10 Respiration and Artificial Ventilation.

10 Respiration and Artificial Ventilation

Multimedia Directory Slide 93 Oxygen Administration via a Non-Rebreather Mask Video Slide 107 In-Hospital Endotracheal Intubation Video These videos appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.

Topics Physiology and Pathophysiology Respiration
Positive Pressure Ventilation Oxygen Therapy Special Considerations Assisting with Advanced Airway Devices Planning Your Time: Plan 180 minutes for this chapter. Physiology and Pathophysiology (45 minutes) Respiration (45 minutes) Positive Pressure Ventilation (30 minutes) Oxygen Therapy (30 minutes) Special Considerations (15 minutes) Assisting With Advanced Airway Devices (15 minutes) Note: The total teaching time recommended is only a guideline. Core concepts: Physiology and pathophysiology of the respiratory system How to recognize adequate and inadequate breathing Principles and techniques of positive pressure ventilation Principles and techniques of oxygen administration

Physiology and Pathophysiology
Teaching Time: 45 minutes Teaching Tips: This lesson lends itself well to multimedia presentations. Anatomical models and web graphics will enhance your presentation on physiology and pathophysiology. Use real-life examples. Adults grasp pathophysiology best when they can apply it to actual situations. For each disorder, discuss actual examples and move from theory to reality. An understanding of alveolar ventilation will improve the assessment of respiratory dysfunction. When later discussing pathophysiology, bring the discussion back to the overall impact on alveolar ventilation. Spend time on the process of diffusion. An understanding of this fundamental concept will enhance comprehension of later lectures on pathophysiology. Reach back to include the concepts of minute volume and alveolar ventilation. Describe how they influence respiration.

Mechanics of Breathing
Ventilation Process of moving air into and out of chest Covers Objective: 10.3 Point to Emphasize: Negative pressure in the chest is used to move air in, and positive pressure in the chest is used to move air out. Discussion Topic: Mechanically speaking, describe how the body moves air into and out of the lungs. Class Activity: Have students work in groups, using household items, to construct a model of respiratory function that uses negative pressure to move air. Have groups present their models to the class and describe their particular processes of moving air. continued on next slide

Inhalation Active process Muscles expand; size of chest increases Negative pressure pulls air into lungs Covers Objective: 10.3 Knowledge Application: Have students describe the pressures of breathing. Discuss the role of both positive and negative pressure in moving air. Talking Points: It may be helpful to think of the chest as a syringe. As the plunger is withdrawn, the diaphragm is lowered and a negative pressure is created in the chest. Air is pulled in through the hole in the top. continued on next slide

Exhalation Passive process Muscles relax; size of chest decreases Positive pressure created; air pushed out Covers Objective: 10.3

Respiration Terminology
Tidal volume Amount of air moved in one breath Minute volume Amount of air moved into and out of lungs per minute Covers Objective: 10.5 Point to Emphasize: Alveolar ventilation refers to the amount of air that actually reaches the alveoli. This volume of air is responsible for gas exchange. Any problem that minimizes air flow to the alveoli diminishes alveolar ventilation. Discussion Topics: Discuss the role of rate and tidal volume with regard to minute volume. Using examples, explain how changes to either of these elements affect minute volume. Define alveolar ventilation. Give examples of how changes in rate and volume impact alveolar ventilation.

Physiology of Respiration
Dead space air Air moved in ventilation not reaching alveoli Alveolar ventilation Air actually reaching alveoli Diffusion Movement of gases from high concentration to low concentration Covers Objective: 10.5 Point to Emphasize: Alveolar ventilation refers to the amount of air that actually reaches the alveoli. This volume of air is responsible for gas exchange. Any problem that minimizes air flow to the alveoli diminishes alveolar ventilation. Discussion Topics: Discuss the role of rate and tidal volume with regard to minute volume. Using examples, explain how changes to either of these elements affect minute volume. Define alveolar ventilation. Give examples of how changes in rate and volume impact alveolar ventilation. continued on next slide

External respiration Diffusion of oxygen and carbon dioxide (exchange of gases) between alveoli and circulating blood Internal respiration Exchange of gases between blood and cells Covers Objective: 10.6 Point to Emphasize: External respiration refers to the mechanical movement of air in and out of the body. Internal respiration refers to the diffusion of oxygen and carbon dioxide at the cellular level. Knowledge Application: Instructors have traditionally "traced the flow of a drop of blood through the heart." Consider tracing the flow of a molecule of oxygen through the respiratory system. Discuss the various factors that influence the ability of oxygen to reach the alveoli. continued on next slide

Cellular respiration Oxygen from blood diffused into cell Carbon dioxide diffused from cell into blood Covers Objective: 10.6 Discussion Topic: Describe how the respiratory system relies on the cardiovascular system to provide normal physiologic function.

Pathophysiology of the Cardiopulmonary System
Mechanics of breathing disrupted Gas exchange interrupted Circulation issues Covers Objective: 10.7 Point to Emphasize: Injuries and illness interrupt normal function of the respiratory and cardiovascular systems. A problem with one system often affects the other. Knowledge Application: Discuss the pathophysiology (the negative impact) of the following disorders on both internal and external respiration: severe bronchospasm, severe external hemorrhage, slowed breathing due to narcotic overdose. Critical Thinking: Anticipate the pathophysiology lecture by asking this question: How might a respiratory challenge (such as asthma) affect minute volume and alveolar ventilation?

Respiration Teaching Time: 45 minutes
Teaching Tips: Teach assessment in the context of decision making—for example, "As an EMT, you will use these findings to identify inadequate breathing." Many of the findings of inadequate breathing are visual. Use pictures and other multimedia graphics to illustrate potential findings. Relate inadequate breathing to hypoxia. Describe how signs and symptoms overlap.

Adequate and Inadequate Breathing
Brain and body cells need a steady supply of oxygen. Hypoxia Low oxygen level in cells Carbon dioxide must be continuously removed. Hypercapnea High carbon dioxide level Covers Objective: 10.2 Discussion Topics: Define adequate breathing. Define hypoxia. Describe three different examples that show how a patient might become hypoxic. continued on next slide

Assesses how well cardiopulmonary system is accomplishing oxygenation and carbon dioxide removal Covers Objective: 10.2 Discussion Topic: Discuss how you would assess breathing. Consider both a conscious patient and an unconscious patient. Class Activity: Describe a respiratory assessment. Based on the findings that you present, ask the class to classify your patient as being in either respiratory distress or respiratory failure. Discuss. Critical Thinking: Certain conditions, such as diabetic ketoacidosis, make the body more acidic. This change in the pH decreases the hemoglobin's ability to hold onto oxygen. What effect might an acidotic condition have upon internal and external respiration? continued on next slide

Compensation for hypoxia or hypercapnea is predictable. Signs Shortness of breath (symptom) Increased respiratory rate and depth Increased heart rate Covers Objective: 10.7 continued on next slide

Early on, steps of adjustment can meet the needs of the body despite respiratory challenge. Respiratory distress Body compensating for a respiratory challenge and meeting metabolic needs Covers Objective: 10.7 Discussion Topic: Explain how the body compensates for inadequate breathing. Discuss the changes that occur. Class Activity: List specific compensatory steps. Have students explain why these steps might fail over time, and discuss the net effect on respiration when the failure occurs. Knowledge Applications: Discuss compensation for inadequate breathing. Describe specific compensatory steps and ask students to describe external findings. Describe a patient scenario that includes a patient who is compensating for a respiratory challenge. Ask students to explain the origins of the signs and symptoms that they identify.

Inadequate Breathing Occurs when challenge are too great for body's compensation mechanisms Also known as respiratory failure Exceptionally important to recognize; often a precursor to respiratory arrest Covers Objective: 10.8

Respiratory Distress Respiratory distress usually involves accessory muscle use and increased work of breathing. Severe or prolonged respiratory distress can proceed to respiratory failure and inadequate ventilation when the body can no longer work so hard to breathe. In this case you will see a reduced level of responsiveness or an appearance of tiring, shallow ventilations, and other signs of inadequate breathing. © Dan Limmer Covers Objective: 10.8

Patient Assessment Signs of adequate breathing
Relatively normal mental status Relatively normal pulse oximetry reading Relatively normal skin color Covers Objective: 10.9 continued on next slide

Patient Assessment Signs of inadequate breathing
Chest movements are absent, minimal, or uneven Abdominal breathing No air can be felt or heard at the nose or mouth Breath sounds are diminished or absent Wheezing, crowing, stridor, gurgling, or gasping during breathing Covers Objective: 10.9 Talking Points: Consider what occurs in respiratory failure: compensation fails. Therefore the assessment should focus on identifying these signs. Look for decompensation. continued on next slide

Patient Assessment Signs of inadequate breathing
Rate of breathing is too rapid or too slow Breathing is very shallow, very deep, or appears labored Cyanosis Inspirations or expirations are prolonged Retractions and nasal flaring in children Low oxygen saturation reading (<95%) Covers Objective: 10.9 Talking Points: Consider what occurs in respiratory failure: compensation fails. Therefore the assessment should focus on identifying these signs. Look for decompensation. continued on next slide

Patient Assessment Hypoxia Major causes
A patient is trapped in a fire. A patient has emphysema. A patient overdoses on a drug that has a depressing effect on the respiratory system. A patient has a heart attack. Covers Objective: 10.9 Discussion Topic: Define respiratory failure. Discuss the changes that occur when compensation fails. Knowledge Application: Compare and contrast respiratory distress with respiratory failure (inadequate breathing) in the following areas: lung sounds, respiratory rate, skin color, mental status.

Patient Care Inadequate breathing
Provide artificial ventilation to the nonbreathing patient and the patient with inadequate breathing. Provide supplemental oxygen to the breathing patient. continued on next slide

Patient Care When Do I Intervene?
Often respiratory failure patients will be breathing and conscious. Identify adequacy of breathing. If breathing is inadequate, immediate intervention is necessary. Covers Objective: 10.10 Knowledge Application: Use media resources or a detailed scenario to present students with a ventilation decision. Discuss.

Think About It What signs might identify the need to intervene in a breathing patient? Covers Objective: 10.10 Talking Points: Any signs of respiratory failure. Altered mental status, slow or irregular respirations, continued cyanosis, or any of the other signs previously discussed could indicate the need for immediate intervention.

Positive Pressure Ventilation
Teaching Time: 30 minutes Teaching Tips: When covering this topic, practice decision making. Understand the negative side effects of positive pressure ventilation before assisting a patient. As you move on to discuss the techniques for artificial ventilation have the students practice the skills and that they are achieving adequate artificial ventilation.

Forcing air or oxygen into lungs when a patient has stopped breathing or has inadequate breathing Uses force exactly opposite of how the body normally draws air into the lungs Covers Objective: 10.12 Points to Emphasize: Artificial ventilation utilizes positive pressure to move air into the lungs. The body normally uses negative pressure to pull air in. As these are very different processes, positive pressure has negative side effects. Cricoid pressure can minimize gastric distention during artificial ventilation. continued on next slide

Negative side effects of positive pressure ventilation Decreasing cardiac output/dropping blood pressure Gastric distention Hyperventilation Covers Objective: 10.12 Discussion Topic: Discuss the negative impact of poor artificial ventilation technique. Consider the outcome of the following problems: rate too fast; too much volume; inadequate mask seal.

Techniques of Artificial Ventilation
Do not ventilate patient who is vomiting or has vomitus in airway PPV will force vomitus into patient's lungs Watch chest rise and fall with each ventilation Ensure rate of ventilation is sufficient Covers Objective: 10.12 Knowledge Applications: Discuss scenarios with the class. Ask the class to determine the need for artificial ventilation. Discuss the decision-making process. Divide the class into two groups. Use a scenario to review the cost-benefit analysis of a "ventilate vs. not ventilate" decision. Have students debate both arguments. Discuss. continued on next slide

Techniques of Artificial Ventilation
Carefully assess the adequacy of respiration Explain procedure to patient Place the mask over the patient's mouth and nose After sealing mask on patient's face, squeeze bag with patient's inhalation Covers Objective: 10.12 Point to Emphasize: Ventilating a breathing patient may be difficult. The goal is not necessarily to take over breathing, but rather to increase tidal volume.

CPAP/BiPAP Form of noninvasive positive pressure ventilation (NPPV)
Continuous positive airway pressure BiPAP Biphasic positive airway pressure Covers Objective: 10.12

Mouth-to-Mask Ventilation
Performed using a pocket face mask Covers Objective: 10.13 Point to Emphasize: A variety of methods are used to artificially ventilate a patient. EMTs should be familiar with the tools and techniques available to them. continued on next slide

Covers Objective: 10.13 Point to Emphasize: A variety of methods are used to artificially ventilate a patient. EMTs should be familiar with the tools and techniques available to them. Pocket face mask. © Laerdal Corporation

Patient without suspected spine injury EMT at top of patient's head Position yourself directly above the patient's head. Apply the mask to the patient. Place your thumbs over the top of the mask, your index fingers over the bottom of the mask, and the rest of your fingers under the patient's jaw. Covers Objective: 10.13 Discussion Topic: Discuss the procedure for ventilating a patient with a pocket mask. continued on next slide

Performing Mouth-to-Mask Ventilation
Patient without suspected spine injury EMT at top of patient's head Lift jaw to the mask as you tilt patient's head backward and place remaining fingers under the angle of the jaw. While lifting the jaw, squeeze the mask with your thumbs to achieve a seal between the mask and patient's face. Give breaths into one-way valve of the mask. Watch for the chest to rise. Covers Objective: 10.13 Discussion Topic: Discuss the procedure for ventilating a patient with a pocket mask.

Performing Mouth-to-Mask Ventilation
Covers Objective: 10.13 Use only a pocket mask with a one-way valve.

Bag-Valve Mask Handheld ventilation device
Used to ventilate nonbreathing patient and/or patient in respiratory failure Covers Objective: 10.13

Adult, child, and infant bag-valve-mask units.
Covers Objective: 10.13 Adult, child, and infant bag-valve-mask units.

Bag-Valve Mask Standard features
Self-refilling shell that is easily cleaned and sterilized Non-jam valve that allows an oxygen inlet flow of 15 liters per minute Nonrebreathing valve Covers Objective: 10.13 Point to Emphasize: A good mask seal is an important and often difficult element of bag-valve-mask ventilation. continued on next slide

Bag-Valve Mask Mechanics of BVM
Supply of 15 liters per minute of oxygen attached and enters reservoir When squeezed, air inlet closed and oxygen delivered to patient When released, passive expiration by patient occurs Covers Objective: 10.13 continued on next slide

Bag-Valve Mask Two-rescuer BVM ventilation—no trauma suspected
Strongly recommended by AHA Most difficult part of BVM ventilation is obtaining adequate mask seal Hard to maintain seal while squeezing bag One rescuer squeezes bag; other rescuer maintains seal. Covers Objective: 10.13 continued on next slide

Open airway with head-tilt, chin-lift maneuver. Select correct bag-valve mask size. Kneel at patient's head; position thumbs over top half of mask, index fingers over bottom half. Covers Objective: 10.13 continued on next slide

Place apex of triangular mask over bridge of nose; lower mask over mouth and upper chin. Use middle, ring, and little fingers to bring patient's jaw up to mask. Maintain head-tilt, chin-lift maneuver. Covers Objective: 10.13 continued on next slide

Second rescuer connects and squeezes bag. Second rescuer releases bag; patient exhales passively. Covers Objective: 10.13 continued on next slide

Bag-Valve Mask Two-rescuer BVM ventilation—trauma suspected
Open airway using jaw-thrust maneuver. Select correct bag-valve mask size. Kneel at patient's head; place thumb sides of your hands along mask to hold it firmly on patient's face. Covers Objective: 10.13 Class Activities: Distribute clean face masks. Have students choose a partner and practice obtaining good hand position and face seal using a pocket mask or BVM face mask. (Do not ventilate.) Try obtaining the seal in different positions (patient supine, patient sitting up, and so on). Have students choose a partner and find the appropriate finger position for cricoid pressure. Check their locations. continued on next slide

Bag-Valve Mask Two-rescuer BVM ventilation—trauma suspected
Use remaining fingers to bring jaw upward toward mask, without tilting head or neck. Second rescuer releases bag; patient exhales passively. Covers Objective: 10.13

Two-Rescuer BVM Ventilation: Trauma Suspected
Covers Objective: 10.13 Delivering two-rescuer BVM ventilation while providing manual stabilization of the head and neck when trauma is suspected in the patient.

Bag-Valve Mask One-rescuer BVM ventilation Open airway.
Select correct size mask. Form a "C" around the ventilation port with thumb and index finger; use middle and little fingers to hold the jaw to mask. Covers Objective: 10.13 continued on next slide

Bag-Valve Mask One-rescuer BVM ventilation Squeeze bag.
Release pressure on bag and let patient exhale passively. Covers Objective: 10.13 continued on next slide

Bag-Valve Mask If the chest does not rise and fall during BVM ventilation, you should: Reposition head Check for escape of air around mask; reposition fingers and mask Check for airway obstruction or obstruction in BVM system Use alternative method Covers Objective: 10.14 Discussion Topic: Discuss the procedure for ventilating a patient with a bag-valve mask. continued on next slide

Bag-Valve Mask Artificial ventilation of a stoma breather
Clear mucus plugs or secretions from stoma Leave head and neck in neutral position Use pediatric-sized mask to establish seal around stoma Covers Objective: 10.16 continued on next slide

Bag-Valve Mask Artificial ventilation of a stoma breather
Ventilate at appropriate rate for patient's age. If unable to artificially ventilate through stoma, seal stoma and attempt artificial ventilation through mouth and nose. Covers Objective: 10.16 Discussion Topic: Discuss the procedure for artificially ventilating a stoma patient.

Flow-Restricted, Oxygen-Powered Ventilation Device
Also called manually triggered ventilation device Uses oxygen under pressure to deliver artificial ventilations through a mask placed over the patient's face Covers Objective: 10.13 continued on next slide

Flow-Restricted, Oxygen-Powered Ventilation Device
Use on adults only. Follow same procedures for mask seal as for BVM. Trigger device until chest rises. Covers Objective: 10.13 Discussion Topic: Discuss the procedure for ventilating a patient with a flow-restricted, oxygen-powered ventilation device.

Using Flow-Restricted, Oxygen-Powered Ventilation Device
Covers Objective: 10.13 Providing ventilations with a flow-restricted, oxygen-powered ventilation device (FROPVD).

Automatic Transport Ventilator
Provides positive pressure ventilations Can adjust ventilation rate and volume Provider must assure appropriate respiratory rate and volume for patient's size and condition. Covers Objective: 10.13 Knowledge Application: Describe a variety of patient scenarios. Ask students to choose a method to artificially ventilate the patient in each scenario. Discuss why the chosen method would be appropriate or inappropriate. Critical Thinking: If using a BVM was ineffective at ventilating a patient, what would the next step be? What are the alternatives?

Automatic Transport Ventilator
Covers Objective: 10.13 Knowledge Application: Describe a variety of patient scenarios. Ask students to choose a method to artificially ventilate the patient in each scenario. Discuss why the chosen method would be appropriate or inappropriate. Critical Thinking: If using a BVM was ineffective at ventilating a patient, what would the next step be? What are the alternatives? An automatic transport ventilator. The coin is shown for scale. © Edward T. Dickinson, MD

Think About It How would you decide which positive pressure delivery method to use for your patient? Covers Objective: 10.17 Talking Points: Each airway management scenario is slightly different. Factors such as resources, personnel, and even levels of training might impact the choice you make. Generally speaking, it is best to start simply and work to a more complex level only when necessary.

Oxygen Therapy Teaching Time: 30 minutes
Teaching Tips: This section deals primarily with psychomotor skills. Although there are didactic components, be sure to allot enough time for skills practice. Have appropriate assistance. Closely monitor and frequently correct students. Use standardized skill sheets to assess competency when practicing the various methods of administering supplemental oxygen. Prepare a variety of oxygen-related visual aids prior to this lesson. This section references many parts and pieces and is significantly enhanced by examples.

Importance of Supplemental Oxygen
Issues to consider when making decisions about oxygen administration Oxygen is a drug. Oxygen can cause harm. Oxygen should be administered based on your overall evaluation of the patient's presentation and possible underlying conditions. Covers Objective: 10.11 Point to Emphasize: Supplemental oxygen therapy can benefit a variety of injuries and illnesses. Discussion Topic: Discuss the value of supplemental oxygen. What conditions might benefit from supplemental oxygen?

Oxygen Therapy Equipment
Portable In the field Lightweight, safe, dependable Installed Inside the ambulance Covers Objective: 10.21 Point to Emphasize: There are many components to an oxygen delivery system. Some are universal, while others are system specific. EMTs always should obtain appropriate training on their specific oxygen delivery system. Discussion Topic: Discuss the general procedure for preparing an oxygen delivery system.

Oxygen Systems Covers Objective: 10.21 Point to Emphasize: There are many components to an oxygen delivery system. Some are universal, while others are system specific. EMTs always should obtain appropriate training on their specific oxygen delivery system. Discussion Topic: Discuss the general procedure for preparing an oxygen delivery system. For safety, to prevent them from tipping over, oxygen cylinders must be placed in a horizontal position or, if upright, must be securely supported.

Larger cylinders are used for fixed systems on ambulances.
Oxygen Systems Covers Objective: 10.21 Point to Emphasize: There are many components to an oxygen delivery system. Some are universal, while others are system specific. EMTs always should obtain appropriate training on their specific oxygen delivery system. Discussion Topic: Discuss the general procedure for preparing an oxygen delivery system. Larger cylinders are used for fixed systems on ambulances.

Oxygen Cylinders Come in various sizes D cylinder E cylinder
About 350 liters of oxygen E cylinder About 625 liters of oxygen M cylinder About 3,000 liters of oxygen Covers Objective: 10.21 continued on next slide

Oxygen Cylinders Come in various sizes G cylinder H cylinder
About 5,300 liters of oxygen H cylinder About 6,900 liters of oxygen Covers Objective: 10.21 continued on next slide

Oxygen Cylinders Use pressure gauges, regulators, and tubing intended for use with oxygen. Use nonferrous wrenches. Ensure valve seat inserts and gaskets are in good condition. Use medical-grade oxygen. Covers Objective: 10.20 Point to Emphasize: Safety is an essential consideration for an EMT who is handling pressurized oxygen. Discussion Topic: Discuss the potential dangers associated with the handling of oxygen and compressed gas in general. continued on next slide

Oxygen Cylinders Open the valve of an oxygen cylinder fully then close it half a turn to prevent someone else from thinking the valve is closed and trying to force it open. Store reserve oxygen cylinders in cool, ventilated room, properly secured in place. Have oxygen cylinders hydrostatically tested every five years. Covers Objective: 10.20 continued on next slide

Oxygen Cylinders Never drop a cylinder or let it fall against any object. Never leave an oxygen cylinder standing in an upright position without being secured. Never allow smoking around oxygen equipment in use. Covers Objective: 10.20 continued on next slide

Oxygen Cylinders Never use oxygen equipment around open flame.
Never use grease, oil, or fat-based soaps on devices that will be attached to an oxygen supply cylinder. Never use adhesive tape on a cylinder. Never try to move an oxygen cylinder by dragging it or rolling it on its side or bottom. Covers Objective: 10.20

Pressure Regulators Connected to the oxygen cylinder to provide a safe working pressure of 30 to 70 psi. Covers Objective: 10.21

Flowmeters Allow control of the flow of oxygen in liters per minute
Low-pressure flowmeters Pressure-compensated flowmeter Constant flow selector valve High-pressure flowmeters Thumper™ CPR device Respirators and ventilators such as CPAP and BiPAP devices Covers Objective: 10.21

Flowmeters Covers Objective: 10.21 Low-pressure flowmeters: (Left) A pressure-compensated flowmeter; (Right) a constant flow selector valve.

Flowmeters Covers Objective: 10.21 High-pressure flowmeter. High-pressure oxygen is delivered through hoses attached to a threaded connector.

Humidifiers Connected to flowmeter
Provide moisture to dry oxygen from supply cylinder Covers Objective: 10.18 Knowledge Application: Describe a series of patients who require supplemental oxygen. Have students choose an oxygen delivery device and explain why they feel that the particular device would work for the specific patient. Discuss. Critical Thinking: You are treating an end-stage COPD patient who is complaining of respiratory distress. You note cyanosis in his lips and nail beds. As you begin to prepare your oxygen tank for delivery of supplemental oxygen, the patient's home health nurse tells you that the patient cannot have oxygen due to his COPD. Given this information, what do you do?

Humidifier in use on board an ambulance.
Covers Objective: 10.18 Knowledge Application: Describe a series of patients who require supplemental oxygen. Have students choose an oxygen delivery device and explain why they feel that the particular device would work for the specific patient. Discuss. Critical Thinking: You are treating an end-stage COPD patient who is complaining of respiratory distress. You note cyanosis in his lips and nail beds. As you begin to prepare your oxygen tank for delivery of supplemental oxygen, the patient's home health nurse tells you that the patient cannot have oxygen due to his COPD. Given this information, what do you do? Humidifier in use on board an ambulance.

Hazards of Oxygen Therapy
Common hazards of oxygen and oxygen equipment If the tank is punctured or a valve breaks off, the supply tank can become a missile. Oxygen supports combustion. Can saturate towels, sheets, clothing Oxygen and oil do not mix under pressure. Covers Objective: 10.20 continued on next slide

Hazards of Oxygen Therapy
Rare medical situations Oxygen toxicity or air sac collapse Infant eye damage Respiratory depression or respiratory arrest Covers Objective: 10.20

Administering Oxygen Work with your instructor or follow your instructor's directions to understand how to use specific equipment. Various devices available Covers Objective: 10.18 Point to Emphasize: Specific oxygen delivery devices can be used to administer different concentrations and flow rates of oxygen. Discussion Topic: Discuss the general procedure for administering supplemental oxygen.

Nonrebreather Mask Best way to deliver high concentrations of oxygen to a breathing patient Covers Objective: 10.18 Point to Emphasize: Specific oxygen delivery devices can be used to administer different concentrations and flow rates of oxygen. Discussion Topic: Discuss the general procedure for administering supplemental oxygen.

Delivery Devices: Nonrebreather Mask
Covers Objective: 10.18 Nonrebreather mask. Note the round disks—flutter valves that allow air exhaled by the patient to escape so it is not rebreathed.

Nonrebreather Mask Provides oxygen concentrations of 80 to 100 percent
Optimum flow rate is 12 to 15 liters per minute. A new design feature allows for one emergency port in the mask to the patient can still receive atmospheric air should the oxygen supply fail. Covers Objective: 10.18

Nasal Cannula Best choice for a patient who refuses to wear an oxygen face mask Covers Objective: 10.18

Delivery Devices: Nasal Cannula
Covers Objective: 10.18 Nasal cannula.

Nasal Cannula Provides oxygen concentrations between 24 and 44 percent
Oxygen is delivered to patient by two prongs that rest in patient's nostrils. Should deliver no more than 4 to 6 liters per minute Covers Objective: 10.18

Partial Rebreather Mask
Very similar to nonrebreather mask No one-way valve in opening to reservoir bag Delivers 40 to 60 percent oxygen at 9–10 liters per minute Covers Objective: 10.18

Venturi Mask Delivers specific concentrations of oxygen by mixing oxygen with inhaled air Some have set percentage and flow rate; others have adjustable Venturi port. Covers Objective: 10.18

Delivery Devices: Venturi Mask
Covers Objective: 10.18 Venturi mask.

Tracheostomy Mask Placed over stoma or tracheostomy tube to provide supplemental oxygen Connected to 8 to 10 liters per minute of oxygen via supply tubing Covers Objective: 10.18

Delivery Devices: Tracheostomy Mask
Covers Objective: 10.18 Discussion Topic: Describe the differences among oxygen delivery devices. Cite specific capabilities of the following: a nonrebreather mask; a nasal cannula; a partial rebreather mask; a Venturi mask. Class Activities: Have a class scavenger hunt. Assign students to a station or a medical facility and have them photograph as many oxygen delivery devices as they can. Discuss. Consider taking a field trip to the back of an ambulance. Many of the referenced systems and appliances will be present there. Tracheostomy mask.

Oxygen Administration via a Non-Rebreather Mask Video
Covers Objective: 10.18 Video Clip Oxygen Administration via a Non-Rebreather Mask What type of patient is this mask indicated for? How does the device work? Explain the procedure for applying a nonrebreather mask. Click on the screenshot to view a video on the topic of oxygen delivery using a simple mask. Back to Directory

Special Considerations
Teaching Time: 15 minutes Teaching Tips: Multimedia graphics of facial injuries may enhance comprehension of special ventilatory circumstances. Have pediatric anatomy models on hand to illustrate differences. Demonstrate pediatric-specific airway equipment.

Facial injuries Bleeding and swelling can disrupt movement of air. Aggressive suction and advanced airway maneuvers may be necessary. Covers Objective: 10.17 Point to Emphasize: Facial injuries may impair breathing and alter the procedure for providing artificial respirations. Discussion Topic: Discuss how a facial injury or airway obstruction might interfere with your ability to provide artificial ventilation. Knowledge Application: Provide examples of facial injuries (and/or show graphics) and discuss methods for properly administering artificial ventilations. Particularly highlight how such injuries might alter normal procedures. continued on next slide

Obstructions Foreign bodies can impede ventilation of patients. If unable to ventilate, always consider the possibility of obstruction. Covers Objective: 10.17 Points to Emphasize: Airway obstructions may require action prior to the administration of artificial ventilations or supplemental oxygen. Dental appliances should be left in place, but they can potentially threaten airway management. If they interfere with the airway, an EMT should remove them. Knowledge Application: Divide the class into small groups. Assign each group a special consideration such as a facial injury, a pediatric patient, dentures, and so on. Have each group discuss the potential challenges, improvise a solution, and present its findings to the class. continued on next slide

Dental appliances Dentures should ordinarily be left in place during airway procedures. Partial dentures may become dislodged during an emergency. Leave a partial denture in place if possible, but be prepared to remove it if it endangers the airway. Covers Objective: 10.17

Pediatric Note Hypoxia often occurs rapidly.
Children burn oxygen at twice the rate of adults Accounted for by the many anatomical differences associated with airway Covers Objective: 10.17 Discussion Topic: Describe examples of pediatric airway anatomy (or pediatric anatomy in general) that might make providing artificial ventilations more difficult. continued on next slide

Pediatric Note Ventilating pediatric patients
Avoid excessive pressure and volume. Use properly sized face masks. Flow-restricted, oxygen-powered ventilation devices contraindicated Use pediatric-sized nonrebreather masks and nasal cannulas. Gastric distention may impair adequate ventilations. Covers Objective: 10.17 Point to Emphasize: Pediatric patients often are anatomically different from adults and may require specialized artificial ventilation techniques and equipment. Class Activity: Referring to a standardized skill competency sheet, and using pediatric airway manikins, demonstrate the proper one- and two-person techniques for delivering ventilations using a bag-valve mask on an infant and a child. Critical Thinking: In this section we highlighted some specific circumstances that might make artificial ventilations and supplemental oxygen delivery more difficult. There are many other difficult situations. What others can you think of? Discuss.

Assisting with Advanced Airway Devices
Teaching Time: 15 minutes Teaching Tips: Invite an advanced provider to discuss the teamwork associated with advanced airway placement. Have advanced airway devices and associated equipment on hand for familiarization. Focus on confirmation. This is an absolutely essential goal for the entire team.

Assisting with Advanced Airway Devices
Devices requiring direct visualization of the glottic opening (endotracheal intubation) Devices inserted "blindly," meaning without having to look into the airway to insert the device. Covers Objective: 10.17 Point to Emphasize: There are two general categories of advanced airway devices: devices that require direct visualization of the glottic opening, and devices that are inserted "blindly." Knowledge Application: Have students work in small groups. Assign each group a specific type of advanced airway. Have the group research and present the procedure used to insert the airway device.

Types of Advanced Airway Devices
Covers Objective: 10.17 Point to Emphasize: There are two general categories of advanced airway devices: devices that require direct visualization of the glottic opening, and devices that are inserted "blindly." Knowledge Application: Have students work in small groups. Assign each group a specific type of advanced airway. Have the group research and present the procedure used to insert the airway device. In the BURP maneuver, press your thumb and index finger on either side of the throat over the cricoid cartilage and gently direct the throat upward and toward the patient’s right. © Edward T. Dickinson, MD

Preparing the Patient for Intubation
Maximize oxygenation prior to procedure. Position patient in sniffing position. Cricoid pressure Confirmation Securing tube in place Points to Emphasize: The most important thing that an EMT can do to further the success of the insertion of an advanced airway is to assure a patent airway and quality ventilations prior to insertion of the device. EMTs often play a role in confirming the correct placement of an advanced airway. Discussion Topics: Explain the importance of hyperoxygenation prior to the insertion of an advanced airway. Discuss the role of an EMT in the process of inserting an advanced airway. Discuss the importance of confirming an endotracheal tube's placement. Discuss methods that you might use.

Ventilating the Intubated Patient
Very little movement can displace an endotracheal tube. Pay attention to resistance to ventilations; report changes. If patient is defibrillated, carefully remove bag from tube. Watch for any change in patient's mental status. Covers Objective: 10.12 Point to Emphasize: When ventilating through an endotracheal tube, an EMT should carefully monitor the tube's position and report any changes in resistance to ventilation. Knowledge Application: Assign an advanced provider to small groups of students. Using an airway manikin, practice advanced airway procedures.

Assisting with a Trauma Intubation
Provide manual in-line stabilization throughout procedure. Position hands to hold stabilization, but allow for movement of jaw. Point to Emphasize: Intubation of the trauma patient requires manual stabilization of the patient's head while the advanced provider inserts the airway. Discussion Topic: Describe the teamwork necessary to intubate a trauma patient. Class Activity: Combine classes. Join with an advanced class and practice the teamwork necessary to insert an advanced airway. Knowledge Application: Using an airway manikin, practice the hand position necessary to maintain stabilization during a trauma intubation.

Blind-Insertion Airway Devices
Examples King LT™ airway Laryngeal mask airway (LMA™) Usually do not require head to be placed in sniffing position Covers Objective: 10.17 Critical Thinking: What is the role of the EMT when an advanced airway fails? How might an EMT help in a "failure to intubate" situation?

In-Hospital Endotracheal Intubation Video
Video Clip In-Hospital Endotracheal Intubation Explain why a patient who requires endotracheal intubation should be pre-oxygenated. How should an EMT test equipment prior to intubating a patient? Where should cricoid pressure be applied during an intubation attempt? How should an endotracheal intubation be confirmed? Why is verification of endotracheal tube placement essential? What should an EMT do if the endotracheal tube is placed in the esophagus? Click on the screenshot to view a video on the subject of in-hospital endotracheal intubation. Back to Directory

Chapter Review

Chapter Review Respiratory failure is the result of inadequate breathing, breathing that is insufficient to support life. A patient in respiratory failure or respiratory arrest must receive artificial ventilations. Oxygen can be delivered to the nonbreathing patient as a supplement to artificial ventilation. continued on next slide

Chapter Review Oxygen can also be administered as therapy to the breathing patient whose breathing is inadequate or who is cyanotic, cool and clammy, short of breath, suffering chest pain, suffering severe injuries, or displaying an altered mental status.

Remember Always use proper personal protective equipment when managing an airway. Assessment of breathing must be an ongoing process. Respiratory status can change over time. Inadequate breathing requires immediate action. continued on next slide

Remember Positive pressure ventilations are very different than normal breathing and can have negative side effects. Select the most appropriate method of positive pressure ventilations based upon the needs of the individual. continued on next slide

Remember Always use appropriate safety measures when handling oxygen.
Select the appropriate delivery device to provide supplemental oxygen.

Questions to Consider What are the signs of respiratory distress?
What are the signs of respiratory failure? For BVM ventilation, what are recommended variations in technique for one or two rescuers? Talking Points: Signs of respiratory distress include increased rate, accessory muscle use. Mental status is typically normal and hypoxia is usually not profound. Signs of respiratory failure include all the signs of respiratory distress plus altered mental status, cyanosis, profound hypoxia and slowing or irregular breathing. The recommended technique for BVM is two providers. One provider seals the mask while the second provider squeezes the bag. With one rescuer, the E-C clamp is used to hold the mask on the face with one hand while the second hand is used to squeeze the bag. continued on next slide

Questions to Consider How does the way positive pressure ventilation moves air differ from how the body normally moves air? Describe a patient problem that would benefit from administration of oxygen and explain how to decide what oxygen delivery device should be used. Talking Points: Normal ventilation uses negative pressure to pull air into the lungs. Positive pressure ventilation uses positive pressure. There are many possibilities of conditions that would benefit from oxygen therapy. Consider any condition that leads to hypoxia. Choosing the correct delivery device requires consideration of the patient's capabilities (breathing or not breathing; positive pressure vs. supplemental delivery) and whether or not the patient will tolerate a face mask.

Critical Thinking On arrival at the emergency scene, you find an adult female patient who is semiconscious. Her respiratory rate is 7 per minute. She appears pale and slightly blue around her lips continued on next slide

Critical Thinking Is this patient in respiratory failure, and if so what signs and symptoms indicate this? Does this patient require artificial ventilations? Talking Points: This patient is in respiratory failure as demonstrated by a slow respiratory rate, altered mental status and cyanosis. This patient needs artificial ventilation.

10 Respiration and Artificial Ventilation.

Similar presentations

Presentation on theme: "10 Respiration and Artificial Ventilation."— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

10 Respiration and Artificial Ventilation.

Similar presentations

Presentation on theme: "10 Respiration and Artificial Ventilation."— Presentation transcript:

Similar presentations

About project

Feedback