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Dr Aqeela BanoEMS 352 ADVANCED AIRWAY MANAGEMENTAIRWAY MANAGEMENTAirway ManagementAir reaches the lungs only through the trachea. In a compromised airway, clearing the airway and maintaining patency are vital.

Positioning the PatientMove 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 ManeuversIf an unresponsive patient has a pulse but is not breathing, you must open the airway. Maneuver patients head to propel the tongue forward and open the airway.

Head Tilt-Chin Lift ManeuverIndications:Unresponsive No spinal injuryUnable to protect airwayContraindications:Responsive Possible spinal injuryAdvantagesNo equipment NoninvasiveDisadvantagesHazardous to spinal injuryNo protection from aspiration

Jaw-Thrust ManeuverIndicationsUnresponsivePossible spine injuryUnable to protect airwayContraindicationsResistance to opening the mouthAdvantagesUsed with spine injury or cervical collarNo special equipment required

Jaw-Thrust ManeuverDisadvantagesCannot maintain if patient becomes responsive or combativeDifficult to maintain for an extended timeDifficult to use with bag-mask ventilationThumb must remain in placeRequires second rescuer No protection against aspiration

SuctioningRemoves material from the mouth or throat quickly and efficientlyVentilating with secretions in the mouth will result in upper airway obstruction or aspiration. Next priority after opening airway manuallySuctioning EquipmentFixed or portableHand-operated suctioning units with disposable canistersMechanical or vacuum-powered suction units

Suctioning EquipmentThe following should be readily accessible:Wide-bore, thick-walled, nonkinking tubingSoft and rigid suction cathetersNonbreakable, disposable collection bottle Supply of water for rinsing the cathetersSuctioning EquipmentYankauer catheter Use with adults (pharynx), infants, childrenWhistle-tip catheterCan be placed in ET tubeUse for nose, back of mouth, when a rigid catheter cannot be used

Suctioning TechniquesSuctioning removes oxygen.Preoxygenate before suctioning.Maximum suctioning timeAdult: 15 secondsChild: 10 secondsInfant: 5 secondsSuctioning TechniquesDo not stimulate back of throat.After suctioning, continue ventilation and oxygenation.Soft-tip cathetersMust lubricate when suctioning the nasopharynxBest when passed through an ET tubeSuction during extraction of catheter

May be needed to help maintain patency in an unresponsive patient after manually opening and suctioningNot a substitute for proper head positioningAirway AdjunctsOropharyngeal (Oral) AirwayCurved, hard plastic deviceFits over back of the tongue Should be inserted in unresponsive patients who have no gag reflex

Oropharyngeal (Oral) AirwayIndicationsUnresponsive patients who have no gag reflexContraindicationsResponsive patientsPatients with a gag reflexAdvantagesNoninvasive and easily placedPrevents blockage by the tongue DisadvantagesNo prevention of aspiration

Nasopharyngeal (Nasal) AirwaySoft, rubber tubeInsert through nose Better toleratedDo not use with trauma to the nose or skull fracture.Lubricate the airway and insert gently.

Nasopharyngeal (Nasal) AirwayIndicationsUnresponsive Altered mental status with an intact gag reflexContraindicationsPatient intoleranceFacial fracture or skull fractureAdvantagesSuctioned throughPatent airwayTolerated by responsive patientsCan be placed blindlyNo requirement for the mouth to be openDisadvantagesImproper technique may result in severe bleeding.Does not protect from aspiration

Causes of Airway ObstructionForeign body TongueLaryngeal edemaLaryngeal spasmTraumaAspirationInfection or severe allergic reactionCauses of Airway ObstructionTongueWith altered LOC, tongue can fall backwards, closing off the airwayPartial obstruction: snoring respirationsComplete obstruction: no respirationsSimple to correct with manual maneuver Causes of Airway ObstructionForeign bodyTypical victim: middle-aged or older, dentures, alcoholSigns may include: ChokingGaggingStridorDyspneaAphonia or dysphoniaLaryngeal Spasm and EdemaLaryngeal spasmSpasmodic closure of vocal cordsCompletely occludes airwayCauses include: Intubation trauma ExtubationLaryngeal edemaGlottic opening narrows or totally closes Causes include: EpiglottitisAnaphylaxisInhalation injuryLaryngeal Spasm and EdemaMay be relieved byAggressive ventilationForceful upward jaw pull May be relieved by muscle relaxantsMay recur; transport patient to hospital for evaluationLaryngeal InjuryFracture of the larynx increases airway resistance by decreasing airway size. Penetrating and crush injuries to the larynx can compromise the airway.AspirationIncreases mortalityCan obstruct the airwayDestroys bronchiolar tissueIntroduces pathogens into the lungsDecreases patients ability to ventilate Have suction readily availableRecognition of an Airway ObstructionMild obstructionPatient is responsive, able to exchange airUsually has noisy respirations and coughingShould be left aloneClosely monitor the patients condition.Be prepared to intervene.Recognition of an Airway ObstructionSevere obstructionInability to breathe, talk, or coughMay grasp at throat, turn cyanotic, make frantic movementsCough is weak, ineffective, or absent Weak inspiratory stridor and cyanosis

Emergency Medical Care for Foreign Body Airway ObstructionBegin 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 ObstructionAbdominal 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 ObstructionIf patient becomes unresponsive, position supine, begin chest compressions30 chest compressions15 with two rescuers or infant/childOpen airway, remove any visible objectAttempt rescue breath, look for chest riseEmergency Medical Care for Foreign Body Airway ObstructionIf 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 hypoxiaSupplemental Oxygen TherapyOxygen SourcesOxygen cylindersStores pure oxygenCheck label and test date.Various sizesOxygen delivery is measured in L/min.

Oxygen SourcesLiquid oxygenCooled to a liquidConverts to a gas when warmedKeep upright.

HELiOS Marathon portable oxygen unit. Courtesy of Nellcor Puritan Bennett in affiliation with Tyco Healthcare.Safety RemindersKeep 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 FlowmetersFlow meters allow oxygen to be adjusted.Pressure-compensated flow meter Bourdon-gauge flow meter

Preparing an Oxygen Cylinder for UseBefore administering, you must prepare the oxygen cylinder and therapy regulator.Nonrebreathing MaskPreferred in pre hospital setting90% to 100% oxygenNon-re breathable maskIndicationsSpontaneously breathing patients ContraindicationsApnea and poor respiratory effort

Jones & Bartlett Learning. Courtesy of MIEMSS.Nasal CannulaTwo small prongs 25% to 45% oxygenBest for patients who need long-term therapyIneffective with: ApneaPoor respiratory effortSevere hypoxiaMouth breathing

Jones & Bartlett Learning. Courtesy of MIEMSS.Partial Rebreathing MaskLacks one-way valve Residual exhaled air is re-breathed35% to 60% oxygen

Jones & Bartlett Learning. Courtesy of MIEMSS.Tracheostomy MasksCover the stoma and have a strap that goes around the neckTo improvise, place a face mask over the stoma.

Ventilatory SupportPatient who is not breathing needs artificial ventilation and 100% supplemental oxygenIndications include signs of:Altered mental statusInadequate minute volumeNormal Ventilation Versus Positive-Pressure VentilationNormal ventilationDiaphragm contractsNegative pressure in chest cavity draws in airPositive-pressure ventilationGenerated by a deviceForces air into the chest cavity from the external environmentNormal Ventilation Versus Positive-Pressure VentilationWith positive-pressure ventilation, more air is needed to achieve the same effects of normal breathing. Increases overall intrathoracic pressureBlood flow is decreased. Normal Ventilation Versus Positive-Pressure VentilationCardiac 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 VentilationExplain the procedure. Place the mask over the patients 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 VentilationBegin artificial ventilation immediately if patient is not breathingMethods includeMouth-to-mask techniqueOne-, two-, or three-person bag-mask device techniqueManually triggered ventilation deviceMouth-to-Mouth VentilationRoutinely performed with a barrier deviceAlternative: mouth-to-noseRequires no special equipmentCan provide adequate tidal volume

Courtesy of AAOS.Mouth-to-Mask VentilationPlaces a physical barrier between your mouth and the patients mouthOxygen 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 paramedicDepends on mask seal integrityBag-Mask DeviceBag-Mask Device ComponentsDisposable, self-inflating bagNo pop-off valve, or capability to disable Nonrebreathing outlet valveOxygen reservoir One-way, no-jam inlet valve system Transparent face maskBag-Mask Device ComponentsTotal 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 TechniqueKneel above patients 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 patients face.Bring the lower jaw up to the mask.Connect the bag to the mask.Bag-Mask Device TechniqueHold 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 AAOSBag-Mask Device TechniqueIf 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 TechniqueSqueeze 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 TechniqueNot adequate if:Chest does not rise and fall Rate of ventilation is too slow or too fastPulse rate does not improveBag-Mask Device TechniqueIf 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 patientsDemand valve delivers 100% oxygenMakes an airtight seal with patients faceImpossible to assess for lung complianceManually Triggered Ventilation DevicesManually Triggered Ventilation DevicesDelivers only the volume of oxygen neededExpensive, not disposableAdapter fits standard ventilation masksComponents of Manually Triggered Ventilation DevicesPeak flow rate: 100% oxygen up to 40 L/min Inspiratory pressure safety release valveAlarm if pressure is exceededProperly positioned trigger (or lever)

Automatic Transport VentilatorsHave bag-mask device available in case ATV malfunctionsMost models have adjustments for respiratory rate and tidal volume.Deliver a preset volume at a preset rate.Automatic Transport VentilatorsSteps 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 VentilatorsGenerally consumes 5 L/min of oxygenPressure-relief valve can lead to:Hypoventilation Increased airway resistanceAirway obstructionContinuous Positive Airway PressureNoninvasive means of providing ventilatory support for patients with respiratory distressIncreases pressure in the lungsOpens collapsed alveoliPushes oxygen across alveolar membraneForces interstitial fluid back into circulationContinuous Positive Airway PressureTypically delivered through a face mask secured with a strapping system. Pressure relief valve determines amount of pressure delivered to the patient Indications for CPAPGuidelines: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 CPAPRespiratory arrestHypoventilation Signs and symptoms of a pneumothorax or chest traumaTracheostomyActive GI bleeding or vomiting Inability to follow verbal commands Inability to properly fit CPAP system mask and strap Inability to tolerate the maskApplication of CPAPGenerally composed of:GeneratorMaskCircuit that contains corrugated tubingBacteria filterOne-way valveApplication of CPAPPatient exhales against a resistance (positive end-expiratory pressure [PEEP])Controlled manually or predetermined 5 to 10 cm H2O is general therapeutic range Complications of CPAPPatients 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 DistensionInflation of the stomach with airLikely to occur when:Excessive pressure is used to inflate the lungsVentilations are performed too fast or too forcefullyAirway is partially obstructed during ventilation attempts Gastric DistensionHarmful for at least two reasonsPromotes regurgitation, can lead to aspirationPushes diaphragm up, limits lung expansionSigns includeIncreased diameter, distension of the stomachIncreased resistance to bag-mask ventilationsGastric DistensionIf 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 DecompressionInvolves inserting a gastric tube into the stomach and suctioning the contentsShould be considered:For any patient who will need positive-pressure ventilation for an extended periodWhen gastric distention interferes with ventilationsInvasive Gastric DecompressionNasogastric tubeInsert through nose Decompresses stomachDecreases pressureLimits risk of regurgitation

Invasive Gastric DecompressionNasogastric tube (contd)Relatively well toleratedContraindicated with severe facial injuriesUse OG route instead.Invasive Gastric DecompressionOrogastric tubeInserted through the mouthNo risk of nasal bleedingSafer in patients with severe facial traumaCan use larger tubes

Orogastric TubeOrogastric tube (contd)Less comfortable for responsive patientsPreferred for patients who are unresponsive without a gag reflex

LaryngectomySurgical removal of the larynxTracheostomy creates a stoma.Total laryngectomy: breathe through stoma Cannot ventilate by mouth-to-mask techniquePartial laryngectomy: breathe through stoma and nose or mouthVentilation of Stoma PatientsHead tilt-chin lift and jaw-thrust not requiredIf no tracheostomy tube, use:Mouth-to-stoma technique Bag-mask deviceUse an infant- or child-sized mask to make an adequate seal.Ventilation of Stoma PatientsTwo rescuers are needed with a bag-mask device. One to seal the nose and mouth The other to squeeze the bag-mask deviceTracheostomy TubesPlastic tube placed within the stomaPatients may receive supplemental oxygen via: Tubing designed to fit over the tubePlacing an oxygen mask over the tube

Tracheostomy TubesPatients who experience sudden dyspnea often have thick secretions in the tubeSuction as you would through a stoma.When tube is dislodged, stenosis may occur.Dental AppliancesDifferent formsDentures (upper, lower, or both)BridgesIndividual teethBraces (in the younger population)Dental AppliancesDetermine 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 TraumaSevere swelling and bleeding in the airway may be present.Control with direct pressure.Suction as needed.

Eddie M. SperlingFacial TraumaInadequate 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 TraumaSuspect 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???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????