Mod 4 Respiratory Emergencies

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Define "inspiration."

An active process in which the intercostal muscles and the diaphragm contract, expanding the size of the chest cavity and causing air to flow into the lungs.

Define "inhalation."

Another term for inspiration. An active process in which the intercostal muscles and the diaphragm contract, expanding the size of the chest cavity and causing air to flow into the lungs.

Define "expiration."

A passive process in which the intercostal muscles and the diaphragm relax, causing the chest cavity do decrease in size and forcing air from the lungs.

Define "exhalation."

Another term for "expiration." A passive process in which the intercostal muscles and the diaphragm relax, causing the chest cavity do decrease in size and forcing air from the lungs.

What is the normal respiration rate for an adult?

12-20 breaths per minute

What is the normal respiration rate for an child?

15-30 breaths per minute

What is the normal respiration rate for an infant?

25-50 breaths per minute

What three components make up the "quality" of somebody's breathing?

Breath sounds, chest expansion, effort of breathing

What three elements paint a picture of a patient's breathing?

Rate, rhythm, quality.

Define "inadequate breathing."

Breathing that is not sufficient to support life.

If the patient is breathing inadequately, what might you see pertaining to their rate of breathing?

Breathing either too fast and too shallowly, or too slowly. Agonal respirations are sporadic, irregular breaths that are usually seen right before respiratory arrest and death.

Is rhythm an absolute indicator of adequate breathing?

No.

What kinds of breath sounds signify inadequate breathing?

Dimished or absent. Also keep your ears open for snoring or gurgling, which indicate airway problems.

What are the major differences between a child's airway and an adult's airway?

1) Child's airway is smaller and more easily obstructed
2) Child's tongue is proportionally larger and more likely to obstruct the airway
3) Child's trachea is smaller, softer, and more flexible, and cricoid cartilage is less rigid, meaning that trauma to this region is more likely to cause obstruction.
4) A child's diaphragm is more developed (compared to their underdeveloped intercostal muscles), so children are more prone to seesaw breathing when breathing is inadequate, meaning that the chest and abdomen move in opposite directions.
5) Children are more prone to nasal flaring, grunting, and retractions

What is your number one priority on a call if a patient's breathing is inadequate?

Treating the inadequate breathing.

In order of preference, what are four methods of providing assisted ventilations?

1) Pocket face mask with supplemental oxygen
2) Two-rescuer bag-valve-max with supplemental oxygen
3) Flow restricted oxygen powered ventilation device
4) One rescuer bag-valve-mask with supplemental oxygen

If you are uncertain about whether a patient's breathing is inadequate and requires artificial ventilation, what do you do?

Provide artificial ventilation!

What interventions should an EMT take for a patient that's breathing adequately, but requires supplemental oxygen due to a traumatic or medical condition?

Administer oxygen by a non-rebreather mask or a nasal cannula.

What interventions should an EMT take for a patient that's breathing inadequately?

Provide assisted ventilations with a pocket-face mask, bag-valve-mask, or FROPVD.

What interventions should an EMT take for a patient that's not breathing at all?

Provide artificial ventilations with a pocket face mask, bag valve mask, or FROPVD at 12/minute for an adult or 20/minute for a child.

When providing artificial ventilation, what should you keep a close eye on?

1) Make sure the chest is rising (sign of adequate ventilation)
2) Make sure you're delivering ventilations at the proper rate -- 12/minute for adults, 20/minute for children (sign of adequate ventilation)
3) Monitor the patient's pulse carefully. A pulse that remains the same or increases may indicate inadequate ventilation. If pulse disappears, patient requires CPR.

What major difference exists between the reaction of a child's pulse and an adult's pulse as hypoxia sets in?

In an adult, the pulse increases. In a child, there's a slight increase in pulse early on, but soon the pulse will drop significantly. If a child or infant's pulse is LOW, you're in trouble!

What do you do if you observe a pulse below the expected rate when you're dealing with a child or an infant?

Evaluate your ventilations or oxygen therapy thoroughly. Check the airway, check your equipment, check that your rate is correct (20/min), check that the child's chest is rising with each breath.

What do you do when you're artificially ventilating and there's no chest rise?

1) Increase force of ventilations
2) Confirm open airway via head-tilt/chin-lift or jaw-thrust maneuver
3) Insert airway adjunct if necessary
4) Suction as necessary
5) Use abdominal thrusts or finger sweeps in the case of large obstructions6) Verify that oxygen equipment is connected correctly, secure, and free of kinks in any hosing

If a child or infant has:1) Wheezing, stridor, or grunting2) Increased breathing effort3) Flared nostrils/retractions4) Rapid breathing5) Cyanosis ... what do you do?

Refrain from placing anything in patient's mouth, administer oxygen, and transport as quickly as possible.

A patient's description of his difficulty breathing is a _____ perception.

Subjective.

Is a patient's description of their breathing difficulty a solid piece of information you can base your treatment on?

No. Your assessment of the patient based on their chief complaint is the basis for your treatment of the patient.

List off some signs that an adult is having breathing difficulty.

Increased pulse rate, Changes in breathing rate (above or below normal levels), Changes in breathing rhythm, Pale, cyanotic, or flushed skin, Noisy breathing , Inability to speak full sentences, Use of accessory muscles, Retractions, Altered mental status, Coughing, Flared nostrils, Tripoding, Unusual anatomy (barrel chest), Oxygen saturation (or SpO2) reading of less than 95%.

What is stridor, and what does it indicate?

Stridor is a harsh, high-pitched sound during breathing. It usually indicates an upper airway obstruction.

If a patient is having difficulty breathing and you have a pulse oximiter readily available, what should you do?

Take a pulse oximetry reading right away to obtain a baseline. Document subsequent readings to see if patient's saturation levels are increasing. However, NEVER delay oxygen delivery for any reason, so ONLY take a reading if it's feasible and the device is readily available.

When a patient is suffering from breathing difficulty, what are the four steps to follow?

1) Assessment
2) Oxygen therapy
3) Positioning -- sit the patient up if their breathing is adequately, otherwise get them supine if they require assisted ventilations
4) Inhaler - If patient has a prescribed inhaler, you could consult medical direction for instructions on helping the patient take their medication

What are the most important sounds that you can hear through your stethescope?

The sounds of air moving in and out.

What do absent lung sounds indicate?

A serious condition such as inadequate breathing, respiratory arrest, or a collapsed lung

What abnormal lung sounds might an EMT hear, and what do they indicate?

1) Wheezes -- high-pitched sounds, almost musical in nature. Indicates narrowed airways, common with asthma, COPD, emphysema, bronchitis. Most commonly heard during expiration.
2) Crackles -- a fine crackling/bubbling sound caused by fluid in alveoli or by the opening of closed alveoli
3) Rhonchi -- lower pitched sounds that resemble snoring or rattling. Caused by secretions in larger airways, may indicate pneumonia, bronchitis, or fluids inhaled into lungs.
4) Stridor -- a high-pitched sound heard upon inspiration. Indicates partial obstruction of trachea or larynx

Where might you listen for lung sounds?

Just below the clavicles on the mid-clavicular line.At the bases of the lungs and just lateral to the mid-clavicular line (under the nipples)These same positions, but on the back of the body.On the mid-axillary line a bit below the armpit.

Is it necessary to diagnose a patient's respiratory condition in order to provide effective treatment as an EMT?

No. The care for all respiratory conditions is virtually the same.

What is COPD?

Chronic obstructive pulmonary disease. This group of diseases includes chronic bronchitis, black lung, and many undetermined respiratory illnesses that cause emphysema-like conditions.Essentially, it's a disorder that prevents proper CO2/O2 exchange in the lungs, and necessitates constant oxygen therapy.

What is emphysema?

Emphysema is a disease in which the walls of the lungs' alveoli break down, reducing the surface area for respiratory gas exchange. The lungs lose elasticity, and these factors allow stale air to sit in the lungs.

What is chronic bronchitis?

Chronic bronchitis is a condition in which the bronchiole lining is inflamed, excess mucus is formed, the cilia that usually sweep away the mucus are damaged, and this combination of inflammation and mucus build up hamper respiratory gas exchange.

Why do most patients with COPD call for an ambulance?

Usually an upper respiratory infection has caused an acute worsening of their chronic disease.

Define "hypoxic drive."

Hypoxic drive is a rare phenomenon. Basically it occurs in COPD patients, and the brain stops using high levels of CO2 as a trigger to breathe. It instead gets used to low oxygen levels and high CO2 levels that are always present, and uses extra-low oxygen levels as a trigger to breathe. In these cases, oxygen therapy can actually cause the patient to go into respiratory arrest, but that is very rare.

What can cause an asthma attack?

Allergic reactions, pollutants, infection, strenuous exercise, or emotional stress.

What happens during an asthma attack?

Bronchioles constrict and an overproduction of mucus begins. The combined effect causes bronchial passages to narrow to a point where adequate breathing is difficult or impossible

Define "bronchoconstriction."

Constriction, or blockage, of the bronchi that lead from the trachea to the lungs.

Who must you consult before helping a patient use their inhaler, and what questions must you ask the patient?

You must consult medical direction.Ask the patient if, and when, they recently used the inhaler.

In what form does the medicine in an inhaler come?

The medicine is a fine powder.

Why are inhalers difficult to use?

Because timing is essential. If you're not inhaling at the correct moment, the medicine will come to rest in your mouth, where it's ineffective. You must inhale the powder so it enters your airway.

What device can make inhaler use easier?

A spacer.

When assisting a patient with using their inhaler, what steps will you take?

1) Consult medical direction
2) Ensure that you have the right patient, the right medication, the right dose, and the right route. Get the inhaler to room temperature and shake it.
3) Make sure that the patient is alert enough to use the inhaler properly. Use spacer if available.
4) Have patient put lips around the opening, press inhaler while he inhales deeply.
5) Make sure that the patient holds his breath as long as possible so that the medication can be absorbed.

Should you assist the following patient with using an inhaler?
Patient is a 14-year-old with difficulty breathing. History of asthma. Pulse 104, strong, regular. Respirations are 28 with audible wheezing. BP is 130/84, and skin is warm and dry. Parents are present, inhaler is prescribed.

Yes -- the patient is breathing adequately enough for the inhaler to do some good, plus it's his inhaler and prescribed to him.

Should you assist the following patient with using an inhaler?
67-year old, difficulty breathing. Has a history of breathing problems, but can't think of the name of the condition. Pulse 122 and strong and regular, respirations 28 with audible wheezes, BP 104/64, skin cool and dry. The daughter presents an inhaler that's not prescribed.

No. The patient's condition may not be asthma, and the inhaler may do more harm than good.

Should you assist the following patient with using an inhaler?
Patient is 24, was just exercising, developed difficulty breathing. Pulse 142, respirations 42 and shallow, BP 96/56, skin cool and moist. Has an inhaler on her person that's prescribed to her.

No. Respirations are too shallow for the medication to do any good. Patient needs oxygen therapy and priority transport.

What are common generic names for prescribed medications delivered by inhaler?

Albuterol, isoetharine, metaproterenol

What are common trade names for prescribed medications delivered by inhaler?

Proventil, Ventolin, Bronkosol, Bronkometer, Alupent, Metaprel

What are indications for use of a prescribed inhaler?

1) Patient exhibits signs and symptoms of respiratory emergency
2) Patient has physician-prescribed inhaler
3) Medical direction gives specific authorization to use.

What are some contraindications against the use of a prescribed inhaler?

1) Patient is unable to use the device
2) Inhaler is not prescribed for the patient
3) No permission has been given by medical direction
4) Patient has already taken maximum prescribed dose prior to EMT's arrival

What is a small-volume nebulizer?

A small-volume nebulizer is a device that can create a continuous flow of aeorosolized medication that the patient can easily and effectively inhale. It uses the same medications as an inhaler.

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