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Respiratory System Assessment Chemeketa Community College Paramedic Program Peggy Andrews, Instructor A & P Review - Upper Airway Nasal Cavity Oral Cavity – Hyoid bone Pharynx – Nasopharynx – Oropharynx – Hypopharynx vallecula Larynx – Thyroid cartilage – Cricoid cartilage – Arytenoid cartilage – Glottic opening – Vocal cords – Crithothyroid membrane A & P Review - Lower Airway Trachea Carina Bronchi – Left and right mainstem – Secondary & tertiary bronchi – Bronchioles 22 divisions – Respiratory bronchioles Alveoli – 1 – 2 cell layers thick Lung parenchyma Pleura – Visceral – Parietal Respiratory cycle Depends on changes in pressure Inspiration – active process Expiration – passive process Pulmonary circulation Exchange of oxygen and carbon dioxide Right side of heart – Pulmonary artery – Deoxegynated blood Left side of heart – Pulmonary vein – Oxygenated blood Measuring oxygen & carbon dioxide levels Partial pressure of gas – Percentage of mixture’s total pressure 21% Diffusion – Movement of gas from higher concentration – lower concent. Oxygen concentration in blood Oxygen saturation (SpO2) – PaO2 90 – 100 torr normal Hemoglobin molecule – Carries 4 oxygen molecules Ventilation/perfusion mismatch Carbon dioxide concent. In blood What regulates respirations? Nervous impulses from the respiratory center Stretch receptors – Hering-Breuer reflex Chemoreceptors Hypoxic Drive Respiratory rates Normal - 12 - 20 Controlled by other factors – – – – Temperature - Emotion Drugs and medications - Hypoxia Pain - Acidosis Sleep Obstruction – Tongue - most common Snoring, correct with positioning Foreign body May cause partial or complete obstruction – – – – Choking, gagging Stridor Dyspnea Aphonia Speechless – Dysphonia Difficulty speaking Hoarseness Total Lung Capacity –~6L Tidal Volume (Vt) – 500 ml (5 – 7 ml/kg) Dead space volume – 150 ml in adult male Minute volume – Vt X RR Laryngeal spasm and edema Spasm – Sudden movement/contraction Most frequently: – Trauma Aggressive intubation – Post-extubation Especially if patient semiconscious 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: – Epiglottitis Bacterial infection – Anaphylaxis Relieved by – Aggressive ventilation – Muscle relaxants – Alternative Airway 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 79 yo 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 Airway evaluation Rate – 12-20? Regularity Steady pattern Irregular patterns are significant until proven otherwise 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 Some Important Patterns Serious Illness/Terminal DKA Head injury/ICP Resp Center Lesions Paramedic Students Recognition of airway problems Respiratory distress – Upper and lower obstruction – Inadequate ventilation – Impairment of respiratory muscles – Impairment of nervous system 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 Visual Clues Another Sample Pt. What are the clues here? Our Lady (continued) . Auscultation techniques Air movement at mouth and nose Bilateral lung fields equal Palpation techniques Air movement at mouth and nose Chest wall – Paradoxical motion – Retractions Bag-valve-mask Resistance/changing compliance with BVM ventilations 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) History Interventions – Evaluations/admissions to hospital – Medications (include compliance and dose) – Ever intubated??? 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 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 Supplemental oxygen therapy Supplemental oxygen therapy – Increases O2 to cells – O2 increases patients ability to compensate – Delivery method continually reassessed Oxygen source Compressed gas Common sizes and volumes –D 400L –E 625L –M 3450L Calculating Tank Life (( PSI in Tank ) (500SafeLevel)) * ( Factor) ( Desired LPM ) Page 386 – Tank Size Factor 0.16 D Tank 0.28 E Tank 1.56 M Tank Regulators High pressure – Transfer gas from tank to tank – Cascade System Therapy regulators – Pressure “stepped down” – Delivery via adjustable low pressure 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 Delivery Devices Nasal cannula – Advantages Well tolerated Easy to communicate – Disadvantages Doesn’t deliver high volume/high concentration % Not guaranteed 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. Delivery Devices Partial rebreather – Indications – Contraindications Apnea Poor respiratory effort – Advantages Higher concentrations – Disadvantages Beyond 10 LPM does not enhance content. Delivery Devices Non-rebreather mask – Mask side ports One-way disc – Reservoir bag attached – 80-95% at 15 Lpm – Indications Highest O2 content (Non PPV) – Contraindications Apnea Poor effort Delivery Devices Venturi mask – Mask with interchangeable adapters Side ports for room air Highly specific content. O2 Oxygen humidifiers Tracheostomy Stoma – Sterile water reservoir for humidifying oxygen – Long term admin. – Desirable for Croup/Epiglottitis/Bronchiolitis Summary Respiratory Assessment concepts Scenario’s Oxygen Delivery Method Review