1. Review the anatomy and physiology of the respiratory system.

Transcription

1 By Mike Stricker

2 1. Review the anatomy and physiology of the respiratory system. 2. Review the assessment process. 3. Review the management of airway and ventilation status. 4. Review the advanced management of the airway. 5. Review the equipment, procedures, and guidelines. 6. Review our equipment and where it is located on the truck.

3 Management and ventilation are the most critical steps in every patient you will encounter. Early detection and intervention are critical to patient survival. Many times, simple, basic airway skills are all that is needed. Without adequate oxygen, the patient will sustain brain injury in as little as 4-6 minutes.

4 The respiratory system consists of: Upper Airway Lower Airway Diaphragm Muscles of the chest wall Accessory muscles of breathing Nerves from the brain and spinal cord

5 Anatomy Upper Airway Nasal Cavity Oral Cavity Pharynx Lower Airway Larynx Trachea Bronchi Alveoli

6 Anatomy Diaphragm Both voluntary and involuntary Expand on inhalation Contract on exhalation Accessory muscles Contract to elevate ribs Creates greater volume

7 Physiology Inhalation Active, muscular part of breathing Diaphragm and intercostal muscles contract Creates greater volume and negative pressure Negative pressure causes air to fill lungs Gases diffuse from higher to lower con. Terms to know: O2 enters tissues CO2 leaves tissues Tidal Volume (TV) - Air moved into or out of the lungs during a single breath. - Average is 5-15 ml/kg ideal body weight. 500ml Minute Volume (MV) - Air moved through the lungs in one minute. - Rate x TV=MV Average is 12x 500 = 6,000 ml Exhalation Passive part of breathing Diaphragm and intercostal muscles relax Creates lesser volume and positive pressure Positive pressure causes air to leave lungs CO2 leaves body

8 Physiology Exchange of O2 and CO2 The body needs constant O2 to function The body needs to get rid of waste: CO2 Exchange takes place at capillaries Gases diffuse from high to low conc. Normal Values: PaO2: 95 in lungs; 40 in veins (mmhg) PaCO2: 40 in veins;.3 in atm. (mmhg) Control of Breathing Medulla Oblongata controls breathing Healthy person is stimulated by CO2 levels - High CO2 results in higher rate - Lower CO2 results in lower rate Chronic Respiratory pts use hypoxic drive - Accustomed to lower O2 levels - Breathing stimulated by low O2 levels Hypoxia: tissues/cells have inadequate O2 Early signs: restlessness, irritability, tachycardia, anxiety, apprehension Late signs: AMS, weak pulse, cyanosis

9 In order to help the patient, we must be able to identify when they are having difficulty breathing. An adult who is awake, alert, and talking to you generally has no airway or breathing problems. Always have oxygen and tubing ready.

10 Assessing the Airway Adequate Breathing Easy, not labored, and quiet ROT: unless directly assessing the pt. airway, you should not be able to see or hear breathing Normal rate for adults for children for infants Regular pattern inhale/exhale Clear, equal bilateral lung sound Regular, equal chest rise/fall Adequate depth Pulse-Oximetry/Skin color Inadequate Breathing Labored breathing Pt. appears to be working hard to breathe Patient outside normal rate Shallow depth (reduced TV) Use of accessory muscles 2ndary muscles of respiration Irregular rhythm Inadequate chest expansion Diminished, absent, or noisy breath sounds Pale, cyanotic, cool, or moist skin Restlessness

11 Terms to know: Retractions Skin pulling in around the ribs or above the clavicle during inspiration Parodoxical breathing Assymetrical chest wall movement that lessens respiratory efficiency Agonal respirations Occasional, gasping breaths that may occur after a pts heart has stopped Ataxic respirations Irregular, ineffective respirations that may not have an identifiable pattern -pnea - Breathing Dys- Abnormal Eu- Normal rate and pattern Tachy- Increased rate Brady- Decreased rate Hyper- Normal rate, Deep depth Kussmauls Tachypnea and hyperpnea. (Renal failure, DKA, metabolic acidosis) Biots Rapid, deep respirations (gasps) with short pauses between sets. (Meningitis, head injury) Cheyne-Stokes Gradual increases and decreases in resperations w/ periods of apnea. (Inc. ICP) Apneustic Prolonged inspiratory phase w/ short expiratory phase. (Lesion in brainstem)

12 Pulse Oximetry Normal Range is between % in a healthy individual. Color Cyanosis in extremities indicates respiratory distress. Work of breathing Intercostal muscle use, retractions, diaphragmatic breathing. How can we improve these? Try giving more O2. Also increase TV if using a BVM. Look for signs of improvement. Higher SpO2, better color, etc.

13 First, assess the airway to assure it is patent. Pt is conscious and speaking No obstruction in the unconscious pt Simple Airway maneuver used Next, determine the adequacy of breathing. Equal chest rise and fall Auscultate Absence of these could indicate pneumothorax or flail chest.

14 Giving too much oxygen will never hurt the patient. However, not giving enough can hurt the patient. General Guidelines: SpO %: Mild hypoxia. Give 2-4 L O2 NC. SpO %: Moderate hypoxia. Give L O2 NRB. SpO2 <85%: Severe hypoxia. Assist breathing, 100% O2 BVM Be cautious administering O2 to patients w/ COPD. False readings can be due to CO poisoning, anemia, or high intensity lights. If you are getting a poor reading or no reading in a patient that appears to be breathing without difficulty, make sure equipment is plugged in.

15 Airway Obstruction: Interference with air movement through the upper airway. Causes: Tongue Most common cause of airway obstruction. Foreign bodies Could have caused the problem. Always LOOK, listen and feel. Trauma Blood, teeth, or vomit can compromise the airway. Always have suction within reach. Laryngeal spasm Aspiration Increased interstitial fluid and PE edema can result from Aspiration

16 Inadequate Ventilation Insufficient O2 intake and CO2 removal Causes Poor face-mask seal Incorrect volume Normal TV of an adult is approximately 500 ml. (5-7 cc/kg) How much ml of air does BVM hold? Incorrect rate Normal rate for an adult is bpm. For BVM use, how often should you give a breath? Incorrect inhalation: exhalation ratio Exhalation should take twice as long as inhalation.

17

18 Respiratory arrest and/or insufficiencies to achieve complete control over the airway

19 Isolates the trachea Protects the airway from aspiration. Prevents gastric distention. Controls the airway Ventilation with 100% oxygen. Suction Delivery of Drugs w/o IV access. LEAN

20 1. Esophageal Intubation 2. Tracheal rupture 3. Right main stem bronchus intubation 4. Broken teeth 5. Laryngospasms 6. Trauma to the oral-pharynx 7. Trauma or puncture of trachea due to misplacement of stylet

21 Always make sure to keep yourself safe. Gloves Gown Mask Goggles

22 1. Assess the patient 2. Look, listen, and feel 3. Open the Airway 4. Suction if needed Head-tilt/Chin-lift Jaw-thrust Maneuver

23 Suctioning the Patient Hard tip Suction tip with a large opening surrounded by a bulbous head and is designed to allow effective suction without damaging surrounding tissues. Yankauer Soft tip Suction tubing that is flexible. Can be inserted within ET tube. Always have distilled water or normal saline within reach to flush suctioning after each use.

24 Nasopharyngeal Airway Passes through nose and extends to posterior pharynx. Can be used in a pt who has an intact gag reflex. Suction can be done through NPA. May use it when pt. teeth are clenched. CONTRAINDICATED In patients with basilar skull fracture. Oropharyngeal Airway Used in unconscious pt. w/out gag reflex. Displaces the tongue anteriorly. Air can pass around and through the device. Makes suctioning of the pharynx easier. Prevents obstruction by the teeth and lips. Serves as a bite block. CONTRAINDICATED In patients that are conscious or have an intact gag reflex.

25 Ventilate the pt. Is the air moving easily? Are Basic maneuvers adequate? Is there possible obstructions or indications to intubate? High Flow O2 at 15 LPM 500 ml per breath Deliver a breath every 6-8 seconds Auscultate lung sounds to establish a baseline

26 If intubation is indicated, pass off ventilation to your partner and check your equipment: EDD/ETCO2 detector Check for leaks. ETCO2 should be purple. If yellow = throw out. Laryngoscope Bright, white, tight ET tube Attach syringe, check cuff for leaks, lubricate ETT, insert stylet. Place ET tube in hockey-puck form. Choosing the right size: 7.5 mm adult, child = diameter of little finger Predicted Size Uncuffed Tube = (Age / 4) + 4 (Up to 8 years old) Predicted Size Cuffed Tube = (Age / 4) + 3 (8 to 16 years old) Adults: Men: mm Women: mm

27 Intubation Make sure your patient is pre-oxygenated. Hyperextend the neck. Advance laryngoscope with Left hand. Do NOT use teeth as fulcrum. Identify Landmarks! 30 seconds per attempt. If you are unable to visualize the vocal cords, consider using the combitube.

28

29 If you are having trouble visualizing the vocal cords, the BURP or Thyroid pressure techniques. 1. View glottic opening 2. Direct tube down right side of mouth through glottic opening 3. Secure ETT manually and note ETT depth at teeth or gums 4. Remove laryngoscope and stylet 5. Attach EID, squeeze bulb, release, evaluate for refill or emesis - Refills = correct. Zero refill or emesis = reintubate

30 Once confirmed: 1. Inflate cuff with 5 to 10 cc and remove syringe 2. Ventilate patient, auscultate over epigastrium and bilateral lung sounds 3. Attach end tidal carbon dioxide detector and evaluate Yellow = Yes Purple = Problem Evaluate clinical signs, chest rise, ETT condensation, patient color improve Secure ETT with device or tape

31 It is important to continually reassess the patient: Limit head movement with C.C. and /or backboard & head blocks. This will help to keep the ET tube from moving, which could cause it to damage the trachea or become dislodged. Be sure to continue to monitor and recheck placement with each movement. Document: Number of attempts, EMTs attempting, ETT size/depth, lung sounds, any complications

32 If an airway is difficult to manage, consider using the combitube. The combitube is a twin lumen device designed for use in emergency situations and difficult airways. No visualization is needed (insertion is blind). In most cases, the esophagus will be intubated. This provides some isolation of the trachea, but not as much as an ET tube will provide. Contraindications: less than 16 years of age, less than five feet tall, intact gag reflex, know esophageal disease, ingestion of caustic substance.

33 Combitube Notice that the esophagus was intubated here. See why you can not suction? This opening connects to Shorter Lumen #2. This is the clear lumen. Suctioning can be done in the rare instance in which the trachea is intubated. Combitube function

34 All of the prior steps to intubation are the same as with ET intubation. Once these steps are completed, check your equipment. Check cuffs on Combitube and then withdraw air fully. Set syringes: the large blue-tipped syringe at 100ml and the smaller syringe at 15ml. Lubricate distal end of device. When performing intubation: Perform tongue and jaw lift. If C-spine concerns second EMT can immobilize in-line position. Insert device along midline of patient s mouth, take care to not damage cuffs on patient s teeth. Advance device until the teeth or gums lie between the 2 black marks on the device.

35 Using the tube: Attach syringes to cuffs if not already done, large blue-tipped syringe to cuff #1 and small syringe to cuff #2. Inflate blue cuff #1 with 100ml and remove syringe. Inflate white cuff #2 with 15 ml and remove, note device may move slightly during cuff inflation. Ventilate through tallest lumen, #1. Confirm placement by observing chest rise with ventilation, absence of sounds over epigastrium and presence of bilateral lung sounds. If no chest rise and sounds heard over epigastrium, cease ventilation and move to shorter lumen #2. Ventilate through shorter lumen #2. Confirm placement by observing chest rise, absence of epigastrium sounds and presence of bilateral lung sounds. After placement verified, attach carbon dioxide detector and evaluate. Remember to secure the Combitube. If successful ventilation is occurring through lumen #1, then prepare for possible emesis from lumen #2.

36 It is important to continually reassess the patient: Limit head movement with C.C. and /or backboard & head blocks. This will help to keep the Combitube from moving, which could cause it to damage the trachea or become dislodged. Be sure to continue to monitor and recheck placement with each movement. Document: Number of attempts, EMTs attempting, lung sounds, any complications

37