The Respiratory System

Emergency Medical Technician - Basic

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 Respiratory System Purpose
• Takes in oxygen
• Disposes of wastes O2 + Glucose

– Carbon dioxide
– Excess water

The Cell

CO2 + H2O

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Respiratory System Anatomy

Nasopharynx
Oropharynx
Epiglottis
Larynx
Trachea
Carina
Bronchi
Bronchioles

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 Respiratory System Anatomy

• Lung
– Right lung 3 lobes
– Left lung 2 lobes

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 Respiratory System Anatomy

• Bronchioles
– Smallest airways
– Walls consist entirely of
smooth muscle (no
cartilage present)
– Constriction increases
resistance to airflow
– Dilation reduces
resistance to airflow

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 Respiratory System Anatomy

• Alveoli
– Air sacs
– Site of oxygen
and carbon
dioxide exchange
with blood

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Respiratory System Anatomy

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 Respiratory System Anatomy
• Diaphragm

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 Respiratory System Anatomy
• Pleura
– Double-walled
membrane
– Visceral layer covers
lung
– Parietal layer lines
inside of chest wall,
diaphragm

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 Respiratory System Physiology

Inspiration
Active process
Chest cavity expands
Intrathoracic pressure falls
Air flows in until pressure
equalizes
Expiration
Passive process
Chest cavity size decreases
Intrathoracic pressure rises
Air flows out until pressure
equalizes
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 Respiratory System Physiology

–Automatic Function
• Primary drive: increase in arterial CO2
• Secondary (hypoxic) drive: decrease in
arterial O2

Normally we breathe to remove CO2 from the

body, NOT to get oxygen in

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 Respiratory Pathophysiology
• Airway (Obstruction)
– Tongue – Aspiration
– Foreign body airway – Asthma
obstruction – Chronic Obstructive Airway
– Anaphylaxis/angioedema Disease
– Upper airway burn • Emphysema
– Maxillofacial/laryngeal/ • Chronic bronchitis
tracheobronchial trauma
– Epiglottitis
– Croup

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 Respiratory Pathophysiology
• Gas Exchange Surface (Blood Flow or Gas Diffusion)
– Pulmonary Edema
• Left-sided heart failure
• Toxic inhalations
• Near drowning
– Pneumonia
– Pulmonary Embolism
• Blood clots
• Amniotic fluid
• Fat embolism

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 Respiratory Pathophysiology
• Thoracic Bellows (Ventilation)
– Chest Trauma
• Simple rib fractures
• Flail chest
• Pneumothorax
• Hemothorax
• Sucking chest wound
• Diaphragmatic hernia
– Pleural effusion
– Spinal cord trauma
(High C-spine lesion)
– Morbid obesity
– Neurological/neuro-
muscular disease
• Poliomyelitis
• Myasthenia gravis
• Muscular dystrophy
• Guillian-Barre
syndrome

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 Respiratory Pathophysiology

• Control System (Decreased Respiratory Drive)

– Head trauma
– CVA
– Depressant drug toxicity
• Narcotics
• Sedative-hypnotics
• Ethyl alcohol

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 Respiratory Assessment
• Initial Assessment (A, B, C, D)
• Manage life threats
• Complete focused history and physical

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 Initial Assessment

• Airway
– Listen to patient breathe, talk
• Noisy breathing is obstructed breathing
• But all obstructed breathing is not noisy
• Snoring = Tongue blocking airway
• Stridor = “Tight” upper airway from partial obstruction

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 Initial Assessment
• Airway
– Anticipate airway problems with
• Decreased LOC
• Head trauma
• Maxillofacial trauma
• Neck trauma
• Chest trauma

OPEN—CLEAR—MAINTAIN
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 Initial Assessment
• Breathing
– Is patient moving air?
– Is air moving adequately?
– Is the patient’s blood being oxygenated?

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 Initial Assessment
• Breathing
– LOOK – FEEL
• Symmetry of chest • Air movement at
expansion mouth, nose
• Increased respiratory • Symmetry of chest
effort expansion
• Changes in skin color – RATE
– LISTEN • Tachypnea
• Air movement at • Bradypnea
mouth, nose
– POSITIONING
• Air Movement in
peripheral lung fields • Orthopnea
• Tripod position

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 Initial Assessment
• Breathing
– Signs of respiratory distress
• Nasal flaring
• Tracheal tugging
• Retractions
• Neck, pectoral muscle use on inhalation
• Abdominal muscle use on exhalation
– Skin Color
• Pale, cool moist skin (Early sign of hypoxia)
• Cyanosis (Late, unreliable sign of hypoxia)

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 Initial Assessment
• Breathing
– If trauma patient has compromised breathing,
bare chest, assess for:
• Open pneumothorax
• Flail chest
• Tension pneumothorax

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 Respiratory Assessment
• Circulation
– Is heart beating?
– Is there major external hemorrhage?
– Is patient perfusing?
– Effects of hypoxia:
• Adults (early): tachycardia
• Adults (late): bradycardia
• Children: bradycardia

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 Initial Assessment

• Circulation
– Don’t let respiratory failure distract you from
assessing for circulatory failure
– Low oxygen or high carbon dioxide levels can
depress cardiovascular function

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 Respiratory Assessment
• Disability
– Restlessness, anxiety, combativeness = hypoxia
Until proven otherwise
– Drowsiness, lethargy = hypercarbia
Until proven otherwise

Just because the patient stops fighting, he’s

not necessarily getting better!!!
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 Initial Management
• Patient Responsive/Breathing Adequate
– Oxygen may be indicated
– Oxygenate immediately if patient has:
• Decreased level of consciousness
• Possible shock
• Possible severe hemorrhage
• Chest pain
• Chest trauma
• Respiratory distress or dyspnea
• History of any kind of hypoxia

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 Initial Management
• Patient responsive, breathing inadequate
– Open/maintain airway
– Place nasopharyngeal airway
– Assist ventilations
• Mouth to Mask
• 2-person Bag-valve Mask
• Manually Triggered Ventilator
• 1-person Bag-valve Mask

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 Initial Management
• Patient unresponsive, breathing adequate
– Open/maintain airway
– Place nasopharyngeal or oropharyngeal airway
– Suction airway as needed
– Provide oxygen by non-rebreather mask
– Frequently reassess

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 Initial Management
• Patient unresponsive, breathing inadequate
• Open/maintain airway
• Place nasopharyngeal or oropharyngeal airway
• Suction airway as needed
• Assist ventilations
– Mouth to Mask
– 2-person Bag-valve Mask
– Manually Triggered Ventilator
– 1-person Bag-valve Mask
• Frequently reassess
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 Initial Management
• Patient not breathing
– Open airway
– Place nasopharyngeal or oropharyngeal airway
– Ventilate patient
• Mouth-to-Mask
• 2-Person Bag-Valve Mask
• Manually Triggered Ventilator
• 1-Person Bag-Valve Mask
– Frequently reassess

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 Initial Management

• Golden Rules
– If you think about giving O2, give it!!!
– If you decide to give oxygen, give a lot of it!!!
– If you can’t tell whether a patient is breathing
adequately, he isn’t !
– If you’re thinking about assisting a patient’s
breathing, you probably should be!

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 Focused History and Physical

• Chief Complaint
– Dyspnea
• Subjective sensation that breathing is excessive,
difficult, or uncomfortable
– Respiratory Distress
• Objective observations that indicate breathing is
difficult or inadequate

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 Focused History and Physical
• History of Present Illness (OPQRST)
– Gradual or sudden onset?
– What aggravates or alleviates?
– How long has dyspnea been present?
– Coughing? Productive cough?
– What does sputum look/smell like?
– Pain present? What does pain feel like? How bad? Does it
radiate? Where?

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 Focused History and Physical
• Past History
If Then???
Hypertension, MI, Diabetes CHF with Pulmonary Edema

Chronic Cough , Smoking, COPD

“Recurrent” Flu

Allergies, Acute Episodes of SOB Asthma

Lower Extremity Trauma, Pulmonary Embolism

Recent Surgery, Immobilization

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 Focused History and Physical

• Medications
If Then???
“Breathing” Pills, Inhalers Asthma or COPD
Albuterol Montelukast
Aminophylline Oxtriphylline
Ipratropium Cromolyn
Terbutaline Prednisone
Salbumatol
Zafirlukast

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 Focused History and Physical
• Medications
If Then???
Lasix, hydrodiuril, digitalis CHF

Coumadin, BCP’s Pulmonary embolism

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 Focused History and Physical Exam
• Crackles (Rales)
– Fine, “crackling”
– Fluid in smaller airways,
alveoli
• Rhonchi
– Coarse, “rumbling”
– Fluid, mucus in larger
airways
• Stridor
– High pitched, “crowing”
– Upper airway restriction
• Wheezing
– “Whistling”
– Usually more pronounced on
exhalation
– Generalized: narrowing,
spasm of the smaller airways
– Localized: foreign body
aspiration
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 Mild Breathing Difficulty
• May be hypoxic
• Can move adequate tidal volume
• Can answer questions, speak in complete
sentences, is alert
• High concentration O2 by non-rebreather
mask
• Consider bronchodilators if patient wheezing

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 Moderate Breathing Difficulty
• May be hypoxic
• May be moving adequate tidal volume
• Having difficulty answering questions, speaks in
choppy sentences, is restless/irritable
• High concentration O2 by non-rebreather mask
• Get ready to assist ventilations if needed (patient
may resist assistance at this time)
• Consider bronchodilators if patient wheezing

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 Severe Breathing Difficulty
• Getting sleepy
• Not speaking or speaking with very few
words
• Previously wild, now seems “cooperative”
• Assist ventilations with BVM and oxygen
• Time BVM ventilation with patient’s
ventilatory efforts
• Interpose extra ventilations if necessary

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