What is respiration?
Exchange of oxygen and carbon dioxide.
What is ventilation?
Mechanical process of moving air in and out of lungs.
What part of the brain is responsible for breathing?
Stimulus to breath comes from the medulla. Involuntary control of breathing originates in the pons in the brainstem.
What motor nerves are present in inspuration?
Phrenic nerve - diaphragm
Intercostal nerves - external intercostal muscles
What is the relationship between intrapulmonary pressure and atmospheric pressure during inspiration?
Intrapulmonary pressure falls slightly below atmospheric pressure.
When does a person stop inhaling?
Atmospheric pressure = intrapulmonary pressure
Normal inspiratory reserve volume.
3,000 mL adult male
2,300 mL adult female.
The nervous system mechanism that terminations inhalation and prevents overexpansion of lungs.
How is expiration initiated?
Mechanical stretch receptors in chest wall and bronchioles send signal to apneustic center via vagus nerve.
Inspiratory/expiratory ratio (I/E ratio)
I/E ratio in asthma.
1:4 or 1:5
Why is the I/E ratio different in a patient with a lower airway obstruction? (i.e. asthma)
Expiratory phase is prolonged as they have more difficulty getting our out.
Signs of normal breathing in adult.
Rate of 12-20 breaths/min Regular pattern Clear and equal breath sounds Regular and equal chest rise and fall Adequate depth Unlabored
s/s of asthma
wheezing on inspiration/expiration
s/s of anaphylaxis
flushed skin hives generalized edema hypotensive laryngeal edema with dyspnea wheezing or stridor
SOB wheezing coughing fever dehydration tachypnea tachycardia wheezing, crackles
chronic cough w/ sputum production
s/s heart failure
Pink, frothy sputum coming from mouth Crackles, rhonchi, wheezing Pedal edema Cool, diaphoretic, cyanotic skin Tachycardia HTN early, deteriorates to hypotension
difficulty breathing and swallowing
thick, gray buildup in throat or nose
barrel chest pursed lip breathing DOE cyanosis wheezing or decreased breath sounds
dyspnea high fever stridor drooling difficulty swallowing severe sore throat tripod or sniffing position
dyspnea chills, fever cough green, red, or rust colored sputum localized wheezing or crackles
sudden pleuritic chest pain w/ dyspnea
decreased breath sounds
Severe findings: AMS pale, diaphoretic, cyanotic unilateral breath sounds hyperresonance to percussion
s/s pulmonary embolus
sudden onset sharp chest pain dyspnea tachycardia tachypnea cyanosis hemoptysis
s/s tension pneumothorax
severe SOB AMS JVD tracheal deviation hypotension signs of shock
productive bloody sputum
What are the two types of cells found in alveoli?
Type I pneumocytes : almost empty allowing for better gas exchange. Lack cellular components hindering ability to reproduce.
Type II pneumocytes : can make new type I cells and produce surfactant
How does the body respond to mild hypocemia?
Increases heart rate
Are alveoli able to be repair themselves after being damaged by infection, cigarette smoke, or other trauma?
The ability to repair themselves correlates w/ type II pneumocytes. After all type II cells have been destroyed, the alveolus cannot make new cells or surfactants.
What happens when alveoli collapse, become fluid-filled, or puss filled?
They do not participate in gas exchange and create a shunt moving blood from right side of the heart bypassing alveoli and returns to the left side of the heart unoxygenated.
What causes right sided heart failure in patient’s with chronic lung disease and/or chronic hypoxia?
These patients produce a surplus of RBC making the blood viscous. The viscosity of the blood causes strain on the right side of the heart.
What is the medical term for right-sided heart failure secondary to chronic lung disease?
What are the reasons for high CO2 levels?
Various lung disease impairing exhalation process.
The body produces too much CO2 due to disease or abnormality.
Define carbon dioxide retention.
Failure of respiratory centers in the brain to respond normally to a rise in CO2 levels in arteries.
pH level of patient w/ hyperventilating.
High pH resulting in respiratory alkalosis.
pH level of patient w/ hypoventilation.
Low pH resulting in respiratory acidosis.
Causes of impaired ventilation.
Upper airway obstruction
Lower airway obstruction
Chest wall impairment
What conditions cause impaired ventilations in upper airway obstructions?
What conditions cause impaired ventilations in lower airway obstructions?
Increased mucus production
What conditions cause impaired ventilation in chest wall impairment?
Restrictive disease (scoliosis, kyphosis)
What conditions cause impaired ventilations in neuromuscular impairment?
Overdose Lou Gehrig disease (ALS) Carbon dioxide narcosis Injury to c-spine Guillain-Barre syndrome Botulism
What conditions may interrupt a pt’s respiratory drive?
Acute opioid narcotic OD
Intoxication w/ ETOH, narcotic, toxins, drugs
Head injury, hypoxic drive, and asphyxia
s/s of pulmonary edema
Dyspnea Rapid, shallow respirations Frothy pink sputum from nose and mouth Orthopnea Fatigue Crackles
Who are at a high risk of spontaneous pneumothorax?
Pt’s with emphysema and asthma. Tall, thin, athletic males.
What are the risk factors of PE?
recent surgery pregnancy oral contraceptives smoking infection cancer Sickle cell anemia prolonged inactivity
Anatomical damage caused by highly water-soluble gases. (i.e. ammonia)
The gas will react w/ the moist mucous membranes of upper airway causing swelling and irritation.
Anatomical damage caused by less water-soluble gases. (i.e. phosogene, nitrogen dioxide)
Gases get deep into the lower airway where pulmonary edema can occur up to 24 hours later.
Genetic disorder that affects the lungs and digestive system. Chloride is unable to move through cells without difficulty causing unusually high sodium levels and abnormally thick mucus secretions.
Why does RSV spread rapidly in schools and child care centers?
The virus is spread through droplets and survive on surface including hands and clothing.
Caused by inflammation and swelling of the phraynx, larynx, and trachea.
Often secondary to acute viral infection of the upper respiraoty tract.
Typically seen in 6 mo. to 3 y/o.
Why is croup commonly found in children and rare adults?
Adult airways are larger and can accommodate the inflammation and mucus production w/o s/s.
Signs of life-threatening respiratory distress in adults.
AMS Severe cyanosis Absent or abnormal breath sounds Audible stridor Two-to-three word dyspnea Coughing Tachycardia (above 130) Abdominal breathing Change in respiratory rate or rhythm Pallor and diaphoresis Retractions and/or use of accessory muscle Tripod positioning
Diseases associated with wheezing.
Asthma COPD CHF Pulmonary edema PNA Bronchitis Anaphylaxis
Diseases associated with rhonchi.
Diseases associated with crackles.
Diseases associated with stridor.
Diseases associated with decreased or absent breath sounds.
Asthma COPD PNA Hemothorax Pneumothorax Atelectasis
Describe crackle breath sounds.
Air trying to pass through fluid in the alveoli.
Crackling or bubbling sound typically heard on inspiration.
High-pitched sounds are fine crackles
Low-pitched sounds are coarse crackles
Described rhonchi breath sounds.
Secretions or mucus in the larger airway.
Lower-pitched rattling sounds.
Describe stridor breath sounds.
Air tries to pass through an obstruction.
Typically partial obstruction in trachea.
High-pitched sound hear on inspiration.
Describe wheezing breath sounds.
Constriction and/or inflammation in the bronchus.
High-pitched whistling sound typically heard on expiration.
Describe pleural friction rub breath sounds.
Pleural layers have lost their lubrication mostly due to pleural inflammation.
Squeaking or grating sound heard on inspiration and/or expiration.
What causes snoring respiration?
Partial upper airway obstruction usually in oropharynx.
rapid and slow respirations alternating w/ periods of apnea.
deep, rapid respirations
Ataxic (Biot) respirations
rapid, irregular respirations w/ periods of apnea
impaired respirations w/ sustained inspiratory effort
What part of exhalation is tested by ETCO2?
Last few milliliters of exhaled air.
Range of normal peak flow values.
How many liters is considered substantial respiratory distress when using a peak flow meter?
> 150 L/min
*chronic asthma pt’s may never exceed 100 L/min
How many liters of oxygen should be used with nebulizers?
Adulet and pediatric dose of Albuterol/
Adult: 2.5 mg diluted with 2.5 mL nl saline
Peds: > 20 kg: 1.25 mg/dose via handheld nebulizer or mask over 20 minutes.
<20 kg: 2.5 mg/dose via handheld nebulizer or mask over 20 minutes.
Contraindications for MDI
Pt unable to help coordinate inhalation w/ depression of the trigger or too confused.
Not prescribed to pt
Did not obtain permission for medical control and/or is not permissible by local protocol
Pt already had max dose before EMS arrival
Contraindications specific to medication
How do you know if your CPAP intervention is successful?
Respiratory rate decreases
Tx for obstructive airway diseases
Peak flow meter to establish baseline expiratory airflow Pulse ox Position of comfort Call for ALS High flow oxygen Assist with ventilations if needed Use humidified oxygen if available IV access IV therapy if necessary MDIs PRN Contact medical control for further orders
Tx for acute pulmonary edema
100% oxygen Suctions secretions if needed Position of comfort Assist ventilations if needed Consider CPAP Establish IV access Call ALS for possible intubation Prompt transport
Tx for aspiration
Aggressively reduce risk of aspiration by avoiding gastric distention during ventilation.
Monitor pt’s ability to protect airway
Tx for COPD
Assist w/ MDI
Tx for anaphylactic reactions
Remove offending agent Maintain airway BVM Prepare for ventilation PRN Rapid transport Early administration of Epi
Tx for spontaneous pneumothorax
Begin w/ ABCs
Position of comfort
Condition w/ determine emergent or non-emergent
Consider ALS if signs of tension pneumo develop
Tx for pleural effusion
Tx for pulmonary embolism
Maintain airway High-flow oxygen BVM if needed Initiate CPR if pulseless and apneic Establish IV access Bolus of isotonic crystalloid solution Fluid hydration based on clinical sxs Reassurance and psychological support Call ALS PRN
Tx for hyperventilation
Coach ventilations if anxiety-related
Tx for obstruction the airway
Pt able to talk and breath, provide supplemental oxygen and transport carefully in a position of comfort.
Remove obstructing body for complete airway obstruction
Open airway w/ head tilt-chin lift (or jaw-thrust for suspected spinal trauma)
No improvement with opening airway, asses the upper airway for obstruction.
Supplemental oxygen and transport promptly.
Tx for environmental/industrial exposure
Pt must be decontaminated first by trained responders.
Gather information about substance and cause of dyspnea.
100% supplements oxygen
Assist w/ ventilations if needed
If upper airway compromised, aggressive airway management may be required. Call ALS.
What medications do you use to treat the three components of asthma?
Airway edema : corticosteroids
Increased mucus production : water and expectorants
Bronchospasm : bronchodilator
Tx for asthma
Prepare to suction
Assist with MDIs
Prepare to assist ventilations w/ BVM