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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