolin, Alupent, etc.)

Prescribed InhalerPrescribed Inhaler

IndicationsIndications Signs/symptoms ofbreathing difficulty

Prescribed by physician Specific authorization by

medical direction

Patient must meet all criteria.Patient must meet all criteria.

Prescribed InhalerPrescribed Inhaler

Patient is unable to use device. Inhaler was not prescribed. No permission has come from

medical

direction. Patient has used maximum dose.

ContraindicationsContraindications

Prescribed InhalerPrescribed Inhaler

Metered dose inhalerMedicationMedicationFormForm

DosageDosage Number of inhalationsbased on physician’s order

Prescribed InhalerPrescribed Inhaler

Obtain orders from medical direction.Obtain orders from medical direction.

Check expiration date.Check expiration date.

Inhaler should be at room tempInhaler should be at room temp

to use device.to use device.

Prescribed InhalerPrescribed Inhaler

or warmer.or warmer. Has patient used one yet? Has patient used one yet?

Make sure patient is alert and ableMake sure patient is alert and able

Right Patient? Right Medication?Right Patient? Right Medication?Right Dose? Right Route?Right Dose? Right Route?

Right Time? Right Documentation? Right Time? Right Documentation?

Shake vigorously.Shake vigorously.

Have patient exhale deeply.Have patient exhale deeply.

Have patient place lips Have patient place lips around inhaler opening.around inhaler opening.

Prescribed InhalerPrescribed Inhaler

Depress handheld inhaler asDepress handheld inhaler aspatient inhales deeply.patient inhales deeply.

Instruct patientInstruct patientto hold breath.to hold breath.

Allow patient to breathe. Allow patient to breathe. Repeat dose if ordered.Repeat dose if ordered.

Reevaluate patient.Reevaluate patient.

Spacer DeviceSpacer Device

ActionsActions Beta agonist

Dilates bronchioles Reduces airway resistance

Prescribed InhalerPrescribed Inhaler

SideSideEffectsEffects

Increased pulse rate Tremors Nervousness

Prescribed InhalerPrescribed Inhaler

ReassessmentReassessment Vital signs Focused reassessment Be alert for development

of inadequate breathing

Prescribed InhalerPrescribed Inhaler

Prescribed Inhaler:Prescribed Inhaler:ChildrenChildren

Commonly prescribed.Commonly prescribed. Retractions more common.Retractions more common. Coughing more commonCoughing more common

than wheezing.than wheezing.

1. Describe signs of adequate and1. Describe signs of adequate andinadequate breathing.inadequate breathing.

2. Explain the indications and 2. Explain the indications and contraindications of a prescribed inhaler.contraindications of a prescribed inhaler.3. List the “rights” of medication 3. List the “rights” of medication administration. administration.

RREVIEW QUESTIONSEVIEW QUESTIONS