Respiratory system management:
Airway management:
Management of the airway involves ensuring that it is both patent AND protected. What this means is, we have to consider:
The possibility of mechanical or positional obstruction.
The ability of the patient to protect the airway themselves.
Mechanical obstructions can include a variety of things, such as:
Blood
Broken teeth
Secretions
Foreign objects
The most common obstruction: The human tongue
An alert patient can clear obstructions themselves, or with minor assistance. However, patients who are significantly altered, may not be able to maintain their own airway. If an obstruction is present, we will have to clear it for them. Once the airway is cleared, we will need to ensure it stays that way. In general, a patient with a GCS <8, or one who does not respond to painful stimuli, should have the airway maintained via some form of adjunct.
The step by step process of airway management is as follows:
1) Open the airway: Use a head-tilt-chin-lift in patients without traumatic mechanism of injury. In the case of trauma, use of a modified jaw thrust is the preferred means of opening the airway, while still protecting the cervical spine.
2) Inspect and clear the airway: Visually inspect the patient’s airway for any evidence of obstruction or potential obstruction, and remove them using the appropriate method (suction, finger sweep, log roll).
3) Keep the airway open: In the case of a patient who is not able to maintain their own airway, utilize OPA, NPA, SGA, or ETT to provide stability to the airway.
Oxygenation and Ventilation management:
When assessing the status of a patient’s breathing, we want to consider:
Respiratory rate, rhythm, and depth of respirations.
If readily available, review their oxygen saturation.
Work of breathing, and accessory muscle use. Word dyspnea is another useful metric.
Lung sounds and the presence of audible adventitious sounds.
It is important that we know how to recognize the difference between respiratory DISTRESS, and respiratory FAILURE.
Respiratory Distress: Technically this refers to a state where an underlying problem leads to impaired oxygenation/ventilation, and the body has to compensate by increasing heart rate and respiratory rate in order to provide sufficient O2 to the cells. Respiratory distress is addressed by treating the underlying cause of these compensatory changes, while supporting oxygenation with a supplemental source.
Respiratory Failure: Respiratory Failure occurs when the body reaches a point of exhaustion and is unable to compensate any longer for the underlying cause of respiratory distress. An example of this would be when an asthma patient becomes exhausted after a prolonged attack. Respirations begin to slow, accessory muscle use become sluggish, and LOC begins to decrease. This is much like decompensated shock, where the mechanisms that were active to maintain homeostasis begin to fail after a period of compensation. Respiratory failure is addressed with ventilatory support via a BVM and oxygen. If not addressed in time, the patient will progress to respiratory arrest, and then cardiac arrest.
To simplify things: Respiratory distress is usually an issue with oxygenation, whereas respiratory failure is an issue with ventilation.
So, during our initial assessment of the patient’s breathing, we are looking to identify any evidence of respiratory distress, and provide early O2, and/or identifying respiratory failure and providing ventilatory support immediately.
“Most” patients do not require interventions here, however, missing respiratory decompensation can mean significant risk of mortality for the patient.
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