What is it?
• A conceptual tool used to understand our approach to assessing and intervening in patients with Airway and Breathing issues with the overall goal of optimising end organ oxygenation.
• The Spiral itself represents all patients either with, or the potential to develop, end organ oxygenation dysfunction
How does it work?
• Movement from the top of the Spiral to the bottom represents increasing patient acuity.
• Patients may initially present anywhere on the vertical scale of the Spiral.
• The width of the spiral represents the relative size of the patient population. Near the top of the Spiral, which represents patients with low acuity, the relative size of the patient population is large. Near the bottom of the Spiral, which represents patients with high acuity, the relative size of the patient population is small. i.e. As the patient’s acuity increases the relative size of the patient population decreases.
• The acuity of the patient is indicated by the relative invasiveness of the interventions listed within the spiral.
• In the top 2/3rd of the Spiral the patient’s condition can usually be categorized into either dysfunction of oxygenation or dysfunction of ventilation.
• Oxygenation refers to the lungs ability to extract oxygen from the gas within the lung
• Oxygenation can be estimated directly by the patient’s pO2 and indirectly by the patient’s SpO2.
• Oxygenation is determined by FiO2, V/Q matching (alveolar recruitment, function, and perfusion), and cardiac output.
• Ventilation refers to the mass movement of gas in and out of the lungs.
• Ventilation can be estimated directly by the patient’s pCO2 and indirectly by the patient’s EtCO2.
• Ventilation is determined by minute ventilation.
• Near the bottom of the spiral (patient’s with high acuity) dysfunction may develop into a mixed problem of both oxygenation and ventilation.
• In all patients regardless of acuity practitioners should consider supplemental oxygen, treatable causes, and initiating help.
• Suggested interventions are listed in a staged manner indicated by increasing invasiveness and are based on patient acuity as you move down the Spiral.
• The goal of treatment is to slow, stop, or reverse the progression of the patient’s condition down the Spiral.
• Interventions should be based on an assessment of the category of dysfunction, the magnitude of the dysfunction, and an estimate of the speed of progression of the dysfunction (CAT Analysis). (Type, size and speed)
• Highly invasive interventions in patients with high acuity presentations should also be based on the results of an airway assessment.
• Interventions should be matched to the patients acuity at initial presentation. (i.e. in high acuity initial presentations, intervention steps may be skipped).
• Interventions should be escalated for a patient who’s condition is predicted to progress rapidly.
*The Spiral was a conceptual tool fleshed out by Critical Care Paramedic Ian MacMillan