Unit 1: Airway Management

Unit 1: Airway Management
Lesson 1: Airway Assessment

Standard 13) Demonstrate concepts and skills of the following in a clinical/lab setting: a. Patient Positioning b. Transfers and Ambulation (including injury prevention and body mechanics) c. O2 Assessment and Administration (including fire safety) d. BLS (Basic Life Support) 11) Outline the gross normal structure and function of all body systems and summarize appropriate medical text(s) in order to relate signs and symptoms of common diseases and disorders associated with each. c. cardiovascular and respiratory systems

Lesson 1 – Airway Assessment
Importance of Airway Assessment First item to be assessed Apnea – patient cannot breathe Patent – open Importance of Airway Assessment In all emergency situations, the first item that must be assessed is the airway. If a patient cannot breathe, a condition known as apnea, all other life saving procedures are meaningless because the human body can only survive for a short period of time without oxygen. No matter what the patient condition, the airway must remain patent, or open.

The Respiratory System Bring oxygen into the body Remove carbon dioxide Ventilation, respiration, oxygenation Primary organ is the lungs The Respiratory System Before you learn how to assess and manage a patient's airway, it is important to understand the key structures of the airway and to review how the respiratory system works. The primary function of the respiratory system is to bring oxygen into the body and to remove carbon dioxide. Without this systematic exchange of gases, the body cannot survive. The respiratory system uses three key processes to ensure that the exchange of oxygen and carbon dioxide takes place: ventilation, respiration, and oxygenation. The primary organ of the respiratory system is the lungs. The respiratory system also includes several other structures that form the passages by which air is brought into the body and down to the lungs.

Use senses of sight, sound and touch Two areas of assessment Evaluate patient’s airway Evaluate patient’s ability to breathe Airway Assessment The key to assessing the airway is to use your sense of sight, sound, and touch to make sure that air is moving in and out of the patient's airway. The two areas of airway assessment include: Evaluating the patient's airway Evaluating the patient's ability to breathe

Evaluate the Airway Physically examine patient’s mouth and throat Clear the airway of obstructions Foreign body airway obstruction (FBAO) Something within the body Evaluate the Airway When EMS professionals evaluate a patient's airway, they must physically examine the patient's mouth and throat and clear the airway of any obstructions. The obstruction may be a foreign body airway obstruction (FBAO), which includes food or small items that were swallowed accidently. Or the obstruction may be caused by something within the body, such as the tongue or swollen body tissue as well as body fluids like blood, saliva, or vomit. Foreign body obstructions are typically cleared by using the finger sweep technique or a series of abdominal thrusts, also known as the Heimlich maneuver. Blockages that are caused by fluids are often cleared by using suctioning. Swollen tissue as well as a blockage caused by the tongue in the airway may require the use of airway adjuncts. You will learn about suctioning and airway adjuncts later in this unit.

Evaluate the Airway (continued) Clear FBAO Finger sweep Abdominal thrusts (Heimlich maneuver) Clear blockages by: Suctioning (fluids) Airway adjuncts (swollen tissue) Evaluate the Airway When EMS professionals evaluate a patient's airway, they must physically examine the patient's mouth and throat and clear the airway of any obstructions. The obstruction may be a foreign body airway obstruction (FBAO), which includes food or small items that were swallowed accidently. Or the obstruction may be caused by something within the body, such as the tongue or swollen body tissue as well as body fluids like blood, saliva, or vomit. Foreign body obstructions are typically cleared by using the finger sweep technique or a series of abdominal thrusts, also known as the Heimlich maneuver. Blockages that are caused by fluids are often cleared by using suctioning. Swollen tissue as well as a blockage caused by the tongue in the airway may require the use of airway adjuncts. You will learn about suctioning and airway adjuncts later in this unit.

Abnormal Airway Sounds Use sense of hearing to identify airway obstructions Sounds indicating airway obstruction: Snoring Stridor Wheezing Gurgling Crowing Rales Abnormal Airway Sounds Emergency providers can also use their sense of hearing to identify airway obstructions. If the patient is conscious, emergency workers should evaluate the patient's ability to breathe and talk. If breathing is noisy and talking is labored or forced, it is likely that the airway is at least partially blocked. The following sounds may also indicate that the airway is obstructed: Snoring is caused when the upper airway is blocked by the tongue or by relaxed tissue in the pharynx. Stridor is a high-pitched sound that occurs during inhalation. It is usually caused by an obstruction or swelling in the larynx. Wheezing is a whistling sound that is created as a result of obstruction or swelling in the lower airway. Gurgling typically indicates the presence of blood, vomit, or other liquids in the airway. Crowing is a bird-like "caw" that occurs as a result of muscle spasms and narrowing the opening of the trachea. Rales is a fine crackling sound that occurs during inhalation. It usually indicates the presence of fluid in the alveoli.

Evaluate Breathing Look Chest rising? Normal skin color? Listen Hear air entering and exiting nose & mouth? Free from abnormal or labored sounds? Feel Patent airway Evaluate Breathing When emergency providers check a patient's ability to breathe, they must determine whether or not air is entering and exiting the patient's airway. To do this, emergency workers must look, listen, and feel for signs for breathing. Look: Do both sides of the patient's chest rise equally during inhalation? Is skin color normal? Listen: Do you hear air entering and exiting the nose and mouth? Is the breathing free from abnormal or labored sounds? Feel: Can you feel air exiting the patient's nose or mouth? Answering no to any of these questions indicates that the patient is not breathing adequately or not breathing at all. Action must be taken immediately to open and maintain a patent airway.

Lesson 2: Opening the Airway

Lesson 2 – Opening the Airway
Open Airway Immediately Manual methods Head-tilt, chin-lift maneuver Jaw-thrust maneuver Airway adjuncts or suctioning may be needed Airway adjuncts Opening the Airway After an EMS professional determines that a patient's airway is closed, immediate action must be taken to open it. The airway can be opened manually, but the use of airway adjuncts or suctioning may also be needed. Typically, emergency providers will try manual methods first. Two manual methods include the head-tilt, chin-lift maneuver and the jaw-thrust maneuver. The head-tilt, chin-lift maneuver is the most common and effective procedure, but it should not be used on patients with suspected neck or spinal injuries. In the case of a suspected neck or spinal injury, use the jaw-thrust maneuver.

Head-Tilt, Chin-Lift Maneuver Most effective means of opening airway Useful when airway blocked by tongue Use for patients who are: Apneic Unresponsive Unable to maintain own airway Head-Tilt, Chin-Lift Maneuver The head-tilt, chin-lift maneuver is the most effective means of opening a patient's airway. It is especially useful when the airway is blocked by the tongue, which often occurs in unconscious patients. The head-tilt, chin-lift maneuver should be used on patients who are apneic, unresponsive, or those who are in a decreased state of consciousness and are unable to maintain their own airway. After this maneuver is performed, it is possible that suctioning will be needed to remove fluids from the airway. In addition, airway adjuncts may be used to keep the airway open. The head-tilt, chin lift maneuver should never be used on patients with suspected neck or head injuries. It should be avoided on elderly patients who may have arthritis in the neck or kyphosis. In addition, special consideration should be made for pediatric patients. Children have proportionally smaller structures in the airway. Because of this, a folded towel or pad should be placed under the child's shoulders to prevent the airway from being pinched when the neck is extended.

Head-Tilt, Chin-Lift Maneuver (continued) Do not use on patients with head/neck injuries Avoid use on elderly Special consideration for pediatric patients Head-Tilt, Chin-Lift Maneuver The head-tilt, chin-lift maneuver is the most effective means of opening a patient's airway. It is especially useful when the airway is blocked by the tongue, which often occurs in unconscious patients. The head-tilt, chin-lift maneuver should be used on patients who are apneic, unresponsive, or those who are in a decreased state of consciousness and are unable to maintain their own airway. After this maneuver is performed, it is possible that suctioning will be needed to remove fluids from the airway. In addition, airway adjuncts may be used to keep the airway open. The head-tilt, chin lift maneuver should never be used on patients with suspected neck or head injuries. It should be avoided on elderly patients who may have arthritis in the neck or kyphosis. In addition, special consideration should be made for pediatric patients. Children have proportionally smaller structures in the airway. Because of this, a folded towel or pad should be placed under the child's shoulders to prevent the airway from being pinched when the neck is extended.

Jaw-Thrust Maneuver Used when head/neck injury suspected Not as effective as head-tilt, chin-lift Use on patients who are: Apneic Unresponsive Unable to maintain airway Jaw-Thrust Maneuver The jaw-thrust maneuver is used to open the airway of patients who are suspected of having a neck or head injury. In these situations, the patient's neck must be kept in a straight, neutral position to avoid further injury. The jaw-thrust maneuver helps to remove the tongue from blocking the patient's airway; although it is not as effective as the head-tilt, chin-lift maneuver. Like the head-tilt, chin-lift maneuver, the jaw-thrust maneuver should be used on patients who are apneic, unresponsive, or unable to maintain their own airway. This maneuver may cause fluid to drain into the airway, so suctioning may be needed. In addition, airway adjuncts may be used to keep the airway open.

Lesson 3: Suctioning the Upper Airway

Lesson 3 – Suctioning the Upper Airway
Removes fluids and small objects Manual or mechanical device Should be performed when: Gurgling sounds are heard in airway Visible fluid is seen in airway Suctioning After a patient's airway has been assessed, suctioning may be required to clear the airway of fluids and other materials. Suctioning is the use of a mechanical or manual device to create a vacuum that removes fluid, vomit, blood, and small objects from a patient's airway. Suctioning should be performed in the following situations: When gurgling sounds are heard in the patient's airway When visible fluid is seen in the patient's airway If larger objects are seen in the airway, the foreign bodies should be removed by using finger sweeps and abdominal thrusts.

Suctioning Devices All devices consist of: Tubing Catheter or tip Collection container Suction source Two categories Mounted suctioning units Portable suctioning units Suctioning Devices All suctioning devices contain similar features. They all consist of tubing, a catheter or tip, a collection container, and a suction source. There are many styles available, but most suctioning devices can be classified into two categories: Mounted suctioning units are permanently installed inside an ambulance for use during transport. They typically have an airflow rate of 30 to 40 LPM (liters per minute) and can create a vacuum of 300 mmHg (millimeters of mercury). Portable suctioning units can be battery-, electric-, oxygen-, or hand-powered. Because they are portable, they can be used on the scene of the emergency. Portable units must provide equal suctioning power to that of a mounted unit, so emergency providers must check the strength and power-source of each unit at the beginning of every shift.

Portable Suctioning Units Mechanical Battery Electricity Oxygen Removes watery liquids Manual Hand-powered Removes larger chunks Mechanical and Manual Suctioning Units Portable suctioning units can be mechanical or manual. Mechanical devices are those that are powered by battery, electricity, or oxygen. Manual devices are hand-powered. Both types are valuable, but they do have differences. Manual devices must be pumped by hand during use. This may be tiring for the emergency provider. However, the manual devices are often more effective at removing larger chunks of material, while the mechanical units are more effective at removing fine watery liquids.

Suction Catheter Placed into patient’s mouth or nose Two primary types: Rigid Non-flexible plastic Straight or curved Soft Soft, flexible plastic tubing Generally used through nose Suction Catheters A suction catheter is the part of the suctioning device that is placed into the patient's mouth or nose to draw out the blockage from the airway. The two primary types of catheters are rigid and soft. Rigid catheters are also called tonsil-tip, tonsil sucker, or Yankauer catheters. They are made of nonflexible plastic and may be straight or curved. They are generally used only to suction the mouth and oropharynx. They should not be inserted farther than you can see, which is usually no further than the back of the tongue. The rigid catheter should not touch the back of the throat, as this may cause gagging or vomiting. Soft catheters are also called French catheters. They are made of soft, flexible plastic tubing. They are generally used for suctioning through the nose and nasopharynx. Before inserting a soft catheter, the tubing should be measured from the tip of the patient's nose to the earlobe. The catheter should not be inserted further than this point, as this may causing gagging or vomiting.

Suctioning Precautions Infection control Face masks/HEPA mask, eyewear, gloves Vacuum strength Adult Pediatric Ventilation Monitor pulse Suctioning Precautions Emergency providers must use extreme caution during suctioning procedures. The following precautions should always be used. Always use infection control precautions during suctioning. Because suctioning involves a patient's bodily fluids, emergency providers must wear protective face masks, eyewear, and gloves. If the patient has tuberculosis or shows signs of tuberculosis, a HEPA mask should be worn. For adult patients, suctioning should be done with a vacuum of at least 300 mmHg. This should be cut in half for pediatric patients. Test the suctioning device before using it. Ventilation is important during suctioning. The suctioning causes the residual air in the dead space of the lungs to be removed. Therefore, it is important to replace this oxygen as soon as possible. Emergency providers should suction the patient for no more than15 seconds at a time, artificially ventilate for 2 minutes, and then repeat the cycle. Because of reduced levels of oxygen in the blood, the patient's heart rate may drop during suctioning. Always monitor the patient's pulse. If it drops too low, especially in pediatrics, stop suctioning and focus on ventilation instead. If the patient has no pulse, begin chest compressions.

Lesson 4: Airway Adjuncts

Lesson 4 – Airway Adjuncts
Airway adjunct is device used to maintain a patent airway Two primary types: Oropharyngeal airway – inserted through mouth Nasopharyngeal airway – inserted through nose Airway Adjuncts After a patient's airway has been opened manually, there is a chance that the tongue will relax and fall back into the airway. Because of this, it is often necessary to use airway adjuncts to maintain a patent airway in an unconscious patient. An airway adjunct is a device that keeps the airway open. Airway adjuncts are frequently used to maintain an airway during artificial ventilation. The primary types of airway adjuncts are the oropharyngeal airway, which is inserted through the mouth, and the nasopharyngeal airway, which is inserted through the nose. Both types extend from the opening of the airway and into the pharynx.

Gag Reflex May be stimulated by oropharyngeal airway insertion May cause patient to retch or vomit Usually not present if patient unconscious Gag Reflex Oropharyngeal airways are inserted through the mouth. They extend past the tongue and into the pharynx. Inserting this device may stimulate a patient's gag reflex. When stimulated, the gag reflex may cause a patient to retch or vomit. If a patient begins to retch or vomit while an oropharyngeal airway is being inserted, the airway should be removed and the mouth should immediately be suctioned. Then, a nasopharyngeal airway may be attempted. When patients are unconscious, the gag reflex usually disappears. However, as a patient begins to regain consciousness, the gag reflex may return. So an oropharyngeal airway that is already in place may need to be removed if the patient begins to retch or vomit. Emergency providers must monitor patients carefully when airway adjuncts are used.

Oropharyngeal Airways Hook-shaped, hard plastic Various sizes Inserted in mouth to keep tongue from blocking airway Oropharyngeal Airways Oropharyngeal airways are hook-shaped devices that are usually made of hard plastic. They are available in various sizes. These devices are inserted into the patient's mouth to prevent the tongue from blocking the air passages. Oropharyngeal airways should be inserted with great care. EMS professionals should follow these guidelines when using the devices. Never insert the device into a patient who demonstrates a gag reflex. Before inserting the device, open the patient's airway manually through the head-tilt, chin-lift maneuver or the jaw-thrust maneuver. The airway must remain in this position while the device is in place. Do not insert the device until after the airway has been cleared of obstructions. If the device is inserted before the airway is cleared, the obstruction will be pushed further into the airway. When inserting the device, be careful not to push the patient's tongue backward into the pharynx. The device does not protect a patient from secretions into the airway, so be prepared to suction while the device is in place.

Oropharyngeal Airways (continued) Guidelines for use Never use if gag reflex present Open airway first Make sure airway cleared of obstructions Don’t push tongue into pharynx Be prepared to suction Oropharyngeal Airways Oropharyngeal airways are hook-shaped devices that are usually made of hard plastic. They are available in various sizes. These devices are inserted into the patient's mouth to prevent the tongue from blocking the air passages. Oropharyngeal airways should be inserted with great care. EMS professionals should follow these guidelines when using the devices. Never insert the device into a patient who demonstrates a gag reflex. Before inserting the device, open the patient's airway manually through the head-tilt, chin-lift maneuver or the jaw-thrust maneuver. The airway must remain in this position while the device is in place. Do not insert the device until after the airway has been cleared of obstructions. If the device is inserted before the airway is cleared, the obstruction will be pushed further into the airway. When inserting the device, be careful not to push the patient's tongue backward into the pharynx. The device does not protect a patient from secretions into the airway, so be prepared to suction while the device is in place.

Alternative Methods for Oropharyngeal Airways Insert airway sideways then rotate 90 degrees Use tongue blade to depress tongue & insert right-side up Alternative Methods for Oropharyngeal Airways There are two alternative methods for inserting oropharyngeal airways. The first alternative is to insert the airway sideways into the mouth. Then, rotate it 90° so that the tip is resting behind the tongue and pointing downward into the pharynx. The second alternative is to use a tongue blade to depress the tongue while inserting the airway. The airway should be inserted right-side-up so that rotating the airway is not needed. This method is recommended for children.

Nasopharyngeal Airways Flexible tubing Inserted into nostril through nasopharynx Secondary choice useful for patients with: Gag reflex Trauma to jaw Clenched jaw Convulsions Nasopharyngeal Airways Nasopharyngeal airways are another type of airway adjunct. They are made of flexible tubing which is inserted into the patient's nostril and through the nasopharynx. The tubing should not touch the patient's throat, so the gag reflex will not be stimulated. The nasopharyngeal airway should be a secondary choice to the oropharyngeal airway since it is less effective at preventing the tongue from blocking the airway. However, nasopharyngeal airways are useful for patients who have: A gag reflex Trauma to the jaw A clenched jaw Convulsions Nasopharyngeal airways should be inserted with great care. EMS professionals should follow these guidelines when using the devices. Nasopharyngeal airways should never be used for patients with a suspected skull fracture, nasal injury, and any type of facial trauma. Before inserting the device, open the patient's airway manually through the head-tilt, chin-lift maneuver or the jaw-thrust maneuver. The airway must remain in this position while the device is in place. The device does not protect a patient from secretions into the airway, so be prepared to suction while the device is in place.

Nasopharyngeal Airways (continued) Guidelines for use: Never use on patients with skull fracture, nasal injury, facial trauma Open airway manually first Be prepared to suction Nasopharyngeal Airways Nasopharyngeal airways are another type of airway adjunct. They are made of flexible tubing which is inserted into the patient's nostril and through the nasopharynx. The tubing should not touch the patient's throat, so the gag reflex will not be stimulated. The nasopharyngeal airway should be a secondary choice to the oropharyngeal airway since it is less effective at preventing the tongue from blocking the airway. However, nasopharyngeal airways are useful for patients who have: A gag reflex Trauma to the jaw A clenched jaw Convulsions Nasopharyngeal airways should be inserted with great care. EMS professionals should follow these guidelines when using the devices. Nasopharyngeal airways should never be used for patients with a suspected skull fracture, nasal injury, and any type of facial trauma. Before inserting the device, open the patient's airway manually through the head-tilt, chin-lift maneuver or the jaw-thrust maneuver. The airway must remain in this position while the device is in place. The device does not protect a patient from secretions into the airway, so be prepared to suction while the device is in place.

Unit 1: Airway Management

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