Respiratory Respiratory System System

AssessmentAssessmentChemeketa Community Chemeketa Community

CollegeCollegeParamedic 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

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 Nervous impulses

from the from the respiratory centerrespiratory center

Stretch receptorsStretch receptors– Hering-Breuer Hering-Breuer

reflexreflex 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 Sudden

movement/contractionmovement/contraction Most frequently: Most frequently:

– Trauma Trauma Aggressive intubationAggressive intubation

– Post-extubation Post-extubation Especially if patient semi-Especially if patient semi-

consciousconscious

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 S: Pt. c/o sudden onset SOB ~ 2 hrs ago S: Pt. c/o sudden onset SOB ~ 2 hrs ago

while at rest. PMH: CHF and 2-vessel while at rest. PMH: CHF and 2-vessel CABG 1 yr ago. On the usual meds.CABG 1 yr ago. On the usual meds.

O: 67 y/o male Pt CAO PPTE, seated on O: 67 y/o male Pt CAO PPTE, seated on edge of bed in tripod position. He claims edge of bed in tripod position. He claims that laying back makes symptoms worse that laying back makes symptoms worse (Orthopnea). Pt. speaks in 2-4 word (Orthopnea). Pt. speaks in 2-4 word sentences and frequently needs to be sentences and frequently needs to be reminded of questions. During reminded of questions. During assessment, pt becomes increasingly assessment, pt becomes increasingly agitated and confused.agitated and confused.

What’s your DDX?What’s your DDX? What’s your Tx?What’s your Tx?

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

S: A 62 year old male c/o SOB. Per S: A 62 year old male c/o SOB. Per wife, pt has been unable to sleep and wife, pt has been unable to sleep and has been having trouble breathing has been having trouble breathing for 4 hours. He has not used his for 4 hours. He has not used his nebulizer treatment because he can nebulizer treatment because he can no longer hold it to his mouth. PMH: no longer hold it to his mouth. PMH: emphysema and asthma.emphysema and asthma.

Our Guy (continued)Our Guy (continued) O: Pt is CAO Person only, upright in O: Pt is CAO Person only, upright in

recliner. RR 46, SaOrecliner. RR 46, SaO22 64%, Skin pale, cool 64%, Skin pale, cool & moist, with cyanosis around lips, gums, & moist, with cyanosis around lips, gums, eyes & nailbeds. EKG leads won’t stick to eyes & nailbeds. EKG leads won’t stick to get reading. Lung sounds with minimal air get reading. Lung sounds with minimal air movement in most fields. No wheezes movement in most fields. No wheezes heard. Significant intercostal, heard. Significant intercostal, supraclavicular, suprasternal and supraclavicular, suprasternal and substernal retractions noted on substernal retractions noted on inspiration. Pursed-lip breathing with inspiration. Pursed-lip breathing with nasal flaring noted.nasal flaring noted.

DDX?DDX? Tx?Tx?

Auscultation techniquesAuscultation techniques

Air movement at mouth and Air movement at mouth and nosenose

Bilateral lung fields Bilateral lung fields

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()((

LPMDesiredFactorSafeLevelTankinPSI

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