Lesson 5
Breathing, Ventilation, and
Oxygenation
Anatomy (1 of 3)
• Ribs
–12 pairs
• 10 pairs attach to sternum and
spine
• 2 pairs (floating ribs) attach only
in back
–An intercostal nerve, artery,
and vein are found along the
inferior border of each rib
Anatomy (2 of 3)
• Lungs
• Mediastinum
–Trachea
–Esophagus
–Main bronchi
Anatomy (3 of 3)
• Mediastinum
–Heart
–Major arteries
• Aorta and branches
• Pulmonary arteries
–Veins
• Superior vena cava
• Pulmonary veins
Physiology of Life Review
• Oxygen is transported across the
alveolar–capillary membrane
• It then attaches to hemoglobin in red blood
cells for transport to the
rest of the body
• At the same time, CO2
moves from the blood
plasma into the alveoli
Breathing
• The mechanical act of moving
air into the lungs and alveoli
• Controlled by the respiratory
center of the brain
• Chemoreceptors located in the aorta and
carotid arteries stimulate the respiratory
center
• Rate and depth of ventilation are
continuously adjusted to maintain normal
PaCO2 levels
Breathing Assessment (1 of 7)
• Normal breathing is not a noticeable
process
• If the patient’s breathing draws your
attention, then there is a problem until
proven otherwise
– Some examples include:
• Breathing you can hear from across the
room
• Inability to speak in complete sentences
• Patient positioning to ease breathing
(e.g., tripoding)
Breathing Assessment (2 of 7)
• Look (observe)
• Listen (auscultate)
• Feel (palpate)
© Jones & Bartlett Learning. Courtesy of MIEMSS.
Breathing Assessment (3 of 7)
• Look (observe)
– Increased respiratory
effort
• Positioning
• Use of accessory
muscles
• Retractions
• Nasal flaring in
children
Courtesy of Health Resources and Services Administration, Maternal and Child
Health Bureau, Emergency Medical Service for Children Program
Breathing Assessment (4 of 7)
• Look (observe) (cont’d)
– Visible signs of trauma
•
•
•
•
•
Contusions
Hematomas
Lacerations
Sucking chest wound
Paradoxical movement
of the chest wall
Breathing Assessment (5 of 7)
• Listen (auscultate)
for breath sounds
– Presence
• Equality (right and
left)
• Asymmetric
– Decreased on one
side
– Absent
© Jones & Bartlett Learning. Courtesy of MIEMSS.
Breathing Assessment (6 of 7)
• Listen (auscultate) for breath sounds
(cont’d)
– Abnormal sounds
•
•
•
•
Wheezing
Rales
Rhonchi
Crepitus (bony or subcutaneous emphysema)
Breathing Assessment (7 of 7)
• Feel (palpate) the chest for:
– Bony crepitus
– Subcutaneous emphysema
– Abnormal movement of the chest wall
– Bony tenderness
Common Injuries That Affect
Breathing
• Pneumothorax
– Simple
– Tension
– Open
• Hemothorax
• Rib fractures
– Simple
– Flail chest
Pneumothorax
• Present in up to 20% of severe chest injuries
• Classified as either:
– Simple
– Tension
– Open
• A simple pneumothorax may progress to a
tension pneumothorax as air continues to
accumulate within the affected hemithorax
– Tension pneumothorax is life-threatening
– Needle decompression may be required
• May be associated with a hemothorax
Simple Versus Tension
Pneumothorax
• Simple
– Blunt or penetrating
injury
– Breath sounds
decreased or
absent
– Mild to moderate
ventilatory distress
– May progress to
tension
• Tension
– Blunt or penetrating
injury
– Breath sounds
decreased or
absent
– Marked ventilatory
distress
– Hemodynamic
compromise
How does the management differ?
Open Pneumothorax
• Penetrating
mechanism
– May be “sucking”
or “bubbling”
chest wound
• Respiratory distress
– Mild to severe
• May be associated with a hemothorax
• Optimal method of field management has
not been demonstrated
Hemothorax
•
•
•
•
Blunt or penetrating mechanism
Bleeding into the pleural cavity
May be associated with a pneumothorax
Air or blood in the
pleural space
compromises lung
capacity
Simple Rib Fractures
•
•
•
•
Most common thoracic injury
Usually involves ribs 4 through 8, laterally
Most common cause of hemothorax
Common complaints are chest pain and
shortness of breath
• May be associated with injuries to liver
and spleen
Flail Chest (1 of 2)
• Two or more adjacent ribs fractured in
more than one place
• Compromises the structural integrity of the
chest, causing
paradoxical
movement while
breathing
Flail Chest (2 of 2)
• Associated with underlying injury
–Pneumothorax
–Hemothorax
–Pulmonary contusion
Treatment of Chest Injuries
• The goal is to maintain or restore
adequate oxygenation and ventilation
– Administer supplemental oxygen
– Assist ventilations as necessary
– Seal open chest wounds
– Recognize and decompress tension
pneumothorax
• Continuous assessment of breathing is
essential
Supplemental Oxygen
• Can be administered by nonrebreathing
mask, a bag-mask device, or an
oxygen-powered ventilator
• Never withhold oxygen from a patient in
respiratory distress
• Monitor oxygen saturation
– Target SpO2 greater than 95%
• Increasing the levels of inspired oxygen
assists in maintaining aerobic metabolism
When to Assist Ventilations
• Ventilatory rate
– Greater than 30
– Less than 10
• Insufficient spontaneous tidal volume:
– Poor chest rise
– Use of accessory muscles
• Decreased SpO2
• Increased ETCO2
• Consider the need for airway management
Assisting Ventilations
Bag-Mask Devices
Manually-Triggered Devices
Automatic Devices
Courtesy of Impact Instrumentation, Inc.
Courtesy of AAOS
Ventilatory Rates and
Tidal Volumes
• Adult
– 10 to 12 breaths per minute (bpm)
– 500 to 800 ml
• Child
– 16 to 20 bpm
– 100 to 500 ml or until good chest rise
• Infant
– 25 bpm
– 6 to 8 ml/kg tidal volume
• Inadvertent hyperventilation may lead to poor
outcomes in patients with traumatic brain
injury
Monitoring Ventilations
• Capnometry and capnography
– Can monitor:
•
•
•
•
Spontaneously breathing patient
Bag-mask device
Endotracheal tube
Supraglottic airways
– Maintain between 35 to 45 mm Hg
– May give false reading in hypotension but can
be used to monitor trends
Needle Decompression
• Used to relieve tension pneumothorax
• Appropriate placement is essential:
– Second intercostal
space, midclavicular
line, over the rib
(preferred site)
– Fifth intercostal space,
midaxillary line, over
the rib (alternate site)
Summary
• Caring for a trauma patient experiencing
respiratory difficulty includes:
– Maintaining a patent airway
– Administering supplemental oxygen
– Supporting and monitoring ventilations
– Recognizing and decompressing tension
pneumothorax
Questions?