Emergency Medical Training Services Emergency Medical Technician Paramedic Program Outlines Outline Topic: AIRWAY Revised: 11/2013

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1 Emergency Medical Training Services Emergency Medical Technician Paramedic Program Outlines Outline Topic: AIRWAY Revised: 11/ Define ventilation and respiration. Respiration is exchange of oxygen and carbon dioxide between the organism and the environment. A good definition is at a cellular level of exchange - pulse-ox, blood gas, etc... Ventilation is the exchange of air into and out of the lungs. A good example is a ventilator machine only moves air in and out of the lungs even though the patient can be dead. You must assess for adequate respirations via pulse-ox or other means and also ventilations via chest rise and fall and depth along with lungs sounds. 2. Differentiate between atmospheric, intrapulmonic, and intrathoracic pressure. Intrapulmonic - pressure of gas in the alveoli. Little above 760 mmhg pressure. Intrathoracic - pressure in the plural space. Normally less that that of the intrapulmonic pressure. That is why when you have a pneumothorax air will go from high to low pressure or out of the lungs and into the plural space. Atmospheric - pressure of gas around us. About 760 mmhg. 3. Describe, in detail, the process of inspiration and expiration.

2 Diaphram contracts making chest larger and intrathoracic pressure drops below atmospheric so air enters. Also the intercostals muscles also contract to enlarge the chest cavity. 4. Define a pressure gradient. 5. Define compliance. The ease with which the lungs and thorax expand during pressure changes. 6. List factors that can increase the work of breathing. Asthma, COPD, bronchitis, pulmonary edema, surfactant loss. 7. What is the purpose of surfactant? Alveoli always want to naturally collapse. They need surface tension to stay open. Kind of like a balloon would rather be deflated versus inflated. Water molecules attract to each other naturally and this creates tension. This is not good for the alveoli. Surfactant intermingles with water molecules to reduce the cohesive force. Think of it as K-Y gel for the alveoli to keep down tension or pressure. 8. List common accessory muscles used when increased work of breathing is required.

3 Scalenes (inner neck) and sternocleidomastoid, posterior neck and back muscles, and abdominal muscles. 9. Define and give approximate volumes for: a. anatomical dead space - air that fills the upper respiratory tract and lower nonrespiratory bronchioles. Tom's language: from the nose to the 23rd bifurcation of the bronchial's. b. physiological dead space - anatomical dead space plus the volume of nonfunctional alveoli. Tom's language: Normally the anatomical and physiological space is the same. But with people with COPD it becomes a problem because the physiological dead space can be 10 times the anatomical dead space. This results in "trapping" of air in the dead space - kind of like a dead end hydrant with dirt and rust. c. tidal volume - gas inhaled and exhaled during normal breathing. Adult to 600 ml, of this 150 ml never make it to the alveioli. Tom's language: You take in people start to climb Mount Everest. You have to leave 150 people that have to stay at the base camp so they never make it to the peak. d. total lung capacity - Sum of vital capacity and the residual volume (about 5800mL)

4 e. inspiratory reserve volume - Amount of gas that can be forcefully inhaled after normal tidal volume. Tom's Language: Take a normal breath then keep going until you pop. f. expiratory reserve volume - opposite example as inspiratory reserve volumes. g. residual volume - Gas that remains in the respiratory system after forceful expiratory activity. About 1100mL. h. functional residual capacity - Is the expiratory reserve volume plus residual volume. This reflects the amount of gas remaining in the lungs at the end of normal expiration. i. minute volume (minute ventilation) - Amount of gas inhaled in 1 minute. Average single breath is 500mL. 10. Define partial pressure and give the partial pressures of various gases in atmospheric air and alveolar air. Mixture of gassed that make up the atmosphere exerts a combined partial pressure.

5 11. What is torr? 1 torr is also 1 mmhg 12. Describe how oxygen and carbon dioxide are exchanged in the tissues and the alveoli. What process is involved? Diffusion 13. Define PO2, PCO2, PaO2, and PaCO2 and give normal values. PO2 PCO2 Pa02 PaCO2 14. Define atelectasis. Results from destroy or collapse of the alveolar wall. Like seen in emphysema. 15. List the two forms in which oxygen is transported in the blood. 16. Define oxyhemoglobin.

6 17. At what PO2 levels does hemoglobin become fully saturated. 18. At what PO2 levels does hemoglobin saturate the quickest? 19. List the three mechanisms by which carbon dioxide is transported in the blood. 20. Describe the Bohr effect and how it effects oxyhemoglobin formation. 21. Define carbaminohemoglobin. 22. Define the Fick principle. Amount of oxygen the lungs deliver to the blood related to the amount of oxygen that the body consumes. Tom's Language. 5 stages of hauling cargo via semis. First you have to have a truck, then load the truck, then drive the truck, then unload at destination. So you have to get the air in the lungs through the lungs, into the blood, through the blood vessels, to the tissue/cells, into and out of the cells, back the the lungs, and out of the body. If any of these steps are affected you influence Fick's principle.

7 23. Differentiate between hypoxia and hypoxemia. Hypoxia - decreased oxygen at the tissue level or available - IE outer space is a hypoxic environment as is a confined space also. Hypoxemia - decreased oxygen state at the arterial blood level. So when do we intubate an asthma patient. It is when the blood gassed drop. The narrowing from asthma creates a hypoxic environment but as long as the blood gasses stay up the patient is fine. Once the blood gasses drop we become hypoxemic and we need to intubate. 24. List abnormal conditions which affect blood oxygenation. Depressed Resp Drive - head injury, sedatives Paralysis - spinal injury, inhalation injury Increased resistance - asthma, bronchitis, COPD Chest wall - flailed chest, chest burns Decreased surface area - COPD, TB, Pneumonia, Atelectasis, Pulmonary Edema Shock Blood - anemia, carbon monoxide poisoning

8 25. Define the phrenic nerve and where does it originate? - two phrenic nerves originate at C3,4 and 5 and travel to the diaphragm. Tom's Language: C4 is the phrenic nerve. Saying is: injury below C5 stay alive. 26. List the two mechanisms responsible for basic respiratory rhythm. Vagal reflex - sends messages throughout the thorax and abdomen organs. At the end of the nerves are stretch or inflation receptors. Located in the bronchi, bronchioles, and lungs. Once the vagus nerve is stimulated by the stretch receptors the message is sent to the medulla. Pneumotaxic center - located in the pons above the medulla. The medullar says stop breathing and the pons say inhale. Active only in labored breathing. In quiet breathing the stretch receptors are the main control. 27. Describe the Hering-Breuer reflex and the role of the vagus nerve in respiration. - Described in 26 vagal reflex. 28. Describe the roles of the pneumotaxic center and the apneustic center. Apneustic center located in pons also and is active during normal breathing. - like sleeping or watching TV. pneumotaxic center is used in active labor breathing - like running.

9 29. Define the roles of ph, carbon dioxide, and oxygen in respiratory control. We spoke about this in pathophysiology - Chemoreceptors in the carotid, aorta, and medulla. Chemoreceptors measure the amount of CO2 in the blood and acid. They tell the brain to adjust the ph by breathing more or less. NOTE: Chemoreceptors do not work well in a shock patient. 30. Where are the receptors for the above chemicals located. Answered in Which of the above mechanisms is the most active in controlling respirations? CO2 levels in the blood. PARAMEDIC OBJECTIVES: AIRWAY II 1. What three parameters are evaluated when assessing airway adequacy? Rate - Regularity - Effort. Normal breathing should be quiet, effortless and equal chest rise. If you do not see these three things the patient is in some form of respiratory distress or arrest. 2. What is considered the normal range for respiratory rates in an adult? Adult (over 8 years) 12 to 20 per minute.

10 Child (1 to 8 years) 15 to 30 min Infant (less than 1) 25 to 50 min 3. What three techniques are used to assess airway patency and breathing? Observation (how are they breathing) - auscultation - palpation 4. Distinguish between a sign and a symptom. Sign - objective or fact. You can see and/or touch. Symptom - subjective or opinion. You can not verify. 5. What signs would indicate a patient in respiratory distress? Read you book for this one. 6. List and describe the various adventitious breath sounds which may be heard through auscultation. Snoring - tongue has fallen back and is blocking the airway. Gurgling - fluid in the upper airway. Wheezing - reversible narrowing of the lower airway.

11 Stridor - Partial upper airway obstruction. High pitched sound heard on inhalation. Rales - fine crackling bubbles in the alveoli. Rhonchi - fluid in the bronchioles. Wet Lung - Pulmonary edema. Note - Crackling lung sounds are not accurate. Not a true breath sound description word. 7. When obtaining a history from a patient in respiratory distress, what questions should you include? 8. Describe the various patterns of abnormal respirations and their significance. Bradypnea - slow Tachypnea - fast but normal depth Hyperventilation (hyperpnea) - fast and shallow Sighing Biot's - can be seen with people with no muscle tone due to long term head injuries. Cheyne-Stokes - head injury/medulla - fast to slow and deep to shallow and period of apnea. Kussmaul - Fast and deep Neurogenic hyperventilation - head injury resulting in fast shallow breathing to blow off CO2.

12 9. List some causes for an increase in respiratory rate. Acidosis, anxiety, aspirin poisoning, pain, pons damage. 10. List some causes for a decrease in respiratory rate. Alkalosis, narcotic, obesity 11. List the two primary reasons for administering supplemental oxygen to a patient. Enrich oxygen in the atmosphere to increase oxygen at alveoli level. Allows patient to compensate without increasing the work load of breathing. 12. List the cylinder constants for D, E, and M cylinders and be able to use them in calculating remaining oxygen in a tank. D 425L factor 0.16 E 680L factor 0.28 M 3450L factor 1.56 Take pressure in cylinder minus the 200 safe residual pressure.

13 Multiply this number by the factor. Then divide the number by the LPM flow rate and this leaves you with minutes left. 13. Define the safe residual volume (pressure). 200PSI 14. List three ways to identify oxygen from other gases. Green, 2-5 pin index, oxygen stamped on stem. 15. Review the flows and concentrations of the following oxygen delivery devices: a. nasal cannula 1 to 6 LPM 24% to 44% b. venture mask 4 to 8 LPM 24% to 50% c. simple face mask 6 to 10 LPM 35% to 60% d. non-rebreather 10 to 15 LPM 80-95% 16. List some complications of positive pressure breathing in a non-intubated patient.

14 Gastric inflation, rupture of lung tissue. 17. List the various methods, advantages, and disadvantages of providing positive pressure breathing. 18. All bag-valve-mask devices have a 15 inner 22 outer mm fitting which will accommodate all endotracheal tubes. 19. Inspiratory pressures in adults average 20 to 30 (can change via instructor) cm H2O and should generally not exceed 60 to 80 cm H2O. 20. Describe the difference between a whistle-tip (French) suction catheter and a hard/rigid (tonsil-tip). Basic Skill 21. Describe the proper procedures for both oropharygeal and endotracheal suctioning in an adult patient. Basic Skill 22. What is the most likely cardiac dysrhythmia to occur during endotracheal suctioning and how can it be avoided? Bradycardia. Also this patient should be preoxygenated for 5minutes in a stable setting.

15 23. Describe the techniques for nasogastric tube placement and gastric evacuation. In Class 24. Describe the various methods of manual airway manipulation. Head Tilt Chin Lift or Jaw Thurst. 25. Describe the various basic airway adjuncts. Basic Skill 26. Describe how endotracheal tubes are sized. Inner diameter in mm. 27. What sizes are generally recommended for men and women. Men 7.0 to 8.0 Women 6.0 to 7.0 Toddlers are age divided by 4 plus Describe the formula for determining ET tube sizes in children. Age divided by 4 plus 4

16 or 16 plus age divided by Review upper airway anatomy. 30. Describe the purpose if each of the following intubation items: a. straight blade - traps the epiglottis and lifts. b. curved blade - enters the Vallecula and lifts. c. stylet - gives shape and support to ET tube d. Magill forceps 31. What external anatomical landmark corresponds with the carina? 32. In an average adult, the distance between the teeth and the carina is 27 cm.

17 33. What is the average depth of insertion at the teeth for a man, a woman? Man 22 cm Woman 21 cm 34. How many ml of air do you put in the cuff of the ET tube? 10mL 35. What is a technique which can be employed to push the vocal cords more posterior making intubation easier. Cricoid Pressure or Sellicks Maneuver 36. List the primary and secondary methods for confirming tube placement. Primary - Chest rise, visualization, tube condensation, color improves, lung sounds Seconday - End Tidal CO2, Capnography, esophageal bulb indicator. 37. Describe the alternate forms of intubation, their advantages and disadvantages. 38. Describe the techniques, indications, and contraindications for nasotracheal intubation.

18 No person is a great nasal intubator. It is luck. Preferred patient has to be spontaneously breathing. Also no facial fractures and use with extreme caution with skull fractures. 39. Identify the various waveforms on an ETCO2 monitor and be able to identify various conditions based on waveforms and values. 40. List the advantages, disadvantages, and techniques for the use of an LMA. Sized by patient weight. 41. Describe the use of an EOA, EGTA, Combitube, and Ptl airways, Combitube sized by height. Most common size 5 foot to 6 foot 7. Must be over 14 years of age. PTL - same requirement as combitube. King Supra Glottic Tube - Sized by height. Size 3 does 4 foot to 5 foot, size 4 does 5 foot to 6 foot patient, etc List the indications and procedures for RSI. In Class 43. Describe the techniques and complications of translaryngeal cannula (jet) ventilation. In Class

19 44. Describe the techniques and complications of surgical cricothyrotomy. In Class The following information is to help you start your study outline. The following are basics. RESPIRATORY EMERGENCIES DEFINITIONS Ventilation - chest movement. Respiration - air in and out. ABG - arterial blood gasses - take blood an analyze it of saturation. Pulse-Ox - goes on finger. Hypoxia - low O2 available Hypoxemia - low O2 in blood stream. Dyspnea - difficult breathing. Artificial Ventilations - breathing for them. A&P Normal people breathe off of CO2 not O2. 21% O2 in air.

20 Respiratory Rate/Quality BPM adult, BPM Child, BPM infant. Should be quiet, effortless with equal chest rise. Terms: Seesaw, nasal flaring, tripod, sniffing, wheezing, rales, rhonchi, stridor, gurgling, snoring, unequal chest rise, no chest rise. Breath Sounds Refer to Assessment outline. Artificial Ventilation Stop Breathing or any one who cannot maintain oxygen levels. Less than 8 or over 30 (with poor pt presentation) ventilations per minute need artificial. Override breathing - when patient breathes in provide greater tidal volume. Medication Oxygen. MDI Albuterol. Neb Albuterol. Albuterol is a beta agonist working primarily on beta 2 and side effects of beta 1.

21 Asthma Lower airway reversible narrowing. Wheezing. Caused by irritant (trigger). First attack is constriction of lower airway. Second attack is fluid swelling to lower airway. Status Asthmaticus is an attack that cannot be broken by common means. Pulmonary Embolism Embolism (traveling clot/plaque and gets stuck in lung blood vessels) blocks blood flow in pulmonary vessels. Sudden onset Dyspnea. Happens when: after/during surgery, after birth given, mixing birth control and smoking. Place on left side if needed. Spontaneous Pneumothorax Weakened lung tissue that is thin. People with lung diseases, infections scare the lung tissue and make it thin Tall white skinny males prone to this. They grow to fast and make lungs thin. Lung tissue ruptures and air leaks into plural space in the chest cavity - collapsing the lung.

22 Usually not life threatening. s/s - first anxiety, then SOB, decreased lung sounds on leaking side, then affected chest rise on affected side. Infections (This is only an overview. You must put it all together. THEIR ARE EXCEPTIONS) URI and LRI. URI can turn into LRI if untreated. Virus comes on slow. Bacterial come on faster. Virus no or mild fever. Bacterial fever. Virus clear drainage. Bacterial colored drainage. Bacteria redness. Virus mild or no redness. COPD Chronic asthma, chronic bronchitis, emphysema. Chronic Bronchitis is blue bloater, obese, grunting, breath holder. Emphysema is pink puffer, skinny, barrel chest. Club fingers. Bronchitis is over stimulated discharge of mucus in bronchus tubes. Emphysema is loss of elasticity of alveoli. Long term problem is hypoxic drive. Start to control breathing with O2 levels not CO2 levels.

23 Hyperventilation Syndrome Breathing over 40 and shallow. Blow off too much CO2. Carpal/pedal spasms. Emotional support. Care: NO PAPER BAG. Care: Use a simple face mask at 2 LPM. Care: DO NOT use non-rebreather at 2 LPM unless you remove both flaps. It is recommended not to use NR at all. Follow medical control. Plural Effusions Fluid collects in plural space of chest. Unexplained major weight gain. Drained out with needle. Pulmonary Edema Most common cause of fluid in the lungs is CHF or irritant. If smoke inhalation or inhaled overdoses cause tissue swelling in lungs. LCHF causes backing up of blood in the lungs.