The Respiratory System

1. The Respiratory System Emergency Medical Technician - Basic Temple College EMS Program

2. Respiratory System Purpose • Takes in oxygen • Disposes of wastes • Carbon dioxide • Excess water O2 + Glucose The Cell CO2 + H2O Temple College EMS Program

3. Respiratory System Anatomy Nasopharynx Oropharynx Epiglottis Larynx Trachea Carina Bronchi Bronchioles Temple College EMS Program

4. Respiratory System Anatomy • Lung • Right lung 3 lobes • Left lung 2 lobes Temple College EMS Program

5. Respiratory System Anatomy • Bronchioles • Smallest airways • Walls consist entirely of smooth muscle (no cartilage present) • Constriction increases resistance to airflow • Dilation reduces resistance to airflow Temple College EMS Program

6. Respiratory System Anatomy • Alveoli • Air sacs • Site of oxygen and carbon dioxide exchange with blood Temple College EMS Program

7. Respiratory System Anatomy Temple College EMS Program

8. Respiratory System Anatomy • Diaphragm Temple College EMS Program

9. Respiratory System Anatomy • Pleura • Double-walled membrane • Visceral layer covers lung • Parietal layer lines inside of chest wall, diaphragm Temple College EMS Program

10. Respiratory System Physiology Inspiration Active process Chest cavity expands Intrathoracic pressure falls Air flows in until pressure equalizes Expiration Passive process Chest cavity size decreases Intrathoracic pressure rises Air flows out until pressure equalizes Temple College EMS Program

11. Respiratory System Physiology • Automatic Function • Primary drive: increase in arterial CO2 • Secondary (hypoxic) drive: decrease in arterial O2 Normally we breathe to remove CO2 from the body, NOT to get oxygen in Temple College EMS Program

12. Airway (Obstruction) Tongue Foreign body airway obstruction Anaphylaxis/angioedema Upper airway burn Maxillofacial/laryngeal/ tracheobronchial trauma Epiglottitis Croup Aspiration Asthma Chronic Obstructive Airway Disease Emphysema Chronic bronchitis Respiratory Pathophysiology Temple College EMS Program

13. Respiratory Pathophysiology • Gas Exchange Surface (Blood Flow or Gas Diffusion) • Pulmonary Edema • Left-sided heart failure • Toxic inhalations • Near drowning • Pneumonia • Pulmonary Embolism • Blood clots • Amniotic fluid • Fat embolism Temple College EMS Program

14. Thoracic Bellows (Ventilation) Chest Trauma Simple rib fractures Flail chest Pneumothorax Hemothorax Sucking chest wound Diaphragmatic hernia Pleural effusion Spinal cord trauma (High C-spine lesion) Morbid obesity Neurological/neuro-muscular disease Poliomyelitis Myasthenia gravis Muscular dystrophy Guillian-Barre syndrome Respiratory Pathophysiology Temple College EMS Program

15. Respiratory Pathophysiology • Control System (Decreased Respiratory Drive) • Head trauma • CVA • Depressant drug toxicity • Narcotics • Sedative-hypnotics • Ethyl alcohol Temple College EMS Program

16. Respiratory Assessment • Initial Assessment (A, B, C, D) • Manage life threats • Complete focused history and physical Temple College EMS Program

17. Initial Assessment • Airway • Listen to patient breathe, talk • Noisy breathing is obstructed breathing • But all obstructed breathing is not noisy • Snoring = Tongue blocking airway • Stridor = “Tight” upper airway from partial obstruction Temple College EMS Program

18. Initial Assessment • Airway • Anticipate airway problems with • Decreased LOC • Head trauma • Maxillofacial trauma • Neck trauma • Chest trauma OPEN—CLEAR—MAINTAIN Temple College EMS Program

19. Initial Assessment • Breathing • Is patient moving air? • Is air moving adequately? • Is the patient’s blood being oxygenated? Temple College EMS Program

20. Breathing LOOK Symmetry of chest expansion Increased respiratory effort Changes in skin color LISTEN Air movement at mouth, nose Air Movement in peripheral lung fields FEEL Air movement at mouth, nose Symmetry of chest expansion RATE Tachypnea Bradypnea POSITIONING Orthopnea Tripod position Initial Assessment Temple College EMS Program

21. Initial Assessment • Breathing • Signs of respiratory distress • Nasal flaring • Tracheal tugging • Retractions • Neck, pectoral muscle use on inhalation • Abdominal muscle use on exhalation • Skin Color • Pale, cool moist skin (Early sign of hypoxia) • Cyanosis (Late, unreliable sign of hypoxia) Temple College EMS Program

22. Initial Assessment • Breathing • If trauma patient has compromised breathing, bare chest, assess for: • Open pneumothorax • Flail chest • Tension pneumothorax Temple College EMS Program

23. Respiratory Assessment • Circulation • Is heart beating? • Is there major external hemorrhage? • Is patient perfusing? • Effects of hypoxia: • Adults (early): tachycardia • Adults (late): bradycardia • Children: bradycardia Temple College EMS Program

24. Initial Assessment • Circulation • Don’t let respiratory failure distract you from assessing for circulatory failure • Low oxygen or high carbon dioxide levels can depress cardiovascular function Temple College EMS Program

25. Respiratory Assessment • Disability • Restlessness, anxiety, combativeness = hypoxia Until proven otherwise • Drowsiness, lethargy = hypercarbia Until proven otherwise Just because the patient stops fighting, he’s not necessarily getting better!!! Temple College EMS Program

26. Initial Management • Patient Responsive/Breathing Adequate • Oxygen may be indicated • Oxygenate immediately if patient has: • Decreased level of consciousness • Possible shock • Possible severe hemorrhage • Chest pain • Chest trauma • Respiratory distress or dyspnea • History of any kind of hypoxia Temple College EMS Program

27. Initial Management • Patient responsive, breathing inadequate • Open/maintain airway • Place nasopharyngeal airway • Assist ventilations • Mouth to Mask • 2-person Bag-valve Mask • Manually Triggered Ventilator • 1-person Bag-valve Mask Temple College EMS Program

28. Initial Management • Patient unresponsive, breathing adequate • Open/maintain airway • Place nasopharyngeal or oropharyngeal airway • Suction airway as needed • Provide oxygen by non-rebreather mask • Frequently reassess Temple College EMS Program

29. Initial Management • Patient unresponsive, breathing inadequate • Open/maintain airway • Place nasopharyngeal or oropharyngeal airway • Suction airway as needed • Assist ventilations • Mouth to Mask • 2-person Bag-valve Mask • Manually Triggered Ventilator • 1-person Bag-valve Mask • Frequently reassess Temple College EMS Program

30. Initial Management • Patient not breathing • Open airway • Place nasopharyngeal or oropharyngeal airway • Ventilate patient • Mouth-to-Mask • 2-Person Bag-Valve Mask • Manually Triggered Ventilator • 1-Person Bag-Valve Mask • Frequently reassess Temple College EMS Program

31. Initial Management • Golden Rules • If you think about giving O2, give it!!! • If you decide to give oxygen, give a lot of it!!! • If you can’t tell whether a patient is breathing adequately, he isn’t ! • If you’re thinking about assisting a patient’s breathing, you probably should be! Temple College EMS Program

32. Focused History and Physical • Chief Complaint • Dyspnea • Subjective sensation that breathing is excessive, difficult, or uncomfortable • Respiratory Distress • Objective observations that indicate breathing is difficult or inadequate Temple College EMS Program

33. Focused History and Physical • History of Present Illness (OPQRST) • Gradual or sudden onset? • What aggravates or alleviates? • How long has dyspnea been present? • Coughing? Productive cough? • What does sputum look/smell like? • Pain present? What does pain feel like? How bad? Does it radiate? Where? Temple College EMS Program

34. Focused History and Physical • Past History If Then??? Hypertension, MI, Diabetes CHF with Pulmonary Edema Chronic Cough , Smoking, COPD “Recurrent” Flu Allergies, Acute Episodes of SOB Asthma Lower Extremity Trauma, Pulmonary Embolism Recent Surgery, Immobilization Temple College EMS Program

35. Focused History and Physical • Medications If Then??? “Breathing” Pills, Inhalers Asthma or COPD Albuterol Montelukast Aminophylline Oxtriphylline Ipratropium Cromolyn Terbutaline Prednisone Salbumatol Zafirlukast Temple College EMS Program

36. Focused History and Physical • Medications If Then??? Lasix, hydrodiuril, digitalis CHF Coumadin, BCP’s Pulmonary embolism Temple College EMS Program

37. Crackles (Rales) Fine, “crackling” Fluid in smaller airways, alveoli Rhonchi Coarse, “rumbling” Fluid, mucus in larger airways Stridor High pitched, “crowing” Upper airway restriction Wheezing “Whistling” Usually more pronounced on exhalation Generalized: narrowing, spasm of the smaller airways Localized: foreign body aspiration Focused History and Physical Exam Temple College EMS Program

38. Mild Breathing Difficulty • May be hypoxic • Can move adequate tidal volume • Can answer questions, speak in complete sentences, is alert • High concentration O2 by non-rebreather mask • Consider bronchodilators if patient wheezing Temple College EMS Program

39. Moderate Breathing Difficulty • May be hypoxic • May be moving adequate tidal volume • Having difficulty answering questions, speaks in choppy sentences, is restless/irritable • High concentration O2 by non-rebreather mask • Get ready to assist ventilations if needed (patient may resist assistance at this time) • Consider bronchodilators if patient wheezing Temple College EMS Program

40. Severe Breathing Difficulty • Getting sleepy • Not speaking or speaking with very few words • Previously wild, now seems “cooperative” • Assist ventilations with BVM and oxygen • Time BVM ventilation with patient’s ventilatory efforts • Interpose extra ventilations if necessary Temple College EMS Program