The Respiratory System

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Emergency Medical Technician - Basic

Respiratory System Purpose

• Takes in oxygen

• Disposes of wastes– Carbon dioxide– Excess water

O2 + Glucose

CO2 + H2O

The Cell

Respiratory System Anatomy

NasopharynxOropharynxEpiglottisLarynxTrachea

Bronchi

Bronchioles

Carina

• Lung– Right lung 3 lobes

– Left lung 2 lobes

• Bronchioles– Smallest airways

– Walls consist entirely of smooth muscle (no cartilage present)

– Constriction increases resistance to airflow

– Dilation reduces resistance to airflow

• Alveoli– Air sacs

– Site of oxygen and carbon dioxide exchange with blood

• Diaphragm

• Pleura– Double-walled

membrane

– Visceral layer covers lung

– Parietal layer lines inside of chest wall, diaphragm

Respiratory System Physiology

Inspiration Active process Chest cavity expands Intrathoracic pressure falls

Air flows in until pressure equalizes

Expiration Passive process Chest cavity size decreases Intrathoracic pressure rises

Air flows out until pressure equalizes

Respiratory System Physiology

–Automatic Function• Primary drive: increase in arterial CO2

• Secondary (hypoxic) drive: decrease in arterial O2

Normally we breathe to remove CO2 from the body, NOT to get oxygen in

Respiratory Pathophysiology

• Airway (Obstruction)– Tongue

– Foreign body airway obstruction

– Anaphylaxis/angioedema

– Upper airway burn

– Maxillofacial/laryngeal/ tracheobronchial trauma

– Epiglottitis

– Croup

– Aspiration

– Asthma

– Chronic Obstructive Airway Disease

• Emphysema

• Chronic bronchitis

• Gas Exchange Surface (Blood Flow or Gas Diffusion)– Pulmonary Edema

• Left-sided heart failure

• Toxic inhalations

• Near drowning

– Pneumonia

– Pulmonary Embolism• Blood clots

• Amniotic fluid

• Fat embolism

• Thoracic Bellows (Ventilation)– Chest Trauma

• Simple rib fractures

• Flail chest

• Pneumothorax

• Hemothorax

• Sucking chest wound

• Diaphragmatic hernia

– Pleural effusion

– Spinal cord trauma (High C-spine lesion)

– Morbid obesity

– Neurological/neuro-muscular disease

• Poliomyelitis

• Myasthenia gravis

• Muscular dystrophy

• Guillian-Barre syndrome

• Control System (Decreased Respiratory Drive)– Head trauma– CVA– Depressant drug toxicity

• Narcotics

• Sedative-hypnotics

• Ethyl alcohol

Respiratory Assessment

• Initial Assessment (A, B, C, D)

• Manage life threats

• Complete focused history and physical

Initial Assessment

• Airway– Listen to patient breathe, talk

• Noisy breathing is obstructed breathing

• But all obstructed breathing is not noisy

• Snoring = Tongue blocking airway

• Stridor = “Tight” upper airway from partial obstruction

Initial Assessment

• Airway

– Anticipate airway problems with• Decreased LOC

• Head trauma

• Maxillofacial trauma

• Neck trauma

• Chest trauma

OPEN—CLEAR—MAINTAIN

Initial Assessment

• Breathing– Is patient moving air?

– Is air moving adequately?

– Is the patient’s blood being oxygenated?

Initial Assessment

• Breathing– LOOK

• Symmetry of chest expansion

• Increased respiratory effort

• Changes in skin color

– LISTEN• Air movement at

mouth, nose• Air Movement in

peripheral lung fields

– FEEL• Air movement at

mouth, nose• Symmetry of chest

expansion

– RATE• Tachypnea• Bradypnea

– POSITIONING• Orthopnea• Tripod position

Initial Assessment

• Breathing– Signs of respiratory distress

• Nasal flaring• Tracheal tugging• Retractions• Neck, pectoral muscle use on inhalation• Abdominal muscle use on exhalation

– Skin Color• Pale, cool moist skin (Early sign of hypoxia)• Cyanosis (Late, unreliable sign of hypoxia)

Initial Assessment

• Breathing– If trauma patient has compromised breathing,

bare chest, assess for:• Open pneumothorax

• Flail chest

• Tension pneumothorax

• Circulation– Is heart beating?– Is there major external hemorrhage?– Is patient perfusing?– Effects of hypoxia:

• Adults (early): tachycardia

• Adults (late): bradycardia

• Children: bradycardia

Initial Assessment

• Circulation– Don’t let respiratory failure distract you from

assessing for circulatory failure– Low oxygen or high carbon dioxide levels can

depress cardiovascular function

• Disability– Restlessness, anxiety, combativeness = hypoxia

Until proven otherwise– Drowsiness, lethargy = hypercarbia

Until proven otherwise

Just because the patient stops fighting, he’s not necessarily getting better!!!

Initial Management

• Patient Responsive/Breathing Adequate– Oxygen may be indicated– Oxygenate immediately if patient has:

• Decreased level of consciousness• Possible shock• Possible severe hemorrhage• Chest pain• Chest trauma• Respiratory distress or dyspnea• History of any kind of hypoxia

Initial Management

• Patient responsive, breathing inadequate– Open/maintain airway– Place nasopharyngeal airway– Assist ventilations

• Mouth to Mask

• 2-person Bag-valve Mask

• Manually Triggered Ventilator

• 1-person Bag-valve Mask

Initial Management

• Patient unresponsive, breathing adequate– Open/maintain airway– Place nasopharyngeal or oropharyngeal airway– Suction airway as needed– Provide oxygen by non-rebreather mask– Frequently reassess

Initial Management

• Patient unresponsive, breathing inadequate• Open/maintain airway• Place nasopharyngeal or oropharyngeal airway• Suction airway as needed• Assist ventilations

– Mouth to Mask

– 2-person Bag-valve Mask

– Manually Triggered Ventilator

– 1-person Bag-valve Mask

• Frequently reassess

Initial Management

• Patient not breathing– Open airway– Place nasopharyngeal or oropharyngeal airway– Ventilate patient

• Mouth-to-Mask

• 2-Person Bag-Valve Mask

• Manually Triggered Ventilator

• 1-Person Bag-Valve Mask

– Frequently reassess

Initial Management

• Golden Rules– If you think about giving O2, give it!!!

– If you decide to give oxygen, give a lot of it!!!– If you can’t tell whether a patient is breathing

adequately, he isn’t !– If you’re thinking about assisting a patient’s

breathing, you probably should be!

Focused History and Physical

• Chief Complaint– Dyspnea

• Subjective sensation that breathing is excessive, difficult, or uncomfortable

– Respiratory Distress• Objective observations that indicate breathing is

difficult or inadequate

• History of Present Illness (OPQRST)– Gradual or sudden onset?

– What aggravates or alleviates?

– How long has dyspnea been present?

– Coughing? Productive cough?

– What does sputum look/smell like?

– Pain present? What does pain feel like? How bad? Does it radiate? Where?

• Past HistoryIf Then???Hypertension, MI, Diabetes CHF with Pulmonary Edema

Chronic Cough , Smoking, COPD

“Recurrent” Flu

Allergies, Acute Episodes of SOB Asthma

Lower Extremity Trauma, Pulmonary Embolism

Recent Surgery, Immobilization

• Medications If Then???“Breathing” Pills, Inhalers Asthma or COPD

Albuterol Montelukast

Aminophylline Oxtriphylline

Ipratropium Cromolyn

Terbutaline Prednisone

Salbumatol

Zafirlukast

• Medications If Then???

Lasix, hydrodiuril, digitalis CHF

Coumadin, BCP’s Pulmonary embolism

Focused History and Physical Exam

• Crackles (Rales)– Fine, “crackling”

– Fluid in smaller airways, alveoli

• Rhonchi– Coarse, “rumbling”

– Fluid, mucus in larger airways

• Stridor– High pitched, “crowing”– Upper airway restriction

• Wheezing– “Whistling”– Usually more pronounced on

exhalation– Generalized: narrowing,

spasm of the smaller airways– Localized: foreign body

aspiration

Mild Breathing Difficulty

• May be hypoxic

• Can move adequate tidal volume

• Can answer questions, speak in complete sentences, is alert

• High concentration O2 by non-rebreather mask

• Consider bronchodilators if patient wheezing

Moderate Breathing Difficulty

• May be hypoxic• May be moving adequate tidal volume• Having difficulty answering questions, speaks in

choppy sentences, is restless/irritable

• High concentration O2 by non-rebreather mask

• Get ready to assist ventilations if needed (patient may resist assistance at this time)

• Consider bronchodilators if patient wheezing

Severe Breathing Difficulty

• Getting sleepy• Not speaking or speaking with very few

words• Previously wild, now seems “cooperative”• Assist ventilations with BVM and oxygen• Time BVM ventilation with patient’s

ventilatory efforts• Interpose extra ventilations if necessary

The Respiratory System

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