2014 aemt airway management cole
DESCRIPTION
This is the introduction to airway management for Advanced EMTs though some medics might find it useful too. Focuses mainly on supraglottic and periglottic airway devices as well as basic anatomy , physiology, etc. Talks about apniec defusion too.TRANSCRIPT
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2014 AEMT COURSEPRESENTED BY:
ROBERT S. COLEPARAMEDIC, OCD
Airway Management
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When ever I’m blue…..I remember to breath again.
- Anonymous
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Basic Concept:
Air Goes in and OutBlood Goes Round and Round
Any thing infringing on this is a BAD THING!
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Respiratory Anatomy
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The Upper Airway
1. Nose Warm and humidify air through
turbinates2. Mouth and oral cavity
Advanced airway Entrance to the digestive system Also involved in the production of
speech Tongue
3. Jaw Facial bones
Maxilla mandible
4. Pharynx Nasopharynx Oropharynx Hypopharynx Laryngopharyx
5. Larynx Epiglottis – muscular structure
which protects the airway of conscious patients during swallowing
Vocal cords – thin muscles which are the center for speech and protect the lower airways
Thyroid cartilage Cricoid ring
6. Jugular notch
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The Upper Airway
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The Lower Airway
1. Trachea Hollow tube which passes
air to the lower airways Supported by cartilage
rings 2. Carina
The bifurcation of the trachea into the two main stem bronchi
3. Bronchi Hollow tubes which
further divide into lower airways of the lungs
Supported by cartilage Alveoli
4. Lungs a. Bronchioles
i. thin hollow tubes leading to the alveoli
ii. remain open through smooth muscle tone Bronchial smooth muscle Beta2 adrenergic receptors
b. Alveoli i. the end of the airway ii. millions of thin walled sacs iii. each alveolus surrounded by
capillary blood vessels iv. site where oxygen and carbon
dioxide (waste) are exchanged c. Pulmonary capillary beds
i. blood vessels that begin as capillary surrounding each alveolus
ii. with adequate blood volume and blood pressure, the vessels return oxygenated blood to the heart
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The Lower Airway
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The Lower Airway
9
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The Lower Airway
10
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Key Point
It takes approximately 150-200 cc of air movement to reach the terminal bronchus and the aveoli…
This is called “Dead Air Space” Tidal volumes less than 200 cc
typically do not oxygenate/ventilate at the aveolar level.
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The Lower Airway
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The Chest Cavity
Thoracic skin, muscle, and bones
Similarities to other regions
Also unique features to allow for ventilation
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Pulmonary Circulation
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The Thoracic “Cage”
Credit: wikipedia.com
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The Rib
Credit: wikipedia.com
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The Chest Cavity
The neurovascular bundle lies closely along the lowest margin of each rib.
The pleura covers each lung and the thoracic cavity The visceral pleura covers the lungs and the parietal
pleura covers the thoracic cavity. There is also a negative pressure between the two that
keeps them stuck together yet not actually attached. Surfactant allows the lungs to move freely against the
inner chest wall during respiration.
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Intercostal Muscles and Diaphram
The Intercostal Muscles are several groups of muscles that run between the ribs
The diaphragm is a muscle that separates the thoracic cavity from the abdominal cavity.
Together they help the “Mechanical Bellows”
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Mechanics of Ventilation
The intercostal muscles (between the ribs) contract during inhalation. The diaphragm contracts at the same time.
The intercostal muscles and the diaphragm relax during exhalation.
The body should not have to work to breathe when in a resting state.
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Mechanics of Ventilation
Patients with a spinal injury below C5 can still breathe from the diaphragm.
Patients with a spinal injury above C3 may lose the ability to breathe altogether.
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The Mechanical Bellows?
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The Mechanical Bellows
The muscles of the ribs expand the size of the chest, creating a (relative) negative pressure.
Air (with O2) moves in to fill the void.
Commonly thought of as Oxygenation.
Actual oxygenation takes place at the cellular level.
Special Thanks to Charlie Miller for this Graphic.
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The Mechanical Bellows
The intercostals muscles relax, allowing the chest to return to its neutral position, expelling air out of the lungs (and CO2 with it.)
Commonly thought of as Ventilation.
Actual ventilation takes place at the cellular level.
Special Thanks to Charlie Miller for this Graphic.
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The Mechanical Bellows
Example of a Compromised Bellows
Positional Asphyxia
Special Thanks to Charlie Miller for this Graphic.
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Key Point:
A comprehensive understanding of the Anatomy of the airway and thorax is essential to managing the airway and respiratory functions of your patient.
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AKA: HOW WE BREATH…. .
Physiology of Respiration
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Key Definitions
Tidal Volume (Vt) Typically 500-700 cc
Minute Volume (Vm) Tidal Volume X Respiratory Rate = Minute Volume
Functional Reserve Capacity (FRC) Typically 2,400 cc in a 70 kg Human
Inspired Oxygen (FiO2) Fraction of Inspired Oxygen Expressed as a decimal, i.e. 80% is 0.8 FiO2. 100% is
1.0 FiO2Work of Breathing (WOB)
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Respiratory Rate
times x
Tidal Volume(amount of air exchanged in one breath)
equals =
Minute Ventilation
Minute Ventilation
RR x TV = minute volume
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Physiology of Respiration
Diffusion of O2 from the lung to the blood is by the binding of O2 to the hemoglobin (Hgb) This is dependant on a pressure gradient. This is a Passive transport system. It is also dependant on available surface area and distance
it must travel to cross the threshold.Capillaries and Alveoli are where the real
Oxygenation and ventilation take place.
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Alveolar Ventilation
Minute Ventilation minus –
Dead Air Space equals =
Alveolar Ventilation
Dead Air Space: the trachea, bronchi, and bronchioles.
There is NO gas exchange in these areas.
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Key components of an intact respiratory system
An appropriate Drive to BreathAirway and respiratory tractMechanical BellowsA diffusion friendly place for gas exchange to
happen.An O2 friendly RBC with hgb.An intact circulatory system to carry the gasses
and waste through out the body. Must have enough of a pressure to promote diffusion.
An intact capillary bed Its like a truck shipping company.
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Drive to breath
Controlled by the CNS through information gathered from receptors in the body.
Located in the pons region of the brainstemDetects increases in CO2 or decreases in
pH and informs the brain to increase the respiratory rate.
Increased respiratory rate reduces CO2 and will increase pH.
Other things can effect our drive to breath
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“Hypoxic Drive”
Develops in some patients with Chronic Lung Disease
Pons region of brain becomes sensitized to constant increased CO2 state
Regulation is now based on O2 level in bloodIncreased oxygen level states may tell the
brain to stop breathing
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Diffusion
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An O2 friendly RBC with hgb.
Hemoglobin is an Iron Based compound essential to the transport of O2. Anemia Cyanide Poisoning CO Poisoning
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An intact circulatory system
Blood LossShock
Pump Problem Volume Problem
Fluid issue O2 carrying issue
Vessel Problem
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KEY POINT: Must have enough of a pulmonary perfusion pressure
to promote diffusion.
Conditions like Hypotension cause
secondary hypoxia by promoting low perfusion.
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Physiology of Respiration
The primary function of the respiratory system is gaseous exchange. Ventilation and Oxygenation.
Air is composed of a mixture of gases. Breathing is largely controlled by the Autonomic
Nervous system, in response to changes sensed in all parts of the body. The biggest part of this is the “Hypoxic Drive”.
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Physiology of Respiration
Ventilation is the body’s ability to move gas (usually atmospheric air) in and out of the chest and lung tissue.
Respiration is the exchange of gases in the alveoli of the lung tissue.
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Physiology of Respiration
Oxygen exchange can be hindered by:
Condition in the airway Disease processes- COPD, asthma, pneumonia, pulmonary
edema Traumatic conditions Abnormalities in pulmonary vessels Altitude Closed environment Toxins or poisonous environment Drowning Occupational exposure
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All cells need a constant supply of oxygen to survive.
Physiology of Respiration
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Inhalation
The active part of breathing
Focused on delivering oxygen to the alveoli
Tidal volume is the amount of air that moves into or out of the lungs during a single breath.
Minute ventilation (minute volume) is the amount of air moved through the lungs in 1 minute minus the dead space.
Ventilation
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Exhalation
Passive process
Diaphragm and intercostal muscles relax.
Smaller thorax compresses air out of the lungs.
Vital capacity is the amount of air that can be forcibly expelled from the lungs after breathing deeply.
Residual volume refers to the air that remains after maximal expiration.
Ventilation
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Regulation of ventilation
The body’s need for oxygen is constantly changing. Failure to meet the need may result in hypoxia.
For most people, the drive to breathe is based on pH changes in blood and cerebrospinal fluid.
Ventilation
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QUICK REVIEWALSO REVIEWED IN MEDICAL
EMERGENCIES
Respiratory Compromise
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Pneumothorax
Commonly called a collapsed lung
Accumulation of air in the pleural space
Blood passing through the collapsed portion of the lung is not oxygenated.
You may hear diminished, absent, or abnormal breath sounds.
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Pneumothorax
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Pneumothorax
Open chest woundOften called an open pneumothorax or a sucking chest wound.
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Tension Pneumothorax
Tension pneumothorax
Results from significant air accumulation in the pleural space
Increased pressure in the chest causes:
Complete collapse of the affected lung
Mediastinum to be pushed into the opposite pleural cavity
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Tension Pneumothorax
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Blood collects in the pleural space from bleeding around the rib cage or from a lung or great vessel.
Hemothorax
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Pulmonary Edema
Heart muscle can’t circulate blood properly. Left ventricle is compromised resulting in “backflow.”
Fluid builds up within alveoli and in lung tissue. Usually result of congestive heart failure Pulmonary trauma Chemical exposures
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Pulmonary Edema
The fluid and thicker tissue makes exchange of gasses less efficient.
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Chronic Obstructive Pulmonary Disease (COPD)
Slow process of constriction and disruption of airways and alveoli
Caused by chronic bronchial obstruction
Tobacco smoke can create chronic bronchitis.
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Chronic Obstructive Pulmonary Disease (COPD)
Emphysema is another type of COPD. Loss of elastic material around air spaces Causes include inflamed airways and smoking.
Most patients with COPD have elements of both chronic bronchitis and emphysema.
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Chronic Obstructive Pulmonary Disease (COPD)
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Chronic Obstructive Pulmonary Disease (COPD)
“Wet lungs” vs. “dry lungs” “Wet lungs” sounds—pulmonary edema “Dry lungs” sounds—COPD
Can be easily confused with congestive heart failure
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Asthma, Hay Fever, and Anaphylaxis
Result of allergic reaction to inhaled, ingested, or injected substance In some cases an allergen cannot be identified.
Asthma is acute spasm of smaller air passages (bronchioles).
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Asthma is acute spasm of smaller air passages (bronchioles).
Asthma
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Signs of Mechanical Ventilation Impairment
Abnormal sounds include wheezing, rales, rhonchi, and stridor.
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Management & Interventions
Insure adequate airway and ventilation Either assisted or on patient’s own Use of adjuncts Pulse oximetry
Provide supplemental oxygen NRB, NC, Nebulizer with Albuterol Reference ACP SWO Appendix A
Provide positive pressure ventilations if indicated BVM Demand valve Automatic transport ventilator (ATV)
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Assessment
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What do we assess?
Primary Assesment Presence or absence? Rate Quality
“Doorway Test”
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First Impressions
Air HungryNasal FlaringTripodingRocking with
respirationsPursed Lip BreathingBarrel or Sparrow
ChestHome O2
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Respiratory Rate
Decreased by: Depressant Drugs Sleep
Increased by: Fever Fear Exertion
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Respiratory Quality
Irregular: Neuro Insult.Shallow:
Respiratory Depressants CNS Depressants Neuro Insult
Deep: Hyperglycemia with Acidosis (DKA): “Kussmal
Respirations Electrolyte Imbalances Neuro Insult
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Skin Signs
Cyanosis Nail Beds Lips Ears
Mottling Chest Lower Ext Abd
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Noisy breathing is obstructed breathing
Snoring: obstruction by tongueGurgling: Funky Junk in upper airwayGrunting: Physiologic PEEPStridor: harsh, high pitched sound on
inhalation: Laryngeal edema Epiglotitis FBAO
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Speech Dyspnea
Inability to speak more than a few syllables in a sentence between breaths.
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Breath Sounds
Listening by comparisonListening anteriorListening posteriorFremitus
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Abnormal breath sounds
Rales (crackles): fine bubbling sound of fluid in alveoli (“Rice Krispies”: snap, crackle and pop) Alveoli popping open.
Rhonchi: fluid in larger airways, obstructing object in the bronchus
Wheezes: high pitched whistling, air through narrowed airways
SILENCE IS BAD NEWS
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Causes of respiratory abnormalities
Brain damage: trauma, drugs, strokeSpinal cord damage: trauma, polioUpper airways: tongue, swelling, foreign
body, traumaLower airways: asthma, chronic bronchitisAlveoli: atelectasis, obstruction Impaired pulmonary circulation: embolism
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Signs/symptoms of distress
DyspneaRestlessness/anxietyTachypnea/BradypneaCyanosis (core)Abnormal soundsRetractionsDiminished ability to speak
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More S/S
Retractions and/or use of accessory musclesAbdominal breathingNasal flaringProductive cough
Color?Irregular breathing Tripod positionPursed-lip breathing
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Take another look ….What do you see?
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Hows this?
Pursed Lips
Sparrow Chest
Tripoding
Retractions
Abd retractions
Kewl Haircut
O2
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Inadequate Breathing: Infants and Children
Retractions
Nasal Flaring
See-Saw Breathing
Diaphragmatic Breathing
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A pulse oximeter measures the percentage of hemoglobin saturation.
Should be 95% to 100% while breathing room air.
AHA recommendations are to maintain a saturation of greater than 94%.
A saturation of 75% is extremely low. Approximately the level of oxygen that should be returning from the tissues.
Assessment
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Inaccurate pulse oximetry readings may be caused by:
Hypovolemia
Anemia
Severe peripheral vasoconstriction (including cold)
Nail polish (turn sensory sideways)
Dirty fingers
Carbon monoxide poisoning
Assessment
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Assessment
Assess for: Gag reflex Airway obstruction
Soft tissue obstruction Foreign bodies Complete or incomplete Upper vs. lower
Work of breathing Laryngospasm Laryngeal edema Penetrating injuries.
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Basic Airway Interventions
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Basic Airway Interventions
Manual Airway maneuver Head tilt/chin lift Jaw thrust
Airway devices OPA NPA IOM (NuMask) BVM
Relief of foreign body airway obstruction (per AHA guidelines)
Upper airway suctioningLower airway suctioning
After placement of advanced airway
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Airway Obstruction
Most common cause: tongue and/or epiglottis
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Manual Opening the AirwayManual Opening the Airway
Jaw thrust Head tilt–chin lift
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The Oropharyngeal AirwayThe Oropharyngeal Airway
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Malposition of Oropharyngeal Airway
Malposition of Oropharyngeal Airway
Too short
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Nasopharyngeal Airway Nasopharyngeal Airway
Insertion technique
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The Bag Valve mask
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The Sniffing Position
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KEY POINTS
BVM ventilation is a perishable skill and surprisingly difficult on mannequins, as well as many patients. A number of studies have demonstrated the difficulties performing BVM ventilation on real patients in field situations.
The “weak link” in using the BVM is the “Face Mask Seal”.
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The E-C Technique
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Poor seal, esp. in victims with:• Obesity• Facial hair• The elderly• Lack of teeth• Facial Trauma
Current masks are fragileand cumbersome
Easy to learn, difficult to retain
Often needs 2 providers for adequate seal on difficult patients
Why traditional facemasks can be problematic
All Rights Reserved. © 2007-2011 NuMask®, Inc.
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Predictors of difficult ventilation…
In addition to the psycho-motor and provider difficulties of retaining this vital skill, research has shown us that the patient themselves present many predictable difficulties to successful BVM ventilation. Some of the major ones are: a body mass index of 30 kg/square meter or more Presence of a beard Mallampati score of three or four Age of 57 or older Severely limited jaw protrusion Snoring. Maxillo-Facial Trauma Short thyromental distance The edentulous, and obese patients.
Of these 9 co-morbid factors, 5 of which are directly dependant on face mask seal, and therefore these five which would be mitigated if not eliminated with the use of the IOM.
Kheterpal S, Han R, Tremper KK, et al. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology. 2006 Nov; 105(5):885-91.
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Nu-Mask
Nu-Mask is a new alternative to the BVM. It is for patients whom a getting a face mask
seal is problematic. It is the only device for difficult aiways that
can be used by both BLS and ALS providers. ACP/ACEMSS is deploying these to all BLS
and ALS units in the system.
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NuMask IOM® and IOM® w/ OPA in Place
NuMask IOM NuMask IOM with OPA
All Rights Reserved. © 2007-2011 NuMask®, Inc.
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An air tight seal in 1/10th the space of a traditional mask
All Rights Reserved. © 2007-2011 NuMask®, Inc.
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KEY POINT
The IOM uses internal oral tissue to obtain a superior “wet seal”. Because hand placement, hand size, and hand position are not as crucial, the IOM is easier to use.
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Key Points about suction…
300 mm hg for adults No more than 120 mm hg for pediatrics
Intervals Prefer < 10 seconds (2010 ECC Guidelines for CPR)
Devices Soft tip Yankour/Big Stick In Line
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Types of Portable Suction
Courtesy of Laerdal Medical Corporation, Armonk, NY
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Supra-glottic Airways
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AEMT “Supraglottic” airway devices
Indications To promote airway management by providing a patent
airway in the unconscious, and/or apneic patient.Contraindications
Responsive patients with an intact gag reflex. Patients with known esophageal disease, i.e.
esophageal varices. Patients known or suspected to have ingested caustic
substances.
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KEY POINT
THE NEW AEMT SCOPE OF PRACTICE DOES NOT CONTAIN ETT. Discussion: Is this a god idea or bad?
This doesn’t mean that the AEMT shouldn’t have a working understanding of the ETT so as to be a better clinical provider and member of the overall health care team.
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Terms
Supra-glotticDouble/Single LumenPeri-glotticEsophageal orburtrator airways
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Lots of devices over the years
Esophageal obturation Esophageal Gastric Tube Airway (EGTA) Esophageal Orbturator Airway (EOA)
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Dual Lumen Supra-Glotic Airways
Pharyngeal-tracheal Lumen Airway (PTLA) AKA: The PTL
Esophageal-Tracheal Combitube (ETC) AKA: The Combi-tube AKA: Rush Easy Tube
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“Peri-Glottic” Airways
Laryngeo-Mask Airways (LMA)Air-QI-Gel
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Laryngeo-Mask Airways
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I Gel
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Single Lumen Airways
King LTDCOBRA Peri-Laryngeal Airway (PLA)
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Cobra PLA
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King Airway
Size determined by Pt’s height:
Yellow: 4-5 ft
Red: 5-6 ft
Purple: > 6 ft
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Instructions for use
Choose appropriate size based on patient’s height.
Test cuffs by inflating to recommended volume of air and deflate cuffs completely before attempting to insert. 60-90ml air based on device size.
Generously lubricate tube using a water based lube.
Pre-oxygenate patient with 100% O2Have suction available.
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Insertion:
Position the head in a slightly sniffing position, unless spinal injury is known or suspected. Then maintain cervical alignment and keep the head in a neutral position.
Insert King rotated 45-90 degrees laterally and insert into mouth
As you gently advance the tube rotate tube to midline.
Advance tube until base of connector aligns with teeth or gums.
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Cuff inflation:
Inflate cuffs with minimum volume necessary to seal the airway according to tube size.
“SEAT THE TUBE” GENTLY tug on the tube to appropriately place
it…Attach to resuscitator bag and ventilate
using 100% O2 source.Assure chest rise and fall. Auscultate
breath sounds.Secure tube, using a commercially
approved device, noting depth of tube placement.
Monitor end tidal CO2 if available.
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ARTIFICIAL VENTILATION
Management Techniques
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Probably the most important skills in EMS at any level.
Basic airway and ventilation techniques are extremely effective.
Airway management is the one advanced skill that can have the greatest impact on patient mortality and morbidity.
It is imperative that you become experts at basic and advance airway management.
Assisted and Artificial Ventilation
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Basic Airway Adjuncts
Chin liftJaw thrustPositioning/suctioningOropharyngeal airway (OPA)Nasopharyngeal airway (NPA)EGTA/Combi-tube/King LT
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Oxygen Delivery Adjuncts
Nasal Cannula: 2-6 LPM 24-44%Simple mask: 6-10LPM 35-60%Non-Rebreather Mask: 10-15LPM 80-
95%Bag-valve-mask 15LPM 95-
100%
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When assisting with a bag-mask device:
Explain the procedure to the patient.
Place the mask over the nose and mouth.
Squeeze the bag each time the patient breathes.
Maintain an adequate minute volume.
Assisted and Artificial Ventilation
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Artificial ventilation
Devices include:
Pocket face masks Bag-mask device CPAP/BiPAP Manually triggered ventilation device Automatic transport ventilator
Assisted and Artificial Ventilation
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Assisted and Artificial Ventilation
Pocket Masks Includes IOM/NEW MASK
Advantages: Small, easy to use Easy to use two handed technique Oxygen optional
Disadvantages Down near the patients face---YUCK High FiO difficult
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Assisted and Artificial Ventilation
Bag Valve MaskAdvantages
Self inflating Can be used with or without an oxygen source Can be used with the IOM/NuMask
Disadvantages Difficult to obtain a mask seal at times (dentures
removed, facial hair, etc. ) Best results if used with more than one rescuer
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Manually triggered ventilation devices Advantages:
Also known as flow-restricted, oxygen-powered ventilation device Allows single rescuer to use both hands to maintain mask-to-face seal
while providing positive-pressure ventilation Should not be used routinely
Disadvantages Difficult to maintain adequate ventilation without assistance Requires oxygen. Typical adult ventilation consumes 5 liters per minute O2 versus 15-25 liters per minute for a bag-valve-mask Typically used on adult patients only Requires special unit and additional training for use in pediatric patients The rescuer is unable to easily assess lung compliance High ventilator pressures may damage lung tissue
Assisted and Artificial Ventilation
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Automatic transport ventilator (ATV) Manually triggered device
attached to a control box Allows the variables of
ventilation to be set Lacks the control of a
hospital ventilator Frees the EMT to perform
other tasks
Assisted and Artificial Ventilation
Courtesy of Impact Instrumentation, Inc.
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CPAP
Continuous Positive Airway PressureAdvantages
Is a BLS intervention in many states May reduce the need for advanced airway management Reduces in hospital stays Better outcomes overall…
Disadvantages Requires an EXCELLENT face-mask seal Will not provide ventilation, only assist the patients own
ventilatory effort May lower the blood pressure May promote gastric distention Can not be used if airway reflexes are compromised.
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Automatic transport ventilator (ATV)
Disadvantages requires oxygen. Typical adult ventilation consumes 5
liters per minute 02 versus 15-25 liters per minute for a bag-valve-mask
may require an external power source must have bag-valve-mask device available may interfere with timing of chest compressions
during CPR must monitor to assure full exhalation barotrauma
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Automatic transport ventilator (ATV)
Generally consumes 5 L/min of oxygen
May lead to hypoventilation in patients with: Poor lung compliance Increased airway resistance Airway obstruction
Assess patient for full chest recoil.
Assisted and Artificial Ventilation
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Patients with tracheostomies do not breathe through their mouth and nose.
Tracheostomy masks may be available. A face mask may also be used.
If the trach has a 15mm
adaptor, a standard BVM
will fit onto the adaptor. If
not you will need to us a pediatric
mask for a seal.
Tracheostomy
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Changes in the body
There are several changes in the bodies physiology during positive pressure ventilation:
Air Movement
Normal ventilation has a negative intrathoracic pressure leading air to get “sucked” into the lungs.
With positive pressure you are “pushing” the air into the cavity
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Changes in the body
Blood Movement
1. Normal ventilation a. Blood return from the body happens naturally b. Blood is pulled back to the heart during normal
breathing
2. Positive pressure ventilation a. Venous return is decreased during lung inflation
Use caution to not overinflate b. Amount of blood pumped out of the heart is reduced
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Changes in the body
Esophageal Opening Pressure Positive pressure ventilation
Air is pushed into the stomach during ventilation Gastric distention may lead to vomiting
Sellick’s maneuver (cricoid pressure) Use during positive pressure ventilation Reduces amount of air in stomach Procedure
identify cricoid cartilage apply firm backward pressure to cricoid cartilage with thumb and index
finger Do not use if
patient is vomiting or starts to vomit patient is responsive breathing tube has been placed by advanced level providers
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Special patient population
Use caution with artificial ventilation with geriatric and pediatric patients.
Geriatric Geriatric disease process break down lung tissue and
elasticity of their lungs, use caution with positive pressure ventilation.
Pediatric Pediatric airways are significantly smaller (the size of
THEIR pinky finger) and require less volume. Large, floppy tongues Padding under shoulders Do not hyperextend pt neck, it will “kink” the trachea Gastric distention
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Take Home Points….
All pt’s with SOB get O2. Lots of O2. Listen to ALL lungs. Beware of the “silent chest”.Noisy Breathing is abnormal breathingVisible Breathing is abnormal breathing.Positional breathing is abnormal breathing.Abnormal Breathing gets O2.
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Questions?