Airway Management and Ventilation 6/30/2018 Airway Management and Ventilation

Outline Review of Respiratory System Opening the Airway Inspecting the Airway Airway Adjuncts Clearing and Maintaining the Airway Breathing Ventilation FBAO Positive Pressure Ventilation Oxygen Delivery

Time is Brain Irreversible brain damage occurs within 4-6 minutes without O2

Open and Clear To ensure a constant supply of O2 the airway must be:

Respiratory Function Brings O2 to the lungs to be delivered to the tissues Removes CO2from the circulatory system

6/30/2018 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Inhalation and Exhalation Chest wall Diaphragm

Inhalation Diaphragm and chest wall contract, enlarging chest cavity Air from outside moves into chest O2 enters blood from lungs and CO2 enters lungs from blood

Exhalation Diaphragm and chest wall muscles relax making the chest cavity smaller Pressure on the air inside the lungs increases as chest wall pushes on it; causes air to rush out

Infant and Child Airway How does airway structure and respiratory function differ in children and infants?

Infants and Children Airway structures smaller More easily obstructed Tongue proportionally larger Airway obstruction by tongue more likely Trachea more flexible and easily closed Positioning important Primary cause of cardiac arrest is respiratory arrest

Tongue Most common cause of airway obstruction in the unresponsive patient Base of tongue attached to lower jaw Moving lower jaw forward pulls tongue away and relieves obstruction

Methods of Opening the Airway Head-tilt chin-lift Jaw-thrust (without head tilt) Trauma chin-lift (tongue jaw-lift)

Head-Tilt Chin-Lift Most effective 6/30/2018 Head-Tilt Chin-Lift Most effective Do not use for patients with suspected spinal trauma Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Jaw-Thrust Safer for trauma patients with suspected spinal trauma 6/30/2018 Jaw-Thrust Safer for trauma patients with suspected spinal trauma More difficult to perform Tiring for rescuer Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Trauma Chin-Lift Also called tongue jaw-lift 6/30/2018 Trauma Chin-Lift Also called tongue jaw-lift Risk of being bitten if patient partially responsive Risk of tearing a glove Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Inspecting the Airway After opening airway perform visual inspection for: Fluids or solids that may cause obstruction or be inhaled into lung Blood, teeth, vomit, food, or foreign bodies

Method chosen depends on situation Clearing the Airway Recovery position Finger sweeps Suctioning Method chosen depends on situation

6/30/2018 Recovery Position Gravity keeps airway free of secretions and keeps tongue away from back of pharynx Continue to monitor patient’s condition Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Finger Sweeps Used to remove solid objects from airway 6/30/2018 Finger Sweeps Used to remove solid objects from airway If foreign material/vomit visible it should be swept away immediately Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Suctioning Uses a vacuum Usually cannot remove larger items 6/30/2018 Suctioning Uses a vacuum Usually cannot remove larger items Gurgling during breathing or ventilation indicates fluid in airway (SUCTION!) Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Airway Adjuncts Nasopharyngeal Airway (NPA) Oropharyngeal Airway (OPA) With either NPA or OPA, still must maintain open airway using: Head-tilt chin-lift Jaw-thrust (without head tilt)

NPA May be tolerated by patient with intact gag reflex

NPA Procedure may be uncomfortable for patient Nasal membranes bleed easily Be prepared to suction Patient may gag briefly on insertion Stop advancing for a moment then continue Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

NPA If it is not possible to pass NPA Try inserting it into other naris Select device of same length but smaller diameter

OPA Only use in patients with no gag reflex 6/30/2018 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

6/30/2018 Properly Sized Airway

Too long Too short

Caution! If patient begins to choke or gag: Remove device immediately Be prepared to turn patient on side and suction Do not try to reinsert OPA

Laryngeal Mask Airway (LMA) Blind insertion Available in pediatric sizes Not as secure as the Combitube Does NOT prevent gastric reflux

LMA Insertion Click to play video

Breathing 1st step is opening/clearing the airway Breathing cannot occur when airway is not open and clear 2nd step is check for breathing No breathing – ventilate immediately Breathing – determine if adequate

Normal breathing is effortless Look around… Normal breathing is effortless

Check for breathing Look Listen Feel Unresponsive patient (5 - 10 sec) 6/30/2018 Check for breathing Unresponsive patient Look Listen Feel (5 - 10 sec) If not breathing, begin ventilations Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Inadequate Breathing Slow breathing rate (or no breathing) Chest does not rise and fall Accessory muscle use Effort to exhale Noisy breathing Nasal flaring Retractions Cyanosis

Do not mistake for breathing! Agonal Breathing Reflex gasping Frequently occurs just after cardiac arrest or impending respiratory arrest Do not mistake for breathing!

Ventilation If breathing absent or inadequate provide ventilations Once a patient stops breathing, O2 remaining in lungs used up quickly Waste products build up in blood The patient will die quickly without ventilation!

Types of Ventilation Bag-valve mask Mouth-to-mask Mouth-to-barrier Mouth-to-mouth

Bag-Valve Mask (BVM)

Bag-Valve Mask (BVM) Available in infant, child, and adult sizes Airtight seal is difficult to maintain with 1 rescuer Chest should rise and fall with ventilations Too much volume will cause gastric inflation

Cricoid Pressure Prevents gastric inflation and regurgitation Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Rule of Twos 2 people 2 airways 2 fingers 2 inches 2 seconds 2 PSI 6/30/2018 Rule of Twos 2 people 2 airways 2 fingers 2 inches 2 seconds 2 PSI Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Mouth-to-Mask “Pocket mask” Safe barrier 6/30/2018 Mouth-to-Mask “Pocket mask” Safe barrier One-way valve to divert exhalations May have supplemental O2 inlet Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Mouth-to-Barrier Barrier devices do not have exhalation valve 6/30/2018 Mouth-to-Barrier Barrier devices do not have exhalation valve Patient exhalation escapes from beneath device Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

EMS providers should always use a barrier device! Mouth-to-Mouth Quick and efficient Requires no special equipment Risk of infection from patient’s body fluids EMS providers should always use a barrier device!

Caution! Too much ventilation (too hard or too fast) moves air into the stomach Can cause vomiting Adequate ventilation provides gentle chest rise

Rescue Breathing Adults Children and Larger Infants 10–12 breaths/min 1 breath / 5–6 sec Children and Larger Infants 12-20 breaths/min 1 breath / 3-5 sec

Rescue Breathing Newborn Infants 40-60 breaths/min 1 breath / 1- 1½ sec Gentle “puffs” of air

Why different breathing rates? Lungs are smaller therefore need smaller volume Since volume smaller, rate must be faster Excessive volumes may damage lungs Greater risk for filling stomach with air

What if ventilation cannot be delivered? Consider airway obstruction Make sure head positioned correctly Airway adjuncts correctly sized and placed If repositioning head/checking adjuncts doesn’t correct airway obstruction Begin Foreign Body Airway Obstruction (FBAO) maneuvers

Causes of FBAO Choking on food, gum, tobacco or other objects Bleeding from trauma or medical conditions Vomiting Loose dentures or teeth

High Risk of FBAO Unresponsive (including cardiac arrest) Intoxication (drugs or alcohol) Infants or toddlers

Infant and Children FBAO > 90% of FBAO deaths occur in children < 5 y.o. 65% of these deaths occur in infants < 1 y.o. Smaller airways = more easily obstructed

Infant and Children FBAO Suspect with any sudden onset of respiratory distress Neutral position to open airway Blind finger sweeps never done Perform only if object visible

6/30/2018 Are You Choking?

Encourage coughing Do not intervene Partial FBAO 6/30/2018 Partial FBAO Confirm airway obstruction Stay with patient Encourage coughing Do not intervene Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Complete FBAO What is the procedure for complete airway obstruction? 6/30/2018 Complete FBAO Poor air exchange Ineffective cough Increasing difficulty breathing Cyanosis May become unresponsive What is the procedure for complete airway obstruction? Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

6/30/2018 Complete FBAO Give chest thrusts for patients who are pregnant or obese. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Complete FBAO Unconscious patients 6/30/2018 Complete FBAO Unconscious patients Give chest thrusts for patients who are pregnant or obese. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Special Considerations 6/30/2018 Special Considerations Mouth-to-Stoma Use barrier device over stoma May need to close mouth and pinch nostrils What is this rescuer doing? Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Special Considerations Dentures Usually left in place Remove if they become loose

O2 Cylinders Tank is green Produced in several sizes Contents high in pressure Pressure of full cylinder is approximately 2000 psi Must be handled carefully and secured properly during transport

Regulator and Flowmeter

6/30/2018 Nonrebreather Mask Best method of providing high-concentration O2 to breathing patient Delivers 90–100% O2 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Nasal Cannula Maximum flow rate 5 - 6 lpm Delivers 24 - 40% O2 Should NEVER be used on patient in respiratory distress Maximum flow rate 5 - 6 lpm Delivers 24 - 40% O2 Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Summary A constant supply of oxygen is essential to life Any impairment of airway or breathing presents an immediate threat to life and must be treated immediately The management of airway and breathing are the foundation of patient care!

Questions?