Airway Management PDF

Chapter 11 {#chapter-11.ChapterNumber} ========== Airway Management Unit Summary After students complete this chapter and the related course work, they will understand the need for proper airway management, including recognizing and measuring adequate and inadequate breathing, maintaining an open...

Chapter 11 {#chapter-11.ChapterNumber} ========== Airway Management Unit Summary After students complete this chapter and the related course work, they will understand the need for proper airway management, including recognizing and measuring adequate and inadequate breathing, maintaining an open airway, and providing artificial ventilation. Students will be able to demonstrate basic competency in applying these concepts to appropriate care through the use of airway adjuncts, suction equipment, oxygen equipment and delivery systems, pulse oximetry, continuous positive airway pressure (CPAP), and resuscitation devices. National EMS Education Standard Competencies Airway Management, Respiration, and Artificial Ventilation Applies knowledge of general anatomy and physiology to patient assessment and management in order to assure a patent airway, adequate mechanical ventilation, and respiration for patients of all ages. Airway Management Airway anatomy (pp 418--423) Airway assessment (pp 431--439) Techniques of assuring a patent airway (pp 439--446) Respiration Anatomy of the respiratory system (pp 418--423) Physiology and pathophysiology of respiration - - - - - - Assessment and management of adequate and inadequate respiration (pp 434--439) Supplemental oxygen therapy (pp 451--457) Artificial Ventilation Assessment and management of adequate and inadequate ventilation (pp 460--469) Artificial ventilation (pp 461--469) Minute ventilation (pp 424--425) Alveolar ventilation (pp 424--425) Effect of artificial ventilation on cardiac output (pp 461--462) Pathophysiology Applies fundamental knowledge of the pathophysiology of respiration and perfusion to patient assessment and management. Knowledge Objectives Skills Objectives 1\. Demonstrate use of pulse oximetry. (pp 435--436, Skill Drill 11-1) 2\. Demonstrate how to position the unconscious patient. (pp 439--440, Skill Drill 11-2) 3\. Demonstrate how to perform the head tilt--chin lift maneuver. (pp 440--441) 4\. Demonstrate how to perform the jaw-thrust maneuver. (pp 441--442) 5\. Demonstrate how to operate a suction unit. (pp 444--446) 6\. Demonstrate how to suction a patient's airway. (pp 444--446, Skill Drill 11-3) 7\. Demonstrate the insertion of an oral airway. (pp 446--447, Skill Drill 11-4) 8\. Demonstrate the insertion of an oral airway with a 90-degree rotation. (p 448, Skill Drill 11-5) 9\. Demonstrate the insertion of a nasal airway. (p 449, Skill Drill 11-6) 10\. Demonstrate how to place a patient in the recovery position. (p 449) 11\. Demonstrate how to place an oxygen cylinder into service. (pp 455--457, Skill Drill 11-7) 12\. Demonstrate the use of a partial rebreathing mask in providing supplemental oxygen therapy to patients. (p 459) 13\. Demonstrate the use of a Venturi mask in providing supplemental oxygen therapy to patients. (p 459) 14\. Demonstrate the use of a humidifier in providing supplemental oxygen therapy to patients. (p 460) 15\. Demonstrate how to assist a patient with ventilations using the bag-mask device. (pp 464--466, Skill Drill 11-8) 16\. Demonstrate the use of an automatic transport ventilator to assist in delivering artificial ventilation to the patient. (pp 468--469) 17\. Demonstrate the use of CPAP. (pp 469--474, Skill Drill 11-9) Readings and Preparation Review all instructional materials including ***Emergency Care and Transportation of the Sick and Injured***, **Twelfth Edition**, Chapter 11, and all related presentation support materials. Instruct students to review respiratory system notes from Chapter 6, "The Human Body," to better prepare for reading Chapter 11, "Airway Management," and expanding on existing knowledge. Support Materials Lecture PowerPoint presentation Case Study PowerPoint presentation Skill Drill PowerPoint presentations Equipment needed to perform the psychomotor skills presented in this chapter Skill Evaluation Sheets Enhancements Direct students to Navigate. Contact a local hospital respiratory therapy department or respiratory specialist practice for guest speakers to present the most current information regarding airway management. **Content connections:** Explain to students that several chapters yet to be covered will provide much more in-depth understanding of breathing problems. The upcoming chapter on respiratory emergencies will add significant depth of understanding of the causes of breathing emergencies, including asthma, anaphylaxis, pulmonary embolism, and more. The cardiovascular emergencies lessons will further emphasize airway management with certain types of heart failure and heart attack. Lessons covering traumatic chest injuries and other injuries will also focus on the importance of maintaining adequate airway function. Subsequent chapters will cover emergencies where airway management may need to be addressed in a manner consistent with the mechanism of injury and rapid transportation to the nearest facility or a specialized facility may be warranted. Such emergencies may include scuba diving injuries, smoke inhalation, envenomations, and obstetric emergencies. Teaching Tips After students have demonstrated competency using airway devices, incorporate these devices into scenarios, making them as realistic as possible. Use of suction, for example, may be made more realistic by placing a container of thick fluid alongside the manikin to be ventilated. The container of fluid may simulate vomitus in the patient's airway necessitating repeated suctioning and perhaps even changing a clogged catheter, the suction unit battery, and the bottle. Be sure to stress proper use of PPE during the suctioning/ventilatory support activity. Unit Activities **Writing assignments:** **Assign students a research paper on the topic of controversies in the administration of supplemental oxygen in patients with a "hypoxic drive." Does current research support or discount the administration of high-flow oxygen "knocking out" the patient's hypoxic drive?** Assign students a brief respiratory assessment of a fictitious patient and have each student write a short scenario of the situation leading to this breathing problem. Include such facts as respiratory rate, depth, and any additional sounds (or absence of sounds). Keep in mind that students will learn more about respiratory emergencies in subsequent chapters. Your provided information may include the following statements: "A 35-year-old man is found in a restaurant with inadequate, weak breathing. His lips are blue and he is lethargic." Student responses may vary from "He was eating shrimp and is now having an allergic reaction" to "He was eating a piece of bread and now has an obstructed airway." Have students make a possible list of clues to look for to aid in the diagnosis and treatment. **Student presentations:** Ask students to give a presentation to the class on each airway adjunct, describing its use, indications, and contraindications. **Group activities:** Have students work in teams of four. Provide each student group with a manikin and airway equipment, including various sizes of oral and nasal airways, oxygen tubing, masks, a bag-mask device, a pocket mask, and an oxygen regulator and tank. One student in each group should be the blindfolded provider, and another student should be the helper. The manikin is the patient. The remainder of the group should act as observers to evaluate the effectiveness of the blindfolded provider's treatment. The blindfolded provider must approach the manikin and check for breathing. The helper then informs the provider, "The patient (manikin) is not breathing." The blindfolded provider must measure, select, and properly insert an oropharyngeal airway, assemble the bag-mask device, and provide adequate ventilations. Upon completion of 2 minutes of effective ventilation, the blindfolded provider should demonstrate proper removal of the oropharyngeal airway. Allow each student a turn at being the provider/blindfolded. **Medical terminology review:** **Give students a handout of airway anatomy, and instruct them to label each portion of the airway and to relate its importance.** After students complete the reading, evenly divide the words/terms from the chapter vocabulary and any student-generated terminology lists among student groups. Ask each group to devise a way to remember the words; examples might include making index cards, a crossword puzzle, or cards with the word and a diagram to link understanding to the word or term. Pre-Lecture ### You Are the Provider "You Are the Provider" is a progressive case study that encourages critical thinking skills. ### Instructor Directions **1.** Direct students to read the "You Are the Provider" scenario found throughout Chapter 11. **2.** You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report. **3.** You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper. Lecture I. Introduction A. The single most important step in caring for patients is to address life threats, and a primary component of that is ensuring that they can breathe adequately. B. When the ability to breathe is disrupted, oxygen delivery to tissues and cells is compromised. C. Oxygen reaches body tissues and cells through two separate but related processes: breathing and circulation. II\. Anatomy of the Respiratory System A. The respiratory system consists of all the structures that make up the airway and help us breathe, or ventilate. B. The airway is divided into the upper and lower airways. C. Anatomy of the upper airway 1\. The upper airway consists of all anatomic airway structures above the vocal cords: a\. Nose b\. Mouth c\. Oral cavity d\. Pharynx e\. Larynx 2\. The main function of the upper airway is to warm, filter, and humidify air as it enters the body. 3\. Pharynx a\. Muscular tube extending from the nose and mouth to the level of the esophagus and trachea b\. Composed, from top to bottom, of the nasopharynx, oropharynx, and laryngopharynx 4\. Nasopharynx a\. Lined with ciliated mucous membrane that filters out dust and small particles b\. Warms and humidifies air as it enters the body 5\. Oropharynx a\. Posterior portion of the oral cavity b\. The epiglottis is superior to the larynx. i\. Helps prevent food and liquid from entering the larynx during swallowing 6\. Larynx a\. Complex structure formed by many independent cartilaginous structures b\. Marks where upper airway ends and lower airway begins c\. Thyroid cartilage: forms a "V" shape anteriorly---the Adam's apple d\. Cricoid cartilage (cricoid ring): first ring of the trachea e\. Cricothyroid membrane: elastic tissue that connects the thyroid superiorly to the cricoid ring inferiorly f\. Glottis (glottis opening): the area between the vocal cords i\. Narrowest portion of the adult's airway g\. Vocal cords: white bands of thin muscle tissue i\. Partially separated at rest ii\. Produce speech iii\. Protects trachea from the entry of substances like water and vomitus D. Anatomy of the lower airway 1\. The function of the lower airway is to deliver oxygen to the alveoli. 2\. The lower airway includes: a\. Trachea i\. Conduit for air entry into the lungs ii\. Begins directly below the cricoid cartilage iii\. Descends anteriorly down the midline of the neck into the thoracic cavity b\. In the thoracic cavity, the trachea divides at the carina into two main stem bronchi, right and left. i\. The bronchi are supported by cartilage. ii\. They distribute oxygen to the two lungs. iii\. On entering the lungs, each bronchus divides into ever-smaller bronchi, which divide into bronchioles. iv\. Bronchioles are made of smooth muscle; they dilate and constrict as oxygen passes through them. v\. Smaller bronchioles connect to alveoli. \(a) Site of oxygen and carbon dioxide exchange \(b) Millions of thin-walled, balloon-like sacs \(c) Alveoli are surrounded by blood vessels (pulmonary capillaries). \(d) Oxygen diffuses across the alveolar membrane into the pulmonary capillaries. vi\. Oxygen in the pulmonary capillaries is transported back to the heart and distributed to the rest of the body. vii\. Carbon dioxide diffuses from the pulmonary capillaries into the alveoli, where it is exhaled and removed from the body. 3\. The thoracic cavity also contains the heart and great vessels (the vena cava and aorta). a\. The mediastinum, which is the area between the lungs, contains: i\. Heart ii\. Great vessels iii\. Esophagus iv\. Trachea v\. Major bronchi vi\. Many nerves b\. The phrenic nerve is found in the thorax. i\. It allows the diaphragm to contract, which is necessary for breathing to occur. III\. Physiology of Breathing A. The respiratory and cardiovascular systems work together. 1\. Ensure that a constant supply of oxygen and nutrients is delivered to all of the cells of the body 2\. Remove carbon dioxide and waste products from the cells B. The processes involved are ventilation, oxygenation, and respiration. C. Ventilation 1\. The physical act of moving air into and out of the lungs, which is necessary for oxygenation and respiration to occur 2\. Inhalation a\. The active, muscular part of breathing b\. The diaphragm and intercostal muscles contract during inhalation, creating a negative pressure within the thorax which allows air to enter the body and travel to the lungs. c\. Lungs require the movement of the chest and supporting structures to expand and contract during inhalation and exhalation. d\. Partial pressure: the amount of gas in the air or dissolved in fluid, such as blood i\. The partial pressure of oxygen in the alveoli is 104 mm Hg. ii\. The partial pressure of carbon dioxide in the alveoli is 40 mm Hg. iii\. Deoxygenated arterial blood from the heart has a partial pressure of oxygen that is lower than the partial pressure of carbon dioxide in the pulmonary capillaries. iv\. The body attempts to equalize the partial pressure, which results in oxygen diffusion across the membrane into the blood. v\. Oxygen and carbon dioxide both diffuse until their partial pressures in the air and blood are equal. e\. Inspiration delivers oxygen to the alveoli. i\. Not all inspired air reaches the alveoli for gas exchange. f\. Tidal volume is a measure of the amount of air in milliliters that is moved into or out of the lungs during a single breath. i\. Tidal volume for an average adult: 500 mL g\. Dead space is the portion of inspired air that fails to reach the alveoli. 3\. Exhalation a\. Does not normally require muscular effort, but rather is a passive process b\. The diaphragm and the intercostal muscles relax, which decreases the size of the thorax. c\. The smaller thorax compresses air in the lungs into a smaller space. i\. The air pressure in the thorax is then higher than the outside pressure. ii\. Air is pushed out through the trachea. d\. Air can enter and leave the lungs only if it travels through the trachea. i\. This is why clearing and maintaining a patent airway is so important. 4\. Regulation of ventilation involves a complex series of receptors and feedback loops that sense gas concentrations in the body fluids and send messages to the respiratory center in the brain to adjust the rate and depth of ventilation. a\. The body's need for oxygen is constantly changing. b\. Failure to meet the need may result in hypoxia, a condition in which the tissues and cells of the body do not get enough oxygen. i\. If not corrected, patients may die quickly. 5\. Hypoxic drive a\. Differs from the primary control of breathing in that it uses levels of oxygen to control breathing b\. Typically seen in patients with end-stage COPD c\. Some believe that administering high levels of oxygen will increase the amount of oxygen dissolved in the plasma and negatively affect the body's drive to breathe. D. Oxygenation 1\. The process of loading oxygen molecules onto hemoglobin molecules in the bloodstream 2\. Required for internal respiration to take place a\. Oxygenation does not guarantee that internal respiration is taking place. b\. Ventilation without oxygenation can occur in places where oxygen levels in the breathing air have been depleted, such as in mines, confined spaces, or high altitudes. E. Respiration 1\. The actual exchange of oxygen and carbon dioxide in the alveoli and in tissues of the body 2\. Cells take energy from nutrients through a series of chemical processes known as metabolism (cellular respiration). a\. Each cell combines nutrients and oxygen, producing energy and waste products (mainly water and carbon dioxide). F. External respiration (pulmonary respiration) 1\. The process of breathing fresh air into the respiratory system and exchanging oxygen and carbon dioxide between the alveoli and the blood in the pulmonary capillaries. 2\. Surfactant reduces surface tension within the alveoli and keeps them expanded, making it easier for gas exchange to occur. G. Internal respiration 1\. Exchange of oxygen and carbon dioxide between the systemic circulatory system and the cells of the body a\. Oxygen passes from blood in the capillaries to tissue cells. b\. Carbon dioxide and cell wastes pass from the cells into the capillaries, where they are then transported via the venous system back to the lungs. c\. All cells need a constant supply of oxygen to survive. d\. When there is adequate oxygen, cells convert glucose into energy through aerobic metabolism. e\. Without adequate oxygen, anaerobic metabolism takes place, which cannot meet the metabolic demands of the cell. IV\. Pathophysiology of Respiration A. Factors in the nervous system 1\. Chemoreceptors monitor levels of oxygen, carbon dioxide, hydrogen ions, and the pH of cerebrospinal fluid and provide feedback to the respiratory centers. 2\. When serum carbon dioxide or hydrogen ions levels increase, chemoreceptors stimulate the medulla to increase the respiratory rate. 3\. Stimulation from the pons affects the rate and depth of respirations. B. Ventilation/perfusion ratio and mismatch 1\. Ventilation and perfusion must be directed to the same place at the same time. 2\. Failure to match ventilation and perfusion is the cause of most abnormalities of oxygen and carbon dioxide exchange. a\. When ventilation is compromised but perfusion continues, blood passes over some alveolar membranes without gas exchange taking place. b\. This results in a lack of oxygen diffusing across the membrane and into blood circulation. c\. Carbon dioxide is not able to diffuse across the membrane into the lungs and, therefore, recirculates within the bloodstream. d\. When perfusion across the alveolar membrane is disrupted optimal exchange of gases is prevented. C. Factors affecting pulmonary ventilation 1\. Intrinsic factors: a\. Infections b\. Allergic reactions c\. Unresponsiveness (eg, tongue obstruction) 2\. Extrinsic factors: a\. Trauma D. Factors affecting respiration 1\. External factors include atmospheric pressure and the partial pressure of oxygen in the environment. 2\. Internal factors include conditions that reduce the surface area for gas exchange and decrease the body's oxygen supply, leading to inadequate tissue perfusion (eg, pneumonia, pulmonary edema, COPD/emphysema). E. Circulatory compromise 1\. Obstruction of blood flow to individual cells and tissue can be related to traumatic emergencies: a\. Simple or tension pneumothorax b\. Open pneumothorax (sucking chest wound) c\. Hemothorax d\. Hemopneumothorax 2\. Other causes of circulatory compromise: a\. Blood loss b\. Anemia c\. Hypovolemic shock d\. Vasodilatory shock V. Patient Assessment A. Wear a mask and protective eyewear that includes eye shields whenever airway management involves suctioning or an aerosol-generating procedure (AGP). 1\. AGPs include CPR, nebulizer treatments, endotracheal intubation, and continuous positive airway pressure. B. Recognizing adequate breathing 1\. Signs of normal breathing for adults: a\. 12--20 breaths/min b\. Regular pattern of inhalation and exhalation c\. Bilateral clear and equal lung sounds d\. Regular, equal chest rise and fall e\. Adequate depth (tidal volume) C. Recognizing abnormal breathing 1\. Signs of abnormal breathing: a\. Fewer than 12 breaths/min b\. More than 20 breaths/min in the presence of shortness of breath (dyspnea) c\. Irregular rhythm d\. Diminished, absent, or noisy auscultated breath sounds e\. Reduced flow of expired air at nose and mouth f\. Unequal or inadequate chest expansion, resulting in reduced tidal volume g\. Increased effort of breathing---use of accessory muscles h\. Shallow depth (reduced tidal volume) i\. Skin that is pale, cyanotic, cool, or moist j\. Skin pulling in around ribs or above clavicles during inspiration (retractions) 2\. A patient may appear to be breathing after the heart has stopped. a\. These occasional, gasping breaths are called agonal gasps. 3\. Cheyne-Stokes respirations are often seen in patients with stroke or head injury. a\. Breathing with increasing rate and depth of respirations followed by apnea 4\. Ataxic respirations have an irregular or unidentifiable pattern and may follow serious head injuries. 5\. Patients experiencing a metabolic or toxic disorder may display other abnormal respiratory patterns such as Kussmaul respirations. a\. Kussmaul respirations: deep, rapid respirations commonly seen in patients with metabolic acidosis 6\. Patients with inadequate breathing need to be treated immediately. 7\. Emergency medical care: a\. Airway management b\. Supplemental oxygen c\. Ventilatory support D. Assessment of respiration 1\. Even though the patient may be ventilating appropriately, the actual exchange of oxygen and carbon dioxide at the tissue level may still be compromised by several factors: a\. High altitudes b\. Poisonous gases, including carbon monoxide c\. Enclosed spaces 2\. A patient's level of consciousness and skin color are excellent indicators of respiration. 3\. When assessing patients, consider proper oxygenation, which can be assessed by pulse oximetry. 4\. Oxygen saturation (Sp[o]{.smallcaps}~2~) measures the percentage of hemoglobin molecules that are bound in arterial blood. a\. A pulse oximeter measures the percentage of hemoglobin saturation. i\. Under normal conditions, the Sp[o]{.smallcaps}~2~ should be greater than 94% while breathing room air. ii\. In conditions such as stroke or heart attack, oxygen is applied when the Sp[o]{.smallcaps}~2~ is less than 94%. iii\. Pulse oximeters can take as long as 60 seconds to reflect changes in a patient's oxygenation status; the patient can develop respiratory insufficiency well before the pulse oximetry values begin to decline. iv\. Pulse oximetry is considered a routine vital sign and can be used as part of any patient assessment (see **Skill Drill 11-1**). b\. Causes of inaccurate pulse oximetry readings: i\. Hypovolemia ii\. Severe peripheral vasoconstriction (eg, chronic hypoxia, smoking, hypothermia) iii\. Time delay in detecting respiratory insufficiency iv\. Dark or metallic nail polish v\. Dirty fingers vi\. Carbon monoxide poisoning c\. Pulse oximeters do not replace a complete assessment. d\. Pulse oximetry cannot measure the effectiveness of ventilation or provide information about cellular metabolism. 5\. End-tidal CO~2~ is the measurement of the maximal concentration of CO~2~ at the end of an exhaled breath. a\. A low CO~2~ level could indicate: i\. Hyperventilation ii\. Decreased CO~2~ return to the lungs iii\. Reduced CO~2~ production at the cellular level b\. A high CO~2~ level may indicate: i\. The patient retaining CO~2~ secondary to ventilation inadequacy ii\. Apnea 6\. End-tidal CO~2~ is measured using capnometry and capnography devices a\. Capnometry refers to use of a device that provides a digital numeric reading of the end-tidal CO~2~ level. b\. Capnography provides both a numeric reading and a graph, from breath to breath. c\. Normal range is 35 to 45 mm Hg. d\. Can be used in spontaneously breathing patients with an adequate airway using a special nasal cannula VI\. Opening the Airway A. Emergency medical care begins with ensuring an open airway. 1\. Rapidly assess whether an unconscious patient has a patent airway and pulse, and is breathing adequately. 2\. Position the patient in a supine position. a\. Unconscious patients should be moved as a unit because of the potential for spinal injury (see **Skill Drill 11-2**). b\. In an unconscious patient, the most common airway obstruction is the patient's tongue, which falls back into the throat when the muscles of the throat and tongue relax. B. Head tilt--chin lift maneuver 1\. Will open the airway in most patients 2\. For patients who have not sustained or are not suspected of having sustained spinal trauma 3\. Follow these steps: a\. With the patient supine, position yourself beside the patient's head. b\. Place the heel of one hand on the patient's forehead and apply firm backward pressure with the palm. c\. Place the fingertips of the other hand under the patient's lower jaw. d\. Lift the chin upward, with the entire lower jaw, helping to tilt the head back. C. Jaw-thrust maneuver 1\. If you suspect a cervical spine injury, use the jaw-thrust maneuver. 2\. Follow these steps: a\. Kneel above the patient's head. b\. Place your fingers behind the angles of the lower jaw. c\. Move the jaw upward. d\. Use your thumbs to help position the lower jaw. D. Opening the mouth 1\. Even though you may have opened the airway, the patient's mouth may be closed. a\. Place the tips of your index finger and thumb on the patient's teeth. b\. Open the mouth by pushing your thumb on the lower teeth and your index finger on the upper teeth. c\. The pushing motion will cause the index finger and thumb to cross over each other, which is why this is called the cross-finger technique. VII\. Suctioning A. You must keep the airway clear to ventilate the patient properly. 1\. If the airway is not clear, you will force the fluids and secretions into the lungs, resulting in aspiration. 2\. If you hear gurgling, the patient needs suctioning. B. Suctioning equipment 1\. Portable, hand-operated, and fixed (mounted) equipment is essential for resuscitation. a\. A portable suctioning unit must provide enough vacuum pressure and flow to allow you to suction the mouth and nose effectively. b\. Hand-operated suctioning units with disposable chambers are reliable, effective, and relatively inexpensive. c\. A fixed suctioning unit should generate airflow of more than 40 L/min and a vacuum of more than 300 mm Hg when the tubing is clamped. 2\. A portable or fixed unit should be fitted with the following: a\. Wide-bore, thick-walled, nonkinking tubing b\. Plastic, rigid pharyngeal suction tips, called tonsil tips (Yankauer tips) i\. Best kind of catheter for infants and children ii\. The large-diameter plastic tips are rigid and do not collapse. c\. Nonrigid plastic catheters, called French or whistle-tip catheters i\. Used to suction the nose and liquid secretions in the back of the mouth and in situations when you cannot use a rigid catheter d\. Nonbreakable, disposable collection bottle e\. Water supply for rinsing the tips 3\. Before inserting any catheter, measure for the proper size. a\. Use the same technique as when measuring for an oropharyngeal airway. C. Techniques of suctioning 1\. Inspect your suctioning equipment. 2\. To operate the suction unit: a\. Check the unit for proper assembly of all its parts. b\. Turn on the suctioning unit and test it to ensure a vacuum pressure of more than 300 mm Hg. c\. Select and attach the appropriate suction catheter to the tubing. 3\. Never suction the mouth or nose for more than 15 seconds at one time for adult patients, 10 seconds for children, and 5 seconds for infants. a\. Suctioning can result in hypoxia. b\. Rinse the catheter and tubing with water to prevent clogging. c\. Repeat suctioning only after the patient has been adequately ventilated and reoxygenated. d\. Do not touch the back of the airway with a suction catheter---this can activate the gag reflex. 4\. To properly suction a patient, see **Skill Drill 11-3**. 5\. Sometimes a patient may have secretions or vomitus that cannot be suctioned quickly and easily, and some units cannot remove objects such as teeth, foreign bodies, and food. In these cases: a\. Remove the catheter from the patient's mouth. b\. Log roll the patient to the side. c\. Clear the mouth carefully with a gloved finger. 6\. If a patient who requires assisted ventilations produces frothy secretions as quickly as you can suction them: a\. Suction the airway for 15 seconds (less in infants and children). b\. Ventilate for 2 minutes. c\. Continue this alternating pattern of suctioning and ventilating until all secretions have been cleared from the airway. VIII\. Basic Airway Adjuncts A. An airway adjunct prevents obstruction of the upper airway by the tongue and allows for passage of air and oxygen to the lungs. B. Oropharyngeal airways 1\. Keep the tongue from blocking the upper airway and make it easier to suction the oropharynx. 2\. Indications: a\. Unresponsive patients without a gag reflex (breathing or apneic) b\. Apneic patients being ventilated with a bag-mask device 3\. Contraindications: a\. Conscious patients b\. Any patient (conscious or unconscious) who has an intact gag reflex 4\. An oral airway that is too large could push the tongue back into the pharynx, blocking the airway. 5\. An oral airway that is too small could block the airway directly, like any foreign body obstruction. 6\. To insert the airway properly, see **Skill Drill 11-4**. 7\. If you encounter difficulty inserting the oral airway, an alternative method may be used: inserting with a 90° rotation (see **Skill Drill 11-5**). C. Nasopharyngeal airways 1\. Used with a patient who has an intact gag reflex, but is unable to maintain his or her own airway spontaneously 2\. Indications: a\. Semiconscious or unconscious patients with an intact gag reflex b\. Patients who otherwise will not tolerate an oropharyngeal airway 3\. Contraindications: a\. Severe head injury with blood draining from the nose b\. History of fractured nasal bone 4\. To insert the airway correctly, see **Skill Drill 11-6**. IX\. Maintaining the Airway A. The recovery position is used to help maintain a clear airway in an unconscious patient who is not injured and is breathing on his or her own with a normal respiratory rate and adequate tidal volume. X. Supplemental Oxygen A. Always give supplemental oxygen to patients who are hypoxic, because not enough oxygen is being supplied to the tissues and cells of their body. 1\. Some tissues and organs, such as the heart, central nervous system, lungs, kidneys, and liver, need a constant supply of oxygen to function normally. 2\. Never withhold oxygen from any patient who might benefit from it, especially if you must assist ventilations. B. Supplemental oxygen equipment 1\. Oxygen cylinders a\. The oxygen that you will give to patients is usually supplied as a compressed gas in green, steel or aluminum cylinders. b\. Check that the cylinder is labeled for medical oxygen. Look for letters and numbers stamped into the metal on the collar of the cylinder. i\. Check the month and year stamps indicating when the cylinder was last tested. ii\. Aluminum cylinders are tested every 5 years. iii\. Composite cylinders are tested every 3 years. c\. Most often the D (or jumbo D) cylinder sizes will be used as portable tanks. d\. The length of time you can use an oxygen cylinder depends on the pressure in the cylinder and the flow rate. 2\. Liquid oxygen is becoming a more commonly used alternative to compressed gas oxygen. 3\. Safety considerations a\. Handle gas cylinders carefully because their contents are under pressure. b\. Make sure the correct pressure regulator is firmly attached before transporting cylinders. c\. A puncture or hole in a tank can turn it into a deadly missile. d\. Secure cylinders with mounting brackets when they are stored on the ambulance. e\. Oxygen cylinders that are in use during transport should be properly secured. 4\. Pin-indexing system a\. Each portable cylinder of a specific gas type has a given pattern and a given number of pins, following accepted national standards. b\. This pin-indexing system prevents an oxygen regulator being accidently connected to an incorrect gas cylinder. c\. When preparing to administer oxygen, check that the pinholes on the cylinder exactly match the corresponding pins on the regulator. d\. For large cylinders, the safety system is the American Standard Safety System. i\. Oxygen cylinders are equipped with threaded gas outlet valves. ii\. Inside and outside thread sizes vary depending on the gas in the cylinder, preventing accidental attachment of a regulator to a wrong cylinder. 5\. Pressure regulators a\. Reduce the cylinder's pressure to a useful therapeutic range for the patient---usually 40--70 psi. b\. After the pressure is reduced to a workable level, the final attachment for delivering the gas is one of the following: i\. A quick-connect female fitting that will accept a quick-connect male plug from a pressure hose or ventilator/resuscitator ii\. A flowmeter that will permit the regulated release of gas measured in liters per minute 6\. Flowmeters a\. Usually permanently attached to pressure regulators on emergency medical equipment b\. A pressure-compensated flowmeter incorporates a float ball within a tapered calibrated tube; it is affected by gravity and must always be upright. c\. The Bourdon-gauge flowmeter is a gauge calibrated to record flow rate; it can be used in any position. C. Procedures for operating and administering oxygen 1\. To place an oxygen cylinder into service and administer medical oxygen to a patient, see **Skill Drill 11-7**. D. Hazards of supplemental oxygen 1\. Combustion a\. Oxygen does not burn or explode; it does speed up the combustion process. b\. Keep any possible source of fire away from the area while oxygen is in use. c\. Make sure the area is adequately ventilated, especially in industrial settings. d\. Never leave an oxygen cylinder standing unattended. 2\. Oxygen toxicity a\. Not all patients require high-flow oxygen. b\. Excessive supplemental oxygen can have a detrimental effect on patients with certain illnesses (ie, COPD, cerebrovascular accidents, and myocardial infarction). c\. Oxygen toxicity refers to damage to cellular tissue due to excessive oxygen levels in the blood. d\. Increased cellular oxygen levels contribute to the production of oxygen free radicals, which can lead to tissue damage and cellular death in some patients. e\. The International Liaison Committee on Resuscitation guidelines published by the American Heart Association recognize there may be negative effects of oxygen toxicity and recommend that oxygen be administered to patients experiencing signs of a myocardial infarction when they have signs of heart failure, are short of breath, or have a room air oxygen saturation less than 94%. i\. Patients experiencing signs of shock should be placed on oxygen. ii\. Hypoxemia is much worse than oxygen toxicity. f\. When pulse oximetry is available, tailor oxygen therapy to the patient's needs and administer the minimum amount of oxygen necessary to maintain oxygen saturation at or above 94%. XI\. Oxygen-Delivery Equipment A. In general, oxygen-delivery equipment used in the field should be limited to nonrebreathing masks, bag-mask devices, and nasal cannulas. B. Nonrebreathing masks 1\. Combines a mask with a reservoir bag system to administer high concentrations of oxygen to significantly hypoxemic patients who are breathing adequately a\. Oxygen fills a reservoir bag attached to the mask by a one-way valve. b\. Exhaled gas escapes through flapper valve ports at cheek areas of the mask. c\. These valves prevent the patient from rebreathing exhaled gases. 2\. Make sure the reservoir bag is full before placing the mask on the patient. 3\. Adjust the flow rate so the bag does not collapse when the patient inhales. a\. Usually 10--15 L/min b\. If the bag does collapse, increase the flow rate. 4\. When oxygen therapy is discontinued, remove the mask from the patient's face. 5\. Available in adult, pediatric, and infant sizes C. Nasal cannulas 1\. Deliver oxygen through two small, tubelike prongs that fit into the patient's nostrils 2\. Can provide 24% to 44% inspired oxygen when the flowmeter is set at 1--6 L/min a\. For patient comfort, flow rates above 6 L/min are not recommended. 3\. Used in patients with mild hypoxemia 4\. A patient who breathes through the mouth, or has a nasal obstruction, will get little oxygen. 5\. Some EMS systems provide humidified oxygen during extended transports. a\. Humidification may be associated with an increased generation of aerosolized droplets of fluid capable of transmitting disease. D. Partial rebreathing masks 1\. Similar to a nonrebreathing mask except there is no one-way valve between the mask and reservoir 2\. Patients can rebreathe a small amount of exhaled air. E. Venturi masks 1\. Has a number of attachments that enable you to vary the percentage of oxygen delivered to the patient while a constant flow is maintained from the regulator 2\. Medium-flow device that delivers 24% to 40% depending on the manufacturer F. Tracheostomy masks 1\. Patients with tracheostomies do not breathe through their mouth and nose. 2\. Tracheostomy masks cover the tracheostomy hole and have a strap that goes around the neck. a\. They may not be available in an emergency setting, in which case you should improvise by placing a face mask over the stoma. XII\. Assisted and Artificial Ventilation A. Basic airway and ventilation techniques are extremely effective when administered appropriately. 1\. Signs and symptoms of inadequate ventilation: a\. Altered mental status b\. Inadequate minute volume c\. Excessive accessory muscle use and fatigue 2\. To assist a patient with ventilations using a bag-mask device: a\. Explain the procedure to the patient. b\. Place the mask over the patient's nose and mouth. c\. Squeeze the bag each time the patient breathes, maintaining the same rate as the patient. d\. After the initial 5 to 10 breaths, slowly adjust the rate and deliver an appropriate tidal volume. e\. Adjust the rate and tidal volume to maintain an adequate minute volume. B. Artificial ventilation 1\. Once you determine that a patient is not breathing, begin artificial ventilation immediately. 2\. Methods: a\. Mouth-to-mask technique b\. Bag-mask device 3\. Normal ventilation versus positive pressure ventilation a\. Artificial ventilations are necessary to sustain life, but are not the same as normal breathing. i\. In normal breathing, the diaphragm contracts and negative pressure is generated in the chest cavity, which sucks air into the chest. ii\. Positive pressure ventilation generated by a device forces air into the chest cavity. b\. Complications with positive pressure ventilation: i\. Increased intrathoracic pressure causes compression of the vena cava and reduces blood return to the heart, which in turn reduces the amount of blood pumped by the heart. ii\. More volume is required to have the same effects as normal breathing, which pushes the airway walls out of their normal anatomic shape. iii\. Air is forced into the stomach, causing gastric distention that could result in vomiting and aspiration. c\. The EMT must regulate the rate and volume of artificial ventilations to help prevent the drop in cardiac output. d\. Ventilation rates (for apneic patients with a pulse) i\. Adult: 1 breath per 6 seconds ii\. Child: 1 breath per 2--3 seconds iii\. Infant: 1 breath per 2--3 seconds 4\. Mouth-to-mouth and mouth-to-mask ventilation a\. A barrier device is routinely used in mouth-to-mouth ventilations. b\. A mask with an oxygen inlet provides oxygen during mouth-to-mask ventilation. 5\. Bag-mask device a\. Provides less tidal volume than mouth-to-mask ventilation but delivers a much higher concentration of oxygen with a flow rate of 15 L/min and an adequate mask-to-face seal. b\. Bag-mask device components i\. A disposable self-inflating mask ii\. No pop-off valve, or if one is present, the capability of disabling the pop-off valve iii\. An inline viral filter iv\. An outlet valve that is a true valve for nonrebreathing v\. An oxygen reservoir that allows for delivery of high-concentration oxygen vi\. A one-way, no-jam inlet valve system that provides an oxygen flow rate at a maximum of 15 L/min with standard 15/22-mm fittings for face mask and endotracheal (or another advanced airway adjunct) connect vii\. A transparent face mask viii\. Ability to perform under extreme environmental conditions c\. The volume of air delivered is based on observing chest rise and fall. 6\. Bag-mask device technique a\. To use the one-person bag-mask device technique (**Skill Drill 11-8**) 7\. Gastric distention a\. Occurs when artificial ventilation fills the stomach with air b\. Most likely to occur when: i\. You ventilate the patient too forcefully or too rapidly with a bag-mask device or pocket mask. ii\. The airway is obstructed as a result of a foreign body or improper head position. c\. Give slow, gentle breaths during artificial ventilation over 1 second. d\. To prevent or alleviate distention: i\. Ensure that the patient's airway is appropriately positioned ii\. Ventilate the patient at the appropriate rate iii\. Ventilate the patient with the appropriate volume e\. If gastric distention makes it impossible to ventilate the patient and an ALS provider is not available to perform decompression, consider applying pressure over the upper abdomen (last resort). f\. If vomiting occurs as a result, turn the patient's entire body to the side, suction and/or wipe out the mouth with your gloved hand, return the patient to a supine position, and continue rescue breathing. 8\. Passive ventilation a\. Sometimes called passive oxygenation or apneic oxygenation b\. Air movement into and out of the chest cavity occurs passively as a result of compressing on the chest. i\. When the chest is compressed, air is forced out of the thorax. ii\. As the chest recoils following compression, a negative pressure is created within the chest, which results in a vacuum. iii\. Air is sucked into the chest cavity, similar to what occurs with the muscle contraction during active inhalation. c\. Passive ventilation can be enhanced by inserting an oropharyngeal airway and providing supplemental oxygen. 9\. Automatic transport ventilator (ATV)/resuscitator a\. The ATV is a ventilation device attached to a control box that allows the variables of ventilation to be set. b\. It frees the EMT to perform tasks such as maintaining the mask seal or ensuring continued airway patency. c\. Constant reassessment of the patient is necessary. XIII\. Continuous Positive Airway Pressure A. Continuous positive airway pressure (CPAP) is noninvasive ventilatory support for patients experiencing respiratory distress. 1\. Many people diagnosed with obstructive sleep apnea wear a CPAP unit at night to maintain their airways while they sleep. 2\. CPAP in the prehospital environment has proven to be an excellent adjunct in the treatment of respiratory distress associated with COPD, acute pulmonary, and acute bronchospasm. 3\. CPAP is becoming widely used at the EMT level. B. Mechanism 1\. CPAP increases pressure in the lungs, opens collapsed alveoli, pushes more oxygen across the alveolar membrane, and forces interstitial fluid back into the pulmonary circulation. 2\. The therapy is typically delivered through a face mask held to the head with a strapping system. a\. A good seal with minimal leakage between the face and mask is essential. 3\. Many CPAP systems use oxygen as the driving force to deliver the positive ventilatory pressure to the patient. a\. Patients benefit the most from CPAP during exhalation. 4\. Use caution with patients with potentially low blood pressure, because CPAP causes a drop in cardiac output. C. Indications 1\. The patient is alert and able to follow commands. 2\. The patient displays obvious signs of moderate to severe respiratory distress from a condition such as pulmonary edema or obstructive pulmonary disease (ie, COPD). 3\. Respiratory distress occurs after a submersion incident. 4\. The patient is breathing rapidly, such that it affects overall minute volume. 5\. Pulse oximetry reading is less than 90%. D. Contraindications 1\. Patient is in respiratory arrest or has agonal respirations. 2\. Patient is hypoventilating. 3\. Patient cannot speak. 4\. Patient is unresponsive or otherwise unable to follow verbal commands. 5\. Patient cannot protect his or her own airway. 6\. Patient has hypotension. 7\. Signs and symptoms of pneumothorax or chest trauma 8\. Patient who has a tracheostomy 9\. Active gastrointestinal bleeding or vomiting 10\. Patient has experienced facial trauma. 11\. Patient is in cardiogenic shock. 12\. Patient cannot sit upright. 13\. CPAP system mask and strap cannot properly fit. 14\. Patient cannot tolerate the mask. 15\. Always reassess the patient for signs of deterioration and/or respiratory failure. E. Application 1\. Components of a CPAP unit: a\. Generator b\. Mask c\. Circuit containing corrugated tubing d\. Bacteria filter e\. One-way valve 2\. The CPAP generator creates resistance throughout the respiratory cycle. 3\. This resistance creates a back pressure into the airways that pushes open the smaller airway structures, such as bronchioles and alveoli, as the patient exhales. 4\. The amount of pressure can be determined by adjusting a valve within the CPAP system or with a separate valve that can be attached. a\. A pressure of 7.0--10.0 cm H~2~O is generally an acceptable therapeutic range. 5\. Since most CPAP units are powered by oxygen, it is important to have a full cylinder of oxygen when using CPAP. 6\. To use CPAP, see **Skill Drill 11-9**. F. Complications 1\. Some patients may find CPAP claustrophobic and will resist the application of the mask. a\. Coach patients through the process rather than forcing the mask on them. 2\. Due to the high volume of pressure generated by CPAP, there is the possibility of pneumothorax. 3\. High pressure in the chest can lower a patient's blood pressure. 4\. If the patient shows signs of deterioration, remove CPAP and begin positive pressure ventilation using a bag-mask device attached to high-flow oxygen. XIV\. Special Considerations A. Stomas and tracheostomy tubes 1\. Patients who have had a laryngectomy have a permanent tracheal stoma, which is an opening in the neck that connects the trachea directly to the skin. a\. Known as a tracheostomy 2\. If the patient has a tracheostomy tube, ventilate through the tube with a bag-mask device. a\. A standard 15/22-mm adapter on the bag-mask device will fit onto the tube in the tracheal stoma. b\. Use 100% oxygen attached directly to the bag-mask device. 3\. If the patient has a stoma but no tube is in place: a\. Use an infant or child mask with your bag-mask device to make a seal over the stoma. 4\. Seal the patient's mouth and nose with one hand to prevent a leak of air through the upper airway when you ventilate through a stoma. a\. Release the seal of the patient's mouth and nose for exhalation. b\. This allows the air to exit through the upper airway. 5\. If you cannot ventilate a patient with a stoma: a\. Try suctioning the stoma and the mouth with a French or soft-tip catheter. b\. Seal the stoma while giving mouth-to-mouth ventilation. XV\. Airway Obstruction A. If an obstruction *completely* blocks the airway, it is a true emergency. 1\. It will result in death if not treated immediately. 2\. In an adult, sudden foreign body airway obstruction usually occurs during a meal. 3\. In a child, it can occur while eating, playing with small toys, or crawling around the house. 4\. The most common airway obstruction in an unconscious patient is the tongue, which relaxes and falls back into the throat. 5\. Causes of airway obstruction that do not involve foreign bodies: a\. Swelling, from infection or acute allergic reaction i\. Repeated attempts to clear the airway could be dangerous. ii\. These patients require specific emergency medical care. iii\. Rapid transport to the hospital is critical. b\. Trauma (tissue damage from injury) B. Recognition 1\. Mild airway obstruction a\. Patients can still exchange air, but will have varying degrees of respiratory distress. b\. Great care must be taken to prevent a mild airway obstruction from becoming a severe airway obstruction. c\. The patient may have noisy breathing and may be coughing. d\. With good air exchange, the patient can cough forcefully, although you may hear wheezing between coughs. i\. As long as the patient can breathe, cough forcefully, or talk, you should not interfere with the patient's efforts to expel the foreign object on his or her own. ii\. Continually reassess the patient. e\. With poor air exchange, the patient has a weak, ineffective cough and may have increased difficulty breathing, stridor, and cyanosis. i\. Stridor indicates mild upper airway obstruction. ii\. Treat immediately as if there is a severe airway obstruction. 2\. Severe airway obstruction a\. Patients cannot breathe, talk, or cough. b\. The patient may clutch or grasp the throat (the universal distress signal), begin to turn cyanotic, and have extreme difficulty breathing. c\. There is little or no air movement. d\. If the patient is found unresponsive, does not appear to be breathing, and does not have a pulse, begin CPR with high-quality chest compressions. i\. When you open the airway and attempt two ventilations following chest compressions, it will be obvious if the airway is blocked. ii\. If there is no chest rise and fall after several attempts to ventilate, or if you feel resistance while ventilating, consider the possibility of an airway obstruction. C. Emergency medical care for foreign body airway obstruction 1\. Perform a head tilt--chin lift maneuver to clear a tongue obstruction. a\. If spinal trauma is suspected, open the airway with a jaw-thrust maneuver. 2\. Large pieces of vomited food, mucus, loose dentures, or blood clots in the mouth should be swept forward and out of the mouth with your gloved index finger. 3\. When available, perform suctioning to maintain a clear airway. 4\. Abdominal thrusts are the most effective method of dislodging and forcing an object out of the airway of a conscious patient. a\. Residual air, which is always present in the lungs, is compressed upward and used to expel the object. b\. Use the abdominal thrusts until the object is dislodged or the patient becomes unconscious. 5\. For the unresponsive patient with a severe foreign body airway obstruction, reassess to confirm apnea and inability to ventilate. 6\. Begin chest compression just as you would for CPR, following the 30 compressions to 2 breaths ratio. 7\. At the completion of the 30 compressions, pull the jaw/mouth open and look at the back of the oropharynx for any foreign objects. a\. If you see an object, remove it with a gloved index finger or suction. b\. Never perform a blind sweep of the back of the oropharynx, which may push an object farther down in the airway, making the obstruction worse. c\. Once the object is removed, or if no object was seen, attempt to ventilate. d\. If you are still unable to ventilate, repeat the process. D. Dental appliances 1\. Many dental appliances can cause an airway obstruction. a\. Examples: a crown, a bridge, dentures, or a piece of braces 2\. Manually remove the dental appliance before providing ventilations. 3\. Leaving well-fitting dentures in place usually makes bag-mask device or mouth-to-mask ventilation much easier. a\. Provides more "structure" to the face b\. Helps you provide a good face-to-mask seal 4\. Loose dentures may interfere with the process and should be removed. 5\. If possible, place dislodged dentures in a container and transport them with the patient. E. Facial bleeding 1\. Airway problems can be particularly challenging in patients with serious facial injuries. 2\. The blood supply to the face is very rich, so injuries can result in severe tissue swelling and bleeding into the airway. 3\. Control bleeding with direct pressure and suction as necessary. XVI\. Assisting with ALS Airway Procedures A. When a critical patient needs and advanced airway intervention, the paramedic will perform the skill, but the EMT will play an essential role in helping set up for the procedure, performing BLS airway and ventilation maneuvers, and helping to monitor the patient. B. Assisting with placement of advanced airways 1\. Endotracheal intubation a\. The first step is preoxygenation which often includes bag-mask ventilation (including the use of an oral or nasal airway) and ensuring a proper seal, ventilation rate, volume of ventilation, and time for patient exhalation. b\. Maintain a high-flow nasal cannula on the patient during the preoxygenation phase and leave the nasal cannula in place during the intubation attempt. i\. Called preoxygenation c\. Equipment setup i\. Personal protective equipment, including face mask and eye shield ii\. Suction unit with rigid, tonsil-tip and nonrigid, whistle-tip catheters iii\. Laryngoscope handle and blade iv\. Magill forceps v\. ET tube vi\. Stylette or tube introducer (gum elastic bougie) vii\. Water-soluble lubricant viii\. 10-mL syringe xiv\. Confirmation device or devices xv\. Commercial ET tube securing device xvi\. Alternate airway management devices, such as a supraglottic airway and/or cricothyrotomy kit d\. Performing the procedure i\. Remember six typical steps by using the BE MAGIC mnemonic \(a) **B** Perform *Bag-mask* preoxygenation. \(b) **E** *Evaluate* for airway difficulties. \(c) **M** *Manipulate* the patient. \(d) **A** *Attempt* first-pass intubation. \(e) **GI** Use a supra*Glottic* airway if unable to intubate. \(f) **C** *Confirm* successful intubation/*Correct* any issues. e\. Monitor for signs of potential compensation. i\. Absence of an end-tidal CO~2~ level ii\. Decreasing Sp[o]{.smallcaps}~2~ level iii\. Increasing resistance when ventilating iv\. Other physical signs of poor ventilation and perfusion v\. Improper positioning or dislodgement of the ET tube Post-Lecture Assessment in Action -------------------- A. Assessment in Action is available in the Navigate course.