Respiratory System, Respiratory Distress

n include restlessness, dyspnea, tachypnea, tachycardia, and an elevation in blood pressure. While more prominent signs of severe hypoxia are cyanosis, head bobbing, altered mental status, and seizures. While "Hypoxemia is a below-normal level of oxygen in your blood, specifically in the arteries. Hypoxemia is a sign of a problem related to breathing or circulation, and may result in various symptoms, such as shortness of breath known as dyspnea"(Hypoxemia, par. 1). Signs of hypoxemia are not being able to catch your breath, mild headaches, severe sleepiness, or severe mood changes or irritability.

Signs of severe hypoxemia are similar to hypoxia where the prominent signs are cyanosis, AMS, and seizures. There are many signs of respiratory distress and dyspnea. Major signs that inform EMT's of respiratory distress include altered mental status, tripod positioning, pulse ox below 94%, abnormal respirations, tachycardia, and shortness of breath. There are several differences between respiratory distress and respiratory failure. Respiratory distress can be categorized into 3 sections mild, moderate, and severe distress.

While respiratory failure is when a patient becomes apneic and there is an inadequate gas exchange which leads to higher carbon dioxide levels and lower oxygenation levels. Respiratory distress can be explained as more of a symptom that could lead to respiratory arrest. While respiratory failure is failure of the respiratory system to function properly in the body, basically when a person is unable to breathe. Respiratory failure can be caused by a number of diseases or problems with the body. Respiratory failure can happen to anyone at any age from an airway blockage to something as life changing as lung cancer.

Ways to Treat Respiratory Distress or Failure A key function in an EMT's primary assessment is airway management. It is important as an EMT that your patient's airway is always patent. A patent airway is one that is open and not obstructed in any form or way. Some forms of airway occlusions are by a relaxed tongue, blood, secretions, vomitus, tissue bone, teeth, or any other substance. If the airway is failed to remain patent this could lead to cellular hypoxia and eventually death. There are many sounds to airway obstruction or occlusion such as snoring, crowing, gurgling, and stridor. It is important to know each sound and what they are caused by. A snoring respiration is from a partially obstruction of the tongue and other tissues, and sounds like they are snoring. Crowing occurs from a laryngospasm where the trachea begins to close or narrow, and sounds like a crow cawing. A gurgling respiration occurs from blood, secretions, vomitus, or other liquids in the airway, and sounds as if a liquid substance is affecting breathing. Lastly there is stridor, which is a loud higher pitched sound when a person inhales usually due to a major airway obstruction, swelling of the larynx, inhalation of poisons or super-heated gasses. There are a few ways these situations can be managed.

In situations when needing to open the air way, the head tilt chin lift maneuver can be used or the jaw thrust maneuver if there is a suspected spinal injury can be used. If an airway is obstructed by vomitus, blood, secretions, and other liquids, a suction rigid catheter also known as a yankauer catheter can be used to clear the airway. For unconscious patients the OPA and NPA can be used to maintain a patent airway. Using the OPA it should be measure from the phalange of the mouth to the corner of the jaw. It should be inserted lightly contacting the roof of the mouth and then gently rotated 180 degrees. When using an NPA measure from the tip of the nose to the earlobe. The NPA must be lubricated with a sterile water soluble liquid before inserted in the nose. Make sure the bevel is facing the septum and there is little resistance. Contraindications when using the NPA and OPA, or reasons why you would not use these devices, are responsive patients and any facial trauma or head trauma. Important to a patient is their ability to breathe adequately. The failure to ventilate a patient adequately or with the correct mechanism could lead to hypoxia and even death. Ventilation is the mechanical process that relies on changes in pressure inside the thorax to move air in and out of the lungs. Ventilation is known as Boyle's law which "determines the relationship between pressure and volume."(Staroscik, par. 1)

Basically what it states is that an increase in pressure will decrease the volume of gas and a decrease in pressure will increase the volume of gas. When a person inhales this is known as negative pressure. When a person exhales this is known as positive pressure. A person who is unable to inhale or exhale usually uses certain accessory muscles that are used to either help increase the size of the chest and bring air in or decrease the chest and exhale air out. Accessory muscles of inhalation and how they are used are the sternocleidomastoid, which lifts the sternum upwards, scalene muscles, that elevate ribs 1 and 2, and the pectoralis minor, which elevates ribs 3 to 5. Accessory muscles of exhalation and how they are used are, the abdominal muscles which contract and increase the pressure inside the abdominal cavity so the diaphragm expands and air is sent out of the lungs, and the internal intercostal muscles which contract and pull the sternum and ribs downward. Accessory muscles used can also be nasal flaring and body positioning such as tripod positioning barrel chest, or Kussmal respirations. It is important that the accessory muscles are maintained in order to be able to breathe properly. Two conditions that could need the use of accessory muscles are poor compliance and airway resistance. The first condition that could need the use of accessory muscles is compliance, "The compliance of the lung describes the relationship between the transmural pressure across the lung compared with organ's volume. By transmural pressure we mean the relative pressure between the alveoli compared with that in the intrapleural space. Positive transmural pressures mean greater alveolar pressures than intrapleural pressures"(Razani 1). Compliance is basically known as the measure of the lung's ability to stretch and expand. If a person has poor compliance it could be due a factor of things such as a structural problem, pneumonia, a flail segment, or a neuromuscular disease.

A high airway resistance makes it harder to move air into the air way while a lower airway resistance makes it easier for air to enter the airways. Airway resistance is the resistance of inhalation and exhalation. If a resistance is too great in the airway accessory muscles will be used to inhale or exhale. When assessing breath sounds you can find additional signs to clarify what steps you need to take next in medical direction. When listening to the lungs there are many sounds you can hear associated with respiratory disease or distress. These "adventitious breathe sounds are the extraneous noises produced over the bronchopulmonary tree and are an indication of an abnormal process or condition"(Frownfelter and Dean 219). These sounds are wheezing, Ronchi, crackles, and rales. Wheezing is usually a high-pitched noise heard on inhalation or exhalation characteristic of asthma, emphysema, and chronic bronchitis. Ronchi this is a snoring or sort of rattling that can be heard upon auscultation. Crackles and rales are bubbly crackling noises from inhalation crackles can be signs of pulmonary edema or pneumonia. There are many ways to ventilate a patient and as an EMT you must know when the best time and what the best mechanism is for the assessed patient. A pulse oximeter is a good way to understand how much oxygen needs to be delivered and how bad the case may be. The pulse oximeter may not always be the best thing to follow because in some cases individuals may be hypoxic from a leak or poisonous gas such as carbon monoxide which pulse ox will be thrown off. The pulse ox is thrown off because the carbon monoxide is attaching to hemoglobin displaying it as 100 percent oxygen. Always remember as an EMT your job is to provide the patient care and to not always get caught up on using the gadgets. "

A normal SpO2 is 98%, although greater than 90% is considered acceptable. In some special cases of severe COPD, your doctor may find that less than 90% is acceptable for you"(Oxygen levels, par. 2). In medical patients you want to keep the spo2 above 94%, and in trauma patients the spo2 should be maintained above 95%. A person with COPD should maintain a spo2 of 88 percent to 92 percent. A bag valve mask is the most common positive pressure ventilation technique. The BVM is a self-inflating bag that is connected to a face mask and can be connected to an oxygen reservoir. When using the BVM you are delivering 21 percent oxygen the oxygen found in room air, but when attached to an oxygen reservoir you can be delivering close to 100 percent oxygen. Next is the continuous positive airway pressure or the CPAP. The CPAP is a device used on impulsive breathing patients. The device is typically applied to patients with respiratory disease or moderate to severe respiratory distress. The CPAP is typically delivered at a rate of 5 to 10 cm H2O. The delivery of the highest concentration of oxygen would be the nonrebreather. The nonrebreather is a mask attached to an oxygen reservoir with flow from an oxygen cylinder usually set around 15 lpm.

For medical patients the best device is the nasal cannula which provides a lower concentration of oxygen. The nasal cannula has 2 nasal prongs which are attached to oxygen usually provide between 2 to 6 lpm. Another way to insure a patient has an adequate respiratory system is by a person's circulation. If a person has a poor skin color, temperature, or condition this can be a sign of respiratory distress or failure. As an EMT you should use a capillary refill to ensure there is good perfusion for an individual. Without the use of the circulatory system the body would not be able to receive oxygen and the lungs would fail. Skin color in relation to oxygenation can be a major and obvious sign of poor perfusion. If a person is turning cyanotic, or blue, then you know that their body is not getting enough oxygen. Common Respiratory Health Issues There are many upper respiratory infections that affect the way people eat, speak, talk, breathe and more. These respiratory infections are sinusitis, tonsillitis, laryngitis, and epiglottitis. These respiratory infections can be crucial in patient care so it is important to know each one. Sinusitis is nasal congestion that blocks the openings leading to the sinuses. The symptoms include "Pain and tenderness usually occur over the lower forehead or over the cheeks. Successful treatment depends on restoring proper drainage of the sinuses" (Mader 198).Patients with sinusitis are usually inflamed and swelled in there nasal cavity. Sinusitis can be cause by the flue, allergies or even smoke inhalation. Tonsillitis is caused from the tonsils becoming inflamed and especially enlarged. This normally induces a surgery of the removal of the tonsils called a tonsillectomy. "Fewer tonsillectomies are preformed today than in the past because it is now known that tonsils trap many of the pathogens that enter the pharynx" (Mader 198). Tonsillitis is typically caused by bacteria build up or a virus in the mouth. Most cases of tonsillitis occur in children. Laryngitis is an infection of the larynx which makes the roughness in the voice and in due course leads to the inability to speak. Usually, "laryngitis disappears with treatment of the URI, but with persistent hoarseness warning signs of cancer should be looked into by a physician"(Mader 198).

Laryngitis can be cause from many other things other than cancer such as bacteria, allergies, inhalation of chemicals, and sinus infections. Lastly is epiglottitis, this is typically an acute inflammation to the epiglottis that can begin to obstruct the airway if left untreated. Epiglottis is typically caused from an infection from some type of bacteria. Patients can be seen leaning forward to keep the epiglottis flap opening in order to breathe. For most of these upper respiratory infections an EMT would not be able to do much for the patient other than completing your primary assessment completing your history and providing supplemental oxygen, unless the patient is in severe respiratory distress. There are many diseases of the respiratory system that can cause respiratory distress, respiratory failure, and respiratory arrest. These diseases and conditions are Emphysema, chronic bronchitis, asthma, pneumonia, pulmonary embolism, pulmonary edema, spontaneous pneumothorax, hyperventilation syndrome, pertussis, cystic fibrosis, viral respiratory infections, lung cancer, infant respiratory distress syndrome, and SIDS. Asthma, chronic bronchitis, and emphysema are the most common chronic obstructive pulmonary diseases also known as COPD. "Chronic bronchitis and emphysema are marked by a progressive loss of lung function and corresponding cardiac dysfunction. At the end of five years, patients with chronic airflow limitation have a death rate four to five times greater than the normal expected value" (Frownfelter and Dean, 515). Many people who develop chronic bronchitis or emphysema are smokers or where subdue to second hand smoke. Chronic bronchitis and emphysema are usually commonly found in COPD patients where they can even have both. Asthma is the most common respiratory complaint you will be on scene to manage. Asthma is a disease that inflames and narrows the airways. This is often the cause of chest tightness and shortness of breath. Pneumonia is another disease process that typically older individuals receive. This disease is cause by HIV, cancer, alcoholism, and primarily smoking. Pneumonia is when the tiny air sacs called alveoli begin to be filled with fluid or puss. All of these diseases can fall under the case of acute or chronic. Acute meaning a new onset of emergency that has never happened before, and chronic meaning the disease process has been there for a while or is reoccurring. The next diseases are pulmonary edema, pulmonary embolism, and spontaneous pneumothorax. Pulmonary edema is the accumulation of fluid filling up the lungs and effecting the alveoli. Pulmonary edema is commonly found in patients with heart failure where fluid then backs up in the lungs. Next is a pulmonary embolism, a pulmonary embolism is a blockage in the blood vessels that carry blood from the heart to the lungs.

Lastly a spontaneous pneumothorax which is a rare case when a lung begins to collapse. A spontaneous pneumothorax occurs from excess air entering your pleural space. This excess air causes the lung to fail which results in a collapsed lung. Hyperventilation syndrome, pertussis, cystic fibrosis, and lung cancer. Hyperventilation syndrome is a disease in which patients rapidly and excessively breathe. Pertussis which is also known as whooping cough is an extreme cough that is violent and makes it difficult to breathe. Viral respiratory infections are your typical common colds that can fall under both your upper respiratory system and your lower. These symptoms can be things such as a cough, runny nose, sore throat, and bronchoconstriction. Lastly lung cancer is a growth of lung cells that can result in a tumor. Lung cancer is a rare disease that usually ends up proceeding to death of a person. The last two disease processes are infant respiratory distress syndrome, and SIDS. These diseases are both infant respiratory issues. Infant respiratory distress syndrome is a respiratory distress in newborns that usually occurs in premature babies. This syndrome is do to the lungs being not fully developed yet. SIDS is sudden infant death syndrome which is caused by a sudden stop of breathing when a child is at rest or a sleep. When the cause of death is typically found it happens to be accidental suffocation. These are all respiratory diseases that can lead to respiratory failure or respiratory arrest. There are many outside resources such as the outside environment and physical features of individuals that ultimately effect the overall health and wellness of a person's respiratory system. Living in the central valley the air quality isn't the greatest because of pollution and all the pollen, almond orchards, dust, and recent wildfires.

Heavy set or obese people have a harder time breathing because of the excess pressure pushed on their lungs. Living with a smokers, or smoking itself can affect a person's respiratory system, as well as the smog from the increased traffic that is now streaming through the valley. The respiratory system is so complex and intricate. It is not just subject to inhalation and exhalation, there is a complex system of measures to help the body run healthy and oxygenated. From the large lungs to the small cells that carry oxygen, there are so many detailed functions and vital pieces. The respiratory system is essential to our everyday life and our ability to function. In the field of Emergency Services it is crucial to know the anatomy and physiology of the respiratory system as well as the signs and symptoms of distress and failure to be able to determine how best to help a patient. It is also important to know what types of diseases and common ailments that can cause distress or failure to be able to help treat and transport. Knowledge is key to serving and saving a patient's life, and by obtaining that knowledge of the respiratory system, a EMT will be better prepared to serve the people of their community.

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