1. 1 Respiratory System Assessment Chemeketa Community College Paramedic Program Peggy Andrews, Instructor

2. 2 Respiratory rates Normal - 12 - 20 Normal - 12 - 20 Controlled by other factors Controlled by other factors –Temperature - Emotion –Drugs and medications - Hypoxia –Pain - Acidosis –Sleep Obstruction Obstruction –Tongue - most common  Snoring, correct with positioning

3. 3 Foreign body May cause partial or complete obstruction May cause partial or complete obstruction –Choking, gagging –Stridor –Dyspnea –Aphonia  Speechless –Dysphonia  Difficulty speaking  Hoarseness

4. 4 Laryngeal spasm and edema Spasm Spasm –Sudden movement/contraction Most frequently: Most frequently: –Trauma  Aggressive intubation –Post-extubation  Especially if patient semi-conscious

5. 5 33 year old female rescued from a structure fire. CAO x 3, RR38, SaO 2 64%, harsh stridor on insp. Edema Edema Glottis Glottis –Extremely narrowed –Totally obstructed Most frequently: Most frequently: –Epiglottitis  Bacterial infection –Anaphylaxis Relieved by Relieved by –Aggressive ventilation –Muscle relaxants –Alternative Airway

6. 6 28 year old male, snowmobile into farmers fence, 20 mph. Fractured larynx Fractured larynx –Airway patency dependent on muscle tone –Increased resistance by decreased size –Decreased muscle tone –Laryngeal edema –Ventilatory effort

7. 7 79 y/o male, liquid diet, hiccup’s during breakfast. Severely SOB SaO 2 72% RA, Upper Resp. fluid audible SaO 2 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 

8. 8 Airway evaluation Rate Rate –12-20?  Regularity  Steady pattern  Irregular patterns are significant until proven otherwise

9. 9 Airway evaluation Effort 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

10. Head injury/ICP Resp. Center Lesions Serious Illness/Terminal DKA Paramedic Students Some Important Patterns

11. 11 Recognition of airway problems Respiratory distress Respiratory distress –Upper and lower obstruction –Inadequate ventilation –Impairment of respiratory muscles –Impairment of nervous system

12. 12 Dyspnea may be result of or result in hypoxia Hypoxia Hypoxia –Inadequate O 2 at cells Hypoxemia Hypoxemia –Lack of O 2 in arterial blood Anoxia Anoxia –No O’s All therapies will fail if airway inadequate All therapies will fail if airway inadequate

13. 13 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.

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17. 17 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. 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.

18. 18 Our Lady (continued) O: Pt is barely conscious, upright in recliner. RR 46, SaO 2 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. O: Pt is barely conscious, upright in recliner. RR 46, SaO 2 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.

19. 19 Auscultation techniques Air movement at mouth and nose Air movement at mouth and nose Bilateral lung fields equal Bilateral lung fields equal

20. 20 Palpation techniques Air movement at mouth and nose Air movement at mouth and nose Chest wall Chest wall –Paradoxical motion –Retractions

21. 21 Bag-valve-mask Resistance/changing compliance with BVM ventilations Resistance/changing compliance with BVM ventilations

22. 22 Pulsus paradoxis Systolic BP drops greater than 10 mmHg with inspiration Seen in Pericardial tamponade

23. 23 History Evolution Evolution –Sudden –Gradual over time –Known cause or “trigger” Duration Duration –Constant –Recurrent Ease - What makes it better? Ease - What makes it better? Exacerbate – Aggravation of symptoms Exacerbate – Aggravation of symptoms Associate - other symptoms (productive cough, etc) Associate - other symptoms (productive cough, etc)

24. 24 History Interventions Interventions –Evaluations/admissions to hospital –Medications (include compliance and dose) –Ever intubated???

25. 25 History Modified form of respiration 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

26. 26 Inadequate ventilation When body can’t compensate for increased oxygen demand or maintain O2/CO2 balance. When body can’t compensate for increased oxygen demand or maintain O2/CO2 balance. Many causes Many causes –Infection –Trauma –Brainstem injury –Noxious or hypoxic atmosphere –Renal failure Multiple symptoms Multiple symptoms –Altered response –Respiratory rate changes

27. 27 Supplemental oxygen therapy Supplemental oxygen therapy Supplemental oxygen therapy –Increases O 2 to cells –O 2 increases patients ability to compensate –Delivery method continually reassessed

28. 28 Oxygen source Compressed gas Compressed gas Common sizes and volumes Common sizes and volumes –D400L –E625L –M3450L

29. 29 Calculating Tank Life Tank Size Factor Tank Size Factor  0.16 D Tank  0.28 E Tank  1.56 M Tank (1800-500) x 0.16 / 10 = 20.8 minutes ((PSI in tank) – (500)) x (factor) (Desired Lpm)

30. 30 Regulators High pressure High pressure –Transfer gas from tank to tank –Cascade System Therapy regulators Therapy regulators –Pressure “stepped down” –Delivery via adjustable low pressure

31. 31 Delivery Devices Nasal cannula 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

32. 32 Delivery Devices Nasal cannula Nasal cannula –Advantages  Well tolerated  Easy to communicate –Disadvantages  Doesn’t deliver high volume/high concentration  % Not guaranteed

33. 33 Delivery Devices Simple face mask 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.

34. 34 Delivery Devices Partial rebreather Partial rebreather –Indications –Contraindications  Apnea  Poor respiratory effort –Advantages  Higher concentrations –Disadvantages  Beyond 10 LPM does not enhance content.

35. 35 Delivery Devices Non-rebreather mask Non-rebreather mask –Mask side ports  One-way disc –Reservoir bag attached –80-95% at 10-15 Lpm –Indications  Highest O 2 content (Non PPV) –Contraindications  Apnea  Poor effort

36. 36 Delivery Devices Venturi mask Venturi mask –Mask with interchangeable adapters  Side ports for room air  Highly specific content. O 2 Oxygen humidifiers Oxygen humidifiers –Sterile water reservoir for humidifying oxygen –Long term admin. –Desirable for Croup/Epiglottitis/Bronchiolitis Tracheostomy Tracheostomy Stoma Stoma

37. 37 Summary Respiratory Assessment concepts Respiratory Assessment concepts Scenario’s Scenario’s Oxygen Delivery Method Review Oxygen Delivery Method Review