Dr Aqeela BanoEMS 352 ADVANCED AIRWAY MANAGEMENT

AIRWAY MANAGEMENT

Airway Management

• Air reaches the lungs only through the trachea. – In a compromised

airway, clearing the airway and maintaining patency are vital.

Positioning the Patient

• Move unresponsive patients found in a prone position to a supine position.– Log roll and assess for breathing.

• If the patient is breathing adequately and is not injured, move to recovery position.

Manual Airway Maneuvers

• If an unresponsive patient has a pulse but is not breathing, you must open the airway. – Maneuver patient’s

head to propel the tongue forward and open the airway.

Head Tilt-Chin Lift Maneuver

• Indications:– Unresponsive – No spinal injury– Unable to protect airway

• Contraindications:– Responsive – Possible spinal injury

• Advantages– No equipment – Noninvasive

• Disadvantages– Hazardous to spinal injury– No protection from aspiration

Jaw-Thrust Maneuver

• Indications– Unresponsive– Possible spine injury– Unable to protect airway

• Contraindications– Resistance to opening the mouth

• Advantages– Used with spine injury or cervical collar– No special equipment required

Jaw-Thrust Maneuver

• Disadvantages– Cannot maintain if patient becomes responsive or combative– Difficult to maintain for an extended time– Difficult to use with bag-mask ventilation– Thumb must remain in place– Requires second rescuer – No protection against aspiration

Suctioning

• Removes material from the mouth or throat quickly and efficiently– Ventilating with secretions in the mouth will result

in upper airway obstruction or aspiration. • Next priority after opening airway manually

Suctioning Equipment

• Fixed or portable– Hand-operated suctioning

units with disposable canisters

– Mechanical or vacuum-powered suction units

Suctioning Equipment

• The following should be readily accessible:– Wide-bore, thick-walled, nonkinking tubing– Soft and rigid suction catheters– Nonbreakable, disposable collection bottle – Supply of water for rinsing the catheters

Suctioning Equipment

• Yankauer catheter – Use with adults

(pharynx), infants, children

• Whistle-tip catheter– Can be placed in ET tube– Use for nose, back of

mouth, when a rigid catheter cannot be used

Suctioning Techniques

• Suctioning removes oxygen.– Preoxygenate before suctioning.– Maximum suctioning time

• Adult: 15 seconds• Child: 10 seconds• Infant: 5 seconds

Suctioning Techniques

• Do not stimulate back of throat.• After suctioning, continue ventilation and

oxygenation.• Soft-tip catheters

– Must lubricate when suctioning the nasopharynx– Best when passed through an ET tube– Suction during extraction of catheter

• May be needed to help maintain patency in an unresponsive patient after manually opening and suctioning– Not a substitute for proper head positioning

Airway Adjuncts

Oropharyngeal (Oral) Airway

• Curved, hard plastic device• Fits over back of the tongue • Should be inserted in unresponsive patients

who have no gag reflex

Oropharyngeal (Oral) Airway

• Indications– Unresponsive patients who have no gag reflex

• Contraindications– Responsive patients– Patients with a gag reflex

• Advantages– Noninvasive and easily placed– Prevents blockage by the tongue

• Disadvantages– No prevention of aspiration

Nasopharyngeal (Nasal) Airway

• Soft, rubber tube• Insert through nose • Better tolerated

– Do not use with trauma to the nose or skull fracture.

• Lubricate the airway and insert gently.

Nasopharyngeal (Nasal) Airway

• Indications– Unresponsive – Altered mental status with an intact gag reflex

• Contraindications– Patient intolerance– Facial fracture or skull fracture

• Advantages– Suctioned through– Patent airway– Tolerated by responsive patients– Can be placed “blindly”– No requirement for the mouth to be open

• Disadvantages– Improper technique may result in severe bleeding.– Does not protect from aspiration

Causes of Airway Obstruction

• Foreign body • Tongue• Laryngeal edema• Laryngeal spasm

• Trauma• Aspiration• Infection or severe allergic

reaction

Causes of Airway Obstruction

• Tongue– With altered LOC, tongue can fall backwards,

closing off the airway• Partial obstruction: snoring respirations• Complete obstruction: no respirations

– Simple to correct with manual maneuver

Causes of Airway Obstruction

• Foreign body– Typical victim: middle-aged or older, dentures,

alcohol– Signs may include:

• Choking• Gagging• Stridor• Dyspnea• Aphonia or dysphonia

Laryngeal Spasm and Edema

• Laryngeal spasm– Spasmodic closure of

vocal cords– Completely occludes

airway– Causes include:

• Intubation trauma • Extubation

• Laryngeal edema– Glottic opening

narrows or totally closes

– Causes include: • Epiglottitis• Anaphylaxis• Inhalation injury

Laryngeal Spasm and Edema

• May be relieved by– Aggressive ventilation– Forceful upward jaw pull

• May be relieved by muscle relaxants• May recur; transport patient to hospital for

evaluation

Laryngeal Injury

• Fracture of the larynx increases airway resistance by decreasing airway size.

• Penetrating and crush injuries to the larynx can compromise the airway.

Aspiration

• Increases mortality– Can obstruct the airway– Destroys bronchiolar tissue– Introduces pathogens into the lungs– Decreases patient’s ability to ventilate

• Have suction readily available

Recognition of an Airway Obstruction

• Mild obstruction– Patient is responsive, able to exchange air– Usually has noisy respirations and coughing– Should be left alone– Closely monitor the patient’s condition.– Be prepared to intervene.

Recognition of an Airway Obstruction

• Severe obstruction– Inability to breathe, talk, or cough– May grasp at throat, turn cyanotic,

make frantic movements– Cough is weak, ineffective, or

absent – Weak inspiratory stridor and

cyanosis

Emergency Medical Care for Foreign Body Airway Obstruction

• Begin treatment immediately if choking is confirmed by a responsive patient.– If large pieces of foreign body are found, sweep

them out of the mouth with your finger. – Insert your finger along the inside of the cheek

and into the throat.– Try to hook the foreign body to dislodge it. – Suction as needed.

Emergency Medical Care for Foreign Body Airway Obstruction

• Abdominal thrust (Heimlich) maneuver – Creates an artificial cough, expelling the object – Perform until the object is expelled or the patient

becomes unresponsive.

Emergency Medical Care for Foreign Body Airway Obstruction

• If patient becomes unresponsive, position supine, begin chest compressions– 30 chest compressions– 15 with two rescuers or infant/child

• Open airway, remove any visible object• Attempt rescue breath, look for chest rise

Emergency Medical Care for Foreign Body Airway Obstruction

• If techniques do not work, proceed with direct laryngoscopy. – If you see the foreign body, remove it with Magill

forceps.

Administer to any patient with potential hypoxia

Supplemental Oxygen Therapy

Oxygen Sources

• Oxygen cylinders– Stores pure oxygen– Check label and test

date.– Various sizes– Oxygen delivery is

measured in L/min.

Oxygen Sources

• Liquid oxygen– Cooled to a liquid– Converts to a gas

when warmed– Keep upright.

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Safety Reminders

• Keep combustible materials away.• No smoking near cylinders.• Store in a cool, ventilated area.• Use only with a properly fitting regulator

valve. • Close all valves when not in use.

Oxygen Regulators and Flowmeters

• Flow meters allow oxygen to be adjusted.– Pressure-compensated flow meter – Bourdon-gauge flow meter

Preparing an Oxygen Cylinder for Use

• Before administering, you must prepare the oxygen cylinder and therapy regulator.

Nonrebreathing Mask

• Preferred in pre hospital setting– 90% to 100% oxygen– Non-re breathable mask

• Indications– Spontaneously breathing

patients

• Contraindications– Apnea and poor respiratory

effort

© Jones & Bartlett Learning. Courtesy of MIEMSS.

Nasal Cannula

• Two small prongs – 25% to 45% oxygen

• Best for patients who need long-term therapy

• Ineffective with: – Apnea– Poor respiratory effort– Severe hypoxia– Mouth breathing

© Jones & Bartlett Learning. Courtesy of MIEMSS.

Partial Rebreathing Mask

• Lacks one-way valve – Residual exhaled air

is re-breathed• 35% to 60% oxygen

© Jones & Bartlett Learning. Courtesy of MIEMSS.

Tracheostomy Masks

• Cover the stoma and have a strap that goes around the neck– To improvise, place

a face mask over the stoma.

Ventilatory Support

• Patient who is not breathing needs artificial ventilation and 100% supplemental oxygen– Indications include signs of:

• Altered mental status• Inadequate minute volume

Normal Ventilation Versus Positive-Pressure Ventilation

• Normal ventilation– Diaphragm contracts– Negative pressure in chest cavity draws in air

• Positive-pressure ventilation– Generated by a device– Forces air into the chest cavity from the external

environment

Normal Ventilation Versus Positive-Pressure Ventilation

• With positive-pressure ventilation, more air is needed to achieve the same effects of normal breathing. – Increases overall intrathoracic pressure– Blood flow is decreased.

Normal Ventilation Versus Positive-Pressure Ventilation

• Cardiac output is a function of stroke volume multiplied by the pulse rate.

• Normally, when a person breathes, air enters the trachea.– Ventilations that are too forceful can cause gastric

distention.

Assisted Ventilation

• Explain the procedure. • Place the mask over the

patient’s nose and mouth. • Squeeze the bag each

time the patient inhales.

• After 5 to 10 breaths, slowly adjust the rate.

• Adjust the rate and tidal volume to maintain adequate minute volume.

Artificial Ventilation

• Begin artificial ventilation immediately if patient is not breathing

• Methods include– Mouth-to-mask technique– One-, two-, or three-person bag-mask device

technique– Manually triggered ventilation device

Mouth-to-Mouth Ventilation

• Routinely performed with a barrier device

• Alternative: mouth-to-nose

• Requires no special equipment

• Can provide adequate tidal volume

Courtesy of AAOS.

Mouth-to-Mask Ventilation

• Places a physical barrier between your mouth and the patient’s mouth

• Oxygen inlet provides oxygen to supplement the air from your own lungs

• May be shaped like a triangle or a doughnut

• Can deliver nearly 100% oxygen.• Can provide adequate tidal volume when used

by an experienced paramedic– Depends on mask seal integrity

Bag-Mask Device

Bag-Mask Device Components

• Disposable, self-inflating bag

• No pop-off valve, or capability to disable

• Nonrebreathing outlet valve

• Oxygen reservoir • One-way, no-jam inlet

valve system • Transparent face mask

Bag-Mask Device Components

• Total amount of gas in an adult bag-mask device is usually 1,200 to 1,600 mL.

• Volume of oxygen to deliver is based on visible chest rise. – Deliver each breath over a period of 1 second at

the appropriate rate.

Bag-Mask Device Technique

• Kneel above patient’s head.

• Maintain neck in a hyperextended position (unless spinal injury).– Open the mouth, suction as

needed. – Insert an oral or nasal

airway.

• Place the mask on the patient’s face.

• Bring the lower jaw up to the mask.

• Connect the bag to the mask.

Bag-Mask Device Technique

• Hold the mask in place while your partner squeezes the bag until the chest visibly rises. – Squeeze every 5 to 6

seconds for adults, 3 to 5 seconds for infants and children.

Courtesy of AAOS

Bag-Mask Device Technique

• If alone, hold your index finger over the lower part of the mask and your thumb over the upper part.

• Observe for gastric distention, changes in compliance, and changes in status.

Bag-Mask Device Technique

• Squeeze bag as patient inhales.– Slowly adjust rate and tidal volume.– If patient is hyperventilating, first assist at the rate

at which the patient is breathing.• Then slowly adjust rate and tidal volume.

Bag-Mask Device Technique

• Not adequate if:– Chest does not rise and fall – Rate of ventilation is too slow or too fast– Pulse rate does not improve

Bag-Mask Device Technique

• If the chest does not rise and fall: – Reposition the head or insert an airway.– If the stomach seems to be rising and falling,

reposition the head. – If too much air is escaping, reposition the mask.

• If chest still does not rise and fall, check for an airway obstruction.

• Main use: apneic or hypoventilating patients• “Demand valve” delivers 100% oxygen• Makes an airtight seal with patient’s face• Impossible to assess for lung compliance

Manually Triggered Ventilation Devices

Manually Triggered Ventilation Devices

• Delivers only the volume of oxygen needed• Expensive, not disposable• Adapter fits standard ventilation masks

Components of Manually Triggered Ventilation Devices

• Peak flow rate: 100% oxygen up to 40 L/min

• Inspiratory pressure safety release valve

• Alarm if pressure is exceeded

• Properly positioned trigger (or lever)

Automatic Transport Ventilators

• Have bag-mask device available in case ATV malfunctions

• Most models have adjustments for respiratory rate and tidal volume.

• Deliver a preset volume at a preset rate.

Automatic Transport Ventilators

• Steps for using:– Attach to wall-mounted oxygen source. – Set tidal volume and ventilatory rate. – Connect to the ET tube or airway device. – Auscultate breath sounds and observe chest rise.

Automatic Transport Ventilators

• Generally consumes 5 L/min of oxygen• Pressure-relief valve can lead to:

– Hypoventilation – Increased airway resistance– Airway obstruction

Continuous Positive Airway Pressure

• Noninvasive means of providing ventilatory support for patients with respiratory distress

– Increases pressure in the lungs– Opens collapsed alveoli– Pushes oxygen across alveolar membrane– Forces interstitial fluid back into circulation

Continuous Positive Airway Pressure

• Typically delivered through a face mask secured with a strapping system. – Pressure relief valve determines amount of

pressure delivered to the patient

Indications for CPAP

• Guidelines:– Patient is alert and able to follow commands.– Obvious signs of respiratory distress from an

underlying disease or after submersion – Rapid breathing (more than 26 breaths/min) that

affects overall minute volume – Pulse oximetry of less than 90%

Contraindications to CPAP

• Respiratory arrest• Hypoventilation • Signs and symptoms of a

pneumothorax or chest trauma

• Tracheostomy• Active GI bleeding or

vomiting

• Inability to follow verbal commands

• Inability to properly fit CPAP system mask and strap

• Inability to tolerate the mask

Application of CPAP

• Generally composed of:– Generator– Mask– Circuit that contains corrugated tubing– Bacteria filter– One-way valve

Application of CPAP

• Patient exhales against a resistance (positive end-expiratory pressure [PEEP])– Controlled manually or predetermined – 5 to 10 cm H2O is general therapeutic range

Complications of CPAP

• Patients may feel claustrophobic and resist.• High volume of pressure can cause a

pneumothorax.• Increased pressure in the chest cavity can

result in hypotension.• Air may enter the stomach.

Gastric Distension

• Inflation of the stomach with air– Likely to occur when:

• Excessive pressure is used to inflate the lungs• Ventilations are performed too fast or too

forcefully• Airway is partially obstructed during ventilation

attempts

Gastric Distension

• Harmful for at least two reasons– Promotes regurgitation, can lead to aspiration– Pushes diaphragm up, limits lung expansion

• Signs include– Increased diameter, distension of the stomach– Increased resistance to bag-mask ventilations

Gastric Distension

• If signs are noted:– Reassess and reposition the airway. – Observe chest for adequate rise and fall. – Limit ventilation times to 1 second or the time

needed to produce adequate chest rise.

Invasive Gastric Decompression

• Involves inserting a gastric tube into the stomach and suctioning the contents– Should be considered:

• For any patient who will need positive-pressure ventilation for an extended period

• When gastric distention interferes with ventilations

Invasive Gastric Decompression

• Nasogastric tube– Insert through nose – Decompresses

stomach• Decreases pressure• Limits risk of

regurgitation

Invasive Gastric Decompression

• Nasogastric tube (cont’d)– Relatively well tolerated– Contraindicated with severe facial injuries

• Use OG route instead.

Invasive Gastric Decompression

• Orogastric tube– Inserted through the mouth– No risk of nasal bleeding– Safer in patients with severe facial trauma– Can use larger tubes

Orogastric Tube

• Orogastric tube (cont’d)– Less comfortable for responsive patients

• Preferred for patients who are unresponsive without a gag reflex

Laryngectomy

• Surgical removal of the larynx– Tracheostomy creates a stoma.– Total laryngectomy: breathe through stoma

• Cannot ventilate by mouth-to-mask technique

– Partial laryngectomy: breathe through stoma and nose or mouth

Ventilation of Stoma Patients

• Head tilt-chin lift and jaw-thrust not required• If no tracheostomy tube, use:

– Mouth-to-stoma technique – Bag-mask device

• Use an infant- or child-sized mask to make an adequate seal.

Ventilation of Stoma Patients

• Two rescuers are needed with a bag-mask device. – One to seal the nose and mouth – The other to squeeze the bag-mask device

Tracheostomy Tubes

• Plastic tube placed within the stoma– Patients may

receive supplemental oxygen via:

• Tubing designed to fit over the tube

• Placing an oxygen mask over the tube

Tracheostomy Tubes

• Patients who experience sudden dyspnea often have thick secretions in the tube– Suction as you would through a stoma.– When tube is dislodged, stenosis may occur.

Dental Appliances

• Different forms– Dentures (upper, lower, or both)– Bridges– Individual teeth– Braces (in the younger population)

Dental Appliances

• Determine whether appliance is loose or fits – If it fits well, leave in place.– Remove if loose.

• Take care if airway obstruction is caused by a bridge (can lacerate pharynx or larynx).

• Generally best to remove before intubating

Facial Trauma

• Severe swelling and bleeding in the airway may be present.– Control with direct

pressure.– Suction as needed.

© Eddie M. Sperling

Facial Trauma

• Inadequate breathing and severe oropharyngeal bleeding may be present.– Suction airway for 15 seconds (less in infants and

children), then ventilate for 2 minutes.• Alternate until secretions have been cleared.

Facial Trauma

• Suspect cervical spine injury.– Endotracheal intubation of a trauma patient is

most effectively performed by two paramedics.• If you are unable to effectively ventilate or

intubate, perform a cricothyrotomy.

QUESTIONS?????????????

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