respiratory1.txt

Gil Forceps are used to remove a foreign body

15% of all intubations are dislodged without head stabilization

Pull it and intubate again

2 then go to BLS

10

7

7-8

• 100cc proximal
• 15cc distal

• 85cc Proximal
• 12cc distal

5-6.5 feet

4-5.5 feet

• Backward
• Upward
• Right
• Pressure

35-45mmHg

93%-95%

• Temperature
• pH
• CO
• CO2

The Corina is the bifurcation in the lungs

An endotrol is used for nasal intubation it has the pull cord

Extubation

Retrograde intubation is where a wire is fed through the exact place you circa and feed a ET tube down the wire into the trachea

• Digital Intubation is where the neck is hyper flexed and the epiglottis is pulled forward toward the rescuer with the index finger on the epiglottis
• Preferred way to intubate children

Bag compliance

3-5cc

When resistance is met of the patient begins to cough

No more than 15 sec

Sudden increase in venue pressure can tear the chordea tenenea

Partial or complete collapse of the lung

Damage to the Liver, Spleen, Kidneys

Two or more adjacent ribs fractured in two or more places producing a free floating segment of the chest wall

• A hole in the chest wall that allows air to enter pleural space
• (The Larger the hole the more likely air will enter there than through the trachea)

4grams of O2 for every 5Liters of blood giving us a 0.8 V?Q match

Around the neck and shoulder

With a gloved hand

Midaxillary line 4-5th intercostal space

50cc/min

Pulmonary contusion

The purpose of ventilations during CPR is to maintain oxygenation and elimination of Carbon Dioxide

Acid-base imbalance

Patients with Hypovolemia

Airway bleeding or intracranial placement

• Co2 detector
• esophageal detector (Tummie syringe, Bulb syringe)
• Auscultation

• It provides some protection
• Aspiration is uncommon with LMA but not unheard of

Yes, however a small portion of patients can not be ventilated after the insertion of the LMA

• morbid obesity
• late pregnancy
• status asthmaticus

• Ensure correct placement
• Asynchronized CPR
• Avoid excessive ventilations

• Power of >40L/min
• Vacum or >300 mmHg

A severe crushing injury to the chest and abdomen that causes an increase in intrathoracic pressure. The increased pressure forces blood from the right side of the heart into the veins of the upper thorax, neck and face

• Narrowing of the bronchial tubes (Contraction of the smooth muscle)
• Inflammation (Swelling of the lining of the bronchial)
• Excess mucus production (Globular cells become overactive)

• Wheezing
• Tightness in the chest
• Trouble breathing
• Shortness of breath
• Cough
• Chest pain
• Exhaustion
• Silent breath sounds

• Albuterol or epinephrine
• Support ABC's
• PROP
• Transport
• IV (Dehydration, help break up mucus formation)
• SPO2
• Consider: Ipratropium (Atrovent) Corticosteroids, Magnesium Sulfate.

• Albuterol: Peak affect in 2hrs Strong effect in 20min, Epinephrine: Peak affect in 3-5min
• Albuterol: must reach the target site, Epinephrine can be given IM or Sub-Q
• Albuterol: Last 4-6hrs, Epinephrine: Lasts 15-20min
• Albuterol: Affects only the part of the airway it reaches, Epinephrine: Systemic affect

2 inches from the front of your mouth

By the time you inhale the Oxygen must be @ 98.6 degrees and 100% Humidity

Bronchitis is characterized by inflamed airway tissue and excessive mucus production

• Chronic irritation and infection of the trachea, bronchi and bronchioles
• Excess mucus obstructs bronchioles, interfering with alveolar ventilation
• To have Chronic bronchitis you must have a respiratory infection for 3 months out of a year, doesn't have to be consecutive
• Leads to persistent, productive cough

• Sometimes the large and small airway of the lungs become narrowed, and the lining of the passageways may become scarred. This makes it hard to move the air in and out of the lungs, resulting in SOB:
• Cough
• Dyspnea
• SOB
• Wheezing
• Ronchi
• Blue blotters (Cyanosis and signs of right sided heart failure)
• Most commonly caused by Cigarette smoking
• Chronic productive cough
• Coarse crackles

• Support ABC's
• PROP
• IV
• SPO2
• Medication may be indicated (Albuterol)
• (Remember, not all wheezing should get Albuterol. Albuterol for wheezing of cardiac origin may further complicate patient condition)

• Locate the Thyroid Cartilage
• Locate the Cricothyroid membrane
• Prep the are with an antiseptic swap
• Make a 1-inch vertical incision through the skin and subcutaneous tissue
• Expose the cricothyroid membrane
• Make a horizontal, transverse incision approximately 1/2 inch long through the membrane
• Using a dilator, hemostat, or gloves finger to maintain surgical opening, insert the cuffed tube into the trachea
• Cric tube of a 6.0 ETT is usually sufficient
• Inflate the cuff with 5-10cc of air and ventilate the patient while stabilizing the tube

No Jaw

Irregular curvature of the spine

Irregular curvature of the spine where the patient is looking down

Large Jaw seen from Giantism in adults

No Neck

• Greater than three fingers from Jaw to Neck
• Jaw is Greater then 3 fingers wide
• You can open the mouth greater then 2 fingers

• Look externally
• Evaluate the 3:3:2 rule
• Mellampati Classification
• Obstruction
• Neck mobility

• Named after Joe, the sleepy, red-faced, fat boy from a charles Dickens book
• Lung function decrease esp. if supine (be aware of respiratory issues)
• Low lung volumes
• Restrictive lung defect
• Atelectasis and air trapping
• Hypoxemic
• Hypercapic
• Plus COPD
• Pulmonary Hypertension/RT-sided heart failure

• Head Elevated Laryngoscope Position
• Remember this is for the non-traumatic patient

• External Laryngeal Manipulation
• The incubator manipulates the larynx by moving the thyroid cartilage with their right hand during direct laryngoscopy

Backward, Upward, Rightward Pressure

• A=Possible
• B=Better
• C=Best
• D=Incorrect

• In emphysema, the walls between the tiny air sacs in the lungs lose their ability to stretch, and they become weakened and break. As the lung tissue become weakened and break. As the lung tissue becomes less elastic, air is trapped inside the air sax, and the exchange of oxygen and carbon dioxide is impaired.
• Most commonly caused by smoking, Chronic disease with years of retained lung gases (Long term exposure to toxins)
• Loss of elasticity and surface area of the alveoli
• Causes cellular change

• Pink puffer
• Dyspnea: Tripod position, Rapid - shallow breathing, Wheezing or crackles, pursed lips
• Thin, barrel chest, clubbed fingers (Clubbed fingers only seen in emphysema)
• (When responding to patient double the patients home O2)
• Caused by n increase in Trypsim (digestive enzyme)

• Trypsin is a digestive enzyme, most often found in the digestive tract, where it is used to help the body digest food
• It is also released by immune cells in their attempt to destroy bacteria and other material
• Excessive amounts of Trypsim is released in the lungs of the emphysema patient
• Normally there is a balance between Alpha-1-antitrypsin and trypsin (There is an imbalance in emphysema)

Breakdown of the alveoli also causes loss of the capillary beds surrounding them. This can lead the pulmonary hypertension which can result in an enlarged right ventricle

35mmHg - 45mmHg

• A-B: Early Exhalation, CO2 free (dead space)
• B-C: Combination of dead space and alveolar gas
• C-D: Alveolar plateau
• D: End Tidal CO2

• Capnography is the vital sign for Ventilation
• Oximetry is the vital sing for oxygenation

Incomplete alveolar emptying or loss of endotracheal airway integrity

• Tube verification
• Tube vigilance
• Judge effectiveness of ventilation
• Identifies ROSC
• Monitoring Hypoventilation Syndromes
• Track Progression of Respiratory Failure

• Capnometry, "Meter" of the CO2 value, either bar scale of number
• Canogram, Waveform Graph of the CO2 values
• Capnography, Number plus waveform
• Mainstream, Measurement at patient adapter
• Sidestream, Gas sample sucked into the devise for measurement there
• "Microstream", sidestream with difference

Movement of gas in and out of the lungs

• Metabolism
• Respiratory System
• Circulatory System
• Equipment

• Metabolism
• Perfusion
• Ventilation

• HVS represents a relatively common presentation that most clinicians readily recognize. However, the syndrome has defied precise definition and explanation of the underlying Pathophysiology for the past 100yrs
• As classically defined, HVS is a condition in which minute ventilation exceeds metabolic demands, resulting in hemodynamic and chemical changes that produce characteristic dysphonic symptoms.
• Said simply the patient is blowing off more CO2 than they need to maintain normal pH. This results in a sense of oxygen starvation
• Excessive deep, rapid ventilations (Excessive CO2 exhaled)

• Acute HVS accounts for only 1% of cases but is diagnosed more easily
• Chronic HVS can present with a myriad of respiratory, cardiac, neurologic, or GI symptoms without any clinically apparent reason other than the breathing pattern

• Panic, excitement
• Deep, rapid ventilation (Air hunger, Clear bilateral BS)
• Numbness/tingling of lips, hands and feet (Carpal/pedal spasms)
• Sharp chest pain
• Obvious tachypnea and hyperpnea
• Chvostek or Trousseau
• Tremor
• Mydraisis
• Pallor
• Tachycardia
• Depersonalization or hallucination may be noted

• Used in Hyperventilation
• Tap behind the ear, if the face twitch then its positive for hyperventilation

Put BP cuff on, fill slightly above systolic pressure, leave on for 2-3 min, if wrist flexes then it is a positive test for hyperventilation

• Not usually apparent
• Frequent sighing respirations, 2-3 per minute
• Frequent yawning
• Chest wall tenderness
• Numbness
• Characteristically, multiple complaints without much supporting physical evidence of disease

• Greater then 14-16 weeks pregnant
• Patients with multiple or massive injury
• Massive thoracic injury
• Massive Maxillofacial trauma
• Patients at risk of aspiration
• Not all Contraindications are Absolute

• Step 1: Size selection
• Step 2: Examination of the LMA
• Step 3: Check deflation and inflation of the cuff
• Step 4: Lubrication of the LMA
• Step 5: Position of Airway

• Nares to earlobe to xyphoid process
• Mark with something

• Ask pt. to talk
• Check mouth with light and tongue blade
• Secure tube
• Check gastric contents/ air auscultation
• Chest/abdomen X-ray

2-3" 12-14G

Second intercostal, Mid-clavicular

A pulmonary embolism is a blockage of an artery in the lungs caused by a clot that travels through the bloodstream to the lungs

• Shortness of breath that starts suddenly for no obvious reason
• Chest pain, especially when breathing or coughing
• Feeling faint, lightheaded, dizzy
• Cough, sometimes with bloody phlegm
• Rapid heartbeat
• Rapid breathing
• Anxiety
• Swollen, distended neck veins

• Filter
• Humidify
• Warming
• Transport

• Filter
• Transport
• Diffusion
• Perfusion

Decreased O2 levels in arterial blood

Decreased O2 content at the tissue level

Easier for the hemoglobin to pick up O2, harder to release

Harder for Hemoglobin to pick up O2, easier to release

• Fick principle one
• The ability for the air to get to the Alveoli
• The actual mechanical movement
• Requires energy (ATP)
• Uses Intercostal muscles:
• Internal = Forced expiration
• External = Inspiration
• Diaphragm

• The actual transfer of gas
• There is Cellular respiration also

• The V/Q ration determines the adequacy of gas exchange in the lungs
• When alveolar ventilation matches pulmonary blood flow, CO2 is eliminated and the blood becomes fully saturated

• Stretch reflex (Buroreceptors)
• Cause inhibitory impulse f the vagus nerve (Prevents excessive stretch, Inhibit inspiration, Allow expiration to occur)

• Central (In the Medulla)
• Peripheral (In the Carotid arteries (Bifurcation of the common carotid) and Aortic Arch)

• 12 each side
• 8 are true 4 are floating

• 7 Cervical
• 12 Thoracic
• 5 Lumbar

• Thin double layer (Perietal, Visceral)
• Pleural space (Pleural fluid)

Covers the actual lung

Covers the Thoracic cavity

Tidal volume

• IRV: Inspiratory Reserve Volume
• ERV: Expiratory Reserve Volume
• RV: Residual volume

6-7cc/kg to get visible chest rise

• Leg is the most common
• Uterus is the second most common

A pulmonary embolism is a blockage of an artery in the lungs caused by a clot that travels through the blood stream to the lungs

• An embolism occurs then a clot moves through the bloodstream from the location where it was formed and becomes stuck in a blood vessel. The clot, called an embolus, can be a from:
• Blood clot
• Air bubble
• Piece of fat
• Bone marrow
• Tumor tissue
• Can be caused by trauma, remember to look for it

• Once the clot is stuck in a lung artery, it blocks the blood from nourishing that lung. The tissues on the other sude of the blockage may die if it doesn't receive enough blood from other sources
• Unlike other ischemic events; CVA or AMI the dying lung cells release toxins that cause additional lung cell to die. This can result in a P.E. that goes past the boundaries of the original insult

• Sudden-onset respiratory distress without difficulty moving air in and out (Normal breath sounds)
• Hypoxia develops quickly (SpO2 low despite given O2)
• Possible sudden, sharp chest pain
• Signs of obstructive shock (JVD, Tachycardia)
• Sudden SOB
• Feeling faint, light headed and dizzy
• Rapid breathing
• Anxiety

• Assure adequate oxygenation and ventilation (O2 NRB @ 15lpm, Ventilate if necessary and an Upright position)
• Rapid transport to an appropriate medical facility

• Vessel wall injury
• Hypercoagulation
• Venous stasis
• Used in P.E.

• Pneumonia is an infection of the lungs that affects the lower respiratory tract (small bronchi and air sacs in the lungs)
• Viral, bacterial of fungal infection of the lungs (Inflammation, fluid or puss in the lungs)

• Bacteria: most commonly Streptococcus pneumonia
• Viral pneumonia: Caused by a virus. Viruses cause half of all pneumonias
• Atypical Bacterial pneumonia: Caused by Mycoplasmas, chlamydias, or other tiny infectious agents that have traits of both bacteria and viruses

• Productive Cough
• Fever
• Crackles
• Wheezing
• Pleuritic Chest Pain (Hurts to breath or cough)

• Fever, chills (may include shaking)
• Cough:
• Produces green, yellow, or rust-colored mucus
• Dry cough
• Violent at times; produce white mucus
• Chest pain
• HA
• Possible nausea or vomiting
• Profuse sweating
• Muscle pain
• Weakness
• Cyanosis of the nails or lips
• Confused mental state
• Weakness

• PROP
• Transport
• IV
• Monitor SPO2

• Cardiogenic pulmonary edema
• Non-cardiac pulmonary edema

• Commonly due to left ventricular failure
• Ineffective pump allows blood to back up into pulmonary circulation (Congestive pulmonary capillaries leak fluid, interfering with gas exchange)
• Lung infection
• Drowning
• Toxic reaction (Smoke inhalation)
• Pregnancy

• Secondary to altered capillary permeability
• Secondary to increased pulmonary capillary pressure
• Secondary to decreased oncotic pressure found with hypoalbuminemia
• Secondary to lymphatic insufficiency
• Secondary to large negative pleural pressure with increased end expiratory volume
• Secondary to mixed or unknown mechanisms

• ARDS
• Infectious causes
• Inhaled toxins
• Circulating exogenous toxins
• Vasoactive substance
• Disseminated intravascular Coagulopathy (DIC)
• Immunologic processes reaction
• Uremia
• Near drowning
• Other aspirations

• Pulmonary venous thrombosis (P.E.)
• Stenosis or veno-occlusive disease
• Volume overload

• Extreme dyspnea
• Wet lung sounds
• Pink, frothy sputum
• Peripheral edema
• JVD
• Tachycardia
• Hypertension
• Skin may be diaphoretic or cold, gray, and cyanotic
• Wheezing or rales
• Lower extremity edema
• Position
• Frothy sputum
• Blood tinged sputum

An Antigen is a toxin or other foreign substance that induces an immune response in the body, produces antibodies

An antibody is a protein produces by the immune system in response to the presence of an antigen

• Exposure
• Manufacture of IgE antibody
• Antibody attach to MAST cells
• Second exposure causes MAST cells to release powerful chemicals

• Usually occurs < 30min of exposure to allergen (Hives and swelling)
• Respiratory distress
• Hypotenstion
• Altered Mental status

Hives are an intensely itchy rash that consists of raised, irregularly shaped wheals. The wheals have blanched center, surrounded by a red flare. Urticaria is caused by histamine released from dermal mast cells. Histamine release is most commonly causes by an immunologic reaction between antigens and IgE antibodies bound to mast cell membranes. Histamines cause increased vascular permeability. Antigens, chemicals and physical agents (Detergents or ultraviolet light) can cause urticaria.

Angioedema is an area of circumscribed swelling of any part of the body. It may be caused by the same mechanisms that cause hives

• An allergic reaction
• Edema of the tongue and pharynx, larynx
• NOT the SAME as anaphylaxis

• Anaphylaxis is the acute reaction that occurs when an antigen is introduced systemically into an individual who has preexisting IgE antibodies
• Affects big 3 systems

A method used by Anesthesiologist, reliable to predict difficulty directing Laryngoscopy

• Class I: Soft palate, uvula, faces and pillars are visible
• Class II: Soft palate, uvula and faces visible
• Class III:Soft palate, base of uvula visible
• Class IV: Hard palate only visible

• POGO (Percentage Glottic Opening Observed)
• Grade I: Largely open
• Grade II: Wide but short
• Grade III: Short and narrow
• Grade IV: No visible opening
• All refer to the larynx

Partial or complete lung collapse

• 2 or more ribs broken in 3 or more locations
• Visible flail segment Paradoxical movement

• 5-8 according to Cy
• 4-8 according to the book

• Liver
• Spleen
• Kidneys

• Can cause a Spontaneous pneumothorax
• Tall, thin males

• Hole in the chest wall that allows air to enter pleural space.
• Larger the hole the more likely air will enter than through the trachea

Around the neck

With a Gloved hand

A tension pneumothorax is a Pneumothorax that compresses the lung to where is is symptomatic

A Hemothorax is where blood accumulates in the pericardial sac, creating tension. A Tension pneumothorax but with blood

An patient with significant blunt or penetrating trauma to chest has heart/great vessel injury until proven otherwise

Rapid accumulation of blood in the inelastic pericardium

• Resistant hypotension
• Increased central venous pressure (Distended neck/arm veins in presence of decreased arterial BP)
• Small quiet heart (Decreased "Muffled heart tones)

Different pressure inspiration VS. Expiration

• Increased Intrathoracic pressure
• Backward flow of blood out of right heart into vessels of upper chest and neck
• Name given to these patients because they looked like they had been strangled or hanged

• Usually due to blunt trauma but may occur with penetrating trauma
• Usually life threatening
• Likely to be associated with other severe injuries

• Establish airway, consider early intubation
• Emergent transport (Intubating Right or Left mainstem may be life saving

• Establish airway
• Consider early intubation if possible
• IV LR/NS titrated to BP 90-100mmHg
• Emergent Transport

• Establish airway
• Assist ventilations with high concentration O2
• IV of LR
• monitor EKG
• NG tube if possible

• Airway with C-spine control
• Assist ventilations with high concentrations of O2
• spinal stablilization
• IV of LR
• Monitor EKG
• MAST in severely hypotensive patients
• Rapid transport

• Establish airway
• High concentration O2
• Maintain minimal BP in dissection
• IV LR/NS TKO
• Emergent transport

• Influenza
• Sinusitis
• Pharyngitis/Tonsillitis
• Epiglottis
• Laryngitis

Influenza is a highly contagious viral respiratory tract infection

• Acute Sinusitis: This type of infection occurs quickly and gets better with the appropriate treatment
• Subacute Sinusitis: This type of infection does not get better with treatment initially and lasts less then three months
• Chronic Sinusitis: These symptoms last longer then three oaths

• Pharyngitis and tonsillitis are infections in the throat that cause inflammation. If the tonsils are primary affected, it is called tonsillitis. If the throat is primarily affected, it is called pharyngitis. A person might even have inflammation and infection of both the tonsils and the throat. This would be called Pharyngotonsillitis.
• Bacterial infections are more common during the winter, Viral infections are more common in the summer and fall.

Epiglottis is a life-threatening condition that occurs when the epiglottis - a small cartilage "lid" that covers the windpipe - swells, blocking the flow if air into the lungs.

• Laryngitis is an inflammation of the voice box (larynx) due to overuse, irritation or infection. Normally your vocal cords open and close smoothly, forming sounds though their movement and vibration. But laryngitis, the vocal cords become inflamed or irritated. They swell, causing distortion of the sound produced by air passing over them. As a result, the voice sound hoarse. In some cases of laryngitis, the voice can become so faint as to be undetectable. Laryngitis may be acute or chronic. Although acute laryngitis usually is nothing more than an irritation and inflammation fro a virus, persistent hoarseness can signal a more serious problem.
• Croup in children