Assessing the Severity of Respiratory Distress

							Joseph J. Mistovich, M.Ed, NREMT-P
                Chair and Professor
  Department of Health Professions
       Youngstown State University
                  Youngstown, Ohio
               jjmistovich@ysu.edu
   Maintain perfusion of
    cells
    ◦ Oxygen
    ◦ Glucose

    ◦ More glucose needs
      more oxygen

   Byproducts
    ◦   ATP
    ◦   Heat
    ◦   CO2
    ◦   H2O
                                                  ATP
Sodium (Na+)
Primary extracellular                           Na+/K+ Pump
ion                                                     Na+

                                        K+

                                Cell


                        Potassium (K+)
                        primary intracellular
                        ion
Airway
Ventilation
Oxygenation
Circulation
   Epiglottis
   Submandibular
    muscles
   Airway
    obstruction
    ◦ Tongue
    ◦ Epiglottis
   Major muscles of breathing
    ◦ Diaphragm (60 to 75%)
      Phrenic nerve (C 3-5)
    ◦ External intercostal muscles
      Motor and sensory innervation from spinal intercostal
       nerves (T 1-4)
   Indicate increase of workload on inhalation
    ◦ Sternocleidomastoid - sternum
    ◦ Scalenes – ribs 1 &2
    ◦ Pectoralis minor – ribs 3 to 5
   Diaphragmatic, abdominal, and internal ICM
    use may indicate increase in workload to
    exhale
   Quiet breathing
    ◦ Inhalation is an active process
    ◦ Exhalation is a passive process
   Forced breathing
    ◦ Inhalation is an active process
    ◦ Exhalation is an active process
   Moves from higher concentration to lower
    concentration
    ◦ Oxygen moves from alveoli to capillary
    ◦ Carbon dioxide moves from capillary to alveoli
   Binding site for oxygen
    transport
   97% of oxygen transport
    ◦ Oxyhemoglobin = red
      hemoglobin
   SpO2
    ◦ Reads color of hemoglobin
   CO
   Cyanide poisoning
 Early   sign = pale, cool, clammy
  skin
 Late sign = cyanosis
 Hypoxia
 Hypercarbia
 Uncomfortable   feeling of
  breathing
 Metabolic demands of body
  not being met
 No direct correlation to level
  of hypoxia
   Reperfusion issues
    ◦ Stroke
    ◦ ACS – MI
    ◦ Trauma?


   SpO2 95%
   Amount of air moved in an out of the
    respiratory structures in one minute
   Determines effectiveness of ventilation
   Two components
    ◦ Tidal volume
    ◦ Frequency (rate)

    MV = VT x F
    MV = 500 mL x 12/minute
    MV = 6,000 mL/minute
   Amount of air that is moved in and out of the
    alveoli during inhalation and exhalation
   Determines effectiveness of oxygenation
   Three components
    ◦ Tidal volume (VT)
    ◦ Dead air space (VD)
    ◦ Frequency (rate) F

    VA   =   (VT – VD) x F
    VA   =   (500 mL – 150 mL) x 12/minute
    VA   =   350 mL x 12/minute
    VA   =   4,200 mL/minute
 VT = 200 ml (shallow VT)
 F = 28/minute


 VM   = 200 x 28 = 5,600 ml

 VA   = (200-150) x 28 = 1,400 ml
   Must assess rate and tidal volume
   Two adequates = adequate breathing
    ◦ Must have adequate rate (f) and adequate tidal
      volume in order to have adequate breathing
   One inadequate = inadequate breathing
    ◦ Inadequate rate (bradypnea or tachypnea) =
      inadequate breathing
    ◦ Inadequate tidal volume = inadequate breathing
   Tachypnea (>20/minute)
    ◦ Normal? 8 to 24/minute
    ◦ R > 30/minute
    ◦ R > 40/minute
   Bradypnea (<8/minute)
   Pattern
    ◦   Cheyne-Stokes
    ◦   Central neurogenic hyperventilation
    ◦   Biot’s (ataxic)
    ◦   Apnea
    ◦   Agonal
   Tachycardia (normal 60 to 100 bpm?)
   Decreased breath sounds
   Decreased airflow at nose or mouth
   Reduced chest wall expansion
   Accessory muscle use (neck)
   Pale, cool clammy skin (early)
   Diaphoresis
   Cyanosis (late)
   Nasal flaring (common in children)
   Seesaw breathing
   Agitation, anxious, confused
Respiratory Distress
Respiratory Failure
Respiratory Arrest
   Positive pressure ventilation
   Perfusing rhythm
    ◦ Adult 10 to 12/minute (every 5 to 6 seconds)
    ◦ Pediatric 12 to 20/minute (every 3 to 5 seconds)
   Non-perfusing rhythm
    ◦ Adult 8 to 10/minute (controlled airway)
   Average of 32/minute in one study of
    prehospital ventilation

   Cardiothoracic pump effect?

   Ventilation rates in cardiac arrest
    ◦ 10 to 12/minute if no advanced airway
    ◦ 8 to 10/minute if advanced airway (ET, ETC, LMA)
   Ventilation
   Perfusion
    ◦ V/Q ratio
    ◦ Treatment based on this principle
    ◦ Assessment findings are related to the V/Q ratio
   Ventilation or
    perfusion
    disturbance?
   Ventilation or
    perfusion
    disturbance?
   Ventilation or
    perfusion
    disturbance?
   Ventilation or
    perfusion
    disturbance?
   Ventilation or
    perfusion
    disturbance?
   Ventilation or
    perfusion
    disturbance?
   Cardiogenic
   Non-cardiogenic