The Respiratory System

Airway Management

ALS & BLS

ObjectivesObjectives

• Review the anatomy and physiology of the

respiratory system.

• Demonstrate the use of basic and advanced • Demonstrate the use of basic and advanced

airway procedures and devices.

Upper AirwayUpper Airway

• Nasopharynx-Nares, Nasal Cartilage, Nasal

Bones, Maxilla

• Oropharynx-Lips, Cheeks, Tongue, Hard • Oropharynx-Lips, Cheeks, Tongue, Hard

and Soft Palates, Teeth, and Mandible.

• Pharynx-Muscular tube that extends from

the back of the soft palate to the upper end

of the Esophagus and Trachea.

Upper AirwayUpper Airway

• Epiglottis-Leaf shaped cartilage located at

the base of the tongue. Prevents food from

entering the respiratory tract during the act entering the respiratory tract during the act

of swallowing.

• Vallecula-Depression between the epiglottis

and base of the tongue.

Upper AirwayUpper Airway

• Larynx-Structure connecting the pharynx

and trachea. Consists of the thyroid

cartilage, cricoid cartilage, the upper end of cartilage, cricoid cartilage, the upper end of

the trachea, and the vocal cords.

• Trachea-Tube 10 to 12 centimeters long

connecting the larynx with the mainstem of

the bronchi. Trachea is somewhat rigid

consisting of C-shaped cartilaginous rings.

Upper AirwayUpper Airway

• Esophagus-Pliable tube running from the

Oropharynx to the digestive system.

Lower AirwayLower Airway

• Trachea extends to the Carina where it

divides into the Right and Left Mainstem of

the Bronchi.the Bronchi.

• Right Mainstem is almost straight whereas

the Left Mainstem acutely angles to the left.

• The Mainstems divide into Bronchioles

which lead to the Alveoli.

Lower AirwayLower Airway

• Alveoli are tiny sacs in the lungs where

most gas exchange takes place. Together

the Alveoli possess more than 40 square the Alveoli possess more than 40 square

meters of surface area.

LungsLungs

• Comprised of Bronchi, Bronchioles, and the

Alveoli

• Lungs are covered by connective tissue • Lungs are covered by connective tissue

called the Pleura. The Pleura is connected

to the lungs only at the Hilum.(point where

the bronchi enter the lungs)

LungsLungs

• Pleura consist of the visceral pleura, which

covers the lungs, and the parietal pleura,

which lines the thoracic cavity.which lines the thoracic cavity.

• Between the pleura is pleural fluid. Which

holds the two together and allows for

movement.

LungsLungs

• Right lung contains three lobes. Upper lobe,

Middle lobe, and Lower lobe.

• Left lung contains two lobes. Upper and • Left lung contains two lobes. Upper and

Lower lobes. Left lung has only two lobes

to allow room for the heart.

RespirationRespiration

• Defined as the exchange of gases between a

living organism and its enviroment

Respiratory Cycle Respiratory Cycle

• Requires coordinated interaction between

the respiratory system, central nervous

system, and the musculoskeletal system.system, and the musculoskeletal system.

• The lungs have no intrinsic capability to

contract or expand.

Respiratory CycleRespiratory Cycle

• Respiratory cycle begins when the lungs

have achieved a normal expiration. At this

point the pressure inside the thoracic cavity point the pressure inside the thoracic cavity

is equal to atmospheric pressure. The

contracting of the diaphragm and intercostal

muscles causes a downward movement and

outward expansion.

Respiratory CycleRespiratory Cycle

• This causes a lower pressure in the lungs

which pulls air in from the higher

atmospheric pressure.(Inspiration)atmospheric pressure.(Inspiration)

• When the pressure in the lungs once again

matches atmospheric pressure inspiration

stops.

Respiratory CycleRespiratory Cycle

• Once the diaphragm and intercostal muscles

relax the size of the chest cavity decreases

and air rushes out of the lungs.(Expiration)and air rushes out of the lungs.(Expiration)

• Inspiration is the active phase of respiration

and expiration is the passive phase.

• Tidal Volume is the volume of gas inhaled

or exhaled during a single respiratory cycle.

Usually 500 cc

Respiratory ProblemsRespiratory Problems

ObstructionsObstructions

• Tongue-Most common in infants and

children.

• Foreign Body-Food, loose teeth…..• Foreign Body-Food, loose teeth…..

• Trauma-Facial bones, teeth, nasal bones,

and clotted blood

• Laryngeal Spasm-Cord edema or Cord

spasm

ObstructionsObstructions

• Aspirations-Vomitus, blood, liquid drink

Inadequate Ventilation Inadequate Ventilation

• Hyperventilation or Hypoventilation

• Rates-Adult 12-20, Children 15-30, Infant

25-5025-50

• Disease such as Asthma or COPD

AssessmentAssessment

VisualVisual

• Adequate chest rise and fall.

• Color of skin.

• Flaring of the nares.• Flaring of the nares.

• Retraction of the intercostal muscles and

suprasternal notch.

AuscultationAuscultation

• Air movement at nose and mouth.

• Listening to bilateral lung fields. Six fields

in anterior thorax(upper, middle, and in anterior thorax(upper, middle, and

lower). Four fields in posterior thorax(upper

and lower).

PalpationPalpation

• Using the back of your hand or cheek.

• Feeling the chest for equal and adequate

chest rise and fall.chest rise and fall.

HistoryHistory

• Past medical history.

• History of present medical complication.

• Mechanism of injury.• Mechanism of injury.

BLS Methods For Maintaining

The Airway

BLS Methods For Maintaining

The Airway The Airway The Airway

Maintaining Airway Maintaining Airway

• Patient

• Head Tilt Chin Lift

• Modified Jaw Thrust• Modified Jaw Thrust

• Oropharyngeal Airway

• Nasopharyngeal Airway

Oropharyngeal AirwaysOropharyngeal Airways

• Allows air to pass around and through

device.

• Helps prevent obstruction by the teeth and • Helps prevent obstruction by the teeth and

lips.

• Helps manage unconscious patients who are

breathing spontaneously or need mechanical

ventilation.

Oropharyngeal Airways

• Makes suctioning of the pharynx easier

• Serves as an effective bite block in case of

seizures or to protect the endotracheal tube.seizures or to protect the endotracheal tube.

Oropharyngeal Airways

• Does not isolate the trachea.

• Cannot be inserted when teeth are clinched.

• May obstruct the airway if it is not inserted • May obstruct the airway if it is not inserted

properly.

• Can be dislodged easily.

• Should not be used on patient with gag

reflex.

Oropharyngeal Airways

• A properly sized Oropharyngeal airway

should measure form the flanged end at the

teeth to the angle of the jaw.teeth to the angle of the jaw.

Nasopharyngeal AirwayNasopharyngeal Airway

• Can be rapidly inserted.

• Bypasses the tongue.

• Can be used in the presence of a gag reflex.• Can be used in the presence of a gag reflex.

• Can be used when trauma has accrued to the

oral cavity.

• Can be used when the patient’s teeth are

clinched.

Nasopharyngeal Airway

• Does not isolate the trachea.

• It is smaller than the Oropharyngeal airway.

• Difficult to suction through.• Difficult to suction through.

• May cause severe nose bleeds if inserted to

forcefully.

• May kink and clog.

• Cannot be used if there is a basilar fracture.

Nasopharyngeal Airway

• Properly sized Nasopharyngeal airway will

be slightly smaller than the diameter of the

nostril and is equal to or slightly smaller nostril and is equal to or slightly smaller

than the distance from the nose to the

earlobe.

Esophageal Obturator Airway

• Insertion is easy and does not need the

visualization of the cords.

• Prevents gastric distention and • Prevents gastric distention and

regurgitation.

• Can be used on trauma patients who have

spinal injuries.

Esophageal Obturator Airway

• Adequate mask seal is difficult to maintain.

• Can cause esophageal trauma and rupture.

• May enter trachea if placed improperly.• May enter trachea if placed improperly.

VentilationVentilation

• Can be achieved utilizing the appropriate

bag valve mask I.e. adult, child, and infant.

• Mouth to mouth using a mask with a one • Mouth to mouth using a mask with a one

way valve.

• Oxygen delivery devices such as Non

Rebreather Mask or Nasal Cannula

ALS Airway ManagementALS Airway Management

ALS Airway ManagementALS Airway Management

• All Methods used in BLS management.

• Endotracheal Intubation

Endotracheal IntubationEndotracheal Intubation

• Inserting a Endotracheal tube into the

trachea.

• Tube Sizes-Adult 7.0 to 9.0, Child 4.0 to • Tube Sizes-Adult 7.0 to 9.0, Child 4.0 to

6.0, Infant 3.5 to 4.0

• General tube size is 7.5

• Adult and some child tubes have an

inflatable cuff to prevent distention.

Endotracheal Intubation

• Two Blade styles in this area Miller and

Macintosh.

• Macintosh is a curved blade which fits in • Macintosh is a curved blade which fits in

the Vallecula and raises the Epiglottis. Also

sweeps the tongue to the left when used

properly.

Endotracheal Intubation

• Miller blade is straight and fits over the

Epiglottis and raises the tongue and

Epiglottis up.Epiglottis up.

• Tube is formed into a “J” shape using a

stylet. Be sure not to insert the stylet past

the “eye of Murphy”, stylet should be one

half of an inch short of eye.

Endotracheal Intubation

• Using blade of choice and laryngoscope

open the airway until the cords are visible.

Insert the tube and visualize passing Insert the tube and visualize passing

through the cords. Once the cuff is no

longer visible inflate the cuff, remove the

stylet, and ventilate patient checking for

breath sounds. Check epigastrium, then left

chest, then right chest.

Endotracheal Intubation

• Make note of the tube depth and secure it

using an appropriate method.

Suctioning Suctioning

Suctioning The AirwaySuctioning The Airway

• Yankauer or “tonsil tip”suctioning devices

can be used to suction the upper airway.

• This device allows for larger volume and • This device allows for larger volume and

larger obstructions to be cleared. Measure

the device in the same method as an

Oropharyngeal airway. Suction only on the

way out and limit the suctioning time

around 10 seconds

Suctioning The Airway

• French catheters or “whistle tip” suctioning

devices can be used to suction upper and

lower airway.lower airway.

• French catheters can be used in stomas,

both Oropharyngeals and Nasopharyngeals,

and ET tubes.

• French catheters cannot remove large

volumes of secretions quickly or large

particles.

Suctioning The Airway

• Control suctioning by using the “on” and

“off” switch or the provided open port or

orifice.orifice.

• For large particles and volumes a thick

walled wide bore suctioning tube may be

used.

Suctioning The Airway

• Caution should be used when suctioning.

Forcibly using a Yankauer tip could cause

lacerations and other injuries. lacerations and other injuries.