Chapter 7: Airway Management

National EMS Education Standard Competencies (1 of 7) Airway Management, Respiration, and Artificial Ventilation Applies knowledge (fundamental depth, foundational breadth) of general anatomy and physiology to assure a patent airway, adequate mechanical ventilation, and respiration while awaiting additional emergency medical services (EMS) response for patients of all ages. Airway Management, Respiration, and Artificial Ventilation Applies knowledge (fundamental depth, foundational breadth) of general anatomy and physiology to assure a patent airway, adequate mechanical ventilation, and respiration while awaiting additional emergency medical services (EMS) response for patients of all ages.

National EMS Education Standard Competencies (2 of 7) Airway Management Within the scope of practice of the emergency medical responder (EMR): Airway anatomy Airway assessment Techniques of ensuring a patent airway Respiration Anatomy of the respiratory system Airway Management Within the scope of practice of the emergency medical responder (EMR): • Airway anatomy (pp 108-109) • Airway assessment (p 111) • Techniques of ensuring a patent airway (pp 111-114) Respiration • Anatomy of the respiratory system (pp 108-110)

National EMS Education Standard Competencies (3 of 7) Respiration (cont’d) Physiology and pathophysiology of respiration Pulmonary ventilation Oxygenation Respiration External Internal Cellular • Physiology and pathophysiology of respiration (pp 108-110) Pulmonary ventilation (pp 108-109) Oxygenation (pp 108-110) Respiration (pp 108-110) External (pp 108-110) Internal (pp 108-110) Cellular (pp 108-110)

National EMS Education Standard Competencies (4 of 7) Respiration (cont’d) Assessment and management of adequate and inadequate respiration Supplemental oxygen therapy Artificial Ventilation Assessment and management of adequate and inadequate ventilation Artificial ventilation • Assessment and management of adequate and inadequate respiration (p 119) • Supplemental oxygen therapy (pp 132-134) Artificial Ventilation Assessment and management of adequate and inadequate ventilation • Artificial ventilation (pp 119-127)

National EMS Education Standard Competencies (5 of 7) Artificial Ventilation (cont’d) Minute ventilation Alveolar ventilation Effect of artificial ventilation on cardiac output Pathophysiology Uses simple knowledge of shock and respiratory compromise to respond to life threats. • Minute ventilation (pp 108-109) • Alveolar ventilation (pp 108-109) • Effect of artificial ventilation on cardiac output (pp 108-109) Pathophysiology Uses simple knowledge of shock and respiratory compromise to respond to life threats.

National EMS Education Standard Competencies (6 of 7) Medicine Recognizes and manages life threats based on assessment findings of a patient with a medical emergency while awaiting additional emergency response. Medicine Recognizes and manages life threats based on assessment findings of a patient with a medical emergency while awaiting additional emergency response.

National EMS Education Standard Competencies (7 of 7) Respiratory Anatomy, signs, symptoms, and management of respiratory emergencies including those that affect the Upper airway Lower airway Respiratory Anatomy, signs, symptoms, and management of respiratory emergencies including those that affect the • Upper airway (pp 119-132) • Lower airway (pp 119-132)

Introduction Two most important lifesaving skills: Airway care Rescue breathing The ABCs of lifesaving skills: Airway Breathing Circulation I. Introduction A. This chapter introduces the two most important lifesaving skills: 1. Airway care 2. Rescue breathing B. Patients must have an open airway and must maintain adequate breathing to survive. C. By using simple skills, you can often make a difference between life and death. D. The “ABCs” of lifesaving skills: 1. Airway 2. Breathing 3. Circulation E. Remember the check-and-correct process for both airway and breathing skills.

Anatomy and Function of the Respiratory System (1 of 9) To maintain life, all humans must have food, water, and oxygen. Lack of oxygen, even for a few minutes, can result in irreversible damage and death. The main purpose of the respiratory system is to provide oxygen and to remove carbon dioxide from the red blood cells. II. Anatomy and Function of the Respiratory System A. To maintain life, all humans must have food, water, and oxygen. 1. Lack of oxygen, even for a few minutes, can result in irreversible damage and death. 2. If brain cells are deprived of oxygen and nutrients for 4 to 6 minutes, they begin to die. 3. Brain death is followed by the death of the entire body. B. The main purpose of the respiratory system is to provide oxygen and to remove carbon dioxide from the red blood cells as they pass through the lungs.

Anatomy and Function of the Respiratory System (2 of 9) C. Parts of the body used in breathing 1. Mouth (oropharynx) 2. Nose (nasopharynx) 3. Throat 4. Trachea (windpipe) 5. Lungs 6. Diaphragm (dome-shaped muscle between the chest and the abdomen) 7. Numerous chest muscles Figure: Anatomy of the respiratory system. © Jones & Bartlett Learning.

Anatomy and Function of the Respiratory System (3 of 9) In an unconscious patient lying on his or her back, the passage of air through both nose and mouth may be blocked by the tongue. The tongue is attached to the lower jaw. A partially blocked airway often produces a snoring sound. D. In an unconscious patient lying on his or her back, the passage of air through both nose and mouth may be blocked by the tongue. 1. The tongue is attached to the lower jaw (mandible). 2. A partially blocked airway often produces a snoring sound.

Anatomy and Function of the Respiratory System (4 of 9) Figure: In an unconscious patient, the airway may be blocked by the tongue (Left) or an open airway (Right). © Jones & Bartlett Learning. © Jones & Bartlett Learning.

Anatomy and Function of the Respiratory System (5 of 9) Other parts of the respiratory system At the back of the throat are two passages: The esophagus The trachea The epiglottis helps prevent food or water from entering the airway. The airway divides into the bronchi. The lungs are located on either side of the heart. E. Other parts of the respiratory system 1. At the back of the throat are two passages: a. The esophagus (the tube through which food passes) b. The trachea 2. The epiglottis is a thin flapper valve that allows air to enter the trachea but helps prevent food or water from entering the airway. 3. Below the trachea, the airway divides into the bronchi (two large tubes supported by cartilage). 4. The lungs are located on either side of the heart and are protected by the sternum at the front of the body and by the rib cage at the sides and back.

Anatomy and Function of the Respiratory System (6 of 9) Other parts of the respiratory system (cont’d) The smaller airways that branch from the bronchi are called bronchioles. The bronchioles end as tiny air sacs called alveoli. The exchange of oxygen and carbon dioxide that occurs in the alveoli is called alveolar ventilation. 5. The smaller airways that branch from the bronchi are called bronchioles. 6. The bronchioles end as tiny air sacs called alveoli. 7. The actual exchange of gases takes place across a thin membrane that separates the capillaries of the circulatory system from the alveoli of the lungs. a. The exchange of oxygen and carbon dioxide that occurs in the alveoli is called alveolar ventilation. b. The amount of air pulled into the lungs and removed from the lungs in 1 minute is called minute ventilation. F. When a patient is not breathing, artificial ventilation is necessary to supply oxygen to the heart and the rest of the body.

Anatomy and Function of the Respiratory System (7 of 9) Figure: The exchange of gases occurs in the alveoli of the lungs. © Jones & Bartlett Learning.

Anatomy and Function of the Respiratory System (8 of 9) The lungs consist of soft, spongy tissue with no muscles. Movement of air into the lungs depends on movement of the rib cage and the diaphragm. When the diaphragm contracts during inhalation, it flattens and moves downward. On exhalation, the diaphragm relaxes and once again becomes dome shaped. G. The lungs consist of soft, spongy tissue with no muscles. 1. Movement of air into the lungs depends on movement of the rib cage and the diaphragm. 2. When the diaphragm contracts during inhalation, it flattens and moves downward. 3. On exhalation, the diaphragm relaxes and once again becomes dome shaped.

Anatomy and Function of the Respiratory System (9 of 9) Figure: Normal mechanical act of breathing. (Left) Inhalation. (Right) Exhalation. © Jones & Bartlett Learning. © Jones & Bartlett Learning.

“A” Is for Airway In healthy individuals, the airway automatically stays open. An injured or seriously ill person is not able to protect the airway and it may become blocked. You must take steps to check the airway and correct the problem. III. “A” Is for Airway A. In healthy individuals, the airway automatically stays open. B. An injured or seriously ill person is not able to protect the airway, so it may become blocked. 1. You must check the condition of the patient’s airway and correct any problem to keep the patient alive.

Check for Responsiveness (1 of 2) Ask the patient, “Are you okay? Can you hear me?” If you get a response, assume that the patient is conscious and has an open airway. If there is no response, gently shake the patient’s shoulder and repeat your questions. C. Check for responsiveness. 1. Determine whether the patient is responsive or unresponsive by asking, “Are you okay? Can you hear me?” 2. If you get a response, you can assume that the patient is conscious and has an open airway. 3. If there is no response, gently shake the patient’s shoulder and repeat your questions. Figure: Establish the level of consciousness. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Check for Responsiveness (2 of 2) If the patient is unresponsive, call 9-1-1 first before doing anything. Then, position the patient by supporting the head and neck and placing the patient on his or her back. Quickly scan the patient’s chest for breathing and check for a pulse. If the patient has a pulse but is not breathing, you need to correct the airway. 4. If the patient is unresponsive, call 9-1-1 first before doing anything for the patient. 5. After calling 9-1-1, position the patient by supporting the patient’s head and neck and placing the patient on his or her back.

Correct the Blocked Airway (1 of 3) Head tilt–chin lift maneuver Place the patient on his or her back. Place one hand on the patient’s forehead and apply firm pressure backward. Place the tips of your fingers under the bony part of the lower jaw. Lift the chin forward and tilt the head back. D. Correct the blocked airway. 1. An unconscious patient’s airway is often blocked because the tongue has dropped back and is obstructing it. a. Simply opening the airway may enable the patient to breathe spontaneously. 2. Head tilt–chin lift maneuver a. Place the patient on his or her back and kneel beside the patient. b. Place one hand on the patient’s forehead and apply firm pressure backward with your palm. c. Place the tips of the fingers of your other hand under the bony part of the lower jaw near the chin. d. Lift the chin forward to help tilt the head back. Figure: Open the patient’s airway using the head tilt‒chin lift maneuver. © Jones & Bartlett Learning.

Correct the Blocked Airway (2 of 3) Jaw-thrust maneuver Use if you suspect a neck injury. Place the patient on his or her back. Place your fingers behind the lower jaw and move the jaw forward. Tilt the head back to a neutral or slight sniffing position. Use your thumbs to pull down the lower jaw, opening the mouth enough to allow breathing. 3. Jaw-thrust maneuver a. Use this technique if you suspect a neck injury. b. Place the patient on his or her back and kneel at the top of the patient’s head. c. Place your fingers behind the angles of the patient’s lower jaw and move the jaw forward with firm pressure. d. Tilt the head backward to a neutral or slight sniffing position. e. Use your thumbs to pull down the patient’s lower jaw, opening the mouth enough to allow breathing through the mouth and nose.

Correct the Blocked Airway (3 of 3) Figure: The jaw-thrust maneuver should open the patient’s airway without extending the neck. (Left) Kneeling above the patient’s head, place your fingers behind the angles of the lower jaw and move the jaw upward. Use your thumbs to help position the lower jaw. (Right) The completed maneuver should look like this. © Jones & Bartlett Learning. Courtesy of MIEMSS. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Check for Fluids, Foreign Bodies, or Dentures Potential blocks include Secretions such as vomitus, mucus, or blood Foreign objects such as candy, food, or dirt Dentures or false teeth If you find anything in the patient’s mouth, remove it. If the mouth is clear, consider using an airway device. E. Check for fluids, foreign bodies, or dentures. 1. After you have opened the patient’s airway, look into the patient’s mouth to see if anything is blocking the airway. 2. Potential blocks include a. Secretions such as vomitus, mucus, or blood b. Foreign objects such as candy, food, or dirt c. Dentures or false teeth 3. If you find anything in the patient’s mouth, remove it. 4. If the patient’s mouth is clear, consider using one of the devices described in the section on airway devices.

Correct the Airway Using Finger Sweeps or Suction (1 of 4) Can be done quickly and require no special equipment except a set of medical gloves Follow the steps in Skill Drill 7-1. Suctioning Suction machines can be helpful in removing secretions. F. Correct the airway using finger sweeps or suction. 1. Vomitus, mucus, blood, and foreign objects must be cleared from the patient’s airway. 2. Finger sweeps a. Finger sweeps can be done quickly and require no special equipment except a set of medical gloves. b. To perform a finger sweep, follow the steps in [Skill Drill 7-1.] 3. Suctioning a. Suction machines can be helpful in removing secretions such as vomitus, blood, and mucus from the patient’s mouth.

Correct the Airway Using Finger Sweeps or Suction (2 of 4) Suctioning (cont’d) Manual suction devices Relatively inexpensive Compact enough to fit into EMR life support kits Insert the end of the suction tip into the patient’s mouth and squeeze or pump the hand-powered pump. b. Manual suction devices i. These devices are relatively inexpensive and are compact enough to fit into EMR life support kits. ii. Insert the end of the suction tip into the patient’s mouth and squeeze or pump the hand-powered pump. Figure: Manual suction device. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Correct the Airway Using Finger Sweeps or Suction (3 of 4) Suctioning (cont’d) Mechanical suction devices Clear the patient’s mouth with your gloved finger. Turn on the suction device and use the rigid tip to remove the rest of the material. Do not suction for more than 15 seconds at a time. Change to the flexible tip and clear out the deeper parts of the patient’s throat. c. Mechanical suction devices i. Use either a battery-powered pump or an oxygen-powered aspirator to create a vacuum. ii. Such a device draws the obstructing materials from the patient’s airway. iii. Clear the patient’s mouth of large pieces of material with your gloved finger. iv. Turn on the suction device and use the rigid tip to remove most of the remaining material. v. Do not suction for more than 15 seconds at a time because the suction also draws air out of the patient’s airway. vi. Change to the flexible tip and clear out material from the deeper parts of the patient’s throat.

Correct the Airway Using Finger Sweeps or Suction (4 of 4) Figure: Battery-powered suction device. © Jones & Bartlett Learning.

Maintain the Airway For unconscious patients, continue holding the head to maintain the head tilt–chin lift or the jaw-thrust position. If the patient is breathing adequately, place him or her in the recovery position. G. Maintain the airway. 1. For unconscious patients, you must continue holding the patient’s head to maintain the head tilt–chin lift or the jaw-thrust position. 2. If the patient is breathing adequately, you can keep the airway open by placing the patient in the recovery position. 3. You can also insert an oral or nasal airway to keep the patient’s airway open.

Recovery Position (1 of 2) If an unconscious patient is breathing and has not suffered trauma, place the patient in the recovery position. Helps keep the patient’s airway open Allows secretions to drain out of the mouth Uses gravity to help keep the patient’s tongue and lower jaw from blocking the airway H. Recovery position 1. If an unconscious patient is breathing and the patient has not suffered trauma, place the patient in the recovery position. a. The recovery position helps keep the patient’s airway open by allowing secretions to drain out of the mouth instead of draining into the trachea. b. It also uses gravity to help keep the patient’s tongue and lower jaw from blocking the airway.

Recovery Position (2 of 2) To place a patient in the recovery position Roll the patient onto one side, as you support the patient’s head. Place the patient’s face on his or her side so any secretions drain out of the mouth. 2. To place a patient in the recovery position: a. Roll the patient onto one side, as you support the patient’s head. b. Place the patient’s face on his or her side so any secretions drain out of the mouth. Figure: Recovery position for an unconscious patient. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Airway Adjuncts (1 of 5) Oral airway Two primary purposes To maintain the patient’s airway To function as a pathway for suctioning Used for unconscious patients who Are breathing Are in respiratory arrest Do not have a gag reflex I. Airway adjuncts 1. Oral airway a. Two primary purposes i. Maintains the patient’s airway ii. Functions as a pathway through which you can suction b. Oral airways can be used for unconscious patients who i. Are breathing ii. Are in respiratory arrest iii. Do not have a gag reflex

Airway Adjuncts (2 of 5) Figure: Oral airways. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Airway Adjuncts (3 of 5) Oral airway (cont’d) Can be used with mechanical breathing devices Select the proper size airway by measuring from the earlobe to the corner of the mouth. Follow the steps in Skill Drill 7-2 to insert an oral airway. c. These airways can be used with mechanical breathing devices such as the pocket mask or a bag-valve mask. d. There are two styles of oral airways: i. One style has an opening down the center. ii. The other has a slot along each side. e. Before you insert the airway, you need to select the proper size. i. Choose the proper size by measuring from the earlobe to the corner of the patient’s mouth. f. Follow the steps in Skill Drill 7-2 to insert an oral airway.

Airway Adjuncts (4 of 5) Nasal airway Used in both unconscious and conscious patients who are not able to maintain an open airway Not as likely to cause vomiting You cannot suction through a nasal airway. © Jones & Bartlett Learning. Courtesy of MIEMSS. 2. Nasal airway a. This device is inserted into the patient’s nose. b. Nasal airways can be used in both unconscious and conscious patients who are not able to maintain an open airway. c. Nasal airways are not as likely as oral airways to cause vomiting. d. You cannot suction through a nasal airway. Figure: Nasal airways.

Airway Adjuncts (5 of 5) Nasal airway (cont’d) Select the proper size by measuring from the earlobe to the tip of the patient’s nose. Coat the airway with a water-soluble lubricant. The airway is fully inserted when the flange or trumpet rests against the patient’s nostril. Follow the steps in Skill Drill 7-3 to insert a nasal airway. e. Be sure to select the proper size nasal airway for the patient. i. Measure from the earlobe to the tip of the patient’s nose. ii. Coat the airway with a water-soluble lubricant before inserting it. iii. The airway is fully inserted when the flange or trumpet rests against the patient’s nostril. f. Follow the steps in Skill Drill 7-3 to insert a nasal airway.

“B” Is for Breathing You can use the look, listen, and feel technique to assess adequacy of breathing. Look for the rise and fall of the patient’s chest. Listen for the sounds of air passing into and out of the patient’s nose or mouth. Feel the air moving on the side of your face. Normal adults have a resting breathing rate of 12 to 20 breaths per minute. IV. “B” Is for Breathing A. After you have checked and corrected the patient’s airway, you will next check and correct the patient’s breathing. B. Signs of adequate breathing 1. Use the look, listen, and feel technique to assess if an unconscious patient is breathing adequately. a. Look for the rise and fall of the patient’s chest. b. Listen for the sounds of air passing into and out of the patient’s nose or mouth. c. Feel the air moving on the side of your face. 2. Normal adults have a resting breathing rate of approximately 12 to 20 breaths per minute. 3. One breath includes both an inhalation and an exhalation.

Signs of Inadequate Breathing (1 of 3) Noisy respirations, wheezing, or gurgling Rapid or gasping respirations Pale or blue skin The most critical sign is respiratory arrest, which is characterized by Lack of chest movements Lack of breath sounds Lack of air against the side of your face C. Signs of inadequate breathing 1. Noisy respirations, wheezing, or gurgling indicate a partial blockage or constriction somewhere along the respiratory tract. 2. Rapid or gasping respirations may indicate that the patient is not receiving an adequate amount of oxygen as a result of illness or injury. 3. The patient’s skin may be pale or even blue. 4. The most critical sign of inadequate breathing is respiratory arrest, which is characterized by three signs: a. Lack of chest movements b. Lack of breath sounds c. Lack of air against the side of your face

Signs of Inadequate Breathing (2 of 3) Causes of respiratory arrest Heart attacks Mechanical blockage or obstruction caused by the tongue Vomitus, particularly in a patient weakened by a condition such as a stroke Foreign objects Illness or disease 5. Causes of respiratory arrest include a. Heart attacks b. Mechanical blockage or obstruction caused by the tongue c. Vomitus, particularly in a patient weakened by a condition such as a stroke d. Foreign objects such as broken teeth, dentures, balloons, marbles, pieces of food, or hard candy (especially in small children) e. Illness or disease

Signs of Inadequate Breathing (3 of 3) Causes of respiratory arrest (cont’d) Drug overdose Poisoning Severe loss of blood Electrocution by electrical current or lightning f. Drug overdose g. Poisoning h. Severe loss of blood i. Electrocution by electrical current or lightning

Check for the Presence of Breathing Assessment of any motionless patient begins by checking for responsiveness and signs of breathing. If a patient is unresponsive (unconscious), quickly scan the chest to see if the patient is breathing. D. Check for the presence of breathing. 1. Your assessment of any motionless patient begins by checking for responsiveness and assessing for breathing. 2. If the patient is responsive and breathing, assist him or her as needed. 3. However, if the patient is unresponsive, you need to determine if the patient requires assistance with breathing or other interventions. 4. While checking to see if the patient is responsive, look for signs of breathing by visualizing the patient’s chest and observing for visible movement.

Correct the Breathing (1 of 6) As you perform rescue breathing, keep the patient’s airway open. Pinch the nose, take a deep breath, and blow slowly into the mouth for 1 second. Remove your mouth and let the lungs deflate. Breathe for the patient a second time. After the first two breaths, breathe once into the mouth every 5 to 6 seconds. E. Correct the breathing. 1. As you perform rescue breathing, keep the patient’s airway open by using the head tilt–chin lift maneuver (or the jaw-thrust maneuver). a. Pinch the patient’s nose with your thumb and forefinger, take a deep breath, and blow slowly into the patient’s mouth for 1 second. b. Remove your mouth and allow the patient’s lungs to deflate. c. Breathe for the patient a second time. d. After these first two breaths, breathe once into the patient’s mouth every 5 to 6 seconds.

Correct the Breathing (2 of 6) Mouth-to-mask rescue breathing Enables you to perform rescue breathing without mouth-to-mouth contact Reduces the risk of transmitting infectious diseases To use a mouth-to-mask ventilation device, follow the steps in Skill Drill 7-4 © Jones & Bartlett Learning. Courtesy of MIEMSS. 2. Mouth-to-mask rescue breathing a. Enables you to perform rescue breathing without mouth-to-mouth contact with the patient b. A mouth-to-mask ventilation device consists of three parts: i. Mask that fits over the patient’s face ii. One-way valve iii. Mouthpiece through which the rescuer breathes c. Because mouth-to-mask devices prevent direct contact between you and the patient, they reduce the risk of transmitting infectious diseases. d. To use a mouth-to-mask ventilation device for rescue breathing, follow the steps in [Skill Drill 7-4] Figure: Types of mouth-to-mask ventilation devices.

Correct the Breathing (3 of 6) Mouth-to-barrier rescue breathing Devices are small enough to carry in your pocket and consist of a port or hole you breathe into and a mask or plastic film that covers the patient’s face Provide variable degrees of infection control To perform mouth-to-barrier rescue breathing, follow the steps in Skill Drill 7-5. 3. Mouth-to-barrier rescue breathing a. Some of these devices are small enough to carry in your pocket. b. Most of these devices consist of a port or hole that you breathe into and a mask or plastic film that covers the patient’s face. c. These devices provide variable degrees of infection control. d. To perform mouth-to-barrier rescue breathing, follow the steps in [Skill Drill 7-5].

Correct the Breathing (4 of 6) Mouth-to-mouth rescue breathing Requires no equipment Carries a somewhat higher risk of contracting a disease 4. Mouth-to-mouth rescue breathing a. This technique requires no equipment. b. There is a somewhat higher risk of contracting a disease when using this method. c. Follow these steps: i. Open the airway with the head tilt–chin lift maneuver. ii. Pinch the patient’s nostrils together with your thumb and forefinger. iii. Keep the patient’s mouth open with the thumb of whichever hand you are using to lift the patient’s chin. iv. Take a deep breath and then make a tight seal by placing your mouth over the patient’s mouth. v. Breathe slowly into the patient’s mouth for 1 second. vi. Remove your mouth and allow the patient to exhale passively. vii. Repeat this rescue breathing sequence 10 to 12 times per minute for adults and about 12 to 20 times per minute for children and infants. Figure: To perform rescue breathing, pinch the patient’s nose with your thumb and forefinger. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Correct the Breathing (5 of 6) Bag-valve mask (BVM) Place the mask over the face of the patient and make a tight seal. Squeezing the bag pushes air through a one-way valve, through the mask, and into the patient’s mouth and nose. As the patient exhales, a second one-way valve releases the air. 5. Bag-valve mask (BVM) a. The bag-valve mask has three parts: i. A self-inflating bag ii. One-way valves iii. A face mask b. To use this device i. Place the mask over the face of the patient and make a tight seal. ii. Squeezing the bag pushes air through a one-way valve, through the mask, and into the patient’s mouth and nose. As the patient passively exhales, a second one-way valve near the mask releases the air. c. The bag-valve mask delivers 21% oxygen without supplemental oxygen attached; however, supplemental oxygen is usually added to the bag-valve mask. d. Many bag-valve masks are designed to be discarded after a single use.

Correct the Breathing (6 of 6) Bag-valve mask (cont’d) The specific steps for using a bag-valve mask are shown in Skill Drill 7-6. Use of a bag-valve mask is best accomplished as a two-person operation. e. A single rescuer may find it difficult to maintain an adequate seal between the patient’s face and the mask with one hand. f. Bag-valve mask technique i. To use a bag-valve mask, follow the steps in Skill Drill 7-6. ii. Use of a bag-valve mask is best accomplished as a two-person operation if additional rescuers are present. Figure: Using a BVM with two rescuers. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Airway and Breathing Review (1 of 3) Check for responsiveness by shouting, “Are you okay?”, and shaking the patient’s shoulder. If the patient is unresponsive, activate EMS. Place the patient on his or her back. Quickly scan the patient for signs of breathing and check for a pulse. If a pulse is present, correct a blocked airway with the head tilt–chin lift or jaw-thrust maneuver. V. Airway and Breathing Review A. You should assume that all patients may be in respiratory arrest until you can assess them and determine whether they are breathing adequately. B. Airway 1. Check for responsiveness by shouting, “Are you okay?”, and gently shaking the patient’s shoulder. 2. If the patient is unresponsive and the EMS system has not been notified, activate the EMS system. 3. Place the patient on his or her back. 4. Correct a blocked airway by using the head tilt–chin lift maneuver or the jaw-thrust maneuver.

Airway and Breathing Review (2 of 3) Airway (cont’d) Check the mouth for any secretions, vomiting, or solid objects. If anything is found, clear the mouth. Correct a blocked airway with finger sweeps or suctioning. Maintain the airway by holding it open or by using an oral or nasal airway. 5. Check the mouth for any secretions, vomiting, or solid objects. If found, clear the mouth. 6. Correct a blocked airway, if needed, by using finger sweeps or suction to remove foreign substances. 7. Maintain the airway by manually holding it open or by using an oral or nasal airway.

Airway and Breathing Review (3 of 3) Check for the presence of breathing while determining responsiveness. Correct the lack of breathing by performing rescue breathing using a mouth-to-mask, or mouth-to-barrier device, if available. C. Breathing 1. Check for the presence of breathing. 2. Correct the lack of breathing by performing rescue breathing using a mouth-to-mask or mouth-to-barrier device, if available.

Performing Rescue Breathing on Children and Infants (1 of 2) Rescue breathing for children Children are smaller and you will not have to use as much force to open their airways and tilt their heads. Give 1 rescue breath every 3 to 5 seconds (about 12 to 20 rescue breaths per minute). D. Performing rescue breathing on children and infants 1. Rescue breathing for children a. Children are smaller and you will not have to use as much force to open their airways and tilt their heads. b. The rate of rescue breathing is slightly faster for children. i. Give 1 rescue breath every 3 to 5 seconds (about 12 to 20 rescue breaths per minute).

Performing Rescue Breathing on Children and Infants (2 of 2) Rescue breathing for infants An infant is tiny and must be treated extremely gently. The steps in rescue breathing for an infant are shown in Skill Drill 7-7. 2. Rescue breathing for infants a. An infant is tiny and must be treated extremely gently. b. The steps in rescue breathing for an infant are shown in Skill Drill 7-7.

Causes of Airway Obstruction (1 of 2) The most common airway obstruction is the tongue. If the tongue is blocking the airway, the head tilt–chin lift maneuver or jaw-thrust maneuver should open the airway. Food is the most common foreign object that causes an airway obstruction. If a foreign body is lodged in the air passage, you must use other techniques to remove it. VI. Foreign Body Airway Obstruction A. Causes of airway obstruction 1. The most common airway obstruction is the tongue. a. If the tongue is blocking the airway, the head tilt–chin lift maneuver or jaw-thrust maneuver should open the airway. b. If a foreign body is lodged in the air passage, you must use other techniques. 2. Food is the most common foreign object that causes an airway obstruction. 3. Children may put small objects in their mouths and inhale such things as tiny toys or balloons. 4. Vomitus may obstruct the airway of a child or an adult.

Causes of Airway Obstruction (2 of 2) © Jones & Bartlett Learning. © Jones & Bartlett Learning. Figure: Common causes of airway obstruction. © Jones & Bartlett Learning. © Jones & Bartlett Learning.

Types of Airway Obstruction (1 of 3) Ask the patient, “Are you choking?” If the patient can reply, the airway is not completely blocked. If the patient cannot speak or cough, the airway is completely blocked. Mild airway obstruction The patient coughs and gags. The patient may be able to speak, but with difficulty. B. Types of airway obstruction 1. The first step in caring for a conscious person who may have an obstructed airway is to ask, “Are you choking?” a. If the patient can reply to your question, the airway is not completely blocked. b. If the patient cannot speak or cough, the airway is completely blocked. 2. Mild airway obstruction a. The patient coughs and gags. b. The patient may even be able to speak, although with difficulty.

Types of Airway Obstruction (2 of 3) Mild airway obstruction (cont’d) Encourage the patient to cough. If the patient cannot expel the object, arrange for prompt transport. c. To treat a mildly constructed airway, encourage the patient to cough. d. If the patient is unable to expel the object by coughing, you should arrange for the patient’s prompt transport to an appropriate medical facility.

Types of Airway Obstruction (3 of 3) Severe airway obstruction The patient is unable to breathe in or out and speech is impossible. Other symptoms may include Poor air exchange Increased breathing difficulty A silent cough Loss of consciousness in 3 to 4 minutes Treatment involves abdominal thrusts. 3. Severe airway obstruction a. The patient is unable to breathe in or out and, because he or she cannot exhale air, speech is impossible. b. Other symptoms may include i. Poor air exchange ii. Increased breathing difficulty iii. A silent cough iv. Loss of consciousness in 3 to 4 minutes c. The currently accepted treatment for conscious patients involves abdominal thrusts (Heimlich maneuver). i. Abdominal thrusts compress the air that remains in the lungs, forcing the object out.

Management of Foreign Body Airway Obstructions (1 of 3) Airway obstruction in an adult If the patient is conscious, stand behind him or her and perform abdominal thrusts. To assist a patient with a complete airway obstruction, follow the steps in Skill Drill 7-8. Perform cardiopulmonary resuscitation (CPR) on a patient who has become unresponsive. C. Management of foreign body airway obstructions 1. Relieving a foreign body airway obstruction requires no special equipment. 2. Airway obstruction in an adult a. If the patient is conscious, stand behind the patient and perform the abdominal thrusts while the patient is standing or seated in a chair. b. To assist a patient with a complete airway obstruction, follow the steps in Skill Drill 7-8. c. Performing cardiopulmonary resuscitation (CPR) on a patient who has become unresponsive has the same effect as performing the Heimlich maneuver on a conscious patient.

Management of Foreign Body Airway Obstructions (2 of 3) Airway obstruction in a child Tilt the head back just past the neutral position. If the child becomes unresponsive, perform CPR for five cycles before activating the EMS system. Airway obstruction in an infant If the infant has an audible cry, the airway is not completely obstructed. 3. Airway obstruction in a child a. When opening the airway of a child or infant, tilt the head back just past the neutral position. b. If you are by yourself and a child with an airway obstruction becomes unresponsive, perform CPR for five cycles (about 2 minutes) before activating the EMS system. 4. Airway obstruction in an infant a. An infant’s airway structures are very small, and they are more easily injured than those of an adult. b. If the infant has an audible cry, the airway is not completely obstructed.

Management of Foreign Body Airway Obstructions (3 of 3) Airway obstruction in an infant (cont’d) Use a combination of back slaps and chest thrusts. If the infant becomes unresponsive Ensure that the EMS system has been activated. Begin CPR. Continue CPR until more advanced EMS personnel arrive. c. Use a combination of black slaps and chest thrusts. d. To assist a conscious infant with a severe airway obstruction, you must i. Assess the infant’s airway and breathing status. ii. Place the infant in a face-down position over one arm so that you can deliver five back slaps. iii. Turn the infant face up and deliver five chest thrusts in the middle of the sternum. iv. Repeat the back slaps and chest thrusts until the foreign object is expelled or until the infant becomes unresponsive. e. If the infant becomes unresponsive, continue with the following steps: i. Ensure that the EMS system has been activated. ii. Begin CPR. iii. Continue CPR until more advanced EMS personnel arrive.

Oxygen Equipment (1 of 3) Oxygen cylinders Oxygen is compressed to 2,000 psi and stored in portable cylinders. The portable oxygen cylinders used by most EMS systems are either D or E size. Depending on the flow rate, each cylinder should last for at least 20 minutes. VII. Oxygen Administration A. Administering supplemental oxygen to a patient who is showing signs and symptoms of shock increases the amount of oxygen delivered to the cells of the body and often makes a positive difference in the patient’s outcome. B. Oxygen equipment 1. Oxygen cylinders a. Oxygen is compressed to 2,000 pounds per square inch (psi) and stored in portable cylinders. b. The portable oxygen cylinders used by most EMS systems are either D or E size. i. Size D cylinders hold 350 liters of oxygen. ii. Size E cylinders hold 625 liters of oxygen. c. Oxygen cylinders must be marked with a green color and be labeled as medical oxygen. d. Depending on the flow rate, each cylinder should last for at least 20 minutes. Figure: Oxygen administration equipment. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Oxygen Equipment (2 of 3) Pressure regulator/flowmeter Single unit attached to the outlet of the oxygen cylinder Can be adjusted to deliver oxygen at a rate of 2 to 15 L/min A gasket ensures a tight seal. 2. Pressure regulator/flowmeter a. The regulator and the flowmeter are a single unit attached to the outlet of the oxygen cylinder. b. Once the pressure has been reduced, you can adjust the flowmeter to deliver oxygen at a rate of 2 to 15 liters per minute. c. A gasket between the cylinder and the pressure regulator/flowmeter ensures a tight seal and maintains the high pressure inside the cylinder. Figure: The regulator/flowmeter attaches to the outlet of the oxygen cylinder. © American Academy of Orthopaedic Surgeons.

Oxygen Equipment (3 of 3) Nasal cannulas and face masks Ensures the oxygen is delivered to the patient and is not lost in the air Nasal cannulas are used to deliver medium concentrations of oxygen. A face mask is placed over the patient’s nose and mouth to deliver oxygen. Nonrebreathing masks are most commonly used by EMRs. 3. Nasal cannulas and face masks a. These devices ensure that oxygen is delivered to the patient and is not lost in the air. b. Nasal cannulas are used to deliver medium concentrations of oxygen (24% to 44%). c. A face mask is placed over the patient’s nose and mouth to deliver oxygen through the patient’s mouth and nostrils. d. Nonrebreathing masks are most commonly used by EMRs.

Safety Considerations Oxygen actively supports combustion and can quickly turn a small spark or flame into a serious fire. All sparks, heat, flames, and oily substances must be kept away. The pressure in an oxygen cylinder can cause an explosion if it is damaged. Oxygen cylinders should be kept inside sturdy carrying cases. C. Safety considerations 1. Oxygen actively supports combustion and can quickly turn a small spark or flame into a serious fire. a. All sparks, heat, flames, and oily substances must be kept away from oxygen equipment. b. Smoking is never safe around oxygen equipment. 2. The high pressure in an oxygen cylinder can cause an explosion if the cylinder is damaged. a. Oxygen cylinders should be kept inside sturdy carrying cases. b. Handle the cylinder carefully to guard against damage.

Administering Supplemental Oxygen (1 of 5) Place the regulator/flowmeter over the stem of the oxygen cylinder and line up the pins on the pin-indexing system. Tighten the securing screw firmly by hand. Turn the cylinder valve two turns counterclockwise. D. Administering supplemental oxygen 1. Place the regular/flowmeter over the stem of the oxygen cylinder and line up the pins on the pin-indexing system correctly. 2. Tighten the securing screw firmly by hand. 3. Turn the cylinder valve two turns counterclockwise to allow oxygen from the cylinder to enter the regulator/flowmeter. Figure: A valve stem with pin-index holes. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Administering Supplemental Oxygen (2 of 5) Check the gauge on the pressure regulator/flowmeter. You will need to adjust the flowmeter to deliver the desired liter-per-minute flow. When the oxygen flow begins, place the face mask or nasal cannula onto the patient’s face. 4. Check the gauge on the pressure regulator/flowmeter. 5. To administer oxygen, you must adjust the flowmeter to deliver the desired liter-per-minute flow of oxygen. 6. When the oxygen flow begins, place the face mask or nasal cannula onto the patient’s face.

Administering Supplemental Oxygen (3 of 5) Nasal cannula Delivers low-flow oxygen at 1 to 6 L/min and in concentration of 24% to 44% oxygen Adjust the liter flow to 1 to 6 L/min and then apply the cannula to the patient. © Jones & Bartlett Learning. Courtesy of MIEMSS. 7. Nasal cannula a. A cannula delivers low-flow oxygen at 1 to 6 liters per minute and in concentrations of 24% to 44% oxygen. b. Adjust the liter flow to 1 to 6 liters per minute and then apply the cannula to the patient. Figure: A nasal cannula.

Administering Supplemental Oxygen (4 of 5) Nonrebreathing mask Used to deliver a high flow of oxygen at 8 to 15 L/min Can deliver concentrations of oxygen as high as 90% 8. Nonrebreathing mask a. Consists of connecting tubing, a reservoir bag, one-way valves, and a face piece b. Used to deliver a high flow of oxygen at 8 to 15 liters per minute c. Can deliver concentrations of oxygen as high as 90% Figure: A nonrebreathing oxygen mask. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Administering Supplemental Oxygen (5 of 5) Nonrebreathing mask (cont’d) Should be used for patients who require higher flows of oxygen, including those experiencing Shortness of breath Severe chest pain Carbon monoxide poisoning Congestive heart failure Signs and symptoms of shock d. Should be used for patients who require higher flows of oxygen, including those experiencing i. Shortness of breath ii. Severe chest pain iii. Carbon monoxide poisoning iv. Congestive heart failure v. Signs and symptoms of shock e. To use a nonrebreathing mask i. Adjust the oxygen flow to 8 to 15 liters per minute to inflate the reservoir bag before putting it on the patient. ii. Place the mask over the patient’s face. iii. Adjust the straps to secure a snug fit. iv. Adjust the liter flow to keep the bag at least partially inflated while the patient inhales.

Hazards of Supplemental Oxygen Supplemental oxygen must be used carefully so that you, your team, and the patient remain safe. You will need additional class work and practical training before you are ready to administer oxygen in emergency situations. E. Hazards of supplemental oxygen 1. Supplemental oxygen must be used carefully so that you, your team, and the patient will remain safe. 2. You will need additional class work and practical training before you are ready to administer oxygen in emergency situations.

Pulse Oximetry (1 of 3) Pulse oximetry is used to assess the amount of oxygen saturated in the red blood cells. Pulse oximeter Consists of a sensor probe and a monitor The monitor displays the percent saturation of the patient’s blood. VIII. Pulse Oximetry A. Pulse oximetry is used to assess the amount of oxygen saturated in the red blood cells. B. The machine that performs this function is called a pulse oximeter. 1. A pulse oximeter consists of a sensor probe and a monitor. 2. To operate the pulse oximeter, turn on the monitor. 3. Once you know that the monitor is operating correctly, place the sensor probe over the patient’s fingertip or earlobe. 4. The monitor should then display the percent saturation of the patient’s blood. © Jones & Bartlett Learning.

Pulse Oximetry (2 of 3) Pulse oximeter (cont’d) In a healthy patient, the oxygen saturation should be between 95% and 100%. The pulse oximeter cannot tell you what is wrong with the patient, but it can help you Recognize that the patient is having a problem Determine whether your treatment is helping the patient a. In a healthy patient, the oxygen saturation should be between 95% and 100% when breathing room air. b. If a patient has difficulty breathing as a result of injury or a disease process, the percent of oxygen saturation may be much lower than 95%. 5. The pulse oximeter cannot tell you what is wrong with the patient, but it can help you a. Recognize that the patient is having a problem b. Determine whether your treatment is helping the patient

Pulse Oximetry (3 of 3) A pulse oximeter has certain limitations. It will not give an accurate reading if the patient Is wearing nail polish or has dirty fingers Is cold Has lost a lot of blood Has experienced carbon monoxide poisoning There is no machine that can replace a careful patient assessment. C. A pulse oximeter has certain limitations. 1. It will not give an accurate reading if the patient is wearing nail polish or if the patient’s fingers are very dirty. 2. If the patient is cold and the blood vessels in the fingertips or earlobes are constricted, the pulse oximeter reading will not be accurate. 3. Patients who have lost a lot of blood will have inaccurate readings. 4. Patients who have experienced carbon monoxide poisoning will have false readings. D. There is no machine that can replace a careful patient assessment, including a good medical history.

Rescue Breathing for Patients With Stomas (1 of 2) Check every patient for the presence of a stoma. If you locate a stoma, keep the patient’s neck straight. Examine the stoma and clean away any mucus in it. If there is a breathing tube, remove it. IX. Special Considerations A. Rescue breathing for patients with stomas 1. Some people have had surgery that removed part or all of the larynx. 2. In these patients, the upper airway has been rerouted to open through a stoma (hole) in the neck. 3. Rescue breathing must be given through the stoma, in a technique known as mouth-to-stoma breathing. a. Check every patient for the presence of a stoma. b. If you locate a stoma, keep the patient’s neck straight. c. Examine the stoma and clean away any mucus in it. d. If there is a breathing tube in the opening, remove it to be sure it is clear.

Rescue Breathing for Patients With Stomas (2 of 2) Place your mouth directly over the stoma and use the same procedures as in mouth-to-mouth breathing. If the patient’s chest does not rise, seal the mouth and nose with one hand and then breathe through the stoma. A bag-valve mask or pocket-mask device can also be used to ventilate the patient. e. Place your mouth directly over the stoma and use the same procedures as in mouth-to-mouth breathing. f. If the patient’s chest does not rise, seal the mouth and nose with one hand and then breathe through the stoma. 4. A bag-valve mask or pocket-mask device can also be used to ventilate a patient with a stoma.

Gastric Distention Occurs when air is forced into the stomach instead of the lungs Increases the chance that the patient will vomit Breathe slowly into the patient’s mouth, just enough to make the chest rise. B. Gastric distention 1. Gastric distention occurs when air is forced into the stomach instead of the lungs. 2. It increases the chance that the patient will vomit. 3. Breathe slowly into the patient’s mouth, just enough to make the chest rise. 4. Remember that the lungs of children and infants are smaller and require smaller breaths during rescue breathing.

Dental Appliances Do not remove dental appliances that are firmly attached. They may help keep the patient’s mouth full so you can make a better seal. Loose dental appliances cause problems. Partial dentures may become dislodged. Remove the dentures and put them in a safe place. C. Dental appliances 1. Do not remove dental appliances that are firmly attached. a. They may help keep the patient’s mouth full so you can make a better seal between the patient’s mouth and your mouth or a breathing device. 2. Loose dental appliances may cause problems. a. Partial dentures may become dislodged during trauma or while you are performing airway care and rescue breathing. b. Remove the dentures and try to put them in a safe place.

Airway Management in a Vehicle (1 of 4) Use the jaw-thrust maneuver if The patient is lying on the floor or seat There is any possibility that the crash could have caused a head or spine injury When the patient is in a sitting or semireclining position Approach the patient from the side by leaning in through the window or across the seat. D. Airway management in a vehicle 1. If the patient is lying on the floor or seat of the car, apply the standard jaw-thrust maneuver. 2. Use the jaw-thrust maneuver if there is any possibility that the crash could have caused a head or spine injury. 3. When the patient is in a sitting or semireclining position: a. Approach the patient from the side by leaning in through the window or across the front seat.

Airway Management in a Vehicle (2 of 4) When the patient is in a sitting or semireclining position: (cont’d) Grasp the patient’s head with both hands. Put one hand over the patient’s chin and the other hand on the back of the patient’s head. Maintain a slight upward pressure to support the head and cervical spine. b. Grasp the patient’s head with both hands. c. Put one hand under the patient’s chin and the other hand on the back of the patient’s head, just above the neck. d. Maintain a slight upward pressure to support the head and cervical spine.

Airway Management in a Vehicle (3 of 4) Figure: Airway management in a vehicle. (Left) To open the airway, place one hand under the chin and the other hand on the back of the patient’s head. (Right) Raise the head to a neutral position to open the airway. © Jones & Bartlett Learning. Courtesy of MIEMSS. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Airway Management in a Vehicle (4 of 4) This technique has several advantages: You do not have to enter the automobile. You can easily monitor the patient’s carotid pulse and breathing patterns by using your fingers. This technique stabilizes the patient’s cervical spine. It opens the patient’s airway. 4. This technique has several advantages: a. You do not have to enter the automobile. b. You can easily monitor the patient’s carotid pulse and breathing patterns by using your fingers. c. This technique stabilizes the patient’s cervical spine. d. It opens the patient’s airway.

Summary (1 of 4) The main purpose of the respiratory system is to provide oxygen and to remove carbon dioxide from the red blood cells as they pass through the lungs. A. The main purpose of the respiratory system is to provide oxygen and to remove carbon dioxide from the red blood cells as they pass through the lungs. The structures of the respiratory system in children and infants are smaller than the corresponding structures in adults. As a consequence, the air passages of children and infants may be more easily blocked by secretions or by foreign objects.

Summary (2 of 4) When a patient experiences possible respiratory arrest, check for responsiveness; open the blocked airway using the head tilt–chin lift or jaw-thrust maneuver; check for fluids, solids, or dentures in the mouth; and correct the airway, if needed, using finger sweeps or suction. B. When a patient experiences possible respiratory arrest, check for responsiveness; open the blocked airway using the head tilt–chin lift or jaw-thrust maneuver; check for fluids, solids, or dentures in the mouth; and correct the airway, if needed, using finger sweeps or suction.

Summary (3 of 4) Maintain the airway by continuing to manually hold the airway open, by placing the patient in the recovery position, or by inserting an oral or a nasal airway. If the airway is obstructed in a conscious adult or child, kneel or stand behind the patient and perform the Heimlich maneuver. C. Maintain the airway by continuing to manually hold the airway open, by placing the patient in the recovery position, or by inserting an oral or a nasal airway. Check for breathing by looking, listening, and feeling for air movement, and correct any problems by using a mouth-to-mask or mouth-to-barrier device, by using a bag-valve mask, or by performing mouth-to-mouth rescue breathing. It is important to use the correct sequence for adults, children, and infants. D. If the airway is obstructed in a conscious adult or child, kneel or stand behind the patient and perform the Heimlich maneuver. Give abdominal thrusts until the obstruction is relieved or the patient becomes unconscious. For an unconscious adult or child with an airway obstruction, perform chest compressions. Move to the head, open the airway, and look in the patient’s mouth. Do not perform a finger sweep—regardless of the patient’s age—unless you can see the object. Attempt rescue breathing. If the airway is still obstructed, repeat chest compressions, visualization of the mouth, and ventilation attempts until the obstruction is relieved.

Summary (4 of 4) Administering supplemental oxygen to patients showing signs and symptoms of shock increases the amount of oxygen delivered to the cells. Pulse oximetry is used to assess the amount of oxygen saturated in the red blood cells. E. Administering supplemental oxygen to patients who show signs and symptoms of shock increases the amount of oxygen delivered to the cells of the body and often makes a positive difference in the patient’s outcome. Patients who have experienced a heart attack or stroke or patients who have chronic heart or lung disease may also benefit from receiving supplemental oxygen. F. Pulse oximetry is used to assess the amount of oxygen saturated in the red blood cells.

Review After opening the airway of a patient who has a pulse but is unconscious, you should perform a blind finger sweep. immediately attempt to insert an oral airway. check for secretions, foreign bodies, or dentures. perform CPR.

Review Answer: C. check for secretions, foreign bodies, or dentures.

Review You should place a patient in the recovery position to prevent the patient from going into respiratory arrest. allow secretions to drain out of the mouth. protect the patient’s spine from injury. facilitate the administration of supplemental oxygen.

Review Answer: B. allow secretions to drain out of the mouth.

Review Pulse oximetry is used to assess the amount of oxygen saturated in the red blood cells. provide supplemental oxygen to the patient. assess how much oxygen the patient requires. eliminate carbon dioxide from the bloodstream.

Review Answer: A. assess the amount of oxygen saturated in the red blood cells.