Planning Your Time: Plan 180 minutes for this chapter.
Physiology and Pathophysiology (45 minutes)
Respiration (45 minutes)
Positive Pressure Ventilation (30 minutes)
Oxygen Therapy (30 minutes)
Special Considerations (15 minutes)
Assisting With Advanced Airway Devices (15 minutes)
Note: The total teaching time recommended is only a guideline.
Core concepts:
Physiology and pathophysiology of the respiratory system
How to recognize adequate and inadequate breathing
Principles and techniques of positive pressure ventilation
Principles and techniques of oxygen administration
Teaching Time: 45 minutes
Teaching Tips: This lesson lends itself well to multimedia presentations. Anatomical models and web graphics will enhance your presentation on physiology and pathophysiology. Use real-life examples. Adults grasp pathophysiology best when they can apply it to actual situations. For each disorder, discuss actual examples and move from theory to reality. An understanding of alveolar ventilation will improve the assessment of respiratory dysfunction. When later discussing pathophysiology, bring the discussion back to the overall impact on alveolar ventilation. Spend time on the process of diffusion. An understanding of this fundamental concept will enhance comprehension of later lectures on pathophysiology. Reach back to include the concepts of minute volume and alveolar ventilation. Describe how they influence respiration.
Covers Objective: 10.3
Point to Emphasize: Negative pressure in the chest is used to move air in, and positive pressure in the chest is used to move air out.
Discussion Topic: Mechanically speaking, describe how the body moves air into and out of the lungs.
Class Activity: Have students work in groups, using household items, to construct a model of respiratory function that uses negative pressure to move air. Have groups present their models to the class and describe their particular processes of moving air.
Covers Objective: 10.3
Knowledge Application: Have students describe the pressures of breathing. Discuss the role of both positive and negative pressure in moving air.
Talking Points: It may be helpful to think of the chest as a syringe. As the plunger is withdrawn, the diaphragm is lowered and a negative pressure is created in the chest. Air is pulled in through the hole in the top.
Covers Objective: 10.3
Covers Objective: 10.5
Point to Emphasize: Alveolar ventilation refers to the amount of air that actually reaches the alveoli. This volume of air is responsible for gas exchange. Any problem that minimizes air flow to the alveoli diminishes alveolar ventilation.
Discussion Topics: Discuss the role of rate and tidal volume with regard to minute volume. Using examples, explain how changes to either of these elements affect minute volume.
Define alveolar ventilation. Give examples of how changes in rate and volume impact alveolar ventilation.
Covers Objective: 10.5
Point to Emphasize: Alveolar ventilation refers to the amount of air that actually reaches the alveoli. This volume of air is responsible for gas exchange. Any problem that minimizes air flow to the alveoli diminishes alveolar ventilation.
Discussion Topics: Discuss the role of rate and tidal volume with regard to minute volume. Using examples, explain how changes to either of these elements affect minute volume.
Define alveolar ventilation. Give examples of how changes in rate and volume impact alveolar ventilation.
Covers Objective: 10.6
Point to Emphasize: External respiration refers to the mechanical movement of air in and out of the body. Internal respiration refers to the diffusion of oxygen and carbon dioxide at the cellular level.
Knowledge Application: Instructors have traditionally "traced the flow of a drop of blood through the heart." Consider tracing the flow of a molecule of oxygen through the respiratory system. Discuss the various factors that influence the ability of oxygen to reach the alveoli.
Covers Objective: 10.6
Discussion Topic: Describe how the respiratory system relies on the cardiovascular system to provide normal physiologic function.
Covers Objective: 10.7
Point to Emphasize: Injuries and illness interrupt normal function of the respiratory and cardiovascular systems. A problem with one system often affects the other.
Knowledge Application: Discuss the pathophysiology (the negative impact) of the following disorders on both internal and external respiration: severe bronchospasm, severe external hemorrhage, slowed breathing due to narcotic overdose.
Critical Thinking: Anticipate the pathophysiology lecture by asking this question: How might a respiratory challenge (such as asthma) affect minute volume and alveolar ventilation?
Teaching Time: 45 minutes
Teaching Tips: Teach assessment in the context of decision making—for example, "As an EMT, you will use these findings to identify inadequate breathing." Many of the findings of inadequate breathing are visual. Use pictures and other multimedia graphics to illustrate potential findings. Relate inadequate breathing to hypoxia. Describe how signs and symptoms overlap.
Covers Objective: 10.2
Discussion Topics: Define adequate breathing. Define hypoxia. Describe three different examples that show how a patient might become hypoxic.
Covers Objective: 10.2
Discussion Topic: Discuss how you would assess breathing. Consider both a conscious patient and an unconscious patient.
Class Activity: Describe a respiratory assessment. Based on the findings that you present, ask the class to classify your patient as being in either respiratory distress or respiratory failure. Discuss.
Critical Thinking: Certain conditions, such as diabetic ketoacidosis, make the body more acidic. This change in the pH decreases the hemoglobin's ability to hold onto oxygen. What effect might an acidotic condition have upon internal and external respiration?
Covers Objective: 10.7
Covers Objective: 10.7
Discussion Topic: Explain how the body compensates for inadequate breathing. Discuss the changes that occur.
Class Activity: List specific compensatory steps. Have students explain why these steps might fail over time, and discuss the net effect on respiration when the failure occurs.
Knowledge Applications: Discuss compensation for inadequate breathing. Describe specific compensatory steps and ask students to describe external findings. Describe a patient scenario that includes a patient who is compensating for a respiratory challenge. Ask students to explain the origins of the signs and symptoms that they identify.
Covers Objective: 10.8
Covers Objective: 10.8
Covers Objective: 10.9
Covers Objective: 10.9
Talking Points: Consider what occurs in respiratory failure: compensation fails. Therefore the assessment should focus on identifying these signs. Look for decompensation.
Covers Objective: 10.9
Talking Points: Consider what occurs in respiratory failure: compensation fails. Therefore the assessment should focus on identifying these signs. Look for decompensation.
Covers Objective: 10.9
Discussion Topic: Define respiratory failure. Discuss the changes that occur when compensation fails.
Knowledge Application: Compare and contrast respiratory distress with respiratory failure (inadequate breathing) in the following areas: lung sounds, respiratory rate, skin color, mental status.
Covers Objective: 10.10
Knowledge Application: Use media resources or a detailed scenario to present students with a ventilation decision. Discuss.
Covers Objective: 10.10
Talking Points: Any signs of respiratory failure. Altered mental status, slow or irregular respirations, continued cyanosis, or any of the other signs previously discussed could indicate the need for immediate intervention.
Teaching Time: 30 minutes
Teaching Tips: When covering this topic, practice decision making. Understand the negative side effects of positive pressure ventilation before assisting a patient. As you move on to discuss the techniques for artificial ventilation have the students practice the skills and that they are achieving adequate artificial ventilation.
Covers Objective: 10.12
Points to Emphasize: Artificial ventilation utilizes positive pressure to move air into the lungs. The body normally uses negative pressure to pull air in. As these are very different processes, positive pressure has negative side effects. Cricoid pressure can minimize gastric distention during artificial ventilation.
Covers Objective: 10.12
Discussion Topic: Discuss the negative impact of poor artificial ventilation technique. Consider the outcome of the following problems: rate too fast; too much volume; inadequate mask seal.
Covers Objective: 10.12
Knowledge Applications: Discuss scenarios with the class. Ask the class to determine the need for artificial ventilation. Discuss the decision-making process.
Divide the class into two groups. Use a scenario to review the cost-benefit analysis of a "ventilate vs. not ventilate" decision. Have students debate both arguments. Discuss.
Covers Objective: 10.12
Point to Emphasize: Ventilating a breathing patient may be difficult. The goal is not necessarily to take over breathing, but rather to increase tidal volume.
Covers Objective: 10.12
Covers Objective: 10.13
Point to Emphasize: A variety of methods are used to artificially ventilate a patient. EMTs should be familiar with the tools and techniques available to them.
Covers Objective: 10.13
Point to Emphasize: A variety of methods are used to artificially ventilate a patient. EMTs should be familiar with the tools and techniques available to them.
Covers Objective: 10.13
Discussion Topic: Discuss the procedure for ventilating a patient with a pocket mask.
Covers Objective: 10.13
Discussion Topic: Discuss the procedure for ventilating a patient with a pocket mask.
Covers Objective: 10.13
Covers Objective: 10.13
Covers Objective: 10.13
Covers Objective: 10.13
Point to Emphasize: A good mask seal is an important and often difficult element of bag-valve-mask ventilation.
Covers Objective: 10.13
Covers Objective: 10.13
Covers Objective: 10.13
Covers Objective: 10.13
Covers Objective: 10.13
Covers Objective: 10.13
Class Activities: Distribute clean face masks. Have students choose a partner and practice obtaining good hand position and face seal using a pocket mask or BVM face mask. (Do not ventilate.) Try obtaining the seal in different positions (patient supine, patient sitting up, and so on). Have students choose a partner and find the appropriate finger position for cricoid pressure. Check their locations.
Covers Objective: 10.13
Covers Objective: 10.13
Covers Objective: 10.13
Covers Objective: 10.13
Covers Objective: 10.14
Discussion Topic: Discuss the procedure for ventilating a patient with a bag-valve mask.
Covers Objective: 10.16
Covers Objective: 10.16
Discussion Topic: Discuss the procedure for artificially ventilating a stoma patient.
Covers Objective: 10.13
Covers Objective: 10.13
Discussion Topic: Discuss the procedure for ventilating a patient with a flow-restricted, oxygen-powered ventilation device.
Covers Objective: 10.13
Covers Objective: 10.13
Knowledge Application: Describe a variety of patient scenarios. Ask students to choose a method to artificially ventilate the patient in each scenario. Discuss why the chosen method would be appropriate or inappropriate.
Critical Thinking: If using a BVM was ineffective at ventilating a patient, what would the next step be? What are the alternatives?
Covers Objective: 10.13
Knowledge Application: Describe a variety of patient scenarios. Ask students to choose a method to artificially ventilate the patient in each scenario. Discuss why the chosen method would be appropriate or inappropriate.
Critical Thinking: If using a BVM was ineffective at ventilating a patient, what would the next step be? What are the alternatives?
Covers Objective: 10.17
Talking Points: Each airway management scenario is slightly different. Factors such as resources, personnel, and even levels of training might impact the choice you make. Generally speaking, it is best to start simply and work to a more complex level only when necessary.
Teaching Time: 30 minutes
Teaching Tips: This section deals primarily with psychomotor skills. Although there are didactic components, be sure to allot enough time for skills practice. Have appropriate assistance. Closely monitor and frequently correct students. Use standardized skill sheets to assess competency when practicing the various methods of administering supplemental oxygen. Prepare a variety of oxygen-related visual aids prior to this lesson. This section references many parts and pieces and is significantly enhanced by examples.
Covers Objective: 10.11
Point to Emphasize: Supplemental oxygen therapy can benefit a variety of injuries and illnesses.
Discussion Topic: Discuss the value of supplemental oxygen. What conditions might benefit from supplemental oxygen?
Covers Objective: 10.21
Point to Emphasize: There are many components to an oxygen delivery system. Some are universal, while others are system specific. EMTs always should obtain appropriate training on their specific oxygen delivery system.
Discussion Topic: Discuss the general procedure for preparing an oxygen delivery system.
Covers Objective: 10.21
Point to Emphasize: There are many components to an oxygen delivery system. Some are universal, while others are system specific. EMTs always should obtain appropriate training on their specific oxygen delivery system.
Discussion Topic: Discuss the general procedure for preparing an oxygen delivery system.
Covers Objective: 10.21
Point to Emphasize: There are many components to an oxygen delivery system. Some are universal, while others are system specific. EMTs always should obtain appropriate training on their specific oxygen delivery system.
Discussion Topic: Discuss the general procedure for preparing an oxygen delivery system.
Covers Objective: 10.21
Covers Objective: 10.21
Covers Objective: 10.20
Point to Emphasize: Safety is an essential consideration for an EMT who is handling pressurized oxygen.
Discussion Topic: Discuss the potential dangers associated with the handling of oxygen and compressed gas in general.
Covers Objective: 10.20
Covers Objective: 10.20
Covers Objective: 10.20
Covers Objective: 10.21
Covers Objective: 10.21
Covers Objective: 10.21
Covers Objective: 10.21
Covers Objective: 10.18
Knowledge Application: Describe a series of patients who require supplemental oxygen. Have students choose an oxygen delivery device and explain why they feel that the particular device would work for the specific patient. Discuss.
Critical Thinking: You are treating an end-stage COPD patient who is complaining of respiratory distress. You note cyanosis in his lips and nail beds. As you begin to prepare your oxygen tank for delivery of supplemental oxygen, the patient's home health nurse tells you that the patient cannot have oxygen due to his COPD. Given this information, what do you do?
Covers Objective: 10.18
Knowledge Application: Describe a series of patients who require supplemental oxygen. Have students choose an oxygen delivery device and explain why they feel that the particular device would work for the specific patient. Discuss.
Critical Thinking: You are treating an end-stage COPD patient who is complaining of respiratory distress. You note cyanosis in his lips and nail beds. As you begin to prepare your oxygen tank for delivery of supplemental oxygen, the patient's home health nurse tells you that the patient cannot have oxygen due to his COPD. Given this information, what do you do?
Covers Objective: 10.20
Covers Objective: 10.20
Covers Objective: 10.18
Point to Emphasize: Specific oxygen delivery devices can be used to administer different concentrations and flow rates of oxygen.
Discussion Topic: Discuss the general procedure for administering supplemental oxygen.
Covers Objective: 10.18
Point to Emphasize: Specific oxygen delivery devices can be used to administer different concentrations and flow rates of oxygen.
Discussion Topic: Discuss the general procedure for administering supplemental oxygen.
Covers Objective: 10.18
Covers Objective: 10.18
Covers Objective: 10.18
Covers Objective: 10.18
Covers Objective: 10.18
Covers Objective: 10.18
Covers Objective: 10.18
Covers Objective: 10.18
Covers Objective: 10.18
Covers Objective: 10.18
Covers Objective: 10.18
Covers Objective: 10.18
Discussion Topic: Describe the differences among oxygen delivery devices. Cite specific capabilities of the following: a nonrebreather mask; a nasal cannula; a partial rebreather mask; a Venturi mask.
Class Activities: Have a class scavenger hunt. Assign students to a station or a medical facility and have them photograph as many oxygen delivery devices as they can. Discuss.
Consider taking a field trip to the back of an ambulance. Many of the referenced systems and appliances will be present there.
Covers Objective: 10.18
Video Clip
Oxygen Administration via a Non-Rebreather Mask
What type of patient is this mask indicated for?
How does the device work?
Explain the procedure for applying a nonrebreather mask.
Teaching Time: 15 minutes
Teaching Tips: Multimedia graphics of facial injuries may enhance comprehension of special ventilatory circumstances. Have pediatric anatomy models on hand to illustrate differences. Demonstrate pediatric-specific airway equipment.
Covers Objective: 10.17
Point to Emphasize: Facial injuries may impair breathing and alter the procedure for providing artificial respirations.
Discussion Topic: Discuss how a facial injury or airway obstruction might interfere with your ability to provide artificial ventilation.
Knowledge Application: Provide examples of facial injuries (and/or show graphics) and discuss methods for properly administering artificial ventilations. Particularly highlight how such injuries might alter normal procedures.
Covers Objective: 10.17
Points to Emphasize: Airway obstructions may require action prior to the administration of artificial ventilations or supplemental oxygen. Dental appliances should be left in place, but they can potentially threaten airway management. If they interfere with the airway, an EMT should remove them.
Knowledge Application: Divide the class into small groups. Assign each group a special consideration such as a facial injury, a pediatric patient, dentures, and so on. Have each group discuss the potential challenges, improvise a solution, and present its findings to the class.
Covers Objective: 10.17
Covers Objective: 10.17
Discussion Topic: Describe examples of pediatric airway anatomy (or pediatric anatomy in general) that might make providing artificial ventilations more difficult.
Covers Objective: 10.17
Point to Emphasize: Pediatric patients often are anatomically different from adults and may require specialized artificial ventilation techniques and equipment.
Class Activity: Referring to a standardized skill competency sheet, and using pediatric airway manikins, demonstrate the proper one- and two-person techniques for delivering ventilations using a bag-valve mask on an infant and a child.
Critical Thinking: In this section we highlighted some specific circumstances that might make artificial ventilations and supplemental oxygen delivery more difficult. There are many other difficult situations. What others can you think of? Discuss.
Teaching Time: 15 minutes
Teaching Tips: Invite an advanced provider to discuss the teamwork associated with advanced airway placement. Have advanced airway devices and associated equipment on hand for familiarization. Focus on confirmation. This is an absolutely essential goal for the entire team.
Covers Objective: 10.17
Point to Emphasize: There are two general categories of advanced airway devices: devices that require direct visualization of the glottic opening, and devices that are inserted "blindly."
Knowledge Application: Have students work in small groups. Assign each group a specific type of advanced airway. Have the group research and present the procedure used to insert the airway device.
Covers Objective: 10.17
Point to Emphasize: There are two general categories of advanced airway devices: devices that require direct visualization of the glottic opening, and devices that are inserted "blindly."
Knowledge Application: Have students work in small groups. Assign each group a specific type of advanced airway. Have the group research and present the procedure used to insert the airway device.
Points to Emphasize: The most important thing that an EMT can do to further the success of the insertion of an advanced airway is to assure a patent airway and quality ventilations prior to insertion of the device. EMTs often play a role in confirming the correct placement of an advanced airway.
Discussion Topics: Explain the importance of hyperoxygenation prior to the insertion of an advanced airway. Discuss the role of an EMT in the process of inserting an advanced airway. Discuss the importance of confirming an endotracheal tube's placement. Discuss methods that you might use.
Covers Objective: 10.12
Point to Emphasize: When ventilating through an endotracheal tube, an EMT should carefully monitor the tube's position and report any changes in resistance to ventilation.
Knowledge Application: Assign an advanced provider to small groups of students. Using an airway manikin, practice advanced airway procedures.
Point to Emphasize: Intubation of the trauma patient requires manual stabilization of the patient's head while the advanced provider inserts the airway.
Discussion Topic: Describe the teamwork necessary to intubate a trauma patient.
Class Activity: Combine classes. Join with an advanced class and practice the teamwork necessary to insert an advanced airway.
Knowledge Application: Using an airway manikin, practice the hand position necessary to maintain stabilization during a trauma intubation.
Covers Objective: 10.17
Critical Thinking: What is the role of the EMT when an advanced airway fails? How might an EMT help in a "failure to intubate" situation?
Video Clip
In-Hospital Endotracheal Intubation
Explain why a patient who requires endotracheal intubation should be pre-oxygenated.
How should an EMT test equipment prior to intubating a patient?
Where should cricoid pressure be applied during an intubation attempt?
How should an endotracheal intubation be confirmed?
Why is verification of endotracheal tube placement essential?
What should an EMT do if the endotracheal tube is placed in the esophagus?
Talking Points: Signs of respiratory distress include increased rate, accessory muscle use. Mental status is typically normal and hypoxia is usually not profound.
Signs of respiratory failure include all the signs of respiratory distress plus altered mental status, cyanosis, profound hypoxia and slowing or irregular breathing.
The recommended technique for BVM is two providers. One provider seals the mask while the second provider squeezes the bag. With one rescuer, the E-C clamp is used to hold the mask on the face with one hand while the second hand is used to squeeze the bag.
Talking Points: Normal ventilation uses negative pressure to pull air into the lungs. Positive pressure ventilation uses positive pressure.
There are many possibilities of conditions that would benefit from oxygen therapy. Consider any condition that leads to hypoxia. Choosing the correct delivery device requires consideration of the patient's capabilities (breathing or not breathing; positive pressure vs. supplemental delivery) and whether or not the patient will tolerate a face mask.
Talking Points: This patient is in respiratory failure as demonstrated by a slow respiratory rate, altered mental status and cyanosis. This patient needs artificial ventilation.
