1. Introduction to Emergency Medical Care 1
Advance Preparation
Prepare anatomy models for demonstration.
Research related multimedia links for illustration purposes.
Prepare airway manikins for psychomotor sessions.
Prepare airway equipment for demonstration and psychomotor sessions.
Invite assistant instructors to assist with psychomotor sessions.

2. Respiration Teaching Time: 20 minutes
Teaching Tips: Identification of inadequate breathing is one of the most important lessons that you will teach. Spend time here to ensure comprehension. This lesson lends itself well to multimedia presentations. Anatomical models and web graphics will enhance your presentation on physiology and pathophysiology. Reach back to the lessons of previous chapters. Add assessment to physiology and pathophysiology as previously discussed. Teach that inadequate breathing means intervention. Prepare students to face a difficult decision that requires action.

3. Bell Work 4-3
The functional respiratory units in the lung where gases are exchanged is called?
What is the flap that closes when food or water is swallowed? Covers opening of trachea
What is the purpose of cilia?
The diaphragm contracts, the ribcage expands and abdomen moves downward. Are you inhaling or exhaling?

4. State Standards
21) Identify and perform skills to manage life threatening illnesses based on assessment findings of a pediatric, adult, and geriatric patient with medical emergencies, utilizing rubrics from textbooks, National HOSA guidelines, or clinical standards of practice in the following areas:
Respiratory distress or Asthma
22) Use assessment information to recognize shock, respiratory failure or arrest, and cardiac arrest based on assessment findings. Demonstrate the ability to manage the situation while awaiting additional emergency response.

5. Objectives Students will be able to…
Determine adequate breathing through assessments
Determine inadequate breathing through assessments
Determine normal and abnormal breath sounds

6. Adequate Breathing Breathing sufficient to support life Signs
No obvious distress
Ability to speak in full sentences
Normal color, mental status, and orientation
Point to Emphasize: Adequate breathing is breathing that is sufficient to support life. Normal rate, rhythm, and quality are typical signs of adequate breathing.
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7. Adequate Breathing
May be determined by observing rate, rhythm, quality
12–24 breaths/minute for adult
15–30 breaths/minute for child
25–50 breaths/minute for infant
Rhythm usually regular
Breath sounds normally present and equal
Discussion Topic: Describe the assessment findings of adequate respiration.

8. Inadequate Breathing Breathing not sufficient to support life Signs
Rate out of normal range
Irregular rhythm
Diminished or absent lung sounds
Poor tidal volume (Amount of air exhaled or inhaled in a normal breath)
Point to Emphasize: Inadequate breathing is breathing that is not sufficient to support life. An abnormally fast rate, irregular rhythm, and poor air movement are signs that point to inadequate breathing.
Class Activities: Discuss the signs and symptoms of a variety of patients with difficulty breathing. Work with the class to develop strategies to identify rapidly those patients in respiratory failure. Assign a take-home assignment similar to the previous activity. List signs and symptoms; then have students identify respiratory distress or respiratory failure.
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9. Inadequate Breathing
Signs of inadequate breathing in infants and children
Nasal flaring
Grunting
Seesaw breathing (
Retractions (
Knowledge Application: Use multimedia graphics to present patients in respiratory distress. Discuss the classification of inadequate breathing and have students defend their decisions.

10. Pediatric Note
Structure of an infant’s and child’s airway differs from that of an adult
Smaller airway easily obstructed
Proportionately larger tongues
Smaller, softer, more flexible trachea
Less developed, less rigid cricoid cartilage
Heavy dependence on diaphragm for respiration
Point to Emphasize: Assessment of breathing adequacy must be adjusted to account for the anatomical differences of pediatric patients.

11. Artificial Ventilation
Can be adequate or inadequate
Chest rise and fall should be visible with each breath
Adequate artificial ventilation rates
12 breaths per minute for adults
20 breaths per minute for infants and children
Talking Points: If the chest does not rise and fall with each artificial ventilation, or the pulse does not return to normal, increase the force of ventilations. If the chest still does not rise, check that you are maintaining an open airway.
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12. Artificial Ventilation
Increasing pulse rates can indicate inadequate artificial ventilation in adults
Decreasing pulse rates can indicate inadequate artificial ventilation in pediatric patients
Talking Points: When adult patients experience a decrease in oxygen in the bloodstream (hypoxia), their pulse increases. In infants and children with respiratory difficulties, you may observe a slight increase in pulse early, but soon the pulse will drop significantly. A low (or bradycardic) pulse in infants and small children in the setting of a respiratory emergency usually means trouble!
Discussion Topic: Describe the assessment findings of inadequate ventilation.
Critical Thinking: What role does reassessment play when treating a patient with adequate respirations? How can your initial findings change?

13. Think About It
How might you recognize the progression from adequate breathing to inadequate breathing in the assessment of your patient?
How might your patient change during this transition?
Talking Points: Look for changes in patient status. Mental status is always an important clue. Look also for respiratory fatigue, slowing respiratory rates, and irregular respiratory rhythm. Look for tachycardia and bradycardia (especially in children).

14. Breathing Difficulty Teaching Time: 45 minutes
Teaching Tips: This lesson lends itself well to multimedia presentations. Very good web-based graphics exist. Consider using these types of examples to underscore your lecture. Expand upon the initial lesson on inadequate breathing. Put it now in the context of the larger respiratory assessment. Use programmed patients (or other students) to practice respiratory evaluations. There is no substitute for actual lung sounds. Give students every opportunity to practice this skill.

15. Breathing Difficulty Patient’s subjective perception
Feeling of labored, or difficult, breathing
Amount of distress felt may or may not reflect actual severity of condition
Points to Emphasize: For the patient, difficulty breathing is a subjective perception. The amount of distress that the patient feels may or may not reflect the actual severity of the condition. Further assessment of a patient in respiratory distress includes observation, auscultation, and evaluation of vital signs. Assessment of breathing adequacy is an important element of assessing any patient with difficulty breathing.

16. OPQRST Onset—When did it begin?
Provocation—What were you doing when this came on?
Quality—Do you have a cough? Are you bringing anything up with it?
Point to Emphasize: OPQRST is a memory aid that can be very useful for gathering a history from a patient in respiratory distress.
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17. OPQRST
Radiation—Do you have pain or discomfort anywhere else in your body?
Severity—On a scale of 1 to 10, how bad is your breathing trouble?
Time—How long have you had this feeling?
Discussion Topic: List and explain the components of the OPQRST memory aid as they apply to a patient with respiratory distress.

18. Assessment: Observation
Altered mental status
Unusual anatomy
Barrel chest
Patient’s position
Tripod position
Sitting with feet dangling, leaning forward
Point to Emphasize: Further assessment of a patient in respiratory distress includes observation, auscultation, and evaluation of vital signs.
Knowledge Application: Have students work in small groups. Assign each group an element of the respiratory assessment. Have each group demonstrate the application of its portion of the assessment.
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19. Assessment: Observation
Work of breathing
Retractions
Use of accessory muscles
Flared nostrils
Pursed lips
Number of words patient can say without stopping
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20. Assessment: Observation
Pale, cyanotic, or flushed skin
Pedal edema
Sacral edema
Coughing
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21. Assessment: Observation
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22. Assessment: Observation
Noisy breathing
Audible wheezing (heard without stethoscope)
Gurgling
Snoring
Crowing
Stridor
Talking Points: Often sounds of breathing may be audible without a stethoscope.
Discussion Topic: Describe the observational elements of a respiratory assessment.
Knowledge Application: Using programmed patients, have students complete simulated respiratory assessments. Include patients with both adequate and inadequate breathing.

23. Assessment: Auscultation
Lung sounds on both sides during inspiration and expiration
Discussion Topic: Describe the correct locations for assessing lung sounds.
Class Activity: Ask students to listen to each other’s lung sounds. Have students practice auscultation of lung sounds on the student next to them.
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24. Breath Sounds Assessed using a stethoscope
Classified as either normal or abnormal
Due to vibration in the walls of the respiratory system
Presence of abnormal breath sounds is used to Diagnose respiratory disorders or diseases.

25. Normal Breath Sounds Tracheal Sounds- hear over the trachea
harsh and sound like air is being blown through a pipe.
Bronchial sounds -present over the large airways in the anterior chest near the second and third intercostal spaces
hollow-sounding and not as harsh as tracheal breath sounds.
Broncho-vesicular sounds-heard in the posterior chest between the scapulae.
softer than bronchial sounds, but have a tubular quality.

26. Abnormal Breath Sounds
Wheeze or 
rhonchi
continuous
expiratory or inspiratory
whistling/sibilant, musical
Caused by narrowing of airways, such as in asthma, COPD, foreign body
Crackles
discontinuous
inspiratory
cracking/clicking/rattling
pneumonia, edema, tuberculosis,
Stridor
continuous
either, mostly inspiratory
whistling/
musical
epiglottitis, foreign body, laryngeal 
edema, croup

27. Assessment: Auscultation
Wheezes—high-pitched sounds created by air moving through narrowed air passages
Crackles—fine crackling caused by fluid in alveoli or by opening of closed alveoli
Talking Points: Some people refer to crackles as rales. You may observe changes over time when listening to lung sounds. An asthmatic patient who has used an inhaler may feel that breathing is easier and the wheezes have diminished. Be careful, however. Sometimes the wheezes will also disappear when a patient worsens and breathing becomes inadequate.
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28. Assessment: Auscultation
Rhonchi—low sounds resembling snoring or rattling, caused by secretions in larger airways
Stridor—high-pitched, upper-airway sounds indicating partial obstruction of trachea or larynx
Discussion Topic: Describe the etiology of the following abnormal lung sounds: wheezes, crackles, rhonchi.
Class Activity: Assign 20 lung sound evaluations as homework. Ask students to document and describe the assessments in a journal.
Knowledge Application: Have students work in small groups. Assign each group an abnormal lung sound. Have the group research and discuss how the sound is generated and associated conditions.
Critical Thinking: Children often will present with a condition referred to as “silent chest.” In this case, what is the significance of hearing no lung sounds at all?

29. Normal Breath Sounds Audio
© 2004 Delmar Learning, a Division of Thomson Learning, Inc.

30. Abnormal Breath sounds audio
© 2004 Delmar Learning, a Division of Thomson Learning, Inc.

31. Assessment: Vital Sign Changes
Increased or decreased pulse rate
Changes in breathing rate
Changes in breathing rhythm
Hypertension or hypotension
Oxygen saturation
Talking Points: Although an oximeter reading between 96 and 100 percent is normal, oxygen should be administered to all patients with respiratory distress regardless of their oxygen saturation readings. Even a patient with a saturation reading of 100 percent should receive oxygen if he has any signs of respiratory distress.

32. Patient Care Assure adequate ventilations
If breathing is inadequate, begin artificial ventilation
If breathing is adequate, non-rebreather mask at 15 Lpm
Talking Points: Use a nasal cannula only in cases where the patient will not tolerate a mask. If the patient has inadequate breathing, provide supplemental oxygen while performing artificial ventilation.
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33. Patient Care Place patient in position of comfort
Administer prescribed inhaler
Administer continuous positive airway pressure (CPAP)
Talking Points: If the patient has a prescribed inhaler, you may be able to assist the patient in taking this medication. This would be done after consultation with medical direction, often during transportation to the hospital.

34. The Prescribed Inhaler
Teaching Time: 15 minutes
Teaching Tips: Have examples of metered-dose inhalers on hand. Allow students to familiarize themselves with the various types of inhalers. Training devices allow for simulation of the delivery of inhaled medications. This will allow students to practice the steps involved in using a metered-dose inhaler. Relate the use of a metered dose inhaler to pharmacology lessons learned in Chapter 18. Require students to consider the “five rights” prior to any administration of medications.

35. The Prescribed Inhaler
Metered-dose inhaler
Provides a metered (exactly measured) inhaled dose of medication
Most commonly prescribed for conditions causing bronchoconstriction
Points to Emphasize: The metered-dose inhaler gets its name from the fact that each activation provides a measured dose of medication. A metered-dose inhaler is typically prescribed for patients with respiratory problems that cause bronchoconstriction.
Knowledge Application: Have students use drug resources to research and then describe medications delivered in the form of metered-dose inhalers. Discuss indications.
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36. The Prescribed Inhaler
Before administering inhaler
Right patient, right medication, right dose, right route
Check expiration date
Shake inhaler vigorously
Patient alert enough to use inhaler
Use spacer device if patient has one
Talking Points: As an EMT you may be allowed to assist a patient in using a prescribed inhaler. You will need to get permission from medical direction to help the patient use the inhaler. This may be accomplished by phone/radio or by standing order, depending on your local protocols.
Art: Emergency Care 11 Ch. 16 PPT Slide 83

37. Spacer Device

38. The Prescribed Inhaler
To administer inhaler
Have patient exhale deeply
Have patient put lips around opening
Press inhaler to activate spray as patient inhales deeply
Make sure patient holds breath as long as possible so medication can be absorbed
Point to Emphasize: Following the appropriate steps for administration of a metered-dose inhaler will optimize the delivery of inhaled medication.
Discussion Topics: Explain how a metered dose inhaler delivers medication. List and describe the steps involved in administering a medication via a metered-dose inhaler.
Knowledge Application: Have students work in small groups, with members taking turns explaining the use of metered-dose inhalers to each other (as they would for a patient). Critique and practice.
Critical Thinking: Should metered-dose inhalers be administered to all patients with respiratory distress? What types of respiratory distress should not receive bronchodilator medications?

39. Activity ***We have now covered our objectives***
With a partner complete Station 4 Lung sounds and Respiratory Rate under respiratory lab activities.
Listen to lung sound THROUGH YOUR PARTNERS SHIRT NOT UNDER IT.
Follow the directions, you will be provided with a stethoscope.
Complete the station 4 analysis questions individually.