Describe Respiration Vs Ventilation
Respiration is the exchange of gasses where as Ventilation is the physical act of moving air into & out of the lungs
What is diffusion?
Movement of a gas fr an area of higher concentration to one of lower concentration
What factors affect O2 concen in blood?
- Lowered hemoglobin Concen
- Inadequate Alveolar Vent
- Lowered diffusion across pulmonary membrane
- Vent/perfusion mismatch when portion of alveoli collapse
What is total lung capacity?
- Total vol of air @ max inhalation
- Avg adult male = 6 liters
What is tidal vol?
- Avg vol of gas inhaled or exhaled in 1 resp cycle
- Approx 500 cc
What is dead space?
Amt of gasses in tidal vol that remains in the airway
What is alveolar vol?
Amt of gas in tidal vol that reaches alveoli for gas exchange
Minute vol is & its formula is?
- Amt of gas moved in & out of resp tract in 1 min
- Minute Vol = Tidal Vol x Breathes/Min
Inspiratory reserve Vol (IRV) is?
Amt of air that can be maximally inhaled after normal inspiration
Expiratory Reserve Vol (ERV) is?
Amt of air that can be exhaled aft normal expiration
What is residual vol?
Amt of remaining in lungs @ end of maximal resp
What is functional residual vol?
Vol of gas remaining @ end of normal expiration
What are 3 airway initial assessment questions?
- Is it patent?
- Is breathing adequate?
- Provide O2 & vent as necessary
What are 6 parts of focused Hx for airway?
- Symptom Development
- Assoc. Symptoms
- Past Med Hx
- Recent Hx
- Does anything make it better or worse
What are 6 parts of Physical Hx for airway?
- Breathing Adequately?
- Pt in best position?
- Is pt breathing normally?
- Is resp pattern normal?
What is atelectasis?
What is a pneumothorax?
Accumulation of air or gas in the pleural cavity
What is a hemothorax?
Accumulation of blood or fluid in the pleural cavity
What is hypoxemia?
Decreased partial pressure of O2 in blood
What are the 4 types of hypoxia?
What is Hypemic Hypoxia?
- Adequate O2 available
- Obstruction prevents O2 fr diffusing across alveolar membrane
- Causes= COPD, Pneumonia, PE, Pulmonary Embolism
What is Stagnant Hypoxia?
- Adequate O2 Available.
- Blood moving slowly & not reaching cells
- Causes = AMI, Cardiomyopathy, Cardiogenic Shock, Crush Inj's
What is Histotoxic Hypoxia?
- Adequate O2 Available
- RBCs cant use O2 due to tissue pathology or poisoning
- Causes = Cyanide Toxicity, CO poisoning, Anaphylaxis
What is Hypoxic Hypoxia?
- Inadequate Availability of O2
- Reduces pO2 in lungs due to lower avail of O2
- Causes = Altitude, Scuba Diving Accidents
What is the 5 airway mgmt techniques triangle?
- Basic Maneuvers
- Basic Adjuncts
- Bail Outs
Effective ventilatory support requires tidal vol of @ least ____ of O2 @ ____ to ____ breaths/min.
What 3 things are required for effective artificial ventilation?
- Patent Airway
- Effective Mask/Face seal
- Delivery of adequate vol
What are 3 forms of suctioning equip?
- Soft Tip Catheters
- Gastric Tubes
How long & when should you suction?
- No longer than 10 secs
- Only while retracting the catheter
What should always be done b/f suctioning?
What are 4 primary O2 delivery devices & their %'s of O2?
- Nasal Cannula - 40%
- Venturi Mask - 24, 28, 35 or 40%
- Simple face mask - 40-60%
- NRB - 80 - 95%
What are the 5 causes of airway obstruction?
- Foreign Bodies
- Laryngeal Spasm & edema
What is anoxia?
Absence or near absence of O2
What are 6 forms of modified resp?
- Hiccoughing (hiccups)
What are Kussmaul's respirations?
- Deep, slow or rapid, gasping breathing
- Common in diabetic ketoacidosis
Describe Cheyne-Stokes Respirations.
- Progressively deeper, faster breathing alternating w/shallow, slower breathing
- Indicative of brain stem inj
Describe Biot's respirations.
- Irregular pattern of rate & depth w/sudden, periodic episodes of apnea
- Indicates ^ ICP
Describe Central Neurogenic Hyperventilation.
- Deep, rapid resp,
- Indicates ^ ICP
What are agonal Respiration?
- Shallow, slow or infrequent breathing
- Indicates brain anoxia
What are the 5 sounds that point to airflow compromise?
What causes snoring respirations?
partial obstruction of upper airway by tongue
What causes gurgling?
An accumulation of blood, vomitus or other secretions in upper airway
- Harsh, high pitched sound heard on inhalation,
- assoc w/ laryngeal edema or constriction
- Musical, squeaking or whistling sound heard in inspiration &/or expiration.
- Indicates bronchiolar constriction
What are quiet respirations?
Diminished or absent breath sounds are an ominous finding & indicate a serious prob w/airway breathing or both
What are 2 sounds that may indicate compromise of gas exchange?
Describe Crackles (rales).
- Fine, bubbling sound heard on inspiration.
- Associated w/ fluid in lower bronchioles
- Course, rattling noise heard on inspiration
- Associated w/ inflammation, mucus or fluid in the bronchioles
What is compliance?
Stiffness or flexibility of lung tissue
A sudden drop of ETCO2 to 0 could indicate?
- Esophageal intubation
- Vent disconnection or defect
- Defect in CO2 analyzer
Sudden decrease in CO2 NOT to 0 could indicate?
- Leak in vent sys or obstruction
- Partial disconnect of vent circuit
- Partial airway obstruction
Exponential decrease in ETCO2 could indicate?
- Pulmonary Embolism
- Cardiac Arrest
- Hypotension (sudden)
- Severe Hyperventilation
Change in CO2 baseline could indicate?
- Calibration Error
- H2O drop in analyzer
- Mechanical failure (ventilator)
Sudden ^ ETCO2 could indicate?
- Accessing area of lung previously obstructed
- Release of tourniquet
- Sudden ^ BP
Gradual lowering of ETCO2 could indicate?
- Decreased cardiac output
- Hypothermia; drop in metabolism
Gradual ^ in ETCO2 could indicate?
- ^ body temp
- CO2 absorption
- Partial airway obstruction
What does Phase I on a capnogram indicate?
- Respiratory baseline
- Corresponds to late inspiration & early experation
What does Phase II on a capnogram indicate?
- Resp upstroke
- Reflects CO2 in the alveoli
What does Phase III on a capnogram indicate?
- Resp Plateau
- Reflects airflow thru vented alveoli w/ constant CO2 level
- Highest level is called ETCO2 & is recorded as such
What does Phase IV on a capnogram indicate?
- Resp inspiration
- Sudden downstroke & returns to baseline during inspiration
5 Reasons to measure ventilation in non intubated pts?
- Assess acute resp disorders
- Gauge response to treatment
- Gauge severity hypoventilation states
- Assess perfusion status
- Noninvasive monitoring of pts in DKA
6 reasons to measure ventilation in intubated pts?
- Verify & document Tube placement
- Immediately see if you lost ur tube
- Effectiveness of chest compressions
- Earliest ind of ROSC
- Indicator of probability of resus success
- Adj manual vents in pts sensitive to CO2 changes
Arterial blood gas is PaCO2 in the rang of ____ mmHg.
Mixed venous blood gas is PeCO2 in the range of ____ mmHg.
Exhaled CO2 is EtCO2 in the range of ____ mmHg.
What does LEMON in the Lemon Law mean?
- L Look externally
- E Evaluate 3-3-2 rule
- M Mallampati
- O Obstruction
- N Neck Mobility
What should you look for when looking externally?
- Obesity or Very small
- Short muscular neck
- Lg breasts
- Buck teeth
- Receding Jaw or dentures
- Facial Trauma
- S/S of anaphylaxis
What Does 3-3-2 stand for?
- 3 = 3 fingers fit vertically in mouth
- 3 = 3 fingers between mentum & hyoid bone
- 2 = 2 fingers fr floor of mouth to hyoid cartilage
Describe Class 1 Mallampati.
Visualization of soft palate, fauces, uvula & anterior & posterior pillars
Describe Class 2 Mallampati.
Visualization of soft palate, fauces & uvula
Describe Class 3 Mallampati.
Visualization of soft palate & base of uvula
Describe Class 4 Mallampati.
Soft palate is not visible @ all
Describe Cormack & Lehane Grading of trachea opening.
- Grade 1: Full aperture visible
- Grade 2: Lower part of cords are visible
- Grade 3: Only epiglottis is visible
- Grade 4: Epiglottis not visible
What constitutes an obstruction in the LEMON law?
- Impales Objects
Issues w/ Neck mobility could include.....
- Spinal Precautions
- Impaled Objects
- Lack of access
What is a quick test to chk neck mobility?
Put chin to chest then move toward ceiling
Name 4 contraindications to ET intubation.....
- Penetrating neck trauma w/rapidly expanding hematoma
- Tracheal inj or Laryngeal Fx
- Pt doesnt want to be intubated
What is avg size tube for an adult male? Female?
How do you adjust ur tube size for nasal intubation?
Go down 1/2 to a full size
What is the formula for determining the size of a pedi tube?
Age +16 divided by 4
What the eye of Murphy?
Dot on an ET tube marking the place where a stylet is never to pass
What is the vocal card marker?
Black line on an ET tube that shows where to stop insertion. Once this passes the cords STOP!
What is ELM maneuver?
Moving the thyroid cartilage & vocal cords in order to attempt to get a better view.
Do we ever move the laryngiscope blade to get a better view?
NEVER!!!! Causes trauma
Give 3 indications for Bougie use....
- Unsuccessful attempts
- Poor view of glottic opening
- Airway full of whatever
Give 2 contraindications for nasal intubation.
- Basil Skull Fx
- Coumadin pt (blood thinners)
Give 5 tricks for nasal intubation.
- Dont rush!
- Viscous/Hurricane/Neosynephrine are your friends
- Maximally deflate cuff
- Bevel AWAY fr septum
- Dont start too deep
What are 4 things to remember when intubating?
- One Shot one tube
- Follow the Map
- NEVER PRY
Discuss Advantages of Combitube (a-h)
- Provides Alternate airway when tube isn't working
- Insertion rapid & easy
- Doesn't require visualization
- Balloon anchors behind hard palate
- Pt can be vented regardless of placement
- Significantly diminishes gastric disten/regurg
- Can be used when spine compromised
- Gastric contents can be suctioned thru tube
What are disadvantages of combitube (a-g)
- Additional ET tube is difficult to place w/ ETC in the way
- Can't be used in conscious pt or w/ gag reflex
- Cuffs can cause ischemia
- Doesn't isolate or completely protect trachea
- Cant be used on pts w/ esophageal disease or caustic ingestion
- Cannot be used in pedi's
- Requires competent assessment
What are 4 advantages of the LMA?
- Comes in several sizes
- Blind insertion requires less skill & training than ET
- Useful when ET insertion is unsuccessful
What are 5 disadvantages of the LMA?
- EMS usually only caries 3 sizes
- Doesn't isolate trachea
- Doesn't protect airway fr regurg or aspiration
- Cannot be used if there is gag reflex
- Cannot be used in conscious or semi-conscious pt
What are 6 indications for ET intubation?
- Resp or cardiac arrest
- Unconscious or obtrusion w/o gag
- Risk of aspiration
- Obstruction due to FBO, trauma, burns or anaphylaxis
- Resp extremis due to disease
- Pneomothorax or hemothorax
Give 5 advantages of ET intubation
- Isolates trachea giving complete ctrl or airway
- Impedes gastric distention b/c of tracheal isolation
- No need for mask seal
- Gives direct route for suctioning resp tracts
- Permits med administration
Give 5 disadvantages of ET tubes.
- Requires training & experience
- Requires specialized equipment
- Requires direct visualization of cords
- Doesn't warm, filter, or humidify air
Give 5 possible complications of ET intubation
- Equipment malfunction
- Teeth breakage or tissue damage
- Esophageal intubation
- Right mainstem intubation
- Tension pneumothorax
Give 6 verifications of proper tube placement.
- Direct visualization
- Chest rise
- Lack of epigastric sounds
- ETCO2 detection
- Esophageal detector devices
- Tube contents: condensation Vs vomitus
Give 6 indications for nasotracheal intubation.
- Spinal Inj
- Clenched teeth
- Jaw Fx, oral inj or recent oral surgery
- Significant angioedema
- Arthritis preventing head placement
What are 5 contraindications for nasal intubation?
- Suspected nasal Fx
- Suspected basilar skull Fx
- Deviated septum or other obstruction
- Cardiac or resp arrest
- Unresponsive pt
Give 4 advantages of nasal intubation.
- Head & neck remains in neutral position
- Less gag response
- More easily secured
- Pt cant bite tube
Give 6 disadvantages of nasal intubation.
- More difficult & time consuming than oro
- May cause nasal trauma
- Tube may kink or clog more easily
- ^ risk of infection
- ^ possibility of improper placement
- Pt must be breathing