TRANSITION SERIES Topics for the Advanced EMT CHAPTER Issues in Airway Management, Oxygenation, and Ventilation 13

Objectives Review pathophysiological changes that occur with upper and lower airway dysfunction. Differentiate respiratory distress from respiratory failure. Discuss current treatment guidelines for oxygenating and ventilating patients.

Introduction Failure to oxygenate a patient will doom all other interventions to failure. Assessment and treatment of respiratory distress and failure remains constant. Immediate identification and action for respiratory issues is more important than differential diagnosis.

Epidemiology Dyspnea accounts for 2 percent of ED visits. The use of certain respiratory interventions is very common: –Oxygenation adjuncts –Airway adjuncts –Ventilatory adjuncts

Pathophysiology Respiratory dysfunction is typically due to: –Obstruction of airflow –Changes to pulmonary structures –Occasionally both Classification by type –Upper airway –Lower airway

Pathophysiology (cont’d) Upper airway dysfunction –Above glottic opening –Reduces the passage of inhaled gas –Multiple reasons

Anatomy of the upper airway

Pathophysiology (cont’d) Lower airway dysfunction –Structures below trachea –Bronchoconstriction –Alveolar damage

Provide oxygen via a nonrebreather mask to the patient who is breathing adequately but with difficulty (respiratory distress).

Assessment Findings Recognition of respiratory distress supersedes a need to determine the cause. –Primary assessment –Minute ventilation and alveolar ventilation

Patient suffering respiratory distress, indicated by his tripod position.

Assessment Findings (cont’d) Respiratory distress –Tachypnea –Accessory muscle use –Tachycardia –Alveolar breath sounds –Speech pattern still good

Barrel chest in an emphysema patient

Assessment Findings (cont’d) Respiratory failure –Absent alveolar sounds –Poor speech patterns –Altered mental status –Low pulse oximeter –Cyanosis

The continuum of breathing ranges from normal, adequate breathing to no breathing at all. It is essential to recognize the need for assisted ventilations even before severe respiratory distress develops.

Assessment Findings (cont’d) Respiratory arrest – No spontaneous effort

Emergency Medical Care Airway –If not open, employ techniques to do so. Breathing –Prevent respiratory failure. –Administer high-flow oxygen. –Evaluate need for PPV.

Two rescuers deliver bag-valve-mask ventilation.

Emergency Medical Care (cont’d) Continuous positive pressure ventilation –“Back pressure” to help ease breathing effort. –Helps with diffusion of gases in alveoli. –Commonly used in acute pulmonary edema.

Emergency Medical Care (cont’d) Applying CPAP –Patient must be spontaneously breathing. –Use carefully in patients with low B/P. –Coach patient to keep device on. –Will need separate training to use at AEMT level.

Continuous positive airway pressure (CPAP) is used for the awake and spontaneously breathing patient who needs ventilatory support. (© Ken Kerr)

Case Study You are called to assist an elderly male with respiratory distress. When you arrive, the patient is found sitting up in his bed with obvious respiratory distress.

Case Study (cont’d) Scene Size-Up –There is only one patient. –BSI precautions are taken. –Male patient, 68 years old, 190 lbs. –Sitting upright, objective respiratory distress. –You see multiple meds on table beside bed.

Case Study (cont’d) Given this patient's age, what could be at least three common pathologies causing respiratory distress? Following the scene size-up, what would be at least three questions you would initially ask?

Case Study (cont’d) Primary Assessment Findings –Patient responds to verbal stimuli. –Airway patent and maintained by patient. –Respirations fast with accessory muscle use. –Speaking in 4-5 word sentences. –Peripheral pulse is present, skin cool and clammy, skin is slightly pale.

Case Study (cont’d) Is this patient a high or low priority? Why? What care should be provided immediately? Is this patient in respiratory distress or failure?

Case Study (cont’d) Medical History –Three heart attacks, high blood pressure Medications –Nitro PRN, lasix, enalapril Allergies –None per the patient

Case Study (cont’d) Pertinent Secondary Assessment Findings –Pupils reactive to light –Breath sounds present bilaterally with inspiratory rales –Peripheral perfusion is intact

Case Study (cont’d) Pertinent Secondary Assessment Findings –Pulse ox 94% on 100% oxygen –Skin cool, diaphoretic, pale –Peripheral edema noted to lower legs –B/P 168/88, Pulse 110, Respirations 26

Case Study (cont’d) Interventions provided prior to transport: –Oxygen maintained via NRB –Patient placed in high-Fowler position –Patient packaged and transported to ambulance

Case Study (cont’d) After transport has started, you find the following with reassessment: –Airway still patent –Breathing slightly more tachypnic –Pulse ox now 92% –Patient conscious, but is starting to become sleepy

Case Study (cont’d) You have decided to apply CPAP to the patient. After instructing the patient on how it works, you apply it and allow it to work for about 3-4 minutes. –What would be indications of patient improvement? –What would be indications of further patient deterioration?

Summary Airway, oxygenation, and ventilation skills are some of the most important the Advanced EMT will ever use. Always try to prevent respiratory failure first rather than waiting for it to occur in order to be aggressive with your interventions.

Summary (cont’d) Ensure first that the patient is ventilating and oxygenating prior to developing differentials.