Chapter 8 Respiratory Support

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 2 Overview  Breathing  Assessment  Oxygen Therapy  Oxygen Delivery Systems  Oxygen Delivery Devices  Artificial Ventilation

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 3 Breathing  Breathing is a complex activity  Some illnesses impair the body’s ability to utilize oxygen  Hypoxia means insufficient body stores of oxygen –Increased respiratory rate –Shortness of breath

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 4 Breathing  Severe difficulty with breathing can lead to respiratory failure  Untreated respiratory failure can lead to death  The EMT must assess the patient’s ventilation and respiration

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 5 Assessment  Initial steps –Look –Listen –Feel  Determination of level of consciousness –Verbal stimuli –Physical stimuli

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 6 Assessment  Quick check –Key to the initial assessment of the unconscious patient –Look for the chest to rise and fall –Listen and feel for air movement –Check for the presence of a carotid pulse

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 7 Assessment  Look –Visual cues provide a lot of information about the patient’s breathing –Position The tripod position allows the patient to expand his lungs and draw in more air

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 8 Assessment

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 9 Assessment  Look –Color Blood lacking oxygen gives the skin a bluish color, known as cyanosis –Respiratory rate Can be too fast, too slow, or about normal Tachypnea is an increased rate of breathing Hypoventilation is a decreased rate of breathing

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 10 Assessment  Look –Effort Any exertion seen with breathing is abnormal Nasal flaring Mouth breathing Pursed lips Accessory muscle use

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 11 Assessment  Look –Pulse oximetry Measures the percentage of red blood cells that are saturated with oxygen Helps assess a patient with respiratory distress Average oxygen saturation is 96–100% Below 95%: Oxygen administration required Below 92%: The patient is significantly hypoxic

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 12 Assessment

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 13 Assessment  Listen –Note what is said and how it is said –Document the chief complaint –The feeling of respiratory distress is called dyspnea

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 14 Assessment  Listen –Speech The EMT should note the patient’s ease of speech Full sentences without frequently stopping—severe distress is not likely Short sentences or monosyllabic answers—severe respiratory distress is present

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 15 Assessment  Listen –Obvious noise Note noises associated with breathing Noticeable noise is a sign of a respiratory problem

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 16 Assessment  Listen –Breath sounds On auscultation, air movement should be evident in both lungs The absence of sounds indicates lack of air movement Diminished breath sounds may indicate poor airflow or lung abnormality

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 17 Assessment  Feel –Palpate the chest wall for tenderness, deformity, and equality of movement –With the hands under the armpits, apply pressure to the rib cage

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 18 Stop and Review  List the signs of adequate breathing.

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 19 Oxygen Therapy  The most common medication administered by the EMT  Be familiar with its indications, contraindications, and administration

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 20 Oxygen Therapy  Indications –Primary indication—to reverse hypoxia –Physical signs of hypoxia Restlessness Anxiety Confusion Tachypnea or hypoventilation Tachycardia or bradycardia Cyanosis –Always rely on clinical judgment

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 21 Oxygen Therapy  Contraindications –No absolute reason not to administer oxygen except: Oxygen toxicity in premature infants –Do not withhold oxygen from a patient who needs it –Careless administration can have potential complications

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 22 Oxygen Therapy  Oxygen humidification –Oxygen can dry the mucous membranes over long period of time –Humidification of oxygen can help prevent injury –Two means of administering Use standard volume nebulizer Attach to standard non-rebreather mask

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 23 Oxygen Delivery Systems  Two types of oxygen delivery systems –Fixed systems On board ambulance May hold 3,000 liters Filled to about 2,000 psi –Portable systems Easily moveable May hold 350 liters Refill before below 200 psi

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 24 Oxygen Delivery Systems  Anatomy of an oxygen delivery system –Cylinder holds oxygen under pressure Must be hydrostatically tested every five years –Regulator controls the flow of oxygen Flow rates should be from 2 lpm to 15 lpm –T-piece mates cylinder with the regulator –Washers ensure an airtight fit

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 25 Oxygen Delivery Devices  Simple facemask –Percentage of oxygen delivered is a function of the patient’s respiratory rate  Venturi mask –Designed to deliver a specific percentage of oxygen regardless of the patient’s respiratory rate

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 26 Oxygen Delivery Devices  The partial non-rebreather mask (NRB) –Provides high concentrations of oxygen –Prevents rebreathing of exhaled air –Liter flow should be between 10 and 15 lpm –Patient must be breathing effectively to ensure delivery –Must monitor patient to ensure that the respiratory status is not changing

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 27 NRB and Nasal Cannula  Watch this clip demonstrating the use of the non-rebreather and nasal cannula

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 28 Oxygen Delivery Devices  Tracheostomy mask –Variation of an oxygen facemask –Fits over the tracheostomy opening and provides oxygen

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 29 Oxygen Delivery Devices  Nasal cannula (NC) –Two small prongs attached to a length of tubing –Flow rates vary from 1 to 6 lpm –Generally restricted to patients who are already on low-flow oxygen at home or cannot tolerate NRB

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 30 Artificial Ventilation  Providing ventilation to a patient who is not breathing at all (apnea) is called artificial ventilation (rescue breathing)  When performing artificial ventilation, EMT must use a barrier device

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 31 Artificial Ventilation  The pocket mask –Most effective ventilation method used by an individual EMT –Is both barrier device and ventilation device –Mouth-to-mask ventilation can deliver 16% oxygen

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 32 Pocket Mask  Watch this clip demonstrating the use of the pocket mask

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 33 Artificial Ventilation  The bag valve mask –Primary device used to ventilate nonbreathing patients –Outstanding feature is the self-inflating bag –Many have attached oxygen reservoirs –Delivery valve ensures one-way flow of oxygen-rich air –Facemask of a BVM is very similar to the pocket mask

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 34 Artificial Ventilation  Ventilation technique –Air volume Overaggressive ventilation can lead to distention and vomiting Insufficient ventilation can lead to hypoxia EMT must be familiar with age-appropriate ventilation rates Overly slow or fast ventilations can result in inappropriately high or low CO 2 levels

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 35 Artificial Ventilation  Ventilation technique –Two-person ventilation Most effective method of ventilating nonbreathing patient First EMT is the airway person; must be prepared to suction Second EMT is the breathing person; focus is on ventilation In cardiac arrest, a third EMT is the circulation person

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 36 Artificial Ventilation  Ventilation technique –Cricoid pressure When possible, gentle cricoid pressure is applied The cricoid is a cartilaginous ring that supports and holds open the trachea Compresses the esophagus, preventing air from entering easily

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 37 Bag Valve Mask  Watch this clip demonstrating the use of a bag valve mask

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 38 Artificial Ventilation  Flow-restricted oxygen-powered ventilation device (FROPVD) –Downsides Easy to overinflate the patient’s stomach with this device The EMT cannot feel the resistance created by the patient’s lungs

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 39 Artificial Ventilation  Single-person BVM ventilation –Pocket mask –FROPVD –Bag valve mask alone (last resort) Insufficient volume of oxygen often generated Efficiency can be improved by pressing the bag against the patient’s face

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 40 Artificial Ventilation  Ventilation of the breathing patient –Patients with extreme difficulty breathing can be assisted with BVM –Patient may stop breathing and allow EMT to ventilate him –By assisting ventilations, the EMT can avoid periods of hypoxia

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 41 Artificial Ventilation  Ventilation of the surgical airway –Tracheostomy The tracheostomy tube will fit onto the BVM connector Less air is needed to ventilate the tracheostomy patient –Stoma EMT should size the stoma’s opening for a properly fitting mask

© 2005 by Thomson Delmar Learning,a part of The Thomson Corporation. All Rights Reserved 42 Stop and Review  Identify the parts of a non-rebreather facemask and state the oxygen flow requirements needed for its use.