2014 AEMT airway management cole

2014 AEMT COURSEPRESENTED BY:

ROBERT S. COLEPARAMEDIC, OCD

Airway Management

When ever I’m blue…..I remember to breath again.

- Anonymous

Basic Concept:

Air Goes in and OutBlood Goes Round and Round

Any thing infringing on this is a BAD THING!

Respiratory Anatomy

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

The Upper Airway

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

The Lower Airway

The Lower Airway

9

The Lower Airway

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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.

The Lower Airway

The Chest Cavity

Thoracic skin, muscle, and bones

Similarities to other regions

Also unique features to allow for ventilation

Pulmonary Circulation

The Thoracic “Cage”

Credit: wikipedia.com

The Rib

Credit: wikipedia.com

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.

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”

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.

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.

The Mechanical Bellows?

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.

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.

The Mechanical Bellows

Example of a Compromised Bellows

Positional Asphyxia

Special Thanks to Charlie Miller for this Graphic.

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.

AKA: HOW WE BREATH…. .

Physiology of Respiration

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)

Respiratory Rate

times x

Tidal Volume(amount of air exchanged in one breath)

equals =

Minute Ventilation

Minute Ventilation

RR x TV = minute volume

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.

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.

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.

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

“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

Diffusion

An O2 friendly RBC with hgb.

Hemoglobin is an Iron Based compound essential to the transport of O2. Anemia Cyanide Poisoning CO Poisoning

An intact circulatory system

Blood LossShock

Pump Problem Volume Problem

Fluid issue O2 carrying issue

Vessel Problem

KEY POINT: Must have enough of a pulmonary perfusion pressure

to promote diffusion.

Conditions like Hypotension cause

secondary hypoxia by promoting low perfusion.

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”.

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.

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

All cells need a constant supply of oxygen to survive.

Physiology of Respiration

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

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

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

QUICK REVIEWALSO REVIEWED IN MEDICAL

EMERGENCIES

Respiratory Compromise

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.

Pneumothorax

Pneumothorax

Open chest woundOften called an open pneumothorax or a sucking chest wound.

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

Tension Pneumothorax

Blood collects in the pleural space from bleeding around the rib cage or from a lung or great vessel.

Hemothorax

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

Pulmonary Edema

The fluid and thicker tissue makes exchange of gasses less efficient.

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.

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.

Chronic Obstructive Pulmonary Disease (COPD)

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

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).

Asthma is acute spasm of smaller air passages (bronchioles).

Asthma

Signs of Mechanical Ventilation Impairment

Abnormal sounds include wheezing, rales, rhonchi, and stridor.

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)

Assessment

What do we assess?

Primary Assesment Presence or absence? Rate Quality

“Doorway Test”

First Impressions

Air HungryNasal FlaringTripodingRocking with

respirationsPursed Lip BreathingBarrel or Sparrow

ChestHome O2

Respiratory Rate

Decreased by: Depressant Drugs Sleep

Increased by: Fever Fear Exertion

Respiratory Quality

Irregular: Neuro Insult.Shallow:

Respiratory Depressants CNS Depressants Neuro Insult

Deep: Hyperglycemia with Acidosis (DKA): “Kussmal

Respirations Electrolyte Imbalances Neuro Insult

Skin Signs

Cyanosis Nail Beds Lips Ears

Mottling Chest Lower Ext Abd

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

Speech Dyspnea

Inability to speak more than a few syllables in a sentence between breaths.

Breath Sounds

Listening by comparisonListening anteriorListening posteriorFremitus

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

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

Signs/symptoms of distress

DyspneaRestlessness/anxietyTachypnea/BradypneaCyanosis (core)Abnormal soundsRetractionsDiminished ability to speak

More S/S

Retractions and/or use of accessory musclesAbdominal breathingNasal flaringProductive cough

Color?Irregular breathing Tripod positionPursed-lip breathing

Take another look ….What do you see?

Hows this?

Pursed Lips

Sparrow Chest

Tripoding

Retractions

Abd retractions

Kewl Haircut

O2

Inadequate Breathing: Infants and Children

Retractions

Nasal Flaring

See-Saw Breathing

Diaphragmatic Breathing

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

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

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.

Basic Airway Interventions

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

Airway Obstruction

Most common cause: tongue and/or epiglottis

Manual Opening the AirwayManual Opening the Airway

Jaw thrust Head tilt–chin lift

The Oropharyngeal AirwayThe Oropharyngeal Airway

Malposition of Oropharyngeal Airway

Malposition of Oropharyngeal Airway

Too short

Nasopharyngeal Airway Nasopharyngeal Airway

Insertion technique

The Bag Valve mask

The Sniffing Position

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”.

The E-C Technique

“Double C” or “two Hand Technique

Pirated from www.emsbasics.com

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.

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.

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.

NuMask IOM® and IOM® w/ OPA in Place

NuMask IOM NuMask IOM with OPA

All Rights Reserved. © 2007-2011 NuMask®, Inc.

An air tight seal in 1/10th the space of a traditional mask

All Rights Reserved. © 2007-2011 NuMask®, Inc.

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.

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

Types of Portable Suction

Courtesy of Laerdal Medical Corporation, Armonk, NY

Supra-glottic Airways

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.

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.

Terms

Supra-glotticDouble/Single LumenPeri-glotticEsophageal orburtrator airways

Lots of devices over the years

Esophageal obturation Esophageal Gastric Tube Airway (EGTA) Esophageal Orbturator Airway (EOA)

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

“Peri-Glottic” Airways

Laryngeo-Mask Airways (LMA)Air-QI-Gel

Laryngeo-Mask Airways

I Gel

Single Lumen Airways

King LTDCOBRA Peri-Laryngeal Airway (PLA)

Cobra PLA

King Airway

Size determined by Pt’s height:

Yellow: 4-5 ft

Red: 5-6 ft

Purple: > 6 ft

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.

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.

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.

ARTIFICIAL VENTILATION

Management Techniques

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

Basic Airway Adjuncts

Chin liftJaw thrustPositioning/suctioningOropharyngeal airway (OPA)Nasopharyngeal airway (NPA)EGTA/Combi-tube/King LT

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%

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

Artificial ventilation

Devices include:

Pocket face masks Bag-mask device CPAP/BiPAP Manually triggered ventilation device Automatic transport ventilator

Assisted and Artificial Ventilation

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

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

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

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.

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.

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

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

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

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

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

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

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

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.

Questions?