Respiratory System Assessment

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Respiratory System Assessment

• Chemeketa Community College
• Paramedic Program

Peggy Andrews, Instructor
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Respiratory rates

• Normal - 12 - 20
• Controlled by other factors
• Temperature - Emotion
• Drugs and medications - Hypoxia
• Pain - Acidosis
• Sleep
• Obstruction
• Tongue - most common
• Snoring, correct with positioning

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Foreign body

• May cause partial or complete obstruction
• Choking, gagging
• Stridor
• Dyspnea
• Aphonia
• Speechless
• Dysphonia
• Difficulty speaking
• Hoarseness

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Laryngeal spasm and edema

• Spasm
• Sudden movement/contraction
• Most frequently
• Trauma
• Aggressive intubation
• Post-extubation
• Especially if patient semi-conscious

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33 year old female rescued from a structure fire.
CAO x 3, RR38, SaO2 64, harsh stridor on insp.

• Edema
• Glottis
• Extremely narrowed
• Totally obstructed
• Most frequently
• Epiglottitis
• Bacterial infection
• Anaphylaxis

• Relieved by
• Aggressive ventilation
• Muscle relaxants
• Alternative Airway

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

• Fractured larynx
• Airway patency dependent on muscle tone
• Increased resistance by decreased size
• Decreased muscle tone
• Laryngeal edema
• Ventilatory effort

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79 y/o male, liquid diet, hiccups during
breakfast. Severely SOB

• SaO2 72 RA, Upper Resp. fluid audible
• Aspiration
• Significantly increases mortality - 25 die
• Obstructs airway
• Destroys delicate bronchiolar tissue
• Introduces pathogens
• Decreases ability to ventilate
• Commonly the beginning of the end ?

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Airway evaluation

• Rate
• 12-20?
• Regularity
• Steady pattern
• Irregular patterns are significant until proven
  otherwise

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Airway evaluation

• Effort
• Should be effortless at rest
• Changes may be subtle in rate or regularity
• Patients compensate by preferential posturing
• Upright sniffing
• Semi-fowlers
• Frequently avoid supine

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Some Important Patterns
Serious Illness/Terminal
DKA
Head injury/ICP
Resp. Center Lesions
Paramedic Students
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Recognition of airway problems

• Respiratory distress
• Upper and lower obstruction
• Inadequate ventilation
• Impairment of respiratory muscles
• Impairment of nervous system

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Dyspnea may be result of or result in hypoxia

• Hypoxia
• Inadequate O2 at cells
• Hypoxemia
• Lack of O2 in arterial blood
• Anoxia
• No Os
• All therapies will fail if airway inadequate

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Visual 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 What are the clues here?

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

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Our Lady (continued)

• O Pt is barely conscious, upright in recliner.
  RR 46, SaO2 64, Skin pale, cool moist, with
  cyanosis around lips, gums, eyes nailbeds. EKG
  leads wont stick to get reading. Lung sounds
  with minimal air movement in most fields. No
  wheezes heard. Significant intercostal,
  supraclavicular, suprasternal and substernal
  retractions noted on inspiration. Her lips are
  pursed and her nostrils are flaring with each
  breath.

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Auscultation techniques

• Air movement at mouth and nose
• Bilateral lung fields equal

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Palpation techniques

• Air movement at mouth and nose
• Chest wall
• Paradoxical motion
• Retractions

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Bag-valve-mask

• Resistance/changing compliance with BVM
  ventilations

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Pulsus paradoxis

• Systolic BP drops greater than 10 mmHg with
  inspiration
• Seen in Pericardial tamponade

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History

• Evolution
• Sudden
• Gradual over time
• Known cause or trigger
• Duration
• Constant
• Recurrent
• Ease - What makes it better?
• Exacerbate Aggravation of symptoms
• Associate - other symptoms (productive cough, etc)

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History

• Interventions
• Evaluations/admissions to hospital
• Medications (include compliance and dose)
• Ever intubated???

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History

• Modified form of respiration
• Protective reflexes
• Cough - forceful, spastic exhalation aids in
  clearing bronchi and bronchioles
• Sneeze - clears nasopharynx
• Gag reflex - spastic pharyngeal and esophageal
  reflex
• Sighing
• Increases opening of alveoli
• Normally sigh _at_ 1/min.
• Hiccough
• Intermittent spastic closure of glottis

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Inadequate ventilation

• When body cant compensate for increased oxygen
  demand or maintain O2/CO2 balance.
• Many causes
• Infection
• Trauma
• Brainstem injury
• Noxious or hypoxic atmosphere
• Renal failure
• Multiple symptoms
• Altered response
• Respiratory rate changes

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Supplemental oxygen therapy

• Supplemental oxygen therapy
• Increases O2 to cells
• O2 increases patients ability to compensate
• Delivery method continually reassessed

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Oxygen source

• Compressed gas
• Common sizes and volumes
• D 400L
• E 625L
• M 3450L

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Calculating Tank Life
((PSI in tank) (500)) x (factor) (Desired Lpm)

• Tank Size Factor
• 0.16 D Tank
• 0.28 E Tank
• 1.56 M Tank
• (1800-500) x 0.16 / 10 20.8 minutes

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Regulators

• High pressure
• Transfer gas from tank to tank
• Cascade System
• Therapy regulators
• Pressure stepped down
• Delivery via adjustable low pressure

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Delivery Devices

• Nasal cannula
• Optimal delivery 40 at 6 Lpm
• Indications
• Low to moderate enrichment
• Long term therapy
• Contraindications
• Poor respiratory effort
• Severe hypoxia
• Apnea
• Mouth breathing

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Delivery Devices

• Nasal cannula
• Advantages
• Well tolerated
• Easy to communicate
• Disadvantages
• Doesnt deliver high volume/high concentration
• Not guaranteed

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Delivery Devices

• Simple face mask
• Indications
• Moderate to high oxygen concentration
• 40-60 at 10 Lpm
• Advantages
• Higher oxygen concentrations
• Disadvantages
• Beyond 10 LPM does not enhance oxygen content.

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Delivery Devices

• Partial rebreather
• Indications
• Contraindications
• Apnea
• Poor respiratory effort
• Advantages
• Higher concentrations
• Disadvantages
• Beyond 10 LPM does not enhance content.

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Delivery Devices

• Non-rebreather mask
• Mask side ports
• One-way disc
• Reservoir bag attached
• 80-95 at 10-15 Lpm
• Indications
• Highest O2 content (Non PPV)
• Contraindications
• Apnea
• Poor effort

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Delivery Devices

• Venturi mask
• Mask with interchangeable adapters
• Side ports for room air
• Highly specific content. O2
• Oxygen humidifiers
• Sterile water reservoir for humidifying oxygen
• Long term admin.
• Desirable for Croup/Epiglottitis/Bronchiolitis
• Tracheostomy
• Stoma

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Summary

• Respiratory Assessment concepts
• Scenarios
• Oxygen Delivery Method Review