Adequate Breathing
To determine if a patient (pt.) is breathing adequately you must assess the rate, rhythm, quality, and depth of the respirations. It is important to assess each of these areas to ensure that a patient is receiving enough oxygen to prevent respiratory arrest or other respiratory related complications.
As you perform the assessment of a patients airway, you must assess the rate at which they are breathing, or how many breaths the patient is taking each minute. According to the DOT EMT-Basic Curriculum the normal respiratory rate for an adult is 12-20/minute, a child is 15-30/minute, and an infant should breath approximately 25-50/minute. Note that a patient's respirations may be slightly outside of the normal limits due only to the stress of the situation. Often times their breathing rates will return to normal after a short amount of time.
Determining rhythm of respirations is also important when doing an assessment of a patient's airway. The patient’s rhythm may be regular or irregular. A regular respiratory rhythm is the same volume of air going into the lungs as coming out. You may find that irregular rhythms present as short breaths then long breaths then short breaths again and or periods of apnea.
Regular Rhythm. The rhythm of respirations is also equally as important. A regular respiratory pattern consists of equal chest rise and fall and a regular cycle of inhalation and exhalation. Any deviation of this would be considered inadequate breathing.
Quality respirations are determined by breath sounds, adequate chest expansion, and minimum effort of breathing. Breath sounds that are bilaterally equal and full are determined to be adequate. When the chest rises and falls appropriately and equally, and there is no accessory muscle use during inhalation and exhalation, this is also adequate. This shows that there is minimum effort to breathe. Note that it may be normal for infants and children to use their abdominal muscles more than adults. Therefore, you should not be alarmed if you find this during your assessment.
Depth refers to tidal volume or the amount of air that the patient is breathing. You will not likely be able to determine the exact tidal volume of each respiration, but if there is visible chest rise then a sufficient amount air is being inhaled and exhaled (Rate must be within normal limits). Current AHA guidelines have the EMT looking for adequate chest rise rather than a particular tidal volume. Research showed tidal volume was nearly impossible to estimate in a prehospital setting.
Good Rate, Rhythm, Quality and Depth are all necessary for adequate respirations. All must be within normal limits to prevent hypoxia, or possible respiratory arrest. If any of these components are abnormal it should be considered inadequate respirations.
Inadequate Breathing
Inadequate breathing can be caused by several factors including trauma, disease process, stroke, diabetes, tumors, airway obstructions etc. Poor respiratory function directly affects the patient's ability to exchange and distribute oxygen to the body's tissues. If not corrected inadequate breathing can cause death secondary to poor perfusion and cellular death. Just as when determining adequate respirations you must appreciate the rate, rhythm, depth and quality in order to determine if it is inadequate.
Bradypnea. The rate at which a patient is breathing has a direct relationship with their perfusion status. A patient that is said to be ventilating below 12 respirations per minute is considered to be hypoventilating or bradypneic
Tachypnea. Conversely, a patient that is breathing too fast is considered to be hyperventilating or tachypneic. E
Cheyne-Stokes respirations are an irregular respiratory pattern characterized by breaths increasing in rate and depth followed by a decrease in rate and depth and then a period of apnea. Cheyne-Stokes respirations are commonly seen in patients that have head injuries or may be having a stroke.
Biots respirations or Cluster Breathing are an abnormal breathing pattern consisting of rapid, shallow breaths followed by periods of apnea. Biots is seen with trauma to the medulla oblongata as well as strokes that affect the same region. Patient’s with serious head trauma may exhibit these irregular, ineffective respirations. Biots respirations are often confused with Ataxic Respirations. They are similar, but technically, Biots is clusters of similar sized breaths where Ataxic respirations are completely irregular in both rate and rhythm.
Kussmaul respirations are marked by a deep rapid breathing rate that is a corrective mechanism against conditions such as diabetic ketoacidosis or CNS problem. Typically this is the body’s way of expelling excess CO2 during metabolic acidosis.
Apneustic respirations are exhibited when there is damage to the upper part of the pons. This respiratory pattern is characterized by prolonged inspiration unrelieved by expiration attempts.
Ataxic Respirations are an irregular breathing pattern intermixed with irregular periods of apnea. As this pattern continues to deteriorate it becomes agonal respirations and finally apnea. Ataxic breathing is usually caused by trauma or stroke involving the Medulla Oblongata.
The quality of respirations must also be assessed when determining inadequate breathing. Quality refers to both lung sounds as well as chest wall expansion. Often times it is difficult to determine either one due to the patient’s size or external noise and distractions. It can be particularly difficult to assess lung sounds when “normal” has not been identified. Because of this, it is highly recommended that lung sounds are obtained in an environment that has minimal noise. A moving ambulance is not the place to get reliable lung sounds. Below are several examples of different abnormal breath sounds. Knowing the difference between lung sounds can help you better understand what the physiology of the respiratory pathology is.
Abnormal Breath Sounds
Stridor A harsh, high-pitched sound heard upon inspiration. This is typically characteristic of and upper airway obstruction such as heard in croup.
Listen to Early Stridor
Listen to Advanced Stridor
Wheezing A whistling sound caused by a narrowing of the airways by edema, foreign bodies or bronchoconstriction.
Listen to Early Asthmatic Wheezes
Severe Asthmatic Wheezes
Rhonchi Rattling sounds that are heard from the larger airways that is caused by an excessive amount of mucus or other material.
Listen to Rhonchi
Crackles Crackling noise associated with fluid accumulating in the smaller airways. This term is also used synonymously with Rales.
Listen to Fine Rales or Crackles
Listen to Medium Rales or Crackles
Listen to Coarse Rales or Crackles
Pleural Friction Rub Occurs when the pleura become inflamed and a sound is produced that sounds like dried pieces of leather rubbing together.
Listen to Pleural Friction Rub
Determining Inadequate Breathing
Abnormal breath sounds can also be characterized as being diminished or absent. As stated before, knowing what is normal is very pertinent. When assessing lung sounds your patient’s history can guide you in determining what you should be hearing. For instance, if a patient has had a left lung lobectomy you would not be expecting to hear anything on the left side. Without the history you may be inclined to draw another conclusion.
Inadequate breathing can also be seen with unequal chest wall expansion. While assessing your patients breathing it is vital that you not only visually inspect, but also palpate the thoracic region to determine the adequacy of expansion. This more detailed examination along with auscultated breath sounds will help the EMT to determine adequate vs. inadequate breathing.
Example: You are assessing a patient who has just been involved in a motor vehicle collision. Upon visually inspecting the patient's chest you note that there is unequal movement (paradoxical motion) of the thoracic region. This visual finding helps you gain further insight into the patient's true respiratory status and will help you better determine if the patient is breathing adequately.
A patient’s skin color, temperature and condition are affected by the respiratory pattern of a patient. When an individual is breathing inadequately the skin may be cool, clammy and or cyanotic. As the patient becomes more hypoxic because of inadequate breathing, there is an increased extraction of oxygen from the red blood cells. This in turn results in poor perfusion of the tissues and is evident with peripheral cyanosis. In extreme cases, core cyanosis can result which will also include cool and clammy skin. Assessing the skin's color, temperature and condition is one of the easiest assessment techniques that can be used to determine perfusion and respiratory status .
Children often exhibit different signs of inadequate breathing than those of an adult. A common sign of inadequate breathing in a pediatric patient is nasal flaring. When a young patient flares his/her nares upon inspiration it is an attempt to increase the volume of air that is being taken in. Seesaw breathing may also be noted in pediatric patients and can be described as a breathing pattern where the abdomen and chest oppose each other during inspiration and expiration. The child is unconsciously trying to enhance the movement of the diaphragm and draw more air into the lungs. Both of these signs should be seen as serious and potentially life threatening for the pediatric patient.
Airway considerations for infants and children
The upper airway of a child is considerably different then that of an adult. The mouth and nose of a child are much smaller in proportion to the size of their heads. Many structural differences make a child's airway more susceptible to becoming obstructed. The tongue of a child is much larger and takes up more space in the pharynx and the epiglottis is generally larger and floppier then that of an adult. The trachea of a child is much narrower and less rigid then that of an adult. At the cricoid cartilage the airway constricts proportionally more than an adult's and is easily obstructed by swelling or foreign objects. These anatomical differences in children make it more appropriate to use a tongue depressor while inserting the OPA parallel to the tongue rather than curved away and then rotated upon entry as is recommend in adult patients. The already constricted nature of the pediatric airway makes it difficult if not impossible to rotate an OPA 180 degrees without injury to the pharynx. Pressing the tongue down creates more space and helps prevent the OPA from pushing the tongue posteriorly.
Remember that children use more of their diaphragm for breathing because of the under developed nature of their ribs and intercostal muscles. The pediatric rib cage cannot allow for much expansion during inhalation. This is often called "belly breathing"as the child's stomach can be seen rising during inhalation rather than the chest as should be seen in adults. It is quite normal as long as as the rhythm, depth, quality and rate are within range of AHA guidelines of 12-20 breaths per minute.
Determining Adequate and inadequate artificial ventilations
Proper artificial ventilation is often dependent on an EMT's familiarity with using the various types of masks and ventilatory devices. Proper positioning of the patient, the EMT and the ventilation device will make this often difficult process go much smoother. There are several methods to help you determine if your ventilations are being adequate. If the patient's chest is rising and falling with each ventilation then the air is likely reaching the alveoli where cellular respiration has the opportunity to occur. If your patient's heart rate returns to within normal ranges then your assisted ventilations are also likely adequate having produced a positive result by reducing hypoxia. The ventilation rate must be within ranges that are acceptable to the newest AHA Guidelines. For adults with or without a simple oral or nasal airway in place, a rate of 10 to 12 breaths per minute is recommended. Children in need of artificial ventilations should be given between 12-20 breaths per minute according to recent AHA guideline changes. This wider range is to allow the rescuer more freedom to tailor the ventilations to the patient and situation.
If your patient has had an advanced airway such as an ET tube or Combi used to secure the airway then the ventilatory rate is reduced to 8-10 breaths per minute. These ventilatory rates are people in respiratory distress only. If your patient does not have a pulse CPR is required then you would deliver approximately 5-6 breaths per minute while allowing for approximately 100 compressions over that same minute.
Inadequate assisted ventilations can be deadly and are often detectable by the absence of proper chest rise and fall. If the chest is not rising then air is not likely reaching the alveoli and the body is not being properly oxygenated. Failure of chest rise can be attributed to several things, foremost is the blocked airway. When a patient is unconscious the tongue often falls back against the pharynx blocking the trachea and inhibiting air passing into the lungs. Use of a simple oral or nasal airway is useful in displacing the tongue and maintaining the airway open during assisted ventilations.
If the rate at which the patient is being ventilated falls outside of acceptable ranges then the assisted ventilations are considered inadequate. Too many assisted breaths can increase the chances of gastric distention and cause vomitus which will further compromise the patient's airway. Not enough ventilations can result in hypoxia and eventual tissue death if the problem is not corrected.
Section II Opening the Airway
Opening the airway is a simple task if it is done correctly. It must be performed after sizing up the scene and triaging the patient. Opening up the airway of a trauma pt. is different than a pt. that has been witnessed to have just “stopped breathing”. There are two ways to effectively open the airway; head-tilt chin-lift and jaw thrust.
Upon arriving on scene of a pt. that just stopped breathing and was witnessed, you should perform a head-tilt chin-lift. You can perform this method of opening the airway as long as you do not suspect a spinal injury. Steps for performing the head-tilt chin-lift: 1. Assure the patient is in the supine position, and kneel beside them. 2. Place the palm of one hand on the patients fore head and apply pressure backward, tilting their head back. This will clear the airway by pulling the tongue forward and away from the throat. 3. Using the fingers of your other hand, place two fingers under the patients chin to assist tilt the head backward. To ensure you do not further block the airway, do not push on the soft tissue near the bony part of the jaw. 4. While tilting the head and lifting on the chin simultaneously you should lift in a slow constant motion. Continue to hold the head in this position while ventilations are being assisted or if the unconscious pt. is breathing on their own.
When you are dispatched to an incident where a pt. was found unconscious, apneic, and you suspect trauma, you should try to open the airway using the jaw thrust method. Often times, for the benefit of the pt., you have to assume that the pt. has a neck injury. Newest AHA guidelines state that a jaw thrust method maybe difficult to perform, thus, you may need revert back to the head-tilt chin-lift. The patient’s airway is still the top priority, even in the unresponsive trauma patient. The jaw thrust maneuver is difficult to master so it is not the preferred method as it once was. Steps for performing the jaw thrust: 1. Kneel above the supine patients head while holding their head in an in-line neutral position. 2. Place your thumbs on the pts. cheek bones while extending the rest of you fingers around the patients cheeks. 3. Place your ring finger and middle finger of both hands on the angle of the mandible and lift anteriorly. This should open the pts airway by lifting the tongue off the back of the throat without compromising spinal integrity.
Does your patient need suctioning? Is there airway clear? Have they aspirated or is there a threat of aspiration? Is there saliva or food compromising their airway? These are items you must consider when you are faced with determining and securing a patent airway. You must constantly assess the airway and be ready to suction at any time. Gurgling is the first sign that an airway needs suctioning.
Section III Techniques of Suctioning
Suctioning the airway of a patient can be the most important thing you do to prevent respiratory arrest or other complications. Why suction the airway? You may need to remove blood, liquids or food particles that could otherwise be aspirated. Note that some suction units are inadequate for removing solid objects such as teeth, foreign bodies and food. Advanced airway techniques are needed to mitigate these situations. When ventilations are performed artificially and gurgling sounds are heard, you must immediately suction the airway to always wear proper personal protective equipment and body substance isolation garments when suctioning airways.
Suctioning equipment consists of mounted and portable equipment. Mounted units are found in the hospital setting and in ambulances. Portable suctions are easy to carry units that are used to suction airways in areas such as a patient’s residence or an MVC. Portable units can be electrically/battery powered or manually powered such as hand suction units
Attached to a suction device is suction tubing with a suction catheter. A suction catheter can be rigid or soft. Rigid suction catheters are used to suction the mouth and oropharynx of an unresponsive or responsive patient. The rigid catheter should be inserted only as far as you can see. You may use the rigid catheter on an infant or child, but you must be cautious not to touch the back of their airway. Soft or French catheters are useful for suctioning the nasopharynx and in other situations where the rigid catheter cannot be used. The french catheter should be measured so that it is inserted only as far as the base of the tongue. In advanced airway situations a french catheter can be used to suction advanced airway devices such as and endotracheal tube.
Before an emergency incident you should inspect the suction device on a regular basis, before it is needed. When inspecting the suction device ensure that all tools (suction hose, catheter, and container) are present, the device turns on, and mechanical suction is present and that the battery is charged (if portable suction device). A properly functioning unit should generate approximately 300 mmHG of vacuum.
Now go through the steps of suctioning>>>KKLKL>>?? Need a few more paragraphs
Techniques for artificial ventilations:
As ventilating a patient can bring the EMT into contact with oral secretions, vomitus and other potentially infectious liquids, proper BSI is always necessary. Gloves at the least and possibly eye protection and a mask should be considered. The EMT Basic should be comfortable with all methods of artificial ventilatory methods including:
Mouth to Mask - Choose the appropriate sized face mask which should include an attached one way valve to prevent contact with oral fluids. Attach oxygen tubing to the O2 port on the mask and then to an oxygen cylinder flowing at a rate of 15 Liters per minute. Ideally you should position yourself at the top of the supine patient's head and include manual stabilization of the head and neck if trauma is suspected. Apply the mask to the patient's face placing the wider portion over the mouth and the narrow portion over the nose. Using your thumbs and forefingers apply downward pressure to the mask making an airtight seal while at the same time using the remaining fingers to pull upward pressure on the mandible. With the mask in place open the airway with the appropriate technique and deliver breaths through the one way valve with just enough volume to make the patient's chest rise and the proper rate for the patients age and condition.
Bag Valve Mask (BVM) - A bag valve mask is often used to artificially ventilate a patient who is breathing too slowly or not breathing at all. It is most effective when being utilized by two EMT's rather than one as maintaining an air air tight seal on the mask can be very difficult with one hand. If you suspect your patient has had trauma involving the neck or back you should have an assistant hold manual C-spine while you ventilate. If you are alone you can kneel and use your knees to help stabilize the patient's head.
A BVM can usually be found in 3 different sizes for infants, children and adults. It should consist of a self inflating bag with a one way valve, an oxygen inlet port and an oxygen reservoir bag for delivering high concentrations of O2. The BVM should have a non clogging valve that operates even in the presence of large pieces of vomitus. The BVM should also work with other standard airway adjuncts , ET tubes, Combitubes etc. with a 15mm/22mm fitting.
The BVM is best utilized with an airway adjunct in place. After the airway is open select and apply the appropriate sized mask. First apply the apex of the mask over the nose and lower it to encompass the mouth. Create an air tight seal by positioning your thumb and index fingers in a C position over the mask. Apply downward pressure with the thumb(s) and index finger(s) while hooking the remaining fingers under the mandible and gently pulling upward toward the mask. If Oxygen has not been attached to the O2 port yet it should be done now delivering 15 Liters Per Minute through the mask. Compress the bag and look for adequate chest rise and fall with each ventilation. If chest rises and falls continue ventilating at appropriate rates stated above. If chest fails to rise adjust the mask seal or try repositioning the airway. If the chest still fails to rise check for airway obstructions and consider utilizing a different method of artificial ventilations like a pocket mask.
Flow Restricted, Oxygen Powered Ventilation Device (FROPVD) - Use of a FROPVD should include all BSI and airway opening maneuvers used for other artificial ventilation devices. This includes manual stabilization of the head and neck for those patients suspected of trauma. The FROPVD is manually triggered and used to deliver 100% oxygen at a rate of up to 40 liters per minute. When the device is activated, usually through depressing a button, the valve opens and delivers a continual flow of pure oxygen until the button is released or the inspiratory pressure relief valve opens. This valve opens at 60 cm of water or less , venting the remaining gas or stopping the flow of oxygen. This mechanism is to lessen the chance of causing a pneumothorax or gastric distention when air is allowed to enter the esophagus. If at any time the pressure on the relief valve is exceeded an audible alarm should sound alerting the EMT to the problem. The device should have a manual trigger positioned so that the EMT can activate it while maintaining both hands on the mask ,holding it in position while the oxygen is being delivered. The EMT should press and hold the oxygen delivery button until the patient's chest rises adequately and then release the button. This process should be repeated every 5 seconds. If the abdomen rises rather than the chest try repositioning the head. If O2 is leaking out from under the FROPVD mask try repositioning your fingers or the mask itself. If adequate chest rise can still not be achieved you must move to a different ventilatory adjunct like a pocket or bag valve mask.
Airway Adjuncts
As mentioned above, the most common issue surrounding airway management is the obstruction by the tongue of the pharynx while the patient is lying supine. Tongue obstructions can often be managed by the head-tilt chin-lift method, but once the maneuver has been released the tongue may again fall back against the pharynx occluding the airway again. The EMT Basic typically has two adjuncts at their disposal to help get the airway patent.
The Oropharyngeal Airway, (OPA), Oral Airway is a plastic device that is rigid with a flange on one end to rest on the teeth. The other end is curved with either open channels on the sides or a hole down through the center for air to pass. The curved end is inserted into the oropharynx and helps displace the tongue . There are several standard sizes of OPA's to choose from that range from infant up to adult sizes. It is imperative that when selecting the appropriate sized airway that you measure from the corner of the patient’s mouth to the angle of the mandible or from the corner of the mouth to the bottom of the earlobe. Remember that this adjunct is used only on a patient that does not have an intact gag reflex. Otherwise, the patient could end up vomiting and further compromising his/her airway.
Once the appropriately sized adjunct has been selected open the patient’s mouth with the thumb and fore finger used in reverse scissor motion. Insert the airway so that the curved portion is toward the hard palate. Once the adjunct is inserted, gently rotate the adjunct 180 degrees so that the curve of the airway is parallel to the patient’s tongue and that the flange rests on the patient’s teeth. While the airway is being rotated, make sure that the tongue is not being pushed posteriorly.
An alternative way of inserting an oral airway is by using a tongue depressor. To use this method, press the tongue downward and with the oral airway curve parallel with the tongue, gently insert the device into the patient’s mouth until the flange rests on the teeth. This way is preferred in pediatric and infant patients.
A Nasopharyngeal Airway, (NPA), Nasal Airway is an alternative airway adjunct that may be used when patient’s have an intact gag reflex. An NPA is less likely to stimulate vomiting than an oral airway and may also be used on patients who are responsive, but still need assistance in keeping the tongue from obstructing the airway.
The nasal airway is a pliable tube that is inserted through the nose that when fully inserted, the tip is located in the posterior pharynx. To appropriately select the size, measure from the tip of the nose to the tip of the patient’s ear. One thing to keep in mind is the diameter of the airway in relation to the patient’s nostril.
Once the appropriately sized device has been chosen, lubricate the airway with a water soluble lubricant. The airway will then be inserted into the nostril with the bevel pointed toward the septum. Gently insert the device until the flange is resting atop the patient’s nostril. If the airway does not insert fully into the nostril then attempt the same procedure in the opposite nostril.
