AirwayIt ALL starts here…

Respiratory System

• Function• Gas exchange with outside environment• Filtration/Humidification/Warming/Conduction of air

• Structures• Nose• Mouth• Naso/Oro/Laryngopharynx• Larynx• Bronchi

• Bronchioles• Lungs• Diaphragm

• Associated muscles • Alveoli

Upper Airway Nose/Mouth

• Function• Filters• Warms• Moistens

Upper Airway Pharynx

• Location• Posterior to mouth• Superior to esophagus,

larynx, trachea

• Function• Conducts air to bronchi

• 3 Divisions• Nasopharynx• Oropharynx• Laryngopharynx

Upper Airway Epiglottis

• Location• Sits posterior to larynx• Attached to tongue

• Structure• Leaf shaped cartilage

• Function• Prevents food/liquid from entering

larynx during swallowing • Guards opening to vocal cords

(glottis)

Upper Airway Larynx

• AKA: “Voice box”• Location

• Inferior to epiglottis• Superior to trachea

• Structure • Cartilaginous rings

• Thyroid Cartilage = “Adam’s Apple”

• Bulk of anterior wall• Cricoid Cartilage

• Firm rings forming lower aspect/base

• Function• Stops foreign objects that pass

epiglottis• Laryngospasm

• Voice production

Lower Airway Trachea

• AKA: “Windpipe” • Location

• Inferior to Larynx• Anterior to Esophagus• Bifurcates into primary bronchi

• Structure • Cartilaginous rings anterior

and lateral• Approx 15-20

• Smooth muscle tissue posterior

• Trachealis muscle • Why????

Lower Airway Bronchi

• Location• Bifurcation of trachea

• 2nd Intercostal space• Angle of Louis

• Right and Left main stem

• Structure• Smooth muscle• Irregular hyaline cartilage

rings

• Function• Conducts air to lungs

Lower Airway Bronchioles

• Location• Distal bifurcations of the

bronchi• Terminate at alveoli

• Function• Conduct air to alveoli

• Structure• 1st airways with NO cartilage• ALL muscle

• Bronchoconstriction • Bronchospasm

• < 1 mm wide =Tiny

Lower Airway Alveoli

• Location• Terminal sacs of bronchial tree• Distal to bronchioles• Particular to mammalian lungs• 150 million/lung

• Structure• 1 cell thick• Surface are= 75m2 (Tennis court)• Increased SA= Increased 02 absorption• 0.2-0.3 mm diameter • Covered in capillaries (70%)• Bathed in surfactant

• Function• Diffusion of gas with capillaries

Lower Airway Lungs

• Location• Bilateral of midline

• Structure• Divided into lobes

• Left= 2• Right= 3

• Function• Houses structure for gas exchange• Alteration of pH

Lower AirwayMucociliary Escalator

• Location• Along epithelium of primary

bronchi• Beat in rhythm

• Structure• Cilia projections• “Hair like”

• Function• Move debris up out of lungs

• Cough or swallow• Smokers…

• Prevent mucous accumulation

Respiratory PhysiologyHow we breathe…

• Ventilation• Mechanical movement of air into/out of the body

• Inhalation (Active)• Muscles Used

• Diaphragm & External Intercostals• Physiology

• Diaphragm contracts downward• External intercostals pull ribs up and out• Increases dimension of chest cavity• Increased diameter of chest drops intra thoracic pressure• Air rushes in until pressure is equalized

Respiratory PhysiologyHow we breathe…

• Ventilation• Mechanical movement of air into/out of the body

• Exhalation (Passive)• Physiology

• Diaphragm relaxes as well as intercostals• Chest cavity dimension decreases• Decrease in dimension increases intrathoracic pressure• Air rushes out • Lungs recoil

Respiratory PhysiologyGas Exchange

• Respiration• Process by which the body utilizes oxygen• Diffusion

• Net movement of molecules from an area of high concentration to an area of low concentration

Respiratory PhysiologyGas Exchange

• Respiration• Process by which the body

utilizes oxygen• Alveolar/Capillary Exchange

• Physiology• O2 rich air enters alveoli• O2 poor blood in capillaries

pass alveoli• O2 diffuses down its

concentration gradient into the capillaries

• CO2 diffuses down its concentration gradient into the alveoli

• CO2 is exhaled and O2 transported to tissues

Respiratory PhysiologyGas Exchange

• Respiration• Process by which the body

utilizes oxygen• Capillary/Cellular Exchange

• Physiology• O2 rich blood passes cells• O2 diffuses across its

concentration gradient into the cells

• CO2 diffuses across its concentration gradient into the capillary

• CO2 is transported to the alveoli

Respiratory Evaluation

• Areas of assessment• Rate. Rhythm. Depth. Quality.

• Rate• Adult = 12-20 per minute• Child = 15-30 per minute• Infant = 30-60 per minute

• Rhythm• Regular or irregular

• Depth• Tidal volume adequate or inadequate

• Amount of air breathed in/out in one ventilation• Approx 500 mL

Respiratory Evaluation cont’d.

• Quality• Breath sounds

• Present or diminished or absent• Chest expansion

• Unequal or symmetrical• Increased effort

• Accessory muscles • “Seesaw” breathing

• Infants• Nasal flaring • Retractions

• Above clavicles, between ribs• Cyanosis• Shortness of breath• Altered mental status

Accessory Muscle Use

Nasal Flaring

Retractions

Respiratory Evaluation cont’d.

• Cyanosis• Blue/pale coloring of skin

• Nail beds• Lips• Eyelids

• Why is this seen in these areas first???

• Indicates poor perfusion

Pulse Oximetry

“5th Vital Sign” Normal SpO2

– 95-100%

Sp02 Ranges– 91-94% = Mild Hypoxia – Supplemental O2– 86-91% = Moderate Hypoxia – Supplemental O2– 85%-< = Severe Hypoxia – IMMEDIATE intervention

False Readings– CO poisoning, high intensity lighting, hemoglobin abnormalities,

no pulse in extremity, hypovolemia, severe anemia

Pediatric Considerations

• Mouth/Nose• Smaller and easily obstructed

• Pharynx• Tongue is BIG

• Trachea• Narrower• Softer and more flexible

• Cricoid Cartilage• Less developed/Less rigid = easily kinked

• Diaphragm • Chest is soft• Depend on diaphragm to do most of the work of breathing

• Seesaw Breathing….

Accessory Muscle Use

Nasal Flaring

Retractions

Respiratory Distress

• “The pt is able to compensate for the underlying problem and get enough O2 to maintain mental responsiveness and muscle tone to move air.”

• Resp. distress can progress to resp. failure • Exhaustion

Respiratory DistressAssessment

• Respiratory Distress• Work of breathing is increased• Maintains LOC

• Signs/Symptoms • Increased resp rate• Accessory muscle use• Nasal flaring• Tripod position• Diff speaking in complete sentences• Agitated/Restless

• Treatments• Maintain clear airway• Supplemental O2

• Bronchodilatory drugs

Respiratory Failure

• “The pt is not able to maintain mental status, display muscle tone, or move adequate amounts of air to the lungs”

• Resp. failure can progress to resp. arrest

Respiratory Failure Assessment

• Respiratory Failure• Inadequate ventilate to support life• LOC diminishes

• Mechanisms• Impaired brain function • Muscle fatigue after respiratory distress• Chest wall injury• Airway obstruction

• Sings/Symptoms• Low O2 sat.• Sleepiness/weakness• Cyanosis• Low respiratory rate• Little/no chest movement• AMS

Respiratory FailureTreatment

• Treatment• Positive pressure ventilation• Err on side of ventilation if in doubt

• If pt accepts then it’s a sign they need it• If a pt fights it it’s a sign they are trying to ventilate

Respiratory Arrest

• Respiratory Arrest • Complete cessation of breathing

• Can progress to cardiac arrest • Treatment

• Secure patent airway • Positive pressure ventilation

Airway ManagementIt ALL starts with “A”…

• Goals of airway management• Est./maintain patent airway• Ensure adequate ventilation• Ensure adequate oxygenation

• Methods of Securing Airways• Manual• Suctioning• Mechanical

Opening the airwayManual techniques

• Tongue• Attached to lower jaw• Obstructs airway in

unconscious pt• Simple manual

techniques can fix this

• 2 Techniques• Head tilt chin lift• Jaw Thrust

Opening the airwayHead Tilt Chin Lift

• When to do it…• Patients not traumatically injured

• How to do it…• Place index and middle finger of 1 hand under the

bony part of pts lower jaw• Place other hand on pts forehead• Lift the jaw with one hand while tilting the head

back with the other

Opening the airwayJaw Thrust

• When to do it…• Traumatically injured pts• Opens airway without neck extension

• How to do it…• Place hands on either side of pt head• Place index and middle fingers beneath the angle of the jaw

just below ears• Place thumbs on either side of mouth at pt chin• Lift jaw up while opening mouth by pushing with your

thumbs

Securing the airwaySuctioning

• Purpose• Remove blood, food, and

other liquids from the airway

• Inadequate for solid material

• Clear airway when ventilating if gurgling is heard

Suctioning Units

• Types of units• Mounted• Portable

• Electrical • Hand operated

Suction Catheters

• Hard/Rigid• Yankauer/“Tonsil sucker/Tonsil tip• Suction of unresponsive pt• Do NOT touch back of pediatric

airway• Insert only as far as you can see

• Base of tongue

• Soft• Suction of nasopharynx• Situations when a rigid catheter

cannot be used• Insert only to base of tongue • Measure from corner of mouth

to earlobe

Suctioning

• How to…• Turn unit on

• Check for 300 mmHg vacuum • Attach catheter• Insert into oro/nasopharynx without suction on• Apply suction • Move catheter from side to side• Suction for NO more than 15 seconds

• Lesser time for infants• If there is a lot of secretions log roll pt and clear• 15 sec. suction-ventilate 2 min- 15 sec. suction

Airway Adjuncts

• Functions• Keeps tongue off posterior oropharynx

• Types• Oropharyngeal Airway (OPA/Oral)• Nasopharyngeal Airway (NPA/Nasal)

Orophayngeal Airway

• Form:• Curved plastic device extending from lips to base of tongue

• When to use it:• Unconscious pt without a gag reflex

• How to use it: • Measure from corner of pt mouth to angle of jaw• Open pt mouth• Insert OPA upside down (curve pointing to roof of mouth)• Insert until slight resistance then invert 180O

• Rest flanges on teeth• ALTERNATELY:

• Use tongue blade and insert curved side down • Pediatric pts

Nasophayngeal Airway

• Form:• Flexible plastic tube beveled on one side that extends from

nostril to base of tongue • When to use it:

• Pt with gag reflex• Unable to advance OPA

• When not to use it:• Pt with facial trauma

• How to use it:• Measure from tip of pt nose to angle of jaw• LUBE it…• Insert it posteriorly with bevel pointing toward septum • If it doesn’t work in one nostril try the next

Ventilating the Airway

• Methods of ventilation• Mouth-to-Mask• Two-person Bag-Valve-Mask• Flow restricted, oxygen powered ventilation

device• One-person Bag-Valve-Mask

Mouth-to-Mouth

• How to…• Open Airway• Seal your mouth over the pt• Pinch pt nostrils closed• Give 2 breaths each over 2

seconds• Assess for chest rise• Reposition head and

reattempt if none• How often:

• 1 breath every 5 seconds= Adult

• 1 breath every 3 seconds= Child

Mouth-to-Mask

• Position yourself directly above pt

• Apply mask to pt • Use bridge of nose as

guide• Secure mask to pt face

using “E-C” technique• Provide rescue breaths over

2 seconds• Breath-release-release”

• Continue at rates previously listed

Ventilating the Airway“E-C” Technique

• Place thumbs on superior aspect of mask (Half C)• Bridge of Nose

• Place index fingers on inferior aspect of mask (Half C)• Chin

• Place remaining fingers on the bony ridge of the lower jaw and form and “E”

• Bring jaw upwards to mask with “E” and push down to seal with “C”

• Ventilate the pt.

Ventilating the Airway Bag-Vale-Mask

Self Inflating Bag

One Way Valve

Face Mask

O2 Reservoir

O2 Tubing

Bag-Vale-Mask

• Issues:• 1600 milliliter volume• Less volume than mouth-

to-mask• Airtight seal is difficult

with 1 EMT• Position above pt head for

ease• Use airway adjunct with

BVM

• Anatomy of the BVM• Self-refilling bag

washable/disposable• Non jam valve with O2 inlet for

15 lpm• Absent or disabled pop-off

valve• Standardized 15/22mm

fittings • O2 inlet and reservoir for high

concentration O2

• True non rebreather valve• Function in extreme conditions• Infant, child, adult sizes

Bag-Vale-Mask

• How to use it… (Non traumatic)• Open airway and select mask size• Place thumbs at apex of mask• Lower mask over pt face using bridge of nose as a guide• Connect BVM if not already• Complete E-C Technique• Have assistant squeeze bag with 2 hands until chest rise is

observed • Ventilate pt

• 1 ventilation every 5 seconds = Adult• 1 ventilation every 3 seconds = Child • “Squeeze – Release – Release”

Bag-Vale-Mask

• How to use it… (Non traumatic)• If alone

• Proceed as before only moving thumbs from apex of mask to around the ventilator port

• Continue with E-C technique as usual

Bag-Vale-Mask

• How to use it… (Traumatic)• Proceed as before only immobilizing the head

with• Knees • Manual stabilization by partner

• Don’t tilt head back to seal to mask• Pull jaw forward with E-C technique

Ventilating the AirwaySpecial Cases

• Bag-to-Stoma or Tracheostomy tube

• Use child/infant bag• Place directly over stoma• Extension of head is not

needed• Squeeze bag until chest rise is

observed• Continue as normal• If you cant ventilate:

• Suction stoma• Move to upper airway

• Seal off stoma

• If pt has tracheostomy:• Connect BVM directly to trach

tube and ventilate through it• Suction may be needed to

clear obstructions

Flow Restricted, Oxygen Powered Ventilation Device

• Flow rate of up to 100% @ 40 lpm• Inspiratory pressure relief valve • Opens at 60 cm of water• Vents remaining air off• Audible alarm that sounds when the

valves pressure is exceeded • Trigger that allows both EMT’s

hands to be on the mask

Flow Restricted, Oxygen Powered Ventilation Device

• How to use it (non traumatic)• Open airway and insert adjunct• Place mask on pt face by E-C technique• Connect device to mask if not already• Trigger the device until the chest rises

• How to use is (trauma)• Immobilize head

• Knees• Partner

• Open airway and insert adjunct• Place mask on pt face by E-C Technique• Proceed as normal without tilting pt head to mask

Adequate Ventilation

• Adequate Ventilation• Chest rise/fall• Lung sounds• “Pinking up” of patient • Sufficient rate

• Adult - 12 bpm• Child – 20 bpm

• If no chest rise is observed:• Reposition head• Assess for a leak and correct• Assess for obstruction and treat• Use another method to ventilate pt

• Complication• Gastric distention

Oxygen…Tanks

• Atmospheric O2 concentration • 21%

• O2 cylinders• Color coded Green• Various sizes

• D = 350 Liters • E = 625 Liters• M =3,000 Liters• G = 5,300 Liters• H = 6,900 Liters

D cylinder

M cylinder

E Cylinder

Oxygen Regulators

• Function:• Reduce high pressure of gas inside cylinder to a

level that is safe for the pt. • Has pressure gage (psi)

• Full tank = 2000 psi

Setting up Oxygen

• How to set your O2 up• Remove protective seal• Find plastic “O” ring and place on the cylinder opening/regulator

opening• Quickly open then shut main valve

• Blows dust out • Attach regulator to tank

• Line up pins from the regulator to the holes in the tank• Open main valve and check pressure (2000psi)• Attach O2 device and turn regulator to desired setting• When complete

• Remove device from pt• Turn off main valve• Bleed pressure out of the regulator

OxygenDelivery Devices

Nasal Cannula– 22-24% Oxygen– 1-6 Lpm

Simple Face Mask– 40-60% Oxygen– 8-12 Lpm – Admin no less than 6 Lpm

Non Rebreather– 80-100% Oxygen, 15 Lpm– No less than 8 Lpm

Venturi Mask– Used for COPD– Controlled precise amount

of oxygen– 24, 28, 35, 40% Oxygen

Nonrebreathers

• How to use them…• Attach NRB to O2 tank• Pre-fill the reservoir • Set to desired flow rate

• Reservoir bag shouldn’t go flat when pt inhales

• i.e. 15 liters per minute• Extend elastic band and

place mask on pt face• Cinch metal band to pt nose• Cinch elastic band to pt

face

Oxygen…Nasal Cannula

• How to use it…• Attach to tank• Set on desired flow rate

• i.e. 6 liters per minute

• Place prongs in pt nose• Curve down

• Loop tubing around pt ear and under chin

• Cinch tubing below chin

Cylinder Calculations

• Can you make it???

• Time(min)= (Tank Pressure[psi]-200psi)xConstantFlow Rate (L/min)

• Constants• D cylinder= 0.16 E cylinder= 0.28• M cylinder= 1.56 H cylinder= 3.4

• Example• You are transporting a patient who is receiving 15L/min of oxygen by NRB. The transport

time is 20 min. On your E cylinder, the psi is 1200. Do you have enough oxygen for your patient, of should you prepare to change you settings?

• Time=(1200psi-200psi)X0.2815L/min

• =18 2/3 min = NOT ENOUGH

Special Considerations

• Laryngectomies (stomas) • If obstructed =suction• If ventilating and air escapes =

Close mouth/nose • Facial Injuries

• Rich blood supply to face• Severe bleeding/swelling• Challenge to manage

• Suctioning• Obstructions

• Foreign Body Airway Obstruction Protocols

• Dental Appliances• Leave in place unless they get

in the way

Special Considerations

• Pediatrics• Do not hyperextend

• Neutral/”sniffing” position = Infant

• Slightly past neutral position = Child

• Use only enough pressure to achieve chest rise

• Gastric distention is common• Consider adjuncts if other

attempts fail• NEVER manipulate the back

of a pediatric airway

Special Considerations

• Breathing Control• Voluntary/Involuntary• Sensors in brain/brainstem

• O2 , CO2 , acid levels

• Normal control to breath is high CO2

• When CO2 increases the brainstem signals to:

• Increase resp rate• Increase depth

• What if CO2 chronically builds up???

• COPD…

Special ConsiderationsCOPD• Chronic Obstructive Pulmonary Disease• Includes:

• Chronic Bronchitis• Emphysema• Asthma

• Causes:• Loss of elasticity of alveoli• Collapse of bronchioles• Decreased inspiratory volume• “Trappe” air• Poor tissue perfusion

• Problem:• Chronic high CO2

• Sensors become desensitized to CO2 and switches to O2

• Resp drive now based on O2 NOT CO2

• Does anyone see the problem????

It all starts with aggressive airway management….