Chapter 6 Breathing and Ventilation

Chapter 6 Breathing and Ventilation
Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Topics The Respiratory System Airway Techniques Artificial Ventilation
Review the topics with the students Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

The Respiratory System

Anatomy of the respiratory system How respiration works Infants and children Review the topics with the students Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy of the respiratory Nose and mouth Warms Humidifies Filters Review the functions of the nose and mouth in respiration Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy of the respiratory system Pharynx Throat Divides into esophagus and trachea Advise the students that the pharynx is also know as the throat Advise the students that this is where the esophagus separates from the airway Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy of the respiratory system Epiglottis Covers trachea during swallowing Review the function of the epiglottis with the students Stress that proper functioning of the epiglottis allows air into the lungs and prevents food from entering the trachea during swallowing Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy of the respiratory system Trachea Carries air to the lungs Larynx Voice box Advise the students that the trachea carries air from the pharynx to the lungs Advise the students that the vocal cords, located in the larynx, separates the upper and lower airways Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy of the respiratory system Bronchi Inferior portion of the trachea Continue to branch off into smaller airways Lungs Principal organs of respiration Contain millions of alveoli Advise the students that the bronchi separate from the trachea and specifically direct air into the left and right lungs Advise the students that the lungs are the principal organs of respiration. Remind the students that there are 5 lobes, 3 on the right and 2 on the left. Advise the students that the bronchi continue to divide into smaller airways to distribute air to the alveoli Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy of the respiratory system Diaphragm Dome-shaped muscle Separates thoracic and abdominal cavity Stress that the diaphragm is necessary for normal respiratory effort in the adult patient Advise the students that any problems with the diaphragm can severely impact the respiratory effort of the patient Describe to the students how the diaphragm functions during normal respiration Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

How respiration works Inhalation Diaphragm and intercostal muscles contract Diaphragm moves down Decreased pressure in chest Air flows into lungs to equal pressure Review the process of respiration Describe how the diaphragm and intercostal muscles contract, increasing to overall size of the thorax As the size of the thorax increases, the internal pressure decreases Advise the students that the body must equalize the pressure with the outside, and the only way to do this is to fill the lungs with air Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

How respiration works Inhalation Air fills alveoli Oxygen passes through capillary wall into blood Carbon dioxide and wastes enter alveoli for exhalation Advise the students that once the lungs are filled, the alveoli become inflated The alveoli are the principal location for gas exchange in the lungs Advise the students that the gases diffuse, or move across the alveolar-capillary membrane. This allows for the elevated levels of oxygen in the alveoli to enter the blood stream. This is also how the blood transfers waste products and carbon dioxide to the alveoli for excretion during exhalation Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

How respiration works Exhalation Diaphragm and intercostal muscles relax Increased pressure in chest Air exhaled to equalize pressure Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

How respiration works Inhalation Active Exhalation Passive Advise the students that inhalation is an active process, where exhalation is typically passive Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

How respiration works Adequate breathing Regular Good depth No accessory muscle usage Appropriate rates Review the indicators for adequate respiration Describe how to determine good depth during inhalation Explain what the accessory muscles are, and how they are indicative of respiratory distress Review the normal respiratory rates for patients of different ages Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Infants and Children Anatomical structures Smaller More easily obstructed Trachea more flexible Diaphragmatic breathing Review the differences in the anatomy of the infants and children Advise the students that the pediatric is more easily obstructed, including obstruction through manual airway maneuvers Stress that infants especially, are abdominal breathers. They do not have strong muscle control in their rib cage and abdomen, so when their diaphragm contracts, it can visibly displace the abdominal contents anteriorly Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Review the differences in the anatomy of the infants and children Advise the students that the pediatric is more easily obstructed, including obstruction through manual airway maneuvers Stress that infants especially, are abdominal breathers. They do not have strong muscle control in their rib cage and abdomen, so when their diaphragm contracts, it can visibly displace the abdominal contents anteriorly Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Airway Techniques Opening the airway Inspecting the airway
Cleaning the airway Assessing breathing Review the airway techniques with the students Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Airway Techniques Opening the airway
Tongue is the most common airway obstruction Methods to open airway Head-tilt/Chin-lift Jaw-thrust Advise the students that opening the airway is the first method to help control the airway. Review the methods for opening the airway, stress that the students should utilize the jaw-thrust maneuver in patients that have suspected trauma Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Airway Techniques Opening the airway Head-tilt/chin-lift maneuver
Place hand on forehead Tilt head back Place fingertips under lower jaw Lift chin forward Review the technique for performing the head-tilt/chin-lift maneuver Remind the students that the head-tilt/chin-lift must be maintained throughout patient care Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Airway Techniques Head-tilt/chin-lift maneuver Precautions
Do not press too deep into soft tissue Do not use thumb to lift chin Do not let patient's mouth close Only remove dentures if loose Advise the students that they must be careful not to compress too forcefully under the chin while performing the head-tilt/chin-lift, as it may displace the tongue superiorly, blocking the airway Remind the students that secure dentures will not create an airway obstruction, and therefore should be left in place Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Airway Techniques Opening the airway Jaw-thrust maneuver
Used with suspected spine injuries Difficult to maintain Head must remain in neutral position Stress that the jaw-thrust maneuver should be utilized with an patient that the students suspect spinal injuries Advise the students that it is difficult to maintain as the head must remain in a neutral position Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Airway Techniques Opening the airway Jaw-thrust maneuver
Position yourself above patient's head Grasp the angle of the jaw with both hands Move jaw forward with lifting motion Keep patient's mouth open Review the procedure for performing the jaw-thrust maneuver Stress the importance of maintaining a neutral position of the head and neck Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Airway Techniques Inspecting if the airway is patent
Determine if the airway is patent Unresponsive patient Open mouth with cross-finger technique Look for potential obstruction Listen for abnormal airway sounds Advise the students that, after opening the airway, the students must then inspect the airway for patency Remind the students that a patient that is talking has a patent airway Review the technique for opening the mouth in the unresponsive patient Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Airway Techniques Inspecting the airway Abnormal airway sounds
Snoring: Airway blocked by tongue Crowing: Muscles around larynx spasming Gurgling: Liquid in airway Stridor: Larynx is swollen Review the abnormal upper airway sounds that may be heard in the unresponsive patient Review the causes of these upper airway noises Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Airway Techniques Clearing the airway Recovery position Suctioning
Review the topics with the students Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Airway Techniques Clearing the airway Recovery position
Used when patient is breathing adequately and has a pulse Allows fluids to drain out of the mouth Only utilized when trauma is not suspected Discuss the use of the recovery position for helping to maintain an open airway Advise the students that it should only be utilized when the patient has an altered mental status with adequate breathing and good circulation Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Airway Techniques Clearing the airway Recovery position
Lift left arm above head Cross right leg over left Roll patient onto left side Flex right leg at the knee Review how to place the patient in the recovery position Advise the students that placing the patient on their left side will also reduce the risk of the patient vomiting as it relieves pressure off the muscle that separates the stomach from the esophagus Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Airway Techniques Clearing the airway Suctioning
Used to remove liquids from the mouth Stress that suctioning should be utilized to remove liquids from a patient’s mouth to prevent aspiration Advise the students that solid particles cannot be suctioned with a suction catheter Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Airway Techniques Assessing breathing
Determining the presence of breathing Pulse oximetry Signs of inadequate breathing Minute volume Stress that, once the airway is open and clear, the students must then assess the patient’s respirations Advise the patient to look, listen, and feel for breathing They must also consider the patient’s overall ventilatory effort to determine to patient’s respiratory Advise the students that they can also apply the pulse oximeter at this time Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Determining the presence of breathing Responsive patient Look for chest rise and fall Look for accessory muscle usage Observe the patient's ability to speak Advise the students that they must not only look for the presence of respirations, but also for the presence of adequate respirations. This will include assessing for accessory muscle usage. Remind the students that a patient in respiratory distress will not be able to talk in complete sentences Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Determining the presence of breathing Unresponsive patient Look for chest rise and fall Listen for air exiting mouth and nose Feel for air exiting mouth and nose Advise the students that when assessing the respiratory status of the unresponsive patient that they must look, listen, and feel for breathing Remind the students that they must also consider the ease of ventilation Advise the students that they must first open the airway with the crossed-finger technique, then perform a head-tilt/chin-lift maneuver prior to assessing breathing. Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Airway Techniques Assessing breathing Pulse oximetry
Measures oxygen saturation Do not withhold oxygen based on pulse oximetry Do not delay oxygen therapy to obtain pulse oximetry Advise the students that it is important to check the patient’s pulse oximeter reading at this point Stress the importance of not relying on the pulse oximeter reading to dictate oxygen therapy Advise the students that they should not delay the administration of oxygen just to obtain a pulse oximeter reading Advise the students that generally a pulse oximeter reading less than 95% indicates hypoxia. Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Signs of inadequate breathing (1 of 3) Too fast or too slow Agonal respirations Inadequate chest wall motion Cyanosis Peripheral vs. central Review the signs of inadequate breathing Describe to the students agonal respirations Describe the difference between peripheral and central cyanosis Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Signs of inadequate breathing (2 of 3) Mental status changes Increased effort to breathe Abdominal breathing Retractions Nasal flaring Advise the students that hypoxia from respiratory distress can cause mental status changes to include confusion and rage Review with the students how to recognize an increased effort to breathe Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Signs of inadequate breathing (3 or 3) Gasping or grunting Slow heart rate with slow respiratory rate Advise the students that abnormal sounds during respirations can be indicative of a patient trying to get more air with each breath Warn the students that a patients heart rate and respiratory rate should increase when a patient is hypoxic. If the patient does not respond accordingly, they are in severe respiratory distress and are no longer compensating Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Airway Techniques Minute volume (rate x depth) – dead space Dead space
About 150 mL per breath Shallow respirations do not ventilate alveoli Describe to the students how to determine a patient’s minute volume Advise the students that dead space is air that does not contribute to air exchange Advise the students that if air does not reach the alveoli during shallow ventilations, the patient will quickly become hypoxic Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Airway Techniques a. No air in respiratory system.
b. Deadspace is filled with air, but it cannot reach the alveoli for gas exchange. Describe to the students how to determine a patient’s minute volume Advise the students that dead space is air that does not contribute to air exchange Advise the students that if air does not reach the alveoli during shallow ventilations, the patient will quickly become hypoxic c. Normal volume, with air filling the lungs including the alveolar sacs Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Artificial Ventilation

Mouth-to-mask ventilation Mouth-to-barrier device ventilation Mouth-to-mouth ventilation Mouth-to-stoma ventilation Special considerations Bag-valve-mask ventilation Assisting inadequate breathing Review the types of artificial ventilation Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Used with inadequate or absent breathing Ventilate at appropriate rate Force of air is consistent Patient's heart rate returns to normal Color improves Advise the students that artificial ventilation should be utilized when a patient has inadequate or absent respirations Stress that the students should ensure that the ventilations they provide must be consistent Review with the students ways in which they can determine if their ventilations are improving the patient’s condition Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Indications of inadequate ventilations Chest does not rise or fall Ventilation rate is too fast or too slow Heart rate does not return to normal Review the indications of inadequate ventilations with the students Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Mouth-to-mask ventilation Preferred technique One-way valve Prevents direct contact and exposure Must be clear Able to form good seal Oxygen port if oxygen available Advise the students that mouth-to-mask ventilation is the most effective at administering an adequate tidal volume, but does not provide the patient with adequate oxygenation Stress that the mask with a one-way valve helps to prevent disease transmission while performing artificial ventilations Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Mouth-to-mask ventilation Position yourself at the patient's head Position the mask on the patient's face Create a good seal Open the airway Review the procedure for performing mouth-to-mask ventilations with the students Stress the need for maintaining a good mask seal while performing artificial ventilations Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Mouth-to-mask ventilation Deliver two slow breaths initially Determine if ventilations are adequate Continue ventilating at proper rate Reposition airway if ventilations unsuccessful or inadequate Review the procedure for performing mouth-to-mask ventilations with the students Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Mouth-to-barrier device ventilation Thin, plastic face shield Provides some protection against contamination May not have one-way valve Provide ventilations as with mouth-to-mask Advise the students about barrier devices Advise the students that a barrier device provides some protection against disease transmission, but is not as effective as a mask Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Mouth-to-mouth Risk of contamination is high Not recommended for regular use Only use when no protective device is available Pinch nose while creating a seal around the patient's mouth Ventilate as with mouth-to-mask ventilations Advise the students that mouth-to-mouth ventilations may be necessary at some times, but are not recommended due to the risk of disease transmission Direct the students to pinch the nose while performing mouth-to-mouth ventilations Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Mouth-to-stoma ventilations Permanent opening through trachea to anterior neck Expose the stoma Clear the stoma of foreign matter with gauze Form seal around stoma, preferably with barrier device Ventilate as with mouth- to-mask ventilation Describe to the students what a stoma is and what function it serves Describe to the students the need to clear the stoma of any foreign material prior to performing ventilations through the stoma Advise the students that use of a barrier device is recommended due to the high likelihood of disease transmission Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Mouth-to-stoma ventilations If ventilations are unsuccessful Patient may have partial laryngectomy Need to seal mouth and nose Tilt patient's head back Attempt to ventilate again Review the need to assess artificial ventilations performed through a stoma, as they may be inadequate Describe how to improve ventilations in the patient with a stoma Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Special considerations Infants and children Keep patient's head in neutral position Consider an oral airway Adult pocket mask can be rotated Risk of gastric distention Stress the concerns with providing artificial ventilations to the infant and child Warn the students of the potential complications associated with gastric distention, to include the increased risk of aspiration and impingement of the stomach and diaphragm on the expansion of the lungs Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Special consideration Patients with dental appliances Dentures If secure, leave them in place If loose, remove to prevent airway obstruction Reassess frequently to ensure patency Advise the students that they are likely to encounter many patients with dentures Advise the students that, if possible, dentures should be left in place to help create and maintain an adequate mask seal Remind the students that, if dentures are loose, they must be removed to prevent an airway obstruction Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Bag-valve-mask ventilation Self-inflating One-way valve Face mask Oxygen reservoir Disable pop-off 15/22 mm fitting Oxygen inlet Nonrebreather valve Describe the components of a bag-valve-mask to the students Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Bag-valve-mask ventilation Open the airway Insert OPA/NPA if necessary Position the mask on the patient Use "C-E" technique if alone Connect bag to mask Ventilate, squeezing only enough to make the patient's chest rise Advise the students that it is important to open the airway and inserting an airway adjunct prior to initiating positive pressure ventilation to help maintain an open airway Describe to the students how to create an adequate mask seal while performing bag-valve-mask ventilations Remind the students that it is important to never over ventilate a patient, and that they should only compress the bag enough to make the chest rise Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Bag-valve-mask ventilation One-person technique Two-person technique Review the different techniques for performing positive pressure ventilations Advise the students that the two-person technique is the most effective for performing positive pressure ventilation Review the difference between the two-person and one-person technique shown Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Assisting inadequate breathing Perform ventilations when patient inhales If respirations too slow Ventilate between breaths too If respirations too fast Ventilate only on inhalations at appropriate rate Advise the students that it can be difficult to perform positive pressure ventilations on the spontaneously breathing patient Advise the students that it is easiest if they attempt to coordinate their ventilations during the patient’s inhalation Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Summary Make sure to assess for an adequate airway and ventilations in all patients Remember, any patient with an altered mental status may be unable to protect their own airway Assess both rate and depth to determine adequate respirations Make sure that the ventilations you provide are adequate for your patient Remember, without a patent airway and adequate respirations, all other interventions will be unnecessary Stress the importance of assessing and maintaining an adequate airway in all patients Warn the students that, if they are unable to maintain the patient’s airway, then they will not have a patient Limmer, First Responder: A Skills Approach, 7th ed. © 2007 by Pearson Education, Inc. Upper Saddle River, NJ

Chapter 6 Breathing and Ventilation

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