1. Siloam Hospitals
EMT-Basic’s
Airway Management

2. Airway Anatomy Review

3. 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

4. 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)

5. 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

6. 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

7. 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

8. 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

9. 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)

10. 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

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

12. 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

13. 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

14. 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

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

16. 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

17. 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

18. 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)

19. 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

20. 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

21. 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

22. 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)

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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!!!

34. 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

35. 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

36. 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

37. 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

38. 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

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