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

2. 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

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

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

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

6. 6/30/2018
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7. Inhalation and Exhalation
Chest
wall
Diaphragm

8. 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

9. 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

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

11. 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

12. 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

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

14. Head-Tilt Chin-Lift Most effective
6/30/2018
Head-Tilt Chin-Lift
Most effective
Do not use for patients with suspected spinal trauma
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15. 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
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16. 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
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17. 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

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

19. 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
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20. 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.

21. 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!)
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22. 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)

23. NPA
May be tolerated by patient with intact gag reflex

24. 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
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25. NPA If it is not possible to pass NPA
Try inserting it into other naris
Select device of same length but smaller diameter

26. OPA Only use in patients with no gag reflex 6/30/2018
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27. 6/30/2018
Properly Sized Airway

28. Too long
Too short

29. 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

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

31. LMA Insertion
Click to play video

32. 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

33. Normal breathing is effortless
Look around…
Normal breathing is effortless

34. Check for breathing Look Listen Feel Unresponsive patient (5 - 10 sec)
6/30/2018
Check for breathing
Unresponsive patient
Look
Listen
Feel
( sec)
If not breathing, begin ventilations
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35. 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

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

37. 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!

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

39. Bag-Valve Mask (BVM)

40. 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

41. Cricoid Pressure Prevents gastric inflation and regurgitation
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42. 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.

43. 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.

44. 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.

45. 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!

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

47. 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

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

49. 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

50. 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

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

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

53. 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

54. 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

55. 6/30/2018
Are
You
Choking?

56. Encourage coughing Do not intervene Partial FBAO
6/30/2018
Partial FBAO
Confirm airway obstruction
Stay with patient
Encourage coughing
Do not intervene
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57. 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.

58. 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.

59. 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.

60. 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.

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

62. 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

63. Regulator and Flowmeter

64. 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.

65. Nasal Cannula Maximum flow rate 5 - 6 lpm Delivers 24 - 40% O2
Should NEVER be
used on
patient in
respiratory distress
Maximum flow rate lpm
Delivers % O2
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66. 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!

67. Questions?