Transcript 100108 no pics Respiratory Assessment

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

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
semi-conscious
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
Paramedic Students
Resp Center Lesions
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
S: Pt. c/o sudden onset SOB ~ 2 hrs
ago while at rest. PMH: CHF and 2vessel CABG 1 yr ago. On the usual
meds.
 O: 67 y/o male Pt CAO PPTE, seated on
edge of bed in tripod position. He
claims that laying back makes
symptoms worse (Orthopnea). Pt.
speaks in 2-4 word sentences and
frequently needs to be reminded of
questions. During assessment, pt
becomes increasingly agitated and
confused.

What’s your DDX?
 What’s your Tx?

Another Sample Pt.
What are the clues here?

S: A 62 year old male c/o SOB.
Per wife, pt has been unable to
sleep and has been having trouble
breathing for 4 hours. He has not
used his nebulizer treatment
because he can no longer hold it
to his mouth. PMH: emphysema
and asthma.
Our Guy (continued)

O: Pt is CAO Person only, upright in
recliner. RR 46, SaO2 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.
Pursed-lip breathing with nasal flaring
noted.
DDX?
 Tx?

Auscultation techniques
 Air
movement at mouth and
nose
 Bilateral
lung fields
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