The Respiratory System

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The Respiratory System

• Emergency Medical Technician - Basic

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Respiratory System Purpose

• Takes in oxygen
• Disposes of wastes
• Carbon dioxide
• Excess water

O2 Glucose
The Cell
CO2 H2O
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Respiratory System Anatomy
Nasopharynx
Oropharynx
Epiglottis
Larynx
Trachea
Carina
Bronchi
Bronchioles
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Respiratory System Anatomy

• Lung
• Right lung 3 lobes
• Left lung 2 lobes

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Respiratory System Anatomy

• Bronchioles
• Smallest airways
• Walls consist entirely of smooth muscle (no
  cartilage present)
• Constriction increases resistance to airflow
• Dilation reduces resistance to airflow

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Respiratory System Anatomy

• Alveoli
• Air sacs
• Site of oxygen and carbon dioxide exchange with
  blood

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Respiratory System Anatomy
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Respiratory System Anatomy

• Diaphragm

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Respiratory System Anatomy

• Pleura
• Double-walled membrane
• Visceral layer covers lung
• Parietal layer lines inside of chest wall,
  diaphragm

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Respiratory System Physiology
Inspiration Active process Chest cavity
expands Intrathoracic pressure falls Air
flows in until pressure equalizes
Expiration Passive process Chest cavity
size decreases Intrathoracic pressure rises
Air flows out until pressure equalizes
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Respiratory System Physiology

• Automatic Function
• Primary drive increase in arterial CO2
• Secondary (hypoxic) drive decrease in arterial O2

Normally we breathe to remove CO2 from the body,
NOT to get oxygen in
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Respiratory Pathophysiology

• Airway (Obstruction)
• Tongue
• Foreign body airway obstruction
• Anaphylaxis/angioedema
• Upper airway burn
• Maxillofacial/laryngeal/ tracheobronchial trauma
• Epiglottitis
• Croup

• Aspiration
• Asthma
• Chronic Obstructive Airway Disease
• Emphysema
• Chronic bronchitis

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Respiratory Pathophysiology

• Gas Exchange Surface (Blood Flow or Gas
  Diffusion)
• Pulmonary Edema
• Left-sided heart failure
• Toxic inhalations
• Near drowning
• Pneumonia
• Pulmonary Embolism
• Blood clots
• Amniotic fluid
• Fat embolism

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Respiratory Pathophysiology

• Thoracic Bellows (Ventilation)
• Chest Trauma
• Simple rib fractures
• Flail chest
• Pneumothorax
• Hemothorax
• Sucking chest wound
• Diaphragmatic hernia

• Pleural effusion
• Spinal cord trauma (High C-spine lesion)
• Morbid obesity
• Neurological/neuro-muscular disease
• Poliomyelitis
• Myasthenia gravis
• Muscular dystrophy
• Guillian-Barre syndrome

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Respiratory Pathophysiology

• Control System (Decreased Respiratory Drive)
• Head trauma
• CVA
• Depressant drug toxicity
• Narcotics
• Sedative-hypnotics
• Ethyl alcohol

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Respiratory Assessment

• Initial Assessment (A, B, C, D)
• Manage life threats
• Complete focused history and physical

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Initial Assessment

• Airway
• Listen to patient breathe, talk
• Noisy breathing is obstructed breathing
• But all obstructed breathing is not noisy
• Snoring Tongue blocking airway
• Stridor Tight upper airway from partial
  obstruction

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Initial Assessment

• Airway
• Anticipate airway problems with
• Decreased LOC
• Head trauma
• Maxillofacial trauma
• Neck trauma
• Chest trauma

OPENCLEARMAINTAIN
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Initial Assessment

• Breathing
• Is patient moving air?
• Is air moving adequately?
• Is the patients blood being oxygenated?

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Initial Assessment

• Breathing
• LOOK
• Symmetry of chest expansion
• Increased respiratory effort
• Changes in skin color
• LISTEN
• Air movement at mouth, nose
• Air Movement in peripheral lung fields

• FEEL
• Air movement at mouth, nose
• Symmetry of chest expansion
• RATE
• Tachypnea
• Bradypnea
• POSITIONING
• Orthopnea
• Tripod position

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Initial Assessment

• Breathing
• Signs of respiratory distress
• Nasal flaring
• Tracheal tugging
• Retractions
• Neck, pectoral muscle use on inhalation
• Abdominal muscle use on exhalation
• Skin Color
• Pale, cool moist skin (Early sign of hypoxia)
• Cyanosis (Late, unreliable sign of hypoxia)

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Initial Assessment

• Breathing
• If trauma patient has compromised breathing, bare
  chest, assess for
• Open pneumothorax
• Flail chest
• Tension pneumothorax

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Respiratory Assessment

• Circulation
• Is heart beating?
• Is there major external hemorrhage?
• Is patient perfusing?
• Effects of hypoxia
• Adults (early) tachycardia
• Adults (late) bradycardia
• Children bradycardia

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Initial Assessment

• Circulation
• Dont let respiratory failure distract you from
  assessing for circulatory failure
• Low oxygen or high carbon dioxide levels can
  depress cardiovascular function

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Respiratory Assessment

• Disability
• Restlessness, anxiety, combativeness hypoxia
  Until proven otherwise
• Drowsiness, lethargy hypercarbia
  Until proven otherwise

Just because the patient stops fighting, hes not
necessarily getting better!!!
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Initial Management

• Patient Responsive/Breathing Adequate
• Oxygen may be indicated
• Oxygenate immediately if patient has
• Decreased level of consciousness
• Possible shock
• Possible severe hemorrhage
• Chest pain
• Chest trauma
• Respiratory distress or dyspnea
• History of any kind of hypoxia

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Initial Management

• Patient responsive, breathing inadequate
• Open/maintain airway
• Place nasopharyngeal airway
• Assist ventilations
• Mouth to Mask
• 2-person Bag-valve Mask
• Manually Triggered Ventilator
• 1-person Bag-valve Mask

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Initial Management

• Patient unresponsive, breathing adequate
• Open/maintain airway
• Place nasopharyngeal or oropharyngeal airway
• Suction airway as needed
• Provide oxygen by non-rebreather mask
• Frequently reassess

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Initial Management

• Patient unresponsive, breathing inadequate
• Open/maintain airway
• Place nasopharyngeal or oropharyngeal airway
• Suction airway as needed
• Assist ventilations
• Mouth to Mask
• 2-person Bag-valve Mask
• Manually Triggered Ventilator
• 1-person Bag-valve Mask
• Frequently reassess

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Initial Management

• Patient not breathing
• Open airway
• Place nasopharyngeal or oropharyngeal airway
• Ventilate patient
• Mouth-to-Mask
• 2-Person Bag-Valve Mask
• Manually Triggered Ventilator
• 1-Person Bag-Valve Mask
• Frequently reassess

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Initial Management

• Golden Rules
• If you think about giving O2, give it!!!
• If you decide to give oxygen, give a lot of it!!!
• If you cant tell whether a patient is breathing
  adequately, he isnt !
• If youre thinking about assisting a patients
  breathing, you probably should be!

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Focused History and Physical

• Chief Complaint
• Dyspnea
• Subjective sensation that breathing is excessive,
  difficult, or uncomfortable
• Respiratory Distress
• Objective observations that indicate breathing is
  difficult or inadequate

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Focused History and Physical

• History of Present Illness (OPQRST)
• Gradual or sudden onset?
• What aggravates or alleviates?
• How long has dyspnea been present?
• Coughing? Productive cough?
• What does sputum look/smell like?
• Pain present? What does pain feel like? How bad?
  Does it radiate? Where?

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Focused History and Physical

• Past History
• If Then???
• Hypertension, MI, Diabetes CHF
  with Pulmonary Edema
• Chronic Cough , Smoking, COPD
• Recurrent Flu
• Allergies, Acute Episodes of SOB Asthma
• Lower Extremity Trauma, Pulmonary Embolism
• Recent Surgery, Immobilization

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Focused History and Physical

• Medications
• If Then???
• Breathing Pills, Inhalers Asthma or
  COPD
• Albuterol Montelukast
• Aminophylline Oxtriphylline
• Ipratropium Cromolyn
• Terbutaline Prednisone
• Salbumatol
• Zafirlukast

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Focused History and Physical

• Medications
• If Then???
• Lasix, hydrodiuril, digitalis
  CHF
• Coumadin, BCPs
  Pulmonary embolism

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Focused History and Physical Exam

• Crackles (Rales)
• Fine, crackling
• Fluid in smaller airways, alveoli
• Rhonchi
• Coarse, rumbling
• Fluid, mucus in larger airways

• Stridor
• High pitched, crowing
• Upper airway restriction
• Wheezing
• Whistling
• Usually more pronounced on exhalation
• Generalized narrowing, spasm of the smaller
  airways
• Localized foreign body aspiration

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Mild Breathing Difficulty

• May be hypoxic
• Can move adequate tidal volume
• Can answer questions, speak in complete
  sentences, is alert
• High concentration O2 by non-rebreather mask
• Consider bronchodilators if patient wheezing

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Moderate Breathing Difficulty

• May be hypoxic
• May be moving adequate tidal volume
• Having difficulty answering questions, speaks in
  choppy sentences, is restless/irritable
• High concentration O2 by non-rebreather mask
• Get ready to assist ventilations if needed
  (patient may resist assistance at this time)
• Consider bronchodilators if patient wheezing

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Severe Breathing Difficulty

• Getting sleepy
• Not speaking or speaking with very few words
• Previously wild, now seems cooperative
• Assist ventilations with BVM and oxygen
• Time BVM ventilation with patients ventilatory
  efforts
• Interpose extra ventilations if necessary