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Airway Management Mask Ventilation of the Breathing Patient Airway, Mask Ventilation Riverside (County) EMS Agency 26 October 2015 Airway Management Mask Ventilation of the Breathing Patient Riverside EMS Agency Daved van Stralen, MD, FAAP Shanna Kissel, MSN, RN References John West, MD, PhD Videos http://meded.ucsd.edu/ifp/jwest/resp_phys/ http://meded.ucsd.edu/ifp/jwest/pulm_path/index.html Books Respiratory Physiology: The Essentials, Ninth Edition Pulmonary Pathophysiology: The Essentials, Eighth Edition Respiratory terms and definitions Assisted ventilation terms CPAP and PEEP- Continuous Positive Airway Pressure for continuous flow systems, Positive End- Expiratory Pressure for positive pressure ventilation (hand ventilation or mechanical ventilation). This back pressure can be good when it recruits alveoli that were collapsed or keeps them open when they take too long (long time constant). It is bad when it causes the lung to stay open and not ventilate or is a measure of trapped air that can lead to lung damage or pneumothorax and death. Bagging the patient We don’t “bag” patients, we hand ventilate. “Bag” and “bagging” are slang terms. Breathing terms Minute ventilation (volume per minute to remove CO2 - Hyperventilation and hypoventilation refer to minute ventilation. Minute ventilation is the volume of air the person breathes in one minute- the depth (tidal volume) and how many breathes (respiratory rate). Hyperventilation is excessive minute ventilation to remove carbon dioxide, generally to correct acidosis, and hypoventilation is lower minute ventilation to retain carbon dioxide to correct metabolic alkalosis or, more commonly, from some pathology. Tachypnea and hyperventilation are not the same. One can hyperventilate with slow respiratory rates (Kuss Maul breathing from diabetic ketoacidosis). Respiratory Rate- Tachypnea is high rate (often a high rate is mistakenly called hyperventilation but one can hypoventilate with fast respiratory rates when chest wall is constrained or poor lung compliance), bradypnea (slow reate), and apnea refer to the respiratory rate. 1 Airway, Mask Ventilation Riverside (County) EMS Agency 26 October 2015 Tidal volume- Hyperpnea and hypopnea refer to tidal volume. Hyperpnea is deep breathing and hypopnea is shallow breathing. Oxygenation Hypoxia and hypoxemia can be confused, with hypoxia commonly used to refer to arterial blood oxygen levels. While hypoxia is commonly used in place of hypoxemia, we reserve hypoxia for absolute concentrations of oxygen in the environment or tissue and hypoxemia for the relative concentration of oxygen in the blood. To avoid confusion, we will define the following terms, from the environment to the tissue: Ambient or environmental hypoxia- this is found at high altitude, acutely at 10,000 feet or more or enclosed space where chemical reactions (oxidation reaction) consume the oxygen. The first is low partial pressure of oxygen and the latter is low fraction of inspired oxygen. Alveolar hypoxia- this is the amount of oxygen in the alveolus which will be affected by oxygen levels in the environment and very high carbon dioxide levels in the blood that replace oxygen. It is important for treatment of pulmonary hypertension as low alveolar oxygen (alveolar hypoxia) causes constriction of the pulmonary arteries and possible failure of the right ventricle. This is the method of death from Obstructive Sleep Apnea or bronchopulmonary dysplasia (BPD) from prematurity. Hypoxemia- Low arterial oxygen levels, usually below 90%. Tissue hypoxia- Low oxygen levels in the tissue leading to anaerobic metabolism. Resistance, Airway Laminar flow- Resistance is proportional to the fourth power of the radius (1/r4), small changes in radius disproportionally increase resistance, a great danger from bronchospasm, bronchoedema, or secretions (a significant problem in low humidity regions). Turbulent flow- Resistance in turbulent flow is proportional to flow velocity, agitation, anxiety, fear, and pain increase respiratory causing increase in resistance (a significant problem and upper airway obstruction such as croup). Sensation The feeling of suffocation comes from inadequate stimulation of stretch receptors in the lung, including the vagus nerve. Poor oxygenation or ventilation do not cause this sensation, hypoxemia causes fatigue or euphoria and hypercarbia causes sleepiness. 2 Airway, Mask Ventilation Riverside (County) EMS Agency 26 October 2015 Time constant Resistance X Compliance; this is the time in seconds for 63% of the lung to empty or fill; determined by airway resistance and lung/chest wall compliance; important to note that increased pressure on ventilator bag DOES NOT change flow rate. Ventilation The pulmonary removal of carbon dioxide from the blood by minute ventilation (the kidneys can also remove carbon dioxide though this can take a few days to come on line). This is separate and distinct from oxygenation though the element of hypoventilation as a shared cause. Visual Respiratory Evaluation- CRAWL This exam is a visual exam useful as you approach a patient, monitoring a patient from a distance or multiple patients, in presence of high ambient noise, response to treatment, and patient description. Color- Hypoxemia Cyanosis occurs when there is 4-5 gm/dL of deoxygenated hemoglobin present while hypoxemia is defined as abnormally low arterial oxygen levels. An anemic person will be cyanotic at much lower oxygen levels than someone with normal hemoglobin levels, and tissue with slow blood flow may be cyanotic when other tissues are not. (Think of blue lips in a cold child who won’t get out of the swimming pool.) This is why we differentiate central cyanosis (arterialized blood in mucus membranes like the gums and tongue) from peripheral cyanosis (lips in a cold child or the digits of a patient with compromised peripheral blood vessels.) Saturation levels less than 90% are generally considered hypoxemia but a healthy person may show few symptoms other than impaired judgment at 80% saturation while a patient with pulmonary hypertension may have cardiac strain at levels less than 95%. Descriptors- Cyanosis describes an absolute amount of de-oxygenated hemoglobin, pulse oximetry describes the ratio of oxygenated red cells; ALWAYS give supplemental oxygen with the pulse oximetry value for effective interpretation. Respiratory rate and rhythm The adult diaphragm has slow twitch muscle fibers resistant to fatigue, meaning they cannot increase their respiratory rate significantly but may “tolerate” tachypnea for a period before someone calls 911. Children have fast twitch muscle fibers that are not resistant to fatigue, meaning they can breathe much faster than expected (infants can reach over 100 breathes per minute) but will fatigue precipitously. Because respiratory muscle fatigue is a major factor in respiratory distress, it is important to note that an increasing respiratory rate may indicate greater respiratory reserve while a decreasing respiratory rate is ominous, indicating imminent 3 Airway, Mask Ventilation Riverside (County) EMS Agency 26 October 2015 respiratory failure. A “normal” respiratory rate may actually be the number you observe during this deterioration. Respiratory rhythm can help determine non-pulmonary tachypnea or, in children, failure of the diaphragm. Infants use the abdomen as an accessory respiratory muscle when the diaphragm fails. The intercostal muscles, respiratory muscles in the adult but not for infants, will contract to make the chest wall firm during abdominal breathing. You will see this “see saw” breathing pattern as the child rests the diaphragm. Apnea can occur slowly or suddenly. When it occurs suddenly in the infant and responds to stimulation of the child it is more likely to be RSV bronchiolitis. Non-pulmonary causes of tachypnea are important to note or you will pursue respiratory treatments and miss metabolic acidosis from diabetic ketoacidosis, hypovolemia, or certain drugs. Pain, agitation, and psychogenic tachypnea are also causes of non-pulmonary tachypnea. Descriptors- respiratory rate (as a value, use of “normal” or “WNL” as in “We Never Looked” cannot be used to evaluate change or trajectory of the patient’s course); apnea, Kuss-Maul, in infants there is sudden apnea (think of RSV bronchiolitis, gastroesophageal reflux, or ALTE), abdominal breathing or see saw breathing in infants. Air entry This is chest expansion. For normal quiet breathing it is surprisingly small, look around you to observe how much expansion you need for a normal patient when you hand ventilate. If they are expanding their chest to a great degree there is something going on. If they are working hard to breath and their chest is not expanding well, there is something serious going on. The second thing to observe for air entry is prolongation of inhalation or exhalation (Inspiratory- Expiratory, or I:E, Ratio) . Normal ratio is 1:2, whether a large or small breath. Prolonged inspiration indicates upper airway obstruction while prolonged expiration indicates lower airway obstruction. For upper airway obstructions it is useful to identify the level of lesion, above or below the vocal cords. Drooling, leaning forward for excessive secretions, or gagging is associated with supraglottic lesions, above the vocal cords. Coughing, “barky” cough, or hoarseness is associated with subglottic lesions, below the vocal cords. Although we think of this as wheeze vs. stridor the limitation of sound is in the need for sufficient respiratory effort to produce sound, the ambient noise on scene or in the ambulance,
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