Airway and respiratory

[Floridastudent]

I am in an EMT class, and we're on the respiratory section. I have a few questions and I'd love some clarification.

1.) If someone is breathing, but they are breathing inadequately - say, shallow breaths, labored breathing, etc. - am I correct in assuming that I would use assisted ventilation (bag valve mask) rather than a nonrebreathing mask? The nonrebreathing mask would generally be used if breathing is adequate but hypoxia is suspected?

Also - once you start the assisted ventilations via BVM - do you continue with the BVM after breathing becomes adequate, or switch to a nonrebreathing mask? My guess is you would continue the assisted ventilations with the BVM until you arrive at the hospital and transfer care - is that right?

2.) Scenario in book - you are called to the scene of a cardiac arrest and find that bystanders have initiated CPR. Patient was not breathing for about 3 minutes before they started CPR. Patient has occasional gasping breaths. You decide to open the patient's airway. You have no history of events leading up to the point of cardiac arrest. What is the preferred method of opening the airway? Head tilt chin lift, jaw thrust, nasal airway, none of the above.

I say jaw thrust because you don't know if there was any trauma - am I right?

2.) "Points to ponder" scenario in the EMTB book - You are dispatched to the local nursing home for an older man who is "difficult to wake". You arrive at the nursing home about five minutes after the initial call and find the patient to be lying supine in bed with oxygen flowing at 2 l/min via nasal cannula. THe nurse states that the patient was fine last evening but they were unable to wake him this morning. They state ha has a history of COPD and recent pneumonia. The patient has shallow gurgling respirations at a rate of about 8 breaths per minute. You also note cyanosis around the lips. WHile you are assembling your suction unit, your partner is placing the patient on a pulse oximeter.

Book question - How would you manage this patient's airway and breathing? Would you change the position of this patient?

My guess - insert oropharyngeal airway if he doesn't have a gag reflex (nasopharyngeal airway if he does), suction the patient for up to 15 seconds, then 100 percent high flow oxygen via bag valve mask, squeezing every 3 to 5 seconds. Ventilate for up to 2 minutes, then suction again if needed.

Change the position of the patient - once they have been suctioned, before putting on the BVM, I would do the head tilt chin thrust maneuver (because no trauma is suspected).

How did I do? I didn't kill my imaginary patient, did I?

Edited February 13, 2010 by Floridastudent

[Ghetto Medic]

1- if the breathing BECOMES adequate, assuming the avg rate 14-18bpm you may stop BVM ventilation and place them on an NRB. You dont want to force air into sombody breathing normally. Just because the breathing is labored or shallow does not nessicairly mean that breathing is "inadequate".

2 - according to the "book" you supposed to automatically suspect the patient fell or what not ie trauma, so go with the jaw thrust and last i checked as a BLS provider you should always place a BLS airway, NPA or OPA.

3 - suction, reposition the airway, BVM if the repositioning of the airway does not improve the patients respiratory rate.

Keep in mind this is all text book garbage. Its difficulty to treat a paper patient. wait till you hit the field if you havent yet, it will come much easier. Just keep in mind Lung sounds are very important and the pulse ox is an "aid" to your assessment, dont treat the pulse ox, treat the patient.

[nypamedic43]

you did very well.

1) assisted ventilations can be stopped if the patients respiratory drive kicks in and they start breathing better. If thier respirations become adequate 100% O2 by NRM is fine, but watch them carefully.

2) jaw thrust is correct because of the unknown trauma.

3)suctioning and repositioning is correct. oropharyngeal if no gag reflex. BVM with 100% O2 to assist. listen to lung sounds...it may be an exacerbation of the COPD or unresolved pneumonia. you also have a change in mental status out of the norm for this patient. seriously consider ALS intercept if your partner isnt an ALS provider.

You didnt kill your patient...hope you are enjoying the class

Edited February 13, 2010 by Nypaemt39

[JakeEMTP]

No you didn't kill your patient.

1) I would continue assisting the patient in his effort to breathe with the BVM. The problem is your patient isn't breathing adequately. Switching to a NRB wouldn't be beneficial to your patient in this case with the info provided. He might just revert back to the condition you found him in. He may be breathing on his own but is he A & O? If not, then continue bagging.

2)A jaw thrust is the appropriate method of opening the airway in this case for the reasons you describe.

In response to the second part of your question, I have improved the breathing of quite a few patient's at nursing homes by simply raising the head end of the bed. Lying supine in respiratory distress is not the preferred method of treatment. Reassess and administer O2 via NRB. If you need to bag them, then by all means do it! The key is to always reassess after you provide an intervention no matter how simple it may seem. Suction if needed and at the EMT-B level, a diesel bolus to the hospital.

[Floridastudent]

1- if the breathing BECOMES adequate, assuming the avg rate 14-18bpm you may stop BVM ventilation and place them on an NRB. You dont want to force air into sombody breathing normally. Just because the breathing is labored or shallow does not nessicairly mean that breathing is "inadequate".

2 - according to the "book" you supposed to automatically suspect the patient fell or what not ie trauma, so go with the jaw thrust and last i checked as a BLS provider you should always place a BLS airway, NPA or OPA.

3 - suction, reposition the airway, BVM if the repositioning of the airway does not improve the patients respiratory rate.

Keep in mind this is all text book garbage. Its difficulty to treat a paper patient. wait till you hit the field if you havent yet, it will come much easier. Just keep in mind Lung sounds are very important and the pulse ox is an "aid" to your assessment, dont treat the pulse ox, treat the patient.

Book vs. street - Tell me about it! I start ridealongs next month. From what I gather - in class we need to memorize and mindlessly parrot back the book when we take quizzes and tests. In the field we need to do what makes sense, as long as we follow our local protocols.

I'm a CNA and what we learned in class doesn't have much to do with what they tell me to do when I go cover nursing home shifts.

No you didn't kill your patient.

1) I would continue assisting the patient in his effort to breathe with the BVM. The problem is your patient isn't breathing adequately. Switching to a NRB wouldn't be beneficial to your patient in this case with the info provided. He might just revert back to the condition you found him in. He may be breathing on his own but is he A & O? If not, then continue bagging.

2)A jaw thrust is the appropriate method of opening the airway in this case for the reasons you describe.

In response to the second part of your question, I have improved the breathing of quite a few patient's at nursing homes by simply raising the head end of the bed. Lying supine in respiratory distress is not the preferred method of treatment. Reassess and administer O2 via NRB. If you need to bag them, then by all means do it! The key is to always reassess after you provide an intervention no matter how simple it may seem. Suction if needed and at the EMT-B level, a diesel bolus to the hospital.

Good to know about raising the head of the bed!

We haven't been taught anything about a diesel bolus yet. I'll go look that up.

[WestSideBorderPatrol]

I am in an EMT class, and we're on the respiratory section. I have a few questions and I'd love some clarification.

1.) If someone is breathing, but they are breathing inadequately - say, shallow breaths, labored breathing, etc. - am I correct in assuming that I would use assisted ventilation (bag valve mask) rather than a nonrebreathing mask? The nonrebreathing mask would generally be used if breathing is adequate but hypoxia is suspected?

Our protocols say to use a BVM if the patient has a respiratory rate of less than 8 (adult), absent/diminished breath sounds, or cyanosis on 100% O2 by nonrebreather mask.

Also - once you start the assisted ventilations via BVM - do you continue with the BVM after breathing becomes adequate, or switch to a nonrebreathing mask? My guess is you would continue the assisted ventilations with the BVM until you arrive at the hospital and transfer care - is that right?

We were taught that if the patient "comes around" that we can still use the BVM but if they're breathing normally, to work with, not against, they're normal breathing.

2.) Scenario in book - you are called to the scene of a cardiac arrest and find that bystanders have initiated CPR. Patient was not breathing for about 3 minutes before they started CPR. Patient has occasional gasping breaths. You decide to open the patient's airway. You have no history of events leading up to the point of cardiac arrest. What is the preferred method of opening the airway? Head tilt chin lift, jaw thrust, nasal airway, none of the above.

I say jaw thrust because you don't know if there was any trauma - am I right?

I agree

2.) "Points to ponder" scenario in the EMTB book - You are dispatched to the local nursing home for an older man who is "difficult to wake". You arrive at the nursing home about five minutes after the initial call and find the patient to be lying supine in bed with oxygen flowing at 2 l/min via nasal cannula. THe nurse states that the patient was fine last evening but they were unable to wake him this morning. They state ha has a history of COPD and recent pneumonia. The patient has shallow gurgling respirations at a rate of about 8 breaths per minute. You also note cyanosis around the lips. WHile you are assembling your suction unit, your partner is placing the patient on a pulse oximeter.

Book question - How would you manage this patient's airway and breathing? Would you change the position of this patient?

My guess - insert oropharyngeal airway if he doesn't have a gag reflex (nasopharyngeal airway if he does), suction the patient for up to 15 seconds, then 100 percent high flow oxygen via bag valve mask, squeezing every 5 seconds. Ventilate for up to 2 minutes, then suction again if needed.

Change the position of the patient - I would try the head tilt chin lift maneuver to open the airway, since there is no indication of trauma/spinal injury.

Since he has a history of COPD, I would sit them up in a fowlers position.

How did I do? I didn't kill my imaginary patient, did I?

I don't think that you killed them...they might have died on their own, but I don't think that you killed them. It is important to remember that high concentrations of oxygen will reduce the respiratory drive in

some COPD patients. We give all Priority 1 and 2 patients with a history of COPD, high flow O2, but for Priority 3 patients, its best to stick with their Dr. prescribed dose.

[Floridastudent]

Yes, that's a tough one with COPD and giving oxygen. What they are having difficulty breathing and if you give them oxygen and they stop breathing? I assume you would provide artificial ventilation via BVM or mouth to mask until you get to the hospital.

[tniuqs]

'Floridastudent'

Yes, that's a tough one with COPD and giving oxygen.

So in the real world:

No this is a myth perpetuated by EMS and uneducated "others" NEVER withhold O2 as hypoxic drive patients are in a scant few ~ 5% of all COPD patient's.

What they are having difficulty breathing and if you give them oxygen and they stop breathing?

Firstly highly likely a respiratory arrest is from another cause, Hypoxia will kill your patient far faster than acid PH imbalances ... if the COPD patient is in extremus their WOB thats "work of breathing" and O2 requirements are far, far higher than the average.

Tripoding, accessory muscle,(forced exhalation) and pursed lip breathing are clinical observations indicative of the level of distress. .... counting breath rate is very elementary.

After experience in the field this will become crystal clear.

I assume you would provide artificial ventilation via BVM or mouth to mask until you get to the hospital.

Yes but this is a far slower process that the EMS myth promote's ... if you have pulse oximetry the "targets in Hospital Care are SpO2 > 88 % < 94 % or serial Blood Gas ... a bit beyond this scenario discussion but worth mentioning.

ps Patients are really going to die on you, despite any book or proper treatment ... its just the way it is, as a CNA im sure this is not a new concept.

cheers

[DwayneEMTP]

1.) If someone is breathing, but they are breathing inadequately - say, shallow breaths, labored breathing, etc. - am I correct in assuming that I would use assisted ventilation (bag valve mask) rather than a nonrebreathing mask? The nonrebreathing mask would generally be used if breathing is adequate but hypoxia is suspected?

Also - once you start the assisted ventilations via BVM - do you continue with the BVM after breathing becomes adequate, or switch to a nonrebreathing mask? My guess is you would continue the assisted ventilations with the BVM until you arrive at the hospital and transfer care - is that right?

I believe both types of answers are correct here. Some have said discontinue and apply your NRB, and this may be correct if they're breathing poorly secondary to say, a seizure or a syncopal episode, as most often they'll come around and breath fine on their own. In most cases though, I'm with Jake. Something made their breathing get froggy and the likelihood is that you didn't correct that simply by assisting them with a few ventilations. Whatever was broken is likely still broken so assistance will need to be continued. I've assisted ventilations many times on pts that were able to talk to me simply because they looked so exhausted that I didn't want them to burn additional physiologic resources with the effort to breath. If in doubt, continue to assist. If it's too much, for too long, they'll simply reach up and pull the mask of and tell you to stop.

2.) Scenario in book - you are called to the scene of a cardiac arrest and find that bystanders have initiated CPR. Patient was not breathing for about 3 minutes before they started CPR. Patient has occasional gasping breaths. You decide to open the patient's airway. You have no history of events leading up to the point of cardiac arrest. What is the preferred method of opening the airway? Head tilt chin lift, jaw thrust, nasal airway, none of the above.

I say jaw thrust because you don't know if there was any trauma - am I right?

Sure. But what about your other mechanical options? Why should you use NPAs and OPAs in this patient? Why not? I ask you this because I want you to think about your pt here, and not the book. Each time you identify an issue, decide what you should do about it and then try and make an argument for why you shouldn't do it. In this way you should be pretty comfortable with your decision. In this case for example my little pea brain would work something like this...

What does my pt need? To be ventilated. What method should I use to open the airway? Jaw thrust chin lift. But the scene and pt presentation makes trauma a likelihood so I think I'll use the jaw thrust instead. Should I use an NPA? It will likely give me additional air movement with less cranking on the head, so yes. Why shouldn't I? I can't think of any reason. Should I use two? Why not? I can't think of any reason. Should I use an OPA? It seems like a good idea. Why shouldn't I? I can't think of any reason.

Now you've got a pt with two NPAs and one OPA and everyone around you thinks you're a complete idiot, until you get into the ER and the doc says, "Nice!" See, he wants air movement and cares not one wit what it looks like or what the book says. We moved air, that was our job, and we used all of the tools we had available to do so, considered all of our contraindications for doing so, and that is our job. Right?

2.) "Points to ponder" scenario in the EMTB book - You are dispatched to the local nursing home for an older man who is "difficult to wake". You arrive at the nursing home about five minutes after the initial call and find the patient to be lying supine in bed with oxygen flowing at 2 l/min via nasal cannula. THe nurse states that the patient was fine last evening but they were unable to wake him this morning. They state ha has a history of COPD and recent pneumonia. The patient has shallow gurgling respirations at a rate of about 8 breaths per minute. You also note cyanosis around the lips. WHile you are assembling your suction unit, your partner is placing the patient on a pulse oximeter.

Book question - How would you manage this patient's airway and breathing? Would you change the position of this patient?

My guess - insert oropharyngeal airway if he doesn't have a gag reflex (nasopharyngeal airway if he does), suction the patient for up to 15 seconds, then 100 percent high flow oxygen via bag valve mask, squeezing every 3 to 5 seconds. Ventilate for up to 2 minutes, then suction again if needed.

Can you rethink this and see if you can explain why this isn't the most logical order of events? (Note, you won't find this answer in your book.)

Change the position of the patient - once they have been suctioned, before putting on the BVM, I would do the head tilt chin thrust maneuver (because no trauma is suspected).

Most wouldn't consider the head tilt chin lift so much a change in position as a maneuver. Why would you change this pts position? Because we're concerned with two things most often when we go to the nursing home. First, this pt will likely have a pillow under their head causing a significant kink in the neck adding to the airway compromise already present because they're unresponsive and their tongue is being allowed to go where it likes. Second, it's likely that this pt has some fluid in their lungs. Sitting them upright will not only put the lungs in a better position to inflate with less effort, but will drain some of this fluid into the bases freeing up some alveolar space. Always, always, always sit your geriatric breathing pts up if there is no contraindication to doing so.

How did I do? I didn't kill my imaginary patient, did I?

This pt may die, but you didn't kill him. You didn't, in this scenario, do everything completely correct, but then, welcome to the world of EMS babe. Sometimes we make mistakes, sometimes they are big, other times small, but often people suffer from them. The sin is not in making mistakes but failing to learn from them and repeating them.

Very brave of you to put forth your questions and your answers instead of doing as so many do and asking the questions but then staying safe behind your computer while you get answers from others first. EMS takes cast iron ovaries at times, good on you for putting yourself and your ideas out there to be judged.

You did good.

Dwayne

Yes, that's a tough one with COPD and giving oxygen. What they are having difficulty breathing and if you give them oxygen and they stop breathing? I assume you would provide artificial ventilation via BVM or mouth to mask until you get to the hospital.

THANK YOU!

Man, I hate this argument, but for the very reason you state. First, you're never going to see this. You're going to hear about it a gazillion times, people are going to swear that it happens to them weekly, but you're almost certainly never going to see it.

Second, if you do see it? OMG what then?? As you said, you bag them to the hospital. First week of basic class right?

When people warn you about this you really need to call bullshit and be thankful that you got your info from EMTCity instead of from some yahoo wannabe making up stories.

Dwayne

[JakeEMTP]

We haven't been taught anything about a diesel bolus yet. I'll go look that up.

Yeah, they might not teach you the term diesel bolus in school. It simply means get them to the hospital ASAP.

Dwayne has given you some excellent advise. Try to think through your interventions instead of just doing them because "the book says so".

Good luck with your class! You're off to a great start!