Download Bledsoe_V1_ch13

Chapter 13
Airway Management
and Ventilation
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Airway management
and ventilation are the first and
most critical steps in the
initial assessment of every
patient you will encounter.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
Anatomy of the Respiratory System
Physiology of the Respiratory System
Respiratory Problems
Respiratory System Assessment
Airway Management
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy of the
Respiratory System
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The respiratory system
provides a passage for oxygen
to enter the body and for carbon
dioxide to exit the body.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy of the upper airway
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Upper Airway
Nasal cavity
Oral cavity
Pharynx
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pharynx
Nasopharynx
Oropharynx
Laryngopharynx
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Nasal Cavity
Maxillary bone
Frontal bone
Nasal bone
Ethmoid bone
Sphenoid bone
Septum
Sinuses
Eustachian tubes
Nasolacrimal ducts
Nares
Mucous
membranes
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Larynx
Thyroid cartilage
Cricoid cartilage
Glottic opening
Vocal cords
Arytenoid cartilage
Pyriform fossae
Cricothyroid cartilage
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Oral Cavity
Cheeks
Hard palate
Soft palate
Tongue
Gums
Teeth
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Internal anatomy of the upper airway
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Lower Airway Anatomy
Trachea
Bronchi
Alveoli
Lung parenchyma
Pleura
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy of the lower airway
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy of the pediatric airway
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy of the alveoli
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Physiology of the
Respiratory System
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction
Respiration is the exchange of gases
between a living organism and its
environment.
Ventilation is the mechanical process
that moves air into and out of the
lungs.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pulmonary circulation
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Diffusion of
gases across
an alveolar
membrane
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Measuring Oxygen and
Carbon Dioxide Levels
Partial pressure is the pressure
exerted by each component of a gas
mixture.
Partial pressure of a gas is its
percentage of the mixture’s total
pressure.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The Respiratory Cycle
Pulmonary ventilation depends
on pressure changes within the
thoracic cavity.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Normal Arterial Partial
Pressures
Oxygen (PaO2) =
100 torr (average = 80 – 100)
Carbon dioxide (PaCO2) =
40 torr (average = 35 – 45)
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Factors Affecting Oxygen
Concentration in the Blood
Decreased hemoglobin concentration.
Inadequate alveolar ventilation.
Decreased diffusion across the
pulmonary membrane when diffusion
distance increases or the pulmonary
membrane changes.
Ventilation/perfusion mismatch occurs
when a portion of the alveoli collapses.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Diffusion
Movement of a gas from an area of
higher concentration to an area of
lower concentration.
Diffusion transfers gases between the
lungs and the blood and between the
blood and peripheral tissues.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Factors Affecting Carbon Dioxide
Concentrations in the Blood (1 of 2)
Hyperventilation lowers CO2 levels due to
increased respiratory rates or deeper
respiration.
Causes of increased CO2 production
include:
–
–
–
–
Fever
Muscle exertion
Shivering
Metabolic processes resulting in the formation of
metabolic acids.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Factors Affecting Carbon Dioxide
Concentrations in the Blood (2 of 2)
Decreased CO2 elimination results
from decreased alveolar ventilation.
– Respiratory depression, airway
obstruction, respiratory muscle
impairment, obstructive diseases
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygen Concentration
in the Blood
Oxygen saturation =
O2 content/O2 capacity x 100%
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Regulation of Respiration
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Respiratory Rate
Involuntary; however, can be
voluntarily controlled.
Chemical and physical mechanisms
provide involuntary impulses to
correct any breathing irregularities.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Chemoreceptors
Located in carotid bodies, arch of the
aorta, and medulla.
Stimulated by decreased PaO2,
increased PaCO2, and decreased pH.
Cerebrospinal fluid (CSF) pH is
primary control of respiratory center
stimulation.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Nervous Impulses from the
Respiratory Center
Main respiratory center is the medulla.
Neurons within medulla initiate
impulses that produce respiration.
Apneustic center assumes respiratory
control if the medulla fails to initiate
impulses.
Pneumotaxic center controls
respiration.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hypoxic Drive
Hypoxemia is a profound stimulus
of respiration in a normal individual.
Hypoxic drive increases respiratory
stimulation in people with chronic
respiratory disease.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Stretch Receptors
The Hering-Breuer reflex
prevents over-expansion of the
lungs.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Normal Respiratory Rates
Age
Rate per
Minute
Adult
12–20
Children
18–24
Infants
40–60
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Respiratory Factors
Factor
Fever
Emotion
Pain
Hypoxia
Acidosis
Stimulants
Depressants
Sleep
Effect
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Dead Space Volume (VD)
Amount of gases in tidal volume
that remains in the airway.
Approximately 150 mL in adult male.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Total Lung Capacity (TLC)
Maximum lung capacity
Average adult male TLC—6 liters
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Alveolar Volume (Vmin)
Amount of gas moved in and out of
the respiratory tract in one minute
Vmin = VT x respiratory rate
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Tidal Volume (VT)
Average volume of gas inhaled
or exhaled in one respiratory cycle
Average adult male:
VT = 500 mL (5–7 cc/kg)
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Alveolar Minute Volume (VA-min)
Amount of gas that reaches the alveoli
for gas exchange in one minute
VA-min = (VT - VP) x respiratory rate
or
VA-min = VA x respiratory rate
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Inspiratory Reserve Volume (IRV)
The amount of air that can be
maximally inhaled after normal
inspiration
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Functional Residual Capacity
(FRC)
The volume of gas that remains in the
lungs at the end of normal expiration
FRC = ERV + RV
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Expiratory Reserve Volume
(ERV)
The amount of air that can be
maximally exhaled after a normal
expiration
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Forced Expiratory Volume
(FEV)
The amount of air that can be
maximally expired after maximum
inspiration
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Residual Volume
(RV)
The amount of air remaining in the
lungs at the end of maximal expiration
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Respiratory Problems
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Airway Obstruction
The tongue is the most common cause
of airway obstruction.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Inadequate minute volume
respirations can compromise
adequate oxygen intake and
carbon dioxide removal.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Other Causes of Airway
Obstruction
Foreign bodies
Trauma
Laryngeal spasm and edema
Aspiration
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Respiratory System
Assessment
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The tongue as an airway obstruction
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Initial Assessment
Is the airway patent?
Is breathing adequate?
Look, listen, and feel.
If patient is not breathing, open the
airway and assist ventilations as
necessary.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Look.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bag-valve-mask ventilation
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Listen.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Focused History
Onset
Symptom development
Associated symptoms
Past medical history
Recent history
Does anything make symptoms
better or worse?
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Feel.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Physical Examination
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Inspection
Skin color
Patient’s position
Dyspnea
Modified forms of respiration
Rate
Pattern
Mentation
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Auscultation
Listen at the mouth and nose for
adequate air movement.
Listen with a stethoscope for normal or
abnormal air movement.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abnormal Respiratory Patterns
(1 of 3)
Kussmaul’s respirations
– Deep, slow or rapid, gasping; common in
diabetic ketoacidosis.
Cheyne-Stokes respirations
– Progressively deeper, faster breathing
alternating gradually with shallow, slower
breathing, indicating brain stem injury.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abnormal Respiratory Patterns
(2 of 3)
Biot’s respirations
– Irregular pattern of rate and depth with
sudden, periodic episodes of apnea,
indicating increased intracranial
pressure.
Central neurogenic hyperventilation
– Deep, rapid respirations, indicating
increased intracranial pressure.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Abnormal Respiratory Patterns
(3 of 3)
Agonal respirations
– Shallow, slow, or infrequent breathing,
indicating brain anoxia.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Positions for auscultating
breath sounds
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Airway Sounds
Airflow
Compromise
Gas Exchange
Compromise
Snoring
Crackles
Gurgling
Rhonchi
Stridor
Wheezing
Quiet
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Palpation
Palpate chest wall for tenderness,
symmetry, abnormal motion, crepitus,
and subcutaneous emphysema.
Assess compliance of lungs.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Personal protective equipment
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Manual Airway Maneuvers
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Head-tilt/chin-lift
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Modified jaw-thrust in trauma
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Jaw-thrust maneuver
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Jaw-lift maneuver
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Airway before
applying Sellick’s
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Sellick’s maneuver
(cricoid pressure)
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Airway with Sellick’s applied (note
compression on the esophagus)
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Basic Mechanical Airways
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Nasopharyngeal airway, inserted
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Nasopharyngeal airway
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert oropharyngeal airway
with tip facing palate.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Rotate airway 180º into position.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Improper placement of
oropharyngeal airway
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Advanced Airway
Management
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal intubation
is clearly the preferred method
of advanced airway management in
prehospital emergency care.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal Intubation
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hyperventilate patient.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Laryngoscope blades
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Engaging laryngoscope
blade and handle
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Activating laryngoscope light source
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotrol ETT
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETT, stylet, and syringe,
unassembled
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETT, stylet, and syringe, assembled
for intubation
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETT and syringe
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal
Intubation Indicators
Respiratory or cardiac arrest
Unconsciousness
Risk of aspiration
Obstruction due to foreign bodies, trauma,
burns, or anaphylaxis
Respiratory extremis due to disease
Pneumothorax, hemothorax,
hemopneumothorax with respiratory
difficulty
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Advantages of
Endotracheal Intubation
Isolates trachea and permits
complete control of airway
Impedes gastric distention
Eliminates need to maintain a mask
seal
Offers direct route for suctioning
Permits administration of some
medications
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Disadvantages of
Endotracheal Intubation
Requires considerable training and
experience
Requires specialized equipment
Requires direct visualization of vocal
cords
Bypasses upper airway’s functions
of warming, filtering, and humidifying
the inhaled air
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Complications of
Endotracheal Intubation
Equipment malfunction
Teeth breakage and soft tissue
lacerations
Hypoxia
Esophageal intubation
Endobronchial intubation
Tension pneumothorax
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Prepare equipment.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Apply Sellick’s maneuver
and insert laryngoscope.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Placement of Macintosh
blade into vallecula
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Placement of Miller blade
under epiglottis
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Visualize larynx and
insert the ETT.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Inflate cuff, ventilate,
and auscultate.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Confirm placement with
an ETCO2 detector.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Esophageal detector device
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
If the bulb does not refill,
the tube is improperly placed.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
An esophageal intubation detector—
bulb style
Attach device to
endotracheal tube
and squeeze
the detector.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
If bulb refills easily upon release, it
indicates correct placement.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Secure tube.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Lighted stylet for
endotracheal intubation
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Glottis visualized
through laryngoscopy
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insertion of lighted stylet/ETT
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Lighted stylet/ETT in position
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Transillumination of a lighted stylet
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Digital Intubation (1 of 2)
Insert your
middle
and index
fingers
into patient’s
mouth.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Digital Intubation
(2 of 2)
Walk your fingers
and palpate the
patient’s epiglottis.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Blind orotracheal
intubation by digital method
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Digital intubation—insertion
of the ETT
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal Intubation with
In-line Stabilization
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hyperventilate patient and
apply c-spine stabilization.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Apply Sellick’s maneuver
and intubate.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilate patient
and confirm placement.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Secure ETT and
apply a cervical collar.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Reconfirm placement.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Rapid Sequence Intubation
A patient who needs intubation may be
awake. RSI paralyzes the patient to
facilitate endotracheal intubation.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Endotracheal Intubation
in a Child
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The Pediatric Airway
Smaller and more flexible than an
adult.
Tongue proportionately larger.
Epiglottis floppy and round.
Glottic opening higher and more
anterior.
Vocal cords slant upward, and are
closer to the base of the tongue.
Narrowest part is the cricoid cartilage.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETT size (mm) =
(Age in years + 16)
4
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hyperventilate the child.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Prepare the equipment.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert the laryngoscope.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert ETT and
ventilate the child.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Confirm placement
and secure ETT.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Reconfirm ETT placement.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilation of
Pediatric Patients
Mask seal can be more difficult.
Bag size depends on age of child.
Ventilate according to current standards.
Obtain chest rise and fall with each breath.
Assess adequacy of ventilations by
observing chest rise, listening to lung
sounds, and assessing clinical
improvement.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Nasotracheal intubation may be
useful in some situations:
Possible spinal injury
Clenched teeth
Fractured jaw, oral injuries, or recent
oral surgery
Facial or airway swelling
Obesity
Arthritis preventing sniffing position
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Blind nasotracheal intubation
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Other Intubation Devices
Esophageal Tracheal CombiTube (ETC)
Laryngeal mask airway (LMA)
Intubating Laryngeal Mask Airway (iLMA)
Cobra Perilaryngeal Airway (CobraPLA)
Ambu Laryngeal Mask (ALM)
Pharyngo-tracheal Lumen (PtL)
Esophageal Gastric Tube Airway (EGTA)
Esophageal Obturator Airway (EOA)
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETC airway—
esophageal placement
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
ETC airway—
tracheal placement
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Laryngeal mask airway
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Intubating laryngeal mask airway
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cobra perilaryngeal airway
Supralaryngeal device
designed to be
positioned in the
hypopharynx where it
abuts the structure of
the laryngeal inlet
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ambu laryngeal mask
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Continuously recheck
and reconfirm the placement of
the endotracheal tube.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pharyngo-tracheal
lumen airway
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Foreign body removal with direct
visualization and Magill forceps
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Magill forceps
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The only indication
for a surgical airway is
the inability to establish an
airway by any other method.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Direct visualization of the larynx with a
laryngoscope may enable the removal
of an obstructing foreign body.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomical landmarks
for cricothyrotomy
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Locate/palpate
cricothyroid membrane.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Proper positioning for
cricothyroid puncture
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Jet ventilation with
needle cricothyrotomy
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Advance the catheter
with the needle.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Open Cricothyrotomy
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Cannula properly
placed in trachea
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Locate cricothyroid membrane.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Stabilize larynx and make a 1–2 cm
skin incision over cricothyroid membrane.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Make a 1 cm horizontal incision
through the cricothyroid membrane.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Using a curved hemostat,
spread membrane incision open.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Insert an ETT (6.0)
or Shiley (6.0).
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Inflate the cuff.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Confirm placement.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilate.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Secure tube, reconfirm
placement, evaluate patient.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Tracheostomy cannulae
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patients with Stoma Sites
Patients who have had a laryngectomy
or tracheostomy breathe through a
stoma.
There are often problems with excess
secretions, and a stoma may
become plugged.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Suctioning
Anticipating complications when
managing an airway is the key for
successful outcomes.
– Be prepared to suction all airways to
remove blood or other secretions and for
the patient to vomit.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Suctioning Techniques
Wear protective eyewear, gloves, and
face mask.
Preoxygenate the patient.
Determine depth of catheter insertion.
With suction off, insert catheter.
Turn on suction and suction while
removing catheter (no more than
10 seconds).
Hyperventilate the patient.
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Tracheostomy suction technique
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygenation
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygen Supply and Regulators
To calculate how long an oxygen tank will last:
D cylinder tank life in minutes =
(tank pressure in psi × 0.16) ÷ liters per minute
E cylinder tank life in minutes =
(tank pressure in psi × 0.28) ÷ liters per minute
M cylinder tank life in minutes =
(tank pressure in psi × 1.56) ÷ liters per minute
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Oxygen Delivery Devices
Device
Oxygen
Percentage
Nasal cannula
40%
Venturi mask
24, 28, 35, or 40%
Simple face mask
40 – 60%
Nonrebreather mask
80 – 95%
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilation Methods
Mouth-to-mouth
Mouth-to-nose
Bag-valve device
Demand valve device
Automatic transport ventilator
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Bag-valve mask with
built-in colorimetric
ETCO2 detector
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Demand valve and mask
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Portable mechanical ventilator
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
Anatomy of the Respiratory System
Physiology of the Respiratory System
Respiratory Problems
Respiratory System Assessment
Airway Management
Bledsoe et al., Paramedic Care Principles & Practice Volume 1: Introduction
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ