Airway Management Air reaches the lungs only through the
trachea. In a compromised airway, clearing the airway and
maintaining patency are vital.
Slide 3
Positioning the Patient Move unresponsive patients found in a
prone position to a supine position. Log roll and assess for
breathing. If the patient is breathing adequately and is not
injured, move to recovery position.
Slide 4
Slide 5
Manual Airway Maneuvers If 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.
Slide 6
Head Tilt-Chin Lift Maneuver Indications: Unresponsive No
spinal injury Unable to protect airway Contraindications:
Responsive Possible spinal injury Advantages No equipment
Noninvasive Disadvantages Hazardous to spinal injury No protection
from aspiration
Slide 7
Jaw-Thrust Maneuver Indications Unresponsive Possible spine
injury Unable to protect airway Contraindications Resistance to
opening the mouth Advantages Used with spine injury or cervical
collar No special equipment required
Slide 8
Jaw-Thrust Maneuver Disadvantages Cannot maintain if patient
becomes responsive or combative Difficult to maintain for an
extended time Difficult to use with bag-mask ventilation Thumb must
remain in place Requires second rescuer No protection against
aspiration
Slide 9
Suctioning Removes material from the mouth or throat quickly
and efficiently Ventilating with secretions in the mouth will
result in upper airway obstruction or aspiration. Next priority
after opening airway manually
Slide 10
Suctioning Equipment Fixed or portable Hand-operated suctioning
units with disposable canisters Mechanical or vacuum- powered
suction units
Slide 11
Suctioning Equipment The following should be readily
accessible: Wide-bore, thick-walled, nonkinking tubing Soft and
rigid suction catheters Nonbreakable, disposable collection bottle
Supply of water for rinsing the catheters
Slide 12
Suctioning Equipment Yankauer catheter Use with adults
(pharynx), infants, children Whistle-tip catheter Can be placed in
ET tube Use for nose, back of mouth, when a rigid catheter cannot
be used
Slide 13
Suctioning Techniques Suctioning removes oxygen. Preoxygenate
before suctioning. Maximum suctioning time Adult: 15 seconds Child:
10 seconds Infant: 5 seconds
Slide 14
Suctioning Techniques After suctioning, continue ventilation
and oxygenation. Soft-tip catheters Must lubricate when suctioning
the nasopharynx Best when passed through an ET tube Suction during
extraction of catheter
Slide 15
Airway Adjuncts May be needed to help maintain patency in an
unresponsive patient after manually opening and suctioning Not a
substitute for proper head positioning
Slide 16
Oropharyngeal (Oral) Airway Curved, hard plastic device Fits
over back of the tongue Should be inserted in unresponsive patients
who have no gag reflex
Slide 17
Oropharyngeal (Oral) Airway Indications Unresponsive patients
who have no gag reflex Contraindications Responsive patients
Patients with a gag reflex Advantages Noninvasive and easily placed
Prevents blockage by the tongue Disadvantages No prevention of
aspiration
Slide 18
Nasopharyngeal (Nasal) Airway Soft, rubber tube Insert through
nose Better tolerated Do not use with trauma to the nose or skull
fracture. Lubricate the airway and insert gently.
Slide 19
Nasopharyngeal (Nasal) Airway Indications Unresponsive Altered
mental status with an intact gag reflex Contraindications Patient
intolerance Facial fracture or skull fracture Advantages Suctioned
through Patent airway Tolerated by responsive patients Can be
placed blindly No requirement for the mouth to be open
Disadvantages Improper technique may result in severe bleeding.
Does not protect from aspiration
Slide 20
Airway Obstruction Recognition and management
Slide 21
Causes of Airway Obstruction Foreign body Tongue Laryngeal
edema Laryngeal spasm Trauma Aspiration Infection or severe
allergic reaction
Slide 22
Causes of Airway Obstruction Tongue With altered LOC, tongue
can fall backwards, closing off the airway Partial obstruction:
snoring respirations Complete obstruction: no respirations Simple
to correct with manual maneuver
Slide 23
Causes of Airway Obstruction Foreign body Signs may include:
Choking Gagging Stridor Dyspnea Aphonia or dysphonia
Laryngeal Spasm and Edema May be relieved by Aggressive
ventilation Forceful upward jaw pull May be relieved by muscle
relaxants May recur; transport patient to hospital for
evaluation
Slide 26
Laryngeal Injury Fracture of the larynx increases airway
resistance by decreasing airway size. Penetrating and crush
injuries to the larynx can compromise the airway.
Slide 27
Aspiration Increases mortality Can obstruct the airway Destroys
bronchiolar tissue Introduces pathogens into the lungs Decreases
patients ability to ventilate Have suction readily available
Slide 28
Recognition of an Airway Obstruction Mild obstruction Patient
is responsive, able to exchange air Usually has noisy respirations
and coughing Should be left alone Closely monitor the patients
condition. Be prepared to intervene.
Slide 29
Recognition of an Airway Obstruction Severe obstruction
Inability to breathe, talk, or cough May grasp at throat, turn
cyanotic, make frantic movements Cough is weak, ineffective, or
absent Weak inspiratory stridor and cyanosis
Slide 30
Emergency Medical Care for Foreign Body Airway Obstruction
Begin treatment immediately if choking is confirmed by a responsive
patient. If large pieces of foreign body are found, sweep them out
of the mouth with your finger. Insert your finger along the inside
of the cheek and into the throat. Try to hook the foreign body to
dislodge it. Suction as needed.
Slide 31
Emergency Medical Care for Foreign Body Airway Obstruction
Abdominal thrust (Heimlich) maneuver Creates an artificial cough,
expelling the object Perform until the object is expelled or the
patient becomes unresponsive.
Slide 32
Emergency Medical Care for Foreign Body Airway Obstruction If
patient becomes unresponsive, position supine, begin chest
compressions 30 chest compressions 15 with two rescuers or
infant/child Open airway, remove any visible object Attempt rescue
breath, look for chest rise
Slide 33
Emergency Medical Care for Foreign Body Airway Obstruction If
techniques do not work, proceed with direct laryngoscopy. If you
see the foreign body, remove it with Magill forceps.
Slide 34
Supplemental Oxygen Therapy Administer to any patient with
potential hypoxia Enhances compensatory mechanisms during shock and
distressed states
Slide 35
Oxygen Sources Oxygen cylinders Stores pure oxygen Check label
and test date. Various sizes Oxygen delivery is measured in
L/min.
Slide 36
Oxygen Sources Liquid oxygen Cooled to a liquid Converts to a
gas when warmed Keep upright. HELiOS Marathon portable oxygen unit.
Courtesy of Nellcor Puritan Bennett in affiliation with Tyco
Healthcare.
Slide 37
Safety Reminders Keep Oxygen Sources 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.
Have the cylinder hydrostat tested every 10 years.
Slide 38
Oxygen Regulators and Flowmeters High-pressure regulators
deliver gas under high pressure. Pressure is approximately 2,000
psi. Therapy regulator controls flow to patient Reduces to 50
psi
Slide 39
Oxygen Regulators and Flowmeters Flow meters allow oxygen to be
adjusted. Pressure-compensated flow meter Bourdon-gauge flow
meter
Slide 40
Nonrebreathing Mask Preferred in pre hospital setting 90% to
100% oxygen Non-re breathable mask Indications Spontaneously
breathing patients Contraindications Apnea and poor respiratory
effort Jones & Bartlett Learning. Courtesy of MIEMSS.
Slide 41
Nasal Cannula Two small prongs 25% to 45% oxygen Best for
patients who need long-term therapy Ineffective with: Apnea Poor
respiratory effort Severe hypoxia Mouth breathing Jones &
Bartlett Learning. Courtesy of MIEMSS.
Slide 42
Partial Rebreathing Mask Lacks one-way valve Residual exhaled
air is re-breathed 35% to 60% oxygen Jones & Bartlett Learning.
Courtesy of MIEMSS.
Slide 43
Tracheostomy Masks Cover the stoma and have a strap that goes
around the neck To improvise, place a face mask over the
stoma.
Slide 44
Ventilatory Support Patient who is not breathing needs
artificial ventilation and 100% supplemental oxygen Indications
include signs of: Altered mental status Inadequate minute
volume
Slide 45
Normal Ventilation Versus Positive- Pressure Ventilation Normal
ventilation Diaphragm contracts Negative pressure in chest cavity
draws in air Positive-pressure ventilation Generated by a device
Forces air into the chest cavity from the external environment
Slide 46
Normal Ventilation Versus Positive- Pressure Ventilation With
positive-pressure ventilation, more air is needed to achieve the
same effects of normal breathing. Increases overall intrathoracic
pressure Blood flow is decreased. Ventilations that are too
forceful can cause gastric distention.
Slide 47
Assisted Ventilation Explain 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.
Slide 48
Artificial Ventilation Begin artificial ventilation immediately
if patient is not breathing Methods include Mouth-to-mask technique
One-, two-, or three-person bag-mask device technique Manually
triggered ventilation device
Slide 49
Mouth-to-Mouth Ventilation Routinely performed with a barrier
device Alternative: mouth- to-nose Requires no special equipment
Can provide adequate tidal volume Courtesy of AAOS.
Slide 50
Mouth-to-Mask Ventilation Places a physical barrier between
your mouth and the patients mouth Oxygen inlet provides oxygen to
supplement the air from your own lungs May be shaped like a
triangle or a doughnut
Slide 51
Bag-Mask Device Can deliver nearly 100% oxygen. Can provide
adequate tidal volume when used by an experienced paramedic Depends
on mask seal integrity
Slide 52
Bag-Mask Device Components Disposable, self- inflating bag No
pop-off valve, or capability to disable Nonrebreathing outlet valve
Oxygen reservoir One-way, Disposable valve system Transparent face
mask
Slide 53
Bag-Mask Device Components Total amount of gas in an adult
bag-mask device is usually 1,200 to 1,600 mL. Volume of oxygen to
deliver is based on visible chest rise. Deliver each breath over a
period of 1 second at the appropriate rate.
Slide 54
Bag-Mask Device Technique Kneel 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.
Slide 55
Bag-Mask Device Technique Hold the mask in place while your
partner squeezes the bag until the chest visibly rises. Squeeze
every 5 to 6 seconds for adults, 3 to 5 seconds for infants and
children. Courtesy of AAOS
Slide 56
Bag-Mask Device Technique If alone, hold your index finger over
the lower part of the mask and your thumb over the upper part.
Observe for gastric distention, and changes in status.
Slide 57
Bag-Mask Device Technique Squeeze bag as patient inhales.
Slowly adjust rate and tidal volume. If patient is
hyperventilating, first assist at the rate at which the patient is
breathing. Then slowly adjust rate and tidal volume.
Slide 58
Bag-Mask Device Technique Not adequate if: Chest does not rise
and fall Rate of ventilation is too slow or too fast Pulse rate
does not improve
Slide 59
Bag-Mask Device Technique If the chest does not rise and fall:
Reposition the head or insert an airway. If the stomach seems to be
rising and falling, reposition the head. If too much air is
escaping, reposition the mask. If chest still does not rise and
fall, check for an airway obstruction.
Slide 60
Automatic Transport Ventilators Have bag-mask device available
in case ATV malfunctions Most models have adjustments for
respiratory rate and tidal volume. Deliver a preset volume at a
preset rate.
Slide 61
Automatic Transport Ventilators Steps for using: Attach to
wall-mounted oxygen source. Set tidal volume and ventilatory rate.
Connect to the ET tube or airway device. Auscultate breath sounds
and observe chest rise. Generally consumes 5 L/min of oxygen.
Slide 62
Continuous Positive Airway Pressure Noninvasive means of
providing ventilatory support for patients with respiratory
distress Increases pressure in the lungs Opens collapsed alveoli
Pushes oxygen across alveolar membrane Forces interstitial fluid
back into circulation
Slide 63
Continuous Positive Airway Pressure Typically delivered through
a face mask secured with a strapping system. Pressure relief valve
determines amount of pressure delivered to the patient.
Slide 64
Indications for CPAP Guidelines: Patient is alert and able to
follow commands. Obvious signs of respiratory distress from an
underlying disease or after submersion Rapid breathing (more than
26 breaths/min) that affects overall minute volume Pulse oximetry
of less than 90%
Slide 65
Contraindications to CPAP Respiratory arrest Hypoventilation
Signs and symptoms of a pneumothorax or chest trauma Tracheostomy
Active GI bleeding or vomiting Inability to follow verbal commands
Inability to properly fit CPAP system mask and strap
Slide 66
Application of CPAP Generally composed of: Generator Mask
Circuit Bacteria filter One-way valve
Slide 67
Application of CPAP Patient exhales against a resistance
(positive end-expiratory pressure [PEEP]) 5 to 10 cm H 2 O is
general therapeutic range
Slide 68
Complications of CPAP Patients may feel claustrophobic and
resist. High volume of pressure can cause a pneumothorax. Increased
pressure in the chest cavity can result in hypotension. Air may
enter the stomach.
Slide 69
Gastric Distension Inflation of the stomach with air Likely to
occur when: Excessive pressure is used to inflate the lungs
Ventilations are performed too fast or too forcefully Airway is
partially obstructed during ventilation attempts
Slide 70
Gastric Distension Harmful for at least two reasons Promotes
regurgitation, can lead to aspiration Pushes diaphragm up, limits
lung expansion Signs include Increased diameter, distension of the
stomach Increased resistance to bag-mask ventilations
Slide 71
Gastric Distension If signs are noted: Reassess and reposition
the airway. Observe chest for adequate rise and fall. Limit
ventilation times to 1 second or the time needed to produce
adequate chest rise.
Slide 72
Invasive Gastric Decompression Involves inserting a gastric
tube into the stomach and suctioning the contents Should be
considered: For any patient who will need positive-pressure
ventilation for an extended period When gastric distention
interferes with ventilations
Slide 73
Invasive Gastric Decompression Nasogastric tube Insert through
nose Decompresses stomach Decreases pressure Limits risk of
regurgitation
Slide 74
Invasive Gastric Decompression Nasogastric tube (contd)
Relatively well tolerated Contraindicated with severe facial
injuries Use OG route instead.
Slide 75
Invasive Gastric Decompression Orogastric tube Inserted through
the mouth No risk of nasal bleeding Safer in patients with severe
facial trauma
Slide 76
Orogastric Tube Orogastric tube (contd) Less comfortable for
responsive patients Preferred for patients who are unresponsive
without a gag reflex
Slide 77
Laryngectomy Surgical removal of the larynx Tracheostomy
creates a stoma. Total laryngectomy: breathe through stoma Cannot
ventilate by mouth-to-mask technique Partial laryngectomy: breathe
through stoma and nose or mouth
Slide 78
Ventilation of Stoma Patients Head tilt-chin lift and
jaw-thrust not required If no tracheostomy tube, use:
Mouth-to-stoma technique Bag-mask device Use an infant- or
child-sized mask to make an adequate seal.
Slide 79
Ventilation of Stoma Patients Two rescuers are needed with a
bag-mask device. One to seal the nose and mouth The other to
squeeze the bag-mask device
Slide 80
Tracheostomy Tubes Plastic tube placed within the stoma
Patients may receive supplemental oxygen via: Tubing designed to
fit over the tube Placing an oxygen mask over the tube
Slide 81
Tracheostomy Tubes Patients who experience sudden dyspnea often
have thick secretions in the tube Suction as you would through a
stoma.
Slide 82
Dental Appliances Different forms Dentures (upper, lower, or
both) Bridges Individual teeth
Slide 83
Dental Appliances Determine whether appliance is loose or fits
If it fits well, leave in place. Remove if loose. Take care if
airway obstruction is caused by a bridge (can lacerate pharynx or
larynx). Generally best to remove before intubating
Slide 84
Facial Trauma Severe swelling and bleeding in the airway may be
present. Suction as needed. Eddie M. Sperling
Slide 85
Facial Trauma Inadequate breathing and severe oropharyngeal
bleeding may be present. Suction airway for 15 seconds (less in
infants and children), then ventilate for 2 minutes. Alternate
until secretions have been cleared.
Slide 86
Facial Trauma Suspect cervical spine injury. Endotracheal
intubation of a trauma patient is most effectively performed by two
paramedics. If you are unable to effectively ventilate or intubate,
perform a cricothyrotomy.
