Airway Management

Airway Physiology

Upper Airway• Begins at mouth and nose

– Air is warmed and humidified in nasal turbinates

• Jaw

• Throat / Pharynx– Oropharynx– Epiglottis – Larynx/voice box

• Ends at glottic opening

Upper Airway

Lower Airway• Begins at glottic opening

• Trachea / Windpipe– Hollow tube which passes air to the lower airways– Supported by cartilage rings

• Bronchi – branches at the carina

• Lungs– Bronchioles

• Thin hollow tubes that lead to alveoli• Remain open through smooth muscle tone

– Alveoli

Alveoli• The end of the airway

• Millions of tiny sacs in grapelike bunches at the end of the airway

• Surrounded by capillary blood vessels

• Oxygen and carbon dioxide diffuse through pulmonary capillary membranes

Lower Airway

The Path of Oxygen1. Oropharynx/Nasopharynx

2. Epiglottis

3. Larynx

4. Trachea – main tube that carries oxygen to the lungs

5. Right/Left Main Stem Bronchus

6. Bronchi

7. Alveoli

9

The Respiratory System

Purpose

• Takes in oxygen

• Disposes of wastes– Carbon dioxide– Excess water

O2 + Glucose

CO2 + H2O

The Cell

Respiratory System Anatomy• Chest cage

• Ribs

• Muscles– Intercostal– Diaphragm

• Pleura

• Phrenic nerve innervation– Originates in C4– Sends motor function to the diaphragm

Respiratory System Anatomy

• Pleura– Double-walled

membrane– Visceral layer

covers lung– Parietal layer lines

inside of chest wall, diaphragm

Respiratory System Anatomy

• Diaphragm– Muscular structure that allows

the body in inhale and

exhale

Respiratory System Anatomy

• Lung– Right lung 3 lobes

– Left lung 2 lobes

Respiratory System Physiology• Pulmonary Ventilation

– Ventilation is defined as the movement of air into and out of the lungs

• Oxygenation– The amount of oxygen dissolved in blood and body

fluids

Respiratory System Physiology• Respiration

– Process by which the body captures and uses oxygen and disposes of carbon dioxide

– External respiration• Exchange of oxygen and carbon dioxide between alveoli and

the blood in the pulmonary capillaries

– Internal respiration• Exchange of oxygen and carbon dioxide between the capillaries

of the body tissues and the individual cells

– Cellular respiration• Each cell of the body performs a specific function

• Oxygen and sugar are essential to produce energy for cells to perform their function

• Produce carbon dioxide as a waste product

Respiration TerminologyRespiration Terminology• Tidal volume — amount of air moved in one

breath

• Dead space air — air moved in ventilation not reaching alveoli

• Alveolar ventilation — air actually reaching alveoli

• Ventilation — both inhaling and exhaling

• Diffusion — movement of gases from high concentration to low concentration

Respiratory System Physiology• Inspiration

– Active process– Chest cavity expands– Negative pressure pulls air

into the lungs– Air flows in until pressure

equalizes– Diaphragm lowers and

contracts

Respiratory System Physiology

• Expiration– Passive process– Muscles relax; size of chest

decreases– Intrathoracic pressure rises– Air flows out until pressure

equalizes– Diaphragm rises and

relaxes

Respiratory System Physiology

–Automatic Function• Primary drive: stimulus to breathe is

based on high levels of arterial CO2

• Secondary (hypoxic) drive: stimulus to breathe is based on low levels of oxygen

Normally we breathe to remove CO2 from the body, NOT to get oxygen in

Vascular Structures That Support Respiration

• Pulmonary capillary structures

• The heart– Right Heart

• Receives system circulation

• Drives pulmonary circulation

– Left Heart• Receives pulmonary circulation

• Drives system circulation

• Arteries, arterioles, capillaries, venules, veins

• Tissue/cellular beds

Respiratory Pathophysiology

• Airway Obstructions– Tongue

– Foreign body airway obstruction

– Anaphylaxis-severe allergic reaction

– Upper airway burn

– Epiglottitis - children

– Croup - children

– Drowning

– Aspiration-crud going into the lungs

– Asthma

– Pneumonia

– Pulmonary edema

– Chronic Obstructive Airway Disease

• Emphysema

• Chronic bronchitis

Respiratory Failure

Reduction of breathing to the point where oxygen intake is not sufficient to support life.

Respiratory Arrest

Breathing stops completely.

Signs of Adequate Breathing

1. Look – bilateral chest expansion. Adequate & equal expansion on both sides.

2. Listen – Auscultate – to listen. Should be free of abnormal sounds (crackles or wheezing)

3. Feel – as the air is expelled from the nose and mouth.

4. Skin – normal color and tone

Pulse Oximetry• Assesses oxygenation

• Quantify hemoglobin saturation

• Complications (inaccurate readings)– shock patients– carbon monoxide poisoning– cold extremity

Normal Breathing Rates

• Adult – 12-20 breaths per minute

• Child – 15-30 breaths per minute

• Infant – 25-50 breaths per minute

Rhythm – regular rate, rhythm and quality

Quality – breath sounds present and equal

- chest expansion adequate

Depth - adequate

Signs of Inadequate Breathing1. Chest movements absent, minimal or uneven.

2. Abdominal breathing

3. Noises – wheezing, stridor, crackles, snoring respirations, silent chest.

4. Cyanosis – skin color is blueish/gray

5. Rate is too fast or too slow

6. Breathing is shallow, very deep and labored or irregular respiratory pattern

Signs of Inadequate Breathing7. Inspirations are prolonged (possible upper

respiratory obstruction).

8. Expirations are prolonged (possible lower airway obstruction).

9. Can not speak or can not speak in complete sentences.

10.Nasal flaring (infants & children)

11.Tripod Position – starving for oxygen

12.Changes in mental status - hypoxia

IF THE PATIENT DEMONSTRATES INADEQUATE VENTILATION

(RESPIRATIONS OF LESS THAN 10 PER

MINUTE OR GREATER THAN 29 PER MINUTE) AND THE PATIENT IS CONFUSED, RESTLESS, OR CYANOTIC THEN YOU MUST CONSIDER PROVIDING OXYGEN WITH A BAG-VALVE-MASK OR POCKET-MASK

A. Methods for Opening an Airway• Head-tilt, chin lift – used in a non-trauma

patient. One hand should be placed on the forehead with the fingertips of the other hand under the lower jaw.

• Jaw-thrust - used in a trauma patient where spinal precautions are a concern. Moves the mandible forward.

Head-TiltHead-TiltChin-Lift ManeuverChin-Lift Maneuver

Jaw-Thrust ManeuverJaw-Thrust Maneuver

Pediatric Note forOpening the Airway

• Infants and small children often have larger occipital regions of their heads

• Lying flat may cause hyperflexion of neck and airway occlusion

• Evaluate need to pad behind patient’s shoulders to achieve neutral airway position

Pediatric Note:Pediatric Note:Opening the AirwayOpening the Airway

B. Responsibilities of the EMT

a. Be sure all equipment is clean and operating properly.

b. Select proper equipment for patient care.

c. Must monitor the patient closely.

d. Must properly clean, discard and test all equipment after use.

C. Airway Adjuncts

• Most common airway obstruction is the tongue.

1. Oropharyngeal airway

1. Oropharyngeal airway -ONLY use on an unconscious patient.-Device used to move tongue forward as it curves back to

pharynxIf there is a gag reflex, REMOVE IMMEDIATELY!!!- If the patient is unconscious assume a spinal cord injury

based on the mechanism of injury.- Practice only on a manikin.- Can induce vomiting and/or bronchospasms.- Made in different sizes - you must measure for correct size.- Correct Size is the distance from the corner of the patient’s

mouth to the tip of the earlobe on the same side of the face.(Alternate: measure from the center of the patient’s mouth to

the angle of the lower jaw bone.)

Sizing Oropharyngeal Airways

Using Oral Airways If the patient becomes conscious, remove the

airway and have suction ready.

• Insert the airway upside down with the tip facing the roof of the mouth.

• When resistance is encountered, turn the airway 180 degrees so that it comes to rest with the flange on the patient’s lips.

• You may also insert the airway right side up, using a tongue depressor to press the tongue down. This is preferred in infants and children

2. Nasopharyngeal Airways - does not stimulate the gag reflex so it may be used

on a patient with a reduced level of consciousness but still has an intact gag reflex.

- can be used when teeth are clenched or patient has an oral injury

- do not use if clear cerebrospinal fluid is coming from the ears or nose – look for the halo effect

- made in different sizes - you must measure for correct size.

- Correct Size is to measure from the tip of the nose to the earlobe or from the patient’s nostril to the angle of the jaw. Also, use the patient’s pinky finger to determine the diameter of the airway to be used.

Using Nasal Airways 1. Establish and maintain an open airway.2. Lubricate with a water-based lubricant.3. Insert into right nostril first, bevel of the

airway toward the septum4. If you feel resistance remove. Do not force!

Try the other nostril. 5. Slide into the nose until the lip is against the

nostril.6. Remain ready to suction the patient if

needed.

D. Suctioning Units

A. Types - Oxygen or air powered

- Electrically powered units (Current or battery)

- Manual (bulb syringe)

Suction Systems

• Fixed or portable

Suction Device Requirements

• Must furnish air intake of at least 30 Lpm at open end of collection tube

• Must generate vacuum of no less than 300 mmHg when collecting tube is clamped

B. Techniques for suctioning 1. Position yourself at the patient’s head.

2. Use a hard or rigid suction catheter : yankauer. (“tonisil sucker”)

3. Measure the suction catheter: corner of the mouth to the earlobe or center of the mouth to the angle of the jaw.

4. Turn the unit on. The gauge should generate 300 mmHg of vacuum.

5. Open the mouth using the crossed finger technique (index finger and thumb)

6. Suction only after the catheter is in place. Suction on the way out, not on the way in.

7. Use great care when suctioning a conscious patient - GAG REFLEX! Never lose sight of the pharyngeal curve

8. DO NOT suction the patient for greater than 15 seconds - the time it takes for a normal breath. You may stimulate the vegus nerve.

9. If the patient has secretion or emesis that cannot be removed quickly and easily by suctioning, the patient should be log rolled and the oropharynx should be cleared

10. If the patient produces frothy secretions as rapidly as suctioning can remove, suction for 15 seconds, artificially ventilate for 2 minutes, then suction for 15 seconds

11. If necessary, rinse the catheter and tubing with sterile water to prevent obstruction of the tubing

12. Hyperventilate the patient before and after suctioning.

Continuous Positive Airway Ventilation (CPAP)

• Forcing air or oxygen into lungs when a patient is still breathing on their own, but has inadequate breathing

• Uses force exactly opposite of how the body normally draws air into the lungs

Negative Side Effects of Positive Pressure Ventilation

• Decreasing cardiac output/dropping blood pressure

• Gastric distention

• Hyperventilation

Key Concerns with PPV

• Do not ventilate patient who is vomiting or has vomitus in airway — PPV will force vomitus into patient’s lungs

• Watch chest rise and fall with each ventilation

• Ensure rate of ventilation is sufficient

Ventilating a Breathing Patient

• Explain procedure to patient

• After sealing mask on patient’s face, squeeze bag with patient’s inhalation

E. Techniques for Artificial Ventilation

In order of preference, the methods for ventilating a patient by the EMT are as follows:

1.Mouth-to-mask

2.Two-person bag-valve-mask

3.Flow restricted, oxygen powered ventilation device

4.One-person bag-valve-mask

1. Pocket Face Mask

a. conforms to facial features.

b. carries in rescuer’s pocket.

c. Most can be fitted to an Oxygen tank.

d. delivers 16% oxygen using just mask without oxygen. (there is 21% oxygen saturation in the atmosphere)

e. Delivers 40-45% with Oxygen at 10 L.P.M.

f. Does allow you to maintain an airway.

2. Bag-valve Maska. Used to ventilate a non-breathing patient or

a patient who has shallow or failing respirations.

b. Sizes: infant, child, adultc. Will deliver Oxygen at 21% when used

alone. When connected to oxygen tank at 15 L.P.M. and reservoir bag it can deliver up to 100% Oxygen.

d. Most will fit a variety of maskse. Atmospheric air delivered thru one-way

valve, adult bag delivers 1000-1200 ml of air

Ventilation Procedures for BVM1. Position yourself at the patient’s head. Establish an

open airway.

2. Insert an oropharyngeal airway.

3. Use the correct mask size for the patient.

4. Hold mask firmly in position - C and E finger positions.

5. With other hand, squeeze bag once every five seconds.

6. Release bag. Allow patient to exhale. Allow bag to refill.

7. The most reliable sign that your patient is being adequately ventilated is the patient’s chest rises

Bag-Valve-Mask

- Face mask should be clear to allow the rescuer to see vomitus.

- When ventilating an unconscious patient, a bag-valve-mask system is only complete if a reservoir bag, oral airway and oxygen are in place.

Standard Features of BVM

Bag-Valve-Mask- Artificial ventilation is adequate when:

- The rate is sufficient, approx. 12 per minute for adults and 20 times per minute for infants and children

- The most reliable sign that your patient is being adequately ventilated is the patient’s chest rises.

Note: Heart rate may return to normal with successful artificial ventilation

- Artificial ventilation is inadequate when:- The chest does not rise and fall with artificial ventilation- The rate is too fast or too slow

Note: Heart rate may not return to normal with artificial ventilation

Sellick’s Maneuver(cricoid pressure)

• Use during positive pressure ventilation

• Reduces the amount of air in the stomach

• Procedure:– identify cricoid cartilage– apply firm backward pressure to cricoid cartilage with

thumb and index finger

• Do not use if:– pt. is vomiting or starts to vomit– patient is responsive

3. Flow restricted, Oxygen Powered Ventilation Device

- Uses Oxygen under pressure, delivered through a mask.

- Peak flow rate of 100% at up to 40 L.P.M.- Has a pressure relief valve with alarm.- CAUTION: DO NOT OVERINFLATE.- Use only on adults.

Using Flow-Restricted, Oxygen-Powered Ventilation Device

4. Mask to Stoma Ventilation - Definition of a tracheostomy – artificial permanent

opening in the trachea- If unable to artificially ventilate, try suction, then

artificial ventilation through mouth and nose; sealing stoma may improve ability to artificially ventilate.

- Need to seal the mouth and nose when air is escaping when artificially ventilating the stoma

5. Bag-valve-mask to Stoma- Use pediatric size mask- Leave head in the neutral

position.- Ventilate at appropriate rates.- If unable to artificially

ventilate through stoma, seal stoma and attempt artificial ventilation through mouth and nose

6. Automatic Transport Ventilator (ATV)

• Provides automated ventilations

• Can adjust ventilation rate and volume

• Provider must assure appropriate respiratory rate and volume for patient’s size and condition

F. Oxygen Therapy A. Safety considerations in the use of Oxygen -

1. Never drop a cylinder or let it fall.

2. Never smoke! Post signs.

3. Never use Oxygen around an open flame.

4. Never use grease or adhesive tape on tanks or gauges.

5. Always use original pressure gauges and regulators.

6. Always use non-ferrous metal

7. Always make sure gaskets are in good condition.

8. Always use medical Oxygen.

9. Always open valve fully then close half a turn.

10. Test cylinders hydrostatically every 5 years

B. Medical Hazards of Oxygen Therapy 1. Oxygen toxicity or air sac collapse –

destruction of the lung tissue due to high concentration of oxygen provided for a long period of time.

Medical Hazards of Oxygen Therapy 2. Infant eye damage – occurs when infants are given too

much oxygen. It is not too much oxygen in the eye directly, but too much oxygen in the bloodstream. Scar tissue will develop behind the lens of the eye (retrolental fibroplasias).

3. Respiratory depression or Respiratory arrest – this problem occurs with patients having COPD (chronic obstructive pulmonary disease). When the patient is given too high a dosage of oxygen. These patients can develop respiratory depression or arrest – hypoxic drive. In patients who are chronically maintained on oxygen and who are being transported for a condition other than the one requiring high concentration oxygen by the protocols, continue administering oxygen at the previously prescribed rate flow.

OXYGEN SHOULD NEVER BE WITHHELD FROM PATIENTS

REQUIRING IT, EVEN THOUGH THEY MAY HAVE COPD!

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Airway management and ventilation take

precedence over other life-support skills because:

• The body needs oxygen to survive• Skills are easiest to perform

• Oxygen is the most readily available drug

C. Oxygen Cylinders1. Sizes: D – contains 350 liters

of Oxygen (19 min)

E – contains 625 liters of Oxygen

M – contains 3000 liters of Oxygen

G – contains 5300 liters of Oxygen

H – contains 6900 liters of Oxygen

Oxygen Cylinders

2. Colors : - green/white

- aluminum & stainless steel

- not painted

**ALWAYS READ LABELS TO BE SURE!!!**

3. PSI – pounds per square inch – pressure created by the oxygen inside an oxygen tank.

4. LPM – liters per minute

5. Full tank has approximately 2000 psi

6. NYS DOH guidelines require that oxygen tanks must be changed at 500 PSI.

G. Oxygen delivery devicesA. Nasal cannula -

- Flow rate 1 to 6 LPM.(4 – 6 LPM is most common in emergency situations)

- Delivers 24 to 44% oxygen.

- Used with patients that cannot tolerate a mask or COPD patients who are not in breathing distress.

B. Non-rebreather mask– Flow rate 12 to 15 LPM

- Delivers 80 – 100% oxygen

- Best way to deliver high levels of oxygen, used on all patients in our protocol.

- Very useful in heart attacks and shock, monitor COPD patients carefully.

C. Venturi mask - Delivers specific concentrations of oxygen

by mixing oxygen with inhaled air- Flow rate 4 to 8 LPM- Delivers 24 – 40 % oxygen on a variable

rate)- Designed for low levels of oxygen

D. Partial Rebreather Mask• Very similar to nonrebreather mask

• No one-way valve in opening to reservoir bag

• Delivers 40%–60% oxygen at 9–10 Lpm

E. Tracheostomy Mask• Placed over stoma or tracheostomy tube to

provide supplemental oxygen

• Connected to 8–10 Lpm

F. Humidifier

• Connected to flow meter

• Provides moisture to dry oxygen from supply cylinder

IF THE PATIENT REQUIRES OXYGEN THERAPY, WHICH MOST OF THEM DO ADMINISTER HIGH CONCENTRATION

OXYGEN A. First choice –

non-rebreather mask

1. Fill the bag to its capacity initially.

2. Adjust the air flow of oxygen (15 LPM) so that the bag remains 1/3 full during inspiration.

B. Second choice –

nasal cannula (6 L.P.M.)

(used only if a mask is not tolerated).

IF THE PATIENT DEMONSTRATES INADEQUATE VENTILATION

(RESPIRATIONS OF LESS THAN 10 PER

MINUTE OR GREATER THAN 29 PER MINUTE) AND THE PATIENT IS CONFUSED, RESTLESS, OR CYANOTIC:

1. Assist the patient’s ventilations with 100% oxygen using a positive pressure adjunctive device

2. If you are working with a PARTNER:First choice – Bag-valve mask with reservoir and

Oxygen (15 LPM)

3. If you are working ALONE: First choice – Pocket mask with supplemental oxygen.

( 15 LPM)

THE END

Respiratory System Anatomy

NasopharynxOropharynxEpiglottisLarynxTrachea

Bronchi

Bronchioles

Carina

Ventilation Procedures 1. Place patient in supine position

(unconscious patient insert an airway)

2. Place mask firmly over mouth and nose (can be used on a facial injury)

3. Maintain airway – keep a good seal on the face.

4. 2 breaths – 1000 cc of air.

5. Remove, allow patient to exhale – continue ventilations