[
    {
        "Introduction to Airway Management": "and welcome to chapter 11 airway management of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand the need for proper airway management including recognizing and measuring adequate and inadequate breathing maintaining an open airway providing artificial ventilation students will be able to demonstrate basic competency in applying these concepts to appropriate care through the use of airway adjuncts suction equipment oxygen equipment and delivery systems pulse oximetry continuous positive airway pressure which is cpap and resuscitation devices okay so let's get started the single most important step in caring for any patient is to address life threats and the primary component of this step is to ensure that they are breathing adequately when the ability to breathe is disrupted oxygen delivery to tissues and cells is compromised and oxygen reaches body tissues and cells through two separate but related processes breathing and circulation",
        "Anatomy of the Respiratory System": "so this figure on the slide illustrates the upper and lower airways of the human body and we're going to talk about the anatomy first of the respiratory system the respiratory system consists of all the structures that make up the airway and help us breathe or ventilate the airway is divided into that upper and lower airways so the anatomy of the upper airway the upper airway consists of all on atomic airway structures above the vocal cords okay so above the vocal cords so this is the nose mouth oral cavity the pharynx and the larynx the main function of this upper airway is to warm filter and humidify air as it enters the body okay so the first structure we're going to talk about is the pharynx and this is the muscular tube that extends from the nose and mouth to the level of the esophagus and trachea it's composed from top to bottom of the nasopharynx oral pharynx and the lowering geopharynx here's a a good cutaway picture of that fairness so the first one we're going to talk about inside the pharynx is the nasopharynx and it's lined with mucous membranes that filter out dust and particles it warms and humidifies air as it enters the body then there's the oropharynx that is posterior portion of the oral cavity the epiglottis and superior to the larynx helps prevent food and liquid from entering the layer next during swallowing here's another really good picture on the figure of the oral caffeine next we're going in the larynx so this is a complex structure formed by many independent structures made of cartilage it marks where the upper airway in the lower airway begins inside the larynx you have the thyroid cartilage which forms the v-shape it's also known as the adam's apple then you have the cricoid cartilage it's also called the cricoid ring it's the first ring of the trachea next is a cricoid thyroid membrane it's an elastic tissue that connects the thyroid and the cricoid inferiorly then you have the glottis you'll hear it called or term the glottic opening and is it is the area between the vocal cords it's the narrowest part of the adult airway next is the vocal cords and they are white bands of thin muscle tissue they are separated at rest and they produce speech and protect the trachea from the entry of substances like water and vomit then moving right along next we're going to go into the lower airway so from the upper into the lower divided by the larynx the function of the lower airway is to deliver oxygen to the alveoli and the elements of the lower airway so first you have the trachea and that is where air enters the air entry to the lungs it begins directly below the cricoid cartilage it descends anteriorly down the midline of the neck into the thoracic cavity so in the thoracic cavity the trachea divides in or at the corona into the two main stem bronchi which is the right and left and the bronchi are separated by cartilage they distribute oxygen to two lungs on entering the lungs each bronchus divides into ever smaller bronchi which divide into bronchiolis and here's a great uh slide it shows a figure of the trachea in the lungs in the lower airway you can see the trachea the alveoli the main bronchi going into smaller bronchi eye and then into bronchiolize okay from the bronchiolis are they are made of smooth muscle they dilate and constrict as oxygen passes through them so smaller bronchiolis connect to alveoli and at alveoli this is the site of oxygen and carbon dioxide exchange there's millions of thin walled balloon sacs and these alveoli are surrounded by blood vessels which are the pulmonary capillaries oxygen diffuses across the alveoli membrane into those pulmonary capillaries oxygen in the pulmonary capillaries is transported back to the heart and distributed to the rest of the body and carbon dioxide diffuses from the pulmonary capillaries into the alveoli where it is exhaled and removed from the body okay so the heart and the great vessels the vena cava and the aorta are known as the great vessels are also present in the thoracic cavity and are very important for respiration the mediastinum this is an area between the lungs and it contains the heart the great vessels the esophagus the trachea the major bronchi and many nerves okay so that's called the mediastinum the phrenic nerve is also found in the thorax this allows the diaphragm to contract which is necessary for breathing to occur so that's a very important nerve to remember and that is the phrenic nerve",
        "Physiology of Breathing": "all right so let's talk about some physiology of breathing the respiratory and cardiovascular systems work together to ensure that there's a constant supply of oxygen and nutrients and it's delivered to all of the cells of the body it also removes carbon dioxide and waste products from the cell the table on the slide defines ventilation oxygenation and respiration okay that's what we're going to talk about next so the process involved in ventilation oxygenation and respiration first ventilation the that's the physical act of air into the and out of the lungs and it's necessary for oxygenation and respiration to occur the first process of ventilation is inhalation this is the active muscle part of breathing during inhalation the diaphragm and intercostal muscles contract they create a negative pressure in that thorax and it allows air to enter the body and travel to the lungs so ventilation is active the lungs require the movement of the chest and supporting structures to expand and contract during inhalation and exhalation partial pressure that's the amount of gas in the air or dissolved in fluid such as blood so partial pressure of oxygen in the alveoli is 104 millimeters of mercury partial pressure of carbon dioxide in the alveoli is 40 millimeters of mercury deoxygenated arterial blood from the heart has a partial pressure of oxygen that is lower than the partial pressure of carbon dioxide in the pulmonary capillaries the body attempts to equalize the partial pressures which results in oxygen diffusion across the membrane into the blood oxygen and carbon dioxide both diffuse until the partial pressures in the air and blood are equal the mechanism of ventilation can be illustrated by using a bell jar so inhalation and checks chest expansion autonomic you'll see on the left side the bell jar on the right side exhalation and chest contraction autonomic left side and bell jar right side okay so inspiration delivers oxygen to the alveoli not all inspired air reaches the alveoli for gas exchange tidal volume that is defined as a measure of depth of breathing tidal volume for an average adult is about 500 milliliters then there's dead space and that's the portion of inspired air that fails to reach the alveoli okay so next we're going to talk about exhalation we talked about inhalation and that is an active process exhalation however is a passive process and that means that it does not require muscular effort the diaphragm and the intercostal muscles relax which decreases the size of the thorax and the smaller thorax compresses the air in the lungs into a smaller space and when that happens the air pressure in the thorax is higher in the in that space than it is in the outside so air is pushed out through the trachea regulation of ventilation involves a complex series of receptors and feedback loops that sense gas concentrations in the body fluids and send messages to the respiratory center in the brain to adjust the rate and depth of ventilation the body's need for oxygen is constantly changing and failure to meet the need may result in hypoxia a condition in which the tissues and cells of the body cannot get enough oxygen so if this is not corrected patients may die quickly so let's talk about hypoxic drive now this hypoxic drive differs from the primary control of breathing in that it uses oxygen to control breathing typically it's seen in patients with end-stage copd and some believe that administering high levels of oxygen will increase the amount of oxygen dissolved in the plasma and negatively affect the body's drive to breathe oxygenation so let's talk about oxygenation next that's the process of loading oxygen molecules onto hemoglobin in the bloodstream it's uh it's required for internal respiration to take place oxygenation does not guarantee that internal respiration is taking place and so ventilation without oxygenation can occur in places where oxygen levels in the breathing air may dip be depleted such as mines or confined spacious or high altitudes and so i like to think of it like this you're breathing normally but you don't have the amount of oxygen in the environment and so you're not getting that oxygen delivery to into the bloodstream okay and then respiration and that's the actual exchange of oxygen and carbon dioxide in the alveoli and in the tissues of the body so cells take energy from nutrients through a series of chemical processes known as metabolism metabolism is cellular respiration each cell combines nutrients and oxygen which produces energy and waste products mainly water and carbon dioxide are the waste products all right so let's talk about external respiration and this is pulmonary respiration so this is the process of breathing fresh air into the respiratory system and exchanging carbon dioxide and oxygen between the alveoli and the blood in the pulmonary capillaries surfactant reduces surface tension within the alveoli and keeps the it keeps them expanded and it makes it easier for gas exchange to occur next we have internal respiration so we just talked about external now it's internal this is what's going on inside the body and so internal respiration that's the exchange of oxygen and carbon dioxide between the systemic circulatory system in the cells of the body so internally oxygen passes from the blood into the capillaries to the tissues carbon dioxide and cells cell waste pass from the cells into the capillaries where they are then transported via the venous system back to the lungs all cells need a constant supply of oxygen to survive and when there is inadequate oxygen cells convert glucose into energy through an aerobic metabolism without adequate oxygen anaerobic metabolism takes place which cannot meet the metabolic demands of the cell",
        "Pathophysiology of Breathing": "all right so let's talk about some patho pathophysiology of the respiratory system and there are factors of the nervous system which have input in in the respiratory system so you have these chemoreceptors and the chemoreceptors monitor levels of oxygen carbon dioxide hydrogen ions and the ph of this cerebral fluid and provide feedback constantly to the respiratory centers when serum carbon dioxide or hydrogen ions levels increase the chemoreceptors in the nervous system stimulate the medulla to increase the respiratory rate and so respiratory rate increases because carbon dioxide and hydrogen levels are increased so stimulation from the pons affects the rate and depth of respirations okay so the next factor that we have that affects the respiratory system is the ventilation and a perfusion ratio or mismatch so when ventilation and perfusion has to be directed at the same place at the same time and failure to match ventilation and perfusion is a cause of most abnormal abnormalities of oxygen and carbon dioxide exchange so this is when ventilation is compromised but perfusion continues so blood passes over of the some of the alveoli membranes without gas exchange taking place this results in lack of oxygen diffusing across that membrane and carbon dioxide is also not able to diffuse out therefore it recirculates in the bloodstream so when perfusion across the avalon membrane is disrupted exchange of gases is prevented so effect factors that affect pulmonary ventilation and so we discuss intrinsic factors and so what this is is intrinsic so this is the body the body affecting that airway obstruction and you could have infections or allergic reactions or how about unresponsiveness and this is when that tongue blocks the passage of the um of the gas exchange then you have extrinsic factors so extrinsic something outside the the body and these factors could be um to cause the airway obstruction you could have trauma that's an example um then you have factors that affect respiration so you actually have the the um the factors that are affecting it you could again have external factors and that could be not enough uh the atmosphere pressure or partial pressure of the oxygen in that environment so that's something like say we're in a cave or we're up in denver and then you can have internal factors and this is such as conditions that reduce the surface area for gas exchange and it decreases the body's oxygen supply and so this is going to lead to an adequate tissue perfusion so that could be something like pneumonia pulmonary edema or copd so the next factor that could affect the respiratory system is we have the circulatory compromise and so this is when there's an obstruction of blood flow to individual cells and tissues and it can cause it could be related to trauma so you could have a simple or tension pneumo and um open pneumo which is a sucking test wound a hemothorax or a hemo pneumothorax and talk a lot about those in the respiratory emergencies chapter other causes of circulatory compromise could you could have blood loss or anemia hypovolemic shock or vasodilatory shock",
        "Patient Assessment": "okay so now we're going to talk about patient assessment of the respiratory system so patient assessment so wear a mask and protective eye wear that includes eye shields whenever airway management involves suctioning or air slicing generating procedures so that's you'll see it written as agp an aerosize generating procedure air slice generating procedures include cpr nebulizer treatments endotracheal innovation and continuous positive airway pressure next patient assessment wise one of the most important things is you need to recognize adequate breathing so signs of normal breathing for adults is 12 to 20 breaths a minute normal breathing you're going to have a regular pattern of inhalation and exhalation you're going to have bilateral so both sides clear and equal lung sounds you're going to have regular and equal chest rise and fall and it needs to be at an adequate depth this is also known as the tidal volume so abnormal breathing so signs of abnormal breathing it could be fewer than 12 breaths a minute more than 20 breaths a minute in the presence of shortness of breath and shortness of breath is also known as dipsnia you could have an irregular rhythm or diminished or absent or noisy auscultated breath sounds auscultated is when you're listening through stethoscope or listening to the breath sounds and reduce flow of expired air at the nose or mouth that could be a sign of abnormal breathing also unequal or inadequate expansion of the chest and this will result in reduced tidal volume so increase effort of breathing using accessory muscles and we'll talk about accessory muscles in a later chapter so the shallow depth that could reduce tidal volume as well and skin that is pale cyanotic cyanotic is blue cool or moist and moist you'll also hear it written as clammy skin and skin pulling in or around the ribs or above the clavicles during inspiration and that's also known as retractions a patient may appear to be breathing after the heart has stopped and so these occasional gasping breasts are called agonal gasps then you also have a pattern it's called cheyenne stokes respirations and they are often seen in patients with a stroke or head injury and this is because breathing with con this is an inc breathing with an increasing rate and depth of respirations followed by apnea a toxic respirations have an irregular or unidentifiable pattern and it may follow serious head injuries and then patients experiencing a metabolic or toxic disorder may display other abnormal respiratory patterns such as cushmal respirations and so couchsmall respirations those are deep rapid respirations and it's commonly seen in patients with metabolic acidosis so when the sugar is super high patients with inadequate breathing need to be treated immediately okay so how do we treat these inadequate breathing patients and so emergency medical care of it is we're going to do airway management supplemental oxygen and perhaps ventilatory support so assessment of respiration even though the patient may be ventilating appropriately the actual exchange of oxygen and carbon dioxide at the tissue level may still be compromised by several factors and so as we mentioned earlier it can be compromised by high altitudes poisonous gas gases such as carbon monoxide or enclosed spaces like perhaps cave um or some type of place where their oxygen is depleted at the patient's level of consciousness and skin color are excellent indicators of respirations when assessing patients consider proper oxygenation which can be assessed by a pulse ox so pulse oximetry and oxygen saturation spo2 is a measure of the percentage of hemoglobin molecules that are bound in arterial blood and so this seems pretty um pretty hard but all it is is the pulse ox it reads the reads the percentage of hemoglobin that is saturated and this sp02 should be greater than 94 when breathing room air in conditions such as a stroke or heart attack oxygen is applied when the spo2 is less than 94. pulse ox can take as long as 60 seconds to reflect changes in a patient's oxygen status the patient can develop respiratory insufficiency while well before the pulse ox values begin to decline so pulse ox is considered a routine vital sign and can be used as part of a patient assessment okay so end tidal co2 and that's the measurement of um of the maximal concentration of co2 at the end of an exhaled breath and a low co2 or carbon dioxide level could indicate hyperventilation or decrease co2 return to the lungs or reduce co2 produced at the cellular level a high co2 or high carbon dioxide level may indicate that the patient is retaining co2 and or apnea not breathing very well entitled co2 is measured using cabinometry and capnography devices so chemonometry refers to the use of a device that provides a digital metric reading of the end title carbon dioxide level encapnography produce provides both a numeric reading and a graph from breadth of breath so a normal range is from 35 to 45 millimeters mercury and this can be used in spontaneously breathing patients with an adequate airway using a special nasal cannula okay so next we're going to talk about very important step and that is opening the airway so emergency medical care begins with ensuring an open airway and rapidly assessing whether the unconscious patient has a patent airway and pulse and is breathing adequately so we need to position the patient in the supine position supine position unconscious patient should be moved as a unit because of the potential for a spinal injury into the supine position if they're not already in it and so in an unconscious patient the most common airway obstruction i cannot stress this enough is the patient's tongue and it's because it falls back into the throat when the muscles of the throat and tongue are relaxed so the most common area obstruction is the patient's tongue all right so opening this airway so you're going to open the airway with the head tilt chin lift maneuver and this will open the airway in most patients for patients who have not sustained or are not suspected of having any spinal cord trauma this simple maneuver is sometimes all that you need for the patient to resume breathing and so ten tilt chin lift maneuver is used when there is no spinal cervical spine injury suspected so what we're going to do is with the patient's supine you're going to position yourself beside the patient's head you're going to place the heel of one hand on the patient's forehead and apply firm backward pressure with the palm you're gonna place the fingertips of the other hand under the patient's jaw and lift the chin upward with the entire lower jaw helping to tilt the head back okay and so when there is spinal cord injury suspected we're going to use this method called the jaw thrust maneuver and the jaw thrust maneuver we're going to follow these steps so we're going to kneel above the patient's head we're going to place the fingers behind the angles of the lower jaw move the jaw upward using your thumbs and to help position the lower jaw and that is for the jaw thrust maneuver that is for cervical spine injury suspected okay so next we're going to talk about opening the mouth and even though you may have opened uh the airway with the head tilt chin lift or the jaw thrust maneuver the patient's mouth may still be closed and so to open the mouth we're going to place the tips of our index finger and thumb on the patient's teeth open the mouth by pushing your thumb on the lower teeth and the index finger on the upper teeth the pushing motion will cause the index finger and the thumb to cross over each other this is why it's called the cross finger technique so the photos on this slide it shows you how to perform that jaw thrust maneuver it shows you uh to kneel at the patient's head place your fingers behind the angles of the jaw move the jaw upward use your thumbs to help position the lower jaw and the completed maneuver should look like the second photo",
        "Suctioning": "okay so next we're going to talk about suctioning and suctioning you must keep the airway clear to ventilate the patient properly if the airway is not clear you will just force fluids or secretions into the lungs and this is going to result in a thing called aspiration so if you hear gurgling the patient needs suctioning suctioning equipment so there's a couple different kinds there's the portable suction and this is a hand operated it could also be a fixed which that means mounted and equipment and so a portable suction unit must provide enough vacuum pressure and flow to allow you to suction the mouth and nose effectively so hand operated suction units with disposable chambers are reliable effective and relatively inexpensive a fixed suction unit should generate airflow of more than 40 liters per minute with a vacuum of more than 300 millimeters of mercury when the tubing is clamped so a portable or fixed unit should be fitted with the following it should have a wide bore thick walled non-kinking tubing plastic or rigid pharyngeal suction tips these are called tonsil tips and also you could hear them called yankar tips the best kind of catheter for infants and children and the large diameter plastic tips are rigid and they don't collapse non-rigid plastic catheters these are also called french or whistle tip catheters they are used to suction the nose and liquid secretions in the back of the mouth and in situations when you cannot use a rigid catheter the portable fixed unit should be non-breakable with a disposable collection bottle and the water supply you should also have water supply for rinsing the tips before inserting any catheter measure the proper size and we use the same technique for measuring for an oropharyngeal so techniques for suctioning is what we're going to talk about next and you want to inspect your suction equipment regularly the steps to operate the suction unit is you're going to check the unit for proper assembly of course of all its parts turn the section unit and test test to see that the vacuum pressure goes up to more than 300 millimeters of mercury select the attachment and appropriate suction catheter to the tubing never suction the mouth or nose for more than 15 seconds for an adult 10 seconds for a child or 5 seconds for an infant suctioning can result in hypoxia so we're also going to rinse the catheter and tubing with water to prevent clogging we're going to repeat suctioning only after the patients have been adequately ventilated or re-oxygenated and do not touch the back of the airway with the suction catheter it can result in activating the gag reflex and so to properly suction the patient we're going to take a look at skill drill 11-3 in your book sometimes a patient may have secretions or vomit that cannot be suctioned quickly and easily and some units cannot remove objects such as teeth foreign bodies and food when this is the case you need to remove the catheter from the patient's mouth immediately log roll them onto the side and clear the mouth with carefully with a glove finger if the patient who requires assisted ventilation produces frothy secretions as quickly as they you can suction them suction the airway for 15 seconds less of course and infants and children then ventilate for two minutes continue this alternating pattern of suctioning and ventilations until all the secretions have been cleared from the airway okay so we talked about suctioning next we're going to talk about airway adjuncts and so basic airway adjuncts prevent obstruction obstruction of the upper airway by the tongue and allows for passage of oxygen and oxygenation to the lungs so the oral pharyngeal airways you're going to hear this called an op airway this keeps the tongue from blocking the upper airway and it also makes it easier to suction the oral pharynx so an indication of the opas or oropharyngeal airway is you have to have an unresponsive patient without a gag reflex in an apnic patient being ventilated with a bvm so contraindications of course are conscious patients or any patients conscious or unconscious who have that gag reflex an oral airway that is too large it can push the tongue back to the pharynx and block the airway and an oral airway that is too small could block the airway directly like any foreign body obstruction so to insert the airway properly you will see the skill drill 11-14 in your book and if you encounter difficulty inserting the oral airway an alternative method is to use an insertion of a 90 degree rotation and uh we're going to take a look at that or you could take a look at that on skill drill in your book 11-5 and that's that 90 degree rotation okay so after the oral pharyngeal airway adjunct the next object we're going to talk about is the np and this is the nasopharyngeal airway and this is used with patients who have that intact category flex but is unable to mean his or her own airway spontaneously and so indications of the npa is a semi-conscious or unconscious patient with an intact gag reflex so these are the gag reflexes that are intact patients who otherwise will not tolerate an opa airway okay so contraindications of the opa or npa i apologize so the npa is a severe head injury with blood draining from the nose also a contraindication of the mpa is a fractured nasal bone a history of that so to insert the airway correctly we're going to see skill drill 11-6 in your book",
        "Recovery Position": "all right so the next step or the next thing we're going to talk about with maintaining the airway is this recovery position this recovery position is is very important it is used to help maintain an airway in an unconscious patient who is not injured and is breathing on his or her own with a normal respiratory rate in an adequate tidal volume so this is an unconscious patient who is not injured okay the recovery position the patient is rolled onto his or her left or right side okay so next we talked about airway adjuncts opening the airways a recovery position next we're going to talk about supplemental oxygen so always give supplemental oxygen to patients who are hypoxic and this is because not enough oxygen is being supplied to those tissues and cells of the body some tissues and organs such as the heart central nervous system lungs kidneys and liver they need a constant supply of oxygen to function normally so we're never going to withhold oxygen from any patient who might benefit from it especially if you must assist the ventilations so next we're going to talk about the supplemental oxygen equipment so this equipment first of all we're going to the first equipment we're going to talk about is the oxygen cylinders and so the oxygen that you will give the patients it's usually supplies in a compressed green gap compressed gas it's a green still or aluminum cylinders so what you want to do is you want to check the cylinder is labeled for medical oxygen so we're going to look at the letters and numbers stamped into the metal on the collar of the cylinder we want to check the month and year that's stamped and this indicates when the cylinder was tested so aluminum cylinders are tested every five years and composite cylinders are tested every three most often the d or jumbo d cylinder size is what we're going to use the length of time you can use the oxygen cylinder depends on the pressure in the cylinder and the flow rate liquid oxygen is becoming more commonly used alternative to compressed gas oxygen you'll see that in hospitals all right so when we talk about supplemental oxygen there are some safety considerations and so we want to handle those gas cylinders carefully because the containers are under pressure and we want to make sure that the correct pressure regulator is firmly attached before we transport the cylinder a puncture or hole in the tank can turn into a deadly missile so secure the cylinders with mounting brackets when they are stored in the ambulance oxygen cylinders that are used during transport should be positioned correctly and secured next on these oxygen cylinders there's this pin indexing system on the neck and so what that does is each of these cylinders they have their the pin indexing system is specific to the gas type that is inside the bottle and this is through a pattern or a given number of pins and it's following accepted national standards so this pin indexing system prevents say an oxygen regulator being accidentally connected to an incorrect gas cylinder so when preparing and to administer the oxygen check that the pin holes on the cylinder exactly match the corresponding pins on the regulator so for large cylinders the safety system is the american standard safety system oxygen cylinders are equipped with threaded gas outlet valves and inside and outside these thread sizes vary on the gas and cylinder and this prism presents accidental attachment of a regulator to the wrong cylinder all right so the next part of this oxygen that we're going to talk about the oxygen is the pressure regulators and so what a pressure regulator does is it reduces the cylinder pressure um to a useful range for the patient so it's usually between 40 to 70 pounds per square inch or psi after the pressure is reduced to a workable level the final attachment for delivering the gas is one of the following so the regulators are either a quick connect female fitting that will accept a quick connect male plug from the pressure hose or regulator or it's a flow meter that will permit the regulator release of gas measured in liters per minute okay so there's either a quick connect female or a flow meter so the next we're going to talk about those flow meters and what a flow meter does is it's usually permanently attached to the pressure regulator on that emergency equipment and so you have a pressure compensated flow meter and incorporates a float ball within the tapered calibrated tube and it's affected by gravity and it must be always be upright so you're going to see these on a fixed position usually in the hospitals or inside the ambulances fixed to the wall next um type of gauge you're going to have is that borgdon gauge flow meter and this is a gauge that's calibrated to record the flow rate and you could use this in any position so on on the bottle say when the bottle is placed in the bag that's that borgdon flow meter",
        "Operating and Administering Oxygen": "so procedures for operating and administering oxygen so you're going to place the oxygen cylinder into service and administer medical oxygen to the patient through the skill drill on 11-7 and there's also hazards of supplemental oxygen so hazards of supplemental oxygen include combustion so oxygen it doesn't burn or explode but it speeds up the combustion process and so we want to keep any possible source of fire away from an area while oxygen is in use especially cigarettes so make sure the area is adequately ventilated especially in industrial settings and never use an oxygen accelerator standing never leave it standing in the standing position all right so oxygen toxicity and this is not all patients require high flow oxygen excessive supplemental oxygen can be detrimental it can have the detrimental effect on patients with certain diseases or illnesses and this is a chronic obstructive pulmonary disease or cerebral vascular accidents or cvas and myocardial infarction so mis oxygen toxicity refers to damage of cellular tissue due to excessive oxygen levels in the blood increased cellular oxygen levels contribute to the production of oxygen free radicals and this can lead to tissue damage and cellular death in some patients the international liaison committee on resuscitation guidelines and this is published by the american heart association recognize that there may be negative effects of oxygen toxicity and recommends the oxygen be administered to patients experiencing signs of an mi or of a myocardial infarction when they have signs of heart failure are short of breath or the room oxygen saturation is less than 94 and so patients experiencing signs of shock should be placed on oxygen hypoxia is much worse than oxygen toxicity so when in doubt or if unable to measure oxygen saturation reliably supplemental oxygen should be administered when the pulse ox is available tailor oxygen therapy to the patient's needs and administer the amount of oxygen necessary to maintain oxygen saturation at or above 94 percent and so that's very important very important need to know thing okay and so the american heart association says that they recommend oxygen be administered i'm just gonna read it again because it's important two patients experiencing signs of an mi when they have signs of heart failure shortness of breath or their room air saturation is less than 94",
        "Oxygen Delivery Equipment": "all right so oxygen delivery equipment that's what we're going to talk about next and these are um in general oxygen delivery equipment is used in the field it should be limited to non-rebreathing masks bag valve devices and nasal cannulas the first one we're going to talk about is that a non-rebreather so a non-re-breather mask it combines a mask with a reservoir bag system so oxygen fills this reservoir attached to the mask by a one-way valve exhaled gas escapes through this flapper valve port at the cheek areas of the mask and it prevents the patient from rebreathing exhaled gases you want to make sure that the reservoir bag is full before you place it on the patient and adjust the flow rate so that the bag does not collapse when the patient exhales so usually between 10 to 15 liters if the bag does collapse increase the flow rate so when oxygen therapy is discontinued make sure you remove the mass from the patient's face uh and these are available in adult pediatric and infant sizes all right after the non-rebreather we're gonna now we're gonna talk about the nasal cannula and this can deliver oxygen through smooth two small tube-like prongs that fit into the patient's nostrils it can provide 24 to 44 percent inspired oxygen when the flow meter is set at six or one to six liters for patient comfort flow rates above six are not recommended and this is used when patients have mild hypoxia and a patient who breathes through the mouth or it has some type of nasal obstruction they won't get any benefit from this so some emo systems provide humidified oxygen during extended transports because humidified oxygen may be associated with an increased generation of air sliced droplets of fluid compatible with transmitting diseases so just know that humidified oxygen can be associated with increased air slice droplets then you have partial re-breathing mask and there these are similar to non-rebreathers except there's a one-way valve between the mask and the reservoir and the patients re-breathe a small amount of their exhaled air that's a partial rebreathing mask okay next we need to talk about venturi mask and this has a number of attachments and they can vary the percentage of oxygen when a constant flow rate is maintained from the regulator so a medium flow rate delivers about 24 to 40 percent it depends on the manufacturer and so that's a good picture of the venturi mask it's on figure 11-41 then you have a trach mask so the tracheostomy mask this is for patients with tracheostomies and they do not breathe through their mouth or nose and so um you could see a figure on 11-42 tracheostomy masks cover just the trach hole and have a strap that goes around the patient's neck and these may be available in emergency setting or they may not be so in in which case if they are not available you should improvise by placing a face mask over the stoma that was a picture of the placing the face mask over the stoma",
        "Assisted or Artificial Ventilation": "all right next we're going to talk about assisted or artificial ventilation so basic airway and ventilation techniques are extremely effective when we administer oxygen appropriately so when we have to the signs and symptoms of inadequate ventilation are altered mental status inadequate minute volume in excessive accessory muscle use and fatigue so when we see this we need to assist a patient with their ventilations and we do this with a bag valve mask and so what we're going to do is we're going to explain the procedure to the patient if they are conscious if they're conscious we're going to place the mask over the patient's mouth and nose and we're going to squeeze the bag each time the patient breathes maintaining the same rate as the patient this is if the patient is conscious and breathing after the initial five to ten breaths we are going to slowly adjust the rate and deliver the appropriate title volume we're going to adjust the rate and tidal volume to maintain an adequate minute volume",
        "Artificial Ventilation": "so artificial ventilation so once we determine that the patient's not breathing we are going to begin artificial ventilation immediately and there are two methods so we're going to use the mouth to mass technique or the one or two person bag valve mass so normal ventilation versus positive pressure ventilation so artificial ventilations are necessary for life but they are not the same as normal breathing with normal breathing the diaphragm contracts and the negative pressure is generated in the chest cavity which sucks air into the chest but with positive pressure ventilation it's generated by a device and it forces air into that cavity with positive pressure ventilation what we're doing is we are increasing inner thoracic pressure and it causes compression of the vena cava so the vena cava and it could reduce blood return to the heart this produces uh reduces the amount of blood that's pumped by the heart so more volume is required to have the same effect as normal breathing and which pushes the air walls out of normal autonomic shape and so air is forced into the stomach it could cause gastric distension and could result in vomiting and aspiration so gastric distension is when you have air in the belly the emt must regulate the rate of volume and volume of artificial ventilations to prevent this drop in cardiac output and so when we want when we're doing the ventilation rates um for and this is for a person who is not breathing but still has a pulse okay so not breathing but has a pulse the adult rate is one breath every six seconds a child is one breath every two to three seconds and the infant is one breath every two to three seconds and so these these are ventilation rates for people or patients who are not breathing but they do have a pulse next we're going to talk about the mouth to mask or mouth to mask ventilation so a mouth to mouth or mouth mask so this is a barrier device and it's routinely used in mouth-to-mouth ventilations a mask with an oxygen inlet provides oxygen during a mouth to mass ventilation so that's those are two different devices and the most the one that we use is a bag valve mask and this provides less tidal volume than the mouth to mass ventilation but it delivers as much concentration of oxygen with the flow of 15 liters as the mask to face seal so bag mass devices the components of them are you have a disposable self-inflating mass no pop off valve or if one is present you should be able to disable it you have an inline a viral filter an outlet valve that is a true valve for re-breathing and you could also have an oxygen reservoir that allows for the delivery of high concentrated oxygen and that's the bag that you see in the back of this photo a one-way or no jam inlet valve system that provides an oxygen flow rate of the maximum of 15 liters with a standard of about 22 liters for face mask and endotracheal a transparent face mask and the ability to perform under extreme environmental conditions the valve the volume of air is based on observing the chest rise and fall and so the bag mass technique you're going to take a look at it so this is a two when you use the one person bvm technique it's on skill drill 11-8 in your book all right so gastric distension and gastric distension occurs when artificial ventilation fills the stomach with air it's most likely to occur when you ventilate the patient too forcefully or too rapidly with that bag mass device or the air is obstructed as a result of the foreign body or improper head position so give slow gentle breaths during your artificial ventilation and the breath should be over one second to prevent or eliminate this distension ensure that the patient's air is properly positioned so that patient's airway needs to be properly positioned so ventilate the patient at the appropriate rate and ventilate the patient at the appropriate volume if gastric distension makes it impossible to ventilate the patient with an advanced life support provider it is not available or if an advanced life support provider is not available to perform decompression administer or consider applying pressure over the upper abdomen this is the last resort if you um and so if vomiting occurs as a result turn the patient's entire body to the side you want to suction or wipe out the mouth with your gloved hand then return the patient to the supine position and continue the rescue breathing",
        "Passive Ventilation": "all right so passive ventilation passive ventilation this is sometimes called passive oxygenation or ethnic oxygenation and it's when the air movement into and out of the chest cavity occurs passively as a result of compressing the chest and so when the chest is compressed air is forced out of the thorax as the chest recoils following that compression the negative pressure is created within the chest which results in a vacuum so air is sucked into that cavity the chest cavity similar to what occurs with the muscle contraction during an active inhalation passive ventilation can be enhanced by inserting an op airway and providing supplemental oxygen",
        "Automatic Transport Ventilator": "all right so next we're going to talk about an automatic transport vent and it's you'll see it written atv or resuscitator so the atv is a ventilation device and it's attached to a control box and allows the variables of ventilation to be set it frees an emt to perform tasks such as maintaining the mass seal or ensuring continued airway patency so it's consists a constant reassessment of the patient is necessary",
        "Continuous Positive Airway Pressure": "right the next thing we're going to talk about is a continuous positive airway pressure and this is a cpap device you'll hear it as a cpap device it's a non-invasive vent support for patients who have respiratory distress so many people diagnosed with obstructive sleep apnea wear a cpap unit at night to maintain their airway while they sleep and cpap in pre-hospital environment has proven to be an excellent adjunct in the treatment of respiratory distress associated with copd acute pulmonary and acute bronchiospasm so cpap is becoming a widely used emt tool at the emt level so what it does is cpap just like it sounds it increases the pressure in the lungs it opens those collapse alveoli and pushes the oxygen across that alveolar membrane and forces interstitial fluid back into pulmonary circulation the therapy is typically delivered through a face mask held to the head with strapping system a good seal with minimal leakage between the face and the mask is essential many cpap systems use oxygen as the driving force to deliver the positive vent pressure to the patient and patients benefit the most from cpap during exhalation so use caution with patients with potentially low blood pressure because cpap causes a drop in the cardiac output all right so why you would use this and that's the indication why you would use the cpap devices so you have to the patient has to be alert and able to follow commands if they go unconscious you have to immediately remove it so the patient is displays obvious signs of moderate to severe respiratory distress from a condition such as pulmonary edema or copd respiratory distress occurs after the submersion incidence so the patient is breathing rapidly such such that the effects uh overall it affects the overall minute volume and the pulse ox reading is usually it has usually less than ninety percent",
        "Contraindications for CPAP": "all right contra indications country indications are when you should not use it so um if the patient's in respiratory arrest of course uh or agonal respirations if the patient is hypoventilating the patient cannot speak if the patient's unresponsive or otherwise unable to follow verbal commands you should not use it if the patient cannot protect his own airway and you should not use it if the patient is hypotensive you should not use it if they have any type of signs or symptoms like a pneumo thorax or chest trauma or of course if they have a tracheostomy you can't use it if they have active gastro bleeding gastrointestinal bleeding or vomiting patients if they have any facial trauma or if they're in cardiogenic shock you can't use it if the patient cannot set up right see you cannot use it if the cpap system it cannot or you cannot properly fit it to the patient and if the patient cannot tolerate a mask do not use cpap all right so cpap is uh fun to put on and uh the components of the unit are you'll have a generator to provide the pressure you're gonna have a mask of course you're gonna have the tubing that connects the two there should be a bacterial filter and also a one-way valve and so the cpap generator what happens is it creates resistance throughout the pulmonary cycle and or the respiratory cycle and the resistance creates a back pressure into the airways and that pushes open the smaller airway structures such as the bronchioles and the alveoli as the patient exhales the amount of pressure can be determined by adjusting the valve within the cpap system or a separate valve can be attached and so a pressure of 7 to 10 is generally an acceptable therapeutic range most cpap units are powered by oxygen so it's important you have to have a full cylinder when you're using the cpap and so to use cpap you could visit the skill drill on 11-9 so chapter 11-9 in your book complications of cpac so some patients may find cpap claustrophobic and resist the application of that mask and so when this happens you need to coach patients through the process rather than forcing the mask on them due to high volume of pressure generated by cpap there is also the risk of a pneumothorax and so a hole in the lung high pressure in the chest can lower the patient's blood pressure that's a complication and also if the patient shows signs of deterioration you need to remove that cpap and begin positive pressure ventilation using a bvm attached to high flow oxygen all right so the next thing we're going to talk about in this airway chapter is special consideration and so special consideration of the airways includes stomas and tracheostomy tubes and so with this the patients they have had a laryngectomy and they have a permanent tracheal stoma which is an opening in the neck that connects the trachea directly to the skin this is known as a tracheostomy if the patient has a tracheostomy tube we ventilate it through the tube with a bvm the standard 15 to 22 millimeter adapter on the bvm will fit onto the tube of a tracheal stoma we want to use 100 oxygen attached directly to the bvm if the patient has a stoma but no tube we can use an infant or a child mask with the bvm to make the seal over the stoma so seal the patient's mouth and nose with one hand to prevent the leak of air through the upper airway and ventilate through the stoma so release the seal of the patient's mouth and nose for exhalation this allows the air to exhale through the upper airway if you cannot ventilate a patient with a stoma try suctioning the stoma with a with the mouth of a french or soft-tipped catheter and seal the stoma while giving mouth-to-mouth ventilation",
        "Foreign Body Airway Obstruction": "all right so the next thing we're going to talk about with the airway is a special consideration is a foreign body airway obstruction so if an obstruction completely keyword is completely blocks the airway this is a true emergency it's going to result in death if not treated immediately in a child sudden foreign airway body obstruction usually occurs during a meal sorry in an adult in a child it can occur when eating in a child they could be playing with small toys or crawling around the house so uh varies in a child with the adult it's usually during the meal so by far as we mentioned earlier the most common airway obstruction in an unconscious patient is that tongue and that is because once again it relaxes back and falls into the back of the throat so causes other causes of airway obstruction that do not involve foreign bodies so this is not involving foreign bodies could be swelling from infection or allergic reactions acute such as anaphylaxis with these repeated attempts to clear the airway could be dangerous these patients they need specific emergency medical care and rapid transport to the hospital is crucial right okay and so another airway obstruction could be trauma and this could be related to tissue damage from that injury so you need to recognize this airway obstruction and so when you have a mild airway obstruction so there's different levels that we're going to talk about next mild airway obstruction this is when the patients can still exchange air but they have varying degrees of the respiratory distress so take great care to prevent this mild airway obstruction to becoming the severe airway obstruction so the patient may have noisy breathing they may be able to cough but with air exchange the patient can uh cough forcefully although you may hear wheezing between coughs wheezing between coughs that's the production of a whistling sound during respiration so as long as a patient can breathe cough forcefully or talk you should not interfere with the patient's efforts to try and expel that foreign body and so continually reassess the patient's condition so when you have this mild airway obstruction the key term the key thing is they're still able to exchange a lit some error and so what you want to be is the cheerleader and you just encourage them and continually reassess with poor air exchange the patient is weak and effective cough and may have increased difficulty breathing and this could be strider or cyanosis strider indicates that mild airway upper upper strider's upper treat immediately as if there is a severe airway obstruction and then of course the severe airway obstruction so this is a patient who cannot breathe or talk and with these patients you want to um they also might be clutching or grasping at their throat when they grasp out their throat that's that universal distress sign and they may also be turning cyanotic and they could have extreme difficulty breathing so there is a little or no airway movement with the severe upper obstructions and if the patient is found unresponsive does not appear to be breathing and does not have a pulse we want to begin cpr with high quality chest compressions when you open the airway and attempt the two ventilations following chest compressions it will be obvious if the airway is blocked so if there is no chest rise or fall after several attempts to ventilate or if you feel resistance when ventilating consider the possibility of that airway obstruction all right so next we're going to talk about the amer uh the emergency care for uh the foreign body airway obstruction so perform that head tilt chin lift maneuver to clear the tongue if spinal trauma of course we're going to use that jaw thrust maneuver so when large pieces of vomited food mucus dentures or blood is in the mouth sweep the mouse should be swept forward and out of the mouth with your glove finger so one available suction uh to maintain the airway all right so abdominal thrusts are the most effective method of dislodging and or forcing an object out of the airway of a conscious patient abdominal thrust or for conscious patients so what happens is residual air always present in the lungs is that you're compressing it upward to expel that object so we're using the abdominal thrust until the object dislodges or until the patient becomes unconscious and so what happens is abdominal thrust conscious patient now for the unconscious patient with the foreign airway obstruction we're going to reassess to confirm apnea and the inability to ventilate so when this patient is unresponsive we're going to begin chest compressions as we would for cpr following 30 compressions and then two breaths so at the completion of the 30 compressions pull the jaw open and look at the back of the oral pharynx to see if you could see any foreign objects if you see an object remove it with your glove finger or suction so never perform blind sweep to the back of the oropharynx because it could push the object further down the airway and it could make that obstruction worse so once the object is removed or if the object was seen attempt eventually if you are still unable to ventilate we're repeating the process of the 30 compressions to the two breasts all right so dental appliances and they could become a cause of airway obstructions so perhaps a crown or a bridge or some pieces of braces so we're going to manually remove the appliance before we provide ventilations leaving well fitting dentures in place makes bdm or bag valve mask easier so if it's well fitting we're going to leave it and this is because it provides a structure and it could help to provide a good face to mass seal if they're well fitting but loose dentures of course that interfere with the process should be removed if possible place to dislodge dentures in a container and transport them to the hospital with the patient all right so next another special consideration is facial bleeding and so airway problems can be particularly challenging in patients with this serious facial injuries the blood supply to the face is very rich so it results in severe tissue swelling and bleeding and this could be into the airway so you want to control bleeding with direct pressure and suction as necessary okay so now we're going to talk a little bit about assisting with a advanced life support procedures all right so when a critical patient needs an advanced airway intervention the paramedic will perform the skill but the emt is going to play an essential role in helping set up for the procedure and performing bls airway and ventilation maneuvers and helping monitor the patient so we're going to assist with the placement of this advanced airway okay so we're going to do the endotracheal innovation we're going to assist with that and the first step is pre-oxygenation which often includes bag valve mass ventilation and so we're going to when we're doing the bdm we're going to include an opr and np and ensure a proper seal ventilation rate a proper ventilation a volume of ventilation and allow for the time for the patient to exhale so bro next we're going to maintain a high flow nasal cannula on the patient during the pre-oxygenation phase and leave the nasal cannula in place during the innovation attempt this is called pre-oxygenation so for the equipment setup the personal protective equipment includes face mask and an eye shield we're going to have suction unit with rigid tonsil tip or non-rigid whistle tip catheters we need a laryngoscope handle and blade magnel forceps the et tube there is going to be a stylet or a tube introducer um so this is the the gum elastic bougie we need water soluble lubricant a 10 ml syringe confirmation device commercial et tube securing device we have to have alternate airway management devices such as a supraglottic or a craig kit available and then performing the procedure so remember six typical steps by using the b magic mnemonic okay so we want to the b magic so b is to perform the b bag valve mass preoxygenation e we're evaluating airway difficulties m we're going to manipulate the patient a is attempt the first pass innovation g is used as supraglottic airway if unable to innovate and c is to confirm success and the correct uh any issues so monitor the signs for a potential compensation so absence of end tidal absence of or decreasing spo2 or increasing resistance when we're ventilating so other physical signs of poor ventilation and perfusion and improper positioning or dislodgement of the et2 we're going to monitor for okay so this has concluded the airway management lecture next we're just going to go through some of the questions at the end of the review the review questions at the end of every chapter in the book okay so breathing is controlled by the area in the do you remember where that was controlled breathing is controlled by the pons and the medulla and they are the respiratory centers in the brain stem so b all right the emt should assess the patient's title volume by how are we assessing the tidal volume hey we're looking for that chest rise and fall and so we're um the volume of air that is moved in and out of the lungs in a single breath and we're looking for through the chest resin fall okay so in a healthy individual how are we breathing what's our stimulus and this is going to be increased levels of carbon dioxide in the blood okay so carbon dioxide is that waste product as that waste product increases in the blood it's going to stimulate the brain stem to change the breathing okay so it's c c under the control rising carbon dioxide levels are going to stimulate us to breathe all right number four signs of adequate breathing and an adult include all of the following except so accept all right so we know that the one on here that is not normal uh adequate breathing is going to be that shallow chest rise shallow chest rise all right during insertion of an op airway into an unconscious patient she begins to vomit what are we going to do in the very very very first thing very first thing that you want to do is whenever you begin the vomit you want to immediately turn the patient you would think that you would want to remove that op no we're going to remove we're going to turn that patient on to the side okay in which of the following patients would an np airway be contra indicated so this is when we're not going to use it so all right so probably i would think it would be a patient who fell 20 feet and landed on his or her head very good so severe head injuries or facial injuries we do not want to use them and this is because there could be some type of fracture we do not want to insert that np right into their brain okay so number seven you're delivering oxygen to a patient with a nasal cannula for leaders when he begins to complain of burning in the nose what should we do and this is because it's dry and over a prolonged period of time it could dry those mucous membranes and so humidified oxygen will be much better of course and so the correct answer is we could hook it up to humidified oxygen all right a patient's found unconscious after falling from the third floor window his respirations are slow and irregular what should we do okay it doesn't say anything about something in his uh airway so we don't need the suction we're not doing a non-rebreather we need to bag for them so we're gonna assist bagging this patient it says slow and irregular okay so d slow and irregular respirations we're going to back for them all right and so when ventilating an apnic adult with a bvm you should squeeze the bag and we know we're going to do the visible chest rise that's it we don't want a gastric distension all right so we're going to do ventilate the patient at a if 10 breaths per minute one every six seconds and we're only doing it until visible chest is noted chest rise all right and then finally number 10 you and your partner are ventilating an aptnic patient when you notice that the stomach is getting bigger and it's becoming distended what should we do okay we need to decrease the ventilation rate but use more volume nope increase the rate no we're going to reposition the head so you want to first reposition the head maybe perhaps and this could be because um the head is not in the correct positioning and air is just entering down into the esophagus so b was the correct answer we're going to reposition the head okay so this concludes the lecture for airway management thank you for listening and have a good day"
    },
    {
        "Introduction": "hello and welcome to chapter 16 respiratory emergencies of the emergency care and transportation of the sick and injured 12th edition",
        "National EMS Education Standard Competencies": "after you complete this chapter in the related coursework you will understand the significance and characteristics of respiratory emergencies in infant child and adult populations you will be able to demonstrate a fundamental comprehension of the following topics respiratory anatomy and physiology pathophysiology signs and symptoms of various respiratory ideologies including asthma copd and pneumonia and the assessment and management necessary to provide basic care in a pre-hospital setting so let's start emts will often encounter",
        "Introduction to Dyspnea": "patients complaining of dyspnea and so what is dypsnia dyspnea is difficulty breathing okay so dipsnia can be caused by many different conditions it can be caused um and the cost can also be difficult to determine so even without a definitive diagnosis you may still be able to save the patient's life so to understand this let's talk a",
        "Anatomy of the Respiratory System": "little bit about the anatomy of the respiratory system and if you've already listened to the airway chapter a lot of this is going to be a review for you okay so let's get started the respiratory system consists of all the structures that contribute to breathing and these include the diaphragm the chest wall muscles and also what we call accessory muscles and nerves from the brain and spinal cord to all these muscles all right so the upper and lower airway uh first we're going to talk about the upper airway and they consist of all the auto atomic structures above the vocal cords above the larynx right and so um or the larynx and above so you have the nose and the mouth the jaw the oral cavity the pharynx and then the larynx and this is a good picture this slide shows a good picture of the division of the upper and the lower airway right there at the larynx you could see this the division okay the principal function of the lungs is respiration and that's the exchange of oxygen and carbon dioxide air travels through the trachea into the lungs and then on to the bronchi eye bronchioles and then the alveoli and that's where the actual exchange takes place of the gases",
        "Physiology of Respiration": "let's talk about the physiology of the respiration so there are two processes and it occurs during respiration so during respiration you have the inspiration and the expiration oxygen is provided to the blood and carbon dioxide is removed and in healthy lungs this exchange of gases takes place rapidly at the lever of the alveolae and this figure shows an up close exchange of that oxygen carbon dioxide\nwithin the alveoli okay so the alveoli lie against the pulmonary capillary vessels and oxygen passes freely through these tiny passages in the alveolar wall into the capillaries through a process called diffusion and it is then carried to the heart which pumps oxygen throughout the body carbon dioxide returns to the lungs and is exhaled out of the body the brain stem it can sense the level of carbon dioxide in the arterial blood and if the level of carbon dioxide drops too low the person will breathe slower then if the level of carbon dioxide raises in the in the blood above normal the person will breathe more rapidly and more deeply",
        "Pathophysiology": "all right so some of the pathophysiology so a proper exchange of oxygen and carbon dioxide can be hindered and this can happen by abnormal conditions in the anatomy of the airway okay so like a process where it's blocked okay and then also disease process or some traumatic conditions and also abnormalities in the pulmonary vessels can cause oxygens change to be hindered so as an emt you have to be able to recognize the signs and symptoms of inadequate breathing and you need to know what to do about it all right so carbon dioxide retention and a hypoxic drive and we're going to talk a little bit about carbon dioxide retention and why somebody would retain carbon dioxide okay so patients will sometimes have elevated levels of carbon dioxide in their arterial blood and if the levels remain elevated for years the respiratory center in the brain will not function properly and these are patients such as chronic obstructive pulmonary disease patients with these patients the exhale or getting the co2 out through the alveoli is hindered okay and so they maintain for years they can have an elevated of carbon dioxide levels in their blood so the brain at that point gradually acclimates to high levels of carbon dioxide and then it switches to this backup system and this backup system to control breathing is based on low levels of oxygen and this is known as a hypoxic drive all right so carb so copd chronic obstructive pulmonary disease patients which maintain higher levels of carbon dioxide in their arterial blood they switch to what's known as a hypoxic drive so use caution we always say when administering oxygen to these patients all right so causes of the of dipsneh so",
        "Causes of Dyspnea": "dypsnia can be caused by many different conditions and so altered mental status may be a sign that the brain is hypoxic so patients often have difficulty breathing or hypoxia with some of the following medical conditions all right so pulmonary edema and what this is is the lungs you have fluid so edema fluid in the lungs hay fever pleural effusion obstruction of the airway hyperventilation syndrome environmental or industrial exposures carbon monoxide poisoning or drug overdose can all cause hypoxia or difficulty breathing\nokay so be aware that one or more of the following situations may exist in a dis dipsnic patient okay so just breathing too fast patient breathing too fast dips think all right so gas exchange between the alveoli and the pulmonary circulation could be obstructive it could be obstructed by fluid or an infection or perhaps a collapsed alveoli okay so that's at the pulmonary alveoli when it at the exchange the alveoli are damaged and cannot transport gas properly across the wall the air passages are obstructed by maybe a spasm or mucus or weakened also blood flow to the lungs could be obstructed by a blood clot and the pleural space is filled with air or excessive fluid so that the lungs cannot properly expand so all those conditions can cause a patient to breathe fast okay and so this is a table and this is going to show the signs and symptoms of inadequate breathing it's written kind of small so if you can't see it it's going to be table 16-2 in your book right dypsnia is a common complaint patients with cardiopulmonary diseases all right so if you break that down it's heart and lung diseases cardiopulmonary alright so congestive heart failure causes the heart to pump ineffectively and deprives the body of oxygen and severe pain can cause a patient to experience rapid shallow breathing without the presence of a pulmonary primary pulmonary dysfunction",
        "Upper or Lower Airway Infection": "all right so let's talk about upper and lower airway infections okay so we'll break it down infectious diseases cause dipsnia may affect all parts of the airway okay so oxygen is a problem um if uh inadequate oxygen is delivered to the tissues the primary causing dipsnia is always come from is always some form of obstruction okay so the obstructions that could come from an infectious disease could be mucus and secretions which obstruct uh airflow of the major um passages so maybe a cold or diphtheria you can also have swelling of the soft tissues of the upper airways all right so in children we see a lot of epiglottitis or croup and those are upper airway infections you're going to get some um what we call strider that's the sound that's produced it's a seal bark it's stridor okay and then impaired oxygen of gases in the alveoli itself and that's pneumonia so when the the infection is lower in the lower airways so you have to be diligent about the use of protective equipment when you're ppe when you're in contact with these patients who have those infectious diseases okay all right and so now we're just going to",
        "Croup": "go on through some of these upper airway infections okay so first you have croup and we just mentioned it this is uh typically in children you'll hear it's an inflammation and swelling of the pharynx larynx and trachea and it's typically seen in children between about six months to three years old the hallmark signs of croup are strider and a seal bark cough now croup is good it responds well to administration of humidified oxygen okay so it's an inflammation responds well to humidified oxygen",
        "Epiglottitis": "all right you have epiglottitis that's another upper airway infection usually typically in kids okay it's an inflammation up right what it sounds like of the epiglottis and it's usually a result of bacterial infection so more predominant children once again but it can also happen in adults and so what's going to happen you're going to see these children they're in the tripod position sitting upright holding themselves up and they'll be drooling so treat them gently because we don't want to get them to cry don't want to get them all wound up right position comfortably provide high flow oxygen and do not put anything in their mouths okay",
        "Respiratory Syncytial Virus": "next we have rsv rsv is common and it's a very common illness in children and causes an infection in the lungs and breathing passages and this leads to bronchitis and pneumonia it's very contagious rsvp is very contagious so assess for signs of dehydration and treat airway and breathing problems appropriately",
        "Bronchiolitis": "all right and then next we're kind of slowly moving down into the bronchioles and if you break this word apart you can see it's bronchiolitis and just what it sounds like it's a it's a type of infection this is a viral inlandness that occurs um it occurs because of the rsv and usually affects newborns and toddlers and it's the bronchioles become inflamed they swell and they fill with mucus and so we need to provide oxygen therapy and frequently reassess for signs of respiratory distress",
        "Pneumonia": "all right now moving down even further from the bronchials we're going down into the lungs and where we have pneumonia all right so pneumonia is a general term that refers to an infection in the lungs and it's often a secondary infection that begins after some type of upper respiratory tract infection has moved low and so just with gravity kind of goes on down and it's a bacterial pneumonia it will come on quickly and result in high fevers then if you have the viral pneumonia it might present more gradually and is less severe all right so bacterial is quick pneumonia could be a slower gradual onset so pneumonia especially affects people who are chronically or terminally ill so assess a temperature determine the presence of fever alright so fever is a big sign with that it's a body still trying to fight this infection and you're going to have an elevated temperature all right and so provide airway support and supplemental oxygen",
        "Pertussis": "all right then you have pertussis this is whooping cough and it's an airborne bacterial infection that mostly affects children younger than six okay and so patients will have a fever and exhibit the whoop sound and that's how it's got that name whooping cough um on inspiration after a coughing attack okay so it's again very highly contagious and is passed through droplet infection so watch for signs of dehydration and suction may be necessary",
        "Influenza Type A": "all right so influenza type a is the next thing we're going to talk about and this is all still the infectious disease section of the respiratory chapter okay so influenza type a it's an animal respiratory disease that has mutated and it infects humans it's transmitted via direct contact with those basal secretions and aerosolized droplets from coughing symptoms include high fever cough sore throat muscle aches headache and fatigue and it may lead to pneumonia or dehydration",
        "COVID-19": "all right and so coven 19 sars cov2 this is what we're living in right now real life real time so it's a coronavirus similar to one that causes the common cold preferably attacks the elderly patients living in close quarters with one another and those with weakened immune systems young and healthy adults can also be infected it's transmitted through the droplets through airborne particles generalized by sneezing or coughing and by direct contact so symptoms include high fever cough inspirational chest pain vomiting diarrhea and an inability to smell okay so respiratory deterioration may occur rapidly",
        "Tuberculosis": "all right and then tuberculosis you'll hear it called tb referred to it as tuberculosis is a bacterial infection that mostly caught mostly affects the lungs but it can also be found in almost any other organ so it can remain inactive for years before producing any symptoms patients often complain of a fever cough or fatigue night sweats and weight loss and it's the prevalence is higher in homeless people prison inmates nursing home residents and persons who abuse iv drugs or alcohol and those with hiv so if you expect your patients may have tb you need to wear at a minimum your gloves eye protection and an n95 respirator okay",
        "Acute Pulmonary Edema": "all right so now we're going to move out of those transmittable diseases now we're moving into other respiratory conditions and so the first one we're really going to talk about is pulmonary edema okay so the left side of the heart cannot remove blood from the lungs as fast as the right side can deliver it you could start to have pulmonary edema so fluid back up within the alveoli and in the lung tissue so it's usually a result of a thing called congestive heart failure and what congestive heart failure is is uh when the muscle of the heart um cannot pump and keep up it's not strong enough to keep up with the with um basically uh the fluid okay so patients usually experience diphtheria with rapid shallow respirations in severe cases they may have frothy pink sputum which is coming out of their mouth and nose and so it's backing up all the way up out of the trachea the tubes okay so most patients have a long history of chronic congestive heart failure that can be kept under control with usually with medications but not all patients with pulmonary edema have heart disease okay all right so this figure it's going to show uh fluid in the alveoli so you can see the front pulmonary edema fluid fills in the alveoli and separates from the capillaries from the alveolar wall and it interferes with gas exchange and carbon dioxide exchange of course because there's food in there",
        "Chronic Obstructive Pulmonary Disease": "all right so um pulmonary edema which we associate with chf or and then the next major one is going to be chronic obstructive pulmonary disease now this is um you'll hear it copd okay so this is a big one that you'll see a lot and it's a lung disease characterized by chronic obstruction of airflow that interferes with normal breathing and is not fully reversible okay so it's an umbrella term used to describe a few lung diseases and these include emphysema and chronic bronchitis okay and so usually it's some type of tobacco smoke which has um um in the bronchial it's irritated the bronchial a bronchial and can create chronic bronchitis right bronchitis an ongoing irritation of the trachea and the bronchi okay and with uh bronchitis excessive mucus is constantly being produced constantly and what that does is it obstructs the small airways and the ideal life all right so when you have this obstruction the airways are weakened and the protective cells and lung mechanisms that remove form particles are destroyed and so chronic oxygenation problems can lead to right-sided heart failure and fluid retention and then pneumonia can easily develop okay so repeated episodes of irritation and pneumonia this scars the lungs in some dilation of the obstructive alveoli it leads to chronic obstructive pulmonary disease okay so\nemphysema is the most common copd so emphysema emphysema is this last loss of elasticity material in the lungs and as a result of chronic stretching of that alveoli okay so smoking can directly destroy the elasticity of that lung tissue and most patients with copd have elements of both chronic bronchitis and emphysema this is a great photo great photo of the examples of copd and how it affects the alveoli and so you have that normal lung then you have this inflamed lung with the blockage of the caused by infection and mucus and then that complete obstructive and then that dilated alveoli or alveolus you could see it it's malformed now okay so you have the malform alveoli and of course it's going to make it crazy hard for that exchange of oxygen you know dioxide and oxygen across the membrane all right so you're going to hear wet lungs versus dry lungs and you'll hear people talking about this okay and so what what how we usually describe it is patients with pulmonary edema it's just what it sounds like pulmonary fluid caused by most often congestive heart failure will have wet lungs in these wet lung sounds we call them bronchi or crackles and you're going to hear that very very often when you listen to lung sounds you'll hear terms crackles and ravioli or crackles and broncos and patients with copd those are dry lung sounds dry lung sounds are wheezes all right so do not assume though that all copd patients will have wheezing and that all chronic congestive heart failure patients will have crackles but treatment of the patient we want to treat the patient not the lung cells okay",
        "Asthma, Hay Fever, and Anaphylaxis": "all right so next we have hay fever asthma and anaphylaxis and and why we have these all grouped together why they're all grouped together is because all of them are result from some type of allergic reaction that's been inhaled ingestion ingested or injected okay so all of these hay fever asthma or anaphylaxis they are all caused by some type of allergen okay all right so when it comes to asthma asthma is a basically as acute spasm of the bronchioles and this is associated with excessive mucous production and swelling of those that mucus lining in the respiratory passages so on this slide you could see a really good figure of a normal um airway um and then a b is that obstructed airway okay because the mucus obstructing the bronchiole right so affects all ages but in is most prevalent in children between like five and 17 years of age asthma is and so it produces a characteristic wheezing as a patient attempts to exhale through a partially obstructed airway so remember we said chronic obstructive pulmonary disease patients they also have dry dry lung sounds that's wheezing okay so an acute asthma attack may be caused by an allergic reaction and that could be some type of food or allergen and it attacks may also be caused by some type of emotional distress or exercise or respiratory infection and in in most severe form an allergic reaction can cause what's called anaphylaxis okay all right so hay fever and hay fever causes cold like symptoms including a runny nose sneezing congestion and sinus pressure so symptoms are caused by an allergic reaction usually some type of outdoor airborne allergens so some people say oh the pollen the pollen in the air it's it's me i had it's creating hay fever all right and then you have anaphylactic reactions okay so this is just a deteriorating another category and anaphylactic reactions are severe allergic reactions and this is characterized by severe airway swelling and dilation of blood vessels all over the body okay so it may be associated with hives itching signs of shock signs of similar similar to asthma the lung sounds okay the airway can swell so much that it can totally obstruct the airway so epinephrine is the treatment of choice and oxygen and of course antihistamines are very helpful",
        "Spontaneous Pneumothorax": "okay so we just moved through we did infectious diseases and then we did airway swelling right different airway swellings now we're going to talk about spontaneous pneumos so pneumothorax what is pneumothorax and so pneumothorax is the partial or total accumulation of air in the pleural space okay and so it's most often caused by trauma but may all also be caused by some type of medical condition so a pneumothorax it could be a spontaneous pneumothorax just happening all of a sudden right and so in this photo you could see a real good photo of that and it's a vacuum-like pressure in the pleural space keeps the lungs inflated so when the surface of the lung is disrupted air escapes into this pleural cavity and the negative vacuum pressure is lost okay so spontaneous pneumo occurs in a patient with certain chronic lung infections or sometimes in young people born with weak areas in the lungs a patient with a spontaneous pneumo becomes dipsnic and might complain of pleural ad pleuratic chest pain okay um so breath sounds are absent or decrease on that side and it has a potential to evolve into a very life-threatening uh pneumothorax okay",
        "Pleural Effusion": "all right so then we have pleural effusion so we just did some some pneumos pleural effusion so this is basically a collection of fluid inside the lung all right and so it compresses the lung and causes dyspnea it can be caused by irritation infection chronic heart failure or cancer and so breast sounds will be decreased all over that area where that effusion is and so patients feel better if they are sitting upright okay",
        "Obstruction of the Airway": "all right and then of course you have some type of obstruction of the airway and so with the patient with dipsnia they may have a mechanical obstruction all right so in a semi-conscious or unconscious the airway may be a result the obstruction may be a result of vomit for an object or improper positioning of the head or also the most common cause is that tongue right so tongue to block the airway if the patient was eating just before the onset of dyspnea we always consider that it could be what do you think could be a possible foreign airway body obstruction from eating right all right and so this figure shows the obstruction of the airway such as uh food is lodged in the airway so mechanical obstruction can also occur when the head is just not properly positioned it causes that tongue to fall back okay",
        "Pulmonary Embolism": "all right and then you have a pulmonary emboli a pulmonary embolus is anything in the circulatory system that moves from its original origin maybe a distinct site and then lodge is there so it obstructs the blood flow in that area right in the pulmonary area okay so circulation can be cut off completely or partially an emboli can be fragments of a blood clot in an artery or vein that broke off and just travels through the bloodstream or it could be foreign bodies such as a bubble of air so pulmonary implies a blood clot that circulates through the venous system and the right side of the heart and then lodges in the pulmonary artery\nsigns and symptoms of pulmonary emboli include dipsy of course tachycardia so that's fast heart rate tachypnea right so so fast breathing to get you know varying degrees of hypoxia so varying degrees of low oxygen cyanosis and they could have acute chest pain so with the large enough emboli you could have a complete obstruction of the output of the blood from the right side of the heart and that can result in a sudden death",
        "Hyperventilation": "all right and then so we move from pulmonary emboli now we're into hyperventilation okay so this is defined as just over breathing to the point that the level of arterial carbon dioxide falls below normal so this may be an indicator of a life-threatening illness the body may be trying to compensate for acidosis so acidosis is a buildup of acid in the blood or body tissues and we'll talk about that type of thing in the endocrine system we talk about it a lot okay it can result in alkalosis so alkalosis means an abnormally low volume it's a basic basic bloodstream so this can be good signs and symptoms of hyperventilation syndrome such as a panic attack so hyperventilation syndrome is a panic attack and this includes anxiety dizziness numbness tingling in the hands and the feet and painful spasms in the hand and the feet and these are carpal pedal spasm carpal pedal spasms okay the decision was that hyperventilation is being caused by life-threatening illness or panic attack should not be made by outside of the hospital okay so we should not make that decision pre-hospital",
        "Environmental/Industrial Exposure": "all right other breathing problems could be caused by an environmental or some type of industrial exposure so pesticides cleaning solutions chemicals and chlorine and other gases can be accidentally released at industrial sites and inhaled by employees right so carbon monoxide poisoning is an odorless and highly poisonous gas it's the leading cause of accidental poisoning deaths in the united states and it's produced by fuel burning household appliances and is present in smoke people who have carbon monoxide poisoning complain of a flu-like symptom and even dyphnia so do not put yourself at risk this high flow oxygen given by a non-re-breathing mask it's the best treatment for conscious patients okay so monoxide i always think of machines they produce carbon monoxide all right so next we're going to talk",
        "Scene Size-up": "about more leading into the patient assessment we'll discuss treatment of all of these cause all of these respiratory situations okay so of course scene size up is important we always start with that we always use that ppe remember when it comes to the respiratory infectious diseases and toxic substances always remember the the respiratory ppe okay so if there are multiple people with dipsnia consider the possibility of some type of airborne hazardous material release okay so multiple people with some type of shortness of breath think of a hazmat situation okay so if the mechanism of injury or nature of illness is in question ask why 9-1-1 is activated okay so by questioning the patient family or bystanders you should be able to determine the nature of illness",
        "Primary Assessment": "all right so identify any immediate life threats of course in this primary assessment and we're going to perform an overall general impression of the patient's level of distress so we're going to note the age and position of the patient we're going to use avpoo scale so alert verbal painful and responsive skill to check for responsiveness and we're going to ask the patient about his or her chief complaint\nnext of course we're going to move into the abcs so we need to know as they are way open is it open and adequate and we're going to evaluate the patient's breathing and see if it's adequate okay then we're going to listen to lung sounds so we want to listen to lung sounds breast sounds very early in these respiratory patients and we want to check breath sounds on the right and left sides of chest abnormal sounds are going to include just like we talked about wheezing rails ronchi or strider and on this slide you could see the locations of the stethoscope bell for those auscultations of the breast sounds okay so the four on the anterior then you have the six on the posterior all right and then after abc a and b of course we're going to go to c and with c we're going to assess the rate rhythm and quality of the pulse we're going to evaluate for any shock or bleeding and then we're going to assess perfusion by looking at the skin color temp and condition and then of course the d a b c d we're going to make that transport decision so is this a life threat or do we need to proceed with this type of rapid transport so load and go or stay in play all right after that of course",
        "History Taking": "we do the history of the illness and are the history of the patient history of the illness we are going to investigate the patient's chief complaint we need to determine what the patient has done for the breathing problem already all right so patients with a history of respiratory distress of course we want to get sample and that is the history of the patient right so history of the patient and if the the patient can't talk we could get it from the bystanders or family if there's any present and then history of the present illness of course is going to be that opqrst so onset provocation quality radiation severity and time and that's assessment that can be used to assess for pain and gather information about the breathing problem okay and then paste paste is an assessment and it's alternative uh assessment for the complaint of shortness of breath or difficulty breathing so paste is that progression associated chest pain sputum is the s t is talking tiredness does she have fragmented speech does he have fragmented speech talking tiredness that's what that means or exercise intolerance right so can he walk across the room without getting short of breath can he walk upstairs so exercise tolerance all right and then of course that's",
        "Secondary Assessment": "secondary assessment so we're only proceeding with that secondary assessment if the life threats have been addressed okay so we're also going to be using monitoring devices if we have them at this time all right\nand so we're going to go through the secondary assessments for the different types of breathing issues so let's talk about copd first chronic obstructive pulmonary disease versus our congestive heart failure okay so first the patients with copd these patients are usually older than 50 years old they often have a history of lung problems they are most always long-term active or formal former cigarette smokers they complain of tightness in the chest and constant fatigue now their chest may have a barrel-like appearance they often use accessory muscles to breathe they exhibit abnormal breath sounds often exhale through pursed lips and they could have digital clubbing and so this is an abnormality um an abnormally enlarged uh ends of their fingertips so it's cl it's clubbing of the fingers",
        "Reassessment": "all right so we want to repeat the primary assessment determine if there's any changes in the patient's condition confirm adequate interventions so interventions for respiratory problems they include so high flow of 2 15 liters non very breather or you might we might need positive pressure ventilations using a bag valve mask a pocket mask or flow restricted or an oxygen powered device using airway management techniques such as an oropharyngeal or nasopharyngeal suctioning and positioning we might also have to provide non-invasive ventilatory support with cpap we might position the patient in a high fowler's position or position of choice and then assist the patient with respiratory medications we have to communicate all this relevant information to staff at the receiving facility",
        "Emergency Medical Care": "all right so management of respiratory distress we're going to administer oxygen immediately and we're going to administer ventilator support if the patient's mental status is declining so if they are if they have moderate or severe respiratory distress or if the depth of the respiration is inadequate okay so we need to monitor the patient's respiratory status we need to provide of course emotional support and the patients who may have a metered dose inhaler or small volume nebulizer we have to call medical control to see if the medication may be indicated all right so we have to ensure that there's no contraindications in the patient's condition and most respiratory inhalation medicines are used to relax muscles that surround air passages in the lungs and what this does is it leads to dilation of those airways so bronchial dilation usually but you do have some side effects of those so you can it increases the pulse and increases nervousness and it increases muscle tremors so medication from an inhaler is delivered through the respiratory tract to the lung we need to follow skill drills okay so that's 16-1 to help a patient self-administer medicine and then follow the steps uh in skilled row 16-2 to help the patient self-administer medication from a small volume nebulizer okay so those skill drills are in your book all right so now let's talk about treating specific conditions okay so just as i kind of talked about it earlier there's the upper or the lower airway infection all right so administer we want to administer humidified oxygen we do not attempt to suction an airway or place in an op in a patient with some type of suspected epiglottitis remember their epiglottis is swollen so we don't want to push anything in that we could harm the patient so we're going to position them comfortably and transport properly all right so treatment specifically with pulmonary edema and remember pulmonary edema is the fluid in the lungs we're going to provide 100 oxygen we need the suction if necessary okay so only if necessary we want to position comfortably and usually that's in that seated position we want to provide cpap if indicated and allowed by our protocols and then we want to transport promptly",
        "Treatment of COPD and Other Conditions": "all right so that was congestive heart failure this is going to be copd and we just talked we talked about it earlier chronic obstructive pulmonary disease we're going to assist with an inhaler but we need to watch for signs of of overuse okay so we need to watch for those side effects transition uh position comfortably and transport promptly with the copd patients that's how we treat them asthma hay fever or anaphylaxis so asthma we need to be prepared to suction um we will be ready to assist the patient if they have that inhaler and then provide aggressive airway management oxygen and prompt transport okay hay fever is usually not emergency and we can manage the airway and give oxygen depending on the level of distress hay fever right so that's like a common allergy maybe to pollen or dust right but anaphylaxis on the other hand that is a true emergency so that's an allergic reaction with airway involvement that is anaphylaxis so we're going to remove the offending agent we need to provide aggressive airway management oxygen and prompt transport",
        "Treatment of Specific Conditions": "and then administer epi if allowed by your local protocol okay then there's spontaneous pneumonia pneumo we just we need to provide um oxygen and get them to the hospital and we need to monitor them very carefully right and they need um uh help right help okay so pleural effusions of course fluid removal must be done at the hospital um just like treatment of that pneumo and so we're going to provide oxygen and transport promptly",
        "Treatment of Obstructions and Other Conditions": "and then of course obstruction so a partial obstruction of the airway we are just providing supplemental oxygen okay complete obstruction however we need to clear the obstruction and then administer oxygen so um so partial we're providing we're not clearing but only when it's a complete obstruction okay we need to transport rapidly to an emergency department for emboli we need to get supplemental oxygen that's mandatory we're going to position them comfortably and if they're coughing up blood we need to clear the airway immediately and of course prompt transport prompt transport all right hyperventilation we're going to complete primary assessment and gather that history we're never going to have the patient breathe in the paper bag we need to reassure the patient and provide oxygen if necessary and then prompt transport some type of environmental or industrial exposure we need to ensure that patients are decontaminated we need to treat with oxygen and adjuncts if we need to and suction based on presentation foreign body airway obstruction perform the appropriate airway clearing technique specific for the age so provide oxygen and transport if there's some type of tracheostomy dysfunction okay so a tracheostomy dysfunction we need to position them comfortably provides suctioning to clear the obstruction all right and then once the obstruction is clear oxygenate the patient",
        "Treatment of Asthma and Cystic Fibrosis": "asthma so for children we're going to give them blow by by holding a mask in front of their face and use meter dose inhalers as we would with older patients and as with any chronic disease asthma may be life-threatening in an older person okay so let's talk a little bit about cystic fibrosis that's a genetic disorder that affects the lungs and digestive system and so it predisposes children to repeated lung infections and so symptoms range from sinus congestion to wheezing and asthma like complaints so we need to suction and oxygenate these patients",
        "Review": "okay so that concludes the lecture portion we're going to go through the review questions and so we'll see how much we've learned this chapter okay so the process in which oxygen and carbonation or carbon dioxide are exchanged in the lungs is called do you guys remember what that is called respiration and so respiration is that exchange of oxygen of gases between the body and its environment okay you're right so which of the following respiratory diseases causes obstruction of the lower airway all right so we know group is upper epiglottitis is upper uh and remember the larynx an infection in the larynx is upper so what do we know asthma asthma is going to be lower the rest are upper so asthma is that lower airway disease it's uh bronchioles right okay which of the following diseases is potentially drug resistant okay and is caused by coughing can be transmitted so it's tuberculosis so why tuberculosis is such an a scary kind of disease is because it is antibiotic resistant drug resistant so tuberculosis is that bacterial infection it's dangerous very dangerous resistant the antibiotics and all of the following are causes of acute dipsnia except all right so look cute remember fast onset and so what they're looking for probably is asthma um pneumo and pulmonary emboli those are all acute emphysema on the other hand that's that long chronic respiratory disease okay so that's the correct answer okay bronchiospasm is the most often associated with bronchus spasm is um a narrowing of that airway spasming and that is asthma okay it's a reactive disease it's caused by bronchiole spasms all right a sudden onset of difficulty breathing with sharp chest pain and cyanosis that persist despite supplemental oxygen okay so we know pneumonia that is kind of a slower onset and mi heart attack yes that'll have chest pain could be chest pain right pulmonary emboli that sounds like it right pulmonary emboli is a blockage it could cause pain in that area specific so let's see yeah pulmonary emboli is that's an onset of pleurotic chest pain so albuterol it's abated to an antagonist and agonist and it's a generic name for so albuterol is a generic name for ventalin so we didn't talk about that but i'm glad we're doing these so we know ventilating or proventol is albuterol okay an acute bacterial infection that results in swelling of that flap that covers the larynx during swallowing so we know that the flap is called that's the epiglottis and then some type of swelling of that flap or infection of the flap should be epiglottitis right all right so epiglottitis yeah that's that uh life-threatening it could be potentially and it's a bacterial infection caused by that epiglottis some young man recently had a heart attack and he's complaining of some difficulty breathing especially when he's lying flat okay so that's the key thing right there if you lay him flat uh and there's fluids um he will not be able to breathe so think about a water bottle you lay the water bottle flat um and then the water is covering all surface of that lung right so you you sit him up um and then at least he'll be breathing with the basically the top lobes right so we're gonna say that this is some type of pulmonary edema and i'm pretty sure it's from some type of heart failure right so um so it's gonna be a recent heart attack we'll have that left side of the heart is damaged so it's a left-sided heart failure okay left-sided heart failure which the following patients is breathing adequately so we have the right way i'm going to look at the number of respiratory okay so 29 year old with respiration is 20 who is conscious and alert i say that that person's breathing breathing adequately okay so that concludes uh chapter 16 respiratory emergencies lecture continue to follow us so go ahead and subscribe and like this video if you found it useful alright so you guys have a great night"
    },
    {
        "Introduction": "hello and welcome back to chapter 15 airway management this is part two of the lecture we're going to pick up right where we left off and we're going to",
        "Laryngectomy": "start with the special patient considerations and when you talk about special patient considerations when it comes to airway management we talk about laryngectomy tracheostomy stomas and tracheostomy tubes okay so let's start with the laryngectomy so a laryngectomy is a surgical procedure in which the larynx is removed it's performed by making a tracheostomy which is a surgical opening in the trachea it creates a stoma and a stoma is the orifice orifice that connects to trachea to the outside air surgical removal of the entire larynx is called a total laryngectomy and people can no longer ventilate by mouth to mass technique okay and so what uh the air blown into the mouth or nose goes into the stoma and will not reach the lower airway so a a partial laryngectomy entails surgical removal of a portion of the larynx so people who have had this procedure breathe through the stoma and the nose or mouth",
        "Suctioning of a Stoma": "a common procedure that you're going to perform is suctioning of a stoma and failure to recognize and identify the need to suction could result in hypoxia it's not uncommon for a stoma to become clogged or occluded with mucus plugs suctioning must be performed with extreme care even the slightest irritation of a tracheal wall can result in violent laryngospasms and complete airway closure limit suction to 10 seconds and there is a skill drill for how to suction the stoma and you it's on 15-5",
        "Ventilation of Stoma Patients": "ventilation of stoma patients so neither a head tilt or chin lift nor a jaw thrust maneuver is required ventilations with a stoma and no tracheostomy tube can be performed with either a mouth to stoma technique or a bag valve mask and regardless of the technique use an infant or child size mask to make an adequate seal over the stoma seal the nose or mouth with one hand to prevent air leaking up the trachea and release the following each ventilation two rescuers are needed with a bag mask device so one to seal the mouth and nose and one to seal the bag valve mass device okay and you are if you're unable to ventilate try sectioning the stoma and mouth with the french or soft tip catheter before providing artificial ventilation through the mouth and nose and it would only work with a partial laryngectomy remember not a total relayer injected me because air is not going to pass through the mouth and nose to properly perform that maltostoma ventilation with the resuscitation mask refer to skill drill 15-6",
        "Tracheostomy Tubes": "so a tracheostomy tube so a tracheostomy tube is a is placed within the tracheostomy site and that's the actual stoma and it requires a 15 to 22 millimeter adapter to be compatible compatible with ventilatory devices patients may receive supplemental oxygen via tubing designed to fit over their tube or placing an oxygen mask over the tube to ventilate attach the back valve mass device to the tracheostomy tube patients who experience sudden dips near often have thick secretions in the tube so perform suctioning through the tracheostomy tube as you would through the stoma when a tracheostomy tube becomes dislodged a narrowing of the stoma may occur this could be a potentially life-threatening um and impairs the patient's ventilatory ability you may have to insert an et tube into the stoma before it becomes totally occluded patients may have may be less tolerant of even brief periods of hypoxia so to properly replace and dislodge trichostomy tube refer to skill drill 15-8 in your book",
        "Dental Appliances": "all right so dental appliances can take many different forms they could be dentures both upper lower both you could have bridges individual teeth braces in the younger population don't forget so you must determine whether the appliance is loose or fitting well when assessing the airway essentially it's important if the patient is unresponsive so leave in place if it fits well but remove if it's loose if an unresponsive patient has an airway obstruction caused by a dental appliance perform the usual steps to cl in clearing the obstruction you want to do chest compressions you could do that direct laryngoscopy where you're looking um directly with the laryngoscope and use miguel forceps so take great care of the obstruction um it's if it's caused by a bridge they often slip metal uh sharp metal ends that can easily lacerate the posterior pharynx or larynx generally best to remove dental appliance appliances before you innovate",
        "Facial Trauma": "okay so facial trauma facial trauma can result in severe tissue swelling and bleeding into the airway we need to control the bleeding with direct pressure and suction the airway as needed you may encounter a patient with severe facial trauma who's breathing inadequately and has severe oropharyngeal bleeding you want to suction the airway for 15 seconds less of course an infant than children and provide positive pressure ventilation for about two minutes alternate suction and ventilation until the oral secret secretions are cleared or the airway has been secured by an et tube facial injuries should increase suspicion of a cervical spine injury so we want to use that jaw thrust maneuver and keep the head in an inline position endotracheal tube innovation of a trauma patient is the most effective effectively performed by two paramedics one maintains neutral inline stabilization of the head and the other innovates alternate technique so an alternate technique stabilize the head with your thighs and then perform the innovation stay alert for changes in ventilatory compliance or sounds that may indicate that laryngeal edema and that we call that stridor so if you are unable to effectively ventilate or orally innovate perform a crike a crichotomy and this is you could do it surgical or needle",
        "Advanced Airway Management": "all right so let's talk about the advanced airway management one of the most common mistakes with respiratory or cardiac arrest is to proceed with advanced airway management too early forsaking the best basic techniques of establishing and maintaining a patent airway in a hypoxic patient establish and maintain a patent airway with basic techniques and maneuvers then consider the advanced airway management okay so patients primarily require advanced airway management for two reasons there is a failure to maintain a patent airway or failure to adequately oxygenate and ventilate so an advanced airway management involves the insertion of a number of advanced airway devices these include an et tube so an endotracheal tube so oral tracheal innovation or blind nasotracheal innovation also digital innovation or innovation via a translumen or face to face innovation or retrograde innovation and there's also the king airways and the lmas and um and then the esophageal tracheal combi tubes of the combi tube and then there's a surgical and needle crike as well",
        "Predicting the Difficult Airway": "so you need to be able to predict a difficult airway and so anatomic finding suggests a suggestive of a difficult airway may include you might have some congenital abnormalities okay or recent surgery trauma infections or a neoplastic disease such as cancer use the pneumatic lemon to guide assessment of a difficult airway and so we're going to talk about",
        "LEMON": "lemon okay so the l in lemon stands for look externally the following can make innovation more difficult so short thick necks morbid obesity or dental conditions such as an overbite or buck teeth all right so e is evaluate and so it's a 3-3-2 and so on the slide you could see the picture of the 3-3-2 and so the first three refers to the mouth opening a width of less than three fingers indicates a potentially different airway difficult airway and then the second is three refers to mandible length and so at least three finger widths is optimal measure from the tip of the chin to the hyoid bone and smaller mandibles have less room for displacement of the tongue and epiglottis and can make airway management more difficult okay and then the two refers to the distance from the hyoid bone to the thyroid thyroid notch and it should be at least two fingers and you could see that really good pictures on the slide and so that's the e the evaluate and then you have the m and that's a malin patty score so a malin patty classification predicts the relative difficulty of innovation all right so it notes the oropharyngeal structures visible in an upright seated patient who is fully able to open his or her mouth in its limited value to patients who are unresponsive okay so it shows the different classes of the mal and patty all right and this figure shows um a classification and then the o stands for obstruction so note anything that might interfere with visualization or et2 placement so affording foreign body of obesity hematoma or any type of mass the n in lemon is the neck mobility so the sniffing position is ideal for visualization and innovation an adult head slightly elevated and extended is the sniffing position neck mobility problems are most difficult with trauma patients due to cervical collar or injury in older adults due to osteoporosis or arthritis",
        "Endotracheal Intubation": "so when we talk about endotracheal tube inhibition that is passing an et tube through a gladic opening and sealing the tube with a cuff inflated against the tracheal wall oral tracheal inhibition is when the tube is passed into the trachea through the mouth and nasotracheal innovation is when the tube is placed into the trachea through the nose innovation of the trachea is the best means of achieving complete control of the airway there are advantages and that is that you could secure the airway you could protect against aspiration and the provision of an alternative route to the iv or io for certain medications and that's of course last result or last resort and then there's disadvantages because it takes special equipment and um the functions of the airway of course the physiologic functions and so there's uh the upper airway is for warming filtering and humidifying and that is bypass when you innovate and then of course there are complications so there's bleeding hypoxia laryngeal swelling laryngospasms vocal cord damage mucosal necrosis and then barotrauma to the lungs",
        "Endotracheal Tubes": "all right so let's talk about some endotracheal tubes the basic structure of an endotracheal tube includes the proximal end the tube the cuff and the pilot balloon the distal tip then you have um so we're going to break it down even further so on the proximal end this is equipped with an adapter that allows it to be attached to a ventilation device it includes an inflation point port with the pilot balloon and then you have a distal cuff and it's inflated with a syringe a pilot balloon indicates whether the distal cuff is inflated or deflated once the tube has been inserted into the mouth centimeter markings along the length of the e2 tube provide a measurement of its depth the distal end of the tube has a beveled tip to facilitate insertion and an opening on the side called the murphy's eye this enables ventilation to occur even if the tip becomes occluded so there's tube sizes and they range from 2.5 to 9.0 millimeters in the inside diameter and 12 to 32 centimeters in length a tube is too small if it's too small it will lead to increased resistance to airflow and difficulty in ventilating if a tube is too large it can be difficult to insert and may cause trauma and then you have a stylet and so stylets are semi-rigid wires and they're inserted into the et tube to mold and maintain the shape of the tube this enables the paramedic to guide the tip of the tube over the cartilage and through the vocal cords you want to lubricate the device with a water soluble gel to facilitate its removal and bend it and to form a gentle almost hockey stick curve the end of the style it should be should be at least half an inch from the line end line of the et2 you want to bend the other end of the stylet over the proximal tube connector so that the stylet cannot slip farther into the tube so in pediatric patients that the tubes are going to range from 2.5 to 4.5 millimeters and their funnel shape cricoid ring forms a autumn an auto atomic seal with the et tube and it eliminates the need for a distal cuff in most cases so the pediatric patient et2 lacks that distal balloon cuff so there's no balloon pilot balloon the anatomic clues can help determine the proper tube size so the internal diameter of the nostril is a good approximation of the diameter of the glottic opening so the diameter of the little finger or the size of the thumbnail is also a good approximate of the airway size okay so a good rule is to always have three et tubes ready one you think will be the appropriate one one a size larger and one a size smaller okay now we're going",
        "Laryngoscopes and Blades": "to talk about laryngoscopes and blades so laryngoscope is required to perform an oral tracheal tube innovation laryngoscope consists of a handle and interchangeable blades and the handle contains the power source for the light on the blade when the blade is perpendicular the light shines near the blades tips there are two most common types of blade there's the straight which is also called the miller or wisconsin and then there's the curved and that is called the macintosh i always think of the macintosh apple so the curved is the mac okay the straight laryngoscope lay the tip will extend beneath the epiglottis and lift it up it's useful in infants and small children who often have a long flappy epiglottis and in the adult use of a straight blade is more likely to damage teeth if used inappropriately and then you have the curve laryngoscope blade and this is the mac or the macintosh it's uh less likely to be leveraged against the teeth by an inexperienced paramedic so direction of the curve conforms to that of the tongue and the pharynx the tip is placed in the vallecula and so the vallecula is the space between the epiglottis and the base of the tongue it indirectly lifts the epiglottis to expose the vocal cords have curved and straight blades available blade sizes range from zero to four zero one and two are appropriate for instant children and then three and four are for adults for pediatric patients blade size is often best on this a child it's often based on the child's age or height okay so for adults usually based on the paramedics experience and the size of the patient and then there's miguel forceps and they have two uses in the emergency settings they remove airway obstructions under direct visualization and then they can guide the tip of the et tube through the gothic opening if the proper angle cannot be achieved with manipulation of the tube",
        "Orotracheal Intubation by Direct Laryngoscopy": "so an oral tracheal inhibition by direct larynx it involves inserting the et tube through the mouth and into the trachea while visualizing the gelatic opening with a laryngoscope so indications are so that you have to have the need for airway control as a result of the coma respiratory rest or cardiac arrest also ventilatory support before impending respiratory failure could be a need or a prolonged ventilatory support may be required absence of a gag reflex traumatic brain injury unresponsiveness or impending airway compromise such as with burns or trauma case contraindications of course people cannot have an intact gag reflex or the inability to open the mouth because of trauma so such as a dislocated jaw or a pathologic condition or the inability to see the gladic opening or copious secretions of vomit or blood in the airway",
        "Standard Precautions": "so standard precautions of course innovation may expose you to blood or other bodily fluids so take proper precautions gloves are a mass that covers the entire face",
        "Preoxygenation": "you need to pre-oxygenate so adequate pre-oxygenation with the back valve device and 100 oxygen is crucial before ventilation pre-oxygenate an apnic and hypoventilating patient for at least two to three minutes during the inhibition attempt the patient will undergo a period of forced apnea the goal of pre-oxygenation is to prevent hypoxia from occurring during this time so you want to monitor the spo2 and achieve as close to 100 oxygenation saturation as possible during the two to three minute period okay so during the innovation attempt continuously monitor the spo2 and maintain it greater than 95 consequences of even brief periods of hypoxia can be disastrous so do not solely rely though on that pulse ox to quantify oxygen status okay so position the patient for this",
        "Positioning the Patient": "inhibition airway has three accesses it's the mouth the pharynx and the larynx when the head is in the neutral position the axises are an acute angle okay so this makes the laryngoscopy difficult so it must be aligned at the greatest extent possible to facilitate visualization of the airway all right so place the patient in the sniffing position sniffing position so approximately a 20 extension of this occipital joint okay so 30 flexation of the neck at the c6 and c7 for a patient with a short neck and no chin and this position can be achieved in most supine patients by extending the neck and elevating the occipital or the back of the head 2.5 to 5 centimeters okay so slightly elevate that occipit area evaluate a value or elevate the head and neck with folded towels until the ear is at the level of the sternum",
        "Laryngoscope Blade Insertion": "all right so when you do the blade insertion after you have positioned the head and provided the pre-oxygenation direct your partner to stop ventilating position yourself at the top of the patient's head you want to grasp the range of scope with your left hand as far down on the handle as possible if the mouth is not open place the side of your right thumb just below the bottom lip and push the mouth open it's a scissors so your thumb and your index finger will will be between the molars open the mouth with a tongue jaw lift maneuver all right so insert the blade into the right side of the mouth you're going to insert the blade into the right side use the blade flange to sweep the tongue gently to the left while moving the blade into the midline slowly advance the blade while sweeping the tongue to the left a curved blade into you're going to place that into the velecula and a straight blade beneath the epiglottis exert gentle traction at a 95 degree angle to the floor as you lift the patient's jaw okay so do not pry back on the laryngoscope and keep your back and your left arm as straight as you can when you pull forward",
        "Visualization of the Glottic Opening": "okay so you're going to be visualizing the gladic opening and after you identify the epiglottis place the tip of the curved blade at the molecular space so the straight blade is positioned directly over the epiglottis and gently lift until the glottic opening becomes comes into full view right so you should see the vocal cords and cartilage so there's also a tool that we use and this is called the gum elastic bougie and it's a flexible device that is approximately 0.2 inches in diameter and about 2 feet long it's used by epic epiglottitis only view to facilitate innovation okay so inserted through the glottic opening under direct laryngoscopy once you once it is placed deeply into the trachea it becomes a guide for the um et tube you slide the tube over the gumbooji and into the trachea and in remove the kombucha ventilate and confirm proper et2 placement",
        "ET Tube Insertion": "so et tube insertion pick up the et tube in your right hand holding it near the connector as you would hold a pencil insert the tube from the right corner of the mouth through the vocal cords continue to insert the tube until the proximal end of the cuff is 0.5 to 0.75 inches past the vocal cords if you could not see the vocal cords you did not insert the two okay so you have to watch it go through the vocal cords a major mistake of beginners is trying to pass a tube down the barrel of the lauren scope blade is designed to visualize the glottic opening it's not used it's not for a guide for the tube and it will obscure your view of the glottic opening and should be voided at all times all right so ventilation so after you have seen the et tube cuff pass roughly a half to three quarters of an inch beyond the vocal cords you're gonna gently remove the blade hold the tube securely with your right hand remove the stylet from the tube and then you're gonna inflate the distal cuff with five to ten ml of air then detach the syringe from the inflation port if the syringe is not removed immediately the air from the cuff will leak back into the syringe so inflating the distal cuff with excessive pressure may also cause tissue necrosis of the tracheal wall because it'll be too much pressure okay so have your assistant attach the back valve to my device to the e.t tube and continue ventilation so inline t piece capnography monitor should be placed on the bvm and et tube as the first ventilations are delivered look at the patient's chest to ensure that it is rising with each ventilation at the same time listen with the stethoscope to the lungs and to the stomach if the tube is properly positioned you will hear equal breath sounds bilaterally and a quiet epigastrum epigastric sounds may indicate or may be transmitted to patients in obese patients or patients with a significant gastric distension so ventilation should continue as dictated by the patient's age all right so we have an ethnic adult with a pulse so you're going to do 10 to 12 breaths an epic child or infant is going to be 12 to 20 and then a patient in cardiac arrest 8 to 10 breaths a minute do not stop chest compressions to deliver ventilations it's asynchronous when you're doing when you have an et2 place in place",
        "Confirmation of Tube Placement": "all right so confirmation of the two placement of course we're going to visualize that to passing between the vocal cords and that's the first and the most reliable way to confirm that the tube has entered the trachea and then you're going to auscultate and that's the next step so you're going to listen to breath sounds if you have unequal or absent breath sounds this can suggest an esophageal placement or right main stem placement a pneumo or a bronchial obstruction bilaterally absent breath sounds or gurgling over the epigastrium indicates that you have innovated the esophagus not the trachea so immediately remove the et tube be prepared to vigorously suction the airway and after clearing the airway ventilate with the bvm and 100 oxygen for 30 seconds to one minute before you attempt a reattempt innovation if breath sounds are heard only on the right side of the chest the tube has likely been advanced too far so you just want to loosen and remove the cuff uh and deflate the distal cuff place your stethoscope over the left side of the chest while ventilation continues slowly retract the tube while simultaneously listening for breath sounds over the left side of the chest stop as soon as you bilaterally hear the equal breath sounds note the depth of the tube and reinflate the distant distal cuff and secure the tube and resume ventilations in the e.t tube when you have properly placed it in the trachea a bvm should be easy to compress you should be uh see corresponding chest expansion and increased resistance during ventilations may indicate gastric distension or esophageal inhibition or possibly attention pneumo also you want to use continuous waveform capnography in addition to a clinical assessment ins it's the most reliable method of confirming and monitoring the correct placement okay so ideal time to attach the capnography t piece is when the bvm is attached to the et tube esophageal detector device uh it's a bulb or syringe with a 10 10 to 22 millimeter adapter and a syringe model so a syringe is attached to the end of the et tube and the plunger is withdrawn if the tube is in the trachea the plunger does not move when released if the tube is in the esophagus the plunger moves back and forth towards zero when released okay so the bulb model a bulb is squeezed and then attached to the end of the et2 if it remains collapse or inflate slowly esophageal inhibition is likely occurred if the bulb briskly expands the tube is properly placed in the trachea",
        "Securing the Tube": "and then when you secure the tube you never want to take your hand off the e.t tube before it has been secured with the appropriate device so support the secured tube manually while you ventilate the patient to avoid a sudden jolt from the bag valve mask the steps to secure it are you um there's many commercial tube securing devices available so steps for securing the et tube include note the centimeter marking of the tube level of the patient's teeth remove the bvm mask from the et tube position the et tube in the center of the mouth you want to place the securing device over the e.t tube tighten in the screw to secure in place fasten the straps reattach the bbm auscultate over the lung sounds again and then over the epigastrium and note the capnography reading and waveform many commercially manufactured et tube securing devices feature a built-in bike block if you do not have a commercially manufactured device you can secure the tube in place with tape and insert a bite block or overall airway it is important to minimize head movement in an innovative patient you could apply cervical collar and place the patient on the long backboard or stabilize the head with lateral immobilization blocks to properly innovate the trachea using a direct laryngoscopy refer to skill drill on 15-9",
        "Orotracheal Intubation by Video Laryngoscopy": "all right so oral tracheal inhibition by a video laryngoscopy so video laryngoscopies facilitate visualization of the glottic opening in vocal cords instead of trying to visualize the vocal cords around you can guide placement of the et tube with the use of a video monitor however video languasapis require better hand-eye coordination that than does the laryngoscopy itself okay so there's types of videos there's one with a laryngoscope and a separate video monitor and then there's um ones with a video monitor attached to the laryngoscope itself so all video laryngoscopes feature single use blades of various sizes and some of the video laryngoscopes require displacement of the tongue and others are inserted in the midline of the mouth and simply follow the curvature of the tongue so certain video laryngoscopes can also allow you to directly visualize the airway structures if the video monitor suddenly stops working okay so the steps for an oral tracheal inhibition by a video laryngoscope are shown on skill drill 15-10 and the figure right here shows some different models of those video leverage scopes and then there's the nasal tracheal inhibition so when you insert the tube into the trachea through the nose this is a nasal tracheal innovation it's usually performed without directly visualizing the vocal cords in a pre-hospital setting it's an excellent technique for establishing control over an airway in situations when it is difficult or hazardous to perform a laryngoscope okay so indications include indicated for patients who are breathing spontaneously but require definitive airway management and these could be responsive patients or patients with altered mental status with an intact gag reflux who are in respiratory failure because of concessions such as copd or asthma or pulmonary edema contra indications for apneic patients patients with head trauma or possible mid face fractures or patients with anatomic abnormalities or frequent cocaine use avoid impatience with blood clotting abnormalities and in patients who take anticoagulant medications all right so we talked about some of the advantages you could perform this on patients who are responsive and breathing there's no need for that laryngoscope it eliminates the risk of trauma to the teeth and soft tissues of the mouth the mouth does not need to be open it's better suited in patients with limited um joint mobility in that jaw and it does not require sniffing position so it's ideal with a spinal injury the tube is inserted through the nose so patient cannot bite the tube and it can be secured more easily than an oral inserted tube but of course there's disadvantages because it's a blind technique so some of the tube conformation methods cannot be used you can't see it passing directly through the chords confirmation of the two position requires even more diligence there are complications and their bleeding is the most common especially with rough technique it poses an additional threat to the already compromised airway an incident of bleeding can be reduced by gentle insertion of the tube and lubrication of the tip with a water soluble gel so equipments it's the same equipment that we're going to use for an oral technical tube innovation minus that laryngoscope and style it so you want to select a tube that is slightly smaller than the nostril some e2 tubes have been designed specifically for blind nasal tracheal innovation all right and so the movement of air through the et2 becomes deter helps determine the proper placement so a number of devices allow paramedic to confirm successful innovation without placing his or her face it next to the tube",
        "Technique for Nasotracheal Intubation": "all right so the technique for nasal gastrointubation so you're going to use the patient's spontaneous respirations to guide a nasal tracheal tube into the trachea and confirm proper placement tube is advanced as the patient inhales after preparing your equipment and pre-oxygenating the patient insert the tube into the nostril with the bevel facing towards the nasal septum the right nostril is typically used if the right nostril is obstructive insert the tube into the left nostril but rotate the tube 180 degrees as its tip enters the nasopharynx aim the tip of the tube straight back towards the ear and position the tube just above the glottic opening so that the patient will draw the tube into the trachea when he or she inhales deeply okay so you can manipulate the patient's head to control the position of the tip of the tube to maximize air movement you could cup your left hand if the tube is in the right nostril under the patient's occipit and move the head to achieve maximum airflow through the tube instruct the patient to take a deep breath and gently advance the tube with the inhalation placement in the trachea will be evident by an increase in the air movement through the tube if you see a soft tissue bulge on either side of the airway the two may be inserted into the pleura form fascia so hold the patient's head still and slightly withdraw the tube once maximum airflow is detected advance the tube on inhalation if you do not see a soft tissue bulge the tube has inserted into the esophagus withdraw the tube with until you detect airflow and then extend the head once the tube has been properly positioned inflate the distal cuff with minimum amount of air necessary attach the bag valve device to the tube and ventilate confirmation and monitoring are extremely important clean up any secretions and excess lubricant and secure the tube with tape document the depth of the insertion into the at the nostril and to properly perform a blind nasal tracheal innovation refer to skill drill 15-11 and then there's digital innovation so this involves directly palpating the glottic structures and evaluating the epiglottis with the middle finger while gliding the et tube into the trachea by feel this gives you an option in some extreme circumstances digital innovation with most is most advantageous in case of equipment failure its primary disadvantage of course it re it requires placing fingers into the patient's mouth risk of being bitten and exposed to infectious disease if the teeth tear through the gloves and perform only if patient is deeply unresponsive or apneic or a bite block is being used this is absolutely contra indicated in patients who are breathing who are not deeply unresponsive and who have an intact gac reflex the major complication of course is misplacement of the et tube",
        "Technique for Digital Intubation": "so the technique you're going to prepare your equipment as your assistant inflates or ventilates the patient with a bag valve mask with 100 oxygen select the et tube that is one half to a full size smaller than what you would use for innovation with the direct layered jaw gossipy tip of the tube is guided into the trachea with index finger as leverage point okay so there are two configurations which are recommended there's the open j configuration and you could see that in the on the slide the figure um and it's a stylet is inserted a large j is made in the distal end of the tube and then there is a u-handle configuration and this is the tube is bent into you and the proximal half of the tube is bent on into a 90 degree handle toward your dominant hand okay so the sniffing position is not required you want to insert a bite block or the flange of an oral airway between the patient's molars insert the index and middle fingers of your left hand into the right side of the mouth press down against the tongue as you slide your fingers until you can feel the epiglottis pull the epiglottis forward with your middle finger hold the et tube in your right hand like a pencil and insert it into the left side of the patient's mouth advance the tube and guide its tip towards the glottis once you feel the the cuff of the tube pass about two inches below beyond your fingertips stabilize the tube while you gently withdraw your fingers from the patient's mouth carefully remove the stylet and deflate or inflate the distal cuff with five to ten milliliters of air attach the bvm to the et tube and ventilate while observing for visible chest rise and fall rigorous protocol for confirmation of tube placement must be followed so you have to auscultate both lungs over the up and over the epigastrum monitor etn title and properly secure the tube in place and continue ventilations according to the patient's clinical condition",
        "Transillumination Techniques for Intubation": "all right so translument technique for innovation so tissue that overlies the trachea is relatively thin bright light source is placed in the trachea and emits a bright well um well seen light so a number of devices can be used to innovate the trachea with the translumen okay so it's a lighted stylet and it describes any malleable stylet with a bright light source at the distal end indications and contraindications so it can be used whenever the patient needs to be innovated but usually performed after other techniques have failed absolutely indicated in patients with an intact gag reflex or airway obstruction and it may be difficult in obese patients with pain and with patients with short necks or muscular necks and st theory theoretically possible with pediatric patients however the stylet must fit inside the et tube so advantages and disadvantages you don't need to use a laryngoscope so problems associated with that laryngoscopy are largely avoided you can visualize a parameter a light at the midline of the neck increases chance for successful tube placement and it does not require visualization of the glottic opening sniffing positions also not required and it's safe with possible spinal injuries major disadvantages though it requires special equipment proficiency with the equipment must you must have proficiency and it can be difficult or impossible in brightly lit areas the complications are misplacement of the tube in the esophagus because the innovator cannot directly visualize the two passing through the vocal cords and it requires strict attention to tube confirmation techniques",
        "Transillumination Equipment": "in the trans illumination so equipment the device is a rigid style and a bright lit source at the end the light should shine laterally and forward stylet must be long enough to accommodate a standard length et tube and the need uh you need a method of securing the stylet within the tube",
        "Technique for Transillumination- Guided Intubation": "and of course the technique for the trans-illumination guided innovation is the you want to oxygenate the same as you would at least two to three minutes with a bvm and a hundred percent oxygen select the appropriate size et tube and check the cuff to ensure that it holds there lubricate and insert the lighted stylet so that the light is positioned at the tip of the tube secure the stylet is firmly seated or ensure it's firmly seated into the tube prepare the two by bending it into the proper shape so a stylet should be straight with a sharp 90 degree angle in the tube stylet assembly just proximal to the cuff place the tube in the neutral or slightly extended position and the innovator is typically at the patient's head while holding the stylet in the dominant hand displace the jaw forward by grasping it up with your thumb and forefinger turn on the lighted stylet and insert it into the midline of the mouth with the tip towards the laryngeal prominence as you continue to insert the assembly draw your wrist towards you so tightly circumscribed light slightly below the thyroid cartilage the tip of the tube has entered the trachea faintly glowing light and bulging of the soft tissue above the thyroid cartilage that means the tip of the tube is in the molecular space would draw the tube slightly displace the jaw forward and re-advance the tube stylet assembly if you see a dim diffused light at the interior part of the neck that's esophageal placement so slightly withdraw the tube stylet assembly and extend the head slightly increasing the angle of the bend of the tube and if you continue to encounter this difficulty abort the procedure and ventilate the patient before reattempting insertion once the light is visible in the midline hold the stylet in place and advance the tube approximately two to four centimeters into the trachea when the tube is secured in the trachea manually stabilize it and carefully withdraw the stylet inflate the distal cuff of the et tube with 5 to 10 milliliters of air detach the syringe from the inflation port and attach the bag valve device to the e.t tube ventilate the patient while auscultating both lungs and the epigastrum and follow confirmation of the tube placement secure tube with the appropriate device and continue ventilations to properly perform the trans illumination intubation refer to skill drill 15-2 in your book",
        "Retrograde Intubation": "okay now we're finally to the retrograde innovation this is rarely performed in the pre-hospital environment only relevant in ems systems where local protocols indicate a needle is placed pure cutaneously within the trachea via the cricoid thyroid membrane a wire is placed towards the head through the needle upward through the trachea and into the mouth the wire is then visualized and secured and the et tube is placed over the wire and then guided back into the trachea the wire is subsequently removed and the et tube is advanced and secured there are indications and that's copious creations in the airway or failure to innovate the trachea with less invasive methods conjure contraindications of course a lack of familiarity with the procedure laryngeal trauma unrecognized or distorted landmarks um you could have uh um severe hypoxia and that's the inability that due to the inability to innovate during the procedure and the time to perform this procedure so complications include of course hypoxia cardiac dysrhythmias mechanical trauma infection and increased intracranial pressure so assessment findings and transport complications are the same as with the standard innovation to properly perform retrograde innovation refer to skill drill 15-13",
        "Face-to-face Intubation": "and then there's a face-to-face innovation i think they used to call this the tomahawk when when i was in school but it's an innovation that can be performed with the paramedics face at the same level as the patient's face when other positions are not possible so especially the same as uh or essentially the same as an oral tracheal inhibition using a direct layer and gospel with the following exceptions the head is manually stabilized by a second paramedic during the entire procedure in there it's not in the sniffing position in a laryngoscope with the curved blade is used and it's held in the right hand with the blade facing downwards an et tube is held in the left hand so the blade is inserted into the right side of the mouth the tongue is swept to the left and the vocal cords are visualized and once the blade has been placed the innovator may slightly adjust the head for better visualization by pulling the mandible forward while pressing down okay so let's talk about failed",
        "Failed Intubation": "innovations now so a failed airway attempt is defined as failure to maintain acceptable oxygen saturation during or after one or more failed innovation attempts a total of three failed innovation attempts even when the oxygen saturation can be maintained",
        "Tracheobronchial Suctioning": "all right so tracheal bronchial suctioning this involves passing a suction catheter into the et tube to remove pulmonary secretions do not do it if you do not have to it requires strict attention to sterile technique and can cause cardiac dysrhythmias and cardiac arrest avoid unless secretions are so massive that they interfere interfere with ventilation if it must be performed use a sterile technique and monitor cardiac rhythm and oxygen saturation you have to pre-oxygenate for at least two to three minutes just like other techniques and it may be necessary to inject three to five mls of sterile water down the et tube to loosen those secretions gently insert the catheter down the tube of the et tube until resistance is felt apply suction to the catheter and then extract it do not exceed 10 seconds in the adult when you're suctioning when complete reattach the bvm continue ventilations and reassess the patient to properly perform tracheal bronchial suctioning refer to skill drill 15-14",
        "Field Extubation": "and then field exhibition so excavation that's the process of removing that tube of an innovative patient it's rarely done in a pre-hospital setting and generally only consider for a patient who is unreasonably intolerant of the et tube it's better to sedate the patient before performing contact medical control or follow local protocols because there's a risk and obvious risk is over overestimation of the patient's ability to protect his or her own airway high risk of laryngospasm when performed on responsive patients most patients experience upper airway swelling do not remove the et tube unless you are absolutely sure you can re-innovate instead sedate the patient with a benzo and if a paralytic drug can be used to facilitate innovation consider administering additional doses absolutely contraindicated if there is any risk of recurrent respiratory failure or uncertainty about the patient's ability to maintain his or her own airway if indicated first ensure adequate oxygenation discuss and explain the procedure to the patient if possible have the patient sit up or lean forward and assemble assemble and have available all equipment to suction ventilate and re-innovate after confirming that the patient can protect his own airway suction the oropharynx deflate the cuff of the et2 and the patient begins to exhale so that the accumulated secretions are not aspire aspirated into the lungs on the next exhalation remove the tube in one steady motion place a towel or emesis basin in front of the patient's mouth and in case of vomiting next we're going to",
        "Pharmacologic Adjuncts to Airway Management and Ventilation": "talk about pharmacologic agents or adjuncts to airway management and ventilation so pharmacologic agents are used to decrease the discomfort decrease the incident of complications and to make aggressive airway management possible for patients who are unable to cooperate",
        "Sedation in Emergency Intubation": "so sedation is emergency innovation it reduces a patient's anxiety induces amnesia and decreases the gag reflex complications are relatively primarily primary to over sedation and under sedation under sedation can result in inadequate patient cooperation and complications of gagging and incomplete amnesia of the event over sedation of course can result in under controlled general anesthesia a loss of protective airway reflexes respiratory depression complete airway collapse or hypotension the level of sedation desire dictates the amount of medication you're going to administer so you want to follow your protocol or contact medical control regarding the appropriate dose two major classes of sedatives that we use are analgesics and they decrease the perception of pain and then sedative hypnotics and that induces sleep and decreases anxiety they do not reduce the pain so",
        "Benzodiazepines": "benzodiazepines are sedative hypnotic drugs diazepam valium or midazolam which is versed it provides muscle relaxation and mild sedation used extensively as um anti-seizure medications it also provides intro or anterior retrograde amnesia midazolam is two to four times as potent as diazepam so it's faster acting shorter duration of action in large doses are necessary so it should not be used as an induction agent its likelihood of complication increases because of the large dose required use of a neuromuscular blocker such as a paralytic to achieve muscle relaxation is preferred because they require smaller doses and a potential side effect is respiratory depression and slight hypotension and so ramazikan is a benzodiazepine and antagonist",
        "Dissociative Anesthetics": "so disassociated anesthetics so a medication that produces anesthesia by distorting the patient's perception of sight sound and inducing a feeling of detachment or dissociation from environment or self it produces anesthesia through hallucinogenic analgesic and sedative effects so ketamine it's commonly disassociated anesthetic in the emergency medicine it's the most common it's rapid acting with a relatively short duration of action at lower doses so 0.2 to 0.3 milligrams per kilogram it is commonly used as an analgesic at higher doses two milligrams per kilogram it induces sedation and are commonly given prior to neuromuscular blocker to facilitate inhibition so ketamine produces a sympathomimetic effect and it makes a it makes it a hemodynamically stable choice among sedative induction agents when performing emergency airway management in patients with hypotension",
        "Opioids/Narcotics": "and then we have opiates and narcotics so they're potent analgesics with sedative properties they're used as pre-medication during induction and in maintenance of sedation or amnesia so then we have fentanyl and uh uh all fentanyl fentanyl is 70 to 150 times more potent than morphine it's a rapid onset of action relatively short duration of action too and then the all fentanyl it's a less potent defendant faster onset of action and a shorter duration of action it's eliminated by the body much faster as well and it can cause profound both of them can cause profound respiratory and central nervous system depression and we have the narcan of course is that narcotic in antagonist",
        "Nonnarcotic/Nonbarbituate": "all right and then we have um a non-narcotic non-barbiturate and that's atomidate or an amidate so it's a um sedative drug often used in the induction of general anesthesia it's fact fast acting short duration little effect on pulse rate blood pressure and icp it does not cause the histamine release or bronchial constriction that may occur with other agents and it's a high incidence of uncontrollable myoclotic muscle movement so useful induction agent in patients with coronary artery disease or increased icp or borderline hypotension",
        "Neuromuscular Blockade in Emergency Intubation": "okay so so let's talk about some neuromuscular blockage in emergency inhibitions so cerebral hypoxi hypoxia can make patients combative aggressive belligerent and uncooperative mo they must be treated aggressively with oxygenation and ventilation a physical restraint used could be used and it's very common but also chemical paralysis with a neuromuscular blocking agent is safer and it its protective airway reflexes are lost though so neuromuscular blocking agents so sedatives alone can facilitate innovation but it is far more effective to use a drug design to induce paralysis so this affects the skeletal muscles though within about one minute of receiving the patient becomes totally paralyzed and they stop breathing their jaw muscles go slack and because of the tongue falls back against that posterior pharynx it obstructs the airway you must be absolutely sure that you can secure the airway with these patients so paralytic agents do not affect cardiac or smooth muscle and paralytic agents have no effect on the level of consciousness a patient can hear feel and think",
        "Pharmacology of Neuromuscular Blocking Agents": "and so when you're using these the skeletal or striated muscles are voluntary and require input from the somatic nervous system to initiate contraction impulse 2 the to contract reaches the terminal end of that motor nerve and this ach or acetylcholine is released into that synaptic cleft and that's the junction between the nerve cell and the muscle cell and so this acetylcholine diffuses and accompanies the receptor sites triggering changes in the electrical properties of that muscle electrical properties of the muscle fiber and this process is called depolarization so when enough motor end plates have been depolarized the muscle fiber will contract depolarization lasts for a few milliseconds because of the presence of coloners an enzyme that quickly removes acetycholine and so paralytic medications they function at the neuromuscular junction it really it relaxes that muscle by in impeding the action of that acetylcholine and it's classified into two categories there are depolarization uh depolarizing agents and non-depolarizing agents okay the first one we're going to talk about is the depolarizing neuromuscular blocking agent it completely binds with the acetylcholine receptor sites but is not affected as quickly and so sexocholine is the only depolarizing neuromuscular blocking agent and fasciculations can be observed during its administration and this is characterized by brief uncoordinated twitching of the muscle small muscle groups so it tends to cause generalized muscle pain when it wears off it's characterized by a very rapid onset of about 60 to 90 seconds with a short duration and i mean very short so five minutes to ten minutes after um it's been used it should be used with caution in patients with burns crush injuries or blood trauma because it could result in hyperkalemia it can cause bradycardia especially in pediatric patients administration of atropine should precede the administered of a suc sexacholine in pediatric patients so non-depolarizing neuromuscular blocking agents it also bind they also bind to the acetylcholine receptor sites but do not cause depolarization of the muscle fiber so if a significant quality is administered the amount of medication may exceed the amount of acetylcholine in that synaptic and it may prevent fasciculations when administered in small quantities before a depolarizing paralytic it's commonly used one is vacuoromium and uh the duration of action longer than that of sexy choline so vac is a rapid onset of about two minutes the duration action is about 45 minutes it's ideal when a patient requires extended periods of paralysis and do not give the patient if you don't have the patient's airway if it hasn't been secured okay so the next thing we're going to talk about is rsi innovation so rapid sequence innovation this includes safe smooth and rapid induction of sedation and paralysis followed by immediately innovating generally used for patients who need to be innovative but are unable to cooperate of course the first thing you have to do is prepare the patient and the equipment expen you need to explain the procedure and reassure the patient apply cardiac monitor and pulse ox check prepare and assemble your equipment and have section immediately available pre-oxygenate so we have to adequately pre-oxygenate all patients before we begin we're going to apply high flow oxygen via non-rebreather mask if the patient is breathing spontaneously and has adequate tidal volume if the patient is hypoventilating assist ventilations with a back valve mask and high flow oxygen may be necessary avoid bad mass ventilation before rsi whenever possible okay so pre-medication is what we're going to talk about next and if your initial paralytic of choice is sucks sexy choline administer a de uh fasciculating dose of a non-depolarization paralytic if time permits typically about 10 of the normal dose so atropine should be administered to decrease potential for bradycardia its usual adult dose is 0.5 milligrams and infants and children we use .02 milligrams per kilogram or 0.02 as soon as the patient is hemodynamically stable and we consider this uh hemodynamic stability a systolic blood pressure of 90 millimeters of mercury and that's systolic of course administer a sedative as soon as the patient is adequately sedated administer the paralytic agent the onset of paralysis should be complete within two minutes signs of adequate paralysis include apnea or the relaxation of the mandible or loss of eyelash reflex so when you innovate the procedure of innovation is no different for rsi than it is for any other situation if you cannot accomplish the animation innovation within short period of time and or if the oxygen of the patient's saturation level falls stop the innovation and ventilate with 100 percent o2 when the patient's oxygen saturation returns to a normal acceptable level re-attempt the innovation if you must ventilate the patient with a bvm do so also one second per breath enough to produce visible chest rise and fall and once the tube is in the trachea inflate the cuff remove the style verify correct placement of the tube secure the tube and continue ventilations at the appropriate rate maintenance of the paralysis and sedation so when you are absolutely sure that you have successfully inhibited the trachea additional paralytic administration may be necessary if you administered sexacholine initially remember a non-depolarizing agent to maintain long-term paralysis if you administer a long-acting paralytic initially additional dosing is not usually necessary general steps of rsi may need to be modified for patients in unstable condition if oxygen saturation drops you must ventilate if patient is hemodynamic dynamically unstable judge whether sedation is appropriate or whether risk of profound hypotension is too great all right so an alternative airway device and this one that you could see is that's a supraglottic airway device there are a couple of them and so we're going to talk about that king lt airway you could use this as latex free single use and it's a single dual lumen or single lumen airway you blindly insert it into the esophagus it can be used to provide positive pressure ventilations to apnic patients and maintain a patient air or pain airway and spontaneously breeding patients who require advanced airway management there are adult and pediatric dose sizes curved tube with ventilation ports located between two inflatable cuffs and distal cuff seals the esophagus and the proximal cuff seals the oropharynx and it can be inserted more easily and quickly than the combi tube and so you can see that's a great picture on the slide of the location of the two cuffs so there's two types there's the ltd and the ltsd the king l ltd can be used in adults and children and the king ltsd is only used on adults so there's five sizes of each type it's based on the patient's height and weight each size has a different color of proximal connector and requires different cuff inflation pressures so the king ltd and ltsd share most of the same features they both have a proximal pharyngeal cuff a distal cuff and several ventilation outlets in both the et tube inducer it's a gum elastic bougie can be inserted through the tube where it exits between the pharma the pharma jewel and the distal cuff the distal and it has a closed ltd and an open ltsd the opening in the ltsd permits insertion of a suction cath for gastric decompression there's indications for them and that's an alternate to bvm for a failed innovation attempt and it has the same advantages and disadvantages complications and special considerations as the combi2 the contraindications it does not eliminate the risk of aspirating and vomiting its high airway pressure can cause air to leak into the stomach or out of the mouth and it should not be used with patients with an intact gag reflex with known esophageal disease and who have ingested a coccyx caustic substance proper placement is confirmed by observing chest rise and fall auscultating lungs and epigastrium and waveform capnography so complications of that king airway are those laryngospasms vomiting and hypoventilation and trauma as a result from improper insertion technique and then ventilation can be difficult if the pharmageal balloon pushes the epiglottitis over the glottic opening insertion technique so the patient's head and weight determine the size that you are going to use to properly insert the king lt airway refer to skill drill 15-15 and then there's the lma so the laryngeal mask airway and it's a viable option for patients who require more airway and ventilatory support than a bvm um but can provide that bvm can provide but do not require innovation so it provides a conduit conduit for the glottic opening to the ventilation device and it surrounds the opening of the with an inflatable silicon cuff positioned in the hypo pharynx when properly inflated the opening is positioned at the glottic opening and the tip is inserted into the proximal esophagus and so you can see it in the photo on the slide the inflatable cuff conforms to the airway contours and it forms a relatively airtight seal indications and copper indication so one alternate to a back valve mask when the patient cannot be innovated it's less effective in obese patients pregnant patients and patients with the hiatal hernias are at an increased risk of regurgitation and it's ineffective with ineffective with patients requiring high pulmonary pressures and then there's some advantages and disadvantages so you could get better ventilation it does not require continual maintenance of a mass seal it does not require a linger laryngoscopy it's significantly less risk of soft tissue um vocal cord and tracheal wall and dental trauma with other than it's less risk than the et tube and main disadvantage it does not protect against aspiration okay and during prolonged lma ventilation some air might be allowed into the stomach we don't usually use these as a primary airway in the in the emergency settings complications of course most significant complications involve regurgitation and aspiration should not be used in patients who are fasting or it should only be used in patients who are fasting and though you have to weigh the risk of aspiration aspiration versus hypoventilation with a bvm look for clinical indications of adequate ventilation hypovolation of patients who require high ventilatory pressure can occur a few cases of upper airway swelling have been reported so there's several sizes of the tr for of the lma and it's going to be based on that patient's weight it consists of a tube and an inflatable mass cuff there's two vertical bars at tube opening to prevent occlusion the proximal end of the tube is fitted with a standard adapter and it's capable of course with any ventilation device the cuff has a one-way valve assembly you inflate it with a predetermined volume of air a six millimeter et tube can be passed through a size three or four lma the fast track lma guides an et tube into the trachea and there's an insertion technique so before insertion check and prepare your equipment to properly insert an lma refer to skill drill 15-16 in your book and this figure shows some examples of those mass the lma oh and then we have the eye gel so it's inserted in the same manner of the as the lma it's designated to create a non-inflatable anatomical seal of the pharyngeal laryngeal and peri-laryngeal structures while avoiding compression trauma that may occur from devices with an inflatable cuff the igel is common rescue airway device and is reasonable at alternative to innovation if innovation is unsuccessful the igel features a bite block a gastric access channel that allows for passage of a gastric tube a supplemental oxygen port to facilitate passive oxygenation a support strap for secure securing the eye gel in position a color-coded hook ring that indicates the size of the eye gel and serves as an anchor for the support strap the steps for inserting an eye gel supraglottic airway are shown in skill drill 15-17 and you can see this figure shows the correct positioning of the eye gel and the table shows the the patient criteria for the igel supraglottic airway and then there's a cobra airway this is named because of the cobra shape of the distal part of the airway it allows the device to slide along the hard palate and to hold soft tissue of the airway away from the laryngeal inlet it's a supraglottic device with a tube for ventilation and a circumferential cuff proximal to the distal end which is uh the ventilation outlet has a standard adapter the distal tip is proximal to the esophagus and seals the hypopharynx and when the cuff is inflated it raises the tongue and creates an airway seal allowing for ventilation there's eight sizes of these that are available and the usage is similar to the supraglottic airway it can be used in pediatric patients and does not protect against aspiration like most other supraglottic airways contrary indications of course are risk for aspiration and massive trauma to the oral cavity and laryngeal spasms may occur if there's an intact gag reflex if not inserted far enough the inflammation of the cuff can cause the tongue to disrupt an adequate seal patient cannot be ventilated if the device is too small all right so insertion technique you're going to fully deflate the cuff and apply water soluble gel to the front and back of the device with the patient's head in the sniffing position you're going to open the airway with the tongue jaw lift maneuver and direct the distal tip of the cobra back between the tongue and the heart palate continue advancing this until a modest resistance is felt inflate the cuff with only enough air to achieve a good seal do not overflake and ventilate the patient while observing for chest rise and fall and auscultating over the neck chest and epigastrium use waveform capno for further confirmation of course and the figure shows how to insert that cobra airway all right so multi lumen airways and of course the most famous one most well used one is the combi tube and they call it a multi-lumen airway because there's multiple tubes right so multi-airway device that is inserted blindly clinically proven to secure the airway and allow for better ventilation than a bvm and it contains two lumens so each lumen has a standard adapter which accommodates for a ventilation device also contains an oral pharyngeal balloon which eliminates the need for a mass seal and so the figure of this shot slide shows the combi tube and the process for inserting that indications and contraindications so it's indicated for airway of a deeply unresponsive ethnic with no gag reflex in whom et tube innovation is not possible or has failed it cannot be used in children under 16 and it should not be used for patients between five and seven or it should only be used for patients be between five and seven feet tall there is a smaller version and it's available for patients four to and 5.5 feet tall conjugations esophageal trauma known pathologic condition of the esophagus so something like esophageal cancer patients who have ingested caustic substance or the history of alcohol okay so there's advantages of course ventilation is possible whether tube enters either or the esophagus or the trachea insertion is technically easier than the et tube and the head is in the neutral position so no cervical spine movement is is very minimal no mask is required if the tube is placed in the trachea functions as an et tube if the tube is placed in the esophageal esophagus the pharmageo balloon creates an airtight seal in the oral pharynx a jaw thrust maneuver should easily alleviate any ventilatory difficulty ventilation in the wrong port results in no pulmonary ventilation and usually considered temporary and should be replaced as soon as possible the pharmageal balloon reduces but does not eliminate the risk of aspiration inhibiting the trachea via a direct laryngoscopy with the multi-lumen airway in place is extremely challenging so complications of multi-luminaire way so most significant complication is unrecognized displacement into the esophagus and use multi-multiple confirmation techniques okay so laryngospasms as well vomiting and possible hypoventilation may occur during insertion farm pharmageal and esophageal trauma may result from improper technique and ventilation may be difficult if the pharmageal balloon pushes the esophagus over the glottic opening okay so with the combi tube you can insertion a technique in include the single tube with dual lumens two balloons two ventilation attachments so before insertion of course we're going to check and prepare our equipment check both cuffs ensure that they hold air pre-oxygenate and do not interrupt ventilation for longer than 30 seconds we're going to um the head is going to be in the neutral position and we're going to displace the jaw and with the head in the neutral position insert your the thumb of your non-dominant hand into the mouth and lift the jaw insert the device and insert the device blindly into the posterior pharynx until the incisors are between the two black lines printed on the tube you need to be gentle stop advancing the tube if you meet resistance two independent inflation valves must be inflated first inflate the balloon on the pharmageal tube so that's blue tube that's number one and it's filled to one with 100 milliliters of air and then second inflate the distal balloon on the tracheal tube and that's filled with 15 milliliters of air confirmed ventilation is is a critical so you have the following inflammation inflation of the balloons ventilate begin to ventilate through the longer one and that's the blue tube observe chest wise and fall and also tape breast sounds and of course epigastric sounds if there is no breast sounds and the chest does not rise and fall switch immediately to the shorter tube continuously monitor ventilation secure the device once ventilations are confirmed and choose continuous capno to confirm the presence of exhaled carbon dioxide okay so one of the final things we're going to talk about today is going to be the surgical and non-surgical cricothyrotomy it's used when conventional techniques fail you have to be familiar with these so there are two methods of securing a patient's airway and they can be used when those conventional techniques fail so you have this open cricothyrotomy and that's called the surgical crike and then you have a catheter ventilation and that's non-surgical um or it's called the needle crike okay so to perform them you must be familiar with these key anatomic landmarks in the anterior aspect of the neck there are important blood vessels in this area and you have just superior the cricoid thyroid vessel runs at the transverse angle across the upper third of the cricoid thyroid membrane then the external jugular veins run vertically and are located lateral to the cricoid thyroid membrane you could see those the carotid arteries in the photo so when performing the cricoid thyrotomy expect minor bleeding from subcutaneous and small skin vessels as you incise the cricoid thyroid membrane should be easily controlled with light pressure after the tube has been inserted so let's first talk about the open crike and it's also called the surgical crike it involves in sizing the cricoid thyroid membrane with a scalpel inserting the e.t or the trach tube directly into the subglottic area of the trachea the cricoid thyroid membrane is the ideal site for the surgical opening into the trachea no important structures lie between the skin and the airway and the airway is at the level um is relatively close to the skin the posterior airway wall at this level is formed by tough cricoid cartilage so that helps prevent accidental perforation into the esophagus there are several types so the open surgical crike involves incising the skin and cricoid thyroid membrane and inserting an et tube or a trach tube it's a modified and then there's a modified cricoid thyrotomy and that you may use a modification of a salinger technique to enable placement of the airway uses of a needle and guide wire or guide catheter for tube placement in blood vessels or other hollow organs and then there's commercially manufactured airway placement devices and they use a device that functions as an inducer and an airway and an airway so indications and contraindications so it's indicated when the patient's airway cannot be secured with a more conventional means and so these can include severe foreign airway obstructions and airway obstructions from swelling or massive maxillofacial trauma or the inability to open the patient's mouth and then the main contraindication is the ability to secure the airway in a less invasive means another contraindication may include the inability to identify the correct and atomic landmarks uh crushing air injury in which the larynx or trachea is transected an underlying anatomic abnormality or age younger than eight so the larynx of a small child is generally unable to support a large tube enough to produce effective ventilation without causing damage to the larynx in situations where cricoid thyrotomy is contraindication the patient may be rapidly transported to the closest appropriate facility and this slide just shows you some advantages and disadvantages so it can be performed quickly and without manipulating the spine it's difficult to perform though in children and patients with short muscular or fat necks it's more difficult than a crike an insertion inserting a large bore tube prevents greater tidal volume which facilitates more effective oxygenation and ventilation and then the complications there could be some bleeding or more severe bleeding is usually the result of a laceration of that external jugular vein and inserting the tube gently minimizing risk of perforating the esophagus and damaging damaging laryngeal nerves it must be performed quickly and it is possible to create a false passage of the tube if the tube undermines the subcutaneous tissue and never even enters the trachea okay so the risk is greater when performing an open crike on a patient who's a be obese all right so the equipment you uh you would want a commercial kit um if it's available okay so if not prepare the following equipment so you need a scalpel an etu trach tube of a six millimeters minimum so commercial device or tape for securing it a curved hemostats or suction and you want sterile gauze for bleeding control and a bvm so the technique for performing an open crike you must proceed rapidly yet cautiously identify the critical thyroid membrane by palpating for the v-notch of the thyroid cartilage okay when you have located that v-notch slide your index finger down into the compression between the thyroid and the cricoid thyroid this is called the cricoid thyroid membrane so males have a more predominant thyroid notch and thyroid prominence whereas females have a more prominent cricoid ring so when palpating the anatomy of females first locate the cricoid thyroid ring when the cricoid thyroid membrane and finally the thyroid cartilage your partner should be prepared with equipment and ensure that the cardiac monitor and pulse ox are attached to the patient maintain an aseptic technique as you cleanse the area with iodine while stabilizing the larynx place a half to a three-quarter inch vertical incision over the cricothyroid membrane so remember it's vertical insert the curved hemostats into the opening and spread them apart so gently insert of the 6ml cuffed et tube or six tracheostomy tube and directly directly into the trachea inflate the distal cuff with the appropriate amount of air attach the bvm to the standard adapter of course 15 to 2 and ventilate the patient while your partner auscultates if epic gastric sounds are heard you have lightly inserted the tube into the esophagus additional confirmation of correct tube placement can be accomplished of course by the entitled detector between the tube and the bvm after confirming the two placement ensure that any minor bleeding has been controlled properly secure the tube and continue to ventilate the at the appropriate rate to perform a crike refer to skill drill 15-8 in your book and then there's the needle crank so a 14 to 16 gauge over the needle iv catheter is inserted through the cricothyroid membrane into the trachea adequate oxygenation inflammation are achieved by attaching a high pressure jet vent to the hub of the catheter this is known as a trans-laryngeal catheter ventilation it's commonly used as a temporary measure until a more effective airway can be obtained there are indications and they're essentially the same for an open crack an inability to ventilate unless the invasive techniques by less massive maxillofacial trauma inability to open the patient's mouth uncontrolled uh oral feral bleeding and then it's indicated with severe airway obstruction above the site of the catheter insertion exhalation is not as effective with a small bore cath as with a large so exhalation via glottic opening is not possible and hypercarbia and hypoxia may occur there are some advantages and disadvantages so needle crack is faster and easier to perform it's a lower risk of damaging adjacent structures because you're not in sizing with a scalpel it allows for subsequent inhibition attempts because it causes just a very small bore catheter opening it does not require a manipulation of the sea spine and using a small bore tube does not provide protection though against aspiration okay complications are improper catheter placement can result in severe bleeding excessive air leakage around the insertion site can cause subcutaneous emphysema if too much air infiltrates into the subcutaneous space compression of the trachea and subsequent obstruction may occur so extreme care must be exercised when ventilating with a jet ventilator so equipment you're going to need large bore iv 14 to 16 gauge 10ml syringe three milliliters of sterile water saline and oxygen source so 50 psi and then the high pressure jet ventilator device and oxygen tubing the technique for performing the needle crike you're going to draw approximately three mls of sterile water or saline into 10 ml syringe and attach the syringe to the iv catheter you're going to place the needle in the neutral position and locate the cricoid thyroid membrane if time permits cleanse the area with iodine containing solution you want to stabilize the larynx and insert the needle into the midline of the cricoid thyroid membrane at a 45 degree angle towards the foot if a pop is felt insert the needle approximately a half inch farther and then aspirate with the syringe if the catheter has been correctly inserted you should be able to easily aspirate air and see is a saline or water bubbling if the blood is aspirated or if you meet resistance you should re-avail your catheter placement advance the catheter over the needle until the catheter hug is flush with the skin then withdraw the needle and place it in a puncture-proof biohazard container sharps container attach one end of the oxygen tubing to the catheter and the other to the jet ventilator begin ventilations by opening the release valve and observing for adequate chest rise and fall auscultation of breath and epigastric sounds will further confirm placement turn the release valve off as soon as you see chest rise and fall exhalation will occur passively via the glottis ventilate as dictated by clinical condition and secure the cathode catheter in place by folding a four by four gauze pad under the catheter and taping it in place continuous ventilations while frequently assessing the patient and to properly perform the needle crike and trans laryngeal catheter ventilation refer to skill drill 15-19 in your book so congratulations you have completed the chapter 15 airway management both part one and part two and if you enjoyed this go ahead and subscribe to the channel we're gonna be completing all the chapters uh here shortly so all right have a great evening"
    },
    {
        "Introduction to Airway Management": "hello and welcome to chapter 15 airway management part one of the emergency care in the streets uh lecture and so this chapter it's uh significantly long so we have split it up into two parts and this is the first part so let's get started",
        "National EMS Education Standard Competencies": "establishing and maintaining a patent airway and ensuring effective oxygenation and ventilation are vital aspects of effective patient care attempting to stabilize the condition of the patient whose airway is compromised is futile the human body needs a constant supply of oxygen to carry out the physiologic process necessary to sustain life the airway is where it all begins few situations will cause such acute deterioration and death more rapidly than airway and ventilation compromise to preserve life the airway must remain patent at all times regardless of the situation this chapter provides complex knowledge of airway management and ventilation methods as well as reviewing anatomic and physiologic considerations",
        "Introduction": "so let's get started establishing and maintaining a patent airway and ensuring effective oxygenation and ventilation are vital to patient care now you'll hear it's called a patent airway patinary that's an open airway it is futile to try to stabilize a patient whose airway is compromised and like i said in the first slide the human body needs a constant supply of oxygen and this begins with the airway airway and ventilation compromise will rapidly lead to acute deterioration and death so the respiratory system brings in oxygen and eliminates carbon dioxide and carbon dioxide is the primary waste product of oxygen metabolism vital organs will not properly function if the process is interrupted is interrupted and permanent death of brain cells occurs after approximately six minutes without oxygenation failure to manage the airway or inappropriate management of the airway is a major cause of preventable death in the pre-hospital setting basic airway management techniques are crucial skills mortality and morbidity increase due to failure to use basic airway techniques improper performance of the techniques a rush to use advanced interventions and failure to reassess the patient's conditions paramedics must understand the importance of early detection of airway problems and rapid and ineffective interventions and then continual reassessment appropriate airway management is to open and maintain a patent airway recognize and treat airway obstructions assess ventilation oxygen status administer supplemental oxygen and provide validatory assistance steps must be performed in uh in order bypass steps that do not apply",
        "Anatomy of the Upper Airway": "all right so let's review the upper airway and remember the upper airway consists of all the anatomic airway structures above the glottic opening so the glottis or the space between the vocal cords first it's the tongue and that's the first anatomic structure that must be manipulated it tends to fall back into the posterior pharynx in unresponsive patients then you have the pharynx that's a muscular tube that extends from the nose and mouth to the esophagus and trachea it's composed of the nasopharynx the oropharynx the laryngeopharynx which is the hypopharynx it's the lowest portion of the fairness and it opens into the larynx anteriorly in the esophagus posteriorly and this is a good picture it shows that oral cavity and the pharynx",
        "Larynx": "so the lower airway is next and the lower airway extends from the glottis to the pulmonary capillary membrane in the first is the larynx and that's the complex structure formed by many independent cartilaginous structures it marks where the upper airway ends and the lower airway begins then you have the thyroid cartilage that's the shield shaped structure it's formed by two plates that join in a y shape anteriorly to form the laryngeal prominence so you could feel that that's known as the adam's apple it's more pronounced than men and can be difficult to locate in obese or short-necked patients it's suspended from the thigh from the hyoid bone by the thyroid ligament and it's directly anterior to the glottic opening this is a good slide it shows the larynx next is a cricoid cartilage we call that the cricoid ring and that lies inferior to the thyroid cartilage it forms the lowest portion of the larynx and it's more prominent in females and then you have the cricoid thyroid membrane that's located between the thyroid and cricoid cartilage it's the site for emergency surgical and non-surgical access to the airway and that's a cricoid thyrotomy and it bordered laterally and inferiorly by the highly vascular thyroid gland because of this locations paramedics must locate in atomic landmarks carefully when assessing the airway via the site",
        "Glottis": "then you have the gladys and this is a great slide you can see the glottic opening and the narrowest it's the narrowest portion of the adult airway the vocal cords are located at the lateral borders of the glottis epiglottis is located at the superior border of the glottis e.t tube innovation requires visualizing the epiglottis glottis and the vocal cords before inserting the et tube the endotracheal tube",
        "Trachea": "and then there's the trachea it immediately descends into the thoracic cavity it's not a straight tube which is the key to understanding when placing an et tube",
        "Ventilation, Oxygenation, and Respiration": "okay so let's talk about ventilation oxygenation and respiration the respiratory and cardiovascular systems work together to ensure that a constant supply of oxygen and nutrients is delivered to every cell waste products are removed from every cell when you talk about ventilation that is the physical act of moving air into and out of the lungs so you inhale that's the active process and it's a muscular part of breathing and then when you exhale this is a passive process it does not normally require muscular effort when i think about ventilation i think about bag valve mask ventilating somebody it's the physical act of air moving into and out of the lungs oxygenation so that's the process of loading oxygen molecules onto hemoglobin molecules in the bloodstream it requires adequate fraction of inspired oxygen and that's written as fi fio2 and that's the percentage of oxygen in inhaled air respiration is the process of exchanging oxygen and carbon dioxide external respiration is a process called pulmonary respiration it's a process of exchanging oxygen and carbon dioxide between the alveoli and blood in the pulmonary capillaries and then internal respiration is also called cellular respiration it's the exchange of oxygen and carbon dioxide between systemic circulation and the body's cells",
        "Pathophysiology of Respiration": "so let's talk about the pathophysiology of respiration multiple conditions can inhibit the body's ability to effectively provide oxygen to cells this disruption of pulmonary ventilation oxygenation and respiration will cause immediate effects on the body you must be able to recognize and correct those immediately it's important to distinguish a primary ventilation problem from a primary oxygenation or respiration problem every cell needs a constant supply of oxygen to survive some tissues are more resilient than others significant levels of external respiration and perfusion are required so perfusion is the circulation of blood within an organ or tissue in adequate amounts to meet cells current needs",
        "Hypoxia": "hypoxia is a dangerous condition in which tissues and cells do not receive enough oxygen death may occur quickly if not corrected varying signs and symptoms so there there's varying signs and symptoms the onset and degree of tissue damage often depend on quality of ventilations early signs include restlessness irritability apprehension tachycardia and anxiety late signs includes mental status changes a weak thready pulse and cyanosis responsive patients often report shortness of breath which is known as dipsnia and may not be able to speak in complete sentences best to administer oxygen before signs and symptoms occur",
        "Ventilation-Perfusion Ratio and Mismatch": "so when you talk about the ventilation to perfusion ratio and mismatch the lungs have a role in placing ambient air in proximity to circulating blood to permanent gas exchange air and blood flow must be directed to the same place at the same time so this is the ventilation and perfusion must be matched failure to match ventilation and perfusion lies behind most abnormalities in oxygen and carbon dioxide exchange in most people normal resting minute volume is approximately 6 liters a minute resting alveolar volume is approximately 4 liters a minute and pulmonary artery blood flow is approximately 3 liters a minute overall ratio of ventilation to perfusion is four to five liters a minute because neither ventilation nor perfusion is disrupted distributed equally both are distributed to dependent regions of the lungs at rest however an increase in gravity dependent flow is more marked with perfusion than with ventilation so ratio of ventilation to perfusion is highest at the apex of the lung and lowest at the base so when ventilation is compromised but perfusion continues blood will pass over alveolar membranes without gas exchange and lack of oxygen diffusion into the circulatory system carbon dioxide is recirculated into the bloodstream this results in a ventilation in perfusion mismatch so it could lead to severe hypoxia if not recognized and treated similar problems can occur when perfusion across the alveoli membrane is disrupted so less oxygen is absorbed into the bloodstream and less carbon dioxide is going to be removed this is going to lead to an increased amount of carbon dioxide in the bloodstream without immediate intervention it is needed to prevent further damage or death",
        "Factors Affecting Ventilation": "all right so there's some factors that affect ventilation and maintaining a patent airway is crucial for provision of oxygen to the tissues intrinsic or internal factors and extrinsic or external factors can cause airway obstruction so let's talk about some intrinsic factors and they include infection allergic reactions and unresponsiveness the tongue of course is the most common obstruction in an unresponsive patient that's easily corrected and it can result in hypoxia and hindu tissue perfusion when you hear so some of the indicators that it's happening are snoring respirations also improper positioning of the head and neck so prom correction is necessary some factors are not necessarily directly part of the respiratory system so in interruptions in the central or peripheral system can drastically affect breathing medications that depress the central nervous system if taken in excess and lower respiratory rate and residual tidal volume so carbon dioxide in the respiratory and circulatory system is increased this increases carbon dioxide in the blood trauma to the head and spinal cord can interrupt nervous control of ventilation and neuromuscular disorders can affect the nervous system's control of the breathing so an examples of some of those are muscular dystrophy and neuromuscular blocking agents such as paralytics can also paralyze a patient and induce apnea and then you have allergic reactions so swelling or angioedema can obstruct the airway and bronchial constriction can decrease pulmonary ventilation also associated with conditions such as copd and asthma so those were the intrinsic factors now the extrinsic factors and they include trauma and foreign body airway obstruction so trauma to the chest or airway this will require immediate evaluation and intervention then blunt or penetrating trauma or burns and this can disrupt airway through the trachea and into the lungs quickly can result in oxygenation deficiencies then you could have trauma to the chest wall and so this can result in structural damage to the thorax leading to inadequate pulmonary ventilation so an example okay so a patient with numerous rib fractures or a flailed chest may purposely bleed breathe shallowly in an attempt to alleviate pain from the injury and this is called respiratory splitting so it can result in decreased pulmonary ventilation proper ventilatory support is crucial hypoventilation occurs when carbon dioxide production exceeds carbon dioxide elimination so carbon dioxide production can exceed the body's ability to eliminate it carbon dioxide elimination can be depressed to the extent that no air keeps up with normal metabolism so hyperventilation occurs when carbon dioxide elimination exceeds carbon dioxide production so hypoventilation and hyperventilation could resent represent the body's attempt to compensate for various abnormal conditions for example if the ph of the blood is too high which is alkalosis the patient's breathing may become slow or shallow in an attempt to retain carbon dioxide to decrease the ph decrease in minute volume decreases carbon dioxide elimination this will result in buildup of carbon dioxide in the blood which is hypercarbia and an increase in mental volume increases carbon dioxide elimination so this lowers carbon dioxide in the blood which is hypocarbia",
        "Internal Factors Affecting Oxygenation and Respiration": "so there are some factors that affect oxygenation and respiration and there are external factors so adequate respiration requires proper ventilation and oxygenation so some external factors in the ambient air have key roles in overall process of respiration some examples are atmospheric pressure or partial pressure of oxygen at high altitudes the percentage of oxygen remains the same but partial pressure decreases because the total atmospheric pressure decreases closed environments may also cause a decrease in ambient oxygen some examples are mines or trenches and then there's toxic gases which displace oxygen in the environment so make proper oxygenation and respiration difficult and in particular co2 has a much greater affinity for hemoglobin than does oxygen so 250 times more this inhibits the proper transport of oxygen to the tissues and then you have some internal factors and these are conditions that reduce the surface area for gas exchange also decrease the oxygen's supply so medical conditions may also decrease surface area of the alveoli by damaging them or by leading to an accumulation of fluid in the lungs so some non-functional alveoli inhibit the diffusion of oxygen and carbon dioxide what happens is blood enters the lungs from the right side of the heart bypasses the alveoli it returns to the left side of the heart in an unoxygenated state this is called intrapulmonary shunting submersion victims and patients with pulmonary edema they have fluid in their aviolae so this inhibits adequate gas exchange the result is decreased oxygenation and respiration exposure to certain environmental conditions or occupational hazards can also result in fluid accumulation in the alveoli over time for example high altitudes or epoxy resins do that these conditions can result in anaerobic respiration and an increase in lactic acid accumulation it can result in life-threatening conditions other conditions that affect cells include hypoglycemia and that's oxygen and glucose levels decrease body is unable to meet the metabolic needs and maintain homeostasis and cell death is likely and then there's infection so that's when increases in metabolic needs disrupts homeostasis while and it will lead to cell death if not corrected and then hormonal imbalances so if insulin levels decrease cellular uptake of glucose will decrease cells will metabolize fatty acids and the result is ketoacidosis and that's a form of metabolic acidosis",
        "Circulatory Compromise": "circulatory compromise so circulatory system must function effectively for respiration to occur compromise leads to inadequate perfusion and oxygen mans will not be met obstruction of blood flow to the cells and tissues is typically related to trauma emergencies including simple or tension pneumo an open pneumo which is also known as a sucking chest womb a hemothorax or a hemo-pneumothorax or a pulmonary embolism these conditions inhibit gas exchange at the tissue level conditions such as heart failure and cardiac tamponade inhibit the heart's ability to effectively pump oxygenated blood to the tissues blood loss and anemia reduce the oxygen carrying ability of the blood that's when there's not enough hemoglobin molecules available to bind with oxygen when the body is in shock oxygen is not delivered to the cells effectively hemorrhagic shock is a form of shock and that's a form of hypovolemic shock and it's once an abnormal decrease in blood volume due to bleeding and it causes inadequate oxygen delivery to the body then there's vasodilatory shock in that caused by an increase in the size of blood vessels the diameter of the blood vessel increases in blood pressure decreases and blood flow diminishes and then oxygen is not delivered effectively to tissues so both forms of shock result in poor tissue perfusion that leads to anaerobic metabolism if shock is suspected you need to treat it aggressively",
        "Acid-Base Balance": "now let's talk a little bit about acid-base balance so hypoventilation hyperventilation and hypoxia can disrupt the acid-base balance and this may lead to rapid deterioration and death respiratory and renal systems must maintain homeostasis in homeostasis tendency towards stability in the body's internal environment it requires a balance between acids and bases it's the fastest way to eliminate excess acid is through the respiratory system and it can be expelled as carbon dioxide from the lungs slowing respirations will increase the level levels of carbon dioxide the renal system regulates ph by filtering out more hydrogen and retaining bicarbonate when needed or when doing the reverse so the fastest way to eliminate excess hydrogen ions is to create water in carbon dioxide and it can be expelled as gas from the lungs as well anything that inhibits respiratory function can lead to acid retention and acidosis alkalosis can develop if the respiratory rate is too high or the volume is too much so there are four main clinical presentations of acid-base disorders first you have respiratory acidosis respiratory alkalosis then you have metabolic acidosis and metabolic alkalosis fluctuations in ph due to available bicarbonate results in metabolic acidosis or alkalosis in fluctuations in ph due to respiratory disorders result in respiratory acidosis or alkalosis acid-base disorders that are not immediately correctable by the body's buffering system caused by the body to initiate compensatory mechanisms to help return the levels to normal patient management often involves treating more than one form of acid-base imbalance",
        "Patient Assessment: Airway Evaluation": "okay so a patient assessment in the airway evaluation the importance of carefully assessing a patient's airway and ventilatory status cannot be overemphasized the quality of your assessment determines the quality of care assessing airway patency so when managing respiratory problems first determine if the patient if the airway is patent an adult who is responsive alert and able to speak in complete sentences with a normal voice has no immediate airway problem an unresponsive patient has a compromised airway until it's ruled out by a careful assessment so signs of aerocompromise and an unresponsive patient include snoring vomit draining from the mouth or gurgling sounds heard during breathing creations pulling in the patient's mouth indicate a markedly depressed or absent gag reflex the gag reflex is a pharmageal and esophageal reflex caused by stimulating the posterior pharynx to prevent foreign bodies from entering the trachea absent significantly increases the risk of aspiration so you need to know how to recognize inadequate breathing an adult who is responsive alert and able to speak to you has no immediate airway or breathing problems normal breathing in an adult at rest is characterized by a rate between 12 to 20 adequate depth which is also tidal volume and regular pattern of inhalation and exhalation clear and equal breath sounds bilaterally and changes in the rate and regularity should be subtle",
        "Recognizing Inadequate Breathing": "so any patients should be assessed for breathing adequacy breathing does not necessarily mean adequate breathing so as a general rule if you see or hear a patient breathe there's usually a problem an adult who is breathing at a rate of less than 12 or more than 20 must be evaluated for other signs of inadequate ventilation such as shallow breathing irregular pattern of breathing altered mentation advantages airway sounds and that's abnormal airway sounds cyanosis such as blue or purple skin color is a clear indicator of low blood oxygen patients with respiratory distress often compensate with preferential positioning such as upright or sniffing that's the tripod position or semi fowler that's semi-sitting position potential causes of respiratory distress and inadequate ventilation include severe infection and that's sepsis trauma they could have a brain stem insult or noxious or oxygen poor environment renal failure upper or lower airway obstruction respiratory muscle impairment such as a spinal cord injury or central nervous system impairment such as a head injury or a drug overdose to properly manage any patient's airway perform the following steps in this order so first you need to open the airway you need to clear the airway assess the breathing and provide appropriate ventilations or interventions evaluation of a patient with a respiratory complaint includes visual observations palpation and auscultation visual techniques use at first sight of the patient so the tripod position if the patient is in the tripod position with the elbows out he is experiencing or she is experiencing orthopedia with his positional dipsnia adequate chest rise and fall of the chest so adequate tidal volume if the patient's gasping for air we call this air hunger also look at the skin the color the if they're moist or clammy that's diaphoresis they could have nostrils flaring breathing through purse lips any retractions and retractions are skin pooling between and around the ribs during inhalation um intercostal at the substernal notch or at the supra clavicular fascia or subcostal so patients using accessory muscles to breathe chest while moving symmetrically asymmetric indicates that airflow into one lung is decreased so patients taking a series of quick breaths followed by a prolonged exhalation a patient with inadequate ventilation may appear to be working hard to breathe and we call this labored breathing okay so signs of inadequate ventilation in adults include the following like we said earlier a respiratory rate of fewer than 12 breasts per minute or more than 20 breasts per minute in the presence of bifia irregular rhythm so a series of deep breaths followed by a period of apnea diminish absent or noisy auscultated breath sounds abnormal breathing or reduced flow of exhaled air at the nose or mouth unequal or inadequate chest expansion resulting in reduced tidal volume or increased effort of breathing use of accessory muscles shallow depth of breathing reduced tidal volume or skin that is pale cyanotic cool moist or mottled retractions also or one to two word diphtheria when assessing a patient with respiratory distress consider possible reduced oxygen levels in the external environment feel for air movement at the nose and mouth so observe the chest for symmetry note any paradoxical motion and that of course is opposite normal opposite normal chest movement and then ss for pulseless paradoxes all right so clinical findings in which the systolic blood pressure drops more than 10 millimeters of mercury during inhalation and you may detect a change in pulse quality or even the disappearance of the pulse during inhalation generally seen in patients with conditions that cause an increase in intrathoracic pressure so decompensating copd severe pericardial tamponade or tension pneumo or a severe asthma attack can cause that pulseless paradoxes ask the question to determine the evaluation of the current problem so was the onset sudden or gradual is there a known cause or trigger the duration is it consistent or recurrent and does anything alleviate or exacerbate the problem other symptoms such as productive cough or color of the sputum chest pain or pressure or fever any interventions attempted prior to ems arrival has a patient been evaluated by a physician or admitted to a hospital for this condition in the past and was the patient hospitalized or seen in an emergency department and released if hospitalized admitted to intensive care clinically significant or a regular unmonitored floor and as the patient currently or is the patient currently taking any medicines if so determine all the overall compliance by asking have you been able to take all of your pills as directed and is there anything that has stopped you from taking your pills as directed is there something that bothers you you are about or bothers you about taking the current pill and look at the prescription date and directions to verify information where were there any changes in the current prescription such as a new medication or changes in the prescribing direction of an existing medications and note any risk factors that could cause or exacerbate the condition such as alcohol or illicit drug use cigarette smoking or an inadequate diet evaluate protective reflexes of the airway so coughing sneezing and gagging a patient whose cough mechanism is suppressed is at risk of aspirating for a material insight a slow deep inhalation following by a prolonged exhalation so periodically hyperinflates the lungs thereby re-expanding the collapsed alveoli an average person's size about once per minute hiccuping is a sudden inhalation due to a spasmodic contraction of the diaphragm it's cut short by closure of the glottis it serves no physiological purpose and persistent hiccups may be clinical significant though patients with serious injuries or illness may present with changes in the respiratory problem so the table on this slide shows abnormal breathing patterns",
        "Assessment of Breath Sounds": "okay so when we talk about auscultation of breath sounds um we're going to talk about these areas that you could see them clearly on the slide and you should be clear and equal on both sides of the chest so we call this bilaterally anteriorly and posteriorly compare each apex or the top of the lung with the opposite apex and each base or the bottom of the lung with the opposite base brass sounds are created as air moves through the tracheobronchial tree the size of the airway determines the type of sound brass sounds heard over the majority of the chest represent air flow into the alveoli tracheal breath sounds or bronchial breath sounds are heard by placing the stethoscope diaphragm over the trachea or sternum ss for duration pitch and intensity vascular breath sounds are softer muscled muffled sounds excretory phase is barely audible and bronchiovascular sounds are a combination of the two they're heard in places where airways and alveoli are found they should be assessed for duration pitch and intensity so the duration is the length of time for the inspiratory and expiratory phase of each breath normally expiration is about twice as long as inspiration the relationship is expressed as the ie ratio or inspiratory expiratory ratio normal ie ratio is one to two when the lower airways obstructive expiratory phase may be four to five times as long as inspiration the ia ratio is one to four or one to five in patients who are tychipnic the expiratory phase is short and approaches that of the inspiration so the ie ratio would be one to one the pitch is described as higher and lower than normal so strider or wheezing intensity of sound depends on air flow rate constant consistency of flow throughout inspiration patient position or the site selected for auscultation less intense sounds are said to be diminished always auscultate directly on the skin and sounds that are present in an unexpected area could indicate an abnormal condition so let's talk about these sounds",
        "Abnormal Breath Sounds": "advantageous or abnormal breath sounds usually classified as continuous or discontinuous so first we're going to talk about wheezing this is continuous sound as air flows through a constricted lower airway high-pitched sound that may be heard on inspiration expiration or both rhonchi is continuous it's a low-pitched sound it indicates mucus or fluid in the lower larger airways crackles formulating formerly known as rails occur when air flows causes mucus or fluid in the airways to move into smaller lower airways they tend to clear with coughing and they may also be heard when collapsed airways or alveoli pop open they're classified as discontinuous sounds they may occur early or late in the inspiratory cycle and early in the inspiratory crackles usually occur when larger proximal bronchial bronchi eye open and this in this is common in patients with copd and tend not to clear with coughing they're late inspiratory crackles and they occur when peripheral alveoli and airways pop open so more common in dependent lung regions and then there's stridor strider results from foreign body aspiration infection swelling disease or trauma within or immediately above the glottic opening this produces a loud high-pitched sound typically heard during inspiration a plural then there's pleural friction rub this results from inflammation that causes the pleura to thicken surfaces of the visceral and parental pleura rub together and they often create stabbing pain when breathing or any movement of the thorax",
        "Pulse Oximetry": "okay so now we're going to talk about quantifying ventilation and oxygenation and you could do this with the pulse ox so a rapid simple safe and non-invasive method for measuring how well a person's hemoglobin is saturated is the pulse oximeter it measures the percentage of hemoglobin in arterial blood that is saturated with oxygen so a light sensor probe transmits light through the vascular bed to the light sensing detector and the amount of light depends on the proportion of the hemoglobin that is saturated with oxygen to ensure that the instrument is measuring arterial not venous oxygen pulse ox uses only pulsating blood mess blood vessels so measure pulse so it can check you can check the device functioning by comparing its pulse reading with your measurement of your patient's pulse by palpation a normally oxygenated normally perfused person should have an spo2 of greater than 95 percent when breathing breathing room air less than 95 in a smoker suggests hypoxia in less than 90 percent signals a need for aggressive oxygen therapy those oximeters may be useful in the following pre-hospital situations monitoring oxygen saturation status of a patient during an innovation attempt or during suctioning low saturation alarm signals that innovation should be aborted and the patient should be ventilated identifying deterioration in the condition of a trauma victim declining spo2 level may prompt a search for a cause and identifying deterioration in a condition of a patient in with cardiac disease it may enable early identification of congestive heart failure following a myocardial infarction identifying high-risk patients with respiratory problems assessing vascular status in orthopedic trauma and use with the fractured extremity to evaluate the pulse distal to the fracture loss of a pulse means that the limb may acquire urgent attention or action in the field a pulse oximeter clipped to a finger or toe on a broken limb might provide information about circulation to the limb circumstances that might produce erroneous readings are bright ambient light so that may enter the meter and create an incorrect reading cover the sensor clip with a towel or aluminum foil to protect it also patient motion and that may mistake motion for arterial pulsation and read oxygen saturation from a vein rather than an artery or poor perfusion this makes it difficult to st to sense a pulse and therefore therefore to generate a reading if the vessels in a patient's limbs are constricted and the limbs are cold you may need to place the clip on the earlobe or nose also nail polish will create an erroneous reading so carry disposable acetone wipes or swabs to remove nail polish quickly venous pulsations occur with right-sided heart failure if a vein is pulsating the oximeter may regard it as an artery and then also abnormal hemoglobin will give an erroneous reading there are two types of hemoglobin normally found so there's the oxyhemoglobin and this is hemoglobin that is accompanied by oxygen and then there's reduced hemoglobin and this is hemoglobin after oxygen has been released to cells normal spo2 values may be observed in the presence of met hemoglobin and carboxy hemoglobin even though the body is not receiving significant or subminifi sufficient oxygenation okay so meth meth hemoglobin or met hb this is a compound formed by oxygen of the iron on hemoglobin and then carboxy hemoglobin is hemoglobin loaded with co2 so carbon monoxide remember it binds to hemoglobin 250 times more readily than oxygen and a co2 meter or a carbon monoxide meter or co monitor um you could use that to and it measures absorption at several wavelengths to distinguish um the hemoglobin reading from the co2 and this determines saturation so there's a portion of our percentage of oxygenated hemoglobin compared to the total amount of hemoglobin and so that's going to be that's going to give that reading so if you want to see the carbon monoxide readings in the bloodstream you need to have a co2 meter peak expiratory flow is the bronchial",
        "Peak Expiratory Flow": "constriction can be evaluated by measuring the peak rate of a forceful exhalation with a peak expiratory flow meter increasing peak expiratory flow suggests patients is a patient is responding to treatment decreasing peak expiratory flow suggests a patient condition is deteriorating so this varies based on the patient's gender height and age healthy adults have a peak expiratory flow rate of about 350 to 750 milliliters to assess peak expiratory flow paste the patie place the patient in a seated position with legs dangling assemble the flow meter ensure that it reads zero ask the patient to take a deep breath place the mouthpiece in his or her mouth and exhale as forcefully as possible make sure there is no air leaks perform this test at least three times and take the best peak flow rate of the three ratings and then there's also arterial gas analysis and this provides the most comprehensive um quantitative information about the respiratory system blood is obtained from a superficial artery and the blood is enough analyzed for ph um in the concentration of bicarbonate ions also base um they're testing the acidosis and the alkalosis and sao2 okay so to maintain normal abg levels or values a balance between alveolar volume and perfusion of the avoid capillaries must be maintained and then of course there's carbon",
        "End-tidal Carbon Dioxide (ETCO2) Assessment": "entitled carbon dioxide assessments and that's etco2 and the body uses as oxygen as fuel and makes carbon dioxide as its byproduct as long as oxygen is delivered carbon dioxide is produced so end tidal co2 monitors detect carbon dioxide in exhaled air important adjuncts for determining ventilation adequacy and the types of monitors include colormetric digital and digital waveform colormetric and so this provides a qualitative it does not assign a numeric value of information regarding the presence of carbon dioxide in the exhaled breath after six to eight positive pressure breaths paper inside the detector should turn from purple to yellow during exhalation this indicates the presence of exhaled carbon dioxide and it should be used during initial confirmation of an et2 placement or placed as soon as possible within a quantitative device sensitive to temperature extremes and humidity it may be less reliable if there's vomit or secretions in it so paper also degrades over time capnography or capnometer displays a numeric reading of exhaled carbon dioxide it's more reliable than the color metric co2 detector and a capnographer performs the same function but provides a graphic representation of exhaled carbon dioxide there's two types we have the waveform and then there's a digital waveform first let's talk about the waveform capno and this provides real-time information regarding exhaled carbon dioxide levels it displays a graphic waveform on the portable cardiac monitor and many portable cardiac monitors provide a numeric reading and a waveform so both and then there's quantitative quantitative waveform capno and this has applications in the emergency medicine including the detection of bronchiospasms hypoventilation hyperventilation it's recommended method of monitoring initial and ongoing placement of an advanced airway device capnography can indicate chest compressions effectiveness and detect return of spontaneous circulation it's possible because blood must circulate through the lungs for carbon dioxide to be exhaled and measured okay so carbon dioxide concentration in exhaled gases normally range between 35 and 45 millimeters of mercury entitled carbon dioxide monitoring is limited with cardiac arrest though in a patient with a short arrest interval exhaled carbon dioxide may be detected despite a lack of perfusion patients with prolonged cardiac arrest will have minimal to no exhaled carbon dioxide because of severe acidosis and minimal or no carbon dioxide returned to the lungs normal capnographic waveform so there are key features of a normal waveform and these include contour baseline level and rate and rise of the carbon dioxide level and so this figure shows a nasal cannula device and also a um an end tidal device so an inline carbon dioxide so the nasal candle we use for somebody who is spontaneously breathing and then of course the inline we're going to use for an innovative patient okay so let's talk more about this entitled carbon dioxide assessments there are four distinct phases of the normal waveform there's phase one and that's that a b and it's also known as the respiratory baseline in it and it's the initial stage of exhalation phase two which is the bc is called the expiratory upslope phase 3 is the cd and it represents the expiratory or alveolar plateau phase 4 is the de and it's the inspiratory downstroke when fresh gas is introduced displacing carbon dioxide and causing the waveform to return to the baseline level of carbon dioxide approximately zero and the duration or width of the waveform corresponds to the duration of ventilation and the space between the waveform corresponds with the patient's respiratory rate abnormal capnography capnographic waveforms so the shape of the capnographic wave is and can provide information about abnormal breathing processes such as hypoventilation or hyperventilation bronchiospasm and rebreathing okay so hypoventilation it's a condition in which the production of carbon dioxide exceeds elimination waveforms are tall and the end tidal value is correspondingly high so greater than 45 millimeters of mercury um greater um slow breathing produces a prolonged avior plateau and longer than normal intervals between waveforms okay so the causes of hypoventilation could be respiratory depression or ventilatory rate is slow such as an innovative patient and then there's hyperventilation so that's a condition in which the elimination of carbon dioxide exceeds production waveforms are small and the end tidal co2 value is correspondingly low so you're going to have less than 35 millimeters of mercury tachypnea produces a short avior plateau and shorter than normal intervals between waveforms causes of hyperventilation include anxiety or panic attacks metabolic acidosis a head injury or pulmonary emboli and uses of waveform capnography in a non-innovative innovative patient so it's an excellent way to assess the severity of asthma copd or any pathologic process that causes pulmonary air trapping it's a way to gauge effectiveness of treatment also okay so these figures show capnographic wave forms caused by um a is going to be hypoventilation and b is hyperventilation c is uh re-breathing and uh um also and a shark fin capnographic waveform that indicates bronchiospasm and incomplete alveolar emptying and that is d if there's an inadvertent exhibition that occurs then you would expect to see a complete loss of the capnographic waveform and end tidal reading on occasion the sampling tubing from an inline adapter to the cardiac monitor gets obstructed with blood or other debris which block the flow of gas to the sensor zeroing out the waveform and end tidal reading so replace the inline adapter to restore the waveform and end title reading this table shows causes of increase and decrease and tidal levels",
        "Airway Management": "all right so there's some let's talk about some airway management so air reaches the lungs through the trachea so a patient's airway is essential okay um patency is obvious if the patient is responsive and able to talk manual maneuvers may be required to open the airway and artificial airway adjuncts may be needed in a compromised airway clearing the airway and maintaining patency are vital clearing the airway means removing obstructed material tissues or fluid from the nose mouth or throat maintaining the airway means keeping the airway patent",
        "Positioning the Patient": "also positioning of the patient is important so unresponsive patients found in the prone position must be positioned in the supine position log roll the patient as a unit once the patient is supine quickly assess for breathing by visualizing the chest rise and fall if the patient is breathing adequately and is not injured move them to the recovery position and that is the left lateral recumbent position used in all non-trauma patients with decreased level of consciousness who can maintain their own airway spontaneously and who are breathing adequately",
        "Manual Airway Maneuvers": "so manual airway maneuvers if the patient is unresponsive but has a pulse but is not breathing you must open the airway manually the most common use of an airway or the most common cause of an airway obstruction in an un responsive patient is the tongue manually maneuver the patient's head to propel the tongue forward and open the airway using either the head tilt chin lift maneuver or the jaw thrust maneuver if there's trauma suspected",
        "Head Tilt-Chin Lift Maneuver": "okay so let's talk about those two methods the head tilt chin lift that's the preferred technique with the patient who has not sustained trauma occasionally the patient will resume breathing on their own with this technique considerations you use them in an unresponsive patient with no mechanism for cervical spine injury a patient is unable to protect his or her own airway and contra indications are responsive patients of course and possible cervical spine injury we're not going to use that the advantages there's no equipment needed it's simple and safe and non-invasive the disadvantages are they may be hazards to the patient's spine so no protection for aspiration also okay so let's talk about the technique with the patient in the supine position position yourself behind the patient's head place one hand on the patient's forehead and apply firm backwards pressure with your palm to tilt the patient's head back place the tips of your fingers of your other hand under the jaw near the bony part of the chin do not compress the soft tissue under the chin because this action may block the airway lift the chin upward bringing the entire jaw with it helping to tilt its head back do not use your thumb to lift the chin lift so that the teeth are nearly brought together but avoid closing the mouth completely and continue to hold",
        "Jaw-Thrust Maneuver": "all right so next is the jaw thrust maneuver and we use this if there's a cervical spine injury or if it's suspected so place your fingers behind the ankle of the jaw and lift the jaw forward is displaced forward so considerations there are indications we use this for the unresponsive patient and possible cervical spine injury the patient is unable to protect his her own airway consideration so responsive patients with resistance to opening the mouth they may be needed in every this may be needed in a responsive patient who has sustained a jaw fracture to keep the tongue away from the back of the throat there are advantages and it may be used with patients with a cervical spine injury of course and it may use the cervical collar we could use it with a cervical collar in place and there's no special equipment required there are disadvantages and you cannot maintain if a patient becomes responsive or combative and it's difficult to maintain for an extended period of time it's very difficult to use in conjunction with the bvm then the thumb must remain in place to maintain the jaw displacement it requires second rescuer for bvm and no protection against aspiration all right so let's talk about the technique you want to position yourself at the top of the of the supine patient's head place the meaty portion of the base of your thumb on that sagamot pro arches stagmatic arches and hook the tips of your index fingers under the angle of the mandible in the indention below each ear while holding the patient's head in neutral in line position displace the jaw upward and open the patient's mouth with the tips of your thumbs because opening and maintaining the airway is so crucial you should carefully perform the head tilt chin lift maneuver if the jaw thrust maneuver fails to adequately open the airway",
        "Tongue-Jaw Lift Maneuver": "all right so the jawlift maneuver is used more commonly to open a patient's airway for the purpose of suctioning or inserting an oropharyngeal it cannot be used to ventilate a patient because it will not allow for an adequate mass seal on the patient's face the technique so position yourself at the side of the patient place the hand closest to the patient's head on the forehead with the other hand reach into the patient's mouth and hook your first knuckle under the excisers incisors or gum line while holding the patient's head and maintaining the hand on the forehead lift the jaw straight upward so when it comes to suctioning you want when the mouth or throat becomes filled with vomit blood or secretions a suction apparatus enables you to remove material quickly and effectively ventilating a patient with secretions in his or her mouth will force material into the lungs so clearing the airway with suction indicated if you're here gurgling is your next priority after opening the airway with manual maneuvers",
        "Suctioning Equipment": "so suctioning equipment ambulance should carry fixed suction in a portable section and regardless of your location you must have quick access to the section hand operated suction units with disposable canisters are reliable effective and relatively inexpensive and can easily fit into your first it can easily fit first in the bag mechanical or vacuum powered suction units should be capable of generating a vacuum of 300 millimeters mercury within four seconds of clamping off the tubing the amount of suction should be adjustable and check the vacuum on the mechanical suction unit at the beginning of every shift you want to turn on the device clamp the tubing and make sure the presence or the pressure gauge resists or registers 300 millimeters of mercury ensure that all battery powered units have fully charged batteries the table on this slide shows some common suction devices the following supply should be readily accessible at the patient's head so you should have a wide bore thick-walled non-kinking tubing soft and rigid suction catheter non-breakable disposable collection bottle in a supply of water for rinsing the catheters so we're going to talk more about these suction catheters and their hollow cylindrical devices and they're used to remove fluids and secretions from the patient's airway first you have a yankar catheter and that's the tonsil tip catheter it's a good option for suctioning the pharynx in adults it's preferred device for infants and children plastic tip catheters with a large diameter they're rigid so they do not collapse and they're capable of suctioning large volumes of fluid rapidly the tips with a curved contour and they allow for easy rapid placement into the oropharynx there are soft plastic non-rigid catheters and those are sometimes called french or whistle tip catheters you can see it on the slide on the right photo and they can be placed in the oral pharynx or nasal pharynx or down the et tube they come in various sizes and have a smaller diameter than rigid and they're used to section the nose to suction liquid secretions in the back of the mouth and in situations in which a rigid catheter cannot be used so suction tubing without the attached catheter facilitates suctioning of large debris in the oral pharynx and allows access to the back of the pharynx suctioning removes oxygen from the airway so adequate pre-oxygenation is required before suctioning each suctioning attempt must be limited to 15 seconds in an adult 10 seconds in children and 5 seconds in infants do not stimulate the back of the throat because the vagal stimulus can cause the pulse to drop after suctioning continue ventilation and oxygenation so soft tip catheters must be lubricated when suctioning the nasal fairness so best used when passed through the et tube suction is applied during extrication of the catheter to clear the airway so on the way out after suctioning re-evaluate the patency of the airway and continue to ventilate and oxygen oxygenate as needed so we know that before inserting anything um especially an oxygen or a suction catheter we need to measure it for the appropriate size and we do this from the corner of the mouth to the earlobe never insert a catheter past the base of the tongue so you want a technique you gotta you have to turn on the suction unit you have to measure the catheter from the corner of the mouth to the earlobe and before applying suction or suction turn the head to the side unless you suspect cervical spine injury open the airway by using a cross finger technique or tongue jaw lift and insert the tip of the catheter at the predetermined length do not suction while inserting the catheter apply suction in a circular motion as you withdraw the catheter and then repeat as needed all right so next we're going to talk about airway adjuncts so an artificial airway adjunct may be needed to help maintain airway patency in an unresponsive patient after manually opening the airway and suctioning our weight adjunct is not a substitute for proper head positioning though even after an airway adjunct has been inserted the appropriate manual position of the head must be maintained so in oropharyngeal airway we also call these oral airways and they're curved hard plastic device that fits over the back of the tongue it makes it easier to ventilate the patient with the bvm it can also serve as an effective bite block should be inserted appropriately in unresponsive patients who have no gag reflex this will stimulate the gag enraging in a responsive patient so to assess for gag reflex use the eyelash reflex if a patient gags during insertion remove the device immediately and prepare for suctioning the figure on this slide shows how to size an oral pharyngeal you measure it from the corner of the mouth to the earlobe or to the angle of the jaw how to insert the airway and how to insert the airway using the tongue blade so there are considerations when you're using an op and of course indications are unresponsive patients who have no gag reflex contraindications are responsive patients or patients with a gag reflex there are advantages they're non-evasive they're easy to place and they prevent blockage of the glottis by the tongue they're disadvantaged they pro there's no prevention of aspiration and then there's complications so an unexpected gag can cause vomiting and an improper technique may cause a pharma pharyngeal or dental trauma if the airway is improperly sized or inserted incorrectly it could push the tongue back into the fairness creating an airway obstruction so rough insertion can injure the hard palate also before insertion suction the orphanics as needed all right so to select an op you need to size it first and you need to measure the device from the corner of the mouth to the earlobe or the angle of the jaw you can insert the oral airway in one of two ways so open the patient's mouth with the cross finger technique or tongue jaw lift hold the airway upside down with your hand and insert the airway in the mouth with the tip facing the hard palate advance the air oral airway until it reaches a soft palate and then rotate 180 degrees allowing it to fl follow the curvature of the tongue until the flange rests on the patient's lips use the tongue blade to depress the tongue ensuring the tongue remains forward insert the oral airway with the tip pointing down and follow the curvature of the tongue until the flange rests on the patient's lips now that's the the second way that you could use it with the tongue with the tongue blade okay so next we're going to talk about nasopharyngeal airways they're soft rubber tipped inserted through the nose into the posterior pharynx it allows passage of air from the nose to the lower airway they range in sizes from 12 french to 32 and depends length depends on the size they're much better tolerated in an airway in patients with an intact category flex but an altered level of consciousness we do not use these with trauma to the nose or if we suspect a skull fracture it may cause the device to enter the brain through a hole caused by the fracture it must be inserted gently to avoid um causing a nose bleed lubricate the airway generously with while you water soluble gel preferably one that contains a local anesthesia right so some type of lidocaine usually slide it gently tip downward into the one nostril if you meet resistance try the other one if the nasal airway is too long then it will obstruct the patient's airway and if the patient becomes intolerant of the nasal airway then gently remove it from the nasal passage have suction ready so there are some considerations and there are indicators of course and that's an unresponsive patient or patient with altered mental status who have an intact yag reflex we can use these contraindications are patient intolerance or the presence of facial trauma specifically the nose nose fracture or a skull fracture advantages are it can be suctioned through and patients it provides a patent airway and it can be tolerated by responsive patients and it can be safely placed blindly no requirement for mouth to be open the disadvantages are an improper technique may result in severe bleeding resulting in epistasis may be extremely difficult to control and it does not protect from aspiration so to select a nasal airway that is the correct size for the patient measure the distance from the tip of the nostril to the earlobe or the angle of the jaw insert a pre-lubricated airway into the larger nostril with the bevel facing the speed the septum until the flange rests on the patient's nostril these figures show how to reins to insert an npa okay so the next section we're going to talk about is airway obstructions the airway connects the body to the life-giving oxygen paramedics must recognize the signs of an obstructive airway and immediately take corrective action there are causes of obstructive airways and we're going to talk about that so sudden foreign body airway obstruction usually occurs during a meal or while playing or eating with small toys with children the multitude of other causes include of course the tongue laryngeal edema laryngeal spasms and trauma aspiration or when obstruction is due to infection or severe allergic reaction repeated attempts to clear the airway will be unsuccessful and potentially harmful it requires specific management and prompt transport to the appropriate medical facility and the tongue so with altered level of consciousness the tongue tends to fall back against the posterior wall of the fairness causing closing off the airway with particular or partial tongue obstructions patients will have snoring respirations with complete obstruction there will be no respirations simple to correct using a manual maneuver either the head tilt or the jaw thrust and then foreign bodies so this can be caused many causes of death often from choking on food the typical victim is a middle aged or older wears dentures consumes alcohol um and they're because it depresses reflex uh protective reflexes adversely affects judgment about sizes of of the pieces of food so it's increased risk with conditions that decrease airway reflexes such as a person with a stroke or obstruction may or be mild or severe depending on the object's size and location so signs may include choking gagging strider dipsnia or dysphonia which is a difficulty speaking so treatment depends on whether the patient is effectively moving air laryngospasms and edema can also cause airway obstructions so laryngeal spasms or laryngospasms result in closure of the vocal cords completely occluding the airway it's often caused by trauma during an overly aggressive innovation attempt or it can occur immediately on excavation or laryngeal edema causes the glottic opening to become extremely narrow or totally closed and common causes are epiglottitis anaphylaxis or an inhalation injury it may be revealed by aggressive ventilation or by forceful upward pull of the jaw muscle relaxant medications may be effective in relieving the laryngeal spasm results do not mean that the laryngeal spasm will not reoccur so transport the patient to the hospital for re-evaluation okay so a laryngeal injury a fracture of the larynx increases airway resistance by decreases airway size due to a decreased muscle tone or laryngeal edema or ventilatory effort penetrating or a crush injury to the larynx can compromise the airway secondary to swelling and bleeding and advanced airway management may be required the next thing we're going to talk about is aspiration so this is this increases mortality potentially obstructs the airway it destroys delicate bronchular tissue it introduces pathogens into the lungs and decreases the patient's ability to ventilate suction should be readily available for patients who are unable to maintain his own airway always assume the patient has a full stomach so there's different levels of airway obstructions and we're going to recognize those and and talk about them there's differences in managing mild versus severe airway obstructions okay and so the differences are very significant a mild obstruction the patient is responsive able to exchange air but may show varying degrees of respiratory distress will usually have noisy respirations and may be coughing but should be left alone because forceful cough is the most effective means of dislodging an obstruction the attempts to manually remove the object could force it farther down into the airway closely monitor the patient's condition and be prepared to intervene if you see any signs of severe airway obstruction all right so now we're going to talk about the severe and so patient typically experiences a sudden inability to breathe talk or cough they may grasp at his or her own throat and that's the universal sign of choking they may begin to turn blue and they may have frequent exaggerated attempts to move air they have weak ineffective or asp absent cough marked respiratory distress a weakened inspiratory stridor in cyanosis is often present okay so when we talk about emergency medical care if the patient is responsive ask are you choking if the patient nods yes and cannot speak begin treatment immediately if the obstruction is not promptly cleared blood oxygen will decrease dramatically if after opening the airway you are unable to ventilate the patient or feel resistance when ventilating reopen the airway and again attempt to ventilate the patient lung compliance is the ability of the alveoli to expand when air is drawn into the lungs during negative pressure ventilation or pushed into the lungs during positive pressure ventilation if large pieces of foreign body are found in the airway sweep them forward out of the mouth with your glove finger attempt to remove only foreign bodies that you could see or that can easily be retrieved once airway is open insert your glove finger alongside the inside of the cheek and into the throat at the base of the tongue try to hook your finger or the foreign body to dislodge it and maneuver it into the mouth do not force the foreign body deeper into the airway do not blindly insert any object other than your finger to remove a foreign body an instrument can damage the pharynx and cause hemorrhaging clear the airway of secretions with suctioning as needed abdominal thrust we used to call this the heimlich maneuver is the most effective way to dislodge the or enforce the object out of the airway in a responsive patient it aims to create an artificial cough thereby expelling the object perform until the object is expelled or until the patient becomes unresponsive if the patient is advanced stages of pregnancy or morbidly obese we perform chest thrusts instead if the patient becomes unresponsive position him or her supine on the ground and begin chest compressions it's 30 compressions if 15 15 if two rescuers are present and if the patient is an infant or a child then open the airway and look in the mouth attempt to remove the foreign body only if you can see it attempt a rescue breath if the first breath does not produce visible chest rise and fall reopen the airway and re-attempt to ventilate if both breasts fail to produce a visible chest ride rise continue chest compressions if techniques do not work proceed with drake direct laryngoscopy so insert the laryngoscope laid into the patient's mouth if you see a foreign body remove it with the mcgill forceps and you can see this on skill drill 15-1 so let's talk next about supplemental oxygen therapy supplemental oxygen should be administered to any patient with potential hypoxia indications of supplemental oxygen are patients with respiratory distress those with suspected or documented hypo hypoxia so oxygen saturation of less than 94 and as directed by ems system protocols so there's oxygen delivery methods are the most appropriate um for the patient's ventilatory status reassess frequency frequently and adjust the oxygen delivery method based on clinical condition and breathing adequacy so this is an oxygen cylinder it's pure 100 oxygen and it's stored in a seamless steel or aluminum cylinder the cylinder color may vary but usually silver chrome green or a combination of the two it makes make sure that the cylinder is labeled medical oxygen and look for letters or symbol or symbols or numbers stamped on the cylinders collar especially the month in the year that indicates the last test date various cylinder sizes so you will most often use the d and that's 350 liters of oxygen typically carried from the ambulance to the patient and then there's the m tanks and that's 3 000 liters of oxygen and that stays on the ambulance it's the main supply tank and oxygen delivery is measured in liters per minute replace the oxygen cylinders with a full one when the pressure falls below 200 psi or lower that level is called the safe residual pressure in some ems systems the safe residual pressure they say it's 500 so using the pressure in the cylinder and the flow rate you can calculate how long the supply of oxygen will last remember there's safety reminders with uh oxygen cylinders and any cylinder containing compressed gas under high pressure has the potential to assume the properties of a rocket so oxygen presents a fire hazard because it supports the convection combustion process safely use safety precautions because they're necessary when handling oxygen cylinders and so these are the safety precautions we want to keep combustible materials away from the cylinder regulator fittings valves and tubing we don't want to smoke near the cylinders store them in cool well ventilated area with temperatures below 125 degrees fahrenheit we want to use only with safe properly fitting regular valve regulator valve enclose all valves when the cylinder is not in use even if the tank is empty secure cylinders so that they will not topple over when working with an oxygen cylinder always position yourself to its size never place any part of your body over the cylinder valve and have the cylinder hydrostatically tested every 10 years to make sure it can sustain the pressure high pressures that are required so oxygen regulator and flow meters their high pressure regulators are attached to the cylinder stem to deliver gas under high pressure used to transfer tanks gas from the tank to tank and pressures in the full cylinder is approximately 2000 psi gas flow from the cylinder to the patient is controlled by a therapy regulator this reduces the high pressure of the gas to the safe range of about 50 psi okay so flow meters allow oxygen delivered to the patient to be adjusted from 1 to 25 liters there are two most of the common types and you have pressure compensated flow regulators or flow meter and that's a float ball and it rises and falls based on the gas flow in the tube gas flow is controlled by a needle valve and this is affected by gravity and it must remain upright for accurate flow reading then you have the bergdahn gauge flow meter and this can be placed in any position this pressure gauge is calibrated to record a flow rate um major disadvantage is it doesn't compensate for back pressure so usually records a higher flow rate than there is any if there's any obstruction to the gas flow downstream so preparing an oxygen cylinder for use so before administering supplemental oxygen you must prepare the oxygen cylinder and therapy regulator so there's a procedure you need to inspect the cylinder and its markings remove the plastic seal covering the valve stem opening and that's usually with when it's being commercially filled inspect the opening to ensure that it's free of debris and dirt with the tank facing away from you and yourself and others use an oxygen wrench to crack the cylinder quickly opening and closing the valve to ensure that dirt particles and other contaminants do not enter the oxygen flow attach the regulator flow meter to the valve stem ensuring that the pin indexing system is correctly aligned a metal or plastic o-ring is placed around the oxygen port to optimize the airtight seal between the collar and the regulator and the valve stem all right so then we're going to place the ox place the regulator collar over the cylinder valve with the oxygen port and pin indexing on the side of the valve stem that has the three holes now line the regulator so that the oxygen port and the pins fit into the correct holes on the valve stem align the screw bolt on the opposite side of the dimpled depression tighten the screw bolt until the regulator is firmly attached to the cylinder at this point you should not see any space between the sides of the valve stems and the interior walls of the collar collar with the regulator firmly attached open the cylinder and read the pressure level on the regulator gauge follow your local protocols regarding minimum cylinder pressures a second gauge or a selector dial on the flow meter indicates the oxygen flow rate attach the oxygen connective tubing to the christmas tree nipple on the flow meter and select the oxygen flow rate that is appropriate for your patient's condition so this figure shows how to attach the oxygen regulator and then the oxygen delivery device all right so the first supplemental oxygen delivery device we're going to talk about is the non-rebreather and this is the preferred device in the pre-hospital setting it can provide between 90 to 100 inspired oxygen it's good a mass to face seal the flow rate is 15 liters combination mask and reservoir bag oxygen fills the reservoir bag that is attached to the mask by a one-way valve it permits the patient to inhale from the reservoir bag but not to exhale back into it so before administering you need to ensure that the reservoir bag is completely filled oxygen flow rate is adjusted from 12 to 15 liters to prevent collapse of the back and use a pediatric non-rebreather mass for infants and small children you want to give this when people are spontaneously breathing but the patient needs high flow oxygen concentrations and are breathing adequately so concentrations or contradictions are apnea or poor respiratory effort the device delivers oxygen passively so the patient's respirations must be adequate depth to draw in air and then there's the nasal cannula so this delivers oxygen via two small prongs that fit into the nostrils the flow rate is one to six liters and the oxygen concentration is 24 to 44. higher flow rates will irritate the nasal mucosa and an oxygen humidifier should be used when giving oxygen via nasal cannula for a prolonged period this provides low to moderate oxygen enrichment most beneficial for patients who require long-term oxygen therapy it's ineffective if the patient is ethnic has poor respiratory effort or is severely hypoxic and is a mouth breeder breather it's going to be ineffective so in the pre-hospital setting primarily used when patients cannot tolerate a non-rebreather or require a low concentration of oxygen to maintain oxygen sets greater than 94 and they're generally well tolerated it does not provide high volumes of concentrations of oxygen so this table shows the types of oxygen delivery devices next there's the partial rebreathing max we're going to talk about and so it's similar to non-rebreather but it lacks that one-way valve between the mask and the reservoir that happens then residual exhaled air is mixed in the mask and re-breathe so it's the contradictions are same as a non-rebreather mask and the higher concentrations are attainable so flow rates are usually 6 to 10 liters and oxygen concentrations of 35 to 60 percent so increasing the oxygen flow rate of beyond 10 liters will not enhance the oxygen concentration next is the ventrima so that what this does is it draws room air into the mask along with oxygen it can deliver different ranges or different percentage depending on the adapter and especially useful in the hospital management of patients with chronic respiratory diseases and little advantage in the pre-hospital care except for long-range transport of patients with those conditions so then there's the trach mass and they cover the trach whole stoma the tracheostomy or stoma and have a strap that goes around the neck usually available in intensive care units and they may not be available in the emergency setting so we improvise by placing a face mask over the stoma and adjusting the strap and then oxygen humidifier so oxygen stored in cylinders have zero humidity dry gases will rapidly dry the mucous membranes and an oxygen humidifier consists of a small bottle of sterile water and moisturizes oxygen before it reaches the patient and um it must be kept upright practical practical for for fixed oxygen units in the ambulance and they use a disposable bottle okay so let's talk about ventilatory support a patient who is not breathing needs artificial ventilation with 100 o2 artificial ventilation is a skill of providing ventilation to patient who is breathing spontaneously or not breathing at all so techniques are extremely effective when performed properly patients who are breathing inadequately are typical unable typically unable to speak in complete senses examples are breathing too fast or too slow with reduced tidal volume may require artificial ventilation to help maintain minute volume fast shallow breathing does not allow for adequate exchange and indications for assisted ventilation include signs of altered mental status inadequate minute volume or signs of potential respiratory failure patients with these signs need immediate treatment two treatment options are you could assist ventilation with a bvm or you could use cpap or continuous positive airway pressure normal ventilation versus positive pressure so normal ventilation the the diaphragm contracts negative pressure is generated in the chest cavity and this negative pressure draws air into the chest cavity through the trachea attempt to equalize the pressure in the chest with the pressure of the external atmosphere so positive pressure ventilation generated by a device such as a bag valve demise device it forces air into the chest cavity from the external environment and the physical act of the chest while expanding and recoiling during breathing aids the circulatory system in returning blood to the heart chest while movement works similar to a pump the table shows normal ventilation versus positive pressure ventilation with positive pressure ventilation more air is needed to achieve the same oxygenation and ventilatory effects of normal breathing increase in airway wall pressure causes the walls of the chest to push up of the normal anatomic shape increases overall intrathoracic pressure within the chest cavity and blood flow is decreased due to increased pressure in the chest this results in insufficient venous return and the amount of blood pumped out of the heart is reduced imperative that paramedics regulate the rate and volume of artificial ventilations cardiac output is the function of stroke volume multiplied by the pulse rate stroke volume is the amount of blood ejected by the ventricle in one cardiac cycle pulse rate is assessed by palpating the pulse for one minute cardiac output is the amount of blood ejected by the ventricle in one minute normally when the person breathes air air enters the trachea it's forced generated from the positive pressure ventilation allows air to enter the trachea and the esophagus so ventilations that are too forceful can open the esophagus and instill air in the stomach and this is gastric distension so assisted ventilation to assist ventilations using a bbm place the mask over the patient's nose and mouth squeeze the bag each time the patient inhales maintaining the same rate of the pain as the patient after the initial five to ten breaths slowly adjust a rate and deliver the approach appropriate title volume adjust the rate and title volume to maintain adequate minute volume all right so without immediately tr immediately treating patients who are in respiratory rest they will die once you determine that the patient is not breathing you must begin artificial ventilations immediately you can do this by methods include the math mouth to mass technique or one two or three person bvm device technique when we talk about the mouth to mask technique use a plastic barrier placed on the patient's face it has a one way valve to prevent backflow of secretions vomiting gases it's easier to scur an effective seal because you can use both hands it enables provisions of adequate title volume so mask with an oxygen inlet provides oxygen during the mouth to mass ventilate ventilation to supplement the air from your lungs a mask may be shaped like a triangle or a donut the apex or the top should be placed across the bridge of the nose and the base or the bottom should be placed in the groove between the lower lip and the chin in the center is a chimney with a 15 millimeter connector to ventilate the patient using the pocket face mask open his or her airway with the head tilt chin lift or draw thrust maneuver insert an o p or an np to maintain that airway and connect the one-way valve to the pocket mask and place the mask on the patient's face connect the top of the mask it and placed over the bridge of the nose and the bottom is over the lower lip and chin hold the mask in position by placing your thumbs over the top part of the mask and your index fingers over the bottom grasp the patient's lower jaw with three fingers on each hand and place the thumbs on the dome of the mask making an airtight seal by applying firm pressure between the thumbs and the fingers maintain an upward and forward pull on the lower jaw with your fingers to keep the airway open exhale slowly over a period of one second just enough to produce physical chest rise then remove your mouth from the one-way valve and allow the patient to passively exhale these figures show how to perform that mouth to mass ventilation so you want to watch the patient's chest rise and fall and fuel for resistance if the patient's lungs have expanded you should hear and feel air escaped as the patient passively exhales provide the current number of breasts per minute for the patient's age okay so next we're going to talk about what we use very often and that's a bag valve mask it can deliver 100 of oxygen with a flow rate of 15 liters and an adequate seal it provides less tidal volume than mouth-to-mouth mouth mask ventilation but delivers a higher concentration it's the most common device used to ventilate patients in the pre-hospital setting and it can the mask seal on a medical patient may be difficult to maintain with one rescuer tidal volume and oxygen concentration depend on the mast seal's integrity a bag valve mask components and characteristics so they're disposable they're self-inflating there's no pop off valve or if one is present the capability is there to disable it a true non-re-breathing outlet valve oxygen reservoir one way or no jam inlet valve stem that produces an oxygen inlet flow of 15 liters and a standard 15 to 22 millimeter fitting for a face mask and an advanced airway so transparent face mask the ability to perform under extreme environmental conditions a total amount of gas in the reservoir bag of an adult bag valve mask is 12 to 1600 liters milliliters so a pediatric bag has 5 to 700 and an infant has 150 to 240 milliliters so the volume of oxygen to deliver to a patient is based on the visible chest rise and fall so deliver tidal volume of 500 to 600 milliliters and per breath will produce visible chest rise and fall in most adults okay so breasts given two forcefully or too fast can result in two negative effects the first one is gastric distension and this will be associated with risk of vomiting and aspiration also decreased venous returns to the heart and that's preload due to increased inert thoracic pressure inadequate tidal volume and oxygen may be delivered because of improper technique or ineffective mass to face seal or presence of gastric distension so bag mask device technique work with partner when possible and skip to two person back valve mass technique um these are the steps for two-person bag valve mass technique okay so kneel be above the patient's head your partner should be at the side of the head if possible select the proper size mask maintain neck hyper in the hyper extension position unless you suspect a cervical spine injury connect the back valve mass device to supplemental oxygen place the mask on the patient's face hold the mask in place while your partner squeezes the bag until the patience has visible chest rise and fall if you suspect a spinal injury stabilize the head and neck while maintaining an adequate mask two face seal squeeze the bag every five to six seconds for adults and every three to five for infants and children if you're alone hold your index finger over the lower part of the mask and your thumb over the upper part of the mask use the remaining fingers to pull the jaw into the mask and that's an ec clamp method observe for gastric distension and changes in compliance if the bag with ventilations or of the bag with ventilations and improper or improvement or deterioration of the patient status when assisting ventilation squeeze the bag as the patient exhales if the patient is breathing too fast with reduced tidal volume explain the procedure first assist ventilations at the rate at which the patient is breathing for the next 5 to 10 seconds then you want to slowly adjust the rate and tidal volume until the adequate minute volume is achieved evaluate the effectiveness of your ventilations note adequate it's not going to be adequate if the chest does not rise and fall the rate of ventilation is too fast or too slow or the pulse rate does not improve if the chest does not rise and fall you may need to reposition the head or insert an oropharyngeal if the stomach seems to be rising and falling reposition the head if too much air is escaped from the mask reposition the mask for a better seal if the chest does not rise and fall check for an airway obstruction if none is found attempt ventilation with another device okay so we're going to talk a little bit about an automatic transport ventilator and the steps for using them so you'll see them written as an atv okay so you need to attach them to a wall mounted oxygen source set the tidal volume and ventilatory rate per the patient's agent condition and connect them to that 15 to 22 millimeter fitting on the et tube or another advanced airway device you have to auscultate the patient's breast sounds and observe for equal chest rise it these atvs free hands to perform non-airway related tasks and so a bag mass device should always be readily available in case of malfunction most models have adjustments for the respiratory rate and tidal volume and they deliver a preset volume at a preset ventilatory rate so that does not guarantee that all of the volume is delivered into the lungs unless the patient is innovated it's generally oxygen powered and some models may require an external power source they generally consume about 15 liters of oxygen and bag valve fast devices 15 to 25 liters a minute pressure relief valve can lead to hypoventilation in patients with inadequate lung compliance or increased airway resistance or airway obstruction in the possibility of barotrauma if relief valve fails or ventilation is overzealous and then there's cpap so continuous positive airway pressure this is a non-invasive means of providing vulneratory support for patients experiencing respiratory distress it's an excellent adjunct in the treatment of respiratory distress caused by the following conditions acute pulmonary edema obstructive lung disease or acute bronchial spasm as in asthma it's typically typically many patients with these conditions would be managed with advanced airway techniques otherwise known as innovation it's effective functions of cpap include the increased pressure in the lungs opens collapse of a alveoli and prevents further alveolar collapse pushes more oxygen across that membrane forces interstitial fluid back into the pulmonary circulation its desired effect is to improve pulmonary compliance make spontaneous ventilations easier so it's typically delivered through a face mask secured with a strapping system the face bask is fitted with a pressure relief valve that determines the amount of pressure delivered to the patient pressure results in a higher inspiratory flow and the need to push a pressure valve open with exhalation there are indications for cpap and so indications for patients in respiratory distress whose compensatory mechanisms cannot keep up with oxygen demand now general guidelines for using it include the patient has to be alert and able to follow commands there has to be obvious signs of moderate to severe respiratory distress from an underlying disease respiratory distress from submersion rapid breathing of more than 26 breaths per minute that affects overall minute volume and then pulse ox readings usually less than 90 and of course local protocols and then there are contraindications and there are a bunch of them but of course you can't use it if the patient's unresponsive or otherwise unable to follow verbal commands you can't use in respiratory arrest or agonal or if the patient's unable to speak or unable to protect their airway hypoventilation hypotension and that's a systolic less than 90. signs and symptoms of a pneumo or chest trauma closed head injury facial trauma cardiogenic shock a trach active gi bleed nausea or vomiting history of the presence of a gi surgery patient that's unable to sit up an inability to properly fit the mast strap or the patient cannot tolerate the mask always assess the patient for signs of clinical deterioration or respiratory failure not all patients will improve with cpap one signs of respiratory failure become apparent the patient can no longer follow commands remove the cpap and in initiate ventilation with the bvm all right so application is generally composed of a generator mask and a circuit that contains a corrugated tubing bacteria filter and a one-way valve during the expiratory phase the patient exhales against this resistance and depending on the device the peep is controlled by manually adjusting it by a nanometer and predetermined by a fixed setting on the peep so there's two types a peep is a 5 to 10 is generally acceptable therapeutic range always consult the manual for assembly instructions but most units are powered by oxygen and some units use continuous flow of oxygen others use oxygen on demand so continuously monitor the amount of oxygen in that cylinder because it's going to go fast some of the newer devices allow you to adjust that fio2 and to properly use cpap reforces skill drill 15-2 now remember there are some complications of cpap and so some patients may find cpap claustrophobic and they'll resist it so high volumes of pressure generated by cpap can also cause a pneumo due to barotrauma so be aware of this and continually assess your patients okay increase pressure in the chest cavity can result in hypotension and air may enter the stomach with which increases the risk of aspiration if vomiting occurs and with this um air that's entering the stomach that leads us to our next um stuff that we're going to talk about and this is gastric distension any form of artificial ventilation that blows air into the patient's mouth may cause inflation of the patient's stomach with air gastric distension it's easily especially likely to occur when excessive pressure is used to inflate the lungs or ventilations are performed too fast or too forcefully airway is partially obstructed during ventilation attempts so pressure in the airway forces forces open the esophagus and air flows into the stomach and it occurs most often in children but it's not uncommon in adults so what happens is a distended stomach is harmful for two reasons because it promotes regurgitation and this can lead to vomiting and aspiration and it also pushes up on that diaphragm upward and so that will reduce space in the lungs that can expand signs include increase in the diameter of the stomach increasing in distension of the abdomen and increased resistance to the bvm if these signs are noted reassess and reposition the head as needed observe the chest for adequate signs that rise and fall and limit ventilation attempts to one second or the time needed to produce adequate chest rise so when it comes to invasive gastric depression so this involves inserting a gastric tube into the stomach and removing the contents with suction in certain cases of positioning or poisoning sorry activated charcoal can be installed into this gastric tube so the tube can be inserted into the stomach via the mouth or the nose it should be considered for any patient who will need positive pressure ventilation for an extended period of time and it must be used with extreme caution in any patient with a known esophageal disease never use a pain patient whose esophagus is not patent so after insertion make sure the tube has been placed into the stomach all right so let's talk about this an ng tube inserted through the nose into the nasal pharynx through the esophagus and into the stomach in airway management and ventilation it depresses the stomach so decrease pressure in the diaphragm and limits the risk of regurgitation it's also used to perform gastric lavage a procedure in which the stomach is decontaminated following a toxic ingestion so it's relatively well tolerated even in responsive patients during insertion most responsive patients will gag and may vomit even if gag reflex is suppressed contradiction in patients with facial trauma and then its improper technique can cause trauma to the nasal passageways esophagus or gastric lining and it may interfere with the mast seal of the bvm so to properly insert the nasogastric tube look at skill drill 15-3 and then there's the oral gastric so it serves the same purpose of an ng but it's inserted through the mouth instead of the nose the advantages and disadvantages are essentially the same as those for the end the ng the major differences though are there's no risk of nasal bleeding and it's safer for patients with a severe facial trauma it can you can use larger tubes such as gastric uh lavage all right it's less comfortable for responsive patients and it causes gagging much more often and it's generally preferred for patients who are unresponsive without a gas gag reflex to properly insert an oral gastric tube refer to skill drill 15-4 okay so this concludes part one of the chapter 15 airway management we're going to pick back up with part two we're going to start with a suctioning of stomas and stoma patients and move into facial trauma and then innovation techniques so thank you for joining us for the part one and we hope that you join us for part two"
    },
    {
        "Introduction to Respiratory Emergencies": "hello and welcome to chapter 16 respiratory emergencies lecture after you complete this chapter and the related coursework you will understand the significance and characteristics of respiratory emergencies in infant child and adult populations you will be able to demonstrate a fundamental comprehension of the following topics respiratory anatomy and physiology pathophysiology signs and symptoms of various respiratory etiologies including asthma chronic obstructive pulmonary disease and pneumonia and the assessment and management necessary to provide basic and advanced care in the pre-hospital setting okay so let's get started respiratory disease is one of the most common emergency medical services dispatches let's talk about the epidemiology so",
        "Epidemiology": "asthma and chronic obstructive pulmonary disease are among the top 10 chronic conditions causing restricted activity approximately 15 million americans have copd and that's chronic obstructive pulmonary disease and approximately 25 million americans have asthma pneumonia is one of the most common fatal illnesses in developing countries some respiratory diseases are genetic or intrinsic while others are caused by external or extrinsic factors researchers have yet to fully decipher the multi-factorial mechanism by which many respiratory diseases develop",
        "Anatomy and Physiology": "so let's talk about the anatomy and physiology next do a little review the primary structures are an inverted tree so the trachea represents the trunk and the alveoli represents the leaves the tracheobronchial tree now the trachea is the windpipe the trunk of the tracheobronchial tree it carries air to the lungs and then extends about four to five inches from the larynx to the right and left main stem bronchi the bronchi you have the right and left main stem bronchi eye they continue to branch into lobes of lungs the secondary or lober bronchii then divide into tertiary or segmental bronchi and then into sub-segmental bronchi before ultimately becoming bronchioles bronchioles the terminal bronchioles are thin and have little cellular structure this is helpful for gas exchange now bronchioles lacilla they have protective mucus and are not shielded by smooth muscle or more rigid structures so once a foreign matter reaches the terminal bronchioles and alveoli it does not come back out smooth muscle surrounds conducting airways down to the subsegmental level bronchial constriction occurs when the smooth muscle narrows these larger airways bronchiodilator medications have little effect below the sub segmental level",
        "Alveoli": "now let's talk about alveoli the terminal airways and alveoli include branches 16 to 24 of the tracheobronchial tree the entire surface of the alveoli and terminal bronchioles is covered in capillaries and participates in gas exchange so the mediastinum that's a space in the middle of the chest that consists of the heart large blood vessels the conducting airways and the conducting airways are the trachea in the main stem bronchi and other organs it might widen if the patient is bleeding from a ruptured aorta and might trap air from a traumatic injury",
        "Pulmonary Blood Flow": "pulmonary blood flow is what we're going to talk about next and the blood flows from the heart to the lungs via the pulmonary artery the pulmonary artery branches into smaller and smaller vessels until the pulmonary capillary bed surrounds the alveoli and terminal bronchioles more gas exchange takes place between the lung bases and the circulatory system than between the apexes or the tops of the lungs and the circulatory system",
        "Pulmonary Capillaries": "pulmonary capillaries are narrow and red blood cells normally pass through in a single file but patients with chronic lung disease and chronic hypoxia often generate more red blood cells making their blood thick the effort to push blood through the pulmonary capillaries can strain the right side of the heart right-sided heart failure because of copd is known as core pulmonal so perfusion is a circulatory component of the respiratory system blood must consistently flow through the pulmonary vessels so adequate oxygen can come into contact with the blood a large pulmonary emboli can block blood flow to the entire lung so let's talk about mechanisms of",
        "Mechanisms of Respiratory Control": "respiratory control you have cardiovascular regulation and the lungs are closely linked to cardiac function changes in the right or left side of the heart can have pulmonary consequences left-sided heart failure typically progresses much faster than right-sided heart failure right-sided heart failure can worsen over days while left-sided heart failure can kill in minutes the right side of the heart pumps blood to the lungs and the left side of the heart receives blood from the lungs and it pumps to and around the body to perfuse organs and tissues mild hypoxia causes an increase in heart rate severe hypoxia often causes bradycardia and uncorrected hypoxic insults may trigger a fatal cardiac dysrhythmia so various forms of heart failure can cause changes in fluid balance right-sided heart pumping pressure or left-sided heart pumping pressure then there's muscle control the body takes in air by negative pressure it's like a vacuum cleaner basically and air is pulled in through the mouth nose or other turbinates and around the epiglottis and glottis",
        "The Thorax": "the thorax is an air type box with the flexible diaphragm at the bottom and an open tube or the trachea at the top the diaphragm flattens during quiet breathing the overall size of the container increases and air is sucked in to fill the increasing space inside the thorax the amount of air moved each minute is the minute ventilation and it can be increased by deep breathing or more rapid breathing dramatic openings in the thorax provide a route for air to be sucked in air ends up in the pleural space causing a sucking chest wound in the cause of a flailed chest multiple ribs are broken in more than one place that's a flailed chest free floating thorax sections are pulled in when the patient breathes this limits the amount of air sucked through the trachea now the next mechanism of respiratory control we're going to talk about is",
        "Renal Status": "renal status the kidneys play a part in controlling fluid balance acid-base balance and blood pressure these factors affect the pulmonary mechanisms that deliver and the delivery of oxygen to body tissues patients with severe kidney disease often present with respiratory signs and symptoms patients with chf because of renal disease can be difficult to manage because diuresis may be difficult acid-base disturbances may cause hyperventilation that may be mistaken for respiratory disorders",
        "Hypoventilation": "and then you have hypoventilation carbon dioxide accumulates in the blood when the lungs fail to work properly it combines with water to form bicarbonate ions and hydrogen ions so it forms carbonic acid and it results in acidosis impaired ventilation is caused by a variety of factors carbon dioxide level is directly related to the ph so hypoventilation patients usually have respiratory acidosis as carbon dioxide levels rise ph levels drop problems that can cause patients to hypoventilate include conditions that impair lung function so you can have carbon dioxide levels rise when the patient is breathing but gas levels are impaired or gas exchange is impaired this situation may occur in cases of pneumonia or pulmonary edema asthma or copd okay so hypoventilation can also be caused by conditions that impair the mechanics of breathing so gas flow can be suppressed by a flailed chest a diaphragmatic rupture severe retractions air or blood filled in the abdomen abdominal or chest binding or anything else that restricts pressure changes that facilitates respiration obesity hypoventilation syndrome is a respiratory compromise related to morbid obesity so conditions that impair the neuromuscular apparatus patients with head trauma or inner cranial infections or brain tumors may have damaged respiratory centers in the brain serious spinal cord injury above c5 may block nerve impulses that stimulate breathing or guillain-barre syndrome which is a progressive muscle weakness and paralysis disorder may cause ineffective breathing if paralysis reaches the diaphragm",
        "Conditions That Reduce Respiratory Drive": "conditions that reduce respiratory drive include intoxication with alcohol narcotics and other drugs head injuries hypoxic drive and asphyxia the ultimate manifestation of hypoventilation is respiratory arrest then followed by cardiac arrest initiate aggressive treatment to assist the patient's respiratory efforts okay so we just talked about hypoventilation now we're going to talk about hyperventilate this occurs when people breathe in excess of metabolic need by increasing the rate and depth of the respiration they expel more carbon dioxide than normal and it results in alkalosis when triggered by emotional distress or panic attack it may be called hysterical ventilation or hyperventilation syndrome",
        "Acute Hyperventilation": "in an in acute hyperventilation syndrome patients feel they cannot breathe at all respiratory alkalosis causes numbness and tingling in the hands and the feet and around the mouth patients complain of chest pain and respiratory alkalosis will ultimately lead to carpal pedal spasm during which the hands and feet are clenched in a claw-like position the traditional therapy of having the patient breathe his or her own carbon dioxide from a paper bag or from a partial re-breathing mask can be dangerous patients quickly exhaust the oxygen and the gas they are breathing and hyperventilation in patients with acidosis may be the body's attempt to raise the ph level to normal some examples are acoustimal respirations or sepsis or shock it should not be treated by rebreathing their own carbon dioxide and important to rule out all possible causes so treatment may include sedation if the patient is truly hysterical and hyperventilating you want to help the patient understand that hyperventilation may occur if the behavior partici precipitating the episode is repeated psychological support techniques include breathing with the patient or having the patient count to two between breaths gradually increasing to higher numbers or distraction techniques having the patient sing a song perhaps okay",
        "Patient Assessment Thorough Respiratory Assessment": "so let's talk about the patient assessment thorough respiratory assessment is needed this includes much more than just listening to the lung sounds many respiratory ailments are life-threatening and respiratory assessments should be done early in the patient assessment so of course we talk about the scene size up we take standard precautions and use proper personal protective equipment and remember minimal protection when treating a person in respiratory distress is exam gloves exam or eye protection and a face shield and gown if patient is suspected of having a respiratory infection a range of dangerous situations and toxins are associated with pulmonary complaints these include diminished oxygen concentrations such as enclosed or improperly ventilated spaces or carbon monoxide or irritant gases or highly contagious respiratory illnesses respiratory disease can impair ventilation diffusion perfusion or combination of all three the most common complaint of patients with a respiratory disease is dipsnia",
        "Dipsnia": "the most common cause of dipsnia is hypercarbia and that's too much carbon dioxide in the blood rapid onset dipsnia may be caused by an acute bronchiospasm anaphylaxis pulmonary emboli or pneumothorax so proximal nocturnal dipsnia presents suddenly in the middle of the night and may signal left-sided heart failure patience ability to move air may be hindered by the factors that limit diaphragm movement restrict chest wall movement and disrupt the integrity of the thoracic cage",
        "Primary Survey": "so let's talk about the primary survey next you want to establish and maintain an open airway form a general impression now the body type may be associated with the particular pathologic condition so emphysema they're going to have that barrel chest muscle wasting they'll be purse lip breathing often on tachypnea and usually without profound hypoxia and cyanosis so severely ill patients with immune system disorders and those with cancer or other end-stage diseases are easy to identify due to their sickly appearance",
        "Chronic Bronchitis": "patients with chronic bronchitis tend to be more sedimentary sedentary and may be obese they often sleep in a chair or recliner have a waste basket overflowing with tissues and a cup of spit up secretions may have a urinal near their chair to avoid frequent bathroom trips and have medications inhalers or other air slides nebulizer nearby assess oxygen demand and work of breathing so if patient is stable to rest observe the condition during typical exertion so note oxygen saturation while at rest and during simple exertion increased work of breathing anxiety hypoxia or fever can trigger tachycardia diaphoresis and polar note the patient's position and determine the degree of distress so patients in respiratory distress prefer sitting positions the tripod position that's leaning forward and rotating the scapula outward if a patient is willing to lay flat it might be a sign of deterioration in condition a patient who holds his head in the head tilt chin lift or sniffing position to maximize airflow through the upper airway a fatigue patient with respiratory severe respiratory disease may present with head bobbin that's an omni sign of immediate decomposition and often a pre-terminal behavior assess breathing alterations can involve the conducting airways the alveoli muscle and nerves involved in breathing or the rigid structures of the thorax increase work of breathing so patients using accessory muscles to breathe are a danger of tiring out using the abdominal muscles to push and pull air out and using the chest and neck muscles to pull air in that's the using accessory muscles when infants and small children use accessory muscles to breathe the flexible sternum cartilage often collapses leaving bony retractions a patient of any age may pull the soft tissues in between the ribs above or below the sternum and clavicles causing soft tissue retractions and profound inner thoracic pressure changes can cause peripheral pulses to weaken or disappear during inspiration altered rate and depth of respiration so count the respirations while you appear to be doing something else a patient with adequate rate but low volume will have an inadequate minute volume remember the minute volume is the respiratory rate times the tidal volume that equals the minute volume monitor trends and respiratory rates and note the pattern in the inspiratory to expiratory ratio so that's the ide ratio",
        "Abnormal Breath Sounds": "now abnormal breast sounds you want to auscultate the sounds systematically whenever possible because the left and right lungs are not symmetric remember the right lung has three lobes and the left lung has two lobes some conditions are gravity dependent and others diffuse throughout lung fields the upper lobes are heard by listening to the anterior part of the chest the middle right lobe is best heard just beneath or lateral to the right breast and the mid axillary line is the best place to listen for confirmation of the et2 placement",
        "Breath Sounds": "breast sounds are created by airflow in the large airways tracheal breast sounds are often harsh and tubular bronchial breath sounds are loud bronchiovascular breath sounds are softer and sound the same during inspiration and expiration soft breezy vascular sounds are the most commonly heard breast sounds this image shows normal breath sounds heard over different parts of the chest some pathologic conditions cause normal breath sounds to be heard in abnormal places the sounds move better through fluid than through air the quality of breath sounds is dependent on the amount of tissue between the stethoscope and the respiratory structures breast sounds and vocalizations travel poorly through a hyper inflated lung abnormal or advantageous breath sounds are extra sounds that can be heard on top of the other breath sounds wheezes are high-pitched whistling sounds from air being forced through narrowed or airways now wheezes may be diffuse such as asthma or localized such as a foreign body obstruction crackles are discontinuous noises heard during lung auscultation they're caused by air spaces popping open such as fine crackles or fluid or secretion movement in larger airways and now that's coarse crackles they're usually associated with increased lung fluid you have rails and that's high pitched crackles in the lung bases heard at the end of inspiration and con consistent with pulmonary edema and then you have bronchi which are low pitched crackles caused by secretion in larger airways so rails are high pitched crackles and lung bases and ronke eye is low pitch crackles caused by secretion and larger airways",
        "Audible Sounds": "audible sounds include strider and that's from the upper airway a grunting from the lower airway obstruction or a death rattle now that's a low pitch gurgling sound heard when patients can no longer clear their own secretions as patients become more ill the audible sounds will become lower as respiratory distress worsens the sounds may become begin to diminish the most omnious breath sounds are no sounds at all which indicates the patient is no longer moving enough air to ventilate the lungs",
        "Noisy Breathing": "noisy breathing is obstructive breathing so snoring gurgling and strider those are obstructive breathing snoring is a partial obstructing of the upper airway by the tongue gurgling is fluid in the upper airway stridor is a harsh high-pitched sound during inhalation it indicates narrowing from swelling or laryngeal edema quiet breathing may suggest hyperventilation or shock now sputum note if the patient is coughing up discolored sputum fever and chills with increased sputum production is a sign of infection blood blood tinge sputum is a warning sign of tuberculosis or that the airway blood vessels have broken from forceful coughing pink foam or froth is a sign that the air is forced through pulmonary edema fluid as in cases of congestive heart failure note pus like mucus color and change of any other characteristic",
        "Abnormal Breathing Patterns": "now abnormal breathing patterns so altered respiratory patterns may indicate a neurologic insult brain trauma any disturbances in brain function or overdose with a central nervous system depressant may depress respiratory con control centers in the medulla severe traumatic brain injuries may damage or deprive blood flow in various parts of the brain changing breathing patterns most of the brain's respiratory centers are in and around the brain stem so you could have um apneic breathing and that's caused by damage to the center of the brain that regulates respiratory pause you could have biot respirations and that's grossly irregular patterns breathing with lengthy apnic periods or cheyenne stokes respiratory pattern and that's breathing deep gradually increases then decreases followed by a period of apnea injury to the spinal cord and certain illnesses may disable the respiratory muscles from functioning normally tidal volume is going to be shallow minute volume correspondingly decreases and patients often need assisted ventilation",
        "Assess Circulation": "you want to assess circulation in the context of respiratory emergencies assessing skin color is the fastest way to begin determining the adequacy of patient circulation note generalized cyanosis from oxygen desaturation or profound paler of shock for more subtle information assess the mucous membranes so variations include cyanosis and that's healthy hemoglobin levels in an adult are 12 to 14. at about five desaturation the person will begin to show cyanotic blue discoloration some patients in cardiac arrest have deep blue skin although some are pale cyanosis may develop earlier in patients with high hemoglobin levels patients with chronic respiratory conditions may have low levels of chronic cyanosis and patients with chronic bronchitis may have chronic peripheral cyanosis when you get a chocolate brown skin that mucous membranes may turn brown from high levels of methyl hemoglobin from nitrates and some toxic exposures it's more evident in venous blood than skin and mucous membranes when you get pale skin it's caused by blood flow reduction to small vessels near the skin surface it could be possible surface sources can be shock hypoxia some type of cold environment or a catecholamine release you also want to check for dehydration",
        "Dehydration": "when you're looking first at the circulation you want to look for dry cracked lips or a dry furrowed tongue or maybe dry sunken eyes that can indicate dehydration patients with respiratory problems are usually transported to the closest hospital if respiratory distress is related to renal failure a facility that can provide emergency dialysis would be a better option if multiple emergency departments are available weigh the benefits of taking the person to his or her preferred facility versus the closest facility then when it comes to the history taking we're going to find the chief complaint and have patients explain what they are feeling in their own words or what change that made you call",
        "Common": "common 911 include increased cough or fever wheezing or dips nia patients may not be able to talk because they are in so having so bad breath difficulty breathing so patients may be able to manage with one art word sentences or a nodding yes or shaking no medical history may have to be taken from the family members or clues and basic therapy oxygen or an air slice therapy may have to be given before you could get a complete history from the patient if innovation is necessary the patient will not be able to give you their history of course if the patient can give the chief complaint he or she may be able to tell you the exact problem such as maybe an acute flare-up or exacerbation of an illness",
        "Asthma with a Fever": "asthma with a fever the typical asthma attack that responds to treatment but occurs again shortly after may be caused by an underlying infection the underlying trigger must be treated before the symptoms will end so that's asthma with a fever non-delivery of medication so medications may be exhausted medications may be outdated or they may have improperly stored the medications travel related conditions so patients may present with significant pulmonary edema after a lengthy journey because they did not want to take their diuretic medications so ask the patient what medications do you use followed by do you take them during your travels dipsnia triggers so even if the patient knows what triggers his or her reactive airway it cannot always be avoided",
        "Seasonal Conditions": "and seasonal conditions so bacteria mold or fungi or excessive heat humidity or cold pollen dust and smog can cause respiratory disease flare-ups also",
        "Non-Compliance Therapy": "non-compliance therapy so some patients with chronic respiratory disease they rebel against therapy the long-term nature of the therapy may be misunderstood or patients may only sporadically use their treatment and then with the history taking you're going to get that sample history you want to use the mnemonic sample to obtain the history of the present illness and medical history s signs and symptoms a is allergy m is medications and you want to review the patient's prescribed and over-the-counter medicines p is pertinent past medical history and respiratory illness are often repeating pathologic conditions and a patient's experience can serve as the baseline to assess the current condition so ask do you feel better or worse than last time or how often does this happen l is the last oral intake and uh events e is events preceding the onset of the complaint and what has the patient already tried and did it have any effect on them then when you get into the secondary assessment that's that focused exam and you want to um do a neuro assessment or neurological assessment you could note the level of consciousness if the lungs are not functioning correctly oxygen may not be delivered to the bloodstream and carbon dioxide may not be removed from the body you could do a neck exam",
        "Jugular Vein Distension": "note any jugular vein distension a condition when the jugular veins are engorged with blood in patients in a semi-sitting position it's common in patients with asthma and copd often seen in healthy young adults with spine when supine and in people who are laughing or singing it could be caused by cardiac tamponade pneumothorax heart failure or copd and it may indicate cardiac failure as the source of the dipsnea note the trachea for deviations when you're looking at the neck it's a sign of attention pneumo this is difficult to see except in extreme cases because it occurs behind the sternum consider palpating the trachea at the substernal notch okay and then you're going to do a chest and abdomen exam the combination of jugular venous distension and heptomegaly may present in right-sided heart failure so feel for vibrations in the chest as the patient breathes chest or abdominal trauma can cause respiratory distress you want to exam do an examination of the extremities so note edema of the ankles or lower back check for peripheral cyanosis and check the pulse so signs check for signs of profound tachycardia note any pulseless paradoxes check the skin temp and note any distal clubbing from chronic hypoxia",
        "Vital Signs and Monitoring Devices": "vital signs and monitoring devices so you want patients under stress can be expected to have tachycardia and hypertension an omnia sign of impending arrest includes hyper or bradycardia hypotension and failing respiratory rates repeated vital signs an ecg and pulse ox reading are the data most commonly collected also use a stethoscope buy the best possible one and take care of it make sure that the ear pieces are clean and wipe the main tubing with an all-purpose cleaner the diaphragm is for high pitch sounds and the bell is for low pitch sounds some newer ones allow a single head to transmit both high and low sounds depending on pressure exerted the ear pieces can be tilted further forward for a better fit and the longer tubing the more noise that can be heard",
        "Pulse Ox": "when it comes to pulse ox this is a non-invasive way to measure the percentage of hemoglobin with oxygen attached oxygen saturation over 94 is normal since a pulse ox must be able to read pulsatile capillary bed correctly nail polish may need to be removed and cold extremities inadequate peripheral perfusion or patient movement can make reading inaccurate a variety of pulse ox probes may be may allow readings to be taken from the earlobe forehead or other areas of the body and those are available if a pulse rate is displayed the oxygen saturation reading should match the patient's palpated heart rate if a patient's hemoglobin level is low the pulse ox reading will be correspondingly high a pulse ox does not differentiate between oxygen and carbon monoxide molecules attached to the hemoglobin so remember that the oxyhemoglobin disassociation curve shows the relationship between oxygen saturation and the amount of oxygen dissolved in the plasma so that's pao2 end-tidal carbon dioxide monitor that's end-tidal detection or waveform capnography and it's discussed in detail in chapter 15 the oxygen management chapter",
        "Peak Expiratory Flow Meter": "peak expiratory flow meter and that's the peak flow it's a maximum flow rate at which the patient can expel air from the lungs the lower value indicates the larger airways have bronchiole constriction or bronchiole edema normal peak flow values are between 350 and 700 liters a minute and are ver variable by age sex and height a peak flow less than 150 liters a minute is an inadequate level and signs of signals significant distress and then you want to do your reassessment you need to contact medical control to report any change in the patient's level of consciousness contact medical control before assisting with administration of any prescribed medicines and document any changes and any orders given by medical control all right so let's talk about emergency",
        "Emergency Medical Care": "medical care that's what we're here for to treat respiratory compromise your goal is to provide supportive care administer oxygen and provide monitoring and transport the exception is bronchial constriction with a host of bronchiodilators available in respiratory failure we need to innovate and manually ventilate also cpap and bipapper also provided to be or proved to be effective strategies and may help avoid innovation in some patients all right so perform standard interventions oxygen administration to keep the saturation greater or equal to 94 percent we're going to establish an iv line if necessary and provide psychological support also allow the patient to assume the position of greatest comfort with decrease the work of breathing so muscles must work much harder during respiratory distress patients can compensate for respiratory distress by using energy for breathing to maintain oxygen and carbon dioxide levels but this requires even more oxygen and ventilation it will become progressively dehydrated malnourished and fatigued and may eventually experience decomposition decompensation and that's respiratory failure some patients with asthma may compensate for days the trendelenburg and supine positions cause the diaphragm compression from abdominal organs especially in overweight patients so shortness of breath from laying flat is known as orthopedia to decrease the work of breathing help the patient sit up if the position is more comfortable remove restricted clothing and do not make the patient walk relieve gastric distension and do not bind the chest or have the patient lay on the unaffected lung",
        "Providing Supplemental Oxygen": "let's talk about providing supplemental oxygen next you want to administer oxygen and effective concentrations bag valve mass ventilation and supplemental oxygen or more advanced airway management techniques should be used on patients who are not breathing adequately reassess breathing status then adjust treatment as needed if it is accurate and if the patient's hemoglobin is normal pulse ox is a good guide to oxygenation oxygen concentrations higher than 50 percent should be used only in patients with hypoxia who do not respond to lower concentrations the use of a hundred percent oxygen should be for the shortest periods possible most patients with good oxygen saturation and that's of course at least 94 percent do not benefit from supplemental oxygen however it remains common practice to administer low flow oxygen to patients with trauma stroke and acute coronary syndrome but don't over oxygenate them follow local protocol and consult medical control in the event of carbon monoxide intoxication or with a pregnant patient administer a bronchiodilator and they have various varying benefits those with bronchiospasms will benefit only slightly and oxygen concentration may need to be reduced while treating with aerosolized sprays use of non-rebreathing masks might be better than air slice spray in these cases bronchiodilators are ineffective in cases with pneumonia pulmonary edema and heart disease",
        "Bronchial Dilators": "fast acting bronchial dilators they're the most common types used by stimulating the beta 2 receptors in the lung past strategy was to give air slice atropine and ibutropium is now available as an air sliced or inhaler these two medications are sometimes prescribed in a pre-mixed cocktail and then there's air slice therapy so",
        "Aerosolized Nebulizer": "aerosolized nebulizers deliver a fine mist of liquid medication and particles of five micrometers or smaller enter the lower respiratory tract to generate the optimal particle size the nebulizer needs a gas flow of at least 6 liters at home most air slice treatments are run with a small air compressor the patients may only receive 30 to 40 percent oxygen via treatment air solids or aerosol law may be contraindicated if removing a patient's non-rebreathing mass causes further hypoxia a nebulizer can be held in front of the patient's face set for a blow by technique and or attached to a mouthpiece or face mask or a tracheostomy collar aeroslice therapy can disperse other drugs through air slice treatment including corticosteroids or antistatic drugs or antitussives newer bronchiodilators cause less tachycardia than older ones and they can be repeated treatments for bronchiospasms",
        "Meter Dose Inhalers": "then you have meter dose inhalers these inhalers deliver or should deliver the same amount of medication as air slice treatments aerosol treatments document how often the patient is taking those puffs at home contact medical control before administering additional doses if required in your protocols ambulance meter dose inhalers should have spacers in them and so tips for your patients to avoid common errors include patients should inhale deeply as the inhaler is discharged patients should not blow into the spacer they should suck the medication out of the bottom the best particle disposition comes from laminar flow that is smooth and low pressure patients should inhale the medication deeply and hold their breath for a few seconds make sure the inhaler contains the medication keep the spacer and canister holder clean to avoid inhaling dust and particles and after using a corticore steroid inhaler rinse the mouth and water or mouthwash",
        "Failure of Meter Dose Inhalers": "failure of meter dose inhalers is often due to user error a patient must be willing and able to use the meter dose inhaler properly so the medication can reach the lungs use of an inhaler is contraindicated if the patient cannot move enough air to draw in the medication into the lungs the patient may not realize inhalers empty and the patient may inhale at the wrong time next we're going to talk about dry",
        "Dry Powder Inhalers": "powder inhalers so some respiratory medications are dispensed by means of a plastic disc and the inhaler holds about a one month's worth of medication other devices require the patient to insert a capsule of powdered medication the capsule is pierced when the patient compresses the button these are rarely used during emergency care so electrolytes such as magnesium may have a role in bronchodilation as well in severe asthma attacks and some physicians use this as a last-ditch effort before innovation",
        "Corticosteroids": "corticosteroids reduce bronchial swelling so they reduce edema they have a variety of adverse effects though so cushing's syndrome and that's a classic moon phase in generalized edema rapidly change in blood glucose levels in a blunt uh to the immune system they uh they need slow discontinuation and one to two weeks therapy to avoid long-term use inhaled could across steroids so do not seem to have the same adverse effects as the oral ones though and it's becoming standard in asthma and copd patients",
        "Iv Corticosteroids": "iv corticosteroids these are common in the medical field a single bolus of iv corticosteroids does not seem to cause negative long-term effects methyl ethyl prednisone and hydrocortisone iv boluses are used for acute asthma attacks or acute copd exacerbations onset of the drug takes hours though so consult medical local protocols and medical control before use okay so",
        "Administer Vasodilator Treatments for Pulmonary Edema": "administer vasodilator treatments for pulmonary edema cause vasodilation sequestering more fluid in vena circulation and decreasing preload nitrates can be used if the patient has adequate blood pressure and does not take an inhibitor so morphine sulfate is not likely to increase venous capacity but it does decrease anxiety",
        "Restore Fluid Balance": "restore fluid balance so it is common to give fluids to dehydrated younger patients but too much fluid in an elderly patient or patient with cardiac dysfunction could result in pulmonary edema assess breast sounds before and after giving fluids to make sure the patient is not over hydrated hydrating patients with pneumonia can cause the pneumonia to blossom or expand and then there's giving a diuretic so giving diuretics to patients with pneumonia or asthma may dehydrate them and cause secretions to plug smaller airways diuretics are used to help reduce blood pressure and maintain fluid balance in patients with heart failure diuretics remove excess fluid from circulation keeping it out of the lungs of patients with pulmonary edema and loop diuretics are commonly used in emergency situations many diuretics cause potassium loss though and this can lead to cardiac dysrhythmias and chronic muscle cramping do not give diuretics to patients with pneumonia or dehydration and patients with renal failure may require large diuretic doses or they may have no response at all so when you talk about support or assisting ventilations aggressive breathing support if the patient becomes fatigued so cpap and bipap are preclude they may preclude innovation in some patients patients may simply require bvm for short periods of time",
        "Continuous Positive Airway Pressure": "continuous positive airway pressure we just talked about that so pcpap it's used to obstructive sleep apnea and respiratory failure many people with obstructive sleep apnea wear a cpap at night to maintain airway while they sleep",
        "Cpap Therapy": "so cpap therapy for respiratory failure is delivered through a mass secured to the face by strapping system and positive pressure is created in the chest when a bag mass device is used so pressure that is too high causes problems too a simple pneumo can evolve air leaks can produce large amounts of subcutaneous air and intrathoracic pressure can or completely block venous returns so recent understanding of ramifications have led to cpr guidelines that emphasize lower ventilation rates smaller volumes and lower pressures if the patient already has low blood pressure too much cpap can stop venous return and cause sudden additional drop in blood pressure so you have to monitor those closely make sure there's a good seal with minimal leaking and some patients may fight or cannot tolerate a cpap mask while others can be talked into the process",
        "Bi-Level Positive Airway Pressure": "bi-level positive airway pressure so with bipap one level of pressure is delivered on inspiration and a different level of pressure is delivered during exhalation so for example bipap that is set to 20 8 gives 20 um centimeters of o2 pressure during inhalation and eight centimeters of ho2 pressure during exhalation so it's more like normal breathing often more comfortable for patients this is more complex and expensive so it's not commonly found in the field then you have automated",
        "Automated Transport Ventilator": "transport ventilator so it's a flow restricted oxygen powered ventilation with built-in timers and some permanently set to deliver 40 liters a minute of oxygen flow and then innovating the patient and this can be life-saving and many can be excavated in the hospital setting and have a good outcome but issues to consider so inhibition should intubation should be the last option for patients with asthma so ventilate the patients before cardiac arrest occurs patients who are severely intoxicated or who have had a stroke may have little or no gag reflex in patients with diabetes or in cases of an overdose an ampoule of 50 dextrose or naloxone may change the need for inhibition so just use a bag valve mask for a few minutes and then ventilate slowly over one second and only enough to produce visible chest rise okay when you talk about giving medications directly through the endotracheal tube the american heart association guidelines discourage this practice iv or io medication administered administration is preferred all right so let's talk about the",
        "Pathophysiology Assessment and Management of Obstructive Upper Airway Diseases": "pathophysiology assessment and management of obstructive upper airway diseases now when you talk about the",
        "Pathophysiology": "pathophysiology the tongue is the most common cause of the airway obstruction if the patient is unresponsive anyone with a decreased level of consciousness especially in the supine position is at an risk for upper airway obstruction audible sounds during breathing include snoring gurgling squeaking or bob bubbling strider may be associated with accessory muscle use or retractions so a pillow under the head of an unresponsive patient may make the problem worse",
        "Obstructive Sleep Apnea": "obstructive sleep apnea may be caused by excessive soft tissue in the airway and it can be manually displaced with different maneuvers such as the recovery position if spinal motion restriction is not needed the safest position for patients with seizures or hypoglycemia or intoxication and it reduces risk of aspiration if the patient vomits infections can cause upper airway swelling and it can lead to inflammation of the larynx trachea and bronchi",
        "Common Cause of Croup": "common cause of croup the common cause is croup and it's characterized by stridor and a barking cough it's commonly occurs in infants and small children there are viral infections and they're common when they cause croup and bacterial infections and then palatine tonsils can be inflamed in children as well this is rarely life-threatening but avoid injury with the laryngoscope so when we talk about the assessment",
        "Assessment": "many deadly upper airway conditions are now rare thanks to widespread immunization croup and tonsillitis are common but other conditions are rare and these are critical emergencies when they are occurring but you want to avoid manipulating the airway unless absolutely necessary airway may be entirely obscured by swelling so the laryngoscopy may worsen the swelling have your partner press on the chest while you check for bubble stream coming from the airway use of an et tube at least two full sizes smaller than typically appropriate and if your efforts fail after a single attempt a needle or surgical crike may be necessary so aspiration inhalation of anything other than breathable gases examples are water or blood vomit food or foreign bodies so there are some patients who are at increased risk and these are tube fed patients when they're placed supine immediately after a large feeding or geriatric patients with impaired swallowing or unresponsive patients aspiration has a high mortality rate common but profoundly dangerous",
        "Complications in Cardiac Arrest": "complications in cardiac arrest and unresponsive patients determine scenario of sudden onset of ditznia so immediately after eating or was there gastric feeding tube and if so how long was the feeding and how large",
        "Management": "so when it comes to management you need to avoid gastric distension when ventilating and use a nasogastric tube to depress the stomach when necessary monitor the patient's ability to protect the airway and use an advanced airway when needed aggressively treat aspiration with suction and airway control patients at risk for aspiration should not eat when they are having difficulty breathing if basic maneuvers fail to clear the airway use laryngoscopy and miguel forceps and perform a needle or surgical crike if allowed by local protocol okay so let's talk about",
        "Obstructive Lower Airway Diseases": "obstructive lower airway diseases and so the most common are emphysema and chronic bronchitis also asthma emphysema and chronic bronchitis are classified as copd because the pulmonary structure and function changes are chronic progressive and irreversible asthma is a condition with reversible narrowing of the airway in obstructive disease the positive exhalation pressure causes small airways to pinch shut which traps gases in the alveoli a number of physical findings can indicate obstructive airway disease purse lips increase i.e ratio abnormal muscle use or jugular vein distension so when it comes to asthma let's talk",
        "Asthma": "about the pathophysiology first bronchial asthma is characterized by increased tracheal and bronchial reactivity to a variety of stimuli in 2014 more than 24 million people in the united states had asthma and the and it's increasing the fastest growth of asthma rates are in children younger than five patients with potentially fatal asthma often have severely compromised ventilation all the time at risk if acute bronchiospasm is triggered or infection so they may be at a high risk of respiratory arrest and can be fatal with severe psychiatric disorders or not following medication regimen asthma is sometimes referred to as a reactive airway disease the patient experiences bronchospasms when exposed to certain triggers and between attacks the patient may be relatively asymptomatic a severe prolonged asthma attack that does not stop with conventional treatment is status asthmaticus and it's a dire medical emergency so assume that any patient with asthma who feels sick enough to call the ambulance may be in status asthmaticus until proved otherwise so return of the symptoms after inhaler use this is sometimes caused by an underlying infection attacks will not subside until the trigger has been removed or mitigated a patient in status asthmaticus will be struggling to move air have predominant a use of accessory muscles and have a maximumly hyper-inflated chest possibly have the entirely inaudible breast sounds or be exhausted and severely acidotic and dehydrated bronchospasm is caused by constriction of smooth muscle surrounding the larger bronchi eye bronchospasm may occur from stimulation by an allergen or irritants and wheezing is caused by vibrations from the air being forced through constricted airways",
        "Bronchial Edema": "bronchial edema is the swelling of the bronchi and bronchioles also caused causes turmeric air flow wheezing and",
        "Increased Mucus Production": "air trapping increased mucus production distal airways may be plugged with thick secretions which contribute to air trapping and the patient may be significantly dehydrated because of the increased fluid loss from tachypnea and inadequate fluid intake antihistamine medications may thicken secretions even more this image shows bronchio spasms compared to bronchial edema so management most patients have some combination of the three conditions bronchospasm bronchial edema and excessive mucous secretion transport considerations include to determine the trigger of the attack and if wheezing clears but peak flow does not improve the patient may need corticosteroids if the patient is under nourished or dehydrated he or she may need iv fluids okay so that was asthma now let's talk",
        "Chronic Obstructive Pulmonary Disease": "about chronic obstructive pulmonary disease and remember this includes",
        "Emphysema and Chronic Bronchitis": "emphysema and chronic bronchitis copd comprom um comprises at least two distinct clinical etiologies and that's emphysema and chronic bronchitis emphysema damages or destroys the terminal bronchial structures groups of alveoli merge into large blebs basically which have less surface area for gas exchange and trauma and diseases of the bones and muscles can significantly impair the ability to move air causing a group of disorders known as restrictive lung disease put patients at risk of infection and may severely limit their ability to compensate for any respiratory insult do not generate many calls for ems response though and then chronic bronchitis is defined as sputum production most days of the month for three or more months out of the year for more than two years excessive mucous production in the bronchial tree accompanied by chronic or recurrent product productive coughs almost always a heavy cigarette smoker or usually overweight or congested and sometimes has a bluish complexion so when it comes to assessment two",
        "Assessment Two Extremes of Copd Emphysema and Chronic Bronchitis": "extremes of copd emphysema and chronic bronchitis most patients follow somewhere between the two extremes patients with emphysema often have a barrel chest are to keep nick and use their own muscle mass for energy in attempting to breathe",
        "Causes of Diffuse Wheezing": "causes of diffuse wheezing our left-sided heart failure and that's cardiac asthma smoke inhalation or chronic bronchitis or acute pulmonary emboli localized wheezing from obstruction from a foreign body or a tumor as well chronic obstructive pulmonary disease patients with pneumonia so patients often have lung infections you want to check for the presence of fever or the presence of other infection signs also auscultate breath sounds that are consistent with pneumonia chronic obstructive pulmonary disease patients with right-sided heart failure so it's difficult for right-sided the right side of the heart to push thick blood through the capillaries copd often causes right-sided heart failure from lung disease the patient takes in too much salt or fluid or does not excrete significant fluid because of renal failure it may cause a chf episode look for peripheral edema jvd crackles progressive increase in dipsnia or greater in usual fluid outtake in improper use of diuretics also chronic obstructive pulmonary disease patients with left-sided heart failure well that's an abrupt left ventricular dysfunction and it can cause a rapid onset of left-sided heart failure then you have exacerbation",
        "Exacerbation of Chronic Obstructive Pulmonary Disease": "of chronic obstructive pulmonary disease so an exacerbation can cause a sudden decomp decomposition with no co-pathologic conditions because of technical advances patients with copd are more mobile but paramedics can be called because oxygen takes may be run out or medications may be left at home end stage chronic obstructive pulmonary disease so the lungs no longer support oxygen and ventilation they may be in hospice care it's difficult to determine whether an exacerbation can be resolved or not et innovation may make it impossible for the patient to make their own wishes and just secure documentation of the patient's wishes and follow local protocol or contact medical control",
        "Copd": "when it comes to copd patients and trauma it lessens the person's ability to tolerate the trauma so monitor closely because of decreased ability to compensate and normal oxygen saturations might be less than 90 percent so achieving a saturation of 98 is unrealistic and possibly harmful",
        "Management Associated Bronchospasm": "when it comes to management associated bronchospasm edema fluid or hypoxia can often be relieved determine what caused the situation to worsen and paramedics must understand that concepts of hypoxic drive and positive",
        "Hypoxic Drive and Positive and Expiratory Pressure": "and expiratory pressure so let's talk about that hypoxic drive when a person's breathing stimulus comes from a decrease in the pao2 rather than an increase in the pao2 so it affects only a small percentage of who have most relentless forms of pulmonary disease and discussion of whether to administer oxygen at this point you must consider the following points even though only a small number of cod copd patients breathe because of a hypoxic drive it's impossible to tell which ones they do not suddenly become ethnic after breathing oxygen use verbal and physical stimulation to encourage breathing and skin appearance may remain perfused if the patient becomes apneic because of increased oxygenation provide artificial ventilation and consider innovation if the patient becomes apnic no withholding oxygen for fear of decreasing the respiratory drive remember that 93 oxygen saturation levels are acceptable",
        "Auto Peep": "okay so let's talk about auto peep when ventilating patients with severe obstructive disease they will have difficulty exhaling auto peep can eventually cause a pneumo and cardiac arrest if there is possibly the possibility of auto peep patients should be ventilated as slowly as four to six breaths a minute okay so allow complete exhalation before the next breath is delivered or pressure in the thorax will continue to rise and that's a phenomenon called auto peep okay so next we just talked about copd so next we're going to talk about",
        "Pulmonary Infections": "pulmonary infections and these infections are caused by bacteria or viruses or fungi or other organisms the respiratory tract is vulnerable to airway agents that cause that and those that reside in the nose and throat infections diseases cause swelling of the respiratory tissues and an increase in mucus production and the production of pus resistance to air flow increases exponentially when the air wide dynamic is diameter is narrowed so alveoli may become non-functional if filled with fluid or pus pneumonia may be caused by a variety of bacterial viral or fungil agents and bacterial pneumonia is usually caused by streptococcus so a vaccine is available for this bacteria patients at a greater risk of pneumonia include older or chronic illness or people who smoke and those who are immunocompromised all high risk patients are strongly encouraged to get an annual vaccine antibiotic resistance organisms can colonize in the respiratory tract and that can be dangerous to paramedics so always ask where the organism was found and where proper respiratory protection if it's in the respiratory tract",
        "Pneumonia": "okay so a patient with pneumonia usually reports several hours to days of weakness a productive call fever or chest pains that worsen by coughing the illness may have started abruptly or gradually pneumonia is often a secondary infection following influenza during physical exam they may look ill or have a toxic appearance or they may be coughing present with crackles on auscultation in advance cases they may have diminished or absent breath sounds or sputum it could be thick or patients may experience pain from breathing a pleural friction rub over the involved area may be heard pneumonia often occurs in lung bases usually only one side so patients are often dehydrated and supportive care includes oxygenation or secretion management success suctioning transport to the closest appropriate facility bronchiodilators will not help pneumonia but may slightly improve the patient's ability to ventilate so management when it comes to an upper airway infection it may require aggressive airway management and a lower airway infection may need supportive care and transport to the hospital okay so the next thing we're going to talk about is atelectasis",
        "Atelectasis": "and that's when the alveoli are vulnerable to many disorders so may collapse from obstruction in the proximal airways or from external pressure may be filled with plus blood or fluid or damage from smoke or toxin exposure about 79 percent of the airway that moves the lungs is gas nitrogen moves into the lungs which keeps the alveoli open it is common for some alveoli in the human body to collapse from time to time so sighing coughing and sneezing and changing positions are believed to help open close aviolae when these actions do not happen increasing numbers of alveoli might collapse and not reopen eventually entire lung segments may collapse so the affected area can harbor pathogens that result in pneumonia and check if the patient with fever has had a recent chest or abdominal surgery post-surgical patients are encouraged to get out of bed cough and breathe deeply use of that of a spirometer helps to quantify breath depth and this is often sent home with the patients after discharge next we're going to talk about cancer so",
        "Cancer": "lung cancer is one of the most common forms of cancer especially among cigarette smokers and those exposed to occupational lung hazards or second-hand smoke",
        "Lung Cancer": "lung cancer often presents with hematophysis and that's coughing up blood and sputum and uncontrolled coughing when tumor in the airway large airways bleed so copd in and improper lung function frequently applying to lung cancer and cancer from other body sites often metabolizes in the lung other cancers may involve lymph nodes in the neck and cancer patients may get pulmonary complications from chemotherapy or radiation tumors or cancer treatments may cause pleural effusions as well so management there's little pre-hospital treatment for pleural fusions paramedics are sometimes called to for and life measures so depressed respiratory causes a large amount large amounts by narcotics so naloxone only to improve respiration do not reverse the patient's pain control when it comes to toxic inhalations the",
        "Toxic Inhalations": "pathophysiology so many toxic substances can be inhaled damage depends on the water solubility of the toxic gases highly water soluble gases like ammonia react most mucous membranes so this causes swelling and irritation in the upper airway and less water-soluble gases may get deep into the lower airways where they could damage over time so uh things like nitrogen dioxide moderately while your soluble gases may have signs and symptoms somewhere between irritation and pulmonary edema so a situation like mixing drain cleaner and chlorine bleach may produce an irritant chlorine gas that can sicken everyone in the home immediately remove the exposed patients from contact with the gas and provide a hundred percent supplemental oxygen or assisted ventilations if the breathing is impaired patients exposed to slightly viable water soluble gases may have an acute dips hours after the incident okay so the next thing we're going to",
        "Pulmonary Edema": "talk about is pulmonary edema that's fluid buildup in the lungs and it occurs when blood plasma fluid enters into the lungs pulmonary edema is classified as high pressure and that's cardiogenic or high permeability and that's non-cardiogenic and non-cardiogenic occurs after acute hypoxia and it's damaged to the pulmonary capillaries by toxins or drugs in the bloodstream some present with significant pulmonary edema after a lengthy journey if they do not if they've not been taking their diuretics when traveling and there are a few early signs by the time fine crackles in the lung bases become audible fluid has leaked into the capillary or leaked out of the capillaries and increased diffusion space between the capillaries and alveoli and swollen the alveolar walls and they've begun to seep into the alveoli listen to the lower lobes on the patient's back crackles may be heard higher in the patient's lung as pulmonary edema worsens and as it worsens patients will start to cough up watery sputum and it's often pink tinged with red blood cells",
        "Acute Respiratory Distress Syndrome": "when acute respiratory distress syndrome so it's seldom seen in the field and it the syndrome is caused by diffuse damage to the alveoli from shock or aspiration of gastric contents pulmonary edema barotrauma or hypoxic event so the syndrome is worsened is worse when there is direct damage to the lungs and during a near death crisis alveoli begins to become stiff and difficult to ventilate so it's similar to that for any patient with respiratory problems the assessment just document oxygen saturation breath sounds and any sudden changes and then carefully monitor and bone light",
        "Pneumothorax": "when we talk about pneumothorax that's when air collects between the visceral and parental pleura and blebs weak spots that can rupture under stress and it may predispose patient with a pneumo it causes of stress may be simple as coughing or as severe as aggressive back valve mass ventilation patients may have had multiple different pneumothoraces and patients may have sharp pain after coughing or increasing diphtheria in subsequent minutes or hours okay when it comes to management of a pneumo most patients will not require acute interventions and they should receive oxygen in close monitoring of their respiratory status with a pleural effusion and it's when a sac of fluid similar to a blister that has formed when fluid collects between the visceral and parental parental pleura so it can be caused by infections or tumors or trauma and the lung tissues rub against each other causing inflammation and fluid accumulation so pleural",
        "Pleural Effusions": "effusions can contain several liters of fluid and a large effusion decreases the lungs capacity and causes dipnia it may be hard to hear breast sounds and the patient's position will affect the ability to breathe a shift in position may cause more dipsnia and the fowler's position will likely be the most comfortable supportive care should be used until the patient is transported transported and large effusions may be drained at a medical facility in a procedure called authoral centesis okay so the next thing we're going to",
        "Pulmonary Embolism": "talk about is a pulmonary embolism and its pulmonary circulation may be compromised by a blood clot and that's an embolism or fat embolism or amniotic fluid embolism or an air embolism from a neck laceration or iv that was improperly or not flushed a large embolism usually large lodges in a major branch of the pulmonary artery and this prevents blood flow normal alveoli will not work if the venous blood cannot reach them",
        "Pulmonary Embolism Assessments": "when it comes to pulmonary embolism assessments it has a confusing presentation so early presentation may have normal breath sounds with good peripheral ascertation the classic presentation is sudden dipsnia and cyanosis with a possible sharp chest pain cyanosis does not end with oxygen therapy pulmonary and bly often begin in a large vein of the neck where clots can form and migrate into the pulmonary circulation clots may form when patients are immobile for prolonged periods when it comes to management veteran patients are often prescribed anticoagulants or special stockings or other devices to reduce blood clot formation in the legs a green filled filter may be inserted into patients with a history of deep veinous thrombosis or dvts and this filter opens like a mesh umbrella to collect clots traveling from the legs in a main vein returning blood to the heart a saddle umbilicus or emboli is an especially large pulmonary emboli that lodges at a bifurcation of the right and left pulmonary arteries and may be immediately fatal few patients survive cardiac arrest caused by these large pulmonary emboli okay so this concludes chapter 16 respiratory emergencies we hope you've enjoyed it and join us here again for more chapters from the 8th edition emergency care in the streets thank you"
    },
    {
        "Introduction to Airway Management": "chapter 11 Airway Management in the care of any patient ient obtaining and maintaining a patent Airway and ensuring adequate respiration are primary steps a pent Airway allows for unobstructed air flow into and out of the lungs which is essential for Effective ventilation adequate respiration ensures that oxygen is efficiently exchanged in the lungs and delivered to the tissues via the bloodstream Airway management requires special consider ation due to the anatomical and physiological differences among patient populations understanding these fundamental principles of Airway management is essential for providing effective care to all patients especially in emergency situations this lecture will explore these principles in detail equipping you with the Knowledge and Skills necessary for Effective Airway management across different patient populations",
        "Anatomy of the Respiratory System": "the respiratory system encompasses all structures in the body that contribute to Airway formation and facilitate breathing or ventilation it is broadly divided into the upper and lower Airways the upper Airway includes the nose mouth ferx LX while the lower airway comprises the trachea bronchi and lungs several structures play a pivotal role in oxygenation and ventilation these include the diaphragm which is the primary muscle responsible for respiration it contracts to create a vacuum that allows air to enter the lungs muscles of the chest wall including the intercostal muscles assist in expanding and Contracting the thoracic cavity during breathing the accessory muscles of breathing such as the sternomastoid and scaling muscles Aid in respiration especially during increased respiratory effort nerves from the brain and spinal cord inate the respiratory muscles coordinating their actions to ensure effective ventilation",
        "Ventilation Process": "ventilation is the process of exchanging air between the lungs and the environment it involves the movement of air into the lungs during inspiration and out of the lungs during expiration this exchange is fundamental to maintaining adequate levels of oxygen and carbon dioxide in the blood ensuring proper cellular function and metabolic processes",
        "Upper Airway Functions": "the upper Airway begins at the nose and mouth and extends down to the fex which is considered the dividing line between the upper and lower Airways the upper Airway has several vital functions that are essential for Effective respiration first the major functions of the upper Airway are to warm filter and humidify the air as it is inhaled this conditioning of the air is critical for protecting the delicate tissues of the lower respiratory tract and for ensuring that the air reaching the lungs is at an appropriate temperature and humidity level particulate matter and pathogens are filtered out by the mucous membranes and cyia lining the nasal passages",
        "Structure and Function of the Upper Airway": "in Upper Airway the ferx a key structure in the upper Airway is composed of three regions the naso feric orox and loparic the naso ferx is located behind the nasal cavity and is responsible for filtering and warming the air the aura ferix located behind the oral cavity serves as a pathway for both air and food the lenio ferx is the section of ferx situated above the Linex and behind the tongue directing air towards the lower airway while ensuring that food and liquids are directed towards the esophagus the naso fairx is an integral part of the upper Airway formed by the union of facial bones and divided by the septum it plays a significant role in the respiratory system and its structure and function are crucial for Effective Airway management the N of ferx is lined with ciliated mucosal membranes the Celia in this membrane are instrumental in moving contaminants and particles out of the body thus helping maintain a clear Airway this self- cleaning mechanism is vital for preventing infections and maintaining respiratory Health the turbinates within the NASA ferx increase the surface area of the nasal mucosa this increased surface area is essential for warming humidifying and filtering the air we breathe the sinuses which are cavities formed by facial bones also play a role in this process that being said the nas of ferx is also susceptible to injury fractures of certain sinus bones can lead to the leakage of CSF into the nasal passageways and the auditory canal posing a significant risk for infection and other complications Additionally the tissues of the naso feric are extremely delicate and highly vascular which can make them more prone to bleeding and other injuries",
        "Role of the Oroferix and Larynx": "the Oro ferix is the section of the throat located in the posterior of the oral cavity it has a role to play in both the respiratory and digestive systems positioned at the base of the tongue and above the LX is the epiglottis a leaf shaped cinis flap the epig glotus functions as a switch between the trachea and esophagus preventing food and liquids from entering the airway during swallowing the Linx also known as the voice box is formed by multiple independent cardom linages structures with the thyroid cartilage being the primary component the thyroid cartilage often referred to as the atoms Apple provides structure and protection to the LX the gtic opening located within the L ERX is the narrowest portion of the adult trachea it is also where a majority of medical providers consider the delineation between the upper and lower airway to be",
        "Lower Airway and Gas Exchange": "the lower airway is responsible for the exchange of oxygen and carbon dioxide a process critical for maintaining proper respiratory function its external boundaries are defined by the fourth cervical vertebrae and the zho process the trachea commonly known as the wipipe serves as the conduit for air entry into the lungs upon reaching the thoracic cavity the trachea divides at the level of the Corina into the right and left main stem bronchi which further facilitates the transport of air into each lung each bronchus divides into smaller bronchi which further subdivide into bronchioli these are thin hollow tubes composed of smooth muscle that play a critical role in air passage these smaller bronchioles Branch into Alvar ducts which terminate at the Alvar Sachs the Alvi located within these Sachs serve as the functional site for the exchange of oxygen and carbon dioxide this process of gas exchange is vital for maintaining adequate oxygen levels in the blood and removing carbon dioxide from the body oxygen diffuses through the lining of the Alvi into the pulmonary capillaries facilitating gas exchange the AI are lined with surfactant a substance that decreases surface tension and helps keep the Alvi expanded this is vital for maintaining open air sacks and ensuring efficient gas exchange if the amount of surfactant is inadequate or the avvi are not properly inflated the Alvi can collapse leading to a condition known as adila Tois this collapse impairs the lung's ability to oxygenate the blood blood and remove carbon dioxide highlighting the importance of surfactant in respiratory function",
        "Mediastinum and Respiratory-Circulatory Synergy": "between the lungs is a space known as the medyum surrounded by tough connective tissue this space contains the heart great vessels esophagus trachea major bronchi and many nerves all of which play Vital roles in respiratory in circulatory function the frenic nerve inates the diaphragmatic muscle enabling its contraction which is essential for Effective respiration by allowing the diaphragm to facilitate the movement of air into and out of the lungs the respiratory and cardiovascular systems work in tandem to maintain homeostasis in the body together they ensure a constant supply of oxygen and nutrients to every cell which is necessary for cellular metabolism an overall physiological function concurrently they are responsible for the removal of carbon dioxide and waste products from every cell which is critical for preventing toxic buildup and maintaining the acidbase balance of the body this synergistic relationship ship between the respiratory and cardiovascular systems is fundamental for sustaining life and ensuring the efficient function of all body systems",
        "Importance of Prompt Airway Management": "the image here underscores the urgent need for prompt and effective Airway management following the cessation of breathing a reduction of oxygenated blood to the brain leads to a rapid decline in cellular function in viability within the first 0 to 1 minute after a patient stops breathing cardiac irritability occurs where the heart is in a state of electrical instability and immediate defibrillation may be the only highly effective method in restoring a normal Rhythm during the 0 to 4 minute window brain damage is unlikely if profusion is restored promptly and this period is often referred to as the golden minutes for resuscitation early intervention can significantly improve the chances of survival without neurological deficit as the duration extends to four to 6 minutes however the probability of brain damage increases due to the prolonged lack of oxygen and nutrient Supply to brain tissues this interval necessitates rapid and continuous Airway management to maintain oxygen delivery between six to 10 minutes brain damage becomes highly probable the lack of oxygen during this period results in significant hypoxic injury to neurons making neurological recovery increasingly difficult Beyond 10 minutes the risk of irreversible brain damage is substantial prolonged hypoxia and esema lead to widespread neuronal death and severe neurological impairment even if the hypoxia is corrected",
        "Inhalation and Exhalation Mechanics": "ventilation is the process of moving air into and out of the lungs enabling gas exchange this process involves two primary phases inhalation and exhalation inhalation which is the active muscular part of breathing begins when air enters the body through the mouth and nose moving down the trachea during inhalation the diaphragm and intercostal muscles contract causing the lungs to fill with air the ability of the lungs to function properly depends on the coordinated movement of the chest and its supporting structures which include the thorax thoracic cage diaphragm and accessory muscles the Thora and thoracic cage provide a rigid yet flexible structure that supports the expansion and contraction of the lungs the diaphragm which is a specialized skeletal muscle plays a critical role in Breathing by acting as both a voluntary and involuntary muscle this dual functionality allows for controlled breathing during activities like speaking or singing as well as un autonomic breathing during rest or sleep accessory muscles including the sternomastoid and scaling muscles assist in the breathing process particularly during increased respiratory demand these muscles enhance the expansion of the thoracic cavity facilitating greater air intake partial pressure refers to the amount of gas in the a air or dissolved in fluid such as blood and is measured in millimeters of mercury the body attempts to equalize partial pressures leading to the diffusion of oxygen across the avvar membrane into the bloodstream atmospheric pressure is typically higher than the air pressure within the thorax and during inhalation this difference creates a slight vacuum gases such as oxygen move from areas of higher concentration to areas of lower concentration until equilibrium is reached the entire process of inspiration focuses on delivering oxygen to the Alvi variations in tidal volume which is the amount of air moved in and out of the lungs with each breath and the respiratory rate directly affect the minute volume which is the total volume of air exchanged per minute exhalation is a passive process that does not require muscular effort under normal conditions the key word here being normal this process is regulated by the Herring Brower reflex which is a feedback mechanism that prevents the overexpansion of the lungs by terminating inspiration during exhalation the diaphragm and intercostal muscles relax leading to an increase in intop ponary pressure as the size of the thoracic cage decreases the air within the lungs is compressed into a smaller space resulting in higher air pressure this increased pressure forces air out of the lungs maximum expiration occurs when the diaphragm and intercostal muscles relax and air is exhaled forcefully contrasting with the typical passive nature of exhalation",
        "Regulation of Ventilation": "the regulation of ventilation is a complex process involving a series of receptors and feedback loops these mechanisms ensure that the body's need for oxygen and the removal of carbon dioxide are consistently met the primary drive to breathe is based on ph changes in the blood and CSF chemo receptors in the medulla oblongata kateed bodies and aortic bodies detect these changes and adjust the rate and depth of breathing accordingly in healthy individuals an increase in oxygen levels leads to a temporary suspension of respiration by the respiratory Center in the brain this pause continues until the rising levels of carbon dioxide in the blood stimulate the respiratory Center to resume breathing this feedback system helps maintain the balance of oxygen in carbon dioxide ensuring effective gas exchange and homeostasis",
        "Oxygenation and Respiration": "oxygenation is the process of looting oxygen molecules onto hemoglobin molecules in the bloodstream hemoglobin which is a protein found in red blood cells has a high affinity for oxygen and transports it from the lungs to tissues throughout the body adequate oxygenation is essential for internal respiration where oxygen is utilized by cells to produce energy through metabolic processes this process ensures that tissues receive sufficient oxygen to meet metabolic demands enabling normal cellular function and overall physiological Health respiration encompasses both cellular respiration and the process of exchanging gases in the body metabolism or cellular respiration involve cells extracting energy from nutrients through a series of chemical processes during this process each cell combines nutrients and oxygen to produce energy with carbon dioxide and other waste products as byproducts the exchange of oxygen and carbon dioxide occurs primarily by diffusion oxygen from inhaled air diffuses across the V membrane into the pulmonary capillaries where it binds to hemoglobin in red blood cells simultaneously carbon dioxide which is a waste product of cellular Metabolism diffuses from the blood into the Alvi to be exhaled this gas exchange is critical for maintaining the body's acidbase balance and ensuring that tissues receive sufficient oxygen from metab abolic processes",
        "External and Internal Respiration": "external respiration refers to the process of breathing fresh air into the respiratory system and the subsequent exchange of gases between the Alvi and the blood in the pulmonary capillaries this process begins with inhalation where air containing oxygen enters the lungs and reaches the alv in the alv oxygen diffuses across the Alvar membrane into the blood within the pulmonary capillaries where it binds the hemoglobin molecules in red blood cells simultaneously carbon dioxide a waste product of cellular Metabolism diffuses from the blood into the Alvi to be exhaled it's important to take note that adequate ventilation which ensures that air is moving in and out of the lungs does not necessarily guarantee effective external respiration the efficiency of gas exchange also depends on factors such as the Integrity of the Alvar capillary membrane and the availability of hemoglobin to transport oxygen internal respiration involves the exchange of oxygen and carbon dioxide between the systemic circul atory system and the cells in the body this process is crucial for cellular metabolism and overall physiological function when oxygen-rich blood arrives at the tissues oxygen molecules detach from hemoglobin in the red blood cells and diffuse to the capillary walls into the interstitial fluid and then into the cells this oxygen is essential for cellular respiration a metabol process where cells use oxygen to convert glucose into ATP the carbon dioxide that is generated by cellular respiration diffuses from the cells into the interstitial fluid and then into the capillaries once in the bloodstream carbon dioxide is transported back to the lungs either dissolved in plasma bound to hemoglobin or as bicarbonate ions when the blood reaches the lungs carbon dioxide diffuses into the Alvi and is expelled from the body during exhalation the efficiency of internal respiration depends on several factors including the availability of oxygen the Integrity of the capillary walls and the presence of adequate hemoglobin to transport gases conditions such as anemia respiratory disorders or circulatory impairments can significantly affect the process leading to inadequate oxygen delivery and the accumulation of carbon dioxide",
        "Aerobic and Anaerobic Metabolism": "in the presence of oxygen the mitochondria within cells convert glucose into energy through a process known as aerobic metabolism this process includes the C cycle and oxidative phosphation which efficiently produces energy in the form of ATP however when oxygen is not available cells resort to Anor robic metabolism to meet their energy demands this process primarily relies on glycolysis which occurs in the cytoplasm and results in the production of a significantly lower amount of ATP compared to aerobic metabolism while glycolysis allows cells to continue producing some energy it is less efficient and leads to the accumulation of lactic acid which can contribute to Cellular and tissue acidosis for aerobic internal respiration to occur effectively adequate levels of profusion and external ventilation are essential perfusion ensures that oxygenated blood is delivered to the tissues while external ventil ation maintains the oxygen supply and removal of carbon dioxide from the lungs any impairment on these processes such as in cases of respiratory or circulatory failure can severely disrupt cellular respiration and lead to metabolic crisis",
        "Neural Control of Respiration": "the neural control of respiration originates in the brain and brain stem primarily involving the medulla oblongata and the ponds these areas contain the respiratory centers that regulate the rate depth and rhythm of breathing through complex systems of feedback mechanisms the medullary respiratory centers are chiefly responsible for initiating and maintaining the basic rhythm of respiration they interact with the ponds through negative feedback loops to modulate breathing patterns the austic center in the ponds acts as a secondary control center stepping in if the medulla fails to initiate respiration ensuring the continuity of the respiratory process the pneumotaxic center which is also located in the ponds exerts an inhibitory influence on inspiration preventing overinflation of the lungs by shortening the inspiratory phase the this Center fine-tunes the respiratory rate and transitions between inspiration and expiration working in tandem with the ATN mustic Center to regulate the Rhythm and the depth of rhythms chemical stimuli play a vital role in modifying respiratory rate and depth through the action of chemo receptors which constantly monitor the chemical composition of body fluids Central chemo receptors which are located adjacent to the respiratory centers in the medulla specifically monitor the pH of the cerebral spinal fluid an increase in the acidity of the CSF triggers these chemo receptors to increase the rate and depth of respiration to help expel excess carbon dioxide and restore pH balance peripheral chemo receptors located in the correct bodies and the aortic Arch measure the amount of carbon dioxide in arterial blood these chemo receptors also respond to decreases in arterial oxygen partial pressure serving as backup mechanism for the primary control of ventilation when the levels of carbon dioxide or hydrogen ions in the blood increase these chemo receptors stimulate the dorsal and vental respiratory groups in in the medulla to elevate the respiratory rate and depth facilitating the removal of carbon dioxide and maintaining homeostasis",
        "Dorsal and Ventral Respiratory Groups": "the dorsal respiratory group or drg and the ventral respiratory group or vrg are key components of the neural control of respiration each with distinct roles based on information from chemo receptors the drg is primarily responsible for initiating inspiration it receives sensory input from peripheral chemo receptors and other receptors in the body processing this information to regulate the rhythm of breathing when the drg detects an increase in carbon dioxide or a decrease in oxygen levels it triggers the inspiratory muscles to contract initiating inhalation the vrg on the other hand is mainly responsible for the motor control of both inspiratory and expiratory muscles this group contains neurons that activate during Force breathing such as during exercise or respiratory distress coordinating the muscle actions required for deep inhalation and forceful exhalation the vrg ensures that the appropriate muscles are engaged to meet the the body's increased respiratory demands",
        "Impact of Ventilation Disruptions": "disruptions in pulmonary ventilation oxygenation and respiration can cause immediate and significant effects on the body compromising cellular function and leading to systemic disturbances effective pulmonary ventilation ensures that air is adequately inhaled and exhaled facilitating the exchange of oxygen and carbon dioxide in the lungs when this process is impaired oxygen levels in the blood drop and carbon dioxide accumulates leading to respiratory acidosis and hypoxemia hypoxia is a condition where tissues and cells do not receive enough oxygen and can rise from several factors including respiratory failure circulatory issues or environmental conditions like high altitudes oxygen is crucial for cellular metabolism and its deficiency can impair ATP production which leads to Cellular and tissue destruction in acute hypoxia symptoms such as confusion tachicardia and cyanosis can occur while chronic hypoxia may be a result of compensatory mechanisms and increased red blood cell production in chronic respiratory conditions such as in stage chronic obstructive pulmonary disease the body adapts through a mechanism known as the hypoxic drive typically the primary respiratory drive is regulated by the levels of carbon dioxide in the blood sensed by chemo receptors in the brain stem however in patients with COPD chronic hypercapnea desensitizes these chemo receptors reducing their responsiveness as a result the body relies more on peripheral chemo receptors which are sensitive to oxygen levels to regulate breathing the hypoxic drive stimulates breathing when arterial oxygen levels fall helping to maintain adequate ventilation this drive however is less sensitive and powerful than the primary carbon dioxide driven respiratory drive clinically managing patients with a hypoxic drive involves careful oxygen therapy to ensure that oxygen levels are sufficient to prevent hypoxia without suppressing the hypoxic drive which could lead to respiratory depression",
        "Hypoxia and Respiratory Distress": "disruptions in pulmonary ventilation oxygenation and respiration can cause immediate and significant effects on the body compromising a cellular function and leading to systemic disturbances effective pulmonary ventilation ensures that air is adequately inhaled and exhaled facilitating the exchange of oxygen and carbon dioxide in the lungs when this process is impaired oxygen levels in the blood drop and carbon dioxide accumulates leading to respiratory acidosis and hypoxemia hypoxia a condition where tissues and cells do not receive enough oxygen can arise from several factors including respiratory failure circulatory issues or environmental conditions like high altitudes the onset and degree of tissue damage caused by hypoxia often depend on the quality of ventilations oxygen is crucial for cellular metabolism and its deficiency can impair ATP production leading to Cellular and tissue dysfunction early signs of hypoxia include restlessness irritability apprehension tacac cardia and anxiety these symptoms reflect a body's initial response to insufficient oxygen attempting to increase oxygen intake and distribution as hypoxia progresses late signs May develop including mental status changes a weak or threy p ults and cyanosis indicating more severe oxygen deprivation and impending organ dysfunction responsive patients experiencing hypoxia will often report shortness of breath and may struggle to speak in complete sentences due to the increased effort required to breathe in clinical practice it's vital to administer supplemental oxygen before signs and symptoms of hypo oxia appear to prevent the progression to more severe hypoxic States and Associated complications in chronic respiratory conditions such as endstage chronic obstructive pulmonary disease the body May rely on a hypoxic drive to stimulate breathing when arterial oxygen levels fall this drive is less sensitive and powerful than the primary respiratory drive which is regulated by by carbon dioxide levels the hypoxic drive becomes critical in COPD patients where chronic hypercapnea reduces the responsiveness to carbon dioxide making oxygen levels the main trigger for respiration",
        "Ventilation-Perfusion Mismatch": "effective gas exchange in the lungs relies on the proper matching of ventilation or air flow and perfusion blood flow the ventilation profusion or VQ ratio is a critical determinant of this process ensuring the oxygen is delivered to the blood and carbon dioxide is removed efficiently in a perfectly matched system each alvus would receive the right amount of blood flow for the right amount of air it receives allowing for optimal gas exchange however various conditions can disrupt this balance leading to a VQ mismatch this mismatch is a common cause of abnormalities in oxygen and carbon dioxide exchange when ventilation is compromised but perfusion continues blood flows through parts of the lung where there is inadequate air flow this situation which we often refer to as a shunt results in blood passing over Alvar membrane without being oxygenated consequently arterial blood oxygen levels drop leading to hypoxemia conditions such as pneumonia adelais and COPD can cause this type of VQ mismatch conversely when profusion is compromised but ventilation is adequate this is known as dead space ventilation where the Alvi is ventilated but not profused with blood this scenario means that the oxygen in the Alvi cannot be absorbed into the bloodstream and carbon dioxide cannot be expelled effectively pulmonary embolism is a typical example of this condition the result of inadequate profusion is less oxygen absorption into the bloodstream and reduced carbon dioxide removal which can lead to to systemic hypoxia in respiratory acidosis",
        "Intrinsic and Extrinsic Factors in Ventilation": "ventilation can be influenced by a variety of intrinsic and extrinsic factors each contributing to potential Airway obstruction and compromised breathing efficiency intrinsic factors such as inflammation mucous buildup and tumors can directly block Airways extrinsic factors include external compression from masses or structural abnormalities both types of obstruction can impede air flow leading to inadequate ventilation interruptions to the central and peripheral nervous systems significantly affect the ability to breathe efficiently for instance neurological disorders can impair the signals that control respiratory muscles leading to insufficient ventilation hypercapnia character cized by an increased level of carbon dioxide is a common consequence of impaired ventilation and results from the body's inability to expel carbon dioxide effectively trauma to the head and spinal cord can also disrupt the nervous control of ventilation damage to these areas can impair the respiratory centers of the brain stem or the neurop pathways that signal the respiratory muscles leading to respiratory in sufficiency muscular distrophy a genetic disorder causing degeneration of muscle fibers affects motor development and muscle contractility this degeneration slows down motor responses and weakens respiratory muscles making it difficult to achieve effective ventilation patients with allergic reactions might experience swelling known as angio edema and Bronco constriction angioedema causes swelling of the airway tissues while Bronco constriction Narrows the Airways both of which reduce pulmonary ventilation extrinsic factors include trauma and foreign body Airway obstruction which physically block air flow and require immediate intervention respiratory splinting where pain or discomfort prevents deep breaths can also result in decreased pulmonary ventilation",
        "Hypoventilation and Hyperventilation": "hypoventilation which is characterized by slow breathing occurs when carbon dioxide production exceeds the body's ability to eliminate it or when carbon dioxide elimination is depressed failing to keep up with normal metabolism this condition leads to hypercapnia and respiratory acidosis where the blood pH drops due to the increased carbon dioxide levels in contrast hyperventilation involves rapid breathing where carbon dioxide elimination it seeds its production leading to hypercapnia and respiratory alkalosis characterized by an elevated blood pH both hypoventilation and hyperventilation can be the body's response to various abnormal conditions attempting to compensate for metabolic imbalances minute volume which is the total volume of air breathed per minute plays a role in maintaining appropriate carbon dioxide levels in the blood decreases or increases in minute volume disrupt this balance leading to either retention or excessive elimination of carbon dioxide",
        "Factors Affecting Oxygenation and Respiration": "oxygenation and respiration can be influenced by both external and internal factors which impact the efficiency of gas exchange externally the attachment of carbon monoxide to hemoglobin forms carboxyhemoglobin reducing the hemoglobin available for oxygen transport and potentially causing false pulse oximeter readings internally conditions such as pneumonia pulmonary edema and COPD reduce the surface area available for gas EX change pneumonia and pulmonary edema fill Alvi with fluid or pus while COPD obstructs air flow and destroys the avvr walls leading to decreased oxygen absorption and impaired carbon dioxide removal nonfunctional Alvi which are unable to participate in gas exchange and intrapulmonary shunting or blood passes the Alvi without being oxygenated both contribute to impaired oxygenation changes in respiratory rate can also impact the efficiency of gas exchange with both excessively rapid and slow breathing potentially leading to respiratory imbalances pain and strong emotions can alter breathing patterns often causing rapid slow breaths that decrease effective ventilation decreased metabolism as seen in conditions like hypothyroidism reduces the body's overall oxygen demand and carbon dioxide production potentially affecting respiratory drive other conditions including hypoxia hypoglycemia and infections can exacerbate respiratory difficulties",
        "Circulatory Compromise": "circulatory compromise refers to conditions that lead to in adequate profusion preventing sufficient blood flow to individual cells and tissues this can result from various obstructions related to trauma which hinder the delivery of oxygen and nutrients necessary for cellular metabolism and the removal of waste products here we see several conditions that can cause circulatory compromise pulmonary embolism is a blockage in one of the pulmonary arteries in the lungs usually due to blood clots and it requires a restoration of blood flow a simple or tension Numa thorax is an accumulation of air in the plural cavity which can cause the lung to collapse the tension in with thorax is more severe where pressure builds up compressing the lungs and all other vital organs in the chest the presence of blood blood in the plural space usually due to trauma or injury and can compress the lungs and impair breathing is known as a hemothorax while a hemon numa thorax is a combination of air and blood in the plural space which causes severe respiratory distress and requires immediate medical intervention continuing on heart failure in cardiac tanod reduces the heart ability to pump effectively cardiac tanod comes from an accumulation of fluid in the pericardial sack where it exerts pressure on the heart further inhibiting its function significant blood loss reduces the volume of circulating blood and anemia decreases the blood's oxygen caring capacity both leading to inadequate tissue oxygenation hemorrhagic shock is a form shock that results from severe blood loss leading to A reduced blood pressure and profusion to vital organs vasod diary shock is due to conditions such as septic shock and can cause widespread vasod dilation resulting in decreased blood pressure and an impaired profusion despite adequate blood volume",
        "Acid-Base Balance Disorders": "hypo ventilation and hyperventilation significantly impact the body's acidbase balance leading to various disorders both conditions can result in Rapid deterioration and death if not managed promply the body expels excess acid as carbon dioxide through the lungs and slowing respirations increase carbon dioxide levels in the blood the quickest way for the body to eliminate excess hydrogen ions is by converting them to water and carbon dioxide any factor that inhibits respiratory function can lead to acid retention in acidosis acidosis can result from a low respiratory rate or tidal volume while alkalosis can be caused by high respiratory rate or volumes the four main clinical presentations of acidbase balance disorders are respiratory acidosis respiratory alkalosis metabolic acidosis and metabolic alkalosis respiratory acidosis is caused by hypoventilation leading to increased carbon dioxide while respiratory alkalosis is caused by hyperventilation leading to decreased carbon dioxide metabolic acidosis results from a decrease in bicarbonate or an increase in acid production and metabolic alkalosis is caused by an increase in bicarbonate or loss of acids fluctuations in PH due to changes in bicarbonate levels result in metabolic acidosis or alkalosis whereas fluctuations due to respiratory disorders result in respiratory acidosis or alkalosis the classic treatment for hyperventilation syndrome focuses on restoring a normal respiratory rate to increase carbon di oxide levels an adult patient breathing at a rate fewer than 12 breaths per minute or more than 20 breasts per minute should be evaluated for additional signs of inadequate breathing",
        "Assessment of Respiratory Distress": "patients experiencing respiratory distress often compensate by adopting preferential positioning to facilitate breathing respiratory distress can result from upper or lower airway obstruction inadequate ventilation impairment of respiratory muscles or impairment of the nervous system disia characterized by difficulty in respiratory rate regularity or effort may lead to or result from hypoxemia if hypoxia remains untreated it can progress to anoxia and subsequently cause cell and tissue death throughout the body evaluation of a patient in respiratory distress involves a comprehensive assessment that includes observation palpation and oscilation when assessing a patient with respiratory distress it's important to consider the patient position such as whether they are in a tripod position with elbows out which can indicate severe respiratory effort evaluate if the patient is exper experiencing orthopnea a form of positional dnia and check for adequate rise and fall of the chest to ensure effective ventilation assess whether the patient is gasping for air and examine the color and condition of the skin noting if it appears moist or clammy when evaluating a patient in respiratory distress assess for flaring of the Nars and breathing through Pur lips this can indicate an increased respiratory effort observe for any retractions such as intercostal Supra sternal notch supraclavicular fossa or subcostal retractions where the skin pulls around the ribs during inspiration determine if the patient is using accessory muscles to breathe which signifies significant respiratory effort check if the patient's chest wall is moving symmetrically ensuring even ventilation of both lungs additionally note if the patient is taking a series of quick breaths followed by a prolonged exhalation phase which can indicate obstructive Airway conditions patients experiencing inadequate breathing often present with labored breathing characterized by increased effort in use of acccessory muscles which are not typically engaged during normal respiration signs of inadequate breathing in adults include a respiratory rate of fewer than 12 breaths per minute or more than 20 breaths per minute irregular Rhythm diminished absent or noisy breath sounds upon oscilation abdominal breathing reduced flow of expired Air at the nose and mouth an unequal or an adequate chest expansion increased work of breathing shallow depth and skin that is pale cyanotic cool modeled and moist retractions and staccato speech patterns are also indicators during assessment pay particular attention to the external environment osculate breathing feel for air movement at the mouth and nose and observe the chest for symmetry noting any paradoxical motion additionally evaluate for pulses paradoxes and assess the history of present illness",
        "Protective Airway Reflexes and Respiratory Patterns": "when assessing a patient in respiratory distress it is important to observe and document the presence of protective Airway reflexes such as coughing and swallowing which help to maintain Airway patency additionally be aware of modified forms of respiration such as sighing and hiccupping sighing is typically a deeper breath taken intermittently and can indicate attempts to open collapsed Alvi while hiccuping can be a benign response or a sign of irritation of the diaphragm serious head injuries are particularly concerning as they can disrupt normal respiratory patterns leading to irregular and ineffective respirations known as axic respirations these respirations may be chaotic and lack regular pattern indicating severe brain stem dysfunction as intracranial pressure continues to push it through the fame and Magnum axic respirations can result from direct trauma to the brain increased intracranial pressure or simply secondary effects such as swelling and bleeding recognizing these signs is crucial for timely intervention a patient may exhibit agonal gasps which are sporadic and inadequate breaths that occur after the heart has ceased beating providers must be vigilant when monitoring patients in respiratory distress as timely identification and intervention are essential to avoid agonal respirations",
        "Monitoring and Oxygenation": "assessing a patient's level of Consciousness and and color are excellent indicators of their respiratory status when treating patients with an altered mental status always consider the possibility that they may not be receiving adequate oxygen to the brain establishing a baseline mental status is crucial for ongoing assessment proper oxygenation should be considered when evaluating patients and pulsox symmetry should be used as a non-invasive method to measure how well a person's hemoglobin is saturated with oxygen to ensure that pulse oximeters measure arterial rather than Venus oxygen saturation these devices are designed to assess only pulsating blood vessels the functionality of a pulse oximeter can be verified by comparing the pulse reading with the measurement obtained by palpation pulse oximeters are useful in various clinical situations such as monitoring oxygenation status during the insertion of an advanced Airway or suctioning identifying deterioration in trauma or cardiac patients assessing high-risk respiratory patients and evaluating vascular status in Orthopedic Trauma however certain circumstances can produce erroneous readings including a bright ambient light patient motion poor profusion nail polish Venus pulsations and abnormal hemoglobin because of this it's important not to base treatment decisions solely on your pulse oximetry reading Peak inspiratory flow measurement is a useful tool for evaluating Bron constriction an increase in Peak expiratory flow indicates that the patient is responding to treatment while a decrease May signify deterioration this measurement varies based on the patient's sex height and age and it's important to perform the test three times and record the best Peak flow rate of the three arterial blood gas or ABG analysis provides the most comprehensive quantitative information about the respiratory system with Normal ABG values summarized in reference tables maintaining Normal ABG values requires a balance between alvr volume and the profusion of alvr capillaries additionally entitled carbon dioxide assessment detects the presence of carbon dioxide in exhaled hair utilizing monitors that can be color metric digital or digital SL waveform to measure this parameter effectively a color metric carbon dioxide detector provides qualitative information about the presence of carbon dioxide in the patient's exhaled breath however it might give a false positive reading if the patient has ingested carbonated beverages leading to carbon dioxide being trapped in the stomach the device is sensitive to extremes of temperature and humidity and is less reliable if vomitous or other secretions enter it Additionally the paper inside the device degrades over time in contrast a capnometer provides quantitative information in real time by displaying a numeric reading of exhaled carbon dioxide levels a capnograph is an essential tool in respiratory monitoring providing a continuous graphic representation of exhaled carbon dioxide levels this device is particularly valuable in critical care and Emergency Settings as it allows healthc care providers to monitor the ventilation status of patients in real time waveform capnography which is a specific type of capnography offers quantitative data by displaying the concentration of carbon dioxide throughout the respiratory cycle this real-time information is crucial for assessing the effectiveness of ventilation detecting respiratory distress and identifying potential issues such as hypoventilation hyperventilation and Airway obstruction waveform capnography can help identify Trends and changes in the patient's respiratory status enabling timely interventions for example a sudden decrease in exhaled carbon dioxide levels might indicate a dislodged endot tral tube or a sudden dropping cardiac output conversely elevated levels may suggest High hypoventilation or respiratory failure this continuous monitoring provided by waveform cograph is indispensable in ensuring patient safety and optimizing Respiratory Care",
        "Capnography and Airway Management": "quantitative waveform capnography is an invaluable tool in both initial and ongoing monitoring of advanced Airway device placement this technology provides continuous real-time feedback on the patient's ventilatory status by displaying a graphical representation of carbon dioxide levels throughout the respiratory cycle by ensuring the airway device remains correctly positioned providers can prevent complications such as hypoxia or inadvertent extubation in addition to Airway management capnography plays a critical role during cardiopulmonary resuscitation the capnography readings offer immediate insight into the effectiveness of chest compressions higher levels of exhaled carbon dioxide indicate more effective compressions which in turn suggest better profusion and circulation conversely low or decreasing etco2 levels May indicate inadequate compressions or other issues that require adjustment capnography is also instrumental in detecting the return of spontaneous circulation or Ros a sudden increase in entitle CO2 levels during CPR can be one of the earliest signs of rasque often preceding palpable pulses as it takes time for after load to build up in systemic circulation this early detection allows for timely adjustments in patient management improving the chances of a successful resuscitation however the utility of entitle monitoring has its limitations especially in patients experiencing Cardiac Arrest during arrest profusion is severely compromised which can lead to significantly reduced carbon dioxide delivery to the lungs and thus lower intital CO2 readings",
        "Endotracheal Suctioning": "for endot tral suctioning of an intubated patient pass the suction catheter into the endot tral tube it is essential to pre- oxygenate the patient before performing tracheobronchial suctioning to prevent hypoxia there is no set time limit for how long the patient needs to be ventilated the patient should be ventilated until spo2 levels are as high as they could possibly be without going any higher apply suction for no longer than 15 seconds as the catheter is extracted to minimize potential trauma and hypoxia continuously ventilate and oxygenate the patient throughout the procedure to ensure adequate gas exchange",
        "Automatic Transport Ventilators": "automatic transport ventilators and resuscitators allow for the precise setting of various ventilation parameters including ventilator rate tital volume and peak expiratory time to ensure optimal respiratory support for patients during transport to use the automatic transport ventilator first attach it to the wall mounted oxygen source next set the ventilator rate tital volume and Peak expire atory time on the ATV according to the patient's condition these will generally be reflected in your protocols connect the ATV to the 1522 mm fitting on the endot tral tube or other Advanced Airway device finally osculate the patient's breath sounds and observe for equal chest rise to ensure adequate ventilation many devices allow for the utilization of the chimney entitled CO2 monitoring device to ensure adequate placement of the tube using an ATV frees your hands to perform other tasks but it's important to have a BVM and mask ready in case the ATV malfunctions most models have adjustments for respiratory rate and tital volume typically the respiratory rate is set at the midpoint or average for the patient's age while tital volume is adjusted based on the patient's chest rise and physiologic response ATVs are volume cycled rate controlled ventilators set at a fixed rate and do not cycle in conjunction with the timing of chest compressions these devices are usually oxygen powered although some models may require an external power source the presence of a pressure relief valve can result in hypo ventilation in patients with poor lung compliance increased Airway resistance or Airway obstruction there is also a possibility of the relief valve failing or overzealous ventilation occurring",
        "Advanced Life Support Airway Procedures": "in assisting with Advanced life support Airway procedures the paramedic performs the skill while the aemt partner plays a crucial supportive role the aemt should help set up for the procedure and perform basic life support Airway and ventilation Maneuvers as well as assisting in monitoring the patient when assisting with the placement of advanced Airways the indot trical tube is passed directly through the LX between the vocal cord Wards and into the trachea patient preparation involves several steps maintaining pre-oxygenation by using a high flow nasal canula leaving the nasal canula in place during intubation and ensuring apnic oxygenation to allow for continuous oxygen delivery down the Airways equipment set up for advanced Airway placement includes direct lenos scopy which involves the visualization of the vocal cords using a lenos scope or video lenos scopy which provides visualization of the vocal cords using a video camera and monitor intubation equipment sets include personal protective equipment such as an appropriate face mask and ey Shield a suction unit with both Yonker and whistle tip French catheters a lingos scope handle and a blade sized for the patient Mill forceps an ET tube size for the patient and either a stylet or tube introducer the intubation equipment set also includes water soluble lubricant a 10 mL syringe confirmation devices such as waveform entitle CO2 monitors or color metric devices a commercial ET tube securing device and importantly an alternate Airway management device such as a superg glaic Airway or a cryo thyrotomy kit performing the procedure involves six typical steps using the B magic memonic the first step or B is to perform bag mask preoxygenation ensuring the patient is adequately oxygenated before the intubation attempt the second step or E is to evaluate for Airway difficulties assessing the patient's anatomy and potential challenges that might complicate intubation the third step M involves manipulating the patient positioning them optimally in order to visualize the vocal records and facilitate a successful intubation a is to attempt a first pass intubation aiming to insert the ET tube correctly on the initial try if intubation is unsuccessful the fist step or GL advises using a super glottic or intermediate Airway as an alternative method to secure the airway lastly C stands for confirm the success uccessful intubation by verifying tube placement through various methods that we have already discussed",
        "Special Considerations in Airway Management": "special considerations include gastric distension which can occur if excessive pressure is applied during lung inflation this condition can lead to regurgitation of stomach contents increasing the risk of aspiration additionally a distended stomach can put push the diaphragm upward into the chest cavity indicators of gastric distension include an increase in the stomach's diameter a progressively distended abdomen and an increased resistance during bag mask ventilations ectomy is a surgical procedure involving the removal of the Linex which is typically performed by creating a tracheostomy and a establishing a stom in cases where the entire Linex is removed this is referred to as a total laryngectomy partial laryngectomy involves the removal of only a portion of the linic following this partial artificial ventilation through the nose and mouth may still be effective when suctioning a sta it's crucial to recognize the need for suctioning to prevent hypoxia perform the procedure with caution as even minor irritation of the tracheal wall can trigger a lenia spasm therefore limit suctioning to a maximum of 10 seconds at a time ventilation for patients with the stom can be performed using either the mouth the sto technique with a resuscitation mask or preferably a bag valve mask it is advisable to to avoid using The Rescuer mouth for ventilation if other methods are available particularly in situations where there's a risk of aerosol transmission of a respiratory illness to achieve an adequate seal over the sto use an infant or child-sized mask keep in mind that two Rescuers are required to use a BVM effectively for stoa ventilation and this method is appropriate only for patients who have undergone a partial lcom proper sealing of the sto during ventilation May enhance the effectiveness of the artificial ventilation a tracheostomy tube is a plastic tube inserted into the tracheostomy site it requires a special adapter to be compatible with ventilatory devices ventilation can be performed by attaching the BVM to the special adapter on the tracheostomy tube for patients with thick secretions suctioning should be carried out through the tracheostomy tube in the same manner as through a sto if the tube becomes dislodged stenosis of the stoa may occur additionally patients with a tracheostomy tube may have reduce tolerance for even brief periods of hypoxia Dental appliances can obstruct the airway loose appliances should be manually removed before administering ventilation please ensure that you put them somewhere safe so they can be returned to the patient or their family at a later time BVM ventilation is generally more effective when Dentures remain in place so it's important to periodically reassess the patient's Airway to ensure the D appliances are securely positioned facial bleeding should be controlled with direct pressure and suction as needed facial injuries often indicate a high risk of cervical spine injury when inserting an airway device it's critical to maintain inline stabilization of the cervical spine if you were unsure whether the patient experienced a traumatic injury or not"
    },
    {
        "Introduction to Respiratory Emergencies": "chapter 17 respiratory emergencies disia or difficulty breathing is a common complaint that you will frequently encounter in the field it serves as a symptom of a wide range of medical conditions and it's important to recognize that multiple issues May simultaneously contribute to a patient's presentation when assessing a patient with dnia it's necessary to consider the potential underlying medical problems during both the history taking and the physical examination effective management involves addressing not only the symptoms but also the underlying condition and any Associated anxiety the patient may experience",
        "Anatomy and Physiology of the Respiratory System": "the respiratory system comprises all anatomical structures involved in the breathing process starting with the upper Airway which includes all structures above the vocal cords gas exchange occurs within the Alvi where deoxygenated blood from the pulmonary circulation releases carbon dioxide and absorbs oxygen the pulmonary circulation begins at the right ventricle with the pulmonary artery branching into progressively smaller vessels until it reaches the pulmonary capillary bed surrounding the Alvi and terminal bronchioles notably there's greater blood flow to the bases of the lungs compared to the opposes this image illustrates the process of gas exchange within the Alvi of the lungs deoxygenated blood is carried from the heart to the lungs via the pulmonary arteries and arterioles where it reaches the Alvar capillaries at the Alvi carbon dioxide is released from the blood and oxygen is absorbed into the bloodstream the newly oxygenated blood then returns to the heart through through the pulmonary veins and venules completing the cycle of pulmonary circulation the image depicts the circulation of blood through the heart lungs and systemic body tissues highlighting the process of oxygen exchange oxygen poor blood returns to the heart via the superior and inferior vnea entering the right atrium and then the right ventricle from there it's pumped through the pulmonary arteries to the lungs where gas exchange occurs in the pulmonary capillaries carbon dioxide is expelled and oxygen is absorbed the oxygen-rich blood then returns to the left atrium via the pulmonary veins moves into the left ventricle and is pumped through the aorta to the systemic circulation where it delivers oxygen to body tissues the the cycle then repeats as De oxidated Blood returns to the heart",
        "Anatomical Differences in Airway Management": "the image compares the anatomy of the upper Airway of a child and an adult emphasizing differences in the size and positioning of the tongue relative to the airway in children the tongue is proportionally larger compared to the rest of the oral cavity which can contribute to a higher risk of Airway obstruction the image also highlights the nasal cavity and its connection to the respiratory system illustrating the air flow path in both individuals understanding these anatomical differences is important for Airway management especially when considering performing procedures such as intubation",
        "Respiration and Ventilation Processes": "respiration involves two primary processes inspiration or inhaling and expiration or exhaling ventilation refers to the movement of air into and out of the lungs during inspiration oxygen enters the Alvi and passes through the small passages in the arvar walls to the surrounding capillaries the heart then pumps this oxygenated blood throughout the body meanwhile carbon dioxide which is a byproduct of cellular metabolism returns to the lungs via the bloodstream and circulates around around the Alvar airspaces during exhalation carbon dioxide diffuses back into the Alvi and is expelled through the upper Airways this process of gas exchange where carbon dioxide is exchange for oxygen is continuous and vital for maintaining the body's physiological balance",
        "Gas Exchange and Capillary Function": "the image on the left illustrates the exchange of gases and nutrients between blood cells and tissue cells at the capillary level oxygen and nutrients carried by red blood cells in the bloodstream diffuse from the capillaries into the surrounding tissue cells where they are utilized for cellular metabolism simultaneously carbon dioxide and metabolic waste products produced by tissue cells diffuse back into the capillaries to be carried away by the blood for elimination from the body this exchange is a continuous process that supports cellular function and overall homeostasis the image on the right depicts the structure of the avoli and bronchioli within the lungs the bronchioles are small Airways that Branch out in the clusters of Alvi which are tiny air sacks surrounded by a dense network of capillaries the avvi are the primary sites for gas exchange where oxygen from inhaled air diffuses into the blood and carbon dioxide from the blood is released into the Alvi to be exhaled the close proximity of the capillaries to the Alvi facilitates this efficient exchange of gases which is crucial for maintaining the body's respiratory function",
        "Breathing Stimulus and Control": "the stimulus to breathe are originates from the respiratory center located in the medulla where involuntary control of breathing is managed by the bloodstream although automatic breathing is primarily regulated by the medulla it can be partially overridden by voluntary control the motor nerves responsible for initiating respiration are the frenic and intercostal nerves during inspiration the diaphragm and intercostal muscles contract causing the thorax to enlarge and intrapulmonary pressures to decrease below atmospheric pressure this pressure difference pulls air into the lungs until the pressure inside the thorax equals the external pressure at which point inhalation ceases the normal inspiratory Reserve volume is approximately 3,000 ml in adult males and approximately 2300 mls in adult females expiration begins when stretch receptors in the chest wall and bronchioles detect the expansion of the chest and send signals via the vagus nerve to the apneustic center this signal inhibits the inspiratory center leading to the process of expiration this mechanism is part of the Herring bow reflex which prevents the lungs from overexpanded the normal expiratory Reserve volume is approximately 1,200 ml typically expiration lasts twice as long as inspiration a relationship known as The inspiratory expiratory Ratio or IE ratio however this ratio can be altered in certain conditions for example the expiratory phase is prolonged in patients with asthma and shortened in those with dpia",
        "Complications Affecting Respiratory Function": "in order for the body to properly receive nutrients and oxygen adequate ventilation diffusion and perfusion are necessary various complications can interfere with oxygen intake including upper Airway obstructions caused by foreign bodies trauma or inflammation lower airway obstructions may result from trauma obstructive lung diseases mucus accumulation smooth muscle spasm or Airway edema chest wall impairments such as trauma hemothorax pnea thorax Emma plural inflammation or neuromuscular diseases can also hinder respiratory function additionally neurologic control problems including brain stem malfunctions Strokes trauma or neuromuscular diseases can impact the regulation of breathing",
        "Alveolar Function and Gas Exchange": "the Alvi which are the primary sites of gas exchange in the lungs are composed of two types of cells type one pneumocytes are almost empty allowing for efficient gas exchange while type two cells are responsible for producing new type one cells and surfactant surfactant plays a critical role in reducing the surface tension within the Alvi making it easier for them to expand during respiration Alvi function optimally when they are partially inflated as this condition supports effective gas exchange however if for material enters the terminal bronchioles and Alvi it generally remains there and may impede respiratory function additionally Alvi that are collapsed filled with fluid or pus filled are unable to participate in gas exchange further compromising respiratory efficiency conditions affecting ventilation profusion or both will hinder oxygen from adequately entering the bloodstream",
        "Chronic Lung Disease and Hypoxia": "pulmonary capillaries are characteristically narrow allowing red blood cells to pass through only in single file which is crucial for Effective gas exchange in individuals with chronic lung disease and chronic hypoxia the body compensates by producing an excess of red blood cells Le leading to polycythemia which thickens the blood and places additional strain on the right side of the heart this strain can eventually result in core pulmonal which is a condition characterized by right-sided heart failure due to Chronic lung disease the level of carbon dioxide in arterial blood can increase for various reasons including lung diseases that impair the exhalation process or conditions where the body produces excessive carbon dioxide either temporarily or chronically when arterial carbon dioxide levels rise gradually and remain elevated the respiratory centers may become less efficient leading to Chronic carbon dioxide retention in such cases the body's normal response to elevated carbon dioxide levels diminishes causing Reliance on on a backup system known as the hypoxic drive the hypoxic drive occurs when the brain adjusts to high carbon dioxide levels and instead regulates breathing based on low oxygen levels in the blood if the arterial oxygen level is increased in these patients it can reduce the stimulus to breathe potentially leading to depressed or halted respirations this takes many many any hours however and in the short time the EMS is generally with their patients it's not likely that you're going to knock out their hypoxic drive because of this it's important to remember that you should never withhold oxygen from a patient who requires it despite the risks associated with hypoxic Drive",
        "Hypoventilation and Respiratory Acidosis": "hypoventilation occurs when the lungs fail to function properly leading to the accumulation of carbon dioxide in the blood this excess carbon dioxide combines with water to form carbonic acid resulting in respiratory acidosis if not addressed the level of carbon dioxide is directly related to the pH balance in the body with increased levels of carbon dioxide leading to decreased pH or acidosis several factors can cause impaired ventilation and including impaired lung function mechanical issues with breathing and neuromuscular impairments opioids are potent central nervous system depressants that can significantly reduce the respiratory rate by depressing the brain's respiratory centers particularly in the medulla oinga in cases of acute opioid overdose such as with Heroin the respiratory drive can be severely diminished or even even completely suppressed this can lead to hypoventilation where insufficient oxygen is inhaled and carbon dioxide is inadequately expelled without timely intervention this can quickly progress to respiratory failure hypoxia and potentially death Naran is an opioid antagonist that can reverse the effects of opioid overdose by binding the opioid receptors and displacing the narcotics thereby restoring the respiratory drive",
        "Substances Affecting Respiratory Drive": "alcohol and various narcotics including benzodiazapines and barbituates are central nervous system depressants that can impair the body's natural respiratory drive when taken in excessive amounts these substances can depress the brain stem's ability to regulate breathing leading to shallow or infrequent breaths other toxins such as carbon monoxide or certain industrial chemicals can also impair cellular respiration and the central respiratory drive contributing to hypoventilation traumatic brain injury or TBI can result in damage to the brain stem where the primary respiratory centers are located some such injuries can disrupt the normal control of breathing leading to hypoventilation depending on the severity of the injury the respiratory drive may be reduced resulting in shallow breathing or apnea increased in cranial pressure from a head injury can further complicate this as it can compress the brain stem exacerbating the impairment of respiratory control",
        "Chronic Lung Diseases and Hypoxic Drive": "in patients with chronic lung diseases such as COPD the body May adapt to persistently high levels of carbon dioxide by Shifting the primary stimulus for breathing from carbon dioxide levels to oxygen levels as we've previously discussed this is a condition known as hypoxic Drive in these individuals the body's urge to breathe is driven by the low levels of oxygen rather than high levels of carbon dioxide",
        "Asphyxia and Hyperventilation": "aixia occurs when the body is deprived of oxygen which can result from Airway obstruction drowning or external compression of the chest and abdomen asfixia can rapidly lead to hypoventilation as the airway is obstructed or the chest ability to expand is compromised hyperventilation occurs when the rate of breathing increases causing the level of carbon dioxide in arterial blood to drop below normal this condition May indicate a life-threatening illness as the body might be attempting to compensate for acidosis by lowering carbon dioxide levels the body tries to counterbalance the other acids present when teia occurs without a physiological need for increased oxygen it can lead to alkalosis hyperventilation can trigger a set of symptoms known as hyperventilation syndrome this is often associated with panic attacks these symptoms include anxiety dizziness numbness tingling in the hands and feet which can lead to carpopedal spasms and a sensation of shortness of breath hyperventilation can also be a response to illness and acid buildup in the body hyperventilation syndrome specifically refers to hyperventilation that occurs in the absence of any other physical problems",
        "Causes and Indicators of Dyspnea": "disia can arise from various underlying conditions in several cases where the brain is deprived of oxygen the patient might not be conscious enough to report the sensation of shortness of breath an alter menal status can then be an important indicator of hypoxia affecting the brain patients frequently experience breathing difficulties or hypoxia in association with several conditions including pulmonary edema hay fever plural effusion Airway obstruction rib fractures cystic fibrosis hyperventilation syndrome prolonged seizures neuromuscular diseases and environmental or industrial exposure to toxic gases carbon monoxide poisoning and drug overdose when dipsia occurs one or more of the following physiological issues is likely present gas exchange between the Alvi and the pulmonary circulation may be obstructed by fluid in the lungs infection or collapsed Alvi known as atal acasis the avvi may be damaged preventing proper gas transport air passages might be obstructed by muscle spasm mucus or weakened Airway walls blood flow to the lungs could be obstructed by blood clots or the plural space might be filled with air or excess fluid hindering lung expansion and function it's essential to identify the underlying specific cause of disia in order to provide appropriate And Timely treatments to alleviate the patient's complaint",
        "Dyspnea and Associated Symptoms": "patients experiencing trouble breathing may also report sensations of air hunger and chest tightness disia is a prevalent symptom in individuals with cardiopulmonary diseases with heart failure being a significant cause of breathlessness it's important to note that severe pain can lead to Rapid shallow breathing even in the absence of pulmonary dysfunction this occurs because deep breathing May exacerbate Pain by expanding the chest wall when assessing a patient who complains of trouble breathing it's essential to inquire about any Associated chest pain in a similar fashion when evaluating a patient for chest pain it's important to ask about trouble breathing and these symptoms often occur together and can provide important Clues to the underlying condition",
        "Infectious Diseases and Respiratory Function": "infectious diseases can impact any part of the airway from the upper to the lower respiratory tract these infections can cause trouble breathing by obstructing air flow in the larger Airways making it difficult for air to pass through additionally infections like pneumonia IIA can impair the exchange of gases between the Alvi and capillaries further compromising the body's ability to oxygenate the blood and expel carbon dioxide this dual effect on both air flow and gas exchange can significantly worse in respiratory function leading to an increased shortness of breath and other related symptoms",
        "Pulmonary Edema and Its Causes": "acute pulmonary edema is characterized by the accumulation of fluid in the lungs which leads to decreased gas exchange and severe dnia this condition often arises due to severe myocardial damage either from an acute or chronic problem which reduces the heart's contractile Force specifically the left side of the heart may become unable to remove blood from the lungs as quickly as the right side delivers it leading to fluid buildup in the Alvi and lung tissue isue pulmonary edema can develop rapidly sometimes within minutes while heart disease is a common cause of pulmonary edema not all cases are cardiogenic other potential cases include poisoning from smoke or toxic chemical fumes traumatic injuries to the chest and exposure to high altitudes when pulmonary edema is cardiogenic in origin patients Pat May exhibit signs and symptoms consistent with a cardiac emergency necessitating prompt recognition and treatment patients with non-cardiogenic pulmonary edema often have a history of factors that contribute to their condition these factors may include a hypoxic episode shock chest trauma recent acute inhalation of toxic gases or particles or a recent Ascent to high altitudes without proper acclimatization these situations can lead to fluid accumulation in the lungs independent of heart function regardless of the cause all patients with pulmonary edema may present with several common symptoms these include trouble breathing orthopnea fatigue reduced Exercise capacity and Pulmonary crackles which are sounds heard during lung oscilation that indicate fluid in the Alvar spaces",
        "Chronic Obstructive Pulmonary Disease": "COPD is a common lung condition characterized by a slow process of dilation and disruption of the Airways and Alvi It's actually an umbrella term that encompasses several lung diseases most notably enyma and chronic bronchitis the most common cause is cigarette smoking which leads to inflammation and damage in the lungs in COPD obstruction primarily occurs in the bronchioli this obstruction is due to the inability of the cyia which are small hairlike structures to effectively remove excess mucus leading to a buildup that blocks the Airways chronic bronchitis a form of COPD results from the over growth of the airway mucus glands and excessive secretion of mucus which further blocks the Airways patients with chronic bronchitis typically experience a chronic productive cough that lasts for at least 3 months per year for two or more consecutive years this persistent cough is a Hallmark symptom of the disease and reflects ongoing Airway obstruction and inflammation pneumonia is an infection that develops when the air passages are persistently obstructed often due to mucus buildup or inflammation if a patient experiences repeated episodes of pneumonia it can contribute to the development of chronic obstructive pulmonary disease over time osma is the most common form of COPD and is characterized by the destruction of the avvar walls which is often related to the break breakdown of pulmonary surfactant as the lvlr walls are destroyed large holes or cavities form in the lung tissue resembling air pockets this structural damage to the lungs is irreversible leading to a permanent reduction in the surface area that's available for gas exchange and a significant impact on respiratory function most patients with COPD exhibit a combination of symptoms and characteristics that are associated with both chronic bronchitis and empyema these patients typically have a history of recurring lung problems and are often long-term smokers a common feature among them is the consistent production of sputum in a chronic cough additionally these patients have difficulty expelling air from their lungs leading to prolonged expiration phases and the characteristic sound of wheezing in cases of acute COPD exacerbation patients will often present with progressively worsening shortness of breath over several days they may also exhale through Pur lips a technique used to ease Breathing by keeping the Airways open longer other symptoms include a sensation of tightness in the chest consistent fatigue and and a barrel-shaped chest which is indicative of hyperinflation of the lungs due to Chronic overexpansion",
        "Progression of Lung Conditions": "here we see the progression of lung conditions from a normal lung to an inflamed and obstructed lung in the normal lung the bronchioles and lvi are clear and unobstructed allowing for efficient gas exchange the inflamed lung shows signs of inflammation or infection with mucus buildt up within the bronchioles leading to trapped air in the Alvi in the obstructed lung there is further progression where the bronchioles are significantly obstructed by mucus and infection resulting in dilated Alvi that are unable to function properly this obstruction impaires the ability of the lungs to effectively exchange gases leading to breathing difficulties and a decreased oxygenation level in the blood",
        "Asthma and Status Asthmaticus": "asthma is characterized by acute spasms of the bronchioles and are accompanied by excessive mucus production and tightening of the bronchiolar muscles a condition known as a bronos spasm the resulting Airway obstruction is typically reversible and caused by a combination of smooth muscle spasm increased mucous production and swelling of the airway walls this combination of factors leads to difficulty breathing wheezing and other respiratory symptoms common in asthma status asthmaticus is a severe and prolonged asthma attack that is not correspond to Conventional treatments such as Broncho dilators or corticosteroids this condition is a dire Medical emergency requiring immediate and aggressive intervention to prevent respiratory failure one of the Hallmark signs of an asthma attack including status as maticus is wheezing which is typically heard when the patient exhales asthma attacks can be triggered by various factors including allergic reactions physical exercise severe emotional distress and respiratory infections recognizing the severity of status asthmaticus and the potential triggers of asthma attacks is important for timely and effective management",
        "Anaphylactic Reactions": "anaphylactic reactions are severe allergic responses that can be life-threatening they are characterized by a rapid Airway swelling and the dilation of blood vessels throughout the body leading to a condition often referred to as anaphylactic shock this reaction can cause extreme respiratory distress potentially leading to coma and death if not treated properly anaphylaxis may also be accompanied by widespread hives itching signs of shock and symptoms that mimic those of an asthma attack most anaphylactic reactions occur within 30 minutes of exposure to an allergen necessitating an immediate medical intervention to prevent serious outcomes",
        "Spontaneous Pneumothorax": "spontaneous pneumothorax is a condition where air accumulates in the plural space which can either be partial or complete while trauma is the most common cause of a numa thorax it can also occur spontaneously due to certain medical conditions hence the term spontaneous Lorax this condition is more likely to occur in patients with chronic lung infections those who were Bor born with weak areas of the lung individuals with osma or asthma and tall thin athletic males who are at a much higher risk patients with a spontaneous pneumothorax often present with acute dnia and pic chest pain which is typically sharp and stabbing localized to one side and exacerbated by breathing or in certain movements of the chest wall additionally some patients May exhibit subcutaneous empyema where air gets trapped under the skin creating a crackling sensation upon palpation upon examination breath sounds are usually absent or decreased on the affected side due to the presence of air in the plural space which prevents the lung from fully expanding keep in mind that if you do have diminished breath sounds this means at least 30 to 40% of the the lung has collapsed",
        "Severe Respiratory Distress": "in cases of severe respiratory distress such as a spontaneous pneumothorax patients May exhibit a range of critical symptoms that signal a life-threat in condition altered mental status may occur indicating that the brain is not receiving sufficient oxygen cyanosis particularly around the lips and fingertips can also be present reflecting significant hypoxemia the patient is likely to experience teoc cardia as the heart rate increases in an attempt to compensate for reduced oxygen levels in the blood on physical examination breast sounds may be unilaterally decreased or absent on the side of the pneuma thorax and percussion of the chest wall May reveal hyperresonance indicating the presence of Trapped air in the plural space subcutaneous empyema might also be observed where air is escaped into the tissues beneath the skin causing a crackling sensation upon palpation in more severe cases tracheal deviation may be noted as a late sign where the trachea shifts away from the affected side due to increased pressure within the chest",
        "Pleural Effusion": "plural affusion refers to the accumulation of fluid outside the lung typically occurring on one or both sides of the chest this fluid buildup can result from various causes including irritation infection heart failure or cancer patients with plural effusion often experience sudden onset of disia as the fluid compresses the lung and impairs its ability to expand fully plural affusion should be considered as a potential diagnosis in patients who have lung cancer and present with shortness of breath given the association between malignancy and the development of plural Fusion in cases of plural effusion physical examination often reveals decreased breath sounds over the areas of the chest where fluid has accumulated displacing the lung away from the chest wall patients typically experience relief from their symptoms particularly shortness of breath when they sit upright as this position allows the lungs to expand more fully and reduces pressure from the fluid the definitive treatment for plural effusion involves the removal of the accumulated fluid usually through a procedure known as thoracentesis which alleviates the pressure on the lungs and improves respiratory function",
        "Pulmonary Embolism": "a pulmonary embolism is a serious condition where a blood clot or a thrombus forms this typically happens in a vein in the legs or pelvis this clot can break off and travel through the Venus system passing through the right side of the heart and lodging in the pulmonary artery once the clot is in the pulmonary artery it can decrease or completely block blood flow to parts of the lung this blockage prevents The Exchange of oxygen and carbon dioxide in the affected area leading to a condition known as ventilation profusion mismatch where parts of the lung receive air but no blood flow this will severely impair respiratory function a pulmonary embolism can also result from factors such as damage to the lining of blood vessels this is a condition known as endothelial injury and it can be caused by trauma or inflammation additionally hyper cagula or an increased tendency for blood to clot can contribute to the development of a thrombus slow blood flow in a lower extremity often due to immobility or Venus insufficiency can further increase the risk of clot formation there are several risk factors that increase the likelihood of developing a pulmonary embolism these include immobilized legs following surgery or fracture recent surgery pregnancy or a history of previous pulmonary embolism a family history of pulmonary embolism particularly in a first-degree relative also raises the risk other significant risk factors include obesity the use of oral contraceptives smoking infection cancer sickle cell anemia prolonged inactivity and being bedridden each of these factors can contribute to the conditions that favor the formation of blood clots making awareness and prevention strategies critical in at risk populations the signs and symptoms of a pulmonary embolism can vary but often include the following key clinical features difficulty breathing is typically the most prominent symptom this is usually accompanied by tacac cardia and tpia as the body attempts to compensate for the decreased oxygen levels hypoxia may be present to varying degrees and cyanosis May develop as a result patients often experience acute chest pain which can be sharp and may worsen with deep breathing hemo typis or the coughing up of blood is another possible symptom indicating damage to the lung tissue these signs and symptoms waren immediate medical attention as they are indicative of a potentially life-threatening condition",
        "Airway Obstruction": "Airway obstruction is a critical condition that can cause severe trouble breathing and may be life-threatening if not promptly addressed mechanical obstruction of the airway can occur due to various causes with two common scenarios Illustrated in the provided images the first image shows a scenario where food is including the upper Airway this type of mechanical obstruction is typical in choking incidents where a foreign object such as a piece of food becomes lodged in the airway preventing air from passing through the trachea to the lungs this blockage can lead to a sudden onset of respiratory distress characterized by inability to speak speak cough or breathe effectively immediate intervention such as performing the himlet maneuver is essential to clear the obstruction and restore normal breathing the second image depicts a situation where the tongue is occluding the upper Airway this is a common issue in unconscious or semiconscious patients particularly those lying on their back in this position the tongue can fall backwards due to gravity blocking the airway and impeding the air passage this type of obstruction is often seen in patients with decreased levels of consciousness such as those who are intoxicated under anesthesia or suffering from a medical emergency like a seizure or head injury in such cases simple Airway Maneuvers like the head tilt chin lift or jaw thrust can reposition the tongue and clear the airway both scenar iios emphasize the importance of recognizing and promptly managing mechanical obstructions in patients with disia identifying the cause of the airway obstruction and taking appropriate action is crucial in preventing severe hypoxia brain injury and death",
        "Mechanical Airway Obstruction": "in unresponsive patients mechanical Airway obstruction is a significant concern and can arise from several causes one common cause is the Pres presence of vomitus which can block the airway if the patient aspirates or if the vomit is not cleared from the mouth and throat another potential cause is the presence of a foreign object such as food or another item that the patient may have aspirated particularly if the incident occurred during eating or drinking additionally improper positioning of the head can lead to Airway obstruction especially in unresponsive patients when the head is not properly positioned the tongue can fall back and block the airway preventing the patient from breathing effectively",
        "Environmental and Industrial Exposures": "environmental and industrial exposures can lead to the inhalation of potentially toxic substances which can have serious health consequences these substances include a wide range of chemicals and Gases such as pesticides Cleaning Solutions chlorine carbon monoxide and other hazardous materials for example when chemicals like ammonia and chlorine bleach are mixed they produce hazardous byproducts that pose additional risks the type and extent of damage caused by inhaled toxic gases largely depend on the water solubility of the gas highly water soluble Gases such as ammonia tend to react quickly with the moist mucous membranes of the upper Airway leading to immediate swelling irritation and inflammation this reaction can cause symptoms like coughing wheezing and difficulty breathing in contrast less water soluble Gases such as phos genene and nitrogen dioxide can penetrate deeper into the lower Airways and lungs these gases may not cause immediate symptoms but they can lead to delayed effects such as pulmonary edema pulmonary edema from such exposures May develop up to 24 hours after the initial inhalation making early recognition and intervention critical to prevent severe respiratory complications in any case of suspected toxic inhalation prompt medical evaluation and appropriate treatment are necessary to mitigate the effects and prevent long-term damage",
        "Cystic Fibrosis": "cystic fibrosis is a genetic disorder that primarily affects the lungs and diges system it's caused by a defective Gene that impairs the movement of chloride through cells this defect results in the loss of unusually high amounts of sodium and the production of abnormally thick mucous secretions these thick secretions clog the Airways leading to breathing difficulties and frequent lung infections which progressively damage the lungs and lead to Chronic lung disease the symptoms can vary widely ranging from sinus congestion to wheezing and symptoms similar to Asthma as the disease progresses it often leads to respiratory insufficiency recurrent respiratory infections and even intestinal blockages due to the thicken secretions in the digestive tract unfortunately cystic fibrosis often results in death during childhood or adolescence primarily due to Chronic pneumonia and other severe respirat complications",
        "Age-Related Respiratory Conditions": "age related respiratory conditions such as bronchiolitis and infections caused by RSV are particularly prevalent in infants and young children bronchiolitis is an inflammation of the bronchioli typically due to viral infections with RSV being the primary causative agent this condition primarily affects infants and children under the age of two the signs and symptoms of bronchitis often resemble those of asthma although asthma itself is rare in children younger than one year notably an infant experiencing their first episode of wheezing during late fall or winter is likely to have bronchitis characteristic clinical findings include mild to moderate retractions Topia diffuse wheezing diffuse crackles and Mild hypoxia RSV is a common cause of respiratory illness in young children it leads to infections in the lungs and breathing passages and can result in serious respiratory issues such as bronchiolitis and pneumonia it poses a significant risk to premature infants and children with compromised immune systems as it can cause severe heart and lung complications in these vulnerable populations RSV is also highly contagious making it a concern in settings where young children are in close contact",
        "Croup and Epiglottitis": "cro is a condition characterized by inflammation and swelling of the ferx LX and trachea usually secondary to an acute viral infection of the upper respiratory tract this condition primarily affects children aged 6 months to 3 years and is easily transmissible among them C typically begins with symptoms similar to a common cold including a cough and low-grade fever which develop over the course of about two days the Hallmark signs of c are Strider a high-pitched wheezing sound heard during breathing and a distinctive seal bark cough which is a harsh barking cough c often has Peak seasonal outbreaks during the late fall and winter months it is rarely seen in adults as their airways are larger and less susceptible to the degree of swelling that causes these symptoms in children treatment of croo often includes humidified oxygen which helps reduce AA irritation in swelling the supportive therapy can significantly improve the symptoms and comfort of children affected by this disease EP latius is a serious medical condition characterized by the inflammation of the epiglottis this inflammation is typically caused by a bacterial infection that leads to severe swelling which can potentially obstruct the airway entirely although epiglotis predominant affects children it can occur at any age the introduction of a childhood vaccine has significantly reduced the incidence of this disease the onset of epiglottitis is usually sudden and patients often present looking very ill common symptoms include a sore throat high fever and Strider affected patients particularly children may assume a tripod position and exhibit drooling due to difficulty swallowing in adults or geriatric patients epiglotis may appear especially if they have underlying health issues such as diabetes in these cases the condition may be caused by different bacterial or viral organisms and can be particularly life-threatening due to the rapid deterioration of the patient's condition",
        "Pneumonia": "pneumonia is an infection of the lung parena and is the eighth leading cause of death in the United States it affects vulnerable populations such as young children and older adults presenting as a localized lung infection that can lead to adasis if left untreated it can become systemic resulting in sepsis and septic shock key symptoms include a sudden onset of fever and chills a productive cough with perul sputum peridic chest pain and Pulmonary consolidation",
        "Pertussis": "pusis also known as whooping cough is an Airborne bacterial infection that primarily affects children under the age of six it's highly contagious and spreads through droplet infection the disease typically presents with cold-like symptoms but is characterized by severe coughing spells that can last over a minute and is often accompanied by a whoop sound during inspiration after a coughing fit infected children may become feverish it may turn red or purple during intense coughing episodes",
        "Airway Obstruction in Children": "Airway obstruction can occur for various reasons and should always be considered especially in young children who present with sudden shortness of breath a foreign body is a common cause in this age group upper Airway obstructions can also result from tonsil inflammation or dysfunction of a tracheostomy obstructions may also occur in the lower airway below the vocal cords due to conditions such as tracheal trauma obstructive Lum disease mucus accumulation or smooth muscle spasm additionally Airway edema May develop in response to exposure to toxic chemicals or superheated air further complicating the airway patency and requiring prompt medical attention",
        "Heart Failure and Respiratory Distress": "heart failure occurs when the heart muscles often injured by a heart attack or illness are unable to maintain aain sufficient cardiac output to meet the body's needs this condition commonly results in pulmonary edema where fluid accumulates in the lungs risk factors for heart failure include hypertension and a history of coronary artery disease or atrial fibrillation many patients with heart failure have a long-standing condition that can typically be managed with medication common signs and symptoms of heart failure include difficulty breathing with exertion sudden respiratory distress coughing a sensation of Suffocation cold sweats and tardia and differentiating between wet lungs and dry lungs it's important to note that wet lungs are typically associated with pulmonary edema on the other hand dry lungs are commonly linked to COPD while comparing the two it's critical to focus on treating the patient based on their overall clinical presentation rather than solely on the presence of specific breath sounds this approach ensures the treatment is tailored to the patient's needs rather than just addressing symptoms in isolation",
        "Assessing Breath Sounds": "assessing lung or breast sounds is a critical component when evaluating a patient in respiratory distress as it provides essential information about their respiratory status to ensure accurate assessment it's necessary to listen over the bare chest with the diaphragm of the stethoscope in firm contact with the skin additionally positioning the patient in a sitting position can help in obtaining cleaner and more precise breast sounds when assessing breast sounds it's important to determine whether they are normal or abnormal vascular breast sound sounds which represent air moving in and out of the Alvi and bronchial breast sounds which indicate air moving through the bronchi are considered normal however adventicius breast sounds which are decreased absent or abnormal require further evaluation to assess breast sounds accurately use a stethoscope to listen to both sides of the chest and then compare each side ensuring to listen for a full respiratory cycle abnormal breath sounds include crackles which sound like fine crackling sounds of air passing through fluid in the Alvi Ron ey low pitch sounds caused by mucus in larger Airways Strider a high-pitch sound heard during inspiration which indicates an upper Airway obstruction wheezing a high-pitch whistling sound usually heard on Expert ation that suggest bronchial constriction or inflammation plural friction rub a squeaking or grading sound due to the plural lining rubbing together and snoring sounds which are indicative of a partial Airway obstruction",
        "Chronic Respiratory Conditions": "patients with chronic respiratory conditions may live relatively normal lives for extended periods of time but can experience acute exacerbations of their conditions chronic lower airway obstruction common in diseases like COPD can make it difficult for patients to breathe deeply enough to clear their lungs a new lung infection in a COPD patient can rapidly decrease arterial oxygen levels these patients typically have a long history of dnia which can suddenly worsen although chest pain is rare their pts may be rapid and occasionally irregular making it essential to Pi close attention to their respiration for patients with asthma identifying and managing potential triggers is important in order to prevent or address acute attacks",
        "Emergency Medical Care for Respiratory Distress": "an emergency medical care for patients experiencing respiratory distress standard interventions should be performed to stabilize the patient this includes administering oxygen to maintain a saturation level above 94% establishing an IV line and providing psychological support to reduce anxiety additionally it's important to decrease the work of breathing by avoiding placing the patient in a Supine position removing any constricting clothing and refraining from making the person walk as these actions can further strain their respiratory system when providing supplemental oxygen it's important to ensure enure that any patient who requires it receives the appropriate concentration to be effective for patients who are not breathing adequately bag Mass ventilation with supplemental oxygen or more advanced Airway management techniques should be employed pulse oxymetry is a helpful tool in guiding oxygenation and is generally safe to administer oxygen at concentrations below 50% to most patients however concentrations higher than 50% should be reserved for those with hypoxia unresponsive to lower concentrations the use of 100% oxygen should be limited to the shortest necessary duration oxygen should be administered aggressively when needed but oxygen saturation should ideally be maintained between 94 and 99% avoiding 100% saturation for responsive patients consider the insertion of an advanced Airway and if necessary call for paramedic backup administering Bronco dilators typically provides only slight benefit to patients who are not experiencing Broncos spasm these medications are of limited value in treating conditions like pneumonia pulmonary edema and heart disease therefore their use should be considered carefully and primarily in cases where Broncos spasm is present",
        "Respiratory Medications and Aerosol Therapy": "respiratory medications particularly inhaled beta agonists are commonly used to manage respiratory conditions by relaxing the smooth muscles within the bronchioli and larger bronchite in the lungs common trade names for these medications include pentil venin alupent metaprel and brethine fast acting Bronco dilators offer rapid relief but do not address underlying issues such as swelling bacterial infections fluid accumulation in the lungs or Alvar closure they are particularly useful in reversing secondary Bronco constriction however inhalers can have side effects such as increased pulse rate nervousness and muscle trimmers aerosol therapy involves the use of aerosol nebulizers to deliver liquid medications in a fine Mist which can be inhaled into the lungs for effective treatment to ensure the medication is delivered at an optimal particle size most nebulizers require a gas or oxygen flow of at least 6 lers per minute this ensures that the medication is properly aerosolized and can reach the deeper parts of the respiratory system aerosol therapy often used in both home and ambulance settings can be operated using a small air compressor or oxygen sources such as tanked oxygen or a wall unit in the ambulance the nebulizer can be attached to different delivery devices including a mouthpiece face mask mask or tracheostomy collar or simply held in front of the patient's face in addition to delivering medication nebulizers provide significant humidity to the airway which is beneficial for patients this therapy is particularly useful for patients experiencing Broncos spasm as it allows for repeated treatments to help relieve symptoms",
        "Metered Dose Inhalers": "meter dose inhalers or MD are a common method for delivering medication directly into the lungs through the mouth often used for administering Bronco dilators and corticosteroids in the home setting it is important to document the frequency of extra Puffs taken by the patient ideally each MDI on an ambulance should be equipped with a spacer to enhance medication delivery proper technique when using an MDI is crucial and requires ongoing reinforcement to ensure the medication is being delivered effectively when using or administering an MDI it's important to ensure that the mist from the inhaler reaches the lungs some patients mistakenly blow into the spacer which should be avoided if a patient sucks too hard on the spacer it may produce a harmonica like sound indicating an incorrect technique patients should inhale the medication deeply and hold their breath for a few seconds afterward to maximize the Drug's Effectiveness always check that the inhaler contains medication before use and keep the spacer and canister holder clean after using a corticosteroid inhaler it's recommended that patients rinse their mouth with water or mouthwash to prevent irritation or infection contraindication for the use of an MDI include situations where the patient is unable to help coordinate the inhalation when the MDI is not prescribed for the patient or if permission for medical control was not obtained and or it was not permissible by local protocol additionally if the patient has already taken the maximum prescribed dose before your arrival the medication is expired or there are other contraindications specific to the medication the use of the MDI should be avoided dry powder inhalers are reasonably convenient and easy to use but they are rarely employed during Emergency Care situations",
        "Fluid Balance and Ventilation Support": "when considering fluid balance in patients it's common practice to administer a fluid bolus to younger patients with certain conditions however in older patients or patients with cardiac dysfunction care must be taken to avoid administering too much fluid as it could lead to pulmonary edema because of this it's essential to always assess breast sounds before and after giving a fluid bolus and is almost always advisable to have an IV line in place when managing these patients when supporting or assisting ventilation it is important to recognize that if a patient becomes fatigued their breathing might need to be supported more aggressively in some cases patients may only require bag Mass ventilation for a short period however caution is necessary as overaggressive ventilation can lead to gastric distension and vomiting which can also complicate the patient's condition proper technique and careful monitoring are essential to avoid these complications",
        "Continuous Positive Airway Pressure": "continuous positive airway pressure or CPAP is a therapeutic technique primarily used to manage obstructive sleep apnea and respiratory failure for individuals with obstructive sleep apnea a CPAP unit is typically worn at night to help keep the Airways open during sleep the device used to treat respiratory failure usually delivers air pressure through a mask that is securely strapped to the face ensuring a continuous flow of air to maintain air patency this approach helps prevent Airway collapse and improves oxygenation when using continuous positive airway pressure it's important to monitor the patient closely for any adverse effects if the patient's blood pressure is already low excessive CPAP can hinder Venus return to the heart leading to a sudden drop in blood pressure this is due to the increase in intrathoracic pressure that is pressing down on the inferior and Superior vnea and the Heart itself additionally CPAP has the potential to exacerbate a simple num thorax quickly converting it into attension Numa thorax it's also essential to monitor the gas supply to ensure consistent delivery of therapy if the patient is unwilling to use the CPAP mask it is not advisible to force them as compliance is critical for effective treatment the effectiveness of CPAP therapy is closely related to the patient's respiratory rate shortly after its application if the patient's respiratory rate increases after starting CPAP it is likely an indication that the therapy may not be successful conversely if the respiratory rate decreases the this generally suggests that the therapy is working effectively and is likely to succeed",
        "Bilevel Positive Airway Pressure": "byle positive airway pressure or BiPAP provides two levels of pressure one during inspiration and another during exhalation this approach is more comfortable for patients as it accommodates natural breathing patterns the pressure variation in the chest created by BiPAP allows for more normal blood flow however this system is more complex and expensive compared to other airwave management methods",
        "Assessment and Management of Airway Diseases": "when assessing and managing upper or lower airway diseases patients typically present with severe respiratory impairment characterized by one to two word dnia diminished or absent breath sounds and potentially altered mental status the chief complaints often include dnia cough or nocturnal disia a thorough history should be obtained focusing on personal or family history of asthma and allergies as well as any acute exposure to pulmonary irritants or similar past episodes wheezing may be present and it is advisable to use Peak flow meters imp pulse oximeters to assess the patient's condition and response to therapy the patient should be placed in a position of comfort and if in severe distress early paramedic backup should be considered Airway monitoring is essential with high flow oxygen and ventilation support as needed preferably using humidified oxygen establishing IV access for circulatory support is important and assisting the patient with a metered dose in inhaler may be necessary continuous monitoring appropriate transport and communication with medical control are all vital along with providing psychological support to the patient",
        "Management of Acute Pulmonary Edema": "acute pulmonary edema which may be associated with cardiac disease or direct lung damage requires immediate and careful management Begin by administering 100% oxygen to ensure adequate oxygenation if the airway is compromised carefully suction any secretions to maintain a clear Airway the patient should be positioned for Comfort typically in an upright position to facilitate easier breathing assisted ventilation particularly with continuous positive airway pressure can be highly beneficial in these situations it is also important to establish intervenous access to allow for medication administration and fluid management while carefully monitoring flow rates to prevent fluid overload in severe cases consider calling for paramedic backup for potential intubation",
        "Aspiration Management": "aspiration is a serious condition associated with a high mortality rate when treating patients at risk for aspiration or those who've already aspirated it's crucial to take specific steps to manage the situation effectively first avoid causing gastric distension during ventilation as this can exacerbate the problem second aggressively monitor the patient's ability to protect the airway to prevent further aspiration if the patient's condition does not improve proceed with aggressive treatment including suction and Airway control to clear the airway and ensure adequate ventilation",
        "Management of COPD": "in patients with chronic obstructive pulmonary disease several Key Management strategies are essential patients may experience an altered level of Consciousness and often find breathing difficult while lying down if a prescribed inhaler is available assist the patient in its use but be cautious as these patients might overuse their inhalers leading to potential side effects transport the patient promptly to the emergency department ensuring they remain upright if that is most comfortable additionally Auto peep is a concern in these patients and it's crucial to allow complete exhalation before delivering the next breath failure to do so can lead to severe complications such as Numa thorax or sudden cardiac arrest for those at risk of Auto peep ventilation should be administered at a slow rate of four to six breaths per minute",
        "Asthma Management": "in managing asthma it's critical to thoroughly assess the patient particularly since asthma is often a reoccurring condition gathering information from family members about the patient's asthma history can provide valuable insights asthma typically involves three primary components Broncos spasm Airway ad Ma and increased mucus production during an asthma attack Vital Signs May reveal a normal or elevated pulse rate slightly elevated blood pressure and increased respiratory rate it's important to inquire about the onset and progression of symptoms when assessing pediatric patients be alert for retractions which will indicate an increased work of breathing be prepared to suction the airway if necessary it administer oxygen to support the patient's breathing if a patient has asthma medication assist them in using an inhaler or nebulize medication as per local protocol if ventilatory support is needed provide slow and gentle breaths with assisted ventilations being a last resort the emergency care for children is essentially the same as adults status asthmaticus is a critical medical emergency the patient's chest may be maximally hyperinflated and breast sounds or wheezes might be inaudible due to minimal air movement these patients will typically appear exhausted and will be acidotic and dehydrated all of which requires aggressive airwave management oxygen therapy and immediate transport",
        "Anaphylactic Reaction Management": "for anaphylactic reactions the first step is to remove the offending agent and ensure the airway is maintained administer supplemental oxygen and assist with breathing is needed epinephrine is the treatment of choice in these cases",
        "Spontaneous Pneumothorax Management": "for spontaneous pneumothorax management begins with the ABCs provide Airway and ventilatory support and be vigilant for signs of tension numat thorax if severe symptoms are present consider initiating IV access the patient should be placed in a position of comfort and transported promptly if signs of attention numo thorax develop consider calling a paramedic unit for additional support",
        "Pleural Effusion Management": "for plural effusion treatment involves removing the fluid collected outside the lung oxygen should be provided along with other routine support measures and the patient should be transported to further care",
        "Pulmonary Embolism Management": "in the case of pulmonary embolism it's essential to manage the air we and provide high flow oxygen assisting with ventilation is needed if the patient is pulses and apnic initiate CPR establish an IV line with an isotonic crystalloid solution and focus on supportive interventions severe cases should be managed as Cardiac Arrest of Unknown Origin",
        "Hyperventilation Management": "hyperventilation can be caused by a life-threatening illness or a panic attack and determining the cause should not be attempted outside of a hospital setting the Primary Response includes administering supplemental oxygen and ensuring prompt transport while interventions for circulatory support and pharmacologic treatments are rarely required psychological support is crucial particularly for anxiety related hyperventilation this may involve guiding the patient to mimic your respiratory rate and volume never place a paper bag over the patient's mouth and nose regardless of what you've seen in the movies finally ensure that the patient is transported to a medical facility for further evaluation",
        "Airway Obstruction Management": "obstruction of the airway may be partial or complete if the patient can still talk and breathe it's important to provide supplemental oxygen and transport them in a position of comfort the obstructing body should be removed following basic life support guidelines",
        "Environmental Exposure Management": "in cases of environmental or industrial exposure industrial sites often have their own medical fire and hazardous materials teams after the patient has been decontaminated it's important to gather information on the substance involved and the cause of the trouble breathing assess the patient carefully with special attention to lung sounds as blood coming from the airway is an ominous sign provide 100% supplemental oxygen or assisted ventilation if necessary and if the upper Airway is compromised remember aggressive Airway management will be required",
        "Age-Related Assessment and Management": "for age related assessment and management treatment of bronchiolitis is entirely supportive the patient should be left in a position of comfort provided with supplemental oxygen and prepared for possible assistance with a bag mask device if necessary call for paramedic backup for OT tral intimation in cases of RSV B look for signs of dehydration treat air weight and breathing problems as appropriate and use humidified oxygen if available to manage a patient with croo start by providing humidified oxygen which is often effective allow the patient to remain in a position that they find comfortable to reduce agitation avoid causing distress as this can worsen symptoms if local protocols dictate administered nebulized Ric epinephrine finally ensure rapid transport to an appropriate medical facility for further treatment for managing epiglotis in children treat them gently and avoid actions that may make them cry keep the patient in a comfortable position and administer high flow oxygen do not insert anything into the patient's mouth for adults the primary focus should be on maintaining a patent Airway in the case of pneumonia monitor the patient ABCs provide high flow oxygen and offer ventilatory support if necessary administer IV fluids if appropriate and cool the patient if a high fever is present for managing pessis some infants and younger children may require hospital treatment due to their higher risk of complications such as pneumonia children may also refuse to eat or drink leading to dehydration so it's important to monitor for this suction is necessary and provide Oxygen by the most appropriate means in adults or geriatric patients prusis typically does not cause the classic whooping call seen in children but it can result in severe upper respiratory infections prolonged coughing spells and even cracked ribs prusis is easily preventable with a vaccine and aemts to check their immunization status and consider getting a booster if needed",
        "Airway Obstruction Techniques": "for managing an airway obstruction perform the most appropriate Airway clearing technique provide oxygen and ensure prompt transport",
        "Heart Failure Management": "in cases of heart failure high blood pressure and low cardiac output often trigger flash pulmonary edema which may present with pink frothy sputum in addition to the classic signs of respiratory distress the patient's pulse will typically be teoc cardic and while early signs may include hypertension deterioration to hypotension can occur as a late finding treatment should focus on providing Airway ventilatory and circulatory support with CPAP considered as part of the management",
        "Tracheostomy Management": "children with chronic pulmonary medical conditions may use a home ventilator connected via a tracheostomy tube complications related to a tracheostomy dysfunction include obstruction by secretions mucus or foreign bodies bleeding leaking dislodgment and infection management involves establishing a patent ear way placing the patient in a position of comfort and using suction to clear any obstruction if unable to clear the airway of a patient with a tracheostomy dysfunction paramedic intervention should be considered once the obstruction is cleared the patient should be oxygenated and treatment should be based on their presentation geriatric patients may have a tracheostomy tube in place due to Airway obstruction lenial cancer severe infection trauma or the inability to manage secretions these two can become obstructive bi secretions foreign bodies or Airway swelling and the stom itself may become infected the immediate goal in any such case is to establish Airway patency as soon as possible",
        "Epidemics and Pandemics": "remember that an epidemic occurs when new cases of a disease in a human population significantly exceed what is expected based on recent experience conversely a pandemic is an outbreak on a global scale typically occurring when a new virus emerges for which people have little to no immunity such as what we saw with covid-19 many potentially serious diseases can be transmitted via of the respiratory route highlighting the importance of monitoring and controlling outbreaks to prevent widespread transmission",
        "Precautions for Respiratory Infections": "when dealing with potential respiratory infections it is essential to take proper precautions wearing PPE and a hepo respirator is a basic requirement given that viruses can survive on surfaces for several days frequent handwashing is also important additionally providers should keep vaccinations current and follow the latest CDC recommendations for patients with suspected or confirmed respiratory diseases placing a surgical mask on them is advised additionally wearing hepo respirators during aerosol generating procedures such as suctioning or CPR is necessary to protect against Airborne transmission",
        "COVID-19 Guidelines": "covid-19 is a highly contagious respiratory illness caused by a new form of Corona virus known as SARS K2 it spreads primarily through respiratory droplets when an infected person coughs sneezes or talks symptoms typically appear 2 to 14 days after exposure and include a wide range of signs and symptoms such as fevers or chills cough sore throat trouble breathing fatigue congestion headache muscle or body aches loss of taste or smell and GI symptoms such as nausea vomiting and diarrhea of course these symptoms vary in severity it may range from mild to life-threatening emergency warning signs of covid-19 include difficulty breathing pain confusion cyanosis and an inability to wake up or stay awake older adults and individuals with serious pre-existing medical conditions are at a higher risk of severe illness or complications from covid-19 to avoid contamination it's essential to follow these guidelines always wear PPE wash your hands frequently with soap and warm water for at least 20 seconds avoid touching your eyes nose and mouth cover your cough and sneeze stay home if you are sick and wear a mask that covers your mouth and nose when out in public you can further protect against contamination by maintaining a 6-ft distance from others especially those outside your household clean and disinfect frequently touch surfaces and objects daily including including electronic devices using approved products Specific Instructions for the aemt include wearing an n95 or higher level respirator or a face mask if a respirator is not available additionally a EMTs should wear eye protection disposable patient examination gloves and a disposable gown to ensure proper protection during patient care the image above provides a step-by-step visual guide for Dawning and doing personal protective equipment the process begins with washing hands thoroughly followed by putting on a gown next the respirator mask is worn followed by eye protection such as goggles or a face shield finally gloves are put on to complete the PPE the Doling process begins with removing gloves followed by the Gown eye protection is then removed and lastly the respirator mask is taking off afterwards hands should be washed thoroughly again when providing care Specific Instructions for the patient include ensuring that the patient wears a face mask if a nasal canula is already in place a face mask should be worn over it a non-re breathing mask can be utilized if clinically indicated but a surgical mask should be worn underneath it the focus should be on treating the symptoms placing the patient in a position of comfort and strictly following local protocol",
        "Conclusion": "this lecture covered a range of emergency medical care and assessment techniques for various respiratory and systemic conditions the topics included General Airway management the administration of supplemental oxygen and the use of Broncho dilators and inhalers each condition or procedure is described with a list of steps or considerations such as the importance of patient positioning the need for psychological support and the necessity of following local protocols for instance conditions like asthma cou and epig itis are discussed with specific guidance on oxygen therapy patient comfort and when to consider Advanced interventions such as paramedic backup or intubation in addition we covered the management of more complex conditions such as COPD heart failure and Pulmonary embolism the focus is on maintaining Airway patency providing high flow oxygen when indicated and supporting circulation with IV fluids when necessary the use of CPAP and other Advanced respiratory interventions is also discussed with detailed instructions on their application and potential complications attention is given to both adult and pediatric patients emphasizing the differences in treatment approaches and the importance of age appropriate care lastly we discuss guidelines for the use of PPE the importance of hand hygiene and the need for Respiratory protection the entries also discussed the importance of following updated protocols and staying informed about the latest recommendations from Health authorities overall we provided a comprehensive overview of emergency care for respiratory and related conditions emphasizing the importance of thorough assessment appropriate intervention and adherence to protocol"
    },
    {
        "Introduction to Respiratory Emergencies and Airway Management": "chapter six respiratory emergencies and Airway management introduction in the realm of critical care the significance and contentious nature of Airway management cannot be overstated taking Center Stage across prehospital provider levels particularly in the dichotomy between basic life support and advanced life support for those at the basic level the ability to assess it manage the airway stands as the foundational point in the intricate web of Airway management moving up the hierarchy Advanced life support serves as the standard to fall back on emphasizing the critical importance of a comprehensive skill set in managing Airways during emergencies the Cornerstone of Airway management lies an effective assessment a Cornerstone that guides the critical care transport professional in formulating a precise treatment plan this process is intrinsic to the overarching goal of ensuring the adequacy of ventilation and oxygenation in critically ill patients in scenarios where respiratory compromise transpires and time becomes a decisive Factor the provider must be Adept at executing rapid accurate respiratory assessments seamlessly followed by the implementation of the most appropriate interventions the dynamic nature of prehospital care demands that these professionals not only possess the theoretical knowledge but are also proficient in the practical application of Airway management techniques thus the controversy surrounding the skill arises from the delicate balance between speed and accuracy scoring the immense responsibility that falls upon the shoulders of those entrusted with prehosp care and Airway management.",
        "Anatomy and Physiology of the Respiratory System": "anatomy and physiology of the respiratory system the upper Airway structures contribute to the complex arrangement of respiratory processes each playing a unique unque role that extends Beyond mere anatomical definition the nose a calines and bony midline structure on the face serves as the Gateway for inspired air Beyond its function in warming and humidifying the air the nose is lined with coarse hairs that filter and trap small particles it is connected to four sinuses the frontal ethmoidal sphenoidal and maxillary these are Hollow chambers that secrete mucus into the nasal cavities the nose opens into the NASA ferx a connection significant enough to be a source of epita taxis complicating Airway patency in management in contrast the mouth primarily designed for phonation and mastication extends from the lips to the AA ferx the size of the oral cavity can significantly impact Airway management with the tongue and teeth adding layers of complexity edema of the lingu or sublingual spaces as well as conditions affecting mandibular range of motion can pose challenges salivary glands continuously secrete saliva hindering topical anesthesia and visualization of Airway structures the tongue attached to the mandible emerges as a common culprit for Airway obstruction in unconscious patients necessitating interventions such as the jaw thrust maneuver the ferx a U-shaped tube from the base of the skull to the lower border of the CID cartilage near the esophagus is divided into the nasofix orox and hypox normal resting muscle tone of the AA feric maintains upper Airway patency with the glossop farango nerve providing sensory inovation to key structures its inferior portion marks the entrance of both the trachea and the esophagus finally the linic housing structures like the thyroid cartilage Airy epiglottic folds epiglottis vallecula and eroid cartilages serves as the ultimate Gateway before air enters to the trachea the Vegas nerve with its robust sensory interations carries the potential for parasympathetic nervous system stimulation resulting in significant decreases in heart rate and blood pressure within the LX lies the cryo thyroid membrane a critical point in Airway management with this proximity of approximately 6 to 8 mm from the superior to inferior Border in adult patients emphasizing the Precision required in medical interventions involving this crucial anatomical region in the comprehensive realm of critical care paramedic training a thorough understanding of lower airway structures is Paramount the trachea beginning at the inferior border of the CID ring and concluding at the Corina is a complex conduit approximately 9 to 15 mm in diameter and 12 to 15 cm long unlike a perfect cylinder it boasts 6 to 12 c-shaped calines rings on the interior portion accompanied by fibrous tissue and muscular fibers on the posterior aspect these Rings play a role in maintaining luminal patency ensuring unimpeded air flow and varying in size being larger in adult males than females the trachea gives rise to the lungs through the division into the right and left main stem bronchi further branching into loes the right lung exhibits three loes while the left lung comprises two the broni continued their division into smaller bronchi eventually leading to bronchioles Alvar ducts and approximately 300 million Alvi where gas exchange occurs each alvus composed of both type one and type two squamous epithelial cells plays a distinctive role type one cells are intricately involved in gas exchange while type two cells manufacture surfactant reducing surface tension within the alvus preventing collapse and facilitating expansion during inhalation Alvar macro fanges contribute to the body's defense mechanism by ingesting inhaled particles the lung's blood supply emanates from the right ventricle where the pulmonary trunk bifurcates into the right and left pulmonary arteries these arteries containing deoxygenated blood rich in carbon dioxide further subdivide into pulmonary capillaries forming a low pressure system with a pressure of approximately 25 over 10 mm of mercury distinct from the normal systemic pressure of about 120 over 80 mm of mercury the interplay between ventilation and profusion known as the VQ ratio is vital for efficient gas exchange disruptions in this ratio influenced by gravitational effects pulmonary artery pressure Alvar pressure Airway obstruction and lung compliance are common culprits of hypoxia conditions such as COPD pulmonary embolism heart failure andonia can lead to alterations in these factors underscoring the critical importance of recognizing and managing lower airway complexities in the realm of critical care paramedics an acute understanding of pediatric considerations is indispensable particularly when navigating the unique intricacies of Airway anatomy and pediatric patients newborns and infants present with proportionally larger heads with a predominant oxop put which may lead to flexation of the airway posing challenges in visualizing laryng structures proper positioning is important and employing a towel under the infant's shoulders to elevate the body and align the airway axes can marketly improve air flow infants characterized as oblate nose breathers are susceptible to respiratory distress in the presence of congestion necessitating Vigilant monitoring and intervention the Pediatric Airway introduces additional complexities such as the tongue occupying a larger proportion of the mouth compared to adults potentially resulting in Airway obstruction in unresponsive pediatric patients this increased tongue size also makes the visualization of the glotus more challenging during lenos scopy the glottic opening is positioned more spolad and interiorly presenting at a 45\u00b0 angle to the anterior Fingal wall in contrast to the parallel orientation in adults the epiglottis in pediatric patients is proportionally larger floppier and u-shaped compared to adults often requiring the use of the lenos scope blade tip to lift it and improve visualization during L roscopy pediatric patients particularly infants possess larger ad noid tissue a feature that increases the vulnerability to significant hemorrhaging when subjected to trauma this enlarged tissue can be a source of bleeding and Care must be taken to minimize any potential harm during medical interventions furthermore the CCO thyroid membrane in young children is notably small emphasizing the need for caution and a deliberate approach in Airway Management in children under the age of 10 there is a preference for needle cryo thyrotomy over surgical cryo thyrotomy due to the size limitations of the crer thyroid membrane this Nuance consideration underscores the importance of tailored techniques in securing the airway while recognizing the unique anatomical challenges present in the Pediatric population adding to the complexity pediatric patients exhibit significantly higher oxygen consumption rates approximately double that of adults this heightened oxygen demand places them at an increased risk for a profound hypo oxia even when pre-oxygenation efforts are deemed adequate careful management of oxygenation is imperative in pediatric Critical Care settings and health care providers must be vigilant in ensuring optimal gas exchange to prevent potential complications a critical aspect of respiratory support in pediatric patients involves the judicious use of bag Val mask devices excessive volumes and forceful ventilations with the bag mask device can lead to several complications including gastric distension vomiting decreased lung compliance and an elevated risk of pneuma thorax the delicacy required in ventilatory support underscores the need for healthc care providers to balance the provision of adequate ventilation with an awareness of the potential adverse effects especially in the Pediatric population.",
        "Physiology of the Respiratory System": "physiology of the respiratory system a fundamental aspect of critical care paramedic education is the comprehension of the meticulous process underlying gas exchange particularly the pressure gradient changes across the Alvar capillary membrane this Exchange transpires in the delicate interchange between the capillaries and Alvi in the capillaries the partial pressure of oxygen or P2 stands at 40 millim of mercury accompanied by a partial pressure of carbon dioxide or pco2 of 45 mm of mercury conversely within the Alvi these values undergo a dynamic shift with a P2 of 100 millimeters of mercury and a PC2 of 40 millim of mercury gas exchange unfolds as oxygen and carbon dioxide undergo diffusion journeying from areas of higher concentration to lower concentration perpetually seeking equilibrium as blood returns to the left side of the heart through the pulmonary vein it carries oxygen and carbon dioxide with distinct concentrations embodying normal arterial blood gas or ABG values the oxygen content in the blood stands at 100 millim of mercury reflecting the enriched oxygen obtained through our vlr capillary exchange simultaneously carbon dioxide a byproduct of cellular metabolism registers at 40 mm of hemoglobin indicative of the successful elimination of this waste product through the same intricate exchange process these ABG values serve as a physiological Benchmark showcasing the effectiveness of the respiratory and circulatory systems in maintaining the delicate balance required for optimal gas exchange in the critical care paramedics realm a nuanced understanding of these gas exchange Dynamics is indispensable for assessing and managing patients with respiratory comp compromise and ensuring optimal oxygenation and ventilation in the comprehensive landscape of critical care paramedic education the intricacies of gas exchange extend to factors that can significantly influence the diffusion of gases across the Alvar capillary membrane encapsulated under the terminology of ventilation profusion mismatch this phenomenon represents a pivotal aspect of respiratory physiology intimately tied to the relationship between ventilation which is air reaching the Alvi and profusion blood flow that reaches the alv the first type of VQ mismatch is characterized by a low VQ ratio signifying inadequate ventilation in relation to blood flow this imbalance can result from conditions such as Airway obstruction or impaired lung function hindering the optimal exchange of gases in the Alvi conversely a high VQ ratio the second type denotes excessive ventilation relative to blood flow conditions such as pulmonary embolism where blood flow is compromised despite ample ventilation exemplify this scenario both low and high VQ ratios can lead to suboptimal gas exchange contributing to respiratory compromise and impaired oxygenation the third type of VQ mismatch introduces the concept of a silent Alvar unit where a ventilation and profusion are entirely absent this condition results in regions of the lungs where neither air nor blood reaches the Alvi rendering them functionally inactive in terms of gas exchange silent Alvar units may be associated with conditions such as adala stasis or areas of the lung affected by certain diseases the oxyhemoglobin disassociation curve is a fundamental Concept in respiratory physiology elucidating the intricate relationship between hemoglobin and the partial pressure of oxygen in arterial blood or pao2 this sigmoidal curve graphically represents the Affinity of hemoglobin for oxygen showcasing the dynamic nature of oxygen binding and release as influenced by the prevailing oxygen levels in clinical scenarios it becomes evident that a patient can experience tissue hypoxia despite having normal values for both pao2 and peripheral oxygen saturation or spo2 this paradoxical situation arises when anemia or dysfunctional hemoglobin is present anemia characterized by a reduced concentration of red blood cells decreases the oxygen carrying capacity of the blood imparing the delivery of oxygen to tissues additionally dysfunctional hemoglobin which may result from genetic mutations or acquired conditions can hinder the normal binding and release of oxygen leading to impaired oxygen transport various substances have the potential to bind to hemoglobin and induce dysfunction thereby influencing the oxyhemoglobin disassociation curve one such substance is carbon monoxide or Co which is a colorless and odorless gas that has a higher affinity for hemoglobin than oxygen when Co binds to hemoglobin it forms a carboxyhemoglobin rendering the affected hemoglobin incapable of effectively carrying oxygen this can lead to tissue hypoxia even in the presence of normal pao2 and SP2 levels nitrate is another substance that can impact hemoglobin function nitrate under certain conditions can react with hemoglobin to form methemoglobin methemoglobin is unable to effectively Bond and transport oxygen contributing to impaired oxygen delivery to tissues this phenomenon can result in tissue hypoxia further highlighting the intricacies of the oxy hemoglobin disassociation curve understanding the curve and the factors influencing it is crucial in clinical practice guiding healthc care providers in the assessment and management of patients with conditions that impact oxygen transport and delivery the complex interplay between hemoglobin and oxygen levels is Central to respiratory physiology playing a role ensuring adequate oxygenation of tissues in health and disease the mechanics of ventilation involve a complex interplay of various Concepts each playing a role in the dynamic process of breathing Central to these mechanisms are the concepts of elastin compliance resistance and pressure gradients which collectively govern the ability of the respiratory system to facilitate the exchange of gases elastins refers to the inherent tendency of a structure to recoil or collapse in the context of ventilation elastins is a critical property of lung tissue the elastic recoil of the lungs during exhalation is essential for the expulsion of air allowing the respiratory system to maintain a cyclic breathing pattern disruptions in lung elastins can lead to difficulties in exhalation impeding the normal mechanics of ventilation compliance on the other hand pertains to the ease with which the thorax and lungs expand during inhalation it is a measure of the change in lung volume per unit of pressure reduced compliance indicates an increased resistance to expansion making it harder for lungs to inflate conditions such as pulmonary fibrosis which is characterized by stiffening of lung tissue can result in decreased compliance impairing the normal expansion of the lung during inh inhalation resistance influences the mechanics of ventilation referring to the amount of force required to move gas or fluid through a single capillary tube pel's law describes the relationship between resistance pressure and flow in a cylindrical tube in the context of the respiratory system Airway resistance is a key determinant of air flow conditions such as asthma or COPD can lead to increased Airway resistance impeding the smooth flow of air during ventilation the mechanism of ventilation begins with the expansion and contraction of the thoracic cavity during inspiration the diaphragm contracts and descends while the external intercostal muscles between the ribs contract causing the rib cage to elevate these coordinated actions increase the thoracic volume creating space for the lungs to expand the expansion of the thorax results in an increase in the volume contained within it this increase in volume volume is pivotal for creating the necessary conditions for air flow into the lungs as the thoracic volume expands the intrathoracic pressure becomes negative relative to atmospheric pressure this negative pressure differential causes air to move from an area of higher concentration the atmosphere to an area of lower pressure the lungs this leads to the inhalation of air at the end of inspiration the muscles responsible for thoracic expansion relax the diaphrag ascends and the external intercostal muscles relax allowing the thorax to return to its original size the contraction of muscles during expiration results and a decrease in thoracic volume this reduction in volume leads to an increase in intrathoracic pressure causing air to be expelled from the lungs during exhalation the primary muscles involved in the mechanics of ventilation are the diaphragm and external intercostal muscles the diaphragm a dome-shaped muscle separating the thoracic and abdominal cavities is a crucial respiratory muscle in times of increased respiratory demand or stress accessory muscles come into play muscles such as the pectorals sternomastoid and scalin assist in expanding the thorax facilitating inspiration however Reliance on these accessory muscles during prolonged or intense respiratory efforts can lead to increased bioc cardial oxygen consumption muscle fatigue and potential complications such as hypercapnia and hypoxemia culminating in respiratory failure the primary impetus for normal breathing stems from the knee to eliminate carbon dioxide which is a byproduct of cellular metabolism in the bloodstream CO2 combines with water to form carbonic acid or H2 CO3 which then dissociates into hydrogen ions and bicarbonate ions as the concentration of CO2 in the bloodstream increases so does the level of hydrogen this rise in hydrogen ions results in a decrease in PH this is a phenomenon that can lead to respiratory acidosis the change in pH is transmitted across the blood brain barrier and serves as a stimulus for the respiratory Centers located within the brain stem chemo receptor act as a backup sensor and are situated in the aortic Arch and cored arteries these chemo receptors monitor changes in blood chemistry providing additional feedback to the respiratory centers notably when the partial pressure of oxygen in the arterial blood drops below 60 mm of hemoglobin the chemo receptors reach their maximal stimulation trigger ing an increased drive to breathe the respiratory centers responsible for coordinating the dance of inhalation and exhalation are situated in the brain stem specifically they are located in two main regions the medulla and the ponds the medullary respiratory Center comprising the dorsal respiratory group and the ventral resp respiratory group assumes a central role in the regulation of the fundamental breathing Rhythm specifically the dorsal respiratory group serves as the primary stimulatory Center for inhalation while the ventral respiratory group is involved in both inhalation and exhalation processes within the ponds the pontine respiratory group plays a significant role in modulating and controlling respiratory patterns through intricate interactions with the medary respiratory centers the pontine respiratory group contributes to the fine-tuning of the respiratory cycle this Dynamic interplay ensures precise and adaptive regulation of respiratory patterns in response to the body's changing physiological demands the proper functioning of the respiratory system is governed by a constellation of factors each one ensuring effective gas exchange and optimal oxygenation these factors can be delineated into the following five components ventilation is the Cornerstone of respiratory physiology representing the bulk flow of gases into an out of the lungs this process is facilitated by the coordinated contraction and relaxation of respiratory muscles primarily the diaphragm and intercostal muscles during inspiration air rich in oxygen is drawn into the lungs and during expiration carbon dioxide is expelled adequate ventilation is essential to maintain a appropriate oxygen and carbon dioxide levels in the Alvi supporting efficient gas exchange the distribution of gas within the lungs is key for ensuring that each region engages in gas exchange ventilation must deliver air to all areas of the lungs from the upper to the lower loes proper distribution ensures that oxygen and carbon dioxide are exchanged uniformly across the lvlr capillary membrane optimizing respiratory function gas exchange occurs at the avar capillary membrane through the process of diffusion oxygen diffuses from the Alvi into the primary capillaries where it binds to hemoglobin for transport to tissues simultaneously carbon dioxide diffuses from the blood into the alv for elimination through exhalation the efficiency of diffusion is critical for maintaining adequate oxygenation and facilitating the removal of carbon dioxide it could easily be said that all negative patient outcomes lie at the feet of of the ability of the body to peruse profusion refers to the flow of blood through the pulmonary vasculature which allows red blood cells to come into close contact with Alvi for gas exchange the coupling of ventilation and perfusion ensures that oxygenated blood is delivered to systemic circulation supporting the metabolic needs of tissues any imbalance in perfusion can lead to ventilation perfusion mismatch compromising gas exchange circulation encompasses the body's ability to pump blood not only to the lungs but also through systemic circulation the right side of the heart receives deoxygenated blood from the body and pumps it to the lungs for oxygenation while the left side receives oxygenated blood from the lungs and pumps it to the rest of the body the rhythmic coordination of the cardiac cycle ensures a continuous flow of oxygenated blood to tissues sustaining cellular metabolism understanding and optimizing these five factors ventilation distribution diffusion perfusion and circulation are essential for maintaining rest respiratory homeostasis any disruption in these processes can lead to respiratory compromise highlighting the interdependence of these components and ensuring the proper function of the respiratory system respiratory volumes and capacities Encompass a spectrum of measurements that reveal the Dynamics of breathing providing valuable insights into lung function utilizing a spirometer which measures respiratory capacities in leaders clinicians can assess various parameters essential for understanding pulmonary Health total lung capacity is a comprehensive measure representing the maximum volume of gas the lungs can hold in a healthy adult male this typically r ranges between 5 to 6 lers this capacity is not a singular entity but rather a composite of various lung volumes and capacities each contributing to the intricate Dynamic of respiratory function spirometric measurements offer a detailed analysis of respiratory capacities and volumes these measurements Encompass the following title volume signifies the volume of air inhaled and exhaled during a single normal breath it serves as the Baseline unit for Respiratory measurements minute volume is the total volume of air breathed in 1 minute it's calculated by multiplying the respiratory rate per minute by the average title volume the normal minute volume Falls within the range of 5 to 8 L per minute inspiratory Reserve volume represents the additional volume of air that can be inhaled after a normal tidal volume inhalation reflecting the maximal inhalation capacity expiratory Reserve volume signifies the volume of air that can be expelled from the lungs after a normal exhalation indicating the additional capacity for forced exhalation inspiratory capacity is the sum of the respiratory Reserve volume and tidal volume reflecting the total volume of air that can be inhaled from the end of a normal exhalation vital capacity also known as pulmonary Reserve is the total volume of air that can be exhaled following a maximal inspiration normal values range from 60 to 70 MLS per kg of ideal body weight varying with factors such as sex age and height fital capacity tends to decrease with age increases with greater height and typically shows sexual dimorphism residual volume denotes the volume of air that remains in the lungs even after maximal exhalation maintaining lung patency and preventing collapse functional Reserve capacity is the sum of residual volume and the expiratory reserve volume this is a pivotal parameter allowing for gas exchange between breaths positive end expiratory pressure or peep can be applied to increase functional residual capacity thereby enhancing oxygenation lastly anatomic Dead Space represents the volume of space in the upper Airway that does not participate in gas exchange approximately 2 MLS per kg the space serves as a conduit went for air flow but lacks the ivr capillary interface essential for Respiratory exchange understanding anatomic Dead Space AIDS in Discerning the distribution of ventilation within the respiratory system disease States affecting the respiratory system can be systematically classified based on distinct pathophysiological mechanisms and two primary categories that emerge are obstructive and restrictive diseases obstructive diseases are characterized by impediments to the expiratory phase resulting in challenges moving air out of the lungs this obstruction is attributed to an elevated level of Airway resistance hindering the normal flow of Air One prominent example is asthma a chronic inflammatory condition marked by Bronco constriction heightened Airway responsiveness and increased mucus production another notable obstructive disease is chronic obstructive pulmonary disease or COPD a progressive disorder encompassing chronic bronchitis and empyema chronic bronchitis involves airwing inflammation and excessive mucus production while empyema is characterized by the destruction of Alvar walls collectively leading to persistent airf flow limitations cystic fibrosis a genetic disorder is also classified as obstructive as it involves the production of thick mucus obstructing the airwaves leading to recurrent infections additionally bronch acasis contributes to obstru pathology involving irreversible dilation and thickening of broni due to chronic inflammation these obstructive diseases share a commonality in the difficulty of expelling air from the lungs primarily due to heightened resistance within the Airways the patho physiological intricacies of each condition necessitate precise diagnostic approach approaches and tailored therapeutic strategies for optimal patient management disease States impacting the respiratory system undergo systematic categorization based on distinct pathophysiological mechanisms restrictive diseases represent a subset of these conditions posing challenges to the expansion of the lungs and hindering inspiratory flow this restriction can manifest within the lung tissue itself or within the chest wall influencing compliance which is the ability of the lungs to expand notable examples of restrictive diseases Encompass various conditions occupational lung diseases such as osis and mesothelioma involve exposure to harmful substances leading to fibrosis and scarring of lung tissue these conditions restrict lung expansion diminishing compliance and impeding the normal inhalation of air idiopathic pulmonary fibrosis a progressive disorder is characterized by the gradual development of fibrotic tissue reducing lung compliance and impairing normal respiratory function pneumonia an inflammatory condition affecting lung tissue can result in consolidation and decreased compliance the Infectious process hampers the lung's ability to fully expand during inspiration atal acasis a partial or complete collapse of a longer lobe leads to reduced lung volume and compliance often caused by factors like Airway obstruction or compression deformities or injuries to the chest wall such as severe fractures or congenital abnormalities contribute to restrictive pathology by restricting the normal expansion of the lungs finally neuromuscular diseases like galain bar syndrome and amyotrophic lateral sclerosis or ALS impact respiratory muscles compromising coordination and strength this results in diminished lung compliance and restrictive breathing patterns when ventilation surpasses blood flow a dead space effect occurs impeding gas exchange this phenomenon is known as teyia an abnormally rapid respiratory rate which can be a manifestation of various conditions including pulmonary embolism in pulmonary embolism a blood clot obstructs pulmonary arteries disrupting the normal VQ ratio and hindering the matching of ventilation and profusion conversely when blood flow exceeds ventilation a shunt effect can compromise gas exchange pneumonia an inflammatory condition affecting lung tissue is a notable example where blood flow is in excess leading to impaired VQ matching anatomic shunts such as congenital heart defects and the presence of bronchial and thees and veins can exacerbate the shunt effect the quantification of the shunt effect which we abbreviate as QT typically ranges from 3 to 5% in Normal conditions that being said a QT value exceeding 20% is indicative of a critical condition emphasizing the severe impairment of gas exchange the assessment of hypoxia a condition characterized by insufficient oxygen and the blood affecting tissues is a key medical domain the necessitating a comprehensive understanding of its diverse etiologies and tailor treatment approaches hypoxic hypoxia stems from various causes both pulmonary and extrapulmonary conditions leading to hypohemia Airway obstruction decreased cardiac output and coronary artery disease contribute to insufficient oxygen tension in the blood additionally factors such as hypoventilation high altitude exposure and Suffocation can instigate low oxygen tension in the Alvis structural issues like fibrosis and edema causing diffusion defects intrapulmonary shunting induced by adelais bronchospasm and pneumonia as well as extrapulmonary shunting associated with congenital heart defects collectively contribute to hypoxic hypoxia anemic hypoxia arises due to a reduction or dysfunction of hemoglobin impeding the transportation phase of respiration and resulting in diminished oxygen carrying capacity this type of hypoxia is often linked to various causative factors including anemias Hemorrhage hemoglobin abnormalities and the use of certain medications like sulfa drugs additionally exposure to chemicals such as carbon monoxide can exacerbate anemic hypoxia further compromising the oxygen carrying capacity of hemoglobin stagnant hypoxia is characterized by a reduction in cardiac output resulting in inadequate tissue oxygenation due to impaired circulation specific causes include pathological conditions such as heart attack heart failure shock continuous positive pressure breathing and Pulmonary embolism physiological stressors such as exposure to acceleration forces can also contribute to stagnant hypoxia furthermore reduction in Regional or local blood flow may occur due to factors like extreme environmental temperatures postural changes the application of tourniquet hyperventilation and embolism by clots or gas bubbles additionally cerebral vascular accidents can significantly impact blood flow exacerbating stagnant hypoxia and affected tissues histotoxic hypoxia arises when cells are unable to effectively utilize oxygen due to the inactivation or destruction of key enzymes this condition is observed in cases of poisoning notably cyanide and strict n poisoning where these toxic substances interfere with cellular respiration rendering cells incapable of utilizing the oxygen delivered to them the later stages of carbon monoxide poisoning which involves The Binding of carbon monoxide to hemoglobin also exemplify histotoxic hypoxia in such instances despite inadequate supply of oxygen cells are unable to perform arobic respiration due to the toxic effects on crucial enzymes leading to Cellular dysfunction and hypoxic tissue damage comprehensive knowledge of these distinct types of hypoxia is essential for healthc Care Professionals to accurately diagnose and effectively manage patients presenting with tissue hypoxia tailoring interventions to the specific ideology ensures optimal patient care care and mitigates the potential cqu associated with inadequate tissue oxygenation.",
        "Patient Assessment": "patient assessment breath sound assessment is a fundamental aspect of respiratory evaluation providing valuable insights into the Dynamics of air movement though the tracho bronchial tree and Alvi these sounds created as a result of the interplay of air flow can be meticulously osculated to discern nuances in respiratory function the size of the airway determines the nature of the breath sound anatomical structures like the trachea and broni characterized by larger diameters engine gender distinct sound profiles The Sounds produced in these regions exhibit higher pitches and are discernible through both inspiration and expiration this differentiation in Pitch is a consequence of the resonance and vibration of the air column within the Airways tracheal breath sounds also known as bronchial breath sounds when heard over the sternum emanate from the trachea and the main bronchi these sounds are characterized by their high pitch and are clearly audible throughout the respiratory cycle during osculation providers assess the duration pitch and intensity of tracheal breast sounds gaining valuable information about the functioning of the upper Airway the duration of tracheal breath sounds is a key metric offering information about the time each breath phase occupies deviations in duration May indicate abnormalities in the respiratory cycle the pitch of these breath sounds is notably High reflective of the resonance within the large Airways higher pitch sounds are characteristic of air flow through the trachea in main bronchi the intensity of tracheal breath sounds is crucial engaging the strength of air flow variations in intensity May signify alterations in Airway patency or resistance vascular breath sounds characterized by softer and muffled tones are predominantly heard over the majority of the chest representing the air flow within the VII the expiratory phase of acicular breath sounds is barely audible emphasizing the prominence of inspiratory air flow during normal breathing Bronco vesicular breath sounds a hybrid of tracheal and vesicular qualities are heard in regions where both Airways and Alvi coexist such as the upper part of the sternum and between the scapula the assessment of Bronco vascular sounds involves evaluating multiple parameters the expiratory phase of Bronco vascular sounds is normally at least twice as long as inspiration reflecting an inspiratory to expiratory ratio of 1 to two the pitch of Bronco vesicular sounds is contingent on factors such as air flow rate consistency of flow throughout inspiration patient position and the specific oscilation site selected the thickness of the chest wall can influence the intensity of Bronco vascular sounds adding another layer of complexity to their assessment healthc Care Professionals must account for these variables to accurately interpret the significance of these breath sounds in clinical practice adventitious breath sounds Encompass a spectrum of abnormal respiratory sounds that deviate from the expected tracheal Bronco vesicular or vesicular patterns these sounds are typically categorized as either continuous or discontinuous each providing valuable diagnostic information the diverse nature of these breath sounds underscores the complexity of respiratory pathology there are continuous sounds and discontinuous sounds wheezes manifest as continuous high-pitch sounds resulting from narrowed Airways and are often associated with conditions such as asthma bronchitis or obstructive pulmonary diseases the these sounds are attributed to turbulent air flow through constricted bronchioles and may be audible during both inspiration and expiration ronai distinguished as low pitched continuous sounds arise from Airway obstruction due to mucus fluid or other secretions commonly associated with chronic bronchitis broni can be heard during both phases of the respiratory cycle reflecting the presence of Airway related issues crackles formerly known as rails are discontinuous sounds categorized by brief non-musical interruptions in air flow these sounds often suggest the presence of fluid or secretions in the small Airways or Alvi fine crackles are associated with conditions like interstial fibrosis is while coarse crackles May indicate conditions such as pneumonia or heart failure Strider is a distinctive high-pitched continuous sound resembling a seal bark and is often indicative of upper Airway obstruction common causes include croo in children epiglottitis or foreign body aspiration Strider warrants immediate attention due to its association with potentially life-threatening conditions plural friction rub is characterized by a grating or rubbing sound often described as two surfaces moving against each other this sound results from inflamed and roughened plural spaces typically due to conditions like pesy or Portis the rubbing of these surface during breathing produces this distinct sound aiding in the diagnosis of underlying plural pathology a comprehensive understanding of adventitious breath sounds is indispensable for Professionals in diagnosing respiratory disorders differentiating between wheezes Ron ey crackles Strider and plural friction rubs provides valuable insights into the nature location and potential causes of respiratory abnormalities guiding clinicians in formulating targeted treatment plans for optimal patient care oscilation is an important component of respiratory assessment and involves the careful listening of breath sounds through a stethoscope this diagnostic technique is invaluable for evaluating Airway function detecting abnormalities and monitoring changes in a patient's respiratory status the following points provide a comprehensive overview of oscilation practices and considerations for patients with invasive Airway devices like endot tral tubes or super glottic Airways the osculatory process extends Beyond conventional methods oscilation sites Encompass the epigastrium sternal notch and six recommended locations on the anterior chest wall and in the axley this approach aims to assess the proper placement of Airway devices and ensure unimpeded air flow establishing a baseline respiratory assessment during this phase creates a standard for subsequent evaluations enabling clinicians to discern changes or anomalies the patient ideally positioned in a semi or high fer position is instructed to take slow deep breaths through an open mouth this posture enhances respiratory efficiency and facilitates optimal sound transmission for accurate assessment in instances where evaluation is Impractical clinicians must osculate as many of the six recommended sites as feasible maintaining a systematic approach the diaphragm of the stethoscope is placed directly on bare skin ensuring optimal sound conduction and minimizing interference patient Comfort is a critical consideration during oscilation rushing through the process May induce hyperventilation or worsen existing dnia compromising the accuracy of the assessment thorough documentation of oscilation results is essential for tracking changes in breath sounds identifying Trends and informing clinical decisionmaking palpation of the chest wall is part of a thorough evaluation of respiratory function offering insights into the condition of the lungs skin subcutaneous tissues and chest expansion this Hands-On approach allows healthc Care Professionals to gather valuable information about the structural and functional aspects of the respiratory system this is because palpation AIDS in identifying abnormalities assessing tissue integrity and determining the overall health of the thoracic region subcutaneous empyema Often manifested by a distinctive snap crackle pop sensation upon palpation is a condition where air becomes trapped in the subcutaneous tissues while subcutaneous empyema itself is generally benign it serves as a clinical indicator of an underlying and potentially life-threatening cause inquiries about recent trauma or invasive medical procedures are important to help uncover the root cause and guiding appropriate interventions vocal fridus an aspect of tactile fremitus involves placing Hands by laterally on the upper thorax and instructing the patient to articulate the phrase 99 the palpated vibrations during vocalization provide valuable information about the underlying lung tissue an increase in fitus indicates that the lung tissue is more solid and contains less air than normal this finding may suggest conditions such as pneumonia or adelais prompting further investigation and intervention in some cases excessive secretions May contribute to increased fridus highlight liting the need for interventions such as suctioning however it is important to note that the practicality of Performing vocal fridus assessment may be limited in a transport setting point of care lung ultrasonography has emerged as a valuable and efficient tool particularly in the assessment of patients presenting with undifferentiated shortness of breath this non-invasive Imaging technique allows healthc care providers to obtain realtime insights into the structural and functional aspects of the lungs aiding in prompt and accurate diagnosis one of the notable applications of lung ultrasonography is the identification of the sliding lung sign characterized by the absence of of shimmering as the parietal and visceral lung plura slide past each other during respiration this absence of movement may suggest the presence of a numa thorax allowing for timely intervention and management ultrasonography facilitates the differentiation of various acoustic artifacts contributing to the distinction between well erated lungs and those affected by Alvar interstitial syndromes a lines observed in well arated lungs represent reverberation artifacts indicating normal air filled spaces in contrast B lines observed in conditions like pulmonary edema or pneumonia signify vertical lines extending from the plural line and are associated with interstital syndrome recognizing these patterns enhances the clinician's ability to diagnose and manage respiratory conditions promptly recognizing normal respiratory patterns provides a baseline for comparison allowing providers to swiftly identify deviations that may signify underlying pathology understanding aent patterns such as to kitney bradia or apnea AIDS paramedics in recognizing and addressing critical conditions promtly respiratory compromise can result from a spectrum of medical emergencies including trauma respiratory infections or toxic exposures Proficiency in Discerning normaly from pathology enhances the paramedics ability to make rapid accurate assessments it initiate appropriate interventions and contribute to improved patient outcomes in critical care settings eia representing the Hallmark of normal breathing exhibits distinct rates across different age groups in adults a respiratory rate ranging from 12 to 20 breasts per minute is considered within the norm contrarily newborns display a higher frequency of 30 to 50 breaths per minute while adolescents align with the adult range Topia an elevated respiratory rate can be attributed to various etiologies fever pneumonia metabolic acidosis hypoxemia certain poisonings drugs lesions affecting the respiratory center of the brain and psychological factors like stress anxiety or pain are potential contributors to this normal pattern bradia characterized by a slowed respiratory rate may arise from narcotic or sedative drug use alcohol consumption metabolic disorders respiratory system decompensation or fatigue traumatic or non-traumatic central nervous system lesions and is considered a normal occurrence during specific sleep stages apnea marked by the temporary cessation of breathing can manifest either episodically or periodically episodes lasting longer than 15 seconds necessitate immediate intervention to prevent potential complications assessing the depth of breathing is an important aspect of respiratory evaluation and critical care paramedics employ various methods for this purpose including direct observation and palpation hyperia characterized by deeper than normal breaths can lead to a reduction in carbon dioxide levels contributing to a state of respiratory alkalosis this abnormality can be observed in conditions such as hyperventilation anxiety or early stages of metabolic acidosis conversely hypona which manifests as shallow breathing may result in an accumulation of CO2 leading to respiratory acidosis conditions like respiratory muscle weakness Airway obstruction or severe lung diseases can precipitate hypena understanding the significance of depth and breathing patterns allows Critical Care paramedics to identify potential acid base imbalances and formulate appropriate interventions to optimize respiratory function in patients experiencing respiratory distress assessing for abnormal respiratory patterns offers valuable insights into underlying pathophysiological conditions Shane Stokes respiration is a distinctive pattern characterized by a cyclical sequence of increased respiratory rate in depth alternating with periods of apnea following an apnic phase the patient initiates breathing with slow shallow breaths that progressively escalate in rate and depth until another apnic episode ensues this pattern may be indicative of various underlying conditions such as increased intracranial pressure renal failure menitis drug overdose or hypoxia associated with congestive heart failure interestingly otherwise healthy individuals may manifest Shane Stokes respiration in response to factors like altitude changes or hypervent ation syndrome acidosis can also serve as a triggering factor for this distinctive respiratory pattern highlighting the importance of recognizing and understanding these variations in critical care paramedic assessments cluster breathing characterized by a grouping of irregular respirations with varied depths interspersed with periods of apnea or irregular intervals is a distinctive respiratory pattern that providers must recognize during patient assessments this irregular breathing pattern may be indicative of various underlying conditions and its identification can provide valuable diagnostic information biots or axic breathing shares similarities with Shane stoke's respirations but is distinguished by its irregular pattern the causes of biet breathing may include conditions such as menitis increased intracranial pressure or central nervous system dysfunction recognizing this irregular breathing pattern is essential for providers in determining the potential neurological or intracranial issues contributing to the patient's respiratory status kall's respiration is characterized by fast and deep deep breathing without periods of apnea with the rate in depth exceeding the normal expectations of the patient's age group this particular breathing pattern may signal metabolic acidosis such as diabetic keto acidosis or renal failure providers must be Adept at identifying kall's respiration as it often manifests in conditions associated with severe acidemia apneustic breathing marked by prolonged inhalation and shortened exhalation serves as a critical indicator of lesions within the respiratory center of the brain stem this abnormal breathing pattern can result in severe hypoxemia and if left uncorrected may lead to Rapid death its identification should direct attention to potential underlying neurological issues that demand prompt intervention Central neurogenic hyperventilation involves deep and Rapid respirations typically occurring at rates of 40 to 60 breaths per minute this abnormal pattern is attributed to midbrain lesions or dysfunction and is frequently observed in com patients with Glascow coma scores below eight Critical Care paramedics must recognize Central neurogenic hyperventilation as it may signify a serious neurological impairment requiring targeted therapeutic interventions hyperventilation syndrome characterized by an increase in both the rate and depth of respiration can result from various triggers including exertion fear anxiety fever hepatic coma acidbase imbalance or mid-brain lesions distinguishing between moderate and severe cases is crucial for accurate assessment and appropriate intervention agonal respirations the Deep slow shallow irregular all or none breaths often accompany a low respiratory rate they may indicate impending respiratory failure or Cardiac Arrest but should not be mistaken for viable breathing pursed lip breathing observed in patients with chronic obstructive pulmonary disease and Asthma often involves exhaling through Pur lips in an attempt to maintain positive-end expiratory pressure or peep providers should be Adept at identifying this breathing pattern as it helps understand the patient's coping mechanism and provides insights into the respiratory condition in preparation for patient transport the comprehensive assessment is fundamental to ensure the well-being and stability of the individual a review of the patient care report is a meticulous process focusing on identifying medications disease processes or trauma that could potentially compromise ventilation this includes a thorough examination of any recent lab or Imaging studies providing critical insights into the patient's current physiological State assessment of the patient's Vital Signs is Central to understanding their hemodynamic status specifically noting the last arterial blood gas measurement and assessing the validity of the data offer valuable information about the patient respiratory function and acidbase balance an important step in preparing for transport involves noting the size type and depth of any artificial Airway such as an endot tral tube or super glaic Airway and confirming its proper placement prior to moving the Pati this is imperative for maintaining an open Airway and facilitating effective ventilation during Transit simultaneously noting the ventilator settings and closely monitoring the patient's response to mechanical ventilation are essential components of this assessment communication is key in addressing any concerns related to the placement of mechanical devices such tracheal tubes nasogastric tubes orogastric tubes are Central lines ensuring the secure and appropriate positioning of these devices is vital for preventing complications during transport altitude induced pressure changes during air travel especially in helicopters or fixed Wing aircraft are a consideration rooted in Bo's law Bo's law is a fundamental principle in physics and gas behavior named after the scientist Robert Bole it states that a constant temperature the pressure of a given amount of gas is inversely proportional to its volume in simpler terms as the volume of gas decreases the pressure increases and vice versa providing the temperature remains constant this law helps explain how changes in pressure affect Gases such such as alterations in atmospheric pressure during changes in altitude which can have implications for gas filled spaces within the body like the lungs when conducting a comprehensive assessment of the respiratory system adhere to a systematic approach commencing with an evaluation of the ABCs encompassing Airway breathing and circulation the airway stability is an important consideration ensuring unimpeded air flow this involves scrutinizing for any obstructions or potential constriction that may compromise respiratory function an analysis of the respiratory Dynamics is then initiated concentrating on the rate pattern depth and character of the respiration this entails a thorough examination of the chest with emphasis on achieving a symmetrical rise and fall during each respiratory cycle importantly Vigilant observation is directed towards the detection of acccessory muscle use as this may signify respiratory distress concurrently scrutiny of the presence of central lines or Hickman catheters is conducted acknowledging the potential impact on respiratory performance Additionally the assessment encompasses the identification of nitroglycerin or other medication patches which may influence respiratory parameters and awareness of indwelling devices that might contribute to respiratory compromise simultaneously the inspection extends to identifying any wounds abrasions or bruising with heightened attention to Discerning the presence and location of bone bony crepitus or subcutaneous empyema such observations are critical indicators of underlying respiratory pathology and potential complications furthermore an examination of dressings on the chest is performed ensuring their dryness and integrity as moist or compromised dressings May predispose the individual to respiratory infections or other complications attention should be directed towards the observation of any drainage being collected necessitating assessment of its color and consistency this involves the scrutiny of bodily fluids for potential signs of infection or abnormality with color variations and alterations in viscosity serving as valuable indicators of underlying pathophysiological processes the comprehensive assessment extends to oscilation of the chest a component that involves the attentive listing to breath sounds the presence or absence quality and type of breath sounds are noted allowing for the identification of abnormalities such as wheezing crackles or diminished breath sounds moreover a comparative analysis of breath sounds between the two sides sides of the chest is conducted aiding in the detection of asymmetric or localized respiratory issues for patients requiring supplemental oxygen a thorough evaluation of the oxygen delivery device is imperative assessment encompasses the delivered fraction of inspired oxygen or F2 ensuring that it meets the patient's physiological requirements and effectively maintains the desired oxygen saturation as measured by pulsox symmetry this approach is important for tailoring oxygen therapy to individual patient needs optimizing respiratory support and preventing complications associated with oxygen therapy in tandem with the respiratory assessment a comprehensive evaluation of cardiac function is undertaken this includes the measurement of blood pressure pulse rate capillary refill time skin color and temperature these parameters offer insights into the cardiovascular systems capacity to support respiratory function and overall tissue profusion furthermore the assessment encompasses an evaluation of mental status recognizing the direct impact of hypoxia on cognitive function the potential poal effects of impaired oxygenation on neurological status such as confusion or altered Consciousness are carefully considered this holistic approach to Patient assessment ensures a thorough understanding of both respiratory and cardiac functions facilitating timely interventions and individualized patient care.",
        "ABG Monitoring": "ABG monitoring measuring arterial blood gas levels stands as the gold standard for the comprehensive assessment of the respiratory system offering crucial insights into its functioning this intricate procedure involves the aseptic collection of blood from a superficial artery typically the radial artery using a heiz syringe the obtained ABG sample is then subjected to analysis wherein key parameters are measured including pH partial pressure of carbon dioxide or P2 partial pressure of oxygen pao2 and bicarbonate H3 Additionally the assessment encompasses the determination of Base excess or be and the measurement of arterial oxygen saturation sao2 the evaluation of ABG levels serves as a multifaceted tool providing a comprehensive understanding of various aspects of respiratory function it offers valuable information on the acidbase status reflecting the balance between respiratory and metabolic processes simultaneously ABG analysis gauges the effectiveness of ventilation by assessing PA CO2 levels and evaluates oxygenation through the measurement of pa2 and sa2 these parameters collectively offer a detailed picture of the respiratory and metabolic components of the patient's physiological status the interpretation of ABG values extends to the maintenance of normal blood gas parameters this involves a delicate equilibrium between Alvar ventilation and profusion of the Alvar capillaries often referred to as VQ ratio the interplay between these two factors is crucial for understanding optimal gas exchange and ensuring the efficient elimination of carbon dioxide while facil facilitating oxygen uptake any deviation from this delicate balance can have profound implications for Respiratory function in overall physiological homeostasis.",
        "Noninvasive Ventilatory and Oxygenation Monitoring": "non-invasive ventilatory and oxygenation monitoring continuous hemodynamic monitoring ing is key in the management of critically ill patients employing Advanced Techniques such as pulse oxymetry and capnography to provide real-time insights into the patient's physiological status the evaluation of the patient's current clinical status is a primary objective of continuous hemodynamic monitoring pulso symmetry for instance enables the non-invasive assessment of oxygen Satur atation in arterial blood offering a valuable indicator of the patient's oxygen status capnography on the other hand measures the partial pressure of carbon dioxide in exhaled breath providing insights into the adequacy of ventilation these parameters are instrumental engaging the overall cardiovascular and respiratory performance of the patient in addition to assessing the current clinical status continuous hemodynamic monitoring plays a pivotal role in determining how the patient is responding to treatments by closely tracking changes in oxygen saturation and intitled carbon dioxide levels clinicians can dynamically assess the effectiveness of interventions such as mechanical ventilation oxygen therapy or pharmacological interventions this real-time feedback is essential for making informed decisions about ongoing therapeutic strategies and for promptly identifying any adverse responses to treatment it allows Health Care Providers to tailor interventions based on the patient's evolving hemodynamic profile ensuring a personalized and optimized approach to Critical Care the integration of continuous hemodynamic monitoring and the care of critically ill patients aligns with the principles of precision medicine enabling healthc care providers to adapt treatments to the unique and dynamic needs of each patient by leveraging Technologies like pulse oxymetry and capnography clinicians gain valuable data that extends Beyond static snapshots providing a continuous and nuanced understanding of the patient physiological State this proactive approach is instrumental in identifying early signs of deterioration optim op imizing therapeutic interventions and ultimately improving outcomes in critically ill patients pulse o symmetry is a vital non-invasive monitoring technique that provides essential information about arterial oxygen saturation and the patient's pulse rate in clinical practice normal pulse oximetry readings typically fall above 92% although variations may occur particularly in patients with underlying conditions such as COPD understanding these Baseline values is crucial for accurate interpretation in the context of individual patient Health the fundamental principle underlying all pulse oxymetry models involves the transmission of two wavelengths of light red and infrared through body tissues toward a photo receptor The Machine's diode emits these light waves and the degree of change in light detected by the photo receptor corresponds to the level of arterial oxygen saturation pulse oximeters are versatile and can be applied to various anatomical sites including the finger ear toe forehead and the bridge of the nose this adaptability allows healthc Care Professionals to choose the most suitable site for monitoring based on the patient's condition and the clinical context the pul oxymetry reading reflects the intricate relationship between oxygen and hemoglobin in the body it serves as a dynamic indicator of the efficiency of oxygen transport and utilization however this measurement can be influenced by factors beyond respiratory function abnormal hemoglobin levels such as in cases of anemia or carbon monoxide poisoning can distort pulse oxim readings additionally decreased tissue profusion as observed in shock or circulatory compromise can impact the accuracy of spo2 readings help care providers must be cognizant of these potential confounding factors when interpreting pulso symmetry values ensuring a comprehensive and accurate assessment of the patient's oxygenation status capnography is a monitoring tool in clinical settings providing a graphic representation of exhaled carbon dioxide this technique is an essential adjunct in assessing Airway patency and the appropriateness of ventilation capnography not only offers A visual representation of the CO2 waveform but also provides quantitative data through capnometry giving providers a numerical value of the intitle CO2 level this numeric information is valuable engaging the efficiency of ventilation and can Aid in Timely interventions to optimize respiratory support devices used for capnography and capnometry continuously monitor the concentration of CO2 in the patients's exhaled air this real-time feedback is particularly valuable in critical care settings enabling Health Care Professionals to promptly identify changes in respiratory status and intervene as necessary kept ography assists in the detection of Airway issues ensuring timely interventions to maintain Airway patency and prevent respiratory compromise clinicians utilizing capnography should be attentive to gradient Trends between arterial oxygen partial pressure and the intital CO2 values a widening gradient between these two parameters May signify a profusion issue and worsening ventilation profusion mismatch suggesting conditions such as pulmonary embolism this Insight is vital for identifying potential circulatory or respiratory compromise and guiding approach Diagnostic and therapeutic interventions conversely a narrowing gradient between pao2 and etco2 may indicate a ventilation issue and the development of shunt pathology recognizing these Trends is integral to the early identification of respiratory distress and allows for timely adjustments in ventilation strategies or the initiation of targeted treatments in the context of continuous capnography monitoring the provider plays a pivotal role in conveying changes in the patient's respiratory status and metabol ISM this communication is essential for maintaining situational awareness and facilitating prompt interventions to address evolving clinical needs utilizing medical terminology the provider should provide detailed and precise information about alterations in the capnography wave form in numerical values as these changes can signify shifts in ventilation profusion or metabolic processes capnography not only serves as a dynamic monitoring tool but also provides valuable diagnostic information the capnography waveform is a graphical representation of exhaled carbon dioxide throughout the respiratory cycle understanding the normal capnography wave form characterized by a rectangular shape with rounded corners and divided into distinct fa pH es is foundational for interpretation capnography waveforms are divided into distinct phases providing unique insights into the respiratory cycle phase one the initial stage of the waveform commences during inspiration when CO2 levels are low this phase serves as the Baseline of the capnography waveform it represents the period when fresh CO2 po air is inspired into the lungs a clear and consistent phase one is needed to establish a reference point in the respiratory cycle following phase one phase two begins with the initiation of exhalation it involves the movement of pco2 from the anatomical Dead Space the portion of each breath that does not participate in gas exchange phase two is represented by the first expiratory upstroke on the capnography waveform this phase is instrumental in reflecting the transition from the anatomical Dead Space to the Alvar space providing information about the efficiency of gas exchange the subsequent phase phase three is characterized by the Alvar Plateau this phase signifies the exhalation of avar gas assessing the entitle CO2 or P CO2 which represents the last Alvar gas sampled during exhalation the measurement is particularly significant as it reflects the CO2 concentration in the Alvi at the conclusion of expiration offering valuable information about the efficiency of ventilation and gas exchange in the lungs finally phase four which is sometimes referred to as phase zero is depicted by the inspiratory upstroke this phase is caused by the sudden reduction in pco2 that occurs during inspiration when fresh CO2 poor air is drawn into the lungs phase four is important for understanding the Dynamics of inspiratory gas exchange and helps to distinguish normal respiratory patterns from potential abnormalities.",
        "Respiratory and Ventilation Abnormalities": "respiratory and ventilation abnormalities respiratory insufficiency is characterized by the incapacity of the respiratory system to fulfill the metabolic demands of the body this inadequacy may stem from deficiencies in ventilation or oxygenation ventilatory insufficiency implies an inability to maintain an adequate respiratory rate or tidal volume while oxygenation insufficiency denotes an incapacity to uphold sufficient oxygen levels in the blood the treatment approach for Respiratory insufficiency hinges upon identifying and addressing the underlying cause whether it be related to the airway lungs or other contributing factors the therapeutic strategy may involve interventions to optimize ventilation enhance oxygenation or a combination of both depending on the specific eyology respiratory depression a subset of respiratory insufficiency manifests as a decreased respiratory rate often associated with hypoventilation it can result from various factors including thoracic head or spinal cord injuries Central nervous system depression drug use or conditions where fatigue impedes normal breathing low respiratory rates particularly those persisting for prolonged periods are indicative of respiratory depression addressing respiratory depression involves interventions aimed at increasing ventilation which may include strategies such as positive pressure ventilation are pharmacological interventions additionally oxygen therapy is warranted for patients unable to maintain normal oxygen saturation levels due to respiratory depression respiratory failure represents an advanced stage of respiratory insufficiency wherein the respiratory system fails to meet the metabolic demands of the body patients experiencing respiratory failure May exhibit symptoms such as anxiety confusion or obtundation reflecting the systemic impact of impaired gas exchange if not properly reversed respiratory failure can progress to respiratory or cardiopulmonary arrest necessitating urgent interventions respiratory failure is categorized into two types oxygen failure and ventilatory failure oxygenation failure characterized by inadequate oxygen Exchange in the lungs often presents with Topia as the body attempts to compensate for the oxygen deficit on the other hand ventilatory failure develops when there is an increased arterial tension of carbon dioxide indic indicating the inability to effectively eliminate CO2 through ventilation accurate identification of the type of respiratory failure is needed in order to tailor an appropriate intervention an intervention that may include mechanical ventilation supplemental oxygen or other supportive measures respiratory insufficiency depression and failure represent a Continuum of respiratory dysfunction ranging from an inability to meet metabolic demands to a critical state where the respiratory system's failure poses a life-threatening risk.",
        "Basic Airway Management": "basic Airway management basic Airway manag management could be considered a Cornerstone of Emergency Care involving several fundamental Maneuvers the first of which is simply positioning the preferred position for a conscious patient is sitting upright in the sniffing position which aligns the oral and Fingal axes for optimal air flow however patients with spinal precautions or a diminished level of consciousness may require assistance in achieving this position a diminished level of Consciousness can lead to the tongue contacting the posterior Fingal wall or soft pallet resulting in an airway obstruction additionally loss of muscular control over the epiglottis may cause partial or total obstruction posing a risk of aspiration due to reduced control over secretions manual Airway Maneuvers are essential in resuscitation scenarios where the patient requires a supine pH these Maneuvers include the head tilt chin lift tongue jaw lift and jaw thrust these techniques help open the airway and facilitate adequate ventilation particularly in cases of respiratory distress or Cardiac Arrest Airway adjuncts such as the Oro farango Airway and naso farango Airway are employed in conjunction with manual Airway Maneuvers to maintain a patent Airway the OPA is inserted into the mouth and requires the absence of a gag reflex proper sizing is crucial measured from the central incizors to the angle of the jaw the OPA does not replace manual methods but serves as a supplementary measure the inpa is better tolerated for semiconscious patients and is sized from the tip of the nose to the tragus of the ear it's important not to force the mpa to prevent laceration of the nasal mucosa contraindications include head trauma with evidence of Basler skull fracture or facial fracture like the OPA the NPA does not replace manual methods but complements them suction is a vital component of basic Airway management for prehosp Hospital providers offering the capability to promptly clear debris such as vomit or blood from a patient's Airway potentially saving their life to effectively utilize suction providers employ large boore suction apparatus available in both fixed and portable forms rigid suction catheters including the Yonker tonsil tip and Kanto catheters are utilized to remove debris from the airway in situations involving large volumes of debris or vomit turning the patient on their side facilitates more effective suctioning flexible or soft type suction catheters are employed when suctioning the naso feric Oro feric and lower Airways in patients with artificial Airway these catheters are not designed to remove large volumes or large particulate matter and must be used cautiously to avoid complications prolonged suctioning with these catheters can lead to hypoxemia and hemodynamic instability necessitating pre-oxygenation and limiting suction attempts to 10 seconds or less providers should Ensure adequate oxygenation and ventilation between suction attempts to mitigate the risk of complications in critical care transport settings suctioning is often performed with an ET tube in place indications for suctioning in this scenario include dnia Airway obstruction and excessive secretions the goal is to maintain a patent Airway and facilitate optimal gas exchange for patients with compromised respiratory function complications associated with suctioning include hypoxemia cardiac arrhythmias mechanical trauma to the airway infection increased intracranial pressure and the inability to remove material due to a mucus plug or dried crusting these poten complications highlight the importance of careful and skilled suctioning techniques providers must be vigilant in monitoring oxygen saturation cardiac Rhythm and patient response during and after suctioning to promptly address any Adverse Events oxygen Administration is a Cornerstone of basic Airway management in both hospital and prehospital environments serving as the most commonly administered drug maintaining adequate oxygenation is needed to ensure cellular function and prevent hypoxia in hypoxic patients subliminal oxygen is provided with the goal of maintaining arterial oxygen saturation levels above 92% however it should be noted that unnecessary administration of oxygen leading to supernormal spo2 or hyperoxia has been associated with increased morbidity and mortality in critically ill patients this underscores the importance of tailored oxygen therapy based on individual patient needs various devices are utilized for oxygen Administration each chosen based on a physical assessment of the patient's condition the nasal canula is a commonly used device providing low to moderate oxygen flow The non-rebreathing Mask allows for the delivery of higher concentrations of oxygen and is equipped with a reservoir bag to prevent the rebreathing of exhaled air the choice of oxygen delivery device depends on factors such as the patient's respiratory status tolerance and the required oxygen concentration in situations where gas flow is inadequate positive pressure ventilation becomes necessary this may involve the use of a bag mask device which allows the provider to manually ventilate the patient by delivering positive pressure to the airway face masks super glottic Airways or endot tracheal tubes may also be employed for positive pressure ventilation depending on the clinical scenario and provider expertise.",
        "Advanced Airway Management": "Advanced Airway management Advanced Airway management involves the placement of a definitive Airway typically achieved through the insertion of an ET tube or tracheostomy tube into the trachea this intervention is considered in cases where maintaining a patent Airway is challenging or when there is a failure to adequately oxygenate or ventilate the patient patients primarily necessitate intubation for two fundamental reasons the first is the failure to maintain a patent Airway which can arise from various factors such as decreased Consciousness loss of Airway control or anatomic obstructions the second reason is the failure to adequately oxygenate or ventilate the patient often associated with conditions leading to respiratory failure or compromised gas exchange several indications warrant the consideration of ET intubation a diminished level of Consciousness with the loss of Airway control is a critical indication this may be characterized by an absent or diminished gag reflex a glass galoma scale score of eight or less and a potential for aspiration of secretions blood or vomitus patients experiencing respiratory failure manifesting as hypoxemia or hypercarbia may also necessitate ET intubation to optimize gas exchange additionally in cases of cardiac arrest after adequate CPR or bag mask ventilations have been provided ET intubation is often pursued to secure the airway and facil fa itate Advanced life support measures the process of intubation is a skilled procedure typically performed by trained healthc Care Professionals it involves passing an endot tral tube through the vocal cords into the trachea to establish a secure Airway this intervention provides a means to protect the airway facilitate mechanical ventilation and administer certain medications directly into the trachea predicting a difficult Airway is a critical aspect of advanced Airway management and various factors contribute to this assessment the patient's medical history is a key factor in identifying potential challenges during intubation anatomic findings suggestive of a difficult Airway include congenital abnormalities recent surgery trauma infection and neoplastic diseases such as cancer these factors can impact the anatomy and condition of the anatomy making intubation more challenging the lemons memonic is a helpful tool for guiding the assessment of a difficult Airway the memonic stands for look externally evaluate 332 Malon potty classification obstruction neck mobility and saturation looking externally involves identifying conditions such as short thick necks morbid obesity and an over bite or buck teeth that may complicate intubation the 332 evaluation ensures that the mouth opens adequately the mandible has sufficient space and the distance from the hyoid bone to the thyroid Notch is appropriate malenotti classification assesses the visib ibility of the aerial structures obstruction considers factors like foreign bodies obesity hematoma and masses neck Mobility especially in trauma or older patients is crucial and the evaluation concludes with considering the physiologic presentation emphasizing saturation or situation an alternative mimon for predicting a difficult Airway is heaven this memonic lists criteria that help providers assess the potential challenges during intubation Heaven stands for hypoxemia extreme of size anatomic disturbance or obstruction vomit blood or fluid exanguination and either neck Mobility or neurologic injury orot tral intubation is a procedure in advanced Airway management and the critical care transport provider must carefully determine the most effective approach to accomplish the task the overarching goal is to innovate the patient successfully on the first attempt without inducing chemodynamics compromise or risking aspiration to guide this decision-making process the provider can consider criteria such as those we have already mentioned which systematically assesses factors that contribute to the difficulty of the intubation to perform orot trical intubation the provider requires a set of specialized equipment this includes personal protective gear such as gloves a mask and goggles the essential equipment comprises ET tubes of various sizes with the usual range being from 2 to 9 most adults can accommodate a size of 7 to8 a properly sized stylet lingos scope handle and Blades either Miller or Macintosh are necessary along with suctioning equipment a 10 mL syringe water soluble lubricant a commercial tube holding device an age and size appropriate bag Mass device with Reservoir supplemental oxygen a stethoscope a device capable of continuous waveform monitoring Migel forets topical anesthetic spray for naso tracheal intubation and a rescue Airway device such as the king or LMA additionally syringes of 20 to 40 ml capacity are essential for various aspects of the procedure the lingos scope handles and Blades must also be appropriately sized for Effective intubation straight blades including Miller and Wisconsin are available in sizes o o 1 2 3 and four curved blades such as Macintosh come in sizes 1 2 three and four the selection of the appropriate blade type and size depends on the patient's age Anatomy as well as the comfort and experience of the provider regardless of what those around you may say pick the most appropriate blade that is fitted to both the patient and your level of comfort for older children and adults the comfort and experience of the provider with a particular blade type and technique are key considerations straight blades may be preferred for smaller children due to their Anatomy the ability to adapt to individual patient characteristics and provider experience enhances the likelihood of successful intubation with minimal complications the decision to perform orotracheal intubation is based on specific clinical scenarios where securing the airway is deemed necessary intubation is indicated in situations where the patient is unresponsive due to Coma or has experienced respiratory or Cardiac Arrest securing the air wve becomes Paramount to ensure effective ventilation and oxygenation intubation is also indicated when a patient requires prolonged mechanical ventilation this may be the case in critical care settings or for patients with conditions leading to sustain respiratory insufficiency orotracheal intubation allows for the administration of certain medications directly into the trachea examples of medications that may be administered include atropine epinephrine and noxin patients with conditions such as Burns or traumatic injuries May face impending Airway compromise intubation is indicated to secure the airway and facilitate effective ventilation in these cases in situations where the clinical course is expected to be complicated such as in critically ill patients or those with severe injuries intubation may be considered to maintain Airway control and optimize the patient outcome there are several notable relative complications if the patient is unable to open their mouth due to trauma dislocation or pathologic condition intubation may be challenging or contraindicated epiglottitis an inflammatory condition affecting the epiglottis may present a relative contraindication to orot tral inhibition due to the risk of causing further inflammation or obstruction if visualization of the glaic opening is hindered perhaps perhaps due to anatomical factors or difficult Airway orot tral ination may be challenging presence of copia secretions vomit or blood in the airway May impede the success of orot tral intubation and is considered a relative complication orot tral lingos scopy a component of advanced Airway management offers two main techniques direct and indirect lentos scopy in the more traditional approach of direct L roscopy vocal cord visualization is achieved by displacing the Tongue with a lingos scope blade while this method boasts High success rates low equipment costs and reliability challenges include difficulty in maintaining proficiency anatomic limitations and precautions for cervical motion restriction the procedure begins with Comprehensive Airway assessment equipment preparation oxygenation and strategic patient positioning the Cormac Lan grading system is employed to categorize the obtained view during lenos scopy ranging from grade one where the entire glaic opening is visible to grade four where only the tongue and or soft pallet remain visible conversely indirect lendos scopy utilizes vide technology to visualize the vocal cords without necessitating precise alignment of Airway axes advantages include minimal need for tongue displacement and increased distance between the providers and the patient faces however drawbacks Encompass the cost of device acquisition and maintenance storage requirements and potential obscuration of the video camera by Airway fluids two types of videoendoscopy are available standard geometry blade and a hyper angular ated Blade with the latter potentially requiring an angulated rigid stylet for optimal use bougie assisted intubation introduces a flexible ET tube introducer known as a bougie with a doual Cod tip this device proves invaluable for l roscopy in challenging a Airways and is suitable for various intubation scenarios including blind insertion or when the layx is visualized Additionally the bougie finds utility in ET tube exchange and surgical Airway placement considering flight needs in air medical environment Tru intubation practitioners May opt to fill the cuff with water to occupy an equivalent volume of air for a seal alternatively cuff pressure momet can be used to Monitor and adjust pressures with changing altitudes or practitioners May employ the minimal uding technique to maintain cuff pressures below 20 to 30 millim of mercury these considerations contribute to the optimization of Airway management during Critical Care transport in Flight settings nasotracheal intubation once a preferred Airway technique has become less common with the widespread adoption of Rapid sequence intubation particularly for spontaneously breathing patients however it still finds application in specific scenarios such as in the prehospital environment where RSI is either not per Ed or when there is a potential for a difficult Airway several disadvantages are associated with nasotracheal intubation contributing to its infrequent use these drawbacks include an extremely high failure rate a longer procedural duration compared to direct lenos scopy and the frequent need for the placement of an ET tube with a smaller diameter than those used in direct lingos scopy prolonged attempts at nasotracheal intubation may result in significant hypoxemia and glaic adeema secondary to trauma making it a less favorable option in certain clinical situations additionally it may cause significant bleeding and vomiting further limiting its applicability several Contra indications must be considered when contemplating this technique these include combativeness facial trauma with suspected Bas or skull fracture coagulopathy and upper Airway infections indications for nasotracheal intubation on the other hand involve scenarios where patients are awake and breathing but at risk of respiratory failure have a preserved gag reflex or are breathing but cannot open their mouths further contraindications to nasotracheal intubation Encompass apnic or near apnic patients the ability to pass the tube through the nostril blood clotting disorders or patients on anti-coagulation therapy and severe nasal facial are basil or skull fractures the these contraindications emphasize the need for careful patient selection and consideration of alternative Airway management strategies based on the clinical context and patient condition face-to-face intubation is a technique employed when other positions for intubation are simply not feasible as in scenarios like a motor vehicle crash with limited space in this method the provider's face is brought to the same level as the patient's face and a technique known as the tomahawk method may be utilized the procedure for face-to-face intubation closely resembles that of orotracheal intubation with some notable differences firstly the patient's head cannot be placed in the traditional sniffing position instead it is manually stabilized by a second provider throughout the entire procedure the lingos scope typically using a Macintosh blade is held in the right hand with the blade facing downward resembling a hatchet while the ET tube is held in the left hand the steps involve inserting the lnos scope blade into the right side of the patient's mouth sweeping the tongue to the the patient's left visualizing the vocal cords unlike traditional orot tral intubation where the head position can be adjusted freely in face tof face intubation the provider May slightly adjust the patient's head for better visualization by pulling the mandible forward and pressing down this adjustment optimizes the view of the vocal cords during the procedure face-to-face intubation is a valuable alternative in situations where space constraints or the patient's position limit the use of more conventional intubation approaches the careful execution of this technique including proper manual stabilization and adjustments for visualization is essential to ensure the success and safety of the procedure in the management of a challenging Airway a systematic approach mitigates potential complications and ensures patient safety one key principle is to limit intubation attempts to around 30 seconds or less as extended attempts can lead to significant hypoxemia hypercarbia and hemodynamic instability if the patient becomes hypo toxic or experiences desaturation during the attempt promptly abort the effort and prioritize oxygenation in situations where visualization of Airway structures is suboptimal it's advisable to pause the attempt provide ventilation and reassess the approach considering alternative techniques and reevaluating the patient's position a strategic intubation approach involves repositioning the patient's head to elevate the ear to the level of the sternal notch with the face parallel to the ceiling this may necessitate the use of blankets Under The Head and Shoulders or Elevate the head of the stretcher if spinal motion restriction precautions are in place removing the front of the collar while maintaining manual spinal precautions can facilitate increased mandibular displacement external lural manipulation is another option where the provider uses the right hand to manipulate the Linex for an improved view while an assistant maintains The View during endot tral tube insertion considering the difficulty of the airway employing a bougier tracheal tube introducer can be beneficial as an adjunct to enhance the chances of successful intubation these strategies collectively aim to optimize the intubation process balancing the need for successful Airway management with patient safety and minimizing potential complications the differentiation between a difficult Airway and a failed Airway is of vital importance in the realm of air way management and the criteria outlined are the difficult Airway course of Stonybrook University Hospital provides a structured framework for this distinction a failed Airway is characterized by a Triad of criteria each indicative of a critical inability in the airway management process firstly the failure to maintain an acceptable peripheral oxygen saturation during or after one or more unsuccessful lenos scopic attempts highlights the incapacity to adequately oxygenate the patient secondly the occurrence of three failed attempts at orotracheal intubation by an experienced intubator even with sustained oxygenation lastly the failure of the single best attempt at intubation in a forced to act situation signifies a critical point where the intervention is necessitated but proves unsuccessful contrastingly a difficult Airway presents an opportunity for providers to anticipate potential challenges enabling a more proactive approach to Airway management utilizing tools like the lmon or Heaven memonic AIDS in systematically assessing anatomical and physiological factors that may contribute to Airway difficulty anatomical issues such as Airway structures that pose challenges to visualization can often be addressed through strategic positioning and the use of specialized equipment on the other hand physiological issues may require additional treatment optimization and resuscitation efforts to prepare the patient for Effective Airway management the inability to predict a difficult Airway remains a leading cause of preventable Airway failures the role of critical care transport professionals becomes pivotal in this context providers must conduct a thorough evaluation to determine whether the patient is is likely to be challenging to ventilate using a bag MK device whether intubation itself poses difficulties or if alternative measures such as a super glottic Airway device or cryo thyrotomy may be necessary this comprehensive assessment ensures a tailored and well-informed approach to Airway management contributing to enhanced patient outcomes and safety in critical care transport scenarios post intubation management is a critical phase in ensuring the efficacy and safety of the airway intervention after the tube has been successfully placed and the balloon inflated to secure it in the trachea several steps must be taken firstly the utilization of continuous waveform entitle capnography is imperative this monitoring tool provides real-time information on carbon dioxide levels in the exhaled air serving as a reliable indicator of the tube's proper placement and the adequacy of ventilation simultaneously oscilation of the chest is performed to assess breath sounds and confirm the distribution of air within the lung in cases where left side breath sounds are detected potential issues with ET tube placement must be considered the tube may be inserted too deep or complications such as pneumothorax pneumonia adelais or pneumonectomy could be contributing to the asymmetry in breath sounds if uncertainty persists regarding the correct placement of the tube immediate action is needed in these instances the tube should be promptly removed and ventilation resumed using a bag Mass device while reassessment and corrective measures are taken once successful intubation is confirmed the next phase involves providing post-intubation analgesia and sedation in accordance with local protocols these medications are administered to ensure patient Comfort alleviate potential discomfort associated with intubation and facilitate tolerance to the artificial Airway proper pain management and sedation contribute to Patient well-being and minimize adverse physiological responses the Len geom mask Airway or El L ma is a valuable tool in advanced Airway management especially in situations where conventional intubation has failed widely advocated for use in both emergency and EMS environments the LMA offers several advantages and considerations one of the primary advantages of the LMA is its ease of insertion eliminating the need for direct laringoscopia which can be challenging in certain scenarios the device facilitates efficient and effective Airway management by providing Superior oxygenation and ventilation when compared to traditional bag mask ventilation techniques however like any medical intervention it's not without its disadvantages one notable concern is the risk of aspiration which underscores the importance of careful patient selection and ongoing monitoring during use additionally achieving and maintaining an adequate seal can be challenging potentially leading to the loss of tital volume and the possibility of gastric inflation indications for use include situations of deep coma Cardiac Arrest Andor respiratory arrest where alternative methods of way management such as ET intubation may not be feasible or successful Contra indications are essential to consider to ensure patient safety patients with an intact gag reflex facial Andor esophageal trauma and those suspected of having a far body Airway obstruction are generally not suitable candidates for LMA placement the king LT Airway represents a significant advancement in Airway management functioning as a single Lumen super glottic Airway that can be placed blindly the device is designed to address specific challenges in Airway management particularly in situations where traditional methods may be impractical or unsuccessful there are two main types the king LTD suitable in both adults and children in prehospital settings and the King ltsd designed exclusively for adult use with five sizes available for each type practitioners have the flexibility to select the most appropriate size based on the patient's anatomy and their height despite its utility the king Airway is not without potential risks one notable concern is the risk of regurgitation and aspiration emphasizing the importance of careful patient selection and monitoring during use another risk has to do with overinflation of the balloon which can compress on the cored arteries and result in a reduction in cerebral oxygenation indications for the use of the airway in compass scenarios where intubation is not feasible including the lack of necessary equipment it also serves as a valuable rescue Airway option in cases of failed intubation particularly following failed rapid sequence induction when used as a rescue Airway post RSI it's imperative to maintain sedation and paralysis once proper placement has been confirmed Additionally the airway is indicated in situations of deep coma Cardiac Arrest respiratory rest and to mitigate the risk of gastric distension contraindications are similar to that of the LMA in that it includes responsive patients with an intact gag reflex upper Airway obstruction as well as known esophagal disease ingestion of costic sub substances and patients weighing less than 26 lbs the igel represents a significant advancement in super glaic Airway technology offering a blind placement option without the need for an inflatable cuff balloon this device provides a valuable alternative in Airway management particularly in scenarios where intubation may be challenging or imprac practical unlike traditional sgas that rely on an inflatable cuff the ey gel is designed with a cuff free construction however practitioners must be mindful of potential risks associated with its use including the risk of regurgitation and aspiration indications for utilizing the eyel are situations where ET intubation is not feasible such as the lack of necessary equipment and as with the King it serves as a rescue Airway in cases a failed intubation particularly following unsuccessful rapid sequence induction in instances where it's utilized as a rescue post RSI it is essential to maintain sedation and paralysis once proper placement has been verified Additionally the eyel is indicated in scenarios of deep coma Cardiac Arrest respiratory arrest and to mitigate the risk of gastric distension during bag mask ventilations contraindications include as with the King and LMA an intact gag reflex upper Airway obstruction known esophageal disease ingestion of costic substances as well as obstructive lesions below the glaus and various conditions that limit mouth opening or pose the risk of trauma when faced with a patient who cannot be intubated or ventilated through traditional means the placement of a surgical Airway becomes a critical intervention executing this procedure necessitates a comprehensive understanding of the anterior neck Anatomy with the thyroid cartilage being the most prominent and the CID cartilage directly inferior to it the cryo thyroid membrane lying between these structures is a vital Landmark for the identification of the surgical Airway insertion site the equipment required for a surgical Airway includes ET tubes or tracheostomy tubes of various sizes a scalpel bougie curved hemat suction equipment a 14 gauge or larger over the needle catheter qu inch tape a 10 mL syringe a three-way stop coock two pieces of standard oxygen tubing A Y connector an oxygen cylinder coupled with a 50 psi step down regulator and needle flow meter providone iodine swabs personal protective equipment including sterile gloves a sterile fitrated drape with a hole in the center a 4x4 in Galls pad a bag mask device a guide wire and a cotton tie or commercial tracheostomy holder in the realm of surgical Airways there are two main procedures the needle CID thyrotomy and the surgical CID thyrotomy needle cryo thyrotomy is indicated when intubation is not feasible intubation does not relieve obstruction or a field procedure is necessary to establish a temporary Airway contraindications include severe Airway obstruction below the sight of catheter insertion complications may include Hemorrhage subcutaneous empyema infection misplacement of The canula Accidental removal subglottic stenosis mediastinal osma tracheal and esophageal laceration and barot Trauma surgical cryo thyrotomy is also indicated in situations where intubation is not feasible does not relieve obstruction or a field procedure is necessary to establish a temporary Airway contraindications include the inability to identify anatomic landmarks usually due to trauma and pediatric patients younger than 10 complications align with those of Neal cryo thyrotomy and several types of surgical cryo thyrotomy including open cryo and modified cryo these interventions are reserved for scenarios where other Airway management techniques are not viable highlighted the need for thorough training and competence among healthc care providers remember surgical Airways are life-saving procedures emphasizing the critical role of well-prepared practitioners in emergent situations rapid sequence induction also known as rapid sequence intubation or RSI is a critical medical procedure involving the Swift administration of sedative induction and neuromuscular blocking agents to induce a state of unconsciousness and paralysis in the patient the primary indications for RSI align with those for endot tral intubation with the exception of patients in Cardiac Arrest who should not undergo medication administration to facilitate intubation it is essential to recognize that the use of sedatives and paralytics during RSI will eliminate the patients ability to protect their Airway and engage in spontaneous breathing while the standard Contra indications and complications associated with regular intubation procedures apply to RSI the most significant contraindication is the predicted inability to successfully intubate the patient Additionally the most devastating complication is the failure to adequately oxygenate or ventilate the patient therefore RSI demands meticulous assessment planning and preparation to ensure the safety and success of the procedure the urgency and precision required in RSI underline the importance of skilled practitioners and thorough training to manage manage Airways in critical and time sensitive situations the procedure is a methodical approach encompassing the seven PS to ensure a systematic and safe intubation process the initial step involves preparation where all necessary equipment is assembled and the availability of medications is confirmed pre-oxygenation follows focusing on optimizing the patient's oxygen levels before the procedure to establish a sufficient Reserve pre-intubation optimization addresses any pre-existing conditions or concerns that might impact the intubation process ensuring a comprehensive assessment of the patient's overall condition next we have paralysis involving the administration of sedative induction agents to induce unconsciousness and neuromuscular blocking agents to induce paralysis proper patient positioning is emphasized to facilitate optimal visualization and intubation placement with proof is crucial and continuous waveform entitle capnography is employed to confirm the correct positioning of the ET tube additional confirmation methods such as puls o Symmetry and chest radiograph if available contribute to the overall verification of tube Placement post-intubation Management ensures the well-being and stability of patients who have undergone RSI this multifaceted process involves a combination of vigilant care and monitoring to address potential complications and maintain optimal physiological conditions medications utilized in RSI are strategically categorized into sedative induction agents and neuromuscular blocking agents each serving distinct purposes in achieving a smooth intubation process sedative induction agents introduce unconsciousness effectively and safely atom8 stands out for its hemodynamic stability making it a Preferred Choice in RSI its rapid onset and minimal impact on cardiovascular parameters contribute to a controlled induction process which is particularly advantageous in patients with compromised hemodynamic status on the other hand neuromuscular blocking aent agents are employed to induce paralysis facilitating intubation by eliminating muscle movement and resistance depolarizing agents like sual choline act by rapidly depolarizing the neuromuscular in plate leading to Temporary paralysis non depolarizing agents such as vecuronium pancuronium and rocuronium offer an alternative for patients with contraindications to sual choline or those requiring prolonged paralysis additionally these non depolarizing agents such as vacon can be used at the 10% loading dose to help alleviate fasiculations that are typically noted with the use of sual choline as state before entitle CO2 monitoring plays a role in the post-intubation phase as it provides real-time feedback on the proper placement of the ET tube this monitoring technique allows Healthcare Providers to confirm that the tube is correctly positioned within the trachea minimizing the risk of complications associated with misplacement such as hypoxia and respiratory compromise post-intubation care extends Beyond tube confirmation encompassing ventilation and ongoing monitoring ensuring adequate ventilation to maintain proper oxygenation and prevent complications such as hypercapnia is essential ongoing monitoring involves continuous assessment of Vital Signs oxygen saturation and entitle carbon dioxide levels this compreh comprehensive approach aims to promptly identify and address any deviations from the desired physiological parameters the success and safety of the RSI procedure hinge on a structured approach that involves careful assessment meticulous planning and thorough preparation this encompasses not only the technical aspects of intubation but also the post-intubation phase where proac Ive management and monitoring are instrumental in achieving optimal patient",
        "Tracheostomy Management": "outcomes trach oity management patients undergoing inner facility transport may present with a pre-existing tracheostomy a surgical procedure involving the creation of an opening into the trachea through the neck to facilitate breathing this intervention is indicated for various reasons such as facial trauma significant tracheal trauma head injury and the need for long-term ventilator support or failure to wean with the latter being the most common indication that being said it is not without its contraindications patients with coagulopathy neck tumors or infection c s may be unsuitable candidates for this procedure additionally there are relative contraindications or the alternative may be deemed more favorable than proceeding with a tracheostomy even if that alternative is death as with any medical intervention this procedure is associated with potential complications accidental removal is a common risk particularly in the early stages of a fresh or non-mature tracheostomy false passages or tracks may form during the procedure leading to difficulties in proper functioning infections hemorrhages aspirations mediastinal empyema tracho esophageal fistulas tracheal stenosis and tracho arterial fistulas are among the complications that may arise this lecture on respiratory emergencies and Airway management provided a comprehensive overview of key topics we began with an exploration of anatomy and physiology of the respiratory system delving into the intricate structures and functions that underly respiratory processes the physiology at the respiratory system segment reviewed the mechanisms governing respiration ensuring a foundational understanding patient assessment techniques were thoroughly covered emphasizing The crucial role of accurate evaluation in respiratory emergencies the lecture progressed to discuss air blood gas monitoring shedding light on the significance of monitoring blood gases to gauge respiratory efficiency non-invasive venor and oxygenation monitoring introduced paramedics to advanc techniques for assessing and optimizing respiratory function without invasive interventions while basic and advanced Airway management strategies were discussed in depth equipping providers with a diverse set of skills to manage Airway challenges across a spectrum of scenarios this lecture aimed to empower Critical Care paramedics with a robust understanding of respiratory emergencies from foundational anatomy and physiology to Advanced Airway management techniques enabling you to deliver Optimal Care in diverse and challenging  situations"
    },
    {
        "Introduction to Ventilation": "chapter 7 ventilation introduction ventilation is the process of supplying oxygen into the lungs to facilitate optimal gas exchange manual ventilation involves the deliberate Hands-On administration of breaths often through techniques such as mouth-to-mouth resuscitation or the use of a bag mask device on the other hand mechanical iCal ventilation performed with the assistance of a machine is a critical intervention in various medical scenarios this method can be categorized based on the application of either positive or negative pressure positive pressure ventilation the prevailing approach to contemporary Medical Practice can be employed invasively via an endotracheal tube or non-invasively using devices such as a nasal canula or full face mask the decision to initiate mechanical ventilation is Guided by specific indications including the management of the work of breathing enhancement of inhaled gas distribution protection of the airway and addressing conditions such as apnea and ventilatory or respiratory failure each mode of ventilation whether manual or mechanical serves as a critical element in the medical Arsenal for ensuring effective respiratory support and gas exchange in patients with varying clinical",
        "Overview of Mechanical Ventilation": "needs overview of mechanical ventilation ventilating a patient is a critical intervention aimed at achieving the fundamental goal of supplying adequate minute ventilation to align with the patients metabolic demands achieving this objective requires an assessment of lung function through precise pressure and flow measurements these measurements provide information regarding various respiratory parameters including respiratory volume resistance compliance and the work of breathing respiratory volume assessment is pivotal for gauging the quantity of air moved during each respiratory cycle while resistance measurement reveals the impediment to air flow within the respiratory system compliance representing the ability of the lungs and chest wall to distend influences the ease with which the lungs expand additionally evaluating the work of breathing quantifies the energy expenditure associated with the respiratory effort clinicians leverage this comprehensive information in order to scrutinize respiratory mechanics and lung function such an evaluation is imperative for tailoring mechanical ventilatory support to the individualized needs of the patient optimizing the effectiveness of Ven ventilation in ensuring that the ventilatory parameters align harmoniously with the patient physiological requirements Respiratory Care practitioners often encounter and navigate through various terminologies for assessing and managing ventilatory support here we will Define dead space ventilation Alva to arterial oxygen gradient ventilation profusion mismatch and minute volume dead space ventilation also known as wasted ventilation represents the volume of gas involved in the inhalation and exhalation processes but does not contribute to gas exchange anatomic Dead Space occurs in specific regions they including the Airways in the mouth and nose and terminal bronchioles notably the anatomic Dead Space for an adult male constitutes 1/3 of the tital volume with the remaining 2/3 considered Alvar ventilation the introduction of additional components to the ventilator such as an inline suction catheter or heat exchangers contributes to Mechanical Dead Space affecting the deled breath the Alvar to arterial oxygen gradient serves as a valuable metric for exposing the source of hypoxemia calculated through arterial blood gas analysis the Alvar to arterial gradient AIDS in distinguishing between intrapulmonary and extrapulmonary causes of hypoxemia a normal gradient expressed by the formula of H + 10 / 4 assists in the evaluation of respiratory function elevated alvr to arterial gradients in conditions like pneumonia indicate ventilation profusion mismatch where excessive secretions within the lung imp gas exchange within the Alvi ventilation profusion mismatch evaluated through the VQ ratio assesses the balance between air entering the respiratory tract and blood passing through the pulmonary capillary system deviations from the healthy ratio of 0.8 signal a VQ mismatch necessitating identification of the underlying cause and an appropriate corrective plan conditions such as pneumonia asthma COPD osma adelais and pulmonary edema contribute to shunts hindering gas exchange across the Alvar capillary membrane conversely dead space ventilation disrupts normal blood flow through the capillary system as seen in scenarios like pulmonary embolism minute volume quantifying the amount of air breathed in 1 minute emerges as a key parameter in ventilatory assessment calculated by multiplying the exhale tital volume by the respiratory rate normal minute ventilation ranges between 5 to 8 L per minute under understanding and adjusting minute volume play a pivotal role in optimizing ventilator settings to meet the individualized respiratory needs of the patients as clinicians delve into these respiratory terminologies they gain a comprehensive understanding of the intricacies involved in providing effective ventilatory support and addressing respiratory challenges in diverse clinical scenarios",
        "Positive-Pressure Ventilators": "positive pressure ventilators mechanical ventilators indispensable in critical care settings exhibit distinct features that intricately contribute to their functionality and customization for individual patient needs firstly the power source for these life-saving devices necessitates an external Supply INF izing the criticality of consistent energy input for sustained ventilation support cycling refers to the variable that terminates the inspiratory phase of breath influencing the synchronization and efficiency of the respiratory cycle breath delivery operates through the application of either positive or negative pressure positive pressure ventilation the prevailing method and involves the delivery of breaths with increased pressure facilitating the expansion of the lungs conversely negative pressure ventilation induces inhalation by decreasing pressure around the chest prompting air entry parameters govering ventilator function are selected by clinicians encompassing mode tital volume or inspiratory pressure respiratory rate set minute volume inspiratory to expiratory ratio flow or inspiratory time fraction of inspired oxygen and positive in expiratory pressure each parameter is individually tailored to optimize ventilation support based on the patient's specific respiratory requirements tidal volume refers to the volume of air delivered in each breath during the ventilatory cycle it represents the amount of air exchanged during a normal breath typically measured in milliliters respiratory rate is the number of breaths delivered by the ventilator in one minute set minute volume is the total volume of air delivered by the ventilator in 1 minute it is calculated by multiplying the tital volume by the respiratory rate and is essential for ensuring an adequate minute volume to meet the patient's respiratory needs the inspiratory to expiratory ratio represents the proportion of time allocated for inspiration compared to expiration during each breath cycle it is expressed as a ratio such as 1 to2 indicating for example that inspiration lasts twice as long as expiration flow or inspiratory time refers to the rate at which gas is delivered to the patient during the inspiratory phase it influences how quickly the tital volume is delivered and is a factor in determining the shape of the flow waveform fraction of inspired oxygen or F2 is the fraction or percentage of oxygen in the gas mixture delivered to the patient it indicates the concentration of oxygen in the inspired air and is an essential parameter in managing the patient oxygenation status positive end expiratory pressure or peep is the positive pressure maintained in the Airways at the end of the expiratory phase it prevents Alvar collapse enhances oxygenation and reduces the work of breathing peep is measured in centimet of water or cmh2o the ventilator circuit an external component integral to the system ensures the delivery of pressurized air to the patient the circuitry allows for efficient and controlled air flow enhancing the Precision of ventilation delivery while we may have a bad habit habit of silencing them alarms serve as Vigilant guardians of patient safety they vary in type and are set according to individual patient characteristics these alarms ranging from those signaling high or low pressure to alarms triggered by deviations in respiratory rate or disconnection are indispensable for timely identification of issues and intervention these alarms should never be disabled underscoring the imperative to maintain constant vigilance over the patient's respiratory status in summary the features of mechanical ventilators from their power source and cycling mechanisms to breath delivery customizable parameters external circuits and alarm systems collectively ensure the effective and tailored provision of life- sustaining respiratory support in critical medical situations as stated earlier mechanical ventilators play a significant role in critical care and understanding the distinctions among various types is important for Effective patient management new Critical Care ventilators are tailored to specific patient populations including adults pediatric or neonatal patients some ventilators are limited by weight capacity While others offer versatility accommodating patients across a broad weight Spectrum these ventilators can be stationary commonly found in intensive care units or portable for use during patient transport offering flexibility in diverse clinical scenarios transport ventilators chosen based on several critical factors require careful consideration patient characteristics such as age weight Acuity and the type and duration of Transport play a role in selecting the appropriate ventilator the means of Transport whether by ground rotor aircraft or fixed wi aircraft further influences this Choice budget considerations for equipment and supplies associated with the ventilator are also factors in decision- making sophisticated ventilators often equipped with flow sensing devices provide valuable feedback through pressure volume and flow waveforms this feedback allows healthc care providers to make precise adjustments to ventilator settings some Advanced ventilators feature pressure volume and flow volume Loops facilitating the detection of compliance changes air leaks and air trapping blower driven ventilators a subset of Transport ventilators offer higher flow rates and utilize The turbin Driven mechanism to deliver gases directly to the output section these ventilators feature a flow control valve for delivering specific settings these ventilators are categorized to three levels of performance sophisticated ventilators akin to those used in icus provide consistent parameters modes accurate monitoring and comprehensive alarm settings however extensive training is required for mastering the multitude of available functions midlevel transport ventilators offer a simpler use interface basic modes and lower costs but may be challenging for patients with specific lung conditions simple transport ventilators while the most cost effective and userfriendly have limitations such as fixed F2 poor trigger performance and minimal alarms transport concerns including battery life and oxygen tank duration are Paramount ensuring uninterrupted ventil support during transport in regards to patient safety providers should familiarize themselves with the operating characteristics capabilities and features of the ventilator in use their responsibility extends to troubleshooting and adapting as necessary underscoring the importance of their expertise in managing ventilatory support during Critical Care transport scenarios non-invasive ventilation represents a significant advancement in Respiratory Care eliminating the need for invasive methods that involve artificial Airways historically conventional ventilation necessitated invasive techniques such as the placement of an ET tube or a tracheostomy tube for Effective mechanical ventilation however non-invasive ventilation by definition refers to any form of mechanical ventilation that operates without the use of an artificial Airway this Paradigm Shift has introduced Innovative techniques that offer effective respiratory support while preserving the Integrity of the patient's natural Airway one of the non-invasive ventilation methods is the high flow nasal canula A system that delivers heated and humidified oxygen at a high high flow rate through nasal prongs this method not only provides supplemental oxygen but also generates positive airway pressure supporting ventilation without the need for invasive intubation continuous positive airway pressure or CPAP is another non-invasive technique that maintains a constant pressure throughout the respiratory cycle preventing Airway collapse and improving oxygenation CPAP is commonly employed in conditions such as obstructive sleep apnea and acute respiratory distress syndrome bi Lev positive airway pressure or BiPAP is a non-invasive ventilation mode that delivers two levels of pressure during the respiratory cycle higher pressure during inspiration and lower pressure during expiration this Dynamic pressure support AIDS in enhancing tidal volume and reducing the work of breathing making it a valuable tool in managing respiratory conditions like COPD exacerbations and respiratory failure these non-invasive ventilation methods exemplify the evolution of respiratory support offering alternatives to invasive procedures like intubation or tracheostomy the Strategic application of high flow nasal canula CPAP or BiPAP underscores the commitment to providing effective and patient-friendly Respiratory Care while minimizing inherent risks associated with invasive procedures as technology and medical understanding progresses non-invasive ventilation methods will continue to play a role in enhancing patient outcomes and expanding the repertoire of tools available to clinicians in the realm of respiratory support the high flow nasal canula or hfnc has emerged as a versatile tool in Respiratory Care offering a range of benefits across diverse patient populations firstly the hfnc stands out for its ability to deliver a high flow air oxygen blend with Precision allowing providers to achieve specific fraction of inspired oxygen targets the capacity to deliver flows ranging from 40 up to 60 L per minute of humidified oxygen particularly in adult patients sets the hfnc apart as an effective method to enhance oxygenation one of the notable advantages of the device is its ability to reduce inspiratory resistance thereby lessening the work of breathing for patients the incorporation of heat and humidification addresses the discomfort associated with conventional oxygen therapy contributing to improved patient tolerance the canula has demonstrated efficacy in enhancing ventilation and oxygenation making it a valuable tool in the management of various respiratory conditions the hfnc provides a level of positive end expiratory pressure or continuous positive airway pressure further supporting patients with conditions such as COPD including osma pneumonia covid-19 asthma exacerbation pulmonary fibrosis cystic fibrosis and lung cancer the neonatal and pediatric populations have also experienced benefits from hfnc emphasizing its versatility across age groups additionally it can be utilized as a bridge therapy while other treatments or medications are being administered showcasing its role in comprehensive patient care the HFN C's advantages extend to increasing functional residual capacity and contributing to the washing out of physiologic dead space this makes it a useful option for pre- oxygenating patients undergoing rapid sequence intubation however like any medical intervention it is not without its limitations it may be impractical for inner facility transports due to its equipment requirements and the need for a constant power source Additionally the exact amount of Peep generated by the device remains somewhat unclear in the neonatal and pediatric population the raim canula has gained popularity as a specific type of nasal canula this variation retains the the advantages of the hfnc making it a preferred choice for younger patients in respiratory distress overall comprehensive benefits of HFN C's coupled with its capability to address a specific spectrum of respiratory conditions position it as a valuable and versatile tool in the Respiratory Care armament continuous positive airway pressure or CPAP stands as a Cornerstone in the management of various respiratory conditions with indications ranging from premature neonates with respiratory distress to adults with obstructive sleep apnea and acute pulmonary edema among other clinical scenarios the physiological mechanism underlying CPAP involves the application of continuous positive pressure to the upper airw way culminating in a profound decrease in the overall work of breathing for the patient in the context of acute pulmonary edema the application of CPAP illustrates its immediate and effective therapeutic impact by delivering continuous positive pressure CPAP prevents additional fluid from leaking out of pulmonary vessels and entering the Airways this not only safeguards against the collapse of fluid fil Airways but also reduces transpulmonary pressure and mitigates the afterload on the heart these combined effects result in a multifaceted approach to improving oxygenation achieved through the delivery of oxygen under continuous positive pressure and the splinting open of terminal Airways this dual strategy significantly contributes to improve clinical outcomes in patients with acute pulmonary edema cpaps capacity to alleviate the work of breathing and enhance oxygenation extends its utility Beyond acute pulmonary edema to a spectrum of respiratory conditions in neonatal care CPAP is a critical intervention for premature neonates experiencing respiratory distress providing respiratory support until their pulmonary systems mature for adults with obstructive sleep apnea CPAP serves as a foundational treatment by maintaining a continuous positive pressure preventing Airway collapse and promoting uninterrupted air flow during sleep the physiological principles underlying cpaps efficacy emphasize its role in addressing both the mechanical and gas exchange components of respiratory distress by reducing the work of breathing and preventing Airway collapse CPAP enhances oxygenation offering a valuable therapeutic tool in the Arsenal of respiratory interventions as healthc Care Professionals continue to refine their understanding of respiratory physiology cpat will remain a stal wart Ally and optimizing clinical outcomes and improving the respiratory well-being of diverse patient populations by Lev positive airway pressure or BiPAP represents an advanced form of non-invasive positive pressure ventilation characterized by the delivery of two distinct presses an inspiratory positive airway pressure or ipap and a lower expiratory positive airway pressure or epap the key feature distinguishing BiPAP from CPAP app is its unique ability to increase tital volumes thereby lowering carbon dioxide levels this mechanism not only provides the support akin to CPAP but also offers the added advantages of reducing the worker breathing during exhalation and improving tital volumes leading to enhanced clearance of carbon dioxide BiPAP serves as a valuable alternative to patients who may be unable to tolerate CPAP or simply require higher CPAP pressures it is particularly beneficial for individuals experiencing respiratory failure related to hypercarbia where elevated carbon dioxide levels necessitate precise ventilatory management the versatility of BiPAP positions it as a reasonable alternative accommodating patients with specific clinical needs that may not be optimally addressed by CPAP alone that being said the the application does come with its own challenges notably the risk of apnea induced by higher levels of pressure support than the patient requires this can occur during the initial setup or if a patient's respiratory status improves unexpectedly during transport providers employing BiPAP should maintain hypervigilance especially when using this modality without respiratory rate monitoring and apnea ventilation capability to optimize the use of the device providers should carefully select and adjust the ipap and epap settings initiating with an ipap setting of 8 to 10 cm of H2O and an epap of 3 to 5 cm of H2O provides a fairly balanced approach offering therapeutic support while mitigating the risk of induced apnea this adjustment ensures that the bypass app is tailored to the specific respiratory needs of the patient enhancing its Effectiveness and providing optimal respiratory support as with any advanced ventilatory support the judicious application of BiPAP requires a deep understanding of the patient's respiratory physiology emphasizing the importance of vigilant monitoring and precise adjustment to achieve therapeutic success positive pressure ventilators represent a prevalent and critical modality in Respiratory Care surpassing negative pressure ventilators in usage unlike the negative pressure counterpart positive pressure ventilation involves delivering tidal volumes at pressures greater than ambient pressure constituting a process that's paradoxical to spontaneous breathing while positive pressure ventilation is instrumental in providing respiratory support it is not without its potential hazards notably barot trauma barot trauma a consequence of excessive pressure can lead to complications such as pneumothorax subcutaneous empyema pumo mediastinum and pumo peritoneum necessitating careful monitoring and adjustment of ventilator settings volue trauma emerges as another significant concern when applying positive pressure to the lungs this is defined as trauma resulting from excessive lung inflation volumes and this concern is particularly relevant in patients with acute respiratory distress syndrome or ards in ards patients poor lung compliance High Airway resistance and the likelihood of heterogenous lung injury make them more susceptible to volue trauma the challenge lies in Striking a delicate balance between providing sufficient positive pressure to support ventilation and avoiding excessive lung inflation that may contribute to further trauma the prevalence of positive pressure ventilators underscores their indispensable role in managing respiratory conditions however healthc care providers must remain Vigilant to the potential hazards associated with this form of ventilation implementing meticulous monitoring and adjustments to minimize risk understanding the specific concerns such as barot trauma and volu Trauma becomes particularly crucial in tailoring ventilatory support to individual patient needs especially in cases of complex respiratory conditions like ards positive pressure ventilators constitute a diverse array of critical respiratory support devices varying in size power sources and capabilities the selection of a particular type of ventilator within an institution is a strategic decision influenced by a multitude of factors encompassing the ventilator capabilities the unique needs of the patients cost considerations and other operational factors institutions typically assess the technical specifications and features of different ventilator models to align them with the clinical requirements of their patient population the capabilities of a ventilator such as its capacity to deliver specific modes of ventilation incorporate Advanced monitoring features or adapt to various patient scenarios patient needs constitute a fundamental criteria guiding the choice of positive pressure ventilator different clinical conditions and patient demographics May necessitate specific ventilatory approaches and institutions prioritize devices that align with these requirements for instance neonatal and pediatric populations May benefit from ventilators design to meet their unique physiological needs the adaptability of a ventilator to a range of scenarios from routine respiratory support to managing acute respiratory distress syndrome or other complex cases is an aspect considered during the selection process while not everyone's favorite thing to talk about cost considerations are integral to the decision-making process especially given the financial constraints faced by Healthcare institutions these institutions evaluate the initial acquisition costs maintenance expenses and the overall cost effectiveness of ventilators over their lifespan operational factors such as ease of use maintenance requirements and compatibility with existing Hospital infrastructure also influence the selection of positive pressure ventilators mechanical ventilators employ various cycling mechanisms to regulate the inspiratory phase of a breath each dictated by specific parameters pressure ventilators terminate the delivery of the tital volume based on a clinician selected predetermined pressure in contrast volume ventilators conclude the breath when a predetermined tital volume is achieved flow cycled ventilators cease inspiration when a predetermined flow rate is attained while time cycled ventilators conclude inspiration after a selected inspiratory time has elapsed when utilizing pressure ventilation the provider must monitor key parameters to ensure optimal patient care this includes Vigilant monitoring of breast sounds oxygen saturation in tial carbon dioxide visual chest inspection and assessment of delivered title volume and exhaled minute volume volume ventilators on the other hand deliver a preset volume during varying pressures the pressure required is contingent on factors such as the size of the tital volume flow rate Airway resistance and lung chest wall compliance the provider must monitor peak airway pressure as volume ventilators using excessive pressures to deliver the tital volume can trigger alarms alerting the provider to potential issues all ventilators regardless of their cycling mechanisms rely on an external circuit connecting to the ventilator to the patient in this closed system exhaled gas is vented into the environment maintaining a separation between the ventilator and the patient a significant concern in mechanical ventilation revolves around the impact of positive pressure on the patient's hemodynamics hypohemia high levels of Peep and increased mean airway pressure are potential contributors to hemodynamic compromise the critical care paramedic must remain Vigilant in assessing these factors and adjusting ventilator settings accordingly to ensure the delicate balance between providing effective respiratory support and preserving hemodynamic stability during",
        "Ventilator Modes and Parameters": "transport ventilator modes and parameters modes in mechanical ventilation describe the types of breaths delivered to the patient categorized into mandatory or machine breaths and spontaneous breaths reflecting the patients independent respiratory efforts parameters Encompass various settings that can be adjusted to optimize ventilation continuous monitoring by the clinician is imperative and some ventilators feature numerous audiovisual alarms to alert providers to deviations or issues these providers must possess a comprehensive understanding of these parameters prior to transport ensuring effective management and response to potential complications airway pressure release ventilation also known by various names such as B level B vent basic duopap or BiPAP is a specialized ventilation mode designed for patients with ards aprv employs high levels of continuous positive airway pressure with intermittent releases in pressure creating a unique inverse inspiratory to exory ratio this mode aims to optimize oxygenation and ventilation in patients with compromised respiratory function adaptive support ventilation represents a closed loop controlled mode that utilizes feedback mechanisms to make realtime adjustments optimizing the patient's work breathing ASV employs sophisticated software that relies on the otus equation a formula calculating the optimal minute ventilation title volume and rate tailored to individual patient needs this advanced mode exemplifies the Evol evolving landscape of ventilatory support leveraging technology to provide personalized and adaptive Respiratory Care positive end expiratory pressure is a ventilatory strategy where a positive pressure is maintained in the Airways at the end of each breath cycle this is achieved by applying pressure above atmospheric pressure during the expiratory phase while peep is a valuable tool in enhancing oxygenation and preventing Alvar collapse its application comes with potential detrimental effects that require careful consideration the detrimental effects of Peep Encompass a range of physiological impacts firstly The increased positive pressure can impede Venus return leading to a decrease in cardiac output this reduction in cardiac output may have significant implications particularly in patients with compromised cardiovascular function Additionally the application of Peep can Elevate intracranial pressure making it a consideration in patients with neurological conditions or traumatic brain injuries the decreased renal and portal blood flow associated with peep May pose challenges in patients with underlying Reno or hepatic issues furthermore The increased risk of barot trauma such as pneuma thorax is a concern necessitating careful monitoring and adjustment of Peep levels certain patient populations present contraindications to the application of Peep patients with untreated pneuma thorax where there is unsealed air within the plural space and those with Broncho plural fistulas which are abnormal connections between the bronchial tree and the plural space are considered at increased risk with the use of Peep during Critical Care transport maintaining appropriate peep levels is crucial even when using a manual resuscitator or bag MK device to achieve this an external peep valve is attached to the bag allowing healthc care providers to regulate and maintain positive pressure during the expiratory phase this ensures the consistent application of Peep optimizing respiratory support and preventing potential complications associated with abrupt changes in positive",
        "Inhaled Gases": "pressure inhaled gases the critical care paramedics proficiency extends Beyond recognizing numerical values requiring a profound familiarity with the most commonly encountered gases and their indications this encompasses an understanding of the physiological implications associated with alterations in oxygen and carbon dioxide levels as well as pH imbalances elevated levels of carbon dioxide May signify hypoventilation prompting the provider to adjust ventilator parameters to enhance minute ventilation conversely hypoxemia indicated by low oxygen levels May necessitate modifications to inspired oxygen concentrations or peep settings by navigating through the intricacies of these gases and their clinical indications the provider becomes Adept at tailoring mechanical ventilation strategies to meet the dynamic resp respiratory needs of critically ill patients during transport inhaled nitric oxide also known as nitrogen monoxide has witnessed an increased utilization during Critical Care transports marking a significant development in respiratory support strategies the rise in use can be attributed in part to the introduction of portable systems in the expanding recognition of patient populations benefiting from its efficacy ongoing research continues to delineate the scope of application with many institutions establishing standing agreements to authorize its use in adults experiencing refractory hypoxemia across various clinical syndromes the titration of parameters demands careful consideration before initiating therapy to ensure its optimal Effectiveness abrupt discontinuation of this gas has been associated with the rebound phenomenon characterized by significant desaturations and hemodynamic instability underscoring the necessity to calculate gas volumes and assess battery lifespan during transport moreover careful planning is essential to guarantee the availability of necessary equipment and supplies for uninterrupted Administration throughout the transport process nitric oxide gas known for its reactivity readily interacts with other gases including oxygen and water vapor within the ventilator circuit tubing necessitating vigilance in managing its delivery methogo anemia arising from the oxidation of hemoglobin to methemoglobin is identified as a potential complication of therapy emphasizing the need for continuous monitoring during its Administration in critical care transport nitric oxide serves as a valuable adjunct for extremely hypoxic patients allowing the optimization of conventional therapies and continuity of care initiated prior to transfer it also functions as a bridge to more advanced interventions such as extracoporeal membrane oxygenation or ECMO or highfrequency jet ventilation the administration of nitric oxide during transport demands a high level of expertise from the critical care transport professional necessitating thorough familiarity with equipment operation troubleshooting and emergency procedures it's important for the provider to have a manual resuscitator readily available for delivering breaths with gas attached ensuring seamless integration of this advanced respiratory therapy into the critical care transport setting epoprostenol is used in the treatment of hypoxemia associated with conditions such as pulmonary hypertension and ARS this prostacylin analog exerts its therapeutic Effects by inducing selective pulmonary vasod dilation this targeted vasod dilation contributes to improvements during ventilation profusion mismatch within the pulmonary vasculature without eliciting any systemic hemodynamic compromise The Selective action of this medication on the pulmonary circulation makes it particularly viable in scenarios where optimizing oxygenation is Paramount as seen in the context of pulmonary hypertension and ARS it is important to recognize that the duration of action for inhaled epoprostenol is relatively short typically spanning 3 to 5 minutes this temporal aspect introduces a critical consideration in the management of patients receiving this medication any interruption in the delivery of the inhaled gas poses a risk for Rebound pulmonary hypertension this phenomenon underscores the necessity for continuous and uninterrupted administration of the medication to sustain its therapeutic effects and prevent the potentially delous consequences associated with abrupt discontinuation as such direct attention to the delivery system and Vigilant monitoring is imperative to ensure the sustained efficacy of inhaled epoprostenol in optimizing pulmonary vase of dilation and ameliorating the VQ mismatch in patients facing hypoxemia related to pulmonary hypertension and ARS helox is a specialized therapeutic gas blend consisting of helium and oxygen with the most prevalent formulations being 80% helium and 20% oxygen or 70% helium and 30% oxygen this unique mixture is employed therapeutically to address specific respiratory challenges by leveraging the distinct properties of helium the administration of this gas serves the purpose of reducing Airway resistance making it particularly beneficial in clinical scenarios where this resistance is elevated one of the primary applications of Helo therapy is in cases of Airway obstruction such as forign body obstruction where the gas gas mixture AIDS in facilitating improved air flow Additionally the gas is employed when patients exhibit Strider due to lul Ema the reduction of Airway resistance is also advantageous in the management of vocal cord dysfunction a condition characterized by abnormal movement of the vocal cords during breathing moreover helox finds utility in the treatment of acute exacerbations of asthma and COPD when conventional interventions have proven ineffective by alleviating Airway resistance this gas can enhance the efficiency of respiratory efforts and contribute to improved oxygenation making it a valuable therapeutic option in the management of various respiratory",
        "Respiratory Distress and Respiratory Failure": "conditions respiratory distress and respiratory failure respiratory failure constitutes a medical emergency characterized by a failure of the pulmonary system to fulfill the body's metabolic requirements for both oxygenation and ventilation initially presenting as respiratory distress respiratory failure reflects a critical imbalance between the demand for oxygen and the lungs capacity to supply it this condition encompasses a spectrum of severity ranging from mild impairment to a life-threatening State necessitating prompt and targeted interventions as respiratory failure progresses the signs and symptoms become more pronounced and can include cyanosis hypercapnia and hypoxia contributing to a Cascade of physiological responses breac cardia may ensue as the body attempts to conserve energy patients often manifest fatigue shallow breathing and in severe cases may experience a loss of consciousness these indicators collectively underscore the severity of respiratory failure emphasizing the urgent need for comprehensive medical intervention to address the underlying causes and restore adequate oxygenation and ventilation respiratory failure is classified into four distinct types each presenting unique challenges and underlying pathophysiological mechanisms type one known as hypoxemic respiratory failure is characterized by the lung's inability to deliver sufficient oxygen to the pulmonary vasculature this may result from various conditions affecting the lung parenchima such as pneumonia or acute respiratory distress syndrome in contrast type two respiratory failure or ventilatory failure is observed in patients with airf flow obstruction heightened work of breathing poor lung compliance increased Airway resistance and a decreased respiratory drive this type often manifests in chronic obstructive pulmonary disease exacerbations or neuromuscular diseases type 3 respiratory failure a peroperative subtype of type one is commonly encountered in post-operative patients a key contributor to this type is atacas the partial or complete collapse of lung tissue often attributed to surgical procedures and associated with changes in lung mechanics lastly type four respiratory failure occurs in the setting of shock where hypo perfusion compromises oxygen delivery to the tissues leading to respiratory distress and failure recognizing the specific type of respiratory failure is important for tailoring appropriate interventions obtaining a recent chess radiograph and the corresponding radiologist report is emphasized to rule out abnormalities and confirm the correct placement of an ET tube this diagnostic approach is essential for informing targeted treatment strategies and optimizing patient outcomes in the management of respiratory failure",
        "Ventilator Management": "ventilator management ventilator management involves the Strategic use of portable ventilators to address various respiratory challenges indications for employing a portable ventilator Encompass a spectrum of conditions including impending or actual respiratory failure inadequate respiratory drive or apnea insufficient gas exchange and the need to reduce the work of breathing and oxygen cost portable ventilators support patients facing compromised respiratory function ensuring timely intervention to optimize oxygenation and ventilation however the utilization of portable ventilators is not without its potential complications mechanical failure is a significant concern posing a risk to patient safety patient anxiety can also arise potentially impacting the overall efficacy of ventilation improper settings on the ventilator may lead to suboptimal respiratory support while increased intrapulmonary pressure can result in barot truma and cardiovascular compromise gastrointestinal disturbances infections and paired clearance of secretions further contribute to the spectrum of potential complications associated with portable ventilator use one critical consideration is the ventilator ability to meet the patient's flow demand emphasizing the need for Vigilant monitoring and adjustment in contemporary practice modern ventilators are designed to match the demands of most patients nevertheless the key aspect in Ventilator man management is a thorough understanding of the equipment's capabilities and the ability to tailor its settings to the specific lung condition of the patient this knowledge ensures that portable ventilators are employed effectively addressing the unique respiratory needs of each individual and minimizing the risk of complications associated with mechanical ventilation during the transport of a critically ill patient receiving mechanical ventilation any adjustments to the ventilator should be judiciously limited to those that are absolutely necessary the primary focus during transport typically revolves around the maintenance of adequate oxygenation minute ventilation and ensuring the patients comfort and safety this cautious approach to ventilator adjustments is in line with established guidelines followed by Critical Care transport professionals who are resp responsible for intubating and initiating mechanical ventilation in critically ill patients the emphasis on stability and consistency in Ventilator settings is important to prevent disruptions in the delicate balance of respiratory support during the transport phase in some instances the critical care paramedic may find themselves transporting a patient who is connected to an unfamiliar ventilator device or in an unfamiliar mode in these cases particularly when using a conventional transport ventilator it becomes important to determine if the patient can be safely transitioned from the current ventilator to the conventional one before initiating transport a preuse check of the ventilator and circuit adhering strictly to the manufacturer's guidelines is a fundamental step in ensuring the equipment's optimal functioning and reliability during transport this approach not only aligns with safety protocols but also contributes to the seamless continuation of mechanical ventilation support for the patient throughout the transport journey adhering to well-defined guidelines is imperative to ensure optimal respiratory support the suggested guidelines Encompass a systematic approach that clinicians can follow for Effective ventilator management firstly the clinician is tasked with making a fundamental choice between volume or pressure delivered breaths this decision hinges on the patients individual needs and the clinical context subsequently a Target title volume of 6 to 8 MLS per kg calculated using the predicted body weight is established this precise volume determination is used to align ventilator settings with the patient's respiratory requirements in selecting an appropriate mode of delivery for transport the clinician considers the respiratory rate opting for a range of 12 to 14 breasts per minute to maintain a physiologically sound respiratory Rhythm an inspiratory time of 1 second is initially chosen contributing to the overall respiratory cycle peep is typically set at 5 cm of H2O enhancing lung Recruitment and preventing Alvar collapse during exhalation F2 is initiated at 6% providing an initial Baseline for oxygen supplementation to ensure responsiveness and adaptability the sensitivity is set at 3 to 5 L per minute or minus 2 cm of H2O allowing the ventilator to detect patient initiated breaths or efforts the inclusion of a heat moisture exchange at a circuit y AIDS in maintaining optimal humidity levels preventing the drying of mucous membranes and enhancing patient Comfort equally vital are the alarm settings including high pressure low pressure minute volume and apne alarms these alarm parameters serve as a safeguard promptly notifying the clinici of any deviations from the preset ventilator parameters and enabling timely intervention understanding the distinction between volume delivered and pressure delivered breaths is essential volume delivered breaths limit the flow available to the patient to the set tital volume and inspiratory time whereas pressure deliver breaths allow for unlimited flow depending on the ventilator maximum capability while transporting a patient on a hospital ventilator matching their current settings is wise especially if those settings effectively ventilate and oxygenate the patient confirming values through recent arterial blood gas analysis and Consulting with the respiratory therapists sending facility physician or medical control before making adjustments is a good idea autop positive end expiratory pressure or Auto peep also known as intrinsic peep is a phenomenon observed in mechanical ventilation when there is an incomplete expiration before the initiation of the subsequent positive pressure breath resulting in air trapping within the lungs this condition is often encountered in patients who are asynchronous with the ventilator struggling to trigger a breath effectively measurement of Auto peep is facilitated by performing an expiratory hold maneuver on the ventilator provided the ventilator has this capability certain patient populations are particularly prone to experiencing Auto peep including individuals with asthma or any obstructive disease such as empyema when autop peep or hyperinflation occurs interventions aimed at alleviating the condition may be impl implemented these interventions include administering Bronco dilators to facilitate bronchial smooth muscle relaxation chest percussion to assist in the mobilization of secretions suction to remove accumulated Airway secretions and potentially steroids to mitigate inflammation in cases where Auto peep is identified a strategic approach involves verifying ET tube placement and if obstructive or restrictive lung dis diseases present shortening the ET tube this adjustment serves to reduce Dead Space optimizing the ventilatory support and mitigating the effects of Auto peep the management of Auto peep is needed to prevent complications such as barot trauma and to ensure efficient gas exchange especially in patients with compromised respiratory",
        "Management of Lung Diseases and Conditions": "function management of of lung diseases and conditions effective management of patients with common lung conditions requires an understanding of the individual's respiratory status emphasizing the importance of tailored strategies for oxygenation and ventilation each patient must undergo a comprehensive evaluation on a caseby casee basis recognizing that there is no one siiz fits-all approach applicable to every lung condition in the nuanced realm of mechanical ventilation providers must interpret and utilize feedback from the ventilator monitored values Graphics scales and Loops these parameters serve as indicators of the patient respiratory Dynamics guiding healthc Care Professionals in making precise adjustments to the ventilator settings the objective Ive is to ensure patient safety and maintain synchrony between the patient and the ventilator optimizing the therapeutic impact collaboration with the sending facilities physician respiratory therapist and medical control is integral during the setup of the ventilator discussion of the selected settings with these key stakeholders ensures a comprehensive and informed approach this multidisiplinary communication allows for the incorporation of diverse perspectives expertise and clinical insights fostering a more holistic and patient centered strategy for oxygenation and ventilation in navigating the complexities of varied BL conditions this collaborative approach is Paramount to achieving optimal patient outcomes ards as defined by the Berlin criteria is a severe and rapidly developing clinical condition characterized by specific criteria that must be met for diagnosis the onset of respiratory symptoms should be within one week of a known clinical insult reflecting the acute and often precipitous nature of the syndrome this temporal Criterion AIDS in distinguishing ARS from chronic respiratory conditions key to the diagnostic criteria is the radiographic manifestation of bilateral opacities on the chest radiographs these opacities indicative of pulmonary edema should not be fully explained by other factors such as plural affusions pulmonary nodules lowbar collapse cardiac failure or fluid overload this Imaging requirement is essential for the accurate identification of ARs and distinguishing it from conditions with similar clinical presentations furthermore the severity of the disease is assessed based on the degree of deficit in oxygenation Quantified by the ratio of partial pressure of arterial oxygen to fraction of inspired oxygen this ratio determined through arterial blood gas analysis categorizes ARS into three severity levels mild with a ratio of 200 to 300 moderate with a ratio of 100 to 200 and severe with a ratio of less than 100 this classification serves as a valuable tool in stratifying the severity of hypoxemia and guiding appropriate therapeutic interventions for these patients in managing the respiratory status of a patient with ARs various strategies are employed with the overarching goal of achieving adequate gas exchange while mitigating the potentially harmful effects of positive pressure ventilation a key emphasis is placed on adopting a lung protective ventilation strategy characterized by a low tidal volume of 4 to 6 MLS per kg of predicted body weight this approach aims to minimize ventilator induced lung injury particularly barot trauma and volum trauma by avoiding excessive lung inflation volumes additionally maintaining a high positive-end expiratory pressure level is integral to improve oxygenation and enhance lung recruitment the ards network has formulated a specific protocol for managing patients with ards particularly those with the pao2 to fi2 ratio less than 300 this protocol emphasizes the use of low tidal volumes elevated levels of Peep and an increased respiratory rate while adhering to a plateau pressure threshold of less than 30 cm of H2O these parameters are balanced to optimize oxygenation and ventilation while minimizing the risk of ventilator induced lung injury another ventilation strategy employed in ARS involves adopting an inverse inory to exory ratio commonly known as inverse ratio ventilation this entails adjusting the inspiratory time to be longer than the expiratory time aiming to increase oxygenation by elevating the mean airway pressure a contemporary iteration of the strategy is airway pressure release ventilation or aprv and is characterized by a high level of CPAP with intermittent drops in pressure aprv aims to maintain lung recruitment enhance oxygenation and facilitate more physiological breathing patterns in these patients recruitment Maneuvers are a component of managing patients with ARs aiming to enhance oxygenation and reduce the risk of adilla trauma typically a continuous positive airway pressure of 40 to 50 cm of H2O is applied for a brief period around 30 to 40 seconds this maneuver while producing a short-term Improvement in oxygenation by stabilizing collapse long areas has limitations as its benefits are not sustained over an extended period in recent advancements esophageal momet has been introduced in the ICU setting for monitoring transpulmonary pressures in arts patients by placing an esophageal balloon catheter in a specific location clinicians can measure transpulmonary pressures providing valuable insights into lung mechanics prone positioning a maneuver where the patient is turned onto their stomach is another technique employed in the hospital setting to improve oxygenation in arts patients while labor intensive and associated with significant risks prone positioning is not commonly performed during patient transport due to logistical challenges selective pulmonary vasodilators such as inhaled nitric oxide and inhaled epoprostenol are frequently utilized for p patients with ARs experiencing refractive hypoxemia during transport it's essential to have specially trained Personnel accompany the patient given the complexities involved in administering these medications administering neuromuscular blocking agents is considered when providing mechanical ventilation to Arts patients with tipia as the higher respiratory rate may lead to Auto peep however the use of these medications is regarded as a short-term solution and the goal is to withdraw these agents as soon as possible fluid management is another consideration involving a delicate balance between adequately perusing organs and avoiding unnecessary fluid in the lungs additionally ECMO is increasingly employed as a rescue therapy for severe ARS cases especially during transports requiring a higher level of care this intervention necessitates specialty teams such as perfusionists specially trained RNs and clinicians to accompany the transport team ECMO is typically considered when the patient's pa2 to F2 ratio is less than 50 and plate pressures exceed 32 cm of H2O patients with Co 19 admitted to the ICCU are managed in a similar fashion to those with ARs if their clinical presentation alliance with the berin definition the approach to treatment decisions for these patients is individualized taking into account the specific circumstances of each case one key assumption in the management of covid-19 patients is that the lungs are adequately ventilated but there is diminished profusion at the the alv capillary membrane the virus has been associated with the formation of micro thrombi in pulmonary vessels leading to a ventilation profusion mismatch and an increased incident of coagulation anomalies throughout the body common complications of covid-19 extend beyond respiratory manifestations and may include elevated liver enzymes s acute kidney injury and cardiac injury which can manifest as late onset complications however acute hypoxemic respiratory failure Remains the most prominent finding in these patients early in the progression of the infection providing supplemental oxygen was important for most covid-19 patients various oxygen delivery methods are employed including low-flow oxygen oxid dependence simple face masks non-er breathing masks HFN C's non-invasive ventilation and self- proning the World Health Organization recommends maintaining a targeted peripheral oxygen saturation of greater than 90% when administering oxygen if these non-invasive methods failed to sufficiently improve the ventilation and oxygenation status of a patient with covid-19 mechanical ventilation becomes the next therapeutic strategy the decision to initiate mechanical ventilation is carefully considered and based on the patient's clinical condition and the progression of the disease chronic obstructive pulmonary disease or COPD is a group of progressive lung disorders notably chronic bronchitis and empyema in patients with COPD increased Airway resistance and diminished elastic recoil contribute to Dynamic hyperinflation this population often experiences Air Flow Restriction making them susceptible to complications if excessive pressure or volume is applied in high rates tobacco smoking stands out as a major contributor to COPD and obtaining a detailed smoking history from patients slated for positive pressure ventilation is important for comprehensive care planning before transporting a COPD patient ensuring the administration of prescribed medications especially those due before transport is essential suctioning should be performed if ronai are present non-invasive positive pressure ventilation is a widely accepted initial strategy for managing respiratory distress in these patients with early application potentially averting the need for intubation careful application of pressure volume is Paramount in non-invasive positive pressure ventilation patients with Bolis osma a result of Alvar destruction require planning for transport involving a thorough history CT scan chest radiograph and ABG analysis oxygen strategies such as a non-rebreathing mask high flow nasal canula or minimal CPAP may be considered when setting initial ventilator parameters for a COPD patient with respiratory failure a pressure or volume Target in assist control mode is commonly employed tital volume is usually set at 6 MLS per kg of predicted body weight with Plateau pressures kept below 30 cm of H2O a respiratory rate of 10 to 12 breasts per minute is chosen aiming at an inspiratory to expiratory ratio of 1:4 or 1:5 peep is maintained at 5 cm of H2O and F2 is titrated to achieve the desired oxygen saturation sedation may be necessary if maintaining a fluid neutral state is prioritized to to ensure optimal patient comfort and stability pneumonia typically induced by a bacterial infection in the lungs can also be caused by viral or fungal infections in cases where the eological agent is unclear empiric antibiotics are initiated based on Regional guidelines it is imperative to start treatment promptly emphasizing the importance of initiating antibiotic therapy after obtaining blood and if feasible sputum cultures to guide targeted treatments for patients with pneumonia undergoing non-invasive positive pressure ventilation the use of heated wire circuits can enhance humidification and comfort during therapy additionally performing deep suction before transport is recommended to clear Airways of excess secretions facilitating improved ventilation in the management of pneumonia chest Physiotherapy and postural drainage represent a valuable option for loosening and mobilizing Pulmonary secretions these interventions can help improve the effectiveness of ventilation and oxygenation promoting better overall respiratory function utilizing a comprehensive approach that includes targeted antibiotic therapy Advan Advanced ventilatory support strategies and adjunctive interventions like heated wire circuits and suctioning ensures a thorough and tailored approach to the care of pneumonia patients during transport pulmonary fibrosis an incurable disease with a suspected genetic component is primarily idiopathic in most cases meaning its cause is simply unknown the management of pulmonary fibrosis focuses on slowing the disease progression and enhancing the patient's quality of life oxygen therapy is initiated when the patient's oxygen saturation level Falls below 88% addressing the compromised respiratory function associated with the condition pharmacological interventions may be prescribed to mitigate the scarring process and potentially improve outcomes pulmonary Rehabilitation plays a role in the overall treatment plan aiming to enhance the patients respiratory function and overall physical capacity in severe cases where the disease significantly impairs lung function lung transplant becomes a strong consideration mechanical ventilation and ECMO may be employed as a bridge to transplant supporting the patient respiratory function while while awaiting a suitable donor organ transporting a patient with pulmonary fibrosis involves a comprehensive strategy that should be discussed and coordinated among all relevant parties this includes Health Care Providers Specialists and transport teams to ensure that the patients unique medical needs and potential complications associated with pulmonary fibrosis are adequately addressed during Transit asthma a prevalent lung disorder manifests with shortness of breath stemming from inflammation of the Airways and heightened mucus production Swift intervention is essential to address compromised ventilation and oxygenation in affected individuals it is imperative for providers to distinguish between respiratory distress and respiratory failure in asthmatic patients ensuring timely and appropriate Management in the case of an asthma exacerbation immediate attention is critical patients should promptly receive supplemental oxygen along with three doses of inhaled short acting beta 2 agonists to a Bronco constriction to mitigate inflammation and minimize air flow obstruction systemic corticosteroids administered orally or interven iously are recommended if Improvement remains elusive intravenous magnesium sulfate can be considered to induce smooth muscle relaxation within the bronchial wall another potential strategy involves the administration of Helo aiming to reduce increased Airway resistance for a subset of patients showing inadequate response intramuscular administration of epinephrine or talene might be considered in cases where respiratory distress persists a trial of non-invasive positive pressure ventilation can be attempted if this fails to provide relief escalation to end tracheal inhibition and mechanical ventilation becomes the next step in managing severe asthma exacerbations in instances where patients exhibit extreme respiratory distress with a risk of autop positive-end expiratory pressure some may require heavy sedation or even paralysis to control respiratory rate and prevent further complications heart failure is a chronic condition characterized by the heart's inability to meet the body's demand for oxygen when evaluating a patient for heart failure the initial step involves identify in whether the condition stems from a pump filling problem such as diastolic malfunction or a pump contract ability problem such as a systolic malfunction utilizing an electrocardiogram proves instrumental in assessing cardiac structures and function allowing for the identification of areas of aeia in the ventricles a more definitive diagnosis of heart failure can be achieved through a comprehensive assessment incorporating the patient's medical history physical examination chest radiograph and ECG when transporting a patient the primary goal may be to provide support for oxygenation and ventilation in cases where the patient presents with trouble breathing non-invasive positive pressure ventilation in the form of CPAP is often the first line strategy to address respiratory distress alternative L BiPAP may be considered these interventions are complemented by standard pharmacologic treatments aimed at managing heart failure in situations where intubation becomes inevitable employing a low tidal volume strategy of 6 to 8 MLS per kg of predicted body weight is recommended as the initial approach this approach helps mitigate the risk of barot trauma and other complications ass associated with mechanical ventilation while ensuring optimal oxygenation and ventilation support for patients experiencing heart",
        "Patient Monitoring": "failure patient monitoring prior to initiating transport a comprehensive preuse check is imperative this involves a thorough assessment of all equipment including the ventilator to ensure optimal functionality and reliability during Transit the preuse check encompasses meticulous scrutiny of various components ranging from the ventilator circuit to Associated monitoring devices verifying that each element is in proper working order throughout the transport process continuous monitoring of key ventilator parameters is essential for the critical care transport paramedic parameters such as Peak inspiratory pressure respiratory rate exhaled tital volume and the inspiratory to expiratory ratio must be vigilantly observed to promptly identify any deviations or abnormalities Peak inspiratory pressure reflects the maximum airway pressure during the ventilatory cycle while providing insights into the resistance encountered by the patients's resp atory system monitoring respiratory rate ensures the adequacy of ventilation while tracking exhale title volume AIDS in addressing the efficiency of gas exchange the IE ratio indicating the duration of inspiration relative to expiration is for maintaining an appropriate balance in the ventilatory cycle this documentation of ventilator parameters is fundamental to ensuring patient safety and facilitates seamless continuity of care fostering an environment where any necessary adjustments can be promptly executed based on real-time physiological",
        "Ongoing Care": "feedback ongoing care it is the transport team's responsibility to safeguard proper ventilator function and the patient's ventilatory status throughout the transport process to maintain a stable and patent Airway the team must employ their expertise in Airway management ensuring that the endot tral tube or other Airway adjuncts are securely in place verification and documentation of the ventilator settings and monitored values represent a key aspect of the team's duties this entails a comprehensive assessment before before during and after arrival at the destination promoting a seamless Continuum of Care the transport team is further tasked with guaranteeing the availability and functionality of essential resources during Transit this includes ensuring a stable power supply for the ventilator and an adequate oxygen supply both of which are critical components for sustaining life support Additionally the team is responsible for conducting a thorough assessment of breast sounds documenting any changes or abnormalities continuous monitoring of oxygen saturation and intitle carbon dioxide is imperative to gauge the patient's oxygenation and ventilation status providing real-time data to guide adjustments in care as a proactive measure the transport team must have a manual resuscitator such as a BVM readily available this serves as a contingency plan in case any doubts arise about the proper functioning of the ventilator during transport by adhering to these guidelines the transport team ensures the delivery of high quality and uninterrupted care to patients relying on mechanical ventilation during",
        "Flight Considerations": "Transit flight considerations in the critical care transport environment it is imperative to recognize that not all ventilators possess the capability to adequately adjust for changes in altitude requiring a specific consideration during Air transport boils law a fundamental principle of gas physics underscores the significance of this concerned at higher altitudes there is a proportional increase in the volume of a given quantity of gas which is particularly pertinent to ventilator delivered tidal volumes this physiological phenomenon becomes more pronounced with altitude as evidenced by a potential 10% increase in tital volumes at altitudes above 8,000 ft furthermore the air present in body cavities can undergo expansion by as much as 25% in response to decreased atmospheric pressure at elevated altitudes to mitigate the potential impact of altitude related changes on mechanical ventilation collaborative communication between the critical care transport team and Pilots is indispensable specifically the provider should engage in discussions with the aviation professionals to ascertain the the feasibility of maintaining sea level cabin pressure during flight this proactive dialogue ensures the critical care transport team remains informed about the flight conditions and allows for strategic planning to optimize mechanical ventilation and patient care throughout the entirety of the Air transport by addressing these altitude related considerations the team can uphold the safety and well-being of ventilated p patients during a transit in the context of mechanical ventilation for patients ensuring optimal air quality is important and this includes proper Heating and humidification of inspired air to achieve this in an outof hospital setting a heat and moisture exchanger or hme is often utilized in line between the OTR braal tube and the ventilator circuit the primary function of the hme is to capture heat and moisture from the patient's exhaled breath during expiration and subsequently release these elements during the inspiratory phase this mechanism helps prevent the potential adverse effects of delivering dry and cold gases to the patients Airways while Incorporated an inline M offers no able advantages the critical care transport paramedic must be mindful of specific considerations firstly selecting the appropriate size hme for the patient is important to ensure Optimal Performance Additionally the provider should vigilantly monitor the Integrity of the hme as any compromise in its functionality could compromise the heating and humidification process to address this having spare Replacements readily available becomes imperative to swiftly address any issues that may arise during transport in tandem with hme usage the implementation of bacterial and viral filters in the ventilator circuit becomes Paramount to safeguard patients against potential infections from Airborne organisms these filters are categorized based on particle size and are strategically placed in accordance with product specifications taking into account factors such as Dead Space restrictive load and particle size filtration by adhering to these practices the provider ensures the delivery of highquality conditioned air to mechanically ventilated patients while minimizing the risk of complications related to inadequate humidification and potential infections inline suction catheters are used to help maintain aseptic conditions while addressing the suctioning needs of mechanically ventilated patients these catheters offer the advantage of enabling Health Care Providers to suction the patient without necessitating the opening of the ventilator circuit this not only prevents the exposure of the clinical environment to potentially harm air born organisms but it also ensures that positive end expiratory pressure a critical component of mechanical ventilation is retained adherence to procedural steps is important when employing inline suction catheters firstly close monitoring of the patient's response during suctioning is needed to promptly identify any adverse effects or signs of respiratory distress secondly the provider must select the appropriate size catheter to ensure effective and safe suctioning without causing trauma to the Airways the flushing of the syringe before and after suctioning serves to maintain the cleanliness of the catheter and prevent potential contamination moreover confirming the proper removal of the catheter and changing it as needed are key steps to prevent complications and maintain the efficacy of the suctioning process periodic checks for leaks in the ventilator circuit further contribute to the overall safety and integrity of the system by strictly adhering to these guidelines the critical care transport paramedic ensures the seamless incorporation of inline suction catheters into the ventilatory management of critically ill patients during transport upholding both infection control principles and the Integrity of mechanical",
        "Basic Ventilator Waveform Analysis": "ventilation basic ventilator waveform analysis ventilators equipped with Advanced monitoring capabilities enhance the critical care transport paramedics ability to assess and manage mechanical ventilation effectively the incorporation of waveforms presented in the form of scalers and Loops serves as a valuable point of care tool these Dynamic Graphics provide visual insights into the intricacies of patient ventilator interaction offering a comprehensive understanding of the ventilatory dynamic the displayed waveforms convey information pertaining to ventilator synchrony illustrating aspects such as time flow volume or pressure by closely analyzing these graphical representations the provider can promptly identify and address any signs of asynchrony ensuring that the ventilator is optimally supporting the patient's respiratory needs this real-time visual feedback is particularly crucial in the dynamic and often challenging environment of patient transport notably some transport ventilators are equipped with sophisticated Graphics packages that go beyond basic waveforms these systems incorporate sensors and Signal processors enabling the display of detailed Graphics that enhance the paramedics ability to assess the patient's respiratory status accurately the integration of such technology into transport ventilators underscores the commitment to providing comprehens ensive and datadriven Care during the critical moments of the patient transport this capability empowers the provider with a more nuanced and precise understanding of the patient ventilator interaction facilitating timely adjustments to optimize ventilatory support and overall patient outcomes in waveform analysis for mechanical ventilation scalar graphics and Loops play a pivotal role in providing detailed insights into the Dynamics of pressure flow and volume over time scalar Graphics which depict three components Against Time include the pressure time scalar flow time scalar and volume time scalar pressure times scalar also known as PT scalar is a graphic iCal representation that illustrates the changes in airway pressure over time during the respiratory cycle it provides information about the pressure delivered by the ventilator during different phases of inspiration and expiration clinicians use this scalar to assess the adequacy and pattern of pressure delivery flowtime scalar or VT scalar depicts the changes in air flow or flow rate over time during the cycle this helps clinicians evaluate the inspiratory and expiratory flow patterns abnormalities in the flow time scalar can indicate issues such as Airway obstruction or inappropriate ventilator settings volume time scalar or VT scalar illustrates the changes in title volume the air moved in and out of the lungs with each breath it provides insights into the distribution of ventilation and helps assess the consistency of tital volume delivery changes in volume time scalar May indicate variations in lung compliance or resistance each of these elements is essential in understanding the ventilatory patterns and Dynamics during the respiratory cycle loops on the other hand represent a two-dimensional graphic display and specific scalar values the pressure volume Loop where pressure is plotted on the x axis and volume on the Y AIS is used to detect compliance changes and identifying potential over distension of the lung this information is particularly valuable in assessing the respiratory mechanics of the patient during mechanical ventilation Additionally the flow volume loop with its ability to identify restrictive or obstructive lung conditions and detect air leaks within the the system contributes to a comprehensive understanding of the patient's respiratory status becoming familiar with the basics of waveform analysis is important especially when equipped with transport monitors featuring graphic monitoring capabilities the pressure time and flowtime scalars are particularly significant in that they provide visual clues that Aid and detect potential issues that may complicate the transport Mission the inspiratory and expiratory flow tracings on the flow time scalar offer visual information above and below the isometric line observing the scale can help the provider identify phenomena such as air trapping or Auto peep providing critical insights into the patient's ventilatory status in similar fashion the pressure time scalar assists in detecting the breaths speed and assessing the slope of the breath an initial Spike at the peak inspiratory pressure or pip May indicate excessive flow delivery leading to a turbulent flow situation this detailed analysis of scalars and Loops empowers the providers to make informed decisions and adjustments during the critical task of patient transport ensuring optimal ventilatory support and patient",
        "Troubleshooting and Diagnosing Ventilator Problems": "care troubleshooting and diagnosing ventilator problems troubleshooting and diagnosing ventilator problems are skills that every transport team member must possess to ensure patient safety and the seamless functionality of mechanical ventilation to initiate this process the team must adhere to a fundamental principle carrying a manual resuscitator for every patient on a ventilator that's because the manual resuscitator serves as a pivotal tool to safeguard the patient in case of uncertainties or issues that may arise during mechanical ventilation when faced with ventilator related challenges a systematic and methodical approach is essential a prudent rule of thumb is to commence troubleshooting at the patient's end and progress methodically toward the equipment or power source this strategy ensures that potential issues related to Patient ventilator interaction or physiological responses are addressed first the team should carefully assess the patient's clinical condition examining factors such as respiratory rate tital volume and oxygenation status the systematic troubleshooting process then extends to evaluating the ventilator settings and parameters this includes a thorough examination of the ventilator display monitoring values and alarms any deviation from the expected values or abnormal alarms should be thoroughly investigated to pinpoint the root cause of the issue Additionally the transport team should verify the Integrity of the ventilator circuit ensuring that there are no leaks or disconnections that could compromise ventilation simultaneously attention must be given to power sources and electrical connections to rule out any equipment malfunctions collaborative communication among the transport team members is needed during this process allowing for a comprehensive assessment of the situation encountering challenges when transitioning a patient from a hospital ventilator to a transport ventilator particularly in awake patients is not uncommon during Critical Care transport in such instances attention and patient- centered approach are pivotal one strategy to address this issue is to strive for a seamless transition by matching the settings of the transport ventilator as closely as possible to those of the hospital ventilator it is important to participate in effective communication especially when dealing with the wake and alert patients the team should transparently describe the process to the patient explaining the rationale behind the transition and any necessary adjustments this communication helps alleviate anxiety and fosters cooperation from the patient in cases where the patient exhibits signs of discomfort or air hunger during the transition prompt adjustments are warranted if utilizing a volume targeted breath potential adjustments include increasing the target title volume decreasing the inspiratory time or transitioning to a pressure targeted breath the objective is to optimize the ventilator settings to better align with the patient comfort and respiratory needs monitoring the exhale title volume becomes a primary concern during these adjustments the team must vigilantly assess the patient's response and titrate the pressure settings to achieve the targeted title volume this process ensures the patient receives adequate ventilation while minimizing any potential discomfort or distress associated with the ventilator transition understanding and appropriately responding to the alarms are essential aspects of ventilator management during Critical Care transport the high- Press alarm activates when the airway pressure surpasses the preset threshold signaling the potential risk of over distension or obstruction conversely the low pressure alarm triggers when the airway pressure Falls below the designated level indicating a potential disconnection or leak in the system these alarms are critical for maintaining optimal ventilation and preventing complications associated with inadequate or excessive pressures the low minute alarm is designed to alert Health Care Providers when the minute ventilation Falls below the set threshold signaling potential respiratory insufficiency apnea backup ventilation alarms activate when the ventilator detects a lack of spontaneous respiratory efforts prompting the initiation of precept backup ventilation frequent monitoring of the ventilator battery status is essential as indicated by the low battery alarm to prevent unexpected power failures during transport high low frequency alarms alert providers to deviations from the prescribed respiratory rate the disconnection alarm is activated if a disconnection between the patient and the ventilator is detected ensuring prompt intervention to restore the connection likewise the oxygen supply failed alarm alerts providers to issues with the oxygen supply whether due to low pressure or insufficient Supply preventing interruptions in oxygen delivery High Peep and Low PEEP alarms focus on the positive end expiratory pressure levels High peep alarms activate when peep exceeds the set limit potentially indicating increased Airway resistance while Low PEEP alarms alert to the risk of decreased peep compromising oxygenation troubleshooting and diagnosing complex ventilator issues require a systematic approach and a comprehensive understanding of both the transport ventilator functionality and the patient's respiratory needs the provider must adhere to a series of steps to effectively address and resolve problems encountered during mechanical ventilation firstly a thorough understanding of the transport ventilator operation is Paramount the critical care paramedic should conduct a preuse ventilator in circuit check before applying the device to the patient ensuring that the equipment is in optimal condition this proactive measure contributes to early detection and resolution of potential issues and is a feature that many new ventilators require prior to initiating patient care secondly the provider needs to be well versed in the ventilator specifications and its ability to meet the specific respiratory demands of the patient familiarity with the ventilator capabilities ens Ur that appropriate settings are chosen to optimize ventilation and oxygenation thirdly the provider must consider a patient's current lung condition and anticipate how it might change during transport factors such as transport duration altitude temperature gravitational forces and even vibrations can impact respiratory status preemptive discussion of potential issues and strategies within the healthcare team is needed for efficient problem solving lastly the provider should calculate the anticipated oxygen consumption based on the patient's condition and verify that there is an adequate oxygen supply on board to meet the anticipated demand during transport troubleshooting specific spe ific issues related to Patient ventilator interaction is an important aspect of managing mechanical ventilation during Critical Care transport these issues include instances where the patient appears desynchronous with the ventilator experiences missed triggering or undergos double triggering dis synchrony between the patient and the ventilator can manifest as a lack of coordination in the initiation and termination of breaths this can lead to discomfort for the patient and compromise the effectiveness of ventilation addressing D synchrony often involves adjusting ventilator settings to better align with the patients's respiratory efforts fine toting parameters such as inspiratory Time title volume and Trigger sensitivity can enhance synchrony and improve patient ventilator interaction mist triggering occurs when the ventilator fails to initiate a breath in response to the patient's inspiratory effort this issue may result in inadequate ventilation and oxygenation to resolve this the provider should assess the ventilator sensitivity settings ensuring that they are appropriately adjusted to detect and respond to the patients's respiratory efforts if necessary recalibration or modification of trigger setting may be implemented double triggering is characterized by the occurrence of two consecutive breaths triggered by a single patient effort this situation can lead to excessive ventilation and potential complications addressing double triggering involves fine-tuning the ventilator sensitivity settings and adjusting parameters such as inspiratory time and tital volume to prevent premature initiation of the next breath following a patient triggered breath in all these cases the provider must maintain a Vigilant approach closely monitoring the patient ventilator interactions and promptly identifying any causes of D synchrony mistt triggering or double triggering an understanding of the ventilator capabilities and the ability to make real-time adjustments based on observed issues are crucial for optimizing mechanical ventilation and ensuring the patient's respiratory needs are met during",
        "Transporting the Patient With a Tracheostomy": "transport transporting the patient with a tracheostomy tracheostomy a surgical procedure involving the creation of an opening in the trachea is employed for various medical conditions necessitating a direct Airway access congenital anomalies of the airway such as lenio malaia or tracheostenosis present from birth may lead to significant respiratory distress prompting the need for a tracheostomy to ensure adequate air flow lomy the surgical removal of the linix is another indication often performed in cases of advanced lenal cancer rendering a tracheostomy essential for maintaining a pton Airway tumors affecting the upper respiratory tract can obstruct air flow prompting the consideration of a tracheostomy for Airway management tracheomalacia a condition characterized by weakened tracheal cartilage may require surgical intervention to stabilize the airway and alleviate breathing difficulties subotic stenosis a narrowing of the airway beneath the vocal cords May necessitate a tracheostomy for the provision of a secured and functional air passage vocal cord paralysis whether due to a neurological disorder or trauma can impede normal respiratory function upper Airway Burns resulting from thermal or chemical injuries they call swelling and compromise the air passage leading to the consideration of a tracheostomy for Airway management and protection preparing for the transport of a patient with a tracheostomy demands meticulous attention to detail and adherence to agency specific guidelines the foremost challenge lies in accurately identifying the type of tracheostomy tube in place as variations exist based on size shape and additional features prioritizing the ability to manually ventilate the patient if needed is crucial emphasizing the importance of having the appropriate equipment readily available once the tracheostomy tube is identified the focus shifts determining the oxygen requirements and humidification necessary during transport this details Gathering comprehensive information about the patient's tracheostomy including whether a speaking valve is present the date of tube placement the reasons for placement and any Associated complications such details contribute to a nuanced understanding of the patient's needs in the case of a ventilator dependent patient with a tracheostomy it is imperative to ensure that the patient transport ventilator aligns with the current ventilatory support provided setting up the transport ventilator involves careful consideration of essential parameters including mode respiratory rate target title volume Peep and F2 collaboration with a respiratory therapist is invaluable during this process allowing for a comprehensive discussion of any concerns and ensuring optimal alignment between the patient's needs and the transport ventilator settings this preparation and communication are an integral part to providing safe and effective care during the transport of patients with tracheostomies to ensure patient safety the transport team should be equipped with a spare trost tube of the appropriate size ensuring Readiness to address any unforeseen issues with the primary tube additionally having a securing device of the same size is important to promptly secure the replace tube in case of dislodgment inner canulas suction catheters and a manual resuscitator device are indispensable components of the transport toolkit inner canulas enable the removal and cleaning of secretions ensuring optimal air flow suction catheters are needed for maintaining Airway patency by effectively clearing the tube and surrounding area of accumulated secretions the manual resuscitator device is used to provide manual ventilation in case of emergencies or complications recognizing signs of tracheostomy tube displacement is a key responsibility during transport any displacement requires immediate assessment of the patient's respiratory status and if a false passage is formed Swift removal of the tube in ventilation through an alternative means becomes imperative various factors Elevate the risk of tracheostomy tube dislodgment including morbid obesity neck Adema excessive coughing improper tube fit patient anxiety leading to tube manipulation tension in the ventilator circuit and Loosely secured tracheostomy tube ties diligent monitoring and proactive measures are are essential to mitigate these risks and ensure the secure transport of patients with tracheostomies effective ventilator management is crucial in critical care requiring continuous monitoring and adjustment to meet the evolving needs of the patient respiratory distress and failure may arise from various causes including acute lung injury pneumonia or sepsis the management of lung diseases and conditions involves tailoring ventilator settings to address specific pathophysiological challenges patient monitoring encompasses regular assessment of ventilator parameters arterial blood gases and clinical indicators to guide therapeutic interventions ongoing care involves addressing complications ensuring patient comfort and promoting weaning strategies as the patient's condition improves special considerations such as flight considerations for ventilated patients tracheostomy care and infection prevention add additional layers to the comprehensive care provided in critical care settings this multifaceted approach to mechanical ventilation underscores the importance of a nuanced and patient- centered strategy in managing these critically ill individuals"
    },
    {
        "Introduction": "In This Chapter Reviewing the structures and functions of the respiratory system Assessing patients\u2019 breathing and knowing whether to oxygenate or ventilate Picking out potential airway and breathing problems Take a deep breath and hold it for as long as you can, until it\u2019s so uncomfortable that it feels like your lungs will burst. When you finally explode and draw in that first panicky breath, let that feeling serve as a reminder of how important your respiratory system is. If it doesn\u2019t function well, life literally comes to a standstill.",
        "Getting an Overview of the Respiratory System": "In a sense, the respiratory system serves a very simple purpose: to bring oxygen in and get carbon dioxide out. However, the task is much more complex than that and requires a sophisticated set of structures: The upper airway (see Figure 9-1a) consists of the nares (nostrils), mouth, nasopharynx, pharynx, and larynx. Combined, they work to not only channel air in and out of the body but to warm, humidify, and filter it as well. The lower airway (see Figure 9-1b) begins at about the level of the vocal cords and includes the trachea, mainstem bronchi, and bronchioles, terminating in the alveoli. The bronchi, bronchioles, and alveoli comprise the lungs. The main function of the lower airway is to produce efficient gas exchange between the alveoli and capillaries surrounding each alveolus (see Figure 9-1c). Blood passing through the capillaries absorbs the oxygen onto red blood cells, and then circulates oxygen to the body\u2019s cells. At the same time, carbon dioxide is released into the alveolus, which is then exhaled out of the body.",
        "Understanding Breathing": "You need oxygen to produce adenosine triphosphate (ATP), the energy block used by the body, and you need to regulate carbon dioxide so just enough is available to the body and the rest is released to the atmosphere. This process takes place in the alveoli, where the cell walls are thin enough to allow gases to diffuse freely from areas of high concentration to areas of low concentration. So, oxygen diffuses from the alveoli to the capillaries (into the blood), and carbon dioxide diffuses from the capillaries into the alveoli (out of the blood).",
        "Ventilation": "Of course, the concentration of gases would equalize quickly if the gases just stayed in the alveoli. Breathing, or ventilation, is the mechanical effort the body makes to move gases into and out of the lungs. Ventilation occurs with the use of the diaphragm and intercostal muscles (see Figure 9-2): Inspiratory phase: When these muscles contract, the chest cavity increases in size as the diaphragm moves downward and the ribs are pulled outward by the intercostal muscles. This produces a slight negative pressure inside the cavity, causing the lungs to expand and drawing air in. This is the inspiratory phase of ventilation. Expiratory phase: During the expiratory phase, the reverse occurs. The diaphragm relaxes and moves upward, and the intercostal muscles relax as the chest returns to its resting position. The chest cavity shrinks, creating a positive pressure on the lungs. They return to their smaller resting state, pushing air out of the alveoli and back through the lower and upper airways into the atmosphere.",
        "Knowing the Airway and Breathing Issues to Look for When You Assess Patients": "As an EMT, you can\u2019t assume anything about your patient\u2019s condition, even when he appears \u201cnormal\u201d at first glance. In your primary assessment, take a few seconds to consciously evaluate how someone is actually breathing. You can start by asking patients how they are feeling; watch and listen to how they respond.",
        "Understanding when breathing is (and isn\u2019t) normal": "Ironically, normal breathing is hard to see. That\u2019s because your respiratory system is very effective at its job. There\u2019s so much surface area in the alveoli that gas exchange is very easy. Therefore, the body needs to exert very little energy to make gases move between the alveoli and capillaries. If everything about the respiratory system is working well, the patient will likely be able to speak in full sentences, spending little energy in the process.",
        "Deciding when to oxygenate": "EMTs used to give oxygen to everyone, regardless of what the complaint was. Chest pain? Give oxygen. Toe pain? Yep, give that gas too! After all, what harm could oxygen do, right? Medical experts have since discovered that inhaling more oxygen than necessary can be harmful for certain conditions, and it isn\u2019t helpful in situations where it isn\u2019t necessary.",
        "Recognizing when to ventilate": "To know when to ventilate is to know when the patient crosses the line between respiratory distress and respiratory failure: Respiratory distress: In respiratory distress, the patient is compensating for a potential hypoxia problem by breathing faster, deeper, and/or harder. By doing so, the patient\u2019s mental status remains good, as do his oxygen saturation levels (see the preceding section). Respiratory failure: If the compensatory mechanisms don\u2019t maintain adequate oxygen or carbon dioxide levels, the patient\u2019s well-being begins to falter. Mental status changes from alert to confused to unconsciousness as the brain runs out of oxygen or fills with carbon dioxide. Oxygen saturation levels drop below normal. The patient\u2019s drive to breathe weakens, causing ventilations to become inadequate. This state, in turn, makes oxygen levels fall even further, creating a vicious cycle. Breathing slows and becomes even more shallow. If left untreated, respiratory failure will deteriorate to respiratory arrest, followed quickly by cardiac arrest.",
        "Taking Action on Potential Airway and Breathing Problems": "Many conditions can affect the airway and breathing, causing someone to become short of breath. And, because the respiratory system reacts to events happening inside the body, many nonrespiratory conditions can cause difficulty breathing as well. I don\u2019t cover them all in the following sections, but a good rule of thumb is to always think beyond the breathing tube when a patient is having trouble breathing yet her respiratory system seems okay.",
        "Upper airway conditions": "Given that the airway is the only way for air to enter and exit the body, anything that partially or completely blocks it is troublesome, to say the least. Table 9-1 lists common conditions you should be familiar with, their signs and symptoms, and treatment options for each.",
        "Lower airway conditions": "Table 9-2 lists a variety of common conditions affecting the lower airway structures, causing shortness of breath.",
        "Nonrespiratory conditions": "When other, nonrespiratory conditions arise that affect oxygen and/or carbon dioxide levels in the body, the respiratory system attempts to compensate by working harder. Some of the more common ones are listed in Table 9-3."
    },
    {
        "The skills of airway management": "RJ is a 34-year-old, 6ft, 100 kg, unhelmeted male operator of an ATV who was thrown from the vehicle. The flight crew arrived, completed their survey, placed the patient on the monitor, established a 20G peripheral IV, and hung normal saline. The patient's GCS was 7, BP 104/50, pulse 128, respiratory rate 24, and oxygen saturation 94% on 15L NRB. The patient's airway was assessed using the LEMON method. Look externally \u2013 noting a possible fractured jaw. Evaluate using the 3-3-2 rule, noting that three fingers could not be placed in the mouth, three fingers could be placed from the angle of the jaw to the mentum, and two fingers could be placed from the thyroid cartilage to the bottom of the jaw. The Mandible was not receding. Obstruction was assessed using a modified Mallampati, which provided a clear view of the posterior oropharynx and uvula when the blood was suctioned. Lastly, the patient's Neck mobility was limited by the cervical collar, which was removed and inline stabilization was held while providing a jaw thrust. Etomidate and succinylcholine were drawn up. Drug choices and dosing were verbalized aloud and confirmed using a challenge-response method and visual inspection by both crew members. A checklist was read aloud while the flight crew prepared for intubation. The BVM and O\u2082 were checked, the suction device was functional, the IV patency confirmed, and the patient's pulse oximetry, pulse, and BP were checked. Oxygen via nasal cannula at 6 LPM was placed on the patient to provide passive oxygenation. An 8.0 and 7.5 ETT were placed next to the patient. The 8.0 balloon was inspected and a stylet was lubricated and inserted. The video laryngoscope (VL) was turned on and was recording. A waveform capnograph was connected as was a commercial tube holder. A #5 King LTD-S was placed on the patient's chest as a contingency. The RSI medications were administered and the patient was oxygenated with a BVM. After fasciculation, the VL was placed while suctioning and the ETT was visualized to pass through the cords. The balloon was inflated and placement confirmed by EtCO\u2082 and five-point auscultation. The tube was secured with a commercial tube holder and the patient was reassessed to ensure stable vitals. The patient was sedated and placed in restraints to preclude self-extubation.",
        "Introduction": "Airway management is one of the most essential interventions in the prehospital care of the critically ill or injured. Many scientific efforts have highlighted the difficulty of endotracheal intubation (ETI) in the prehospital setting, the adverse events associated with the procedure, and the challenges in attaining and maintaining clinical proficiency. Other studies highlight the uncertain connections with improved patient outcomes. These observations underscore that airway management is not simply a discrete procedure but a comprehensive strategy of care that requires close, system-level medical oversight. The most successful prehospital airway management programs incorporate multiple elements including training, skills verification, equipment selection, decision support, continuing education, and total quality management. The goal of this chapter is to describe the medical direction paradigms and considerations necessary for a high-quality airway management program. The practicing EMS physician must also be aware of these issues, and must be an expert in out-of-hospital airway management.",
        "The challenges of airway management in the prehospital setting": "Airway management in the prehospital setting comes with unique challenges. Prehospital airway management occurs in an uncontrolled environment where patients are severely ill, undifferentiated in presentation and medical history, and may be situated in awkward positions (e.g. on the floor, in a bed, or in the wreckage of a car). Prehospital providers, including EMS physicians, have fewer monitoring and pharmacological options than exist in the hospital. Unlike the hospital setting, there are very limited resources with respect to personnel and equipment. These factors significantly increase the complexity and difficulty of airway management and underscore the need for simple and efficient field approaches. While the individual components may resemble techniques performed in the hospital, prehospital airway management often requires approaches different from the hospital setting. The medical director must be keenly aware of these distinctions and provide appropriate guidance. When it is the EMS physician who is managing the airway in the field, he or she must be aware of the differing resources and conditions from those in a hospital where the bulk of his or her experience might have been garnered.",
        "Which airway, when, and how?": "Successful prehospital airway management relies on the optimized combination of basic, advanced, and rescue airway interventions. Medical directors must choose strategies appropriate for the needs of their services based on available personnel, resources, and environment. An exclusive focus on any one management technique will limit the providers' abilities to adapt to difficult situations and failed procedures.",
        "Basic airway interventions": "Basic airway interventions include measures to provide supplemental oxygen and/or ventilation without the use of an advanced invasive airway device. Basic airway interventions are used by providers of all skill levels. While they lack protection from aspiration (and in fact may increase aspiration risk through inadvertent gastric insufflation), they are the essential foundation of any successful airway management program. Providers of all levels \u2013 even practitioners who perform more advanced airway interventions \u2013 must master basic airway techniques. Practitioners will rely on basic airway intervention skills when advanced airway interventions fail. The medical director may define conditions for which basic airway management is the preferred technique. These situations may include scenarios with short transport times where the time and risk necessary to perform advanced airway maneuvers outweigh the benefits of a secure airway. Another example is pediatric respiratory arrest, where most providers are more experienced with bag-valve-mask ventilation than endotracheal intubation.",
        "Endotracheal intubation": "Endotracheal intubation is the most widely recognized method of invasive airway management and has been performed by paramedics in the United States for over 25 years. ETI has many theoretical advantages, including isolation of the airway from secretions or gastric contents and the provision of a direct conduit to the trachea without separate airway opening maneuvers. However, equipoise exists with respect to the clinical benefit of ETI in the prehospital environment. Endotracheal intubation is associated with several risks, including failed intubation, unrecognized esophageal intubation, hypoxia, hypotension, bradycardia, aspiration, and airway trauma. Many of the risks of ETI can be mitigated through proper training and equipment. However, prehospital systems are often unable to make the substantial investments necessary to ensure a high degree of safety in the procedure. Medical directors who choose ETI as a method of airway management must be prepared to properly educate and train their providers, ensuring that they have the decision-making and psychomotor skills necessary to perform the procedure. This must include a minimum of didactic training on the indications, contraindications, and techniques for endotracheal intubation, and simulated live intubations in supervised environments. The medical director must determine how best to provide suitable training to providers performing ETI. Strategies may include mandatory minimums for yearly ETI experience supplemented by simulation and supervised experience in the operating room (OR) or emergency department (ED). In order to concentrate limited field experiences, it may be necessary to restrict the skill to a few selected providers. A commitment to continuous quality improvement is also necessary, requiring rigorous review of all airway cases. Direct observation in the field or through video review is often desirable. Quantitative assessment of ETI should include not only procedural success rates but also physiological measurements. ETI attempts should be confirmed by end-tidal carbon dioxide (EtCO\u2082) and monitored for vital sign abnormalities including hypoxia, hypotension, and bradycardia. When available, quality assurance should also include time to intubation and review of video images. Several adjunctive techniques are available to facilitate ETI, each with distinct advantages and disadvantages. For example, the tracheal introducer or gum elastic bougie has been widely described as a device either for blind intubation or as an adjunct for difficult intubation. While use of such devices may improve intubation success, the medical director must consider their added complexity as well as the need for additional training and skills maintenance. The latter point deserves emphasis. Each newly acquired tool intended to improve the likelihood of successful or optimal airway management also increases the burden or obligation to maintain skills regarding its use. This reality is too easily overlooked in the enthusiasm to deploy something new which is perceived to make circumstances easier.",
        "Does prehospital ETI improve survival?": "Few studies link prehospital ETI to improved patient survival. Gausche et al. performed the only randomized, controlled trial of prehospital ETI, finding no differences in survival or neurological outcome between children receiving ETI and those receiving bag-valve-mask (BVM) ventilation. Davis et al. evaluated patient survival after paramedic rapid sequence intubation (RSI) for traumatic brain injury, associating prehospital RSI with an increased risk of death compared with matched historical controls. A variety of other studies encompassing a range of different patient subsets observed equivocal or worsened outcomes associated with prehospital ETI. While most cases of prehospital ETI occur for patients in cardiac arrest, there have been only observational analyses of this subset. This is primarily due to the large sample sizes (>10,000 patients) that would be required to detect survival differences or equivalence in this population. Thus, while ETI is common prehospital practice, its survival benefit remains unproven.",
        "Do adverse events occur during prehospital ETI?": "Recent studies have drawn attention to previously unrecognized adverse events associated with prehospital ETI. Successful prehospital airway management programs have placed strong emphasis on minimizing these and other adverse events. Many of these adverse events have been detected only through the advent of monitoring technology and rigorous airway management review. Katz and Falk described 108 paramedic-placed endotracheal tubes brought to an Orlando trauma center, finding that the tube was misplaced in 25% of the cases. Other studies have identified lower but not insignificant incidences of endotracheal tube misplacement. Other efforts describe the frequency of endotracheal tube dislodgment during prehospital care. Use of continuous EtCO\u2082 has reduced the incidence of the unrecognized misplaced endotracheal tube. Dunford et al. examined a subset of patients receiving prehospital RSI and found that a considerable portion experienced iatrogenic oxygen desaturation or bradycardia during intubation attempts. Hypoxia and bradycardia may be prevented by continuous monitoring of pulse oximetry with the provision of oxygen and supplemental ventilation during any period of hypoxia. Episodes of hypoxia can be mitigated using apneic oxygenation through a high-flow nasal cannula applied during the endotracheal intubation attempt. Prehospital ETI can also interact or interfere with other important resuscitation tasks. For example, Davis et al. linked post-RSI hyperventilation with worsened TBI outcomes. Aufderhiede et al. showed that hyperventilation after successful ETI of cardiac arrest patients can compromise coronary perfusion during cardiopulmonary resuscitation (CPR) chest compressions. Studies on human simulators suggest that conventional ETI efforts may increase CPR \u201chands-off\u201d or no-flow time (pauses in CPR to facilitate endotracheal intubation) compared with other airway devices. Models of high-performance CPR now teach providers to defer airway management in favor of providing uninterrupted compressions.",
        "Should emergency medical technicians perform ETI?": "The prior national EMT curriculum included ETI as an optional module. However, the ability of EMTs to acquire and maintain clinical ETI skills remains unclear. Two independent studies of EMT ETI found suboptimal success rates (<50%). Most medical directors are not comfortable with EMTs performing ETI. However, several series describe the ability of basic EMTs to use supraglottic airways (SGA) (e.g. Combitube). The current National EMS Education Standards do not list either ETI or SGA as EMT skills; SGAs are listed for advanced EMTs.",
        "Should EMS providers limit the number of ETI attempts?": "While many prehospital EMS personnel define an ETI \u201cattempt\u201d as an effort to insert the endotracheal tube, national consensus guidelines suggest that an ETI \u201cattempt\u201d should be defined as an insertion of the laryngoscope blade, to maintain consistency with other airway management definitions used in other medical disciplines. Selected studies indicate that a substantial portion of prehospital ETI require multiple attempts. Evaluations of inhospital ETI efforts suggest that more than one ETI attempt is associated with an increased risk of developing cardiac arrest. Some EMS agencies use a \u201cthree attempts and out\u201d rule, limiting intubation efforts to no more than three attempts. Given the low probability of success following the second attempt, medical directors may choose to limit providers to two attempts, followed by immediate use of a supraglottic rescue airway.",
        "Drug-facilitated intubation": "Drug-facilitated intubation (DFI) is the use of intravenous sedative and/or neuromuscular blocking agents to facilitate ETI of patients with intact protective airway reflexes. The most common forms of DFI include RSI, also termed \u201cneuromuscular blockade-assisted intubation,\u201d and sedation-assisted intubation. Most medical directors regard DFI as an advanced technique that should be reserved for only the most qualified practitioners. The National Association of EMS Physicians has published national consensus standards for drug-facilitated intubation. Rapid sequence intubation denotes the use of a neuromuscular blocking (paralytic) agent combined with a sedative or induction agent to facilitate ETI. The key challenge of RSI is that administered paralytic agents will result in rapid and complete loss of airway reflexes. EMS personnel (including EMS physicians) performing prehospital RSI must possess exceptional ETI skills. The consequence of failed RSI may be a patient who cannot be intubated nor ventilated, with ensuing cardiac arrest from hypoxia. Agencies performing RSI must use monitors capable of continuous physiological monitoring, including cardiac rhythm, heart rate, blood pressure, pulse oximetry, and waveform capnography. These measures are important to warn of physiological decompensation such as oxygen desaturation and bradycardia. Finally, there must be a plan and appropriate preparation for those times when RSI fails, including a rescue airway. Many medical directors believe that intensive continuing training is essential for maintaining a prehospital RSI program. Some medical directors require that paramedics perform at least 12 ETIs annually, either on prehospital or in-hospital (ED or OR) patients. Others have integrated human simulator-based training to provide exposure to difficult airway scenarios. The requirement for live ETI training remains controversial, with some proponents citing the value of live airway experience and opponents citing the absence of supporting data. Experts recommend restricting RSI to EMS agencies with the highest standards of clinical airway management practice, including a comprehensive commitment to airway management quality. Colloquially speaking, \u201cRSI is not just about the drugs.\u201d As with ETI, medical directors and providers considering RSI must place an emphasis on clinical decision making, not just procedural technique. A modification of RSI is rapid sequence airway (RSA), which replaces ETI with placement of a SGA. RSI is difficult because of the need to rapidly accomplish tracheal intubation after the administration of paralytics. The appeal of RSA is that SGA insertion is simpler and contains fewer pitfalls than ETI. This approach is theoretically safer than traditional RSI. RSA case reports using the Combitube and King LT have demonstrated the feasibility of this approach. In a simulation study, when compared to RSI, Southard demonstrated that RSA reduced time to airway placement and reduced hypoxia episodes. When examined in an air medical system, however, no difference was detected between the two techniques. While other anecdotal reports exist, RSA has not been described in larger scientific series. However, in systems using traditional RSI, RSA may provide an important alternative option in the face of an anticipated or encountered airway management difficulty. Sedation-assisted intubation is a common approach that uses a sedative agent only, without concurrent neuromuscular blocking agents. Most medical directors discourage this technique. The anesthesia community has promoted sedation-assisted intubation as being safer than RSI, citing that patients receiving only sedatives may retain adequate native reflexes to preserve airway patency in the event of unsuccessful ETI efforts. However, it is not clear if this principle can be generalized to the prehospital setting. Prehospital EMS personnel often do not possess the laryngoscopy skills of anesthesiologists, and the environments are at opposite ends of the spectrum in terms of optimal control. Adverse events associated with RSI (e.g. iatrogenic oxygen desaturation and bradycardia) may be at least as likely with sedation-assisted ETI. Sedation-assisted intubation with etomidate has been demonstrated to have lower success rates when compared to RSI. While etomidate results in more profound sedation than benzodiazepines, a formal comparison of etomidate with midazolam for prehospital sedation-assisted intubation identified similar ETI success rates. Many EMS systems use other combinations of slow-onset benzodiazepines and opiates to facilitate endotracheal intubation, such as combinations of diazepam, morphine, or other agents. This practice is particularly unsafe since the single or combination use of these agents has a rather slow onset and unpredictable sedative effects, as well as strong potential for causing hypotension. From a medical oversight point of view, the system-level measures necessary to ensure airway management quality with sedation-assisted intubation are essentially equal to those required for RSI programs.",
        "Video laryngoscopy": "Video laryngoscopy is increasingly being adopted for use in training and difficult airway scenarios in both the OR and ED. Prehospital application of this tool has resulted in improved laryngoscopic view, increased intubation success, and decreased time to tracheal intubation. However, these devices, while useful, are not a replacement for basic intubation training and skills. In addition, practitioners must be familiar with the skills particular to the device. Complications associated with video laryngoscopy are similar to those for traditional intubation, including multiple intubation attempts and airway perforation. Key considerations for the medical director are the need for specialized training with the video laryngoscope and skill maintenance requirements similar to ETI. If video laryngoscopy is employed, the medical director must also decide whether it is used as the primary intubation method, which may erode skills associated with direct laryngoscopy, or if it is used as a rescue technique, which will require greater efforts at skill maintenance given the relative infrequency of use. Cost is also a factor as many of these devices cost several thousands of dollars to acquire and maintain. If the number of airway interventions in the service is low, the medical director may consider applying those resources to training or more frequently used equipment.",
        "Supraglottic airways": "Supraglottic airways facilitate ventilation without the use of a conventional endotracheal tube. The medical director\u2019s choice to utilize supraglottic devices will vary with service type, provider level, and nature of the jurisdiction. Supraglottic airways are typically used as rescue devices for failed ETI. They are generally easier to insert and have greater success rates than surgical airway techniques, especially in situations potentially involving difficult airway anatomy. National consensus guidelines recommend that all EMS personnel carry at least one type of SGA (e.g. Combitube, King LT, or LMA) for airway management in the event of failed ETI efforts. Medical directors should develop airway management paradigms that include clear indications for failed intubation and an alternative management strategy which may include SGAs. The 2010 Advanced Cardiac Life Support guidelines emphasize the delivery of uninterrupted chest compressions during CPR. Espousing this principle, a growing number of EMS agencies have elected to substitute ETI with the rapid insertion of an SGA in patients suffering cardiopulmonary arrest. Some experts point to the additional benefits of using SGAs as the primary invasive airway device, including the simplicity of operation, the reduced risk of significant adverse events (such as inadvertent airway dislodgment), and the reduced baseline and skills maintenance burdens. Additionally, SGA insertion skills may be more easily translated from mannequin training to clinical application on live patients. Limited data verify the ability of EMS personnel to place SGAs during cardiac arrest without interrupting compressions and in less time than an endotracheal tube. However, the outcomes related to SGA use in cardiac arrest remain unclear. Some EMS agencies have allowed BLS providers to insert SGAs. Previous studies have demonstrated the use of SGAs with a high degree of success. One study compared the first-pass success rates during cardiac arrest of BLS providers using SGAs and ALS providers using ETI. First-pass success was five times more likely with the SGA. BLS use of SGAs outside of cardiac arrest has not been studied.",
        "Surgical airways": "When developing alternatives for failed laryngoscopy, the medical director should consider the option of surgical airway management. In rare circumstances, when the patient cannot be intubated or ventilated, surgical airway management may be the only viable option. Prehospital surgical airway procedural success is highly variable, ranging from 77% to 93%. However, survival after prehospital surgical airway placement is poor, ranging from 15% to 37%. Limited data describe the complications associated with prehospital cricothyrotomy. Some medical directors question the role of cricothyrotomy in the prehospital setting, citing the difficulty of the procedure and the rarity of the intervention with associated need to maintain appropriate clinical skills.",
        "Non-invasive positive pressure ventilation": "Non-invasive positive pressure ventilation (NIPPV), including both continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP), is used to reduce the work of breathing and to improve oxygenation. The clinical indications for prehospital CPAP or BiPAP include patients with acute respiratory distress who possess intact ventilatory drive, protective airway reflexes, and mental status. NIPPV is safe and can be used to treat a variety of respiratory problems even in the face of diagnostic uncertainty. NAEMSP recommends the use of NIPPV for the treatment of acute dyspnea. Although not a replacement for ETI, NIPPV reduces the need for ETI in many patients with acute congestive heart failure, chronic obstructive pulmonary disease, or respiratory failure from other causes. CPAP is feasible for use in BLS systems and may provide an important tool to services where ALS is unavailable or too remote. The medical director should incorporate NIPPV into an airway management scheme with specific indications for use.",
        "Pediatric airway management": "Gausche et al.'s study demonstrated no survival or neurological benefit from prehospital pediatric ETI. Given the strength of these data and the relatively low number of pediatric procedures performed by individual prehospital providers, some physicians recommend using BVM ventilation instead of ETI for critically ill children. However, many medical directors have dismissed the generalizability of the Gausche study, citing that the paramedics in that trial did not have adequate experience with pediatric ETI. Consequently, there appears to be variation in prehospital ETI practices nationally. Pediatric airways have unique features that may pose difficulties for those not accustomed to caring for critically ill children. Since pediatric patients comprise a small proportion of all prehospital ETI, medical directors must weigh the benefits of pediatric ETI against the challenges of providing adequate pediatric airway training and clinical experience. Some SGAs come in pediatric sizes. Pilot and simulator series describe the viability of SGA use in children. There are no large-scale studies of prehospital pediatric SGA use.",
        "Preventing common pitfalls of airway management": "Avoidable errors in airway management may include failures of training, preparation, technique, confirmation, or device management. Insufficient training is an inherent problem in EMS given the cost of training, relative infrequency of the procedure, and limited access to live patient training and high-fidelity educational tools.",
        "Who should manage the airway?": "The degree to which EMS providers participate in airway management is determined by their scope of practice and the discretion of their medical directors. EMS protocols for airway management may vary based on the level of available provider and the system architecture. While all providers should be adept at basic airway management, invasive airway management may be limited to ALS providers. The medical director must choose which providers receive advanced airway training, taking into account the ability to acquire and maintain airway skills, as well as distance to the hospital and the availability of back-up personnel. For instance, some jurisdictions may allow for SGA placement by BLS providers when transport times are long or back-up is remote. Some systems may employ a tiered response, providing additional providers for airway calls. The additional provider may be a supervisor or a more experienced provider capable of a wider range of airway management techniques. In systems where this type of back-up is readily available, protocols may specify that the providers responding for back-up have additional tools or skills which would be impractical for training or cost-prohibitive if deployed among the entire service. In systems where ETI is a low-frequency event, it may be beneficial to focus education on BLS interventions or supraglottic techniques. Limiting ETI to supervisors or a specific cohort of providers has the benefit of concentrating field experience for the procedure and decreasing the resources necessary for training and competency verification. In some regions it may be possible to train the second-tier providers in advanced adjunctive techniques such as RSI, video laryngoscopy, or use of the bougie. The ideal airway management paradigm for a given service may vary based on the level of provider, available resources, coverage area, and volume of calls requiring airway management.",
        "Provider training and competency": "Endotracheal intubation is a complex and difficult procedure that requires substantial training to attain and maintain proficiency. Recent studies highlight the difficulties of providing prehospital providers with adequate ETI training. These observations underscore the importance of medical director involvement in developing and maintaining airway management skills. Provider training requires three components: baseline acquisition of skill, maintenance of skill, and an iterative process of quality assurance used to identify deficits and guide skills maintenance. Provider competency requires a program of initial training followed by periodic skill verification and continuing education. Training should begin with didactics to review basic airway management. Advanced airway procedures should be introduced by discussing indications and contraindications for airway management, an algorithm for airway management, procedural complications, relevant pharmacology, local protocols, and special considerations. Psychomotor skills should also be taught and verified using a model or low-fidelity simulator. Skills reviewed should include all those necessary for the airway management algorithm, including BLS airway skills, invasive airways, and surgical airways when applicable. High-fidelity simulators may provide added realism for teaching psychomotor skills and also provide the ability to run scenarios to test decision making and practice the procedures needed to move through the airway management algorithm. High-fidelity simulators can also be used to assess protocol knowledge, teamwork dynamics, and adherence to policies. Obtaining live intubation training in the OR or other controlled environment is the gold standard of airway training. However, access to ORs is often limited by availability, liability, and cost. The prevalence of non-invasive forms of airway management in the OR combined with an increase in the number of trainees and professionals seeking intubation experience (residents, nurse anesthetists, respiratory therapists, etc.) has reduced the opportunity for prehospital providers to obtain ETI experience in controlled environments. Furthermore, selection bias introduced by the supervising professional may limit the trainee to only less challenging airways. Liability concerns about allowing minimally trained providers into the OR have further curtailed intubation experiences for EMS providers. The current national standards recommend that paramedic students perform at least five ETIs before graduation. However, one study suggests that paramedic students need at least 20-25 ETIs to attain baseline ETI proficiency. Most successful prehospital airway management programs require EMS personnel to perform at least 12 ETIs annually; these programs have access to ORs to provide supplemental training. Although live training supervised by an expert operator is ideal, experience may also be gained through field intubations during actual calls. Unfortunately, or fortunately depending on one's perspective, field intubation is a relatively rare event, with paramedics in one state indicating that they perform on average only one intubation per year. Whenever possible, the medical director should seek opportunities for EMS practitioners to obtain live patient intubation experience. Ideally, this would be done in ORs and EDs under close supervision. The medical director should develop relationships with local hospitals to allow for live intubation training. Contracts and memoranda of understanding may help limit medicolegal exposure, define expectations, and improve access to procedures. Many training programs and EMS agencies use mannequins and human simulators for ETI training. Simulators do not accurately recreate the \u201cfeel,\u201d range, or variability of live human airway anatomy. However, they are convenient, widely available, flexible, and can be relatively less expensive than other methods of airway training. Low-fidelity human simulators, which often consist of just a mannequin head, are useful for limited psychomotor training. Some medical directors advocate integrating high-fidelity human simulator-based training to recreate complex \u201cdifficult airway\u201d situations. The rationale for this additional training is to develop airway management decision making skills, which cannot be fostered in the controlled OR setting. These experts believe that it is essential that paramedics develop good airway management decision-making skills, not just good laryngoscopy skills.",
        "Protocol development and equipment selection": "Airway management protocols may include several components including inclusion and exclusion criteria, an airway management algorithm, descriptions of mandatory procedures, benchmarks for quality assurance, and parameters for difficult or failed management. Protocols should clearly delineate inclusion and exclusion criteria based on physiological parameters, which indicate failures of ventilation or oxygenation. These may include vital signs (including respiratory rate, oxygen saturation, end-tidal carbon dioxide), respiratory mechanics (fatigue, accessory muscle use), and mental status (Glasgow Coma Scale). An airway management algorithm needs to be specific to the equipment and skills available within the system. One example of an airway management algorithm is shown in Figure 2.1. Airway management algorithms should begin with providers performing an initial assessment including the ABCs and initiation of BLS airway management. If the personnel are not able to provide ventilation or oxygenation, then they proceed directly to a rescue airway. If they are able to ventilate and oxygenate using BLS skills, then they reassess the patient to determine if invasive airway management will be necessary. If ETI fails, then the provider determines if he can ventilate the patient. Adequately ventilated patients would warrant a second attempt with actions designed to improve intubating conditions (better positioning, different laryngoscope blade, different operator). Those who cannot be ventilated prompt the need for additional resources and for the airway to be managed with a supraglottic device or surgical airway. Airway attempts should be limited to two per operator or three total, as the probability of success drops dramatically after the second attempt. In some jurisdictions and patient populations (e.g. pediatrics), medical directors advocate for no attempts at ETI given a lack of field experience or low probability of success. How to proceed through the airway algorithm is often a matter of judgment. Furthermore, providers may have to alter the response to the algorithm based on patient (lack of reserve) or scene (unsafe environment) conditions. Provider judgment can be developed through case review of errors and best practices, as well as practice with high-fidelity simulation. Key among these skills is the ability to recognize a difficult airway and preplanning contingencies for a difficult or failed airway. Given the challenges inherent in prehospital airway management, it may be prudent to anticipate all prehospital airways as difficult. ",
        "Strategic approaches to airway management": "In addition to the airway management algorithm described above, the medical director may employ a variety of tools to reduce risk in airway management. Some systems choose to automatically dispatch a second unit to airway calls, providing additional equipment and operators to facilitate successful airway management. Medical directors may also choose to focus the use of ETI on patients with a high probability of success. Those who fail a single attempt might be transitioned to BLS or SGA management to reduce the risk of secondary injury due to hypoxia or direct airway trauma. Given the equipoise surrounding the use of ETI, the choice to forego ETI entirely may be predicated on the available resources and skill of the provider. A pilot study in rural EMS demonstrated SGA use as the primary means for invasive management. Such an approach may be appropriate based on an analysis of risk and benefit of invasive airway management in a particular EMS system. Equipment choices are also critical to successful airway management. The medical director should consider devices based on efficacy, reliability, ease of use, and cost. To the extent possible, devices that have been demonstrated to be effective in out-of-hospital studies are preferable. The prehospital environment is austere, and equipment that functions only within limited ranges of environmental conditions may not be desirable. As advanced airway management is a relatively infrequent need in the field, devices should be chosen that are easy to use and for which it is easier to retain proficiency. In general, the equipment chosen for the airway algorithm should include a full range of BLS devices, a method for ETI, an SGA and, when appropriate, a surgical airway technique.",
        "Total quality management": "In order to maintain a highly functioning system of airway management, the medical director must develop a system of total quality management (TQM). TQM is an iterative process of training, continuing education, data collection, assessment, and reeducation. This process begins with initial training and skills verification, ensuring that each provider can perform airway management skills for his or her level of training. Providers should then be educated on the application of those skills in simulation and scenario-based education. Skill maintenance should occur at regular intervals for all providers with special attention to providers who have been unsuccessful in field airway management or who have not had the opportunity to manage airways in the field.\n\n    If possible, all airway management cases should be reviewed with an emphasis on failed airway, misplaced or dislodged invasive airway devices, number of attempts, and death. Continuous physiological data should also be reviewed as abnormalities may draw attention to unrecognized adverse events. Case review requires the reliable abstraction of pertinent data elements as described in NAEMSP position statement on recommended guidelines for uniform reporting of data for out-of-hospital intubation. Review of airway cases should be used to inform directed feedback to the provider, assessment of system processes that may have contributed to the error, and future continuing education so that all providers can learn from the error. Directed provider feedback may include case review, skill reassessment, or additional scenario-based training. In order to encourage self-report of errors and a culture of safety, discipline should be reserved only for careless or reckless behavior that has been refractory to reeducation. System-based assessment should allow the medical director to examine the protocols and procedures asking the question, \u201cWould other providers make the same error in the same situation?\u201d In rare cases, it may be necessary to send an immediate system-wide message out to prevent such an error from recurring. Lastly, in order to prevent a recurrence of the same type of error, incorporation into simulation or scenario-based training will allow others to learn from the event in a safe environment.",
        "Critical decision making": "Paramedics are dispatched to a patient with respiratory distress who is noted to have swelling and pain involving the submental tissues, which began within the last 24 hours. He has been suffering from a tooth infection and was recently placed on penicillin and advised to see a dentist for an extraction. The crew arrives to find the man with trismus, drooling, and limited mouth opening. His vital signs are BP 136/84, pulse 110, RR 26, SpO\u2082 97% on room air. The crew assesses the patient\u2019s airway and elects to perform RSI, as they are concerned that he will not be able to protect his airway for the 20-minute transport to the emergency department. The crew prepares medications and paralyzes the patient. They are unable to advance a 4 Macintosh blade into the patient\u2019s mouth and switch to a 3 Miller. Over three more attempts, they note significant swelling in the airway and have difficulty identifying structures and cannot clearly visualize the vocal cords. They place an endotracheal tube but quickly remove it when it does not return EtCO\u2082. They are forced to abandon the attempts when the patient\u2019s oxygen saturation falls to 60% and he becomes bradycardic. They place a SGA and are able to ventilate and to recover the patient\u2019s oxygen saturation.\n\nThe medical director reviews the case and the crew is reeducated on the following points. 1 Given the patient\u2019s ability to protect his own airway, it may have been better to manage the patient conservatively, keeping him upright with humidified oxygen and suction (know when not to intubate). 2 When it is clear that there will be a difficult airway, ask for additional resources including, perhaps, a second unit, supervisor, EMS physician, or critical care team (call for help). 3 Intubation attempts should be discontinued if they are not likely to be successful. The conditions of the intubation (positioning, equipment, or provider) should be changed after a failed attempt. 4 The back-up plan should be discussed prior to the attempt and prepared for implementation. The crew was sent to rerun this scenario in a high-fidelity simulation to review alternative actions, which could have resulted in a better outcome. The simulation included multiple iterations of the scenario and debriefing to discuss the points noted above. The scenario was then used to build a simulation demonstrating and evaluating decision making for all the paramedics in the service during the following year\u2019s education sessions."
    },
    {
        "Introduction": "Oxygenation and ventilation are critical life-sustaining functions, and their evaluation and management are primary components of out-of-hospital care. While these two parameters are related, they are distinct physiological functions that require independent assessment. The focus of this chapter will be on diagnostic aids and management, and EMS physicians and providers must develop and maintain expert physical examination skills for the proper assessment of these important processes. The astute provider will observe for demeanor, mentation, ability to speak, ease and volume of air exchange, work of breathing, upper or lower airway obstruction, pulmonary congestion, and central and peripheral cyanosis. These findings should be considered together with diagnostic test results to determine the status of oxygenation and ventilation in an individual patient, whether intervention is needed, and, if so, which treatment modalities are indicated.",
        "Assessment of oxygenation": "Adequate oxygen delivery to body tissues is a necessity for life, and is dependent on both the transfer of oxygen from the alveolar airspace to the blood and sufficient tissue perfusion with oxygenated blood. Oxygenation of the blood is dependent on a number of distinct factors, each of which can be impaired by various pathological processes. Normal hemoglobin oxygen saturation in peripheral arterial blood is 96\u201399%. It is important to understand the relation between oxygen saturation and the partial pressure of oxygen. This is depicted by the oxyhemoglobin saturation curve. This curve demonstrates that above 90%, the saturation percentage is very insensitive to changes in partial pressure of oxygen between 750 and 760 mmHg. This means that, especially in patients on supplemental oxygen, severe impairment in oxygen transfer into the blood can occur without major changes in the saturation level. Considered another way, as long as the partial pressure of oxygen in blood is at least 60 mmHg, hemoglobin is able to transport oxygen efficiently to the periphery.\n\nSeveral tools have been developed that can reliably measure oxygenation of blood in the prehospital environment. Portable devices are available that can measure oxygen content in arterial blood samples (i.e. pO2). However, because of cost and the need to perform arterial puncture, these devices are typically only used at selected special event venues and by critical care teams. Most commonly, oxygen levels in the field are determined by pulse oximetry (i.e. SpO2). This simple, non-invasive method reports the percentage of hemoglobin in arteriolar blood that is in a saturated state. It is critically important for prehospital clinicians to understand that standard pulse oximetry does not discriminate between hemoglobin saturated with oxygen and hemoglobin saturated with carbon monoxide (oxyhemoglobin versus carboxyhemoglobin). In cases of carbon monoxide exposure, pulse oximetry will be misleading to the unsuspecting clinician. Fortunately, newer generation devices, cooximeters, are now available and can measure carboxyhemoglobin levels distinct from oxyhemoglobin.\n\nPulse oximetry may also be unreliable in states of low tissue perfusion, such as with shock or local vasoconstriction due to cold temperature. Additionally, as this technology relies on transmission and reflection of light waves, barriers such as fingernail polish or skin disease can interfere with accuracy.\n\nMeasurement of tissue oxygenation (StO2) uses near-infrared light resorption to measure oxygen saturation of blood in the skin and underlying soft tissue. This allows assessment of oxygen delivery to local tissue rather than simply the amount of oxygen circulating in the arterial system. Initial studies are promising, but further research will be needed to determine the most appropriate clinical use of this modality.",
        "Assessment of ventilation": "Ventilation refers to the volume of air moved in and out of the lungs, and is measured as minute ventilation (volume of air exchanged per minute, which can be estimated by the equation tidal volume \u00d7 respiratory rate). Normal ventilation ranges from 6 to 7L/minute. Although hypoventilation can lead to decreased oxygenation and hemoglobin oxygen saturation, ventilatory effectiveness is better evaluated by how well carbon dioxide (CO2) is being eliminated. Ventilation can be compromised by a number of conditions, and its assessment is of equal importance to that of oxygenation.\n\nVentilatory function can be determined directly by measuring the volume of air inhaled or exhaled per minute or indirectly by measuring the CO2 level in blood or exhaled air. The partial pressure of carbon dioxide (pCO2) may be measured in either arterial or venous blood samples using portable devices, as both provide similar results. However, just as oxygen content in the blood is usually assessed by non-invasive modalities in the out-of-hospital setting, so too is CO2. Three types of devices are currently in use to detect and measure the presence and level of CO2 in exhaled air, which serves as a surrogate for the level of CO2 in blood. The simplest, but least useful, are semi-quantitative colorimetric devices that use litmus paper to detect the acid generated by absorption of CO2 from exhaled air. These devices are compromised by prolonged exposure to air and by contamination from acidic gastric secretions. They may not be able to detect the extremely low levels of CO2 generated by patients in cardiac arrest. For these reasons and due to the increasing availability of devices that can measure and continuously monitor exhaled CO2, colorimetric devices are being used less often than quantitative devices.\n\nCapnometry uses light absorption to measure the level of CO2 in exhaled air. Clinically the level at the end of exhalation is the most useful value and is referred to as end-tidal CO2 (EtCO2). This measurement reflects the CO2 content in alveolar gas and therefore in the pulmonary venous blood returning to the left heart. The EtCO2 level is typically about 5mmHg lower than the actual pCO2 level in the blood due to alveolar dead space, but various clinical conditions can widen this gap.\n\nContinuous waveform capnography provides additional information on the frequency and flow rate of inhalation and exhalation by displaying a graphic depiction of measured expired CO2 versus time. Field providers should have a good understanding of the interpretation of EtCO2 values as well as waveform morphology as they both are altered by a variety of clinical conditions and may provide diagnostic information to EMS clinicians.\n\nAs a monitor of respiratory function, capnography is superior to pulse oximetry because it changes nearly immediately with ventilation. On the other hand, hypoxia may be delayed by the body\u2019s reserve and the shape of the hemoglobin oxygen dissociation curve as discussed above. When capnography waveform analysis is included, a near real-time assessment is possible and EMS clinicians may identify inadequacy of ventilation or the presence of various respiratory disease states, and they may glean information about circulatory and metabolic function as well. When EtCO2 values rise above normal ranges (35\u201340 mmHg), impaired ventilation is easily detected. When combined with waveform analysis, respiratory effort may also be monitored as to rate and depth of breathing. When respiratory rate or respiratory depth has become inadequate and EtCO2 values rise, clinicians can initiate or augment respiratory support prior to the development of hypoxia. In the prehospital environment, this application of waveform capnography is especially useful in monitoring respiratory status following the administration of opiate analgesics, benzodiazepines, and other medications capable of producing respiratory depression.\n\nObstructive respiratory physiology is the most often described diagnosis made upon EtCO2 waveform analysis. Both chronic obstructive pulmonary disease (COPD) and asthma fall into this category, and the waveform produced will be similar. The classic description of this waveform is the \u201cshark fin\u201d morphology consisting of a shallower upward sloping of the initial rise of the EtCO2 wave. This represents a slower rate of exhalation and may be thought of as conceptually similar to the FEV1 measurement of the pulmonary function test. This slower exhalation is precipitated by collapse or partial occlusion of bronchioles in emphysema and chronic bronchitis and spasm in acute asthma attacks. As the reactive airway physiology is relieved with bronchodilation, the initial upward segment will become more vertical. In more severe cases, the numeric value of the EtCO2 will also rise, heralding respiratory insufficiency, and should lead the clinician to consider ventilatory support measures.\n\nAlthough less commonly employed, EtCO2 and waveform analysis may also be useful in assessment of metabolic derangements such as diabetic ketoacidosis and aspirin overdose. These conditions cause a respiratory compensation to a metabolic acidosis and will present with hyperventilation, typically with a decreasing level of EtCO2. But, potentially due to markedly high CO2 production, the EtCO2 level may not decrease or it may even increase.",
        "Assisting oxygenation and ventilation": "While oxygenation and ventilation are distinct parameters, their assessment and management are often interdependent. Thus we will discuss their management together.\n\nThe initial and most basic treatment for inadequate oxygenation is the administration of supplemental oxygen to increase the relative amount, or fraction, of oxygen in inspired gases (i.e. FiO2). Supplemental oxygen is widely available as compressed gas in portable tanks for mobile settings or larger tanks for more fixed settings such as homes and ambulances. Additionally, devices that generate oxygen from chemical reactions are available but typically provide short duration of flow. Oxygen concentrators are often used in the outpatient setting by persons with chronic hypoxemia. Fixed venues may have plumbed systems from central oxygen storage tanks.\n\nOxygen should be provided to all patients with respiratory distress, with any clinical markers of respiratory compromise (e.g. altered mental status), or with measured inadequate oxygenation or ventilation. There is an increasing trend toward more selective application of oxygen with the growing recognition of oxygen toxicity. Newer recommendations suggest administering supplemental oxygen only if the oxygen saturation is <94%. Unnecessarily elevating the pO2 above normal levels may in fact be harmful to patients experiencing neurological or cardiac insults associated with ischemic damage.\n\nPatients with underlying pulmonary disease, such as COPD and interstitial fibrosis, may have oxygen saturations below 94% on a chronic basis. A subset of these patients will also have chronically high pCO2 levels (hypercapnia), which lead to dependence on a hypoxic drive for ventilatory control and stimulation. Providing supplemental oxygen, especially at high flow rates, may contribute to respiratory depression and potentially produce apnea. Providers must carefully assess and monitor these patients, administering oxygen if needed and being prepared to assist ventilation.\n\nSupplemental oxygen can be administered through various devices that deliver different ranges of oxygen concentration. Most EMS systems carry the nasal cannula and non-rebreather face mask, allowing clinicians to choose either a higher or lower amount of FiO2 supplementation. When supplemental oxygen itself does not lead to adequate oxygenation of blood, non-invasive positive pressure ventilation (NIPPV) can be beneficial to supplement ventilatory function in addition to providing increased FiO2. This modality is most effective in patients with pulmonary edema, causing poor oxygen diffusion between alveolar air and pulmonary capillary blood. But, it is also useful for patients with other conditions, including asthma, COPD, and pulmonary hypertension. NIPPV is described in more detail below.\n\nWhile hypoxemia in the setting of adequate ventilation can be treated with supplemental oxygen and augmentation of ventilatory function, inadequate ventilation requires immediate intervention. The provider must rapidly determine the likely cause of the patient's ventilatory insufficiency and determine if it can be quickly corrected. Examples of this would be removal of upper airway obstruction, administration of bronchodilators for bronchospasm, sealing of sucking chest wounds, administration of naloxone for opioid overdose, and needle decompression of tension pneumothorax. Some conditions cannot be immediately alleviated, particularly in the prehospital setting, such as muscle weakness from Guillain\u2013Barr\u00e9 syndrome or severe physical fatigue, vital capacity reduction from a large pleural effusion, and non-reversible drug toxicity. In other cases, medical interventions may not be sufficiently effective immediately, such as for acute pulmonary edema or severe asthma. Whenever ventilation is compromised and cannot be immediately alleviated, mechanical ventilatory support must be provided. This can be accomplished non-invasively or invasively, through a device placed in the airway.",
        "Non-invasive positive pressure support": "Patients who are awake, protecting their airway, have respiratory drive, and can cooperate may be given ventilatory support with non-invasive modalities that provide positive airway pressure. These include continuous positive airway pressure (CPAP), which delivers constant pressure above that of the atmosphere throughout the ventilation cycle, and bilevel positive airway pressure (BiPAP), which delivers different pressures during the inspiratory and expiratory phases. Portable devices for the delivery of CPAP in the prehospital setting are generally of three types. Two of these require a high-pressure (50 psi) oxygen source. One continuously delivers oxygen under pressure to a mask with a pop-off valve that opens when the desired pressure is reached. The other uses a controller that essentially acts as a demand valve, adjusting flow to maintain the desired pressure. The third type of device uses oxygen flow from a standard regulator and a Venturi valve to create a virtual valve resulting in elevated pressure. Usually treatment is started at 5\u201310 cmH2O and increased as needed to a maximum of 20 cmH2O. Prehospital devices generally deliver near 100% FiO2, while more advanced devices allow FiO2 to be titrated. BiPAP is generally only available to EMS personnel who carry full-function mechanical ventilators, and so is not widely used in the prehospital setting.\n\nNon-invasive positive pressure ventilation has been shown to improve oxygen delivery, likely due to the hydrostatic pressure effects of increasing the gas diffusion gradient, promoting displacement of fluid in the alveoli back into the capillary bed, and stenting open small bronchioles (which do not have cartilaginous walls), thereby increasing both the volume of air exchanged and the number of alveoli ventilated. NIPPV also decreases the work of breathing in these patients. The ultimate clinical effects are that patients will often have improved oxygenation, improved ventilation, marked improvement in respiratory distress, and a significantly lower likelihood of needing intubation and mechanical ventilation.",
        "Bag-mask ventilation": "Patients with marked respiratory failure may need more intensive ventilatory support. This is true for patients with inadequate ventilatory effort and those with depressed mental status who cannot protect their airways. Immediate assistance should be provided for these patients using a bag-mask (also known as bag-valve-mask) device to either assist spontaneous ventilations or provide full mechanical ventilation. Proper positioning (head and neck tilt, sniffing position), mechanical airway opening (jaw thrust or modified jaw thrust), and placement of a nasal or oral airway can markedly improve airflow. High-flow oxygen should flow into the bag device, preferably with a reservoir bag. Using this device can be difficult for a single provider, using one hand to seal the mask and the other to squeeze the bag. Whenever possible, a two-person technique should be used, with one provider using both hands and a jaw thrust maneuver to make a firm seal around the mask and open the airway, while the other provider squeezes the bag.\n\nProviders must be cognisant of the volume and rate when assisting ventilation. Patients who are severely hypoxic or hypercarbic may initially require a period of hyperventilation, as do those with severe metabolic acidosis such as diabetic ketoacidosis or sepsis. However, absent such conditions, unnecessary hyperventilation will have detrimental effects, including decreased cerebral perfusion, venous return, and cardiac output, and metabolic impairment from respiratory alkalosis. Capnography can facilitate awareness of EtCO2 levels, but this information must then be interpreted based on the clinical situation.",
        "Mechanical ventilation": "While bag-mask ventilation can be an effective and life-saving initial measure, it is difficult to maintain effectiveness in the longer term, especially in a moving vehicle. Additionally, it provides no protection from aspiration of stomach contents, blood, or other secretions. When adequately trained personnel are available, a more definitive airway should be sought in patients who have marked depression of consciousness, inability to protect their airway, or who require full mechanical ventilatory support to maintain oxygenation and ventilation. Usually this will entail placement of either an endotracheal tube or supraglottic advanced airway device. Patients can then be ventilated either manually (i.e. with a bag device) or with a portable mechanical ventilator. There are many models and types of mechanical ventilators and the decision on which to use should be based on local EMS system and patient characteristics.\n\nManagement of mechanical ventilators is a complex topic and a comprehensive tutorial is beyond the scope of this text. However, a basic understanding of the modes, settings, and troubleshooting of mechanical ventilators is important. Mechanical ventilators are typically used in the prehospital setting by air medical services and by ground critical care teams during interfacility transports. EMS providers may also encounter patients who are chronically on ventilators in residential or long-term care settings.",
        "Modes of ventilation": "There are three common modes of mechanical ventilation: assist control (AC), synchronized intermittent mandatory ventilation (SIMV), and pressure support (PS). The key to understanding these modes is recognizing that the time of the respiratory cycle (i.e. respiratory rate), tidal volume, flow rate, and pressure developed in the airways are all interdependent and affected by the individual patient's airway physiology. In each of these modes, different combinations of these variables are controlled by the machine, and the patient's respiratory function determines the uncontrolled variables.\n\nIn AC mode, the ventilator delivers a set tidal volume with each breath. A default respiratory rate is set but the patient may trigger breaths above that default rate. In AC mode the machine will deliver the full set tidal volume on either a patient-triggered or machine-triggered breath. SIMV is very similar to AC, and, in fact, in patients without spontaneous respiratory effort the two are effectively identical. The major difference is that in SIMV the machine does not deliver the full set tidal volume in response to a patient-triggered breath, but rather allows the patient's effort to determine the volume of the breath. In SIMV mode the ventilator will synchronize ventilator-triggered breaths with patient-triggered breaths, assuring that the set rate is met or exceeded. In both AC and SIMV care must be taken to monitor the airway pressures developed during the respiratory cycle. In contrast, PS mode delivers a set inspiratory pressure above a baseline positive end-expiratory pressure (PEEP) with each patient-triggered breath. The patient's respiratory drive determines the rate and the patient's lung compliance and airway resistance determine the tidal volume developed.",
        "Ventilator settings and troubleshooting": "Once the mode of ventilation is selected, prehospital providers will need to set several variables. In AC and SIMV modes, tidal volume (TV), respiratory rate (RR), and PEEP are all determined by the clinician. Tidal volumes are normally chosen to be 6\u201312 mL/kg of ideal body weight. Tidal volumes closer to 6mL/kg are felt to be protective against the development of acute respiratory distress syndrome and should be used when possible. Respiratory rates are often set at a default of 12 per minute, but should be adjusted based upon the patient's clinical situation (e.g. increased rate in patients who are dependent upon respiratory compensation of a metabolic acidosis).\n\nPositive end-expiratory pressure may also be applied to assist with oxygenation via mechanisms similar to NIPPV, discussed above, and is often initially set at 5\u201310 mmHg. In patients with obstructive physiology (e.g. asthma and COPD), care should be taken to maximize expiratory time to avoid incomplete expiration and breath stacking which can lead to increased airway pressures. If air trapping is suspected, excess pressure can be alleviated by disconnecting the endotracheal tube from the ventilator for a few seconds and compressing on the patient's chest.\n\nPeak inspiratory pressure (PIP) represents the maximum pressure developed during the inspiratory phase. Changes in PIP are a common source of ventilator alarms. Low PIP usually indicates a leak in the ventilator circuit. High PIP may represent either an increase in airway resistance (e.g. blocked tube, bronchospasm, secretions) or a decrease in lung compliance (e.g. pulmonary edema, atelectasis, pneumothorax, pleural effusion, hyperinflation). These two states can be distinguished by performing an inspiratory hold test to measure a plateau pressure. This test is performed by pressing the hold button on the ventilator for approximately 5 seconds during inspiration without allowing the patient to exhale. This effectively eliminates the airway resistance from the measured pressure and allows independent assessment of pressure being developed in the lungs with a given tidal volume. This is equivalent to a measurement of lung compliance. If the plateau pressure rises along with PEEP, clinicians should look for correctable causes of decreased lung compliance.",
        "Pneumothorax": "Pneumothorax is air in the otherwise \u201cvirtual space\u201d between the parietal and visceral pleurae. The volume and pressure of the air in this space determine the clinical effect, which can range from asymptomatic to life-threatening. Early signs and symptoms may be subtle and the condition is often not expected. It is therefore important for EMS clinicians to maintain a high index of suspicion for pneumothorax in a variety of presenting complaints and to be aware of potential predisposing or associated conditions.\n\nPatients may present with pleuritic pain, sudden onset of a sharp pain, minimal to severe shortness of breath, and hypoxemia. Physical exam findings that should prompt consideration of pneumothorax include decreased or absent unilateral breath sounds, subcutaneous emphysema, and evidence of thoracic trauma. Pulse oximetry may or may not decrease depending on the size of the pneumothorax and the underlying pulmonary function and comorbidities of the individual patient. Similarly, EtCO2 may or may not appreciably change and its interpretation may be further complicated by compensatory hyperventilation or other comorbid conditions. A potentially more sensitive indicator in patients already receiving mechanical ventilation may be decreases in tidal volumes and increases in peak pressures. Ultrasound, if available, can also be used to identify pneumothorax.\n\nThe one case in which a pneumothorax definitely should be recognized clinically is a tension pneumothorax. This occurs when the intrathoracic pressure is so great that ventilation and venous return to the heart are obstructed, leading to respiratory distress and shock. Besides unilateral decreased or absent breath sounds and subcutaneous emphysema, tracheal deviation and jugular venous distension may be present, but these should not be relied upon. Tension physiology must be recognized and treated immediately. A radiograph of a tension pneumothorax is considered a marker of suboptimal care.\n\nTension pneumothorax must be treated immediately with needle thoracostomy (needle decompression). To accomplish this, following skin cleansing, a large-bore IV catheter (14 gauge or larger) should be inserted through the anterior chest wall in the second intracostal space at the midclavicular line. When the needle enters the pleural space, a rush of air is often heard. The needle is then removed, leaving the catheter in place. Patients may require decompression with several needle thoracostomies in the prehospital environment as air reaccumulates in the pleural space. Needle decompression may alternatively be accomplished using the same technique at the fourth or fifth intracostal space at the anterior axillary line. Some prefer this site because of the decreased likelihood of puncturing vascular structures. In either case, treatment failure is typically due to using too short a needle or the catheter becoming occluded, which requires placement of additional needle(s). The hub of the catheter should either be left open or attached to a Heimlich (one-way) valve. Subsequently, the patient should receive a formal thoracostomy tube placed on suction with water seal. This is often deferred until arrival in the emergency department but may be considered in the prehospital setting if an appropriately trained physician or other advanced provider is available and in the appropriate circumstances.\n\nA patient with a penetrating wound to the chest should have an occlusive dressing applied with watchful monitoring for the development of tension physiology. If tension develops, the dressing should be immediately vented. Some types of occlusive dressings provide one-way air flow (pleural space to environment) to prevent the accumulation of gas in the pleural space that leads to a tension pneumothorax. Alternatively, an occlusive dressing may be left unsealed on one side or corner, which allows it to act like a one-way flap valve.\n\nA frequent concern with the management of patients with pneumothorax is air transport. Boyle's law (P1\u00d7V1=P2\u00d7V2) describes that the air in the pleural space will expand with decreasing atmospheric pressure associated with increasing altitude. The EMS provider should be aware that helicopter transport is not typically associated with sufficient altitude to have a significant clinical effect. For example, most medical helicopters fly at 1,000\u20133,000 feet above the ground. But at 6,000 feet, an altitude sometimes associated with instrument flight conditions (e.g. inclement weather), the increase in size would be about 25%. The clinical effects of such an increase in pneumothorax size are very much patient specific, depending on such things as lung compliance and comorbid conditions. Patients generally should not be flown in fixed-wing aircraft (especially without cabin pressurization) without tube thoracostomy decompression.",
        "Conlcusion": "Oxygenation and ventilation are distinctly different but interrelated physiological processes. In general, adequate oxygenation requires sufficient ventilation to deliver gas to alveolar spaces, where oxygen can then enter pulmonary capillaries for transport to peripheral tissues. Pulse oximetry is a useful tool, except in cases of carbon monoxide poisoning, to help determine the extent of tissue oxygenation. Patients with respiratory distress and/or SpO\u2082 less than 94% should receive supplemental oxygen. However, use of oxygen should not be indiscriminate.\n\nVentilation is about gas moving in and out of the lungs. Clearly, it can occur without oxygen, and in that sense is a distinct process. The adequacy of ventilation is generally assessed in terms of minute ventilation. Waveform capnography is a useful tool to both monitor ventilation and evaluate its effectiveness. NIPPV may provide needed support to an awake patient with inadequate ventilation but intact drive. Mechanical ventilation represents the option for maximum ventilatory support tool to deliver the greatest FiO\u2082. Especially in a dynamic prehospital environment, vigilant monitoring is imperative to promptly identify and address deficiencies in ventilation and oxygenation and complications arising from their treatment."
    },
    {
        "Introduction": "Choking emergencies are important in EMS because of their time-sensitive nature. Victims of choking can rapidly progress from airway obstruction to loss of consciousness and cardiac arrest. Bystanders must act quickly to resolve true choking episodes. EMS personnel will likely arrive on scene several minutes after the onset of choking. Therefore, they must be prepared to manage a patient in the advanced stages of crisis. Choking is an emergency that must be solved on scene; there is limited value in bringing an unresolved choking victim to the emergency department for definitive treatment.",
        "Pathophysiology and epidemiology": "Choking results from obstruction of the trachea by a foreign object. It is the nature of the so-called \u201ccaf\u00e9 coronary\u201d that occurs during or shortly after a meal. Although most choking episodes are associated with food, non-edible objects may also cause airway occlusion; particularly, children may inadvertently aspirate coins, toys, or other objects. Choking can occur with liquids as well as solid substances. Although most obstructions occur in the hypopharynx, a small foreign body may lodge in either bronchus, causing selective obstruction of a lung or lung segment. Because the right bronchus travels more directly off the trachea, most selective obstructions involve the right lung. Choking may be classified as partial or complete. A complete obstruction impairs the ability to breathe, to talk, and to cough and is an immediate life threat. A partial obstruction results in incomplete occlusion of the airway. In these instances the individual may still be able to breathe, talk, or cough. A complete occlusion generally mandates immediate intervention (such as the Heimlich maneuver, or direct laryngoscopy if ALS personnel are present). Other less invasive maneuvers may be appropriate in individuals with partial obstruction. However, in instances of partial obstruction with compromised air exchange, cyanosis, or loss of consciousness, the rescuer must approach the case as though it involves a complete airway obstruction. The incidence of choking varies with age. Children younger than 1 year of age are most likely to choke, with food and liquids causing most of these episodes. Toddlers aged 1\u20134 years tend to choke on non-food items such as coins or latex balloons. Choking is less common in those aged 4\u20139 years and often occurs from gum and candy. Choking incidence rises again at age 60 years from concurrent conditions impairing coordinated swallowing (e.g. Alzheimer dementia, stroke, drinking alcohol, seizure, or Parkinson disease). A prior choking episode significantly increases the chances of future choking.",
        "Patient assessment": "Because complete or partial airway obstruction may rapidly lead to cardiopulmonary arrest, expeditious recognition of choking is essential. Ideally, bystanders will recognize and immediately treat choking victims. Delay of recognition and treatment until EMS arrival will likely result in clinical deterioration. Patients suffering from complete airway obstruction usually present with classic signs, including aphonia, hands to the throat, and hyperemia of the face. Other more serious signs include altered mental status, cyanosis, and unconsciousness. Many conscious choking victims will exhibit the universal choking sign (hands crossed over the throat) and will nod in affirmation to the question, \u201cAre you choking?\u201d Partial airway obstruction may be more difficult to assess, especially in pediatric patients. These individuals may still have partial speaking ability. In many cases, the victim may exhibit paroxysmal coughing, drooling, stridor, or poor feeding. Common conditions mimicking foreign body aspiration include pneumonia, asthma, croup, and reactive airway disease. An esophageal foreign body may also cause or mimic airway obstruction. Vital signs, pulse oximetry, and other diagnostic tools are not typically useful in establishing the severity of a choking episode. In one series, 2% of admitted adult choking patients had normal prehospital vital signs.",
        "Clinical management": "The clinical course and subsequent deterioration due to choking progress rapidly. In ideal circumstances, bystanders should resolve the airway obstruction, because even the most prompt EMS agencies will not arrive in time to perform needed interventions. Patients presenting with complete airway obstruction should receive the Heimlich maneuver. In the classic Heimlich procedure, the rescuer positions himself behind the sitting or standing patient, placing his arms around the chest at the level of the epigastrium. The rescuer places one fist against the epigastrium, using the other hand to apply quick upwards thrusts. The rescuer repeats the process until the obstruction clears. For the unconscious patient, current ACLS guidelines recommend performing standard cardiopulmonary resuscitation (CPR) chest compressions. The only caveat is that when giving breaths, rescuers should look inside the mouth to visualize and remove any foreign bodies. Abdominal compressions and blind finger sweeps are no longer recommended for unconscious persons. For infants less than 1 year of age, the rescuer typically positions the victim with the head downward, alternating back blows with chest compressions. Bulb suction, visualized finger sweeps, and back blows often work well without the need for chest compressions. Emergency medical services personnel responding to a choking emergency must be prepared to manage the advanced stages of crisis, and must act quickly on arriving at the scene. Bystanders may have failed to recognize that the patient is choking, leading emergency medical dispatchers to miscategorize the call as a condition other than choking (e.g. respiratory distress, chest pain, or unconscious person) due to inaccurate or incomplete information from the 9-1-1 caller. Bystanders may have already made unsuccessful attempts to clear the obstruction with the Heimlich maneuver. The patient may be unconscious or in cardiac arrest. On confirming the presence of complete airway obstruction, rescuers should perform the Heimlich maneuver or chest compressions. In cases of partial airway obstruction, rescuers should monitor for signs of cyanosis, inadequate breathing, or unconsciousness, signifying the need to immediately provide the Heimlich maneuver or chest compressions. If the Heimlich maneuver does not resolve the obstruction, ALS personnel may attempt to directly visualize the airway with a laryngoscope, making efforts to remove visualized foreign bodies using Magill forceps. Foreign bodies below the vocal cords may be more problematic. Anecdotal reports suggest using a rigid suction catheter in these situations. Although data in this area are lacking, intubation is risky in these cases and may further lodge the foreign body. As a last resort, rescuers may consider performing cricothyroidotomy or transtracheal jet ventilation (TTJV). This approach will only work if the surgical airway is placed below the foreign body. There are anecdotal reports of high-pressure TTJV to eject entrapped foreign bodies. However, there are no organized reports of choking management using cricothyroidotomy or TTJV. For patients with partial airway obstruction, there are additional management options. The patient should be encouraged to cough and expel the object. High-flow supplemental oxygen may be appropriate, although the sensation of the mask may make the patient feel uncomfortable, aggravating the situation. If the patient is able to adequately move air, it may be acceptable (and even preferable) to carefully transport the patient to the hospital for definitive care. In these cases, close monitoring of vital signs, oxygen saturation, respiratory effort, and level of consciousness are prudent. Monitoring of end-tidal carbon dioxide may also help to reveal early clinical deterioration, though research data on this are lacking. EMS personnel should provide advance notification to the receiving facility so that the emergency department can prepare its equipment and summon appropriate personnel. Because this is an airway emergency, it typically makes the most sense to go to the nearest hospital. At the receiving hospital, the patient may require urgent sedation, direct or video laryngoscopy, or surgical airway intervention by an emergency physician, otolaryngologist, gastroenterologist, anesthesiologist, or surgeon. Many emergency departments have a \u201cdifficult airway\u201d algorithm that involves summoning various specialists to the emergency department to provide assistance in these situations. Many choking victims refuse EMS care and/or transport. In general, however, it is recommended that patients who have their choking resolved before EMS arrival or by EMS providers be transported to the hospital for further evaluation to ensure that no complications have occurred. This recommendation is based primarily on case reports of laryngospasm, pulmonary edema, anoxic brain injury, and retained foreign body occurring after choking episodes. In addition, there are case reports of damaged internal organs following abdominal and chest thrusts. A patient who persists in refusing transport should be made aware of these possible risks. Informed refusal should be obtained by field personnel following system protocols. As a final consideration, an anaphylactic reaction may masquerade as an upper airway obstruction, especially if the patient has recently eaten nuts. If the history and presentation are suggestive of this situation, rescuers should consider therapy with epinephrine and antihistamines.",
        "Medical oversight considerations": "Deterioration after complete airway obstruction occurs so rapidly that direct medical oversight by phone or radio likely provides only limited value. In cases of partial obstruction, direct medical oversight may provide useful guidance regarding management and receiving hospital options. The most important consideration is to educate EMS personnel to recognize signs and symptoms of partial and complete obstruction. As bystander intervention is essential in treating choking, EMS community outreach and education efforts are equally important. Emergency medical services physician presence at the scene may potentially play a role in selected complicated choking cases. Patients with partial airway obstructions may prove tenuous and difficult to manage, requiring a fine balance between supportive care and skilled airway intervention. An on-scene EMS physician may facilitate selection of optimal treatment strategies. In the event of complete airway obstruction unresolved by basic techniques, an on-scene EMS physician may be best qualified to perform advanced airway interventions, such as direct or video laryngoscopy and foreign body removal, rapid sequence intubation, or cricothyroidotomy. In all cases, the EMS physician\u2019s value will be greatest if he/she is present at the earliest stages of the event, before complete airway obstruction or anoxic injury. The most important controversies in choking management are the use of back blows and chest thrusts. The Heimlich Institute opposes both of these techniques. The American Heart Association (AHA) recommends these interventions if the Heimlich maneuver fails and the American Red Cross (ARC) also advocates for both. The AHA and the ARC recommend chest thrusts instead of the Heimlich maneuver for unconscious, pregnant, and obese patients and for children less than 1 year of age. Critics note that back blows can cause the object to lodge deeper and waste valuable time better spent performing the Heimlich maneuver. In a recent study, the Heimlich maneuver was 86.5% effective at removing an obstruction. Back blows may prove effective in children less than 5 years of age. Chest thrusts are associated with significantly higher morbidity and mortality than the Heimlich maneuver and should probably be reserved for the most serious choking victims. Advanced Cardiac Life Support- and PALS-trained public and EMS providers have improved choking survival rates beyond 95%. Expeditious recognition and treatment of choking are essential and should ideally be accomplished by bystanders. EMS personnel arriving on the scene should be prepared to manage a significantly deteriorated patient. Patients with partial airway obstructions may tolerate supportive care and rapid transport to the hospital. All choking victims should receive transport to the hospital for evaluation."
    },
    {
        "Introduction": "Airway management is one of the most essential interventions in the prehospital care of the critically ill or injured. This chapter provides an overview of the techniques and current controversies surrounding prehospital airway management.",
        "Basic airway interventions": "Basic airway interventions include measures to provide supplemental oxygen and/or ventilation without the use of an advanced airway device. These techniques are practiced by all prehospital providers, including first responders, EMTs, paramedics, and EMS physicians.",
        "Oxygen cannulas and face masks": "In spontaneously breathing patients, prehospital EMS personnel may deliver supplemental oxygen using nasal cannulas or oxygen masks. The nasal cannula provides low-flow (2\u20135L/ min) oxygen in inhaled fractions (FiO\u2082) from 21% to 40%. Oxygen masks used in the prehospital setting include simple face masks (6\u201310L/min oxygen delivery, 40\u201360% FiO\u2082) and non-rebreather masks (10\u201315L/min oxygen delivery, close to 100% FiO\u2082). Oxygen cannulas and masks are designed for patients with spontaneous respiratory drive and intact protective airway reflexes. Patients with frank respiratory compromise or apnea should receive bag-valve-mask ventilation support or advanced airway management. The standard teaching for EMS personnel is to provide oxygen to all patients with actual or potential for hypoxia. In practice, it is best to base supplemental oxygen protocols and practices on clinical findings. While some EMS agencies use pulse oximetry to titrate oxygen therapy for specific oxygen saturation deficits, this approach may shift EMS personnel focus to oxygen saturation readings, rather than the patient's physical findings. Many patients with acute respiratory compromise present with increased respiratory rates (over 40\u201350 breaths/minute), not necessarily hypoventilation, hypoxia, or apnea.",
        "Bag-valve-mask ventilation": "Bag-valve-mask (BVM) ventilation is the primary method for providing active ventilatory support without the use of an advanced airway device. The key BVM device components include a self-inflating bag, oxygen reservoir, and conforming face mask. The primary indications for BVM ventilation include hypoventilation (inadequate respiratory drive or effort) or frank apnea. The technique of BVM ventilation is difficult, requiring rescuers to open the airway and maintain a mask seal with one hand while squeezing the ventilation bag with the other hand. Seasoned providers often recommend performing BVM using a two-person technique, with one rescuer opening the airway and holding the mask with both hands, and the other squeezing the bag. Two-handed BVM techniques provide greater tidal volumes than one-handed techniques. Several studies have demonstrated the difficulty of performing effective BVM ventilation, particularly in a moving ambulance or during prolonged resuscitation efforts; this is one of the motivations for the use of advanced airway in many prehospital patients. An important potential adverse effect associated with BVM ventilation is gastric insufflation, which may result in regurgitation and aspiration of gastric contents into the airway. Many anesthesiologists use Sellick's maneuver (cricoid pressure) to minimize gastric insufflation during operating room BVM ventilation. While probably not harmful, this technique has not been proven to be helpful in the prehospital setting.",
        "Demand valve ventilation": "The demand valve is an oxygen-powered resuscitator that delivers high-flow oxygen through a mask via a trigger valve. The valve is actuated by a single finger, allowing the rescuer to use both hands to seal the mask and open the airway. The major limitation of this device is the inability to sense lung compliance, which may be important in the presence of barotrauma or pneumothorax. Formal comparisons to BVM ventilation or other ventilatory devices remain limited [8,9]. Although once popular, fewer agencies appear to be using these devices.",
        "Oropharyngeal and nasopharyngeal airways": "Oropharyngeal and nasopharyngeal airways are important adjuncts for basic airway support. The oropharyngeal airway is a curved plastic device that is inserted into the oropharynx, maintaining airway patency by lifting the tongue forward from the posterior wall of the pharynx. The nasopharyngeal airway is a soft plastic tube that is inserted through the nose, similarly facilitating airway patency. EMS personnel should use one of the adjuncts during BVM ventilation. Many clinicians report the simultaneous use of both devices in selected patients. While either adjunct may be suitable with a non-rebreather mask for a spontaneously breathing patient, insertion of the oropharyngeal airway should be reserved for patients without a gag reflex.",
        "Advanced airway management": "Advanced airway management involves the insertion of an airway tube into the oropharynx and hypopharynx to facilitate oxygen delivery and ventilatory support. Advanced airway management is indicated in hypoventilating or apneic patients or individuals with actual or potential airway compromise. Current options for prehospital airway management include endotracheal intubation (ETI), supraglottic airways (SGA), and surgical airways. While advanced providers typically perform these techniques, ETI was an optional module in the prior national emergency medical technician curriculum; it is not listed as an emergency medical technician (EMT) or AEMT skill in the current National EMS Education Standards. In some areas EMTs may use SGAs. SGAs are not included at the EMT level, but are included at the AEMT level, in the National EMS Education Standards.",
        "Endotracheal or tracheal intubation": "Endotracheal intubation is the most widely recognized method of advanced airway management. Paramedics have performed ETI in the United States for over 30 years. ETI has many theoretical advantages, including the isolation of the airway from secretions or gastric contents and the provision of a direct conduit to the trachea without separate airway opening maneuvers.",
        "Orotracheal intubation": "Direct orotracheal intubation is the most common method of ETI. In this approach the rescuer uses a lighted laryngoscope to displace the patient\u2019s tongue and expose the epiglottis and vocal cords, permitting direct insertion of the endotracheal tube into the trachea. The most common laryngoscope blades used for orotracheal intubation include Macintosh (curved) and Miller (straight) blades, which require slight variations in laryngoscopic technique. The rescuer places the curved Macintosh blade into the vallecula (the space immediately anterior to the epiglottis), facilitating indirect lifting of the epiglottis and exposure of the vocal cord structures. In contrast, the rescuer uses the broad side of the straight Miller blade to displace the oropharyngeal structures, using the tip of the blade to directly lift the epiglottis. Blade selection is a matter of personal preference; there are no data indicating the superiority of either blade in prehospital ETI. Orotracheal intubation optimally requires the absence or near-absence of protective airway reflexes. It is extremely difficult in patients who are awake or have intact airway reflexes. In these situations, drug-facilitated intubation techniques are often necessary to facilitate access to the oropharynx. In scenarios with potential cervical spine fracture or injury, EMS personnel must perform orotracheal intubation with \u201cmanual in-line stabilization\u201d of the cervical spine, without hyperextension of the head or neck during laryngoscopy. This approach requires a second rescuer to manually hold the cervical spine \u201cin line\u201d during laryngoscopy attempts. Laryngoscopy and exposure of the vocal cord structures are relatively difficult while maintaining cervical spine stabilization. A critical review questions the value of manual in-line stabilization, suggesting that it significantly impairs laryngoscopy while not affording adequate spinal cord protection. However, video laryngoscopy may provide adequate visualization of the glottis while minimizing cervical spine movement during ETI.",
        "Video laryngoscopy": "Video laryngoscopy uses a camera attached to the distal end of the blade of the laryngoscope to obtain images of the anatomy that are then displayed on a video screen. Newer generation video laryngoscopes include portable and disposable configurations that may be used in the prehospital setting. While video laryngoscopy has demonstrated equal or improved ETI success rates when compared to traditional laryngoscopy in nearly all clinical settings, its cost is higher than conventional laryngoscopy. Some studies suggest that proficiency with video laryngoscopy may be obtained in as few as five ETIs. Some video laryngoscopes also allow providers to record their ETI efforts for offline review for quality improvement or educational initiatives. Endotracheal intubation technique using video laryngoscopy depends upon the brand and model used. Although several different video laryngoscopes are available, the GlideScope (Verathon, Bothell, WA) and C-MAC (Karl Storz Corp., Tuttingen, Germany) currently appear to be the most widely used. While some manufacturers provide standard Macintosh curved blades that allow for conventional direct laryngoscopy, such as the C-MAC, other manufacturers provide a hypercurved blade, including the GlideScope. With the latter device, visualization of the vocal cords can only occur through the video screen; direct visualization of the vocal cords is not possible. In addition, because the pathway from the mouth to the vocal cords is no longer a straight line, the endotracheal tube and stylet must be bent with a slightly deeper curve. The GlideScope requires a specialized stylet for this application.",
        "Nasotracheal intubation": "Nasotracheal intubation involves insertion of an endotracheal tube through the nose and into the trachea. It is possible only in patients with intact respiratory efforts, for example, individuals with congestive heart failure or acute pulmonary edema. The approach may be possible for patients who cannot lay supine, for example, patients entrapped after a motor vehicle collision. In contrast with orotracheal methods, nasotracheal intubation is often possible in awake patients, and those with intact gag reflexes or trismus. Successful nasotracheal intubation requires a skilled and experienced operator. The rescuer chooses an endotracheal tube one-half size smaller than customary for orotracheal intubation, inserting the tube into the nares without a stylet and directing the endotracheal tube inferiorly and anteriorly towards the vocal cords. Experts recommend first entering the right nostril, which is often larger than the left. The rescuer coordinates insertion of the tube through the vocal cords with patient inhalation. The Endotrol (Mallinckrodt, Inc., Hazelwood, MO) endotracheal tube has a special trigger device that flexes the tip of the tube, facilitating its direction toward the larynx as the tube is advanced. A sometimes helpful adjunct is the Beck Airway Airflow Monitor (BAAM, Great Plains Ballistics, Lubbock, TX). When placed on the connector end of the endotracheal tube, the device \u201cwhistles\u201d as the tube approaches the vocal cords. Important complications associated with nasotracheal intubation include nasal trauma and epistaxis, sinusitis (which may cause sepsis), and perforation of the cribiform plate with subsequent intracranial placement.",
        "Other intubation techniques": "Digital intubation is one of the original methods of endotracheal intubation. In this technique, the rescuer places his/her second and third fingers into the patient\u2019s pharynx, forming a cradle extending to the epiglottis and the vocal cords. The rescuer then uses the other hand to guide an endotracheal tube along the cradle and through the vocal cords. Some clinicians recommend twisting the endotracheal tube into a corkscrew shape to facilitate the technique. Digital intubation may be viable in unresponsive patients where EMS personnel have limited access to the airway. The technique could result in rescuer injury should the patient bite down during the procedure. Some clinicians advocate the concurrent use of a dental prod or mouth gag during digital intubation efforts. The lighted stylet is a semi-rigid stylet equipped with a battery-powered lighted tip. The rescuer inserts the stylet through the endotracheal tube and bends the combination into a \u201chockey stick\u201d shape. The rescuer then inserts the stylet/endotracheal tube combination blindly into the oropharynx and uses the light to facilitate movement of the tube through the vocal cords. When properly placed, the bulb of the lighted stylet is visible through the patient\u2019s cricoid membrane. Few EMS agencies use lighted stylet intubation due to the cost of the device and difficulty of the technique. Further, the procedure is limited by the need for low ambient lighting. In retrograde intubation, the rescuer places a large-bore needle through the cricothyroid membrane, pointing it cephalad, and then inserts a guidewire through the needle, advancing it superiorly until the wire tip comes out through the mouth. A conventional endotracheal tube can then be threaded over the guidewire and through the vocal cords. It is important that the wire be threaded through the \u201cMurphy\u2019s eye\u201d of the tube. Commercial kits exist for retrograde intubation. Only limited data support this technique in the prehospital environment. The gum elastic bougie, an adjunct for orotracheal intubation, is essentially a semi-rigid stylet. The rescuer performs conventional orotracheal laryngoscopy, placing the bougie through the vocal cords and into the trachea. Because the bougie is smaller and stiffer than an endotracheal tube, it is usually easier to place through the vocal cords. The angled, \u201chockey stick\u201d tip also provides tactile feedback from the tracheal rings, assuring that the device is in the correct endotracheal position. The rescuer can slide a conventional endotracheal tube over the bougie and through the vocal cords before removing the bougie. Limited data describe the use of the bougie in the prehospital setting but generally describe improved ETI success.",
        "Supraglottic airways": "Supraglottic airways are advanced airway devices used to facilitate ventilation without the use of conventional endotracheal tubes. Other terms commonly used to describe SGAs include extraglottic airway, rescue airway, secondary airway, failed airway device, difficult airway device, salvage airway, alternate airway, and back-up airway. In current prehospital practice, EMS personnel typically reserve SGAs use for situations with failed ETI efforts, but recent reports suggest a potential primary role for SGAs. The most common SGAs in current North American prehospital use are the esophageal tracheal Combitube (ETC), the King laryngotracheal (King LT) airway, and the laryngeal mask airway (LMA). When EMS personnel have inserted a SGA, instead of ETI, they should provide advance notification to the receiving ED. The SGA may require exchange to an endotracheal tube or surgical airway, and the receiving ED may need additional time to prepare or to assemble an appropriate team.",
        "Esophageal tracheal Combitube": "The ETC is a double-lumen tube with a distal and a proximal balloon. The rescuer inserts the ETC blindly into the patient's mouth, typically positioning the smaller distal balloon in the esophagus and the larger proximal balloon in the oropharynx. If the distal part of the ETC is correctly positioned in the esophagus (the most common position), insufflation through the longer, blue-colored lumen will deliver oxygen indirectly to the trachea through holes in the blue-colored tube at the level of the vocal cords. If the distal part of the ETC is positioned in the trachea, insufflation through the shorter, white-colored tube will deliver oxygen directly to the trachea. Auscultation or visualization of chest rise may not correctly discriminate between esophageal and endotracheal placement of the airway. End-tidal carbon dioxide detection is recommended to help identify the correct port for insufflation. Multiple studies have verified the adequacy of ventilation and feasibility of ETC insertion in the prehospital setting. The ETC currently comes in two sizes, including a standard size (for patients >5'6). The smaller SA size often works satisfactorily in taller patients. Pediatric ETC sizes do not exist. Complications attributed to ETC include oropharyngeal bleeding, esophageal perforation, and aspiration pneumonitis, among others. Some agencies have trained EMTs to insert ETCs.",
        "King laryngotracheal airway": "The King LT is a SGA that resembles an ETC but consists of a single-lumen tube. A single insufflation port simultaneously inflates two balloon cuffs. Shorter and smaller than an ETC, the King LT design is supposed to facilitate more consistent placement in the esophagus. Insertion of the King LT airway is very similar to the Combitube. After balloon cuff inflation, the rescuer may need to withdraw the tube slightly to seal the balloon against the oropharyngeal structures. Disposable versions of the device exist for prehospital application. There is also a version with an esophageal port permitting concurrent placement of an orogastric tube. In addition to three different adult sizes, pediatric sizes of the King LT are also available. Given the simplicity of its design, the King LT can be rapidly placed by providers with a range of skills in a variety of clinical settings.",
        "Cricothyroidotomy": "Cricothyroidotomy involves exposure and incision of the cricothyroid membrane (directly inferior to the thyroid cartilage) and direct insertion of a tracheostomy or endotracheal tube into the trachea. In the classic \u201copen technique,\u201d the rescuer identifies the thyroid cartilage, uses a scalpel to place a longitudinal midline incision, then transversely incises the cricothyroid membrane, placing a tracheostomy tube or 6.0 endotracheal tube through the opening and into the trachea. Some providers prefer a transverse incision, although this approach may heighten the risk of inadvertent thyroid vessel laceration. An alternative approach uses commercially packaged Seldinger-type devices. For example, the Pertrach kit consists of a needle, wire, dilator, and cannula. The rescuer makes a small skin incision and inserts a needle/dilator combination through the cricothyroid membrane, subsequently using the dilator to spread the tissues. The rescuer can then feed the tracheal tube over the guidewire and into the trachea. Limited data describe the complications associated with prehospital cricothyroidotomy. Medical directors question the role of cricothyroidotomy in the prehospital setting, citing the difficulty of the procedure and the rarity of the intervention with associated need to maintain appropriate clinical skills.",
        "Laryngeal mask airway": "The LMA is a SGA originally designed for use in the operating room. The distal tip of the airway contains a spade-shaped balloon designed to seal around the vocal cord structures. The rescuer inserts the device blindly through the oropharynx, positioning the cuff around the laryngeal structures. Inflation of the cuff facilitates proper sealing of the device. Limited studies describe LMA use by prehospital EMS personnel. Prehospital use in the United States remains relatively limited, possibly due to concerns about the device\u2019s inability to prevent aspiration as well as its potential for inadvertent dislodgment. A variation is the LMA Fastrach, or Intubating LMA, which is designed to allow passage of an endotracheal tube. Disposable versions of both the LMA as well as the LMA Fastrach currently exist. Some EMS agencies favor the LMA due to the availability of pediatric sizes.",
        "Other supraglottic airways": "Supraglottic airways no longer used in contemporary prehospital EMS practice include the esophageal obturator airway, esophageal gastric tube airway, and pharyngotracheal lumen airway. Other SGAs currently available include the cuffed oropharyngeal airway (COPA), and the Cobra perilyngeal airway (Engineered Medical Systems, Indianapolis, IN), among others. Some prehospital systems have reported success with the I-gel, which resembles a solid LMA without an inflatable perilyngeal cuff. Only limited data describe these techniques in the prehospital setting.",
        "Surgical airways": "Surgical airways involve the placement of the airway directly into the trachea through an incision in the neck. The primary prehospital surgical airway methods include cricothyroidotomy and transtracheal jet ventilation (TTJV). EMS personnel typically use surgical airways in the event of failed endotracheal intubation efforts or where significant facial trauma precludes conventional intubation techniques.",
        "Transtracheal jet ventilation": "Transtracheal jet ventilation, occasionally referred to as \u201cneedle cricothyroidotomy,\u201d involves the insufflation of high-pressure oxygen via a large-bore intravenous type catheter (16 gauge or larger) inserted through the cricothyroid membrane. This technique requires 50 psi oxygen equipment capable of delivering oxygen at >50 L/min through a catheter. This is equivalent to \u201cwall\u201d oxygen pressure. TTJV cannot successfully be performed using conventional BVM equipment or a standard 25 L/min flow meter. While TTJV has many theoretical limitations, the clinical implications remain unclear. For example, because TTJV primarily facilitates oxygenation, most clinicians assume that the technique can only be used for short periods of time. However, extensive data underscore the utility of the technique for prolonged periods. A16 gauge catheter with a flow rate >50 L/min and a ventilatory rate of 20 breaths/ min can deliver a tidal volume of 950 mL. Aspiration is also a concern, but only limited data clinically quantify this phenomenon. EMS personnel may also use a properly placed jet ventilation catheter to help convert to an open cricothyroidotomy.",
        "Confirmation of airway placement": "After ETI, verification of endotracheal tube placement is essential. Tube placement verification is particularly important given the uncontrolled nature of the prehospital environment and the risks of unrecognized tube dislodgment or misplacement. Because of the amount of patient movement in prehospital care, EMS personnel must frequently (and preferably continuously) verify correct tube positioning. In addition to visualizing the endotracheal tube passing through the vocal cords into the trachea, endotracheal tube placement should be confirmed using multiple techniques. Auscultation is the most common method for verifying endotracheal tube placement. In this technique the rescuer auscultates both lung fields to verify the presence of breath sounds, and also auscultates the epigastrium to verify the absence of gastric sounds. Several adjunct devices are available for verifying correct endotracheal placement of the endotracheal tube. The esophageal intubation detector (EID) consists of a Toomey syringe with a special adaptor for the endotracheal tube. The rescuer attaches the EID to the end of the endotracheal tube and quickly withdraws the plunger. Easy plunger withdrawal suggests correct endotracheal tube placement. Conversely, plunger resistance suggests esophageal tube placement. The esophageal detector device (EDD) is a large, bulb-type device. The rescuer squeezes the bulb before attaching it to the endotracheal tube. Complete bulb inflation suggests correct endotracheal tube placement. Incomplete bulb reinflation suggests esophageal placement. Both of these devices are based on the concept that the esophagus will collapse, producing resistance to the vacuum, while the trachea will not collapse and will therefore not produce any resistance as the bulb or plunger produces suction. The most important technique for verifying endotracheal tube placement is the detection of exhaled (or end-tidal) carbon dioxide. Patients exhale carbon dioxide through the bronchotracheal tree; the presence of carbon dioxide in the endotracheal tube indicates correct endotracheal tube placement. There are currently three types of devices used for detecting exhaled (or end-tidal) carbon dioxide: colorimetric end-tidal carbon dioxide detector, digital capnometer, and waveform end-tidal capnographer. The colorimetric end-tidal carbon dioxide detector uses a chemically treated paper detector that changes color from purple to yellow when exposed to carbon dioxide. If the paper color remains purple, this suggests esophageal tube placement. Designed for single use, these devices can be used for only a limited duration (<2 hours). Exposure to liquid (for example, vomitus or blood) renders these devices non-functional. Digital end-tidal carbon dioxide capnometry samples exhaled gases, measuring and displaying carbon dioxide level. A positive carbon dioxide level connotes correct endotracheal tube placement. Waveform end-tidal capnography is similar to digital capnometry, except that the exhaled carbon dioxide level is depicted continuously in graphical form. The on the display makes it easier to observe changes in the exhaled carbon dioxide level. This also enables measurement of ventilation rate. There are two primary designs for capnometers and capnographers: sidestream and mainstream. Sidestream capnographers draw a sample of the exhaled gases from a port attached to the endotracheal tube. In mainstream capnography, the sensor is placed in the gas delivery line near the endotracheal tube. In general, with sidestream devices there is a short (<1 second) delay between gas sampling and delivery of a carbon dioxide level reading. In contrast, in-line devices provide instant carbon dioxide readings. The sensor for an in-line device is placed near the endotracheal tube. Some practitioners find this positioning awkward with the potential for tube dislodgment. However, the sensors for newer in-line devices are light and compact. Sidestream devices may be more prone to condensation. EMS personnel may use sidestream devices with a nasal cannula in spontaneously breathing patients, broadening their potential application. Medical directors and EMS agencies should select a particular design based upon individual considerations. Waveform end-tidal capnography is the most accurate tube placement verification technique. However, waveform capnographs are expensive (over $3,000 per unit). However, most newer multiparameter monitors can be purchased with built-in capnography. In addition, in situations with low perfusion (e.g., cardiopulmonary arrest), there may be inadequate circulation of carbon dioxide to the lungs. In these situations, carbon dioxide detectors may incorrectly indicate a misplaced endotracheal tube. Some systems have made waveform capnography mandatory for all intubated patients. An essential consideration is that prehospital patients undergo considerable movement during field care, which may heighten the risk for tube dislodgment. Many medical directors have emphasized the need for frequent reverification or continuous monitoring of endotracheal tube placement, especially after each patient movement sequence; for example, after moving the patient onto the stretcher or loading into an ambulance. Only capnometers and capnographs are currently capable of providing continuous tube placement information. EMS personnel using other confirmation techniques will need to pause and reconfirm tube placement frequently during care. While some clinicians rely upon fogging of the endotracheal tube to indicate its correct placement, a well-executed animal study demonstrated the inaccuracy of this technique.",
        "Methods for securing the endotracheal tube and supraglottic airways": "Emergency medical services personnel must secure the endotracheal tube or supraglottic airway to prevent device dislodgment. The most common method for securing the tube is the use of adhesive tape wrapped around the neck and the tube (Lillehei method). Another method uses umbilical twill tape, which is a flat, woven cloth tape designed for tying off umbilical cords after childbirth. Some EMS personnel use intravenous or oxygen tubing to tie the endotracheal tube in place. A variety of commercial tube holders also exists, typically consisting of a plastic bite-block strapped to the patient's face using Velcro tape, and a plastic strap or screw clamp to hold the endotracheal tube in place. Because of the theoretical risk of tube dislodgment with flexion-extension or lateral rotation of the head, some EMS providers also place the intubated patient on a spinal immobilization board and apply a cervical immobilization device to the patient's head. Current advanced cardiovascular life support (ACLS) guidelines recommend the use of commercial tube holders. However, one cadaver study found that conventional adhesive taping of the endotracheal tube surpassed most commercial tube holders. The one exception was the Thomas Tube Holder (Laerdal Medical, Inc., Stavanger, Norway) which performed better than taping. Only limited prehospital clinical data describe the effectiveness of endotracheal tube securing methods at preventing tube dislodgment. There are also no data describing the effectiveness of spinal or cervical immobilization devices at preventing tube dislodgment. Some EMS personnel manually hold the endotracheal tube in place without using tape or other tube securement methods. We do not recommend this method as anecdotal reports have associated this technique with inadvertent tube dislodgment. EMS personnel should also secure alternative airway devices such as the Combitube, King LT airway, and LMA. The manufacturers recommend conventional taping methods for securing these airways. We have anecdotally observed that some commercial tube holders are not designed for supraglottic airways (which have wider outer diameters than endotracheal tubes) and do not adequately hold these devices in place.",
        "Drug-facilitated intubation": "Drug-facilitated intubation (DFI) is the use of intravenous sedative and/or neuromuscular blocking agents to facilitate ETI of patients with intact protective airway reflexes. The most common forms of DFI include rapid sequence intubation (RSI, also termed neuromuscular blockade-assisted intubation) and sedation-assisted intubation. Most medical directors regard drug-facilitated intubation as an advanced technique that should be reserved for only the most qualified practitioners. The National Association of EMS Physicians has published national consensus standards for drug-facilitated intubation.",
        "Rapid sequence intubation": "Rapid sequence intubation denotes the use of a neuromuscular blocking (paralytic) agent combined with a sedative or induction agent to facilitate ETI of a patient with intact protective reflexes. The salient goals of RSI are to facilitate rapid sedation and paralysis of the patient and insertion of the endotracheal tube while effecting minimum physiological disturbances (heart rate, blood pressure, intracerebral pressure, etc.). Current prehospital RSI practices closely parallel ED practices. The general clinical indications for prehospital RSI include the need for airway and ventilatory control in patients with intact protective airway reflexes; for example, victims of traumatic brain injury.",
        "RSI technique": "The main elements of prehospital rapid sequence intubation include the following. \u2022 Insertion of an intravenous line \u2022 Attachment of continuous monitors (electrocardiogram, blood pressure, and pulse oximetry) \u2022 Preoxygenation of the patient (non-rebreather mask or BVM ventilation) \u2022 Rapid administration of pretreatment, sedative/induction, and neuromuscular blocking agents \u2022 Performance of laryngoscopy and tube placement \u2022 Verification of tube placement and securing of the endotracheal tube",
        "Agents used for RSI": "Pretreatment agents may be administered prior to attempting RSI; for example, intravenous lidocaine to attenuate the intracerebral pressure response to laryngoscopy. Because there are only limited data supporting the effectiveness of pretreatment regimens, protocols often exclude the use of these agents during prehospital RSI. A wide range of sedative/induction and neuromuscular blocking agents exists. The most popular sedative/induction agent for RSI is etomidate. Most clinicians favor this agent because of its minimal effect upon blood pressure, heart rate, and intracerebral pressure. The typical induction dose for etomidate is 0.3 mg/kg intravenously (20 mg in a typical 70kg patient). Recent studies raise concern regarding the clinical consequences of adrenosuppression resulting from etomidate administration. Limited data describe the link between etomidate's adrenocortical suppression and patient outcomes. Another commonly used agent for sedation/induction is midazolam administered at a dose of 0.1 mg/kg. However, because midazolam and other benzodiazepines may cause clinically significant hypotension, and because many prehospital patients requiring RSI have significant hemodynamic compromise, many EMS physicians prefer not to use these agents for prehospital RSI. The neuromuscular blocking agent most commonly used for RSI is succinylcholine, typically administered at a dose of 1.0\u20132.0 mg/kg intravenously (70\u2013140 mg in a typical 70kg patient). Succinylcholine's rapid onset and short duration are ideal for RSI. The rationale for using a rapid-acting paralytic is to achieve intubating conditions as quickly as possible. The rationale for using a short-acting paralytic is to facilitate rapid recovery of the patient's spontaneous airway reflexes in the event of unsuccessful laryngoscopy and intubation efforts. Relative contraindications to succinylcholine include conditions with known hyperkalemia, such as acute renal failure or rhabdomyolysis. Succinylcholine-induced hyperkalemia in these settings may cause cardiopulmonary arrest. While burn injuries can cause hyperkalemia, this complication usually does not occur until 2\u20133 days after the acute injury. Succinylcholine can be safely used for the acute management of burn victims. Other relative contraindications to succinylcholine include muscular wasting diseases (which can cause hyperkalemia) and pseudocholinesterase deficiency (where succinylcholine may cause prolonged neuromuscular blockade). While other neuromuscular blocking agents such as vecuronium and rocuronium are available, these agents have longer durations of action, making them less favorable for the prehospital setting. After completion of the RSI procedure, it is essential to administer additional pharmacological agents to maintain sedation and paralysis. Therefore, EMS practitioners performing RSI should also carry longer-acting paralytics (for example, vecuronium or pancuronium), as well as longer-acting sedative agents (for example, lorazepam, midazolam, or diazepam).",
        "Pediatric RSI": "Pediatric practices for RSI often vary slightly from adult protocols. The pediatric literature raises concern regarding the possibility of unrecognized muscular myopathies, which would result in hyperkalemia with administration of succinylcholine. Therefore, many specialty pediatric transport teams use non-depolarizing agents instead to facilitate paralysis. The use of etomidate for children remains unresolved. Prehospital RSI protocols appear to vary between the use of etomidate and midazolam for sedation. Because of paradoxical bradycardia with RSI agents in children, many practitioners pretreat these patients with intravenous atropine.",
        "Additional RSI considerations": "The administered paralytic agents will result in rapid and complete ablation of intact airway reflexes. Therefore, EMS personnel performing prehospital RSI must possess exceptional ETI skills. State-of-the-art practice requires utilization of waveform end-tidal capnography to immediately verify and continuously monitor correct endotracheal tube placement. Finally, SGAs should be readily available in the event of failed RSI efforts.",
        "Sedation-assisted endotracheal intubation": "Sedation-assisted intubation is a common approach using a sedative agent only without concurrent neuromuscular blocking agents. Practitioners typically use benzodiazepines such as midazolam or diazepam for this technique. Recently, some agencies have used etomidate to facilitate intubation. Sedation-assisted intubation is common due to the wide availability of benzodiazepines for other prehospital applications; for example, treatment of seizures or agitation. Furthermore, anesthesiologists in inhospital settings commonly use sedation-only regimens when facilitating airway management.",
        "Sedation-assisted ETI technique": "Except for the omission of a neuromuscular blocking agent, the clinical procedures for sedation-assisted intubation are similar to RSI. A typical regimen involves uses intravenous midazolam 0.1 mg/kg (7 mg in a 70 kg patient). While clinicians commonly use midazolam doses on the order of 2 mg for a 70 kg patient, anecdotal experience indicates the inadequacy of this low dose. While midazolam has rapid onset and short duration, it may cause clinically significant hypotension, potentially harming critically ill prehospital patients. Etomidate 0.3 mg/kg IV (approximately 20 mg for a typical 70 kg patient) is another alternative for sedation-assisted intubation. Etomidate has extremely rapid onset (5\u201310 seconds) and short duration (5\u201310 minutes). Some clinicians believe that etomidate is a safer option compared with benzodiazepines given its more profound sedative effect as well as its lower propensity for causing hypotension. However, adverse events associated with single-dose etomidate include myoclonus (muscle spasms, specifically in the jaw) and adrenocortical suppression. The former development may theoretically impede airway management efforts should the patient develop trismus.",
        "Other drug-facilitated techniques": "Some practitioners parallel anesthesia practice by using topical anesthetic sprays (benzocaine, etc.) to facilitate ETI. Limited data support this technique in the prehospital setting.",
        "Non-invasive positive pressure ventilation": "Prehospital providers are more commonly using non-invasive ventilatory support, or non-invasive positive pressure ventilation (NIPPV), as an alternative to ETI or SGAs. This includes continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP). These systems deliver high-pressure oxygen through a specially designed, tight-sealing face mask. CPAP provides continuous positive pressure throughout inspiration and exhalation phases. BiPAP separately controls inspiratory pressure support and positive end-expiratory pressure. Both modalities reduce work of breathing and improve physiological response through a variety of mechanisms, including increase of intrathoracic pressure, reduction of left ventricular afterload, and increase of functional residual capacity. Contrary to popular belief, NIPPV does not \u201cblow fluids out of the lungs.\u201d Both CPAP and BiPAP have been used extensively in hospital settings to treat patients with respiratory failure, including congestive heart failure and pulmonary edema, among others. Portable systems permit prehospital application of NIPPV. These systems typically use a separate oxygen delivery control unit coupled with a standard oxygen cylinder. The control unit requires a significant capital investment (of the order of $1,000, not including mask and tubing). A notable prehospital innovation is the Boussignac CPAP device, which uses turbulent oxygen flow to create a virtual CPAP valve. The Boussignac system is simple, single use, and costs less than $75 per use, and does not require a separate control unit. Some prehospital ventilators used by air medical and critical care transport units can be configured to provide CPAP. The range of applicable CPAP pressure varies with each device. The clinical indications for prehospital NIPPV include patients with acute respiratory distress who possess intact ventilatory drives, protective airway reflexes, and adequate mental status. In other situations, endotracheal intubation may prove more appropriate. While more common applications of NIPPV are for congestive heart failure or pulmonary edema, some clinicians have reported success with other conditions such as pneumonia or asthma. Emergency medical services personnel may initially set CPAP to 7 cmH\u2082O pressure support, titrating to clinical effect. BiPAP systems permit independently set inspiratory and expiratory airway pressures. Common initial settings include inspiratory pressure at 10 cmH\u2082O and expiratory pressure at 5 cmH\u2082O, with titration to clinical effect. EMS personnel should provide concurrent pharmacological therapies with NIPPV; for example, nitrates, furosemide, morphine, beta-agonists, etc. EMS personnel may gauge the response to NIPPV through subjective assessment of work of breathing, respiratory rate, heart rate, and oxygen saturation. End-tidal capnography may provide another measure to gauge clinical response. Considerable scientific data support the utility and effectiveness of NIPPV in the hospital. Multiple studies have documented the ability of NIPPV to decrease intubation rates, shorten hospital length of stays, and improve survival when used in the prehospital setting. ",
        "Conclusion": "Airway management is one of the most important elements of prehospital emergency care. Prehospital airway management involves numerous clinical, educational and system-level complexities. EMS physicians and medical directors must be familiar with the many issues related to prehospital airway care."
    },
    {
        "Introduction": "Respiratory distress is the second most common chief complaint after minor trauma, making up 13% of adult EMS calls. It is both challenging and rewarding for the EMS provider. Diagnosis depends on often subtle and overlapping signs and symptoms. While incorrect management is potentially detrimental, with correct diagnosis comes the potential for life-saving intervention and rapid improvement. The landmark Ontario Prehospital Advanced Life Support study demonstrated a significant survival benefit in respiratory distress when interventions including nebulized beta-agonists, sublingual nitroglycerin, intubation, and intravenous medications and fluids were added to the EMS systems of the included cities.",
        "Prehospital assessment and diagnosis": "The approach to the dyspneic patient must always begin with a focus on immediate threats to survival, such as airway obstruction. Once this has been dealt with, provisional causes can be considered so as to guide specific therapy. Accurate diagnosis of the cause of dyspnea in prehospital settings remains difficult. Studies have shown that paramedics are able to determine the etiology of dyspnea with only moderate accuracy. In one of the more positive retrospective studies, a prehospital diagnosis of cardiac, pulmonary, or other as the cause of 'difficulty breathing' agreed with that of the emergency department (ED) diagnosis 81% of the time. However, Jaronik et al. studied 144 patients given furosemide in the field and noted that it was given appropriately only 58% of the time to patients with a subsequent diagnosis of congestive heart failure or an elevated B-type natriuretic peptide (BNP) level. It was given inappropriately 42% of the time, and for diagnoses in which it was potentially harmful 17% of the time. Almost one-quarter of patients who received furosemide from EMS in this study subsequently required IV fluid therapy in the hospital. Therefore, prehospital treatment must carefully find a balance between disease severity, diagnostic certainty, and the likelihood of harm. Much of the assessment of disease severity comes from general observation of the patient supplemented by physical examination and close monitoring of vital signs, cardiac rhythm, pulse oximetry (SpO\u2082), and end-tidal carbon dioxide (EtCO\u2082) levels. Some of the useful questions that can be asked by a medical oversight physician over the radio or phone include how many words the patient can speak at a time, whether there is associated diaphoresis, and if the patient appears to be fatiguing. If the initial assessment reveals the possibility of impending respiratory failure, appropriate supplemental ventilation should be considered, including the use of non-invasive positive pressure ventilation (NIPPV) or bag-valve-mask (BVM) ventilation in conjunction with oral/nasopharyngeal airways, supraglottic devices, or endotracheal intubation (ETI). An important early task is to question the family/caregivers and gather available paperwork regarding the patient\u2019s wishes for life-sustaining treatment or end-of-life care. Once disease severity and the immediate needs have been addressed, the next step is to attempt to categorize the underlying cause. The four most common categories for respiratory distress are upper airway obstruction, small airway obstruction including chronic obstructive pulmonary disease (COPD) and asthma, acute cardiogenic pulmonary edema (ACPE), and pneumonia. In addition, there are a host of other medical conditions that can cause subjective dyspnea and/or objective impairment of oxygenation and ventilation. Acute coronary syndrome is an important consideration among these disparate causes of shortness of breath. It can present as cardiogenic shock with ACPE but can also cause subjective dyspnea without severe impairment of cardiac function. Dyspnea associated with acute coronary syndrome may not be accompanied by chest discomfort and is more common in women, older individuals, and those with diabetes. Dysrhythmias can also cause dyspnea and are readily diagnosed by cardiac monitoring.\n\nIf time and the patient\u2019s condition allow, a 12-lead electrocardiogram (ECG) may be useful in guiding treatment and destination decisions for the dyspneic patient. Severe sepsis can also present with respiratory distress due to increased oxygen consumption. Toxic exposures can cause respiratory distress either through direct irritation of the respiratory tract or secondarily by central nervous system impairment of respiratory function. Tachypnea and subjective dyspnea may also be compensatory for an underlying metabolic acidosis as with diabetic ketoacidosis or salicylate toxicity. If these acidotic patients require ETI and mechanical ventilation, it is important to continue to hyperventilate them to maintain their preexisting respiratory compensation for the underlying metabolic acidosis. This can be facilitated through the use of continuous EtCO\u2082 monitoring. Neuromuscular diseases such as myasthenia gravis and Guillain\u2013Barr\u00e9 syndrome are rare causes of inadequate ventilation and respiratory failure. Although a diagnosis of exclusion, shortness of breath is also a common manifestation of anxiety disorders, panic attacks, and psychogenic hyperventilation. Having a patient breathe into and out of a paper bag, which is sometimes done by the uninformed for hyperventilation, actually decreases inspired oxygen and has no place in EMS.\n\nAlthough auscultation of breath sounds is an important part of the physical examination for respiratory distress, there can be much overlap in the cause of any one particular finding. Thus breath sounds must be interpreted in the context of the rest of the focused exam. For example, a common mistake is to equate \u201ccrackles\u201d with an ACPE exacerbation and \u201cwheezing\u201d with asthma, although both findings can be found in either disease process. Examination should also include a careful auscultation of heart sounds as well as palpation and inspection of the neck for jugular venous distension (JVD), chest for retractions and injury, lower back for sacral edema, and extremities for edema or evidence of deep vein thrombosis (DVT) (Box 5.2).\n\nThe physical exam may be enhanced through the use of ultrasound of the chest in the patient with acute respiratory distress. Ultrasound is now commonly used in the ED for evaluation of pneumothorax, pleural effusion, pericardial effusion, large pulmonary embolism, cardiac function and volume status.",
        "General treatment": "As with most potential threats to life, initial therapy should begin with supplemental oxygen, application of monitoring devices, and often IV access. With standard use of SpO\u2082 monitoring, growing information suggests that oxygen therapy should be carefully titrated to a goal between 93% and 96% in patients with general respiratory distress, and to a goal of 88\u201392% in patients with known COPD. A recent randomized controlled prehospital trial by Austin et al. showed decreased mortality among patients who were treated with a titrated oxygen regimen versus those treated with uncontrolled high flow oxygen. Mortality was reduced 58% in patients with any respiratory distress and 78% in patients with known COPD with the titration strategy. Inhaled bronchodilators, including short-acting inhaled beta2-agonists (SABAs) and anticholinergics, are commonly included in protocols for respiratory distress of unclear etiology. Although there is usually little downside to their use, especially if a component of bronchospasm is suspected, SABAs can be potentially harmful in those with ACPE, acute coronary syndrome, and cardiac arrhythmias due to their chronotropic, inotropic, and vasoactive effects on the cardiovascular system. A review of the Acute Decompensated Heart Failure National Registry Emergency Module (ADHERE) database by Singer et al. revealed that 21% of patients ultimately diagnosed with acute decompensated heart failure (ADHF) exacerbation received SABA treatments by EMS or in the ED. The authors also reported an association between bronchodilator use and a subsequent need for IV vasodilators and ETI. It is important to note, however, that no mortality difference was found between patients who did or did not receive SABAs. In addition, patients with combined ADHF and COPD were not studied separately. Fisher et al. reported six cases of acute myocardial infarction precipitated by bronchodilators. Unfortunately, the relationship between cardiac manifestations and bronchodilator use is poorly understood and these cases likely reflect publication bias. SABAs are known to decrease serum potassium concentration by approximately 0.5 meq/L, which could precipitate hypokalemia-associated dysrhythmias. In addition, SABAs may temporarily worsen hypoxemia by increasing the ventilation/perfusion mismatch. Inhaled anticholinergics, such as ipratropium, are not absorbed systemically and have no cardiovascular toxicity. But in the final analysis and in the absence of well-designed trials to better guide the empirical use of bronchodilators in undifferentiated respiratory distress, it seems to make physiological sense to continue to include them in EMS protocols or at the discretion of a medical oversight physician. Two forms of NIPPV have become standard for treatment of several forms of respiratory distress. A mask is used to deliver ventilation support either at a constant pressure (CPAP) or with a higher pressure during inspiration (BiPAP). The use of NIPPV in the prehospital setting has become accepted as an early intervention, and studies of its use in this setting have demonstrated decreased mortality, reduced intubation rates, shorter intensive care unit (ICU) lengths of stay, and improved vital signs. Although NIPPV has been most studied in COPD and ACPE, a recent systematic review and meta-analysis supports its use in all forms of undifferentiated acute respiratory failure. NIPPV may also permit administration of a lower concentration of inspired oxygen, thereby decreasing the potential deleterious effects of hyperoxia. It is important that prehospital providers understand the limitations of this intervention, including patient factors that are specific contraindications to its use. NIPPV is inappropriate for patients who require immediate ETI such as those who are unable to protect their airways, have altered mentation, or cannot tolerate the pressure mask. The patient must have an acceptable respiratory drive prior to application of NIPPV. Advanced airway management with supraglottic airways or ETI is the final common pathway for most individuals with severe respiratory distress who have failed to respond to the above-mentioned strategies.",
        "Asthma": "Asthma is a chronic inflammatory lung disorder characterized by acute attacks of airway hyperresponsiveness with reversible obstruction. Precipitating factors include upper respiratory tract infections, exposure to allergens, high pollution indices, and failure to use preventive and maintenance therapies. The disease affects more than 22 million individuals in the United States. Although there are hallmark features of an acute exacerbation, assessment of asthma exacerbations can be challenging and potentially misleading. For example, absence of wheezing may indicate either severely restricted airflow or clinical improvement following appropriate treatment. A multi-component guide can be helpful in assessing severity and monitoring the effectiveness of treatment of asthma. Oxygen should be provided to relieve hypoxemia and titrated to a SpO\u2082 of 93\u201396%. The initial drug of choice for treatment is a SABA, which acts by relaxing bronchial smooth muscle and increasing mucociliary clearance. Nebulization is the preferred route of administration in the acute setting with either intermittent or continuous delivery. SABAs can also be administered through the use of metered dose inhalers (MDI). The use of subcutaneous epinephrine (a non-selective beta-agonist) has declined with the availability of SABAs, but epinephrine can be very useful when the patient is critically ill or when the inhaled SABA cannot be delivered effectively. For more severe exacerbations an anticholinergic bronchodilator agent, such as ipratropium, can be added to the SABA. Patients who fail to respond promptly and completely to inhaled bronchodilators benefit from the administration of systemic corticosteroids. The benefits of prehospital corticosteroid administration have not been proven through randomized controlled clinical trials. Non-randomized observational studies, however, have shown that EMS delivery of corticosteroids is associated with decreased hospital admission rates. It has also been suggested that early use of corticosteroids may enhance the effectiveness of SABAs. Corticosteroid options include prednisone (oral), dexamethasone (oral, IM, IV), and methylprednisolone (IV). For severe exacerbations that fail to respond to inhaled bronchodilators and systemic corticosteroids, adjunctive therapies, such as IV magnesium sulfate or heliox, if available, should be considered. A meta-analysis of seven randomized controlled trials of magnesium sulfate administered in the ED showed it improved peak expiratory flow rates and reduced hospital admission rates compared with placebo in severe asthma exacerbations. Although NIPPV for acute exacerbations of asthma is traditionally viewed as a last resort due to the fear of worsening air trapping and secondary barotrauma, studies of its use in the ED and ICU settings in children have shown benefit. A retrospective study of pediatric patients who were placed on BiPAP and given SABAs in the ED, with initial disposition plans for ICU admission, found that 22% of the patients tolerated BiPAP and were able to be downgraded to ward admission. None required subsequent ICU admission. All of these patients had improved SpO\u2082 levels as well as respiratory rates and there were no BiPAP-related adverse events. If rapid sequence ETI is necessary for an asthma patient, the preferred induction agent is ketamine due to its inherent bronchodilator properties. Once intubated, ventilation should be provided at reduced volumes and rates to prevent air trapping and secondary barotrauma. The inspiratory-to-expiratory (I/E) ratios should be adjusted to provide a prolonged expiratory phase. Permissive hypercarbia is generally well tolerated in these individuals. All NIPPV and intubated asthma patients should be monitored closely for signs of secondary barotrauma, such as tension pneumothorax and pneumomediastinum.",
        "Chronic obstructive pulmonary disease": "Chronic obstructive pulmonary disease is a chronic disease characterized by expiratory lung flow obstruction that is only partially reversible. The underlying pathophysiology involves a complex process of chronic inflammation, remodeling of the small airways with destruction of alveoli, and increase in extracellular matrix production. COPD is usually a response to noxious particles and gases including cigarette smoke and environmental pollutants, though genetic factors also play a part. It is the fourth leading cause of death in the United States. COPD patients who continue smoking will eventually require permanent oxygen and/or ventilator assistance. EMS is often called to evaluate a COPD patient during an acute exacerbation of the condition precipitated by respiratory tract infections, exposure to pollutants or allergens, or medication non-compliance. The clinical presentation is similar to asthma. COPD patients should receive oxygen with a goal to maintain SpO\u2082 between 88% and 92%, which was associated with reduced mortality by twofold in the study by Austin et al. Impending respiratory failure can be detected by continuous EtCO\u2082 monitoring. Increasing EtCO\u2082 levels indicate a deteriorating condition. As with asthma, the primary treatments during acute exacerbations are directed toward reversing airway obstruction through the use of SABAs and anticholinergic agents. The latter are much more effective in COPD and should be used early. Corticosteroids and antibiotics are also important adjuvant therapies. Use of NIPPV has become established as a life-saving therapy in the treatment of COPD exacerbations. If it is necessary to intubate a COPD patient, appropriate settings for mechanical ventilation include decreased respiratory rates, lower tidal volumes, and increased expiratory phase. As with asthma, these patients must be monitored closely for evidence of secondary barotrauma.",
        "Acute decompensated heart failure/acute cardiogenic pulmonary edema": "No widely accepted guidelines exist for the treatment of ADHF either in the prehospital or ED setting. One pathway proposed by DiDomenico et al. for the ED bases the initial management strategy on whether the problem appears to be a state of volume overload versus one of inadequate cardiac output, which can often be differentiated on exam. If the patient is volume overloaded, positioning in an upright posture is the first step. It allows pleural effusions and edema to localize at the lung bases and venous blood to pool in the lower extremities, thereby reducing cardiac preload. If immediate prehospital pharmacotherapy is required, nitrates are the preferred option. If the patient has poor cardiac output, which is far less common, field treatment is largely supportive, although this category of diagnosis should prompt EMS providers to consider causes such as acute myocardial infarction (MI) as well as hypovolemic, distributive, or obstructive causes for shock. If the cause is truly low output cardiac failure, specific treatment might include the use of inotropic and vasopressor medications such as dobutamine, milrinone and dopamine. If the patient has volume overload with an adequate or high blood pressure and is in acute distress, nitrates should be administered. Diuretics are rarely indicated in prehospital settings. Nitroglycerin acts rapidly to dilate veins, allowing blood to distribute to the periphery, thereby decreasing cardiac preload. At higher doses, typically above 30\u03bcg/min intravenously, nitroglycerin also acts as an arterial vasodilator, decreasing cardiac afterload. Sublingual nitroglycerin is 50% bioavailable. A dose of 400\u03bcg given every 5 minutes, with frequent reassessment to ensure maintenance of a systolic blood pressure of at least 100mmHg, is often effective. However, for patients in extremis in terms of respiratory distress, and with an adequate blood pressure, sublingual nitroglycerin spray can be safely administered more frequently, as often as every 2 minutes in some cases, to rescue the patient from invasive airway intervention and ventilation. Sublingual nitroglycerin also has the advantage of a rapid time to peak effect of 5\u201315 minutes and duration of action of less than 1 hour. Transdermal nitroglycerin paste is not recommended since its effectiveness is limited by slow absorption, which is further worsened by the presence of decreased skin perfusion during ADHF. Intravenous access should ideally be obtained before the administration of nitroglycerin, as it has the rare potential to produce hypotension and bradycardia. However, inability to obtain IV access should not preclude or delay its use. Observational studies of nitroglycerin use have shown relatively low rates of serious adverse effects ranging from 0.3% to 3.6%. EMS providers must also remember the potential interaction with all antierectile dysfunction phosphodiesterase-inhibiting drugs (e.g. sildenafil), which are contraindications to the use of nitroglycerin. Notably, however, NIPPV is not a contraindication to concomitant nitroglycerin use. Loop diuretics, including furosemide, have also been used in the prehospital setting for patients with ADHF, especially those presenting with ACPE. However, intravenously, peak response time is 30 minutes, and this is even more delayed in patients with decreased cardiac output and renal vasoconstriction. The duration of action of furosemide is 2 hours, and up to 6\u20138 hours in renal failure. Further, because of its effects on plasma electrolytes, which in general are not assessed in most field situations, its use is discouraged. Because furosemide has less of an immediate benefit than nitroglycerin, a long duration of action, and unforeseen potential side-effects, it probably has limited utility in the prehospital setting. Many EMS systems have eliminated its use in favor of nitroglycerin alone. Morphine, once a staple of therapy for ADHF, has also been largely supplanted by other therapies. A review of the large ADHERE database found a significant association between receiving morphine and death, as well as several other adverse outcomes. One explanation may be that as morphine causes hypotension, it takes away the therapeutic room available for other medications used to reduce preload and afterload. In addition, as a respiratory depressant, morphine may decrease the respiratory drive of an already struggling patient. Non-invasive positive pressure ventilation is very useful in the immediate treatment of ACPE. Continuous pressure at a level of 5\u201310 cmH\u2082O improves oxygenation by recruiting atelectatic alveoli and decreasing the work of breathing. The increase in intrathoracic pressure also alters hemodynamics by decreasing the transmural wall tension of the heart. Small EMS case series have demonstrated decreased intubation rates and shorter ICU lengths of stay, although effect on mortality is less clear. As mentioned, sublingual nitrate therapy should be continued in conjunction with NIPPV. An emerging modality for diagnosis of ADHF and ACPE in the ED, which may also be useful in the prehospital setting, is focused ultrasonography. In a prospective prehospital study, Prosen et al. reported that the combined use of NT-prBNP (a marker of cardiac atrial stretch) and chest ultrasound had a sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of 100% for the diagnosis of ADHF and ACPE. More recently, Neesse et al. reported that the presence of a pleural effusion on the prehospital chest ultrasound appears to be a novel marker for ADHF. Portable chest ultrasonography may therefore hold promise as a tool in the differentiation of COPD and ACPE in the prehospital setting.",
        "Pneumonia and infectious respiratory disease": "In general, there are few specific field interventions for patients who are determined to have pulmonary infectious causes of their shortness of breath. Pneumonia treatment guidelines are universally focused on prompt diagnosis and early treatment with antibiotics. Pneumonia should be considered in patients with cough and/or fever. Specific etiologies of these diseases and issues regarding crew protection are discussed in Chapter 25 of both Volumes 1 and 2. It is important to note that some of these diseases can be highly contagious, and it is recommended that some type of respiratory precaution (e.g. an N95 mask to protect against novel viruses as well as tuberculosis) is maintained when evaluating a respiratory distress patient who is presumed to have an infectious etiology. Treatment of these patients will typically consist of oxygen, NIPPV if ventilation support is needed to further improve oxygenation, IV fluids if hypotensive, and transport. Patients with known asthma or COPD who have reactive airways in response to the inflammation may also benefit from bronchodilators. Many pneumonia patients may also wheeze from infectious inflammatory processes within the small airways, and hence may respond to inhaled bronchodilators.",
        "Pulmonary embolus": "Pulmonary embolus (PE) is another clinical condition that can present with respiratory distress. Classic risk factors for venous thromboembolism (VTE) include the Virchow triad of venous stasis, trauma, and hypercoagulability. There are many risk factors for VTE but the ones that have been clinically validated by Wells criteria and the PERC rule for risk stratification include recent surgery or immobilization of an extremity, malignancy, exogenous estrogen use, and prior DVT. Other notable risk factors include genetic deficiency of anticoagulation factors, pregnancy, obesity, and extended travel. Most PEs are the result of DVTs in the pelvic or lower extremity veins, though a DVT from any location can result in a PE. PE is a challenging clinical diagnosis because the manifestations can be subtle. The most common symptom is dyspnea and the most common clinical signs are tachycardia and tachypnea. The pulmonary exam is usually unremarkable, though examination of the extremities, particularly the legs, may reveal swelling, erythema, and/or pain in a limb with a DVT. With the increased use of peripherally inserted central venous catheters, PEs are also reported more frequently as a result of upper extremity DVTs. Small PEs often present with respiratory distress. Larger emboli that cause lung infarction can present with more severe findings, and those with saddle embolism cause findings suggestive of obstructive shock. The latter can be detected by findings such as right axis deviation, right ventricle strain, and right bundle branch block on a 12-lead ECG. Additional useful ECG features are the presence of T-wave inversions in both V, and lead III as well as the presence of an S-wave in lead I and a Q wave and inverted T wave in lead III (S1Q3T3). Acute right ventricular dysfunction can also be visualized using portable cardiac ultrasonography. In some severe cases, the embolus can even be visualized directly within the heart. Emergency medical services treatment priorities include high-flow oxygen, vascular access, and cardiac monitoring. A fluid bolus is indicated in the patient who presents with a suspected massive PE and perfusion failure. In some patients, the presentation can take the form of a cardiac arrest with a narrow complex pulseless electrical activity (PEA) rhythm. The presence of prearrest respiratory distress, altered mental status, and shock, along with a presenting rhythm of PEA, has been shown to be predictive of PE as a cause of cardiac arrest. Although the use of prehospital thrombolysis in these instances has been reported to be effective in selected cases, a randomized controlled clinical trial failed to show improved outcomes during cardiac arrest when tissue plasminogen activator (t-PA) was administered compared to placebo for patients with refractory PEA.",
        "Spontaneous pneumothorax": "Spontaneous pneumothorax is an uncommon condition that can present as acute respiratory distress. It is caused by rupture of the alveolar air sacs into the pleural space, followed by variable collapse of the lung. Symptoms include dyspnea as well as pleuritic chest pain. The exam may reveal decreased breath sounds on the affected side. Typically, spontaneous pneumothorax occurs in male patients who are taller than average with a slim build. There are also secondary causes of spontaneous pneumothorax, most notably COPD. Other underlying causes include tumor, infection, or a connective tissue disorder. Spontaneous pneumothorax rarely progresses to tension pneumothorax. Patients with a suspected simple pneumothorax should be monitored closely for evidence of tension physiology such as worsening respiratory distress, hypoxia, hypotension, JVD, and tracheal deviation, in which case immediate chest needle decompression is indicated. In the future, the clinical diagnosis of pneumothorax will be supplemented by objective evidence through the use of portable chest ultrasound.",
        "Conclusion": "Respiratory distress is a very common complaint in the prehospital setting. Initial evaluation should be focused on identifying immediate threats to life and determining needs for an immediate intervention such as NIPPV, BVM ventilation, or ETI. Once this evaluation is completed, efforts should be focused on attempting to determine the provisional underlying cause of the respiratory distress. Respiratory distress may be caused by a primary pulmonary problem, a cardiac problem, an infectious problem, or as part of compensation for another non-pulmonary problem. A vast number of these patients will remain 'undifferentiated' through their EMS and possibly even their ED courses. In general, treatment should include titrated oxygen and monitoring of cardiac rhythm, SpO\u2082, and ETCO\u2082 while ensuring timely transport. In stable situations, the emphasis should focus on avoiding overtreatment and resisting the urge to give multiple medications in an undirected fashion. However, little harm comes to the patient with an initial trial of inhaled bronchodilator therapy, and nitrates should be considered as first-line therapy in the patient with findings consistent with ADHF or ACPE."
    },
    {
        "Introduction": "The prehospital environment presents unique challenges or barriers to patient care. Airway management in these situations may be difficult or impossible. For example, airway management may need to be carried out with the patient on the floor or upright while entrapped in a vehicle. This chapter describes considerations and strategies for airway management in special prehospital situations.",
        "Ground-level airway management": "The classic position for intubation has the patient supine at the level of the rescuer\u2019s xiphoid. However, prehospital patients requiring airway management are often found in unusual positions, such as on the ground. Conventional approaches to laryngoscopy and intubation must be modified in these scenarios.\n\nThere are several approaches to rescuer positioning for ground-level endotracheal intubation (ETI).\n\n\u2022 Prone. The rescuer lies prone on the ground in line with the patient\u2019s head. The rescuer places both elbows on the ground. With this approach, laryngoscopy requires lifting at the wrist rather than with the forearm. Placement of the tracheal tube must be accomplished using movements of the wrist.\n\n\u2022 Left lateral decubitus position. With this approach, the rescuer lays on his or her left side, perpendicular to the head of the patient. As with the prone position, the rescuer stabilizes the left elbow on the ground, relying upon wrist movement to perform laryngoscopy. However, the right arm is free to facilitate tube placement in a conventional fashion.\n\n\u2022 Kneeling. The rescuer kneels at the patient\u2019s head. The left elbow and forearm may be supported by the rescuer\u2019s knee. In this position, the rescuer assumes a slightly more vertical position over the patient\u2019s head, and thus the angle for glottis visualization may be steeper than usual.\n\n\u2022 Sitting. The rescuer sits at the patient\u2019s head with legs either crossed or extended to each side of the patient\u2019s head. The left arm may be braced against the rescuer\u2019s leg (if sitting with crossed legs).\n\n\u2022 Straddling the patient. The rescuer straddles the patient in a face-to-face position. The rescuer holds and inserts the laryngoscope with the right hand, and passes the tube with the left hand.\n\nBecause prehospital patients are frequently found and treated at ground level, rescuers should learn each of these techniques. Note that compared with traditional positioning, the rescuer\u2019s face is closer to the patient\u2019s oropharynx with ground-level intubation, and thus visualization of glottic structures may differ from conventional approaches.\n\nLimited studies suggest that the left lateral decubitus (LLD) positioning may result in higher intubation success rates than the other ground-level techniques. Adnet et al. compared the LLD intubating position versus kneeling with the patient (mannequin) supine on the ground, finding that the LLD position afforded better glottic exposure. A follow-up study of EMS ground level intubations by Adnet et al. again studied LLD positioning versus kneeling in real EMS patients as opposed to mannequins. During this study, they found that provider incidence of laryngoscopic difficulty was lower in the LLD position: 11.1% versus 26.9% for the kneeling group. They also found that there were a higher number of intubation attempts in the kneeling group than the LLD position. This research group postulated that LLD was a better position than kneeling for three reasons: the operator has better visual alignment with the larynx in the LLD position, the left forearm acts as a lever during exposure which minimizes operator effort, and the right arm is completely free during the procedure for tube placement and suctioning.\n\nThe rescuer\u2019s ability to visualize the glottis during ground-level intubation may be altered. Video laryngoscopy has been proposed as an adjunct for facilitating ground-level intubation. Komatsu et al. evaluated the Airway Scope\u2122 (Pentax) and Macintosh laryngoscope for tracheal intubation in patients lying on the ground. While both the Airway Scope and Macintosh blade had high intubation success rates (98% and 100%, respectively), time to intubation was 17 seconds faster with the Airway Scope.",
        "Face-to-face intubation": "A patient may require intubation while positioned upright; for example, when entrapped in a car. One described approach is to perform ETI while directly facing the patient. With this technique, the operator holds the laryngoscope with the right hand, inserting the laryngoscope blade in an inverted fashion (\u201ctomahawk\u201d or \u201cice axe\u201d approach) and passing the tracheal tube with the left hand.\n\nIn a mannequin study, Wetsch et al. studied face-to-face intubation comparing five types of video laryngoscopes and traditional Macintosh laryngoscopy in a simulated model of an entrapped motor vehicle victim. Interestingly, their findings noted that the fastest time to intubation was with traditional Macintosh laryngoscopy, although the video laryngoscopes provide a better view of the glottis. Of the five video layngoscopes studied, the authors did note a shorter time to intubation with the two devices that had tube guides (Airtraq\u2122 and Ambu Pentax\u2122) than the non-guided scopes.\n\nAmathieu et al. also examined face-to-face mannequin intubation times with the LMA Fastrach\u2122, Glidescope\u2122, and Airtraq laryngoscopes. Time to intubation was shorter, intubation success rate was higher, and perceived intubation difficulty was lower with the Airtraq. Silverton et al. compared glottic views during face-to-face Glidescope laryngoscopy and fiberoptic intubation. They noted the Glidescope could be used to obtain adequate intubation visualization in live humans.\n\nWhen face-to-face intubation is the only available option, the provider should assess whether immediate airway intervention or patient extrication is most appropriate. The estimated time of extraction combined with patient condition may influence the decision-making process. High-flow oxygen devices and supraglottic airways may provide suitable alternatives in these situations.",
        "Intubating under low light conditions": "Optimal lighting is important in airway management. Increased ambient lighting allows for better gear preparation and procedure execution. EMS practitioners may need to perform airway management in suboptimal lighting conditions such as at night, while conducting military operations, in a confined space rescue, or in indoor areas with poor lighting. There are two major lighting considerations in prehospital airway management: the light illuminating the patient environment, and illumination of the airway.\n\nSimple interventions can significantly improve available lighting. Could a family member or colleague turn on additional lights? At the site of an accident, can portable lighting be provided to illuminate the scene? In some cases, a flashlight or headlamp may provide vital additional illumination.\n\nA common pitfall of intubation is equipment failure resulting in suboptimal airway illumination; for example, broken laryngoscope bulbs, dead laryngoscope batteries, or damaged airway equipment. Regular equipment checks and the use of protective carrying cases are essential aspects of practice. Spare bulbs and batteries should always be part of the standard airway kit. Simple maneuvers such as rotating batteries on a regular basis might have a big effect on airway illumination.\n\nStudies have identified that there is variation in light output among different laryngoscopes. Levitan et al. studied the light output of curved laryngoscope handles at 19 emergency departments in the Philadelphia area. The median luminance varied widely from 11 lux to 5,627 lux (lux is the SI unit of illuminance equal to one lumen per square meter). Factors that may influence illumination brightness include bulbs/laryngoscope type (fiberoptic versus regular), condition of batteries, and equipment condition (e.g. multiple sterilizations potentially causing damage to light output).\n\nMoore et al. examined the influence of laryngoscope illumination grade upon time to successful mannequin intubation. Intubations were conducted on mannequins with three clinically plausible intensities of light: high (600 lux), medium (200 lux), and low (50 lux). At perceived suboptimal intubation lighting conditions (50 lux), there was no difference in time to intubation on mannequins in this study. Scholz et al. studied minimum and optimum light output of Macintosh size 3 blades in mannequins and again noted that providers could see the larynx at very low light levels. The minimal acceptable lighting depending on bulb type was found to be anywhere from 9 to 34 lux. It was hypothesized that straightforward, low-complexity intubations may be possible at very low light conditions, as the airway operator is familiar with anatomy and other visual clues that will lead to a successful intubation. Difficult airways may require increased lighting to identify anatomical landmarks.\n\nIf conditions are such that achieving sufficient lighting to facilitate laryngoscopy is not possible, then at least three options exist. Digital intubation may be accomplished using solely tactile feedback. If available, intubation may be achieved using a lighted stylet. Finally, supraglottic airway insertion requires no illumination of the airway.",
        "Minimizing airway management equipment": "The standard prehospital intubation kit contains a range of equipment and may take up considerable space. For example, it might include a laryngoscope handle, multiple blades, multiple sizes of tracheal tubes, stylets, syringes, tape, a capnometer, and spare batteries and bulbs. There are situations where minimizing the airway management pack might be necessary. For example, a wilderness or tactical mission requires smaller, compact equipment kits. Over the past three decades there have been major advances in miniaturizing medical devices, offering new options for portability, including, for example, portable versions of continuous quantitative end-tidal CO\u2082 devices, suction devices, and video laryngoscopes.\n\nAn example of a condensed airway management kit is shown in Figure 4.8.\n\n\u2022 Condensed primary airway device\n\n\u2022 Difficult airway device (gum elastic bougie and/or supraglottic device)\n\n\u2022 Condensed surgical airway kit\n\n\u2022 \u201cTurkey baster\u201d suction (not pictured)\n\n\u2022 Small bag-valve-mask (not pictured)\n\nIt may be possible to select gear with multiple uses. For instance, a 14 gauge IV catheter may be bent and used as a cricothyroid-otomy hook. Along the same lines, one might secure the endotracheal tube with tape rather than a commercial endotracheal tube holder.",
        "Telemedicine-assisted airway management": "The field of telemedicine has experienced a tremendous amount of development in the past decade. Applications for providing remote care have been seen in many disciplines including maritime, combat, and concierge medicine. Telemedicine may potentially play a role in prehospital airway management.\n\nSakles et al. describe tele-intubation assistance for remote hospital and prehospital intubations. In their tele-intubation set-up, ambulances were fitted with wireless modules allowing monitoring of intubations from a distance of 500 feet from the ambulance. Rescuers used a modified video laryngoscope capable of transmitting images back to the telemedicine center. Sibert et al. conducted a feasibility study demonstrating remote assistance of intubation. In this project, mannequin intubation footage was transmitted from the back of an ambulance to a physician in a remote monitoring station. A third study by Mosier et al. used readily available smartphone technology (Apple Facetime\u2122, TangoMe\u2122, Skype\u2122) to facilitate tele-intubation.\n\nIt is important to recognize that while telemedicine may potentially aid airway management decision making, it cannot replace the actual motor or dexterous actions of airway management. The primary benefit of tele-intubation is to facilitate the airway decision-making process. For example, a remote advisor may guide the decision to intubate (or not intubate) an apneic victim of a drug overdose. This same remote observer may also coach the rescuer through performance of airway procedures. With the advent of new and inexpensive transmission devices such as smartphones, application of this airway assistance paradigm might be closer than we think.",
        "Airway management in the tactical setting": "Since 11 September 2001, continuous combat operations in both Iraq and Afghanistan have added greatly to our knowledge base regarding tactical medicine and tactical airway management. Concurrently, there has been growth in the field of tactical EMS (TEMS) as the current wars have demonstrated the utility of specialized tactical medical care. Events in the United States due to active shooters and bombers have also demonstrated the need for specialized providers in tactical medicine.",
        "Providing airway management during combat or tactical operations": "Current Tactical Combat Casualty Care (TCCC) guidelines offer medical interventions based on three phases of care: care under fire, tactical field care, and tactical evacuation care. The Tactical Emergency Casualty Care (TECC) guidelines, the civilian equivalent of TCCC, similarly specify three phases: direct threat care, indirect threat care, and evacuation care. In both guidelines, the range of potential airway management techniques increases in scope as the threat from the enemy diminishes. Sophisticated airway techniques are usually not in the best interest of safety for the provider, the tactical team, or the patient in the highest threat environments.\n\nThe highest threat environments in both sets of guidelines include the TCCC care under fire phase or TECC direct threat care phase. In both of these situations, the tactical medical team is taking direct fire/under direct threat. The goal in this phase of care is to accomplish the mission while minimizing casualties, usually accomplished by suppressing or neutralizing the threat. TCCC recommends that airway management be generally deferred until the tactical field care phase. TECC provides similar guidance during direct threat care, including placing or directing the casualty to be placed in a position to protect the airway if tactically feasible.\n\nThe next phases of care in TCCC/TECC are tactical field care and indirect threat care. At this stage, direct engagement has ceased, and the provider and patient have been able to move to safe cover. Here more attention can generally be afforded to airway management. Both guidelines advocate for simple airway maneuvers in the field to include chin lift/jaw thrust, nasopharyngeal airway placement, and placement of the casualty in the recovery position for unconscious casualties without airway obstruction. For those patients with airway obstruction or impending airway obstruction, all of the above techniques are useful, including sitting the patient up to allow blood and secretions to drain. If unsuccessful, the military recommends quick transition to surgical cricothyroidotomy. TECC recommends the same, with considerations for oral or nasotracheal intubation and placement of supraglottic airway devices.\n\nIn the evacuation phase of field care, the threat has diminished and the provider and patient are normally on their way to higher levels of care via an air, ground, or sea platform. Airway management interventions at this point more closely mirror the normal prehospital environment with more extensive options available to the provider. TCCC and TECC recommend expanding options, including supraglottic airway placement, endotracheal intubation, and surgical cricothyroidotomy.\n\nLarsen et al. compared endotracheal intubation, digital intubation, and use of the King LT\u2122 airway device in a simulated tactical setting. They compared the times to successful ventilation, numbers of attempts to successful intubation, and heights of presentation of the participants above a barricade used to simulate concealment. Important points from this study are that the choice of airway management technique can affect the exposure of the tactical provider above cover or concealment and time to first ventilation was relatively quick for both King LT and standard intubation (59.7 seconds for King LT, 63.3 seconds for endotracheal intubation). The time to ventilation was longer for digital intubation (125.4 seconds) and there was greater risk due to exposure over the barricade (23.5 inches above the barricade for digital intubation versus 17.7 inches for King LT placement).\n\nTactical operations may occur under low light or near-blackout conditions. Savoy et al. examined endotracheal intubation in ambient light and in the dark with night vision goggles. Providers were able to intubate using the goggles, but were noted to have much longer times to intubation than with typical ambient light.",
        "Surgical airways in the tactical setting": "United States military personnel often proceed directly to surgical airway placement due to complex facial injuries or the need to expedite care during various tactical scenarios. A study of 72 battlefield prehospital cricothyroidotomies by Mabry et al. noted a success rate of 68%, with a 21% rate of miscannulating the trachea. Combat medics performed most of these procedures. Patients undergoing cricothyroidotomy had a high mortality rate at 66%. The authors recommend that tactical EMS providers should be well versed in surgical airway techniques.\n\nIn a study of Israeli defense forces, Katzenell et al. noted that intubation success rates fall with each subsequent attempt. Therefore rescuers should determine thresholds for abandoning initial intubation efforts in favor of surgical airway placement.",
        "Conclusion": "Emergency medical services providers may need to manage the airway in unusual prehospital situations. Important considerations include the following.\n\n\u2022 Ground-level intubation. Many different intubation positions are described for ground-level intubation. Left lateral decubitus positioning may prove the best approach in this situation.\n\n\u2022 Face-to-face intubation. The \u201ctomahawk\u201d approach may be viable in this situation.\n\n\u2022 Low light intubation. Optimizing available ambient light may help to facilitate intubation in low light conditions.\n\n\u2022 Minimize field equipment. A minimal airway management kit may be necessary. New miniaturized technology affords options for minimizing the airway kit.\n\n\u2022 Telemedicine assistance. Remote airway management guidance may be possible with new telemedicine technology.\n\n\u2022 Tactical airway management. Airway management is best deferred until the intensity of the threat has decreased. Operational constraints may force the operator to consider early surgical airway."
    },
    {
        "Introduction": "The EMS airway follows the same basic principles as in the hospital; however, it comes with its own unique challenges and limitations. In the emergency department there is greater staffing, better lighting, more supplies, as well as physical space. EMS personnel may be providing airway management on the bathroom floor, on a crowded sidewalk with multiple onlookers, in a wrecked vehicle, or in the back of the ambulance. The key to a successful EMS airway is to remember one\u2019s training while being flexible and able to improvise.",
        "EMS Airway Management": "You will find that the tools available for the EMS personnel vary greatly by level of training as well as by system and company. Most EMS personnel do not have access to RSI, so intubation and some adjuncts can be done mainly on patients who no longer have a gag reflex. This leaves a large group of patients who require oxygenation and ventilation yet who cannot be intubated in the field. An airway adjunct often will be used and breaths assisted with a bag-valve-mask (BVM) until arrival at the hospital or the patient either improves or loses his or her gag reflex to allow for intubation. There is the possibility of a conscious, nasal intubation mainly in the setting of a very cooperative patient with flash pulmonary edema; however, as many systems are now providing CPAP to their paramedics, nasal intubations have become increasingly rare.",
        "The Airway Bag": "Below you will see what is available to EMS personnel. Remember, you will not find all options in every ambulance, so familiarize yourself with what is available at the start of your field shift.",
        "Airway Bag Contents": "\u2219Suction:  There is often a portable suction in the airway bag or a separate bag in addition to a standing unit in the ambulance. This is a wonderful invention allowing suction for airway management anywhere a patient may be found: on the sidewalk, the edge of a mountain, or in the living room. \u2219Various sized ET tubes: Paramedics are equipped to intubate neonates to 100-year-old patients. Each ambulance should be equipped with all tube sizes. \u2219Nasal cannula (NC): Available to all EMS providers. \u2219Nonrebreather (NRB):  Available to all EMS providers. \u2219Neb Mask:  Who can use nebulizers varies greatly depending on the EMS system you are in. Some places, EMTs can give albuterol nebulizers to known asthmatics only. There are other systems where EMTs cannot give any nebulizers, or saline only for a croup patient. \u2219In-line Nebulizer:  To provide nebs to intubated patients. May be limited to critical care / flight crews. \u2219Mac and Miller blades  of various sizes. \u2219Colormetric CO2 detector:  This helps verify placement after intubation. The detector should turn from purple to gold if ET tube is in the trachea. This is only used initially after intubation. Less reliable than capnography. \u2219End-tidal CO2 monitor: Used for confirmation of initial tube placement and to monitor CO2 values throughout the transport. Waveform capnography is generally preferred to value-only capnometry.",
        "Airway Adjuncts": "\u2219Oropharyngeal Airway (OPA): Inserted through the mouth to help prevent the tongue from falling back. These adjuncts only work with patients without a gag reflex. Sometimes you will see a paramedic use an OPA to \u201ctest\u201d if the patient has a gag reflex prior to attempting intubation. Available to all levels of training. For a cardiac arrest patient, this is the primary airway management for an EMT. \u2219Nasopharyngeal Airway (NPA): Inserted through the nose - great for obtunded patients. These should not stimulate a gag reflex. Available to all levels of training.",
        "Advanced Airways": "\u2219Endotracheal Tube  (ET Tube) \u2219Nasotracheal Tube:  These are for awake and breathing patients who require advanced airways. They are exceedingly rare, especially with CPAP becoming more common on ALS ambulances. \u2219Laryngeal Mask Airway (LMA): You may be familiar with these in the OR. The LMA has an airway tube that connects to an elliptical mask with a cuff. When the cuff is inflated, the mask conforms to the anatomy with oxygen delivering portion of the mask facing the space between the vocal cords. After correct insertion, the tip of the LMA laryngeal mask sits in the throat against the muscular valve that is located at the upper portion of the esophagus. \u2219Combitube:  Also known as the double-lumen airway, this is a blind insertion airway device. It consists of a cuffed, double-lumen tube that is inserted into the patient\u2019s airway, facilitating ventilation. Inflation of the cuff allows the device to function similarly to an ET tube and usually closes off the esophagus, allowing ventilation and preventing aspiration of gastric contents. \u2219King LT: Also known as the laryngeal tube. Comes as either a single lumen or double lumen, with the second lumen allowing access for an OG tube to aspirate gastric contents. This is also a blind insertion airway device. With balloon inflated, the esophagus is closed off protecting the airway from aspiration.",
        "CPAP and Ventilators": "CPAP:  This is becoming more common to find on ALS ambulances. Usually used for CHF exacerbations and flash pulmonary edema, but also used in some asthmatics or COPD exacerbations. Ventilators: These are typically found on ALS transport ambulances. They have limited settings (typically only rate and tidal volume), but are quite small and compact. Great for inter-facility transports.",
        "The Difficult Airway": "\u2219Bougie: You may be familiar with these from the ED. A bougie is a long, flexible plastic stylet with an angle at the end used to facilitate difficult intubations. It can be placed into the trachea when only the epiglottis may be seen. By placing the angled end of the device in first, the tip can be felt \u201cbouncing\u201d over the tracheal rings, and then an ET tube can be advanced into the trachea over it. \u2219Needle Cricothyrotomy:  Not all paramedics are authorized to use this skill; however, it is more common as a backup airway than a surgical cricothyrotomy. This protocol varies widely from system to system. The procedure itself varies greatly as well, depending on the system and the supplies available. \u2219Surgical Cricothyrotomy: This tends to be found in more advanced EMS systems, and requires advanced training for paramedics. This procedure is typically found in systems that also allow RSI. \u2219RSI: Rapid sequence intubation is only found in more advanced systems. It requires advanced training and medical oversight, and its use in the field is controversial, with mixed outcomes. The indications, medications, and protocols for RSI will be different in each system. \u2219Needle Decompression: All paramedics receive training in needle decompression. This procedure is allowed in most systems for suspected tension pneumothorax."
    },
    {
        "INTRODUCTION": "Although most of the care you provide will not require the use of breathing devices or airway adjuncts, in some situations they can be used effectively as part of your care. Breathing devices and airway adjuncts can assist with:\n\uf0a7 Helping maintain an open airway.\n\uf0a7 Ventilating a patient.\n\uf0a7 Administering supplemental oxygen.\nIn this chapter, you will learn the purpose and use of airway adjuncts, suctioning and how to handle situations involving foreign body airway obstructions (FBAOs).",
        "SUCTIONING": "Sometimes injury or sudden illness results in foreign matter, such as mucus, fluids or blood, collecting in a patient\u2019s airway. One method of clearing the airway is to roll the patient onto the side and sweep the mouth with a gloved finger. However, finger sweeps should only be performed on an unconscious patient and only when material is visible in the mouth. Another method of keeping the airway clear is to place an unresponsive patient who is breathing in a recovery position. But a more effective method is to suction the airway clear. Suctioning is the process of removing foreign matter from the upper airway by means of a mechanical or manual device.\nSuctioning is an important step, when fluids or foreign matter are present or suspected, because the airway must be open and clear in order for the patient to breathe or for any CPR breathing barrier to be effective. Ensure that you always have a suction device at the patient\u2019s side when providing care.",
        "Suctioning Equipment": "There are two types of suction devices: mechanical and manual (Fig. 11-1, A\u2013B). A variety of mechanical and manual devices are used to Airway adjunct: A mechanical device used to help keep the tongue from obstructing the airway; can be either nasal or oral.\nNasal (nasopharyngeal) airway (NPA): An airway adjunct inserted through the nostril and into the throat to help keep the tongue from obstructing the airway; may be used on a conscious or an unconscious patient.\nOral (oropharyngeal) airway (OPA): An airway adjunct inserted through the mouth and into the throat to help keep the tongue from obstructing the airway; used only with unconscious patients.suction the airway. Not all suction units are able to remove solid objects like teeth, foreign bodies and food. Always follow standard precautions when using a suctioning device. Mechanical suction units are electrically powered. They produce a vacuum that is powerful enough to suction substances from the throat (see Skill Sheet 11-1). Mechanical units operate on batteries, which must be checked to ensure they are fully charged, unless the units are of a type with batteries that can be constantly charged. Otherwise, there may be insufficient vacuum to operate the unit effectively and for a sufficient amount of time. Mechanical suction devices are normally found on ambulances or other transport vehicles and use either battery-powered pumps or oxygen-powered aspirators. Manual suction units, as the term implies, are operated by hand (see Skill Sheet 11-2). They are lightweight, compact and relatively inexpensive. Because they do not require an energy source, they avoid some of the problems associated with mechanical units and are easily taken to the side of the patient in case they are needed. For either type of unit, several sizes of sterile suction catheters should be kept on hand for use, depending on the size of the patient. An installed suction unit should be powerful enough to provide an airflow of > 40 liters per minute (LPM) at the end of the delivery tube and, when clamped, a vacuum of > 300 mmHg.",
        "How to Suction": "To use a mechanical suctioning device: 1. Position the patient on the side with the mouth open. If the patient has an obvious sign of injury, suction them in the position found, as appropriate. 2. Remove any visible large debris from the mouth with a gloved finger if the patient is unconscious. 3. Measure and check the suction tip. 4. Turn on the machine and test it. 5. Suction the mouth of an adult for no more than 15 seconds at a time as you withdraw the catheter using a sweeping motion . Suctioning for longer periods can starve the patient of air. This can create an environment that is too low in oxygen to sustain life. To use a manual suctioning device: 1. Position the patient on the side with the mouth open. If the patient has an obvious sign of injury, suction them in the position found, as appropriate. 2. Remove any visible large debris from the mouth with a gloved finger if the patient is unconscious. 3. Measure and check the suction tip. 4. Suction the mouth of an adult for no more than 15 seconds at a time as you withdraw the catheter using a sweeping motion . CRITICAL FACTSSuctioning is the process of removing foreign matter, such as mucus, fluids or blood, from a patient\u2019s upper airway. Suctioning can be done through mechanical or manual devices. Pediatric Considerations: When using mechanical or manual suction on a child or an infant, suction for no more than 10 seconds at a time for a child and 5 seconds at a time for an infant.",
        "BREATHING DEVICES": "Breathing devices allow the emergency medical responder (EMR) to provide positive pressure ventilations to patients in need of CPR, supplemental oxygen and/or artificial ventilations. These devices include CPR breathing barriers such as face shields and resuscitation masks, bag-valve-mask (BVM) resuscitators and oxygen equipment. CPR breathing barriers should have certain standard features such as a one-way valve to reduce the possibility of direct contact with, or exposure to, body fluids and a patient\u2019s exhaled breath. Such devices can help to deliver life-sustaining ventilations when a patient is unable to breathe on their own. See Chapter 10 for more information and how to use these devices.",
        "AIRWAY ADJUNCTS": "The tongue is the most common cause of airway obstruction in an unconscious person. Keeping the tongue from blocking the air passage is a high priority. Mechanical airway adjuncts known as oral (oropharyngeal) airways (OPAs) and nasal (nasopharyngeal) airways (NPAs) can help you accomplish this task. (For more information on NPAs, refer to the Enrichment at the end of this chapter.) Airway adjuncts come in a variety of sizes. The curved design fits the natural contour of the mouth and throat. Once you have positioned the device, you can use a resuscitation mask or BVM to ventilate a nonbreathing patient.",
        "Oropharyngeal Airway": "As the name implies, this type of airway is inserted into the mouth (see Skill Sheet 11-3). When properly positioned, the OPA keeps the tongue away from the back of the throat, thereby helping to maintain an open airway. An improperly placed airway device can compress the tongue into the back of the throat, further blocking the airway. When preparing to insert an OPA, first be sure the patient is unconscious. OPAs are used only on unconscious patients with no gag reflex. If a patient begins to gag, remove the airway immediately. OPAs should not be used if the patient has suffered oral trauma, such as broken teeth, or has recently undergone oral surgery. Follow local protocols for the use of OPAs. Next, select the proper size of airway. Measure the device on the patient to see that it extends from the angle of the jaw to the corner of the mouth. To insert the airway, grasp the patient\u2019s lower jaw and tongue and lift upward. With the patient\u2019s jaw raised, insert the OPA with the curved end (tip) along the roof of the mouth. As the tip of the device approaches the back of the throat, you will feel resistance. Rotate it a half turn to drop it into the back of the patient\u2019s throat. The OPA should drop into the throat without resistance. The flange end should rest on the patient\u2019s lips. If the patient begins gagging as the device is positioned in the back of the throat, remove the device. Suction the airway, ensuring all debris is removed from the airway. Thoroughly clean the device and reinsert into the airway only if the patient is still unconscious and does not have a gag reflex. Pediatric Considerations: The airway of a child or infant is smaller than an adult\u2019s. The size can also vary according to the age of the child or infant, so it is important to use an appropriately sized OPA for pediatric patients. Additionally, the palate of a child and an infant is softer than that of an adult. It can be injured if an OPA is inserted with the tip pointing upward toward the roof of the mouth and rotated 180 degrees as is performed on an adult. Because of this risk of injury, when inserting an OPA in a child or an infant, the airway is inserted with the tip of the device either sideways then rotated 90 degrees into position or, using a tongue depressor, inserted with the tip of the device pointing toward the back of the tongue and throat in the position it will rest after insertion.",
        "CRITICAL FACTS": "When preparing to insert an OPA, first be sure the patient is unconscious. OPAs are used only on unconscious patients with no gag reflex.",
        "Types of Airway Obstruction": "There are two types of airway obstruction, anatomical and mechanical: Anatomical obstruction occurs when an airway is blocked by an anatomical structure, such as the tongue or swollen tissues of the mouth or throat. The tongue is a common cause of airway obstruction in an unconscious patient because the tongue relaxes when the body is deprived of oxygen, causing the tongue to rest on the back of the throat, blocking the flow of air to the lungs. Mechanical obstruction, also known as foreign body airway obstruction, occurs when foreign objects, such as food or toys, or fluids, such as vomit, block the airway.",
        "Foreign Body Airway Obstruction": "Foreign body airway obstruction (FBAO) causes choking and commonly occurs because of poorly chewed food; eating too fast; or laughing, talking, running or walking while eating. A conscious person who is clutching the throat is showing what is commonly called the \u201cuniversal\u201d sign of choking. A person with a mild FBAO, or partial airway obstruction, can still move some air to and from the lungs, often while wheezing as long as the person can cough forcefully, encourage continued coughing but do not provide first aid care for choking. Severe airway obstruction is apparent when the person cannot cough, speak, cry or breathe and requires immediate action.",
        "FBAO in an Adult": "As an EMR, you must get consent before helping a choking adult. When caring for a choking adult, several skills\u2014abdominal thrusts, back blows and chest thrusts\u2014have been shown to be effective at clearing an obstruction (see Skill Sheet 11-4). Generally, EMRs should provide abdominal thrusts to attempt to clear an obstruction, but they may perform a combination of skills such as back blows followed by abdominal thrusts based on local protocols. Each abdominal thrust, back blow or chest thrust should be a distinct attempt to dislodge the object. Using more than one technique is often necessary to dislodge an object and clear a patient\u2019s airway. Continue performing abdominal thrusts or a combination of skills until the object is dislodged and the patient can cough forcefully, speak or breathe, or until the patient becomes unconscious. Abdominal thrusts may not be an effective method of care for choking adults in cases where you cannot reach far enough around the patient to give effective abdominal thrusts or if the patient is obviously pregnant or known to be pregnant. In these situations, you should give back blows followed by chest thrusts. To perform abdominal thrusts: 1. Stand behind the patient and use one or two fingers of one hand to find the navel. 2. Make a fist with your other hand and place the thumb side of your fist against the middle of the patient\u2019s abdomen, just above the navel. 3. Grab your fist with your other hand and give quick inward and upward thrusts. 4. Continue providing abdominal thrusts until the patient begins to cough forcefully, speak or breathe, or until the patient becomes unconscious. To perform back blows: 1. Stand to the side and slightly behind the patient. 2. Place one arm diagonally across the patient\u2019s chest (to provide support) and bend the patient forward at the waist so their upper body is as close to parallel to the ground as possible. 3. Firmly strike the patient between the scapulae with the heel of your other hand. 4. Continue providing back blows until the patient begins to cough forcefully, speak or breathe, or until the patient becomes unconscious. To perform chest thrusts: 1. Stand behind the patient and make a fist with one hand. 2. Place the thumb side of your fist against the center of the patient\u2019s chest. 3. Grab your fist with your other hand and give quick inward thrusts. 4. Continue providing chest thrusts until the patient begins to cough forcefully, speak or breathe, or until the patient becomes unconscious. If a patient who is choking becomes unconscious, carefully lower the patient to a firm, flat surface while protecting their head, send someone to get an AED, and summon additional resources if appropriate and you have not already done so. Immediately begin CPR, starting with chest compressions. (CPR will be discussed in detail in Chapter 13.) As you open the airway to give ventilations, look in the patient\u2019s mouth for any visible object. If you can see an object, use a finger sweep motion to remove it. If you don\u2019t see an object, do not perform a blind finger sweep, but continue CPR. Remember to never try more than 2 ventilations during one cycle of CPR, even if the chest doesn\u2019t rise. Continuing cycles of 30 compressions and 2 ventilations is the most effective way to provide care. Even if ventilations fail to make the chest rise, compressions may help clear the airway by moving the blockage into the upper airway where it can be seen and removed.",
        "Science Note 1": "Evidence suggests that it may take more than one technique to relieve an airway obstruction in the conscious patient, and that abdominal thrusts, back blows and chest thrusts are all effective.",
        "Science Note 2": "Based upon local protocols or practice, It is permissible to provide a series of back blows in addition to abdominal thrusts to an adult or child who is choking. Always follow local protocols, practice or medical direction instructions.",
        "Airway Obstruction - Pediatric Considerations": "Children are prone to choking on small objects as well as food. Choking hazards among children include small objects such as coins, buttons, small toys, and parts of toys and balloons, as well as certain food items. While hazardous for all children, these objects generally pose a larger threat to children under 4 years of age. Children under 4 do not have a full set of teeth and cannot chew as well as older children, so large chunks of foods may lodge in the throat and cause choking. The American Academy of Pediatrics (AAP) recommends that children younger than 4 not be fed any round, firm food unless it is cut into small pieces no larger than one-half inch. It further recommends keeping the following foods away from children younger than 4: \uf0a7 Hot dogs \uf0a7 Nuts and seeds \uf0a7 Chunks of meat or cheese \uf0a7 Whole grapes \uf0a7 Hard, gooey or sticky candy \uf0a7 Popcorn \uf0a7 Chunks of peanut butter \uf0a7 Raw vegetables \uf0a7 Raisins \uf0a7 Chewing gum While food items cause the most choking injuries in children, toys and household items can also be hazardous. Balloons, when not inflated or when broken, can choke or suffocate young children who try to swallow them. According to the Consumer Product Safety Commission (CPSC), more children have suffocated on non-inflated balloons and pieces of broken balloons than any other type of toy.",
        "Consent and Procedure for Choking Child": "As an EMR, you must get consent from a parent or legal guardian, if present, before helping a choking child or infant. For a conscious child, the process of relieving an obstructed airway is similar to that of an adult. However, responders should use less force when giving abdominal thrusts or back blows. Using too much force may cause internal injuries. Remember, you may need to kneel to provide care for an obstructed airway in a child. Continue care until the child can cough forcefully, speak, cry or breathe, or until the child becomes unconscious. If a child becomes unconscious, follow the same general steps as you would for an adult.",
        "Procedure for Choking Infant": "When an infant is choking and awake but unable to cough, cry or breathe, you\u2019ll need to perform a series of 5 back blows and 5 chest thrusts. Start with back blows. Hold the infant face-down on one arm using your thigh for support. Make sure the infant\u2019s head is lower than their chest and that you are supporting the infant\u2019s head and neck. With your other arm, give firm back blows with the heel of your hand between the infant\u2019s scapulae. After 5 back blows, start chest thrusts. Turn the infant over onto your other arm using your thigh for support. Make sure to support the head and neck as you move the infant. Place two fingers in the center of the infant\u2019s chest, just below the nipple line. Give 5 thrusts. Continue this cycle of 5 back blows and 5 chest thrusts until the object is forced out; the infant can cough, cry or breathe; or the infant becomes unconscious. If an infant does become unconscious while choking, carefully lower the infant onto a firm, flat surface while protecting their head, send someone to get an AED, and summon additional resources if appropriate and you have not already done so. Immediately begin CPR, starting with chest compressions.",
        "PUTTING IT ALL TOGETHER": "As an EMR, you may need to know how to insert OPAs, use a suctioning device and care for a conscious or an unconscious patient who is choking. Breathing devices and airway adjuncts allow the EMR to help maintain an open airway, ventilate a patient and supply supplemental oxygen. OPAs can help maintain an open airway by keeping the tongue away from the back of the throat. An OPA can be used on an unconscious patient who does not have a gag reflex and requires an airway adjunct. Suction equipment helps clear the upper airway of substances, such as fluids, blood, saliva or vomit. You should also know the difference between a mechanical and anatomical obstruction and the actions required to assist a patient who is choking as a result. Special considerations must be given when caring for a child or an infant, including the size of equipment used. You may need to alter your position based on the size of the child and use less force to clear an obstructed airway.",
        "Using a Mechanical Suctioning Device": "NOTE: Size up the scene for safety, and follow standard precautions. If needed, assemble the device according to manufacturer\u2019s instructions. STEP 1 Position the patient. If the patient has an obvious sign of injury, suction them in the position found, as appropriate.\n\u25a0Roll the body as a unit onto one side.\n\u25a0Open the mouth. STEP 2 Remove any visible large debris from the mouth with a gloved finger if the patient is unconscious. STEP 3 Measure and check the suction tip.\n\u25a0Measure from the angle of the patient\u2019s jaw to the corner of the mouth.\n\u25a0Note the distance to prevent inserting the suction tip too deeply. STEP 4 Turn on the machine and check that the suction is working according to the manufacturer\u2019s instructions. STEP 5 Suction the mouth.\n \u25a0Insert the suction tip into the back of the mouth.\n \u25a0Apply suction as you withdraw the catheter using a sweeping motion, if possible.\n \u25a0Suction for no more than 15 seconds at a time for an adult, 10 seconds for a child and 5 seconds for an infant.",
        "Using a Manual Suctioning Device": "NOTE Size up the scene for safety, and follow standard precautions. If needed, assemble the device according to manufacturer\u2019s instructions. STEP 1 Position the patient. If the patient has an obvious sign of injury, suction them in the position found, as appropriate. Instructions [ Measure from the angle of the patient\u2019s jaw to the corner of the mouth, Note the distance to prevent inserting the suction tip too deeply, Check that the suction is working by placing your gloved finger over the end of the suction tip as you squeeze the handle of the device]. STEP 2 Remove any visible large debris from the mouth with a gloved finger if the patient is unconscious. STEP 3 Measure and check the suction tip. STEP 4 Suction the mouth.\n \u25a0Insert the suction tip into the back of the mouth.\n \u25a0Squeeze the handle of the suction device repeatedly to provide suction.\n \u25a0Apply suction as you withdraw the catheter using a sweeping motion, if possible.\n \u25a0Suction for no more than 15 seconds at a time for an adult, 10 seconds for a child and 5 seconds for an infant.",
        "Inserting an Oral Airway": "NOTE: Size up the scene for safety, follow standard precautions and then perform a primary assessment. Before inserting an oral airway (OPA), be sure the patient is unconscious, has no oral trauma such as broken teeth and has not had recent oral surgery. If the patient gags, remove the airway immediately. STEP 1 Select the proper size. \u25a0Measure the OPA from the angle of the patient\u2019s jaw to the corner of the mouth. STEP 2 Open the patient\u2019s mouth. \u25a0Use the cross-finger technique to open the patient\u2019s mouth. STEP 3 Insert the OPA. NOTE: When inserting an OPA in a child or an infant, the OPA is inserted using a tongue blade or a tongue depressor, then inserted with the tip of the device pointing toward the back of the tongue and throat in the position it will rest in after insertion. \u25a0To insert the OPA, grasp the patient\u2019s lower jaw and tongue and lift upward. \u25a0Insert the OPA with the curved end along the roof of the mouth. \u25a0As the tip approaches the back of the mouth, rotate it one-half turn (180 degrees). \u25a0Slide the OPA into the back of the throat. NOTE: The alternative procedure for a child or an infant is to insert the OPA sideways and then rotate it 90 degrees. STEP 4 Ensure correct placement. \u25a0The flange should rest on the patient\u2019s lips. \u25a0If the patient begins to gag, immediately remove the OPA. \u25a0If the patient vomits, remove and suction the airway, ensuring all debris is removed from the airway. Thoroughly clean the device and reinsert into the airway only if the patient is still unconscious and does not have a gag reflex.",
        "Choking\u2014Adult and Child": "NOTE: Obtain consent from a choking adult. If a child is choking, obtain consent from the parent or legal guardian if present. Tell the child\u2019s parent or legal guardian your level of training and the care you are going to provide. If the parent or legal guardian is not available, consent is implied. Always follow standard precautions when providing care. STEP 1 Ask the patient, \u201cAre you choking?\u201d \u25a0Identify yourself and ask if you can help. \u25a0If the patient is coughing forcefully, encourage continued coughing. STEP 2 If the patient cannot cough, speak or breathe, have someone else summon more advanced medical personnel. STEP 3 Give abdominal thrusts. Instructions: Stand behind the patient, For a child, stand or kneel behind the child, depending on the child\u2019s size. Use less force on a child than you would on an adult. Use one or two fingers of one hand to find the navel. Make a fist with your other hand and place the thumb side of your fist against the middle of the patient\u2019s abdomen, just above the navel. Grab your fist with your other hand. Give quick inward and upward thrusts. Each thrust should be a distinct attempt to dislodge the object. Continue providing abdominal thrusts until The patient begins to cough forcefully, speak or breathe on their own. The patient becomes unconscious. If the patient becomes unconscious, Carefully lower the patient to a firm, flat surface while protecting their head. Immediately begin CPR, starting with compressions. After 30 compressions, open their mouth and look for an object. If you see an object, remove it with a finger sweep. Attempt ventilations. Continue CPR. OPTION BASED ON LOCAL PROTOCOLS Provide a combination of 5 back blows followed by 5 abdominal thrusts. To perform back blows Stand to the side and slightly behind the patient. Place one arm diagonally across the patient\u2019s chest (to provide support) and bend the patient forward at the waist so their upper body is as close to parallel to the ground as possible. Firmly strike the patient between the scapulae with the heel of your other hand. Continue providing back blows until the patient begins to cough forcefully, speak or breathe, or until the patient becomes unconscious. NOTE Some choking patients may need chest thrusts instead of abdominal thrusts. Use chest thrusts if You cannot reach far enough around the patient to give effective abdominal thrusts. The patient is obviously pregnant or known to be pregnant.",
        "Choking\u2014Infant": "NOTE: If an infant is choking, obtain consent from the parent or legal guardian if present. Tell the infant\u2019s parent or legal guardian your level of training and the care you are going to provide. If the parent or legal guardian is not available, consent is implied. Always follow standard precautions when providing care. STEP 1 If the infant cannot cough, cry or breathe, carefully position the infant face-down along your forearm.\n \u25a0Support the infant\u2019s head and neck with your hand.\n \u25a0Lower the infant onto your thigh, keeping the infant\u2019s head lower than their chest. STEP 2 Give 5 firm back blows.\n \u25a0Use the heel of your hand.\n \u25a0Give back blows between the infant\u2019s scapulae.\n \u25a0Each back blow should be a distinct attempt to dislodge the object. STEP 3 Position the infant face-up along your forearm.\n \u25a0Position the infant between both of your forearms, supporting the infant\u2019s head and neck.\n \u25a0Turn the infant face-up.\n \u25a0Lower the infant onto your thigh with the infant\u2019s head lower than their chest. STEP 4 Give 5 chest thrusts. Instructions: Put two fingers on the center of the chest, just below the nipple line. Compress the chest 5 times about 1\u00bd inches. Each chest thrust should be a distinct attempt to dislodge the object. Continue giving 5 back blows and 5 chest thrusts until: The infant begins to cough or breathe on their own. The infant becomes unconscious. If the infant becomes unconscious: Carefully lower the infant onto a firm, flat surface while protecting their head and immediately begin CPR, starting with compressions. CPR Instructions: After 30 compressions, open their mouth and look for an object. If you see an object, remove it with a finger sweep. Attempt ventilations.Continue CPR.",
        "Nasopharyngeal Airway": "When properly positioned, the nasal (nasopharyngeal) airway (NPA) keeps the tongue out of the back of the throat, thereby keeping the airway open. An NPA may be used on a conscious, responsive patient or an unconscious patient. Unlike an oral airway, the NPA does not cause the patient to gag. NPAs must not be used on a patient with suspected head trauma or a suspected skull fracture. When using an NPA, select the proper size (see Skill Sheet 11-6). Measure the device on the patient to see that it extends from the angle of the jaw to the tip of the nose. Also, make sure the diameter of the NPA is not larger than the internal diameter of the nostril. To insert the NPA, lubricate the airway and the opening of the nostril with a water-soluble lubricant. Insert the NPA into the right nostril, with the bevel toward the septum (the wall of tissue that separates the nostrils). Advance the NPA gently, straight in, not upward, until the flange rests on the nostril. If you feel even minor resistance, do not force the NPA. If you cannot get the NPA to pass easily, remove it and try the other nostril. If you use the left nostril, you need to ensure that the bevel is inserted toward the septum and the NPA is rotated as you advance it in, similar to the OPA. Inserting a Nasal Airway: NOTE: Size up the scene for safety, follow standard precautions and then perform a primary assessment. NPAs must not be used on a patient with suspected head trauma or a suspected skull fracture.STEP 1: Select the proper size.\n \u25a0Measure the NPA from the angle of the patient\u2019s jaw to the tip of the nostril. Ensure that the diameter of the NPA is not larger than the internal diameter of the nostril. STEP 2 Lubricate the NPA and the opening of the nostril.\n \u25a0Use a water-soluble lubricant to lubricate the NPA prior to insertion. STEP 3: Insert the NPA.\n \u25a0Insert the NPA into the right nostril, with the bevel toward the septum (center of the nose).\n \u25a0Advance the NPA gently, straight in, following the floor of the nose.\n \u25a0If resistance is felt, do not force it.\n \u25a0If you are experiencing problems, try the left nostril and ensure that you rotate the NPA as you insert it past the nasal structures. STEP 4\nEnsure correct placement.\n\u25a0The flange should rest on the nostril."
    },
    {
        "Key Terms": "Apnea: A condition that causes breathing to stop periodically or be significantly reduced., Artificial ventilation: A mechanical means used to assist breathing, such as with a bag-valve-mask (BVM) resuscitator or resuscitation mask., Aspiration: To take, suck or inhale blood, vomit, saliva or other foreign material into the lungs., Asthma: An ongoing condition in which the airways swell; the air passages can become constricted or blocked when affected by various triggers., Asthma attack: The sudden worsening of asthma signs and symptoms, caused by inflammation of the airways and the tightening of muscles around the airways of a person with asthma, making breathing difficult., Asthma trigger: Anything that sets off an asthma attack, such as animal dander, dust, smoke, exercise, stress or medications., Bag-valve-mask (BVM) resuscitator: A handheld breathing device consisting of a self-inflating bag, a one-way valve and a face mask; can be used with or without supplemental oxygen., Breathing emergency: An emergency in which breathing is impaired; can become life threatening; also called a respiratory emergency., Chronic obstructive pulmonary disease (COPD): A progressive lung disease in which the patient has difficulty breathing because of damage to the lungs; airways become obstructed and the alveolar sacs lose their ability to fill with air., Crackles: An abnormal fine, crackling breath sound on inhalation that may be a sign of fluid in the lungs; also known as rales., Cricoid: A solid ring of cartilage just below and behind the thyroid cartilage., Cyanosis: A condition in which the patient\u2019s skin, nail beds and mucous membranes appear a bluish or greyish color because of insufficient levels of oxygen in the blood., Deadspace: The areas within the respiratory system between the pharynx and the alveoli that contain a small amount of air that does not reach the alveoli., Emphysema: A chronic, degenerative lung disease in which there is damage to the alveoli., Finger sweep: A method of clearing the mouth of foreign material that presents a risk of blocking the airway or being aspirated into the lungs., Foreign body airway obstruction (FBAO): The presence of foreign matter, such as food, that obstructs the airway., Hyperventilation: Rapid, deep or shallow breathing; usually caused by panic or anxiety., Hypoxia: A condition in which insufficient oxygen is delivered to the body\u2019s cells., Midaxillary line: An imaginary line that passes vertically down the body starting at the axilla (armpit); used to locate one of the areas for listening to breath sounds., Midclavicular line: An imaginary line that passes through the midpoint of the clavicle (collarbone) on the ventral surface of the body; used to locate one of the areas for listening to breath sounds., Midscapular line: An imaginary line that passes through the midpoint of the scapula (shoulder blade) on the dorsal surface of the body; used to locate one of the areas for listening to breath sounds., Overventilation: Blowing too much air into the patient, which can enter the stomach, causing gastric distention and likely vomiting. Overventilation can also increase the amount of pressure in the chest, which compresses the blood vessels returning to the heart, thus limiting effective circulation., Oxygenation: The addition of oxygen to the body; also, the treatment of a patient with oxygen., Paradoxical breathing: An abnormal type of breathing that can occur with a chest injury (e.g., flail chest); one area of the chest moves in the opposite direction to the rest of the chest., Pathophysiology: The study of the abnormal changes in mechanical, physical and biochemical functions caused by an injury or illness., Pneumonia: A lung infection caused by a virus or bacterium that results in a cough, fever and difficulty breathing., Positive pressure ventilation: An artificial means of forcing air or oxygen into the lungs of a person who has stopped breathing or has inadequate breathing., Pulmonary embolism: Sudden blockage of an artery in the lung; can be fatal., Rales: An abnormal breath sound; a popping, clicking, bubbling or rattling sound, also known as crackles., Respiratory failure: Condition in which the respiratory system fails in oxygenation and/or carbon dioxide elimination; the respiratory system is beginning to shut down; the person may alternate between being agitated and sleepy. , Resuscitation mask: A pliable, dome-shaped breathing device that fits over the mouth and nose; used to provide artificial ventilations and administer supplemental oxygen., Rhonchi: An abnormal breath sound when breathing that can often be heard without a stethoscope; a snoring or coarse, dry rale sound., Stridor: An abnormal, high-pitched breath sound caused by a blockage in the throat or larynx; usually heard on inhalation., Suctioning: The process of removing foreign matter, such as blood, other liquids or food particles, by means of a mechanical or manual suctioning device., Tidal volume: The normal amount of air breathed at rest., Ventilation: The exchange of air between the lungs and the atmosphere; allows for an exchange of oxygen and carbon dioxide in the lungs., Wheezing: A high-pitched whistling sound heard during inhalation but heard most loudly on exhalation; an abnormal breath sound that can often be heard without a stethoscope.",
        "INTRODUCTION": "Because oxygen is vital to life, always ensure that the patient has an open airway and is breathing. Ensuring an open airway is one of the most important steps you can take for any patient. Without an open airway, a person cannot breathe and will die. The airway is the pathway from the mouth and nose to the lungs. A person who can speak or cry is conscious, has an open airway, is breathing and has a pulse. It is more difficult to tell if an unconscious person has an open airway. You will have to take into consideration possible injury or illness. Once you have an open airway, you may need to clear any obstructions and then assess breathing. If the person is experiencing a breathing emergency, you may need to provide artificial ventilations. A breathing emergency is often detected during the primary assessment. In a breathing emergency, a person\u2019s breathing can become so impaired that life is threatened. There are two types of respiratory emergencies: respiratory distress, a condition in which breathing becomes difficult; and respiratory arrest, a condition in which breathing stops. This chapter will address the causes, signs and symptoms of respiratory emergencies. Some of these emergencies are caused by chronic conditions such as chronic obstructive pulmonary disease (COPD), and others are caused by acute emergencies such as asthma and pulmonary embolism.",
        "THE RESPIRATORY SYSTEM - Anatomy": "The respiratory system is divided into the upper and lower airway tracts. The upper airway tract begins where air enters the respiratory system, through the mouth and nose. Air that is inhaled through the nose is warmed and humidified. Air may also be inhaled through the mouth and over the tongue, within the oral cavity. The mouth provides an airway, especially during an emergency. Once air is inhaled, it passes through the throat, or pharynx. The pharynx is divided into three parts, from superior to inferior: the nasopharynx, the oropharynx and the laryngopharynx. The nasopharynx lies behind the nasal cavity. The oropharynx lies behind the oral cavity and is the shared passageway for both food and air. Below the oropharynx is the laryngopharynx, the lowest part of the throat, which divides into two passageways. In the posterior (back) portion is the entrance to the esophagus, the passageway for food. In the anterior (front) is the larynx, which is the continuation of the respiratory system. Above the larynx is the epiglottis, a flap of cartilage that folds down over the larynx to close off the entrance to the trachea during swallowing, so that food cannot enter. This airway protection does not occur if a person is unconscious. Once air has traveled through the pharynx, it passes through the larynx. At the top of this structure, made mostly of cartilage, muscle and membranes, is the hyoid bone\u2014a horseshoe-shaped bone that supports the structures of the larynx below and attaches to the tongue and other oral structures above. Below the hyoid bone are the thyroid and cricoid cartilages, which form the larynx. Within the larynx lie the vocal cords, narrow muscles that stretch horizontally across from anterior to posterior. The lower airway tract begins below the level of the vocal cords, and consists of the trachea, bronchi and lungs. The trachea, or windpipe, is a hollow tube, supported by rings of cartilage. It extends downward until it divides into two branches called bronchi, one of which travels into each lung. The two bronchi are hollow tubes, also supported by cartilage, that further divide into lower airways called bronchioles. Bronchioles are thin hollow tubes that lead to the alveoli, and that remain open through smooth muscle tone. The millions of alveoli are small sacs that form the end of the airway. Each one has a thin walled sac that shares a wall with the capillary blood vessels in contact with it. It is at this site, where the one-celled walls of the alveoli and capillaries come into contact, where external respiration\u2014the exchange of oxygen and carbon dioxide between the respiratory and circulatory system\u2014takes place. The circulatory system then transports the oxygen-rich blood to the brain, organs, muscles and other parts of the body. Some body tissues, such as those in the brain, are very sensitive to oxygen deprivation. Other vital organs can be adversely affected unless oxygen supplies are restored quickly. The brain is the control center for breathing. It adjusts the rate and depth of breaths according to the oxygen and carbon dioxide levels in the body. Breathing requires that the respiratory, circulatory, nervous and musculoskeletal systems work together. Injuries or illnesses that affect any of these systems may cause breathing emergencies.",
        "THE RESPIRATORY SYSTEM - Pathophysiology": "Normal breathing occurs in ambient (surrounding) air, which contains all the necessary gases for normal respiration. Patients may suffer breathing difficulties because of an inadequate amount of oxygen breathed in during respiration. Breathing difficulties may also occur as a result of breathing in a low-oxygen environment or when poisonous gases are in the air. Other causes of breathing difficulties include infection of the lungs; illnesses such as asthma, which narrows the airway and causes wheezing; excess fluid in the lungs or excess fluid between the lungs and blood vessels; traumatic injuries to the lungs that cause bruising (lung contusion); and poor circulation. Breathing difficulties may also develop due to upper airway problems caused by swelling, obstruction or trauma. Swelling of the upper airway can occur due to anaphylaxis (severe allergic reaction) or asthma. Choking, caused by airway obstruction, is one of the most common causes of breathing emergencies, and can occur due to anatomical or mechanical obstruction. Trauma can occur due to a blow to the upper chest, a puncture or a crush injury. Breathing problems may develop because of ineffective circulation. This can be the result of shock\u2014an acute condition in which the circulatory system fails to adequately circulate oxygen-rich blood to all cells of the body\u2014or cardiac arrest, when the heart stops functioning as a pump. Sometimes the rate or depth of breathing is inadequate, leading to an insufficient volume of air moving into and out of the lungs. Respiration may be ineffective due to unconsciousness, altered level of consciousness, injury to the chest, poisoning, overdose, or diseases such as COPD or emphysema. Oxygenation refers to the amount of oxygen in the bloodstream. Oxygen is exchanged between the alveoli of the lungs and the capillaries, and at the cellular level between the capillaries and the cells. If an insufficient amount of oxygen is delivered to the cells, this is referred to as hypoxia, and may result from an obstructed airway, shock, inadequate breathing, drowning, strangulation, choking, suffocation, cardiac arrest, chest or head trauma, carbon monoxide poisoning or complications of general anesthesia.",
        "CRITICAL FACTS": "Ensuring an open airway is one of the most important steps you can take in caring for a patient, because a person cannot breathe without an open airway. A patient who can speak or cry is conscious, has an open airway, is breathing and has a pulse.",
        "CRITICAL FACTS 2": "There are many reasons why a person may have difficulty breathing. Reasons include an inadequate amount of oxygen being taken in, a low-oxygen environment, the presence of poisonous gases, infection, trauma, poor circulation or other health-related issues. Oxygenation refers to the amount of oxygen in the bloodstream. Hypoxia is the term used to describe an insufficient amount of oxygen delivered to the cells.",
        "RESPIRATORY EMERGENCIES": "A respiratory emergency occurs when air cannot travel freely and easily into the lungs, and can be life threatening because it greatly cuts down on the oxygen the body receives or because it cuts off the oxygen entirely. This can stop the heart and prevent blood from reaching other vital organs. Unless the brain receives oxygen within 4 to 6 minutes, brain damage is possible. Within 6 to 10 minutes, brain damage is likely, and after 10 minutes, brain damage is certain. There are two types of respiratory emergencies: respiratory distress, a condition in which breathing becomes difficult, and respiratory arrest, a condition in which breathing stops. Respiratory distress can be caused by: \uf0a7 A partially obstructed airway. \uf0a7 Illness. \uf0a7 Chronic conditions such as asthma. \uf0a7 Electrocution, including lightning strikes. \uf0a7 Heart attack. \uf0a7 Injury to the head, chest, lungs or abdomen. \uf0a7 Allergic reactions. \uf0a7 Drugs. \uf0a7 Poisoning. \uf0a7 Emotional distress. Trouble breathing can be the first sign of a more serious emergency such as a heart problem. Recognizing the signs of breathing problems and providing care are often the keys to preventing these problems from becoming emergencies that are more serious. If you encounter someone with a breathing problem, the patient will most likely be conscious. Breathing problems can be identified by watching and listening to the patient\u2019s breathing and by asking how the patient feels. Although breathing problems have many causes, you do not have to know the exact cause of a breathing emergency to care for it. Signs and symptoms of respiratory emergencies include: \uf0a7 Slow or rapid breathing. \uf0a7 Unusually deep or shallow breathing. \uf0a7 Gasping for breath. \uf0a7 Wheezing, gurgling or high-pitched noises. \uf0a7 Unusually moist or cool skin. \uf0a7 Flushed, pale, ashen or bluish skin color. \uf0a7 Shortness of breath. \uf0a7 Dizziness or light-headedness. \uf0a7 Pain in the chest or tingling in the hands, feet or lips. \uf0a7 Apprehensive or fearful feelings.",
        "Chronic Obstructive Pulmonary Disease": "Chronic obstructive pulmonary disease (COPD) is a progressive lung disease in which the patient has difficulty breathing because of damage to the lungs. In a patient with COPD, the airways become partly obstructed and the alveolar sacs lose their ability to fill with air, making it difficult for air to be inhaled and exhaled. The most common cause of COPD is cigarette smoking, but it may also be caused by inhaling other types of lung irritants, pollution, dust or chemicals over a long period of time. It is usually diagnosed when patients are middle aged or older. Combined with asthma, COPD is the third-ranking cause of death in the United States and a major cause of illness. Signs and symptoms include the following: \uf0a7 Coughing up a great deal of mucus \uf0a7 A tendency to tire easily \uf0a7 Loss of appetite \uf0a7 Bent posture with shoulders elevated and lips pursed to make breathing easier \uf0a7 A fast pulse \uf0a7 Round, barrel-shaped chest \uf0a7 Confusion (caused by lack of oxygen to the brain) Patients with COPD require help focusing on breathing, as deep breaths help fill the lungs with air and maintain flexibility in the chest wall. Patients can learn special breathing exercises to help them relax and breathe slowly, which increases the flow of oxygen to the lungs.",
        "Asthma": "Asthma is an ongoing illness in which the airways swell. An asthma attack happens when an asthma trigger, such as exercise, cold air, allergens or other irritants, affects the airways, causing them to suddenly swell and narrow. This makes breathing difficult, which can be very frightening. The Centers for Disease Control and Prevention (CDC) estimates that approximately 24 million Americans are diagnosed with asthma in their lifetimes. Asthma is more common in children and young adults than in older adults, but its frequency and severity are increasing in all age groups. Asthma results in about 1.6 million visits to emergency departments annually in the United States. You can often tell when a person is having an asthma attack by the hoarse whistling sound the person makes while inhaling and/or exhaling. This sound, known as wheezing, occurs because air becomes trapped in the lungs. Coughing that occurs after exercise, crying or laughing is another sign that an asthma attack is taking place. Signs and symptoms of an asthma attack include: \uf0a7 Coughing or wheezing noises. \uf0a7 Difficulty breathing. \uf0a7 Shortness of breath. \uf0a7 Rapid, shallow breathing. \uf0a7 Sweating. \uf0a7 Tightness in the chest. \uf0a7 Inability to speak in complete sentences. \uf0a7 Bent posture with shoulders elevated and lips pursed to make breathing easier. \uf0a7 Feelings of fear or confusion. Usually, people diagnosed with asthma control their attacks by controlling environmental variables and through medication and other forms of treatment. The medications stop the muscle spasms and open the airway, which makes breathing easier. Controlling the environmental variables, whenever possible, helps reduce the triggers that can lead to the start of an asthma attack. A trigger is anything that sets off or starts an asthma attack. A trigger for one person is not necessarily a trigger for another. Some asthma triggers are: \uf0a7 Dust, smoke and air pollution. \uf0a7 Exercise. \uf0a7 Plants and molds. \uf0a7 Perfume. \uf0a7 Medications, such as aspirin. \uf0a7 Animal dander. \uf0a7 Temperature extremes and changes in the weather. \uf0a7 Strong emotions, such as anger, fear or anxiety. \uf0a7 Infections, such as colds or other respiratory infections. Some anti-inflammatory medications prescribed for the long-term control of asthma are taken daily. Other medications are prescribed for quick relief and are taken only when a person is experiencing the signs and symptoms of an asthma attack. These medications help relieve the sudden swelling and are called bronchodilators.",
        "Pneumonia": "Pneumonia Pneumonia is an infection that causes inflammation of the lungs. Because of the inflammation, the air sacs in the lungs begin to fill with fluid, and oxygen has trouble reaching the bloodstream. Pneumonia can be a serious illness in older adults because of normal age-related changes such as a weakened cough reflex and impaired mobility, and can even result in death. Pneumonia can be caused by viruses (often a complication of the flu), bacteria, fungi or other organisms. Symptoms include high fever, chills, chest pain and shortness of breath. In addition to these symptoms, older patients commonly exhibit other symptoms including increased respiration rate, breathing difficulty and congestion. Altered mental status may also present in older patients. Older adults may also develop aspiration pneumonia. Residents who are in a coma or using feeding tubes are especially at risk for developing pneumonia. Bacterial pneumonia is treated with antibiotics. Administering supplemental oxygen may help relieve some of the symptoms of pneumonia.",
        "Acute Pulmonary Edema": "Pulmonary edema is an abnormal build-up of fluid in the lungs that can result in death if not properly treated. It is usually caused by inadequate heart pumping when the left ventricle starts to eject less blood than the right. This places excessive pressure on the lungs and allows fluid to leak into the alveoli and capillaries. Acute pulmonary edema causes severe respiratory distress, altered mental status and coughing, with some bloody sputum. Signs and symptoms of pulmonary edema include shortness of breath; difficulty breathing, including wheezing or gasping for breath; cyanosis  (a bluish color of the skin and mucous membranes); frothy (foamy) pink sputum; pale skin; excessive sweating; restlessness, anxiety and a feeling of apprehension; a feeling of suffocating or drowning; and chest pain when the condition is caused by coronary artery disease. Gradual symptoms include difficulty breathing when lying flat, awakening at night with a feeling of breathlessness, unusual shortness of breath during physical activity and significant weight gain when the condition develops because of congestive heart failure. Administering supplemental oxygen is a primary step in the care of pulmonary edema.",
        "Hyperventilation": "Hyperventilation  occurs when a person breathes faster and shallower or deeper than normal. When a patient is hyperventilating, carbon dioxide levels in the blood decrease, reducing blood flow to the brain. This causes fear, anxiety and confusion, as well as dizziness and a numb and tingly feeling in the fingers and toes.Fear or anxiety is often the cause of hyperventilation but it can also result from a head injury, severe bleeding or conditions such as infection, heart failure and lung disease. Asthma and stress can also trigger hyperventilation. Note that anxiety is only one cause of rapid breathing, and most patients experiencing this symptom are not hyperventilating. If you are certain the patient is not experiencing life-threatening symptoms, the most effective response is to calm the patient. Listen to the patient\u2019s concerns and try to reassure and encourage the patient to breathe slower or breathe through pursed lips. If the patient does not respond to this, administer supplemental oxygen, if it is available, based on local protocols.",
        "Pulmonary Embolism": "A pulmonary embolism  is a blockage in the arteries of the lungs. Symptoms include a sudden onset of dyspnea (difficulty breathing; shortness of breath), chest pain that is localized and does not radiate, coughing, coughing up blood and fainting. The embolism usually has traveled from a blood clot in another part of the circulatory system (typically the legs), and then lodges somewhere in an artery in the lung. With a pulmonary embolism, there is poor oxygen and carbon dioxide gas exchange in the alveoli, as the clot prevents blood from flowing through the capillaries; this inadequate exchange results in respiratory distress. The degree of distress depends on the size of the clot. Pulmonary embolism is more common in smokers, cancer patients, fracture patients, surgery patients, patients with cardiovascular disease, and those who have been on prolonged bed rest or suffered a trauma. It is also more common in older adults. Larger clots can cause death very quickly. Therefore, rapid recognition, care and transport of the patient to a hospital is crucial.",
        "Emphysema": "Emphysema  is a chronic disease caused by damage to the air sacs in the lungs. It is also degenerative, in that it worsens over time. When the alveoli lose elasticity, they become distended (swollen and expanded) with trapped air and stop working properly. As the number of affected alveoli increases, breathing becomes increasingly difficult. The most common symptom of emphysema is shortness of breath. Exhaling is also extremely difficult. Other signs include cyanosis, barrel-shaped chest, fatigue, loss of appetite and weight loss, mild cough and breathing through pursed lips. The patient may feel restless, confused and weak.",
        "Pediatric Considerations": "Respiratory Emergencies  It is very important to recognize breathing emergencies in children and infants and to act before the heart stops beating. When adult hearts stop beating, it is frequently due to disease. Children\u2019s and infants\u2019 hearts, however, are usually healthy. When a child\u2019s or an infant\u2019s heart stops, it is usually the result of a breathing emergency. When attending to a child with respiratory problems, keep in mind that lower airway disease may be caused by birth problems or infections such as bronchiolitis, bronchospasms, pneumonia or croup. Several of the illnesses and diseases that affect the respiratory system in children are preventable through vaccines. These include diphtheria; Haemophilus influenzae  type b (Hib); measles, mumps and rubella (MMR); meningococcal; pertussis (whooping cough); pneumococcal disease; mycoplasma pneumonia (pneumonia-like illnesses); and varicella (chickenpox). Other diseases may not have respiratory symptoms but may be spread through respiratory transmission, such as mumps and rotavirus (severe diarrhea).",
        "Considerations for Older Adults": "Respiratory Emergencies  It is sometimes less obvious that older adult patients are suffering symptoms of a respiratory emergency, as they may be less sensitive to pain. You are more likely to encounter older patients who suffer from pneumonia or chronic, age-related breathing problems such as emphysema and pulmonary edema. Remember that older patients may present with different symptoms from those experienced by younger patients.",
        "Opening the Airway": "As you learned in Chapter 7, there are two common methods used to open a patient\u2019s airway: the head-tilt/chin-lift maneuver and the jaw-thrust (without head extension) maneuver. The first is generally the preferred method except  in cases where spinal injury is suspected. Both maneuvers lift the tongue from the back of the throat and allow air to move into and out of the lungs. Once the airway is open, it is important to maintain an open airway as you continue to provide care.",
        "Signs of an Open Airway": "If the airway is open and clear (patent), you will be able to see the rise and fall of the patient\u2019s chest, hear air coming out of the patient\u2019s mouth and nose, and feel air as the patient exhales. If the patient is able to speak in full sentences without distress, the airway is open and adequate. The ability to speak is a sign that air is moving past the vocal cords. The sound of the patient\u2019s voice is another indication of airway status. A patient who is speaking in normal tones has an adequate airway and is breathing effectively.",
        "Signs of an Inadequate Airway": "Patients with an inadequate airway need close attention and monitoring. They may be visibly unable to catch their breath or they may gasp for air and make grunting sounds. Some signs are subtle, but if you are not sure, play it safe and take steps to maintain an open airway at all times. Not every sign is present in every patient who has an inadequate airway. If you observe any unusual sounds with breathing, take prompt action to open the airway, as they may be signs of an airway obstruction. Stridor  is a harsh, high-pitched sound the person may make when inhaling possibly due to the larynx being swollen and blocking the upper airway. If the patient is snoring, the tongue or other tissues in the mouth may be relaxed and blocking the upper airway. A patient who is awake and alert but unable to speak, can only speak a few words or has a hoarse-sounding voice may be having severe difficulty breathing. Inadequate breathing may also be caused by swelling due to trauma, infection or an allergic reaction. If there is no air movement, the patient is experiencing apnea, which is the complete absence of breathing. In this situation, the chest will not rise and fall and you will not be able to hear or feel any air coming out of the patient\u2019s mouth and nose. The patient needs artificial ventilation, and if apnea is not corrected in a timely manner, there will be significant consequences. Sometimes there may be no detectable air movement because of an airway obstruction. In an unconscious patient, if efforts to open the airway are unsuccessful and ventilations do not make the chest begin to rise, immediately provide CPR, starting with compressions. Before attempting ventilations, check the airway for an obstruction. Look inside the mouth for liquid, food, teeth, dentures, blood, vomit or other foreign objects that may be blocking the airway, such as a small toy. If you see the obstruction, remove it and continue CPR until there is an obvious sign of life. CPR is discussed in detail in Chapter 13.",
        "Causes of Airway Obstruction": "There are two types of airway obstruction: mechanical and anatomical. Any foreign body lodged in the airway is a mechanical obstruction and an emergency situation that needs immediate attention. The most common cause of foreign body airway obstruction (FBAO) in adults is a solid object, such as food. Fluids such as saliva, blood or vomit can also block the airway. Other causes of airway obstruction include loose or broken dentures. In the case of small children under age 4, large chunks of food and small objects such as toy parts and balloons commonly cause airway obstruction. In an unconscious patient, the most common cause of airway obstruction is the tongue. This is known as an anatomical obstruction. An unconscious patient loses muscle tone, which may cause the tongue to fall back and block the airway. As the patient tries to breathe, the tongue moves further into the throat. Other conditions that can block the airway anatomically include swelling due to trauma, infection, asthma, emphysema or anaphylaxis. An obstruction may also be caused by trauma to the neck. See Chapter 11 for more information on airway obstruction.",
        "Techniques to Clear an Airway Obstruction": "More than one method exists to clear the airway in conscious patients. Protocols may vary but abdominal thrusts, back blows and chest thrusts each have been proven to effectively clear an obstructed airway in conscious patients. Frequently, a combination of more than one technique may be needed to expel an object and clear the airway. See Chapter 11 for more information on airway obstruction.",
        "Techniques to Remove Foreign Matter from the Upper Airway": "Two techniques can be used to remove visible foreign matter and fluids from the upper airway of an unconscious patient: finger sweeps and suctioning. The particular technique you choose will depend on the patient\u2019s condition and the foreign matter, and may require the use of both skills. \uf0a7 Finger sweeps. Finger sweeps involve removing an object or other foreign matter from a patient\u2019s mouth with a finger. They are only performed on an unconscious patient and only when you can see foreign matter in the patient\u2019s mouth. Always wear disposable latex-free gloves when performing a finger sweep. \uf0a7 Suctioning. The purpose of suctioning is to remove blood, fluids or food particles from the airway. Some suctioning devices cannot remove solid objects such as teeth, foreign bodies or food. See Chapter 11 for more information on how to perform a finger sweep and how to use a suctioning device.",
        "Recovery Positions": "In some cases, the person may be unresponsive but breathing normally. For patients who are unresponsive, but breathing normally with no suspected head, neck, spinal, hip or pelvic injury, move the patient into a side-lying recovery position after completing your assessment and gathering a patient history, based on local protocols. Patients with a suspected head, neck, spinal, hip or pelvic injury should not be placed in a recovery position unless you are unable to manage the airway effectively or you are alone and need to leave the patient to call for additional resources. Placing a person in a recovery position will help keep the airway open and clear. Refer to Chapter 5 for the steps for a recovery position.",
        "CRITICAL FACTS 3": "A patient who is awake and alert but unable to speak, can only speak a few words or has a hoarse-sounding voice may be having severe difficulty breathing. Inadequate breathing may also be caused by swelling due to trauma, infection or an allergic reaction. Foreign body airway obstruction (FBAO) is an emergency situation that needs immediate attention. The most common cause of an FBAO is a solid object, such as food.",
        "Determining the Presence of Breathing": "To determine whether or not the patient is breathing, look for the rise and fall of the chest, listen for the sounds of breathing, and feel for movement as air escapes from the patient\u2019s mouth and nose as you simultaneously check for a pulse. Adequate breathing requires both sufficient rate and depth.",
        "Signs of Adequate Breathing, Oxygenation and Ventilation": "Breathing is considered adequate when respiratory rate, depth and effort are normal. The following are normal rates, although some people naturally breathe at slightly slower or faster rates:\n\uf0a7\tAdults\u201412 to 20 breaths per minute\n\uf0a7\tChildren\u201415 to 30 breaths per minute\n\uf0a7\tInfants\u201425 to 50 breaths per minuteThe depth of respiration is as important as the rate. Breathing must be deep enough to bring oxygen into the lungs and from there to the bloodstream. The normal rise and fall of the patient\u2019s chest indicates adequate depth.\nA healthy adult should breathe regularly, quietly and effortlessly. No muscles in the neck or shoulders are involved, and there is not excessive use of the abdominal muscles. There are no unusual sounds, such as wheezing or whistling.",
        "Oxygenation": "Oxygenation happens naturally with ventilation , the mechanical process of moving air in and out of the lungs. A healthy person with adequate oxygenation is clear thinking and calm and has normal skin color.",
        "Signs of Inadequate Breathing": "Inadequate breathing needs careful monitoring. You may not notice all of the signs and symptoms at once, and some can be hard to spot. If you see any of them, be prepared to give assisted ventilation.",
        "Ventilation": "Any of the following signs suggests that the patient is expending too much effort to breathe and that breathing is inadequate:\n\uf0a7\tMuscles between the ribs pull in on inhalation: As the patient breathes in, you may notice the muscles pulling inward between the ribs, above the collarbone, around the muscles of the neck and below the rib cage.\n\uf0a7\tPursed lips breathing: The patient exhales through pursed lips (much like a whistling); this maneuver helps control the patient\u2019s breathing pattern.\n\uf0a7\tNasal flaring: Flaring out of the nostrils on inhalation is a sign of inadequate breathing in children and infants.\n\uf0a7\tFatigue: Apparent signs of fatigue are also an indication of the work of breathing. \uf0a7 Excessive use of abdominal muscles to breathe: This means the patient is using the abdominal muscles to force air out of the lungs. \uf0a7 Sweating: A patient who is sweating and anxious may be in severe respiratory distress. \uf0a7 Sitting upright and learning forward (tripod position): A patient who is sitting upright and leaning forward with hands on knees is struggling to breathe. \uf0a7 Deviated trachea: If you observe pendulum motions of the trachea while the patient is breathing in, this may be the result of chest trauma resulting in a lung injury. The trachea will move to the side of the uninjured lung. This is typically a very late sign of a life-threatening situation. Abnormal breath sounds are also a sign of inadequate breathing. Listen for abnormal sounds such as stridor, wheezing or crackles/rales. Wheezing or whistling sounds indicate restricted air flow and are common with conditions such as asthma, allergic reactions or emphysema. Crackles/rales have a fine cracking sound on inhalation (much like the sound of Velcro\u00ae being pulled apart) and may indicate fluid in the lungs. Inadequate depth of breathing may also indicate problems with ventilation. Shallow breathing, even if it is rapid, often means that the patient is not getting enough oxygen. Markedly increased breathing that is unusually deep is also a sign of inadequate respiration. If the person is struggling to breathe, the depth is not adequate. Rate provides additional information about the adequacy of breathing. A very slow breathing rate\u2014less than 8 breaths per minute for adults, less than 10 breaths per minute for children and less than 20 breaths per minute for infants\u2014is a sign of inadequate breathing. Breathing that is too fast is often shallow and inadequate. Unusual or irregular movement of the chest wall may indicate inadequate breathing. A chest injury needs immediate attention because it can cause rapid and severe deterioration of the person\u2019s breathing. Chest wall trauma may cause a few different problems. In paradoxical breathing, an area of the chest moves in the opposite direction to the rest of the chest, i.e., moving in while the patient is breathing in (inspiration), and out while the patient is breathing out (expiration). This is often seen when the patient has flail chest. A patient with an injury to the chest wall or ribs will often place an arm over the area to protect and \u201csplint\u201d it. (For further information on chest wall movement, see Chapter 21.) A penetrating wound to the chest can cause rapid deterioration in breathing as well. An injury to one side of the chest wall will cause unequal movement; one side will remain hyper-inflated and not move with the other side during breathing. Irregular respiratory patterns may also be a sign of inadequate breathing, particularly when associated with a slow or rapid heart rate. These signs typically occur together in children.",
        "Inadequate Oxygenation": "Problems with inadequate oxygenation may occur for a variety of reasons and can cause headaches, increased breathing rate, nausea and vomiting, altered mental status and, ultimately, death. The ambient air may be abnormal, for example in an enclosed space or at a high altitude, or there may be poisonous gas or carbon monoxide present. Breathing in poison has an almost immediate impact, destroying lung tissue and causing respiratory distress or respiratory failure. Carbon monoxide is a colorless, odorless and tasteless gas with a severe impact because the gas blocks the ability of the red blood cells to carry oxygen throughout the body. A reduction of oxygen in the body causes headaches, increased breathing rate, nausea and vomiting, altered mental status and, ultimately, death. One of the signs of inadequate oxygenation may be cyanosis, an abnormal blue or grey discoloration of the skin, mucous membranes or nail beds of the fingers and toes. Cyanosis is a serious sign that the body is not receiving enough oxygen. Pale, cool, clammy skin is an early and frequent sign of severe breathing difficulties resulting in falling oxygen levels. Mottling, another sign of inadequate oxygenation, is a blotchy pattern of skin discoloration, often caused by shock. Without enough oxygen, patients also experience an altered mental state, becoming restless, agitated, confused or anxious.",
        "Minute Volume": "A patient may appear to be breathing adequately but not be getting enough air to sustain life \ufffd One way of determining the adequacy of breathing is by measuring the minute volume \ufffd Minute volume is the amount of air breathed in per minute, and it depends on both the rate and depth of breathing \ufffd (Both rate and depth must be sufficient for breathing to be considered adequate \ufffd) Minute volume is calculated by multiplying these two factors: rate \u00d7 volume per breath = minute volume \ufffd The amount of air breathed in at each breath, the depth, is also referred to as the tidal volume \ufffd Normally, a single breath contains approximately 500 milliliters (mL) of air \ufffd Tidal volume is best assessed by watching for adequate chest movement (rise and fall), and listening and feeling for air movement from the mouth and nose during inhalation and exhalation \ufffd For example, a patient who is breathing 12 times per minute and taking in 500 mL of air per breath has a minute volume of 6000 mL (500 \u00d7 12 = 6000 mL of air per minute) \ufffd While most of that 6000 mL of air reaches the alveoli, a small amount, approximately 150 mL, remains in the area between the pharynx and the alveoli \ufffd This area is referred to as the deadspace \ufffd This amount must be taken into consideration, as it reduces the volume of each breath \ufffd In this example, 150 \u00d7 12 breaths = 1800 mL that never reaches the alveoli within a minute \ufffd For a patient who is breathing quickly, it may seem that breathing is adequate when it is not\ufffd Remember to reduce the calculated minute volume taking deadspace into consideration \ufffd",
        "CRITICAL FACTS 4": "The normal rate of breathing for adults is 12 to 20 breaths per minute. For children, it is 15 to 30 breaths per minute, and for infants, it is 25 to 50 per minute. Adequate breathing means that respiratory rate, depth and effort are normal.\nAny of the following signs suggests that breathing is inadequate: muscles between the ribs pull in on inhalation, pursed lips breathing, nasal flaring, fatigue, excessive use of abdominal muscles to breathe, sweating and deviated trachea.",
        "Artificial ventilation": "Artificial ventilation refers to the various mechanical ways that can be used to help a patient \u201cbreathe.\u201d When assisting a patient with artificial ventilations, make sure the force of air is consistent and just strong enough to cause the chest to begin to rise during each breath.",
        "Mouth-to-Mask Ventilation": "Resuscitation Mask Using a resuscitation mask allows you to breathe expired air (with or without supplemental oxygen) into a patient without making mouth-to-mouth contact. Use of the mask reduces the risk of disease transmission while providing enough oxygen (about 16 percent oxygen in your exhaled breath) to sustain life. Flexible and shaped to fit over the patient\u2019s mouth and nose, resuscitation masks: \uf0a7 Help get air quickly to the patient through both the mouth and nose. \uf0a7 Create a seal over the patient\u2019s mouth and nose. \uf0a7 Can be connected to supplemental oxygen, if equipped with an oxygen inlet. \uf0a7 Protect against disease transmission. \uf0a7 Are more effective for delivering ventilations when only one responder is present. Resuscitation masks should be easy to assemble and use, and made of a transparent, pliable material that allows you to make a tight seal over the patient\u2019s mouth and nose. They have a one-way valve for releasing exhaled air and a standard 15-mm or 22-mm coupling assembly (the size of the opening for the one-way valve). Resuscitation masks work well under different environmental conditions, such as extreme heat or cold. A limitation of the resuscitation mask is that, without use of a BVM or supplemental oxygen, it only delivers 16 percent oxygen through the responder\u2019s exhaled breath (50 percent with supplemental oxygen), which is considerably less than what is delivered using a BVM with supplemental oxygen. When serious injury or sudden illness occurs, the body does not function properly, and supplemental oxygen can help meet the increased demand for oxygen for all body tissues. If the patient requires a higher concentration of oxygen than normal and the resuscitation mask has an oxygen inlet, connect it to supplemental oxygen. Normal concentration of oxygen in the air is 21 percent. Your exhaled breath (expired air) contains about 16 percent. A resuscitation mask can deliver approximately 35 to 55 percent oxygen to a person when the oxygen is delivered at 6 to 15 liters per minute (LPM). For more information on administration of oxygen, see Chapter 12. For step-by-step instructions on giving ventilations to adults, children and infants, see Skill Sheets 10-1 and 10-2.",
        "Mouth-to-Mouth Ventilation": "As an emergency medical responder (EMR), you should follow standard precautions whenever providing ventilations\ufffd However, there may be circumstances when you do not have immediate access to a resuscitation mask or BVM\ufffd The risk of contracting a disease from mouth-to-mouth ventilations is low \ufffd Although protocols may vary, you may decide to give mouth-to-mouth ventilations without a barrier \ufffd To provide ventilations to a patient without a mask: 1\ufffd Use the head-tilt/chin-lift maneuver to open the airway, provided you do not suspect an injury to the head, neck or spine\ufffd 2\ufffd Gently pinch the patient\u2019s nose shut with the thumb and index finger of your hand that is on the patient\u2019s forehead \ufffd 3\ufffd Make a tight seal around the patient\u2019s mouth with your mouth \ufffd For an infant, seal your mouth over the mouth and nose, instead of pinching the nose shut \ufffd 4\ufffd Blow into the patient\u2019s mouth until you see the chest begin to rise \ufffd Each breath should last about 1 second, with a brief pause between breaths to let the air flow back out \ufffd Watch that the patient\u2019s chest rises each time you blow in, to ensure that your breaths are effective \ufffd",
        "ARTIFICIAL VENTILATION - Pediatric Considerations": "Infant and child resuscitation masks are available and should be used to care for infants and children (Fig. 10-7). Adult resuscitation masks should not be used in an emergency situation unless a pediatric resuscitation mask is not available and medical control advises you to do so. Always use the appropriate equipment matched to the size of the patient.",
        "ARTIFICIAL VENTILATION - Special Considerations": "Air in the Stomach When providing ventilations, blow slowly, with just enough air to make the patient\u2019s chest begin to rise. If you blow too much air into the patient (overventilation ), it may enter the stomach, causing gastric distention. The patient will then likely vomit, which can obstruct the airway and complicate resuscitation efforts. Vomiting When you provide ventilations, the patient may vomit. If this occurs, quickly turn the patient onto the side to keep the vomit from blocking the airway and entering the lungs. Support the head and neck and turn the body as a unit toward you. After vomiting stops, clear the patient\u2019s airway by wiping the patient\u2019s mouth out using a finger sweep and suction if necessary, turn the patient onto the back and continue with ventilations.",
        "Mask-to-Nose Breathing": "If the patient\u2019s mouth is injured, you may need to provide ventilations through the nose. To perform mask-to-nose breathing using a resuscitation mask:\n\uf0a7 Open the airway using the head-tilt/chin-lift maneuver.\n\uf0a7 Place the resuscitation mask over the patient\u2019s mouth and nose.\n\uf0a7 Use both hands to keep the patient\u2019s mouth closed.\n\uf0a7 Seal the resuscitation mask with both hands.\n\uf0a7 Provide ventilations.",
        "Mask-to-Stoma Breathing": "On rare occasions, you may see an opening in a patient\u2019s neck as you tilt the head back to check for breathing. If the patient has a stoma and needs artificial ventilation, follow the same steps for mouth-to-mask breathing, except:\n\uf0a7 Look, listen and feel for breathing with your ear over the stoma.\n\uf0a7 Maintain the airway in a neutral position. (This ensures the patient\u2019s airway is neither flexed nor extended, as the stoma provides access to the lower airway.)\n\uf0a7 Use a pediatric resuscitation mask over the patient\u2019s stoma.\n\uf0a7 If possible, pinch the nose and close the mouth, as some patients with a stoma may still have a passage for air that reaches the mouth and nose in addition to the stoma.\n\uf0a7 Provide ventilations.",
        "ARTIFICIAL VENTILATION - Patients with Dentures": "Leave dentures in place unless they become loose and block the airway. Dentures help support the patient\u2019s mouth and cheeks, making it easier to seal the resuscitation mask during ventilation.",
        "ARTIFICIAL VENTILATION - Patients with Suspected Head, Neck or Spinal injuries": "If you suspect a patient has sustained an injury to the head, neck or spine, there are special considerations you must keep in mind. You may not always know if a patient has sustained this kind of injury and may have to rely on bystander information or mechanism of injury (MOI). Suspect an injury to the head, neck or spine if the patient:\n\uf0a7 Was involved in a motor-vehicle, motorcycle or bicycle crash as an occupant, rider or pedestrian.\n\uf0a7 Was injured as a result of a fall from greater than standing height.\n\uf0a7 Complains of neck or back pain, tingling in the extremities or weakness.\n\uf0a7 Is not fully alert.\n\uf0a7 Appears to be intoxicated.\n\uf0a7 Appears frail or over 65 years of age.\n\uf0a7 Has an obvious head or neck injury.\nCheck for the following signs and symptoms of a possible head, neck or spinal injury before you attempt to provide care:\n\uf0a7 Changes in the level of consciousness (LOC)\n\uf0a7 Severe pain or pressure in the head, neck or back\n\uf0a7 Loss of balance \n\uf0a7Partial or complete loss of movement of any body part \uf0a7 Tingling or loss of sensation in the hands, fingers, feet or toes \uf0a7 Persistent headache \uf0a7 Unusual bumps, bruises or depressions on the head, neck or back \uf0a7 Seizures \uf0a7 Blood or other fluids in the ears or nose \uf0a7 External bleeding of the head, neck or back \uf0a7 Impaired breathing or vision as a result of injury \uf0a7 Nausea or vomiting \uf0a7 Bruising of the head, especially around the eyes and behind the ears If you suspect an unconscious patient may have an injury to the head, neck or spine, remember to first take care of severe, life-threatening bleeding, the airway and breathing. Try to open the airway using the jaw-thrust (without head extension) maneuver first (see Skill Sheet 10-3). If the jaw-thrust (without head extension) maneuver does not open the airway, use the head-tilt/chin-lift maneuver.",
        "ARTIFICIAL VENTILATION - Bag-Valve-Mask Resuscitator": "A bag-valve-mask (BVM) resuscitator is a handheld device used to ventilate patients and administer higher concentrations of oxygen than a pocket mask. BVMs are used by either one responder responsible for managing the airway and delivering ventilations or two responders in a multiple-responder situation. A BVM has three parts: a bag, a valve and a mask. By placing the mask on the patient\u2019s face and squeezing the bag, you open the one-way valve, forcing air into the patient\u2019s lungs. When you release the bag, the valve closes and air from the surrounding environment refills the bag. BVMs have several advantages. They: \uf0a7 Increase oxygen levels in the blood by using the air in the surrounding environment instead of the air exhaled by the responder. \uf0a7 Can be connected to supplemental oxygen. \uf0a7 Are more effective for delivering ventilations than using a resuscitation mask, when used correctly. \uf0a7 Protect against disease transmission and inhalation hazards if the patient has been exposed to a hazardous gas. \uf0a7 May be utilized with advanced airway adjuncts. To use a BVM with one responder: 1. Assemble the BVM as needed. 2. Open the airway past a neutral position (for an adult) while positioned at the top of the patient\u2019s head (cephalic position). 3. Use an E-C hand position: \u25cfPlace one hand around the mask, forming an E with the last three fingers and a C with the thumb and index finger around the mask. \u25cfSeal the mask completely around the patient\u2019s mouth and nose by lifting the jaw into the mask while maintaining an open airway. 4. Provide ventilations: With the other hand, depress the bag about halfway to deliver between 400 to 700 milliliters of volume to make the chest begin to rise. Give smooth and effortless ventilations that last about 1 second. While a BVM is often used by a single responder (see Skill Sheet 10-4), evidence shows that two responders are needed to most effectively operate a BVM. One responder opens and maintains the airway and ensures the BVM mask seal, while the second responder delivers ventilations by squeezing the bag slowly with both hands at the correct intervals to the point of creating chest rise (see Skill Sheet 10-5).  To use a BVM with two responders: 1. Assemble the BVM as needed. 2. Open the airway past a neutral position (for an adult) while positioned at the top of the patient\u2019s head (cephalic position). 3. Use an E-C hand position (first responder): Place both hands around the mask, forming an E with the last three fingers on each hand and a C with the thumb and index finger around both sides of the mask. Seal the mask completely around the patient\u2019s mouth and nose by lifting the jaw into the mask while maintaining an open airway. 4. Provide ventilations (second responder): Depress the bag about halfway to deliver between 400 to 700 milliliters of volume to make the chest begin to rise. Give smooth and effortless ventilations that last about 1 second.",
        "ARTIFICIAL VENTILATION - Providing Controlled Ventilation": "Knowing the recommended ventilation rates for use with a BVM will ensure that you provide patients with adequate oxygen without causing harm. For example, too many breaths (hyperventilation) or too much volume of air (overventilation) can result in air going into the stomach, which can cause vomiting. Ventilation rates vary with the age of the patient. Adequate ventilation rates are: 30\u201360 ventilations per minute at about 1 second each for a newborn (0 to 1 month). 20 ventilations per minute at 1 second each for a child or an infant. 10\u201312 ventilations per minute at 1 second each for an adult. You can determine whether ventilation is adequate by watching the chest rise and fall. Ventilating a patient at rates that are too fast or with too much volume can be dangerous.",
        "ARTIFICIAL VENTILATION - Pediatric BVMs": "Infant and child BVMs are available and should be used for infants and children. Using an adult BVM on an infant has the potential to cause harm and should not be used unless a pediatric BVM is not available and medical control advises you to do so. Always use the appropriate equipment matched to the size of the patient.",
        "ARTIFICIAL VENTILATION - Overventilation and Hyperventilation": "In any resuscitation situation, it is essential not to overventilate or hyperventilate the patient. With each ventilation provided, intrathoracic pressure (i.e., pressure in the chest cavity) increases, causing the blood vessels returning to the heart to be compressed. This decreases the amount of blood filling the heart and the coronary blood flow. Overventilation and hyperventilation further increase the intrathoracic pressure, which in turn further decreases the amount of blood filling the heart and the coronary blood flow. The reduction of blood flowing back into the heart significantly limits effective circulation to the brain and other vital organs. Overventilation and hyperventilation should be avoided to improve patient outcomes. Responders should hyperventilate a patient only if directed by a specific protocol.",
        "Science Note": "Hyperventilation most commonly occurs when patients are being ventilated when they are in respiratory arrest or when an advanced airway is placed during cardiac arrest. It is critical to avoid hyperventilation of the patient because it leads to increased intrathoracic pressure and a subsequent decrease in coronary filling and coronary perfusion pressures by putting pressure on the vena cava.",
        "Assisted Ventilation During Respiratory Distress": "Assisted ventilation improves both oxygenation and ventilation. A patient in respiratory distress cannot breathe easily. Without adequate breathing, not enough oxygen reaches the cells, resulting in hypoxia. The patient becomes agitated and aggressive. Assisted ventilation is given when the patient shows signs and symptoms of inadequate breathing, including:\n\uf0a7\tBreathing and heart rates that are too fast or too slow.\n\uf0a7\tCyanosis.\n\uf0a7\tInadequate chest wall motion.\n\uf0a7\tChanges in consciousness.\n\uf0a7\tRestlessness.\n\uf0a7\tChest pain. \n Procedure: When providing assisted ventilation to a patient during respiratory distress:\n\uf0a7\tExplain the procedure if the patient is conscious. A patient who is not breathing properly can become anxious or panic. Calming the patient may make them more receptive to your assistance.\n\uf0a7\tPlace the mask over the patient\u2019s mouth and nose.\n\uf0a7\tInitially assist at the rate at which the patient has been breathing. Squeeze the bag each time the patient begins or tries to inhale.\n\uf0a7\tAdjust the rate as the patient\u2019s breathing begins to return to normal.\nIf breathing is slower than usual, provide extra ventilations in between the patient\u2019s own breaths. If breathing is rapid and shallow, provide ventilations when the patient inhales. If the patient has adequate breathing, administer oxygen at 15 LPM based on local protocols. Keep checking for signs of inadequate breathing. \n Limitations: Patients who are hypoxic may become combative. A patient with this kind of altered mental status may deteriorate quickly and become unable to breathe adequately. Maintain the airway and monitor the patient closely. Make sure the mask fits tightly around the patient\u2019s mouth and nose. If there is not a good seal, an insufficient volume of air will be delivered to the patient.",
        "Ventilation of an Apneic Patient with a Pulse": "Absence of breathing (apnea) is a life-threatening condition that requires urgent care. Begin artificial ventilation at once using a resuscitation mask or BVM. Ventilation is provided for an apneic (nonbreathing) patient if the chest wall is not moving and there is no air moving in and out of the mouth and nose, or if occasional gasping breathing is noted. Continue to monitor the patient\u2019s condition. Ensure you have the proper size equipment for the apneic patient when providing artificial ventilation.",
        "Normal Ventilation Versus Positive Pressure Ventilation": "There are several differences between normal ventilation and positive pressure ventilation \ufffd First, in normal ventilation, the movement of the diaphragm dropping creates negative pressure inside the chest, which causes air to be sucked into the lungs \ufffd During positive pressure ventilation using a resuscitation mask or BVM, the movement of air is created by the responder pushing the air artificially into the lungs \ufffd A second difference is in how the blood moves within the body during normal versus positive pressure ventilation \ufffd In normal ventilation, the blood returns to the heart from the body and is pulled back to the heart as a part of breathing \ufffd During positive pressure ventilation, there is a decreased volume of blood returning to the heart when the lungs are inflated \ufffd Also, the amount of blood pumped out of the heart is reduced \ufffd Esophageal opening pressure is also different in the two kinds of ventilation \ufffd During normal ventilation, the esophagus remains closed, and no air enters the stomach \ufffd During positive pressure ventilation, air is pushed into the stomach during ventilation \ufffd If there is excess air in the stomach, this may lead to vomiting and aspiration \ufffd Finally, positive pressure ventilation has the added risk of harming the patient due to excess rate or depth of ventilation \ufffd Ventilating the patient too quickly or too deeply may cause low blood pressure, vomiting or a decrease in blood flow when the chest is compressed during CPR \ufffd",
        "CRITICAL FACTS 5": "Suspect an injury to the head, neck or spine if the patient was involved in a motor-vehicle, motorcycle or bicycle crash as an occupant, rider or pedestrian; was injured as a result of a fall from greater than standing height; complains of neck or back pain, tingling in the extremities or weakness; is not fully alert; appears to be intoxicated; appears frail or over 65 years of age; or has an obvious head or neck injury.",
        "CRITICAL FACTS 6": "BVMs can hold more than 1000 milliliters of volume and should never be completely deflated when providing ventilations. Doing so could lead to overventilation and hyperventilation. Also, pay close attention to any increasing difficulty when providing BVM ventilation. This difficulty may indicate an increase in intrathoracic pressure, inadequate airway opening or other complications. Be sure to share this information with the team for corrective actions.",
        "CRITICAL FACTS 7": "Assisted ventilation is given when the patient shows signs and symptoms of inadequate breathing, including breathing and heart rates that are too fast or too slow, cyanosis, inadequate chest wall motion, changes in consciousness, restlessness and chest pain.",
        "PUTTING IT ALL TOGETHER": "Ensuring that a patient\u2019s airway is open and clear is an important step in providing care. A patient whose airway is blocked for any reason may die unless immediate steps are taken to open the airway. Once the patient\u2019s airway is clear, you can begin to assess breathing. Inadequate breathing causes problems with inadequate ventilation and oxygenation. Breathing abnormalities can be assessed by observing physical signs and breath sounds, and by measuring the rate and depth of breathing. A breathing emergency can become life threatening and should be detected during the primary assessment. Knowing the signs and symptoms of respiratory distress and respiratory arrest will help you determine the appropriate care for each condition. For a patient with a pulse who is not breathing, provide artificial ventilation by using a resuscitation mask or BVM. Under specific circumstances, artificial ventilation can be provided mask-to-nose or mask-to-stoma. When using a resuscitation mask, be careful not to breathe too much air into the patient, as this may cause air to enter the stomach and cause vomiting. Also, special considerations must be made for children, patients with dentures and patients suspected of having a head, neck or spinal injury.",
        "Giving Ventilations": "Adult and Child Always follow standard precautions when providing care. Size up the scene for safety and then perform a primary assessment. Always select the properly sized mask for the patient. If there is a pulse but no breathing. STEP 1: Assemble the resuscitation mask as necessary, and position the mask. STEP 2: Seal the mask. STEP 3: Open the airway by tilting the head back and lifting the chin. STEP 4: Blow into the mask.\n \u25a0For an adult, give 1 ventilation about every 5\u20136 seconds.\n \u25a0For a child, give 1 ventilation about every 3 seconds.\n \u25a0Each ventilation should last about 1 second and make\nthe chest begin to rise. The chest should fall before the\nnext ventilation is given.\nNOTE: For a child, tilt the head slightly past a neutral position.\nDo not tilt the head as far back as for an adult. For a patient with\na suspected head, neck or spinal injury, use the jaw-thrust (without\nhead extension) maneuver to open the airway to give ventilations. STEP 5: Recheck for breathing and a pulse about every 2 minutes:\n \u25a0Remove the mask and simultaneously check for breathing and a pulse for at least\n5 seconds, but no more than 10 seconds.\nIf the chest does not begin to rise:\n \u25a0Retilt the head, and then give another ventilation.\n \u25a0Provide care based on the conditions found.",
        "Giving Ventilations\u2014Infant": "NOTE Always follow standard precautions when providing care. Size up the scene for safety and then perform a primary assessment. Always select the properly sized mask for the patient. If there is a pulse but no breathing: STEP 1 Assemble the resuscitation mask as necessary, and position the resuscitation mask. STEP 2 Seal the mask. STEP 3 Open the airway by tilting the head to a neutral position and lifting the chin. STEP 4 Blow into the mask.\n \u25a0Give 1 ventilation about every 3 seconds.\n \u25a0Each ventilation should last about 1 second and make the chest begin to rise. The chest should fall before the next ventilation is given. STEP 5 Recheck for breathing and a pulse about every 2 minutes:\n \u25a0Remove the mask and simultaneously check for breathing and a pulse for at least 5 seconds, but no more than 10 seconds.\nIf the chest does not begin to rise:\n \u25a0Retilt the head, and then give another ventilation.\n \u25a0Provide care based on the conditions found.",
        "Giving Ventilations\u2014Head, Neck or Spinal Injury Suspected": "Jaw-Thrust (Without Head Extension) Maneuver\u2014Adult and Child NOTE Always follow standard precautions when providing care. Size up the scene for safety and then perform a primary assessment. Always select the properly sized mask for the patient. If there is a pulse, but no breathing and a head, neck or spinal injury is suspected. STEP 1 Assemble the resuscitation mask. STEP 2 Position the mask Position the mask instructions Kneel above the patient\u2019s head. Place the mask over their mouth and nose, starting from the bridge of the nose. Place the bottom of the mask below the mouth but not past the chin. STEP 3 Seal the maskk Seal the mask instructions Slide the fingers into position under the angles of the patient\u2019s jawbone without moving the head or neck. STEP 4 Open the airway.\n \u25a0Thrust the jaw upward without moving the head or neck to lift the jaw and open the airway. STEP 5 Blow into the mask.\n \u25a0For an adult, give 1 ventilation about every 5\u20136 seconds\n \u25a0For a child, give 1 ventilation about every 3 seconds.\n \u25a0Each ventilation should last about 1 second and make the chest begin to rise. The chest should fall before the next ventilation is given. STEP 6 Reassess for breathing and a pulse about every 2 minutes:\n \u25a0Remove the mask and simultaneously check for breathing and a pulse for at least 5 seconds, but no more than 10 seconds .",
        "Giving Ventilations Using a Bag-Valve-Mask Resuscitator\u2014One Responder": "NOTE: Always follow standard precautions when providing care. Size up the scene for safety and then perform a primary assessment. Always select the properly sized mask for the patient. Assemble the BVM if necessary. STEP 1 Assemble the BVM as needed. STEP 2 Open the airway past a neutral position (for an adult) while positioned at the top of the patient\u2019s head (cephalic position). STEP 3 Use an E-C hand position: \u25a0Place one hand around the mask, forming an E with the last three fingers and a C with the thumb and index finger around the mask. \u25a0Seal the mask completely around the patient\u2019s mouth and nose by lifting the jaw into the mask while maintaining an open airway. STEP 4 Provide ventilations: \u25a0With the other hand, depress the bag about halfway to deliver between 400 to 700 milliliters of volume to make the chest begin to rise. \u25a0Give smooth and effortless ventilations that last about 1 second. NOTE: For a child, tilt the head slightly past a neutral position. Do not tilt the head as far back as for an adult. For an infant, position the head in a neutral position.",
        "Giving Ventilations Using a Bag-Valve-Mask Resuscitator\u2014Two Responders": "NOTE: Always follow standard precautions when providing care. Size up the scene for safety and then perform a primary assessment. Always select the properly sized mask for the patient. Assemble the BVM if necessary. STEP 1 Assemble the BVM as needed. STEP 2 Open the airway past a neutral position (for an adult) while positioned at the top of the patient\u2019s head (cephalic position). STEP 3 Use an E-C hand position (first responder): \u25a0Place both hands around the mask, forming an E with the last three fingers on each hand and a C with the thumb and index finger around both sides of the mask. \u25a0Seal the mask completely around the patient\u2019s mouth and nose by lifting the jaw into the mask while maintaining an open airway. STEP 4 Provide ventilations (second responder): \u25a0Depress the bag about halfway to deliver between 400 to 700 milliliters of volume to make the chest begin to rise. \u25a0Give smooth and effortless ventilations that last about 1 second. NOTE For a child, tilt the head slightly past a neutral position. Do not tilt the head as far back as for an adult. For an infant, position head in a neutral position.",
        "Assessing Breath Sounds": "Unobstructed airways are easy to identify with a stethoscope. You should hear air moving on inspiration (breathing in) and expiration (breathing out). If there are decreased lung sounds in a particular area of the lungs, you will hear no sound or a reduced sound compared with the other areas in the lungs. To listen to the lungs in the front, you must identify the midclavicular lines and move down the chest. Place your stethoscope at the second intercostal space, usually just above the sternum line. Do this on both the left and right sides to compare sounds. To listen on the side, identify the midaxillary lines and place your stethoscope between the fourth and fifth intercostal space, approximately in line with the nipple. Again, do this on both sides to be able to compare sounds. Finally, listen in the back by identifying the midscapular lines and moving down the back. Do this again on both sides. When the airway becomes obstructed due to accumulation of fluid in the lungs or a blockage in the airway, you may hear other sounds, such as: \uf0a7 Wheezing\u2014a high-pitched whistling sound heard during inspiration but heard most loudly on expiration. Wheezing can often be heard without a stethoscope. \uf0a7 Rales\u2014a popping, clicking, bubbling or rattling sound. \uf0a7 Rhonchi \u2014described as a snoring or coarse, dry rale sound. \uf0a7 Stridor\u2014a wheeze-like sound heard on inhalation and exhalation.",
        "Assisting the Patient with Asthma": "As an EMR, you may find yourself in the position of needing to assist a patient with asthma in using an inhaler (see Skill Sheet 10-6). Having a basic knowledge of inhalers is of benefit to an EMR and to the patient with asthma to whom you may provide care.",
        "Asthma Medication: Types, Indications and Contraindications": "There are three types of medications used in the management of asthma, each with a different purpose:\n\uf0a7 Long-term-control medications are used regularly to control chronic symptoms and prevent attacks.\n\uf0a7 Quick-relief medications, also called rescue medications, are used as needed for relief of symptoms during an asthma attack.\n\uf0a7 Medications for allergy-induced asthma are used to decrease sensitivity to a particular allergen and prevent the immune system from reacting to allergens.\nIndications for asthma medication include recurrent wheezing, coughing, trouble breathing and chest tightness. Contraindications include increased risk of skin thinning and bruising. Asthma medication may also affect children\u2019s growth.",
        "Metered-Dose Inhaler": "A metered-dose inhaler is a small, handheld aerosol canister with a mouthpiece. It is designed to allow patients to inhale a specific amount of asthma medication into the lungs in one puff. A spacer, a tube attached to an inhaler that serves as a reservoir for the medication, may be present.",
        "Dry Powder Inhaler": "A dry powder inhaler (DPI) is similar to a metered-dose inhaler. A DPI is a handheld device that delivers a dry powder form of the medication inside a small capsule, disc or compartment inside the inhaler. Some dry powders may have no taste, while others are mixed with lactose to give them a sweet taste. The DPI is administered by breathing in quickly to activate the inhaler, so there is no depressing of the inhaler.",
        "Small-Volume Nebulizer": "A small-volume nebulizer is designed to administer aerosolized medication (mist) over a few minutes, ensuring the efficacy of drug delivery during treatment will not be jeopardized, even if the patient takes a single ineffective breath. Nebulizers are common for children under the age of 5, those who have difficulty using inhalers and those with severe asthma.",
        "Other Delivery Systems for Asthma Medication": "Asthma medication can also be taken in pill or liquid form. Most recently, asthma medication can be given through an injection just under the skin.",
        "Peak Flowmeter": "A peak flowmeter is a handheld asthma management tool that tracks a person\u2019s breathing. It assists in warning the person if their asthma is worsening, and helps show how they are responding to treatment. A peak flowmeter measures the person\u2019s ability to push air out of the lungs in one quick breath.",
        "Assisting a Patient in the Use of an Inhaler": "When assisting a patient in the use of an asthma inhaler, always obtain consent then follow these general guidelines, if local protocols allow: 1. If the patient has prescribed asthma medication, help the person take it first. 2. Shake the inhaler and then remove the cover from the mouthpiece. Position the spacer if you are using one. 3. Have the patient breathe out fully through the mouth and then place the lips tightly around the inhaler mouthpiece. 4. The patient should inhale deeply and slowly as you or the patient depresses the inhaler canister to release the medication, which is then inhaled into the lungs. 5. The patient should hold the breath for a count of 10. If using a spacer, the patient takes 5 to 6 deep breaths with the spacer still in the mouth, without holding the breath. 6. Reassess the patient\u2019s breathing. 7. Always wash your hands immediately after providing care.",
        "Side Effects": "Common side effects of asthma medication include: \uf0a7 Increased heart rate. \uf0a7 Palpitations. \uf0a7 Nausea. \uf0a7 Vomiting. \uf0a7 Nervousness. \uf0a7 Headache. \uf0a7 Sleeplessness. \uf0a7 Dry mouth. \uf0a7 Cough. \uf0a7 Hoarseness. \uf0a7 Headache. \uf0a7 Throat irritation.",
        "Dose and Route": "The effectiveness of treatment for asthma can vary based on the dose given to the patient, as well as the route by which it is administered. In severe cases, this is tracked by the patient\u2019s healthcare provider in order to find which is the most effective.",
        "Medical Control Role": "Any time you assist a patient with an inhaler, you need to obtain an order from medical direction. The order can be obtained through radio or phone contact with the medical director or through protocols and standing orders. Always verify the order by restating the name of the medication. This helps reduce the chance of improper medication or inappropriate dose or route. Know and follow local protocols for administration of inhalers.",
        "Assisting with an Asthma Inhaler": "REMEMBER: Always obtain consent and wash your hands immediately after providing care. Read and follow all instructions printed on the inhaler prior to administering the medication to the patient. Always follow standard precautions when providing care. If the person has medication for asthma, help them take it: STEP 1 Help the patient sit up and rest in a position comfortable for breathing. STEP 2 Ensure that the prescription is in the patient\u2019s name and is prescribed for \u201cquick relief\u201d or \u201cacute\u201d attacks. Ensure that the expiration date of the medication has not passed. STEP 3 Shake the inhaler. STEP 4 Remove the cover from the inhaler mouthpiece. If an extension tube (spacer) is available, attach and use it. STEP 5 Tell the patient to breathe out as much as possible through the mouth. STEP 6 Have the patient place their lips tightly around the mouthpiece and take a long, slow breath.\n \u25a0As the patient breathes in slowly, administer the medication by quickly pressing down on the inhaler canister, or the patient may self-administer the medication.\n \u25a0The patient should continue a full, deep breath.\n \u25a0Tell the patient to try to hold their breath for a count of 10.\n \u25a0When using an extension tube (spacer), have the patient take 5 to 6 deep breaths through the tube without holding their breath.\nNOTE: The patient may use different techniques, such as holding the inhaler two-finger lengths away from the mouth. STEP 7 Note the time of administration and any change in the patient\u2019s condition.\n \u25a0The medication may be repeated once after 1 to 2 minutes.\nNOTE: The medication may be repeated every 5 to 10 minutes thereafter, as needed, for emergency calls in areas with long EMS response times such as rural locations. STEP 8 Call for more advanced medical care if difficulty breathing does not improve quickly. NOTE These medications might take 5 to 15 minutes to reach full effectiveness."
    },
    {
        "INTRODUCTION": "When someone has a breathing or cardiac emergency, supplying supplemental oxygen can be critical. During such an emergency, the amount of oxygen carried by the blood cells to the brain, heart and body is reduced, resulting in hypoxia. If breathing stops (respiratory arrest), the brain and heart will soon be starved of oxygen, resulting in cardiac arrest and ultimately death if not managed quickly and appropriately. The air you normally breathe contains about 21 percent oxygen. When you provide ventilations using a bag-valve-mask (BVM) resuscitator, you deliver that 21 percent oxygen to the patient. The expired air in your exhaled breath, however, contains about 16 percent oxygen, and this is the concentration delivered when using a resuscitation mask. Neither of these percentages of oxygen alone may be adequate for the patient. By administering supplemental oxygen, you can deliver a higher percentage of oxygen that an injured or ill person may need. Supplemental oxygen can be given for many breathing and cardiac emergencies. It can be given to nonbreathing patients, sometimes in conjunction with an airway adjunct. If a patient is breathing but has no obvious signs or symptoms of injury or illness, oxygen may be considered for:\n\uf0a7\tAn adult breathing fewer than 12 breaths or more than 20 breaths per minute.\n\uf0a7\tA child breathing fewer than 15 breaths or more than 30 breaths per minute.\n\uf0a7\tAn infant breathing fewer than 25 breaths or more than 50 breaths per minute.\nAdminister oxygen based on local protocols to all patients with respiratory distress or respiratory failure with low oxygen saturation or signs and symptoms of hypoxia, as these conditions are usually caused by abnormal oxygen levels to the tissues. Always administer oxygen for suspected CO poisoning and all smoke-inhalation cases.\nOxygen should be delivered with properly sized equipment for the patient and appropriate flow rates for the delivery device. For step-by-step instructions on oxygen delivery, see Skill Sheet 12-1.",
        "KEY TERMS": "Flowmeter: A device used to regulate, in liters per minute (LPM), the amount of oxygen administered to a patient., Hypoxia: A condition in which insufficient oxygen reaches the body\u2019s cells., Nasal cannula: A device used to administer oxygen through the nostrils to a breathing person., Non-rebreather mask: A type of oxygen mask used to administer high concentrations of oxygen to a breathing person., \u201cO-ring\u201d gasket: Plastic, O-shaped ring that makes the seal of the pressure regulator on an oxygen cylinder tight; can be a built-in or an attachable piece., Oxygen cylinder: A steel or alloy cylinder that contains 100 percent oxygen under high pressure., Pressure regulator: A device on an oxygen cylinder that reduces the delivery pressure of the oxygen to a safe level. Supplemental oxygen: Oxygen delivered to a patient from an oxygen cylinder through a delivery device; can be given to a nonbreathing or breathing patient who is not receiving adequate oxygen from the environment.",
        "ADMINISTERING SUPPLEMENTAL OXYGEN": "To deliver supplemental oxygen, you must have:\n\uf0a7\tAn oxygen cylinder.\n\uf0a7\tA pressure regulator with flowmeter.\n\uf0a7\tA delivery device.\nAccording to the U.S. Food and Drug Administration (FDA), oxygen units may be marketed without a prescription when used for emergency resuscitation and when administered by an individual who is authorized, certified or licensed by state authorities. Such units must deliver a minimum flow rate of 6 liters of oxygen per minute for a minimum of 15 minutes (90 liters). Labeling for emergency oxygen for OTC use may not contain references to any medical conditions, disorders or diseases. The filling and refilling of empty or spent oxygen cylinders is strictly controlled by state and local regulations. Local protocols must always be followed.",
        "Variable-Flow-Rate Oxygen": "Variable-flow-rate oxygen systems allow the responder to vary the flow of oxygen. Because of the large amount of oxygen emergency medical services (EMS) systems deliver and the variety of equipment and emergency situations they respond to, variable-flow-rate oxygen is practical. To deliver supplemental oxygen using a variable-flow-rate system, you must assemble the equipment.",
        "Fixed-Flow-Rate Oxygen": "Some supplemental oxygen systems have the regulator set at a fixed-flow rate. Most fixed-flow-rate tanks are set at 15 LPM; however, an emergency medical responder (EMR) may come across tanks set at 6 LPM, 12 LPM or another rate. In some cases, the fixed-flow-rate systems may have a dual (high/low) flow setting. Fixed-flow-rate oxygen systems typically come with the delivery device, regulator and cylinder already connected to each other. This eliminates the need to assemble the equipment, which makes it quick and very simple to deliver oxygen. A drawback to using fixed-flow-rate oxygen systems is that you cannot adjust the flow rate to different levels. This limits both the type of delivery device you can use and the concentration of oxygen you can deliver. For example, a fixed-flow-rate unit with a preset flow of 6 LPM can only be used with a nasal cannula or resuscitation mask, while a preset flow rate of 12 LPM only allows the use of a resuscitation mask or non-rebreather mask.",
        "CRITICAL FACTS": "Oxygen cylinders have U.S.P. and yellow diamond labels that make them easy to recognize. In the United States, oxygen cylinders typically have green markings.Because of the simplicity of the preconnected fixed-flow-rate systems and the lifesaving benefits of oxygen, these systems are becoming increasingly popular in the workplace, schools and other places where EMRs may have to respond to on-site emergencies.",
        "Oxygen Cylinders": "Oxygen cylinders are made to be easily recognizable. These cylinders, made of steel or alloy, can hold between 350 and 625 liters of oxygen, and have internal pressures of approximately 2000 pounds per square inch (psi). Oxygen cylinders are labeled \u201cU.S.P.\u201d and are marked with a yellow diamond that says \u201cOxygen\u201d. The U.S.P. stands for United States Pharmacopeia, which indicates the oxygen is medical grade. In the United States, oxygen cylinders typically have green markings, such as a green top; however, the color scheme is not regulated. Different manufacturers and other countries may use different color markings. Oxygen cylinders are under high pressure and must be handled carefully; do not drop. Ensure oxygen cylinders have proper hydrostatic testing and are marked appropriately.",
        "Pressure Regulator and Flowmeter": "The pressure inside an oxygen cylinder is far too great to allow you to open the cylinder and administer the oxygen. Therefore, a device called a pressure regulator is attached to the cylinder to reduce the delivery pressure of the oxygen to a safe level. The pressure regulator reduces the pressure from approximately 2000 psi inside the cylinder to a safe pressure range of 30 to 70 psi. The amount of pressure inside the cylinder is indicated on a gauge. By checking the gauge, you can determine how full a cylinder is. A full cylinder will show 2000 psi, while a nearly empty cylinder will show about 200 psi. Always monitor the pressure in the oxygen cylinder to make sure it is above 200 psi. When the cylinder reaches 200 psi, replace the oxygen cylinder with a new tank. A pressure regulator typically has two metal prongs that fit into the valve at the top of the oxygen cylinder. This is called the pin index safety system. It is standard on any type of tank that has these pins; a different pin placement depending on the type of tank prevents unintentional use. To ensure a tight seal between the regulator and the tank, a gasket, commonly called an 'O-ring' gasket, must be used. Never lubricate any part of an oxygen system. A flowmeter controls the amount of oxygen administered in LPM, with a normal delivery rate from 1\u201325 LPM.",
        "Oxygen Delivery Devices": "An oxygen delivery device is the piece of equipment a patient breathes through when receiving oxygen. Tubing carries the oxygen from the regulator to the delivery device. When delivering oxygen, make sure the tubing does not get tangled or kinked so as to stop the flow of oxygen to the mask. These devices can include nasal cannulas, simple face masks, non-rebreather masks, BVMs and resuscitation masks. Various sizes of these devices are available for adults, children and infants. Appropriate sizing is important to ensure adequate airway management.",
        "Nasal Cannula": "The nasal cannula is used only on breathing patients and delivers oxygen through the patient\u2019s nostrils. A plastic tube is held in place over the patient\u2019s ears, and oxygen is delivered through two small prongs inserted into the nostrils. Nasal cannula use is limited, as it normally delivers oxygen at a flow rate of 1\u20136 LPM, which provides a peak oxygen concentration of approximately 44 percent. Flow rates above 4 LPM are not commonly used because of the tendency to quickly dry out mucous membranes and cause nosebleeds and headaches. Because of these limitations, the nasal cannula is commonly used for patients with only minor breathing difficulty or for those who have a history of respiratory medical conditions. Patients experiencing a serious breathing emergency generally breathe through the mouth and need a device that can supply a greater concentration of oxygen. The nasal cannula can be ineffective for patients who have a nasal airway obstruction, nasal injury or a bad cold causing blocked sinus passages. It is useful for patients who cannot tolerate a mask over their face.",
        "Resuscitation Mask with Oxygen Inlet": "The resuscitation mask with an oxygen inlet can be used with supplemental oxygen to deliver oxygen to a nonbreathing patient. It also can be used to deliver oxygen to someone who is breathing but still requires oxygen. Some resuscitation masks come with elastic straps to place over the patient\u2019s head to keep the mask in place. If the mask does not have a strap, you or the patient can hold it in place. With a resuscitation mask, set the oxygen flow rate at 6\u201315 LPM. A resuscitation mask can deliver up to 55 percent oxygen to a breathing person, when delivered at 6 LPM or more. When used on a nonbreathing patient while you perform ventilations, it will deliver an oxygen concentration of approximately 35 percent. The oxygen concentration is reduced because oxygen mixes with your exhaled breath as you perform mouth-to-mask ventilations.",
        "Non-Rebreather Mask": "A non-rebreather mask is used to deliver high concentrations of oxygen to breathing patients. It consists of a face mask with an attached oxygen reservoir bag and a one-way valve between the mask and bag to prevent the patient\u2019s exhaled air from mixing with the oxygen in the reservoir bag. The patient inhales oxygen from the bag, and exhaled air escapes through flutter valves on the side of the mask. To inflate the reservoir bag, cover the one-way valve with your gloved thumb before placing it on the patient\u2019s face. The oxygen reservoir bag should be sufficiently inflated (about two-thirds full) so as not to deflate when the patient inhales. If this happens, increase the flow rate of the oxygen to refill the reservoir bag. The flow rate should be set at 10\u201315 LPM. When using a non-rebreather mask with a high flow rate of oxygen, up to 90 percent oxygen concentration can be delivered to the patient.",
        "BVM": "A BVM can be used on a breathing or nonbreathing patient. With a BVM, the oxygen flow rate should be set at 15 LPM or more. The BVM with an oxygen reservoir bag is capable of supplying 90 percent or more oxygen concentration when used at 15 LPM or more. Squeeze the bag between each breath for patients breathing less than 10 times per minute. To assist a person breathing more than 30 times per minute, squeeze the bag on every second breath.",
        "Assembly for a Variable-Flow-Rate System": "Begin by examining the cylinder to be certain that it is labeled \u201cOxygen.\u201d The cylinders come with a protective covering over the tank opening. Remove this covering. If it is not built into the tank, remove the O-ring gasket. While pointing the cylinder away from you, open the cylinder for 1 second. This will remove any dirt or debris from the cylinder valve. If necessary, reposition the O-ring gasket. Next, examine the pressure regulator to be sure it is designed for delivering supplemental oxygen. It may be labeled \u201cOxygen Regulator.\u201d Check to see that the pin index corresponds to an oxygen tank. Attach the pressure regulator to the cylinder, seating the prongs inside the holes in the valve. Hand-tighten the screw until the regulator is snug. Open the cylinder one full turn and listen for leaks. Check the pressure gauge to determine how much pressure is in the cylinder. A full cylinder should have approximately 2000 psi. Attach the chosen delivery device to the oxygen port near the flowmeter, using the appropriate tubing.",
        "Oxygen Administration": "To administer oxygen using a variable-flow-rate system, follow the steps described earlier, then turn on the flowmeter and adjust it to the desired flow rate. Listen and feel to make sure that oxygen is flowing into your delivery device. If you are using a non-rebreather mask, ensure that the reservoir bag is two-thirds full before placing the device on the patient. Finally, place the delivery device on the patient. If young children and infants are frightened by a mask being placed on their face, use a \u201cblow-by\u201d technique. To perform this technique, you, a parent or legal guardian holds the mask about 2 inches from the child\u2019s or infant\u2019s face waving it slowly from side-to-side as if you are playing a game, thus allowing the oxygen to pass over the face and be inhaled. You should monitor the effectiveness of the oxygen delivery; a pulse oximeter can be used to do so.",
        "CRITICAL FACTS 2": "Oxygen devices, such as nasal cannulas, simple face masks, non-rebreather masks, BVMs and resuscitation masks, allow the patient to effectively receive supplemental oxygen.",
        "Assembly and Administration for a Fixed-Flow-Rate System": "To operate a fixed-flow-rate system, simply turn it on according to the manufacturer\u2019s instructions, check that oxygen is flowing and place the delivery device on the patient. You can also use the \u201cblow-by\u201d technique using a fixed-flow-rate system by following the same procedure outlined above.",
        "Securing and Handling Cylinders": "Never attempt to refill an oxygen cylinder; only an appropriately licensed professional should do this. When high-pressure oxygen cylinders have been emptied, close the cylinder valve, replace the valve protection cap or outlet plug where provided, and mark or tag the cylinder as EMPTY. Then return the cylinder promptly, to be refilled according to state and local regulations. Specific attention should be given to the following areas concerning oxygen cylinders: \uf0a7 Check for cylinder leaks, abnormal bulging, and defective or inoperative valves or safety devices. \uf0a7 Check for the physical presence of rust or corrosion on a cylinder or cylinder neck. \uf0a7 Any foreign substances or residues, such as adhesive tape around the cylinder neck, oxygen valve or regulator assembly, can hamper oxygen delivery and in some cases may have the potential to cause a fire or explosion. \uf0a7 Ensure that all oxygen cylinders have proper hydrostatic testing and are marked appropriately. \uf0a7 Be aware of the specific testing requirements of steel and aluminum tanks (e.g., 10 years initial testing for steel cylinders and 5 years for aluminum cylinders).",
        "SAFETY PRECAUTIONS": "When preparing and administering oxygen, safety is a major concern. Use oxygen equipment according to the manufacturer\u2019s instructions and in a manner consistent with federal and local regulations. Also, follow these recommended guidelines: \uf0a7 Be sure that oxygen is flowing before putting the delivery device over the patient\u2019s face. \uf0a7 Do not use oxygen around flames or sparks including smoking materials, such as cigarettes, cigars and pipes. Oxygen causes fire to burn more rapidly and intensely. \uf0a7 Do not use grease, oil or petroleum products to lubricate or clean the regulator. This could cause an explosion. \uf0a7 Do not stand oxygen cylinders upright unless they are well secured. If a cylinder falls, the regulator or valve could become damaged or cause injury due to the intense pressure in the tank. \uf0a7 Do not drag or roll cylinders. \uf0a7 Do not carry a cylinder by the valve or regulator. \uf0a7 Do not hold on to protective valve caps or guards when moving or lifting cylinders. \uf0a7 Do not deface, alter or remove any labeling or markings on the oxygen cylinder. \uf0a7 Do not attempt to mix gases in an oxygen cylinder or transfer oxygen from one cylinder to another. If defibrillating using an automated external defibrillator (AED), make sure that no one is touching or is in contact with the patient or the resuscitation equipment. Do not defibrillate someone when around flammable materials, such as free-flowing oxygen or gasoline.",
        "PUTTING IT ALL TOGETHER": "Administering supplemental oxygen to someone experiencing a breathing emergency can help improve hypoxia. It can also help reduce pain and breathing discomfort. When using oxygen, follow safety precautions and use the equipment according to the manufacturer\u2019s instructions. An oxygen delivery device is the piece of equipment a patient breathes through when receiving oxygen. These delivery devices include nasal cannulas, resuscitation masks, simple face masks, non-rebreather masks and BVMs. The resuscitation mask and BVM are the most appropriate devices for EMRs, as they can be used with breathing and nonbreathing patients. These devices can significantly increase the oxygen concentration that an injured or ill person needs, help ventilate a nonbreathing patient and reduce the likelihood of disease transmission. Be familiar with the unique features and benefits of these devices as well as their appropriate flow rates and situations in which they should be used based on local protocols.",
        "Oxygen Delivery": "STEP 1 Make sure the oxygen cylinder is labeled \u201cU.S.P.\u201d (United States Pharmacopeia) and marked with a yellow diamond that says \u201cOxygen.\u201d STEP 2 Clear the valve.\n \u25a0Remove the protective covering.\n \u25a0Remove and save the O-ring gasket, if necessary.\n \u25a0Turn the cylinder away from you and others before opening.\n \u25a0Open the cylinder valve for 1 second to clear the valve of any debris. STEP 3 Attach the regulator.\n \u25a0Put the O-ring gasket into the valve on top of the cylinder, if necessary.\n \u25a0Make sure that it is designed for delivering supplemental oxygen and that the O-ring gasket is secure.\n \u25a0Check to see that the pin index corresponds to an oxygen tank.\n \u25a0Secure the regulator on the cylinder by placing the two metal prongs into the valve.\n \u25a0Hand-tighten the screw until the regulator is snug.STEP 4 Open the cylinder counterclockwise one full turn.\n \u25a0Check the pressure gauge.\n \u25a0Determine that the cylinder has enough pressure \n(more than 200 psi). If the pressure is lower than \n200 psi, do not  use. STEP 5 Attach the delivery device.\n \u25a0Attach the plastic tubing between the flowmeter \nand the delivery device. STEP 6 Adjust the flowmeter.\n \u25a0Turn the flowmeter to the desired flow rate.\n \u25cfWith a nasal cannula, set the rate at 1\u20136 LPM.\n \u25cfWith a resuscitation mask, set the rate at \n6\u201315 LPM.\n \u25cfWith a non-rebreather mask, set the rate \nat 10\u201315 LPM.\n \u2751Ensure that the oxygen reservoir bag is two-thirds inflated by placing your \nthumb over the one-way valve at the bottom of the mask until the bag is \nsufficiently inflated.\n \u25cfWith a BVM, set the rate at 15 LPM or more. STEP 7 Verify the oxygen flow.\n \u25a0Listen for a hissing sound and feel for oxygen flow through the delivery device. STEP 8 Place the delivery device on the patient and continue care until more advanced medical personnel take over. STEP 9 Break down the oxygen equipment.\n \u25a0To break down the tank, reverse the steps from above, being sure to bleed the pressure regulator by turning on the flowmeter after the tank has been turned off."
    },
    {
        "Introduction": "This chapter introduces the two most important lifesaving skills: airway care and rescue breathing. To survive, patients must have an open airway and must maintain adequate breathing. By learning and practicing the simple skills in this chapter, you can often make the difference between life and death for a patient.\n\nThis chapter begins with a review of the major structures of the respiratory system. After you learn the functions of these structures, you will have the base knowledge you need to become proficient in performing airway care and rescue breathing skills.\n\nThe skills of airway care and rescue breathing are as easy as A and B\u2014the A stands for airway, and the B stands for breathing. Because you must assess and correct the airway before you turn your attention to the patient\u2019s breathing status, it is helpful to remember the AB sequence. (Note: In Chapter 8, Professional Rescuer CPR, the letter C will be added to this sequence for the assessment and correction of the patient\u2019s circulation. Airway, breathing, and circulation are known together as the ABCs. As you will learn, in the case of an unresponsive patient who may be in cardiac arrest, you should check the patient\u2019s circulation first before checking the airway and breathing. This CAB sequence minimizes the time to the beginning of compressions.)\n\nA second mnemonic that will be used throughout both this chapter and Chapter 8 is \u201ccheck and correct.\u201d This two-step sequence will help you remember the steps needed to check and correct problems involving the patient\u2019s airway, breathing, and circulation.\n\nThe A, or airway, section presents airway skills, including how to check a patient\u2019s level of consciousness (responsiveness) and manually correct a blocked airway by using the head tilt\u2013chin lift and jaw-thrust maneuvers. You must check the patient\u2019s airway for foreign objects. If you find a foreign object blocking the airway, you must remove the object by using either a manual technique or a suction device. You will learn when and how to use oral and nasal airways to keep the patient\u2019s airway open.\n\nThe B, or breathing section describes how to check patients to determine whether they are breathing adequately. You will learn how to correct breathing problems by using four rescue breathing techniques: mouth-to-mask, mouth-to-barrier device, bag-valve mask (BVM), and mouth-to-mouth. You will learn the indications for using supplemental oxygen and how to administer it using a nasal cannula and a nonrebreathing mask. You will also learn how to check patients to determine whether they have an airway obstruction. Such respiratory blockages can cause death in only a few minutes. You will learn how to correct this condition using manual techniques that require no special equipment. Remember that patients with airway problems will likely be extremely anxious during the episode. It is your responsibility as an emergency medical responder (EMR) to treat these patients and their families with compassion while you provide care. As you study this chapter, remember the check-and-correct process for both airway and breathing skills. Do not forget that the airway and breathing skills presented in this chapter will be performed with circulation skills in Chapter 8. After you have learned the airway, breathing, and circulation skills, you will be able to perform cardiopulmonary resuscitation (CPR). CPR is used to save the lives of people who are experiencing cardiac arrest (stoppage of the heart).",
        "Anatomy and Function of the Respiratory System": "To maintain life, all organisms must receive a constant supply of certain substances. In humans, these basic life-sustaining substances are food, water, and oxygen. A person can live several weeks without food because the body can use nutrients it has stored. Although the body does not store as much water, it is possible to live several days without fluid intake. However, lack of oxygen, even for a few minutes, can result in irreversible damage and death.\n\nThe most sensitive cells in the human body are located in the brain. If brain cells are deprived of oxygen and nutrients for 4 to 6 minutes, they begin to die. Brain death is followed by the death of the entire body. Brain cells cannot be replaced once they are destroyed, which is why it is important for you to understand the anatomy and function of the respiratory system and the critical role it plays in supporting life. \n\nThe main purpose of the respiratory system is to provide oxygen and to remove carbon dioxide from the red blood cells as they pass through the lungs. This action forms the basis for your study of the lifesaving skill of CPR. The parts of the body used in breathing are shown in Figure 7-1 and include the mouth (oropharynx), the nose (nasopharynx), the throat (pharynx), the trachea (windpipe), the lungs, the diaphragm (the muscle between the chest and the abdomen), and numerous chest muscles (including the intercostal muscles). Air enters the body through the nose and mouth. In an unconscious patient lying on his or her back, the passage of air through both nose and mouth may be blocked by the tongue Figure 7-2.\n\nThe tongue is attached to the lower jaw (mandible). When a person has a loss of consciousness, the jaw relaxes and the tongue falls backward into the rear of the mouth, effectively blocking the passage of air from both the nose and the mouth to the lungs. A partially blocked airway often produces a snoring sound. At the back of the throat are two passages: the esophagus (the tube through which food passes) and the trachea. The epiglottis is a thin flapper valve that allows air to enter the trachea but helps prevent food or water from entering the airway. Air passes from the throat to the larynx (voice box), which can be seen externally as the Adam\u2019s apple in the front of the neck. Below the trachea, the airway divides into the bronchi (two large tubes supported by cartilage). The bronchi branch into smaller and smaller airways in the lungs. The lungs are located on either side of the heart and are protected by the sternum at the front of the body and by the rib cage at the sides and back.\n\nThe smaller airways that branch from the bronchi are called bronchioles. The bronchioles end as tiny air sacs called alveoli. The alveoli are surrounded by very small blood vessels, the capillaries. The actual exchange of gases takes place across a thin membrane that separates the capillaries of the circulatory system from the alveoli of the lungs. The incoming oxygen passes from the alveoli into the blood, and the outgoing carbon dioxide passes from the blood into the alveoli. The exchange of oxygen and carbon dioxide that occurs in the alveoli is called alveolar ventilation. The amount of air pulled into the lungs and removed from the lungs in 1 minute is called minute ventilation.\n\nWhen a patient is not breathing, artificial ventilation is necessary to supply oxygen to the heart and the rest of the body. During CPR, the blood being pushed out of the heart (cardiac output) depends on the oxygen supplied by artificial ventilation.\n\nThe lungs consist of soft, spongy tissue with no muscles. Therefore, movement of air into the lungs depends on movement of the rib cage and the diaphragm. As the rib cage expands, air is drawn into the lungs through the trachea. The diaphragm, a muscle that separates the abdominal cavity from the chest, is dome shaped when it is relaxed. When the diaphragm contracts during inhalation, it flattens and moves downward. This action increases the size of the chest cavity and helps draw air into the lungs through the trachea. On exhalation, the diaphragm relaxes and once again becomes dome shaped. In normal breathing, the combined actions of the diaphragm and the rib cage automatically produce adequate inhalation and exhalation.",
        "Special Populations": "The structures of the respiratory system in children and infants are smaller than they are in adults. Therefore, the air passages of children and infants may be more easily blocked by secretions or by foreign objects.\nIn children and infants, the tongue is proportionally larger than it is in adults. Therefore, the tongue of these smaller patients is more likely to block the airway than it would in an adult patient. Because the trachea of an infant or child is more flexible than that of an adult, it is more likely to become narrowed or blocked than that of an adult. The head of a child or an infant is proportionally larger than the head of an adult. You will learn slightly different techniques for opening the airways of children. Children and infants have smaller lungs than adults. You need to give them smaller breaths when you perform rescue breathing. Most children and infants have healthy hearts. When a child or infant experiences cardiac arrest, it is usually because the patient has a blocked airway or has stopped breathing, not because there is a problem with the heart.",
        "A Is for Airway": "The patient\u2019s airway is the pipeline that transports life-giving oxygen from the air to the lungs and transports the waste product, carbon dioxide, from the lungs to the air. In healthy people, the airway automatically stays open. An injured or seriously ill person, however, may not be able to protect the airway and it may become blocked. If a patient cannot protect his or her airway, you must take certain steps to check the condition of the patient\u2019s airway and correct the problem to keep the patient alive.",
        "Check for Responsiveness": "The first step you will take in assessing a patient\u2019s airway is to check the patient\u2019s level of responsiveness. When you first approach a patient, you can immediately determine whether the patient is responsive (conscious) or unresponsive (unconscious) by asking, \u201cAre you okay? Can you hear me?\u201d If you get a response, you can assume the patient is conscious and has an open airway.\n\nIf you do not get a response, grasp the patient\u2019s shoulder and gently shake the patient. Then repeat your questions. If the patient still does not respond, you can assume the patient is unconscious and you will need more help. Before doing anything for the patient, call 9-1-1 if the emergency medical services (EMS) system has not already been activated, especially if you are the only rescuer. Position the patient by supporting the patient\u2019s head and neck and placing the patient on his or her back.",
        "Treatment": "The steps in airway assessment are as follows:\n1. Check for responsiveness.\n2. Correct the blocked airway using the head tilt\u2013chin lift or jaw-thrust maneuver.\n3. Check the airway for fluids, foreign bodies, or dentures.\n4. Correct the airway using finger sweeps or suction if a foreign body is seen.\n5. Manually maintain the airway with an oral or nasal airway, or place the patient in the recovery position (explained later in this chapter).",
        "Correct the Blocked Airway": "An unconscious patient will not be able to keep his or her airway open. An unconscious patient\u2019s airway is often blocked (occluded) because the tongue has dropped back and is obstructing it. In this case, simply opening the airway with the head tilt\u2013chin lift or jaw-thrust maneuver may enable the patient to breathe spontaneously.",
        "Head Tilt\u2013Chin Lift Maneuver": "To open a patient\u2019s airway using the head tilt\u2013chin lift maneuver, place one hand on the patient\u2019s forehead and place the fingers of your other hand under the bony part of the lower jaw near the chin. Push down on the forehead and lift up and forward on the chin. Be certain you are not merely pushing the mouth closed when you use this maneuver.\n\nFollow these steps to perform the head tilt\u2013chin lift maneuver:\n1. Place the patient on his or her back and kneel beside the patient.\n2. Place one hand on the patient\u2019s forehead and apply firm pressure backward with your palm. Move the patient\u2019s head back as far as possible.\n3. Place the tips of the fingers of your other hand under the bony part of the lower jaw near the chin.\n4. Lift the chin forward to help tilt back the head.",
        "The jaw-thrust maneuver": "The jaw-thrust maneuver is another way to open a patient\u2019s airway. If a patient was injured in a fall, diving mishap, or motor vehicle crash and has a suspected neck injury, tilting the head may cause permanent paralysis. If you suspect a neck injury, first try to open the airway using the jaw-thrust maneuver. Open the airway by placing your fingers under the angles of the jaw and pushing upward. At the same time, use your thumbs to open the mouth slightly. The jaw-thrust maneuver should open the airway without extending the neck.\n\nFollow these steps to perform the jaw-thrust maneuver: 1. Place the patient on his or her back and kneel at the top of the patient\u2019s head. Place your fingers behind the angles of the patient\u2019s lower jaw and move the jaw forward with firm pressure. 2. Tilt the head backward to a neutral or slight sniffing position. Do not extend the cervical spine in a patient who has sustained an injury to the head or neck. 3. Use your thumbs to pull down the patient\u2019s lower jaw, opening the mouth enough to allow breathing through the mouth and nose. If you are unable to open the patient\u2019s airway using the jaw-thrust maneuver, try the head tilt\u2013chin lift maneuver as a secondary attempt to open the patient\u2019s airway.",
        "Safety": "Take standard precautions whenever you may be in contact with body secretions that might contain blood.",
        "Check for Fluids, Foreign Bodies, or Dentures": "After you have opened the patient\u2019s airway by using either the head tilt\u2013chin lift or the jaw-thrust maneuver, look in the patient\u2019s mouth to see if anything is blocking the patient\u2019s airway. Potential blocks include secretions, such as vomitus, mucus, or blood; foreign objects, such as candy, food, or dirt; and dentures or false teeth that may have become dislodged and are blocking the patient\u2019s airway. If you find anything in the patient\u2019s mouth, remove it by using one of the techniques noted in the following sections. If the patient\u2019s mouth is clear, consider using one of the devices described in the section on airway devices.",
        "Correct the Airway Using Finger Sweeps or Suction": "You must clear vomitus, mucus, blood, and foreign objects from the patient\u2019s airway. You can accomplish this step by using finger sweeps, suctioning, or by placing the patient in the recovery position.",
        "Finger Sweeps": "Finger sweeps can be done quickly and require no special equipment except a set of medical gloves. Finger sweeps should be your first attempt at clearing the airway even if suction equipment is available. To perform a finger sweep, follow the steps in Skill Drill 7-1: 1. Turn the patient onto his or her side Step 1. 2. Insert your gloved fingers into the patient\u2019s mouth Step 2. 3. Curve your fingers into a C-shape and sweep them from one side of the back of the mouth to the other side Step 3. Scoop out as much of the foreign material as possible. A gauze pad wrapped around your gloved fingers may help remove the obstructing materials. Repeat the finger sweeps until you have removed all the foreign material in the patient\u2019s mouth.",
        "Suctioning": "Sometimes a finger sweep is not enough to clear the materials completely from the patient\u2019s mouth and upper airway. Suction machines can be helpful in removing secretions such as vomitus, blood, and mucus from the patient\u2019s mouth. Two types of suction devices are available: manual and mechanical. Suctioning the airway (either manually or mechanically) is a lifesaving technique. Although a gauze pad and your gloved fingers can do most of the work, the use of supplementary suction devices enables you to remove a greater amount of obstructing material from the patient\u2019s airway.",
        "Safety_0": "If the possibility of a spinal cord injury exists, log roll the patient onto his or her side and keep the head, neck, and spine aligned. Open the mouth and use your gloved fingers in the same manner to clean out the mouth.",
        "Manual Suction Devices.": "Several manual suction devices are available to EMRs. These devices are relatively inexpensive and are compact enough to fit into your life support kit. With most manual suction devices, you insert the end of the suction tip into the patient\u2019s mouth and squeeze or pump the hand-powered pump. Be sure that you do not insert the tip of the suction device farther than you can see. Manual suction devices are used in the same way as the mechanical suction devices described in the following section. The only difference is the power source. Follow local medical protocols on authorization to use suction devices in the field.",
        "Safety_1": "Do not suction any deeper than you can see into the patient\u2019s mouth.",
        "Mechanical Suction Devices": "A mechanical suction device uses either a battery-powered pump or an oxygen-powered aspirator to create a vacuum that will draw the obstructing materials from the patient\u2019s airway. Usually, both a rigid suction tip and a flexible whistle-tip catheter can be used with mechanical suction devices. To use this type of suction machine, you must first learn how to operate the device and control the force of the suction. When using mechanical suction, first clear the patient\u2019s mouth of large pieces of material with your gloved fingers. After the mouth is clear, turn on the suction device and use the rigid tip to remove most of the remaining material. Do not suction for more than 15 seconds at a time because the suction draws air out of the patient\u2019s airway, as well as any obstructing material. If the rigid tip has a suction control port (a small hole located close to the tip\u2019s handle), place a finger over the hole to create the suction. Do not keep your finger over this control port for longer than 15 seconds at a time because you may rob the patient of oxygen.\n\nAfter you have cleared most of the obstructing material out of the patient\u2019s mouth and upper airway with the rigid tip, change to the flexible tip and clear out material from the deeper parts of the patient\u2019s throat. Flexible whistle-tip catheters also have suction control ports, which are located close to the end of the catheter that attaches to the suction machine. Again, place a finger over the control port to achieve suction.",
        "Special Populations_2": "Do not suction a child\u2019s airway longer than 10 seconds at a time.\nDo not suction an infant\u2019s airway longer than 5 seconds at a time.",
        "Maintain the Airway": "If your patient is unable to keep his or her airway open, you must open the airway manually by using the head tilt\u2013chin lift or jaw-thrust maneuver. You can continue to keep the airway open by holding the patient\u2019s head to maintain the head tilt\u2013chin lift or the jaw-thrust position.\nIf the patient is breathing adequately, you can keep the airway open by placing the patient in the recovery position. You can also insert an oral or nasal airway adjunct to maintain the patient\u2019s airway after you have opened it manually.",
        "Treatment_3": "Do not forget to ventilate all patients who are not breathing.",
        "Recovery Position": "If an unconscious patient is breathing and has not sustained trauma, one way to keep the airway open is to place the patient in the recovery position. The recovery position helps keep the patient\u2019s airway open by allowing secretions to drain out of the mouth instead of draining into the trachea. It also uses gravity to help keep the patient\u2019s tongue and lower jaw from blocking the airway. To place a patient in the recovery position, carefully roll the patient onto one side, while you support the patient\u2019s head. Roll the patient as a unit without twisting the body. You can use the patient\u2019s hand to help hold his or her head in the proper position. Place the patient\u2019s face on its side so any secretions drain out of the mouth. The head should be in a position similar to the tilted-back position of the head tilt\u2013chin lift maneuver.",
        "Safety_4": "Take standard precautions when clearing the patient\u2019s airway.",
        "Airway Adjuncts": "This section discusses the indications for the use of oral airways and nasal airways and the steps required for the proper insertion of each.",
        "Signs and Symptoms of respiratory arrest": "The signs and symptoms of respiratory arrest include the following:\nNo chest movement\nNo breath sounds\nNo air movement\nBlue skin (cyanosis), especially around the lips\nSlow, gasping respirations",
        "Oral Airway": "An oral airway, also called an oropharyngeal airway, has two primary purposes: It maintains the patient\u2019s airway after you have manually opened the airway, and it functions as a pathway through which you can suction the patient. You can use oral airways for unconscious patients who are breathing or who are in respiratory arrest (sudden stoppage of breathing). You can use an oral airway in any unconscious patient who does not have a gag reflex. You cannot use oral airways in conscious patients because they have a gag reflex. These airways can be used with mechanical breathing devices such as the pocket mask or a bag-valve mask (BVM).\n\nTwo styles of oral airways are available: One style has an opening down the center, and the other has a slot (or opening) along each side. The slot permits the free flow of air and allows you to suction through the airway. Before you insert the oral airway, you need to select the proper size. Choose the proper size by measuring from the earlobe to the corner of the patient\u2019s mouth. When properly inserted, the airway will rest inside the mouth. The curve of the airway should follow the contour of the tongue. The flange should rest against the lips. The other end should be resting in the back of the throat.\n\nFollow these steps to insert an oral airway:\n 1. Select the proper size airway by measuring from the patient\u2019s earlobe to the corner of the mouth Step 1. \n2.Open the patient\u2019s mouth with one hand after manually opening the patient\u2019s airway with either a head tilt\u2013chin lift or jaw-thrust maneuver.\n 3. Hold the airway upside down with your other hand. Insert the airway into the patient\u2019s mouth and guide the tip of the airway along the roof of the patient\u2019s mouth, advancing it until you feel resistance Step 2. \n4.Rotate the airway 180\u00ba until the flange comes to rest on the patient\u2019s teeth or lips Step 3.\n\nBe especially careful when you insert the airway. You could injure the roof of the patient\u2019s mouth by the rough insertion of an oral airway. Remember, an oral airway does not open the patient\u2019s airway. It will maintain the open airway after you have opened it with a manual technique.",
        "Special Populations_6": "The roof of a child\u2019s mouth is more fragile than that of an adult, so be especially careful to avoid injuring it as you insert the oral airway. The technique for inserting an oral airway in a child is almost the same as for an adult patient. However, to make it easier to insert the airway, use two or three stacked tongue blades and depress the tongue. This method will press the tongue forward and away from the roof of the mouth so you can insert the airway.",
        "Treatment_7": "If a patient has sustained severe head trauma, it is possible that the insertion of a nasal airway may further damage the brain. Check with your local medical control to determine the protocol for using a nasal airway in patients with head trauma.",
        "Nasal Airway": "A second type of device you can use to keep the patient\u2019s airway open is a nasal airway, also called a nasopharyngeal airway. This device is inserted into the patient\u2019s nose. You can use nasal airways in both unconscious and conscious patients who are unable to maintain an open airway. Usually a patient will tolerate a nasal airway better than an oral airway. It is not as likely to cause vomiting. One disadvantage of a nasal airway is that you cannot suction through it because the inside diameter of the airway is too small for the standard whistle-tip catheter suction tip.\n\nYou will have to select the proper size nasal airway for the patient. Measure from the earlobe to the tip of the patient\u2019s nose. Coat the airway with a water-soluble lubricant before inserting it. This step makes it easier for you to insert the airway and reduces the chance of causing trauma to the patient\u2019s airway. Insert the airway in the larger nostril. As you insert the airway, follow the curvature of the floor of the nose. The airway is fully inserted when the flange or trumpet rests against the patient\u2019s nostril. At this point, the other end of the airway will reach the back of the patient\u2019s throat and it will maintain an open airway for the patient.\n\nFollow these steps to insert a nasal airway: Skill Drill 7-3: 1. Select the proper size airway by measuring from the earlobe to the tip of the patient\u2019s nose Step 1. 2. Coat the airway with a water-soluble lubricant. 3. Select the larger nostril. 4. Gently stretch the nostril open by using your thumb. 5. Gently insert the airway until the flange rests against the nose Step 2 and Step 3. Do not force the airway. If you feel any resistance, remove the airway and try to insert it in the other nostril.",
        "Treatment_10": "To open the patient\u2019s airway:\n1. Perform the head tilt\u2013chin lift maneuver, or\n2. Perform the jaw-thrust maneuver.\nTo maintain the patient\u2019s airway:\n1. Continue to apply the head tilt\u2013chin lift or jaw-thrust maneuver,\nand\nInsert an oral airway, or\nInsert a nasal airway.\n2. Place the patient in the recovery position.\nAfter you open and maintain the patient\u2019s airway, continue to monitor\nthe status of the patient\u2019s breathing.",
        "Voices of Experience": "The way I was immobilized on the spine board was actually making my injuries worse.\nOften we forget that proper spinal immobilization is a critical part of\nairway control. Let me explain. I was nearly killed in a logging accident\non December 13, 1983, while cutting large pine trees for a saw mill. I\nsuffered multiple fractures and other injuries when a 65-foot (20-m) tree fell on me. I was transported by the ambulance being towed through the mud and snow with a log skidder and then driven a few miles on icy roads to the emergency department. This was just a few years before I was to become a paramedic\u2014in fact, this accident is what sparked my interest in becoming an emergency medical responder.\nTo make a long story short, my chief complaint changed en route to the hospital from pain in my legs, arms, and chest to pain on the back of my head and difficulty breathing and swallowing. I couldn\u2019t keep the blood out of my airway. My face was badly lacerated and a couple of teeth had sheared off when the chainsaw came up into my face as the tree slammed me to the ground. Why did my head hurt so much after being put on a long backboard? Why was it so hard to breathe and swallow, making me feel like I was constantly choking? The way I was immobilized on the backboard was actually making my injuries worse. Tape was placed over my head, pulling the back of my skull tightly against the hard surface of the spine board, each jar and bump driving my head harder into the backboard. Imagine how much worse this would be for a trauma patient with gravel or broken glass embedded in his or her hair pushing into his or her skull as well. Not only does this position hurt, it also makes it hard to breathe and to control your own airway.\n\nThe standard of care where I work now is to pad the back of the patient\u2019s head to align the \u201chole in the ear,\u201d called the external meatus, with the anterior shoulder. For pediatric patients, we use the same alignment landmarks, but often the padding needs to be behind the body and not the head. Even then, some padding is added behind the head for comfort. When swallowing is easier, the patient\u2019s airway remains clear; breathing is easier and more effective. Pain and anxiety are decreased, lowering adrenaline release and decreasing both heart rate and oxygen demand. If advanced life support providers need to install an advanced airway later, it will be much easier with the trachea aligned properly.\n\nBy being a patient, I learned this valuable lesson. Hopefully you won\u2019t have to be a patient to learn it, too.\n\nKent Courtney, NREMT\nEMS Instructor\nPeabody Western Coal Company\nKayenta, Arizona",
        "B Is for Breathing": "After you have checked and corrected the patient\u2019s airway, you will next check and correct the patient\u2019s breathing. To do this, you must understand the signs of adequate breathing, the signs of inadequate breathing, and the signs and causes of respiratory arrest.",
        "Signs of Adequate Breathing": "You will use the look, listen, and feel technique to assess if an unconscious patient is breathing adequately. In using this technique, you look for the rise and fall of the patient\u2019s chest, listen for the sounds of air passing into or out of the patient\u2019s nose and mouth, and feel the air moving on the side of your face. Place the side of your face close to the patient\u2019s nose and mouth and watch the patient\u2019s chest. By positioning yourself in this way, you can look for chest movements, listen for the sounds of air moving, and feel the air as it moves in and out of the patient\u2019s nose and mouth. A normal adult has a resting breathing rate of approximately 12 to 20 breaths per minute. Remember, one breath includes both an inhalation and an exhalation.",
        "Signs of Inadequate Breathing": "If a patient is breathing inadequately, you will detect signs of abnormal respirations. Sounds such as noisy respirations, wheezing, or gurgling indicate a partial blockage or constriction somewhere along the respiratory tract. Rapid or gasping respirations may indicate that the patient is not receiving an adequate amount of oxygen as a result of illness or injury. The patient\u2019s skin may be pale or even blue, especially around the lips or fingernail beds (cyanosis). The most critical sign of inadequate breathing is respiratory arrest (total lack of respirations). As discussed previously, this critical state is characterized by a lack of chest movements, lack of breath sounds, and lack of air against the side of your face. In patients with severe hypothermia, respirations can be slowed (and/or shallow) to the point that the patient does not appear to be breathing.\n\nMany causes of respiratory arrest exist.: One common cause is heart disease, which claims 610,000 lives each year in the United States according to the Centers for Disease Control and Prevention. Other major causes of respiratory arrest include:\nMechanical blockage or obstruction caused by the tongue\nVomitus, particularly in a patient weakened by a condition such as a stroke\nForeign objects such as broken teeth, dentures, balloons, marbles, pieces of food, or pieces of hard candy (especially in small children)\nIllness or disease\nDrug overdose\nPoisoning\nSevere loss of blood\nElectrocution by electrical current or lightning",
        "Check Breathing": "As discussed previously, your assessment of any motionless patient begins by checking for responsiveness and assessing for breathing. If the patient is responsive (conscious) and breathing, assist him or her as needed. However, if the patient is unresponsive (unconscious), you need to determine if the patient requires assistance with breathing or other interventions. While checking to see if the patient is responsive, also check quickly to see if the patient is breathing. This step is accomplished by visualizing the patient\u2019s chest and observing for visible movement. If the patient is breathing adequately (about 12 to 20 breaths per minute with adequate depth), you can continue to maintain the airway and monitor the rate and depth of respirations to ensure that adequate breathing continues.",
        "Correct the Breathing": "You must breathe for any patient who is not breathing adequately. As you perform rescue breathing, keep the patient\u2019s airway open by using the head tilt\u2013chin lift maneuver (or the jaw-thrust maneuver for patients with suspected head or spinal injuries). To perform rescue breathing, pinch the patient\u2019s nose with your thumb and forefinger, take a deep breath, and blow slowly into the patient\u2019s mouth for 1 second. Use slow, gentle, sustained breathing and just enough breath to make the patient\u2019s chest rise to minimize the amount of air blown into the stomach. Remove your mouth and allow the patient\u2019s lungs to deflate. Breathe for the patient a second time. After these first two breaths, breathe once into the patient\u2019s mouth every 5 to 6 seconds. The rate of breaths should be 10 to 12 per minute for an adult. With an unresponsive patient, recall that you need to check for the presence of circulation before you correct the patient\u2019s breathing. These situations are described in Chapter 8, Professional Rescuer CPR.\n\nYou can perform rescue breathing by using a mouth-to-mask device, a barrier device, a BVM, or just your mouth. The skill of performing mouth-to-mouth ventilation is no longer recommended as a primary means of performing CPR but is presented here as a fallback method of performing ventilation if you have no equipment for performing other means of ventilation. The mouth-to-mask devices, barrier devices, and BVMs prevent you from putting your mouth directly on the patient\u2019s mouth. These devices should be available to you as an EMR. If a rescue breathing device is unavailable, you must weigh the potential good to the patient against the limited chance that you will contract an infectious disease if you perform mouth-to-mouth rescue breathing.",
        "Mouth-to-Mask Rescue Breathing": "Your EMR life support kit should contain an artificial ventilation (breathing) device that enables you to perform rescue breathing without mouth-to-mouth contact with the patient. This simple piece of equipment is a mouth-to-mask ventilation device. A mouth-to-mask ventilation device consists of a mask that fits over the patient\u2019s face, a one-way valve, and a mouthpiece through which the rescuer breathes. It may also have an inlet port for supplemental oxygen and a tube between the mouthpiece and the mask. Because mouth-to-mask devices prevent direct contact between you and the patient, they reduce the risk of transmitting infectious diseases. To use a mouth-to-mask ventilation device for rescue breathing, follow the steps in Skill Drill 7-4: 1. Position yourself at the patient\u2019s head.\n\n2.Use the head tilt\u2013chin lift to open the patient\u2019s airway Step 1. Alternately, use the jaw-thrust maneuver for a patient with suspected head or spinal injuries Step 2.\n\n3.Place the mask over the patient\u2019s mouth and nose. Make sure the mask\u2019s nose notch is on the nose and not the chin.\n\n4.Grasp the mask and the patient\u2019s jaw, using both hands. Use the thumb and forefinger of each hand to hold the mask tightly against the face. Hook the other three fingers of each hand under the patient\u2019s face Step 3. \n\n5.Maintain an airtight seal as you pull up on the jaw to maintain the proper head position.\n\n6.Take a deep breath and then seal your mouth over the mouthpiece.\n\n7. Breathe slowly into the mouthpiece for 1 second Step 4. Breathe until the patient\u2019s chest rises.\n\n8. Monitor the patient for proper head position, air exchange, and vomiting.\n\n9. Practice this technique frequently on a manikin until you can do it well.",
        "Mouth-to-Barrier Rescue Breathing": "Mouth-to-barrier devices also provide a barrier between the rescuer and the patient. Some of these devices are small enough to carry in your pocket. Although a wide variety of devices is available, most of them consist of a port or hole that you breathe into and a mask or plastic film that covers the patient\u2019s face. Some also have a one-way valve that prevents backflow of secretions and gases. These devices provide variable degrees of infection control.\n\nTo perform mouth-to-barrier rescue breathing, follow the steps in Skill Drill 7-5:\n1. Open the airway with the head tilt\u2013chin lift maneuver. Press on the forehead to maintain the backward tilt of the head Step 1.\n2. Keep the patient\u2019s mouth open with the thumb of whichever hand you are using to lift the patient\u2019s chin.\n3. Place the barrier device over the patient\u2019s mouth Step 2.\n4. Pinch the patient\u2019s nostrils together with your thumb and forefinger. Take a deep breath and then make a tight seal by placing your mouth on the barrier device around the patient\u2019s mouth.\n5. Breathe slowly into the patient\u2019s mouth for 1 second. Breathe until the patient\u2019s chest rises Step 3.\n6. Remove your mouth and allow the patient to exhale passively. Check to see that the patient\u2019s chest falls after each exhalation.\n7. Repeat this rescue breathing sequence 10 to 12 times per minute (one breath every 5 to 6 seconds) for an adult.",
        "Mouth-to-Mouth Rescue Breathing": "The skill of performing mouth-to-mouth ventilation, although no longer recommended as a primary means of performing CPR, is presented here as a method of performing ventilation if you have no equipment for performing other means of ventilation. Mouth-to-mouth rescue breathing is an effective way of providing artificial ventilation for patients who are not breathing and requires no equipment except you. However, because there is a somewhat higher risk of contracting a disease when using this method, use a mask or barrier breathing device if available.\n\nTo perform mouth-to-mouth rescue breathing, follow these steps:\n1. Open the airway with the head tilt\u2013chin lift maneuver. Press on the forehead to maintain the backward tilt of the head.\n2. Pinch the patient\u2019s nostrils together with your thumb and forefinger.\n3. Keep the patient\u2019s mouth open with the thumb of whichever hand you are using to lift the patient\u2019s chin.\n4. Take a deep breath and then make a tight seal by placing your mouth over the patient\u2019s mouth.\n5. Breathe slowly into the patient\u2019s mouth for 1 second. Breathe until the patient\u2019s chest rises.\n6. Remove your mouth and allow the patient to exhale passively. Check to see that the patient\u2019s chest falls after each exhalation.\n7. Repeat this rescue breathing sequence every 5 to 6 seconds or 10 to 12 times per minute for adult patients and every 3 to 5 seconds or 12 to 20 times per minute for children and infants.",
        "Bag-Valve Mask": "The BVM has three parts: a self-inflating bag, one-way valves, and a face mask. To use this device, you place the mask over the face of the patient and make a tight seal. Squeezing the bag pushes air through a one-way valve, through the mask, and into the patient\u2019s mouth and nose. As the patient passively exhales, a second one-way valve near the mask releases the air. The self-inflating bag refills with air when you release the pressure on it. The BVM delivers 21% oxygen (the percentage of oxygen in room air) without supplemental oxygen attached. However, supplemental oxygen is usually added to the BVM. A BVM can deliver up to 90% oxygen to a patient if 10 to 15 liters per minute (L/min) of oxygen is supplied into the reservoir bag. Many BVMs are designed to be discarded after a single use. The BVM is used for the same purpose as a mouth-to-mask device\u2014to ventilate a nonbreathing patient. Although the BVM can administer up to 90% oxygen when used with supplemental oxygen, there are two disadvantages to its use. As a single rescuer, you may find it difficult to maintain a seal between the patient\u2019s face and the mask with one hand. Additionally, the BVM may be difficult to use if you have small hands because you may not be able to squeeze the bag hard enough to get an adequate volume of air into the patient.",
        "Treatment_13": "The three methods for performing rescue breathing are all potentially lifesaving. Use a mouth-to-mask device, a mouth-to-barrier device, or a BVM whenever possible. If a rescue breathing device is not available, you must weigh the potential good to the patient against the limited chance that you will contract an infectious disease from mouth-to-mouth breathing.",
        "BVM Technique.": "To use a BVM, follow the same steps you use to perform rescue breathing. Determine whether the patient is unresponsive. Open the patient\u2019s airway using the head tilt\u2013chin lift maneuver or the jaw-thrust maneuver for patients with suspected head or spinal injuries. Check to see if the patient is breathing by looking at the patient\u2019s chest, listening for the sound of air movement, and feeling for the movement of air on the side of your face and ear. If the patient is not breathing, consider using an oral or nasal airway.\n\nThe specific steps for using a BVM are shown in Skill Drill 7-6: 1. Kneel above the patient\u2019s head. This position will enable you to keep the airway open, make a tight seal on the mask, and squeeze the bag. Maintain the patient\u2019s neck in an extended position. The BVM does not maintain the patient\u2019s airway in an open position. You must continue to stabilize the head and maintain the head either in an extended position for the head tilt\u2013chin lift maneuver or in a neutral position for the jaw-thrust maneuver. 2. Open the patient\u2019s mouth and check for fluids, foreign bodies, or dentures Step 1. Suction if needed. Consider the use of an oral or nasal airway. 3. Select the proper mask size Step 2. The mask should be large enough to seal over the bridge of the patient\u2019s nose and fit in the groove between the lower lip and the chin. A mask that is too small or too large may make it impossible to maintain a seal. 4. Place the mask over the patient\u2019s face. Start by putting the angled or grooved end of the mask over the bridge of the nose. Then bring the bottom of the mask against the groove between the lower lip and the chin Step 3. 5. Seal the mask. Place the middle, ring, and little fingers of one hand under the angle of the jaw. Lift up on the jaw. Make a C with the index finger and thumb of the same hand and place them over the mask. Clamp the mask by lifting the jaw and bringing the mask in contact with the jaw. Continue to hold the mask in position Step 4.\n6.\nUsing your other hand, squeeze the bag once every 5 seconds. Try to squeeze a large volume of air. Squeeze every 3 seconds for infants and children.\n7.\nCheck for chest rise.\nStep 5. While you squeeze the bag, watch for a rise in the chest. If you do not see the chest rise, air is probably leaking around the mask or an obstruction is present in the airway. If air is leaking around the mask, try to make a better seal between the mask and the patient\u2019s jaw. If you suspect an airway obstruction, follow the steps already learned in this chapter regarding resolving airway obstructions.\n8.\nAdd supplemental oxygen.\nStep 6. Using a BVM without supplemental oxygen supplies the patient with 21% oxygen. By adding 10 to 15 L/min of oxygen to the BVM, you can increase the oxygen concentration to 90%. Adjust the liter flow on the pressure regulator/flowmeter to deliver between 10 and 15 L/min and connect the oxygen tubing from the flowmeter outlet to the inlet nipple on the BVM. This higher percentage of oxygen is beneficial for a nonbreathing patient. The specific steps for using supplemental oxygen are explained later in this chapter.\n\nWith sufficient training and practice, a single rescuer can ventilate a patient using a BVM; however, it can be difficult to maintain a good seal and squeeze the bag. Use of a BVM is best accomplished as a two-person operation if additional rescuers are present. With two rescuers, one person squeezes the bag and the other person uses both hands to seal the mask to the patient. Use the middle, ring, and little fingers of both hands under the angles of the jaw and use the index fingers and thumbs of both hands to form two C\u2019s around the face mask. Most people can seal the mask much more easily using both hands.\n\nsUsing the BVM requires proper training and practice. The BVM can be a lifesaving tool. Your EMS agency may use BVMs for nonbreathing patients, or you may be asked to assist emergency medical technicians or paramedics in ventilating nonbreathing patients so they can perform other needed skills. Check with your supervisor or medical director to learn the protocols for your service.",
        "Treatment_14": "If paramedics have inserted an endotracheal tube down the patient\u2019s windpipe (trachea), the BVM is connected directly to the end of the endotracheal tube. In this case, no face mask is needed. When you squeeze the BVM, you force air directly into the patient\u2019s lungs. You should receive instruction in this type of ventilation if you will be performing it.",
        "Airway and Breathing Review": "Assume that all patients may be in respiratory arrest until you can assess them and determine whether they are breathing adequately. A summary of the steps required to recognize respiratory arrest and perform rescue breathing in adults follows. Remember, you will learn the steps for checking and correcting circulation in Chapter 8, Professional Rescuer CPR.",
        "Airway": "1. Check for responsiveness by shouting, \u201cAre you okay?\u201d and gently shaking the patient\u2019s shoulder. If the patient is unresponsive and has no pulse, place the patient on his or her back, activate the EMS system, and begin CPR as outlined in Chapter 8, Professional Rescuer CPR. If the patient has a pulse, continue with Step 2.\n2. Correct a blocked airway by using the head tilt\u2013chin lift maneuver or, if the patient has sustained any injury to the head or neck, use the jaw-thrust maneuver.\n3. Check the mouth for any secretions, vomitus, or solid objects. If found, clear the mouth.\n4. Correct a blocked airway, if needed, by using finger sweeps or suction to remove foreign substances.\n5. Maintain the airway by manually holding it open or by using an oral or nasal airway.",
        "Breathing": "1. Check that the patient is breathing adequately by looking for the rise and fall of the patient\u2019s chest and listening for the sound of air moving in and out of the patient\u2019s nose and mouth. If the patient is breathing adequately, place him or her in the recovery position. If the patient is not breathing, go to Step 2.\n2. Correct the lack of breathing by performing rescue breathing using a mouth-to-mask or mouth-to-barrier device, if available. Blow slowly into the patient\u2019s mouth for 1 second, using slow, gentle, sustained breaths with enough force to make the chest rise. If using a BVM, slowly squeeze the bag for 1 second. Remove your mouth and allow the lungs to deflate. Breathe for the patient a second time. After these first two breaths, breathe once into the patient\u2019s mouth about every 5 to 6 seconds or 10 to 12 times per minute.\n\nOften, when rescue breathing is necessary, external cardiac compressions are also required. External cardiac compressions are explained in Chapter 8, Professional Rescuer CPR.",
        "Performing Rescue Breathing on Children and Infants": "The steps required to determine responsiveness and check and correct the patient\u2019s airway and breathing are similar for adults, children, and infants. However, some differences exist. You must learn and practice the different airway and breathing sequences for children and infants.",
        "Rescue Breathing for Children": "For the purposes of performing rescue breathing, a child is a person between age 1 year and the beginning of puberty (age 12 to 14 years). Keep the following differences between adult patients and children in mind: 1. Children are smaller and you will not have to use as much force to open their airways and tilt their heads. 2. The rate of rescue breathing is slightly faster for children. Give 1 rescue breath every 3 to 5 seconds (about 12 to 20 rescue breaths per minute) instead of the adult rate of 1 rescue breath every 5 to 6 seconds (10 to 12 rescue breaths per minute).",
        "Rescue Breathing for Infants": "If the patient is an infant (younger than 1 year), you must vary rescue breathing techniques slightly. Remember, an infant is tiny and must be treated extremely gently. The steps in rescue breathing for an infant are shown in Skill Drill 7-7: Responsiveness 1. Check for responsiveness by gently shaking the infant\u2019s shoulder or tapping the bottom of the foot Step 1. If the infant is unresponsive, place the infant on his or her back and shout for help or activate the emergency response system with a mobile phone. Proceed to Step 2. Check Circulation and Breathing 2. Check the brachial pulse (located inside of the upper arm). Simultaneously check for the absence of breathing or only gasping breaths by looking for the rise and fall of the infant\u2019s chest and listening for the sound of air moving in and out of the infant\u2019s mouth and nose Step 2. If the patient is not breathing and a pulse is present, proceed to Step 3. Airway 3. Check the airway and open it by using the head tilt\u2013chin lift maneuver. Do not tip the infant\u2019s head back too far because this may block the infant\u2019s airway. Tilt it only enough to open the airway Step 3. Breathing 4. Begin rescue breathing. Cover the infant\u2019s mouth and nose with your mouth. Blow gently into the infant\u2019s mouth and nose for 1 second Step 4. Watch the chest rise with each breath. Remove your mouth and allow the lungs to deflate. 5. Do not overinflate an infant\u2019s lungs. Use small puffs of air, enough to make the chest rise with each breath. After these first two breaths, give one rescue breath every 3 to 5 seconds, or 12 to 20 rescue breaths per minute.\n\nThe rate of rescue breathing for infants is the same as for children. If the patient is breathing adequately, place him or her in the recovery position. Often when rescue breathing is necessary, external cardiac compressions are also required. External cardiac compressions, the C part of the CABs, are explained in Chapter 8, Professional Rescuer CPR.",
        "Foreign Body Airway Obstruction": "The first part of this section discusses the causes and recognition of mild airway obstruction and severe airway obstruction. The second part of this section discusses the management of foreign body airway obstruction in adults, children, and infants.",
        "Causes of Airway Obstruction": "Your attempt to perform rescue breathing on a patient may not be effective because of an airway obstruction. The most common airway obstruction is the tongue. If the tongue is blocking the airway, the head tilt\u2013chin lift maneuver or jaw-thrust maneuver should open the airway. However, if a foreign body is lodged in the air passage, you must use other techniques. Food is the most common foreign object that causes an airway obstruction. An adult may choke on a large piece of meat; a child may inhale candy, a peanut, or a piece of a hot dog. Children may put small objects in their mouths and inhale such things as tiny toys or balloons. Vomitus may obstruct the airway of a child or an adult.",
        "Types of Airway Obstruction": "Airway obstruction may be partial (a mild obstruction) or complete (a severe obstruction). The first step in caring for a conscious person who may have an obstructed airway is to ask, \u201cAre you choking?\u201d If the patient can reply to your question, the airway is not completely blocked. If the patient is unable to speak or cough, the airway is completely blocked.",
        "Mild Airway Obstruction": "In partial or mild airway obstruction, the patient coughs and gags. This indicates that some air is passing around the obstruction. The patient may even be able to speak, although with difficulty. To treat a mildly obstructed airway, encourage the patient to cough. Coughing is the most effective way of expelling a foreign object. If the patient is unable to expel the object by coughing (if, for example, a bone is stuck in the throat), arrange for the patient\u2019s prompt transport to an appropriate medical facility. Such a patient must be monitored carefully while awaiting transport and during transport because a mild obstruction can become a severe (complete) obstruction at any moment.",
        "Severe Airway Obstruction": "A patient with a severe (complete) airway obstruction will have different signs and symptoms than a patient with a mild airway obstruction. With no fresh oxygen entering the lungs, the body quickly uses all the oxygen breathed in with the last breath. The patient is unable to breathe in or out and, because he or she cannot exhale air, speech is impossible. Other symptoms of a severe airway obstruction may include poor air exchange, increased breathing difficulty, and a silent cough. If the airway is completely obstructed, the patient will become unconscious in 3 to 4 minutes. The currently accepted treatment for a completely obstructed airway in an adult or child involves abdominal thrusts, also called the Heimlich maneuver. Abdominal thrusts compress the air that remains in the lungs, pushing it upward through the airway so that it exerts pressure against the foreign object. The pressure pops the object out, in much the same way that a cork pops out of a bottle after the bottle has been shaken to increase the pressure. Many rescuers report that abdominal thrusts can cause an obstructing piece of food to fly across the room. A person who has had an obstruction removed from his or her airway by the Heimlich maneuver should be transported to a hospital for examination by a physician.",
        "Management of Foreign Body Airway Obstructions": "Relieving a foreign body airway obstruction requires no special equipment. The following sections describe the steps that you need to learn to relieve foreign body airway obstructions in adults, children, and infants. Performing these steps can make the difference between life and death for these patients.",
        "Airway Obstruction in an Adult": "The steps to treat severe airway obstruction vary, depending on whether the patient is conscious or unconscious. If the patient is conscious, stand behind the patient and perform the abdominal thrusts while the patient is standing or seated in a chair.\n\nLocate the xiphoid process (the bottom of the sternum) and the navel. Place one fist above the navel and well below the xiphoid process, thumb side against the patient\u2019s abdomen. Grasp your fist with your other hand. Then apply abdominal thrusts sharply and firmly, bringing your fist in and slightly upward. Do not give the patient a bear hug; rather, apply pressure at the point where your fist contacts the patient\u2019s abdomen. Each thrust should be distinct and forceful. Repeat these abdominal thrusts until the foreign object is expelled or until the patient becomes unresponsive. Review the steps in Skill Drill 7-8 until you can carry them out automatically. To assist a conscious patient with a complete airway obstruction, you must:\n1. Ask, \u201cAre you choking? Can you speak? Can I help you?\u201d If there is no verbal response, assume the airway obstruction is complete Step 1.\n2. Stand behind the patient and position the thumb side of your fist just above the patient\u2019s navel Step 2.\n3. Press into the patient\u2019s abdomen with a quick, upward thrust Step 3.\nRepeat the abdominal thrusts until either the foreign body is expelled or the patient becomes unresponsive.\n4. If the patient has obesity or is in the late stages of pregnancy, use chest thrusts instead of abdominal thrusts. Chest thrusts are done by standing behind the patient and placing your arms under the patient\u2019s armpits to encircle the patient\u2019s chest. Press with quick, backward thrusts.\n5. If the patient becomes unresponsive, continue with the following steps.\n6. Ensure the EMS system has been activated.\n7. Begin CPR:\nA. Perform chest compressions. (This part of the CPR sequence is covered in Chapter 8, Professional Rescuer CPR).\nB. Open the airway and look in the mouth. Remove the foreign body only if you can see it.\nC. Attempt to ventilate. If you are unable to ventilate, reposition the patient\u2019s head and reattempt ventilation. If both breaths do not produce visible chest rise, continue chest compressions.\n8. Continue these steps of CPR until more advanced EMS personnel arrive.\n\nRecent studies have shown that performing chest compressions on an unresponsive patient increases the pressure in the chest similar to performing abdominal thrusts and may relieve an airway obstruction. Therefore, performing CPR on a patient who has become unresponsive has the same effect as performing the Heimlich maneuver on a conscious patient.",
        "Skill performance sheet: Foreign Body Airway Obstruction in an Adult": "CASE 3: You are the Provider\nYou are enjoying a well-deserved day off. It is a mild and sunny day in spring, so you decide to go for a run in a local park. After a tiring but refreshing run, you are heading back to your vehicle when you notice an energetic group of young children from a daycare center. They seem to be enjoying an afternoon snack on the lawn. As you pass by, one of the caregivers begins to yell for help. You look over and see a boy about 9 years old, who is holding his neck and has a panicked look in his eyes. You run over and introduce yourself to the caregiver. She tells you the children were enjoying a snack and she thinks that Matt may have gotten something caught in his throat.\n\nWhat is the first step you should take?\n\nWhat else should you do for this patient?\n\nHow long should you continue your treatment?",
        "Airway Obstruction in a Child": "The steps for relieving an airway obstruction in a conscious child (age 1 year to the onset of puberty) are the same as for an adult patient. The anatomic differences between adults, children, and infants require that you make some adjustments in your technique. When opening the airway of a child or infant, tilt the head back just past the neutral position. Tilting the head too far back (hyperextending the neck) can actually obstruct the airway of a child or infant. If you are by yourself and a child with an airway obstruction becomes unresponsive, perform CPR for five cycles (about 2 minutes) before activating the EMS system.",
        "Airway Obstruction in an Infant": "The process for relieving an airway obstruction in an infant (younger than 1 year) must take into consideration that an infant is extremely fragile. An infant\u2019s airway structures are very small, and they are more easily injured than those of an adult. If you suspect an airway obstruction, assess the infant to determine whether there is any air exchange. If the infant has an audible cry, the airway is not completely obstructed. Ask the person who was with the infant what was happening when the episode began. This person may have seen the infant put a foreign body into his or her mouth.\n\nSuspect a severe airway obstruction if you observe no movement of air from the infant\u2019s mouth and nose, a sudden onset of severe breathing difficulty, a silent cough, or a silent cry. To relieve an airway obstruction in an infant, use a combination of back slaps and chest thrusts. You must have a good grasp of the infant to alternate the back slaps and the chest thrusts. Review the following sequence until you can carry it out automatically. To assist a conscious infant with a severe airway obstruction, you must:\n1. Assess the infant\u2019s airway and breathing status. Determine that there is no air exchange.\n2. Place the infant in a facedown position over one arm so you can deliver five back slaps. Support the infant\u2019s head and neck with one hand and place the infant facedown with the head lower than the trunk. Rest the infant on your forearm and support your forearm on your thigh. Use the heel of your hand and deliver up to five back slaps forcefully between the infant\u2019s shoulder blades.\n3. Support the head and turn the infant faceup by sandwiching the infant between your hands and arms. Rest the infant on his or her back with the head lower than the trunk.\n4. Deliver five chest thrusts in the middle of the sternum. Use two fingers to deliver the chest thrusts in a firm manner.\n 5. Repeat the series of back slaps and chest thrusts until the foreign object is expelled or until the infant becomes unresponsive.\n6. If the infant becomes unresponsive, continue with the following steps:\n7. Ensure the EMS system has been activated.\n8. Begin CPR: Perform chest compressions. (This part of the CPR sequence is covered in Chapter 8, Professional Rescuer CPR). Open the airway and look in the mouth. Remove the foreign body only if you can see it. Attempt to ventilate. If you are unable to ventilate, reposition the patient\u2019s head and reattempt ventilation. If both breaths do not produce visible chest rise, continue chest compressions.\n9. Continue these CPR steps until more advanced EMS personnel arrive.\n\nNOTE: If you are by yourself, perform CPR for five cycles (about 2 minutes) and then activate the EMS system.\n\nRecent studies have shown that performing chest compressions on an unresponsive patient increases the pressure in the chest similar to performing chest thrusts and may relieve an airway obstruction. Therefore performing CPR on an infant who has become unresponsive has the same effect as performing the chest thrusts on a conscious patient.",
        "Oxygen Administration": "Under normal conditions, the body can operate efficiently using the oxygen that is contained in the air, even though air contains only 21% oxygen. The amount of blood loss that occurs after a traumatic injury could mean that insufficient oxygen is delivered to the cells of the body. This results in shock. Administering supplemental oxygen to a patient showing signs and symptoms of shock increases the amount of oxygen delivered to the cells of the body and often makes a positive difference in the patient\u2019s outcome.\n\nPatients who have experienced a heart attack or stroke or patients who have a chronic heart or lung disease may be unable to get sufficient oxygen from room air. These patients will also benefit from receiving supplemental oxygen.\n\nNot all EMRs know how to administer oxygen; however, knowing this skill can help you when you are in a situation where EMS response may be delayed.\n\nBy learning this skill, you will be able to assist other members of the EMS team. Administer oxygen only after receiving proper training and with the approval of your medical director.",
        "Oxygen Equipment": "Several pieces of equipment are required to administer supplemental oxygen, including an oxygen cylinder, a pressure regulator/flowmeter, and a nasal cannula or face mask. The characteristics and operation of each piece of equipment are described in the following section",
        "Oxygen Cylinders": "Oxygen is compressed to 2,000 pounds per square inch (psi) and stored in portable cylinders. The portable oxygen cylinders used by most EMS systems are either size D or E. D size cylinders hold 350 liters of oxygen, and E size cylinders hold 625 liters of oxygen. Oxygen cylinders must be marked with a green color and be labeled as medical oxygen. Depending on the flow rate, each cylinder lasts for at least 20 minutes. A valve at the top of the oxygen cylinder allows you to control the flow of oxygen from the cylinder.",
        "Pressure Regulator/Flowmeter": "Oxygen in the cylinder is stored at 2,000 psi. Oxygen can be used only when that pressure is regulated down to about 50 psi, which is done by using a pressure regulator. The pressure regulator and the flowmeter are a single unit attached to the outlet of the oxygen cylinder. After the pressure has been reduced, you can adjust the flowmeter to deliver oxygen at a rate of 2 to 15 L/min. Because patients with different medical conditions require different amounts of oxygen, the flowmeter lets you select the proper amount of oxygen to administer. A gasket between the cylinder and the pressure regulator/flowmeter ensures a tight seal and maintains the high pressure inside the cylinder. Always check for this gasket before attaching the regulator.",
        "Nasal Cannulas and Face Masks": "The third part of an oxygen-delivery system is a device that ensures the oxygen is delivered to the patient and is not lost in the air. A nasal cannula has two small holes, which fit into the patient\u2019s nostrils. At 1 to 6 L/min, the nasal cannula delivers between 24% and 44% oxygen. A face mask is placed over the patient\u2019s nose and mouth to deliver oxygen through the patient\u2019s mouth and nostrils. Nonrebreathing masks are most commonly used by EMRs. Nonrebreathing masks deliver high concentrations of oxygen (up to 90%). These two oxygen-delivery devices are discussed more fully in the section on administering supplemental oxygen.",
        "Safety Considerations": "Oxygen does not burn or explode by itself. However, it actively supports combustion and can quickly turn a small spark or flame into a serious fire. Therefore, keep all sparks, heat, flames, and oily substances away from oxygen equipment. Smoking is never safe around oxygen equipment. The pressurized cylinders are also hazardous because the high pressure in an oxygen cylinder can cause an explosion if the cylinder is damaged. Secure the oxygen cylinder so that it will not fall. If the shut-off valve at the top of the cylinder is damaged, the cylinder can take off like a rocket. Oxygen cylinders should be kept inside sturdy carrying cases that protect the cylinder and regulator/flowmeter. Handle the cylinder carefully to guard against damage.",
        "Administering Supplemental Oxygen": "To administer supplemental oxygen, place the regulator/flowmeter over the stem of the oxygen cylinder and line up the pins on the pin-indexing system correctly. Check for the mandatory gasket. Tighten the securing screw firmly by hand. With the special key or wrench provided, turn the cylinder valve two turns counterclockwise to allow oxygen from the cylinder to enter the regulator/flowmeter. Check the gauge on the pressure regulator/flowmeter to see how much oxygen pressure remains in the cylinder. If the cylinder contains less than 500 psi, the amount of oxygen in the cylinder is too low for emergency use and should be replaced with a full cylinder (2,000 psi). To administer oxygen, you will need to adjust the flowmeter to deliver the desired liter-per-minute flow of oxygen. The patient\u2019s condition and the type of oxygen delivery device you use (a mask or a nasal cannula) dictate the proper flow. When the oxygen flow begins, place the face mask or nasal cannula onto the patient\u2019s face.",
        "Nasal Cannula": "A nasal cannula is a simple oxygen-delivery device. As mentioned previously, it consists of two small prongs that fit into the patient\u2019s nostrils and a strap that holds the cannula on the patient\u2019s face. A cannula delivers low-flow oxygen at 1 to 6 L/min and in concentrations of 24% to 44% oxygen. Low-flow oxygen can be used for fairly stable patients, such as those with slight chest pain or mild shortness of breath. To use a nasal cannula, first adjust the liter flow to 1 to 6 L/min and then apply the cannula to the patient. The cannula should fit snugly but should not be tight.",
        "Nonrebreathing Mask": "A nonrebreathing mask consists of connecting tubing, a reservoir bag, one-way valves, and a face piece. It is used to deliver a high flow of oxygen at 8 to 15 L/min. A nonrebreathing face mask can deliver concentrations of oxygen as high as 90%. The mask works by storing oxygen in the reservoir bag. When the patient inhales, oxygen is drawn from the reservoir bag. When the patient exhales, the air is exhausted through the one-way valves on the side of the mask.",
        "A nonrebreathing oxygen mask.": "Use nonrebreathing face masks for patients who require higher flows of oxygen. These include patients experiencing serious shortness of breath, severe chest pain, carbon monoxide poisoning, and congestive heart failure. Patients who are showing signs and symptoms of shock should also be treated with high-flow oxygen from a nonrebreathing face mask. To use a nonrebreathing mask, first adjust the oxygen flow to 8 to 15 L/min to inflate the reservoir bag before putting it on the patient. After the bag inflates, place the mask over the patient\u2019s face. Adjust the straps to secure a snug fit. Adjust the liter flow to keep the bag at least partially inflated while the patient inhales.",
        "Hazards of Supplemental Oxygen": "Supplemental oxygen can be lifesaving, but you must use it carefully so that you, your team, and the patient remain safe. Although this chapter provides you a basic outline on setting up oxygen equipment, you will need additional class work and practical training before you administer oxygen in emergency situations.",
        "Safety_16": "Avoid using oxygen around fire or flames. Secure oxygen cylinders to minimize the danger of explosion.",
        "Words of Wisdom": "Some patients who suffer from respiratory conditions such as asthma or emphysema may use a metered dose inhaler (MDI) to administer medications to help them breathe. An MDI is a miniature spray container used to direct medications through the mouth and into the lungs. MDIs deliver the same amount of medication each time they are used. MDIs should be shaken before medications administered to ensure the patient receives a uniform amount of medicine each time he or she uses the inhaler. Many patients will use their inhaler before they call for EMS assistance. If your local protocols permit you to assist patients with using their MDIs, you need to have special training in the proper use of these devices.",
        "Pulse Oximetry": "Pulse oximetry is used to assess the amount of oxygen saturated in the red blood cells. It does this through the use of a photoelectric cell that measures the light that passes through a fingertip or an earlobe. The machine that performs this function is called a pulse oximeter. A pulse oximeter consists of a sensor probe and a monitor. The sensor probe attaches to the patient\u2019s fingertip or earlobe by means of a spring-loaded clip. The sensor probe contains a light source and a receiving chamber. The sensor probe attaches to the monitor of the pulse oximeter by means of a cable. The pulse oximeter monitor contains an on-and-off switch and a screen for displaying the percent of oxygen saturation.\n\nTo operate the pulse oximeter, turn on the monitor. Most pulse oximeters perform a self-check to ensure the machine is operating correctly. This self-check will vary depending on the brand of the oximeter. After you confirm the monitor is operating correctly, place the sensor probe over the patient\u2019s fingertip or earlobe. The monitor should then display the percent of saturation of the patient\u2019s blood. In a healthy patient, the oxygen saturation should be between 95% and 100% when breathing room air.\n\nIf a patient has difficulty breathing as a result of injury or a disease process, the percent of oxygen saturation may be much lower than 95%. The pulse oximeter cannot tell you what is wrong with the patient. You must perform a thorough patient assessment, including a good medical history. The pulse oximeter can help you to recognize that the patient is having a problem. It can also help you to determine whether your treatment is helping the patient. If the steps you are taking to treat the patient coincide with an increased percentage of oxygen saturation, you can take that as a positive sign.\n\nLike any other device, a pulse oximeter has certain limitations. It will not give you an accurate reading if the patient is wearing nail polish or if the patient\u2019s fingers are very dirty. Also, if the patient is cold and the blood vessels in the fingertips or earlobes are constricted, the pulse oximeter reading will be inaccurate. Patients who have sustained considerable blood loss will also have an inaccurate pulse oximetry reading. Patients who have experienced carbon monoxide poisoning will have false readings because their red blood cells are saturated with carbon monoxide instead of with oxygen. It is important to understand that the pulse oximeter is a valuable tool to help you assess a patient\u2019s condition. However, like any tool, it has certain limitations that you must consider. Remember, no machine can replace a careful patient assessment, including a good medical history.",
        "Special Considerations": "As an EMR, you will encounter some situations that require a slight modification in your CPR technique. These situations include rescue breathing for patients with stomas, gastric distention, patients with dental appliances, and airway management in a vehicle. By adapting to these situations you can achieve effective CPR on these patients.",
        "Rescue Breathing for Patients With Stomas": "Some people have had surgery that removed part or all of the larynx. In these patients, the upper airway has been rerouted to open through a stoma (hole) in the neck. These patients are called neck breathers. Therefore, you must give rescue breathing through the stoma in the patient\u2019s neck. The technique is called mouth-to-stoma breathing.\n\nThe steps in performing mouth-to-stoma breathing are as follows:\n1. Check every patient for the presence of a stoma.\n2. If you locate a stoma, keep the patient\u2019s neck straight; do not hyperextend the patient\u2019s head and neck.\n3. Examine the stoma and clean away any mucus in it.\n4. If you observe a breathing tube in the opening, remove it to be sure the opening is clear. Clean the breathing tube rapidly and replace it into the stoma. Moistening the tube will make it easier to insert the tube.\n5. Place your mouth directly over the stoma and use the same procedures as in mouth-to-mouth breathing. It is not necessary to seal the mouth and nose of most people who have a stoma.\n6. If the patient\u2019s chest does not rise, he or she may be a partial neck breather. In these patients, seal the mouth and nose with one hand and then breathe through the stoma. You can also use a BVM or pocket-mask device to ventilate a patient with a stoma.",
        "Gastric Distention": "Gastric distention occurs when air is forced into the stomach instead of the lungs. This condition makes it harder to get an adequate amount of air into the patient\u2019s lungs, and it increases the chance that the patient will vomit. Breathe slowly into the patient\u2019s mouth just enough to make the chest rise. Remember, the lungs of children and infants are smaller and require smaller, gentler breaths during rescue breathing. The excess air may enter the stomach and cause gastric distention. Preventing gastric distention is much better than trying to correct it later after it has occurred.",
        "Dental Appliances": "Do not remove dental appliances that are firmly attached. They may help keep the patient\u2019s mouth full so you can make a better seal between the patient\u2019s mouth and your mouth or a breathing device. Loose dental appliances, however, may cause difficulties. Partial dentures may become dislodged during trauma or while you perform airway care and rescue breathing. If you discover loose dental appliances during your exam of the patient\u2019s airway, remove the dentures to prevent them from occluding the airway. Put them in a safe place so they will not get damaged or lost.",
        "Airway Management in a Vehicle": "If you arrive on the scene of a motor vehicle crash and find that the patient has an airway problem, how can you best assist the patient and maintain an open airway? If the patient is lying on the seat or floor of the vehicle, you can apply the jaw-thrust maneuver. Use the jaw-thrust maneuver if you suspect the crash could have caused a head or spine injury. If the patient is in a sitting or semireclining position, approach him or her from the side by leaning in through the window or across the front seat. Grasp the patient\u2019s head with both hands. Put one hand under the patient\u2019s chin and the other hand on the back of the patient\u2019s head just above the neck. Maintain a slight upward pressure to support the head and cervical spine and to ensure the airway remains open. This technique will often enable you to maintain an open airway without moving the patient. This technique has several advantages: 1. You do not have to enter the vehicle. 2. You can easily monitor the patient\u2019s carotid pulse and breathing patterns by using your fingers. 3. It stabilizes the patient\u2019s cervical spine. 4. It opens the patient\u2019s airway.",
        "Prep Kit-Ready for Review": "The main purpose of the respiratory system is to provide oxygen and to remove carbon dioxide from the red blood cells as they pass through the lungs. The structures of the respiratory system in children and infants are smaller than they are in adults. Thus, the air passages of children and infants may be more easily blocked by secretions or by foreign objects.\n When a patient experiences possible respiratory arrest, check for responsiveness; open the blocked airway using either the head tilt\u2013chin lift or jaw-thrust maneuver; check for fluids, solids, or dentures in the mouth; and correct the airway, if needed, using finger sweeps or suction.\n Maintain the airway by continuing to manually hold the airway open, by placing the patient in the recovery position, or by inserting an oral or a nasal airway. Check the chest for signs of breathing and correct any problems by using a mouth-to-mask or mouth-to-barrier device, bag-valve mask, or by performing mouth-to-mouth rescue breathing. It is important to use the correct sequence for adults, children, and infants.\nIf the airway is obstructed in a conscious adult or child, kneel or stand behind the patient and perform the Heimlich maneuver. Give abdominal thrusts until the obstruction is relieved or the patient becomes unconscious. For an unconscious adult or child with an airway obstruction, perform chest compressions. Move to the head, open the airway, and look in the patient\u2019s mouth. Do not perform a finger sweep\u2014regardless of the patient\u2019s age\u2014unless you can see the object. Attempt rescue breathing again. If the airway is still obstructed, repeat chest compressions, visualization of the mouth, and ventilation attempts until the obstruction is relieved.\nAdministering supplemental oxygen to patients showing signs and symptoms of shock increases the amount of oxygen delivered to the cells of the body and often makes a positive difference in the patient\u2019s outcome. Patients who have experienced a heart attack or stroke or patients who have chronic heart or lung disease may also benefit from receiving supplemental oxygen.\nUse pulse oximetry to assess the amount of oxygen saturated in the red blood cells.",
        "Vital Vocabulary": "airway: The passages from the openings of the mouth and nose to the air sacs in the lungs through which air enters and leaves the lungs., airway obstruction: Partial (mild) or complete (severe) obstruction of the respiratory passages resulting from blockage by food, small objects, or vomitus., alveolar ventilation: The exchange of oxygen and carbon dioxide that occurs in the alveoli., alveoli: The air sacs of the lungs where the exchange of oxygen and carbon dioxide takes place., aspirator: A suction device., bag-valve mask (BVM): A patient ventilation device that consists of a bag, one-way valves, and a face mask., bronchi: The two main branches of the trachea that lead into the right and left lungs. Within the lungs, they branch into smaller airways., capillaries: The smallest blood vessels that connect small arteries and small veins. Capillary walls serve as the membrane to exchange oxygen and carbon dioxide., cardiopulmonary resuscitation (CPR): The artificial circulation of the blood and movement of air into and out of the lungs in a pulseless, nonbreathing patient., esophagus: The tube through which food passes. It starts at the throat and ends at the stomach., external cardiac compressions: A means of applying artificial circulation by applying rhythmic pressure and relaxation on the lower half of the sternum; also called chest compressions., face mask: A clear plastic mask used for oxygen administration that covers the mouth and nose., flowmeter: A device on oxygen cylinders used to control and measure the flow of oxygen., gag reflex: A strong involuntary effort to vomit caused by something being placed or caught in the throat., gastric distention: Inflation of the stomach caused when excessive pressures are used during artificial ventilation and air is directed into the stomach rather than the lungs., head tilt\u2013chin lift maneuver: A method of opening the airway by tilting the patient\u2019s head backward and lifting the chin forward, bringing the entire lower jaw with it., Heimlich maneuver: A series of manual thrusts to the abdomen to relieve an upper airway obstruction., jaw-thrust maneuver: A method of opening the airway by bringing the patient\u2019s jaw forward without extending the neck., lungs: The organs that supply the body with oxygen and eliminate carbon dioxide from the blood., mandible: The lower jaw., manual suction devices: Hand-powered devices used for clearing the upper airway of mucus, blood, or vomitus., mechanical suction device: A battery-powered pump or an oxygen-powered aspirator used for clearing the upper airway of mucus, blood, or vomitus., metered dose inhaler (MDI): A miniature spray container used to direct medications through the mouth and into the lungs., minute ventilation: The amount of air pulled into the lungs and removed from the lungs in 1 minute., mouth-to-mask ventilation device: A piece of equipment that consists of a mask, a one-way valve, and a mouthpiece. Rescue breathing is performed by breathing into the mouthpiece after placing the mask over the patient\u2019s mouth and nose., mouth-to-stoma breathing: Rescue breathing for patients who, because of surgical removal of the larynx, have a stoma., nasal airway: An airway adjunct that is inserted into the nostril of a patient who is unable to maintain a natural airway; also called a nasopharyngeal airway., nasal cannula: A clear plastic tube, used to deliver oxygen, that fits onto the patient\u2019s nose., nasopharynx: The posterior part of the nose., oral airway: An airway adjunct that is inserted into the mouth to keep the tongue from blocking the upper airway; also called an oropharyngeal airway., oropharynx: The posterior part of the mouth., oxygen: A colorless, odorless gas that is essential for life., pharynx: The throat., pocket mask: A mechanical breathing device used to administer mouth-to-mask rescue breathing., pulse oximeter: A machine that consists of a monitor and a sensor probe that measures the oxygen saturation in the capillary beds., pulse oximetry: An assessment tool that measures oxygen saturation in the capillary beds., rescue breathing: Artificial means of breathing for a patient., respiratory arrest: Sudden stoppage of breathing., stoma: A surgical opening in the neck that connects the windpipe (trachea) to the skin., trachea: The windpipe."
    },
    {
        "Introduction": "The purpose of this chapter is to teach you the remaining skills to perform cardiopulmonary resuscitation (CPR). CPR consists of three major skills: the C (circulation) skills, the A (airway) skills, and the B (breathing) skills. In Chapter 7, Airway Management, you learned the airway and breathing skills. These airway and breathing procedures may be lifesaving for a patient who has stopped breathing and whose heart is still beating. In most cases, however, by the time you arrive on the scene, the patient has not only stopped breathing, but the heart has stopped beating as well. If the patient has no heartbeat and is not breathing or only gasping, rescue breathing alone will not save the patient\u2019s life. Forcing air into the lungs is useless unless the circulatory system can carry the oxygen in the lungs to all parts of the body. In this chapter, you will learn the C (circulation) skills. If the patient\u2019s heart has stopped, you can maintain or restore circulation manually through the use of chest compressions (closed-chest cardiac massage). According to recent studies, it is important to restore circulation before starting rescue breathing. Therefore, in this chapter you will learn to perform the circulation skills before you perform the airway and breathing skills (a CAB sequence). To maintain both a heartbeat and ventilation, chest compressions and rescue breathing must be done together. By combining the circulation, airway, and breathing skills, you will be able to perform CPR. Statistics show that about 70% of the patients who experience cardiac arrest are in a state of ventricular fibrillation\u2014a condition in which the heart muscle is quivering and not effectively pumping blood. Therefore, this chapter covers the theory and the steps you need to learn to use an automated external defibrillator to defibrillate these patients.",
        "Anatomy and Function of the Circulatory System": "The circulatory system consists of a pump (the heart), a network of pipes (the blood vessels), and fluid (blood). After blood picks up oxygen in the lungs, it travels to the heart, which in turn pumps the oxygenated blood to the rest of the body. In Chapter 6, The Human Body, you learned how the heart functions as a pump. The heart, which is about the size of your fist, is located in the chest between the lungs. The cells of the body absorb oxygen and nutrients (glucose) from the blood and produce waste products (including carbon dioxide) that the blood carries back to the lungs. In the lungs, the blood exchanges the carbon dioxide for more oxygen. Blood then returns to the heart to be pumped out again. Other metabolic waste products are removed by the kidneys and liver. The human heart consists of four chambers, two on the right side of the heart and two on the left side. Each upper chamber is called an atrium. The right atrium receives blood from the veins of the body; the left atrium receives highly oxygenated blood from the lungs. The bottom chambers are known as the ventricles. The right ventricle pumps deoxygenated blood to the lungs; the left ventricle pumps highly oxygenated blood throughout the body. The most muscular chamber of the heart is the left ventricle, which needs the most power because it must force blood to all parts of the body. The four chambers of the heart work together in a well-ordered sequence to pump blood to the lungs and to the rest of the body. One-way valves in the heart and veins allow the blood to flow in only one direction through the circulatory system. The arteries carry blood away from the heart at high pressure; therefore, the walls of arteries are thick. The main artery carrying blood away from the heart, the aorta, is quite large (about 1 inch [2.5 cm] in diameter), but arteries become smaller in diameter farther away from the heart. These smaller arteries eventually branch into the capillaries, the smallest pipes in the circulatory system. Some capillaries are so small that only one blood cell at a time can go through them. At the capillary level, oxygen passes from the blood cells into the cells of body tissues, and carbon dioxide and other waste products pass from the tissue cells to the blood cells, which then return to the lungs. Veins are the thin-walled pipes of the circulatory system that carry blood back to the heart. The four major artery locations are as follows: the neck (carotid arteries); the wrist (radial arteries); the arm (brachial arteries); and the groin (femoral arteries). The locations of these arteries are shown in Figure 8-2. Because these arteries lie between a bony structure and the skin, you can use them to measure the patient\u2019s pulse. A pulse is generated when the heart contracts and sends a pressure wave through the artery. The carotid pulse is measured on either side of the neck, the radial pulse is taken at the thumb side of the wrist, the brachial pulse is taken on the inside of the upper arm, and the femoral pulse is taken at the groin. Blood has several components plasma (a clear, straw-colored fluid), red blood cells, white blood cells, and platelets. The red blood cells give blood its red color. Red blood cells carry oxygen from the lungs to the body and bring carbon dioxide back to the lungs. The white blood cells are called infection fighters because they devour bacteria and other disease-causing organisms. Platelets start the blood-clotting process",
        "Locations for assessing the patient\u2019s pulse.": "A. Neck (carotid pulse). B. Wrist (radial pulse). C. Arm (brachial pulse). D. Groin (femoral pulse).",
        "Cardiac Arrest": "Cardiac arrest occurs when the heart stops contracting and no blood is pumped through the blood vessels. Without a supply of blood, the cells of the body will die because they cannot get any oxygen or nutrients and they cannot eliminate waste products. As the cells die, organ damage occurs. Some organs are more sensitive to low oxygen levels than others. Brain damage begins within 4 to 6 minutes after the patient has gone into cardiac arrest. Within 8 to 10 minutes, the damage to the brain may become irreversible. Cardiac arrest may have many different causes, including the following: Heart and blood vessel diseases such as heart attack and stroke. Respiratory arrest, if untreated. Medical emergencies such as epilepsy, diabetes, allergic reactions, electric shock, and poisoning. Drug overdose. Drowning. Suffocation. Trauma and shock caused by massive blood loss. A patient who has experienced cardiac arrest is unconscious and is not breathing or only gasping. You cannot feel a pulse and the patient looks dead.Regardless of the cause of cardiac arrest, the initial treatment is the same: provide CPR.",
        "Words of Wisdom": "Certain physiologic and lifestyle factors can increase the chance that a person will have a heart attack. These factors include high blood pressure, uncontrolled diabetes, obesity, high blood cholesterol or lipids, and high stress. These factors can affect your patients, but they can also affect you. Developing and maintaining a healthy lifestyle will be beneficial in reducing your chance of experiencing a heart attack.",
        "Components of CPR": "The technique of CPR requires three types of skills: C (circulation) skills, A (airway) skills, and B (breathing) skills. From the airway and breathing skills that were detailed in Chapter 7, Airway Management, you learned how to check patients to determine whether the airway is open and to correct a blocked airway by using the head tilt\u2013chin lift or jaw-thrust maneuver. You learned how to check patients to determine whether they are breathing. You also learned to correct the absence of breathing by performing rescue breathing. To perform CPR, you combine the A (airway) and B (breathing) skills with C (circulation) skills in a CAB sequence. You begin by checking for the patient\u2019s pulse. With practice, you will be able to check for a pulse at the same time you are checking for signs of breathing. This helps to reduce the time it takes to begin treating the patient. If the patient has no pulse, you must restore the patient\u2019s circulation by starting external chest compressions. The airway and breathing techniques you learned previously will then be used to push oxygen into the patient\u2019s lungs. External chest compressions move the oxygenated blood throughout the body. By compressing the patient\u2019s sternum (breastbone), you change the pressure in the patient\u2019s chest and force enough blood through the system to sustain life for a short period of time. CPR by itself cannot sustain life indefinitely. However, once it is recognized that the patient is pulseless and is not breathing or only gasping, start CPR as soon as possible to give the patient the best chance for survival. By performing all three parts of the CPR sequence, you can keep the patient alive until an AED is available and more advanced medical care can be delivered. In many cases, the patient will need defibrillation and medication to be successfully resuscitated from cardiac arrest.",
        "CPR: Words of Wisdom": "Patients who are experiencing cardiac events\u2014as well as their family members and friends\u2014will usually be fearful and anxious about the episode. It is important for you to demonstrate a caring attitude and to acknowledge those feelings. Although your primary goal is to ensure that the patient receives appropriate and timely care, you should understand that compassion is an important part of your care for patients experiencing a cardiac event.",
        "The Cardiac Chain of Survival": "In most cases of cardiac arrest, CPR alone is not enough to save lives, but it is the first treatment in the out-of-hospital chain of survival presented by the American Heart Association (AHA). The five links in the chain include:\n1. Recognition of cardiac arrest and activation of the emergency response system\n2. Immediate CPR with emphasis on high-quality chest compressions\n3. Rapid defibrillation\n4. Basic and advanced emergency medical services (EMS) care\n5. Advanced life support (ALS) and postarrest care\nAs an emergency medical responder (EMR), you can help the patient by providing early CPR with an emphasis on high-quality chest compressions and by making sure that the EMS system has been activated. Some EMRs are trained in the use of automated external defibrillators. By keeping these links of the chain strong, you will help keep the patient alive until early ALS care can be administered by paramedics and hospital personnel. Just as an actual chain is only as strong as its weakest link, the chain of survival is only as good as its weakest link. Your actions in performing early CPR are vital to giving cardiac arrest patients their best chance for survival",
        "The Cardiac Chain of Survival - Words of Wisdom": "Patients with chest pain are often in denial as to the reason for their chest pain. Many people will try to deny that their pain could be caused by a cardiac event. They may tell you that they are experiencing indigestion or that they have a cold. This denial often results in long delays before the patient decides to call 9-1-1. Treat any patient with chest pain as if his or her pain could be caused by a significant heart problem.",
        "When to Start CPR": "CPR should be started on all nonbreathing, pulseless patients, unless they are obviously dead or they have a do not resuscitate (DNR) order that is valid in your jurisdiction. (DNR orders are discussed more fully later in this chapter.) Few reliable criteria exist to determine death immediately. As discussed in Chapter 4, Medical, Legal, and Ethical Issues, the following criteria are reliable signs of death and indicate that CPR should not be started: 1. Decapitation. Decapitation occurs when the head is separated from the rest of the body. When this occurs, there is obviously no chance of saving the patient. 2. Rigor mortis. This is the temporary stiffening of muscles that occurs several hours after death. Rigor mortis indicates the patient has been dead for a prolonged period of time and cannot be resuscitated. 3. Evidence of tissue decomposition. Tissue decomposition or actual flesh decay occurs only after a person has been dead for more than 1 day. 4. Dependent lividity. Dependent lividity is the red or purple color that appears on the parts of the patient\u2019s body that are closest to the ground. It is caused by blood seeping into the tissues on the dependent, or lower, part of the person\u2019s body. Dependent lividity occurs after a person has been dead for several hours. If any of the preceding signs of death are present in a pulseless, nonbreathing person, do not begin CPR. If none of these signs is present, you should activate the EMS system and then begin CPR. It is far better to start CPR on a person who is later declared dead by a physician than to withhold CPR from a patient whose life might have been saved.",
        "When to Stop CPR": "You should discontinue CPR only when:\n1. Effective spontaneous circulation and ventilation are restored or the patient begins to move.\n2. Resuscitation efforts are transferred to another person with an equal or higher level of training who continues CPR.\n3. A physician orders you to stop.\n4. The patient is transferred to properly trained EMS personnel.\n5. Reliable criteria for death (as previously listed) are recognized.\n6. You are too exhausted to continue resuscitation, environmental hazards endanger your safety, or continued resuscitation would place the lives of others at risk.",
        "External Cardiac Compression": "External Chest Compressions on an Adult\nAn adult patient in cardiac arrest is unconscious, has no carotid pulse, and is not breathing or only gasping. If you suspect that the patient has experienced cardiac arrest, check the carotid pulse and look for no breathing or only gasping. To check the carotid pulse, place your index and middle fingers on the larynx (Adam\u2019s apple). Slide your fingers into the groove between the larynx and the muscles at the side of the neck. Keep your fingers there for at least 5 seconds but no more than 10 seconds to be sure the pulse is absent and not just slow. At the same time, look for signs of chest movement and feel for air exchange. If there is no carotid pulse in an unresponsive, nonbreathing patient, you must begin chest compressions. For chest compressions to be effective, the patient must be lying on a firm, horizontal surface. If the patient is on a soft surface, such as a bed, it is impossible to compress the chest. Immediately place all patients needing CPR on a firm, level surface. To position yourself so that you can perform chest compressions effectively, stand or kneel beside the patient\u2019s chest and face the patient. Place the heel of one hand in the center of the patient\u2019s chest, on the lower half of the sternum. Place the heel of your other hand on top of the hand on the chest and interlock your fingers. 1. Place the heel of your hand in the center of the chest, on the lower half of the sternum.\n Place your other hand on top of your first hand and interlock your fingers.\n, It is important to locate and maintain the proper hand position while applying chest compressions. If your hands are too high, the force you apply will not produce adequate chest compressions. If your hands are too low, the force you apply may damage the liver. If your hands slip sideways off the sternum and onto the ribs, the compressions will not be effective and you may damage the ribs and lungs.\n After you have both hands in the proper position, compress the chest of an adult at least 2 inches (5 cm) straight down. For compressions to be effective, stay close to the patient\u2019s side and lean forward so that your arms are directly over the patient. Keep your back straight and your elbows stiff so you can apply the force of your whole body to each compression, not just your arm muscles. Between compressions, make sure you completely release pressure on the chest to allow maximum filling of the patient\u2019s heart. Never lean on the chest during compressions. Compressions must be rhythmic and continuous. Each compression cycle consists of one downward push followed by a rest so that the heart can refill with blood. Push hard and push fast. Compressions should be at the rate of 100 to 120 compressions per minute in all patients\u2014adults, children, and infants. After every 30 chest compressions, give two rescue breaths (1 second per breath). Practice on a manikin until you can compress the chest smoothly and rhythmically.",
        "Performing Adult Chest Compressions": "Step 1. Place the heel of your hand in the center of the chest, on the lower half of the sternum. Step 2\nPlace your other hand on top of your first hand and interlock your fingers.\nStep 3\nCompress the chest of an adult at least 2 inches (5 cm) straight down.",
        "Chest Compressions - Treatment": "Do not let your fingers touch the chest wall; your fingers could dig into the patient, causing injury. Interlocking your fingers will help avoid this.",
        "External Chest Compressions on an Infant": "Infants (children younger than 1 year) who have experienced cardiac arrest will be unconscious, not breathing or only gasping, and will have no pulse. To check for cardiac arrest, begin by checking responsiveness. If the infant is unresponsive, check the brachial pulse and look, listen, and feel for signs of breathing. If a pulse is absent and there are no signs of breathing, begin CPR starting with chest compressions. To check an infant\u2019s circulation, feel for the brachial pulse on the inside of the upper arm. Use two fingers of one hand to feel for the pulse and use your other hand to maintain the head tilt. If the infant has no pulse and is not breathing or only gasping, begin CPR starting with chest compressions. Draw an imaginary horizontal line between the two nipples and place your index finger just below the imaginary line in the center of the chest. Place your middle and ring fingers next to your index finger. Use your middle and ring fingers to compress the sternum at least one-third the depth of the chest (about 1.5 inches [4 cm]). Compress the sternum at a rate of 100 to 120 times per minute. If you are the only rescuer, give two rescue breaths (1 second per breath) after every 30 chest compressions. If two rescuers are present, give two rescue breaths after every 15 chest compressions. When you perform chest compressions, place the infant on a solid surface such as a table or cradle the infant in your arm. You do not need to use much force to achieve adequate compressions on infants because they are so small and their chests are so flexible.",
        "External Chest Compressions on a Child": "The signs of cardiac arrest in a child (from age 1 year to the onset of puberty [age 12 to 14 years]) are the same as those for an adult. Determine if the child is responsive. If the child is unresponsive, simultaneously check the carotid pulse and for no breathing and for gasping. If there is no pulse, no breathing, and only gasping, the patient is in cardiac arrest. Check the carotid pulse by placing two or three fingers on the larynx. Slide your fingers into the groove between the Adam\u2019s apple and the muscle. Feel for the carotid pulse with one hand.\n\nTo perform chest compressions on a small child, place the heel of one hand in the center of the chest, on the lower half of the sternum. In larger children, perform chest compressions with two hands, as with the adult. Compress the sternum at least one-third the depth of the chest (about 2 inches [5 cm]). Compress the chest at a rate of at 100 to 120 times per minute. If you are the only rescuer present, give two rescue breaths after every 30 chest compressions. If two rescuers are present, give two rescue breaths after every 15 compressions.",
        "One-Rescuer Adult CPR": "In Chapter 7, Airway Management you learned how to open the airway and perform rescue breathing. Now that you have learned how to check for circulation and do chest compressions, you are ready to put all your skills together to perform CPR. If you are the only trained person at the scene, you must perform one-rescuer CPR. Follow the steps in Skill Drill 8-2: \n1. Establish unresponsiveness Step 1. Ask the patient, \u201cAre you okay?\u201d Gently shake the patient\u2019s shoulder. If you do not get a response, call for additional help, activate the EMS system, and send someone to get an AED if one is available. \n2. Position the patient so he or she is flat on his or her back on a hard surface. Position yourself so that your knees are alongside the patient\u2019s chest.\n3. Determine pulselessness by checking the carotid pulse and simultaneously checking for no breathing or only gasping. Check the pulse and breathing for no more than 10 seconds Step 2.\n 4. If the patient has no pulse and is not breathing or only gasping, begin chest compressions. Place the heel of one hand in the center of the chest, on the lower half of the sternum. Place your other hand on top of the first. Lock your fingers together and pull upward so that the only thing touching the patient\u2019s chest is the heel of your hand Step 3. 5. Lean forward so your shoulders are directly over your hands and the patient\u2019s sternum. Keep your arms straight and compress the sternum at least 2 inches (5 cm), using the weight of your body. Relax between compressions, allowing the chest to fully recoil. Give 30 compressions at a rate of 100 to 120 compressions per minute, and count each one out loud as follows: \u201cOne and two and three and\u2026.\u201d Each set of 30 compressions should take between 15 and 18 seconds to complete. 6. After 30 chest compressions, open the airway using a head tilt\u2013chin lift or a jaw-thrust maneuver if you suspect a head or spinal injury Step 4. Give two rescue breaths (1 second each). Ensure that each breath produces visible chest rise Step 5. 7. Continue the cycles of 30 chest compressions and two breaths until additional personnel arrive, an AED arrives, or the patient starts to move\n\nWhen performing one-rescuer CPR\u2014whether the patient is an adult, child, or infant\u2014deliver chest compressions and rescue breathing at a ratio of 30 compressions to two breaths. Immediately give two rescue breaths after each set of 30 chest compressions. Because you must interrupt chest compressions to ventilate, you should perform each series of 30 chest compressions in approximately 18 seconds (a rate of 100 to 120 compressions per minute). Although one-rescuer CPR can keep the patient alive, two-rescuer CPR is preferable because it is less exhausting for the rescuers. Whenever possible, CPR for an adult should be performed by two rescuers.",
        "One-Rescuer Adult CPR - Words of Wisdom": "If you do not have a partner with you to help perform CPR, do not wait for another rescuer to arrive. Call 9-1-1 to activate EMS and then begin one-rescuer CPR immediately!",
        "Performing One-Rescuer Adult CPR": "Step 1 Establish unresponsiveness by shouting and gently shaking the shoulder.\nStep 2 If the patient is unresponsive, simultaneously check the carotid pulse and check for signs of breathing. Take no more than 10 seconds to do this. If the patient is unresponsive, activate the EMS system.\n Step 3 If breathing and pulse are absent, begin a cycle of 30 chest compressions at a rate of 100 to 120 compressions per minute. Compress the chest at least 2 inches (5 cm) and release the pressure on the chest after each compression.\nStep 4 After 30 compressions, open the airway with a head tilt\u2013chin lift or a jaw-thrust maneuver if you suspect a head or spinal injury.\nStep 5 Give two rescue breaths over 1 second. Watch for chest rise to ensure air is going into the lungs. Continue cycles of 30 compressions and two rescue breaths until an AED arrives, patient care is assumed by other providers, or the patient starts to move.",
        "Two-Rescuer Adult CPR": "In many cases, a second trained person will be on the scene to help you perform CPR. Two-rescuer CPR is more effective than one-rescuer CPR. One rescuer delivers chest compressions while the other performs rescue breathing. Chest compressions and ventilations can be given more regularly and without interruption. However, to avoid rescuer fatigue\u2014which may result in less effective chest compressions\u2014the two rescuers should switch roles after every five cycles of CPR (about every 2 minutes). Two rescuers should be able to switch roles quickly, interrupting CPR for 5 seconds or less. In any circumstance, CPR should not be interrupted for longer than 10 seconds. In two-rescuer CPR, one rescuer delivers ventilations (mouth-to-mouth, bag-mask, or mouth-to-mask breathing) and the other gives chest compressions. If possible, position yourselves on opposite sides of the patient\u2014one rescuer near the head and the other near the chest. The sequence of steps is the same as for one-rescuer CPR, but the tasks are divided.Skill Drill 8-3\n\n1. Rescuer One establishes unresponsiveness. Rescuer Two moves to the patient\u2019s side to be ready to deliver chest compressions. Rescuer One activates the EMS system Step 1. 2. If the patient is unresponsive, Rescuer One determines pulselessness. Rescuer One simultaneously checks for signs of circulation and breathing by checking the carotid pulse and watching for chest rise for no more than 10 seconds Step 2. If the patient has no pulse and is not breathing or only gasping, continue to Step 3. 3. The rescuers begin CPR, starting with chest compressions. Rescuer Two performs 30 chest compressions at a rate of 100 to 120 compressions per minute Step 3. 4. Rescuer One opens the airway with a head tilt\u2013chin lift or, in the case of a trauma or if a head or spinal injury is suspected, a jaw-thrust maneuver Step 4. 5. Rescuer One gives two ventilations of 1 second each and observes for visible chest rise Step 5. 6. Continue CPR for five cycles of 30 compressions and two ventilations (about 2 minutes). After 2 minutes of CPR, the rescuers switch.positions. The switch time should take no longer than 5 seconds. 7.Continue cycles of 30 chest compressions and two ventilations until an AED arrives, ALS personnel take over, or the patient starts to move. Compressions and ventilations should remain rhythmic and uninterrupted. By counting out loud, Rescuer Two can continue to deliver compressions at the rate of 100 to 120 compressions per minute, briefly pausing as Rescuer One delivers two rescue breaths. Once you and your partner establish a smooth pattern of CPR, you should limit interruptions in CPR to 10 seconds or less, such as when reassessing or moving the patient. A skill performance sheet titled Two-Res cuer Adult CPR is shown in Figure 8-9 for your review and practice.",
        "Performing Two-Rescuer Adult CPR": "Step 1 Establish responsiveness and lack of breathing. Step 2\nIf the patient is unresponsive, simultaneously check the carotid\npulse and check for no breathing and only gasping. This should take\nno more than 10 seconds.\n Step 3: Perform 30 chest compressions. Step 4 Open the airway using the head tilt\u2013chin lift or jaw-thrust maneuver. Step 5: Perform rescue breathing; give two breaths. Continue cycles of 30 compressions and two rescue breaths until an AED arrives, care is assumed by other providers, or the patient starts to move.",
        "Two-Rescuer Adult CPR - Words of Wisdom": "When you have a patient who is in cardiac arrest, always be prepared for vomiting. It is a frequent event, and your preparation for it can be lifesaving.",
        "Switching Positions During CPR": "If you and your partner must continue to perform two-rescuer CPR for any length of time, the rescuer performing chest compressions will become tired. Once a rescuer gets tired, the effectiveness of chest compressions decreases. Therefore rescuers should switch positions after every five cycles of CPR (about every 2 minutes). This will improve the quality of chest compressions and give the patient the best chance for survival. A switch allows the person giving compressions (Rescuer Two) to rest his or her arms. Switching positions should be accomplished as smoothly and quickly (5 seconds or less) as possible to minimize the break in rate and regularity of compressions and ventilations. There are many orderly ways to switch positions. Learn the method practiced in your EMS system. One method is as follows:\n1. As Rescuer Two tires, he or she says the following out loud (instead of counting): \u201cWe\u2014will\u2014switch\u2014this\u2014time.\u201d One word is spoken as each compression is done. These words replace the counting sequence for the first five compressions. After 25 more chest compressions (a total of 30 compressions), Rescuer One completes two ventilations and moves to the chest to perform compressions. Rescuer Two moves to the head of the patient to maintain the airway and ventilation. Rescuer One then begins chest compressions. Practice switching positions until you can do it smoothly and quickly. Switching positions is much easier if the rescuers work on opposite sides of the patient.",
        "One-Rescuer Infant CPR": "An infant is defined as anyone younger than 1 year. The principles of CPR are the same for adults and infants. In actual practice, however, you must use slightly different techniques for an infant. Follow these steps for one-rescuer infant CPR: 1. Position the infant faceup on a firm, flat surface. 2. Establish the infant\u2019s level of responsiveness. An unresponsive infant is limp. Gently shake or tap the infant to determine whether he or she is unconscious. Call for additional help if the patient is unconscious. Activate the EMS system. 3. If the infant is unresponsive, simultaneously check the brachial pulse and check for signs of no breathing or only gasping. The brachial pulse is on the inside of the arm. You can feel it by placing your index and middle fingers on the inside of the infant\u2019s arm, halfway between the shoulder and the elbow. Check for at least 5 seconds but no more than 10 seconds. Assess for breathing by looking at the infant\u2019s chest and abdomen. 4. If the infant has no pulse and is not breathing or only gasping, begin chest compressions. An infant\u2019s heart is located relatively higher in the chest than an adult\u2019s heart. Imagine a horizontal line drawn between the infant\u2019s nipples. To correctly position your fingers for chest compressions, imagine a line between the infant\u2019s nipples. Place your index finger in the middle of the sternum and just below the nipple line and your middle and ring fingers next to your index finger. Raise your index finger so that your middle finger and ring fingers remain in contact with the chest. 5. Perform chest compressions on an infant using two fingers in the middle of the chest just below the nipple line. Compress the chest at least one-third the depth of the chest (about 1.5 [4 cm] inches) at a rate of 100 to 120 compressions per minute. 5. With your fingers in the correct location, compress the chest 30 times with the pads of your fingertips. Compress the chest at least one-third the depth of the chest (about 1.5 inches [4 cm]) at a rate of 100 to 120 compressions per minute. 6. Open the infant\u2019s airway. This step is best done by the head tilt\u2013chin lift maneuver. Gently tilt the infant\u2019s head to a neutral or slight sniffing position. Tilting it too far can obstruct the airway. 7. Give two breaths, each lasting 1 second. To breathe for an infant, place your mouth over the infant\u2019s mouth and nose. Because an infant has very small lungs, you should give only very small puffs of air, just enough to make the chest rise. Do not use large or forceful breaths. 8. Continue compressions and ventilations. If you are alone, give 30 compressions and two breaths. Continue to give 30 compressions followed by two rescue breaths until other providers arrive to take over the care of the infant or the infant begins to move.",
        "Two-Rescuer Infant CPR": "If you are performing two-rescuer infant CPR, use the two-thumb/encircling hands technique for chest compressions. This technique is done by placing both thumbs side by side over the lower half of the infant\u2019s sternum and encircling the infant\u2019s chest with your hands. Compress the sternum at a rate of 100 to 120 compressions per minute. When you are performing two-rescuer infant CPR, perform a compression-to-ventilation ratio of 15 to 2. Rescuers should switch roles after 10 cycles of CPR (about 2 minutes) when using a compression to ventilation ratio of 15:2.",
        "One-Rescuer and Two-Rescuer Child CPR": "A child is defined as a person between age 1 year and the onset of puberty (age 12 to 14 years). The steps for child CPR are essentially the same as for an adult; however, some steps may require modification for a child. These variations are as follows:\n1.\nUse less force to compress the child\u2019s chest.\n2.\nIn small children, use only one hand to depress the sternum at least one-third the depth of the chest (about 2 inches [5 cm]). Use two hands in larger children.\n3.\nUse less force to ventilate the child. Ventilate only until the child\u2019s chest rises.\nFollow these steps to administer CPR to a child:\n1.\nEstablish the child\u2019s level of responsiveness. Tap and gently shake the shoulder and shout, \u201cAre you okay?\u201d If a second rescuer is available, have him or her activate the EMS system and get an AED if available. 2. Place the child faceup on a firm, flat surface. 3. Check for circulation and simultaneously check for signs of no breathing or only gasping. Locate the larynx with your index and middle fingers. Slide your fingers into the groove between the larynx and the muscles at the side of the neck to feel for the carotid pulse. Check for at least 5 seconds but no more than 10 seconds. 4. If the child has no pulse and is not breathing or only gasping, begin chest compressions. 5. Begin a cycle of 30 chest compressions. Compress the chest at least one-third the diameter of the chest (approximately 2 inches [5 cm] in most children) at a rate of 100 to 120 compressions per minute. Count the compressions out loud: \u201cOne and two and three and\u2026.\u201d In between compressions, allow the chest to fully recoil. 6. After 30 compressions, open the airway. Use the head tilt\u2013chin lift maneuver or, if the child is injured, use the jaw-thrust maneuver. Maintain an open airway. 7. Give two rescue breaths. Blow slowly for 1 second, using just enough force to make the chest visibly rise. Allow the lungs to deflate between breaths. 8. Coordinate chest compressions and ventilations in a 30:2 ratio for one rescuer and 15:2 for two rescuers, making sure the chest rises with each ventilation. 9. After five cycles (about 2 minutes) of CPR, assess for signs of breathing or a pulse. If the child has no pulse and you have an AED, apply it now. 10.If you are alone with no communications device, perform 2 minutes of CPR before leaving the patient to activate the EMS system. 11. Continue until other EMS providers arrive to take over the care of the patient or the patient starts to move. A skill performance sheet titled One-Rescuer Child CPR is shown in Figure 8-14 for your review and practice. In large children, remember that you may need to use two hands to achieve an adequate depth of compression. When you are performing two-rescuer CPR on a child, administer 15 compressions followed by two rescue breaths.",
        "Signs of Effective CPR": "It is important to know the signs of effective CPR so you can assess your efforts to resuscitate the patient. The signs of effective CPR are as follows:\n1. A second rescuer feels a carotid pulse while you are compressing the chest.\n2. The patient\u2019s skin color improves (from blue to pink).\n3. The chest visibly rises during ventilations.\n4. Compressions and ventilations are delivered at the appropriate rate and depth.\nIf some of these signs are not present, evaluate and alter your technique to try and achieve these signs.",
        "Complications of CPR - Broken Ribs": "If your hands slip to the side of the sternum during chest compressions or if your fingers rest on the ribs, you may break a patient\u2019s ribs while delivering a compression. To prevent this complication, use proper hand positioning and do not let your fingers come in contact with the ribs. If you hear a cracking sound while performing CPR, check and correct your hand position but continue CPR. Sometimes you may break bones or cartilage even when using proper CPR technique.",
        "Complications of CPR - Gastric Distention": "Bloating of the stomach is called gastric distention. It is caused when too much air is blown too fast and too forcefully into the stomach. A partially obstructed airway, which allows some of the air you breathe into the patient\u2019s airway to go into the stomach rather than into the lungs, can also cause gastric distention. Gastric distention causes the abdomen to increase in size. A distended abdomen pushes on the diaphragm and prevents the lungs from inflating fully. Gastric distention also often causes regurgitation. If regurgitation occurs, quickly turn the patient to the side, wipe out the mouth with your gloved fingers, and then return the patient to a supine position. You can prevent gastric distention by making sure you have opened the airway completely. Do not blow excessive amounts of air into the patient (deliver each breath over a period of 1 second). Be especially careful if you are a large person with a large lung capacity and the patient is smaller than you.",
        "Complications of CPR - Regurgitation": "Regurgitation (passive vomiting) is a common occurrence during CPR, so you must be prepared to manage this complication. You can minimize the risk of regurgitation by minimizing the amount of air that enters the patient\u2019s stomach. Regurgitation commonly occurs if the patient has experienced cardiac arrest. When cardiac arrest occurs, the muscle that keeps food in the stomach relaxes. If there is any food in the stomach, it backs up, causing the patient to vomit. If the patient regurgitates as you are performing CPR, immediately turn the patient onto his or her side to allow the vomitus to drain from the mouth. Clear the patient\u2019s mouth of remaining vomitus, first with your fingers and then with a clean cloth (if one is handy). Use suction if it is available. The patient may experience frequent episodes of regurgitation, so you must be prepared to take these actions repeatedly. EMS units carry a mechanical suction machine that can clear the patient\u2019s mouth. However, you cannot wait until the mechanical suction machine arrives before beginning or resuming CPR. You must manage the regurgitation as it occurs so that CPR is not delayed. Do your best to clear any vomitus from the patient\u2019s airway. If the airway is not cleared, two complications may arise: The patient may breathe in (aspirate) the vomitus into the lungs. You may force vomitus into the lungs with the next artificial ventilation. It takes a strong stomach and the realization that you are trying to save the patient\u2019s life to continue with resuscitation after the patient has regurgitated\u2014but you must continue. Remove the vomitus from the patient\u2019s mouth with a towel, the patient\u2019s shirt, your gloved fingers, or a manual suction unit if available. As soon as you have cleared away the vomitus, continue rescue breathing.",
        "Voices of Experience": "When emergency medical responders arrived, they found Paul unconscious and unresponsive. Paul, my friend of 10 years, was 70 years old and very physically fit. One day, while mowing the lawn, he began experiencing shortness of breath. He went inside to rest and felt better. Later that day, he had the same problem when he walked up the stairs. Paul called his doctor and made an appointment to be seen in his office the next week. The following day, while eating breakfast, he began to complain of chest pain. Paul\u2019s wife, Donna, called 9-1-1 and help was on the way, but before they arrived, Paul\u2019s wife says, \u201cHe turned green and that was it.\u201d When emergency medical responders arrived, they found Paul unconscious and unresponsive. With the ambulance still on the way, they immediately began to administer professional rescuer CPR. A pulse check was done and they opened his airway, but Paul had no pulse and was not breathing. The team initiated compressions and an AED was attached, \u201cShock advised, stand clear of patient.\u201d A shock was delivered. Paul had been in cardiac arrest for 4 minutes and 30 seconds. Two weeks after Paul\u2019s incident, I sat at a local restaurant listening to this story. As Paul\u2019s wife spoke, it sent chills up my spine. Paul was in cardiac arrest for over 4 minutes. Yet, due to rapid implementation of the cardiac chain of survival and the actions of the EMRs, my friend sat beside his wife with tears in his eyes that day thanking me for teaching others the lifesaving skills that had saved his life.\n\nAs you study the material in this textbook, consider the following: Will you someday be the Paul whose life is saved by someone, or will you be a lifesaver yourself and save someone\u2019s Paul?",
        "Creating Sufficient Space for CPR": "As an EMR, you will frequently find yourself alone with a patient in cardiac arrest. One of the first steps you must take is to create or find a space where you can perform CPR. Ask yourself, \u201cIs there enough room in this location to perform effective CPR?\u201d To perform CPR effectively, you need 3 to 4 feet (approximately 1 m) of space on all sides of the patient. This will provide you with enough space so that rescuers can change places, advanced life support procedures can be implemented, and an ambulance stretcher can be brought in. If there is not enough space around the patient, you have two options: 1. Quickly rearrange the furniture in the room or arrange objects at the scene to make space.2. Quickly drag the patient into an area that has more space; for instance, out of the bathroom and into the living room but not into a hallway. Space is essential to a smooth rescue operation for a cardiac arrest patient. It takes a minimal amount of time to either clear a space around the patient or move the patient into a larger area.",
        "Early Defibrillation by EMRs": "According to the AHA, about 424,000 people in the United States die each year of coronary heart disease in an out-of-hospital setting. As mentioned previously, more than 70% of all out-of-hospital cardiac arrest patients have an irregular heart electrical rhythm called ventricular fibrillation. This condition, often referred to as V-fib, is the rapid, disorganized, and ineffective vibration of the heart. An electric shock applied to the heart will defibrillate it and reorganize the vibrations into effective heartbeats. A patient in cardiac arrest stands the greatest chance for survival when early defibrillation is available.\n\nAs an EMR, you are often the first emergency health care provider to reach a patient who has collapsed in cardiac arrest. When you perform effective CPR, you are helping to keep the patient\u2019s brain and heart supplied with oxygen until a defibrillator and advanced life support (ALS) providers arrive at the scene.\n\nTo get defibrillators to cardiac arrest patients more quickly, increasing numbers of EMS systems are equipping EMRs with automated external defibrillators (AEDs). These machines accurately identify ventricular fibrillation and advise you to deliver a shock if needed. Such equipment allows you to combine effective CPR with early defibrillation to restore an organized heartbeat in a patient. AEDs may be appropriate for your community if you work to strengthen all links of the cardiac chain of survival. The links of the chain of survival include the following:\nRecognition of cardiac arrest and activation of the EMS system\nImmediate CPR with emphasis on high-quality chest compressions\nRapid defibrillation \n Basic and advanced EMS care \n Advanced life support and post arrest care,",
        "Performing Automated External Defibrillation": "The steps for using an AED are listed in Skill Drill 8-4:\n1. If CPR is in progress when you arrive, check the effectiveness of the chest compressions by checking for a pulse Step 1. It is important to limit the amount of time compressions are interrupted. If the patient is responsive, do not apply the AED.\n2. If the patient is unresponsive, begin providing chest compressions as soon as possible Step 2. Perform compressions and rescue breaths at a ratio of 30 compressions to two breaths, continuing until an AED arrives and is ready for use. It is important to start chest compressions and use the AED as soon as possible. Compressions provide vital blood flow to the heart and brain, improving the patient\u2019s chance of survival. If the cardiac arrest is witnessed, attach the AED as soon as it is available.\n3. Turn on the AED. Remove clothing from the patient\u2019s chest area. Apply the pads to the chest: one just to the right of the breastbone (sternum) just below the collarbone (clavicle), the other on the left lower chest area with the top of the pad 2 to 3 inches (5 cm to 8 cm) below the armpit. Be sure that the pads are attached to the patient cables (and that they are attached to the AED in some models). Plug in the pads connector to the AED Step 3.\n4. Stop CPR.\n5. State aloud, \u201cClear the patient,\u201d and ensure that no one is touching the patient.\n6. Push the analyze button, if there is one, and wait for the AED to determine if a shockable rhythm is present.\n7. If a shock is not advised, perform five cycles (about 2 minutes) of CPR beginning with chest compressions. Then reassess the patient\u2019s pulse and reanalyze the cardiac rhythm. If a shock is advised, reconfirm that no one is touching the patient and push the shock button. After the shock is delivered, immediately resume CPR, beginning with chest compressions Step 4.\n8. After five cycles (about 2 minutes) of CPR, reanalyze the patient\u2019s cardiac rhythm. Do not interrupt chest compressions for more than 10 seconds Step 5.\n9. Repeat the cycle of 2 minutes of CPR, one shock (if indicated), and 2 minutes of CPR.\n10. Arrange for transport, and contact medical control as needed. AEDs vary in design and operation, so learn how to use your specific AED. You must have the training required by your medical director to practice automated external defibrillation. Practice until you can perform the procedure quickly and safely. Because the recommended guidelines for using the AED change, always follow the most current CPR and Emergency Cardiac Care (ECC) guidelines.",
        "Procedure for Automated External Defibrillation": "Step 1 Check for responsiveness by shouting and gently shaking the shoulder. If the patient is unresponsive, simultaneously check the carotid pulse and check for signs of breathing or only gasping. If pulse is absent and there are no signs of breathing, proceed to Step 2. Begin cycles of 30 compressions and two breaths. Use the AED as soon as it is available. If cardiac arrest is witnessed, proceed to Step 3. Step 4 Turn on the AED. Apply the adhesive pads and connect them to the AED. Press the analyze button. If your AED has voice prompts, follow the verbal instructions. Do not touch the patient. Allow the AED to analyze the rhythm.\n\nIf a shock is advised, press the button to defibrillate the patient. If no shock is advised, perform five cycles of CPR. Step 5 As soon as the shock is delivered, begin CPR starting with chest compressions. Perform five cycles of CPR (about 2 minutes). After 2 minutes of CPR, go back to Step 3 to reanalyze the cardiac rhythm.",
        "Automated External Defibrillation - Special Populations": "You can safely use AEDs in pediatric patients using the pediatric-sized pads and a dose-attenuating system (energy reducer). However, if these items are unavailable, use an adult AED. During CPR, the AED should be applied to infants or children after the first five cycles of CPR have been completed. Cardiac arrest in children is usually the result of respiratory failure; therefore, oxygenation and ventilation are vitally important. After the first five cycles of CPR, use the AED to deliver shocks in the same manner as with an adult patient. If the child is between 1 month and 1 year of age (an infant), a manual defibrillator is preferred to an AED; however, manual defibrillation is a paramedic-level skill. Therefore, call for paramedic backup immediately if you suspect an infant may be in cardiac arrest. If paramedic backup with a manual defibrillator is not available, an AED equipped with a pediatric dose attenuator is preferred. If neither is available, an AED",
        "Automated External Defibrillation - Treatment": "When preparing to defibrillate a patient, be alert for the following situations:\nIf the patient is wet, dry the patient before initiating defibrillation. This will ensure that the defibrillation pads stick to the patient\u2019s chest and that the full shock is delivered safely.\nIf the patient has excessive hair on his chest and a razor is available, quickly shave the area where the pads will be placed.\nIf the patient has a pacemaker, you may need to reposition one of the defibrillation pads so that it is not placed directly over the pacemaker.\nIf the patient has a transdermal medication patch on his or her chest, remove the patch and wipe the skin before defibrillating the patient.",
        "CPR Training": "As an EMR, you should successfully complete a CPR course through a recognized agency such as the Emergency Care and Safety Institute or the AHA. You should also regularly update your skills by successfully completing a recognized recertification course. You cannot achieve proficiency in CPR unless you have adequate practice on adult, child, and infant manikins. Your department should schedule periodic reviews of CPR theory and practice for all EMRs.",
        "Legal Implications of CPR": "Advance directives, living wills, and durable powers of attorney for health care are legal documents that specify the patient\u2019s wishes regarding specified medical procedures. These documents are explained in Chapter 4, Medical, Legal, and Ethical Issues. You may sometimes wonder whether you should start CPR on a person who has an advance directive or a living will. Because you are not in a position to determine whether the advance directive or living will is valid, CPR should be started on all patients unless signs of obvious death are present (such as rigor mortis, tissue decay, or decapitation) or a resuscitation attempt would put you in harm\u2019s way. If a patient has an advance directive or living will, the physician at the hospital will determine whether you should stop CPR. Follow your department\u2019s protocols regarding advance directives, living wills, and do not resuscitate (DNR) orders. Do not hesitate to begin CPR on a pulseless, nonbreathing patient. Without your help, the patient will certainly die. Make sure you perform a careful assessment of the patient before beginning CPR. Another potential legal pitfall is abandonment\u2014the discontinuation of CPR without the order of a licensed physician or without turning the patient over to someone who is at least as qualified as you are. If you avoid these pitfalls, you need not be overly concerned about the legal implications of performing CPR. Your most important protection against a possible lawsuit is to become thoroughly skilled in the theory and practice of CPR.",
        "Prep Kit Ready for Review": "\nThe circulatory system transports oxygenated blood from the lungs to the rest of the body. Each beat of the heart produces a pulse, which can be felt at various sites on the body, such as the inside of the wrist (radial), the neck (carotid), the inside of the upper arm (brachial), and the groin (femoral).\n Cardiac arrest occurs when the heart stops contracting and no blood is pumped through the blood vessels. Brain damage begins within 4 to 6 minutes after the patient has experienced cardiac arrest. Within 8 to 10 minutes, the damage to the brain may become irreversible.\n The chain of survival includes five links that are essential to successful emergency cardiac care: (1) recognition of cardiac arrest and activation of the emergency response system; (2) immediate high-quality CPR; (3) rapid defibrillation; (4) basic and advanced emergency medical services (EMS); and (5) advanced life support (ALS) and post cardiac arrest care. \nWhen you arrive at an emergency scene, first assess the area for potential safety hazards. If the scene is unsafe, make it as safe as possible for yourself and the patient. As you approach the patient, look for possible causes of illness or injury. Next, establish unresponsiveness. If he or she is unresponsive, simultaneously check for signs of circulation and breathing by checking the pulse and watching for chest rise. If the patient has no pulse and is not breathing or only gasping, begin cardiopulmonary resuscitation (CPR) with chest compressions, followed by rescue breathing.\nBasic life support for adults and children follows the same general steps: Check responsiveness, circulation, airway, and breathing. Intervene at any point if the patient\u2019s airway is obstructed, the patient is not breathing or only gasping, or the patient has no pulse. \nUse the jaw-thrust maneuver to open the airway if you suspect a head or spinal injury and the head tilt\u2013chin lift maneuver if you do not suspect a head or spinal injury.\nRescue breathing should be performed at a rate of one breath every 5 to 6 seconds (10 to 12 breaths per minute) for adults and one breath every 3 to 5 seconds (12 to 20 breaths per minute) for children and infants.\nChest compressions should be performed at a rate of 100 to 120 compressions per minute for adults and children. Perform 30 compressions and two breaths for adults and for one-rescuer CPR. Perform 15 compressions and two breaths for two-rescuer child and infant CPR. \nBasic life support for infants is similar to that provided for adults and children. The techniques may vary somewhat, but the same general steps apply: check responsiveness, simultaneously check circulation and for the absence of breathing or just gasping. Intervene at any point if the infant\u2019s airway is obstructed, the infant is not breathing or only gasping, or the infant has no pulse.\nOpen an infant\u2019s airway by using the head tilt\u2013chin lift maneuver if you do not suspect a spinal injury. Be careful not to hyperextend the neck, which could obstruct the airway.\nIf the infant has no pulse, begin CPR. If you are alone, use two fingers to compress the chest 30 times, at a rate of 100 to 120 compressions per minute, to a depth equal to at least one-third the depth of the chest. After 30 compressions, give two breaths. If two rescuers are present, use the two-thumb/encircling hands technique and provide 15 compressions to two breaths.\nThe single most important cardiac arrest survival factor is early defibrillation. The indications for using an automated external defibrillator (AED) are that the patient is unresponsive, pulseless, and not breathing or only gasping. After determining that a patient is in cardiac arrest, begin immediate CPR and apply the AED as soon as possible.\nOnce you turn on the AED and attach it to the patient\u2019s bare chest, the AED will analyze the heart rhythm and advise whether a shock is indicated. If a shock is advised, ensure that no one is touching the patient, deliver the shock, and immediately perform CPR for 2 minutes before reanalyzing the patient\u2019s rhythm. If no shock is advised, perform CPR for 2 minutes and then reanalyze the patient\u2019s rhythm. Continue CPR and rhythm analysis until advanced life support personnel arrive.",
        "Vital Vocabulary": "automated external defibrillator (AED): A portable, battery-powered device that recognizes ventricular fibrillation and advises when a countershock is indicated. The device delivers an electric shock to patients with ventricular fibrillation., brachial pulse: The pulse on the inside of the upper arm., cardiac arrest: Sudden cessation of breathing and heart function., carotid pulse: The pulse taken on either side of the neck., chest compression: A means of applying artificial circulation by applying rhythmic pressure and relaxation on the lower half of the sternum; also called external cardiac compressions., child: A person between the age of 1 year and the onset of puberty (age 12 to 14 years)., circulatory system: The heart and blood vessels, which together are responsible for the continuous flow of blood throughout the body., femoral pulse: The pulse taken at the groin., gastric distention: Inflation of the stomach caused when excessive pressures are used during artificial ventilation and air is directed into the stomach rather than the lungs., infant: A person younger than 1 year., one-rescuer CPR: Cardiopulmonary resuscitation performed by one rescuer., plasma: The fluid part of the blood that carries blood cells, transports nutrients, and removes cellular waste materials., platelets: Microscopic disc-shaped elements in the blood that are essential to the process of blood clot formation, the mechanism that stops bleeding., pulse: The wave of pressure created by the heart as it contracts and forces blood out into the major arteries., radial pulse: Pulse located on the inside of the wrist on the thumb side., two-rescuer CPR_9: Cardiopulmonary resuscitation performed by two rescuers., ventilation: The movement of air in and out of the lungs., ventricular fibrillation: An uncoordinated muscular quivering of the heart; the most common abnormal rhythm causing cardiac arrest; also called V-fib."
    },
    {
        "Oxygen Flow Rates": "The cheat sheet provides oxygen flow rates for various devices used in emergency care. For a BC EMALB device, the flow rates range from 6 to 15 liters per minute (lpm) for a standard mask, 8 to 15 lpm for a non-rebreather mask, 15 lpm for a bag valve mask, and 2 to 4 lpm for a nasal canula. The Canadian Red Cross Emergency Care Manual recommends 6 to 10 lpm for a standard mask, 10+ lpm for a non-rebreather mask, and 10+ lpm for a bag valve mask. For a resuscitation mask (pocket mask), the flow rate is 6+ lpm. Normal room air has an oxygen concentration of 20.7% to 21%, while exhaled air has an oxygen concentration of 16%. The O2 percentage for different devices ranges from 24-36% for a nasal canula to 90+% for a non-rebreather mask and bag valve mask.",
        "Glasgow Coma Scale": "The Glasgow Coma Scale evaluates a patient's level of consciousness by assessing eye opening, verbal response, and motor response. Eye opening is rated from 1 (no response) to 4 (spontaneously). Verbal response includes 5 (oriented), 4 (confused), 3 (inappropriate words), 2 (incomprehensible sounds), and 1 (no response). Motor response is rated from 6 (obeys commands) to 1 (no response). The total score ranges from 3 to 15, with a score of 13 or less indicating rapid transport. Abnormal flexion (decorticate) is characterized by internally rotated arms, adducted legs, and plantar flexion, while abnormal extension (decerebrate) is characterized by extended arms, pronated hands, and extended legs.",
        "APGAR": "The APGAR scoring system assesses a newborn's condition at birth. It evaluates five parameters: Activity, Pulse, Grimace, Appearance, and Respiration. Activity is scored from 0 (limp) to 2 (active movement). Pulse is scored based on the heart rate: absent, below 100 bpm, or 100 bpm or higher. Grimace is scored from 0 (no response) to 2 (cough, sneeze, cry). Appearance is scored based on skin color: blue/pale, pink with blue extremities, or completely pink. Respiration is scored based on breathing pattern: absent, slow and irregular, or strong and crying. A score of 7-10 indicates normal conditions, 4-6 indicates fairly low, and 0-3 indicates critically low."
    },
    {
        "CPR Compression to Ventilation Ratios": "The cheat sheet outlines CPR compression-to-ventilation ratios based on age and number of rescuers. For one rescuer, the ratio is 30:2 for adults, children, and infants, while for neonates it is 3:1. With two rescuers, the ratio remains 30:2 for adults but becomes 15:2 for children and infants. Neonates do not receive AED, and CPR is recommended if their heart rate falls below 60 bpm. If a patient is hypothermic, rescuers should check the pulse for 45\u201360 seconds before starting CPR and limit to three AED cycles. Once compressions begin, they should be continued until return of spontaneous circulation (ROSC).",
        "High Performance 'Pit Crew' CPR": "This section explains the High Performance 'Pit Crew' CPR approach, which involves a sequence of steps for both airway clear and obstructed scenarios. In the airway clear scenario, rescuers perform compressions, use an AED if available, attempt two successful ventilations, place an OPA, and continue compressions and ventilations until return of spontaneous circulation (ROSC) or obvious signs of life are observed. If ventilation doesn't go in, rescuers readjust and try a second ventilation, remove the OPA, perform compressions and AED, look in the mouth, and attempt ventilation again. If two successful ventilations occur with the OPA in place, the process continues. In the airway obstructed scenario, rescuers follow similar steps but prioritize removing the OPA, performing compressions and AED, looking in the mouth, attempting ventilation, and repeating until either two successful ventilations or ROSC are achieved.",
        "CPR in transport - Treatable CPR": "This section lists treatable conditions requiring CPR during transport, along with their causes and actions to take. Conditions include hypoxia caused by asthma, COPD, CHF, anaphylaxis, or tension pneumothorax; hypovolemia due to trauma, GI bleed, or ruptured abdominal aortic arch; known acidosis from sepsis, diabetic ketoacidosis, or post-workout; hyperkalemia resulting from kidney failure, pressure sores, crush injury, or burns; hypothermia from submersion, cold weather, or being found on the floor; toxins from ingestion, injection, or inhalation; tamponade (cardiac) following cardiac surgery, infection, IV drug use, or trauma; tension pneumothorax from trauma, COPD, asthma, or Marfan's syndrome; thrombosis (pulmonary) from sudden death, IVDU, pregnancy, fractures, flights, bed rest, or cancer; and thrombosis (coronary) from sudden death or coronary artery disease. For each condition, the action recommended is consulting medical oversight (CliniCall).",
        "Oxygen Cylinder Calculations": "This section provides formulas for calculating the duration of flow from oxygen cylinders. The formula is Duration of Flow = (gauge pressure - 200 psi) x C / Flow Rate (lpm), where C is the cylinder constant. For D-cylinders, C = 0.16 L/psi, E-cylinders have C = 0.28 L/psi, and M-cylinders have C = 1.56 L/psi."
    },
    {
        "National EMS Education Standard Competencies": "Medicine\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient. Respiratory\nAnatomy, signs, symptoms, and management of respiratory emergencies, including those that affect the\nUpper airway\nLower airway Respiratory (cont\u2019d)\nAnatomy, physiology, pathophysiology, assessment, and management of\nEpiglottitis\nSpontaneous pneumothorax\nPulmonary edema\nAsthma\nChronic obstructive pulmonary disease Respiratory (cont\u2019d)\nAnatomy, physiology, pathophysiology, assessment, and management of (cont\u2019d)\nEnvironmental/industrial exposure\nToxic gas\nPertussis\nCystic fibrosis\nPulmonary embolism Respiratory (cont\u2019d)\nAnatomy, physiology, pathophysiology, assessment, and management of (cont\u2019d)\nPneumonia\nViral respiratory infections",
        "Introduction Patients often complain of dyspnea.": "Can be caused by many different conditions\nCause can be difficult to determine.",
        "Anatomy of the Respiratory System": "Respiratory system includes all the structures that contribute to breathing\nDiaphragm\nChest wall muscles\nAccessory muscles of breathing\nNerves to the muscles Upper airway consists of structures above the vocal cords.\nNose and mouth\nJaw\nOral cavity\nPharynx\nLarynx FIGURE 16-1 The upper airway includes the nose, mouth, jaw, oral cavity,\npharynx, and larynx. The lower airway includes the trachea, bronchi,\nbronchioles, and alveoli surrounded by the pulmonary capillaries. \u00a9 Jones & Bartlett Learning. Principal function of lungs is respiration.\nExchange of oxygen and carbon dioxide\nAir travels through trachea into lungs to:\nBronchi (larger airways)\nBronchioles (smaller airways)\nAlveoli (where actual exchange takes place)",
        "Physiology of Respiration": "Respiration process\nInspiration\nExpiration\nOxygen is provided to the blood.\nCarbon dioxide is removed.\nTakes place rapidly at level of alveoli FIGURE 16-2 An enlarged view of a single alveolus (air sac) showing where the exchange of oxygen and carbon dioxide between air in the sac and blood in the pulmonary capillaries takes place \u00a9 Jones & Bartlett Learning. FIGURE 16-3 The exchange of oxygen and carbon dioxide in the tissues. A. Oxygen passes from the blood through\ncapillaries to tissue cells. Carbon dioxide passes from tissue cells through capillaries to the blood. B. In the lungs, oxygen is picked up by the blood, and carbon dioxide is given off. A, B, C: \u00a9 Jones & Bartlett Learning. In the alveoli:\nOxygen passes into capillaries.\nCarbon dioxide returns to lungs.\nBrainstem senses blood\u2019s carbon dioxide levels.\nRegulates breathing rate and depth",
        "Pathophysiology": "Oxygen exchange can be hindered by:\nConditions in the anatomy of the airway\nDisease processes\nTraumatic conditions\nAbnormalities in pulmonary vessels Recognize the signs and symptoms of inadequate breathing and know what to do about it.\nSome patients have chronic carbon dioxide retention.\nLow levels of oxygen control breathing.\nUse caution when administering oxygen.",
        "Causes of Dyspnea": "Patients often have dyspnea or hypoxia with:\nPulmonary edema\nHay fever\nPleural effusion\nObstruction of the airway\nHyperventilation syndrome\nEnvironmental/industrial exposure\nDrug overdose Dyspneic patients may have:\nGas exchange obstructed \nDamaged alveoli\nObstructed air passages\nObstructed blood flow to the lungs\nExcess fluid in pleural space Patients may also complain of chest tightness or air hunger.\nCommon with cardiopulmonary diseases\nPain can cause rapid, shallow breathing.",
        "Upper or Lower Airway Infection Infectious diseases may affect all parts of the airway.": "Some forms of obstruction cause dyspnea.\nMucus and secretions obstructing airflow in major passages \nSwelling of soft tissues in upper airways \nImpaired exchange of gases in the alveoli",
        "Croup Inflammation and swelling of pharynx, larynx, and trachea": "Stridor and seal-bark cough\nResponds well to humidified oxygen FIGURE 16-4 Croup results in swelling of the whole\nairway: pharynx, larynx, and trachea. \u00a9 Jones & Bartlett Learning.",
        "Epiglottitis Bacterial infection causing inflammation of epiglottis": "Children are often found in tripod position and drooling.\nPosition comfortably and provide oxygen. FIGURE 16-5 Acute epiglottitis is caused by a bacterial infection that results in severe swelling of the epiglottis, which could obstruct the airway. \u00a9 Jones & Bartlett Learning.",
        "Respiratory Syncytial Virus (RSV) Common cause of illness in young children": "Causes infection in the lungs and passages\nLook for signs of dehydration.\nTreat airway and breathing problems.\nHumidified oxygen is helpful.",
        "Bronchiolitis Viral illness often caused by RSV": "Usually affects newborns and toddlers\nBronchioles become inflamed, swell, and fill with mucus.\nProvide oxygen therapy and frequently reassess",
        "Pneumonia Bacterial pneumonia will come on quickly and result in high fever.": "Viral pneumonia presents more gradually and is less severe.\nEspecially affects people who are chronically ill\nAssess temperature and provide airway support and supplemental oxygen.",
        "Pertussis Airborne bacterial infection that mostly affects children younger than 6 years": "Patients will be feverish and exhibit a \u201cwhoop\u201d sound on inspiration after a coughing attack.\nWatch for dehydration and suction as needed.",
        "Influenza Type A Became pandemic in 2009": "Symptoms include fever, cough, sore throat, muscle aches, headache, and fatigue.\nMay lead to pneumonia or dehydration",
        "COVID-19 (SARS-CoV-2) Similar to the virus that causes the common cold": "Preferentially affects the elderly, those living in close quarters with one another, and those with weakened immune systems.\nTransmitted by aerosol droplets and airborne particles\nRespiratory deterioration may occur rapidly.",
        "Tuberculosis (TB) Bacterial infection that most often affects the lungs": "Can remain inactive for years\nPatients often complain of fever, coughing, fatigue, night sweats, and weight loss.\nWear gloves, eye protection, and an N-95 respirator (at a minimum).",
        "Acute Pulmonary Edema": "Heart muscle cannot circulate blood properly.\nFluid builds up within alveoli and in lung tissue.\nUsually result of congestive heart failure\nMost patients have a long-standing history of chronic congestive heart failure.\nIn severe cases, a frothy pink sputum forms at the nose and mouth. FIGURE 16-6 In pulmonary edema, fluid fills the alveoli and separates the capillaries from the alveolar wall, interfering with the exchange of oxygen and carbon dioxide. \u00a9 Jones & Bartlett Learning",
        "Chronic Obstructive Pulmonary Disease": "Slow process of dilation and disruption of airways and alveoli\nCaused by chronic bronchial obstruction\nTobacco smoke can create chronic bronchitis. FIGURE 16-7 Repeated episodes of irritation and inflammation in the alveoli result in the obstruction, scarring, and some dilation of the alveolar sac characteristic of COPD. \u00a9 Jones & Bartlett Learning.",
        "Emphysema is most common type of COPD.": "Loss of elastic material in the lungs\nCauses include inflamed airways, smoking.\nMost patients with COPD have elements of both chronic bronchitis and emphysema.",
        "Patients with pulmonary edema will have \u201cwet\u201d lung sounds.": "Patients with COPD will have \u201cdry\u201d lung sounds.\nCan be easily confused with congestive heart failure\nTreat the patient, not the lung sounds.",
        "Asthma, Hay Fever, and Anaphylaxis": "Result of allergic reaction to inhaled, ingested, or injected substance\nIn some cases, allergen cannot be identified.\nIn some cases, there is no identifiable allergen. Asthma is acute spasm of smaller air passages (bronchioles), associated with excessive mucus production and swelling of the mucus membranes. FIGURE 16-8 Asthma is an inflammation of the lungs\nassociated with excessive mucus production and\nswelling of the bronchioles. A. Cross section of a normal\nbronchiole. B. The bronchiole in spasm; a mucus plug has\nformed and partially obstructed the bronchiole. A, B: \u00a9 Jones & Bartlett Learning Asthma affects all ages.\nMost prevalent in children 5\u201317 years\nProduces characteristic wheezing\nAsthma attack may be caused by allergic reaction to foods or allergens or severe emotional distress, exercise, and respiratory infections. Hay fever causes cold-like symptoms.\nAllergens include pollen, dust mites, pet dander.\nAnaphylactic reaction can produce severe airway swelling. \nTotal obstruction is possible.\nTreat with epinephrine, oxygen, and antihistamines.",
        "Pneumothorax is accumulation of air in pleural space.": "Most often caused by trauma\nMay be caused by medical conditions\nSpontaneous pneumothorax Occurs with lung infections or in weak lungs\nPatient becomes dyspneic.\nBreath sounds may be absent on affected side. FIGURE 16-10 A pneumothorax occurs when air leaks into the pleural space from an opening in the chest wall or the surface of the lung. The lung collapses as air fills the pleural space and the two pleural surfaces are no longer in contact. \u00a9 Jones & Bartlett Learning",
        "Pleural Effusion Collection of fluid outside the lung": "Compresses lung and causes dyspnea\nCan stem from irritation, infection, congestive heart failure, or cancer\nUpright position eases pain.",
        "Obstruction of the Airway": "Patient with dyspnea may have mechanical obstruction.\nIn unconscious patients, obstruction may be caused by aspiration of vomitus or tongue blocking the airway.\nIf patient was eating just before dyspnea, always consider foreign body obstruction. FIGURE 16-12 A. Foreign body obstruction occurs when an object, such as food, is lodged in the airway. B. Mechanical obstruction also occurs when the head is\nnot properly positioned, causing the tongue to fall back into the throat. \u00a9 Jones & Bartlett Learning",
        "Pulmonary Embolism": "A blood clot that circulates through the venous system\nCirculation cut off partially or completely\nSignificantly decreases blood flow\nIf large enough, can cause sudden death Signs and symptoms include:\nDyspnea\nTachycardia\nTachypnea\nVarying degrees of hypoxia\nCyanosis\nAcute chest pain\nHemoptysis",
        "Hyperventilation": "Overbreathing to the point that arterial carbon dioxide falls below normal\nMay be indicator of life-threatening illness\nBody may be trying to compensate for acidosis. \nBuildup of excess acid in blood or body tissues Can result in alkalosis\nBuildup of excess base in body fluids\nCan cause symptoms of panic attack:\nAnxiety\nDizziness\nNumbness\nTingling or painful spasms of the hands/feet\n\nComplete primary assessment and gather history.\nDo not have patient breathe into paper bag.\nReassure the patient and provide supplemental oxygen.\nTransport promptly.",
        "Environmental/Industrial Exposure Pesticides, cleaning solutions, chemicals, chlorine, and other gases can be released.": "Carbon monoxide\nOdorless\nHighly poisonous\nProduced by fuel-burning appliances and smoke.\nDo not put yourself at risk.",
        "Scene Size-up Scene safety": "Use standard precautions and PPE.\nConsider possibility of infectious disease or toxic substance.\nMechanism of injury/nature of illness\nIf in question, ask why 9-1-1 was activated.\nQuestion the patient, family, and/or bystanders to determine NOI.",
        "Primary Assessment": "Identify immediate life threats.\nForm a general impression.\nNote age and position of patient.\nUse AVPU scale.\nAsk patient about chief complaint. Airway and breathing\nMake sure airway is patent and adequate.\nAssess rate, rhythm, and quality.\nAsk the following questions:\nIs the air going in?\nDoes the chest rise and fall with each breath?\nIs the rate adequate for the victim\u2019s age? Assess breath sounds\nCheck breath sounds on the right and left sides of the chest.\nAbnormal sounds include wheezing, rales, rhonchi, and stridor. FIGURE 16-15 Locations of the stethoscope bell for\nauscultation of breath sounds. \u00a9 Jones & Bartlett Learning. Circulation\nAssess pulse rate, rhythm, and quality.\nEvaluate for shock and bleeding.\nAssess perfusion by evaluating skin color, temperature, and condition. Transport decision\nIf condition is unstable and there is possible life threat:\nAddress the life threat.\nProceed with rapid transport.",
        "History Taking": "Investigate chief complaint.\nFind out what the patient has done for the breathing problem.\nSAMPLE history OPQRST assessment\nOnset, provocation/palliation, quality, radiation/region, severity\nPASTE assessment\nSpecific for patients with dyspnea\nProgression, associated chest pain, sputum, talking tiredness, exercise tolerance",
        "More in-depth assessment of body systems": "Proceed only after addressing life-threats.\nUse monitoring devices if you have them.",
        "Look for signs of COPD": "Patient older than 50 years of age\nHistory of lung problems\nActive or former cigarette smoker\nTightness in chest\nConstant fatigue\nBarrel-like appearance to chest\nUse of accessory muscles\nAbnormal breath sounds",
        "Reassessment Repeat the primary assessment.": "Assess for changes in condition.\nInterventions may include:\nOxygen via nonrebreathing mask at 15 L/min\nPositive pressure ventilations\nAirway management techniques\nPositioning in high Fowler position or position of choice\nAssisting with respiratory medications",
        "Emergency Medical Care": "Administer supplemental oxygen.\nSome patients may need CPAP or bag-mask device.\nPatient may have metered-dose inhaler (MDI) or small-volume nebulizer.\nConsult medical control and make sure medication is indicated. Ensure there are no contraindications\nMost medications are used relax the muscles that surround the air passages in the lungs. \nCommon side effects of inhalers:\nIncreased pulse rate\nNervousness\nMuscle tremors",
        "Upper or lower airway infection": "Administer humidified oxygen (if available).\nDo not attempt to suction the airway or place an oropharyngeal airway. \nPosition comfortably.\nTransport promptly.",
        "Acute pulmonary edema": "Provide 100% oxygen.\nSuction if necessary.\nPosition comfortably. \nProvide CPAP if indicated and allowed by protocol. \nTransport promptly.",
        "Chronic obstructive pulmonary disease": "Assist with prescribed inhaler.\nWatch for side effects from overuse.\nPosition comfortably.\nTransport promptly.",
        "Asthma": "Be prepared to suction.\nAssist asthma patient with prescribed inhaler.\nProvide aggressive airway management, oxygen, and prompt transport.",
        "Hay fever": "Unlikely to need emergency treatment\nAnaphylaxis \nRemove the offending agent.\nMaintain the airway.\nTransport rapidly.\nAdminister epinephrine.",
        "Spontaneous pneumothorax": "Provide supplemental oxygen.\nTransport promptly.\nMonitor carefully.\nPleural effusion\nFluid removal must be done in hospital.\nProvide oxygen.\nTransport promptly.",
        "Obstruction of airway": "Partial obstruction\nProvide supplemental oxygen and transport.\nComplete obstruction\nClear obstruction and administer oxygen.\nTransport rapidly to emergency department.",
        "Pulmonary embolism": "Supplemental oxygen is mandatory.\nPosition comfortably. \nIf hemoptysis is present, clear airway immediately.\nTransport promptly.",
        "Environmental/industrial exposure": "Ensure patients are decontaminated.\nTreat with oxygen, adjuncts, and suction based on presentation.",
        "Treatment of Specific Conditions": "Foreign body aspiration\nClear the airway.\nProvide oxygen and transport.\nTracheostomy dysfunction\nPosition comfortably.\nSuction to clear the obstruction.\nProvide oxygen. Asthma\nProvide blow-by oxygen.\nUse MDIs.\nCystic fibrosis\nGenetic disorder that affects the lungs and digestive system\nSuction and oxygenate as needed."
    },
    {
        "National EMS Education Standard Competencies": "Airway Management, Respiration, and Artificial Ventilation\nApplies knowledge of general anatomy and physiology to patient assessment and management in order to assure a patent airway, adequate mechanical ventilation, and respiration for patients of all ages. Airway Management\nAirway anatomy\nAirway assessment\nTechniques of assuring a patent airway Respiration\nAnatomy of the respiratory system\nPhysiology and pathophysiology of respiration\nPulmonary ventilation\nOxygenation\nRespiration (external, internal, cellular) Respiration (cont\u2019d)\nAssessment and management of adequate and inadequate ventilation\nSupplemental oxygen therapy Artificial Ventilation \nAssessment and management of adequate and inadequate ventilation\nArtificial ventilation\nMinute ventilation\nAlveolar ventilation\nEffect of artificial ventilation on cardiac output Pathophysiology\nApplies fundamental knowledge of the pathophysiology of respiration and perfusion to patient assessment and management.",
        "Introduction The primary component of caring for patients is ensuring that they can breathe adequately.": "When the ability to breathe is disrupted, oxygen delivery to tissues and cells is compromised.\nOxygen reaches body tissues and cells through breathing and circulation.",
        "Anatomy of the Respiratory System": "FIGURE 11-1 The upper and lower airways contain the structures in the body that help us breathe. \u00a9 Jones & Bartlett Learning. The respiratory system consists of all the structures that make up the airway and help us breathe, or ventilate.\nThe airway is divided into the upper and lower airways.",
        "Anatomy of the upper airway": "Nose\nMouth\nOral cavity\nPharynx\nLarynx The upper airway\u2019s main function is to warm, filter, and humidify air as it enters the body.\nPharynx\nMuscular tube extending from nose and mouth to level of esophagus and trachea\nComposed, from top to bottom, of the nasopharynx, oropharynx, and laryngopharynx Nasopharynx\nFilters out dust and small particles\nWarms and humidifies air as it enters the body FIGURE 11-2 The pharynx. \u00a9 Jones & Bartlett Learning. Oropharynx\nPosterior portion of the oral cavity\nThe epiglottis is superior to the larynx. FIGURE 11-3 The oral cavity. \u00a9 Jones & Bartlett Learning. Larynx\nComplex structure formed by many independent cartilaginous structures\nMarks where the upper airway ends, and the lower airway begins FIGURE 11-6 The larynx. \u00a9 Jones & Bartlett Learning. Larynx (cont\u2019d)\nThyroid cartilage forms a \u201cV\u201d shape anteriorly.\nCricoid cartilage is the first ring of the trachea.\nGlottis is the area between the vocal cords.",
        "Anatomy of the Lower Airway": "The lower airway\u2019s function is to deliver oxygen to the alveoli.\nLower airway includes:\nTrachea\nBronchi\nLungs Trachea\nConduit for air entry into the lungs\nDivides at the carina into two main stem bronchi, right and left\nBronchi are supported by cartilage.\nBronchi distribute oxygen to the lungs. FIGURE 11-7 The trachea and the lungs are lower airway structures. \u00a9 Jones & Bartlett Learning. Trachea (cont\u2019d)\nBronchioles are made of smooth muscle.\nSmaller bronchioles connect to alveoli.\nOxygen is transported back to the heart and distributed to the rest of the body. The heart and great vessels (vena cava and aorta) are found in the thoracic cavity. FIGURE 11-8 The thoracic cavity contains important\nanatomic structures for ventilation, oxygenation, and\nrespiration, including the lungs and bronchi, heart, great vessels (the vena cavae and aorta), and trachea. \u00a9 Jones & Bartlett Learning. FIGURE 11-9 The mechanism of ventilation can be illustrated by using a bell jar. Inhalation and chest expansion, anatomic (left) and bell jar (right). \u00a9 Jones & Bartlett Learning. The mediastinum contains:\nHeart\nGreat vessels\nEsophagus\nTrachea\nMajor bronchi\nMany nerves",
        "Physiology of Breathing": "The respiratory and cardiovascular systems work together.\nEnsure a constant supply of oxygen and nutrients is delivered to cells\nRemove carbon dioxide and waste products",
        "Physical act of moving air into and out of the lungs": "Inhalation\nActive, muscular part of breathing\nThe diaphragm and intercostal muscles contract.\nThis generates a negative pressure in the thorax, allowing air to enter. Inhalation (cont\u2019d)\nThe lungs require the movement of the chest and supporting structures to expand.\nPartial pressure: the amount of gas in the air or dissolved in fluid (blood)\nOxygen and carbon dioxide both diffuse until the partial pressures in the air and the blood are equal. FIGURE 11-9 The mechanism of ventilation can be illustrated by using a bell jar. Exhalation and chest contraction, anatomic (left) and bell jar (right). \u00a9 Jones & Bartlett Learning. Inhalation (cont\u2019d)\nInspiration delivers oxygen to the alveoli.\nTidal volume\nDead space Exhalation\nDoes not normally require muscular effort\nPassive process\nDiaphragm and intercostal muscles relax.\nSmaller thorax compresses air into the lungs. Regulation of ventilation involves a complex series of receptors and feedback loops.\nFailure to meet the body\u2019s need for oxygen may result in hypoxia.\nBased on pH changes in the blood and cerebrospinal fluid\nHypoxic drive\nTypically seen in patients with end-stage COPD",
        "Oxygenation Process of loading oxygen molecules onto hemoglobin molecules in bloodstream": "Required for internal respiration to take place\nDoes not guarantee that internal respiration is taking place\nVentilation without oxygenation can occur where oxygen levels have been depleted.",
        "Actual exchange of oxygen and carbon dioxide in the alveoli and tissues of the body": "Cells take energy from nutrients through metabolism. External respiration (pulmonary respiration) \nBrings fresh air into the respiratory system\nExchanges oxygen and carbon dioxide between alveoli and blood in pulmonary capillaries FIGURE 11-11 External respiration. \u00a9 Jones & Bartlett Learning. Internal respiration\nExchange of oxygen and carbon dioxide between systemic circulatory system and cells FIGURE 11-12 Internal respiration. \u00a9 Jones & Bartlett Learning.",
        "Pathophysiology of Respiration": "Factors in the nervous system\nChemoreceptors monitor levels of:\nOxygen\nCarbon dioxide\nHydrogen ions\npH of cerebrospinal fluid\nProvide feedback to the respiratory centers Ventilation/perfusion ratio and mismatch\nAir and blood flow must be directed to the same place at the same time.\nVentilation and perfusion must be matched.\nFailure to match is the cause of most abnormalities of oxygen and carbon dioxide exchange. Ventilation/perfusion ratio and mismatch (cont\u2019d)\nGas exchange does not take place.\nLack of O2 in bloodstream\nCO2 is recirculated within bloodstream.\nSevere hypoxemia can occur. Factors affecting pulmonary ventilation\nIntrinsic factors:\nInfections\nAllergic reactions\nUnresponsiveness (tongue obstruction)\nExtrinsic factors:\nTrauma Factors affecting respiration\nExternal factors:\nAtmospheric pressure\nPartial pressure of O2\nInternal factors:\nPneumonia\nPulmonary edema\nCOPD/emphysema Circulatory compromise\nTrauma emergencies can obstruct blood flow to individual cells and tissue:\nSimple or tension pneumothorax\nOpen pneumothorax\nHemothorax\nHemopneumothorax Circulatory compromise (cont\u2019d)\nOther causes:\nBlood loss\nAnemia\nHypovolemic shock\nVasodilatory shock",
        "Aerosol-generating procedures (AGPs)": "CPR\nNebulizer treatments\nEndotracheal intubation\nContinuous positive airway pressure Recognizing adequate breathing\nBetween 12 and 20 breaths/min\nRegular pattern of inhalation and exhalation\nBilateral clear and equal lung sounds \nRegular, equal chest rise and fall\nAdequate depth (tidal volume) Recognizing abnormal breathing\nFewer than 12 breaths/min\nMore than 20 breaths/min\nIrregular rhythm\nDiminished, absent, or noisy auscultated breath sounds\nReduced flow of expired air at nose and mouth Recognizing abnormal breathing (cont\u2019d)\nUnequal or inadequate chest expansion \nIncreased effort of breathing\nShallow depth \nSkin that is pale, cyanotic, cool, or moist\nSkin pulling in around ribs or above clavicles during inspiration A patient may appear to be breathing after the heart has stopped.\nCalled agonal gasps\nCheyne-Stokes respirations are often seen in patients with stroke or head injury. FIGURE 11-15 Cheyne-Stokes breathing shows irregular\nrespirations followed by a period of apnea. \u00a9 Jones & Bartlett Learning. Ataxic respirations\nIrregular or unidentifiable pattern\nMay follow serious head injuries\nKussmaul respirations\nDeep, rapid respirations\nCommon in patients with metabolic acidosis\nPatients with inadequate breathing need to be treated immediately. Assessment of respiration\nEven though the patient may be ventilating appropriately, respiration may be compromised.\nLevel of consciousness and skin color are excellent indicators of respiration. Assessment of respiration (cont\u2019d)\nAlso consider oxygenation\nPulse oximetry is considered a routine vital sign.\nCan be used as part of any patient assessment",
        "End-tidal CO2": "Measurement of the maximal CO2 at the end of an exhaled breath.\nLow CO2 level\nHyperventilation\nDecreased CO2 return to the lungs\nReduced CO2 production at the cellular level\nHigh CO2 level\nVentilatory inadequacy\nApnea Measured using capnometry and capnography devices\nNormal range is 35\u201345 mm Hg\nCan be used in spontaneously breathing patients with a special nasal cannula",
        "Opening the Airway": "Emergency medical care begins with ensuring an open airway.\nRapidly assess whether an unconscious patient has an open airway and is breathing adequately.\nPosition the patient correctly.\nSupine position is most effective. Unconscious patients should be moved as a unit.\nMost common airway obstruction is the tongue. FIGURE 11-23 The most common airway obstruction is\nthe patient\u2019s own tongue, which falls back into the throat when the muscles of the throat and tongue relax. \u00a9 Jones & Bartlett Learning.",
        "Will open the airway in most patients": "For patients who have not sustained or are not suspected of having sustained trauma FIGURE 11-24 The head tilt\u2013chin lift maneuver is a simple technique for opening the airway in a patient without a suspected cervical spine injury. \u00a9 Jones & Bartlett Learning. Follow these steps:\nWith the patient supine, position yourself beside the patient\u2019s head.\nPlace the heel of one hand on the forehead, and apply firm backward pressure with the palm.\nPlace the fingertips of the other hand under the lower jaw.\nLift the chin upward, with the entire lower jaw.",
        "Jaw-Thrust Maneuver If you suspect a cervical spine injury, use this maneuver.": "Follow these steps:\nKneel above the patient\u2019s head.\nPlace your fingers behind the angles of the lower jaw.\nMove the jaw upward.\nUse your thumbs to help position the jaw. FIGURE 11-25 Performing the jaw-thrust maneuver.\nA. Kneeling above the patient\u2019s head, place your fingers behind the angles of the lower jaw, and move the jaw upward. Use your thumbs to help position the lower jaw.\nB. The completed maneuver should look like this. A, B: \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Opening the Mouth": "Even if the airway is opened, the mouth may be closed.\nFor the cross-finger technique:\nPlace the tips of your index finger and thumb on the patient\u2019s teeth.\nPush your thumb on the lower teeth.\nPush index finger on the upper teeth.\nThe index finger and the thumb cross over each other.",
        "You must keep the airway clear to ventilate properly.": "Portable, hand-operated, and fixed equipment is essential for resuscitation. FIGURE 11-27 Suctioning equipment is essential for resuscitation. A. Hand-operated unit. B. Fixed unit.\nC. Portable unit. A, C: \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. B: \u00a9 Jones & Bartlett Learning. A portable or fixed unit should have:\nWide-bore, thick-walled, nonkinking tubing\nPlastic, rigid pharyngeal suction tips\nNonrigid plastic catheters\nA nonbreakable, disposable collection bottle\nWater supply for rinsing the tips",
        "Techniques of Suctioning": "Inspect the equipment regularly.\nTo operate the suction unit:\nCheck the unit for proper assembly of its parts.\nTest the suctioning unit to ensure vacuum pressure of more than 300 mm Hg.\nSelect and attach the appropriate suction catheter to the tubing. Never suction the mouth or nose for more than 15 seconds at one time for adult patients, 10 seconds for children, and 5 seconds for infants.\nSuctioning can result in hypoxia. When patients have secretions or vomitus that cannot be suctioned easily:\nRemove the catheter from the patient\u2019s mouth.\nLog roll the patient to the side.\nClear the mouth carefully with a gloved finger. If the patient produces frothy secretions as quickly as you can suction them:\nSuction the airway for 15 seconds (less in infants and children).\nVentilate for 2 minutes.\nContinue this alternating pattern until all secretions have been cleared.",
        "Basic Airway Adjuncts": "Prevent obstruction by the tongue and allow for passage of air and oxygen to the lungs\nOropharyngeal airways\nKeep the tongue from blocking the upper airway\nMake it easier to suction the oropharynx Oropharyngeal airways (cont\u2019d)\nIndications:\nUnresponsive patients without a gag reflex\nApneic patients being ventilated with a bag-mask device\nContraindications:\nConscious patients\nAny patient who has an intact gag reflex Nasopharyngeal airways\nUsed in a patient who:\nIs unresponsive or has an altered LOC\nHas an intact gag reflex\nIs unable to maintain his or her own airway spontaneously Nasopharyngeal airways (cont\u2019d)\nIndications:\nSemiconscious or unconscious patients with an intact gag reflex\nPatients who will not tolerate an oropharyngeal airway\nContraindications:\nSevere head injury with blood in the nose\nHistory of fractured nasal bone",
        "Maintaining the Airway Use the recovery position.": "Used to help maintain a clear airway in an unconscious patient who is not injured and is breathing on his or her own FIGURE 11-32 In the recovery position, the patient is rolled\nonto his or her left or right side. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Always give oxygen to patients who are hypoxic.": "Some tissues and organs need a constant supply of oxygen to function normally.\nNever withhold oxygen from any patient who might benefit from it. Supplemental oxygen equipment\nOxygen cylinders contain compressed gas.\nLiquid oxygen is becoming a more commonly used alternative. Safety considerations\nHandle gas cylinders carefully.\nMake sure the correct pressure regulator is firmly attached before transport.\nA puncture hole in a tank can turn it into a deadly missile.\nSecure cylinders when stored on ambulance and when in use during transport. Pin-indexing system\nPrevents such mistakes as an oxygen regulator being accidentally connected to a carbon dioxide cylinder\nEvery cylinder of a specific gas type has a given pattern and a given number of pins. Pressure regulators\nReduce the cylinder\u2019s pressure to a useful therapeutic range, usually 40 to 70 psi.\nFinal attachment for delivering the gas is either a quick-connect female fitting or a flowmeter. Flowmeters\nUsually permanently attached to pressure regulators on emergency medical equipment\nPressure-compensated flowmeter\nBourdon-gauge flowmeter Hazards of supplemental oxygen:\nCombustion\nOxygen toxicity Combustion\nOxygen does not burn or explode, but it does speed up the combustion process.\nKeep any sources of fire away.\nMake sure the area is adequately ventilated.\nNever leave an oxygen cylinder standing unattended. Oxygen toxicity\nNot all patients need high concentrations of oxygen.\nOxygen can have detrimental effects in patients with certain illnesses (COPD).\nWhen pulse oximetry available, tailor oxygen therapy; administer the minimum amount necessary to maintain oxygen saturation at or above 94%.",
        "Oxygen-Delivery Equipment Nonrebreathing masks": "Bag-mask devices\nNasal cannulas",
        "Nonrebreathing Masks": "Preferred way to give oxygen in the prehospital setting\nPatients who are breathing adequately but are suspected of having hypoxia\nCombination mask and reservoir bag system FIGURE 11-39 The nonrebreathing mask contains flapper valve ports at the cheek areas of the mask to prevent the patient from rebreathing exhaled gases. \u00a9 Jones & Bartlett Learning Make sure the reservoir bag is full before placing the mask on the patient.\nAdjust the flow rate so the bag does not collapse when the patient inhales.\nWhen oxygen therapy is discontinued, remove the mask.",
        "Nasal Cannulas": "Deliver oxygen through two small, tubelike prongs that fit into the nostrils\nCan provide 24% to 44% inspired oxygen when the flowmeter is set at 1\u20136 L/min FIGURE 11-40 The nasal cannula delivers oxygen directly through the nostrils. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Used in patients with mild hypoxemia\nA patient who breathes through the mouth, or has a nasal obstruction, will not benefit.\nWhen you anticipate a long transport time, consider using humidification.",
        "Partial Rebreathing Masks Similar to nonrebreathing masks": "There is no one-way valve between the mask and the reservoir.\nPatients rebreathe a small amount of exhaled air.",
        "Venturi Masks A number of settings can vary the percentage of oxygen while a constant flow is maintained.": "Delivers 24%\u201340% FIGURE 11-41 The Venturi mask. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Patients with tracheostomies do not breathe through their mouth and nose. FIGURE 11-42 For a patient with a tracheostomy, if you do": "not have a tracheostomy mask, use a face mask instead. \u00a9 Jones & Bartlett Learning. Tracheostomy masks cover the tracheostomy hole and have a strap that goes around the neck.\nMay not be available in an emergency setting\nImprovise by using a face mask placed at the tracheostomy opening.",
        "Assisted and Artificial Ventilation": "Basic airway and ventilation techniques are extremely effective.\nFollow standard precautions as needed when managing a patient\u2019s airway. Signs and symptoms of inadequate ventilation:\nAltered mental status\nInadequate minute volume\nExcessive accessory muscle use and fatigue When assisting with a bag-mask device:\nExplain the procedure to the patient.\nPlace the mask over the nose and mouth.\nSqueeze the bag each time the patient breathes.\nAfter the initial 5 to 10 breaths, deliver an appropriate tidal volume.\nMaintain an adequate minute volume. Artificial ventilation\nOnce a patient is not breathing, begin artificial ventilation immediately via:\nMouth-to-mask technique\nOne- or two-person bag-mask device Normal ventilation versus positive pressure ventilation\nIn normal breathing, the diaphragm contracts and negative pressure is generated in the chest cavity.\nPositive pressure ventilation is generated by a device that forces air into the chest cavity. With positive pressure ventilation:\nIncreased intrathoracic pressure reduces the blood pumped by the heart.\nMore volume is required to have the same effects as normal breathing.\nAir is forced into the stomach, causing gastric distention. Mouth-to-mouth and mouth-to-mask ventilation\nBarrier device is routinely used in mouth-to-mouth ventilations.\nMask with an oxygen inlet provides oxygen during mouth-to-mask ventilation. Bag-mask device\nProvides less tidal volume than mouth-to-mask ventilation\nAn experienced EMT can provide adequate tidal volume. FIGURE 11-45 A bag-mask device with an oxygen\nreservoir can deliver nearly 100% oxygen if a good\nseal between the mouth and mask is achieved and if\nsupplemental oxygen is used. \u00a9 American Academy of Orthopaedic Surgeons. Gastric distention (cont\u2019d)\nTo prevent or alleviate distention:\nEnsure the patient\u2019s airway is appropriately positioned.\nVentilate at the appropriate rate.\nVentilate with the appropriate volume.\nIf the stomach appears distended, recheck and reposition the head and perform rescue breathing. Passive ventilation\nExpansion and contraction create a \u201cpump\u201d for air movement.\nBenefits patients who are receiving chest compressions\nCan be enhanced using oropharyngeal airway and supplemental oxygen Automatic transport ventilator (ATV)/resuscitator\nManually triggered device attached to a control box\nAllows the variables of ventilation to be set\nLacks the sophisticated control of a hospital ventilator\nFrees the EMT to perform other tasks",
        "Gastric distention": "Occurs when artificial ventilation fills the stomach with air\nMost likely to occur when you ventilate the patient too forcefully or too rapidly\nMay also occur when the airway is obstructed",
        "Continuous Positive Airway Pressure": "Noninvasive ventilatory support for respiratory distress\nMany people diagnosed with obstructive sleep apnea wear a CPAP unit at night.\nBecoming widely used at the EMT level FIGURE 11-48 Many people in whom obstructive sleep\napnea has been diagnosed wear a CPAP unit at night to\nmaintain their airway while they sleep. \u00a9 Andrey_Popov/Shutterstock. Mechanism\nIncreases pressure in the lungs\nOpens collapsed alveoli\nPushes more oxygen across the alveolar membrane\nForces interstitial fluid back into the pulmonary circulation Mechanism (cont\u2019d)\nTherapy is delivered through a face mask held to the head with a strapping system.\nUse caution with patients with potentially low blood pressure. Indications\nPatient is alert and able to follow commands.\nPatient displays obvious signs of moderate to severe respiratory distress.\nRespiratory distress occurs after a submersion incident.\nPatient is breathing rapidly.\nPulse oximetry reading is less than 90%. Contraindications\nPatient in respiratory arrest\nPatient is hypoventilating.\nPatient cannot speak.\nPatient is unresponsive or cannot follow verbal commands.\nPatient cannot protect his or her airway.\nPatient has hypotension. Contraindications (cont\u2019d)\nSigns and symptoms of a pneumothorax or chest trauma\nPatient has a tracheostomy.\nActive gastrointestinal bleeding or vomiting\nPatient has experienced facial trauma.\nPatient is in cardiogenic shock.\nPatient cannot sit upright.\nPatient cannot tolerate the mask. Application\nResistance creates back pressure that pushes open smaller airway structures as the patient exhales.\n7.0 to 10.0 cm H2O is acceptable. Complications\nSome patients may find CPAP claustrophobic.\nRisk of pneumothorax\nCan lower the patient\u2019s blood pressure\nIf the patient shows signs of deterioration, remove CPAP and begin positive pressure ventilation using a bag-mask device.",
        "Special Considerations": "Stomas and tracheostomy tubes\nPatients who have had a laryngectomy have a permanent tracheal stoma.\nKnown as a tracheostomy FIGURE 11-49 A tracheal stoma is typically located in the midline of the neck. The midline opening is the only one that can be used to ventilate the patient. \u00a9 American Academy of Orthopaedic Surgeons. Stomas and tracheostomy tubes (cont\u2019d)\nNeither the head tilt\u2013chin lift maneuver nor the jaw-thrust maneuver is required.\nIf the patient has a tracheostomy tube, ventilate through the tube with a bag-mask device. Stomas and tracheostomy tubes (cont\u2019d)\nIf the patient has a stoma but no tube is in place, use an infant or child mask with your bag-mask device to make a seal over the stoma.\nIf you cannot ventilate a patient with a stoma:\nTry suctioning the stoma.\nSeal the stoma while giving mouth-to-mouth.",
        "If an obstruction completely blocks the airway, it is a true emergency.": "Will result in death if not treated immediately\nIn an adult, usually occurs during a meal\nIn a child, can occur while eating, playing with small toys, or crawling The tongue is the most common airway obstruction in an unconscious patient.\nCauses of airway obstruction that do not involve foreign bodies:\nSwelling, from infection or acute allergic reaction\nTrauma (tissue damage from injury) Mild airway obstruction\nPatients can still exchange air but will have respiratory distress.\nNoisy breathing, wheezing, coughing\nWith good air exchange, do not interfere with the patient\u2019s efforts to expel the object on his or her own. Mild airway obstruction (cont\u2019d)\nWith poor air exchange, the patient may have increased difficulty breathing, stridor, and cyanosis.\nTreat immediately. Severe airway obstruction\nPatients cannot breathe, talk, or cough.\nPatient may use the universal distress signal, begin to turn cyanotic, and have extreme difficulty breathing. FIGURE 11-50 The universal sign of choking is a person\nwho grasps his or her throat and has difficulty breathing. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Severe airway obstruction (cont\u2019d)\nProvide immediate treatment to the conscious patient.\nIf not treated, the patient will become unconscious and die.\nIf the patient is unresponsive, not breathing, and has no pulse, begin CPR with chest compressions.",
        "Emergency Medical Care for Foreign Body Airway Obstruction Perform a head tilt\u2013chin lift maneuver to clear a tongue obstruction.": "Large obstructions should be swept forward out of the mouth with your gloved index finger.\nAbdominal thrusts are the most effective method of dislodging and forcing out an object.",
        "Dental Appliances Can cause an airway obstruction": "Examples: crown, bridge, dentures, piece of braces\nManually remove the appliance before providing ventilations.\nLeave well-fitting dentures in place.\nLoose dentures interfere with the process and should be removed.",
        "Facial Bleeding Airway problems can be particularly challenging in patients with serious facial bleeding.": "The blood supply to the face is very rich.\nInjuries can result in severe tissue swelling and bleeding into the airway.\nControl bleeding with direct pressure, and suction as necessary.",
        "Assisting With ALS Airway Procedures Placement of advanced airways": "Preoxygenation\nEquipment setup\nPerforming the procedure \u201cBE MAGIC\u201d\nB- Perform Bag-mask preoxygenation.\nE- Evaluate for airway difficulties.\nM- Manipulate the patient.\nA- Attempt first-pass intubation.\nGI- Use a supraGlottic airway if unable to intubate.\nC- Confirm successful intubation/Correct issues."
    },
    {
        "definition of pe": "blood clot obstructing arterial pulmonary circulation",
        "most common causes of pe": "dvt (deep vein thrombosis)",
        "common signs/symptoms of pe": "tachycardia, tachypnea, anxiety, restlessness, sudden dyspnea, clear lung sounds, decrease spo2 levels, cough, dizziness, syncope, chest pain, signs of dvt, diaphoresis",
        "common causes of blood clots": "recent surgery, pregnancy or recent childbirth, use of oral contraceptives (i.e. birth control), history of blood clots, atrial fibrillation, recent prolonged travel, sedintary lifestyle or long periods without movement",
        "treatment/management of pe": "support abcs, supplemental oxygen, ventilatory assistance, rapid transport",
        "pe is a common cause of:": "shock and cardiac arrest",
        "signs/symptoms of dvt": "leg pain, non-traumatic bruising on leg, redness/swelling of leg, affected area warm to the touch",
        "cause of pe": "a blood clot obstructs blood flow in the arterial pulmonary circulation",
        "most common cause for blood clots resulting in pe's": "dvts (deep vein thrombosis)",
        "common causes for dvt resulting in pe": "recent surgery, pregnancy or childbirth, oral contraceptive use (i.e. birth control), history of blood clots (i.e., stroke), atrial fibrillation, recent prolonged travel or airplane ride, extended period of time without movement",
        "type of shock most commonly associated with pes": "obstructive",
        "pe falls under what category of the h's and t's?": "thrombosis (pulmonary)",
        "definitive treatment for pe": "thrombolytics, anticoagulants, thrombectomy",
        "most common ecg findings with pe": "tachycardia",
        "common 12-lead ecg findings (paramedic only):": "s1q3t3 pattern, rbbb, diffuse st depression/inverted t-waves, right atrial enlargement (peaked t-wave in lead ii), right ventricular strain pattern (inverted t-waves in v1-v4, ii, iii, avf)"
    },
    {
        "normal breath sounds made by air moving in and out of the alveoli?": "vesicular breath sounds",
        "normal breath sounds made by air moving through the bronchi?": "bronchial breath sounds",
        "stridor is an indication of?": "airway obstruction",
        "rales": "a crackling, rattling breath sound that signals fluid in the air spaces of the lungs.",
        "wheezing": "high-pitched, musical, whistling sound heard most commonly on exhalation. caused by a constriction of bronchioles.",
        "high-pitched sound that is indicates an upper airway blockage?": "stridor",
        "tachypnea": "rapid breathing",
        "crackles": "caused by fluid in the small airways. they are popping sounds that are heard when air is forced through the small airways that are being narrowed by the accumulation of fluid, mucus, or pus.",
        "apnea": "absence of breathing",
        "conditions that could cause tachypnea?": "fever, exercise, anxiety, shock."
    },
    {
        "hemoglobin can carry ___ o2 molecules": "four",
        "the process of loading oxygen molecules onto hemoglobin molecules in the bloodstream": "oxygenation",
        "explain what pulse oximetry is?": "pulse oximetry is a non-invasive device that measures the amount of \noxygen that is bound to hemoglobin in the blood.",
        "aerobic metabolism": "the process of cells converting glucose into energy with the presence of oxygen.",
        "what is cyanosis and how does it relate to the respiratory system?": "cyanosis is the bluish or purple coloration of the skin or mucous \nmembranes. cyanosis occurs when the blood in the body does not carry \nenough oxygen. this lack of oxygen in the blood can be due to an airway \nobstruction, lung disease, or hypoventilation/apnea.",
        "normal breathing rate in adults": "12-20 bpm",
        "what type of process is inhalation": "active process. muscles in the chest expand at the same time the diaphragm contracts in a downward motion. this increases the size of the chest cavity and creates negative pressure. this pulls air in through the glottic opening and inflates the lungs.",
        "digital clubbing?": "a sign of chronic hypoxia in older and younger people.",
        "explain how oxygen enters the bloodstream": "within the alveoli, oxygen-rich air inhaled through the lungs meets capillaries, where oxygen molecules are able to attach to red-blood cells and travel back to the heart.",
        "what are three causes of an incorrect reading on the pulse oximeter?": "nail polish, cold extremities, carbon monoxide poisoning",
        "what does pulse oximeter measure?": "hemoglobin in arterial blood",
        "normal breathing rate in children": "15-30 bpm",
        "what drive is responsible for breathing control? what is the backup system?": "the carbon dioxide drive- increased co2 levels will stimulate the body to increase the respiratory rate. as a backup, the hypoxic drive will stimulate breathing when low o2 levels are sensed.",
        "normal breathing rate in infants": "25-50 bpm",
        "oxygen percentage in the atmosphere?": "21%",
        "early signs of hypoxia?": "restlessness, tachycardia, and anxiety",
        "late signs of hypoxia?": "mental status changes, weak thready pulse, cyanosis",
        "what are the dangers of hyperventilating a patient?": "increased risk of gastric distention/aspiration. reduced blood flow to the heart and causes co to fall."
    },
    {
        "what medications can be given via nebulizer for copd?": "albuterol and ipratropium bromide",
        "what does copd stand for?": "chronic obstructive pulmonary disease",
        "what are the two main branches of copd when it comes to the prehospital patient?": "emphysema and chronic bronchitis",
        "how old are the majority of emphysema patients?": "greater than 75 years old",
        "name 3 risk factors for emphysema": "possible answers include smoking, exposure to secondhand smoke, occupational exposure to inhalants, history of tuberculosis, asthma, congestive heart failure",
        "what physical change occurs in emphysema that leads to decreased oxygenation?": "decreased alveolar surface area participating in pulmonary respiration",
        "emphysema is more common in males or females?": "males",
        "what is the goal oxygenation for patients in respiratory distress?": "94% or greater",
        "what is important documentation to look for in elderly patients\u2019 houses?": "polst form or dnr/dni",
        "deficiency in what naturally occurring protein can cause emphysema?": "alpha-1 antitrypsin",
        "what is the greatest argument to not use cpap in an emphysema patient?": "breath stacking/air trapping",
        "what would breath stacking look like on continuous waveform capnography look like?": "a slowly rising baseline reading, with etco2 not reaching zero in-between breaths as incomplete exhalation occurs",
        "what drug class do drugs such as dexamethasone or prednisone belong to and what is their effect?": "corticosteroids, relaxation of lung tissue"
    },
    {
        "what are the four causes of airway obstruction?": "tongue, edema(swelling), fluid, foreign bodies",
        "name two ways to open up airway in an unconscious patient:": "head-tilt chin-lift and the jaw-thrust maneuver (cervical spin injury)",
        "how do you artificially ventilate a patient with a stoma?": "clear mucus plug or secretions from the stoma. leave head and neck in neutral position. use a pediatric bag-valve-mask and establish a seal around the stoma. ventilate at the appropriate rate for the age of the patient.",
        "the main advantage of using an npa over an opa is that?": "it is less likely to be rejected if the patient has a gag reflex.",
        "what is the general sequence of evaluation a conscious vs unconscious patient?": "conscious patients are evaluated with the traditional abc: airway first, then breathing, and circulation last. unconscious patients are evaluated with cab order: circulation, airway, then breathing.",
        "what are the three rules of suctioning?": "1. wear ppe, 2. suction no longer than 10-15 seconds, 3. suction on the way out.",
        "one-rescuer bvm finger positioning?": "e-c clamp",
        "what can happen if you hyperventilate a patient?": "increased negative pressure in the thorax leading to decreased blood flow to the heart.",
        "jaw-thrust-maneuver is used when?": "you suspect trauma",
        "what are three contraindications of using a combitube?": "intact gag reflex, less than 16-years-old, caustic substance ingestion.",
        "how to measure an npa?": "measure from tip of nose to earlobe",
        "an spo2 of less then ____ indicates hypoxia": "94%",
        "how do you measure an opa?": "measure from the corner of the mouth to the earlobe",
        "when inserting an opa and the patient vomits, what do you do?": "remove the adjunct and suction as needed.",
        "anaphylaxis": "severe allergic reaction; airway swelling and dilation of blood vessels (within 30 mins of exposure). treatment is epinephrine, antihistamines, oxygen.",
        "croup": "caused by an infection of the upper airway. inflammation/swelling of the pharynx, larynx and trachea will be observed. most often seen in children and they'll have a 'bark-like' cough.",
        "two methods of opening airway?": "head-tilt, chin-lift and jaw-thrust maneuver"
    },
    {
        "what does cpap stand for?": "continuous positive airway pressure",
        "what does bipap stand for?": "bi-level positive airway pressure",
        "how does cpap work?": "cpap provides a positive pressure that helps stint open the alveoli and recruit more alveoli to participate in gas exchange.",
        "how does bipap work?": "non-invasive positive pressure ventilation (nippv). delivers two different pressures which allows a higher pressure to be delivered during inspiration, and a lower pressure during expiration, thereby reducing the work of exhaling.",
        "what types of respiratory emergencies do we use cpap and bipap for?": "cardiogenic pulmonary edema, non cardiogenic pulmonary edema, copd and asthma.",
        "true or false. early use of cpap or bipap can prevent the patient from \nundergoing intubation?": "true",
        "list the anatomy of the upper airway": "nasal cavity, pharynx, larynx",
        "list the anatomy of the lower airway": "trachea, bronchi, bronchioles, alveoli",
        "what is peep?": "positive end expiratory pressure",
        "what is ventilation?": "mechanical process of moving air in and out of the lungs. two phases of ventilation are inspiration and expiration.",
        "what are the two processes of breathing?": "inspiration and expiration",
        "true or false. albuterol can be used in conjunction with cpap or bipap?": "true",
        "what are the indications for cpap and bipap?": "exhibits two or more of the following: respiratory greater than 25 breaths per minute, spo2 of less than 94%, use of accessory muscles during respiration.",
        "what are the contraindications for cpap and bipap?": "respiratory arrest or apnea, patient who has suspected pneumothorax or suffered trauma to the chest, patient with tracheotomy, patient who is vomiting or has an upper gi bleed, hypotension, non-cooperative patient or inability to maintain a mask seal.",
        "what is the treatment we provide for hypoxia secondary to pulmonary edema?": "cpap or bipap",
        "true or false. we can use cpap for the pulseless and apneic patient.": "false",
        "what are three forms of non-invasive positive pressure ventilation?": "bvm, cpap, bipap",
        "true or false. early use of cpap or bipap can prevent the patient from undergoing intubation?": "true",
        "what benefit does bipap have over cpap?": "cpap can cause the patient to breath stack, whereas bipap will help prevent breath stacking due to exhaling at a lower pressure.",
        "true or false. albuterol can be used in conjuction with cpap or \nbipap?": "true",
        "what is the treatment we provide for hypoxia secondary to\n pulmonary edema?": "cpap or bipap",
        "true or false. we can use cpap for the pulseless and apneic \npatient.": "false",
        "how are cpap and bipap measured?": "cm/h2o",
        "why are cpap and bipap beneficial in cardiogenic pulmonary edema?": "cpap will cause a positive pressure in the thoracic cavity, decreasing venous return to the heart and decreasing preload.",
        "true or false. albuterol can be used in conjunction with cpap or \nbipap?": "true",
        "what treatment can be utilized in dealing with cardiogenic pulmonary edema?": "cpap/bipap, nitroglycerine, iv, lasix, 12 lead, etco2 waveform monitoring.",
        "what types of treatment for asthma can be utilized in conjunction with cpap and bipap?": "etco2 waveform monitoring, duo-neb, iv dexmethasone, 0.3 mg im epinephrine, iv mag sulfate",
        "why is nitroglyceine beneficial with cpap and bipap?": "it will remove the fluid from the alveoli and shift it back into the vasculature, which will improve oxygenation",
        "true or false. bipap is beneficial with helping offload co2?": "true"
    },
    {
        "leading cause of chronic obstructive pulmonary disease?": "smoking",
        "copd physiology?": "alveoli collapse, mucus inside bronchioles, smaller airway. air trapped into lungs. inhalation is easier and exhalation is harder and takes longer",
        "what happens during an asthma attack?": "the bronchioles become enflamed, causing bronchospasm and increased mucous that results in: coughing, wheezing, and sob.",
        "asthma irritants?": "pollen, exercise, food, cigarette smoke, dust mites, pollution",
        "signs/symptoms of asthma?": "chest tightness, shortness of breath, wheezing, cough, anxiety.",
        "what does a nebulizer do?": "produces a continuous flow of aerosolized medication that can be taken in during multiple breaths, over several minutes giving the patient a greater exposure.",
        "what are some side effects from a prescribed inhaler?": "increased pulse rate, tremors, nervousness.",
        "common bronchodilator": "albuterol. when aerosolized, it causes the bronchioles/bronchi to expand allowing more room for airflow into the lungs.",
        "flow rate for a nebulizer?": "6-8 liters per minute",
        "two common conditions that contribute to copd?": "chronic bronchitis and emphysema",
        "\"pink puffer\" refers to a patient with what condition?": "emphysema",
        "\"blue bloater\" refers to a patient with what condition?": "chronic bronchitis"
    },
    {
        "tachypnea": "respiratory rate >20 bpm in adults",
        "bradypnea": "respiratory rate <12 bpm in adults",
        "example of a bronchodilator": "albuterol",
        "alveoli": "air sacs at the terminal end of the bronchioles; location of gas exchange",
        "alveolocapillary membrane": "single-cell layer surrounding the alveoli where gas moves between the lungs and bloodstream",
        "nasopharynx": "the most superior region of the airway; runs from posterior aspect of the nasal opening to the plane of the soft\npalate",
        "oropharynx": "lies jut inferior to the nasopharynx, and runs from the plane of the soft palate to the hyoid bone",
        "laryngopharynx": "extends posteriorly from the hyoid bone to the esophagus and anteriorly to the larynx",
        "larynx": "a complex structure that joins the pharynx with the trachea",
        "trachea": "main airway",
        "the result of high partial pressure of o2 in the lungs  compared to that of the bloodstream": "o2 diffuses from the lungs into the bloodstream, where it can be carried throughout the body",
        "the result of high partial pressure of co2 in the bloodstream compared to that of the lungs": "co2 diffuses from the bloodstream into the lungs where it can be offloaded into the atmosphere",
        "chemoreceptors": "detect changes in ph",
        "primary location of central chemoreceptors": "pons and medulla",
        "the cranial nerves that communicate with peripheral chemoreceptors": "glossopharyngeal nerve (ix) and vagus nerve (x)",
        "location of the peripheral chemoreceptors": "carotid and aortic bodies",
        "the function of the peripheral chemoreceptors is reliant upon": "changes in o2 levels",
        "the function of the central chemoreceptors is reliant upon": "changes in co2 levels",
        "mechanoreceptors": "detect stretch in the airways, trachea, lungs, and pulmonary vessels; also stimulate the cough reflex",
        "bronchospasm is often caused by": "copd,  allergic reaction, and asthma.",
        "pulmonary edema is often caused by": "chf and lower airway infections such as pneumonia",
        "cpap and bvm are examples of": "positive pressure ventilation",
        "wheezing": "constriction; lower airway; expiratory",
        "stridor": "obstruction/edema, upper airway, inspiratory",
        "nasal cavity": "the most superior part of the airway",
        "pharynx": "muscular tube that extends vertically from the back of the soft palate to the superior aspect of the esophagus",
        "oral cavity": "cheeks, hard and soft palates, and tongue form the mouth also known as oral cavity",
        "carina": "the location where the trachea divides into right and left bronchi",
        "visceral pleura": "inner pleural layer; covers the lung tissue, vessels, nerves, and bronchi",
        "parietal pleura": "outer pleural layer; attaches to the chest wall",
        "left mainstem bronchus": "bronchus leading to the left lung; angles more acutely to the left compared to the right mainstem bronchus",
        "right mainstem bronchus": "bronchus leading to the right lungis fairly straight; often times when an endotracheal tube is inserted too far it will enter here causing ventilation to the right lung only",
        "both central and peripheral chemoreceptors": "detect changes in ph",
        "peripheral chemoreceptors": "rely more heavily on changes in o2 levels",
        "central chemoreceptors": "rely primarily on changes in co2 levels",
        "primary location central chemoreceptors": "pons and medulla",
        "location of peripheral chemoreceptors": "in the carotid and aortic bodies",
        "diaphragm": "located below the lungs; the major muscle used during ventilation",
        "during inhalation, the diaphragm...": "contracts and flattens",
        "during exhalation, the diaphragm and intercostal muscles...": "relax and lengthen/expand",
        "ventilation": "the mechanical movement of air into and out of the lungs",
        "respiration": "the process of gas exchange at a cellular level",
        "normal adult respiratory rate": "12-20 bpm"
    },
    {
        "what is a measurement of the carbon dioxide that is transported by the circulatory system and exhaled during respiration?": "capnography or end tidal co2",
        "what diagnostic tool changes more rapidly with the patient's condition, pulse oximetry or capnography?": "capnography",
        "what measurement is used to communicate the value of etco2?": "mmhg or millimeters of mercury",
        "what is a normal measurement of etco2?": "35-45 mmhg",
        "how does a qualitative capnography device indicate the presence of co2?": "change colors",
        "what two types of devices are used to measure quantitative capnography?": "sidestream and mainstream",
        "what type of quantitative capnography device pulls a sample of air to a measuring device?": "sidestream",
        "what type of quantitative capnography device measures co2 at the site of the patient's exhaled air?": "mainstream",
        "name two types of quantitative capnography devices?": "etco2 nasal cannula and in-line device",
        "what factors can impact the effectiveness of a qualitative capnography device?": "age and how it is stored",
        "true or false.  an in-line quantiative capnography device can be used on a bag valve mask device?": "true",
        "name three types of respiratory patients that should receive capnography monitoring.": "respiratory distress, copd exacerbation, asthma, pulmonary embolism, chest trauma with suspected lung involvement",
        "name two types of metabolic complaints that would benefit from capnography monitoring.": "diabetic ketoacidosis, sepsis, hyperosmolar hyperglycemic non-ketoacidosis",
        "name two types of circulatory complaints that would benefit from capnography monitoring.": "hypovolemic shock, congestive heart failure, trauma with significant blood loss, trauma to the circulatory system",
        "true or false.  during a cardiac arrest, capnography can indicate the quality of chest compressions?": "true",
        "how does capnography change when return of spontaneous circulation occurs during cardiac arrest?": "there will be a rapid rise in capnography values",
        "why is capnography a valueable tool for patients with an advanced airway?": "it provides continuous monitoring of the airway's placement and efficacy",
        "fill in the blanks.  capnography with a reading consistently below ___ mmhg after __ minutes of cpr can predict death with 100% sensitivity and specificity.": "10 mmhg, 20 minutes",
        "in addition to providing an etco2 value, what additional informaiton can a quantitative capnography device provide?": "capnography waveform",
        "what three physiological factors can impact a patient's capnography?": "metabolism, circulation and ventilation"
    },
    {
        "organs within the thorax": "the heart, lungs, trachea, esophagus, thymus, and breast",
        "fractures of the chest wall may lead to": "paradoxical movement",
        "paradoxical movement": "when a portion of the chest moves in the opposite direction than the rest of the chest wall",
        "inspection of the chest wall is": "visual",
        "palpation of the chest wall is part of the": "physical assessment",
        "auscultation of the chest is performed using": "a stethoscope to listen to the patient\u2019s chest.",
        "what can be used to assess oxygenation status": "pulse oximeter and etc02",
        "what can be assessed during inspection of the chest wall": "rate, depth, and pattern of breathing",
        "when should an object be removed from the chest wall": "only when it interferes with cpr",
        "blebs": "small blisters on the lung",
        "possible secondary causes of pneumothorax": "copd, cystic fibrosis, and pneumonia",
        "primary spontaneous pneumothorax": "occurs without a cause",
        "resonant sounds": "heard over normal lung tissue and are low-pitched",
        "flat or extremely dull sounds": "heard over solids such as bones",
        "dull or thud-like sounds": "heard over dense organs such as the heart",
        "dullness may also be heard over the lungs during": "pneumonia, pleural effusions, or if a tumor is present",
        "hyperresonant sounds": "louder and lower-pitched than resonant sounds",
        "when are hyperresonant sounds normal": "when percussing a pediatric patient or a very thin adult",
        "hyperresonant sounds in one area of the lung may indicate": "pneumothorax",
        "tympanic sounds": "high, hollow, and drum-like",
        "subcutaneous emphysema": "occurs when air collects outside the lungs and is trapped at the subcutaneous layer of the skin",
        "in addition to air, _______ may accumulate in the pleural cavity due to damaged vessels and organs": "blood",
        "tension pneumothorax results from": "an untreated open, spontaneous, or simple pneumothorax",
        "as the pressure continues to increase, mediastinal structures shift to the opposite side of the thorax, causing": "kinking of great veins and decreasing cardiac output",
        "changes in _________ may indicate that a tension pneumothorax has developed": "blood pressure",
        "_______________ sounds are more commonly associated with abnormalities such as pneumothorax": "unilateral absent",
        "if the hole in the chest wall is at least ______ size of the trachea, more air will enter from the atmosphere-sucking sound will be present": "2/3",
        "levatores costarum": "play a role in elevating the ribs and allowing for rotation and lateral flexion of the thoracic vertebrae",
        "subcostal muscles": "accessory muscles that cause the ribs to be depressed when expiration is forced",
        "the spaces between the ribs are known as": "intercostal spaces",
        "the chest wall is also known as": "thorax",
        "what makes up an intercostal neurovascular bundle": "nerve, vein, and artery",
        "what are the two most important thoracic muscles": "diaphragm and intercostal muscles",
        "transversus thoracis prevents": "paradoxical chest movements by stiffening during inspiration",
        "catamenial pneumothorax": "a rare type of secondary simple pneumothorax that affects women aged 30-40 within 72 hours prior to or after menstruation",
        "brit hogg dube (bhd) syndrome": "a genetic disorder that causes pneumothorax and lung cysts."
    },
    {
        "what does peep stand for?": "positive end expiratory pressure",
        "true or false. peep is used during mechanically assisted ventilation.": "true",
        "what effect does peep have on the alveoli?": "peep maintains a pressure higher than atmospheric pressure in the alveoli at the end of expiration",
        "what is the root physiological problem peep aims to fix?": "alveoli collapsing under atmospheric pressure and not being recruited or available for pulmonary respiration",
        "what is the indication for peep, under the simplest terms?": "lack of oxygenation, even with high flow oxygen via bvm",
        "what is surfactant and what is its function within the alveoli?": "surfactant is a mixture of lipids and proteins with a primary function of lowering the surface tension at the air/liquid interface of the alveoli",
        "peep values generally start at what pressure?": "5 cm/h2o",
        "how does peep affect intrathoracic pressure?": "peep increases intrathoracic pressure",
        "does peep have any contraindications?": "in some protocols, cardiac arrest and hypotension are contraindicated due to peep increasing intrathoracic pressure",
        "does peep help obstructive or nonobstructive causes of alveolar collapse?": "nonobstructive"
    },
    {
        "what is pulmonary edema?": "the accumulation of fluid within the lungs and air spaces",
        "pulmonary edema is primarily related to what disease?": "congestive heart failure (chf)",
        "there are 2 types of pulmonary edema. what are they?": "high pressure (cardiogenic) and high permeability (noncardiogenic)",
        "what is the most common cause?": "coronary heart disease",
        "general symptoms of pulmonary edema": "dyspnea, fatigue, exercise intolerance, fluid retention (edema), chest pain, orthopnea, restlessness, anxiety, confusion, limited word sentences",
        "assessment: lung sounds": "crackles; start in the bases and move up with worsening symptoms",
        "assessment: skin signs/ perfusion": "pale/ cyanotic, cool skin, delayed cap refill, weak distal pulses, decreased urinary output",
        "classic sign of pulmonary edema": "frothy, blood-tinged sputum",
        "what is key with patient's experiencing pulmonary edema?": "reassurance",
        "maintain systolic blood pressure at what level (or above)": "100 systolic or above",
        "maintain o2 saturation at what level (or above)": "94% or above",
        "basic prehospital treatment": "oxygenation and maintain adequate perfusion",
        "pulmonary edema is related to what disease?": "congestive heart failure (chf)",
        "what is the goal with patient's experiencing pulmonary edema?": "reassurance",
        "3 important interventions/ diagnostic interventions": "oxygen, vascular access, monitor with 12-lead",
        "interventions: alert patient": "cpap (or other non-invasive positive pressure ventilation); nitroglycerin (if systolic blood pressure above minimum)",
        "how does cpap help with pulmonary edema?": "decreases venous return and preload; improves gas exchange",
        "how does nitroglycerin help with pulmonary edema?": "decreases preload with peripheral vasodilation",
        "what is occurring during left ventricle failure?": "pressure within the pulmonary veins is increasing which causes blood to backup into the lungs; pulmonary edema and poor gas exchange are present",
        "what is occurring during right ventricle failure?": "blood backs up into the venae cavae; this causes congestion of the venous system",
        "describe high pressure (cardiogenic) pulmonary edema": "caused by heart failure; dysfunction of either the left or right ventricle, chronic hypertension, cardiac diseases, or dysrhythmias",
        "describe high permeability (noncardiogenic) pulmonary edema": "caused by acute hypoxemia; \"leaky capillaries\"",
        "what dysrhythmias can be caused with high pressure": "ventricular tachycardia and supraventricular tachycardia",
        "examples of possible causes of high permeability": "inhaled toxins or near submersion (this can damage alveolar tissue)",
        "what medication can be used with cpap?": "nitroglycerin",
        "if the patient is on cpap and their gcs drops to 3, what do you do?": "take cpap off immediately; intubation is indicated",
        "when must cpap be removed?": "patient becomes altered or blood pressure drops",
        "how does lasix help pulmonary edema?": "used to remove toxins and promote excretion of excess amounts of electrolytes (and fluids)"
    },
    {
        "air and food pass through what portion of the upper air way together?": "pharynx",
        "what is the carina?": "the split of air to the left and right bronchi.",
        "alveoli": "small air sacs in the lungs that fill with air upon inhalation",
        "bronchi/bronchioles": "imagine them as bronchi being the large tree branches and bronchioles as the smaller ones. air enter the bronchi then bronchioles lead off into the alveoli.",
        "what is surfactant?": "a combination of phospholipids that reduces surface tension within the alveoli and keeps them expanded.",
        "the right lung has how many lobes?": "three",
        "average tidal volume": "500-800 ml",
        "parietal pleura": "the serous membrane outer layer of the pleura that protects the lungs and provides cushioning.",
        "how many lobes does the left lung have?": "two",
        "where is the larynx located?": "superior to the trachea",
        "what is the space between the larynx and vocal cords?": "glottic opening",
        "visceral pleura": "membranes that cover the outside of the lungs"
    },
    {
        "how to position a patient in the sniffing position": "elevate the patient's head to the point that the ear and the sternal notch are aligned horizontally",
        "benefits of the sniffing (or ramped in obese patients) position": "maximizes upper airway patency allowing for effective ventilation",
        "posterior displacement of _____________ is often the cause of airway obstruction in unconscious patients or those with a decreased loc.": "the tongue",
        "how to perform the head-tilt/chin-lift": "place the palm of one hand on the patient's forehead, and use firm downward pressure to tilt the head back. two fingers of the other hand are then placed under the bony part of the chin and lift the jaw anteriorly; avoid soft tissues of the neck and chin",
        "this manual airway technique can be performed on patients with suspected c-spine injuries": "jaw thrust",
        "s/s of a complete airway obstruction": "begin by asking pt if they are choking, look for the universal sign for choking",
        "treatment for partial airway obstruction": "do not perform abdominal thrusts. allow pt to maintain a position of comfort, and provide oxygen as needed per local protocols. monitor for changes",
        "limit suctioning to no more than _____ seconds": "limit suctioning to no more than 10 seconds",
        "hard/rigid catheters can only be used in this airway": "oropharyngeal airway",
        "procedure for inserting an oropharyngeal adjunct": "gently insert the opa upside down into the mouth, and advance the airway until resistance is met at the pharynx. when resistance is met, rotate the opa 180\u00ba (right side up) while inserting the remainder of the adjunct or insert directly using a tongue depressor to compress the tongue"
    },
    {
        "cheyne-stokes respirations": "deep, rapid breaths that slow down to a period of apnea, and then repeat again.",
        "kussmaul respirations": "deep, labored, continuous breaths.",
        "cause of biot respirations": "may indicate severe brain injury or brain stem herniation.",
        "apnea": "absence of breathing",
        "what is bradypnea?": "slow and shallow respirations",
        "eupnea": "normal breathing. in adults, it's a breathing rate of 12-20 breaths per minute with symmetrical chest rise and fall.",
        "biot respirations": "abnormal breathing pattern. deep breaths (gasps) followed by periods of apnea.",
        "what conditions can cause cheyne-stokes respirations?": "stroke, heart failure, brain tumor, traumatic brain injuries",
        "agonal breathing": "gasping breaths, usually due to cardiac arrest.",
        "paradoxical breathing": "respiratory distress noted by the chest wall moving in the opposite direction when taking a breath (moves inward).",
        "you respond to the scene of a 55 year old male who is unconscious. he is breathing deep and rapid and has a blood sugar of 512. what type of respiratory pattern is this patient exhibiting and what is causing it?": "this patient's deep, rapid respirations are indicative of kussmaul respirations, which is caused by diabetic ketoacidosis, or dka.",
        "seesaw breathing": "movement of the diaphragm causes the chest and abdomen to move in opposite direction. seen in infants and children in respiratory distress."
    },
    {
        "four causes of an airway obstruction?": "tongue, fluid, edema (swelling), foreign body",
        "narrowest part of a child's airway?": "cricoid cartilage",
        "best way to free a complete airway obstruction in a\nconscious choking adult?": "abdominal thrusts. **back blows are for infants. coughing is for a patient with only a partially obstructed airway. magill forceps are used with unconscious patients when you can see the objects.**",
        "you have just finished giving five abdominal trust to a choking victim when they becomes unresponsive, falling to the ground. you are unable to control the fall, but the victim is unresponsive and not breathing. how do you proceed?": "start cpr",
        "if someone is choking and they're too large to get your hands around their abdomen, how should you proceed?": "provide chest thrusts while standing behind them.",
        "choking infant": "five back blows followed by five chest thrusts.",
        "magill forceps": "device used to remove a visible airway obstruction.",
        "most effective method of relieving a complete airway obstruction in an adult?": "abdominal thrusts",
        "your patient is visibly in distress, coughing, and they tell you they're choking on a piece of chicken. how do you proceed?": "encourage them to continue coughing."
    },
    {
        "how to measure npa?": "measure from tip of nose to earlobe",
        "suggested flow rate of an albuterol neb set?": "6-8 liters per minute",
        "d cylinder volume": "~350 l",
        "e cylinder volume": "~625 l",
        "m cylinder volume": "3000 l",
        "how is an opa measured?": "corner of the mouth to the earlobe",
        "most commonly used artificial airway?": "opa",
        "a bvm will deliver roughly ___ml of air": "600-750 ml",
        "rate and time to deliver ventilations by bvm?": "deliver breath over 1 second with rate at 8 to 10 breaths per minute.",
        "what percentage of oxygen does a bvm without attached o2 provide?": "21%",
        "what is the purpose of an oxygen regulator?": "manage the flow rate and reduce the pressure.",
        "venturi mask": "best device to administer a precise amount of oxygen to a patient",
        "what are the limitations of a flow powered (lpm) cpap device vs a ventilator-based cpap device?": "a flow powered cpap device is dependent on the lpm that can be provided. therefore, if you were to run out of oxygen, your cpap would no longer maintain its pressure.",
        "under what conditions should oxygen delivery specifically be titrated?": "when administering oxygen to a pt. with a history of copd, suspected cva, suspected mi, suspected tbi, neonate resuscitation, rosc, and pt.\u2019s who have achieved 100% spo2.",
        "what signs and symptoms may indicate oxygen administration?": "signs of respiratory distress and/or hypoxia (tachypnea, dyspnea, cyanosis\u2026) poor perfusion, altered mental status, combativeness, adventitious lung sounds, cardiac arrest, and spo2 <94%.",
        "what are some methods at the advance-emt scope to secure an airway for oxygen delivery?": "jaw thrust/head tilt, npa, opa, and supraglottic airway.",
        "what oxygen cylinders are commonly carried on an ambulance?": "d cylinder, e cylinder, and m cylinder.",
        "what harm can be cause to a pt. by hyperoxia?": "the formation of \u201cfree radicals\u201d occurs which are unstable and reactive molecules or atoms that causes damage to cells, dna and other molecules.",
        "if you are using a flow based (lpm) cpap device with a pt. who is taking rapid breaths >35/min, what concern should you consider?": "depending on the pt.\u2019s tidal volume and respiratory rate. it is possible for the pt. to out breathe the cpap device if their minute volume is higher than the lpm supplied.",
        "what flow rate should a nebulizer be set at?": "6-8 lpm.",
        "why is the flow rate of a nebulizer particularly important?": "to have effective medication delivery the flow rate needs to be high enough to aerosolize the medication but not so high that it disrupts delivery of the medication.",
        "when using positive pressure ventilation, what harm can be caused by inappropriate ventilation?": "gastric inflation leading to poor venous return and emesis/airway compromise and barotrauma.",
        "what are the advantages of using positive end expiratory pressure (peep) when ventilating a pt.?": "peep helps recruit more alveoli during positive respirations and allows for increased delivery of oxygen across the capillary membrane of the lungs.",
        "what is the average amount of volume contained in an adult bvm?": "1.5 l",
        "what is the average tidal volume of an adult?": "400-500 ml of air depending on size and sex. female tidal volumes are closer to 400ml.",
        "what are some key characteristics of ppv with a bvm?": "a breath should be delivered at the appropriate rate based on age and the breath should be given over 1 second at a steady pressure to achieve chest rise.",
        "what are contraindications for the application of cpap devices?": "hemodynamic instability, recent or high risk of emesis, altered level of consciousness, and respiratory arrest.",
        "what is a key limitation of a flow powered (lpm) cpap device vs a ventilator-based cpap device?": "a flow powered cpap device is dependent on the lpm that can be provided. therefore, if you were to run out of oxygen, your cpap would no longer maintain its pressure.",
        "what is denitrification and how does oxygen administration play a role in achieving it?": "denitrification is the process by which the available nitrogen in the lungs is \u201cpush out\u201d by administering high volumes/lpm of oxygen to a pt. attempting to increase the \u201csafe apnea\u201d time during an intubation attempt and reduce the risk of desaturation during intubation.",
        "what are some methods at the paramedic scope to secure an airway for oxygen delivery?": "jaw thrust/head tilt, npa, opa, supraglottic airway, intubation and surgical airway.",
        "during cpr of what pt. population should oxygen be withheld?": "neonates",
        "at what flow rate should a nebulizer be set?": "6-8 lpm",
        "if you have an established airway and good oxygen supply to a pt., what can prevent the pt. from being oxygenated?": "either the oxygen is not able to attach to rbcs at the capillary membrane of the lungs or the oxygen is not arriving at the tissue due to an issue with perfusion.",
        "during positive pressure ventilations, what observation should determine the amount of volume no matter the age/size of the pt?": "visible chest rise is an appropriate gauge when delivery ppv in the field.",
        "if ppv ventilations are not working with a bvm, what actions should be considered?": "readjust airway, obstructed airway, disease process (copd/asthma/pneumornia/pneumothorax), consider two handed mask seal, considered bls adjuncts, considered need for advance airway, consider equipment failure."
    },
    {
        "this position maximizes upper airway patency allowing for effective ventilation": "sniffing position, or ramped position (in obese patients)",
        "airway techniques should go from __________ invasive/ ______ risk procedures first, then move onto __________ invasive/ ______ risk.": "based on the principle of least invasive/lower risk procedures first, simple or manual techniques should be considered first before moving on to other, more invasive/higher risk, procedures.",
        "this is often posteriorly displaced in altered or unconscious patients, resulting in airway obstruction": "the tongue",
        "this manual airway maneuver should be avoided in suspected c-spin injury patients": "head tilt/chin lift",
        "s/s of airway obstruction": "look for universal sign of choking (hands circled around neck), stridor or high pitched audible noise may be present with respirations",
        "tx for complete airway obstruction": "perform abdominal thrusts\nattempt to ventilate\nif unable to ventilate, and pt becomes unconscious and pulseless, begin cpr",
        "fluids and secretions should be suctioned to avoid this": "airway obstruction and aspiration",
        "advantages of hard/rigid suction catheters": "can remove larger particles, suctions large volumes of fluid rapidly",
        "anatomical region soft catheters may be used to suction": "the oropharynx, nasopharynx, or down an endotracheal tube",
        "suction should be limited to _____ seconds": "limit suction to no more than 10 seconds, withdrawing the catheter while suctioning",
        "technique for tracheobronchial suctioning": "insert a well-lubricated soft tip catheter into the stoma or et tube until resistance is felt, then apply suction for no more than 10 seconds while withdrawing the catheter",
        "contraindications for a nasopharyngeal airway": "contraindications include age less than 1-year-old or head/facial trauma. if pt has a basilar skull fracture, the tube could accidentally pass into the cranium",
        "how to measure for an orophanryngeal airway": "from the ear lobe to the corner of the mouth, or from the angle of the jaw to midline of the lips",
        "advantages of sga's over et tubes": "evidence has suggested that they are faster and easier to insert than endotracheal tubes, and may be associated with fewer complications",
        "considered the gold standard for sga confirmation": "capnography and/or etco2",
        "what are the benefits of the ear to sternal notch position?": "optimal position for maintaining upper airway patency, allowing for effective ventilations and endotracheal intubation, if required",
        "alternate names for ear to sternal notch position": "sniffing, or ramped position (in obese patients)",
        "this is often the cause of airway obstruction in unconscious or altered loc patients": "posterior displacement of the tongue",
        "two common manual airway maneuvers": "head tilt chin lift, and jaw thrust",
        "this manual airway maneuver is not to be used in patients with suspected c-spine injuries": "head tilt chin lift",
        "technique for jaw thrust": "lift the jaw using fingers behind the mandibular angle, thumbs on cheekbones to provide counter force",
        "where can hard/rigid suction catheters be used?": "only in the oropharyngeal airway",
        "where can soft tip suction catheters be used?": "oropharynx, nasopharynx, or for tracheobronchial suctioning",
        "contraindications for npa's": "age less than 1 years old, or head/facial trauma. if pt has a basilar skull fracture tube could accidentally pass into the cranium",
        "how to measure for an npa": "measure from the tip of the nostril to the tragus (cartilaginous bump) of the ear",
        "what to do if you meet resistance when inserting npa?": "do not attempt to force an npa past resistance. remove it and try the other nostril",
        "how to measure for an opa": "from the ear lobe to the corner of the mouth, or from the angle of the jaw to midline of the lips",
        "indications for endotracheal intubation include:": "a diminished level of consciousness with concern for the loss of airway control (glasgow coma scale less than 8)\nhypoxemic or hypercarbic respiratory failure\nrisk of aspiration with vomiting, secretions, or blood\nairway obstruction",
        "contraindications for endotracheal intubation include:": "while there are no absolute contraindications for this procedure, there are considerable complications, risks, and adverse effects.\nrelative contraindications include: severe pharyngeal or esophageal burns (thermal or caustic), possible epiglottis, or a difficult airway",
        "complications for endotracheal intubation include:": "hypoxia\nesophageal or right main stem bronchus-intubation\naspiration during the procedure\nvagal stimulation with severe bradycardia and hypotension\nlaryngospasm\nincreased intracranial pressure\nairway trauma (including vocal cords, dental, tracheal, laryngeal)",
        "subjective et tube placement techniques": "direct visualization: watching the et pass through the cords\ncondensation: \"tube misting\", or vapor inside the et tube\nauscultation: breath sounds need to be checked bilaterally, as well as the epigastric region to ensure absence of gurgling sound",
        "objective et tube placement techniques": "capnography: gold standard for proper placement. (note both c02 level and waveform)\nesophageal detector device\nendotracheal tube introducer",
        "two blind insertion techniques": "nasotracheal intubation\ndigital intubation",
        "indications for percutaneous cricothyrotomy": "upper airway obstruction, after other methods have failed.",
        "site used for needle cricothyrotomy": "cricothyroid membrane"
    },
    {
        "v in v/q  stands for _____, representing  _____": "ventilation, relating to the air breathed in to our body",
        "q in v/q stands for  _____, representing  _____": "perfusion,  relating blood flow",
        "lung volume": "volume of air in the lungs at different phases of the respiratory cycle",
        "tidal volume (definition)": "the amount of air that is moved into or out of the lungs during a single breath",
        "tidal volume (ml)": "approx. 500 ml",
        "total lung capacity (definition)": "the amount of air that can be moved within the respiratory system",
        "total lung capacity (adult male)": "approx 6000 ml",
        "total lung capacity (adult female)": "approx 2/3 that of adult males, or 4000 ml",
        "residual volume (definition)": "the amount of gas that remains in the lungs to keep lungs from collapsing, this volume of gas does not move during ventilation",
        "residual volume (ml)": "1200 ml",
        "dead space (definition)": "this volume of gas does not move during ventilation",
        "dead space (ml)": "approx 150 ml, or 30% of tidal volume",
        "minute tidal volume (ml)": "resting minute ventilation is about 6 l/minute. approximately 1/3 of this volume is lost to dead space. this results in the resting alveolar volume being about 4 l/minute",
        "pulmonary blood flow (l/minute)": "approx 5 l/minute",
        "normal v/q ratio": "4:5, or 0.8 l/min",
        "apex/zone 1 v/q ratio": "due to gravity, blood flow is naturally lower here, resulting in ventilation exceeding perfusion. v/q ratio is higher",
        "middle/zone 2 v/q ratio": "v/q ratio is neutral here",
        "base/zone 3 v/q ratio": "bases have a lower v/q ratio than the rest of the lung due to gravity's effect on blood, as well as compression on the alveoli.",
        "intrapulmonary shunting (definition)": "intrapulmonary shunting is when blood passes through the lungs, however no re-oxygenation takes place. perfusion (q) without ventilation",
        "intrapulmonary shunting (causes)": "conditions include pneumonia, pulmonary edema, asthma, tumors, and copd. these conditions decrease the surface area of the alveoli by damaging the alveoli or an accumulation of fluid in the lungs, preventing ventilation.",
        "vascular dead space (definition)": "where there is appropriate aeration without adequate blood flow",
        "vascular dead space (causes)": "conditions such as pulmonary embolisms, pulmonary arteriovenous malformations (avms), congenital heart defects, cardiogenic shock, air emboli, and hypoxic pulmonary vasoconstriction"
    },
    {
        "primary structure needed to be accessed to perform a cricothyrotomy:": "cricothyroid membrane",
        "type of cricothyrotomy performed in pediatrics:": "needle cricothyrotomy",
        "dividing point between the upper and lower airway:": "larynx",
        "three portions of pharynx:": "nasopharynx, oropharynx, laryngopharynx",
        "lowest cartilage of larynx before trachea:": "cricoid cartilage",
        "proper name for the \"adam's apple\"": "thyroid cartilage",
        "\"gold standard\" for advanced airway placement:": "waveform capnography",
        "when should a cricothyrotomy be performed?": "inability to oxygenate or ventilate",
        "what does the acronym short stand for?": "the pneumonic used to help predict difficulties that may arise with a cricothyrotomy: surgery, hematoma, obseity, radiation and trauma",
        "what are some difficult airway predictors?": "trauma, excessive secretions/hemorrhage, mouth opening size, mandibular length, neck mobility/size, facial hair",
        "what is the highest bone present on the larynx": "hyoid bone",
        "what structure helps cover the opening to the larynx to prevent aspiration?": "epiglottis",
        "bone that makes up the upper jaw:": "maxilla",
        "what happens when the vocal cords suddenly close shut due to liquids or objects coming in contact with the structures:": "laryngospasm",
        "another term for the opening to the larynx:": "glottic opening",
        "thick mucous membranes that are found next to the vocal fords (cords):": "vestibular or false folds (cords)",
        "lower jaw bone:": "mandible",
        "above what weight can a surgical or device-assisted cricothyrotomy be performed?": "> or = 40 kg (88 lbs)",
        "gland that lies next to the larynx:": "thyroid (anterior) and parathyroid (posterior) glands",
        "what size et tube adapter fits into the hub of an iv catheter? what size fits into the end of a 3 cc syringe?": "3.0 ett adapter (iv hub) and 7.5 ett adapter (3 cc syringe)"
    },
    {
        "the most superior portion of the upper airway is?": "nasal cavity",
        "________________ occurs in the lungs when the respiratory gases are exchanged between the alveoli and red blood cells in the pulmonary capillaries.": "pulmonary respiration",
        "the process of moving air in and out of the lungs is known as?": "ventilation",
        "pulmonary ventilation is dependent on the change in pressure of the:": "thoracic cavity",
        "this nerve is responsible for signaling contraction of the diaphragm": "phrenic nerve",
        "define hyperventilation": "an increase in respiratory rate, which leads to the excess elimination of co2, and a progressively lower exhaled co2 level",
        "when hyperventilation occurs without no other lung abnormalities it is called:": "hyperventilation syndrome",
        "excess co2 elimination leads to:": "respiratory alkalosis",
        "_____ will cause respiratory alkalosis due to hypoxia-induced hyperventilation": "congestive heart failure (chf)",
        "define hypoventilation": "a decrease in respiratory rate that results in co2 retention and a progressive elevation in exhaled co2",
        "define minute volume": "the amount of air moved in and out of the respiratory tract in one minute",
        "the average volume of gas inhaled in one respiratory cycle is called": "tidal volume",
        "___________ occurs when the respiratory system cannot effectively eliminate the appropriate amount of co2": "acidosis",
        "what is the normal range for etco2?": "35 - 45 mmhg",
        "an etco2 of less than 35 mmhg is an indication of:": "hyperventilation",
        "an etco2 greater than 45 mmhg is an indication of:": "hypoventilation",
        "the normal ph  in the human body is:": "7.35 to 7.45",
        "if a patient is acidotic their ph will be:": "less than 7.35",
        "if a patient is alkalotic their ph will be:": "greater than 7.45",
        "the tidal volume for the average adult patient is": "5-7 ml/kg"
    },
    {
        "what are your biggest concerns about patients who need advanced airway management?": "hypoxic brain injury, aspiration of vomitus/secretions, worsening of present condition (airway swelling), patient condition worsening",
        "what are some examples of depolarizing and non-depolarizing neuromuscular blocking agents?": "depolarizing: succinylcholine non-depolarizing: rocuronium, vercuronium, rancuronium",
        "what are common sedation agents used for rsi/dsi?": "midazolam (versed), etomidate (amidate), ketamine (ketalar), lorazepam (ativan), propofol (diprivan)",
        "ett size calculations for pediatrics:": "cuffed: (age/4) + 3.5. uncuffed: (age/4) + 4",
        "ways to confirm proper tube placement:": "re-visualization of ett through vocal cords, present bilateral breasth sounds, chest rise/fall, absent epigastric sounds, present capnography waveform and adequate capnometry reading, end-tidal colormetric device",
        "back-up devices if failed intubation occurs:": "supraglottic device (i.e. king airway, i-gel, lma), bvm with opa/npa, cricothyrotomy",
        "what are some options for difficult intubation attempts?": "bougie to guide tube placement, try different laryngoscope blade size and/or stylet, apply cricoid pressure, consider video laryngoscopy, have another als provider attempt, consider re-shaping ett or using smaller tube, reposition patient, reposition yourself if applicable.",
        "considerations for rapid deterioration of intubated patients?": "dope: dislodgement of tube, obstruction, pneumothorax and equipment failure",
        "when to consider advanced airway management?": "impaired breathing abilities, inability to maintain own airway, airway/breathing protection, complete airway obstruction, expected path of symptoms patient is following, hyperactive/combative patients who could be worsening their condition/impeding critical patient care needs, severe ams with concerns of airway management.",
        "general equipment needed for rsi/dsi:": "suction device(s), oxygen source, oxygen devices, ett and associated equipment, medications needed, back-up devices, monitoring/vital signs equipment.",
        "acronyms to remember for rsi/dsi procedure:": "speedbomb (suction, positioning, equipment, end-tidal, drugs, back-ups, oxygen, monitoring, briefing).",
        "what to do with ett placement:": "place at proper depth, remove stylet or bougie, maintain tube while holding with hand until tube securing device is placed, do not delay providing ventilations once tube is in place/cuff inflated/tube is securely held in place with available hand.",
        "post-intubation needs?": "reasses vital signs every 5 minutes, reasses tube placement upon every patient movement, repeat administration of sedation and paralytics as needed, consider og/ng tube placement, place patient onto ventilator as needed.",
        "ett sizing for adults and consideratios into chosing tube size:": "considerations: patient height and overall size, compare patient pinky size. adult average sizing: male (7.5-8.5 id), female (6.5-7.5 id).",
        "what is the difference between rsi and dsi?": "dsi may be used when patient condition requires more intervention prior to intubation."
    },
    {
        "introduction": "when taking a breath in (inhaling) and out (exhaling), you are exchanging gasses between the blood in your body and the outside world. during inhalation, oxygen enters your lungs and diffuses into your bloodstream. during exhalation, carbon dioxide diffuses from your bloodstream into your lungs so it can be expelled into the atmosphere.",
        "study guide overview": "this study guide will discuss the anatomy and physiology involved with breathing and why any disruptions in this process can be incredibly detrimental to your patients.",
        "ventilation vs. respiration": "ventilation refers to the mechanical movement of air into and out of the lungs. respiration refers to the process of gas exchange at a cellular level.",
        "ventilation": "muscle involvement: during inhalation, the diaphragm contracts and flattens. intercostal muscles contract to draw the rib cage up and out. the chest cavity enlarges substantially. an increase in container size with no change in the volume of air means a drop in pressure. when intrathoracic pressure drops below atmospheric pressure, air is drawn into the lungs.",
        "exhalation": "during exhalation, the diaphragm and intercostal muscles relax. the chest cavity returns to its normal size. as the volume of the chest cavity decreases and the volume of air remains the same, pressure increases substantially. to bring equilibrium between intrathoracic pressure and atmospheric pressure, air is expelled from the lungs, marking exhalation.",
        "respiration": "during respiration (gas exchange), oxygen moves from the lungs to the bloodstream. simultaneously, carbon dioxide passes from the blood into the lungs. this occurs via a network of tiny blood vessels called capillaries, which are located in the walls of the alveoli.",
        "anatomy of the upper and lower airway": "upper airway anatomy: 1. nasal cavity: the most superior part of the airway. 2. oral cavity: cheeks, hard and soft palates, and tongue form the mouth, also known as the oral cavity. 3. pharynx: muscular tube that extends vertically from the back of the soft palate to the superior aspect of the esophagus. larynx: this is a complex structure that joins the pharynx with the trachea.",
        "lower airway anatomy": "1. trachea: location where air first enters the lower airway. it is a 10-12 cm long tube that connects the larynx to the two mainstem bronchi (right and left). contains cartilaginous, c-shaped, open rings that form a frame to keep it open. 2. alveoli: air sacs at the terminal ends of the bronchioles. location of gas exchange.",
        "pleural membranes": "attaches to the chest wall.",
        "recognizing complications": "problems with rate: a respiratory rate >20 bpm is considered 'too fast' and indicates an issue in need of correction. in some cases, this rate needs to be slowed by an external force. in other cases, the body is driving this rate to compensate for a metabolic issue, and the underlying issue needs to be corrected, not the rate itself. a respiratory rate <12 bpm is considered 'too slow' and indicates an issue in need of correction as well.",
        "interventions": "we can increase respiratory rate via positive pressure ventilation (ppv). again, the underlying issue driving down respiratory rate ultimately needs to be corrected. the absence of respirations requires external support. we need to 'breathe for them'. inadequate ventilation requires assistance as well. this can be too shallow of breaths or a respiratory rate that is outside normal limits; all require intervention. interventions include ppv.",
        "other signs and symptoms of complications": "labored respirations. diaphragmatic breathing. adventitious lung sounds. crackles (fluid; opening and closing of alveoli). stridor (obstruction). wheezing (constriction). rhonchi (lower airway gurgling or snoring). bronchospasm. often caused by: copd. allergic reaction. asthma. pulmonary edema. often caused by: chf. lower airway infections (such as pneumonia).",
        "scenario": "dispatch info: you are dispatched to a 20-year-old female in respiratory distress. dispatch advises the scene is secure and to respond code 3. scene info: upon your arrival, you see the scene is secure and don appropriate bsi equipment. patient info: as you enter the home, you see your patient sitting on the couch in fowler's position. as you approach her, you note labored breathing and tachypnea. the patient tells you she has a severe history of asthma and has used her albuterol inhaler twice this morning with no relief. auscultation of lung sounds reveals wheezing bilaterally on expiration.",
        "treatment info": "you instruct your partner to obtain vitals, and he gives you the following information: rr is 24 per minute, all other vitals are within normal limits. treatment info: you elect to provide the following treatments for your patient: - oxygen - request paramedic intercept if the patient does not improve - als intercept will provide nebulized bronchodilators, iv steroids, and possibly advanced airway management.",
        "expected re-evaluation info": "we could expect to see improvement with the patient after the above treatments are rendered. these improvements include: - a reduction in work of breathing (and therefore a reduced respiratory rate) - an increase in spo2 - a reduction in adventitious lung sounds - relaxed airway muscles and opening of the airway, making it easier for your patient to breathe - increase in hr from albuterol.",
        "diffusion of gases": "movement of oxygen and carbon dioxide at the alveolocapillary membrane occurs because of partial pressures. the high partial pressure of o2 in the lungs on inhalation, compared to lower partial pressure in the bloodstream, causes o2 to diffuse from the lungs into the bloodstream, where it can be carried throughout the body. the high partial pressure of co2 in the bloodstream on exhalation, compared to lower partial pressure in the lungs, causes co2 to diffuse from the bloodstream into the lungs, where it can be offloaded into the atmosphere",
        "chemoreceptors": "chemoreceptors detect changes in ph with the ultimate goal of maintaining homeostasis. as carbon dioxide and oxygen levels fluctuate, ph changes. chemoreceptors send signals to the brain's respiratory centers to help regulate the respiratory activity. the pons and medulla of the brainstem are the primary locations of these chemoreceptors. these 'central' chemoreceptors rely primarily on changes in co2 levels. peripheral chemoreceptors may be found in the carotid and aortic bodies and communicate with the brain via the cranial nerves. specifically the glossopharyngeal nerve (ix) and vagus nerve (x). these rely more heavily on changes in o2 levels. both central and peripheral chemoreceptors detect changes in ph. as ph changes, information is sent to the brain to drive changes in respiratory rate and rhythm",
        "mechanoreceptors": "detect stretch in the airways, trachea, lungs, and pulmonary vessels. they provide information to the brain regarding flow, volume, and stretch. this information is also relayed to the brain to help control respiratory rate and volume. also, detect harmful foreign bodies and can stimulate the cough reflex",
        "muscle involvement": "during inhalation, the diaphragm contracts and flattens. intercostal muscles contract to draw the rib cage up and out. the chest cavity enlarges substantially. an increase in container size with no change in the volume of air means a drop in pressure. when intrathoracic pressure drops below atmospheric pressure, air is drawn into the lungs. during exhalation, the diaphragm and intercostal muscles relax. the chest cavity returns to its normal size. as the volume of the chest cavity decreases and the volume of air remains the same, pressure increases substantially. to bring equilibrium between intrathoracic pressure and atmospheric pressure, air is expelled from the lungs, marking exhalation",
        "innervation": "the phrenic nerve helps active the diaphragm. it consists of a right phrenic nerve and a left phrenic nerve. as the diaphragm is stimulated, it contracts, marking inhalation"
    },
    {
        "introduction": "chronic obstructive pulmonary disease (copd) refers to a group of diseases that causes airflow blockage and breathing-related problems. more than 16 million americans are diagnosed with copd and millions more suffer undiagnosed. common types of copd include emphysema and chronic bronchitis. copd is not curable, however, its symptoms can be treated to provide relief. copd commonly is known to be caused by tobacco smoking, which smoke causes irreversible damage to the lungs and can also cause lung cancer.",
        "causes of copd": "copd can also be caused by other issues including: exposure to dusts, chemicals, fumes, etc. (air pollution, coal mines, occupational hazards). asthma can be a risk factor for developing copd later in life. genetics (uncommon genetic disorder; alpha-1 antitrypsin deficiency).",
        "symptoms of copd": "copd causes many different issues or conditions that can be life-threatening. these include: frequent cough, sputum production, and shortness of breath, bronchoconstriction, hypoxia or hypoxemia, pneumonia, respiratory distress, failure, or arrest, altered mental status, severe dyspnea upon minimal exertion or activities.",
        "ems and copd": "respiratory distress is a common cause for ems to be called. estimated in studies that one in eight or approximately 11.7-12.1% ems calls were related to respiratory distress. ems plays a very important role in the recognition and treatment of patients suffering from copd-related respiratory emergencies.",
        "anatomy and physiology of copd": "the upper respiratory tract: the respiratory tract is divided into the upper and lower airways. the dividing point between the two is the larynx or the \"vocal cords\". the upper airway includes the mouth, throat, nasal cavity, and other surrounding structures.",
        "the lower respiratory tract": "the lower airways are what allow for the passage of air to reach the alveoli deep within the lungs where gas exchange of oxygen and carbon dioxide can occur to allow for adequate tissue perfusion within the body.",
        "respiratory system physiology": "the main goal of the respiratory system is to provide oxygen for the cells of the body and get rid of carbon dioxide byproducts of metabolism. gas exchange within the respiratory tract as well as other parts of the body occurs by diffusion.",
        "copd's impact on the respiratory system": "copd is a progressive disease that will worsen over time as the lungs continue to suffer from damage from symptoms of the disease. different forms of copd affect the lungs in different ways.",
        "recognition": "copd typically is lived with on a day-to-day basis having minimal to no issues, however as previously stated, symptoms can \"flare-up\" developing worsened shortness of breath that typically requires interventions.",
        "signs and symptoms of copd": "signs and symptoms will vary based on other underlying conditions or causes that may be present. they may include: difficulty breathing (dyspnea), tachypnea, tachycardia, anxiety, nausea or vomiting, dry or productive cough.",
        "assessment findings": "as stated above, thoroughly assess the respiratory system as well as the chest for any signs of breathing difficulties. assess lung sounds, chest wall pain upon palpation or with breathing, chest wall stability, presents of muscle retractions or accessory muscle use.",
        "treatment and management": "response: consider any scene safety concerns, need for additional resources, and response to the scene (emergent/non emergent). assessment: consider where the patient is found and what they appear to have been doing.",
        "treatments": "supplemental oxygen, inhaled bronchodilators, corticosteroids, positive airway pressure: cpap and bipap.",
        "advanced airway management": "if the patient begins to present respiratory failure, respiratory arrest, or ams, the patient may require placement of an advanced airway.",
        "transport considerations": "most facilities can stabilize copd exacerbation in patients, however, long-term care may be required depending on the extent of the situation.",
        "scenario": "medic 120 and engine 121 are dispatched to a high-priority breathing compliant.",
        "tips and tricks": "scene safety, request additional resources, c-spine, and abc's take first priority (in that order)!"
    },
    {
        "introduction": "hyperventilation and hypoventilation are a sign/symptom of a variety of emergencies that range from life-threatening (such as an acute pulmonary embolism) to more mild (anxiety). it is important to identify these emergencies and how to appropriately manage them.",
        "lessons and concepts": "in the section, we will look at the anatomy of the respiratory system, respiratory cycle, hyperventilation, and hypoventilation.",
        "anatomy of respiratory system": "upper airway anatomy: nasal cavity: this is the most superior part of the airway. lateral and superior walls of nasal cavity have maxillary, frontal, nasal, ethmoid, and sphenoid bones. floor of nasal cavity is the hard palate. septum separates the right and left nasal cavity. oral cavity: cheeks, hard and soft palates, and tongue form the mouth also known as oral cavity. pharynx: muscular tube that extends vertically from the back of the soft palate to the superior aspect of the esophagus. this allows the air to flow in and out of the respiratory tract. it is divided into three regions: nasopharynx: uppermost region which runs from back of nasal opening to the plane of the soft palate. oropharynx: it runs from the plane of the soft palate to the hyoid bone. laryngopharynx is extremely important in airway management. it extends posteriorly from the hyoid bone to the esophagus and anteriorly to the larynx. larynx: this is a complex structure that joins the pharynx with the trachea. midline the neck and attached to and lies inferior to hyoid bone and anterior to the esophagus. consist of thyroid and cricoid cartilage, glottic opening, vocal cords, arytenoid cartilage, pyriform fossae, and cricothyroid membrane.",
        "lower airway anatomy": "trachea: location where air first enters the lower airway. it is a 10-12 cm long tube that connects the larynx to the two mainstem bronchi (right and left). contains cartilaginous, c-shaped, open rings that form a frame to keep it open. carina: location that the trachea divides into right and left bronchi. right mainstem bronchus is fairly straight. often times when an endotracheal tube is inserted to far it will enter here causing only ventilation to the right lung. left mainstem bronchus angles more acutely to the left. alveoli: air sacs at the terminal ends of the bronchioles. location of gas exchange. surrounded by the alveolocapillary that is only 1 cell layer thick.",
        "respiration and ventilation": "respiration: exchange of gases between living organism and its environment. pulmonary respiration occurs in the lungs when the respiratory gases are exchanged between the alveoli and red blood cells in the pulmonary capillaries. ventilation: mechanical process that moves air in and out of lungs. respiratory cycle: includes inhalation and exhalation. inhalation is an active process. exhalation is a passive process. ventilation is dependent on the change in pressure within the thoracic cavity.",
        "pathology of hyperventilation": "hyperventilation is an increase in respiratory rate. increased respirations --> increased elimination of co2 --> progressively lower exhaled co2 level --> respiratory alkalosis. an increase in metabolic rate can trigger hyperventilation. hyperventilation syndrome is when dyspnea occurs with no other lung abnormalities. this is caused by the brain's respiratory centers being stimulated by things such as: anxiety, fear, or hysteria.",
        "causes of hyperventilation": "emotional situations: anxiety, fear, or hysteria. metabolic disorders: amino acid metabolism disorder, hemochromatosis, lipid metabolism disorder, etc. medical disorders: congestive heart failure (chf), liver failure, hyperthyroidism, etc. environmental: hot and cold weather emergencies, higher altitude changes, etc.",
        "pathology of hypoventilation": "hypoventilation is a decrease in respiratory rate. decreased respirations --> increased co2 retention --> progressively elevated exhaled co2 levels --> respiratory acidosis.",
        "causes of hypoventilation": "overdose. brainstem injury. injury to the thorax. some infections. pain. inability to inspire (traumatic asphyxia). lung collapse as seen in a pneumothorax, hemothorax, or combination of the two. airway obstructions. obstructive diseases such as asthma and emphysema.",
        "recognition": "in this section, we will look at the signs and symptoms for hyperventilation and hypoventilation. important values: normal respiratory rate is 12-20 breaths per minute with an etco of 35-45 mmhg. hyperventilation is anything over 20 breaths per minute with an etco: under 35 mmhg. hypoventilation is anything under 12 breaths per minute with an etco over 45 mmhg.",
        "symptoms": "symptoms associated with hyperventilation: anxiety. dizziness/lightheadedness. chest pain. numbness. tingling of hands and feet. sense of dyspnea even though they present with rapid breathing. symptoms associated with hypoventilation: fatigue. headache. cyanosis. confusion. hypoxia.",
        "treatment and management": "in this section, we will look at respiratory system assessment as well as treatment and management of hyperventilation and hypoventilation. respiratory system assessment: primary assessment: remember abcs. assess make sure that the patient's airway is patent (no snoring or gurgling). ensure airway is open either by jaw thrust or head-tilt chin-lift.",
        "respiratory system assessment (continued)": "determine if breathing is adequate. provide adequate ventilatory assistance as needed for those patients with decreased respiratory drive. you may use supplementary oxygen and/or bvm to maintain an spo2 of 94% or greater or a co2 of 35-45 mmhg.",
        "secondary assessment": "once you have corrected any life-threatening issues, you should conduct a secondary assessment. history: this is the time you need to try to get the patient's history from either the patient or family/friends that may be around. physical examination: for respiratory patients, it is important to continue to evaluate the abcs.",
        "scenario 1": "dispatch information: you are dispatched to a 39-year-old african american male complaining of weakness and not feeling well. scene information: you enter a single-story residence to find your patient sitting on a couch.",
        "scenario 1 (continued)": "the house is noted to be cluttered with multiple medication bottles sitting around. he is alert and oriented but appears to have deep and respirations. patient is also noted to have the smell of acetone on his breath.",
        "scenario 2": "dispatch information: you respond to a very prominent neighborhood for a 16-year-old caucasian female who was found unresponsive in her room. scene information: upon arrival her frantic parents meet you at the front door and lead you up to her room.",
        "scenario 2 (continued)": "she is found lying on her bed with snoring respirations. her parents state they last saw her approximately an hour ago after she returned from a friend's house.",
        "tips and tricks": "patients with altered level of consciousness should have ventilatory support given. when providing ventilatory assistance make sure to maintain a rate of 1 breath every 6 seconds.",
        "respiratory system assessment continued": "determine if breathing is adequate. provide adequate ventilatory assistance as needed for those patients with decreased respiratory drive. you may use supplementary oxygen and/or bvm to maintain an spo2 of 94% or greater or a co2 of 35-45 mmhg. patients receiving ventilatory assistance or who have an altered level of consciousness should have an airway adjunct in place such as a npa or opa.",
        "scenario 1 continued": "he is alert and oriented but appears to have deep and respirations. patient is also noted to have the smell of acetone on his breath. it is important to note the deep rapid respirations and smell of acetone on the patient's breathe. these are key indicators of the possible cause of the patient's reason for seeking ems today.",
        "scenario 2 continued": "she is found lying on her bed with snoring respirations. her parents state they last saw her approximately an hour ago after she returned from a friend's house. patient information: her parents state she has no known allergies, takes no regular medications, and has no medical problems.",
        "symptoms associated with hyperventilation": "anxiety. dizziness/lightheadedness. chest pain. numbness. tingling of hands and feet. sense of dyspnea even though they present with rapid breathing.",
        "symptoms associated with hypoventilation": "fatigue. headache. cyanosis. confusion. hypoxia.",
        "field tip": "sometimes providing a ventilatory assistance alone in narcotic overdoses will cause the patient respirations to spontaneously increase."
    },
    {
        "introduction": "this study guide will cover peep ventilation and the anatomy and physiology knowledge required to understand when peep should, or should not, be applied. peep is a valve applied to mechanical ventilation (bvm) that maintains a certain amount of airway pressure, even during exhalation. peep is an intervention similar to cpap (continuous positive airway pressure), except that it is applied via a bag-valve-mask ventilations instead of a mask. it is used to improve oxygenation at the cost of increased intrathoracic pressure.",
        "overview of pulmonary respiration": "normal pulmonary respiration is the process of inhalation (breathing in) and breathing out (exhalation). inhalation results from the diaphragm and intercostal muscles contracting which increases the size of the intrathoracic cavity therefore decreasing intrathoracic pressure. this allows air to rush into the lungs and reach the alveoli, the location of gas exchange. during inhalation, the alveoli expand to increase surface area and maximize gas exchange. during exhalation the diaphragm relaxes causing the volume of the intrathoracic cavity to decrease and increase intrathoracic pressure, pushing air out of the lungs. during exhalation the alveoli constrict partially to help with exhalation. the interior of the alveoli are coated in a substance called pulmonary surfactant. this is a mixture of lipids and proteins with a primary function of lowering the surface tension at the air/liquid interface a preventing alveolar collapse. during exhalation when the intrathoracic pressure is increased and the alveoli are partially constricted, surfactant is helping keep the alveoli open and ready for the next inhalation instead of collapsing completely. many types of lung disease, for example acute respiratory distress syndrome (ards) or pneumonia, can lead to decreased production or availability of surfactant. this puts these individuals at a higher risk of alveolar collapse, known as atelectasis.",
        "goal of peep": "the goal of peep is to prevent alveolar collapse therefore improving ventilation and oxygenation. a peep valve is simply a spring the patient exhales against. they will commonly be rated for 0-20 cm h2o pressure. most protocols have an initial peep of 5 cm h20, with increases in intervals of 5 cm h2o up to 15 or 20 cm h2o.",
        "recognition in the field: what patients benefit from peep?": "alveolar collapse can be caused by many factors both obstructive and non-obstructive. an obstructive cause would be a physical block such as a tumor inside the airway, mucus plugs, or a foreign body inside the lung. nonobstructive causes include pneumothorax, pleural effusion, pneumonia, scarring of lung tissue, and lung disease. peep treats non-obstructive causes of alveolar collapse, as changing pressure will not have an effect on a physical object interfering with the alveoli. any time peep is used, it will be on a higher acuity patient who is unable to provide adequate ventilations of their own. if a patient requires positive pressure but is breathing for themselves, continuous positive airway pressure (cpap) is indicated. the main indication for peep is a patient with hypoxia despite bag valve mask ventilation with 100% oxygen. it is important to understand the physiology of pulmonary respiration and know when alveolar collapse could be contributing to a patients respiratory distress. peep should be applied to patients that need oxygenation, and have a perfusing blood pressure. peep is contraindicated in some protocols for cardiac arrest and relatively contraindicated in some protocols for hypotensive or shock patients. peep increases intrathoracic pressure, which can decrease blood flow in a cardiac arrest or shock state.",
        "scenario": "peep can sometimes seem a bit confusing, but examples help demonstrate when it is indicated and in which patients the intervention will benefit. an elderly male patient calls 911 and presents with severe respiratory distress. the patient states a history of ards and copd and has medical paperwork indicating recent pneumonia. upon listening to lung sounds the paramedics find significantly diminished lung sounds in the lower lungs. the patient has an initial oxygen saturation of 78% on room air with a blood pressure of 134/68. the patient is placed on high flow oxygen and has been taking his prescribed inhaler and corticosteroid with no relief. even on 15l oxygen the patients oxygen saturation is sitting at 82%. the paramedics are trying to initiate a breathing treatment and consider cpap for the patient but as they are setting it up the patient becomes very sleepy and goes unconscious. the person in charge delegates a crew member to start providing mechanical ventilations via bag valve mask with 100% oxygen. patients repeat blood pressure comes back at 150/78, but even after 3-4 minutes of bagging, the patients oxygen saturation has not climbed at all. this is the moment its important to remember the anatomy and physiology of the lungs and different respiratory conditions. the patient has a perfusing blood pressure, but due to lack of available alveoli in the lungs it is difficult for the body to fully oxygenate that blood at the alveoli. in this scenario, if the paramedics applied a peep valve to their bvm it would help alveoli remain open, not collapse, allowing more area for the lungs to exchange carbon dioxide for oxygen, and for the patients oxygen saturation to climb into the 90s.",
        "extra reminders": "peep is contraindicated in some protocols for cardiac arrest, even if cardiac arrest was preceded by respiratory distress or arrest. with adequate perfusion being one of the key pillars of cardiac arrest management, the increase in intrathoracic pressure (reducing perfusion) could have a negative effect on the patient. some protocols also advise against peep in shock patients. in all situations its important to understand that peep could mildly decrease perfusion due to an increase in intrathoracic pressure.",
        "important notes": "the goal of peep is to prevent alveolar collapse, therefore, improving ventilation, and oxygenation. a peep valve is simply a spring the patient exhales against. they will commonly be rated for 0-20 cm/h2o pressure. most protocols have an initial peep of 5 cm/h20, with increases in intervals of 5 cm/h2o up to 15 or 20 cm/h2o.",
        "example scenario": "peep can sometimes seem a bit confusing, but examples help demonstrate when it is indicated and in which patients the intervention will benefit. an elderly male patient calls 911 and presents with severe respiratory distress. the patient states a history of ards and copd and has medical paperwork indicating recent pneumonia. upon listening to lung sounds the paramedics find significantly diminished lung sounds in the lower lungs. the patient has an initial oxygen saturation of 78% on room air with a blood pressure of 134/68. the patient is placed on high flow oxygen and has been taking his prescribed inhaler and corticosteroid with no relief. even on 15l oxygen, the patient's oxygen saturation is sitting at 82%. the paramedics are trying to initiate a breathing treatment and consider cpap for the patient but as they are setting it up the patient becomes very sleepy and goes unconscious. the person in charge delegates a crew member to start providing mechanical ventilations via bag valve mask with 100% oxygen. the patient's repeat blood pressure comes back at 150/78, but even after 3-4 minutes of bagging, the patient's oxygen saturation has not climbed at all. this is the moment it's important to remember the anatomy and physiology of the lungs and different respiratory conditions. the patient has a perfusing blood pressure, but due to the lack of available alveoli in the lungs, it is difficult for the body to fully oxygenate that blood at the alveoli. in this scenario, if the paramedics applied a peep valve to their bvm it would help alveoli remain open, not collapse, allowing more area for the lungs to exchange carbon dioxide for oxygen, and for the patient's oxygen saturation to climb into the 90s.",
        "the goal of peep": "the goal of peep is to prevent alveolar collapse therefore improving ventilation and oxygenation. a peep valve is simply a spring the patient exhales against. they will commonly be rated for 0-20 cm h2o pressure. most protocols have an initial peep of 5 cm h20, with increases in intervals of 5 cm h2o up to 15 or 20 cm h2o.",
        "recognition in the field: which patients benefit from peep?": "alveolar collapse can be caused by many factors both obstructive and non-obstructive. an obstructive cause would be a physical block such as a tumor inside the airway, mucus plugs, or a foreign body inside the lung. nonobstructive causes include pneumothorax, pleural effusion, pneumonia, scarring of lung tissue, and lung disease. peep treats non-obstructive causes of alveolar collapse, as changing pressure will not have effect on a physical object interfering with the alveoli. any time peep is used, it will be a higher acuity patient that is unable to provide adequate ventilations of their own. if a patient requires positive pressure but is breathing for themselves, continuous positive airway pressure (cpap) is indicated. the main indication for peep is a patient with hypoxia despite bag valve mask ventilation with 100% oxygen. it is important to understand the physiology of pulmonary respiration and know when alveolar collapse could be contributing to a patients respiratory distress. peep should be applied to patients that need oxygenation, but have a perfusing blood pressure. peep is contraindicated in some protocols for cardiac arrest and relatively contraindicated in some protocols for hypotensive or shock patients. peep increases intrathoracic pressure, which can decrease blood flow in a cardiac arrest or shock state."
    },
    {
        "introduction": "cpap and bipap",
        "what is cpap?": "cpap is a form of non-invasive positive pressure ventilation (nippv) that helps to improve a patient's ventilatory and oxygenation efforts. if used early enough, cpap can prevent the patient from having to undergo endotracheal intubation and mechanical ventilation. cpap will generally start off with 5 cmh20 and increase by 2.5 mmhg as needed based off of patient presentation up to 20cm/h20.",
        "how does it work?": "cpap will provide a constant pressure helping to stint open the alveoli. this will also recruit alveoli, that were previously closed due to atelectasis, to open and participate in oxygenation. it also increases intrathoracic pressure, which will decrease venous return to the heart, and in turn reduce preload. this can be very beneficial in patients with pulmonary edema secondary to chf.",
        "indications for cpap": "indications for cpap include: \n* patient is awake and able to follow commands \n* the age of the patient is greater than 12-years-old and can fit into a cpap mask \n* able to maintain an open airway \n* respiratory greater than 25 breaths per minute \n* spo2 of less than 94% \n* use of accessory muscles during respiration",
        "contraindications of cpap": "contraindications of cpap include: \n* respiratory arrest or apnea \n* patient who has a suspected pneumothorax or suffered trauma to the chest \n* patient with a tracheotomy \n* patient who is vomiting or has an upper gi bleed \n* hypotension \n* non-cooperative patient \n* an inability to maintain a mask seal",
        "what is bi-level positive pressure ventilation?": "bipap is another form of non-invasive positive pressure ventilation (nippv). delivers two different pressures, inspiratory positive airway pressure (ipap) and expiratory positive airway pressure (epap). this allows a higher pressure to be delivered during inspiration, and a lower pressure during expiration, thereby reducing the work of exhaling. generally, settings will start off with 10 cmh2o for ipap and 5 cmh20 for epap. adjust as needed for patient presentation.",
        "how does bipap work?": "while cpap is continuous pressure, bipap has two different pressures known as ipap and epap. ipap will force air into the lungs, decreasing the work of the accessory muscles. epap makes it easier for the patient to breath against the lower pressure. the greater the difference in pressures, the higher the patient's tidal volume will be. the ability of bipap to increase tidal volumes and therefore, lower co2 levels, is what most differentiates it from cpap.",
        "indications for bipap": "indications for bipap are the same as cpap, they include: \n* patient is awake and able to follow commands \n* the age of the patient is greater than 12-years-old and can fit into a cpap mask \n* able to maintain an open airway \n* respiratory greater than 25 breaths per minute \n* spo2 of less than 94% \n* use of accessory muscles during respiration",
        "contraindications of bipap": "contraindications of bipap are the same as cpap, they include: \n* respiratory arrest or apnea \n* patient who has a suspected pneumothorax or suffered trauma to the chest \n* patient with a tracheotomy \n* patient who is vomiting or has an upper gi bleed \n* hypotension \n* non-cooperative patient \n* an inability to maintain a mask seal",
        "cpap and bipap benefits": "cpap and bipap help improve patients ventilation and oxygenation efforts in patients progressing into respiratory failure secondary to cardiogenic and non-cardiogenic pulmonary edema, copd, and asthma. these forms of nippv help improve the patient's clinical outcome and can prevent the patient from having to be intubated and on a ventilator.",
        "anatomy and physiology review": "upper airway: nasal cavity, pharynx, and larynx lower airway: trachea, bronchi, bronchioles, and alveoli physiology: main function of the respiratory system is gas exchange. oxygen is taken by inspiration and offloaded into the blood to be oxygenated. while the carbon dioxide (co2) is off loaded into the alveoli and blown out through expiration. ventilation: mechanical process of moving air in and out of the lungs. two phases of ventilation are inspiration and expiration. normally breathing is a negative pressure system.",
        "pathophysiology": "obstructive lung disease (copd and asthma): caused by bronchospasm (constricted bronchioles). caused by increase in mucus production and inflammation. this leads to air trapping distal to the obstruction in the bronchioles. these patients will usually have pursed lip breathing because they are trying to create their own peep.",
        "recognition": "asthma signs and symptoms: \n* dyspnea \n* wheezing \n* persistent cough \n* hyperinflation of chest (air trapping) \n* tachypnea \n* speaking in 2-3 word sentences \n* accessory muscle use \n* pulsus paradoxus (drop in systolic blood pressure of 10 mmhg on inspiration) \n* tachycardia \n* decreased spo2 \n* anxiety \n* agitation",
        "chronic obstructive pulmonary disorder (copd) emphysema and chronic bronchitis": "exertional dyspnea \n* barrel chest appearance \n* prolonged expiratory phase \n* pursed lip breathing \n* accessory muscles \n* pink skin (emphysema pink puffers) \n* finger clubbing \n* wheezing \n* rhonchi, or diminished lung sounds \n* 12-word dyspnea \n* accessory muscle use \n* productive cough with sputum (chronic bronchitis) \n* cyanosis (chronic bronchitis/ blue bloaters)",
        "cardiogenic pulmonary edema (chf exacerbation)": "cyanosis \n* tachycardia \n* labored breathing \n* rales (crackles) \n* rhonchi for lung sounds \n* coughing \n* pink frothy sputum \n* dyspnea \n* feeling of drowning when lying supine \n* extremity edema \n* ascites (typically right heart failure) \n* jvd (typically right heart failure) \n* tachypnea \n* hypertension \n* paroxysmal nocturnal dyspnea \n* pillow orthopnea \n* anxiety \n* agitation",
        "non cardiogenic pulmonary edema/ acute respiratory distress syndrome (ards)": "usually, clinical symptoms will depend on the cause. people who develop ards secondary to sepsis will present with signs and symptoms consistent with their infection. \n* dyspnea \n* agitation \n* confusion \n* tachypnea \n* tachycardia \n* central cyanosis \n* rales (crackles) for lung sounds \n* fatigue \n* reduced exercise ability",
        "treatment and management": "asthma/copd: \n* prioritized needs: scene safety, wear gloves, consider wearing eye protection, mask or face shield, and gown for aerosolizing procedures. \n* initial actions: early placement of high flow oxygen for patients in respiratory distress and low oxygen saturation. \n* ongoing treatment/ treatment goals: consider assisting the patient using their albuterol inhaler and coaching their breathing. consider using albuterol. consider the use of cpap/bipap if patient starts to head towards respiratory failure. be prepared to ventilate with a bvm as needed.",
        "transport considerations": "consider als intercept. transport to nearest appropriate facility.",
        "scenario": "dispatch: it is 2200 on a clear night, weather is approximately 100 f. m10 you are being dispatched to a breath1 at a local residence. patient reporting, he feels short of breath and has ran out of his inhaler. als intercept is 10 minutes away, with the nearest hospital being 30 minutes away.",
        "tips and tricks": "the golden standard for treatment with someone with pulmonary edema will be cpap/bipap. they cannot oxygenate if they have fluid in the lungs. \n* for copd and asthma, if your efforts to combat the hypoxia with high flow oxygen and breathing treatments do not work, consider the use of cpap/bipap. \n* remember right sided heart failure causes fluid to back up in extremities, abdomen, and causes jvd. whereas left sided heart failure backs up into the lungs.",
        "what is continuous positive pressure ventilation (cpap)?": "cpap is a form of non-invasive positive pressure ventilation (nippv) that helps to improve ventilatory and oxygenation efforts. if used early enough, it can prevent the patient from having to undergo endotracheal intubation and mechanical ventilation. cpap will generally start off with 5 cmh20 (centimeters of water) and increase as needed based on patient presentation.",
        "what is the difference?": "cpap is continuous pressure, bipap has two different pressures known as ipap and epap. ipap will also help open up the lower airways and alveoli recruitment. epap makes it easier for the patient to breath against the lower pressure. the greater the difference in pressures, the higher the patients tidal volume will be. the ability of bipap to increase tidal volumes and therefore, lower co2 levels, is what most differentiates it from cpap.",
        "indications or bipap": "indications or bipap are the same as cpap, they include: use of accessory muscles during respiration, spo2 less than 94%, respiratory rate greater than 25 breaths per minute, exhibits two or more of the following: able to maintain an open airway, the age of the patient is greater than 12-years-old and can fit a cpap mask, patient is awake and able to follow commands",
        "contraindications for bipap": "contraindications for bipap are the same as cpap, the include: respiratory arrest or apnea, patient who has a suspected pneumothorax or suffered trauma to the chest, patient with a tracheostomy, patient who is vomiting or has an upper gi bleed, hypotension, a non-cooperative patient, inability to maintain a mask seal.",
        "cpap and bipap": "cpap and bipap help improve patients ventilation and oxygenation efforts in patients with cardiogenic/non-cardiogenic pulmonary edema, copd, and asthma. these forms of nippv help improve the patients clinical outcome and can prevent the patient from being intubated and placed on a ventilator.",
        "ventilation": "the mechanical process of moving air into and out of the lungs. the two phases of ventilation are inspiration and expiration. normally, breathing is a negative pressure system. during inspiration, the diaphragm contracts and a negative pressure environment is generated moving air into the lungs. this negative intrathoracic pressure also decreases right atrial pressure in turn increasing venous return to the heart. during expiration, the pressure in the lungs returns to normal.",
        "reources": "1. bledsoe, b. e., cherry, r. a., & porter, r. s. (2017). paramedic care: principles & practice. in paramedic care: principles & practice (vol. 3, pp. 27-143). boston: pearson education. 2. cdc - basics about copd - chronic obstructive pulmonary disease (copd). (2019, july 19). retrieved april 01, 2021, from https://www.cdc.gov/copd/basics-about.html"
    },
    {
        "introduction": "airway management is a wide subject, combining a complex knowledge of anatomy, physiology, assessment and techniques with the goal of stabilizing and securing a patient's airway. understanding anatomy of the upper and lower respiratory system is integral to proper airway assessments, which in turn can lead to proper implementation of airway management techniques. literature has often shown little survival benefit for prehospital endotracheal intubation, and the procedure is associated with significant complications. many ems systems are moving to supraglottic airways/blind insertion airway devices. ultimately the tools and techniques are limited by the provider who uses them, each one requires practice",
        "proper positioning": "unconscious patients who require airway and ventilation interventions are usually best maintained in an ear to sternal notch position. in the ear to sternal notch position, the patient's head is elevated to the point where the ear and the sternal notch are aligned horizontally. often referred to as the sniffing position, or the ramped position in obese patients. both the sniffing and ramped positions maximize upper airway patency allowing for effective ventilation",
        "manual airway maneuvers": "the simplest airway management techniques require no equipment, are noninvasive, and can be highly effective. based on the principal of least invasive/lowest risk procedures first, these techniques should be considered first before moving on to other, more advanced, procedures. posterior displacement of the tongue is often the cause of airway obstruction in unconscious or decreased loc patients. these techniques are not to be used on responsive patients, and do not protect the airway from aspiration.",
        "head tilt/chin lift": "avoid in patients with confirmed or suspected c-spine injuries. technique: palm of one hand on patient's forehead, use firm downward pressure to tilt head back. two fingers of other hand under the bony part of chin and lift jaw anteriorly; avoid soft tissues of neck and chin",
        "jaw thrust maneuver": "recommended for patients at risk for c-spine injury who cannot protect their airway. difficult to maintain for extended periods of time. technique: lift the jaw using fingers behind the mandibular angle, thumbs on cheekbones to provide counter force",
        "foreign body airway obstruction": "fbao can be split into two types; partial/mild or complete/severe. partial: obstruction is partially blocking the airway, still allowing adequate air movement for the patient to remain conscious. pt will likely be able to speak, commonly coughing frequently. encourage coughing, no direct action is needed by the provider directly unless the obstruction becomes more severe. complete: obstruction is completely blocking airway. if pt is unable to cough or speak obstruction is complete.",
        "foreign body obstructions": "commonly referred to as \"cafe coronaries\" or \"steakhouse syndrome\", food bolus' can get stuck in the esophagus, occluding the posterior trachea and resulting in inadequate airflow. whether the obstruction is in the trachea or esophagus can be difficult to determine, and they should be treated essentially the same in the field.",
        "airway suctioning": "suctioning must be available to remove fluid, such as emesis, blood, or mucus, that can obstruct an airway or lead to aspiration. types of suctioning catheters: hard/rigid catheter, soft catheters",
        "basic airway adjuncts": "without trauma, excess secretions, foreign bodies, or edema, basic airway adjuncts can be used to prevent the tongue from falling back to block the airway. indications for basic airway adjuncts are decreased level of consciousness with absent or suppressed gag reflex. two types of adjuncts are used: nasopharyngeal airway, oropharyngeal airway",
        "special considerations": "do not use an undersized opa. stimulation of an eyelash reflex is indicative of a gag reflex. improper insertion of opa's may push the tongue into the posterior pharynx and create an airway obstruction.",
        "scenario": "dispatch info: a bls ambulance is dispatched to the report of cpr in progress in an alley behind a local dive bar. dispatch reports pre-arrival cpr instructions are being provided. scene info: on arrival, there is one patient laying supine in a dark alley, with surgical tubing tied as a tourniquet around their arm. track marks from assumed recreational drug use are clearly visible. pd arrived just prior to the ambulance and secured the scene."
    },
    {
        "introduction": "an introduction to oxygen (o2). humans, like many other living organisms, require oxygen to maintain metabolic processes (aerobic). oxygen is a gas at room temperature and is available at 20.9 % of ambient air. during a medical emergency, chronic medical condition, or at high altitudes, supplemental oxygen can be vital to improving the condition of a patient. this emt basic study guide will explore the devices for containing and supplying oxygen in the medical environment. it will also review when oxygen administration is indicated or not indicated as a medical intervention.",
        "containers": "there are many different types/sizes of medical oxygen cylinders. the most commonly used in the prehospital environment are d tanks and m tanks. d tanks are small portable cylinders while m is large and generally used to supply oxygen systems in an ambulance. cylinder oxygen level is measured in psi.",
        "important safety considerations": "the oxygen is held under pressure in cylinders. oxygen cylinders are an explosive/projectile hazard if damaged or improperly used. keep oxygen tanks secured, regularly inspect them for damage, and handle them with care. oxygen is flammable. never expose oxygen lines, tanks, or flow to open flame or a heat source.",
        "routes of administration": "the route of administration will depend on the specific needs of the patient. oxygen flow is measured in liters per minute (lpm). a nasal cannula provides the lowest amount of oxygen flow while non-rebreathers (nrb) provide the greatest flow. devices such as the bag valve masks (bvm) provide high flow and positive pressure. other devices, such as nebulizers, use moderate oxygen flow to aerosolize a medication that assists with oxygen administration. if needed, nebulizers can be plumed into nrb for hands-free use, or bvms for positive pressure ventilation.",
        "oxygen delivery devices and flow rates": "nasal cannula (1-6 lpm), nonrebreather (10-15 lpm), bvm (10-15 lpm & ppv), nebulizer (6-8 lpm w/ medication)",
        "oxygen delivery times": "when administering oxygen, it is important to have an understanding of how long you can provide that treatment. for most prehospital care, short patient care times make this concern relatively unimportant. that said, situations such as extended scene times, transport times (interfacility or inclement weather), low oxygen tanks, or difficult/critical patients, may threaten to empty your oxygen tank. the amount of time an oxygen tank will provide depends on its size, its psi, and the flow rate (lpm).",
        "when to administer oxygen": "oxygen is not a harmless drug and its administration should be based on clinical findings. symptoms: shortness of breath, difficulty breathing, lightheadedness, headache. signs: adventitious lung sounds, cyanosis, altered level of consciousness, combativeness, unconsciousness, or cardiac/respiratory arrest. exposure: toxic gas exposure (e.g., carbon monoxide) objective data (spo2): spo2 < 94%.",
        "when to avoid/titrate oxygen administration": "chronic obstructive pulmonary disease (copd). when deciding to administer medication, it is important to have an understanding that not every patient will have the same response. patients with copd (chronic bronchitis or emphysema) may chronically present with oxygen saturations well below 94%. due to their medical condition, these patients have changes to their respiratory drive and are used to lower oxygen saturation. administering oxygen to them based on their spo2 could actually cause the patient to breathe less (respiratory depression). as a result, oxygen should be administered to these patients cautiously. if the patient has no signs/symptoms of poor oxygenation, it may be indicated to withhold oxygen administration.",
        "special considerations": "return of spontaneous circulation (rosc). while under most circumstances, medical and prehospital guidelines encourage oxygen administration above 94%, the american heart association recommends that during post-cardiac arrest care, an oxygen saturation between 92-98% should be the clinical goal. cardiac chest pain. in the instance of cardiac chest pain, some protocols suggest withholding oxygen, if the patient's room air oxygen saturation is above 90%. head injury/cerebral vascular attack (cva). similar calls to titrate oxygen occur in prehospital protocols when there is a high concern for a head injury or suspected cva/stroke.",
        "scenario": "you are dispatched as a two-person bls crew to a person with breathing problems. dispatch information includes: 67 y/o female, cannot catch her breath, conscious. other resources are delayed due to winter weather. you are conveniently 4 blocks away from the call.",
        "scenario continued": "you and your partner arrived to find the patient. from the door, you see tripoding on the edge of a bed and significant work of breathing. she does not greet you or look up when you enter and introduced yourselves. she is unable to give complete verbal responses to questions. you notice that she has a nasal cannula and a long length of tubing that goes to a home oxygen tank next to the bed.",
        "patient assessment and treatment": "your partner starts on a set of vitals. he gets a heart rate of 110 bpm, a blood pressure of 176/102, oxygen saturation of 85%, and respiratory rate of 30 breaths/min with wheezing in all fields.",
        "oxygen administration decision": "upon seeing that oxygen saturation your partner starts reaching for the d tank. you look to the patient's oxygen tank and find it empty. your partner asks, what should we put her on?",
        "oxygen administration decision continued": "you select your oxygen treatment and you start to see some improvement with your patient. heart rate and bp remain the same, spo2 increases to 93% and her respirations are 28 breaths/min. she is still focused on her breathing and answers questions with a head shake.",
        "nebulizer administration": "you see an inhaler next to her bed, it is an expired albuterol inhaler. at this time her neighbor walks in and starts asking how her patient is doing. you take him to the side and ask him if he knows the patient's medical history. he states that she frequently has respiratory problems and he thinks she has emphysema from decades of smoking cigarettes.",
        "adjusting oxygen administration based on patient's condition": "having learned your patient has emphysema or copd, does this change your oxygen administration?",
        "nebulizer oxygen flow rate": "based on the clinical findings, you have your partner starts setting up a nebulizer to plum into the nrb for albuterol administration. what oxygen flow should be used for a nebulizer?",
        "oxygen tank management": "you get a radio update from dispatch that an als ambulance is 30 min out due to high call volume and heavy snow. your vehicle is not equipped to transport the patient. you notice that your d tank is below 500 psi.",
        "oxygen tank management continued": "based on the chart provided on your airway bag and a flow rate of 8 lpm, how much time do you have with this bottle?",
        "spare oxygen tank": "you send your partner to grab the spare d tank and he comes back with one that has 1500 psi. your patient has improved after the first nebulized treatment and is now speaking with ease. vitals are as follows, hr 120 bpm, blood pressure 166/90, rr 18 and nonlabored, wheezing present in lower lobes on auscultation.",
        "oxygen administration for potential decompensation": "if your patient decompensated and required another albuterol treatment, how much time could you flow your new d tank for at 8 lpm? (see chart from the previous question).",
        "conclusion and patient transport": "you place your patient on 2 lpm since she states she is chronically on this amount and als arrives early after clearing from a different call. they take reports, thank you for your help, and transport the patient to the hospital.",
        "answers": "c, c, b, less than 10 minutes",
        "oxygen delivery devices": "nasal canula (1-6 lpm) nonrebreather (10-15 lpm) bvm (10-15 lpm & ppv) nebulizer (6-8 lpm with medication) continuous positive airway pressure (cpap) is another route to deliver oxygen generally used by advanced and als prehospital providers.",
        "flow rate and peep": "when administering oxygen, it is important to have an understanding of how long you can provide that treatment. for most prehospital care, short patient care times make this concern relatively unimportant. that said, situations such as extended scene times, transport times (interfacility or inclement weather), low oxygen tanks, or difficult/critical patients, may threaten to empty your oxygen tank. the amount of time an oxygen tank will provide depends on its size, its psi, and the flow rate (lpm).",
        "when to administer?": "oxygen is not a harmless drug and its administration should be based of clinical findings. symptoms: shortness of breath, difficulty breathing, lightheadedness, headache. signs: adventitious lung sounds, cyanosis, altered level of consciousness, combativeness, unconsciousness, or cardiac/respiratory arrest. exposure: toxic gas exposure (e.g., carbon monoxide) objective data (spo2): spo2 < 94%.",
        "when to avoid/titrate oxygen administration?": "chronic obstructive pulmonary disease. when deciding to administer a medication, it is important to have an understand that not every patient will have the same response. patients with copd (chronic bronchitis or emphysema) may chronically present with oxygen saturations well below 94%. these patients have changes to their respiratory drive due to their condition and are used to lower oxygen saturations. administering oxygen to them based on their spo2 could actually cause the patient to breath less (respiratory depression).",
        "return of spontaneous circulation (rosc)": "while under most circumstances, medical and prehospital guidelines encourage oxygen administration above 94%, the american heart association recommends that during post-cardiac arrest care, an oxygen saturation between 92-98% should be the clinical goal.",
        "cardiac chest pain": "in the instance of cardiac chest pain, some protocols suggest withholding oxygen, if the patients room air oxygen saturation is 90% of above.",
        "head injury/cerebral vascular attack (cva)": "similar calls to titrate oxygen occur in prehospital protocols when there is high concern for a head injury or suspected cva/stroke. oxygen should be administered to patients to achieve 94% oxygen saturation but should not be increased beyond this point.",
        "ventilators": "ventilators. depending on where you work and the credentials you maintain, you may use or be exposed to ventilators. ventilators provide significant control in oxygenating the patient. you can select a specific tidal volume, percentage of oxygen, and choose modes such as cpap, bipap, on-demand, etc.",
        "preoxygenation and delayed sequence intubation (dsi)": "good prehospital medicine frequently involves thinking outside of the box. when it comes to more advanced airway techniques, studies have shown the importance of preoxygenation/denitrification and dsi.",
        "when to administer": "oxygen is not a harmless drug and its administration should be based of clinical findings. symptoms: shortness of breath, difficulty breathing, lightheadedness, headache. signs: adventitious lung sounds, cyanosis, altered level of consciousness, combativeness, unconsciousness, or cardiac/respiratory arrest. exposure: toxic gas exposure (e.g., carbon monoxide) objective data (spo2): spo2 < 94%."
    },
    {
        "introduction": "acute pulmonary embolism (pe) is a high-mortality medical emergency that occurs when a blood clot becomes lodged in a patient's pulmonary circulation. pe is also a common cause of sudden cardiac arrest. as always, treatment is focused on supporting airway, breathing, and circulation within a clinician's scope of practice. not all pes are as obvious as one might think.",
        "lessons and concepts": "background of pulmonary embolism. deep vein thrombosis (dvt) is a condition of undesired blood clot formation in the veins of the patient's extremities. these clots almost always originate in the legs. an embolism occurs when a clot breaks away from the blood vessel and enters systemic circulation. an embolism originating in the leg will travel through the inferior vena cava (ivc) and enter the patient's right atrium. next, it will travel through the right ventricle and out through the pulmonary artery. once the clot leaves the heart, it will eventually get trapped in the arterial pulmonary circulation.",
        "pathophysiology": "when a blood clot becomes trapped in the pulmonary circulation, it obstructs the flow of blood to a portion of the lung tissue. small clots may obstruct small peripheral arteries, causing mild symptoms. in many cases, several small clots break loose at once and occlude several small arteries. a larger clot may obstruct a larger blood vessel such as the right pulmonary artery or the left pulmonary artery. when a massive blood clot obstructs the main pulmonary artery, it is called a saddle embolism and carries a very high risk of sudden death. this occludes blood flow to both lungs at once.",
        "respiratory effects": "because blood is unable to make it to the lungs, blood is now unable to pick up oxygen or offload carbon dioxide in the affected area. a patient may experience shortness of breath due to high co2, low oxygen, or both. because the affected portion of the lungs is still ventilated but not adequately perfused, we use the term \"dead space\" to describe the affected territory. as time goes on, affected lung tissue may infarct (die).",
        "cardiovascular effects": "if a blood clot is large enough, it will obstruct a large volume of blood that would normally circulate through the lungs. this is a type of obstructive shock. it creates a backlog of blood and ultimately leads to right ventricular failure if the heart's muscle cannot overcome the resistance. this may lead to signs and symptoms associated with right ventricular heart failure, including: distention of the jugular veins (jvd), swelling of extremities, fluid accumulation in the abdomen. as the right ventricle begins to swell, it shifts the heart's interventricular septum and may ultimately occlude the left ventricle as well. this will lead to hypotension and eventually cardiac arrest if untreated.",
        "cardiovascular effects signs and symptoms": "distention of the jugular veins (jvd)\nswelling of extremities\nfluid accumulation in the abdomen",
        "recognition": "pulmonary embolism may present with a variety of chief complaints, making it challenging to conclusively identify in the prehospital setting. common complaints reported in patients with pe include: chest pain - often pleuritic in nature, shortness of breath (sob), cough, especially coughing up blood (hemoptysis), dizziness or syncope. examination may reveal: tachycardia, tachypnea, unexplained hypoxia (secondary to hypoxemia), signs of right ventricular heart failure (e.g. jvd). major hemodynamic compromise may also be present (e.g. hypotension). signs of dvt such as unilateral painfully or swollen legs.",
        "recognition common complaints": "chest pain - often pleuritic in nature\nshortness of breath (sob)\ncough, especially coughing up blood (hemoptysis)\ndizziness or syncope",
        "recognition examination may reveal": "tachycardia\ntachypnea\nunexplained hypoxia (secondary to hypoxemia)\nsigns of right ventricular heart failure (e.g. jvd)",
        "stable vs. unstable": "it is important to differentiate whether there is hemodynamic compromise. hemodynamically stable pe presents with adequate blood pressure and no major impairment of a patient's circulation. this is usually the case with smaller emboli and carries a lower risk. unlikely to present with definitive signs in the field, but they should always be transported for evaluation. hemodynamically unstable pe presents with a major circulatory compromise. hypotension or a sudden drop in normal bp.",
        "treatment and management": "prehospital care always begins with assessing and supporting the abcs. supplemental oxygen is indicated if a patient presents with oxygen saturation < 94%. or per local protocol. ventilatory support may be necessary in severe cases. treat for shock if signs and symptoms are present. initiate rapid transport for any patient with serious symptoms or hemodynamic compromise. e.g. hypoxia, hypoxemia, hypotension, altered mental status, or signs of clinical deterioration.",
        "treatment and management prehospital care": "assessing and supporting the abcs\nsupplemental oxygen if oxygen saturation < 94%\nventilatory support may be necessary in severe cases\ntreat for shock if signs and symptoms are present",
        "scenario": "dispatch info: you and your emt partner are dispatched to the home of a 42-year-old female with the chief complaint of sob. scene info: on arrival, you note that the patient is protecting her own airway, but breathing rapidly and speaking in 3-5 word sentences. patient info: you note that the patient's skin is pale and cool to the touch, with cyanosis around the lips.",
        "tips and tricks": "while some pulmonary emboli are obvious, many present with mild symptoms that still need care and evaluation in the emergency room. remember that the early concerns are for obstructive shock and impaired gas exchange rather than ischemia of the lung tissue itself. always remember to focus on the abcs and administer oxygen aggressively if needed. rapid transport should be initiated for any patient with severe symptoms or hemodynamic compromise.",
        "examination": "examination may reveal: tachycardia, tachypnea, unexplained hypoxia (secondary to hypoxemia), signs of right ventricular heart failure (e.g. jvd), major hemodynamic compromise may also be present (e.g. hypotension), signs of dvt such as unilateral painfully or swollen legs.",
        "medical history": "a complete medical history may reveal: history of dvt or pe, risk factors of dvt such as: lower limb fracture, recent childbirth, long periods without movement (e.g. travel or hospitalization), history of blood clots elsewhere (e.g. prior stroke), oral contraceptive use (e.g. birth control).",
        "12-lead ecg": "12-lead ecg - while there are no ecg patterns diagnostic of pe, you are likely to find some of the following: tachycardia is the most common ecg finding in acute pe, right ventricular strain pattern, inverted t-waves in early precordial and inferior leads (v1-4, ii, iii, avf), right bundle branch block (rbbb), right atrial enlargement (peaked t-wave in lead ii), s1q3t3 pattern, dominant s-wave in lead i, pathologic q, and inverted t-wave in lead iii.",
        "non-specific signs of ischemia": "diffuse st depression, inverted t-waves, etc. any patient with symptoms suspicious of pe should be transported to a facility capable of diagnostic imaging and blood work.",
        "iv therapy": "obtain large bore iv access if possible, without delaying care or transport. ensure your iv meets local requirements for a ct scan with contrast. avoid large volumes of iv fluid.",
        "pressure support": "as stated above, avoid excessive use of iv fluids. pressers may be indicated (depending on local protocols) for hypotension that does not improve with patient positioning or small fluid bolus.",
        "definitive management": "definitive management of a pe occurs in the hospital. this may include: administration of anticoagulants (\"blood thinners\"), thrombolytics (\"clot-busting\" drugs) for unstable patients. if the hospital is capable, patients may also receive endovascular treatment or surgical intervention.",
        "treatment info": "at this point, you place the patient on a non-rebreather mask and note that oxygen saturation climbs to 92%. in your assessment, the patient tells you they suddenly became short of breath when doing some remodeling around her home.",
        "differential diagnosis": "should include acute coronary syndrome (acs) and acute pe at minimum. this history of dvt, pleuritic-type chest pain, and sudden onset of sob of accompanying hypoxia lead you to believe pe is more likely.",
        "transport info": "you elect to administer spirit per local protocol, which is unlikely to help or hurt if this patient is, in fact, suffering from a pe. because of your assessment and clinical impressions, you decide to take the patient to a large hospital with the capability of a ct scan and start a large-bore iv en route."
    },
    {
        "introduction": "pneumonia is a lower airway infection that most often targets the bronchi, bronchioles, and alveoli. pneumonia infections may result from bacteria, fungi, or viruses1, but regardless of cause, they often present with airway irritation and eventual respiratory complications.",
        "pneumonia statistics": "\u2022 from the american thoracic society2\n\u2022 in the united states, over 1 million adults seek hospital care for pneumonia every year\n\u2022 in the u.s., 50,000 adults die yearly from pneumonia\n\u2022 worldwide, there are approximately 120 million cases per year in children, accounting for 16% of all deaths in children under five years of age\n\u2022 pneumonia is the suspected cause for 50% of all sepsis cases\n\u2022 financially, pneumonia is one of the top 10 most expensive hospitalizations in the u.s.\n\u2022 any single microbe causing pneumonia is not responsible for more than 10% of all diagnosed cases",
        "lessons and concepts": "physiology of pneumonia\n\u2022 rooted in the lower airway\n\u2022 microbes enter the respiratory tract and end up in the alveoli\n\u2022 the body launches an immune response to the foreign microbes\n\u2022 as a result of the immune response, localized swelling, fluid build-up, and airway irritation occur\n\u2022 due to the immune response, respiratory function is diminished due to the impedance of portions of the airway",
        "common sources of pneumonia": "\u2022 there are three main etiologies of pneumonia\n\u2022 bacterial infection3\n\u2022 the most common cause of pneumonia\n\u2022 viral infection3\n\u2022 influenza (flu)\n\u2022 rhinovirus (common cold)\n\u2022 respiratory syncytial virus (rsv)\n\u2022 sars-cov-2 (covid-19)\n\u2022 fungal infection3",
        "routes of infection": "\u2022 \u201ctype\u201d of pneumonia varies\n\u2022 defined by infection origin\n\u2022 there are two main \u201csources\u201d of infection, with one sub-source4\n\u2022 community-acquired pneumonia (cap)\n\u2022 exposure and development outside of a hospital/healthcare setting\n\u2022 transmission through common methods\n\u2022 airborne & aerosolized (person-to-person)\n\u2022 surface contamination\n\u2022 residing in environments harmful to respiratory health\n\u2022 smoke\n\u2022 dust\n\u2022 fine particulates and other pollutants\n\u2022 increased chance of infection with other health conditions\n\u2022 asthma\n\u2022 diabetes\n\u2022 heart disease\n\u2022 lung disease\n\u2022 immunocompromised\n\u2022 age, younger than 2, greater than 65",
        "hospital-associated pneumonia (hap) and ventilator-associated pneumonia (vap)": "\u2022 hospital-associated pneumonia (hap)\n\u2022 develops during or after hospital admission, long-term-care facility, or dialysis center\n\u2022 defined as developing 48 hours after admission without incubation occurring/in progress at the time of admission5\n\u2022 ventilator-associated pneumonia (vap)\n\u2022 pneumonia occurring 48-72 hours after tracheal intubation5\n\u2022 affects 10-20% of patients who receive mechanical ventilation for over 48 hours",
        "risk factors for hap and vap": "\u2022 iv antibiotic use in the previous 90 days\n\u2022 septic shock at the time of intubation\n\u2022 acute respiratory distress syndrome (ards) before intubation\n\u2022 hospital admission of 5 days or longer\n\u2022 acute renal replacement therapy",
        "recognition": "signs and symptoms\n\u2022 generalized\n\u2022 chest pain during inspiration or coughing\n\u2022 chills\n\u2022 cough with or without mucus production\n\u2022 fever\n\u2022 hypoxia\n\u2022 shortness of breath at rest or with exertion\n\u2022 headache\n\u2022 muscle pain\n\u2022 weakness\n\u2022 tiredness\n\u2022 nausea\n\u2022 vomiting\n\u2022 diarrhea\n\u2022 diminished lung sounds\n\u2022 ronchi",
        "geriatric and pediatric patients": "\u2022 geriatric patients may present with low body temperature instead of fever and altered mental status, typically sudden in onset1\n\u2022 pediatric patients may also exhibit1:\n\u2022 cyanosis\n\u2022 grunting\n\u2022 intercostal retractions\n\u2022 tachypnea\n\u2022 nostril flaring",
        "advanced complications": "\u2022 septicemia or septic shock\n\u2022 lung abscess\n\u2022 pleural disorders\n\u2022 respiratory failure",
        "diagnosis": "\u2022 physical assessment\n\u2022 lung auscultation\n\u2022 medical history questioning\n\u2022 blood work\n\u2022 complete blood count (cbc)\n\u2022 blood cultures\n\u2022 blood gas\n\u2022 imaging\n\u2022 chest x-ray\n\u2022 chest ct scan\n\u2022 sputum sample",
        "treatment": "out-of-hospital\n\u2022 oxygen therapy\n\u2022 titrate to need\n\u2022 treat any other associated signs and symptoms\nin-hospital\n\u2022 mild cases\n\u2022 for cases of bacterial or fungal pneumonia, antibiotics are prescribed, and the patient is discharged home\n\u2022 for some viral pneumonias, antiviral medication is prescribed but is less effective and, therefore, less common",
        "scenario": "dispatch: emergent response to a senior living facility for \u201cbreathing problems\u201d for a 79 yof\nscene info: you and your partner arrive at a senior living facility and are led to the patient room by staff.\npatient info: the patient tells you she has been having a hard time breathing, with increased effort on exertion.",
        "scenario cont.": "treatment: quality physical assessment and in-depth pmh questioning on scene.\nreassessment: while transporting, the patient\u2019s spo2 has risen to 100%, and she states she feels like she is breathing much better.",
        "history": "atrial fibrillation, hypertension, arthritis, asthma \nmedications: cardizem, metoprolol, prn mdi, dietary supplements \nvitals: hr: 80-87 irregular, rr: 16 at rest, 28 and labored on exertion, bp: 142/79, spo2: 91% ra, temp: 96.3f temporal, ecg: a-fib",
        "treatment cont.": "quality physical assessment and in-depth pmh questioning on scene. recent hospital admission for 1 week raises concerns about potential for a cardiac event. after loading the patient on the gurney, you place her on a simple oxygen mask at 6 lpm and see an immediate improvement in spo2 by the time you reattach telemetry in the ambulance. the nearest hospital is a 10 minute drive.",
        "reassessment": "while transporting, the patient\u2019s spo2 has risen to 100%, and she states she feels like she is breathing much better. all other vital signs remain the same. you arrive at the ed and transfer patient care to the ed staff, giving your report to the er nurse. later in the day you check-in on the patient, and she tells you she has pneumonia. she states the md suspects she acquired it from her hospital stay, and is going to prescribe a course of antibiotics for her. patient says they are preparing to discharge her home with supplemental oxygen."
    },
    {
        "introduction": "airway management is a wide subject, combining a complex knowledge of anatomy, physiology, assessment and techniques with the goal of stabilizing and securing a patient's airway. understanding anatomy of the upper and lower respiratory system is integral to proper airway assessments, which in turn can lead to proper implementation of airway management techniques. literature has often shown little survival benefit for prehospital endotracheal intubation, and the procedure is associated with significant complications. many ems systems are moving to supraglottic airways/blind insertion airway devices. ultimately the tools and techniques are limited by the provider who uses them, each one requires practice",
        "lessons and concepts": "proper positioning: unconscious patients who require airway and ventilation interventions are usually best maintained in an ear to sternal notch position. in the ear to sternal notch position, the patient's head is elevated to the point where the ear and the sternal notch are aligned horizontally. often referred to as the sniffing position, or the ramped position in obese patients. both the sniffing and ramped positions maximize upper airway patency allowing for effective ventilation.",
        "manual airway maneuvers": "the simplest airway management techniques require no equipment, are noninvasive, and can be highly effective. based on the principal of least invasive/lowest risk procedures first, these techniques should be considered first before moving on to other, more advanced, procedures. posterior displacement of the tongue is often the cause of airway obstruction in unconscious or decreased loc patients. these techniques are not to be used on responsive patients, and do not protect the airway from aspiration.",
        "head tilt/chin lift": "avoid in patients with confirmed or suspected c-spine injuries. technique: palm of one hand on patient's forehead, use firm downward pressure to tilt head back. two fingers of other hand under the bony part of chin and lift jaw anteriorly; avoid soft tissues of neck and chin.",
        "jaw thrust maneuver": "recommended for patients at risk for c-spine injury who cannot protect their airway. difficult to maintain for extended periods of time. technique: lift the jaw using fingers behind the mandibular angle, thumbs on cheekbones to provide counter force.",
        "foreign body airway obstruction": "fbao can be split into two types; partial/mild or complete/severe. partial: obstruction is partially blocking the airway, still allowing adequate air movement for the patient to remain conscious. pt will likely be able to speak, commonly coughing frequently. encourage coughing, no direct action is needed by the provider directly unless the obstruction becomes more severe.",
        "foreign body obstructions": "commonly referred to as 'cafe coronaries' or'steakhouse syndrome', food bolus' can get stuck in the esophagus, occluding the posterior trachea and resulting in inadequate airflow. whether the obstruction is in the trachea or esophagus can be difficult to determine, and they should be treated essentially the same in the field.",
        "airway suctioning": "suctioning must be available to remove fluid, such as emesis, blood, or mucus, that can obstruct an airway or lead to aspiration. types of suctioning catheters: hard/rigid catheter, soft catheters.",
        "basic airway adjuncts": "without trauma, excess secretions, foreign bodies, or edema, basic airway adjuncts can be used to prevent the tongue from falling back to block the airway. indications for basic airway adjuncts are decreased level of consciousness with absent or suppressed gag reflex. two types of adjuncts are used: nasopharyngeal airway, oropharyngeal airway.",
        "blind insertion airway devices/supraglottic airways": "blind insertion airway devices, also known as supraglottic airways (ega's), are tools used to help secure airways that do not require the use of direct laryngoscopy. supraglottic is the broad term used to describe airway devices that sit above the glottis, or space between the vocal cords.",
        "scenario": "dispatch info: an als ambulance, staffed with an aemt and an emt partner, is dispatched to a motor vehicle accident, with report of major injuries, approximately 10 miles from the nearest level 2 trauma center.",
        "treatment and management": "airway suctioning suctioning must be available to remove fluid, such as emesis, blood, or mucus, that can obstruct an airway or lead to aspiration. types of suctioning catheters hard/rigid catheter comes in standard size, can remove larger particles, suctions large volumes of fluid rapidly, used in oropharyngeal airway only soft catheters long, flexible tubes, smaller diameter than hard tip catheters, come in multiple sizes slower suction rate than rigid catheters can be placed in the oropharynx, nasopharynx, or down the endotracheal tube",
        "endotracheal intubation": "1. direct laryngoscopy: purpose: isolates the trachea and permits complete control of the airway, limits gastric distension with ventilation, provides direct route for suctioning of respiratory passages, route for administering medications via endotracheal tube indications: based on policy, but generally restricted to patients in respiratory arrest (or cardiac) or patients in severe respiratory failure.",
        "nasotracheal intubation (nti)": "nti is used to secure airways in spontaneously breathing pts who are facing imminent respiratory decompensation, both conscious and unconscious. special equipment: no specialized equipment is required, but there are products available to aid in success: specific tubes, such as the mallinckrodt endotrol endotracheal tube, have a tip that can be manipulated to aid in proper placement.",
        "digital intubation": "allows intubation without a laryngoscope or a view of the larynx. another skill that requires practice and experience, and has largely fallen out of use. use with caution, digital intubation could stimulate even an unconscious patient to bite down. may be performed with a bougie. requires use of a bite block to ensure provider safety.",
        "needle cricothyrotomy": "also referred to as percutaneous cricothyrotomy, this procedure can be utilized as a way to establish an airway after other methods have failed. procedure is done according to local policy and available equipment, but may be done with a transtracheal over the needle catheter, 12-14 gauge angiocatheter, or prepackaged kit (eg. quicktrach)",
        "scenario 1": "dispatch info: an als ambulance, staffed with a paramedic and an emt parter, is dispatched to a motor vehicle accident, with report of major injuries, approximately 10 miles from the nearest level 2 trauma center. there is no air support due to inclement weather. scene info: upon arrival, you note a single vehicle rollover with one patient who has already been extricated by fire.",
        "scenario 2": "dispatch info: an als ambulance is dispatched to a local burger joint for a report of a 63 y/o male choking. dispatch has provided pre-arrival choking instructions to bystanders. scene info: upon arrival, you find a group of people standing around an older male, reporting that he was eating when he started coughing and wringing his hands around his neck."
    },
    {
        "introduction": "what is rsi/dsi? airway management procedure in which an advanced airway is placed in a perfusing patient. during this procedure, pharmacologic agents may be used to sedate and paralyze a patient for proper tube placement.",
        "importance of rsi/dsi": "understanding the knowledge, anatomy, and skills involved with both procedures is crucial for a paramedic provider. both medical and traumatic emergencies may result in the need for rsi/dsi, therefore proficiency in this skill is crucial. life-threatening injury or even death may occur if a provider fails to recognize the need for an advanced airway.",
        "challenges of rsi/dsi": "although rsi/dsi is performed both in and out of the pre-hospital setting, ems providers typically perform these skills in an unstable environment. this means one often lacks ideal positioning, conditions, visibility, adequate resources, or personnel. however, with sufficient training and education, paramedics can master and successfully perform this procedure in even the most unstable environments.",
        "rsi vs. dsi?": "rapid sequence intubation (rsi) has been a standard procedure for advanced airway placement for years. delayed sequence intubation has created a shift in common practices with dsi slowly becoming a more preferred method throughout ems systems.",
        "rapid sequence intubation (rsi)": "rapid sequence intubation involves rapidly preparing equipment and the patient for administration of medications to facilitate advanced airway placement. the primary goal of rsi is to pre-oxygenate the patient until medications can be administered. both induction agents and paralytics will be given virtually back-to-back with only a brief delay before an intubation attempt.",
        "risks of rsi": "rsi can increase the risk of hypoxia/hypoxic brain injury due to less emphasis placed on pre-oxygenation and maintenance of oxygen saturation levels during the procedure. providers must remain aware of both throughout the procedure. rsi also has risks of hemodynamic instability. this is primarily the result of a provider needing to focus a great deal of attention on the skill itself and losing sight of the patient's overall condition. while this is an understandable mistake, it does not change the fact that the patient is now at risk of falling into a peri-arrest state or actual cardiac arrest. providers must acknowledge and treat any hemodynamic instability to prevent hypo-perfusion and cardiac arrest.",
        "delayed sequence intubation (dsi)": "compared to rapid sequence intubation, delayed sequence intubation involves a slower approach to advanced airway placement. dsi involves focusing on idealizing the patient's hemodynamics, oxygen saturation levels, and treatment of any underlying conditions that may be related to the patient's condition (whether they be medical or trauma in origin) prior to advanced airway placement.",
        "benefits of dsi": "dsi essentially elongates the time allowed for each step of the process, including the time a provider is allotted between the onset of the drugs used and the intubation attempt itself. this alone optimizes the patient's hemodynamics and ensures they remain stable with adequate pre-oxygenation prior to an intubation attempt, thus decreasing the chance of hypoxia or hypoxic brain injury. dsi requires the induction agent to be administered early in the procedure to help facilitate adequate pre-oxygenation. once oxygen saturation reaches 94%, a minimum of three minutes is waited to allow for denitrogenation. denitrogenation is the idea of \"washing out\" nitrogen in the lungs and replacing it with oxygen to prolong the time before a patient's oxygen saturation begins to slip."
    },
    {
        "introduction": "anatomy and physiology review one of the byproducts of cellular metabolism is carbon dioxide. carbon dioxide travels through the blood stream and remains in the circulatory system until it reaches the lungs. once carbon dioxide reaches the lungs, it is expelled into the air through respiration.",
        "what is capnography?": "capnography is a measurement of the carbon dioxide that is transported by the circulatory system and exhaled during respiration. capnography can be impacted by metabolism, a ventilation perfusion mismatch, or a failure of the circulatory system. a change to one of these factors will change the patients capnography reading. capnographys ease of use and diagnostic capabilities make it a valuable tool for the ems provider. unlike pulse oximetry, capnography changes rapidly with the patients condition and can provide immediate feedback after interventions are taken. capnography can also indicate a patients impending decompensation much more quickly than changes in blood pressure, pulse rate or pulse oximetry.",
        "what are the indications for capnography?": "patients with respiratory complaints. respiratory distress copd exacerbation asthma pulmonary embolism chest trauma with suspected lung involvement patients with metabolic related complaints. diabetic ketoacidosis hyperosmolar hyperglycemic non-ketoacidosis sepsis exacerbation of disease processes that can alter a patients metabolism. patients with circulatory complaints. congestive heart failure hypovolemic shock trauma with significant blood loss trauma to the circulatory system capnography should be used in any patient with an advanced airway. capnography can be used as a tool to confirm advanced airway placement. continuous monitoring of capnography can provide constant feedback on tube placement and prevent failure to recognize airway dislodgement. capnography should be used during cpr to determine chest compression effectiveness and determine when to cease resuscitation efforts. capnography can provide immediate feedback on chest compression quality. a decline in capnography could indicate a decrease in the quality the chest compressions provided. capnography with a reading consistently below 10 mmhg after 20 minutes of cpr can predict death with 100% sensitivity and specificity",
        "what is the procedure for measuring capnography?": "capnography is measured using a device that actively samples exhaled air and provides a measurement of the carbon dioxide. this measurement is referred to as etco2, also known as end tidal carbon dioxide. capnography is measured in mmhg or millimeters of mercury. a normal measurement of etco2 is 35-45 mmhg. capnography can be measured by qualitative and quantitative devices. a qualitative device indicates to the provider if carbon dioxide is present by changing colors in a measuring device. the device is placed directly on an advanced airway. depending on age and how it is stored, it can be unreliable for use in the prehospital environment or only work effectively for a short duration of time.",
        "types of capnography devices": "there are two types of devices that measure quantitative capnography, sidestream and mainstream. a quantitative device provides a specific measurement of expired etco2 and provides a capnography waveform with diagnostic value. sidestream: a sidestream capnography monitor pulls a sample of air from the patients breath when they exhale. this sample of air travels to a measuring device and provides a measurement of etco2. sidestream capnography monitors are more commonly used by prehospital agencies. capnography nasal cannulas, commonly referred to as etco2 nasal cannulas, can be used on conscious and alert patients to measure their respiratory rate and etco2. they are placed on the patient similarly to how you would place a standard nasal cannula. they can also be used under bvm, cpap or bipap masks as they typically do not interfere with the seal of the mask against the patient. they can also be used under non-rebreather masks. capnography in-line monitors can be placed on an advanced airway to monitor the effectiveness of ventilations, continuously confirm airway placement and alert providers to patient decline. in-line devices are placed between the advanced airway and the bag valve mask or ventilator. mainstream: a mainstream capnography monitor actively measures expired co2 from where the patient is exhaling with a reusable device.",
        "what complications can occur when using capnography?": "the capnography monitor (nasal cannula or in-line) may become dislodged during patient care. this can provide inaccurate readings and even cause false apnea alarms to occur. the capnography monitor tubing, specifically for sidestream devices, can become plugged with bodily fluids. this prevents the sample of air to travel to the measuring device.",
        "conclusion": "capnography provides an additional vital sign, that when used in conjunction with a physical exam and patient history, can provide valuable information regarding the cause and severity of a patients condition."
    },
    {
        "introduction": "pneumothorax the lungs are one of the most vital organs in our body. they are responsible for oxygenating the blood to adequately perfuse all vital organs throughout the body. they are also responsible for excreting carbon dioxide, a waste product of cellular respiration. the lungs can be easily compared to balloons. when a balloon is filled with air, it expands, and the walls become thinner and weaker. when air is released, it deflates, becomes smaller, and loses shape. if the balloon's walls are damaged, it can no longer inflate. our lungs work similarly, though the consequences of damage are far more severe, including death. this study guide will provide an overview of the anatomy and physiology of the lungs and a detailed review of the types of pneumothoraxes.",
        "anatomy": "the thorax is also known as your chest. starts at the bottom of the neck and ends at the diaphragm, which separates the thoracic cavity from the abdominal cavity. the thoracic wall surrounds and protects the organs within the cavities that make up the thorax. there are two major openings. superior thoracic aperture is the opening near the neck where the first pair of ribs, manubrium of the sternum, and t1 are located. this opening allows communication between the neck and thoracic cavity. inferior thoracic aperture is the opening at the base of the thoracic wall where the diaphragm sits and can move up and down during ventilation. this opening allows communication between the thorax and the abdominal cavities. the thoracic skeleton creates a firm barrier around the internal organs and comprises 12 pairs of ribs that connect to the sternum in the center of the front of the thorax. the ribs also connect to the 12 thoracic vertebrae on the posterior aspect of the thorax. the spaces between the ribs are known as the intercostal spaces, where the intercostal muscles and intercostal neurovascular bundle (nerve, vein, and artery) are found. thoracic muscles provide support for ventilation and help to strengthen the thorax. the two most important muscles are the intercostal muscles and the diaphragm, but there are a few others.",
        "cavities": "the mediastinum is in the center of the chest and contains the heart; the location between the lungs where the heart sits. the pleural space (pleural cavity) is on either side of the mediastinum and contains the lungs.",
        "neurovasculature": "the thorax is highly vascular, containing multiple arteries and veins. the autonomic nervous system innervates the thorax and contains many nerves.",
        "organs": "the heart, lungs, trachea, esophagus, thymus, and breast are all organs found within the thorax.",
        "open pneumothorax": "open wound to the chest wall, such as from a gunshot wound or an object penetrating the chest wall. air collects in the pleural cavity from the open wound. loss of lung adhesion to the chest wall due to loss of surface tension leads to lung collapse. if the hole in the chest wall is at least 2/3 the size of the trachea, more air will enter from the atmosphere, and a sucking sound will be present. with large holes, air enters both the trachea and the hole, rapidly collapsing the lung. delayed or improper treatment will lead to tension pneumothorax with large open wounds. underlying organs and vessels may be injured depending on the location and depth of the injury. in addition to air, blood may accumulate in the pleural cavity due to damaged vessels and organs. fractures of the chest wall may lead to paradoxical movement (when a portion of the chest moves in the opposite direction expected) during breathing. hypoxia and respiratory distress will occur unless the wound can be closed and the lung is reinflated. an occlusive dressing is often used to cover the wound and prevent more air from entering the pleural space.",
        "specific assessment considerations": "ventilation and oxygenation assessment is completed as part of the initial abc assessment but is ongoing while the patient is in our care. the rate, depth, and breathing pattern can be seen without touching the patient. to assess oxygenation status, a pulse oximeter and etco2 can be used. chest assessment. inspection of the chest wall is visual. this assessment might be better completed by exposing the chest so that all wounds can be seen clearly. some other things to look for include the following: equal rise and fall of the chest, accessory muscle use, color of the skin, location/severity of any obvious wounds (bruising/deformities). palpation of the chest wall is part of the physical assessment.",
        "specific management considerations for penetrating chest trauma": "management will vary depending on which organs are injured within the chest. internal bleeding is likely to occur. if an object is sticking out of the chest, such as a knife, do not remove it unless it interferes with chest compressions. instead, stabilize the object with a bulky dressing so it does not move.",
        "spontaneous or simple pneumothorax": "spontaneous or simple pneumothorax can be broken down into two types based on the cause. primary occurs without a cause, such as an injury or underlying disease. it is truly random. secondary is more common and occurs in people with known lung diseases such as copd, cystic fibrosis, and pneumonia. blebs (small blisters on the lung) can also burst and lead to a simple pneumothorax.",
        "tension pneumothorax": "tension pneumothorax results from an untreated open, spontaneous, or simple pneumothorax that has led to enough built-up pressure (tension) within the thorax that the other anatomy is also being compressed. as the pressure continues to increase, mediastinal structures shift to the opposite side of the thorax, causing kinking of great veins and decreasing cardiac output, resulting in hypotension and poor systemic perfusion.",
        "recognition": "respiratory distress (doesn't go away with oxygen administration), absent or diminished lung sounds on one side, tachycardia, hypotension refractory to fluid resuscitation, penetrating trauma to the thorax, underlying lung tissue diseases (copd, cf), history of pneumothorax, jvd, tracheal deviation, pulsus paradoxus.",
        "treatment and management": "prioritize needs. scene safety (especially if there has been major trauma such as a gunshot wound or stabbing). control any major bleeding and cover any open-sucking chest wounds. provide ventilation assistance to patients who are apneic or have insufficient spontaneous ventilatory efforts. provide high-flow oxygen in patients with an increased work of breathing. assess lung sounds. call als if not already on scene. transport urgently to the closest appropriate facility."
    },
    {
        "introduction": "hyperventilation and hypoventilation are a sign/symptom of a variety of emergencies that range from life-threatening (such as an acute pulmonary embolism) to more mild (anxiety). it is important to identify these emergencies and how to appropriately manage them.",
        "lessons_and_concepts": "in the section, we will look at the anatomy of the respiratory system, respiratory cycle, hyperventilation, and hypoventilation.",
        "causes_of_hyperventilation": "fever and hyperthyroidism. congestive heart failure (chf) and liver failure. - liver failure causes an accumulation of ammonia in the blood. the increase in ammonia will often stimulate the respiratory center and cause hyperventilation and results in metabolic alkalosis. higher altitudes can result in oxygen levels decreasing and increased respiration to assure adequate oxygen levels. this will often level out after you either become acclimated to the altitude or descend to a lower level",
        "causes_of_hypoventilation": "overdose. brainstem injury. injury to the thorax. some infections. pain. inability to inspire (traumatic asphyxia). lung collapse as seen in a pneumothorax, hemothorax, or combination of the two. airway obstructions. obstructive diseases such as asthma and emphysema",
        "anatomy_of_respiratory_system": "upper airway anatomy: nasal cavity: this is the most superior part of the airway. lateral and superior walls of nasal cavity have maxillary, frontal, nasal, ethmoid, and sphenoid bones. floor of nasal cavity is the hard palate. septum separates the right and left nasal cavity. oral cavity: cheeks, hard and soft palates, and tongue form the mouth also known as oral cavity. pharynx: muscular tube that extends vertically from the back of the soft palate to the superior aspect of the esophagus. this allows the air to flow in and out of the respiratory tract. it is divided into three regions: - nasopharynx: uppermost region which runs from back of nasal opening to the plane of the soft palate. - oropharynx: it runs from the plane of the soft palate to the hyoid bone. - laryngopharynx is extremely important in airway management. it extends posteriorly from the hyoid bone to the esophagus and anteriorly to the larynx. larynx: this is a complex structure that joins the pharynx with the trachea. - midline the neck and attached to and lies inferior to hyoid bone and anterior to the esophagus. - consist of thyroid and cricoid cartilage, glottic opening, vocal cords, arytenoid cartilage, pyriform fossae, and cricothyroid membrane. lower airway anatomy: trachea: location where air first enters the lower airway. it is a 10-12 cm long tube that connects the larynx to the two mainstem bronchi (right and left). contains cartilaginous, c-shaped, open rings that form a frame to keep it open. carina: location that the trachea divides into right and left bronchi. right mainstem bronchus is straight. - often times when an endotracheal tube is inserted too far it will enter here causing only ventilation to the right lung. left mainstem bronchus angles more acutely to the left. alveoli: location where respiratory bronchioles divide into the alveolar ducts. - contain alveolar membrane that is only 1-2 cell layers thick. - this is the location where most oxygen and carbon dioxide gas exchange gases. lung parenchyma: two pulmonary lobules that form the anatomic division of the lungs. - lobules further organize into lobes. right lung: 3 lobes: upper, middle, and lower. left lung: 2 lobes: upper and lower (smaller as it shares space with the heart). pleura: membranous connective tissue that covers the lungs. two layers: visceral pleura: envelopes the lungs but does not contain nerve fibers. parietal pleura: lines the thoracic cavity and contains nerve fibers. space between the two is called pleural space-contains small amount of fluid that reduces friction between pleural layers during respirations",
        "respiration_and_ventilation": "respiration: exchange of gases between living organism and its environment. pulmonary respiration occurs in the lungs when the respiratory gases are exchanged between the alveoli and red blood cells in the pulmonary capillaries. ventilation: mechanical process that moves air in and out of lungs. this is necessary for respiration to occur. respiratory cycle: nothing within the lungs make them expand and contract. pulmonary ventilation is dependent on the change in pressure of the thoracic cavity",
        "pathology_of_hyperventilation": "hyperventilation is an increase in respiratory rate. increased respirations --> increased elimination of co2 --> progressively lower exhaled co2 level --> respiratory alkalosis. an increase in metabolic rate can trigger hyperventilation. hyperventilation syndrome is when dyspnea occurs with no other lung abnormalities. this is caused by the brain's respiratory centers being stimulated by things such as: anxiety, fear, or hysteria",
        "pathology_of_hypoventilation": "hypoventilation is a decrease in respiratory rate. decreased respirations --> increased co2 retention --> progressively elevated exhaled co2 levels --> respiratory acidosis. hypoventilation can occur when the minute volume falls. minute volume: amount of air moved in and out of the respiratory tract in 1 minute. equation: (vmin = vt x respiratory rate). vmin = minute volume. vt = tidal volume: the amount of air moved through the respiratory system with each breath. it is the average volume of gas inhaled or exhaled in one respiratory cycle",
        "important_notes_on_respiratory_acidosis": "hypoventilation can lead to respiratory acidosis. respiratory acidosis is when the respiratory system cannot effectively eliminate all the carbon dioxide generated through metabolic activities in the peripheral tissues. there is in increase in pco2 and a decrease in ph",
        "recognition": "in this section, we will look at the signs and symptoms for hyperventilation and hypoventilation. important statistics: normal respiratory rate is 12-20 breaths per minute with an etco of 35-45 mmhg. hyperventilation is anything over 20 breaths per minute with an etco: under 35 mmhg. hypoventilation is anything under 12 breaths per minute with an etco over 45 mmhg. normal blood ph is 7.35-7.45",
        "symptoms": "symptoms associated with hyperventilation: - anxiety. - dizziness/lightheadedness. - chest pain. - numbness. - tingling of hands and feet. - sense of dyspnea even though they present with rapid breathing. symptoms associated with hypoventilation: - fatigue. - headache. - cyanosis. - confusion. - hypoxia",
        "treatment_and_management": "in this section, we will look at respiratory system assessment as well as treatment and management of hyperventilation and hypoventilation. respiratory system assessment: primary assessment: 1. remember #1: abc: airway, breathing, and circulation problems. 2. assess make sure that the patient's airway is patent (no snoring or gurgling) - make sure the airway is open first. either by jaw thrust or head-tilt chin-lift. 3. determine if breathing is adequate - provide adequate ventilatory assistance as needed for those patients with decreased respiratory drive - you may use supplementary oxygen and/or bvm to maintain an spo2 of 94% or greater or a co2 of 35-45 mmhg",
        "secondary_assessment": "once you have corrected any life-threatening issues, you should conduct a secondary assessment. 1. history: this is the time you need to try to get the patient's history from either the patient or family/friends that may be around. 2. physical examination: for respiratory patients, it is important to continue to evaluate the abcs. you will use this time for inspection, auscultation, and palpation.",
        "scenarios": "scenario 1: dispatch information: you are dispatched to a 39-year-old african american male complaining of weakness and not feeling well.... scenario 2: dispatch information: you respond to a very prominent neighborhood for a 16-year-old caucasian female who was found unresponsive in her room.",
        "tips_and_tricks": "in this section, we will look at tips and tricks for test taking. patients with altered level of consciousness should have ventilatory support given. when providing ventilatory assistance make sure to maintain a rate of 1 breath every 6 seconds.",
        "field_tips": "sometimes providing a ventilatory assistance alone in narcotic overdoses will cause the patient respirations to spontaneously increase"
    },
    {
        "introduction": "pleural effusions are often overlooked in prehospital treatment plans, and a thorough understanding is important in proper recognition and treatment for patients with pleural effusions. pleural effusions often present with similar signs and symptoms to other respiratory emergencies. in spite of similarities, key differences can greatly impact treatment guidelines and improve patient outcomes.",
        "lessons and concepts": "a pleural effusion is the accumulation of fluid in the pleural space. the pleural space is also known as the pleural cavity, which is the cavity that exists between the lungs and the interior of the chest wall. there are two pleural spaces in the human body, with one pleural space surrounding each lung. the pleura is the lining of the lung. like many other spaces in the body, the pleural space normally has very little fluid, with each lung resting directly against the interior portion of the chest wall during normal inspiration and expiration. when fluid accumulates in the pleural space, this is a pleural effusion.",
        "understanding pleural effusion": "...to better understand a pleural effusion, consider a blister... a blister is a bubble of accumulated fluid underneath the skin. a blister is most often caused by damage to the skin due to friction, heat or pressure (sometimes all three). when excessive friction or heat occurs, the first layer of skin, called the epidermis, tears away from subsequent layers of tissue, called the dermis. when this tear occurs, fluid fills the space. this fluid is often clear and is called serum, but may also contain blood, depending on the depth and location of the damage caused to the skin. the liquid located inside a blister is actually a natural form of protection that helps shield the wound from harmful bacteria.",
        "relation to pleural effusion": "...so, how does a blister relate to a pleural effusion? remember that a pleural effusion is the accumulation of fluid in the pleural space. the pleural space is normally nearly empty in healthy individuals, with the lungs pressing up against the chest wall during maximum inspiration. like a blister, a pleural effusion is the accumulation of fluid, which causes an increase in friction between the pleura and the chest wall. this friction causes irritation of the pleura, resulting in many signs and symptoms of a pleural effusion, including pleuritic chest pain and difficulty breathing.",
        "relevant anatomy": "the following is a review of relevant anatomy that will help you better understand the pathophysiology of various types of pleural effusions. the human body contains two lungs, which are responsible for ventilation. in other words, the lungs are the sacs that are filled with air that are essential in order for respiration to occur. the main muscle that controls the expansion and contraction of the lungs is the diaphragm. the diaphragm is a thin muscle that extends to the inferior portion of the chest and is the landmark that separates the abdomen from the chest.",
        "lung function": "when the diaphragm contracts, the lungs expand, causing a negative pressure vacuum. boyle's law asserts that pressure and volume are inversely proportional at a given temperature of gas. in other words, when the volume of each lung increases during inspiration, the pressure inside each lung decreases. this change in pressure (specifically, negative pressure) causes air to be drawn into the lungs. this is known as inspiration. when the diaphragm relaxes, the volume of each lung decreases. this is known as expiration.",
        "pleura and pleural fluid": "the pleura are thin membranes that protect the lungs from damage. the pleura can be subdivided into two types: the visceral and parietal pleura. the visceral pleura is the inner layer, which is tightly attached to the lung itself. the parietal pleura is the outer, thicker layer, and lines the inside of the chest wall. the thin space between the visceral and parietal pleura is known as the pleural space. located inside the pleural space is a lubricating liquid, called pleural fluid.",
        "pleural fluid function": "in healthy adults, an average of 15-20 ml of pleural fluid is located within the pleural space at any given time. pleural fluid (composed of various proteins and white blood cells) serves to reduce friction between the visceral and parietal pleura. pleural fluid also creates a vacuum between the visceral and parietal pleura. think of this as a lubricant that also provides a type of suction that causes the pleura to remain close together.",
        "pathology of pleural effusion": "understanding the basic anatomy helps in understanding the pathology of pleural effusion. we now know that a small amount (approximately 15-20 ml) of pleural fluid is normal in healthy adults, as it serves as a lubricating fluid between the visceral (inner) and parietal (outer) pleura. this fluid is located in the space between the visceral and parietal pleura, known as the pleural space.",
        "types of pleural effusions": "there are two main pathologies that lead to a pleural effusion. the first is called a transudative pleural effusion. a transudative pleural effusion is caused by fluid leaking into the pleural space, often due to increased pressure in surrounding vessels. the most common causes of transudative pleural effusions are cirrhosis and congestive heart failure.",
        "transudative pleural effusion": "congestive heart failure causes an increase in pressure among blood vessels throughout the body and a potential loss of blood proteins. the increase in systemic pressure among vessels in the body can cause fluids to leak out of the vessels and into the pleural space, creating a pleural effusion.",
        "exudative pleural effusion": "the second main type of pleural effusion is called an exudative pleural effusion. an exudative pleural effusion is caused primarily by increased capillary permeability, which leads to a leakage of fluids into the pleural space. exudative pleural effusion can also be caused by blocked blood or lymph vessels, lung injury, inflammation, or tumors.",
        "recognition": "early recognition of patients experiencing severe dyspnea is essential in providing quality patient care. the definitive treatment of a severe pleural effusion is often a procedure called a thoracentesis, in which the pleural space is drained of fluid. this is not performed in the field, meaning that rapid transport to a hospital is extremely important.",
        "signs and symptoms": "below are common signs and symptoms to help recognize a pleural effusion in the field; symptoms include, but are not limited to: shortness of breath (dyspnea), orthopnea (positional dyspnea, usually relieved with upright or standing position), cough, pleuritic chest pain.",
        "pleural friction rub": "pleural friction rub is a sign of pleurisy. pleurisy is the inflammation of the visceral and parietal pleura. pleural friction rub is a grating, raspy sound that is the result of the visceral and parietal pleura rubbing against one another. pleural friction rub occurs on inspiration and expiration and is best heard at the base of the lung.",
        "treatment": "prehospital treatment of pleural effusion is centered on proper management of hypoxia, although specific treatment can vary based on the underlying cause of the pleural effusion. assuming a patient maintains a patent airway, the most important priority is to assure that the patient maintains adequate ventilation, and to improve oxygen saturation if the patient presents with an oxygen saturation indicative of hypoxia.",
        "oxygen application": "oxygen application is essential, although the device used to administer oxygen, as well as the quantity, varies based on the severity of the patient. some patients may feel relief with a nasal cannula, while others may require more aggressive oxygen therapy, such as the application of continuous positive airway pressure (cpap) or manual ventilation."
    },
    {
        "introduction": "within ems, there are two mains categories of copd symptoms seen within patients, chronic bronchitis, and emphysema. in short, chronic bronchitis is caused by destruction of cilia which makes it hard for the lungs to clear mucus. this traps bacteria in the lungs and lots of bacteria leads to chronic inflammation of the lungs. emphysema is the other main branch of copd, caused by weakening or destruction of the alveolar walls. this limits ability for gas exchange and can lead to hypoxia as well as respiratory distress. emphysema is a disease branch under the overarching respiratory disease chronic obstructive pulmonary disease (copd). emphysema presents almost only in patients older than 45 years old. the majority of patients with emphysema are older than 75 years old. emphysema is more common in males than females.",
        "pathophysiology of emphysema": "emphysema is weakened or damaged alveoli. generally, a risk fact such as smoking or chemical exposure over time causes the damage to the alveoli. rarely, a deficiency in the natural occurring protein alpha-1 antitrypsin causes breakdown of the alveolar walls. as the alveolar walls weaken or collapse it impairs the body's natural ability to participate in pulmonary respiration. the collapsing of alveoli decreases available surface area for respiration to occur. in addition, damaged alveoli can cause old air to become trapped during exhalation. this prevents fresh, oxygenated air from participating in respiration the next breath because the alveolar membranes are filled with the old, stale air.",
        "emphysema symptoms": "dyspnea with or without exertion\naccessory muscle use\nhypoxia\ncyanosis of lips or nail beds\ntachycardia\nnonproductive cough\nbarrel chest\nweight loss and fatigue\npink skin\nworsens with exposure to cold air and inhaled irritants",
        "risk factors for emphysema": "smoking\nexposure to secondhand smoke\noccupational exposure to inhalants\nhistory of tuberculosis\nasthma\ncongestive heart failure\nalpha-1 antitrypsin deficiency",
        "prehospital care for emphysema": "oxygen administration by nasal cannula or non-rebreather mask to a goal spo2 of 94%\nipratropium bromide and albuterol duoneb delivered by nebulizer\nconsider cpap (be careful if air trapping is suspected)\nmonitor etco2, be aware of possible breath stacking\nconsider corticosteroid such as dexamethasone for relaxation of lungs\niv ns/lr to keep open, or if patient condition worsens"
    },
    {
        "introduction": "cricothyrotomy introduction what is a cricothyrotomy? a cricothyrotomy or \"cric\" is a last resort in the case of a failed airway als skill utilized only when other means of airway management have failed (i.e., airway edema, severe facial or airway trauma, airway hemorrhage, excessive vomiting or secretions, etc.) cric's are one of the most invasive skills providers can execute with this skill comes significant responsibility and liability this procedure is often thought to be used only for trauma patients; however, medical patients may become candidates for this procedure in the case of: anaphylaxis airway edema (ace-inhibitor induced) complete airway obstruction (choking) failed airway management due to patient anatomy various types of cricothyrotomies exist, including but not limited to: surgical (via scapula) needle (via small cannula device, i.e., iv catheter) device-assisted (via large cannula device, i.e. pertrach, quicktrach devices) cricothyrotomy is practiced by providers ranging from those in the field to emergency room physicians statistics vary regarding the utilization of cricothyrotomies; however, understanding the skill and how to perform it correctly is crucial often referred to as a \"high-risk/low-frequency\" procedure some ems providers may perform multiple crics in a career, whereas others may never attempt one",
        "ems and cricothyrotomy": "there are significant responsibilities associated with performing a cricothyrotomy the stakes are high, and so is the stress paramedics must know when, why, and how to perform this procedure it must be something easily brought to the front of their mind as time is limited in these scenarios frequent refreshing of the procedure and the equipment utilized by your agency is key per one study in 2016 asking pennsylvania ems providers, 73% of providers in this survey did not believe they were well trained to perform out-of-hospital surgical airway management only 20% stated they had performed a cricothyrotomy in their career with various years of experience questioned in this survey varying from <5 years and >26 years",
        "lessons and concepts": "airway anatomy review: as we review cric's, it's essential to understand the anatomy of the airway and associated structures, we'll start by looking into the upper airway and the larynx upper airway: nasal cavity: the cavity encompassing the nose, which contains nasal passages for the movement of air the nasal septum divides the left and right sides of the cavity functions of the nose: filter air using the cilia (nasal hair) in our nose warm the air add moisture to the air to prevent excessive drying of the nasal cavity sense of smell mouth and oral cavity: encompasses the lips, cheeks, teeth, gums, tongue, soft and hard palates, uvula, and buccal space mandible and maxilla: these hard bones contained within the oral cavity provide structure for the mouth the maxilla (upper jaw bone) is fixed and does not move in normal circumstances composes the hard palate as well as the upper teeth and gums the mandible (lower jaw one) moves via skeletal muscles to help with the opening and closing of the mouth also composes structure for the lower teeth and gums pharynx: composed of the throat up to the posterior nasal cavity and superior to the esophagus includes: nasopharynx: posterior portion of the nasal cavity where air breathed in through the nose is directed down to the lower airways oropharynx: posterior portion of the oral cavity that acts as a passage directing air, food, and liquids. contains the vallecula, which is located at the base of the tongue acting as a small cavity or depression in the tongue above the epiglottis laryngopharynx: also referred to as the hypopharynx, this is the lowest portion of the pharynx (or throat) that helps make sure food is directed to the esophagus and air to the trachea pyriform sinus: small recessed portions on either side of the glottic opening, which help funnel contents down into the esophagus epiglottis: cartilage-formed flap that covers the glottic opening to prevent aspiration during swallowing and opens during breathing the larynx: we will specifically focus on the larynx for the lower airway, as this structure is essential when performing a cricothyrotomy. what is the larynx? a hollow structure that forms a pathway for air to enter and leave the lungs contains both muscle and cartilage contains the vocal cords (glottic opening) that act as the division between the upper and lower airways also known as the \"voice box\" as it creates sounds when speaking the \"true\" vocal folds (cords) are folds of tissue found on each side of the structure they help produce sound but also act as a protective mechanism to prevent unwanted solids or liquids from entering the lower airway, known as a laryngospasm the vestibular or \"false\" folds (cords) are thick mucous membranes found next to the vocal folds various cartilages exist, each with different purposes involving protection and structure for the larynx: arytenoid cartilage: helps with the movement of vocal folds corniculate cartilage: adds support for muscles attached to the larynx cuneiform cartilage: supports vocal folds and portions of the epiglottis posterior arytenoids: a muscle that opens the glottis (vocal cords) as seen above, various cartilaginous structures exist over the larynx to help protect the underlying soft tissues these also provide landmarks for performing a cric",
        "cricothyrotomy review": "we will begin by identifying the landmarks used to perform a cric: landmarks for a cricothyrotomy are the same regardless of which type of procedure you perform remember, in both pediatrics and females, the landmarks may be more difficult to identify: smaller structures (more pronounced in pediatrics) smaller thyroid cartilage size compared to males (females) the three key parts to identify are the thyroid cartilage, cricoid cartilage, and the cricothyroid ligament often, once one of the following is found, the rest are quickly identified these structures are all aligned midline on the anterior aspect of the neck the image below gives an idea of what to look for and how it corresponds to the anatomy **in non-trauma patients or when cervical spine precautions are not of concern, hyperextend the neck to help protrude the structures and pull the skin taught** the \"adam's apple\" is the most superior structure and is often palpable the hyoid bone may not be as easily palpated, so attempt to feel for the curvature and protruding portion inferior to the thyroid cartilage is the cricothyroid membrane, which is a slightly recessed portion felt on the neck having the ability to hyperextend the neck will help aid in feeling this area the cricoid cartilage lies just superior to the trachea inferior to the cricoid cartilage, one can palpate the tracheal rings palpating top-down versus bottom-up? often, it is good to try both options once you have found the cricothyroid membrane, mark an \"x\" on the location so it is not lost best practice includes having all equipment ready so once the area is found, you can immediately perform the procedure but like everything in ems, there may be difficulties or situations that could hinder this! the \"laryngeal handshake\" is a technique used to palpate your landmarks and complete the procedure in a methodical manner",
        "surgical cricothyrotomy procedure": "surgical crics utilize a surgical-grade scalpel to complete the procedure supplies needed: scalpel antiseptic agent (iodine, betadine, etc.) bougie medical tape or tube tamer (securing options) lubricant cuffed-ett (size ranging from 5.0-6.0 cm i.d.) 10 cc syringe verification devices (etco2, stethoscope, colormetric, etc.) bvm oxygen source suction unit various gauze (4x4's often sufficient) additional crew members present (at least 1-2 if available to help assist) be extremely careful when performing a surgical cric, as the scalpel is incredibly sharp like with any needles, watch your sharps, safely cap and dispose of them when completed! with a surgical cric, utilize your non-dominate hand to locate the landmark as usual and have the scalpel in your dominant hand locate the cricothyroid membrane, quickly clean the area without losing your landmark, then re-confirm your landmark take the scalpel and create a vertical incision over the cricothyroid membrane incision length varies, but ensure the incision is large enough to extend over the entire membrane surface! once the vertical incision is done, you should be able to visualize the \"white\" membrane at your site take the scalpel and create a horizontal incision, fully \"puncturing\" the membrane once this is done, carefully use your bougie, or remove your grip of the larynx with your non-dominate hand, and utilize either to keep your landmark while removing the scalpel from the site remember to be careful with the scalpel! cap the device or place it into the sharps container if you chose the bougie, advance it by directing it caudally into the trachea until you meet resistance this ensures the bougie is at an adequate depth so it is not accidentally withdrawn if your finger is still inserted into the opening, replace this with a bougie and follow the instructions above utilize additional crew members, if possible, to hand you your cuffed ett with the cuff and tapered tip lubricated, slide the ett over the bougie advancing it only to a depth that the cuff is fully inserted through the incision you can also utilize the black line often found on etts to know the adequate depth to reach inflate the cuff using the 10 cc syringe, confirm your tube placement, and secure the ett in place using medical tape or another tube-securing device",
        "needle cricothyrotomy procedure": "needle cric's are performed using either a large-bore iv catheter (small caliber cannulation) or a specific commercial kit (large caliber cannulation) see below for images and examples: quicktrach ii cricothyrotomy device available in adult size (i.d. 4mm) rusch quicktrach emergency cricothyrotomy kit available in 2.0 mm and 4.0 mm sizing curaplex pertrach kits offered in adult (14 g) and pediatric (17 g) sizing (training kit version seen in the image) ems supplies can be gathered on an als unit to perform another version of small-caliber cannulation utilizing the following: 14g or 16g angiocath 3 cc syringe 7.5 ett adapter anti-septic solution oxygen bvm locating the membrane is identical to a surgical cric ensure you thoroughly cleanse the area with an antiseptic solution before puncturing or cutting commercial devices: with many commercial devices, a scalpel can be used to make a vertical incision through the soft tissues however, some devices can also puncture through the soft tissue layers covering the cricothyroid membrane some commercial device(s) may recommend using a scalpel to make a vertical incision through the soft tissues to expose the membrane, following manufacturers' recommendations regardless of the brand, all devices recommend inserting the needle at a 90-degree angle through the membrane once resistance frees up, use the syringe attached to the needle to see if the air is freely aspirated if air is not freely aspirated, the device is not in the trachea consider assessing whether the depth is too deep, shallow, or potentially inaccurately placed next, drop the angle and further advance the device caudally into the trachea often, commercial devices utilize a catheter that can be advanced after the needle portion is removed if there is a depth gauge to prevent insertion of the needle too deep, ensure this is removed when advancing the catheter into the trachea firmly hold the device while placement is verified once verified, secure the device using the tube-securing option creating a needle-cric with ems supplies: as stated above, small-caliber cannulation can be done using equipment in an als kit this version often is used for pediatric patients under the age of 10-12 years old where a surgical cric would be difficult to complete because of patient and anatomy size the technique is similar. if using an iv catheter, be aware that the needle will need to be \"locked out,\" then you will have to attach the syringe to aspirate, checking for placement the 3 cc syringe is utilized by using the luer-lock on the end to connect to the iv catheter hub, and then the 3.0 ett adapter fits into the end of the iv catheter when the plunger is removed a bvm can then be attached to provide ventilations due to the small catheter size, there will be more resistance when providing ventilations, and tidal volume will likely decrease depending on the age of the patient the device can further be secured using medical tape and ensure placement verification once completed lung sounds may not be present due to the decreased tidal volume placement should be based on aspiration with a syringe, etco2 levels (which also may be impacted by the device's small size and exhalation through the mouth/nose), and the patient's vital signs",
        "additional thoughts with cric's": "do not lose your incision site or let go of the ett once it is in place! keep a firm grasp on the ett until it has been secured! incision sites may have varying levels of hemorrhaging; suction or gauze can be used to manage this remember basic anatomy, greater vessels lie on both sides of the trachea (i.e. jugular vein(s), carotid artery) their depths vary, so practice extreme caution when making incisions ensuring you are cutting at the correct landmark! ett sizing varies from person to person. use the largest size ett possible likely, 5.0-6.0 should fit most individuals. although be ready to size up or down and be aware of your limits with what bougie size(s) your agency carries know that this procedure is for individuals weighing >40 kg (88 lbs) or who are roughly 10-12 years of age or older (depending on size/weight and local protocols) commercial cricothyrotomy kits often have all the supplies needed to perform the procedure and may also contain cric-specific ett's and tube-securing options \"trach-hooks\" or trachea hooks can be utilized by inserting the device into the incision using the \"hook\" capturing the cricoid cartilage to lift the airway providing some additional traction, further dilating the incision site",
        "contraindications to performing the procedure": "often, this is a last resort option to obtain an airway, and there are no contraindications to performing this procedure when the right situation(s) or circumstance(s) arise don't cric before attempting ett or supraglottic devices unless circumstances determine otherwise the only time this procedure may be contraindicated would be: patient seizing (choosing the right type of procedure or equipment sizing) or performing this procedure when other means of airway management could have been performed (as well as other airway placement options being adequate and choosing to perform a cric)",
        "sedation and pain management": "often we would presume that patients are unconscious if this procedure is required however, whether the patient is fully conscious or unconscious, administer medications to sedate and manage pain during this invasive procedure paralytic usage may be necessary, though remember to utilize increased sedation and pain management before administering paralytic(s) repeat sedation and pain management should be administered as well in some situations, rsi/dsi may be used in conjunction with a cricothyrotomy",
        "recognition": "recognizing when a cricothyrotomy must be performed is often a split-second decision though some factors may hint at a need for a cricothyrotomy earlier in airway management we will review some options for identifying an inadequate/unstable airway, identifying potential difficulties, and some various examples of when you might choose to perform this procedure identifying an inadequate/unstable airway: a cric is rarely the first choice for airway management the following options are preferred: endotracheal intubation supraglottic devices (i-gel, lma, king airway, etc.) bvm with opa/npa with this being said, the options above may not be successful or a viable option before diving in too deep, let's review some common findings for a \"non-patent\" or inadequate airway: altered mental status absent gag-reflex inability to manage secretions, emesis, hemorrhage, etc. trismus (lock jaw) traumatic injuries to the face or airway airway edema (burns, anaphylaxis, etc.) expected clinical path (assuming the airway will be lost) foreign body airway obstruction (complete obstruction) examples of conditions that may lead to a non-patent airway include: stroke status seizures trauma respiratory failure or arrest risks for aspiration (ams, excessive vomiting, oral hemorrhage, secretions, etc.) severe sepsis anaphylaxis overdose airway burns or obstruction combative or hyperactive patients recognizing the need to perform a cricothyrotomy: the \"need\" to perform a cric comes when there is an: inability to oxygenate your patient because of an inability to ventilate your patient oxygenation: ability to successfully provide oxygen to a patient, meaning the ability to both ventilate and oxygenate ventilation: movement of air into and out of the lungs a patent airway is required to allow for respiration respiration: the exchange of gas (specifically o2 and co2 in this case) if we cannot provide ventilation (or artificial breaths) to a patient, then gas exchange cannot occur what situations might require a cric? the decision may be a split-second if you have a failing airway and cannot utilize other options (ett, supraglottic, bvm), and a patient's spo2 levels are dropping this is why having a plan a, b, c, and even d is extremely important on this list, a cric would most likely be \u00e2\u20ac\u00a6 while not \"plan a\", the decision may be initially known from the start, or you might assume the need for it examples include: complete airway obstruction due to a foreign body that cannot be removed with magill forceps, and a supraglottic or ett is rendered ineffective \u00e2\u20ac\u00a6plan d' due to the obstruction severe facial trauma, airway hemorrhage, or facial/oral landmarks have been compromised, i.e.: loss of landmarks injury to an important structure burns causing edema excessive hemorrhaging, obstructing view to perform ett spinal precautions or trauma limit neck mobility when attempting to intubation (if video laryngoscopy is not available) prior history: prior history of difficult airway management? underlying conditions that may affect your ability to perform airway management? excessive vomiting: obstructs view for ett placement if ett fails, other means of airway management (besides a cric) could pose a risk of aspiration in the presence of emesis mouth opening: small mouths often result in difficulties in obtaining an adequate view for intubation even with video laryngoscopy, it may cause difficulties with attempting to maneuver etts in a reduced area mandibular length: short mandible length indicates the glottic opening may be more \"anterior,\" causing a difficult view for ett neck mobility and size: decreased neck mobility will cause difficulties with maneuvering the patient's neck to obtain a better view of the vocal cords short neck size also indicates alignment issues with the mouth opening and larynx facial hair: excessive facial hair can result in difficulties with obtaining a bvm mask seal, hence causing difficulties ventilating your patient in various scenarios (i.e. pre-oxygenation, intubation prep, etc.) short pneumonia: short can be a tool to help predict difficulties that may arise with cricothyrotomies: surgery (neck surgery or scar present over membrane) hematoma obesity radiation (history or evidence of radiation therapy) trauma (laryngeal trauma) other difficult airway indicators? lemon: an airway assessment that can help you predict a difficult airway look: refers to looking externally at the patient's mouth and facial structures, assessing for things like trauma, facial hair, large tongue or incisors, etc. evaluate: utilize the \"3-3-2\" rule; use the patient's fingers (not ideal, but you can use yours as well, sizing may differ between you and the patient) can the patient fit three of their fingers between their incisors? is the mandible length 3 fingers? is the hyoid bone to the thyroid cartilage 2 fingers? mallampati: used to evaluate the distance between the base of the tongue and the roof of the mouth mallampati score varies from class i (best access) to class iv (most difficult access) to help predict the difficulties you may have in obtaining a view of the glottic opening when intubating obstruction: various conditions such as laryngitis, epiglottitis, edema, cancerous masses, hematoma, foreign body obstructions, etc., all can affect the ability to access the airway neck mobility: the ability of the patient's neck to extend significantly impacts your ability to align their airway for the proper view and placement of the ett patients with arthritis, cervical collars, or spinal stenosis may have poor neck mobility the patient's tongue has swollen so badly that the majority of their mouth is compromised (i.e. allergic reaction/anaphylaxis) gcs 3; severe head trauma patient presents with trismus on your arrival and requires rapid airway placement to reduce the risk of hypoxic brain injury and/or cardiac arrest what do all of these have in common? impending or already compromised airway presumed difficult airway management a total loss of airway with a rapid need to provide ventilator support to the patient heavy secretions likely impair the ability to intubate facial or oral trauma that may cause difficulties in adequately identifying landmarks the key to the information above is that an issue has arisen with ventilation or oxygenation!",
        "assessment": "having an adequate number of resources for cric management is crucial to patient care and outcomes proper ppe/bsi varies based on the scenario masks, face shields, eye protection, and even gowns or double gloves help protect you and your crew from exposure to blood and other bodily fluids assessment: what do you see as you approach from the doorway or a distance? depending on the scenario(s), this initial impression may indicate the immediate need for advanced airway management, including a cricothyrotomy is the patient conscious? breathing? are they tracking you as you approach? how are their verbal responses? full sentences, few words, or only sounds? do they appear dyspneic? do they have audible stridor or visible signs of impending airway loss? does their airway appear open/patent? is there trauma, edema, excessive hemorrhage, or signs of foreign body obstruction? complete loc/abcde/history: level of consciousness (loc): your \"doorway\" assessment should allow you to immediately determine this the patient may be conscious or unconscious various signs of dyspnea may be present short responses audible stridor or wheezing rapid respiratory rate ams? often a sign of respiratory failure and/or immediate airway loss rule out other possible causes for ams exsanguination because the need for a cricothyrotomy is often secondary to trauma, assess and manage any life-threatening hemorrhage on initial contact severe hemorrhaging from the airway and significant facial/head trauma should alert you to the possible need for a cricothyrotomy perform a head-to-toe exam, rapidly searching for severe bleeding assess gloves periodically for blood staining to help identify the location of the hemorrhage airway: patency of the airway determines the need for advanced airway management be aware with progressing edema or excessive hemorrhage that a total airway loss can occur at any point manage the airway with positioning, suctioning, and airway adjuncts as required if you approach a patient with total airway loss (i.e. edema, foreign body obstructions, severe facial trauma, etc.), you must recognize this and take the airway if unable to oxygenate/ventilate via bls adjuncts, supraglottic airways, or ett, you must perform a cricothyrotomy breathing: the rate may be slightly elevated in dyspneic patients with little to no airway compromise those with respiratory tract involvement will be in respiratory distress or failure assess for injuries affecting the chest, lungs, diaphragm, or brainstem provide supplemental oxygen as needed: provide high-flow oxygen to those who present with total airway loss or impending airway loss bvm usage may be required for ams, unconscious, or respiratory arrest/failure assess lung sounds: lung sounds are crucial in identifying the cause of your patient's condition and will help guide your treatment symptoms like wheezing may indicate bronchoconstriction from asthma, copd, or an allergic reaction audible stridor indicates concerns of upper airway edema and/or impending airway loss circulation: patients will likely be tachycardic a weak/thready pulse may indicate hypovolemia or declining blood pressure the absence of radial pulses indicates hemodynamic instability development of bradycardia can indicate an increased icp, but also can indicate peri-arrest developing diaphoresis and cyanosis indicate your patient may be developing shock treat for shock to prevent further progression of hypoperfusion any other significant bleeding that has not already been managed should be treated disability: assess cbg and temperature, and look for other causes of ams trauma is likely in patients who appear altered exsposure: especially in trauma, expose your patient fully, and if time/resources allow, ensure a full secondary assessment is completed if there are time or patient care constraints or difficulties managing the abcs arise, defer your secondary assessment in patients with abnormalities around their neck, face, or head, quickly examine these areas and determine if the airway or breathing is likely to be impacted do they have edema, hematoma(s), or other injuries present? assess for lemon and potentially examine the anterior midline neck for structures if you anticipate the need for cricothyrotomy obtain baseline vital signs and thorough history: obtaining vital signs and history may be impacted in some trauma scenarios always attempt to obtain as much history as possible and obtain quick vital signs (blood pressure by palpation, palpate pulses, assess respirations) when scene concerns arise obtain full vital signs when time allows including: hr, bp, rr, spo2, cbg, temperature etco2 monitoring should be monitored in ams, respiratory distress, or unconscious patients 3/4-lead ecgs and 12-lead ecgs, as indicated monitor 3/4-lead ecgs in all trauma patients to closely monitor changes in heart rate and note any arrhythmias obtaining history: key conditions should be asked about, including copd, asthma, chf, ami, htn, stroke, seizure, diabetes, etc. key into other pertinent questions, including: past intubations past airway difficulties, if known hx of throat or oral cancers previous surgical or cricothyrotomy airways allergies and medication lists should be documented be aware of trauma patients who are on blood thinning medications attempt to rule out any pertinent negatives: n/v/d, chest pain, abdominal pain, dizziness, loc, weakness, head/neck/back pain or trauma, extremity pain, numbness/tingling or cms deficits present, medication compliance recently, treatments prior to arrival, etc.",
        "treatment and management": "treatments: sedation and pain management: many factors affect the need for sedation and pain management often, you have already begun this process if rsi/dsi was attempted consider whether you have time to administer sedative and analgesic medications if the patient's airway is already significantly compromised, you may have to act immediately and treat later what's going to kill the patient first? painful response or hypoxia? midazolam (versed) offers retrograde amnesia, meaning the patient will not remember events that occurred immediately before the medication was administered things to consider when making this decision: is their airway already compromised severely (i.e. anaphylaxis, airway burns, etc.)? have other options already failed? or will they increase the risk of hypoxia? when should sedation and pain management come into the picture? this should always be considered; iv or io access is likely already present administer pain/sedation medications asap when the decision to perform a cricothyrotomy is made options: pain: fentanyl or morphine are often commonly used for pain management in ems. 50-100 mcg of fentanyl or 4-8 mg of morphine should be used and repeat doses will be needed sedation: benzodiazepines (midazolam, diazepam, lorazepam) all are great sedative options, with midazolam being the most commonly utilized be aware of the respiratory depression and hypotension that can occur with benzo's doses often vary, though are commonly between 0.1-0.4 mg/kg (2-5 mg commonly used) to a max single dosage of 5-10 mg depending on the situation and route of administration ensure that repeat sedation is administered throughout patient care depending on the protocols and/or situation, etomidate may also be an option that does not affect hemodynamics 0.3 mg/kg for weight-based or 20-30 mg iv/io other: ketamine is a great option due to its sedative and analgesic effects with minimal effects to hemodynamics 2 mg/kg or roughly 100-200 mg iv/io is a common dosage range however, in this case, doses are often higher on the end due to sedative effects occurring at higher dosage ranges in certain circumstances, paralytic agents may be administered for rsi/dsi before a cric is needed, and they may also be used post-cricothyrotomy in conjunction with proper sedative/pain management depolarizing agents: succinycholine, 1.5 mg/kg) non-depolarizing agents - rocuronium 1.2 mg/kg or vecuronium 0.1 mg/kg be aware of contraindications with succinylcholine in trauma and renal failure patients",
        "transport considerations": "transport distance must be heavily considered often, these patients will be critical and require extensive management. with this, consider the following: air ambulance: if total pre-hospital time/transport can be reduced by 10 minutes or greater, it should be considered air ambulance often offers some critical care management and quick transport times it can also ensure additional resources with als capabilities if resources are limited or delayed know what your local air ambulance provider's capabilities are often they can be crucial in patient survivability, with access to blood products, advanced ventilators, extensive pharmacology, and critical care providers resources: considering the above, critical patients often require additional crews to help assess, stabilize, and manage adequately call for resources early; they can always be canceled if not needed know that when the time comes to perform a cric, you likely will not have time to wait for more crews airway failure and nearest facility: if you ever run into a situation where you have a failed airway, always divert to the nearest er regardless of capabilities failed airways require additional resources and a higher level of care to help secure an airway it's crucial that once you recognize a failed airway is likely, immediately divert and notify the new er as soon as possible so they have time to prepare ideally, transport these patients to the highest level of care as they will likely require an intensive care unit and a prolonged admission in the hospital to recover",
        "scenario": ""
    },
    {
        "introduction": "rapid sequence intubation (rsi) and delayed sequence intubation (dsi) are airway management techniques used to obtain an advanced airway in perfusing patients with the use of pharmacologic agents to aid in amnesia for the patient and muscle relaxation for tube placement.",
        "what is rsi/dsi?": "an airway management produce to obtain an advanced airway in perfusing patients with the use of pharmacologic agents to aid in amnesia for the patient and muscle relaxation for tube placement. both airway management techniques are crucial in medical or trauma emergencies and paramedic level providers need to be proficient with the knowledge, anatomy and the skills of the procedure(s).",
        "importance of rsi/dsi": "life threatening injury, morbidity or mortality can develop if proper recognition is missed and providers do not proceed with placement of an advanced airway. rsi/dsi is performed in and out of the pre-hospital setting.",
        "rsi vs. dsi": "rapid sequence intubation has been a standard procedure for advanced airway placement for years. delayed sequence intubation has created a shift in common practices with dsi slowly becoming a more preferred method throughout ems systems.",
        "rapid sequence intubation (rsi)": "rapid sequence intubation involves rapidly preparing equipment and the patient for administration of medications to facilitate advanced airway placement. the primary goal of rsi is to pre-oxygenate the patient until medications can be administered.",
        "delayed sequence intubation (dsi)": "delayed sequence intubation involves a slower approach in comparison to rsi in regards to total time required for placement of an advanced airway as well as time needed prior to intubation attempts. primary goal of dsi is to optimize the patients hemodynamics and ensure they remain stable with adequate pre-oxygenation for a period of time prior to attempting to intubate.",
        "lessons and concepts": "anatomy of airway: upper airway anatomy serves as landmarks or identifying areas when inserting a laryngoscope.",
        "anatomy of the airway": "the upper airways serves as a passage for food/liquids as well as air breathed in and out of the lungs. it also serves to heat, humidify and filter the air and helps with coughing, swallowing and speech.",
        "upper airway structures": "pharynx: refers to the mouth, nasal cavity and region which all connect/lead to the esophagus and trachea.",
        "lower airway structures": "trachea: wind-pipe or a cartilaginous structure leading from the larynx down to the carina where it further splits into the lungs.",
        "physiology of the airway and the respiratory system": "remember that the main goal of the respiratory system is gas exchange. air and breathing mechanisms are regulated to help ensure that adequate gas exchange is occurring.",
        "what equipment is needed for rsi/dsi?": "providers must maintain knowledge of the necessary equipment involved in this procedure.",
        "equipment needed": "oxygen and oxygen administration devices, suction unit(s), endotracheal tubes and associated equipment, end-tidal devices, medications, back-up device(s), monitoring options and vital signs devices.",
        "medications": "induction agent: multiple different induction agents or sedatives can be used to induce amnesia (being unaware of self and surroundings) in a patient.",
        "post-intubation": "once an advanced airway has been secured, providers must remain aware that other medications may begin to wear off due to metabolism of medications with body result in amnesia, paralysis and pain relief all will begin to wear off.",
        "back-up device(s)": "having multiple options to securing an airway is just as important as placement and management of chosen airway device(s).",
        "monitoring/vital signs": "before, during, and after rsi/dsi, vital signs must be obtained multiple times to ensure absence of hypoxia and hypotension from occurring.",
        "recognition": "signs and symptoms will vary heavily based on the underlying cause of the situation. common signs and symptoms will be related to respiratory failure, arrest or compromise in a patient's ability to ventilate or oxygenate affecting multiple different body systems.",
        "when to rsi/dsi": "recognition of when to perform this airway treatment will better be learned and understood as providers build experience in the field of ems.",
        "treatment and management": "treatment and management of an rsi/dsi situation will heavily vary on the specific complaint or cause(s).",
        "ongoing treatment/treatment goals": "treatments/treatment goals heavily rely on your treatment pathways and care you have provided for your patient.",
        "transport considerations": "for successfully intubated patients, most emergency departments should be able to handle without any issues.",
        "scenario": "dispatch information: medic unit #1 with 2 paramedics and engine #1 with 3 als personnel dispatched to a breathing complaint.",
        "tips and tricks": "cognitive exam: remember to always consider scene safety concerns as well as start with bls treatments before als."
    },
    {
        "introduction": "ventilation and perfusion ratios can be a difficult, yet important topic to cover and understand. hopefully this breakdown will help to understand normal vq ratios, the difference, and the pathological changes that cause these shifts along with what happens internally.",
        "cardiovascular system review": "deoxygenated blood is going to enter into the right atrium, travel through the tricuspid valve into the right ventricle. from here the blood is pumped up into the pulmonary truck. from here blood will flow either to the right or left. now the pulmonary arteries will experience a systolic force of 25 mmhg of pressure with a 8 mmhg of diastolic pressure. right lung: right pulmonary artery is going to separate into the superior lobar artery and the middle lobar artery. the superior lobar artery is going to brink the deoxygenated blood into the upper right lobe of the lung. where as the middle lobar artery is going to have another branch called the inferior lobar artery. the middle lobar artery will supply the deoxygenated blood to the middle lobe, while the inferior lobar artery will go to the lower right lobe. left lung: the left lungs pulmonary artery is much more variable than the right. the left pulmonary artery is going to give off several superior lobar arteries to the upper lobe before finally branching off into a variable number of inferior lobar arteries to supply the lower lobe.",
        "respiratory system review": "the trachea brings in air from our environment to participate in gas exchange. the trachea is going to continue from the larynx down until the level of the carina. here at the carina the trachea is going to separate into the main bronchi. from the main bronchi, the airway path will continue to divide into the lobar bronchi that supply each lobe of the lungs (right will have 3 lobar bronchi, while the left will have two), the lobar bronchi will continue to divide into smaller and smaller air pathways. until eventually reaching the alveolar ducts. once at the alveolar ducts here we find the alveolar sacs (clusters of alveoli). here at the alveoli gas exchange takes place.",
        "lung volumes": "lung volumes: this plays an important role in diagnosis, treatment, and maintaining adequate homeostasis. tidal volume (tv): the amount of air that is moved into or out of the lungs during a single breath. about 500ml. total lung capacity: the substantial amount of air that can be moved within the respiratory system. about 6,000ml in the adult male, 1/3 less in adult females due to smaller lung size. inspiratory reserve volume: the deepest breath you can take after normal breathing. about 3,000ml. expiratory reserve volume: the maximum amount of air that you can forcibly breath out after normal breathing. about 1,200ml. residual volume: the amount of gas that remains in your lungs to keep your lungs from collapsing. about 1,200ml. this volume of gas does not move during ventilation.",
        "dead space": "it is also very important to remember that your respiratory system has dead space. dead space is the areas that do not participate in gas exchange. we lose a part of the ventilated air to the dead spaces. about 30% of our tb is lost. meaning about 150ml.",
        "ventilation perfusion ratios": "when we talk about ventilation perfusion (vq) ratios it is important to understand what is normal, what is abnormal, and factors that can cause or effect our vq. normal vq: the normal resting minute ventilation is about 6l/min. about 1/3 of this volume is lost to dead space. meaning that the resting alveolar volume is approximately 4l/min. where is pulmonary blood flow is approximately 5l/min. making the overall ratio of ventilation (v) to perfusion (q) 4:5 or 0.8l/min.",
        "normal vq ratios": "one simple way to understand what is normal is divide the lungs into three sections to understand what normal vq ratios are. it is important to understand that v and q throughout the lungs differs. now the values and information provided below are in an upright person. gravity is going to play a significant role in how much blood flow the different sections of the lungs are going to receive. apex (zone 1): vq ratio is higher. due to gravity the blood flow is going to be lower. the ventilation coming to the apex of the lungs is not going to be fully able to be involved in gas exchange due to the lower q.",
        "vq mismatch": "intrapulmonary shunting: this is where you have blood flow without appropriate aeration. where the amount of o2 going into the respiratory system is not involved in gas exchange. resulting in a decreased minute ventilation from the 4l/min. as co2 comes to the alveolar capillary membrane it is not able to diffuse properly out from the red blood cells into the alveoli to be breathed off.",
        "causes of vq mismatch": "causes: pneumonia, pulmonary edema, asthma, and copd can result in a disturbance of cellular metabolism. by decreasing the surface area of the alveoli by damaging the alveoli or by leading to an accumulation of fluid in lungs. creating a state where the alveoli are nonfunctional, stopping or reducing gas exchange.",
        "vascular dead space": "this is when you are still getting an appropriate aeration, without blood flow. as you have no blood flow to the pulmonary capillaries, the oxygen being brought into the alveoli does not participate in diffusion. increasing the overall tv that is lost to dead space.",
        "signs & symptoms": "with vq mismatches patients are going have an increase in co2 in the arterial blood with a decrease in etco2 readings. because the individual is not about to get co2 to diffuse across the membrane. this increase in co2 being bound to the hemoglobin is going to continue preventing o2 to come in and bind.",
        "scenario": "dispatched out to a 67-year-old male. sob. code 3. to a residence on the far end of town. arrive on scene. the male patient is sitting in a chair in the kitchen. home smells of smoke for heavy cigarette use. patient is sitting in a tripod position."
    }
]