1 Respiratory System Assessment Chemeketa Community College Paramedic Program Peggy Andrews, Instructor

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Respiratory System Assessment

Chemeketa Community Chemeketa Community CollegeCollege

Paramedic ProgramParamedic Program

Peggy Andrews, Instructor

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Respiratory ratesRespiratory rates

Normal - 12 - 20Normal - 12 - 20 Controlled by other factorsControlled by other factors

– Temperature Temperature - Emotion- Emotion– Drugs and medications Drugs and medications - Hypoxia- Hypoxia– Pain Pain - Acidosis- Acidosis– SleepSleep

ObstructionObstruction– Tongue - most commonTongue - most common

Snoring, correct with positioningSnoring, correct with positioning

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Foreign bodyForeign body

May cause partial or complete obstructionMay cause partial or complete obstruction– Choking, gaggingChoking, gagging– StridorStridor– DyspneaDyspnea– AphoniaAphonia

SpeechlessSpeechless

– DysphoniaDysphonia Difficulty speakingDifficulty speaking HoarsenessHoarseness

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Laryngeal spasm and edemaLaryngeal spasm and edema

SpasmSpasm– Sudden movement/contractionSudden movement/contraction

Most frequently: Most frequently: – Trauma Trauma

Aggressive intubationAggressive intubation

– Post-extubation Post-extubation Especially if patient semi-consciousEspecially if patient semi-conscious

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33 year old female rescued from 33 year old female rescued from a structure fire. CAO x 3, RR38, a structure fire. CAO x 3, RR38, SaOSaO2 2 64%, harsh stridor on insp.64%, harsh stridor on insp.

EdemaEdema GlottisGlottis

– Extremely narrowedExtremely narrowed– Totally obstructedTotally obstructed

Most frequently:Most frequently:– EpiglottitisEpiglottitis

Bacterial infectionBacterial infection

– AnaphylaxisAnaphylaxis

Relieved byRelieved by– Aggressive Aggressive

ventilationventilation– Muscle relaxantsMuscle relaxants– Alternative AirwayAlternative Airway

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28 year old male, snowmobile into28 year old male, snowmobile intofarmers fence, 20 mph.farmers fence, 20 mph.

Fractured larynxFractured larynx– Airway patency dependent on muscle toneAirway patency dependent on muscle tone– Increased resistance by decreased sizeIncreased resistance by decreased size– Decreased muscle toneDecreased muscle tone– Laryngeal edemaLaryngeal edema– Ventilatory effortVentilatory effort

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79 y/o male, liquid diet, hiccup’s 79 y/o male, liquid diet, hiccup’s during breakfast. Severely SOBduring breakfast. Severely SOB

SaOSaO2 2 72% RA, Upper Resp. fluid audible72% RA, Upper Resp. fluid audible

– AspirationAspiration Significantly increases mortality - 25% dieSignificantly increases mortality - 25% die Obstructs airwayObstructs airway Destroys delicate bronchiolar tissueDestroys delicate bronchiolar tissue Introduces pathogensIntroduces pathogens Decreases ability to ventilateDecreases ability to ventilate

– Commonly the beginning of the end Commonly the beginning of the end

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Airway evaluationAirway evaluation

RateRate– 12-20?12-20?

RegularityRegularity Steady patternSteady pattern Irregular patterns are significant until Irregular patterns are significant until

proven otherwiseproven otherwise

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Airway evaluationAirway evaluation

EffortEffort– Should be effortless at restShould be effortless at rest– Changes may be subtle in rate or Changes may be subtle in rate or

regularityregularity– Patients compensate by preferential Patients compensate by preferential

posturingposturing Upright sniffingUpright sniffing Semi-fowlersSemi-fowlers Frequently avoid supineFrequently avoid supine

Head injury/ICP

Resp. Center Lesions

Serious Illness/Terminal

DKA

Paramedic Students

Some Important PatternsSome Important Patterns

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Recognition of airway Recognition of airway problemsproblems

Respiratory distressRespiratory distress

– Upper and lower obstructionUpper and lower obstruction

– Inadequate ventilationInadequate ventilation

– Impairment of respiratory musclesImpairment of respiratory muscles

– Impairment of nervous systemImpairment of nervous system

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Dyspnea may be result ofDyspnea may be result of or result in hypoxia or result in hypoxia

HypoxiaHypoxia

– Inadequate OInadequate O22 at cells at cells

HypoxemiaHypoxemia

– Lack of OLack of O22 in arterial blood in arterial blood

AnoxiaAnoxia

– No O’sNo O’s

All therapies All therapies willwill fail if airway inadequate fail if airway inadequate

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Visual CluesVisual Clues S: You are responding to a 75 year old, 325#

male with a complaint of SOB. He has a hx of CHF and bypass surgery. On the usual medications.

O: Pt alert and on edge of bed, his hands are on his knees, his arms straight. He claims that laying back makes symptoms worse (Orthopnea). He is answering in 2-4 word answers and frequently needs to be reminded of questions, because he becomes distracted. Through your assessment he is becoming increasingly agitated and confused.

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Another Sample Ptatient Another Sample Ptatient What are the clues here?What are the clues here?

S: You are responding to a 62 year old S: You are responding to a 62 year old female with a complaint of SOB. Her female with a complaint of SOB. Her husband explains that she has been husband explains that she has been unable to sleep and has been having unable to sleep and has been having trouble breathing four 4 hours. She has trouble breathing four 4 hours. She has not successfully taken her nebulizer not successfully taken her nebulizer treatment because she can no longer hold treatment because she can no longer hold it to her mouth. She has a hx of it to her mouth. She has a hx of emphysema and asthma.emphysema and asthma.

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Our Lady (continued)Our Lady (continued)

O: Pt is barely conscious, upright in O: Pt is barely conscious, upright in recliner. RR 46, SaOrecliner. RR 46, SaO22 64%, Skin pale, 64%, Skin pale, cool & moist, with cyanosis around lips, cool & moist, with cyanosis around lips, gums, eyes & nailbeds. EKG leads won’t gums, eyes & nailbeds. EKG leads won’t stick to get reading. Lung sounds with stick to get reading. Lung sounds with minimal air movement in most fields. No minimal air movement in most fields. No wheezes heard. Significant intercostal, wheezes heard. Significant intercostal, supraclavicular, suprasternal and supraclavicular, suprasternal and substernal retractions noted on inspiration. substernal retractions noted on inspiration. Her lips are pursed and her nostrils are Her lips are pursed and her nostrils are flaring with each breath. flaring with each breath.

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Auscultation techniquesAuscultation techniques

Air movement at mouth and noseAir movement at mouth and nose

Bilateral lung fields equalBilateral lung fields equal

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Palpation techniquesPalpation techniques

Air movement at mouth and noseAir movement at mouth and nose

Chest wallChest wall

– Paradoxical motionParadoxical motion

– RetractionsRetractions

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Bag-valve-maskBag-valve-mask

Resistance/changing compliance Resistance/changing compliance

with BVM ventilationswith BVM ventilations

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HistoryHistory

EvolutionEvolution– SuddenSudden– Gradual over timeGradual over time– Known cause or “trigger”Known cause or “trigger”

DurationDuration– ConstantConstant– RecurrentRecurrent

Ease Ease - What makes it better?- What makes it better? Exacerbate Exacerbate – Aggravation of symptoms– Aggravation of symptoms AssociateAssociate - other symptoms (productive - other symptoms (productive

cough, etc)cough, etc)

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HistoryHistory

InterventionsInterventions

– Evaluations/admissions to hospitalEvaluations/admissions to hospital

– Medications (include compliance Medications (include compliance

and dose)and dose)

– Ever intubated???Ever intubated???

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HistoryHistory Modified form of respirationModified form of respiration

– Protective reflexesProtective reflexes Cough - forceful, spastic exhalation; aids in Cough - forceful, spastic exhalation; aids in

clearing bronchi and bronchiolesclearing bronchi and bronchioles Sneeze - clears nasopharynxSneeze - clears nasopharynx Gag reflex - spastic pharyngeal and Gag reflex - spastic pharyngeal and

esophageal reflexesophageal reflex

– SighingSighing Increases opening of alveoliIncreases opening of alveoli Normally sigh @ 1/min.Normally sigh @ 1/min.

– HiccoughHiccough Intermittent spastic closure of glottisIntermittent spastic closure of glottis

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Inadequate ventilationInadequate ventilation When body can’t compensate for When body can’t compensate for

increased oxygen demand or maintain increased oxygen demand or maintain O2/CO2 balance.O2/CO2 balance.

Many causesMany causes– InfectionInfection– TraumaTrauma– Brainstem injuryBrainstem injury– Noxious or hypoxic atmosphereNoxious or hypoxic atmosphere– Renal failureRenal failure

Multiple symptomsMultiple symptoms– Altered responseAltered response– Respiratory rate changesRespiratory rate changes

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Supplemental oxygen therapySupplemental oxygen therapy

Supplemental oxygen Supplemental oxygen

therapytherapy

– Increases OIncreases O22 to cells to cells

– OO22 increases patients increases patients

ability to compensateability to compensate

– Delivery method Delivery method

continually reassessedcontinually reassessed

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Oxygen sourceOxygen source

Compressed gasCompressed gas

Common sizes Common sizes

and volumesand volumes

– DD 400L400L

– EE 625L625L

– MM 3450L3450L

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Calculating Tank LifeCalculating Tank Life

Tank Size FactorTank Size Factor

0.16 D Tank0.16 D Tank

0.28 E Tank0.28 E Tank

1.56 M Tank1.56 M Tank

(1800-500) x 0.16 / 10 = 20.8 minutes

((PSI in tank) – (500)) x (factor)

(Desired Lpm)

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RegulatorsRegulators

High pressure High pressure

– Transfer gas from tank to tankTransfer gas from tank to tank

– Cascade SystemCascade System

Therapy regulatorsTherapy regulators

– Pressure “stepped down”Pressure “stepped down”

– Delivery via adjustable low pressureDelivery via adjustable low pressure

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Delivery DevicesDelivery Devices

Nasal cannulaNasal cannula– Optimal delivery; 40% at 6 LpmOptimal delivery; 40% at 6 Lpm– IndicationsIndications

Low to moderate enrichmentLow to moderate enrichment Long term therapyLong term therapy

– ContraindicationsContraindications Poor respiratory effortPoor respiratory effort Severe hypoxiaSevere hypoxia ApneaApnea Mouth breathingMouth breathing

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Nasal cannulaNasal cannula– AdvantagesAdvantages

Well toleratedWell tolerated Easy to communicateEasy to communicate

– DisadvantagesDisadvantages Doesn’t deliver high volume/high Doesn’t deliver high volume/high

concentrationconcentration % Not guaranteed% Not guaranteed

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Simple face maskSimple face mask– IndicationsIndications

Moderate to high oxygen concentrationModerate to high oxygen concentration 40-60% at 10 Lpm40-60% at 10 Lpm

– AdvantagesAdvantages Higher oxygen concentrationsHigher oxygen concentrations

– DisadvantagesDisadvantages Beyond 10 LPM does not enhance Beyond 10 LPM does not enhance

oxygen content.oxygen content.

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Partial rebreatherPartial rebreather– IndicationsIndications– ContraindicationsContraindications

ApneaApnea Poor respiratory effortPoor respiratory effort

– AdvantagesAdvantages Higher concentrationsHigher concentrations

– DisadvantagesDisadvantages Beyond 10 LPM does not enhance content.Beyond 10 LPM does not enhance content.

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Non-rebreather maskNon-rebreather mask– Mask side ports Mask side ports

One-way discOne-way disc

– Reservoir bag attachedReservoir bag attached– 80-95% at 10-15 Lpm80-95% at 10-15 Lpm– IndicationsIndications

Highest OHighest O22 content (Non PPV) content (Non PPV)

– ContraindicationsContraindications ApneaApnea Poor effortPoor effort

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Venturi maskVenturi mask– Mask with interchangeable adaptersMask with interchangeable adapters

Side ports for room airSide ports for room air Highly specific content. OHighly specific content. O22

Oxygen humidifiersOxygen humidifiers– Sterile water reservoir for humidifying oxygenSterile water reservoir for humidifying oxygen– Long term admin.Long term admin.– Desirable for Croup/Epiglottitis/BronchiolitisDesirable for Croup/Epiglottitis/Bronchiolitis

TracheostomyTracheostomy StomaStoma

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SummarySummary

Respiratory Assessment conceptsRespiratory Assessment concepts

Scenario’sScenario’s

Oxygen Delivery Method ReviewOxygen Delivery Method Review

Documents

1 Respiratory System Assessment Chemeketa Community College Paramedic Program Peggy Andrews, Instructor