Airway and ventilatory Management 33 EMS Professions Temple College Dr. Sarwar Arif

Respiration is the process of exchanging gases between the atmosphere and body cells.

Stages of Respiration Ventilation: Movement of air into and out of lungs External respiration: Gas exchange between air in lungs and blood Transport of oxygen and carbon dioxide in the blood Internal respiration: Gas exchange between the blood and tissues

The mechanics of breathing

Anatomy of the Upper Airway Pediatric vs Adult Upper Airway Larger tongue in comparison to size of mouth Floppy epiglottis Delicate teeth and gums Larynx is more superior Funnel shaped larynx due to undeveloped cricoid cartilage Narrowest point at cricoid ring before 10 yoa

Opening the Airway Tongue is most common cause of airway obstruction Use the head tilt–chin lift to lift tongue from back of throat and open airway In a trauma patient, use jaw thrust

Chin lift

Chin lift Fingers of one hand are placed under the mandible, which is gently lifted upward to bring the chin anterior. The thumb of the same hand lightly depresses the lower lip to open the mouth. Not hyperextend the neck.

Jaw trust

Jaw thrust Grasping the angles of lower jaw ,one hand on each side,& displacing the mandible forward.

Airway & Ventilation Methods: ALS Patient Positioning for Intubation Goal Align the 3 planes of view, so that The vocal cords are most visible T - trachea P - Pharynx O - Oropharynx From AHA PALS

Airway Assessment After opening airway, assess that it’s patent and clear of fluids/solids Assess airway in unresponsive patients and responsive patients with injuries or altered mental status who may not be able to protect their own airway

Check Airway for Patency Open mouth with gloved hand Listen for sounds indicating liquid in airway Look inside for fluids, solids, or objects Clear using finger sweep or suction

Clearing a Compromised Airway With Finger Sweep Perform finger sweep if fluids/solids seen in mouth/airway Roll patient onto one side (left preferred) Wipe liquids or semi-liquids from mouth For solid objects, hook index finger, sweep object to side and out of mouth

Maintaining Open Airway in Unresponsive Patients When patient is supine, airway must be kept open with either the head tilt–chin lift or the jaw thrust An airway adjunct may be used to help maintain an open airway If you must leave the patient’s side, move patient into recovery position to keep airway open

Recovery Position Helps keep airway open Allows fluid to drain from mouth Prevents aspiration If possible, put victim onto left side Continue to monitor breathing

Assessing Breathing

Assessing Breathing Look for adequate breathing in adults Look for presence or absence of breathing in children and infants

Assessing Breathing If adult not breathing adequately (breathing rate < 10 breaths per minute) Begin rescue breaths

Respiratory Emergencies

Severe Airway Obstruction Victim is getting no air at all Victim will soon become unresponsive Heart will soon stop

Assessment & Recognition of Airway & Ventilatory Compromise Visual Assessment Position tripoid orthopnea Rise & Fall of chest Paradoxical motion Audible gasping, stridor, or wheezes Obvious pulm edema Skin color Flaring of nares Pursed lips breathing (PLB) is the act of exhaling through tightly pressed, pursed lips Retractions Accessory Muscle Use Altered Mental Status Inadequate Rate or depth of ventilations

Signs/Symptoms of Respiratory Distress Gasping for air Panting Breathing faster/slower than normal Making wheezing or other sounds Using accessory muscles in effort to breathe

Signs/Symptoms of Respiratory Distress (continued) Inability to speak a full sentence without pausing to breathe Skin may look pale, be cool and moist; lips/nail beds may be bluish Dizziness or disorientation Extreme distress Sitting and leaning forward, hands on knees

Respiratory Distress in an Infant or Child Crucial to act quickly - may rapidly progress to arrest Infant/child may have flaring nostrils, and more obvious movements of chest muscles

Respiratory Distress Is a Medical Emergency Unless condition progresses to inadequate breathing/respiratory arrest, ventilation is not needed Patient will benefit from supplemental oxygen

Ventilation

Masks/Barrier Devices Barrier devices recommended when giving ventilation by mouth Pocket masks/face shields offer personal protection from patient’s fluids With either device, keep patient’s head positioned to maintain open airway as you deliver breaths

Face Masks Resuscitation mask seals over mouth/nose with port through which you blow air to give ventilations One-way valve allows your air through mouthpiece, patient’s exhaled air exits through different opening. When using face mask, seal mask well to face while maintaining an open airway Use bridge of nose as guide for correct placement

Face Masks continued Seal mask well while maintaining open airway How you hold mask depends on: Your position by patient Method to open airway Whether you have one or two hands to seal mask

Position at Victim’s Side With thumb and index finger seal top and sides of mask to victim’s head Put thumb of second hand on lower edge of mask Put remaining fingers of second hand under jaw to lift chin Press mask down firmly to make seal as you lift chin

Position at Top of Victim’s Head: Using Head Tilt – Chin Lift Put thumbs on both sides of mask Put remaining fingers of both hands under angles of victim’s jaw As you tilt head back, press mask down firmly to make seal as you lift chin

Position at Top of Victim’s Head: Jaw Thrust Without tilting head back, position thumbs on mask with fingers under angles of jaw Lift jaw as you press down with thumbs to seal mask, without tilting head back

Face Shield Positioned over mouth as protective barrier Nose must be pinched closed when giving a ventilation to prevent air from coming out Mask is generally preferred to face shield because air may leak around shield Face Shield

If No Barrier Device Is Available Give ventilations directly from your mouth to patient’s mouth, nose, or stoma Risk of disease transmission is very low

Mouth to Mouth Pinch victim’s nose shut Seal your mouth over victim’s Breathe into victim’s mouth Watch chest rise to confirm air is going in

Mouth to Nose Use victim’s nose if: Mouth cannot be opened Mouth is injured You cannot get a good seal with mouth to mouth

Mouth to Nose Hold victim’s mouth closed Seal your mouth over victim’s nose to breathe in Open mouth to let air escape

Mouth to Stoma Some people breathe through hole in lower neck – called a stoma Cup your hand over victim’s nose and mouth Seal your mouth over stoma or a round pediatric face mask Give rescue breaths as usual

Mouth to Nose and Mouth Infants and very small children are given rescue breaths through mouth and nose Seal mouth over both mouth and nose Give gentle breaths Watch to see chest rise and fall with each breath

Techniques of Ventilation With patient supine, open airway with head tilt–chin lift or the jaw thrust Blow air while watching chest rise to make sure air is going into lungs Don’t try to rush or blow too forcefully Don’t take big breath to exhale more air; take a normal breath Give each breath over about 1 second

Skill: Rescue Breathing

Open the airway. Look, listen, and feel for adequate breathing for up to 10 seconds.

If not breathing adequately, give 2 breaths over 1 second each If not breathing adequately, give 2 breaths over 1 second each. Watch chest rise and fall.

If first breath doesn’t go in, open the airway and try again If first breath doesn’t go in, open the airway and try again. If it still does not go in, proceed to CPR for choking.

If first 2 breaths go in, check for pulse.

If pulse but no breathing, continue ventilations Recheck for a pulse about every 2 minutes

Assessing An Airway Obstruction Most cases in adults occur while eating Most cases in infants and children occur while eating/playing

Mild Obstruction Victim is coughing forcefully Victim is getting some air Wheezing or high pitched sounds with breath Do not interrupt coughing or attempts to expel object

Severe Obstruction Victim getting little air or none Victim may have pale or bluish coloring around mouth and nail beds Victim may be coughing weakly and silently or not at all Victim cannot speak

Severe Foreign Body Airway Obstruction (Responsive Adult or Child) Skill: Severe Foreign Body Airway Obstruction (Responsive Adult or Child)

One leg between victim’s legs. Stand behind victim. One leg between victim’s legs. Head to one side.

Make fist with one hand – thumb side in to victim’s abdomen

Grasp fist with other hand. Thrust inward and upward.

For pregnant victim or victim you can’t get arms around, give chest thrusts. 5

Responsive Choking Infant Who Cannot Cry/Cough Give alternating back slaps/chest thrusts to expel object If Choking Infant Becomes Unresponsive Give CPR, start with chest compressions Check for object in mouth, remove any object you see

Severe Foreign Body Airway Obstruction (Responsive Infant) Skill: Severe Foreign Body Airway Obstruction (Responsive Infant)

Give up to 5 back slaps between shoulder blades

Roll infant face up.

Check for expelled object. If not present, continue with next step.

Give 5 chest thrusts. Check mouth for expelled object. Repeat back slaps and chest thrusts as necessary. Un07_10

Rapid Sequence Endotracheal Intubation 1.Prepair for surgical aiway. 2.Preoxigenation with 100./. O2. 3.Apply cricoid pressure at cricoid cartilage “below thyroid cartilage "or below Adam's apple. 4.Adminster a sedative drug “Midazolam 2-3 mg i.v”. 5.Adminster “1-2 mg/kg succinylcholine i.v . 6.Intubate the patient with orotracheal tube. 7.Inflate the cuff and confirm tube placement by.. auscultation the chest or by capneogragh ”presence of CO2 in exhaled air” 8.Release cricoid pressure. 9.Ventilate the patient.

Indications of Endotracheal Intubation 1. when pt can not protect their airway ( coma, resp. and cardiac arrest). 2. In patient with upper airway compromise 3. In unresponsie patient who lack a gag reflex 4. when there is airway obstruction caused by foreign body, trauma, anaphylaxis 5. when prolonged artificial respiration is needed 6. effective root for administration of medications (epinephrine, atropine, lidocaine, vasopressin)

Laryngeal Mask Airway (LMA)

Stylet Plastic-coated wire may be inserted in the ET tube to add rigidity and shape to the tube. Bend the tip of the stylet to form a gentle curve in adults. Bend the tip of the stylet to form a hockey stick shape for an infant and child. Confirm that the stylet is not sticking out past the end of the ET tube.

Intubation Complications Intubating the right main stem bronchus Intubating the esophagus Aggravating spinal injuries Taking too long to ventilate Patient vomiting Soft-tissue trauma Mechanical failure Patient intolerant of the ET tube Decrease in heart rate

Laryngoscope Sweeps the tongue out of the way and aligns the airway Has a light powered by batteries in handle Has blades that connect to handle Blades are curved or straight. They range in size from 0 to 4.

Curved Blade

Straight Blade

Cricothyroidectomy absolute need for a definitive airway unable to perform ETT due for structural or anatomic reasons, unable to clear an upper airway obstruction multiple unsuccessful attempts at ETT

Surgical Cricothyrotomy Can't intubate Can't ventilate Severe facial or nasal injuries (that do not allow oral or nasal tracheal intubation) Massive midfacial trauma Possible cervical spine trauma preventing adequate ventilation Anaphylaxis Chemical inhalation injuries foreign body, angioedema

Contraindications (relative) Age < 10 years evidence of tracheal transection

سوپاس بۆ ئەو کاتەی پێتان بەخشین پرسیارکردن مافی خۆتە ؟؟؟؟؟؟؟؟؟؟؟؟؟؟؟؟ Dr. Sarwar Arif Star E Mail: sarwararif@yahoo.com Sarwar.starr@univsul.edu.iq Mobile no.: 0770 152 17 85 face book: Sarwar Arif