Siloam Hospitals EMT-Basic’s Airway Management

Airway Anatomy Review

Airway Function Passage that allows air to move from atmosphere to alveoli Must remain patent (open) at all times Anything that blocks airway will cause decrease in oxygen available to body Size of obstruction affects available air exchange

Adequate Breathing Normal Rate Regular Rhythm Adequate Quality Adult: 12 to 20/minute Child: 15 to 30/minute Infant: 25 to 50/minute Regular Rhythm Adequate Quality Movement of air at mouth, nose Chest expansion adequate, symmetrical (equal) Breath sounds present, equal Minimum effort of breathing Adequate tidal volume (depth)

Inadequate Breathing Abnormal Rate Irregular Rhythm Inadequate Quality Adult: <12 to >20/minute Child: <15 to >30/minute Infant: <25 to >50/minute Irregular Rhythm Inadequate Quality Absent or reduced at mouth, nose Dyspnea (shortness of breath) Chest expansion inadequate or asymmetrical (unequal) Breath sounds diminished, unequal, noisy, absent Increased effort of breathing, use of accessory muscles Inadequate (shallow) tidal volume Noisy respirations

Oxygen Supply Oxygen cylinder sizes Contents under pressure D cylinder 350 liters E cylinder 625 liters M cylinder 3,000 liters G cylinder 5,300 liters H cylinder 6,900 liters Contents under pressure Should be positioned to prevent falling, blows to valve-gauge assembly

Oxygen Supply Operating procedures Remove protective seal Quickly open, then shut valve Check if tank is full, or has adeqaute amount of oxygen/pressure for trip. Make sure back-up is available Attach regulator-flow meter to tank Select proper size of oxygen mask for patient Attach oxygen mask to flow-meter Open flow-meter to desired setting Apply device to patient When complete, remove device from patient, turn off device, remove all pressure from regulator

Oxygen Concerns about giving too much oxygen to patients with COPD, infants, and children are NOT valid during short-term emergency administration Patients with COPD, infants, and children who require oxygen should be given high concentration oxygen

Oxygen Delivery Devices Non-rebreather mask (NRB mask) Preferred method of giving oxygen to prehospital patients Up to 90% oxygen can be delivered Non-rebreather bag must be full before mask is placed on patient Flow rate should be adjusted so when patient inhales, bag does not collapse (~15 lpm)

Oxygen Delivery Devices Nasal cannula Rarely best method for giving adequate oxygen in emergency care settings Should be used only if patient will not tolerate non-rebreather mask in spite of coaching Usually use 6 lpm or less oxygen flow

Opening the Airway Techniques Head-tilt/Chin-lift Jaw Thrust Suctioning Nasopharyngeal airway (through nose) Oropharyngeal airway (through mouth)

Head-Tilt/Chin-Lift Used when no neck injury is suspected Temporary procedure Must be replaced with an airway adjunct unless patient begins adequate spontaneous ventilation Technique Place one hand on patient’s forehead Apply firm, backward pressure with palm causing head to tilt backward Place fingers of other hand under bony part of patient’s lower jaw near chin Lift jaw upward to bring chin forward

Head-Tilt/Chin-Lift Patients needing head-tilt/chin-lift Unresponsive patient without history of trauma Cardiac arrest patients without signs of trauma Apneic patients without signs of trauma

Jaw Thrust Used when spinal injury suspected Temporary procedure Must be replaced with airway adjunct unless patient begins adequate spontaneous ventilation Technique Place one hand on either side of patient’s head, resting elbows on surface on which victim is lying Grasp angles of patient’s lower jaw, lift with both hands If patient’s lips close, retract lower lips with thumbs

Jaw Thrust Patients needing jaw thrust Unresponsive trauma patient Unresponsive patient with undetermined mechanism of injury

Suctioning Purpose Suction devices Remove blood, vomit, other liquids, food particles from airway May not be adequate for removing large, solid objects (teeth, foreign bodies, food) Should be performed immediately when gurgling is heard with spontaneous or artificial ventilation Suction devices Mounted in ambulance Portable Electrical Hand operated Should generate 300mm Hg vacuum Ensure batteries in units remain properly charged

Suctioning Techniques Turn on unit Attach catheter Insert catheter into oral cavity without suction Insert only to base of tongue Apply suction, move catheter from side to side Suction no longer than 15 seconds in adults, 10 seconds in children, 5 seconds in infants Rinse catheter with saline or water to prevent obstruction

Suctioning Catheters Rigid Suction Catheter Used to suction mouth, oropharynx (back of throat) of unresponsive patient Inserted only as far as you can see Take caution not to touch back of airway, particularly in infants and children (can cause heart rate to drop)

Suctioning Catheters Soft Suction Catheter Useful for suctioning nasopharynx (through nose) or tracheostomy tubes Should be inserted only as far as base of tongue or end of tracheostomy tube

Nasopharyngeal Airway Used on responsive patients who need help keeping tongue out of airway Insertion is uncomfortable for responsive patients sometimes When inserting, aim towards back of head, not up towards top of nose Patients needing nasal airway Unresponsive patients who are snoring Unresponsive patients with gag reflex

Nasopharyngeal Airway Technique Measure from tip of nose to earlobe Ensure airway will fit through nostril Lubricate with water-soluble lubricant Insert with bevel toward base of nostril or septum If resistance is met, try other nostril Do not use in patients with mid-face trauma or possible basilar skull fractures

Oropharyngeal Airway Used on unresponsive patients without gag reflex Helps hold tongue away from back of throat Patients needing oral airway Unresponsive, apneic patients (no breathing) with or without trauma Any apneic patient being ventilated with a BVM (bag valve mask)

Oropharyngeal Airway Technique Measure from corner of mouth to earlobe or angle of jaw Open patient’s mouth In adults insert with tip facing roof of patient’s mouth, advance until resistance encountered, turn 180o until flange comes to rest on patient’s teeth Or in adults can try and insert right side up, being careful not to push the tongue back, often easier with a jaw thrust In infants and children use tongue depressor to lift tongue, insert oral airway right side up

Airway Limitations Nasal/oral airways are not definitive devices Manual maneuvers must be used with nasal/oral airways to ensure airway stays open Patients may require frequent suctioning to remove blood, vomit, other secretions from airway Definitive devices such as endotracheal tubes are required to completely protect the airway

Ventilation Techniques Mouth-to-mask with supplemental oxygen Two-person bag-valve mask with oxygen reservoir and supplemental oxygen Flow restricted, oxygen-powered ventilation device (manually-triggered ventilator) One-person bag-valve mask with oxygen reservoir and supplemental oxygen

Ventilation Techniques Mouth-to-Mask Connect mask to oxygen at 15 liters per minute Kneel directly above patient’s head Apply mask to patient’s face Place thumbs along sides of mask, index fingers of both hands under patient’s mandible Lift jaw into mask, tilt head if neck injury not suspected Blow into one-way valve slowly over 2 seconds until patient’s chest rises

Ventilation Techniques Bag-valve mask (BVM) Self-inflating bag One-way valve Face mask Oxygen reservoir Must be connected to oxygen to perform most effectively

Ventilation Techniques Bag Valve Mask Issues Provides less volume than mouth-to-mask Single rescuer may have difficulty maintaining air-tight seal Two rescuers using device are more effective Position yourself at top of patient’s head for best performance Oral or nasal airway should be inserted

Ventilation Techniques BVM Technique (Two Rescuer) Open airway, insert oral or nasal airway Position thumbs over top half of mask, index and middle fingers over bottom half Place apex of mask over bridge of nose, lower mask over mouth/upper chin Use ring and little fingers to bring jaw up to mask Have assistant squeeze bag with two hands until chest rises Ventilate every 5 seconds for adults, every 3 seconds for infants and children

Ventilation Techniques BVM Technique (One Rescuer) Open airway, insert oral or nasal airway Form a “C” around ventilation port with thumb, index finger Use middle, ring, little fingers under jaw to maintain chin lift, complete seal Squeeze bag with other hand until chest rises Ventilate every 5 seconds for adults, every 3 seconds for infants and children

Ventilation Techniques BVM Technique (Suspected Trauma) Open airway, insert oral or nasal airway Have assistant hold patient’s head or use your knees to prevent movement Position thumbs over top half of mask, index and middle fingers over bottom half Place apex of mask over bridge of nose, lower mask over mouth/upper chin Use ring and little fingers to bring jaw up to mask without tilting head or neck Have assistant squeeze bag with two hands until chest rises Ventilate every 5 seconds for adults, every 3 seconds for infants and children continue to hold jaw up without moving head or neck

Ventilation Techniques If chest does not rise, reevaluate If abdomen rises, reposition head or jaw If air escapes under mask, reposition fingers and mask Check for obstruction If chest still does not rise and fall use another method of ventilation

Ventilation Techniques Flow Restricted, Oxygen-Powered Ventilation Devices (Manually-Triggered Ventilator) Peak flow of 100% oxygen at maximum of 40 lpm Pressure relief valve that opens at 60 cm H2O Audible alarm that sounds when relief valve pressure is exceeded Trigger so both hands remain on mask to maintain seal Do NOT use on children or infants!!!

Ventilation Techniques Manually-Triggered Ventilator Open airway, insert oral or nasal airway Position thumbs over top half of mask, index/middle fingers over bottom half Place apex of mask over bridge of nose, lower mask over mouth and chin Use ring/little fingers to bring jaw up to mask Trigger device until chest rises Repeat every 5 seconds

Ventilation Techniques Manually-Triggered Ventilator (Suspected Trauma) Open airway, insert oral or nasal airway Have assistant hold head manually or use knees to prevent movement Position thumbs over top half of mask, index/middle fingers over bottom half Place apex of mask over bridge of nose, lower mask over mouth and chin Use ring/little fingers to bring jaw up to mask without tilting head and neck Trigger device until chest rises Repeat every 5 seconds

Assisting Patients Who are Breathing Who needs assistance? A patient who is not breathing A patient who has reduced respiratory rate and tidal volume A patient whose breathing rate is increased, but whose tidal volume is inadequate

Assisting Patients Who are Breathing Patients with rapid, shallow breathing Explain procedure to patient Place mask over patient’s mouth and nose Initially assist ventilations at rate at which patient is breathing. Squeeze bag as patient inhales Slowly adjust rate and tidal volume until adequate ventilations are achieved Patients with slow, shallow breathing Place bag over patient’s mouth and nose Squeeze bag each time patient inhales Adjust rate and tidal volume until adequate ventilations are achieved

Special Considerations Stoma or tracheostomy tube Attach BVM to tube, or use infant/child mask to make seal over stoma Seal mouth/nose if air is escaping when ventilating at stoma If unable to ventilate Suction stoma or tracheostomy tube then seal stoma, attempt to ventilate through mouth/nose Infants and children Place infant’s head in neutral position Extend child’s head slightly past neutral Avoid excessive hyperextension Avoid excessive ventilation, just make chest rise Gastric distension is more common in children Do not use BVMs with pop-off valves

Special Considerations Dentures Leave in place unless obviously loose Remove if loose Be prepared to remove if displacement occurs