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Airway Management, Ventilation, Oxygen Therapy

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Respiratory Anatomy

Nose and mouth (warms, moistens, and Nose and mouth (warms, moistens, and filters air).filters air).

PharynxPharynx OropharynxOropharynx NasopharynxNasopharynx

EpiglottisEpiglottis Trachea (windpipe)Trachea (windpipe)

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Respiratory Anatomy

Cricoid cartilage (adams apple).Cricoid cartilage (adams apple). Larynx (voice box).Larynx (voice box). BronchiBronchi LungsLungs

Visceral pleura (surface of lungs)Visceral pleura (surface of lungs) Parietal pleura (internal chest wall)Parietal pleura (internal chest wall) Interpleural space (potential space)Interpleural space (potential space)

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Respiratory Anatomy

DiaphragmDiaphragm Inhalation (active process)Inhalation (active process)

Diaphragm and intercostal muscles contract, Diaphragm and intercostal muscles contract, increasing the size of the thoracic cavity.increasing the size of the thoracic cavity.

Diaphragm moves slightly downward, ribs Diaphragm moves slightly downward, ribs move upward and outward.move upward and outward.

Air flows into the lungs creating a negative Air flows into the lungs creating a negative pressure in the chest cavity.pressure in the chest cavity.

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Respiratory Anatomy

Exhalation (passive process)Exhalation (passive process) Diaphragm and intercostal muscles relax Diaphragm and intercostal muscles relax

decreasing the size of the thoracic cavity.decreasing the size of the thoracic cavity. Diaphragm moves upward, ribs move Diaphragm moves upward, ribs move

downward and inward.downward and inward. Air flows out of the lungs creating a Air flows out of the lungs creating a

positive pressure inside the chest cavity.positive pressure inside the chest cavity.

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Respiratory Physiology Oxygenation - blood and the cells become saturated Oxygenation - blood and the cells become saturated

with oxygenwith oxygen Hypoxia - inadequate oxygen being delivered to the Hypoxia - inadequate oxygen being delivered to the

cellscells Signs of HypoxiaSigns of Hypoxia

Increased or decreased heart rateIncreased or decreased heart rate Altered mental status (early sign)Altered mental status (early sign) AgitationAgitation Initial elevation of B.P. followed by a decreaseInitial elevation of B.P. followed by a decrease Cyanosis (often a late sign)Cyanosis (often a late sign)

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Alveolar/Capillary Exchange

Oxygen-rich air enters the alveoli during Oxygen-rich air enters the alveoli during each inspiration.each inspiration.

Oxygen-poor blood in the capillaries passes Oxygen-poor blood in the capillaries passes into the alveoli.into the alveoli.

Oxygen enters the capillaries as carbon Oxygen enters the capillaries as carbon dioxide enters the alveoli.dioxide enters the alveoli.

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Capillary/Cellular Exchange

Cells give up carbon dioxide to the Cells give up carbon dioxide to the capillaries.capillaries.

Capillaries give up oxygen to the cells.Capillaries give up oxygen to the cells.

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Infant and Child Considerations

Mouth and nose - generally all structures are smaller Mouth and nose - generally all structures are smaller and more easily obstructed than in adults.and more easily obstructed than in adults.

Pharynx - infant’s and children’s tongues take up Pharynx - infant’s and children’s tongues take up proportionally more space in the mouth than adults.proportionally more space in the mouth than adults.

Trachea - (windpipe) Trachea - (windpipe) Infants and children have narrower tracheas that are Infants and children have narrower tracheas that are

obstructed more easily by swelling.obstructed more easily by swelling. Trachea is softer and more flexible in infants and Trachea is softer and more flexible in infants and

children.children.

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Infant and Child Considerations

Cricoid cartilage - like other cartilage in the infant Cricoid cartilage - like other cartilage in the infant and child, the cricoid cartilage is less developed and child, the cricoid cartilage is less developed and less rigid. It is the narrowest part of the and less rigid. It is the narrowest part of the infant’s or child’s airway.infant’s or child’s airway.

Diaphragm - chest wall is softer, infants and Diaphragm - chest wall is softer, infants and children tend to depend more heavily on the children tend to depend more heavily on the diaphragm for breathing.diaphragm for breathing.

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Opening the Mouth

Crossed-finger techniqueCrossed-finger technique Inspect the mouthInspect the mouth

VomitVomit BloodBlood SecretionsSecretions Foreign bodiesForeign bodies

Be extremely cautiousBe extremely cautious FingersFingers Gag or vomitGag or vomit

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Opening the Airway

Head-tilt, chin lift maneuverHead-tilt, chin lift maneuver Adults vs.. Infants and ChildrenAdults vs.. Infants and Children

Jaw thrust maneuverJaw thrust maneuver

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Techniques of Suctioning

BSI precautionsBSI precautions PurposePurpose

Remove blood, other liquids, and food particles Remove blood, other liquids, and food particles from the airwayfrom the airway

Some suction units are inadequate for removing Some suction units are inadequate for removing solid objects like teeth, foreign bodies, and foodsolid objects like teeth, foreign bodies, and food

A patient needs to be suctioned immediately when A patient needs to be suctioned immediately when a gurgling sound is heard with artificial a gurgling sound is heard with artificial ventilationventilation

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Types of Suction Units

Mounted Suction DevicesMounted Suction Devices Fixed on-board the ambulanceFixed on-board the ambulance 300mmHg pull on gauge when tubing is 300mmHg pull on gauge when tubing is

clampedclamped Should be adjustable for infants and childrenShould be adjustable for infants and children Powered by ambulance engine manifoldPowered by ambulance engine manifold

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Portable Suction Devices

Electric - battery powered Electric - battery powered Oxygen - poweredOxygen - powered Hand - poweredHand - powered Each device must haveEach device must have

Wide-bore, thick walled, non-kink tubingWide-bore, thick walled, non-kink tubing Plastic collection bottle, supply of waterPlastic collection bottle, supply of water Enough vacuum to clear the throatEnough vacuum to clear the throat

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Suction Catheters

Hard or rigid catheter (Yankaeur)Hard or rigid catheter (Yankaeur) Tonsil tipTonsil tip Used to suction mouth and oropharynxUsed to suction mouth and oropharynx Inserted only as far as you can seeInserted only as far as you can see Use extreme caution on infants and childrenUse extreme caution on infants and children

Soft tissue damageSoft tissue damage

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Soft catheter (French catheter)Soft catheter (French catheter) Nose or nasopharynx, mouthNose or nasopharynx, mouth Measured from tip of the nose to the tip of his Measured from tip of the nose to the tip of his

ears.ears. Not inserted beyond the base of the tongueNot inserted beyond the base of the tongue

Suction Catheters

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Techniques of Suctioning

Positioned at patient’s headPositioned at patient’s head Turn on the suction unitTurn on the suction unit Select catheterSelect catheter Measure and insert without suction if possibleMeasure and insert without suction if possible Suction from side to sideSuction from side to side

Adults no more than 15 secondsAdults no more than 15 seconds Infants & children no more than 5 secondsInfants & children no more than 5 seconds

Rinse catheter with water if necessaryRinse catheter with water if necessary

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Special Considerations

Secretions that cannot be removed log roll and finger sweepSecretions that cannot be removed log roll and finger sweep Patient producing frothy secretions as rapidly as suctioning Patient producing frothy secretions as rapidly as suctioning

can remove themcan remove them Suction 15 secondsSuction 15 seconds Positive pressure with supplemental oxygen for 2 minutes Positive pressure with supplemental oxygen for 2 minutes

then suction again and repeat the processthen suction again and repeat the process Residual air removed from lungs, monitor pulse and heart rateResidual air removed from lungs, monitor pulse and heart rate Before and after suctioning hyperventilate 24 per/min. x 5 Before and after suctioning hyperventilate 24 per/min. x 5

min.min.

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Oropharyngeal Airway (OPA)

Used to maintain a patent airway only on Used to maintain a patent airway only on deeply unresponsive patientsdeeply unresponsive patients

No gag reflexNo gag reflex Designed to allow suctioning while in placeDesigned to allow suctioning while in place Must have the proper sizeMust have the proper size If patient becomes responsive and starts to If patient becomes responsive and starts to

fight the OPA remove it...fight the OPA remove it...

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Inserting the OPA

Select the proper size (corner of the mouth to tip Select the proper size (corner of the mouth to tip of the ear)of the ear)

Open the patient’s mouthOpen the patient’s mouth Insert the OPA with the tip facing the roof of the Insert the OPA with the tip facing the roof of the

mouth mouth Advance while rotating 180°Advance while rotating 180° Continue until flange rests on the teethContinue until flange rests on the teeth Infants and children insertionInfants and children insertion

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Nasopharyngeal Airway (NPA)

Nose hose, nasal trumpetNose hose, nasal trumpet Used on patients who are unable to tolerate an Used on patients who are unable to tolerate an

OPA or is not fully responsiveOPA or is not fully responsive Do not use on suspected basilar skull fractureDo not use on suspected basilar skull fracture Still need to maintain head-tilt chin lift or jaw Still need to maintain head-tilt chin lift or jaw

thrust when insertedthrust when inserted Must select the proper sizeMust select the proper size Made to go into right nare or nostrilMade to go into right nare or nostril

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Inserting the NPA

Select the proper size in length and diameterSelect the proper size in length and diameter LubricateLubricate Insert into right nostril with bevel always Insert into right nostril with bevel always

toward the septumtoward the septum Continue inserting until flange rests against Continue inserting until flange rests against

the nostrilthe nostril Insertion into left nostrilInsertion into left nostril

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Assessment of Breathing

After establishing an airway your next step After establishing an airway your next step should be to assess breathingshould be to assess breathing

LookLook Breathing pattern regular or irregularBreathing pattern regular or irregular Nasal flaringNasal flaring Adequate expansion, retractionsAdequate expansion, retractions

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ListenListen Dyspnea when speakingDyspnea when speaking Unresponsive place ear next to patients mouthUnresponsive place ear next to patients mouth Is there any movement of air?Is there any movement of air?

Assessment of Breathing

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FeelFeel Check the volume of breathing by placing you Check the volume of breathing by placing you

ear and cheek next to the patient’s mouthear and cheek next to the patient’s mouth

Assessment of Breathing

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AuscultateAuscultate StethoscopeStethoscope

Mid clavicular about the second intercostal space Mid clavicular about the second intercostal space and the fourth or fifth anterior midaxillary line or and the fourth or fifth anterior midaxillary line or next to sternumnext to sternum

Check both sidesCheck both sides Present and equal bilaterallyPresent and equal bilaterally Diminished or absentDiminished or absent

Assessment of Breathing

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Adequate Breathing

Normal rateNormal rate Adult 12 - 20/minAdult 12 - 20/min Child 15 - 30/minChild 15 - 30/min Infant 25 - 50/minInfant 25 - 50/min

RhythmRhythm Regular Regular IrregularIrregular

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QualityQuality Breath sounds present and equalBreath sounds present and equal Chest expansion adequate and equalChest expansion adequate and equal Effort of breathingEffort of breathing

use of accessory muscles predominately in infants use of accessory muscles predominately in infants and childrenand children

DepthDepth Adequate chest rise and fallAdequate chest rise and fall Full breath sounds heardFull breath sounds heard

Adequate Breathing

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Inadequate Breathing

RateRate Outside the normal limitsOutside the normal limits

Tachypnea (rapid breathing)Tachypnea (rapid breathing) Badypnea (slow breathing)Badypnea (slow breathing)

RhythmRhythm Irregular breathing patternIrregular breathing pattern

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QualityQuality Breath sounds diminished or absentBreath sounds diminished or absent Excessive use of accessory muscles, retractionsExcessive use of accessory muscles, retractions Diaphormatic breathingDiaphormatic breathing Nostril flaring (infants & children)Nostril flaring (infants & children)

DepthDepth Shallow breathingShallow breathing Agonal respirations - occasional gasping respirationsAgonal respirations - occasional gasping respirations

Any of these signs is by itself is a reason to ventilate a Any of these signs is by itself is a reason to ventilate a patient without delaypatient without delay

Inadequate Breathing

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Positive Pressure ventilation

The practice of artificially ventilating, or The practice of artificially ventilating, or forcing air into a patient who is breathing forcing air into a patient who is breathing inadequately or not breathing at allinadequately or not breathing at all

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Techniques of Artificial Ventilation

In order of preferenceIn order of preference Mouth to maskMouth to mask Two-person bag-valve-maskTwo-person bag-valve-mask Flow-restricted oxygen-powered ventilation Flow-restricted oxygen-powered ventilation

devicedevice One-person bag-valve-maskOne-person bag-valve-mask

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Considerations When Using Artificial Ventilation

Maintain a good mask sealMaintain a good mask seal Device must deliver adequate volume of air Device must deliver adequate volume of air

to sufficiently inflate the lungsto sufficiently inflate the lungs Supplemental oxygen must be usedSupplemental oxygen must be used

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Adequate Artificial Ventilations

Chest rises and falls with each ventilationChest rises and falls with each ventilation Rate of ventilations are sufficientRate of ventilations are sufficient Heart rate returns to normalHeart rate returns to normal Color improvesColor improves

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Inadequate Artificial Ventilations

Chest does not rise and fallChest does not rise and fall Ventilation rate is too fast or slowVentilation rate is too fast or slow Heart rate does not return to normalHeart rate does not return to normal

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Mouth-to-Mouth Ventilation

Air we breath contains 21% oxygenAir we breath contains 21% oxygen 5% used by the body5% used by the body 16% is exhaled16% is exhaled Danger of infectious diseaseDanger of infectious disease

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Mouth-to-Mask

Eliminates direct contact with patientEliminates direct contact with patient One-way valve systemOne-way valve system Can provide adequate or greater volume Can provide adequate or greater volume

than a BVMthan a BVM Oxygen port (should be connected to 15 Oxygen port (should be connected to 15

lpm)lpm)

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Bag-Valve-Mask (BVM)

EMT-B can feel the lung complianceEMT-B can feel the lung compliance Consists of self-inflating bag, one-way valve, Consists of self-inflating bag, one-way valve,

face mask, intake/oxygen reservoir valve, and face mask, intake/oxygen reservoir valve, and an oxygen reservoir.an oxygen reservoir.

By adding oxygen and a reservoir close to By adding oxygen and a reservoir close to 100% oxygen can be delivered to the patient100% oxygen can be delivered to the patient

When using a BVM an OPA/NPA should be When using a BVM an OPA/NPA should be used if possibleused if possible

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Bag-Valve-Mask Cont...

Volume of approximately 1,600 millilitersVolume of approximately 1,600 milliliters Provides less volume than mouth-to-maskProvides less volume than mouth-to-mask Single EMT may have trouble maintaining Single EMT may have trouble maintaining

sealseal Two EMT’s more effectiveTwo EMT’s more effective Pop-off valve must be disabledPop-off valve must be disabled Available in infant, child, and adult sizesAvailable in infant, child, and adult sizes

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Flow-Restricted, Oxygen-Powered Ventilation Device Known as a demand-valve deviceKnown as a demand-valve device Can be operated by patient or EMTCan be operated by patient or EMT Unable to feel lung complianceUnable to feel lung compliance With proper seal will deliver 100% oxygenWith proper seal will deliver 100% oxygen Designed for use on adult patientsDesigned for use on adult patients Gastric distensionGastric distension Rupture of the lungsRupture of the lungs A trigger positioned to allow EMT to keep both hands A trigger positioned to allow EMT to keep both hands

on the maskon the mask

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Automatic Transport Ventilators

Deliver 100% oxygenDeliver 100% oxygen Provide and maintain a constant rate and tidal volume during Provide and maintain a constant rate and tidal volume during

ventilationventilation AdvantagesAdvantages

Frees both handsFrees both hands Rate, & tidal volume can be setRate, & tidal volume can be set Alarm for low oxygen tankAlarm for low oxygen tank

DisadvantagesDisadvantages Oxygen poweredOxygen powered not used in children under 5not used in children under 5 Cannot feel increase in airway resistanceCannot feel increase in airway resistance

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Oxygen Therapy

Oxygen is a drug that can be given by the Oxygen is a drug that can be given by the EMT-BEMT-B

““Generally speaking”, a patient who is Generally speaking”, a patient who is breathing less than 12 and more than 24 breathing less than 12 and more than 24 times a minute needs oxygen of some kindtimes a minute needs oxygen of some kind

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Oxygen Dangers

Oxygen supports combustion, (it is not Oxygen supports combustion, (it is not flammable)flammable)

Avoid contact with petroleum productsAvoid contact with petroleum products SmokingSmoking Handle carefully since contents are under Handle carefully since contents are under

pressurepressure Strap the cylinder between the patients legs Strap the cylinder between the patients legs

on the cot so it doesn’t fallon the cot so it doesn’t fall

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Oxygen Cylinders

All of the cylinders when full are the same All of the cylinders when full are the same pressure of 2,000 psi.pressure of 2,000 psi.

Usually green or aluminum greyUsually green or aluminum grey D cylinder - 350 litersD cylinder - 350 liters E cylinders - 625 litersE cylinders - 625 liters M cylinders - 3,000 litersM cylinders - 3,000 liters G cylinders - 5,300 litersG cylinders - 5,300 liters H cylinders - 6,900 litersH cylinders - 6,900 liters

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High-Pressure Regulator

Provides 50 psi to an oxygen-powered, Provides 50 psi to an oxygen-powered, ventilation device.ventilation device.

Flow rate cannot be controlledFlow rate cannot be controlled

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Low Pressure/Therapy Regulator

Permit oxygen delivery to the patient at a Permit oxygen delivery to the patient at a desired rate in liters per minutedesired rate in liters per minute

Flow rate can go from 1 to 25 liters/min.Flow rate can go from 1 to 25 liters/min.

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Oxygen Humidifiers

Dry oxygen is not harmful in the short termDry oxygen is not harmful in the short term Generally not needed in prehospital careGenerally not needed in prehospital care Transport time of an hour or more Transport time of an hour or more

humidifier should be consideredhumidifier should be considered

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Changing Oxygen Bottle

Check cylinder for oxygen remove protective sealCheck cylinder for oxygen remove protective seal Quickly open and shut tank to remove debrisQuickly open and shut tank to remove debris Place regulator over yoke and and align pins.Place regulator over yoke and and align pins. Make sure new O ring is in placeMake sure new O ring is in place Hand tighten the T screwHand tighten the T screw Open to check for leaksOpen to check for leaks

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Nonrebreather Mask

Preferred method of giving oxygen to prehospital Preferred method of giving oxygen to prehospital patientspatients

Up to 90% oxygen can be deliveredUp to 90% oxygen can be delivered Bag should be filled before placing on patientBag should be filled before placing on patient Flow rate should be adjusted to 15 liters/min.Flow rate should be adjusted to 15 liters/min. Patients who are cyanotic, cool, clammy or short of Patients who are cyanotic, cool, clammy or short of

breath need oxygenbreath need oxygen Concerns of too much oxygenConcerns of too much oxygen Different size masksDifferent size masks

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Nasal Cannula

Provides limited oxygen concentrationProvides limited oxygen concentration Used when patients cannot tolerate maskUsed when patients cannot tolerate mask Prongs and other usesProngs and other uses Concentration of 24 to 44%Concentration of 24 to 44% Flow rate set between 1 to 6 litersFlow rate set between 1 to 6 liters For every liter per minute of flow delivered, For every liter per minute of flow delivered,

the oxygen concentration the patient inhales the oxygen concentration the patient inhales increases by 4%increases by 4%

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Nasal Cannula Flow Rates

1 liters/min. =24%1 liters/min. =24% 2 liters/min. = 28%2 liters/min. = 28% 3 liters/min. = 32%3 liters/min. = 32% 4 liters/min. = 36%4 liters/min. = 36% 5 liters/min. = 40%5 liters/min. = 40% 6 liters/min. = 44%6 liters/min. = 44%

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Simple Face Mask

No reservoirNo reservoir Can deliver up to 60% concentrationCan deliver up to 60% concentration Rate 6 to 10 liters/min.Rate 6 to 10 liters/min. Not recommended for prehospital useNot recommended for prehospital use

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Partial Rebreather Mask

Similar to nonrebreather except it has a Similar to nonrebreather except it has a two-way valve allowing patient to rebreath two-way valve allowing patient to rebreath his exhaled air.his exhaled air.

Flow rate 6 to 10 liters/min.Flow rate 6 to 10 liters/min. Oxygen concentration between 35 to 60%Oxygen concentration between 35 to 60%

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Venturi Mask

Provides precise concentrations of oxygenProvides precise concentrations of oxygen Entrainment valve to adjust oxygen deliveryEntrainment valve to adjust oxygen delivery Mostly used in the hospital setting for Mostly used in the hospital setting for

COPD patientsCOPD patients

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Laryngectomies (Stomas)

A breathing tube may be presentA breathing tube may be present If obstructed, suction itIf obstructed, suction it Some patients may have partial Some patients may have partial

laryngectomieslaryngectomies Be sure to close the mouth and nose to Be sure to close the mouth and nose to

prevent air escapingprevent air escaping

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Infants and Child Patients

Neutral position infantNeutral position infant Just a little past neutral for childJust a little past neutral for child Avoid hyperextension of headAvoid hyperextension of head Avoid excessive BVM pressureAvoid excessive BVM pressure Gastric distension more common in childrenGastric distension more common in children Oral or nasal airway may be considered when Oral or nasal airway may be considered when

other procedures fail to clear the airwayother procedures fail to clear the airway

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Facial Injuries

Rich blood supply to the faceRich blood supply to the face Blunt injuries and burns to the face result in Blunt injuries and burns to the face result in

severe swellingsevere swelling Bleeding into the airway can be a challenge Bleeding into the airway can be a challenge

to manageto manage

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Dental Appliances

Dentures ordinarily should be left in placeDentures ordinarily should be left in place Partial dentures (plates) may become Partial dentures (plates) may become

dislodged during an emergencydislodged during an emergency Leave in place, but be prepared to remove it Leave in place, but be prepared to remove it

if it becomes dislodgedif it becomes dislodged