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Chapter 8

Chapter 8. Respiratory Support. Overview. Breathing Assessment Oxygen Therapy Oxygen Delivery Systems Oxygen Delivery Devices Artificial Ventilation. Breathing. Breathing is a complex activity Some illnesses impair the body’s ability to utilize oxygen

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Chapter 8

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  1. Chapter 8 Respiratory Support

  2. Overview • Breathing • Assessment • Oxygen Therapy • Oxygen Delivery Systems • Oxygen Delivery Devices • Artificial Ventilation

  3. Breathing • Breathing is a complex activity • Some illnesses impair the body’s ability to utilize oxygen • Hypoxia means insufficient body stores of oxygen • Increased respiratory rate • Shortness of breath

  4. Breathing • Severe difficulty with breathing can lead to respiratory failure • Untreated respiratory failure can lead to death • The EMT must assess the patient’s ventilation and respiration

  5. Assessment • Initial steps • Look • Listen • Feel • Determination of level of consciousness • Verbal stimuli • Physical stimuli

  6. Assessment • Quick check • Key to the initial assessment of the unconscious patient • Look for the chest to rise and fall • Listen and feel for air movement • Check for the presence of a carotid pulse

  7. Assessment • Look • Visual cues provide a lot of information about the patient’s breathing • Position • The tripod position allows the patient to expand his lungs and draw in more air

  8. Assessment

  9. Assessment • Look • Color • Blood lacking oxygen gives the skin a bluish color, known as cyanosis • Respiratory rate • Can be too fast, too slow, or about normal • Tachypnea is an increased rate of breathing • Hypoventilation is a decreased rate of breathing

  10. Assessment • Look • Effort • Any exertion seen with breathing is abnormal • Nasal flaring • Mouth breathing • Pursed lips • Accessory muscle use

  11. Assessment • Look • Pulse oximetry • Measures the percentage of red blood cells that are saturated with oxygen • Helps assess a patient with respiratory distress • Average oxygen saturation is 96–100% • Below 95%: Oxygen administration required • Below 92%: The patient is significantly hypoxic

  12. Assessment

  13. Assessment • Listen • Note what is said and how it is said • Document the chief complaint • The feeling of respiratory distress is called dyspnea

  14. Assessment • Listen • Speech • The EMT should note the patient’s ease of speech • Full sentences without frequently stopping—severe distress is not likely • Short sentences or monosyllabic answers—severe respiratory distress is present

  15. Assessment • Listen • Obvious noise • Note noises associated with breathing • Noticeable noise is a sign of a respiratory problem

  16. Assessment • Listen • Breath sounds • On auscultation, air movement should be evident in both lungs • The absence of sounds indicates lack of air movement • Diminished breath sounds may indicate poor airflow or lung abnormality

  17. Assessment • Feel • Palpate the chest wall for tenderness, deformity, and equality of movement • With the hands under the armpits, apply pressure to the rib cage

  18. Stop and Review • List the signs of adequate breathing.

  19. Oxygen Therapy • The most common medication administered by the EMT • Be familiar with its indications, contraindications, and administration

  20. Oxygen Therapy • Indications • Primary indication—to reverse hypoxia • Physical signs of hypoxia • Restlessness • Anxiety • Confusion • Tachypnea or hypoventilation • Tachycardia or bradycardia • Cyanosis • Always rely on clinical judgment

  21. Oxygen Therapy • Contraindications • No absolute reason not to administer oxygen except: • Oxygen toxicity in premature infants • Do not withhold oxygen from a patient who needs it • Careless administration can have potential complications

  22. Oxygen Therapy • Oxygen humidification • Oxygen can dry the mucous membranes over long period of time • Humidification of oxygen can help prevent injury • Two means of administering • Use standard volume nebulizer • Attach to standard non-rebreather mask

  23. Oxygen Delivery Systems • Two types of oxygen delivery systems • Fixed systems • On board ambulance • May hold 3,000 liters • Filled to about 2,000 psi • Portable systems • Easily moveable • May hold 350 liters • Refill before below 200 psi

  24. Oxygen Delivery Systems • Anatomy of an oxygen delivery system • Cylinder holds oxygen under pressure • Must be hydrostatically tested every five years • Regulator controls the flow of oxygen • Flow rates should be from 2 lpm to 15 lpm • T-piece mates cylinder with the regulator • Washers ensure an airtight fit

  25. Oxygen Delivery Devices • Simple facemask • Percentage of oxygen delivered is a function of the patient’s respiratory rate • Venturi mask • Designed to deliver a specific percentage of oxygen regardless of the patient’s respiratory rate

  26. Oxygen Delivery Devices • The partial non-rebreather mask (NRB) • Provides high concentrations of oxygen • Prevents rebreathing of exhaled air • Liter flow should be between 10 and 15 lpm • Patient must be breathing effectively to ensure delivery • Must monitor patient to ensure that the respiratory status is not changing

  27. NRB and Nasal Cannula • Watch this clip demonstrating the use of the non-rebreather and nasal cannula

  28. Oxygen Delivery Devices • Tracheostomy mask • Variation of an oxygen facemask • Fits over the tracheostomy opening and provides oxygen

  29. Oxygen Delivery Devices • Nasal cannula (NC) • Two small prongs attached to a length of tubing • Flow rates vary from 1 to 6 lpm • Generally restricted to patients who are already on low-flow oxygen at home or cannot tolerate NRB

  30. Artificial Ventilation • Providing ventilation to a patient who is not breathing at all (apnea) is called artificial ventilation (rescue breathing) • When performing artificial ventilation, EMT must use a barrier device

  31. Artificial Ventilation • The pocket mask • Most effective ventilation method used by an individual EMT • Is both barrier device and ventilation device • Mouth-to-mask ventilation can deliver 16% oxygen

  32. Pocket Mask • Watch this clip demonstrating the use of the pocket mask

  33. Artificial Ventilation • The bag valve mask • Primary device used to ventilate nonbreathing patients • Outstanding feature is the self-inflating bag • Many have attached oxygen reservoirs • Delivery valve ensures one-way flow of oxygen-rich air • Facemask of a BVM is very similar to the pocket mask

  34. Artificial Ventilation • Ventilation technique • Air volume • Overaggressive ventilation can lead to distention and vomiting • Insufficient ventilation can lead to hypoxia • EMT must be familiar with age-appropriate ventilation rates • Overly slow or fast ventilations can result in inappropriately high or low CO2 levels

  35. Artificial Ventilation • Ventilation technique • Two-person ventilation • Most effective method of ventilating nonbreathing patient • First EMT is the airway person; must be prepared to suction • Second EMT is the breathing person; focus is on ventilation • In cardiac arrest, a third EMT is the circulation person

  36. Artificial Ventilation • Ventilation technique • Cricoid pressure • When possible, gentle cricoid pressure is applied • The cricoid is a cartilaginous ring that supports and holds open the trachea • Compresses the esophagus, preventing air from entering easily

  37. Bag Valve Mask • Watch this clip demonstrating the use of a bag valve mask

  38. Artificial Ventilation • Flow-restricted oxygen-powered ventilation device (FROPVD) • Downsides • Easy to overinflate the patient’s stomach with this device • The EMT cannot feel the resistance created by the patient’s lungs

  39. Artificial Ventilation • Single-person BVM ventilation • Pocket mask • FROPVD • Bag valve mask alone (last resort) • Insufficient volume of oxygen often generated • Efficiency can be improved by pressing the bag against the patient’s face

  40. Artificial Ventilation • Ventilation of the breathing patient • Patients with extreme difficulty breathing can be assisted with BVM • Patient may stop breathing and allow EMT to ventilate him • By assisting ventilations, the EMT can avoid periods of hypoxia

  41. Artificial Ventilation • Ventilation of the surgical airway • Tracheostomy • The tracheostomy tube will fit onto the BVM connector • Less air is needed to ventilate the tracheostomy patient • Stoma • EMT should size the stoma’s opening for a properly fitting mask

  42. Stop and Review • Identify the parts of a non-rebreather facemask and state the oxygen flow requirements needed for its use.

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