The document provides information on respiratory emergencies for different levels of medical training. It covers topics like anatomy of the upper and lower airways, respiratory physiology and pathophysiology, patient assessment of the respiratory system, management of airway obstructions and other respiratory conditions, and mechanical airway techniques. Key points include the definitions of terms like hypoxia and atelectasis, factors that can affect respiration, signs to assess the respiratory system, abnormalities in ventilation and perfusion, management of conditions like asthma and pneumonia, and indicators for endotracheal intubation. The document aims to equip medical responders with knowledge to recognize and treat a variety of respiratory distress presentations.
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1. Respiratory Emergencies
Respiratory
We are going to cover material for ALL
Emergencies levels of training
East Region (Washington) OTEP
M-7 YOU CAN ONLY PRACTICE AT THE
LEVEL YOU HAVE BEEN CERTIFIED
Brian Reynolds, MD
Deaconess Medical Center
Spokane, WA
Anatomy of the Upper Airway
Topics
Anatomy and function of the Respiratory
System
Patient Assessment
Airway Management
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3. Internal Anatomy of the Upper Airway
Larynx
Thyroid cartilage
Cricoid cartilage
Glottic opening
Vocal cords
Arytenoid cartilage
Pyriform fossae
Cricothyroid cartilage
Anatomy of the Lower Airway
Lower Airway Anatomy
Trachea
Bronchi
Alveoli
Lung parenchyma
Pleura
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4. Definitions Introduction
Atelectasis – collapse of small segments of Ventilation is the mechanical process that brings
lung O2 to the lungs, and clears CO2 from the
lungs
Oxygenation is the diffusion of O2 to the blood
Hypoxia – lack of oxygen
Perfusion is the flow of blood through the lungs
(thus exchanging oxygen and CO2)
Hypoxemia – lack of oxygen in arterial
Brain stem is the involuntary regulator of
blood
respirations
Respiratory Physiology Pathophysiology
Ventilation
Disruption in Ventilation
Body Structures
Upper & Lower Respiratory Tracts
Chest Wall
Obstruction due to trauma or infectious processes
Pleura
Diaphragm Chest Wall & Diaphragm
Trauma
Tidal Volume:
Pneumothorax
7ml/kg Hemothorax
(Adult 500ml) Flail chest
Neuromuscular disease
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5. Pulmonary Circulation
Oxygenation
Room air – 21% FiO2
Roughly 3% increase per liter
Nasal cannula – 8L max (40%)
Mask – 10L (55%)
NRB mask – 15L (80%)
Respiratory Physiology Pathophysiology
Pulmonary Perfusion Disruption in Perfusion
Requirements
Alteration in systemic blood flow
Adequate blood volume
Changes in hemoglobin
Intact pulmonary capillaries
Efficient pumping by the heart Pulmonary shunting
Hemoglobin Damaged alveoli
Carbon Dioxide
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6. Respiratory Factors Assessment of the Respiratory
Factor Effect System
Fever Increases
Emotion Increases Scene Assessment
Pain Increases Threats to Safety
Hypoxia Increases
Make sure you are safe first
Acidosis Increases
Identify rescue environments having
Stimulants Increase decreased oxygen levels
Depressants Decrease
Gases and other chemical or biological
Sleep Decreases agents
Clues to Patient Information
Assessment of the Respiratory Assessment of the Respiratory
System System
Initial Assessment Airway
Proper ventilation cannot take place without an
General Impression adequate airway
Position
Breathing
Color
Mental status
Signs of life-threatening problems
Alterations in mental status
Ability to speak
Severe central cyanosis, pallor, or diaphoresis
Respiratory effort
Absent or abnormal breath sounds
Speaking limited to 1–2 words
Tachycardia
Use of accessory muscles or intercostal retractions
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7. Abnormal Respiratory Patterns Abnormal Respiratory Patterns
Kussmaul’s respirations:
Deep, slow or rapid, gasping; common Agonal respirations:
in diabetic ketoacidosis Shallow, slow, or infrequent breathing,
Cheyne-Stokes respirations: indicating brain anoxia
Progressively deeper, faster breathing
alternating gradually with shallow,
slower breathing, indication brain
stem injury
Focused History Focused History
& Physical Exam & Physical Exam
History Physical Examination
SAMPLE History Inspection
Look for asymmetry, increased diameter, or
Paroxysmal nocturnal dyspnea and orthopnea paradoxical motion
Coughing, fever, hemoptysis
Palpation
Associated chest pain Feel for subcutaneous emphysema or tracheal
Smoking history or environmental exposures deviation
Similar Past Episodes Percussion
Auscultation
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8. Focused History Focused History
& Physical Exam & Physical Exam
Auscultation Diagnostic Testing
Normal Breath Sounds Pulse Oximetry
Bronchial, Bronchovesicular, and Vesicular
Inaccurate Readings
Abnormal Breath Sounds
Snoring
Stridor
Wheezing
Rhonchi
Rales/Crackles
Pleural friction rub
Ausculation Airway Obstruction
The tongue is the most common cause of
Listen at the mouth and nose for adequate air airway obstruction
movement
Foreign bodies
Listen with a stethoscope for normal or
Trauma
abnormal air movement
Proper listening positions Laryngeal spasm and edema
Aspiration
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9. Congestive Heart Failure Obstructive Lung Disease
Wet, crackly lung sounds Types
Emphysema
Lower extremity edema Chronic Bronchitis
Asthma
Must sit and sleep upright Causes
Genetic Disposition
Smoking & Other Risk Factors
Frothy, pink sputum
Emphysema Chronic Bronchitis
Assessment Physical Exam
Physical Exam Often overweight
Barrel chest Rhonchi present on
Prolonged expiration and auscultation
rapid rest phase Jugular vein distention
Thin Ankle edema
Pink skin due to extra red Hepatic congestion
cell production “Blue Bloater”
Hypertrophy of accessory
muscles
“Pink Puffers”
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10. Asthma Pneumonia
Physical Exam
Infection of the Lungs
Presenting signs may include dyspnea, wheezing,
cough Immune-Suppressed Patients
No wheezing is severe disease Pathophysiology
Speech may be limited to 1–2 word sentences
Look for hyperinflation of the chest and accessory
Bacterial & Viral Infections
muscle use/feel chest wall for crepitus Hospital-acquired vs. community-acquired
Carefully auscultate breath sounds and measure Alveoli may collapse, resulting in a ventilation
peak expiratory flow rate disorder
Lung Cancer Toxic Inhalation
Pathophysiology
Pathophysiology Includes inhalation of heated air, chemical irritants,
General and steam
Majority are caused by carcinogens secondary to Airway obstruction due to edema and laryngospasm
cigarette smoking or occupational exposure due to thermal and chemical burns
May start elsewhere and spread to lungs Assessment
High mortality Focused History & Physical Exam
Types SAMPLE & OPQRST History
Adenocarcinoma Determine nature of substance
Epidermoid, small-cell, and large-cell carcinomas Length of exposure and loss of consciousness
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11. Carbon Monoxide Inhalation Pulmonary Embolism
Pathophysiology Pathophysiology
Binds to Hemoglobin Obstruction of a pulmonary artery
Prevents oxygen from binding to RBC’s Emboli may be of air, thrombus, fat, or amniotic
Room air half life – 6 hrs., HBO – 23 minutes fluid
Assessment Foreign bodies may also cause an embolus
Focused History and Physical Exam Risk Factors
SAMPLE & OPQRST History Recent surgery, long-bone fractures
Determine source and length of exposure Pregnant or postpartum
Presence of headache, confusion, agitation, lack of Oral contraceptive use, tobacco use
coordination, loss of consciousness, and seizures Immobility
Blood disorders
Spontaneous Pneumothorax
Pathophysiology
Hyperventilation Syndrome
Pneumothorax Assessment
Can occur in the absence of blunt or penetrating trauma
Focused History & Physical Exam
Risk factors
SAMPLE
Assessment Fatigue, nervousness, dizziness, dyspnea, chest
Focused history pain
SAMPLE
Numbness and tingling in mouth, feet, and both
Presence of risk factors hands
Rapid onset of symptoms Presence of tachypnea and tachycardia
Sharp, pleuritic chest or shoulder pain Spasms of the fingers and feet
Often precipitated by coughing or lifting
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12. Airway Sounds
Airflow
Compromise
Gas Exchange
Compromise
Basic Mechanical Airways
Snoring Crackles
Gurgling Rhonchi
Stridor
Wheezing
Quiet
Insert oropharyngeal airway Rotate airway 180º into position
with tip facing palate
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13. Nasopharyngeal Airway
(Do not use if significant facial trauma)
Advanced Airway Management
Advanced Airway Management Advantages of Endotracheal Intubation
Endotracheal intubation
Isolates trachea and permits complete control
of airway
Combitube
Maximizes ventilation and oxygenation
CPAP and BiPAP Impedes gastric distention
Eliminates need to maintain a mask seal
CO2 monitors – measure exhaled CO2 Offers direct route for suctioning
Normal – 5-6%
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14. Placement of Macintosh blade into
Laryngoscope Blades vallecula
Placement of Miller blade under epiglottis Endotrol ETT
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15. ETT, stylet, syringe Combitube
CPAP Endotracheal Intubation Indicators
Respiratory or cardiac arrest
Unconsciousness
Risk of aspiration
Obstruction due to foreign bodies, trauma,
burns, or anaphylaxis
Respiratory extremis due to disease
(Pneumothorax), hemothorax,
(hemopneumothorax) with respiratory
difficulty
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16. Complications of Endotracheal Tracheostomies/Stomas
Intubation
Equipment malfunction Use patient’s supplies
Teeth breakage and soft tissue injury
Hypoxia Ambu bag attaches easily
Esophageal intubation
Endobronchial intubation Treat as an endotracheal tube
Tension pneumothorax
Extubation Suction
Questions Questions
1. Which one is lack of oxygen in the blood? 2. Which one is the best airway?
a. Hypoxia a. Nasal cannula
b. Hypocarbia b. Endotracheal tube
c. Hypoxemia c. Oral airway
d. Hypocarbemia d. Combitube
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17. Questions Questions
3. Which one is a contraindication to nasal 4. Which one is the correct tidal volume for a
trumpet use? 200 pound patient?
a. Seizure a. 500cc
b. Bloody nose b. 600cc
c. DNR patient c. 700cc
d. Significant facial trauma d. 800cc
Questions
5. Which one is not an indication for
endotracheal intubation? Now you know everything
a. Respiratory failure about respiratory emergencies
b. Cardiac arrest
c. GCS of 5
d. Hyperventilation syndrome
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