Airway and Breathing

ETAT Module 2

Adapted from Emergency Triage Assessment and Treatment (ETAT): Manual for Participants, World Health Organization, 2005

Learning Objectives

• Accurately determine whether or not a patient’s airway is patent and adequate.

• Accurately assess the effectiveness of the patient’s breathing (oxygenation and ventilation).

• Effectively perform maneuvers to relieve choking.

• Effectively position the patient to open the airway (with and without possible cervical spine injury).

• Give supplemental oxygen.

• Effectively provide bag mask ventilation with and without airway adjuncts.

Target Audience

• Healthcare providers in any facility who are likely to manage sick patients, including physicians, nurses, and assistants.

• Teachers and trainers for healthcare professionals

Airway

Breathing

Essential assessment questions

• Is the patient breathing?

• Is the airway obstructed? Partial or complete?

• Is the patient blue?

• Does the patient have severe respiratory distress?

AB

AIRWAY BREATHING

Any positive signs

• Not breathing

• Central cyanosis (blueness)

• Severe respiratory distress

Manage

• Open airway

• Give oxygen

• Keep patient warm

Airway and breathing: overview of assessment and management

Overview of airway and breathing

• Is the airway obstructed? Is the obstruction partial or complete? – Assessment: Is there a history of choking (as with foreign body)?

• Treatment: For complete obstruction, back slaps/chest thrusts or abdominal thrusts

• Position the airway – Treatment: Chin lift

– Assessment: Is there a history of neck injury? • Treatment: Jaw thrust rather than chin lift

• Is the patient breathing? – Assessment: Look, listen, and feel

• Treatment: Bag mask ventilation

• Does the child have severe respiratory distress or cyanosis (blueness)?

Is the airway obstructed?

• Is there a history of choking? • Sudden onset of symptoms.

• Associated with eating or foreign object in mouth.

• Is the obstruction complete?

• There is no sound, even though the child is appears to be coughing or choking.

• Is the obstruction partial?

• Audible crying, coughing, or choking.

Management of choking

(complete airway obstruction) < 12 months

Alternate

Back slaps (5) and

Chest thrusts (5)

ETAT manual for participants, page 14

How to perform back slaps

• Lay infant on your arm or thigh with head down.

• Give 5 blows to back with heel of hand.

ETAT manual for participants, page 14

How to perform chest thrusts

• From the back slap position, turn the infant over, keeping the head down.

• With two fingers, perform 5 chest thrusts in the midline just below the nipple line.

Circulation 2005;112:IV-156

Back slap chest thrust sequence for choking child < 12 months

• Infant with a history of choking is not breathing. • Deliver 5 back thrusts. • Assess breathing. • Obstruction persists, deliver 5 chest thrusts. • Assess breathing. • Obstruction persists, check mouth and remove any visible

foreign body. • Assess breathing. • Obstruction persists. • Continue to deliver alternating back slaps and chest thrusts,

checking the mouth after each series of chest thrusts.

Demonstration

Choking manoeuveres for infants

< 12 months

Management of choking

(complete airway obstruction) > 12 months

Abdominal thrusts

(Heimlich manoeuvre)

ETAT manual for participants, page 15

How to perform abdominal thrusts

• Go behind patient.

• Pass your arms around the patient’s body.

• Immediately below the patient’s sternum, make a fist with one hand and place the other hand over it.

• Pull inward and upward into the patient’s abdomen.

• Repeat this manoeuvere 5 times.

• If obstruction persists, check the patient’s mouth and remove visible obstructions.

www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/18153.j

Demonstration

Choking manoeuveres for

children > 12 months

Positioning the airway

• The most common cause of upper airway obstruction is the tongue.

• Use chin lift for patients without concern for neck trauma.

ETAT manual for participants, page 15

©2008 UpToDate®

Position airway with neck injury

• For patients who may have neck injury, you must NOT move the neck.

• Use jaw thrust.

ETAT manual for participants, page 16

©2008 UpToDate®

Demonstration

Positioning the airway

Is the patient breathing?

• Look – Active, crying, talking?

– Chest wall moving?

– Color?

• Listen – Any breath sounds?

– Are they normal?

• Feel – Can you feel the breath at the

nose or mouth? ETAT manual for participants, page 17

Is there increased work of breathing?

• Can child talk or nurse?

• Signs of distress

– Anxious

– Nasal flaring

– Indrawing of chest • Between the ribs

• Below the breast bone

PALS: Rapid Cardiopulmonary Assessment, American Heart Association 2001

What is the rate and pattern of breathing?

• Too fast

• Too slow

• Agonal breathing: irregular, slow

• Abnormal patterns – Deep, slow (as with acidosis)

– Irregular (as with brain abnormalities)

Assess for fast breathing

Manual for health care of children in humanitarian emergencies, WHO 2008, page 7

Are there abnormal sounds?

• Stridor: upper airway obstruction (foreign body, croup)

• Wheezing: lower airway obstruction (bronchospasm)

• Grunting: increased end expiratory pressure (pneumonia)

Who needs oxygen?

• Any patient with airway or breathing problems

• Patients with shock

• Children with severe anemia (< 5 gm Hb)

– They will not show cyanosis

www.cdc.gov/niosh/fire/images

Oxygen sources

Refillable cylinders Oxygen concentrator

• Portable • Require reliable oxygen source to refill • Flammable hazard

• Can supply 95% oxygen • Requires electricity • Requires maintenance

Oxygen delivery systems

• Nasal prongs

• Blow by

• Mask

– Simple

– Non-rebreather

ETAT manual for participants, page 21

Patient not breathing: needs ventilation

Bag Mask Ventilation

2008 UpToDate®

Proper airway positioning

Proper positioning aligns the oral (O), pharyngeal (P), and tracheal (T) axes to open the airway.

Bag mask ventilation

• EC clamp technique

• Oxygen source

• Delivering breaths

– Deliver slowly (over one second)

– Rate: 12 to 20 per minute

Airway adjuncts Oral airway Nasal airway

• Can only be used in unconscious patients. • Tongue can be inadvertently pushed into the hypopharynx, causing obstruction.

• Can be used for conscious patients.

Demonstration

Bag Mask Ventilation

When management resources are limited

• Use guidelines from Integrated Management of Childhood Illness (IMCI).

• IMCI chartbook uses the same assessment and classification principles as ETAT.

• Management recommendations emphasize recognizing patients that should be stabilized and transferred.

ABCD

• Severe disease OR

• Local bacterial infection

Positive sign

• Not feeding well OR

• Convulsion OR

• Rapid breathing OR

• Severe chest indrawing OR

• Fever OR low temperature

• Poorly responsive

Manage • Keep patient warm

(skin to skin)

• Give first dose of antibiotic

• Refer urgently to hospital

Assessment and classification: IMCI under 2 months

AB

AIRWAY BREATHING

Positive signs

• Cyanosis

• Chest indrawing

• Stridor at rest

Manage • Keep patient warm

• Give first dose of antibiotic

• Refer urgently to hospital

Airway and breathing: IMCI 2 months to 5 years

Summary

Obstructed airway

Not breathing

Hypoxia

Severe respiratory distress

Choking manoeuvers

Give oxygen

Give oxygen, Ventilate

Ventilate