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Respiration

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The gas exchange process that occurs between the alveoli or cells and the capillaries

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Four distinct components of respiration

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1) pulmonary ventilation 2) external respiration 3) internal respiration 4) cellular respiration and metabolism

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Pulmonary ventilation

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the mechanical process of moving air in and out of the lungs

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External respiration

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the gas exchange process that occurs between the alveoli and the surrounding pulmonary capillaries; serves to oxygenate the blood and eliminate carbon dioxide in the lungs

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Internal respiration

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cell/capillary gas exchange; is responsible for delivering oxygen to the cells and removing carbon dioxide from the cell

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Cellular respiration and metabolism

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Breaks down glucose in the presence of oxygen, produces high amounts of energy in the form of ATP, and releases carbon dioxide and water as a by-product

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The upper airway

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Nasal cavity, Nasopharynx, Oropharynx, Hypopharynx (laryngopharynx), epiglottis, esophagus, trachea, and larynx

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Pharynx

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Throat

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Nasopharynx

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Where air from the nasal passages enter

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Oropharynx

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Where air from the mouth travels to get to the lungs

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Importance of keeping a clear pharynx

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Obstructions can prevent air from traveling into the lower airways or the substance may be aspirated into the lungs.

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The two passageways found at the lower end of the pharynx

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The trachea and the esophagus

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Larynx

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Above the trachea and below the epiglottis; the voice box

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Thyroid cartilage

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the anterior portion of the larynx; the adams apple

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Cricoid cartilage

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the inferior portion of the larynx; the only completely circular cartilaginous ring of the upper airway

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The lower airway

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From the cricoid cartilage to the alveoli

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Trachea

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The windpipe; the passageway for air entering the lungs

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The carina

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the point at which the trachea splits into the right and left main stem bronchi

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The anterior portion of the trachea

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composed of strong C-shaped cartilaginous rings that provide support and structure

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The posterior wall of the trachea

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Made up of muscle and is not a rigid structure

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Bronchi

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the two major branches of the trachea; extends from the carina into the lungs

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Bronchioles

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Smaller sections of the bronchi; lined with smooth muscle and mucous membranes

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When the mucous lining of the bronchioles becomes inflamed and swollen

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Severely narrows the diameter of the bronchiole and causes lower airway obstruction (as seen in asthma). The narrowing causes an increase in airway resistance inside the bronchiole, which makes it difficult to move air

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An increase in airway resistance

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Causes the patient to work harder to breathe which may lead to fatigue and failure of the respiratory muscles

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Leads to cell hypoxia

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ineffective and inadequate ventilation and oxygenation

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Alveoli

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Tiny air sacs in the lungs

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Pulmonary capillaries

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a web of thin-walled capillaries that wrap the alveoli; the site of gas exchange

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The composition of the lungs

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elastic tissue

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The pleura

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The two layers of connective tissue that surround the lungs

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The visceral pleura

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the innermost covering of the lung

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The parietal pleura

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thicker, more elastic layer that adheres to the inner portion of the chest wall

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Between the two pleura layer

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the pleural space; at negative pressure

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Serous fluid

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acts as a lubricant to reduce friction in the pleura space

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The diaphragm

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muscle that separates the chest cavity from the abdominal cavity; major muscle used in breathing; responsible for 60-70% of the effort of ventilation

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Ventilation

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Passage of air into and out of the lungs; creates pressure changes in the lungs to draw air in and force air out

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Inhalation/inspiration

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breathing air in

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Exhalation/expiration

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process of breathing air out

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Inhalation mechanics

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diaphragm and the external intercostal muscles contract; increases the size of the chest cavity, creating negative pressure inside the chess cavity; active process

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Exhalation mechanics

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Diaphragm and external intercostal muscles relax; reduced chest cavity size; positive pressure; forces volume of air out of the lungs; passive

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Control of Respiration

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The respiratory organs do not have the ability to control their function from within the respiratory system; respirations are controlled by the nervous system

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The response to an increase level in arterial blood

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The chemoreceptors sense the increase and the brainstem sends impulses to the respiratory muscles to increase the rate and depth of respiration

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The main stimulus for breathing in healthy people

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Carbon dioxide

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Hypercarbic drive

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What healthy people breath

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The difference between COPD people and normal people

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In people with COPD the carbon dioxide level in arterial blood is typically chronically elevated as a result of the disease process. Because of the constant high carbon dioxide level the chemoreceptors become relatively insensitive to changes in carbon dioxide. Instead the chemoreceptors in COPD patients tend to rely on oxygen levels in the blood to regulate their breathing.

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Why do COPD people breath?

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To increase their oxygen levels instead of decrease their Carbon dioxide level

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Oxygenation

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the process by which the blood and the cells become saturated with oxygen

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Internal respiration and external respiration

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the process in which fresh oxygen replaces waste carbon dioxide, a gas exchange that takes place between the alveoli and the capillaries in the lungs, and between the capillaries and the cells throughout the body

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Hypoxemia

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Low oxygen content in arterial blood. Typically occurs from a ventilation-perfusion mismatch

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Ventilation-perfusion mismatch

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occurs when there is a lack of available oxygenated air in the alveoli even though perfusion (blood flow) to the alveoli is adequate or when the alveoli are adequately oxygenated but perfusion to the alveoli is poor or when there is a combination of both poor ventilation and poor perfusion in the alveolar-capillary structures

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Other causes of hypoxemia

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inadequate ventilatory drive, anemia, and carbon monoxide poisoning

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Hypoxia

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inadequacy in the amount of oxygen being delivered to the cells

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Different causes of hypoxia

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Occluded airway, inadequate breathing, inadequate breathing, inadequate delivery of oxygen to the cells by the blood (hyper fusion or shock), inhalation of toxic gases, lung and airway deceases, etc

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Signs of Mild to Moderate Hypoxia

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Tachypnea (increased respiratory rate) Dyspnea (shortness of breath) Pale, cool, clammy skin (early) Tachycardia Elevation in blood pressure Restlessness and agitation (from hypoxic brain cells) Disorientation and confusion (from high CO2 levels) Headache

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Signs of Severe Hypoxia

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Tachypnea Dyspnea Cyanosis Tachycardia that may lead to dysrhythmias and eventually bradycardia Severe confusion Loss of coordination Sleepy appearance Head bobbing with droopy eyelids Slow reaction time Altered mental status Seizure

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Cyanosis

answer

a bluish gray color, a late sign of hypoxia and may be found in and around several areas including the lips, mouth, nose, fingernail beds

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Gas content of the blood entering the capillaries

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High oxygen content and a low carbon dioxide content

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Causes of disruption in the mechanical process of pulmonary ventilation

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•Interruption of the nervous system's control and stimulation of the diaphragm or of the external intercostal muscles •Structural damage to the thorax may interfere with the bellows action of the chest. This will impede the ability of the thorax to generate pressure changes necessary to draw air into the lungs for inhalation and to allow airflow out of the lungs during exhalation. Pain associated with chest injury, flail chest (two or more ribs fractured in two or more places), rupture or injury to the diaphragm, or compression of the chest wall can reduce the effective bellows action of the chest •Increased airway resistance will reduce airflow through the respiratory tract and reduce the amount of air in the alveoli. This will make less oxygen available for gas exchange. An increase in airway resistance may occur from bronchoconstriction or from inflammation inside the vessel •Disruption of airway latency can occur from swell in caused by infection, allergic reaction, or burns; from trauma; from foreign body obstruction; or from loss of muscle tone associated with an altered mental status or unresponsiveness. Reduction or loss of airway latency will reduce the tidal volume, minute ventilation, alveolar ventilation, and volume of gas in the lungs for gas exchange

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The mouth and nose of children

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The noses and mouths of infants and children are smaller than those of adults; thus it is especially important to keep the nose clear of obstructions

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The pharynx of children

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The tongue of an infant or child is relatively large in proportion to the size of the mouth.

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The trachea and lower airway of children

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Narrower, softer, and more flexible than adults. Airway obstructions occur more easily from mucus, pus, blood, secretions, swelling, constriction, and kinking of the trachea with flexion or extension

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Chest wall in children

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Softer and more pliable than in an adult; leads to greater compliance during ventilation

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Patent airway

answer

open airway

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Functions and considerations regarding the airway

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•the airway and respiratory tract is the conduit that allows air to move from the atmosphere and into the alveoli for gas exchange •No matter what the patient's condition, the airway must remain patent at all times •Any obstructions of the airway will result in less air movement, which will lead to some degree of poor gas exchange and potential hypoxia •The degree of the obstruction will directly affect the amount of air available for gas exchange. The tongue may create only a partial airway obstruction, whereas a piece of food may completely stop airflow

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A patient's mental status typically correlates to the status of his airway

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An alert, responsive patient who is talking to you in a normal voice has an open airway. A patient with an altered mental status or who is completely unresponsive connote adequately protect his own airway.

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Signs of an open airway

answer

1) air can be felt and heard moving in and out of the mouth and nose 2) the patient is speaking in full sentences or with little difficulty 3) the sound of the voice is normal for the patient

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Snoring

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occurs when the upper airway is partially obstructed by the tongue or by relaxed tissues in the pharynx.

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Crowing

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sounds like a crow cawing that occurs when the muscles around the larynx spasm and narrow the opening into the trachea, air rushing through the restricted passage causes the sound

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Gurgling

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sounds like gargling, usually indicates the presence of blood, vomitus, secretions, or other liquid in the airway

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Stridor

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a harsh, high-pitched sound heard during inspiration, characteristic of a significant upper airway obstruction from swelling in the larynx, may also be heard if a mechanical obstruction by food or other object is presence

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Head-tilt, Chin-lift maneuver

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no spinal injury

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Jaw-thrust maneuver

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suspected spinal injury

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Standard precaution during suctioning

answer

Protective eyewear, a mask, and gloves. If a patient is known to have TB an N-95 should be worn

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Suction Equipment

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The device that creates the suction and the catheters

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Mounted Suction Devices

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On-board the ambulance, should be powerful enough to provide an airflow of ;40 lpm and create a vacuum of more than -300 mmHg

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Portable Suction Devices

answer

Should be capable of generating -300 mmHg of pressure when the suction hose is clamped. A pressure of -80 to -120 mmHg is generally necessary to provide adequate suction. Can be electric, oxygen, air or hand powered

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Hard or rigid catheter

answer

Rigid plastic tube; Yankauer catheter or the tonsil tip. Used to suction the mouth and oropharynx of an unresponsive patient. Only be inserted as far as you can see and no farther than the back of the tongue.

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Soft catheter

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Flexible tubing; also called the "French" catheter. Used in suctioning the nose and nasopharynx and in other situations where the rigid catheter can not be used. Length should be determined by measuring from the tip of the patient's nose to the tip of the ear

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Special considerations when suctioning

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•If the patient has secretions or vomitus that cannot be removed quickly and easily by suctioning, the patient should be log rolled onto his side and the oropharynx cleared by finger sweeping the foreign material out •If the patient needs artificial ventilation and is producing frothy secretions as rapidly as suctioning can remove them, apply suction for 10 seconds, provide positive pressure ventilation with supplemental oxygen for 2 minutes, then apply suction for another 10 seconds.

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Two types of artificial airways

answer

Oropharyngeal and nasopharyngeal

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Points to keep in mind when using artificial airways

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1) adjunct must be clean and clear of obstructions 2) proper size must be selected 3) airways adjuncts do not protect the airway from aspirations of secretions, blood, vomitus, or foreign substances 4) the mental status of the patient will determine if an adjunct can be used

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The oropharyngeal airway (OPA)

answer

Patient must be completely unresponsive and have no gag or cough reflex. Measure the airway by holding it next to the patient's face, should extend the distance from the corner of the mouth to the tip of the ear

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Nasopharyngeal airway (NPA)

answer

Use in patients whom the oral airway cannot be inserted because of clenched teeth, biting, or injuries to the maxilla or face. Can be used in patients who are not fully responsive and have a minimally intact gag reflex. Measure from the nose to the tip of the earlobe

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Inadequate breathing leads to

answer

Poor gas exchange in the alveoli and ineffective delivery of oxygen to the cells

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Determining the adequacy of breathing

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Assets the relationship between the volume and the rate at which a patient is breathing

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Minute volume

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Dept and rate; typically correlates with how adequately the patient is breathing

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Tidal volume

answer

Respiratory rate; amount air breathed in and out in one normal respiration

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Alveolar ventilation

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Amount of air breathed in that reaches the alveoli

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Dead air space

answer

Anatomical areas in the respiratory tract where air collects during inhalation but no gas exchange occurs

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Minute volume

answer

Tidal volume multiplied by rate

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Amount of dead air

answer

150 mL of the 200 mL breathed in

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Assessing for adequate breathing

answer

1) look (inspect) chest rise/fall, general appearance, breathing pattern, nostrils 2) listen 3) feel 4) ausculate

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Rate

answer

12-20 adults 15-30 children 25-50 infants

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Signs of adequate breathing

answer

Normal respiratory rate Clear and equal breath sounds bilaterally Adequate air movement heard and felt from nose and mouth Good chest rise and fall with each ventilation

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Rhythm

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The pattern is regular

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Quality

answer

Equal and full bilateral breath sounds. No excessive accessory muscle use

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Respiratory distress

answer

The patient is working harder to breathe

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The effects of inadequate oxygen

answer

Brain death in about 4-6 minutes

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Respiratory failure

answer

When the respiratory rate and/or tidal volume is insufficient

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Respiratory arrest

answer

Apnea; occurs when the patient completely stops breathing

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Causes of respiratory arrest

answer

Stroke MI OD Toxic inhalation Electrocution and lighting strike Suffocation Traumatic injuries to the head, spine, chest or abdomen Infection to the epiglottis Away obstruction by a foreign body

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Agonal respirations

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Gasping breath

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Deciding if you need to ventilate

answer

Inadequate respiratory rate or inadequate tidal volume

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Positive pressure ventilation

answer

Forcing air into the lungs

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Methods of artificial ventilation

answer

Mouth to mouth Bag-valve mask (BVM)- 2 person Flow-restricted, oxygen powered ventilation device BVM 1 person

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3 major considerations when using a device for artificial ventilation

answer

1) must be able to maintain a good seal 2) device must be able to deliver an adequate volume of air to sufficiently inflate the lungs 3) must be a connection to allow for simultaneous oxygen delivery while ventilating

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Indications of adequate Ventilation

answer

1) tidal volume must be consistent; it must also be sufficient to cause the chest to rise during each ventilation. (Adequate chest rise) 2) The patient's HR returns to normal 3) Color improves

question

Inadequate Ventilation

answer

1) The rate is too fast or too slow 2) Chest does not rise and fall with artificial ventilation 3) The heart rate does not return to normal 4) Color does not improve

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Atmospheric air concentration

answer

21% oxygen, 78% nitrogen, and 1% carbon dioxide and other gases

question

Preferred method of artificial ventilation

answer

Mouth-to-mask

question

Advantages of mouth-to-mask ventilation

answer

•One EMT can ventilate using the two-handed mask seal technique, achieving a better mask seal •The mask eliminates direct contact with the patient's nose, mouth, and secretions •Use of a one-way valve at the ventilation port prevents exposure to the patient's exhaled air •The method can provide adequate tidal volumes and possibly greater tidal volumes that bag-valve-mask ventilation •Supplemental oxygen can be administer through the oxygen inlet that most pocket masks have in addition to the ventilation port.

question

Disadvantages of mouth-to-mask ventilation

answer

•The make is perceived by some EMTs as having an increased risk of infection •The EMT providing the ventilation my fatigue after a period of time •The device doesn't allow for the highest possible concentration of oxygen to be delivered with each ventilation

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Volume of Adult sized BVMs

answer

1600 milliliters

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FROPVD

answer

Flow-restricted, oxygen-powered ventilation device

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ATV

answer

Automatic transport ventilator

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CPAP

answer

Continuous Positive Airway Pressure

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Criteria of CPAP

answer

Awake, alert, and oriented enough to obey commands Able to maintain airway Able to breath and has a RR of ;25 breaths/min Exhibits signs of moderate to severe respiratory distress or failure

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Indications of CPAP

answer

Congestive heart failure Pulmonary edema COPD Asthma Pneumonia

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Stoma

answer

Surgical opening in the from of the neck that may be temporary or permanent

question

Complications with patients with facial injuries

answer

1) Blunt injury can cause excessive swelling that may partially or completely occlude the airway. It may be necessary to insert an airway adjunct to establish and maintain the airway. Avoid the use of a nasopharyngeal airway with mid-face trauma. Also, positive pressures ventilation may be needed to force ventilation past the swollen airway. 2) Bleeding into the pharynx may be severe and can cause problems with the airway management. Frequent or constant suctioning may be necessary

question

Signs of a serve partial airway obstruction with poor air exchange

answer

Cough that becomes silent Stridor heard on inhalation Increase in labored breathing

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D cylinder

answer

350 litters Constant=.16

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E cylinder

answer

635 litters Constant=.28

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M cylinder

answer

3000 litters Constant=1.56

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Indications for Oxygen Use

answer

•Cardiac arrest or respiratory arrest •When a patient is being ventilated via positive pressure •Any signs of hypoxia in a patient with an adequate respiratory rate and an adequate tidal volume •Any patient with an pulse ox reading of less than 94% •Anyone with a stroke, MI, OD, toxic inhalation, suffocation, foreign body obstruction, drowning, asthma attack, allergic reaction and seizure •Any patient with an altered mental status or who is unresponsive •Injuries to any body cavity or CNS component •Multiple fractures and multiple soft tissue injuries •Severe bleeding that is either internal or external •Any evidence of Shock (hypo perfusion) •Exposure to toxins

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Oxygen Administration Procedures

answer

1. Check cylinder; remove the protective seal on the tank valve 2. Open and shut the cylinder for 1 second to clean it 3. Place the yoke of the therapy regulator over the valve and align the pins. 4. Slowly open the main cylinder valve 5. Attach oxygen delivery device 6. Open the flowmeter 7. Apply oxygen delivery device to patient

question

Nonrebreather mask

answer

High concentration; 15 lpm; 100% oxygen

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Nasal Cannula

answer

Low concentration; up to 6 lpm; 24-44% oxygen

EMT Chapter 10 Airway management, Artificial Ventilation, and Oxygenation – Flashcards

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