Hyperventilation and hypoventilation are a sign/symptom of a variety of emergencies that range from life-threatening (such as an acute pulmonary embolism) to more mild (anxiety).
It is important to identify these emergencies and how to appropriately manage them.
Lessons and Concepts:
In the section, we will look at the anatomy of the respiratory system, respiratory cycle, hyperventilation, and hypoventilation.
Anatomy of Respiratory System:
Upper Airway Anatomy:
Nasal Cavity: This is the most superior part of the airway
Lateral and superior walls of nasal cavity have maxillary, frontal, nasal, ethmoid, and sphenoid bones
Floor of nasal cavity is the hard palate
Septum separates the right and left nasal cavity
Oral Cavity: Cheeks, hard and soft palates, and tongue form the mouth also known as oral cavity
Pharynx: Muscular tube that extends vertically from the back of the soft palate to the superior aspect of the esophagus. This allows the air to flow in and out of the respiratory tract. It is divided into three regions:
Nasopharynx: uppermost region which runs from back of nasal opening to the plane of the soft palate
Oropharynx: it runs from the plane of the soft palate to the hyoid bone
Laryngopharynx is extremely important in airway management. It extends posteriorly from the hyoid bone to the esophagus and anteriorly to the larynx
Larynx: this is a complex structure that joins the pharynx with the trachea
Midline the neck and attached to and lies inferior to hyoid bone and anterior to the esophagus
Consist of thyroid and cricoid cartilage, glottic opening, vocal cords, arytenoid cartilage, pyriform fossae, and cricothyroid membrane
Lower Airway Anatomy:
Trachea: location where air first enters the lower airway
It is a 10-12 cm long tube that connects the larynx to the two mainstem bronchi (right and left). Contains cartilaginous, C-shaped, open rings that rom a frame to keep it open
Carina: location that the trachea divides into right and left bronchi
Right mainstem bronchus is fairly straight
Often times when an endotracheal tube is inserted to far it will enter here causing only ventilation to the right lung
Left mainstem bronchus angles more acutely to the left
Alveoli: air sacs at the terminal ends of the bronchioles
Location of gas exchange
Surrounded by the alveolocapillary that is only 1 cell layer thick
Left lung: 2 lobes: upper and lower (smaller as it shares space with the heart
Pleura: membranous connective tissue that covers the lungs
Two layers: Visceral pleura: envelopes the lungs but does not contain nerve fibers
Parietal pleura: lines the thoracic cavity and contains nerve fib
Space between the two is called pleural space-contains small amount of fluid that reduces friction between pleural layers during respirations
Respiration and Ventilation:
Respiration: exchange of gases between living organism and its environment
Pulmonary respiration occurs in the lungs when the respiratory gases are exchanged between the alveoli and red blood cells in the pulmonary capillaries
Ventilation: mechanical process that moves air in and out of lungs
Respiratory Cycle: includes inhalation and exhalation
Inhalation is an active process
Exhalation is a passive process
Ventilation is dependent on the change in pressure within the thoracic cavity
Breathing occurs as follows:
1. Begins when lungs have achieved a normal expiration and the pressure inside the thoracic cavity is the same as the atmospheric pressure
2. Respiratory centers in the brain signal the diaphragm through the phrenic nerve, causing it contract
3. As the diaphragm contracts, the thorax increases in size, dropping intrathoracic pressure lower than atmospheric pressure
4. This "negative" pressure draws air into the thorax through the airways
5. Visceral and parietal pleura remain in contact with each other, and the lungs assume the thoracic cavity's internal contour, causing them to expand as the rib cage opens
6. As air is drawn into the lungs, the alveoli inflate
7. They become thinner as they expand, and oxygen and carbon dioxide diffuse across the alveolocapillary membrane
8. Once the pressure in the thoracic cavity reaches atmospheric pressure again, the alveoli are maximally inflated
9. Stretch receptors signal the vagus nerve to inhibit inspiration and air influx stops, in turn preventing overinflation of the lungs
10. At the end of inspiration, the respiratory muscles relax; the chest cavity decreases in size and intrathoracic pressure is now greater than atmospheric pressure
11. The lungs recoil and force air out through the airway. This is known as expiration, which will continue until intrathoracic and atmospheric pressure equalize
One way to understand hypoventilation and hyperventilation is to see them as noticeable (and often prolonged) change in normal minute volume (the total volume of air that moves in and out of the respiratory tract in one minute).
The equation for minute volume is as follows: Vmin = Vt x Respiratory Rate * Vmin = minute volume *Vt = tidal volume: the amount of air moved through the respiratory system with each breath
Pathology of hyperventilation
Hyperventilation is an increase in respiratory rate
Increased respirations --> Increased elimination of CO2 --> Progressively lower exhaled CO2 level --> Respiratory alkalosis
**An increase in metabolic rate can trigger hyperventilation
Hyperventilation syndrome is when dyspnea occurs with no other lung abnormalities. This is caused by the brain's respiratory centers being stimulated by things such as: anxiety, fear, or hysteria Causes of hyperventilation
Liver failure causes an accumulation of ammonia in the blood. The increase in ammonia will often stimulate the respiratory center and cause hyperventilation and results in metabolic alkalosis
Note: Higher altitudes mean lower air pressure and subsequently lower volumes of oxygen. To compensate, respiratory rate will increase. This condition can be corrected wither over time (the body increased RBC count) or by bringing the individual to a lower altitude
Pathology of hypoventilation
Hypoventilation is a decrease in respiratory rate
Decreased respirations --> Increased CO2 retention --> Progressively elevated exhaled CO2 levels --> Respiratory acidosis
Causes of hypoventilation
Overdose
Brainstem injury
Injury to the thorax
Some infections
Pain
Inability to inspire (traumatic asphyxia)
Lung collapse as seen in a pneumothorax, hemothorax, or combination of the two
Airway obstructions
Obstructive diseases such as asthma and emphysema
Important notes on respiratory acidosis
Hypoventilation can lead to respiratory acidosis
Respiratory acidosis is when the respiratory system cannot effectively eliminate all the carbon dioxide generated through metabolic activities in the peripheral tissues
There is in increase in PCO2 and a decrease in pH
Recognition
In this section, we will look at the signs and symptoms for hyperventilation and hypoventilation
Important values
Normal respiratory rate is 12-20 breaths per minute with an EtCO of 35-45 mmHg Hyperventilation is anything over 20 breaths per minute with an EtCO: under 35 mmHg
Hypoventilation is anything under 12 breaths per minute with an EtCO over 45 mmHg
Normal blood pH is 7.35-7.45
--> Hyperventilation causes respiratory alkalosis which results in hypocapnia (deficiency in CO2)
Alkalosis is an excess of base in the body. The pH will be higher than 7.45
--> Hypoventilation causes respiratory acidosis which results in hypercapnia (excess CO2)
Acidosis is an excess of acid in the body. The pH will be lower than 7.35
Tidal volume (Vt) is 5-7mL/kg. In an adult male it is approximately 500 mL
Symptoms associated with hyperventilation:
Anxiety
Dizziness/lightheadedness
Chest pain
Numbness
Tingling of hands and feet
Sense of dyspnea even though they present with rapid breathing
Symptoms associated with hypoventilation:
Fatigue
Headache
Cyanosis
Confusion
Hypoxia
Treatment and Management
In this section, we will look at respiratory system assessment as well as treatment and management of hyperventilation and hypoventilation
Respiratory System Assessment:
Primary Assessment:
Remember ABCs
Assess make sure that the patient's airway is patent (no snoring or gurgling) Ensure airway is open either by jaw thrust or head-tilt chin-lift
Determine if breathing is adequate
Provide adequate ventilatory assistance as needed for those patients with decreased respiratory drive
You may use supplementary oxygen and/or BVM to maintain an SPO2 of 94% or greater or a CO2 of 35-45 mmHg
Patients receiving ventilatory assistance or who have an altered level of consciousness should have an airway adjunct in place such as a NPA or OPA
PARAMEDIC LEVEL: Intubation should be considered in patients who are difficult to ventilated with basic ventilatory support or who have trouble maintaining their airway
*Considerations*
Have suctioning device readily available
Place patient on a cardiac monitor and obtain a 12-lead ECG
Make sure to NEVER allow a patient to blow in a paper bag if they are hyperventilating
Even though blowing in a paper bag will help correct the decreased CO2 levels, it can worsen hypoxia and the patient's overall condition
Always make sure to encourage the patient to be transported and be seen in a hospital setting
Secondary Assessment:
**Once you have corrected any life-threatening issues, you should conduct a secondary assessment
History: This is the time you need to try to get the patients history from either the patient or family/friends that may be around
Physical Examination: For respiratory patients, it is important to continue to evaluate the ABCs. You will use this time for inspection, auscultation, and palpation.
Inspection: You use this time to check for any obvious signs of trauma, observe patient's position, i.e. tripod positioning (leaning forward with hands or elbows resting on lower legs), or orthopnea (difficulty breathing when lying down)
Auscultation: Listen for adequate movement of air. Begin by listening to the mouth and nose and then to the chest. When listening to the chest, you should be checking right and left apex (beneath the clavicle), right and left base (8th or 9th intercostal space, midclavicular line, and the right and left lower thoracic back or right and left midaxillary line (4th or 5th intercostal space, on lateral aspect of chest.) During this time, you should be checking for any sounds that indicate airflow compromise such as: stridor, wheezing, or quiet. You should also be listening for crackles or rhonchi which indicate a comprise of gas exchange (see videos on lung auscultation and lung sounds)
Palpation: During this time you should check the chest for rise and fall as well as for tenderness, abdominal distension, symmetry, abnormal motion, crepitus, and subcutaneous emphysema
Dispatch Information: You are dispatched to a 39-year-old African American male complaining of Scenario 1 weakness and not feeling well. Scene Information: You enter a single-story residence to find your patient sitting on a couch. The house is noted to be cluttered with multiple medication bottles sitting around. He is alert and oriented but appears to have deep and respirations. Patient is also noted to have the smell of acetone on his breath. It is important to note the deep rapid respirations and smell of acetone on the patients breathe. These are key indicators of the possible cause of the patient's reason for seeking EMS today. Patient Information: Patient a known history of HTN, CHF, and Diabetes Type 2. Patient is also currently taking steroids for a respiratory infection. Treatment information: The patient is alert to time, place, person, and events. Airway is open and clear. Breathing is deep and rapid at a rate of 40 breaths per minute. Breath sounds are clear and equal bilaterally. Radial pulses are weak, rapid, and regular at a rate of 120 beats per minute. Skin is warm, dry, and pale. Upon assessment the patient has poor skin turgor and dry mucus membranes. His blood pressure is 98/52, SPO2 91% on room air and capnography shows a rapid and deep waveform with a CO2 of 29 mm/hg. When you assess the patient's blood glucose your meter reads HI. A 12 lead assessment reveals sinus tachycardia with peaked T-waves. Treatment for this patient should consist of high flow oxygen to help with removal of ketones that are being produced as a result of DKA. The patient should also receive either a Lactated Ringers or 0.9% Normal Saline bolus of 20 mL/kg due to signs of dehydration. Transport information: During transport the patient's level of consciousness begins to decrease and the patient is only alert to verbal stimuli. He states that his fingertips are numb, and he feels dizzy. Due to the patient having increased the reservoir on the non-rebreather is not staying inflated even at 15 lpm. At this time, it would be appropriate to insert a BLS airway adjunct (most likely an NPA) and provide ventilatory assistance with a BVM and high flow oxygen.
Scenario 2 Dispatch Information: You respond to a very prominent neighborhood for a 16-year-old Caucasian female who was found unresponsive in her room. Scene Information: Upon arrival her frantic parents meet you at the front door and lead you up to her room. She is found lying on her bed with snoring respirations. Her parents state they last saw her approximately an hour ago after she returned from a friend's house. Patient Information: Her parents state she has no known allergies, takes no regular medications, and has no medical problems. She is a straight A student at her local high school and plays basketball for her high school team. Treatment Information: You find the patient does not respond to stimuli. She has snoring respirations that subside when the airway is repositioned. She is breathing 6 times a minute with shallow respirations. Radial pulses are weak and thready at 140 beats per minute. Skin is pale and clammy with peripheral cyanosis noted. Initial SP02 is 77% on room air and capnography waveform is slow and shallow with a CO2 of 78. Initial blood pressure is 82/40. After placing a NPA you begin providing ventilatory assistance with a BVM with on breath every six seconds. You placed the patient on an EKG monitor which shows sinus tachycardia. This is confirmed by 12 lead assessment. Her blood glucose is 100 mg/dL. You obtain an IV and administer a 0.9% Normal Saline Bolus at 20 mL/kg. A detailed assessment of the body reveals no signs of injury. Transport Information: During transport minimal improvement is noted in the patient's status. You assess the patient's pupils and find them pinpoint. You also, find an unknown substance in a baggy located in the patient's shirt pocket. Due to these findings, you administer 0.4 mg Naloxone IVP. Soon after administration you note improvement in the patient's respiratory drive and her skin is now pink with no cyanosis noted.
Tips and Tricks
Patients with altered level of consciousness should have ventilatory support given
When providing ventilatory assistance make sure to maintain a rate of 1 breath every 6 seconds. This will decrease the amount of gastric distention
Padding behind the shoulders of a pediatric patient will help when providing ventilatory support
Placing a towel roll behind an adult patient's neck will help keep the airway open
Hyper means "above" or "in excess". In hyperventilation you have an increase in respiration and pH (low ETCO2)
Hypo means "below" or "less than normal". In hypoventilation you have a decrease in respirations and pH (high ETCO2)
Correcting both hyperventilation and hypoventilation is most often done by correcting the underlying issue
Field Tip
Sometimes providing a ventilatory assistance alone in narcotic overdoses will cause the patient respirations to spontaneously increase
References
1. American Academy of Orthopaedic Surgeons (AAOS) (2012). Nancy Caroline's: Emergency Care in the Streets (7th edition). (A. N. Pollak, Ed.). Jones & Bartlett Learning.
The Respiratory System Is A Complex Network of Organs Responsible For Gas Exchange, Ensuring Oxygen Is Supplied To The Body and Carbon Dioxide Is Expelled. Here's A Detailed Overview Based On The
The Respiratory System Is A Complex Network of Organs Responsible For Gas Exchange, Ensuring Oxygen Is Supplied To The Body and Carbon Dioxide Is Expelled. Here's A Detailed Overview Based On The
