Transcript 092607 NoPic Respiratory Assessment

Respiratory System
Assessment
Chemeketa Community
College
Paramedic Program
Peggy Andrews, Instructor
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Respiratory rates
Normal - 12 - 20
 Controlled by other factors

– Temperature
– Drugs and medications
– Pain
– Sleep

- Emotion
- Hypoxia
- Acidosis
Obstruction
– Tongue - most common
 Snoring, correct with positioning
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Foreign body

May cause partial or complete obstruction
–
–
–
–
Choking, gagging
Stridor
Dyspnea
Aphonia
 Speechless
– Dysphonia
 Difficulty speaking
 Hoarseness
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Laryngeal spasm and edema
 Spasm
– Sudden movement/contraction
 Most
frequently:
– Trauma
 Aggressive intubation
– Post-extubation
 Especially if patient semi-conscious
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33 year old female rescued from
a structure fire. CAO x 3, RR38,
SaO2 64%, harsh stridor on insp.

Edema
 Glottis
– Extremely narrowed
– Totally obstructed

Most frequently:

Relieved by
– Aggressive
ventilation
– Muscle relaxants
– Alternative Airway
– Epiglottitis
 Bacterial infection
– Anaphylaxis
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28 year old male, snowmobile into
farmers fence, 20 mph.

Fractured larynx
– Airway patency dependent on muscle tone
– Increased resistance by decreased size
– Decreased muscle tone
– Laryngeal edema
– Ventilatory effort
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79 y/o male, liquid diet, hiccup’s
during breakfast. Severely SOB

SaO2 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 
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Airway evaluation
 Rate
– 12-20?
 Regularity
 Steady pattern
 Irregular patterns are significant until
proven otherwise
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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
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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
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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
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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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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.
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Our Lady (continued)

O: Pt is barely conscious, 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.
Her lips are pursed and her nostrils are
flaring with each breath.
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Auscultation techniques
 Air
movement at mouth and nose
 Bilateral
lung fields equal
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Palpation techniques
 Air
movement at mouth and nose
 Chest
wall
– Paradoxical motion
– Retractions
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Bag-valve-mask

Resistance/changing compliance
with BVM ventilations
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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)
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History
 Interventions
– Evaluations/admissions to hospital
– Medications (include compliance
and dose)
– Ever intubated???
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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
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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
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Supplemental oxygen therapy

Supplemental oxygen
therapy
– Increases O2 to cells
– O2 increases patients
ability to compensate
– Delivery method
continually reassessed
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Oxygen source

Compressed gas

Common sizes
and volumes
–D
400L
–E
625L
–M
3450L
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Calculating Tank Life
((PSI in tank) – (500)) x (factor)
(Desired Lpm)
Tank Size Factor
 0.16 D Tank
 0.28 E Tank
 1.56 M Tank
(1800-500) x 0.16 / 10 = 20.8 minutes
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Regulators

High pressure
– Transfer gas from tank to tank
– Cascade System

Therapy regulators
– Pressure “stepped down”
– Delivery via adjustable low pressure
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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
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Delivery Devices
 Nasal
cannula
– Advantages
 Well tolerated
 Easy to communicate
– Disadvantages
 Doesn’t deliver high volume/high
concentration
 % Not guaranteed
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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.
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Delivery Devices

Partial rebreather
– Indications
– Contraindications
 Apnea
 Poor respiratory effort
– Advantages
 Higher concentrations
– Disadvantages
 Beyond 10 LPM does not enhance content.
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Delivery Devices

Non-rebreather mask
– Mask side ports
 One-way disc
– Reservoir bag attached
– 80-95% at 10-15 Lpm
– Indications
 Highest O2 content (Non PPV)
– Contraindications
 Apnea
 Poor effort
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Delivery Devices

Venturi mask
– Mask with interchangeable adapters
 Side ports for room air
 Highly specific content. O2

Oxygen humidifiers
– Sterile water reservoir for humidifying oxygen
– Long term admin.
– Desirable for Croup/Epiglottitis/Bronchiolitis

Tracheostomy
 Stoma
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Summary

Respiratory Assessment concepts

Scenario’s

Oxygen Delivery Method Review
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