AIRWAY

Sweet & Simple !

A Patient Without an Airway is a Dead Patient !!!

OVERVIEW

• Anatomy & Physiology of the Respiratory System
• Recognize Adequate & Inadequate Breathing
• How to Open an Airway, Maintain an Airway, and Ventilate a Patient
• Techniques of O2 Administration
• Techniques of Suctioning

RESPIRATORY ANATOMY

• Mouth & Nose

• Pharynx

• Pharynx

• Oropharynx
• Nasopharynx

• Epiglottis

• Leaf-Like Structure
• Protects Airway

• Trachea

• Windpipe

• Larynx

• Voice Box

• Cricoid Cartilage

• Sellick Maneuver

• Diaphragm

• Dome Shaped
• Separates Thorax & Abdomen

• Inhalation

• Active Process
• Diaphragm & Intercostal Muscles Contract

• Diaphragm Flattens, Moves Downward
• Ribs Move Up & Out
• Increases Size of Thoracic Cavity

• Air Pressure Decreases In Thoracic Cavity

• Air Flows Into Lungs

• Exhalation

• Diaphragm & Intercostal Muscles Relax

• Diaphragm Returns to Dome Shape
• Ribs move Down & In
• Size of Thoracic Cavity Decreases

• Air Pressure In Thoracic Cavity Increases

• Air Flows Out of Lungs

RESPIRATORY PHYSIOLOGY

• Alveolar / Capillary Exchange

• O2 Rich Air Into Alveoli
• O2 Poor Blood In Capillaries
• CO2 From Capillary to Alveoli
• O2 From Alveoli to Capillary

• Capillary / Cellular Exchange

• Cells Convert O2 to CO2
• Cell Gives CO2 to Capillary
• Capillary Gives O2 to Cell

• Adequate Breathing

• Normal Rate

• Adult 12 – 20 / Minute
• Child 15 – 30 / Minute
• Infant 25 – 50 / Minute

• Rhythm

• Regular
• Irregular

• Adequate Breathing (cont)

• Quality

• Breath Sounds – Present & Equal
• Chest Expansion – Equal & Adequate
• Effort of Breathing – Use of Accessory Muscles

• Depth (Tidal Volume)

• Adequate

• Respiratory Failure

• Oxygen intake not enough to
  support life

• Respiratory Arrest

• Breathing stops completely

• Inadequate Breathing

• Rate – Outside Range
• Rhythm – Irregular
• Quality

• Breath Sounds – Diminished, Absent, Noisy
• Chest Expansion – Unequal, Inadequate
• Effort of Breathing – Increased Accessory Muscles

• Depth (Tidal Volume) – Shallow, Inadequate

• Inadequate Breathing (cont)

• Skin

• Pale, Cyanotic (Blue)
• Cool, Clammy

• Retractions (Especially Kiddos)

• Clavicles, Ribs

• Nasal Flaring (Especially Kids)
• "Seesaw" Breathing in Infants
• Agonal Breathing – Occasional Gasps

INFANT & CHILD ANATOMY

• Mouth & Nose

• Generally Small
• Easily Obstructed

• Pharynx

• Large Tongue

• Proportionally Take Up More Space Than Adult Mouth

• Trachea

• Narrow
• Swelling Obstructs
• Soft & Flexible

• Cricoid Cartilage

• Soft, Underdeveloped

• Diaphragm

• Diaphragm Dependent
• Chest Wall Not Strong

OPENING the AIRWAY

• Review of BLS Skills

• Non-Traumatic ?

• Easiest Way
• Hint H-T C-L

• Suspected Spinal Injury ?

• Not So Easy
• Hint J T

• How Do You Assess Need for Suctioning ?

ARTIFICIAL VENTILATION

• Adequate Artificial Ventilation

• Chest rises & Falls w/ Each Ventilation
• Sufficient Rate

• Adult 12 / Minute
• Infant & Child 20 / Minute

• Heart Rate Returns to Normal
• Skin Color Improves

• Inadequate Artificial Ventilation

• Chest Does Not Rise & Fall w/ Each Ventilation
• Rate Too Fast / Too Slow
• Heart Rate Does Not Return to Normal
• Skin Color Does Not Improve

ARTIFICIAL VENTILATION

• Reposition head.
• Check for seal at mask and no air leaks.
• Check for blockages in BVM or tubing.
• Check for Airway Obstruction
• Try Another Mode of Delivery

ARTIFICIAL VENTILATION

• Order of Preference (Ease of Use)
• Mouth to Mask
• Easiest to Assess Effectiveness
• Connect to O2 if Possible
• Two Person BVM
• One Seals Mask
• Other Provides Large Tidal Volume

Order of Preference (Ease of Use) {cont.}

• Flow Restricted Oxygen-Powered Vent. Device

• Easy to Seal
• No Effort to Provide Tidal Volume

• One Person BVM

• Not Easy to Keep Seal
• Not Easy to Provide Adequate Tidal Volume

BAG VALVE MASK

• Components
• Connect to O2
• Capacity 1600 ml
• Less Volume Than Mouth to Mask
• Difficult For 1 EMT to Use
• Optimal Position – Top of Patient’s Head
• Adjunctive Airway Help

BAG VALVE MASK

• Most are Disposable
• Some Models Can Be Sterilized
• Self Refilling Bag or Long Tube Reservoir
• Non-Jam Valve that Allows 15 L/min O2
• No Pop-off Valve or Disabled
• Standardized Fittings
• True Valve for Non-Rebreather
• Should Work in All Environmental Conditions
• Available Infant, Child, & Adult Sizes

USING the BVM

• Hands-On Device
• Little Hints & Facts
• Point of Mask Goes Toward Nose
• Round Mask Opening Over Mouth
• Use Your Hand On Mask as "C" & "E"
• More Tidal Volume w/ 2 EMT’s
• Use Your Thigh if Possible

USING the BVM

• Adult Ventilation Q 5 Seconds
• Kiddos 3 Seconds
• If You Breath the Patient Breaths
• No Rise & Fall of the Chest – Re-evaluate
• Reposition
• Check Mask
• Look for Obstruction
• If it is Still Not Working Try Pocket Mask or Demand Valve

USING the BVM

• If Cervical Trauma is Suspected
• Use Same Rules Except:
• 2 EMT’s Needed

• One on Bag
• Other on Mask Using Jaw Thrust and Maintaining Stabilization
• Use Your Knees / Thighs

• If Air Does Not Go In, Reposition Jaw, Not Neck

"DEMAND VALVE"

• Flow Restricted, Oxygen-Powered Ventilation Device
• Use On Adults Only
• Peak Flow of 100% at 40 Liters / Minute

• This Thing Can Pass Gas !

• Inspiratory Pressure Relief Valve

• Opens at 60 cm of H2O, Vents Excess O2

• Audible Alarm When Relief Valve Pressure is Exceeded
• Operates in Any Environmental Condition
• Trigger in Location Where Both Hands Are On Mask

USING the F.R.O.P.V.D.
(Flow Restricted, Oxygen-Powered Ventilation Device)

• Special Interest Using Demand Valve
• Place Mask Same as BVM Except One Thumb Needed to Trigger Valve
• Depress Trigger Long Enough to Make Chest Rise
• Concentrate On Your Actions !
• Injury to Patient Can Occur !
• Do Not Use On Kids !

STOMA & TRACHEOSTOMY

TRACHEOSTOMY

• BVM / Ventilating
• If Done at Trach., Seal Mouth & Nose
• If Done at Mouth & Nose, Seal Trach.
• No Need For Head-Tilt Chin-Lift

TRACHEOSTOMY

• Supplemental O2 via Trach Mask
• Suction Trach as Needed

AIRWAY ADJUNCTS

• Oropharyngeal Airway
• aka: Oral Airway
• Assists in Maintaining an Open Airway in an Unconscious Patient Without a Gag Reflex
• Open Airway Manually First

Rules for Airway Adjuncts

• Do not force tongue into pharynx.
• Have suction available.
• Remove adjunct if patient gags or regains consciousness.
• Maintain infection control.

AIRWAY ADJUNCTS

• If Gag Reflex is Present the Patient Will Vomit
• Measure for Proper Size
• Corner of Mouth to Tip of Ear Lobe
• Corner of Mouth to Angle of the Jaw
• Insert Tip Toward Roof of Mouth
• Insert Gently Until Resistance
• Turn 180°
• Rest Flange On Teeth

AIRWAY ADJUNCTS

AIRWAY ADJUNCTS

• Alternate Method and Preferred Pediatric Method
• Use Tongue Depressor to Trap Tongue
• Insert Airway with Tip Facing Tongue
• Flange to Teeth, Remove Tongue Depressor

• If Gag Reflex Returns or LOC Improves
• Remove Oral Airway Immediately
• Have Suction Ready

AIRWAY ADJUNCTS

• Nasopharyngeal Airway
• Less Likely to Stimulate Vomiting
• Patient Not Completely Unconscious
• Needs Assistance Keeping Tongue Out of Airway
• Painful Stimuli During Insertion

AIRWAY ADJUNCTS

• Size
• Diameter of Nostril
• Tip of Nose to Ear Lobe
• Lube the Tube
• Water Soluble, KY Jelly
• Insert Posteriorly
• Bevel Toward Septum
• If One Doesn’t Work, Use the Other

SUCTIONING

• Purpose
• Remove Blood, Secretions/Liquids, Food from Upper Airway
• Some Suction Devices Can’t Remove Large Objects
• Artificial Ventilation + Gurgling = Suction
• Wear BSI

SUCTION CATHETER

• Hard or Rigid Catheter
• Tonsil Tip
• Yankauer
• Suction Oropharynx
• As Far as You Can See
• Kiddos – Don’t Touch Back of Throat
• Soft Catheter
• French
• Suction Nasopharynx or Oropharynx
• Insert to Base of Tongue

USING SUCTION

• Check Every Shift – Portable & Wall-Mounted
• Battery Charged
• Tubing, Catheters, and Water Present
• Unit Produces 300 mmHg Vacuum ?
• Attach Tubing
• Turn On Unit
• Attach Appropriate Catheter
• Insert Into Mouth WITHOUT Suction
• Insert to Base of Tongue
• Apply Suction – Place Thumb Over Hole
• Move Catheter Tip Side to Side
• Suction No More Than 15 Seconds
• Ventilate for 2 Minutes Between Suctioning
• Excess Emesis – Log Roll
• Use Water Bottle to Rinse Tubing & Catheter
• Pediatric Considerations
• Use Tonsil Tip For Mouth
• Use Bulb Syringe for Nose or French w/ Low to Medium Suction
• Suction Less Than 15 Seconds

OXYGEN

• Common Portables
• D – 350 Liters
• E – 650 Liters
• Ambulance Fixed Bottles
• M – 3000 Liters
• G – 5300 Liters
• H – 6900 Liters

OXYGEN

• Handle With Care
• 2000 to 2200 PSI
• Secure During Transport
• Lay Bottle Down When Not Secured
• Use Non-Sparking Wrench
• DO NOT USE OIL
• DO NOT SMOKE OR USE OPEN FLAME

OXYGEN

• Operating Procedures
• Remove Protective Seal
• Crack Valve Open/Closed, Assure No Dirt
• Attach Flowmeter/Regulator to Bottle

• Assure Medical O2 Fitting
• Check Gasket

• Open Flowmeter to Desired Setting
• Apply Delivery Device to Patient
• When Complete, Remove Device from Pt., Turn Off Valve, Drain Excess from Regulator

OXYGEN

• Non-Rebreather Mask
• Preferred Pre-Hospital
• 90% O2 Concentration
• 15 Liter Administration
• Fill Bag Before Applying
• Adult & Peds Sizes

OXYGEN

• Old School
• U & I Use CO2 as Drive to Breath
• COPD Uses O2 as Drive to Breath

• Oh No! If COPD Pt Gets too Much O2, They Will Stop Breathing
• Not In Pre-Hospital Setting, Takes 24 Hours to Get to That Point
• If Patient Needs O2, GIVE THEM 02 !!!

OXYGEN

• Nasal Cannula
• Comfort When NRM is Not Tolerated
• Don’t Exceed 6 Liters
• Dry vs. Humidified O2
• Pre-Hospital Dry
• Long Routine Transports Humidified

SPECIAL CONSIDERATIONS

• Pediatrics
• Don’t Hyperextend Neck to Open Airway

• Head-Tilt Chin-Lift Just Past Neutral

• Avoid Excessive Ventilation Pressure

• Make Chest Rise
• Avoid Gastric Distention

• Disable "Pop-Off" Valves On BVM
• Airway Adjuncts Can Be Used

SPECIAL CONSIDERATIONS

• Facial Injuries
• Swelling & Bleeding Can Be Significant
• Airway Management Can Be Difficult
• Foreign Body Airway Obstructions
• The EMT Should Do 3 Cycles of FBAO Procedures Then Transport

SPECIAL CONSIDERATIONS

• Dental Appliances
• Dentures & Partials
• Leave In Place if Possible
• Remove if Dislodged