Transcript for:
Understanding Airway Management Essentials

all right looks like it's a little after six we'll go ahead and get started hope everybody's doing all right tonight others could jump on when they uh get on here but uh tonight's the airway lecture and it is uh it is quite a long one that's why it split up over two nights starting off uh the first part of it quite a bit of review on the the amp part of it but that's something we'll never get away from but because you never never have to review that but uh airway is the most one of the most important subject that we can cover uh in the healthcare field because without it nothing really really ever matters at all don't get past that part because if you look at it pretty much the way the uh the body functions especially the airway pulmonary system functions to carry the brain around just about every system we have it can be related to uh carrying the brain around keeping the brain alive in some form respiration one of the first terms we'll talk about tonight is has to do with uh it's divided up into three different uh categories and respiration is simply gas exchange it it it differs in what one would call ventilation it's mainly the movement of air in and out but respirations for gas exchange takes place and uh talks about external that's moving air into the large airways mouth nose trachea internal has to do uh within the distal terminal ends of the airway bronchioles the tributaries to the alveoli that way and then of course at the cellular level is the gas exchange between the uh alveoli and the red blood cells so that's the uh i mean as far as cellular respiration and that takes place in every uh cell within the body once the blood has to get to the uh it takes the oxygen to the blood to the cells and it tray it makes a trade-off they have to give up some oxygen in order to get some co2 too to bring it out so the artificial ventilation anytime you hear the word artificial that in the medical field that's going to be in relation to something being done outside what the body's been able to do itself so we're going to talk about artificial ventilation a little while and a few more terms that's pretty important uh to remember and as we uh we'll talk about ventilators and stuff later on and based on local protocol and guidelines determines on who may or may not be using those but we will have to touch on some of those and i find that stuff kind of pretty interesting but artificial ventilation we'll talk about that later minute ventilation uh we'll learn some formulas and some uh information surrounding what that concerns and minute ventilation is simply how much air someone moves in and out of their lungs in a minute time and that's measured by the uh tidal volume and by the respiratory rate so if someone was breathing uh let's say they were moving 500 cc's of air with each breath and you do that times 60 you know that would be 3 000 would be their minute volume there's also formulas that when we talk about ventilator management and strategies as to how much uh and i'll hit on a little bit later as well but for example uh you require everyone requires a certain amount of minute ventilation to function and one way we would figure that out would be to like figure someone's ideal body weight if you have someone let's say a male that is uh six foot six foot tall i'd make him 72 inches anything over 60 inches they uh multiply that by like 2.3 equals 27.6 plus uh the 60. and uh it gives them about let's say 120. so we said that that would uh earlier was just a rough generation about 3 000 species of air for example someone six foot tall a male six foot tall would require about nine liters 9.3 liters of o2 per minute and if we divide that up by uh what their let's say the re their title volume would be let's say 500 that means that they would have to breathe we'd have to set their ventilatory rate about 18 times a minute in order to get that that's something we're not gonna have to worry about now just gives you a rough idea of how that's measured and how it actually is a physiological requirement of individuals in the alveolar venerate ventilation which occurs that's air getting down to the alveoli it may get there we'll talk about uh vq mismatch a little bit later but the air may get to the alveoli as far as ventilation but it doesn't necessarily mean that respiratory respiration will occur it could be because there's too much fluid in between the others and inflamed or the cell wall of the alveoli is broken down so just because they get there doesn't mean that it's actually providing respiration but right now we're simply just talking about the movement artificial ventilation when we bag somebody or ventilate them with a bag valve mask or even if you have an advanced airway in place we got to keep them in what would be their normal rate would be if they were breathing on their own because if we if you breathe in if you push in too much air either by too much of a volume like if you squeeze the bag all the way with both hands you're going to overfill the lungs or if you're moving air in and out faster than what it should be what that artificial ventilation does on cardiac output is all that increased air in the chest cavity if you got too much air in there that's much less blood that can get in and refill the heart or it makes the blood hard to get out of the heart to go to the peripheral areas of the the body so adequate and the appropriate amount of ventilation rate uh not only the rate but the amount that you put in can have an effect on someone's cardiac output so we'll talk about that a little bit later but bear that in mind also now uh pathophysiology is a word we heard earlier this gets a little bit more deeper in depth into the uh the way the cells of the pulmonary system the gases in the bloods uh function once obtaining getting an airway and hanging on to it that is uh the paramount step that you're going to have treating patients in ems once you get the airway you may get it initially but hanging on to it may prove another challenge for example you may have swelling or fluid that accumulates in the airway or you can lose or have an advanced airway dislodged and that's gonna cause you to have to reinsert it and sometimes once you take one out it's very difficult to get get it back in so we'll talk about maintaining the airway securing these advanced airways a little later the oxygen during inhalation that moves in it moves let's say if we don't have any supplemental oxygen but given just the regular amount of oxygen in the atmosphere which is 21 percent moves from the atmosphere into the lungs that's inhalation that's active and exhalation is when the carbon dioxide leaves the body it's not just pure carbon dioxide that goes out same way it's not just pure oxygen and it goes in there's a lot of other inner gases that are in there as well so the these are the most crucial skills that any ems provider can learn obtaining maintaining the airway and maintaining oxygenation the airway we'll see a picture in just a moment but it is divided into the upper and the lower airways the upper airway is simply that from the mouth to the to the larynx so your mouth nose oral pharynx nasopharynx all that is considered your upper airway now once you get to the glottic opening which is the voice box or larynx in this case that's when the lower airway begins the ventilation of course is the air exchange respiration is a gas exchange so kind of remember it that way ventilation is movement of air respiration is the exchange of gases but you got other structures that aid in ventilation and uh the one that comes to uh mine first is a diaphragm it's like a sheet muscle and when i say sheet muscle it's like a sheet that's inside the body but it's muscular and it has a dome flap shape when it is relaxed and when it contracts it goes down and that's what pulls the air in it forms a vacuum inside the chest cavity and actually draws the air in now the other muscles you got muscles that are support the chest and the back muscles of the diaphragm that support it to the to areas below the diaphragm which kind of pulls it against the back to help move it up and down but those are muscles of breathing is what we call them and they're accessory muscles most of the time it doesn't take a lot of effort under normal circumstances to uh to take breath however someone is distressed whether it be because the gas exchange is not good or if it's because the the anatomical structure of the lungs are messed up itself then they're going to you they may have to start using accessory muscles in order to be able to meet their uh respiratory demand now this diagram here if you look at it straight on remember if i refer to any right or left i'm referring to the patient's right but as you can see the diaphragm is like a flat dome-shaped sheet muscle and and that's what separates the thorax from the abdominal cavity it's attached on the rib cage pretty much it goes uh if you think of like one of those dawn tents that sets up in the bottom of your rib cage it's kind of a good out ideal way to picture it but it's attached to the bottom of the ribs and it comes up as high as almost uh just below the nipple line is about how far up that diaphragm comes and it has uh and you see the chest wall the muscular chest wall the muscular diaphragm all of that forms a container or cavity around the lungs themselves now the muscle area has a that parietal pleura around it it's a it's really a big sack but it's lubricated it's got two sides to it the parietal pleura is the one that touches the muscle wall the visceral pleura is the one that covers the lung cat the lungs themselves and in between those two uh pleura that's when they have this uh this lubrication it is uh it's very slick viscous and that provides the lungs a space for they can glide back and forth and hopefully not create any type of friction now areas of friction that could occur would be like if they have pleurisy or we talked about a uh a poetic rub a couple nights ago that's where it will occur between the the visceral parado pleura and even on it can even happen on the bottom side of the lungs and that this be very painful because it's a grating type noise the you can see up at the top if you start at the head you get the nasopharynx oral pharynx the mouth and it comes down to the point of the epiglottis that is uh that structure is when someone swallows it folds over the opening of the vocal cords to prevent food from coming in and you can see the trachea right where it says larynx no the top of the larynx below the larynx is where you start the lower airway anatomy and as you can see the trachea and the part of where it separates to where it forks a couple of terms that you'll learn there that is called a it's a bifurcation it's when something divides and forks if it forks just in two places into two areas it becomes a bifurcation but that site to where that happen is happens is is called the carina and uh if we if we were to insert a uh like a endotracheal tube or anything into that area what would happen there would be is that you don't want to go all the way down the the right main stem for instance for instance right in there uh the carina is if someone was to intubate this patient or put in a uh an oral tracheal airway it would have to sit right above the level of the quran if it goes too far down that it's going to go into one side or the other mainly the right main stem and cause ventilation just to one side and all that other lung tissue would not get any ventilation and that's you know that's not good you'd have to back it up to uh where they both can get it as you can see how the uh after that at the point of the karana the uh bronchi divide into bronchioles which is uh smaller tubes that gets into the alveoli and the lung tissue and it even breaks up even further than that and they call them bronchioles on the bottom right hand of that picture it shows how the uh terminal airways divide into the alveoli now the alveoli is uh you know if you look at the inside kind of grape-like clusters and there's a lot of uh very small capillaries pulmonary capillaries that's where the arteries and the the veins come together and they surround those alveoli and provide gas exchange those are very very uh minute capillaries where it probably only could be seen under a microscope uh something that magnifies at that point so that's the airway and the lower airway upper airway is that above the larynx lower airway is that simply below the larynx now the upper airway what it's for it's a filter it's to gather the lungs i mean the air to funnel toward the lungs is to also filter it that's why uh breathing through the nose is the way that the airway system is to set up because it's supposed to have hairs and the large mucous membranes in there that warm the air they heal the humidifier but when you breathe through the mouth sometimes uh people may cough something a little bit more or inhale larger objects and it will kind of dry your throat out a lot if if you continue to breathe through the mouth if you've ever woke up uh been snoring all night with your mouth open you wake up with that big dry mouth that's because the oral passages do not lubricate and humidify like the nasal passages does now the area behind the oral cavity in the nasal cavity the pharynx that comes from the from the back of the nose uh all the way to the top of the larynx and it is divided up the pharynx is the large that is simply the back of the nose all to the top of the larynx it's divided up as far as original areas like the part that's in the nose of course nasal pharynx oral pharynx has to do with the mouth and the laurential pharynx is that area right around the larynx itself the uh the laryngeal pharynx is the lowest part of it it's right above the trachea in the bottom part it's probably the smallest the oral fair should be the largest part but the laryngeal furnace is the lowest portion of the pharynx right above the larynx this picture here is uh it's it's pretty good picture i hope you can see it pretty good but uh because on the left you can see uh when we talk about under the tongue the tongue is raised up and that's what we call a sublingual area anything sub when you hear the word sub it means below so we're looking at uh if you raise the tongue up that is uh some very uh vascular uh mucous membrane in there it's very absorbent that's why some medications are given uh sublingual like aspirin and other type of medication some type of nausea medications and some migraine medications they placed under the tongue they absorb directly into the bloodstream from there and they don't get digested or anything like that in the stomach but directly into the bloodstream the uh you can see the uvula hanging in the back now we talked about some snoring earlier and the mouth being open uh that's when you do that that's irritable very ear to to uh the structures inside the mouth and that uvula sometimes if you ever wake up in your dry mouth and uh or maybe even hoarse or heck if you're uh if you your partner or whoever uh significant other you hear them snoring or whatever and they'd wake up with a dry mouth that you've a lot of times will be swollen and inflamed i've seen him to the point where he looks like a big grape back there but it gets uh and when it does that a lot of times it will when it gets engorged and swollen it'll actually become a source of mucus fluid clearing their throat that's why a lot of times in the mornings people may have that problem and eventually it goes back down but the uvula is a structure the back of the throat that comes from the roof and we'll talk about i know advanced emts don't orally intubate but we will talk about that and you'll have an understanding of it later because i think it's important but that's some structures and landmarks that you'll look for when going into advanced airways and even examining the mouth for injuries uh any type of structural difficulties or things like that so the one on the left that's pretty much what you should see unless they roll their tongue back on purpose but that's the structures that are in there the uh the picture in the middle as you can see the tongue how much space it takes up inside the mouth it uh you can see it's attached to the bottom of the mouth very very sound and we've always i've always heard the wives tell growing up that someone had swallowed their tongue or be careful you'll swallow your tongue well you'll look at it there's no way in the world that's going to come off and you swallow it but it will fall back against the back of it but no one is really going to ever swallow their tongue so you see the uh if you follow the tongue around you can see at the base of it you see where it talks about a linguino uh lingua tonsil and behind that the epiglottis now the epiglottis you see how there's not a lot of room back there so that's why it's important you know people chew their food right so when someone swallows that epiglottis flaps down and blocks the opening to the vocal cords and the food should go down back against the esophagus the esophagus is the most father uh back tube back there but then epiglottis when we talk about when someone orally tracheally intubates they put that laryngoscope inside the mouth and if they're using a curved blade they follow the curvature of the tongue and the end of it goes right in that area between the lingual tonsil and the epiglottis so what they're doing is they're actually picking that up to where they can see down into the vocal cords so that's where the laryngoscope actually goes for a curved blade now if they're using a straight blade they will actually stick it all the way to the back of the throat and even pick up the epiglottis instead of going into the little notch above it the little notch above it is called the vallecula but that's what that's some important landmarks they're looking for back like that so even think about oral airways king airways when we get into that a little bit later but like the oral airway you see how an oral airway has to be properly sized because and it goes from the like the angle of the jaw as you can see for the angle the jaw would be approximate on this to the end of the mouth you see why it has to be like that because it holds that tongue away and still leaves the airway open now when it is too short it's not going to go all the way back to the back of the tongue and it's still going to cause some obstruction and if it's too long it can actually block the opening to the airway itself if it goes in too far and same way with a nasal top if you look at the nasal cavity where that airway wants to rest is you want to get it in to where it goes back in far enough to the point to where it blocks that tongue from closing off that opening above the epiglottis so that's kind of uh what inside that should look like now the nasal the uh you see the nasal cavity up there you can't really see the the bones of the nose or anything from this picture but you kind of see where the uh the eustachian tube or on here it says entrance to the auditory tube uh you know those are working if you ever hold your nose and blow and your ears pop because that directly goes to the ears from there and that's why when you swallow some time or if you uh go up to high altitudes and you feel your ears like they're stopped up it's because the pressure's unequal and that's what those are there for like if someone was to swallow or hold their nose on blow it will it equalizes the pressure inside the ears that's but it comes all the way into that point uh and you can see some of the tonsils uh in those areas they become inflamed how they might uh interfere as well uh the hyoid bone that is uh that's what holds the larynx and epiglottis in place and you really some people can't really feel it but it's high up into the lower structures of the chin over there the uh on the right is a cut away section of the trachea uh i'm sorry yeah the whole throat area the nasopharynx at the very top those little four little bulbs you see that are like that is like nasal bones that's inside the nose those are turbinates and they are what warms the air moisturizes it when the air comes in through the nose also they can become inflamed and swell and sometimes they can grow abnormally and that's when someone can have like like sinus drainage issues where it can't drain the nose constantly stays stuffed up like mine does is because those bones get up and the tissue around those bones get swollen they may do a septoplasty rhinoplasty they go in they actually grind those bones down i've had that done before too however it seems like it always comes back the oral pharynx uh goes to the base of the tongue and you're looking at this from if you're standing if you cut away the back of the head looking forward that's the way you're looking at this so uh talks about the oral pharynx you can see the tongue you can see the uvula this is looking at it from behind and you see the epiglottis and how the epiglottis uh opens up and it covers the trachea so that's that's what it's garden there and it simply flaps down and covers it up and there again was talking about putting all the advanced airways in when you lift that up that's what you're looking is down the trachea to go into the vocal cords the nasopharynx has to do with uh it's combined with nasal bones we talked about the turbinates also the septum the the nasal bones that surround that part which are the ones under the behind the eyes it forms part of the orbits and we talk about ciliated mucosal membrane it has like wave like little hair-like structures very you can't really even see them but it so these are supposed to kind of sweep material out that's why people they keep gathering uh and there's really i've never been able to find a medical term for it but when it sweeps this uh mucus and this debris out of your nose it forms like little hard clusters or whatever and referred to as boogers there's i haven't never found if you found one let me know but i've searched and searched i've never found a medical term for those but that's what's happening it sweeps it up toward the front of the nose where it can be gotten to or blown out and that's what these ciliating mucus mucosal membranes how they work the turbines we just talked about and you can uh it's hard for us to see really with the the materials that we have but like ents and uh er tools and things like that can see up in those turbines but sometimes if someone if you look at somebody's face straight on and you can see like clearly up one nasal cavity but you can't the other one it looks like it's blocked or whatever that's because that septum instead of going straight back it's actually starting to turn like an s and it's deviated so that's actually what you're looking at is actually the side of the center piece of that going back inward excuse me sinuses are cavities that are formed by the cranial bones that have like uh open spaces inside there to equalize pressure they also accumulate fluid and they're supposed to always they're still it's lined with ciliated uh mucosa it's supposed to always still uh sweep impurities and sweeping fluid that's created out however sometimes due to allergies and uh possibly injuries but allergies where it swells and it blocks and it can't get out that's when it gets in there it gets stagnant starts to get infected that's when someone may have uh like sinus infections uh sinus pressure things of that sort now these bones that line the nasal cavities on the other side of those bones especially the ones in the top of the nasopharynx on the other side of those bones is the brain and skull fractures uh trauma things of that nature can actually cause uh leakages in the in the cranial cavity and those uh and that's csf or cerebral spinal fluid inside there can actually drain out through the nose right now through the ears as well but it can drain out through the nose because it's those nasal bones are just on the other side of the brain cavity now the nasal pharynx of membranes very very vascular they are very easy to bleed a lot of blood vessels in there that's why they swell so easy a lot of times when someone has nasal congestion that when those membranes swell up so big the blood vessels aren't strong enough or have the capacity to hold the fluid in and that's when it starts leaking out you'll start getting the runny nose and start leaking out and stuff however even then sometimes it gets to the point to where they get so swollen it's not really the mucus bother obstructing so much as it is the membranes that are so swollen and that's because of these blood vessels that dilate that swell up so big that's why uh like a lot of decongestants oral decongestants especially like uh sudafed so that pseudoephren and they've got the the gene the you know it requires a prescription i know it doesn't mississippi it's harder it's harder to get that than it is a lot of locals in a lot of places but then they have the like pseudo fed pe which is fine uh like neo-synephrine and what these are is they constrict blood vessels that's why they tell people that have a lot of blood pressure issues or cardiac issues and not only its strengths in blood vessels and it may even raise blood pressure and in some cases if you notice the middle word what's that you know we talk about epinephrine speeds heart rate up raises blood pressure constricts blood vessels so when it's called pseudoephren it does have that property in it so that's why there's a lot of warning labels on there about people high blood pressure over a certain age should not take uh certain types of oral decongestants because that's what it does but it works on the blood vessels it shrinks them down and hopes to that it'll restrict some of the blood flow also they have these nasal sprays that work the same way a lot of times it's almost the same type of medication but it's uh it goes directly onto the to the membranes and it shrinks down blood vessels and alleviates a lot of that congestion now when it wears off i don't you've ever heard of anybody or maybe yourself has been hooked on nose spray no spray sometimes people can get hooked on that and they get in this vicious cycle where they have to use the nose spray to shrink down those blood vessels those inflamed nasal membranes and then when that wears off it gets worse every time and then they find themselves using more and more they'll use the 12-hour stuff you know maybe every six hours then every three hours and then every hour they're always you know it's like they carry the nasal spray with them all the time it's a very very hard cycle to break i've been there but anyway that's how that work that's how those work that's it works against those swollen membranes in the nasal cavities the oral pharynx is uh back behind the oral cavity and we we saw how it's got part of the epiglottis in it the epiglottis almost looks like a pig's ear if you can picture that one like if we're looking back there to intubate or whatever it almost looks like a it's a pig's ear leaf shapes made of cartilage base of the tongue lays over the uh larynx when it works right but when it go when things go proper it works uh when someone gets choked or something like that that's when it may when something may actually get lodged between the epiglottis and the vocal cords it gets kind of trapped in there or it can actually be big enough where it blocks the whole area off so with the vocal cords also contract as well so it's kind of a partner thing that when uh when the vocal cords close the epiglottis falls over the trachea the vocal cords close that that helps the airway from getting contaminated with the material food or liquid or anything like that however inside there it has one heck of a reflex that uh uh what reflex that helps to cough and get material out now once it goes past the gets in just inside didn't take much but just inside the vocal cords inside that first part of the trachea there's some reef reflex cells there and you know yourself if you swallow your own sputum or get strangled on something how strong the urge is to get that out it almost takes over everything that's happening and that's what that's made for is those you also have those cilia type cells in there as well but it is actually trying to force whatever came in there is trying to force it out and uh it doesn't take very much at all to get that does it seems like it always happens at the most embarrassing times however but that is a reflex to keep that from happening now the larynx itself is made of a lot of different cartilages ligaments it's at the top of the trachea and all this working together it forms that structure now it can be fractured it can be broke it's it's it's made out of cartilage there's no bones in it and uh you can see on the front here below the uh the very top it looks like a saddle almost you see the epiglottis at the top and then you got the uh the big cartilage ring structure around uh the first part of it got the the thyrohyoid ligament and then you got the laryngeal prominence which is the adam's apple itself now you can feel that how it's kind of triangular shaped toward the front uh it's uh more prominent in males than it is females and that's a it's pretty good landmark in order to be able to find the tracheal deviation uh tracheal alignment of that matter now sometimes that trachea can be fractured and some people might have a stridor type noise or something like that so it doesn't hurt to palpate it and feel it make sure everything's okay with it now below that you see the cryco thyroid membrane you know try to find it on your cells right now if you one of the best ways to find it is uh i'll put my index finger on the very tip prominence of my uh larynx their laryngeal prominence and i'll simply just roll my finger down and simply roll it down and it should go almost right into that cricothyroid membrane a lot of times you can feel that and right in that area just a little small indention not very big but you can feel where they got a change in structure there now that is where the landmark to where paramedics will use to do like a cracow cricothyrotomies or needle cracks that's where the insertion goes right there or the critical parametrics and flight crews that will do can do the uh the tracheostomy that's the membrane that they cut in order to go in there with that and of course below that you got the uh the the crack that cartilage just sits on the top of the very end of the trachea and as you can see how the trachea has cartilage wrapped around it in like bands that supports that structure that saw a softer structure underneath so that's it's a pretty complex structure there and it can become fractured it can become injured you know some people get punched in the throat or things like that there can be some serious injuries you can also have like from a fractured larynx you can also start to develop subcutaneous emphysema in those areas so that's one area if you speak neck trauma or laryngeal edema from the outside you want to check that you want to mark and you want to look and see hey is there any damage to it now and go back and look at it later because like subcutaneous emphysema might not show up right away now below the larynx that's when the lower airway starts that's where the gas exchanges take place the o2 and co2 swap places and if you were to look about where this starts talks about uh the fourth cervical vertebrae give or take a little bit and then as far as the xiphoid process uh where the rib cage splits that's about where the lower airway as far as the trachea uh extends to now the trachea is simply like ductwork like an hvac system that's simply the duct work to get the air into the lungs and i showed a picture earlier when it divides it's called the when it bifurcates that is called the corona this is a little uh more detailed picture to where it shows that the uh bronchi breaking off into the the uh the bronchioles smaller bronchial smaller bronchi and it just terminates down into the ends to where the alveoli is on the very end of that a lot of uh it does it looks like tree branches on the inside and not everyone develops exactly the same but it's a pretty good idea of how these extend now you see how it extends chest width it also extends front to back as well if we had to turn this person sideways it would show a picture of them it be the lungs taken up the whole inside of the chest cavity itself so there again you see how the trachea more it's not a much detailed picture here but as it uh divides down it keeps diverging to smaller and smaller airways now one thing you'll look at is on the right lung you see that there is three lobes in the right lung you can see where it is separated in three different places on the left lung it's only separated it only has two now they think maybe that's involved that way because the when the most a lot of the heart sits on the left side to allow uh room for that so we're on the right side you got three lobes on the left side you've got two lobes two lobes in the lumps and then again you see the diaphragm about how all that sits now this is a little bit of review the visceral pleura think of visceral visceral think of oregon you might have heard the term visceral organs before but when you heard the term as far as visceral pleura versus parietal pleura visceral is against the organ itself parietal is against the uh thoracic cavity or even in the like the abdominal you have the uh anything between visceral and plural visceral means around the organ and parietal means around the cavity itself so oxygen doesn't diffuse into the blood system until it gets down into the alveoli the ductwork of the bronch bronchi and bronchioles oxygen exchange doesn't take place there but when it gets down into the end of the uh alveoli where the capillaries are right up next to the blood cells i mean this cells that is where the exchange takes place now your lungs have uh in the alveoli just in the alveoli it has what they call a surfactant and that's a it's a fluid type material it is kind of firm it performs structure uh it's kind of if you will uh like a liquid form of uh like if you put a pump tent up or pop-up tent those little uh cables or bands that hold it open that's kind of what the surfactant does as far as the alveoli now it doesn't develop a lot of times until uh the like eighth or ninth month of uh gestation that's why when babies are born too early they haven't made this surfactant yet and their lungs are so uh have a large potential to collapse that's why a lot of these babies have to be on uh sometimes these babies are on bipap cpap uh they're intubated it's simply because they don't have surfactant and their lungs start to immediately collapse when they try to use them so surfactant comes on about the last part of the eighth ninth month of gestation and in healthy lungs it is there however it can be uh deteriorate with disease stagnation or with age and what happens here is uh for example someone that is in that's bedridden for a long time they may start to develop like pneumonias and every now and then whether you realize it or not and you've seen somebody like uh you'll be sitting next to somebody and all of a sudden you hear them just take a sigh or they think yawning may do this as well but what that does is someone take a deep breath they just kind of side out and a lot of times i don't even think about it and you may find yourself doing this without realizing it but that's your body's way of expanding the aussie alveoli and making sure the surfactant is getting where it needs to be it's kind of like throwing some more on the wall if you will but when someone is bedridden can't move or they develop what they call atelectasis those uh those alveoli may collapse and when that happens sometimes that's why a lot of people in nursing homes are bedridden get pneumonias for example or someone with a chest injury they said man they can't expand their ribs they can't take deep breaths uh they'll start to they may develop a pneumonia or something because of those alveoli collapse because surfactant is inadequate and uh it it's not able to get fluid out it just fills with fluid then it gets infected and it starts to cycle so that's that's what's happening there that's why sometimes in uh you've heard of people like in the hospital they make them blow on those spirometers they can blow real hard and that back pressure is kind of like a muffler and causes those alveoli to expand so that's uh could be what's going on with uh that's why there's a factor there now the between the lungs that cavity between the lungs and it is has its own membrane and cavity as well it's called the mediastinum it's got a lot of connective tissue around it it supports the heart it's almost like the heart and those great vessels are in their own sac the heart's got the pericardium but the pericardium is also within the pericar uh the mediastinal cavity surrounded by a lot of tough tissue and it pretty much that's what holds it in place there's no other special ligaments or anything like that to hold the heart attached other than that mediastinum that's uh holding everything it's kind of like a pendulum severe blunt force trauma or severe trauma can cause that to actually tear loose so as you can see here you got the heart uh arc the superior vena cava the aorta all that is in what we call the mediastinum and the mediastinum should be in the middle so sometimes when they have a someone has like a pneumothorax a tension pneumothorax on either the left or the right side they talk about man they got a mediastinal shift it's because it's pushing it over from where it's supposed to be or uh i've heard like we've brought in a trauma patient the other night that they've been hit by a car and they said hey he's got a very wide media style and that they got that by the x-ray they had to send him the ct and what else what would be doing that what would be making that mediastinum widen up like that you got to think about those great vessels and there may be torn and leaking so that's why it's starting to swell out they've got a large mediastinum or some mediastinal shift so that's kind of what they refer to when they got that if you look at that diaphragm right quick you see down at the bottom has got those it's almost like an upside down u uh that's some other muscles i just want to tell you about when we talked about accessory muscles uh muscles outside of the diaphragm but that's what borders it down to like the back and that area to kind of help it pull down as well so it's not just attached to the sides uh that's why sometimes people pull a back muscle where they say hey it hurts to breathe it hurts to breathe it's kind of just let you know look look at how that's involved and stuff now the phrenic nerve you can't see it on here don't have it marked but this phrenic nerve is what makes the diaphragm move it controls the diaphragm now you heard me you've also heard me say as well that when uh blood is not where it's supposed to be it hurts real bad it makes things get upset so if uh someone has abdominal bleeding the phrenic nerve is on the bottom side of the diaphragm someone has abdominal bleeding in there and they start having shoulder pain it's because the blood is irritating that phrenic nerve and that affects the shoulder and usually the left shoulder but it can make it hurt real bad as well so a lot of referred paint to that now the before the respiratory system work it requires help from the cardiovascular system because they one couldn't really exist without the other the respiratory system puts oxygen in the blood takes co2 out that's what the brain and body needs to survive the cardiovascular system after the lungs does its job it pumps the blood it pumps the new product if you will to the customers which are the sales so these working together you know it's got it's this works supposed to work every you figure every second of your life this is what's going on this is pretty impressive uh it's a constant supply it ensures that the uh it's it takes oxygen nutrients to the cells but it also plays uh as the garbage or sanitation service as well because not only does it drop off good product it picks up the bad product and you can't just pick up one and not take the other it's a trade-off so they don't like to be in the same place so they generally just swap places the uh we've talked about the heart before you know it breaks down into the aries arterios goes into the capillaries and the arteries carry uh you know there's one i don't like what this text says right here says arteries carry oxygenated blood which it does except in one case and that's the from the uh pulmonary artery going from the heart to the lungs that is deoxygenated so a better term that you know i'd rather use is oxygen or arteries carry blood away from the heart and because that that one exception makes that statement not true in the same way with veins all veins carry the oxygenated blood except one and that's the pulmonary vein coming from the lungs going back to the heart so it uh in that case it that that vein is oxygenated the cells survive when they have a constant supply of oxygen it has to uh they're they don't have a reserve a very long reserve at all they need it all the time it needs to constantly be replenished so especially like with a heart and a brain they can't handle it long at all muscle can handle it a little bit better so within you know someone some people can hold their breath just for a couple of minutes and they start feeling some palpitations but zero to one minute of uh deprived oxygen could start to have your heart to have some cardiac irritability there's a lot of times in that when someone's having an mi when that pump that cardiac artery is occluded the heart cells are not getting the oxygen and the blood that it needs they'll start getting irritable that's why they'll start throwing like pvcs or uh pacs they'll start having dysrhythmias well if uh and that's like with a heart attack or something but let's say the heart completes it stops completely no oxygen is getting there in uh four to six minutes brain damage is starting to happen you know it's very possible that it's starting to happen during that point and after six to ten minutes it's pretty much uh for sure that it's going to happen and more than 10 minutes it's irreversible to get that back so the uh and if they do we've probably seen uh if you've been in the transport business any period of time you've probably seen patients in nursing homes or rehab centers that have they have a hypoxic brain injury where they may uh have some mild deficits or they may be totally totally dependent on someone else for their care that's because they if they've been deprived without oxygen that amount of time it's not nothing it's not coming back the uh ventilation think of the ac system it's what's moving air in it is active in other words it takes energy someone just don't lay on the floor and all of a sudden they just an air goes in passively they have to participate in this and it can be i mean it don't have to be when i say they have to participate it can be involuntary but the body's making it happen and the uh diaphragm contracting intercostal muscles contracting causing the chest cavity to ex to expand that's when air moves in to those areas it is a pass i mean an active process it takes uh energy to do this now partial pressure you may have heard terms like when they do blood gases arterial blood gases i'll talk about pao2 or po paco2 which is a partial pressure of those gases and that's simply how much gas is dissolved in a fluid in case of abg's it's b it's how much it's dissolved into the blood now as you can see here we have on the an a diaphragm picture is uh and they've got like a simulation on the right side where they got two two balloons tied to an artificial trachea but when that diaphragm contracts it forms a negative pressure on the inside of the chest that in the air then is lower on the inside of the chest is on the outside and that's when air it goes in air goes in until it's actually equal on the outside and that is uh what is considered a respiration but er if uh if that capacity is torn up for example if they have a hole in the chest wall or one of the lungs collapsed then they're going to lose that vacuum and that's when they may need help uh getting air in also if they have an unstable chest wall it's not able to form a vacuum like it would be otherwise and that person would need support and down at the bottom you see when the diaphragm relaxes uh it's causing the higher pressure on the inside than is on the outside and air goes away because air likes going to where the low pressure is it wants to get away from the other high pressure so low air is going to go toward where the low pressure is to make up to kind of equal things out so exhalation there again smoking that picture is wrong by the way those areas should be going the other way but it doesn't require effort someone can uh i've seen people that actually faked like they were unconscious and what they would do was take a big deep breath of air and then hold it no that takes effort so but when someone relaxes there's no muscular effort required simply uh the diaphragm uh relaxes and the air simply goes out there's no energy that's required here at all now ventilation is regulated by factors inside the brain structures in the brain and also the chemoreceptors throughout the body so it's simply a a revolving cycle given feedback it's like okay hey i got enough oxygen right now you don't have to breathe as fast or hey i've uh my co2 is under control and it tells the brain let's not breathe as fast but let's say if the co2 in the blood starts picking up then those uh those receptors that are in the aorta and the carotid arteries they're going to say okay brain tell the lungs to breathe faster let's blow this stuff off and that usually responds to like co2 or ph changes in the blood and it can be according to the csf as well uh in some people the backup system is the when the oxygen level rises enough the respiratory center might suspend the respiration say hey i've got enough uh we can slow down now don't have to breathe as hard but that usually happens in someone where the primary system of the co2 measurement is deteriorated it's more like advanced copd or something like that but this is uh these have chemo receptors in the carotid arches and aortic arch and when it senses these deficiencies or excesses that's what regulates uh respiratory drive so you know what is oxygenation that's putting oxygen where it needs to be moving it into uh to the bloodstream once it gets into the blood that's when it combines to the hemoglobin what is hemoglobin is that it's the uh material on the blood cell that that carries oxygen to the tissues so it requires hemoglobin to be able to do that you know sometimes people can lose hemoglobin through blood loss and uh that's when they talk about doing h h their hematocrit hemoglobin or they measure it if hemoglobin's low they're not going to be able to carry oxygen as good as they should be other things that affect this is uh like high altitudes and pressure now you go to top of mount everest or if you've been in an airplane and uh or been to some place with high elevation where it feels different when you're up at the top uh is they still have you know you got 21 oxygen at sea level you got 21 percent oxygen at uh 40 000 feet however the atmospheric pressure up there is different and your body has to work harder to get that air into the lungs that's why they'll make up for it with for by giving extra oxygen or in some cases it has to be in a pressurized environment now i know i was at klingon's dome one time in the smokies it's only about six almost it's a little less than seven thousand feet and uh i was carrying my daughter up the hill and man it was no time i mean it hit me like oh my god i just run 10 miles but it's atmospheric pressure issues i've heard of people when they go to denver colorado from mississippi when they get out up there and they try to exert themselves too far they actually get short of breath because the altitude change and it's because of the pressure they got their body has to accommodate to it over a couple of days uh if you've flown it in a uh an airliner they are uh you know going from sea level to a mile high pretty quick can sometimes affect you and make you a little bit short of breath or you can feel the difference in some people now once if you get in an airline or you're flying somewhere they may be uh 40 000 feet high but the cabin is pressurized to about 8 000 feet which means you're still pressurized over a mile high and i've noticed that before getting up in an airplane moving around going to the restroom i just kind of felt like man i feel kind of out of breath a little bit but that's why because it's only pressurized to about 8 000 feet so you may feel some differences in that and it's not the lack of oxygen it's the lack of pressure of getting to where it needs to be that's why uh airplanes aircraft above a certain that fly a certain uh altitude has to be not only oxygenated but pressurized now metabolism is the work of the process of getting energy uh to the cells then utilizing it and giving it back up turns out to where it's a it breaks down from uh material to chemicals the body uses it takes what it needs uh processes it then it gets rid of the waste like i said it's a never-ending cycle and the process that that's used by is simply diffusion one moving from uh area of low concentration to an area of higher concentration or simply crossing those cell membranes to get to where they need to be now we touched on this term a little bit later but external respiration that's getting air into the respiratory system itself it's moving it in to uh the airways to where it can be used the hemoglobin is the molecules that are on the blood cells like we talked about that carries blood and if you're an environment that has uh carbon monoxide it's going to uh compete for those receptor sites on a hemoglobin and you know oxygen may be dissolved in the plasma or surrounding stuff but as far as getting on the hemoglobin uh carbon monoxide will be o2 out on that so that's why sometimes you may not get a real accurate reading on a pulse ox with a hemoglobin it may say 100 percent then you may have 100 oxygen in the blood but as far as getting the hemoglobin to the cells that co2 is blocking it from getting there so the the exchanging of oxygen and co2 between the alveoli and the blood and the pulmonary capillaries it's what's happening with uh external respiration now remember ventilation is the movement of air so adequate ventilation does not guarantee adequate uh respiration you may getting air in but it might not be crossing the uh alveoli barriers that we need to and that's we'll talk about a vq mismatch in a minute so just like i said there could be things causing that causing it uh not to be able to get through to it so we're going to uh talk about that in a little bit internal respiration is the exchange of oxygen between the circulatory system and the cells of the body so remember the external is getting air into the respiratory system internal is the exchange of oxygen at co2 between the circulatory system and the cells of the body now if you look at that picture there those little capillaries you see how you can just imagine how small a red blood cell is they have that concave structure and everything so those capillaries are only big enough for about one blood cell to go through you know they got to go through single file and you can see those cells how they're not much bigger either so that's how my new how delicate those walls are as you can see where the as the oxygen goes in to the blood cell it has to change place with the co2 it has to give it up but like i said that that part might not be happening if they're blocked by fluid or uh inflammation or something like that the air may be getting down there but that gas exchange may not be taking place if you've got structures or problems bothering it and we talk about metabolism of course it goes into the little organelles of the cells the mitochondria go japanese and all this stuff but the mitochondria the powerhouse of cells that convert glucose to energy but it has to have oxygen to do it so uh without oxygen glucose turns to acid we've seen how that happens you've got dka and stuff like that but these cells could take glucose and turn it into energy but it has to happen with oxygen in order to work right and that's what they call aerobic metabolism remember aerobic metabolism has to do with oxygen that's what requires oxygen now it talks about anaerobic metabolism that is without remember and the word and means without so anaerobic metabolism it uh oxygen is not there and it can't meet the demands of the cell and what happens a lot of times in this case is it starts to build up uh lactic acid they become acidotic these uh that acid in those little bitty my new delicate blood cells or blood vessels that you saw it starts to eat away at those walls when that happens blood starts to get out and swell uh muscles start to hurt and that's not get muscle soreness and things of that matter like if they if a muscle is overworked that's what you're feeling when that happens that acid getting out into those cells now the brain controls the actual movement of uh of the respiratory system you probably heard of the medulla oblongata the pons those little structures in the brain stem that's what they call the primitive areas of the brain because all types of mammals and animals usually have this but their cerebrum and cerebellum may not be as big big for all the other uh cognitive effects take place but this is pretty primal vegetative type functions so the the medullary response center control the rate depth and rhythm it's in the brainstem medulla area so you can imagine it controls how fast someone breathes how deep they breathe and uh the rhythm means is it regular is it irregular they breathe real fast slow down and as long as everything's getting there okay you'll have normal respirations however if you have a brain stem injury a head injury or if you have cerebral edema inside the skull to where that brain is starting to swell and it pushes down on the medulla in the brain stem that's when people start having irregular respiratory patterns they have uh they start breathing like a lot of time with head injuries they'll start breathing real fast and slow down or a lot of times with uh like someone's in dka or they have those big cool small top respirations it's because it's got all of this uh your your body your brain's picking up on all of this acid this low ph so what it's trying to do is blow it off so it tells your body to breathe hard and fast let's get this off uh the atmostic center ponds very small area and it takes over if the medullary response center starts to fail now this when that usually happens it can have uh what they call a new stick breathing it can be fast slow it could be irregular because it's not as capable of taking care of the system as the medullary response center has and once uh if those areas start to go out get damaged uh or become affected by an overbalance of negative chemicals the pneumotoxics do pneumotaxic center that actually kind of uh wants to shut breathing down so sometimes people are severely injured it's because maybe all of those sinners are injured in a pneumotaxic center it inhibits these other centers from trying to make the respiratory system breathe better so severe brain damage brain stem injury that's one reason they may start to stop breathing later on have to be intimated and take of course taking care take over now the chemo receptors are touching us a little bit earlier and what it does is when they detect a chemical imbalance they figure out which is it is it too much co2 not enough co2 and it starts to affect well uh remember if you got the way to correct too much co2 and when we talk about etco2 and capnography later if you've got too much co2 in a system the body breathes harder and faster it breathes deeper and faster the way you get rid of co2 is tidal volume and rate so these these chemo scepters again are in the carotid arch carotid arteries and the aortic arch that's where those chemoreceptors are and they uh they respond to the partial pressure of oxygen in the blood and when the co2 level starts to get up they simulate the respiratory centers to increase respiratory rate that's why uh you know you need some co2 but someone that might be hyperventilating may be blowing off too much because their rates the rate's high their volume is high and they're blowing off too much co2 and that's why they get them to breathe into a paper bag to reabsorb some of that and that's not something we really teach anymore but that's what's going on with that so these uh that's the chemo receptors remember they're in the carotid bodies aortic arch they measure co2 the uh central chemoreceptors outside the uh those arteries like that are located in the medulla area this little chemical stimula group just remember dorsal is on the back think of is it's in the is in the back part of it not on the actual back of you but in that respiratory group dorsal means next to the back think of the dorsal fin on a shark or dolphin or something like that so and ventral is along the front ventral veins you think of a fish you know the ventral fins and everything's along the front of that so remember dorsal is toward the back ventral is toward the front now any type of disruption in this system ventilation respiration any that's going to have an immediate effect on the body because remember the little chart i showed you earlier it doesn't take very long for your cardiac system to start feeling irregularities uh then your neurological system starts having irregularities real quick and this is simply when there's not enough oxygen getting there it's called hypoxia remember hypo means below that what is normal so uh they're not getting enough oxygen and the cells can start to be deprived they can start to act up they can start to have negative effects and they can start to die with that now people that have uh like copd they got this barrel chest a lot of time are so hyper inflated and it's because one reason is those little alveoli and copd patients has broken down there's really uh you might have let's say you got 10 alveoli at the end of one of those branches uh with copd those walls may break down instead of 10 you might have one big one but think of all that surface area that's been lost by those other 10 walls that went away but what happens here is a lot of time can't exhale all they need to they always have retained copd in there and that's why their body is like well hex if they can't get rid of this copd we're going to stop measuring it we'll just measure how much oxygen is in the blood that's the kind of way that uh works it's called a hypoxic drive they don't breathe on the amount of co2 anymore like someone without copd does because their body is used to it all the time it kind of wore out it's it's it's it's old news it's kind of like if you've got an odor in the room after a while you get used to it you don't pay attention to it but the hypoxic drive is like when these people like it's like well i don't have enough oxygen i'm going to breathe more but when they do get enough oxygen their bodies will say hey i don't need to breathe anymore i got enough so hypoxia the brain is one of the first things that tells on itself when it's without that anybody simply being restless uh acting up uh getting anxious i've seen people that just started developing a fast respiratory rate before so that uh restless irritability apprehension you know they're acting anxious or excited uh just kind of out of the norm of what they maybe should be in base in view of the circumstance think of that maybe early signs of hypoxia let's don't wait till it gets bad because once a lot of times once it gets bad it's hard to turn around and these patients if they're in early signs of hypoxia once they start getting in a deeper state of it they may be very very difficult to control to the point to where you can't do anything to them until they they pass out pretty much but of course the later the signs they get you know cyanosis that is without oxygen you got blood flow but you don't have any oxygen in it that's when they start turning blue uh mental status changes they go to get unresponsive they may not be able to answer questions appropriately that is signs that the hypoxia is pretty significant now many times you can have enough blood getting to those alveoli but there's no gas exchange taking place and we call this a a ventilation profusion or vq mismatch and what's going on here is the the profusion uh the blood is getting there but the ventilation but the air is getting there but the blood may not be getting it where it needs to be there again you know what could cause that like heart failure with a pulmonary edema or fluid building up in the lungs to form that barrier or they could have a chest injury and that part of the lung is inflamed and it's not getting the oxygen exchange that it needs although the blood may be getting through there so that's what we call a mismatch uh about when we were flying on them we had patients on ventilator sometimes we would see to where the pressure was normal uh we were moving the right amount of tidal volume in and out we had the vent settings set correctly and however it may be because there's some type of a respiratory issue going on where they might have ards or acute respiratory distress syndrome to worry we're getting it there it's just the lungs aren't able to use it they they won't use it they're not able to there's a barrier the door's locked they can't get through so that's kind of what that type of injury means so uh some factors that would really affect ventilation of course we talk about interruptions to the central peripheral nervous system hey are they uh are they injured do we have a an injured spinal cord that's causing it not to receive or transmit messages it's causing some type of paralysis uh hypercapnia is uh let's say you got all kinds of you got too much co2 built up into the bloodstream and that can affect uh ventilation because your you know before and you can't really tell unless you got that type of equipment to measure it with but many times someone may you know we want them to breathe between 12 and 20 minutes per minute but if they got a hypercapnia too much co2 in there and like i said without a blood gas you're not going to be able to know that i'm just telling this for just some information then that person would probably need to breathe a lot be put on a vent or bag faster than what their normal rate would be to blow that off uh head trauma spinal cord injury remember head trauma the brain swelling that brain stem swelling that uh midori respiratory system agnostic system is going to be altered and they may have erratic or irregular breathing difficulties to where they're not able to uh properly get the title volume volume in place muscular dystrophy uh it's an autoimmune disease a lot of effects it starts off usually in childhood develops more and more later on to where their diaphragm is things don't work it's simply in their chest muscles and their thoracic muscles do not work enough in order to be able to properly ventilate move air also with like uh las or uh you know they call it lou gehrig's disease as well it's also a neurological disease that eventually gets to the point to where the villatory muscles simply do not work anymore allergic reactions you know when histamines are released into the uh the bloodstream and respiratory system one way that that works is that causes bronchial constriction it causes restrictive airflow you'll hear wheezing but those are that restricts uh ventilation that's that's factors that can happen like uh you know not always immediate but it can develop uh as time goes on during the call uh of course uh we talk about extrinsic factors that's trauma or things that occurred outside the body where they shot where they hit they have blunt force trauma something that's causing trauma to the uh respiratory system that causes it not be able to work right that's a primary injury or are they choked is something blocking it respiratory splinting uh someone that might have broke ribs or chest trials where they're not able to take a deep breath that they're not able to take a deep enough breath or minute volume goes down instead of taking real deep breaths they may start having real uh real fast breath and when they start breathing real fast they uh they may start blowing off too much co2 though and then they'll start getting in this hyperventilation syndrome so that's why remember anybody that has uh the rest of us hoary rate that's too low or too slow too low too slow too fast uh they're not getting that minute volume they need let's let's help them out let's put them on oxygen they may even need to be have a bag valve mask to have assisted ventilation so think about what's going on with that they've got to have that minute volume they've got to move so much in and so much out per minute and they do it by how fast and then how deep they breathe if one of them is altered help take care of the other one to make up for it hyper and hypo there's those two terms again you know hypo is too slow hyper is too fast and uh it a lot of time that can have an effect because of what the ph level is in the blood if it's uh if it's too high they're going to want to breathe uh fast to try to blow it off and a lot of times my slowing respiratory rate down can help it catch up so there again back in reference to the like carbon monoxide will cause you not to be able to get an accurate uh pulse ox reading so don't be don't depend on that alone they need uh of course give them more high flow oxygen but our skin may be red cherry red uh oxygen may read 100 percent and but there again their brain is being affected by this they can be unconscious and still has a 100 percent pulse ox but remember look at your history the history of present illness the events sounding surrounding the circumstance and seeing how that uh what else might be going on with it now that stuff comes from the outside some internal factors uh you know something that reduces the surface area like copd uh pneumonia this is blocking these are barriers that block the gas exchange between the alveoli and the circulatory system so that's thing it's a barrier and you're not going to get uh accurate uh blood or pulse ox readings with that and of course the alveoli might not be functioning even remember due to adolescences or ards which is uh acute respiratory distress syndrome and we're starting to transport a lot more sick patients uh and this may have become more uh obvious to a lot of people we we're seeing you know you know we've got coven uh everywhere and uh some of these patients are in the nursing homes and some people having these this stuff on top of other respiratory diseases some that would have been sick anyway and uh so we're gonna start transporting more of these people they lay there they get septic they get pneumonia and i mean how many people do we transport they say they've got pneumonia they've got pneumonia they're in a bed you know and they're not real active and that's that's simply what's happening these alveoli stop functioning it simply builds up and it creates a mess intrapulmonary shunting is when blood enters uh the lungs from the right side of the heart and bypasses alveoli and stuff and you see this like in babies right about the time they're born that blood is shunning inside the heart with newborns because uh they haven't needed their lungs because they've been inside their mom so it takes a little bit for that to swap over some of them have delayed reactions with it uh it sometimes it takes a couple hours around delivery before this happens but it's called intrapulmonary shunting and that's simply the blood doesn't go to the lungs it just goes from one side of the heart to the other to the body because it's had to bypass that and the ventricle the the that ovum inside the heart has not closed up yet that's what that means uh because respiration is too fast too slow it's not going to provide the amount of oxygen or any vitamins someone needs pain and strong emotion that uh gonna make someone breathe fast or maybe not breathe deep enough like if it's a chest wall pain back pain sometimes abdominal pain can cause someone not to take the breaths that they need to take strong emotion someone is angry uh excited breathing real fast can't control that that uh that could be a factor as well uh hypoxia lack of oxygen and other conditions it affects the cells you know what could that be it could be uh someone in ketoacidosis hypoglycemia infection sepsis all of these are conditions that affects the cells that can cause problems with respiratory now the the lungs can work great but the circulatory system has to look good as well so you know problem with the circulatory system blood and oxygen is not going to get to where it needs to get that could be through to uh you know why is that is it simply leaking out and not getting there is the pump not working uh is uh blood flow being obstructed like for example someone may have attention pneumothorax blood can't get pumped out where it needs to go do they have a pericardial tamponade blood's not able to be pumped to where it needs to go the respiratory system is doing its job now the circulatory system can't do its job things that may happen with this you know we talked about the pneumothorax hemothorax and blood bleeding out in the chest cavity not getting into the system uh pulmonary embolism uh pulmonary embolism you know a lot of times it starts from uh blood clot in the leg ddt deep vascular thrombosis and sometimes it can happen in a lot of times it happens in like i've seen it happen in truck drivers they're they sit still all day they're driving and i've worked a couple of codes with truck drivers a lot of time they were purple from the nipple line up and that is signs of the pulmonary embolism so you think about hey what could be going on with this person uh females especially the ones that smoke and are on birth control are prone to pulmonary embolism uh people that are in bed after surgery certain types of surgery uh a lot of times they'll put those uh those uh pe stockings on their legs they inflate deflate inflate deflate the whole time they're in the bed that's to prevent some types of pulmonary embolism but these pulmonary embolisms a lot of times they can be small just cause a lot of discomfort however sometimes they can be big and block off a whole area of the lung and the and they can exchange and they can be fatal that way but it does happen so uh those are some factors that can affect that heart failure we talked about the tamponade but like heart failure itself let's say uh congestive heart failure pulmonary edema when the heart is uh not able to pump blood through the system that's required you know the left side of the heart may be given out and blood starts backing up into the lungs because it can't pump it out quick enough and that causes uh it's not just a cardiac problem but then it's a pulmonary problem because that fluid is building up in the lungs it can't do the gastric exchange that it needs uh those vessels in the those small blood vessels can't contain the fluid that it needs to and it starts leaking out into the lungs it starts coming out of those uh vessel walls that vasodilation and starts getting in the lungs that's why sometimes with pulmonary edema you'll see that pink frothy or that white frog is sputum it's because the blood says that alveoli and those capillaries cannot handle anymore and the blood won't take it so they're going to put it back in the lungs uh vaso of course hemorrhagic shock if the blood goes away it can't be used you can't carry blood it can't carry oxygen finance there and the vasodilation towards shock is a lot of time neurogenic uh it's where the vessels dilate and they're not able to maintain adequate blood pressure to get the blood and oxygen where it needs to go so when you have a problem with the hypoventilation hyperventilation when this is affected when it's just think about what's happening because it's supposed to breathe 12 to 20 times a minute for an adult is what usually to maintain homeostasis now if i have a respiratory acidosis ph is low etco2 is going to be high uh if you remember the word rome and like i said this is just extra information it's just no no knowledge is wasted but like if you have a if you're able to look at a ph scale or abg bacterial blood gas uh one reason they look at how they figure out respiratory acidosis from a metabolic acidosis you think a respiratory opposite metabolic equal rom uh if i have a respiratory acidosis i'm gonna have a low ph but i'm gonna have a high etco2 you see it's opposite that's corrected by deep and fast ventilations now respiratory alkalosis it means i'm going to have a high ph and my atco2 is going to be uh uh high as well metabolic uh i'm gonna have a low ph but a high bicarb and same with metabolic it's gonna be just opposite and that's just fyi i don't have to remember that or anything but uh that's kind of way that those work so uh when you have acidosis your body's gonna try to breathe hard to blow it off uh when you have alkalosis they may be breathing fast already and they're blowing off more co2 than they need to they're probably breathing fast already if they're in alkalosis and they have to correct that in order to bring it down so treatment for hyperventilation syndrome focus on restoring normal respiratory rate to increase increased co2 level i know back in the old day when i went through it we put a paper bag on somebody's face let them breathe in and out uh follow local protocol on that on whatever it says i'm not giving you medical advice telling you what to do because uh they say follow local protocol because there was people putting people on paper bags without getting a full history of what's going on they actually were having heart attacks and things like that they misdiagnosed in the field and caused all kind of problems for the rest of us so follow local guidelines on what that scenario is uh breathing should people should be able to talk have a conversation while breathing they should be able to say full sentences remember your normal respiratory rate 12 to 20 breaths per minute uh depth they shouldn't look uncomfortable when they're taking breaths uh every now and then an occasional sigh or yawn may happen uh and sometimes when that happens you know a lot of time that happens when people are like at rest or maybe bored because they're sitting there they're not moving their lungs a whole lot they might be reading the book watching tv and they're not using their respiratory status whole lot and what happens is that co2 may build up a little bit and your body just takes a big deep breath or a big sigh and lets it out and that's kind of like might be what's going on with that and you know how they say yawns are catching uh you know i've always heard that and i've read stuff back and forth on it and they say maybe one reason that is is that for most part when people are yawning and stuff like that one starts yawning you're probably listening to a boring powerpoint lecture or in a classroom or something like that or you're in a similar scenario a similar location to where everybody may be needing having the same requirements so that's just one that's out there i don't know if you find something different i'd like to hear about it but uh remember normal respirations adequate tidal volume regular pattern and you shouldn't be able to really hear them breathe uh you know very loud and stuff so that's what's normal is remember normal and that way you can tell when something's wrong because respiratory problems to me is one of the most difficult cause to work and therefore i don't always know what's wrong i have to look at what's not right well they're breathing 30 times a minute okay there's something there's that's not right uh they're not breathing very shall uh they're not breathing very deep they're breathing shallow i know that's not right do i know what's wrong yet no but i know what ain't right man they're irregular they're breathing this real deep top breathing they start slowing down i know that's not right so anyway that's the kind of way i have to look at respiratory because as we've talked about just a few things you know they got asthma chf copd they got cystic fibrosis they got all kind of stuff out there but and i don't know i can't tell a lot of times what it is but i can tell you what's not right so we need to really think of learn the normal and then try to put normal back that's the way we have to treat respiratory problems sometimes it's like well i'm not sure what to do with this i'm not sure which way it's going well what's not right about it but i'm breathing too slow okay well make them breathe uh the amount of the right amount well they're not breathing deep enough okay well make them breathe deep enough so that's the kind of way i have to look at respiratory i've been doing this a long time and responds challenging so just think about if you don't know what's wrong look at what ain't right and see what you can do about making it right so in a respiratory distress it simply means hey they're having trouble it means the respiratory system still working but they got trouble they're having to work to make it work and it could be you know airway obstructions inadequate ventilation impairment of the muscles or the nervous system but this has to be jumped on right away don't wait to see how bad it gets because i've been there i've been that medic that's like well let me see what happens next and you almost didn't get somebody turned around and we shouldn't use mistakes to really mistakes is something you learn by and that was a young medic when some of those things happened and it's like no nobody died or anything like that however what i'm saying is a lot of times other people's mistakes is uh stuff to be learned by and passed on so we want to uh think about when you see somebody that's having respiratory issues respiratory distress don't waste to see how bad it gets hey i'm having trouble breathing okay jump on it uh you know they're having signs of hypoxia fix it oxygen you know as far as you go that's why we treat these life-threatening emergencies as we find them we don't go to the next step so that's why i don't wait to see how bad it gets because a lot of respiratory patients especially those with like flash pulmonary edema uh sudden you know cardiac failure that comes on all of a sudden or severe pulmonary edema those patients if it's not jumped on quick they will die on you i've had them happen real quick before so uh i had one the other night uh the tripod position modeled skin his skin was so wet that the ekg pads just slid off of him and uh you know you know i've seen that before and it didn't take long before they were before having the two of them and intimate them we got in the hospital banded up doing okay but because of experience uh he got him on cpap right away he was new to it it scared him i had to coach him and but he uh ended up making a good recovery i was told so there again don't wait for stuff bad to happen jump on this and head it off uh what we look at here is like determining a patient's respiratory distress when we talk about how are they positioned are they laying back are they laying flat uh you know they may be laying flat i mean who would lay flat if you can't breathe maybe someone that can't help it so you know if they're laying flat and they're having trouble breathing hey let's set them up see if that changes anything and remember that term as trouble breathing when laying flat so uh but remember that term so how are they positioned are they sitting up on the other side of the bed they had a tripod position in a sniffing position uh are they laying on their side laying on one side or the other saying they can't breathe how how hard are they working at it uh are they focused on their breathing could it be the fact that uh if they're distracted from it the phone rings they stop talking they answer the phone nut drone you're like well okay that might not be a whole lot going on but there again ask yourselves these questions are is there adequate rise and fall on the chest and these are things you can do before even touching a patient uh i always note even in my transfers symmetrical expansion of the chest get in a habit of looking at everybody well they got symmetrical extension of the chest it's uh adequate rise and fall uh are they gasping no they're they're struggling but they're not gasping gasping means you know it's just kind of they take a deep breath and they take another one and they take another one it's like each uh it's like each breath is not satisfying enough so they got to get another one they're so and they're short a lot of time they uh they're real quick to go in and they don't come out as fast look at their skin color is it moist is it clammy is it diaphoretic pale mottled uh cyanosis look at that's when you're walking in and this is all done without it without any laying on the head of the hands at this point uh the firing of the nostrils and the nerves you see that more so in kids but is any of this this is what you recognize this problem from across the room uh perched lips are they really concentrating on getting this area out you see this a lot of times in like copd patients they can get the air in but it's getting it out that's the problem so they kind of actually you know take a deep breath and then they actually have to blow that air out they have to think about blowing this out yeah and uh when people are breathing in do they have the retractions the sub you know the clavicular tract contractions around retractions around the collarbones shoulders uh younger kids maybe the xiphoid process even adults sometimes typhoid process or that area uh intercostal muscles are they uh retracting are they having to use extra muscles they use their shoulders they take a deep breath or like even some people like well even our uh uh you know archer back backwards to take these breaths and there again is it symmetrical is there one side of the other moving different and that can happen not always due to trauma but it may be a big pneumonia in there that's not allowing them to move that side of the chest so note symmetrical chest rise and fall on everybody uh and now as far as and we're talking about the quick breath and prolonged expert exhalation that's when you usually see the pursed lips they'll take a deep breath real quick and then they'll take their time to blow it out this is kind of like they're blowing out like they're trying to whistle uh this guy here looks real sick he's got uh as you can see the abdominal muscles are working with him he's got intercostal uh retractions intramuscular intercostal muscular contractions he's having the retractions around his sternocleidomastoid muscles above the collarbones and uh this guy if he's having that much trouble breathing in that type of a position you figure he's probably pending respiratory failure uh because for the most part someone gets to at that point they don't want to lay back they'll fight you they'll get very combative at this point try to get him to lay back uh remember the minute volume we talked about people need a certain minute volume in order to survive and that's usually maintained most adults that are not into stress between 20 12 to 20 breaths per minute so is it slower than that or is it higher than that that's the first thing you look at hey you know are they they look like they're having trouble what's the respiratory rate when we talk about too fast or too slow if you're in an immediate assessment you know you fear okay it's less than 12 that's too slow spreader 20 is too fast and it really don't take me long some time to get a real quick assessment of what the breathing rate is so remember they got to have a certain amount of minute volume if they're not making those numbers there then they need like supplemental o2 or something to help them out or they might need some other type of intervention now what is uh how are their breathing rate are they breathing four or five times a minute real fast and slowing down uh if they're conscious of doing that they may be something going on that they're not able to control a lot of times unconscious patients will have an irregular breathing rate like shame stokes bias or cooch balls then you think about their like their lung sounds can you hear it from across the room uh noisy i mean we talked about back and forth listening to the breast sounds listen to the back axillary areas as well as the front and uh is uh one side uh more diminished than the other or do you have someone who has an increased work of breathing and you don't hear any lung sounds much at all that's simply because they may not be moving any air at all and uh you know why is that you know they may have be having a bad asthma attack they may have bronchoconstriction but if they're moving in the air you're not going to hear it that's why sometimes the bronchial dilators and things will open that up where you open it up enough to where you can get air movement and then you can hear those breath sounds so just because you have no breast sounds if you didn't hear anything then look at hey what is their chest rising fall like are they moving air in if they're trying to or they're not you got to think man there's something causing this problem and they need interventions depending on what level of training you're at maybe all you can do is sit with bronchial dilators and high flow oxygen and and go get to where you need to get in some local areas you may be able to do a little more for these patients but these type patients want to get to this point they pretty much need some pretty uh some pretty advanced drugs in order to get this turned around a lot of times uh we talk about air going in it's got to come out you're not really able to measure how much air is coming out but sometimes uh you'll see this in uh these uh copd patients you'll see them take a breath it looks like they take a normal breath when they go to breathe out it's just like they're having problems they can't get it all out and that's what happens it causes their chest to be hyper expanded and uh that one at the bottom just reiterates what i was talking about as far as having unequal chest expansion unequal or inadequate and that has to do with the tidal volume remember they got to have a certain minute volume in order to be able to survive uh the uh staccato peach speech patterns that is simply someone that's like if you remember staccato uh if you never can read music or anything staccato but it might be they're trying to talk and you ask them sir uh how long have you been feeling like this and there'll be something like you know this is accented uh forcible uh speech patterns which is like you hear every other word or they you hear one come through every now and then but it's really accented uh if you can hear their breathing you shouldn't be able to hear breathing it's normal uh feel for air movement of course that if they're uh if they're unconscious you're not able to adequately look at this with them telling you or they're participating make sure you can feel the air move and pulses paradoxes now take pulses on each side of the body when you have someone with a cardiac a respiratory event and the reason that is is what we are looking for is uh remember that the hyperventilated chest or too much air in the thorax causes reduced blood cardiac output and pulses paradoxes a lot of times you see it in younger kids many times ones that are in puberty or pubescent and what's going on with them is that they uh you can take their pulse rate and you tell them to take a deep breath and due to the intrathoracic pressure that's already in their lungs they take that deep breath and it actually reduces cardiac output many times it will slow the heart rate down uh during deep inspiration and it will go back to its normal rate when they exhale so there again note that when you've taken somebody's pulse tell them take a deep breath in and out and see if that changes and that simply means that the intrathoracic pressure inside the chest is great it don't necessarily mean that something bad's wrong because you do see this a lot of time in in children the uh the brain centers in the medulla the uh atmosphere the brain when they you know their control respiratory rate depth volume they uh when they are impaired it goes along with severe head injuries or cerebral edema when those areas are being impacted or pressure put against them you may have uh the airways the ventilation rate stuff almost gets reflexive remember we talked about the uh you know toxic areas of the breathing system to where it actually tries to impede the influence on respiratory dry so we had like a chain stokes type breathing and what happens is is that that center of the brain actually tries to impede breathing to a point when it gets that damaged to where it'll slow breathing down and then the body has a reflexes wait wait i can't survive without this i got to breathe deep so it'll start breathing and override it it'll get real the restorations will start out very shallow get real deep they're real fast and then they'll taper off again and then they simply override that uh inhibiting reflex of the brain again and start over so this is usually seen during certain types of head injuries where they have intracerebral pressure now agonal respirations are agonal gas or simply that people try to take a deep breath or they or you see a lot of time before someone codes or when they're about to code or even uh you see that reflect sometimes when you're actually starting to code somebody and it's a very very fresh is their mouth will open and close it's almost like they try to take a gas but nothing happens uh and it can happen even after the heart stop because you still got some a little bit of residual capacity going on so agonal respirations mean ineffective breaths they try to it's got going through the motion but nothing ever really happens it's a grave sign these people are fixing to code on you if they have not already so respiratory patients remember don't wait to see how bad something gets jump on it early and hang on because once they start to get to that point of spiraling downward then they're gonna be hard to turn around if they do so again it focuses a lot on but again it focuses a lot on appearance from across the room and what you see when you walk in skin color level of consciousness how that's how good is it working uh hopefully someone's there to know what kind of a baseline they are hey are they always confused and acting inappropriately uh responsible words they might say yes they are like or they'll say hey no this is brand new they normally are not like this at all so know what a baseline is so try to find out what a baseline is if you don't know and just treat for the worst case scenario the after you do the looking part the viewing part the visual like okay i've got an impression that's when you want to start getting into your equipment you know go ahead uh pulse oximetry but don't rely on that totally to make sure of what you're going to do or what you're not going to do remember that can always have issues so don't let that be the only thing that helps guide you in uh treating a patient so the you know they really only uh pick up the pulsating blood vessels that are like in the fingers if they're on the ears something of that matter now if uh someone's in cardiogenic shock and the blood is not getting there or if the cardiac arrest you're not going to have a good greeting at all and uh anybody's respiratory problems should be monitored like this anybody that's on oxygen because you want to see what your changes are it also can help you identify if something starts to go wrong and uh it can uh for example it's a good idea if someone has like a broke leg or a broke extremity you're able to evaluate what kind of blood flow and stuff you got to it uh that you might be going to that extremity now uh we talked about earlier in the hospital when some people may be uh not moving around as much as what they're used to they're that that atelectasis may set in they don't get to take these deep breaths and things like they should but what they start using is what they call a peak expiratory flow measurement and that simply it helps if a couple things it sees how it measures how good the patient's responding to treatment it also helps keep their it's kind of like forms of back pressure on the lungs to keep the alveoli uh inflated and not collapsing and uh if someone's being measured or chronic breathing problems or if they're in hospital being treated for that then it also monitors for if there's any worse than conditions sometimes it starts to go down like people that have been in there for a while hey yesterday you were blowing this amount today you're blowing this amount we need to do a chest x-ray make sure you don't have a pneumonia or something forming like that arterial blood gases is uh you know some community or critical care services may do this in the field uh at the advanced emp level you're not but we need to kind of understand how it does work and what this is is they draw blood from an artery usually the radial artery and it's got uh that's what the heart is delivering to the body that's why they measure it like that it measures ph uh it measures by carb it measures amount of of the hemoglobin uh the hematocrit it measures those numbers in there to kind of tell how it's all working the end tidal co2 uh remember the other night we talked about uh that is it goes on the end of the airway and uh it monitors the amount of carbon dioxide that can cell excel in the air now if you're perfusing and you've got this in the right place in the airways and they're actually saying now you should put it on someone without an advanced airway you can they got the nasal cannula type i'll show you in just a couple seconds and they got the type it fits on to the end of an advanced airway and it measures perfusion because it shows you the amount of co2 that's been delivered to the uh to the device a color metric it's uh those don't work good when they get wet but when you put it in it should change from purple to yellow purple to yellow and it measures the amount of oxygen or carbon dioxide coming out with each breath and it should be between the numbers 35 and 45. so these things do a couple of uh the color metric are the one that changes the color the one on the bottom is the ketonometer and it actually measures the amount of co2 coming out and also another thing is it helps measure the actual respiratory rate so this kind of gives you two things that's going on let's say uh that co2 starts coming up to about 50 then whoever's controlling that airway would want to start bagging the patient faster they want to increase the respiratory rate to blow off that excess co2 once it slows back down between around 45 below that then they can go back down for the respiratory rate again that's one how uh capnometry can uh be used with the advanced airway and in fact anybody that's been at debate or after intubated with advanced airway this should be on the patient all the way to the hospital continuous monitoring to make sure that the airway is in place and the o2 is being delivered the co2 has been been removed now you see that 38 on there now what this shows here is this is the vice the uh the waveform capnography that's on many of the monitors now this uh you can't see all the way up to the top the way they got this set is probably set to zero this is set to zero to 40. remember we went 35 to 45 and that other one said it was at 38. so if you look at where that dot is on the peak of this waveform it's around 38 so that's at the end of exhalation when when it exhales it goes up it raises it squares off and as soon as the body starts to inhale that's when it drops back to the bottom and this is a good uh indicator of how good they're perfusing now if you were doing cpr on this person and they were intubated uh that number would only be probably about 10 15 and that's all you're gonna get with at least you've got one if you've got a reading then you know you're in the right place however with cardiac arrest it may be only like 10 to 15. let's say you're doing uh you're doing cpr you got about 10 to 15 and all shutting it shoots up to 35 to 40. you know the only way that does that is with perfusing that's when usually you check and see if they've got a pulse to come back because usually when it goes that high it's only for because their heart is coming back because you're not going to do cpr good enough to put it that high uh these are some devices that measure etco2 how we measure it now the uh the nasal cannula one uh i love those you can put those on just about everybody uh cpap or anybody like that they should have that on as well or and it also delivers oxygen through it as well the medium are set up to deliver oxygen so a lot of copd patients patients you wanted to monitor for uh etco2 problems arrest sort of stress problems that is a good device to use a lot of places don't use them because they're so expensive each one of those are probably about 22 25 or something like that for the top one the bottom one probably eight to ten dollars the one on the bottom is the one that attaches to et tubes or on the end of bdm's bbm masks so that's the difference in those two but a lot of places are like i said the top one they simply just don't get them because they're so expensive and a lot of people mis appropriately use them like they may want to instead of using a regular oxygen candle someone may just be mildly short of breath they'll use those on everybody and you can see how it gets expensive that's why you don't see a whole lot of them anymore it's a great tool and not utilized enough for the most part now back to the basics opening the airway uh that's what these next few slides cover but we see how we talked about earlier how there's no way that you can swallow your tongue despite what a lot of old people say because it's attached to the bottom of the mouth however it will fall back against the back of the throat and it will block that airway you can see where the epiglottis uh is where it is supposed to uh go downward to cover the trachea however in this point the tongue is against the back of it and there's no air moving at all simply doing a head chin lift will bring that tongue away from the back of the throat now the tongue is one of the biggest objects that cause airway obstruction so remember head tilt chin lift bring the head back jaw thrust if you suspect any type of trauma to reduce uh any type of spinal injury a tongue jaw lift now this can work as well you simply reach in pull it up i don't like doing this because i don't like sticking my hand in people's mouth unless i really have to but there's a couple of ways this could be uh used utilized in fact for for a simple reason you may want to suction to be able to get it in there deep enough to see what you're doing this can be used also to put like uh i've used it before when i wanted to put a combi tube in or king airway that has assisted in that as a matter of fact so that is also when you maybe want to look into the back of the mouth uh recovery position hey if there's no trauma involved uh and they uh if you don't have the equipment if you're probably waiting on some trans transport then uh if they're breathing on their own turn on the recovery position so they can maintain this uh sideways to where it allows for drainage and it allows that the tongue won't fall back against the back of the throat and if they're breathing on their own it will help them maintain their own airway now suctioning many times i see crews come in the house without suction now i'd much rather bring it in and then not need it have to take it back out but uh if you need suction you need it in a hurry and you need it fast because uh and i've seen them to where people would just go ahead and bag someone anyway and they blow all that back down into the lungs and that acid in the stomach contents eats as long as up cause pneumonia so suctioning is a priority something's in the way of the airway you get it out you hear something in there you suction it out the uh if you hear anything gurgling or bubbling at all it needs to be suctioned out so that needs to be readily available and you don't wait on it too and uh because a lot of time at the time somebody goes back to the truck you know you've lost uh that precious time not to mention probably caused some type of damage or aspiration now uh some places don't want you to open up the tip uh like the yonker tip or uh trochanter or whichever kind you use but uh if they don't then i would have it ready to be hooked up pretty quick because i know when i need it i need it real quick and i nothing i can't stand this when i have to with a suction canister or whatever is not ready so you got wide board thick walled non-kinking type tubing you got just like rigid casters that you could have to reach into like the back of the throat there's also the soft top catheter suction catheters that goes down like et tubes or uh sometimes nasally and uh they a lot of times somebody has to have saline some type of saline or sterile water because the secretions that they're trying to suction out gets very thick sometimes and has to be diluted so here's a couple different ones the yonker which is that's a brand name that's not the actual uh tip of it but it's called the tonsil tip catheter which is one at the top little bitty suction hole it doesn't work good for a lot of thick stuff then they got you got the hole that you place your finger over to be able to suction it out and of course the top or the the soft or the french tip is also good for like suctioning out et tubes or getting stuff from the way the back of the airway or even smaller individuals for that now the all i'm say here is know how to operate your suction unit the uh there are a lot of different portables out there if it's on your truck you should be more familiar with how to use it now down to the bottom here according to this text it talks about suctioning time limits to 15 seconds for adults 10 seconds for children 5 seconds for infants uh that's what the book's saying however i'm going to ask you let's say you suction for 15 seconds and this patient's mouth is still full of vomit what are you going to do then you uh it's got to come out so there again well i suctioned for 15 seconds and i put the bag on and started bagging them and blew that vomit into lungs that there again that doesn't make any sense you can do that uh you know you so well i've suctioned airways out before sometimes i've had to put the suction device in move it over to one side and it may pass it because there was so much fluid and blood coming up that suction on that one time it was just one gonna do it so for the most part if it's still coming up you gotta suction it out you can't blow it back down into the airway so uh but i said as far as the text goes on this if it asks that in a quiz just remember those numbers however here again even like for for an infant well i suctioned for five seconds and the mouth was still full of fluid you'd probably get more trouble causing infant more harm if you blew hot was left in there down in the lungs uh this is the uh the soft ones the uh flexible ones it's usually good for suction out an et tube now for the most part uh the paramedics do the e.t tubes and they should be doing the suction however this is the way that this works now they may uh may ask for assistance sometime but follow your local guidelines on that as far as how whether or not you can suction et tubes but many times it does have to be done especially if that patient was suffering from uh congestive heart failure pulmonary edema that fluid is going to keep accumulating in the lungs and it needs to be suctioned out i've seen it to the point of where it just bubbled from the top it looked like a washing machine from running over but that has to be suctioned out oral pharyngeal airways remember it prevents the tongue from obstructing the glottis uh remember the i showed you the pictures of the airways earlier about as far as getting the the right size in if it's too small it's not going to go back far enough to pull the tongue away from the back of the throat if it's too large you can actually block the laryngeal opening now remember that these are you know should be used with people with no gag reflex unresponsive uh any patient that's being bagged with a bag valve mask should have an oral airway in place as well for the simple reason uh you want to be able to get that air in now uh gag reflexes you can make things worse with this they may have uh they may vomit may not let you put it in but uh hopefully everybody is familiar with putting those in now my favorite if i'm doing a bbm with somebody and uh if they're able to be ventilated through the nose or the bvm i do like the nasal airways the best that's just that's a personal uh choice uh but these a lot of times can be tolerated better if someone has an altered airway alternate mental status or someone still has a gag reflex intact they uh you uh they may tolerate these better now uh a trauma head trauma is not an absolute contraindication for these even though in the past it used to be absolute it just remember that is a possibility in certain abyss if it was to go to a baseline skull fracture but the studies they can't find any reliable studies where that's actually happened i know they talk about it i know in the old days i'd heard a bunch of stuff about it but uh the latest ph till standards say there's actually not any documented evidence where that's actually went up into somebody's head before so always also due to the vasculature mucosa of the brain i'm sorry the nasal cavities these may cause some bleeding when you put them in so a little bleeding is uh a possible uh side effect to these but a lot of being's one thing but a little bleeding it's probably not a real big deal with that but just remember there are some vessels inside the nose and stuff that uh if someone has high blood pressure or bleeding tendencies takes coumadin then again i may would not want to uh i might think twice about putting that in because you rupture blood vessels on the head with that or the nose and they can bleed a lot from it cause aspiration so uh the common sense-wise or making informed decisions now you know like i said there was no evidence of that going up into the skull however if you do see csf or blood coming out of the nose you know i probably think twice about it it might not only just go up in the back of the head but it could penetrate into a sinus or something like that as well so uh just remember they got direct nasal trauma and things like that it probably would not be a good idea to do it but just general head trauma itself i'll just do it with a high regard of caution or see what your protocol is on that now uh the as far as oxygen administration tonight the we're going to talk about uh some of the well the o2 cylinders i always use the right i ain't going to tell you what each size is and things like that but also make sure you get the right color and what it is the um there was a i got an ambulance once in new orleans who got their oxygen from a local hospital and uh so we go to do our morning check off the night crew said they had changed it out so we're doing a check off that morning and when we go to check the oxygen it's a big old black tank it was like uh pure nitrous oxide somebody to put on there instead of oxygen and they did it in a dark you know we had there is such thing as flashlights and things like that but just think about what would happen they get pure nitrous so there again make sure it's the right color green is oxygen uh and everybody should know how to work those at this point with liquid oxygen that's uh these liquids usually got to be cooled stored in specific tanks you're not going to have those on the trucks they uh these way they're transported now a lot of these cylinders these regulators are the way they're threaded the way that they are pinned it's not going to allow you to put like a uh an oxygen regulator connected to a co2 regulator or something of that matter now that's what most of them are supposed to be however now this was a long time ago that that nitrous tank was put on there so uh and it was connected up that like i said it was a long time ago uh i'm going to board death about these regulators we've uh been around and be familiar with them because remember the ones that you got that uh also don't leave the next crew with the with the but not enough oxygen know how long the oxygen is going to last in some of these uh tanks now if you work in a urban area and you're you don't go out of town much you'll have a long transport time you might get by with letting it get down to 700 600 pounds but if you're in a rural area think about if you got these long transports you know you don't want to get caught halfway on a trip and then run out of oxygen uh the flow meters be familiar with those know how to read them know how to use them know what they're capable of a lot of these flow meters are not capable of supplying a ventilator or a bipap or a cpap machine in those cases a lot of times what they have to do is be hooked to a special part on a regulator but a lot of time going through the regular type regulator like that christmas tree like that will not support those devices okay uh oxygen is flammable the uh you get hurt with it oxygen toxicity remember we are we're going away from the where everybody gets high flow oxygen all the time uh the rate the desired o2 rate we want to get at spo2 you know it's anywhere from like 94 to 99 depending on the patient but too much oxygen high flow oxygen can cause uh cellular damage oxygen is a vasoconstriction that's why even in someone with severe head injury remember the etco2 uh we don't want to hyperventilate them unless it's to the point of where they are herniating because what happens is oxygen causes vasoconstriction and even with the think about that with even with cardiac patients they need enough to maintain an adequate uh spo2 however you give them too much it causes the vessels of the heart to contract and what's that going to do also with uh a brain that needs oxygen or a lot of that needs blood flow and oxygen too much oxygen will actually cause the blood vessels to constrict and reduce blood flow that's why remember your respiratory rates try to keep things within that parameter uh proper devices non-rebreathers bag valve devices nasal cannulas know which ones properly uh fit these patients now nasal cannulas you know for a regular one up to six liters or so however sometimes people have before we would intubate somebody uh pre-oxygenate we would give 10 12 15 liters of oxygen to a cannula to hyperoxidate these people before intubation and people thought well you can't do that but if you got a cannula hooked up to a christmas tree do you turn it on 10 liters where else is it going to go so uh think about that so that you know you normally don't use it for that however they may be a case to where they can't tolerate a mask or something for some reason so you know local guidelines on that now laundry breathing mask prefer device in a pre-hospital setting if uh if it is indicated now if they got uh epic or poor uh respiratory effort remember it's not going to work it takes cooperation they have to be breathing on their own because it's not going to force air in if you can't get there so uh how much o2 do you need in there you know 10 12 15 liters i just put it on enough until the uh bag is inflated the reservoir stays inflated uh nasal cannula with those the uh parcel non rebreathing mask how do we ever see these anymore uh it's just like a non-rebreathing mask but it just doesn't have the little one-way valve flaps on it and a venturi mask we don't use those in the field very much however you may see them on inter-facility transports and it's like if the patient needs a certain amount of fio2 delivered 24 to 40 percent they have those settings on there you might have uh your regulator set at a certain rate however with these vending masks they only going to get a certain percentage uh tracheostomy masks simply uh they're not always available everywhere but o2 mask over that will work adequately as well humidifiers a lot of places don't have them on the trucks if they're short-term but if it's gonna be a long-term transport 30 minutes or more or something like that a humidifier would be a great thing full store water because oxygen dries out the mucous membranes makes people uncomfortable pretty quick so uh i'm going to uh stop right there for tonight because we'll continue this on uh wednesday night but right now tonight i'm gonna stop on slide uh 87 and uh does anybody have any comments questions or concerns tonight so far now sir you're doing a good job man i wish i it's uh hard to make some of this stuff interesting but we're getting toward the good stuff you know we're getting toward the good stuff a lot of this stuff i just have to like okay i i don't like reading for powerpoint sometimes use them as a guideline a lot of it i just play back to stuff that i've done before but anyway uh and i'm i'm gonna get uh like tonight we won't have as many slides coming up next meeting but i want to try to look at the material and try to pull some stuff over uh from uh critical care slides and things like that that may give you some better pictures to look at than what that we got in here and it still follows the parameters and everything however it's uh and you can only get so much out of what's printed and uh you know make better sense to you but i know this chemical stuff this uh cellular level stuff is very interesting i mean it's not very interesting very important but it is really hard to get a grasp on it and then when you see it's coming into play later and then things will work out you know it'll come to better for you but anyway uh i appreciate y'all's patience tonight and everything been a crazy week at the house we we had we've had a little dog for 14 years we had to put her down a couple days ago that's been kind of rough week you know they become part of your family and stuff but anyway i start back to work thursday night for a week but uh i'll see y'all back here on wednesday night at six o'clock and uh tonight your pin will be let's say two one eight one one two one eight one one that's on the twenty uh it's february first at eight eleven all right guys all right see you later lynn all right y'all have a good couple of days and we'll see y'all later