Airway Management PDF 2022

Airway Management PCP  Objectives A/P Review Assessment Methods of opening an airway Oxygen devices Airway adjuncts Ventilation Suctioning FBAO SP02 & ETCO2  Contents A&P Review Assessment Oxygenation BLS...

Airway Management PCP  Objectives A/P Review Assessment Methods of opening an airway Oxygen devices Airway adjuncts Ventilation Suctioning FBAO SP02 & ETCO2  Contents A&P Review Assessment Oxygenation BLS airway BIADs  Anatomy/Physiology O2 is a vital component of life. It helps convert essential nutrients into energy for use in the body. Lack of oxygen leads to: – 1) Ischemia (reversible) – 2) Injury (reversible) – 3) Infarction (irreversible) Cellular death occurs at different rates for different tissue: Brain/Nervous cell 4-6min, Cardiac 30min, Muscles/Organ cells up to 1 hour.  Anatomy/Physiology Adequate ventilation requires the following: An open airway An open respiratory tract Adequate pulmonary blood flow Stimulation to breathe  Anatomy/Physiology Respiration The movement of gases through a membrane What are the major gases of respiration? Oxygen – ATP production Carbon – primary building block for almost everything in the body Hydrogen – body pH What are their roles? Which body systems work together to control respiration?  Anatomy/Physiology Ventilation The process of moving air in and out of the lungs. Inspiration & Expiration The medulla holds the respiratory control center which signals the muscles of respiration. Responds to changes in chemicals in the blood Inspiration – decreased thoracic pressure form increased space allows air in. Expiration – reverse of above, the chest wall relaxes and decreases thoracic space, increasing pressure.  Anatomy/Physiology Ventilation Mechanisms of inspiration & expiration Copyright © 2003 by Mosby, Inc.  Anatomy/Physiology Volume: The average adult inhales & exhales between 500 – 800 cc of air per ventilation. The total lung capacity averages at 6 L. The amount of air that reaches the alveoli is approx. 350 cc, and the remainder is called dead air space. Minute volume: the amount of air exchanged over the course of one minute. Tidal volume: the amount of air inhaled & exhaled in one ventilation.  Anatomy/Physiology The amount of carbon dioxide in the body depends on the rate of ventilations. If ventilations are high, carbon dioxide levels are low. If ventilations are low, carbon dioxide levels are high.  Anatomy/Physiology List some of the ways the body uses reflexes to help maintain and protect the airway. (Here’s one example: coughing)  Assessment Look Listen Feel Chest rise Gurgling Chest rise Trismus Snoring Equal chest rise Vomit/blood Absent sounds Skin colour Lung sounds Retractions Stridor Respiratory rate Potato voice Anatomy  Assessment Auscultation: Normal healthy lungs are clear and equal in apices and basis. Auscultate one side and compare directly to the opposite. Anterior sites: L/R Mid clavicular line just under the clavicle L/R mid axillary line ~ 5 intercostal space (nipple line)  Assessment Normal RR: 12-20 Assist at < 10 or >30 Tachypnea-increase RR Bradypnea-decreased RR Posterior sites: L/R paraspinal border above the scapula L/R mid axillary line ~ 8th intercostal space (half way down the back) Posterior site is preferred due to greater surface area of the lungs. To assess the R middle lobe you must auscultate the anterior thorax.  Oxygenation Adequate oxygenation is dependant on 4 things: Adequate 1 concentration of inspired O2 2 Movement of O2 across (FiO2) the alveolar capillary membrane (external respiration) 3 Adequate RBC and Hgb to transport oxygen 4 Offloading of O2 at (oxygen transport) the cellular level (internal respiration) O2 may then be used by mitochondria to create energy through aerobic respiration  Oxygenation Hypoxia: decreased or inadequate supply of oxygen. SPO2 < 95% Tachycardia is the S/S first compensatory Altered LOC response to nearly *Tachycardia* every physiological Dyspnea stressor and should Cyanosis never be Headache/dizziness overlooked. Nausea  Oxygenation Why 94%? There must be a certain amount of O2 in the blood for oxygen to passively diffuse into cells where it can be used for energy. This “amount” is called PO2 (partial pressure of O2) The relation of SPO2 (O2 Sat probe) to PO2 (actual oxygen in the blood) is shown to the right. Note that at ~90% SPO2 there is a precipitous drop in actual PO2 in the blood, nearing a PO2 of 60 94% gives a buffer between stable oxygenation and a precipitous drop. It is best to take an SPO2 on room air prior to applying oxygen  Oxygenation-Pulse Oximetry Pulse oximeter measures the percentage of Hgb that is saturated with O2 Saturated Hgb will absorb a certain wavelength of light. The less light that is detected by the detector, the higher the SPO2 (and therefor oxygenation). A proper SPO2 waveform is needed so the SPO2 probe knows whether it is reading arterial (peeks) or venous (valleys) blood. This is why a poor waveform will read a falsely low SPO2  Pulse Oximetry When is Pulse Oximetry inaccurate? A reduction in peripheral blood flow produced by peripheral vasoconstriction (hypovolemia, severe hypotension, cold, cardiac failure, some cardiac arrythmias) or peripheral vascular disease. Bright ambient light may cause the oximeter to be inaccurate. Shivering may cause difficulties in picking up an adequate signal. Nail polish may cause falsely low readings. The units are not affected by jaundice, dark skin or anemia.  Pulse Oximetry TREAT THE PATIENT NOT THE MACHINE  Oxygenation-End Tidal CO2 ETCO2 measures the concentration of CO2 at the end of exhalation, which very closely matches the PCO2 in the blood. Normal 35-45 mmHg ETCO2 (PCO2) can change from 2 related but different processes: 1. Retaining/blowing off CO2 from the lungs 2. Increased/decrease production of CO2 in the cells It is the most sensitive V/S we have to indicate a change in ventilation  Oxygenation-End Tidal CO2 ETCO2 ETCO2 R Hyperventilation Hypoventilation Anxiety (opioids) E Low % Oxygen Poor BVM S (altitude) Head injury P Poor BVM Phrenic damage A falling ETCO2 in decompensated shock represents catastrophic Hemorrhagic NA cellular hypoperfusion C shock V Septic shock The goal for ETCO2 in S Cyanide cardiac arrest is 10 mmHg. poisoning Low ETCO2 represents Cardiac arrest POOR CHEST COMPRESSIONS.  Oxygenation-ECO2 Equipment In-line ETCO2 Nasal prongs Intubated patients Conscious (spontaneously Used to confirm tube placement breathing) patients Can deliver oxygen up to 6 lpm  Oxygenation-ECO2 Equipment In-line ETCO2 Nasal prongs Attaches to the end of a BIAD or ETT Attached the same as nasal prongs  Oxygenation-ECO2 Equipment Plug it in here CapnoMETRY CapnoGRAPHY  Oxygenation-ETCO2 Equipment Colormeter Qualitative measurement of CO2 Only for the intubated patient Litmus paper changes color each ventilatory cycle Purple indicates the absence of CO2 Yellow indicates the presence of CO2 Does not provide at measurable number Advantages: disposable and easy to interpret Disadvantages: easily occluded, often produces false results, doesn’t deliver a waveform, doesn’t indicate CO2 levels of greater then 38mmHg  ETCO2 vs SPO2 ventilation vs oxygenation Oxygenation Ventilation IS NOT! Changes oxygen values in the Changes carbon dioxide values blood in the blood Affected by Affected by FiO2 (% O2 inhaled) Respiration rate PEEP (essentially the Tidal volume pressure generated after a deep inhalation) In other words-you can NOT oxygenate your patient more by bagging faster or deeper. They are 2 separate physiological processes and you will cause undue harm to your patient  Oxygenation-Delivery Devices Nasal cannula Simple face mask Non-rebreather mask Bag-valve mask  Oxygen Devices Nasal cannula For every 1L of O2 administered, the percentage increases by 4% Copyright © 2003 by Mosby, Inc.  Oxygen Devices Simple face mask Copyright © 2003 by Mosby, Inc.  Oxygen Devices Nonrebreather mask Copyright © 2003 by Mosby, Inc.  Oxygen Devices Bag-valve-mask Copyright © 2003 by Mosby, Inc.  Ventilation Devices BVM Typically the bag-valve-mask is available in three sizes. Adult (capable of storing between 1000 and 1600 mL of air) Child (capable of storing 500 to 700 mL of air) Infant (capable of storing 150 to 240 mL of air)  Ventilation Devices BVM Advantages It provides an immediate means of ventilatory support. It conveys to you a sense of compliance of the patient's lungs. It can be used with spontaneously breathing patients. It can deliver an oxygen-enriched mixture to the patient. It eliminates the risk of the rescuer coming into contact with a patient's blood or body fluids. Rescuers can ventilate for extended periods without Copyright © 2003 by Mosby, Inc.  Ventilation Devices BVM Disadvantages It is a difficult skill to master. It is hard to maintain an adequate seal while delivering the required volume of air. It is sometimes difficult to deliver the required tidal volume. It is difficult to ventilate a patient when cervical immobilization is in place. It can cause lung damage. Copyright © 2003 by Mosby, Inc.  Ventilation Devices BVM Bag-valve-mask ventilation procedure with one rescuer Copyright © 2003 by Mosby, Inc.  Ventilation Devices BVM Two person BVM ventilation One holds the mask in place and maintains A and open airway. The other squeezes the bag with two hands. B Copyright © 2003 by Mosby, Inc.  Ventilation Devices Pocket mask It is a clear plastic device that covers the patient's mouth and nose. They are often supplied with a one-way valve. Copyright © 2003 by Mosby, Inc.  Assessment of Manual and Internal Ventilations Patency (is the bag easy to squeeze?) Chest rise (equal/bilat?) Lung sounds (improvement/equal?) LOC improvement Respiratory rate (intrinsic) Mucous membrane color (cyanosis improvement) Pulse oximetry readings (don’t treat the machine!) Gastric distention Inadequate or hyperextension of the head (path of least resistance) Too much pressure being generated by the ventilatory device Improperly placed airway adjuncts  Dangers of poor BVM Gastric insufflation Vomiting and aspiration Hypoxia Cerebral vasoconstriction Acid base imbalances Pneumothorax  Dangers of poor BVM You work in EMS to help people. Do not waste an entire call of good decisions and hard work on poor airway management. Perfection is the only standard  BLS Airway Upper airway obstruction may be caused by a number of factors, including: Tongue Foreign bodies Vomit Trauma, blood, teeth Laryngeal spasm and edema Burns Infection  BLS Airway Unconscious patients lose muscle control, allowing the tongue to fall back against the back of the throat. Copyright © 2003 by Mosby, Inc.  BLS Airway Treatment Head-tilt/chin-lift maneuver Modified jaw thrust Jaw-lift maneuver  BLS Airway Head-tilt/chin-lift maneuver Copyright © 2003 by Mosby, Inc.  BLS Airway Modified Jaw-thrust maneuver Copyright © 2003 by Mosby, Inc. BLS Airway  BLS Airway-OPA The OPA is used to maintain an open airway in an unresponsive patient who has no gag reflex. Copyright © 2003 by Mosby, Inc.  BLS Airway - OPA Oropharyngeal airway in proper use Copyright © 2003 by Mosby, Inc.  BLS Airway - OPA Procedure for inserting the oral airway (adult patient only) Measure to determine the appropriate size. A Open the patient's mouth and begin to insert the airway with B the tip pointing toward the roof of the mouth. Slide the airway along the roof C of the mouth. Copyright © 2003 by Mosby, Inc.  BLS Airway – OPA Rotate the airway 180 degrees. The flange of the airway should D rest on the patient's lips. Ventilate the patient with 100% E oxygen through a bag-valve-mask device. F Copyright © 2003 by Mosby, Inc.  BLS Airway - OPA In infants, insert the OPA straight in (no rotation) visualizing proper placement  BLS Airway - OPA Improper placement of an oropharyngeal airway can lead to an airway obstruction. Copyright © 2003 by Mosby, Inc.  BLS Airway - OPA Advantages: Insertion is easy & quick. It facilitates suctioning of the pharynx because a large suction tube can pass on either side. Disadvantages: It does not isolate the trachea. It cannot be inserted when the patient's teeth are clenched. It can obstruct the airway if not inserted properly. It can easily be dislodged. It can become occluded with emesis, blood, etc. Can cause trauma if not put in correctly.  BLS Airway - NPA Nasopharyngeal airways are used when an OPA is contraindicated. These pt’s may be alert with an intact gag reflex. Copyright © 2003 by Mosby, Inc.  BLS Airway - NPA Nasopharyngeal airway in use Copyright © 2003 by Mosby, Inc.  BLS Airway - NPA Procedure for insertion (all ages) Measure the airway to determine the appropriate A size. Lubricate the airway with a water-soluble lubricant. B Copyright © 2003 by Mosby, Inc.  BLS Airway - NPA Insert the airway into the nostril with the bevel facing the septum. Advance the airway until C the flange rests against the patient's nostril. D Copyright © 2003 by Mosby, Inc.  BLS Airway - NPA Advantages Insertion is quick & easy, and may be inserted blindly. It may be used when a gag reflex is present. It can be used when the patient's teeth are clenched. Disadvantages It doesn’t isolate the trachea, and therefore does not protect against aspiration. It is difficult to suction through. It can cause severe nosebleed if inserted too forcefully.  BLS Airway - NPA Contraindications: Patients who have nasal obstructions Patients who are prone to nosebleeds Indications of nasal injury Presence of facial fractures Possible skull fractures Copyright © 2003 by Mosby, Inc.  BLS Airway-Suction Types of suction units Portable suction unit A Handheld portable suction unit Rigid (top) and soft (bottom) suction catheters B C Copyright © 2003 by Mosby, Inc.  BLS Airway-Suction Each suctioning attempt should be restricted to 15 seconds or less. If possible, the patient should be hyper-oxygenated with 100% oxygen both before and after each attempt. Suction should not be activated during insertion of the catheter because it depletes the air of oxygen. Once the catheter is properly positioned, suction should be applied and the catheter withdrawn.  BLS Airway-Suction Suctioning a patient's airway Measure the catheter from the tip of the patient's ear to the corner of the mouth. With suction off, insert the catheter into the patient's mouth With suction on, withdraw the catheter SUCTION ONLY AS FAR AS YOU CAN SEE Copyright © 2003 by Mosby, Inc.  Nasopharyngeal Suctioning A regulated member registered on the general register, provisional register or courtesy register may, in the practice of the paramedic profession, perform the following restricted activities in accordance with the standards of practice: (c) to insert or remove instruments or devices beyond the point in the nasal passages where they normally narrow for the purpose of airway management Copyright © 2003 by Mosby, Inc.  Nasopharyngeal Suctioning Indications: Visible foreign substances in the pharynx Noisy respirations Cyanosis Contraindications: Acute asthmaticus Upper airway obstruction Bleeding tendencies Hemophilia Leukemia Fractures of the nasal passages – Basal skull fracture Copyright © 2003 by Mosby, Inc.  Nasopharyngeal Suctioning Complications: Hypoxia Aspiration Laryngospasm Bronchospasm Nasal obstruction Esophageal suctioning Catheter coiling in the nasopharynx  Nasopharyngeal Suctioning Equipment: Suction device (mechanical) Catheters (size 6.5-18 French) Sterile water (to clean the catheter after suctioning) Lubricant If your suction catheters do not have a thumb hole, you will also need a Y connector.  BLS Airway-Suction Precautions: Suctioning can stimulate the gag reflex, inducing vomiting. Suctioning can cause vagal stimulation which can depress the heart rate and blood pressure. Suctioning can stimulate the patient to cough, which can cause an increase in ICP in patients with a head injury.  BLS Airway-Suction Complications Hypoxia Aspiration Laryngospasm Bronchospasm  BLS Airway- FBAO Review current FBAO guidelines Conscious/Choking with air movement Conscious/Choking with no air movement Unconscious from Choking with no air movement Blind Insertion Airway Devices (BIAD) Airway adjuncts IN SCOPE of PCP LMA King LT Laryngeal Mask Airway  BIADS I-Gel  King-LT Designed to take place of Combi-tube Two cuffs, distal (small) and proximal (large) Only one line to fill both cuffs One ventilation tube Has no distal ventilation opening, only ports between cuffs Can facilitate a Bougie tube placement (ACP Scope) Comes in multiple sizes 3: 4-5 feet (yellow) 4: 5-6 feet (red) 5: >6 feet (purple) King-LT  King-LT Indications Unconscious pt no gag reflex with: Cardiac arrest Patient requiring airway management with transport time > 20 minutes SPO2 < 90% refractory to effective BLS management  King-LT Contra-indications Intact gag reflex Upper airway burns Ingestion of caustic substances Esophageal varices  LMA Contraindications and Indications are identical to King LT  LMA Sizing 6’ packaging King LT is for adults only LMA is for pediatrics  BIAD-Placement I-Gel sizing  BIAD-Placement Minimal Occlusive Pressure King LT cuff is located next to the internal jugular vein. Inflation of the cuff should only be enough to see the BIAD seat itself (raise up during inflation) Failure will increase ICP  BIAD-Proof PROOF IS THE SINGLE MOST IMPORTANT STEP IN THE INTUBATION PROCESS X  BIAD-Proof 3 consecutive ETCO2 waveforms Capnometric value is irrelevant to confirmation PLUS positive lung sounds and negative epigastric sounds. X  BIAD-Troubleshooting DOPE Displacement ETCO2? Auscultate Tug up on BIAD Obstruction Ear to sternal notch? Vomit? Blood? FBAO? Trismus? Pneumothorax Auscultate Equipment O2 tank? Cuffs? Spo2 waveform?  BIAD Extras None of these devices completely protect airway Watch for aspiration Need continual monitoring Cannot suction down these devices King LT has ability but is ACP scope Careful with trauma patients Must wear eye & respiratory protection If the OPA/BVM is working, stay simple  BIAD-IGEL Currently being trialed for AHS EMS use. You may see it on car. Essentially an LMA you don’t have to inflate. Questions?