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Respiratory System Assessment Chemeketa Community College Paramedic Program Peggy Andrews, Instructor 1 Respiratory rates Normal - 12 - 20 Controlled by other factors – Temperature – Drugs and medications – Pain – Sleep - Emotion - Hypoxia - Acidosis Obstruction – Tongue - most common Snoring, correct with positioning 2 Foreign body May cause partial or complete obstruction – – – – Choking, gagging Stridor Dyspnea Aphonia Speechless – Dysphonia Difficulty speaking Hoarseness 3 Laryngeal spasm and edema Spasm – Sudden movement/contraction Most frequently: – Trauma Aggressive intubation – Post-extubation Especially if patient semi-conscious 4 33 year old female rescued from a structure fire. CAO x 3, RR38, SaO2 64%, harsh stridor on insp. Edema Glottis – Extremely narrowed – Totally obstructed Most frequently: Relieved by – Aggressive ventilation – Muscle relaxants – Alternative Airway – Epiglottitis Bacterial infection – Anaphylaxis 5 28 year old male, snowmobile into farmers fence, 20 mph. Fractured larynx – Airway patency dependent on muscle tone – Increased resistance by decreased size – Decreased muscle tone – Laryngeal edema – Ventilatory effort 6 79 y/o male, liquid diet, hiccup’s during breakfast. Severely SOB SaO2 72% RA, Upper Resp. fluid audible – Aspiration Significantly increases mortality - 25% die Obstructs airway Destroys delicate bronchiolar tissue Introduces pathogens Decreases ability to ventilate – Commonly the beginning of the end 7 Airway evaluation Rate – 12-20? Regularity Steady pattern Irregular patterns are significant until proven otherwise 8 Airway evaluation Effort – Should be effortless at rest – Changes may be subtle in rate or regularity – Patients compensate by preferential posturing Upright sniffing Semi-fowlers Frequently avoid supine 9 Some Important Patterns Serious Illness/Terminal DKA Head injury/ICP Paramedic Students Resp. Center Lesions Recognition of airway problems Respiratory distress – Upper and lower obstruction – Inadequate ventilation – Impairment of respiratory muscles – Impairment of nervous system 11 Dyspnea may be result of or result in hypoxia Hypoxia – Inadequate O2 at cells Hypoxemia – Lack of O2 in arterial blood Anoxia – No O’s All therapies will fail if airway inadequate 12 Visual Clues S: You are responding to a 75 year old, 325# male with a complaint of SOB. He has a hx of CHF and bypass surgery. On the usual medications. O: Pt alert and on edge of bed, his hands are on his knees, his arms straight. He claims that laying back makes symptoms worse (Orthopnea). He is answering in 2-4 word answers and frequently needs to be reminded of questions, because he becomes distracted. Through your assessment he is becoming increasingly agitated and confused. 13 14 15 16 Another Sample Ptatient What are the clues here? S: You are responding to a 62 year old female with a complaint of SOB. Her husband explains that she has been unable to sleep and has been having trouble breathing four 4 hours. She has not successfully taken her nebulizer treatment because she can no longer hold it to her mouth. She has a hx of emphysema and asthma. 17 Our Lady (continued) O: Pt is barely conscious, upright in recliner. RR 46, SaO2 64%, Skin pale, cool & moist, with cyanosis around lips, gums, eyes & nailbeds. EKG leads won’t stick to get reading. Lung sounds with minimal air movement in most fields. No wheezes heard. Significant intercostal, supraclavicular, suprasternal and substernal retractions noted on inspiration. Her lips are pursed and her nostrils are flaring with each breath. 18 Auscultation techniques Air movement at mouth and nose Bilateral lung fields equal 19 Palpation techniques Air movement at mouth and nose Chest wall – Paradoxical motion – Retractions 20 Bag-valve-mask Resistance/changing compliance with BVM ventilations 21 History Evolution – Sudden – Gradual over time – Known cause or “trigger” Duration – Constant – Recurrent Ease - What makes it better? Exacerbate – Aggravation of symptoms Associate - other symptoms (productive cough, etc) 23 History Interventions – Evaluations/admissions to hospital – Medications (include compliance and dose) – Ever intubated??? 24 History Modified form of respiration – Protective reflexes Cough - forceful, spastic exhalation; aids in clearing bronchi and bronchioles Sneeze - clears nasopharynx Gag reflex - spastic pharyngeal and esophageal reflex – Sighing Increases opening of alveoli Normally sigh @ 1/min. – Hiccough Intermittent spastic closure of glottis 25 Inadequate ventilation When body can’t compensate for increased oxygen demand or maintain O2/CO2 balance. Many causes – – – – – Infection Trauma Brainstem injury Noxious or hypoxic atmosphere Renal failure Multiple symptoms – Altered response – Respiratory rate changes 26 Supplemental oxygen therapy Supplemental oxygen therapy – Increases O2 to cells – O2 increases patients ability to compensate – Delivery method continually reassessed 27 Oxygen source Compressed gas Common sizes and volumes –D 400L –E 625L –M 3450L 28 Calculating Tank Life ((PSI in tank) – (500)) x (factor) (Desired Lpm) Tank Size Factor 0.16 D Tank 0.28 E Tank 1.56 M Tank (1800-500) x 0.16 / 10 = 20.8 minutes 29 Regulators High pressure – Transfer gas from tank to tank – Cascade System Therapy regulators – Pressure “stepped down” – Delivery via adjustable low pressure 30 Delivery Devices Nasal cannula – Optimal delivery; 40% at 6 Lpm – Indications Low to moderate enrichment Long term therapy – Contraindications Poor respiratory effort Severe hypoxia Apnea Mouth breathing 31 Delivery Devices Nasal cannula – Advantages Well tolerated Easy to communicate – Disadvantages Doesn’t deliver high volume/high concentration % Not guaranteed 32 Delivery Devices Simple face mask – Indications Moderate to high oxygen concentration 40-60% at 10 Lpm – Advantages Higher oxygen concentrations – Disadvantages Beyond 10 LPM does not enhance oxygen content. 33 Delivery Devices Partial rebreather – Indications – Contraindications Apnea Poor respiratory effort – Advantages Higher concentrations – Disadvantages Beyond 10 LPM does not enhance content. 34 Delivery Devices Non-rebreather mask – Mask side ports One-way disc – Reservoir bag attached – 80-95% at 10-15 Lpm – Indications Highest O2 content (Non PPV) – Contraindications Apnea Poor effort 35 Delivery Devices Venturi mask – Mask with interchangeable adapters Side ports for room air Highly specific content. O2 Oxygen humidifiers – Sterile water reservoir for humidifying oxygen – Long term admin. – Desirable for Croup/Epiglottitis/Bronchiolitis Tracheostomy Stoma 36 Summary Respiratory Assessment concepts Scenario’s Oxygen Delivery Method Review 37