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Chapter 15 Airway Management and Ventilation National EMS Education Standard Competencies Airway Management, Respiration, and Artificial Ventilation Integrates complex knowledge of anatomy, physiology, and pathophysiology into the assessment to develop and implement a treatment plan with the goal of ensuring a patent airway, adequate mechanical ventilation, and respiration for patients of all ages. National EMS Education Standard Competencies Airway Management • Airway anatomy • Airway assessment • Techniques of ensuring a patent airway National EMS Education Standard Competencies Respiration • Anatomy of the respiratory system • Physiology and pathophysiology of respiration − Pulmonary ventilation − Oxygenation − Respiration • External • Internal • Cellular National EMS Education Standard Competencies Respiration (cont’d) • Assessment and management of adequate and inadequate respiration • Supplemental oxygen therapy National EMS Education Standard Competencies Artificial Ventilation • Assessment and management of adequate and inadequate ventilation − Artificial ventilation − Minute ventilation − Alveolar ventilation − Effect of artificial ventilation on cardiac output Introduction • Establishing and maintaining a patent airway and ensuring effective oxygenation and ventilation are vital to patient care. − The human body needs a constant supply of oxygen. Introduction • Respiratory system − Brings in oxygen − Eliminates carbon dioxide • Vital organs will not function properly if process is interrupted. Introduction • Failure to manage the airway is a major cause of preventable death in the prehospital setting. − Understand the importance of: • Early detection of airway problems • Rapid and effective intervention • Continual reassessment Introduction • Appropriate airway management − Open, maintain patent airway − Recognize, treat obstructions − Assess ventilation, oxygenation status − Administer oxygen. − Provide ventilatory assistance. Anatomy of the Respiratory System • Consists of all structures in the body that make up the airway and help us breathe − Diaphragm − Intercostal muscles − Accessory muscles of breathing − Nerves from the brain and spinal cord to those muscles Anatomy of the Respiratory System Anatomy of the Upper Airway • Upper airway − Airway structures above the vocal chords • Larynx − Divides upper and lower airways • Pharynx − Extends from the nose and mouth to the esophagus and trachea • Nasopharynx • Oropharynx • Laryngopharynx Anatomy of the Upper Airway Nasopharynx • Receives air from the nose • Formed by the union of facial bones • Lined with a ciliated mucous membrane − Keeps contaminants out of the respiratory tract − In illness, additional mucus traps agents Nasopharynx • Divided into two passages by nasal septum − May be deviated • Numerous openings extend into the paranasal sinuses. Nasopharynx • Paranasal sinuses − Prevent contaminants from entering respiratory tract • Fractures may cause: − Cerebrospinal rhinorrhea − Cerebrospinal otorrhea Oropharynx • Forms the posterior of the oral cavity − Fracture or avulsion of teeth may result in aspiration − Tongue • Attached to mandible and hyoid bone • Most common cause of airway obstruction Oropharynx • Palate − Separates oropharynx and nasopharynx − Hard palate and soft palate • Palatopharyngeal arch: entrance to the throat (pharynx) Oropharynx • Tonsils − Adenoids and tonsils may become swollen and infected. − May cause upper airway obstruction Anatomy of the Lower Airway • Exchanges oxygen and carbon dioxide Larynx • Marks where the upper airway ends and lower airway begins • Thyroid cartilage − Formed by two plates that form the laryngeal prominence (Adam’s apple) Larynx • Cricoid cartilage (cricoid ring) − First ring of the trachea • Cricothyroid membrane: ligament between the thyroid and cricoid cartilage − Site for emergency surgical and nonsurgical access to the airway (cricothyrotomy) Glottis • Space between the vocal cords Glottis • Vallecula − Pocket between base of tongue and epiglottis − Important landmark for ET intubation • Arytenoid cartilages − Posterior attachment of the vocal cords − Valuable guides for ET intubation Glottis • Piriform fossae − Airway devices are occasionally inadvertently inserted into these pockets • Laryngospasm: spasmodic closure of the vocal cords − Seals off the airway Trachea • Conduit for air entry into the lungs − Begins below the cricoid cartilage − Descends down the midline of the neck and chest to the fifth or sixth thoracic vertebra • Esophagus lies posterior to the trachea Trachea • Divides into right and left mainstem bronchi • Trachea and mainstem bronchi lined with: − Goblet cells − Cilia − Beta-2 adrenergic receptors Lungs • Consist of smaller bronchi, bronchioles, and alveoli Lungs • Alveoli − Functional site for the exchange of oxygen and carbon dioxide − Increase surface area of the lungs − Lined with a phospholipid compound (surfactant) Lungs • These landmarks will help you assess and manage the airway. Physiology of Breathing • Respiratory and cardiovascular systems work together. − Bring oxygen and nutrients to cells − Remove waste Ventilation • Process of moving air into and out of lungs − Two phases • Inhalation (inspiration) • Exhalation (expiration) • You must ensure adequate ventilation. Inhalation • Active, muscular part of breathing • Boyle’s law: The pressure of gas is inversely proportional to its volume. • Air enters the mouth and nose, moves to the trachea. − Diaphragm and intercostal muscles contract. Inhalation • Diaphragm − Specialized skeletal muscle (voluntary and involuntary) • Lungs − Have no muscle tissue − Depend on movement of the chest and supporting structures Inhalation • The thoracic cage expands during inhalation and air pressure within the thorax decreases. − Negative-pressure ventilation • Inhalation stops when pressure is equalized. Inhalation • Thoracic cage: like a bell jar in which balloons are suspended Inhalation • The role of diffusion − Involves oxygen transfer from air into capillaries − Partial pressure: amount of gas in air or dissolved in a liquid • Governed by Henry’s law • Measured in mm Hg or torr Inhalation • The role of diffusion (cont’d) − Deoxygenated arterial blood from the heart has a partial pressure of oxygen (PaO2) that is lower than the partial pressure of oxygen in the alveoli. • Body attempts to equalize the partial pressure Lung Volumes • Breathing becomes deeper as tidal volume responds to increased demand for oxygen − Alveolar volume: volume of air that reaches the alveoli − Tidal volume: amount of air moved into or out of the respiratory tract during one breath • Adult: 5 to 7 mL/kg • Infants/children: 6 to 8 mL/kg Lung Volumes • Dead space volume: portion of tidal volume that does not reach the alveoli • Minute volume: amount of air moved through the respiratory tract in 1 minute − Including anatomic dead space Lung Volumes • Alveolar minute volume: volume of air that reaches the alveoli each minute − Affected by variations in tidal volume and/or respiratory rate Lung Volumes • Inspiratory reserve volume: amount of air inhaled in addition to normal tidal volume • Functional reserve capacity: amount of air forced from the lungs in one exhalation • Expiratory reserve volume: amount of air exhaled following normal exhalation Lung Volumes • Residual volume: air that remains in the lungs after maximal exhalation • Vital capacity: amount of air that can be forcefully exhaled after a full inhalation − Total lung capacity: vital capacity plus residual volume Exhalation • Passive process • Stretch receptors signal apneustic center as chest expands − Inhibits respiration − Exhalation occurs • Feedback loop: Herring-Breuer reflex Regulation of Ventilation • The need for oxygen changes constantly. − Respiratory system responds by altering the rate and depth of ventilation • Primarily regulated by pH of CSF Regulation of Ventilation • Receptors and feedback loops send messages about gas concentrations to the respiratory center. − Rising oxygen level suspends breathing. − Rising CO2 level stimulates breathing. Neural Control of Ventilation • Originates in medulla oblongata and pons − Medulla • Controls rate, depth, and rhythm of breathing in interaction with the pons − Apneustic center of the pons • Secondary control center if the medulla fails Chemical Control of Ventilation • Chemoreceptors − Affect respiratory rate and depth − Monitor chemical composition of body fluids − Provide feedback on metabolic processes Chemical Control of Ventilation • Chemoreceptors (cont’d) − Three sets affect respiratory function • Those in the carotid bodies • Those in the aortic arch • Central chemoreceptors Chemical Control of Ventilation • Chemoreceptors in the carotid bodies and the aortic arch − Measure carbon dioxide in arterial blood • Central chemoreceptors − Monitor the pH of the CSF Chemical Control of Ventilation • Chemoreceptors in the aortic arch and carotid bodies are a backup to the primary control of ventilation. − Dorsal group: initiates inspiration based on information from chemoreceptors − Ventral group: responsible for motor control of inspiratory and expiratory muscles Hypoxic Drive • Patients with COPD have trouble eliminating carbon dioxide through exhalation. − Always have higher blood levels • Can alter primary respiratory drive • Body uses backup system Hypoxic Drive • Hypoxic drive: secondary control − Stimulates breathing when arterial oxygen level falls − Providing high concentrations of oxygen over time will increase PaO2. Control of Ventilation by Other Factors • Fever • Certain medications • Pain, strong emotions • Excessive amounts of narcotic analgesics and benzodiazepines • Hypoxia and acidosis • Metabolic rate Oxygenation • Oxygen molecules loaded onto hemoglobin molecules in the bloodstream • Required for ventilation but does not guarantee it Oxygenation • Fraction of inspired oxygen (FIO2) − Percentage of oxygen in inhaled air − Increases with supplemental oxygen − Commonly documented as a decimal number Oxyhemoglobin Dissociation Curve • Hemoglobin − Protein necessary for life − Normal values • Men: 14–16 g/dL • Women: 12–14 g/dL • Hematocrit values − Percentage of red blood cells in whole blood − Normal values • Men: 45%–52% • Women: 37%–48% Oxyhemoglobin Dissociation Curve • Oxygen saturation − SpO2/SaO2 is proportional to the amount of oxygen dissolved in the plasma (PaO2). Oxyhemoglobin Dissociation Curve • Acidosis and increased carbon dioxide − Curve shifts to the right − Hemoglobin gives up oxygen faster • Alkalosis and decreased carbon dioxide − Curve shifts to the left − Hemoglobin holds on to more oxygen Respiration • Metabolism: process of cells taking energy from nutrients • Respiration: process of exchanging oxygen and carbon dioxide − Involves ventilation, diffusion, and transport of oxygen and carbon dioxide External Respiration • Exchange of O2 and CO2 between alveoli and blood in pulmonary capillaries − Adequate ventilation is necessary but does not guarantee it. Internal Respiration • Exchange of O2 and CO2 between the systemic circulation and the cells • Aerobic metabolism: The mitochondria of the cells convert glucose into energy. Internal Respiration • Kreb cycle and oxidative phosphorylation − Energy is produced in the form of ATP. • Anaerobic metabolism − Without adequate oxygen, cells do not completely convert glucose into energy. − Cells will eventually die. Internal Respiration • When mitochondria use oxygen to convert glucose to energy, carbon dioxide accumulates in the cell. − Without oxygen, anaerobic metabolism leads to cell death. Internal Respiration Pathophysiology of Respiration • Disruption of pulmonary ventilation, oxygenation, and respiration causes immediate effects. − Must recognize and correct immediately Pathophysiology of Respiration • Every cell needs a constant supply of oxygen to survive. − Perfusion: circulation of blood in adequate amounts to meet cells’ needs Hypoxia • Tissues and cells do not receive enough oxygen • Varying signs and symptoms, including: − Early signs: restlessness, irritability, tachycardia, and anxiety − Late signs: mental status changes, a weak pulse, and cyanosis Ventilation-Perfusion Ratio and Mismatch • Air and blood flow must be directed to the same place at the same time. − Ventilation and perfusion must be matched. • If not, V/Q mismatch results. − Blood passes over alveolar membranes without gas exchange. − Carbon dioxide is recirculated into bloodstream. Factors Affecting Ventilation • Patent airway is critical for the provision of oxygen to tissues • Intrinsic and extrinsic factors can cause an airway obstruction. Factors Affecting Ventilation • Intrinsic factors: infection, allergic reactions, unresponsiveness − The tongue is the most common obstruction in an unresponsive patient. − Factors may not be directly part of the respiratory system. Factors Affecting Ventilation • Extrinsic factors: trauma and foreign body airway obstruction − Trauma requires immediate intervention. • Blunt/penetrating trauma and burns can disrupt airflow into the lungs. • Trauma to the chest wall can lead to inadequate pulmonary ventilation. Factors Affecting Ventilation • Hypoventilation − Carbon dioxide production exceeds elimination. • Hyperventilation − Carbon dioxide elimination exceeds production. External Factors Affecting Oxygenation and Respiration • Factors in ambient air − High altitudes: partial pressure decreases − Closed environments: oxygen decreases • Toxic gases displace oxygen in the environment. Internal Factors Affecting Oxygenation and Respiration • Conditions that reduce surface area for gas exchange also decrease oxygen supply − Nonfunctional alveoli inhibit diffusion. − Fluid in the alveoli inhibits gas exchange. • Submersion victims • Patients with pulmonary edema • Exposure to environmental conditions or occupational hazards Internal Factors Affecting Oxygenation and Respiration • Hypoglycemia − Oxygen and glucose levels decrease • Infection − Increases metabolic needs • Hormonal imbalances − May result in ketoacidosis Circulatory Compromise • Inadequate perfusion; oxygen demands will not be met. − Obstruction of blood flow is typically related to trauma. • Inhibits gas exchange at the tissue level Circulatory Compromise • Heart conditions reduce blood flow to tissues. • Blood loss and anemia reduce the blood’s oxygen-carrying ability. • Shock: oxygen is not delivered efficiently. − Poor tissue perfusion; anaerobic metabolism Acid-Base Balance • Can be disrupted by − Hypoventilation − Hyperventilation − Hypoxia • May rapidly lead to deterioration, death Acid-Base Balance • Respiratory and renal systems help maintain homeostasis. − Tendency toward stability in the body − Requires balance between acids and bases • Acid in the body can be expelled as carbon dioxide from the lungs. Acid-Base Balance • Acidosis can develop if respiratory function is inhibited. • Alkalosis can develop if the respiratory rate is too high. − Respiratory acidosis/alkalosis − Metabolic acidosis/alkalosis Patient Assessment: Airway Evaluation • Quality of care depends on assessment • Adequate breathing − Patient is responsive, alert, able to speak − Rate between 12 and 20 breaths/min − Adequate depth − Regular pattern of inhalation and exhalation − Clear and equal breath sounds Recognizing Inadequate Breathing • Breathing rate of less than 12 breaths/min or more than 20 breaths/min • Cyanosis: indicator of low blood oxygen • Preferential positioning − Upright sniffing (tripod) position − Semi-Fowler (semi-sitting) position Recognizing Inadequate Breathing • Potential causes: − − − − Severe infection Trauma Brainstem insult Noxious or oxygenpoor environment − Renal failure − Upper and/or lower airway obstruction − Respiratory muscle impairment − Central nervous system impairment Recognizing Inadequate Breathing • Airway management steps: − − − − Open the airway. Clear the airway. Assess breathing. Provide appropriate intervention(s). • Evaluation includes: − Observe − Palpate − Auscultate Inadequate Breathing • Note the following: − − − − − − − Position Orthopnea Chest rise/fall Skin Flared nostrils Pursed lips Retractions − Use of accessory muscles − Asymmetric chest wall movement − Quick breaths, long exhalation − Labored breathing Inadequate Breathing • Signs: − Fewer than 12, more than 20 breaths/min plus dyspnea − Irregular rhythm − Diminished, absent, or noisy sounds − Abdominal breathing − Reduced flow − Unequal chest expansion − Increased effort − Shallow breathing − Pale, clammy skin − Retractions − Staccato speech Inadequate Breathing • Feel for air movement. • Observe chest for symmetry. • Note any paradoxical motion. • Assess for pulsus paradoxus. − Systolic blood pressure drops more than 10 mm Hg during inhalation. Inadequate Breathing • Ask about history of present illness − Onset, trigger, duration? − Other symptoms? − Interventions, previous hospitalization? − Medications and overall compliance? − Risk factors? Protective Airway Reflexes • Evaluate protective reflexes. − Coughing, sneezing, gagging • Gag reflex (eyelash reflex) − Sighing − Hiccupping Assessment of Breath Sounds • Auscultate breath sounds with stethoscope. − Should be clear and equal Assessment of Breath Sounds Assessment of Breath Sounds • Duration: length of time for inspiratory and expiratory phases − Normal I/E ratio: 1:2 − Expiration is prolonged with lower airway obstruction. − Expiration is short with tachypneic patients. Assessment of Breath Sounds • Pitch: higher or lower than normal (stridor or wheezing). − Intensity of sound depends on: • Airflow rate • Constancy of flow throughout inspiration • Patient position • Site selected for auscultation Abnormal Breath Sounds • Wheezing: continuous, highpitched • Stridor: loud, highpitched, heard during inspiration • Rhonchi: continuous, low-pitched • Pleural friction rub: surfaces of visceral and parietal pleura rub together • Crackles: discontinuous Pulse Oximetry • Pulse oximeter: measures oxygen saturation of hemoglobin (Hb) − Normal: SpO2 of greater than 95% Pulse Oximetry • Used for: − Monitoring oxygenation status during intubation attempt or suctioning − Identifying deterioration in a patient with trauma or cardiac disease − Identifying high-risk patients − Assessing vascular status in orthopaedic trauma Pulse Oximetry • Erroneous readings may result from: − Bright ambient light (cover clip) − Patient motion − Poor perfusion − Nail polish − Venous pulsations − Abnormal hemoglobin Pulse Oximetry • Types of hemoglobin − Oxyhemoglobin (HbO2) − Reduced hemoglobin • CO-oximeter − Determines HbO2 saturation (percentage of oxygenated Hb compared with total hemoglobin) Courtesy of Mike Panté. Peak Expiratory Flow • Measured to evaluate bronchoconstriction − Increasing: patient is responding to treatment − Decreasing: patient’s condition is deteriorating • Perform three times and take the best rate. Arterial Blood Gas Analysis • Blood is analyzed for pH, PaO2, HCO3−, base excess, and SaO2. − pH, HCO3−: acidbase status − PaCO2: effectiveness of ventilation − PaO2 and SaO2: oxygenation End-tidal Carbon Dioxide (ETCO2) Assessment • Detects carbon dioxide in exhaled air − Adjunct for determining ventilation adequacy − Confirms advanced airway placement − ETCO2 detector types: • Digital • Waveform • Digital/waveform • Colorimetric End-tidal Carbon Dioxide (ETCO2) Assessment • Capnometer − Numeric reading of exhaled CO2 • Capnographer − Graphic representation of exhaled CO2 − Three types: • Waveform • Digital/waveform • Colorimetric Courtesy of PHASEIN Medical Technologies. End-tidal Carbon Dioxide (ETCO2) Assessment • Waveform capnography − Exhaled carbon dioxide level displayed as a graphic waveform − Includes contour, baseline level, rate, and rise of carbon dioxide level End-tidal Carbon Dioxide (ETCO2) Assessment • Waveform capnography (cont’d) − Phase A–B: initial stage of exhalation − Phase B–C: expiratory upslope − Phase C–D: expiratory or alveolar plateau − Phase D–E: inspiratory down stroke End-tidal Carbon Dioxide (ETCO2) Assessment • Colorimetric capnographer − Reading after 6 to 8 positive-pressure breaths − Replace with quantitative device as soon as possible Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP End-tidal Carbon Dioxide (ETCO2) Assessment • Capnography can: − Indicate effectiveness of chest compressions − Detect return of spontaneous circulation • Use is limited with cardiac arrest Airway Management • Air reaches the lungs only through the trachea. − In a compromised airway, clearing the airway and maintaining patency are vital. Positioning the Patient • Move unresponsive patients found in a prone position to a supine position. − Log roll and assess for breathing. • If the patient is breathing adequately and is not injured, move to recovery position. Manual Airway Maneuvers • If an unresponsive patient has a pulse but is not breathing, you must open the airway. − Maneuver patient’s head to propel the tongue forward and open the airway. Head Tilt-Chin Lift Maneuver • Indications: − Unresponsive − No spinal injury − Unable to protect airway • Contraindications: − Responsive − Possible spinal injury • Advantages − No equipment − Noninvasive • Disadvantages − Hazardous to spinal injury − No protection from aspiration • Refer to Skill Drill 15-1. Jaw-Thrust Maneuver • Indications − Unresponsive − Possible spine injury − Unable to protect airway • Contraindications − Resistance to opening the mouth • Advantages − Used with spine injury or cervical collar − No special equipment required Jaw-Thrust Maneuver • Disadvantages − Cannot maintain if patient becomes responsive or combative − Difficult to maintain for an extended time − Difficult to use with bag-mask ventilation − Thumb must remain in place − Requires second rescuer − No protection against aspiration • Refer to Skill Drill 15-2. Tongue-Jaw Lift Maneuver • Used more commonly to open airway for: − Suctioning or − Inserting an oropharyngeal airway • Cannot be used to ventilate a patient − Does not allow for an adequate mask seal • Refer to Skill Drill 15-3. Suctioning • Removes material from the mouth or throat quickly and efficiently − Ventilating with secretions in the mouth will result in upper airway obstruction or aspiration. • Next priority after opening airway manually Suctioning Equipment • Fixed or portable − Hand-operated suctioning units with disposable canisters − Mechanical or vacuum-powered suction units Suctioning Equipment • The following should be readily accessible: − − − − Wide-bore, thick-walled, nonkinking tubing Soft and rigid suction catheters Nonbreakable, disposable collection bottle Supply of water for rinsing the catheters Suctioning Equipment • Yankauer catheter − Use with adults (pharynx), infants, children • Whistle-tip catheter − Can be placed in ET tube − Use for nose, back of mouth, when a rigid catheter cannot be used Suctioning Techniques • Suctioning removes oxygen. − Preoxygenate before suctioning. − Maximum suctioning time • Adult: 15 seconds • Child: 10 seconds • Infant: 5 seconds Suctioning Techniques • Do not stimulate back of throat. • After suctioning, continue ventilation and oxygenation. • Soft-tip catheters − Must lubricate when suctioning the nasopharynx − Best when passed through an ET tube − Suction during extraction of catheter Suctioning Techniques • Before inserting, measure for proper size. − Corner of the mouth to the earlobe • Never insert a catheter past the base of the tongue. • Refer to Skill Drill 15-4. Airway Adjuncts • May be needed to help maintain patency in an unresponsive patient after manually opening and suctioning − Not a substitute for proper head positioning Oropharyngeal (Oral) Airway • Curved, hard plastic device • Fits over back of the tongue • Should be inserted in unresponsive patients who have no gag reflex Oropharyngeal (Oral) Airway • Indications − Unresponsive patients who have no gag reflex • Contraindications − Responsive patients − Patients with a gag reflex • Advantages − Noninvasive and easily placed − Prevents blockage by the tongue • Disadvantages − No prevention of aspiration • Refer to Skill Drill 15-5 and 15-6. Nasopharyngeal (Nasal) Airway • Soft, rubber tube • Insert through nose • Better tolerated − Do not use with trauma to the nose or skull fracture. • Lubricate the airway and insert gently. Nasopharyngeal (Nasal) Airway • Indications − Unresponsive − Altered mental status with an intact gag reflex • Contraindications − Patient intolerance − Facial fracture or skull fracture • Advantages − Suctioned through − Patent airway − Tolerated by responsive patients − Can be placed “blindly” − No requirement for the mouth to be open Nasopharyngeal Airway • Disadvantages − Improper technique may result in severe bleeding. − Does not protect from aspiration • Refer to Skill Drill 15-7. Causes of Airway Obstruction • Foreign body • Trauma • Tongue • Aspiration • Laryngeal edema • Infection or severe allergic reaction • Laryngeal spasm Causes of Airway Obstruction • Tongue − With altered LOC, tongue can fall backwards, closing off the airway • Partial obstruction: snoring respirations • Complete obstruction: no respirations − Simple to correct with manual maneuver Causes of Airway Obstruction • Foreign body − Typical victim: middle-aged or older, dentures, alcohol − Signs may include: • Choking • Gagging • Stridor • Dyspnea • Aphonia or dysphonia Laryngeal Spasm and Edema • Laryngeal spasm − Spasmodic closure of vocal cords − Completely occludes airway − Causes include: • Laryngeal edema − Glottic opening narrows or totally closes − Causes include: • Epiglottitis • Intubation trauma • Anaphylaxis • Extubation • Inhalation injury Laryngeal Spasm and Edema • May be relieved by − Aggressive ventilation − Forceful upward jaw pull • May be relieved by muscle relaxants • May recur; transport patient to hospital for evaluation Laryngeal Injury • Fracture of the larynx increases airway resistance by decreasing airway size. • Penetrating and crush injuries to the larynx can compromise the airway. Aspiration • Increases mortality − Can obstruct the airway − Destroys bronchiolar tissue − Introduces pathogens into the lungs − Decreases patient’s ability to ventilate • Have suction readily available Recognition of an Airway Obstruction • Mild obstruction − Patient is responsive, able to exchange air − Usually has noisy respirations and coughing − Should be left alone − Closely monitor the patient’s condition. − Be prepared to intervene. Recognition of an Airway Obstruction • Severe obstruction − Inability to breathe, talk, or cough − May grasp at throat, turn cyanotic, make frantic movements − Cough is weak, ineffective, or absent Courtesy of Rhonda Beck − Weak inspiratory stridor and cyanosis Emergency Medical Care for Foreign Body Airway Obstruction • Begin treatment immediately if choking is confirmed by a responsive patient. − If large pieces of foreign body are found, sweep them out of the mouth with your finger. − Insert your finger along the inside of the cheek and into the throat. − Try to hook the foreign body to dislodge it. − Suction as needed. Emergency Medical Care for Foreign Body Airway Obstruction • Abdominal thrust (Heimlich) maneuver − Creates an artificial cough, expelling the object − Perform until the object is expelled or the patient becomes unresponsive. Emergency Medical Care for Foreign Body Airway Obstruction • If patient becomes unresponsive, position supine, begin chest compressions − 30 chest compressions − 15 with two rescuers or infant/child • Open airway, remove any visible object • Attempt rescue breath, look for chest rise Emergency Medical Care for Foreign Body Airway Obstruction • If techniques do not work, proceed with direct laryngoscopy. − If you see the foreign body, remove it with Magill forceps. − Refer to Skill Drill 15-8. Supplemental Oxygen Therapy • Administer to any patient with potential hypoxia − Enhances compensatory mechanisms during shock and distressed states Oxygen Sources • Oxygen cylinders − Stores pure oxygen − Check label and test date. − Various sizes − Oxygen delivery is measured in L/min. Oxygen Sources • Oxygen cylinders (cont’d) − Replace cylinder when pressure falls to 200 psi or lower. − Using the pressure and flow rate, you can calculate how long the supply will last. − Cooled to a liquid − Converts to a gas when warmed − Keep upright. HELiOS® Marathon™ portable oxygen unit. Courtesy of Nellcor Puritan Bennett in affiliation with Tyco Healthcare. Oxygen Sources • Liquid oxygen Safety Reminders • Keep combustible materials away. • Close all valves when not in use. • No smoking near cylinders. • Secure cylinders. • Store in a cool, ventilated area. • Use only with a properly fitting regulator valve. • Position yourself to the cylinder’s side. • Have the cylinder hydrostat tested every 10 years. Oxygen Regulators and Flowmeters • High-pressure regulators deliver gas under high pressure. − Pressure is approximately 2,000 psi. − Therapy regulator controls flow to patient • Reduces to 50 psi Oxygen Regulators and Flowmeters • Flowmeters allow oxygen to be adjusted. − Pressure-compensated flowmeter − Bourdon-gauge flowmeter Preparing an Oxygen Cylinder for Use • Before administering, you must prepare the oxygen cylinder and therapy regulator. • Refer to Skill Drill 15-9. Nonrebreathing Mask • Preferred in prehospital setting − 90% to 100% oxygen − Mask and reservoir bag • Indications − Spontaneously breathing patients • Contraindications − Apnea and poor respiratory effort © Jones & Bartlett Learning. Courtesy of MIEMSS. Nasal Cannula • Two small prongs − 24% to 44% oxygen • Best for patients who need long-term therapy • Ineffective with: − Apnea − Poor respiratory effort − Severe hypoxia − Mouth breathing © Jones & Bartlett Learning. Courtesy of MIEMSS. Partial Rebreathing Mask • Lacks one-way valve − Residual exhaled air is rebreathed • Flow rates of 6 to 10 L/min © Jones & Bartlett Learning. Courtesy of MIEMSS. • 35% to 60% oxygen Venturi Mask • Draws room air into the mask along with oxygen • Can deliver 24%, 28%, 35%, or 40% oxygen Tracheostomy Masks • Cover the stoma and have a strap that goes around the neck − To improvise, place a face mask over the stoma. Oxygen Humidifier • Bottle of sterile water moisturizes oxygen − Keep upright; only practical with fixed unit on ambulance − Can be source of infection Ventilatory Support • Patient who is not breathing needs artificial ventilation and 100% supplemental oxygen − Indications include signs of: • Altered mental status • Inadequate minute volume Normal Ventilation Versus Positive-Pressure Ventilation • Normal ventilation − Diaphragm contracts − Negative pressure in chest cavity draws in air • Positive-pressure ventilation − Generated by a device − Forces air into the chest cavity from the external environment Normal Ventilation Versus Positive-Pressure Ventilation Normal Ventilation Versus Positive-Pressure Ventilation • With positive-pressure ventilation, more air is needed to achieve the same effects of normal breathing. − Increases overall intrathoracic pressure − Blood flow is decreased. Normal Ventilation Versus Positive-Pressure Ventilation • Cardiac output is a function of stroke volume multiplied by the pulse rate. • Normally, when a person breathes, air enters the trachea. − Ventilations that are too forceful can cause gastric distention. Assisted Ventilation • Explain the procedure. • After 5 to 10 breaths, slowly adjust the rate. • Place the mask over the patient’s nose and mouth. • Adjust the rate and tidal volume to maintain adequate minute volume. • Squeeze the bag each time the patient inhales. Artificial Ventilation • Begin artificial ventilation immediately if patient is not breathing • Methods include − Mouth-to-mask technique − One-, two-, or three-person bag-mask device technique − Manually triggered ventilation device Mouth-to-Mouth Ventilation • Routinely performed with a barrier device • Alternative: mouthto-nose • Requires no special equipment • Can provide adequate tidal volume Courtesy of AAOS. Mouth-to-Mask Ventilation • Places a physical barrier between your mouth and the patient’s mouth • Oxygen inlet provides oxygen to supplement the air from your own lungs • May be shaped like a triangle or a doughnut • Refer to Skill Drill 15-10. Bag-Mask Device • Can deliver nearly 100% oxygen. • Can provide adequate tidal volume when used by an experienced paramedic − Depends on mask seal integrity Bag-Mask Device Components • Disposable, selfinflating bag • No pop-off valve, or capability to disable • Nonrebreathing outlet valve • Oxygen reservoir • One-way, no-jam inlet valve system • Transparent face mask Bag-Mask Device Components • Total amount of gas in an adult bag-mask device is usually 1,200 to 1,600 mL. • Volume of oxygen to deliver is based on visible chest rise. − Deliver each breath over a period of 1 second at the appropriate rate. Bag-Mask Device Technique • Kneel above patient’s head. • Place the mask on the patient’s face. • Maintain neck in a hyperextended position (unless spinal injury). • Bring the lower jaw up to the mask. − Open the mouth, suction as needed. − Insert an oral or nasal airway. • Connect the bag to the mask. Bag-Mask Device Technique • Hold the mask in place while your partner squeezes the bag until the chest visibly rises. − Squeeze every 5 to 6 seconds for adults, 3 to 5 seconds for infants and children. Courtesy of AAOS Bag-Mask Device Technique • If alone, hold your index finger over the lower part of the mask and your thumb over the upper part. © Jones & Bartlett Learning. Courtesy of MIEMSS. • Observe for gastric distention, changes in compliance, and changes in status. Bag-Mask Device Technique • Squeeze bag as patient inhales. − Slowly adjust rate and tidal volume. − If patient is hyperventilating, first assist at the rate at which the patient is breathing. • Then slowly adjust rate and tidal volume. Bag-Mask Device Technique • Not adequate if: − Chest does not rise and fall − Rate of ventilation is too slow or too fast − Pulse rate does not improve Bag-Mask Device Technique • If the chest does not rise and fall: − Reposition the head or insert an airway. − If the stomach seems to be rising and falling, reposition the head. − If too much air is escaping, reposition the mask. • If chest still does not rise and fall, check for an airway obstruction. Manually Triggered Ventilation Devices • Main use: apneic or hypoventilating patients • “Demand valve” delivers 100% oxygen • Makes an airtight seal with patient’s face • Impossible to assess for lung compliance Manually Triggered Ventilation Devices • Delivers only the volume of oxygen needed • Expensive, not disposable • Adapter fits standard ventilation masks Components of Manually Triggered Ventilation Devices • Peak flow rate: 100% oxygen up to 40 L/min • Inspiratory pressure safety release valve • Alarm if pressure is exceeded • Properly positioned trigger (or lever) Automatic Transport Ventilators • Steps for using: − Attach to wallmounted oxygen source. − Set tidal volume and ventilatory rate. − Connect to the 15/22-mm fitting on the ET tube or airway device. − Auscultate breath sounds and observe chest rise. Courtesy of Impact Instrumentation, Inc. Automatic Transport Ventilators • Have bag-mask device available in case ATV malfunctions • Most models have adjustments for respiratory rate and tidal volume. − Deliver a preset volume at a preset rate. Automatic Transport Ventilators • Generally consumes 5 L/min of oxygen • Pressure-relief valve can lead to: − Hypoventilation − Increased airway resistance − Airway obstruction Continuous Positive Airway Pressure • Noninvasive means of providing ventilatory support for patients with respiratory distress − Increases pressure in the lungs − Opens collapsed alveoli − Pushes oxygen across alveolar membrane − Forces interstitial fluid back into circulation Continuous Positive Airway Pressure • Typically delivered through a face mask secured with a strapping system. − Pressure relief valve determines amount of pressure delivered to the patient Indications for CPAP • Guidelines: − Patient is alert and able to follow commands. − Obvious signs of respiratory distress from an underlying disease or after submersion − Rapid breathing (more than 26 breaths/min) that affects overall minute volume − Pulse oximetry of less than 90% Contraindications to CPAP • Respiratory arrest • Hypoventilation • Signs and symptoms of a pneumothorax or chest trauma • Tracheostomy • Active GI bleeding or vomiting • Inability to follow verbal commands • Inability to properly fit CPAP system mask and strap • Inability to tolerate the mask Application of CPAP • Generally composed of: − Generator − Mask − Circuit that contains corrugated tubing − Bacteria filter − One-way valve Application of CPAP • Patient exhales against a resistance (positive end-expiratory pressure [PEEP]) − Controlled manually or predetermined − 5 to 10 cm H2O is general therapeutic range Application of CPAP • Continuously monitor available oxygen. • Some newer units allow you to adjust FIO2 • Refer to Skill Drill 15-11. Complications of CPAP • Patients may feel claustrophobic and resist. • High volume of pressure can cause a pneumothorax. • Increased pressure in the chest cavity can result in hypotension. • Air may enter the stomach. Gastric Distension • Inflation of the stomach with air − Likely to occur when: • Excessive pressure is used to inflate the lungs • Ventilations are performed too fast or too forcefully • Airway is partially obstructed during ventilation attempts Gastric Distension • Harmful for at least two reasons − Promotes regurgitation, can lead to aspiration − Pushes diaphragm up, limits lung expansion • Signs include − Increased diameter, distension of the stomach − Increased resistance to bag-mask ventilations Gastric Distension • If signs are noted: − Reassess and reposition the airway. − Observe chest for adequate rise and fall. − Limit ventilation times to 1 second or the time needed to produce adequate chest rise. Invasive Gastric Decompression • Involves inserting a gastric tube into the stomach and suctioning the contents − Should be considered: • For any patient who will need positive-pressure ventilation for an extended period • When gastric distention interferes with ventilations Invasive Gastric Decompression • Nasogastric tube − Insert through nose − Decompresses stomach • Decreases pressure • Limits risk of regurgitation Invasive Gastric Decompression • Nasogastric tube (cont’d) − Relatively well tolerated − Contraindicated with severe facial injuries • Use OG route instead. − Refer to Skill Drill 15-12. Invasive Gastric Decompression • Orogastric tube − Inserted through the mouth − No risk of nasal bleeding − Safer in patients with severe facial trauma − Can use larger tubes Orogastric Tube • Orogastric tube (cont’d) − Less comfortable for responsive patients • Preferred for patients who are unresponsive without a gag reflex − See Skill Drill 15-13. Laryngectomy • Surgical removal of the larynx − Tracheostomy creates a stoma. − Total laryngectomy: breathe through stoma • Cannot ventilate by mouth-to-mask technique − Partial laryngectomy: breathe through stoma and nose or mouth Suctioning of a Stoma • May become occluded with mucous plugs − Suction with extreme care. − Limit suctioning to 10 seconds. • See Skill Drill 15-14. Ventilation of Stoma Patients • Head tilt-chin lift and jaw-thrust not required • If no tracheostomy tube, use: − Mouth-to-stoma technique − Bag-mask device • Use an infant- or child-sized mask to make an adequate seal. Ventilation of Stoma Patients • Two rescuers are needed with a bag-mask device. − One to seal the nose and mouth − The other to squeeze the bag-mask device • See Skill Drill 15-15 and Skill Drill 15-16. Tracheostomy Tubes • Plastic tube placed within the stoma − Patients may receive supplemental oxygen via: • Tubing designed to fit over the tube • Placing an oxygen mask over the tube Tracheostomy Tubes • Patients who experience sudden dyspnea often have thick secretions in the tube − Suction as you would through a stoma. − When tube is dislodged, stenosis may occur. • See Skill Drill 15-17. Dental Appliances • Different forms − Dentures (upper, lower, or both) − Bridges − Individual teeth − Braces (in the younger population) Dental Appliances • Determine whether appliance is loose or fits − If it fits well, leave in place. − Remove if loose. • Take care if airway obstruction is caused by a bridge (can lacerate pharynx or larynx). • Generally best to remove before intubating Facial Trauma • Severe swelling and bleeding in the airway may be present. − Control with direct pressure. − Suction as needed. © Eddie M. Sperling Facial Trauma • Inadequate breathing and severe oropharyngeal bleeding may be present. − Suction airway for 15 seconds (less in infants and children), then ventilate for 2 minutes. • Alternate until secretions have been cleared. Facial Trauma • Suspect cervical spine injury. − Endotracheal intubation of a trauma patient is most effectively performed by two paramedics. • If you are unable to effectively ventilate or intubate, perform a cricothyrotomy. Advanced Airway Management • One of the most common mistakes with respiratory or cardiac arrest is to use advanced techniques too early. − Establish and maintain a patent airway with basic techniques first. Advanced Airway Management • Primary reasons: − Failure to maintain a patent airway and/or − Failure to adequately oxygenate and ventilate • Involves insertion of advanced airway devices Predicting the Difficult Airway • Anatomic findings: − Congenital abnormalities − Recent surgery − Trauma − Infection − Neoplastic diseases • LEMON − − − − − Look externally Evaluate 3-3-2 Mallampati Obstruction Neck mobility LEMON • Look externally. − The following can make intubation difficult: • Short, thick necks • Morbid obesity • Dental conditions LEMON • Evaluate 3-3-2. − 3 — mouth width of more than 3 fingers is best − 3 — mandible length of 3 fingers is best − 2 — distance from hyoid bone to thyroid notch of 2 fingers wide is best LEMON • Mallampati − Note oropharyngeal structures visible in an upright, seated patient. LEMON • Obstruction − Note anything that might interfere with visualization or ET tube placement. • Foreign body • Obesity • Hematoma • Masses LEMON • Neck mobility − Sniffing position is ideal − Neck mobility problems most common with: • Trauma patients • Elderly patients Endotracheal Intubation • ET tube passes through glottic opening and is sealed with a cuff inflated against the tracheal wall − Orotracheal intubation: through the mouth − Nasotracheal intubation: through the nose Endotracheal Intubation • Advantages − Secure airway − Protection against aspiration − Alternative to IV or IO route • Disadvantages − Special equipment − Physiologic functions bypassed • Complications − − − − − − − Bleeding Hypoxia Laryngeal swelling Laryngospasm Vocal cord damage Mucosal necrosis Barotrauma Endotracheal Tubes • Basic structure includes: − Proximal end − Tube − Cuff and pilot balloon − Distal tip Endotracheal Tubes • Sizes range − 2.5 to 9.0 mm in inside diameter − 12 to 32 cm in length Endotracheal Tubes • Pediatric patients − 2.5 to 4.5 mm tubes used − Funnel-shaped cricoid ring forms an anatomic seal with ET tube • No need for distal cuff in most cases. Endotracheal Tubes • Anatomic clues can help determine tube size − Internal diameter of the nostril approximates diameter of glottic opening − Diameter of the little finger or size of thumbnail approximates airway size. • Always have three sizes ready! Laryngoscopes and Blades • A laryngoscope is required to perform orotracheal intubation by direct laryngoscopy. • Consists of a handle and interchangeable blades Laryngoscopes and Blades • Straight (Miller and Wisconsin) blades − Tip extends beneath epiglottis and lifts it up • Useful with infants and small children • More likely to damage teeth in adults Laryngoscopes and Blades • Curved (Macintosh) blades − Curve conforms to tongue and pharynx − Tip is placed in the vallecula • Indirectly lifts epiglottis to expose vocal cords Laryngoscopes and Blades • Blade sizes range from 0 to 4 − 0, 1, and 2 appropriate for infants and children − 3 and 4 considered adult sizes − Pediatric patients: based on age or height − Adults: based on experience, size of patient Laryngoscopes and Blades • Stylet: semirigid wire inserted into ET tube − Molds and maintains shape of tube − Should be lubricated for removal − End should be bent to form a gentle curve − End should rest at least 1/2″ from end of ET tube Laryngoscopes and Blades • Magill forceps − Remove airway obstructions under direct visualization. − Guide tip of ET tube through glottic opening if the proper angle cannot be achieved by manipulating the tube Orotracheal Intubation by Direct Laryngoscopy • ET tube inserted through mouth and into trachea while visualizing the glottic opening with a laryngoscope Orotracheal Intubation by Direct Laryngoscopy • Indications − Airway control needed due to coma, respiratory arrest, and/or cardiac arrest − Ventilatory support before impending respiratory failure − Prolonged ventilatory support − − − − Absence of gag reflex Traumatic brain injury Unresponsiveness Impending airway compromise − Medication administration Orotracheal Intubation by Direct Laryngoscopy • Contraindications − Intact gag reflex − Inability to open mouth because of trauma, dislocation of the jaw, or a pathologic condition − Inability to see the glottic opening − Copious secretions, vomitus, or blood in airway Standard Precautions • Intubation can expose you to bodily fluids. − Take proper precautions. • Gloves • Mask that covers your entire face Preoxygenation • Critical before intubating − 2–3 minutes for apneic or hypoventilating patient − Prevents hypoxia from occurring − Monitor SpO2 and achieve as close to 100% saturation as possible. Positioning the Patient • Airway has three axes: mouth, pharynx, and larynx − At acute angles in neutral position − Place patient in “sniffing” position to facilitate visualization of the airway. Positioning the Patient • Sniffing position − 20° extension of the atlanto-occipital joint − 30° flexion at C6 and C7 with short neck and/or no chin − Elevate head and/or neck until ear is at the level of the sternum Blade Insertion • Position yourself at the patient’s head. • Grasp laryngoscope. • If mouth is not open: − Place thumb below bottom lip and push open. − “Scissor” thumb and index finger between molars − Open with tonguejaw lift Blade Insertion • Insert blade into right side of mouth • Sweep tongue to the left while moving blade into midline • Slowly advance the blade. © Jones & Bartlett Learning. Courtesy of MIEMSS. Specimens provided by the Maryland State Anatomy Board, Department of Health and Mental Hygiene at the Anatomical Services Division, University of Maryland School of Medicine Blade Insertion • Exert gentle traction at a 45° angle as you lift the patient’s jaw. © Jones & Bartlett Learning. Courtesy of MIEMSS. Specimens provided by the Maryland State Anatomy Board, Department of Health and Mental Hygiene at the Anatomical Services Division, University of Maryland School of Medicine − Keep your back and arm straight as you pull upward. Visualization of the Glottic Opening • Continue lifting the laryngoscope as you look down the blade. • Work the tip of the blade into position. − The glottic opening should come into view. • The vocal cords lie within. Courtesy of James P. Thomas, M.D. www.voicedoctor.net Visualization of the Glottic Opening • Gum elastic bougie − Flexible device − Approximately 1 cm in diameter, 60 cm long − Used in epiglottis-only views to facilitate intubation Visualization of the Glottic Opening • Gum elastic bougie (cont’d) − Insert through the glottic opening under direct laryngoscopy. − Once placed, it becomes a guide for the ET tube. Tube Insertion • Pick up preselected ET tube. − Hold it near connector as you would a pencil. • Insert tube from the right corner of mouth through the vocal cords. − Continue until the proximal end of the cuff is 1 to 2 cm past the vocal cords. Tube Insertion • Do not pass the tube down the barrel of the laryngoscope blade. − Will obscure your view of the glottic opening Ventilation • After you have seen the ET tube cuff pass roughly 1/2″ beyond the vocal cords − Gently remove the blade. − Secure tube with right hand − Remove stylet from tube Ventilation • Inflate the distal cuff with 5 to 10 mL of air, then detach the syringe from the inflation port. • Have your assistant attach the bag-mask device to the ET tube; continue ventilation. − Ensure that the patient’s chest rises with each ventilation. Ventilation • Listen to both lungs and to the stomach. − You should hear equal breath sounds and a quiet epigastrium. • Ventilation should be dictated by age. − Adult with a pulse: 10 to 12 breaths/min − Infant/child with a pulse: 12 to 20 breaths/min − Patient in cardiac arrest: 8 to 10 breaths/min Confirmation of Tube Placement • Visualize the ET tube passing between the vocal cords. • Auscultate. − Unequal or absent breath sounds suggest: • Esophageal placement • Right mainstem bronchus placement • Pneumothorax • Bronchial obstruction Confirmation of Tube Placement • Auscultate (cont’d). − Bilaterally absent breath sounds or gurgling over the epigastrium: esophagus was intubated • Immediately remove ET tube. • Be prepared to suction the airway. Confirmation of Tube Placement • Auscultate (cont’d). − Breath sounds only on right: tube has been advanced too far. • Reposition the tube. Confirmation of Tube Placement • With proper tube position: − Bag-mask device should be easy to compress. − You should see corresponding chest expansion. • Increased resistance may indicate: − Gastric distention − Esophageal intubation − Tension pneumothorax Confirmation of Tube Placement • Continuous waveform capnography plus clinical assessment − Most reliable method of confirming placement − Attach capnography T-piece when bag-mask device is attached to the ET tube. Confirmation of Tube Placement • Esophageal detector device − Syringe model: plunger is withdrawn • Tube in the trachea: plunger does not move • Tube in the esophagus: plunger moves back Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP Confirmation of Tube Placement • Esophageal detector device (cont’d) − Bulb model: bulb is squeezed • Tube in the esophagus: bulb remains collapsed • Tube in the trachea: bulb briskly expands Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP Confirmation of Tube Placement • After confirming proper placement, mark ET tube where it emerges from the mouth − Shows others whether tube has slipped in or out Securing the Tube • Never take your hand off the ET tube before securing with an appropriate device. − Support the tube manually while you ventilate to avoid a sudden jolt from the bag-mask device. Securing the Tube • Steps: − Note the centimeter marking on the ET tube. − Remove the bag-mask device. − Position the tube in the center of the mouth. − Place the securing device over the tube. − Reattach the bag-mask device, auscultate, and note the capnography reading and waveform. Securing the Tube • Many devices feature a built-in bite block. − Alternative: Secure tube with tape and insert a bite block or oral airway. • Minimize head movement in patient. • See Skill Drill 15-18. Nasotracheal Intubation • Insertion of tube into trachea through nose • Indicated: − Breathing spontaneously but requires definitive airway management • Contraindicated: − Apnea − Head trauma and midface fractures − Anatomic abnormalities; frequent cocaine use Nasotracheal Intubation • Advantages − Can be performed on responsive patients − No need for laryngoscope − Mouth does not need to be opened − Does not require sniffing position − Patient cannot bite the tube. − Can be secured more easily • Disadvantage − Blind technique • Complications − Bleeding Nasotracheal Intubation Equipment • Same as for orotracheal intubation − Minus laryngoscope and stylet • Some tubes are designed for blind method • Some devices allow confirmation of intubation without placing face next to tube Technique for Nasotracheal Intubation • Patient’s spontaneous respirations guide the tube and confirm proper placement. − Tube is advanced as patient inhales Technique for Nasotracheal Intubation • Insert tube into nostril, bevel facing toward the nasal septum − Aim tip straight back toward ear − Position just above the glottic opening © Jones & Bartlett Learning. Courtesy of MIEMSS. Technique for Nasotracheal Intubation • Manipulate head to control tube tip position and to maximize air movement. • Instruct patient to take a deep breath, and gently advance tube. − Placement will be evidenced by an increase in air movement through the tube. Technique for Nasotracheal Intubation • Soft-tissue bulge on either side of the airway − Tube is probably in the piriform fossa • Hold head still, slightly withdraw the tube • Once maximum airflow is detected, advance tube • No soft-tissue bulge − Tube has entered the esophagus. • Withdraw until you detect airflow; extend head. Technique for Nasotracheal Intubation • Once tube is in place, inflate the distal cuff − Attach bag-mask device and ventilate. − Clean up any secretions or excess lubricant. − Secure the tube with tape. − Document depth of insertion at the nostril. − See Skill Drill 15-19. Digital Intubation • Directly palpate the glottic structures and elevate the epiglottis with your finger while guiding the ET tube into the trachea. − Option in extreme circumstances Digital Intubation • Indications (exceptional circumstances) − Laryngoscope, or other techniques, have failed − Patient in confined space − Patient is obese or has a short neck − Copious secretions − Head cannot be moved − Cannot visualize intubation landmarks Digital Intubation • Can be performed in pediatric patients, but usually impossible due to finger size • Absolutely contraindicated if patient is: − Breathing − Not deeply unresponsive − Has intact gag reflex Digital Intubation • Advantages − Does not require a laryngoscope − Ideal if vocal cords are obscured by secretions − Does not require sniffing position • Disadvantages − Risk of being bitten − Risk of exposure to infectious disease Digital Intubation • Complications − Misplacement of the ET tube − Bite block can cause lip and tooth damage − Vigorous or improper attempts can cause airway trauma or swelling. − Can result in hypoxia Digital Intubation Equipment • Same as for orotracheal intubation (minus laryngoscope), plus fingers − Stylet − ETCO2 detector or esophageal detector device − Appropriate device to secure the tube Technique for Digital Intubation • Prepare equipment as assistant ventilates − Select tube: one half to a full size smaller than with direct laryngoscopy • Tip of the tube is guided into the trachea Technique for Digital Intubation • Two configurations are recommended. − “Open J” configuration − “U-handle” configuration © Jones & Bartlett Learning. Courtesy of MIEMSS. Technique for Digital Intubation • Sniffing position is not required • Insert bite block between molars. − Insert index and middle fingers into right side of the mouth. − Press against tongue. − Pull epiglottis forward. Technique for Digital Intubation • Hold ET tube in right hand; insert it into the left side of the mouth • Advance tube toward the glottis − Once you feel the cuff pass 2″ beyond your fingertip, stabilize the tube and withdraw fingers − Remove the stylet and inflate the cuff. Technique for Digital Intubation • Attach bag-mask device and ventilate. • Confirm placement. − Auscultate lungs and epigastrium. − Monitor ETCO2. − Properly secure the tube in place. • See Skill Drill 15-20. Transillumination Techniques for Intubation • Bright light source placed inside the trachea emits a bright, wellcircumscribed light © Jones & Bartlett Learning. Courtesy of MIEMSS. Transillumination Techniques for Intubation • Indicated − Other techniques have failed. • Contraindicated − − − − Intact gag reflex Airway obstruction May be difficult in obese or short neck patients Pediatric patients: stylet must fit inside tube Transillumination Techniques for Intubation • Advantages − No laryngoscope − Visual parameter − Does not require visualization of the glottic opening − Safe with possible spinal injuries • Disadvantages − Special equipment − Proficiency with equipment − Can be difficult in brightly lit areas • Complications − Misplacement Transillumination Equipment • Device with a rigid stylet and a bright light source at the end − Light should shine laterally and forward. − Stylet must be long enough to accommodate a standard-length ET tube − Stylet must be secured within the tube Technique for TransilluminationGuided Intubation • Preoxygenate for at least 2 to 3 minutes. • Choose ET tube and check the cuff • Lubricate and insert the lighted stylet. − Ensure it is firmly seated into the tube. Technique for TransilluminationGuided Intubation • Bend tube into the proper shape − Head in neutral or slightly extended position • While holding the stylet, displace the jaw forwardly. • Turn on the lighted stylet, and insert it in the midline of the mouth. Technique for TransilluminationGuided Intubation • Continue insertion; draw wrist toward you . − Tightly circumscribed light slightly below the thyroid cartilage: tube has entered trachea − Faintly glowing light and bulging of the soft tissue: tube is in the vallecular space. − Dim, diffuse light at the anterior part of the neck: esophageal placement Technique for TransilluminationGuided Intubation • Once light is visible at the midline, hold the stylet in place and advance the tube. • When the tube is in the trachea, stabilize it and withdraw the stylet. • Inflate the distal cuff, detach the syringe, and attach the bag-mask device. Technique for TransilluminationGuided Intubation • Ventilate the patient while auscultating both lungs and the epigastrium. • Secure the tube and continue ventilations. • See Skill Drill 15-21. Retrograde Intubation • Needle: placed percutaneously within the trachea via the cricothyroid membrane • Wire: placed through the needle, through the trachea, into the mouth − Wire is visualized, secured − ET tube is placed over wire and guided into trachea Retrograde Intubation • Indications − Upper airway obstruction − Copious secretions in the airway − Failure to intubate by less invasive methods • Contraindications − Lack of familiarity with the procedure − Laryngeal trauma − Unrecognizable or distorted landmarks − Coagulopathy − Severe hypoxia Retrograde Intubation • Complications − Hypoxia − Cardiac dysrhythmia − Mechanical trauma − Infection − Increased intracranial pressure • See Skill Drill 15-22 Face-to-Face Intubation • Paramedic’s face is at the same level as the patient’s face − Head is stabilized, not in sniffing position. − Laryngoscope is held in the right hand; ET tube in left hand. − Once blade is placed, head may be adjusted by pulling mandible forward while pressing down. Failed Intubation • Definition: − Failure to maintain oxygen saturation during or after one or more failed intubation attempts − Total of three failed intubation attempts Failed Intubation • Many rescue airway techniques − Simple BLS airway maneuvers with oral airway and/or nasal airway and bag-mask device − Rescue airway device Tracheobronchial Suctioning • Involves passing a suction catheter into the ET tube to remove pulmonary secretions − Do not do it if you do not have to! − If it must be performed: • Use sterile technique. • Monitor cardiac rhythm and oxygen saturation. Tracheobronchial Suctioning • Preoxygenate for at least 2 to 3 minutes. • Insert suction catheter until resisted. − Apply suction as the catheter is extracted • Reattach bag-mask device, continue ventilations, and reassess. • See Skill Drill 15-23. Field Extubation • Extubation: process of removing tube from an intubated patient − Before performing, contact medical control or follow local protocols. Field Extubation • Risks − Over-estimating patient’s ability to protect airway − Laryngospasm − Upper airway swelling • Do not remove tube unless you can reintubate! Field Extubation • Contraindicated with any risk of recurrent respiratory failure or uncertainty about a patient’s ability to maintain airway • If indicated, ensure adequate oxygenation. Field Extubation • Explain procedure to patient • Have patient sit up or lean slightly forward. • Assemble equipment to suction, ventilate, and reintubate. Field Extubation • Confirm patient can protect airway • Suction oropharynx • Deflate distal cuff as patient exhales • On next exhalation, remove tube Pediatric Endotracheal Intubation • If bag-mask is not producing adequate ventilation, patient should be intubated − Indications are the same as those in adults Laryngoscope and Blades • Thinner pediatric handles are preferred. • Straight blades facilitate lifting of epiglottis • Blade should extend from mouth to ear Laryngoscope and Blades • Use length-based resuscitation tape measure or the following guidelines: − Premature newborn: size 0 straight blade − Newborn to 1 year: size 1 straight blade − 2 years to adolescent: size 2 straight blade − Adolescent and older: size 3 straight or curved blade Endotracheal Tubes • To estimate the appropriate size: − Length-based resuscitation tape measure − Formulas • [Age (in years) + 16] ÷ 4 © Jones & Bartlett Learning. Courtesy of MIEMSS. • [Age (in years) ÷ 4] + 4 − Anatomic clues − General guidelines Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP Endotracheal Tubes • Cuffed ET tubes are generally not used in the field until the child is 8 to 10 years old. − Can cause ischemia and damage the tracheal mucosa • Have tubes one size smaller and one size larger than expected Endotracheal Tubes • Appropriate depth of insertion is 2 to 3 cm beyond the vocal cords − Record depth at corner of mouth − Uncuffed tubes: stop when black band is at the vocal cords. − Cuffed tubes: stop when cuff is just below the vocal cords. Pediatric Stylet • Insert into tube, stop at least 1 cm from end • Fit tube sizes 3.0 to 6.0 mm • After inserting into tube, bend tube into a gentle upward curve Preoxygenation • Preoxygenate for at least 2 to 3 minutes. • Ensure that the child’s head is in the sniffing position or the neutral position. • If needed, insert an airway adjunct. Additional Preparation • Monitor cardiac rhythm. • Monitor pulse rate and oxygen saturation. • Have suction available. • Atropine sulfate may be administered. Pediatric Intubation Technique • With head in sniffing position, apply thumb pressure on chin to open mouth. • If an oral airway was inserted, remove it. • Suction if needed. • Hold the laryngoscope in “trigger finger” position. Pediatric Intubation Technique • Insert the blade in the right side of the mouth. − Sweep tongue to the left, keep under blade. • Advance the blade; apply traction upward. − Never use teeth/gums as a fulcrum for the blade Pediatric Intubation Technique • Straight blade: When the blade passes the epiglottis, gently lift the epiglottis. • Curved blade: place blade tip in vallecula; lift jaw, tongue, and blade at a 45° angle. • Identify vocal cords and other landmarks. Pediatric Intubation Technique • Hold tube in right hand; insert from the rightside corner of the mouth. • Guide tube through the vocal cords, advancing until black band is just beyond − Record the depth, and remove the blade. Pediatric Intubation Technique • Remove stylet; hold tube in place. • Recheck tube depth. • Cuffed tube: inflate to form seal • Attach tube to bag-mask device. Pediatric Intubation Technique • Confirm tube placement. − Bilateral chest rise during ventilation − Auscultate lungs bilaterally. − If sounds are decreased on left, tube may be too deep. • To correct, withdraw tube until sounds are equal. − Rerecord tube depth. Pediatric Intubation Technique • Auscultate over epigastrium. − Bubbling sounds indicate esophageal intubation. • Additional methods to confirm placement: − Improvement in skin color, pulse rate, and oxygen saturation − Waveform capnography Pediatric Intubation Technique • Colorimetric ETCO2 detector or EDD − Cannot be used in children weighing < 15 kg − Esophageal bulb or syringe cannot be used in children weighing < 20 kg • After placement, secure tube − Reconfirm placement following any movement. Pediatric Intubation Technique • If tube is too large or you cannot identify the vocal cords and glottic landmarks: − Abort intubation and ventilate. − Modify equipment and start from the beginning. − If intubation cannot be accomplished after two attempts, discontinue. Pediatric Intubation Technique • See Skill Drill 15-24. • If child’s condition deteriorates, use DOPE for common causes. − − − − Displacement Obstruction Pneumothorax Equipment failure Complications of Endotracheal Intubation • Essentially the same as for adults − − − − Unrecognized esophageal intubation Induction of emesis and aspiration Hypoxia Damage to teeth, soft tissues, and intraoral structures Pharmacologic Adjuncts to Airway Management and Ventilation • Decrease the discomfort of intubation • Decrease the incidence of complications • Make aggressive airway management possible for patients who are unable to cooperate Sedation in Emergency Intubation • Reduces anxiety, induces amnesia, decreases gag reflex • Undersedation: − Inadequate cooperation − Complications of gagging − Incomplete amnesia Sedation in Emergency Intubation • Oversedation: − Uncontrolled general anesthesia − Loss of protective airway reflexes − Respiratory depression − Complete airway collapse − Hypotension Sedation in Emergency Intubation • Desired level of sedation dictates dose • Two major classes: − Analgesics: decrease perception of pain − Sedativehypnotics: induce sleep, decrease anxiety Butyrophenones • Potent, effective sedatives − Haloperidol and droperidol relieve anxiety. • Do not produce apnea • Little effect on cardiovascular system • Not recommended to induce anesthesia Benzodiazepines • Sedative-hypnotic drugs • Diazepam and midazolam − Provide muscle relaxation, mild sedation − Used as anxiolytic and antiseizure medications − Provide anterograde amnesia Benzodiazepines • Neuromuscular blockers preferred for muscle relaxation • Potential side effects: − Respiratory depression − Slight hypotension • Flumazenil: benzodiazepine antagonist Barbituates • Sedative-hypnotic medications • Thiopental − Short acting − Rapid onset • Methohexital − Ultra-short acting − Twice as potent • Can cause − Respiratory depression − Drop in blood pressure • Potentially irreversible in hypovolemic patients Opioids/Narcotics • Potent analgesics with sedative properties • Two most common: fentanyl, alfentanil • Can cause respiratory and central nervous system depression • Naloxone: narcotic antagonist Nonnarcotic/Nonbarbituate • Etomidate − Hypnotic-sedative drug − Often used in induction of general anesthesia − Fast-acting, short duration − Little effect on pulse rate, blood pressure, intracranial pressure (ICP) Nonnarcotic/Nonbarbituate • Etomidate (cont’d) − No histamine release and bronchoconstriction − High incidence of myoclonic muscle movement − Useful induction agent in patients with: • Coronary artery disease • Increased ICP • Borderline hypotension/hypovolemia Neuromuscular Blockade in Emergency Intubation • Cerebral hypoxia can make patients combative and uncooperative. − Requires aggressive oxygenation, ventilation − Neuromuscular blocking agents are safer. Neuromuscular Blocking Agents • Affect every skeletal muscle • Within about 1 minute, patient is paralyzed • Must be able to secure the airway • No effect on LOC. Pharmacology of Neuromuscular Blocking Agents • Skeletal muscles are voluntary. − Impulse to contract reaches a motor nerve − Acetylcholine (Ach) is released. • Diffuses, occupies receptor sites • Triggers changes in electrical properties of the muscle fiber (depolarization) Pharmacology of Neuromuscular Blocking Agents • Paralytic medications − Relax the muscle by impeding the action of Ach − Two categories: depolarizing and nondepolarizing Depolarizing Neuromuscular Blocking Agent • Competitively binds with ACh receptor sites − Not affected as quickly by acetylcholinesterase • Succinylcholine chloride is the only agent. − Fasciculations can be observed during its administration. Depolarizing Neuromuscular Blocking Agent • Very rapid onset of total paralysis • Short duration of action • Use with caution in patients with burns, crush injuries, and blunt trauma • Can cause bradycardia Nondepolarizing Neuromuscular Blocking Agents • Bind to ACh receptor sites but do not cause depolarization of the muscle fiber. • Prevent fasciculations before a depolarizing paralytic Nondepolarizing Neuromuscular Blocking Agents • Most commonly used − Vecuronium bromide (Norcuron) − Pancuronium bromide (Pavulon) − Rocuronium bromide (Zemuron) • Do not give before the airway is secured. Rapid-Sequence Intubation (RSI) • Safe, smooth, rapid sedation and paralysis followed immediately by intubation • Generally used for patients who are unable to cooperate Preparation of the Patient and Equipment • Explain procedure, reassure the patient • Apply a cardiac monitor and pulse oximeter. • Check, prepare, assemble equipment − Have suction available Preoxygenation • Adequately preoxygenate all patients. − If the patient is breathing spontaneously and has adequate tidal volume: • Apply high-flow oxygen via nonrebreathing mask. − If patient is hypoventilating: • Assist ventilations with a bag-mask device and highflow oxygen. Premedication • Stimulation of the glottis with intubation can cause dysrhythmias and increase ICP. • If your initial paralytic is succinylcholine, administer nondepolarizing paralytic. • Atropine sulfate should be administered to decrease potential for bradycardia. Sedation and Paralysis • As soon as patient is sedated, administer paralytic agent − Onset should be complete within 2 minutes. − Signs of adequate paralysis include: • Apnea • Laxity of the mandible • Loss of the eyelash reflex Intubation • Intubate trachea as carefully as possible. − If you cannot intubate within 30 seconds, ventilate for 30–60 seconds before trying again. • If ventilating with a bag-mask device, do so slowly. Intubation • Once tube is in the trachea: − Inflate cuff. − Remove stylet. − Verify position of the ET tube. − Secure the tube. − Continue ventilations. Maintenance of Paralysis and Sedation • Additional paralytic administration may be necessary after intubation. − If you administered succinylcholine, administer a nondepolarizing agent to maintain paralysis. − If you administered a long-acting paralytic, additional dosing is usually not necessary. Maintenance of Paralysis and Sedation • Modification for unstable patients − If oxygen saturation drops, ventilate slowly. − If patient is hemodynamically unstable, judge whether sedation is appropriate. Multilumen Airways • Inserted blindly • Proven to secure airway and allow for better ventilation. • Two devices: − Pharyngotracheal lumen airway − Combitube Multilumen Airways • Combitube − Long tube − Can be used for ventilation whether it is inserted into the esophagus or trachea Multilumen Airways • Indications − Unresponsive, apneic patients with no gag reflex in whom intubation is not possible • Cannot be used in children younger than 16 years • Only use for patients between 5′ and 7′ tall. • Contraindications − Esophageal trauma − Known pathologic condition of the esophagus − Ingestion of a caustic substance − History of alcoholism Multilumen Airways • Advantages − Ventilation in esophagus or trachea − Insertion is easier than ET intubation − Minimal cervical spine movement − No mask seal − Airway patency • Disadvantages − Wrong port results in no pulmonary ventilation − Should be replaced when possible − Risk of aspiration − Intubating the trachea via direct laryngoscopy is challenging. Complications of Multilumen Airways • Unrecognized displacement into esophagus • Laryngospasm, vomiting, hypoventilation • Pharyngeal or esophageal trauma • Ventilation may be difficult if the pharyngeal balloon pushes the epiglottis over the glottic opening. Insertion Techniques • Combitube consists of: − Single tube with two lumens − Two balloons − Two ventilation attachments • Before insertion, prepare equipment. Insertion Techniques • Head should be in a neutral position − Insert thumb into the mouth and lift the jaw. • Insert device until incisors are between the two black lines • Two valves must be inflated sequentially. • See Skill Drill 15-25. Insertion Techniques • After inflation of balloons, begin to ventilate − Through the longer (blue) tube first • Observe for chest rise and auscultate. − If there are no breath sounds, switch to the shorter (clear) tube. • Continuously monitor ventilation. Laryngeal Mask Airway (LMA) • Option for patients who: − Require more support than bagmask − Do not require ET intubation • Conduit from glottic opening to ventilation device Laryngeal Mask Airway (LMA) • Surrounds larynx opening with an inflatable cuff − Cuff conforms to airway contours, forms airtight seal Laryngeal Mask Airway (LMA) • Indications and contraindications − Alternative to bag-mask ventilation − Less effective in obese patients − Pregnant patients and patients with a hiatal hernia are at risk for regurgitation. − Ineffective with patients requiring high pulmonary pressures Laryngeal Mask Airway (LMA) • Advantages − Better ventilation − No continual maintenance of a mask seal − No laryngoscopy − Less risk of trauma − Protection from secretions • Disadvantages − No protection against aspiration − Air may be insufflated into the stomach − Not a primary airway in emergency situations Complications of Using LMA • Involve regurgitation and aspiration − Weigh against risk of hypoventilation • Hypoventilation of patients who require high ventilatory pressures can occur. • Upper airway swelling has been reported. Equipment for LMA • Seven sizes; based on the patient weight • Consists of tube and inflatable mask cuff • Two bars at opening prevent occlusion • Proximal end is fitted with standard adapter Equipment for LMA • Cuff has a one-way valve assembly • 6.0-mm ET tube can be passed through size 3 or 4 LMA • Fasttrach LMA guides ET tube into trachea King LT Airway • Latex-free, singleuse, single-lumen − Positive-pressure ventilation for apneic patients − Maintains airway in spontaneously breathing patients who need advanced management Courtesy of King Systems. King LT Airway • Curved tube with ventilation ports between two inflatable cuffs − Can be inserted more easily than the Combitube King LT Airway • Two types: − King LT-D: used for adults and children − King LTS-D: used for adults • Five sizes of each type King LT Airway • King LT-D and LTS-D share many features: − Proximal pharyngeal cuff, distal cuff, ventilation outlets − ET tube introducer (gum elastic bougie) can be inserted through the tube − Distal end: closed in LT-D; open in LTS-D King LT Airway • Indications − Alternative to bagmask ventilation when a rescue airway device is required − Same considerations as Combitube • Contraindications − Patients with an intact gag reflex − Patients with known esophageal disease − Patients who have ingested a caustic substance Complications of the King LT Airway • Laryngospasm, vomiting, hypoventilation • Trauma from improper insertion technique • Pharyngeal balloon may push the epiglottis over the glottic opening − May make ventilation difficult Insertion Technique • Patient’s height and weight determine size you should use. • See Skill Drill 15-27. Cobra Perilaryngeal Airway (CobraPLA) • Shape lets device: − Slide easily along the hard palate − Hold airway’s soft tissue away from the laryngeal inlet • Available in eight sizes Courtesy of Candice M. Thompson, NREMT-P Cobra Perilaryngeal Airway (CobraPLA) • Indications − Usage similar to other supraglottic airway devices − Can be used in pediatric patients − Does not protect against aspiration • Contraindications − Risk for aspiration − Risk for massive trauma to oral cavity Contraindications and Complications • Complications − Laryngospasm may occur with intact gag reflex − Cuff inflation may cause tongue to disrupt seal. − Patient cannot be ventilated if device is too small. • Insertion technique − See Skill Drill 15-28. Surgical and Nonsurgical Cricothyrotomy • Used when conventional techniques fail • Be familiar with: − Anatomy of the anterior aspect of the neck − Important blood vessels in area Open Cricothyrotomy • Involves: − Incising the cricothyroid membrane − Inserting an ET or tracheostomy tube directly into the subglottic area of the trachea • Cricothyroid membrane is ideal for surgical opening into the trachea Open Cricothyrotomy • Several types: − Open (surgical) cricothyrotomy − Modified cricothyrotomy (Seldinger technique) − Device that functions as an introducer and an airway Courtesy of Cook Medical Open Cricothyrotomy • Indications − Patent airway cannot be secured with conventional means • Severe foreign body obstructions • Swelling of airway • Maxillofacial trauma • Inability to open mouth Open Cricothyrotomy • Contraindications − Ability to secure a patent airway − Inability to identify anatomic landmarks − Crushing injuries to the larynx and tracheal transection − Underlying anatomic abnormalities − Age younger than 8 years Open Cricothyrotomy • Advantages − Can be performed quickly − Do not need to manipulate cervical spine • Disadvantages − Difficult to perform in children and patients with short, muscular, or fat necks − More difficult than needle cricothyrotomy Open Cricothyrotomy • Complications − Severe bleeding from laceration of the external jugular vein. − Risks of perforating the esophagus and damaging the laryngeal nerves − Taking too long will result in hypoxia − Subcutaneous emphysema from tube misplacement Open Cricothyrotomy Equipment • If a commercial kit is not available, prepare: − Scalpel − ET or tracheostomy tube − Commercial device (or tape) to secure tube − − − − Curved hemostats Suction apparatus Sterile gauze pads Bag-mask device attached to 100% oxygen Technique for Performing Open Cricothyrotomy • Proceed rapidly yet cautiously • Palpate for V notch of thyroid cartilage • Slide index finger into depression between thyroid and cricoid cartilage − That is the cricothyroid membrane. Technique for Performing Open Cricothyrotomy • Partner prepares equipment • Maintain aseptic technique. • Stabilize larynx; make a 1- to 2-cm vertical incision over the cricothyroid membrane. Technique for Performing Open Cricothyrotomy • Insert a 6.0-mm cuffed ET tube or a 6.0 tracheostomy tube into trachea. • Inflate the distal cuff. • Attach the bag-mask device, and ventilate while your partner auscultates. Technique for Performing Open Cricothyrotomy • Confirm proper tube placement. • Ensure bleeding has been controlled. • Secure tube and continue to ventilate. • See Skill Drill 15-29. Needle Cricothyrotomy • 14- to 16-gauge over-the-needle IV catheter inserted into the trachea • High-pressure jet ventilator attached to catheter hub − Translaryngeal catheter ventilation Needle Cricothyrotomy • Indications − Inability to ventilate by less invasive means − Maxillofacial trauma − Inability to open mouth − Uncontrolled oropharyngeal bleeding • Contraindications − Severe airway obstruction above catheter insertion • High-pressure ventilator leads to barotrauma and pneumothorax − If equipment is not immediately available Needle Cricothyrotomy • Advantages − Easier than open cricothyrotomy − Lower risk of damaging structures − Allows for intubation − No manipulation of cervical spine • Disadvantages − Does not provide protection from aspiration − Technique requires a specialized, highpressure jet ventilator Needle Cricothyrotomy • Complications − Improper placement can cause severe bleeding. − Excessive air leakage can cause subcutaneous emphysema and compression of the trachea. − Overinflation of lungs: barotrauma − Underinflation of lungs: hypoventilation Needle Cricothyrotomy Equipment • Large-bore IV catheter (14–16 gauge) • 10-mL syringe • 3 mL of sterile water or saline • Oxygen source (50 psi) • High-pressure jet ventilator device and oxygen tubing Technique for Performing Needle Cricothyrotomy • Draw up approximately 3 mL of sterile water or saline into a 10-mL syringe. − Attach to IV catheter. • Place head in neutral position • Locate the cricothyroid membrane. • Cleanse area if time permits. Technique for Performing Needle Cricothyrotomy • Stabilize the larynx; insert the needle at a 45° angle toward the feet. − You should feel a pop as the needle penetrates the membrane. • After a pop is felt, insert needle 1 cm farther; aspirate with the syringe. Technique for Performing Needle Cricothyrotomy • Advance catheter over needle until catheter hub is flush with skin − Withdraw the needle; dispose of properly. • Attach one end of the oxygen tubing to the catheter; other end to the jet ventilator Technique for Performing Needle Cricothyrotomy • Begin ventilations by opening the release valve on the jet ventilator − Turn release valve off with chest rise. • Secure catheter and continue ventilations. • See Skill Drill 15-30. Summary • The upper airway consists of all structures above the vocal cords. • The lower airway consists of all structures below the vocal cords. • The diaphragm is the major muscle of breathing. The intercostal muscles and the accessory muscles also play a role. Summary • The respiratory and cardiovascular systems deliver oxygen and nutrients to cells and remove waste products. • Ventilation, oxygenation, and respiration are crucial for tissues to receive nutrients. • Ventilation, the act of moving air into and out of the lungs, requires the diaphragm and intercostal muscles. Diffusion allows oxygen transfer from air into the capillaries. Summary • Changes in oxygen demand are regulated primarily by the pH of CSF. Medullary respiratory centers control rate, depth, and rhythm of breathing. • Negative-pressure ventilation draws air into the lungs. Positive-pressure ventilation forces air into the lungs. • Oxygenation is the process of loading oxygen molecules onto hemoglobin in the bloodstream. Summary • Respiration is the exchange of oxygen and carbon dioxide in the alveoli and tissues. • Primary respiratory drive is based on increasing arterial CO2 level and pH of CSF. Hypoxic drive is based on decreasing arterial oxygen levels. • Many conditions can inhibit oxygen delivery to cells. Ventilation/perfusion mismatch can lead to severe hypoxemia. Summary • Other factors that impede oxygen delivery include airway swelling and obstruction, some medications, neuromuscular disorders, respiratory and cardiac diseases, hypoglycemia, circulatory compromise, submersion, and trauma. • Disruptions in the acid-base balance can lead to rapid deterioration and death. Summary • Adequate breathing features a respiratory rate between 12 and 20 breaths/min, adequate tidal volume, regular inhalation and exhalation, symmetric chest rise, and bilaterally clear and equal breath sounds. • Inadequate breathing features a rate that is too slow or too fast, shallow breathing, irregular inhalation and exhalation, asymmetric chest movement, adventitious airway sounds, cyanosis, and altered LOC. Summary • Abnormal breathing patterns include agonal gasps; Cheyne-Stokes, Kussmaul, ataxic, or apneustic respirations. • Auscultate breath sounds with a stethoscope to assess breathing. Breath sounds should be clear and equal. • The pulse oximeter measures the percentage of blood oxygen saturation (SpO2). Summary • Peak expiratory flow assesses bronchoconstriction and is used to gauge treatment effectiveness. • End-tidal CO2 monitors detect carbon dioxide in exhaled air and help determine ventilation adequacy in spontaneously breathing patients or with an advanced airway. Summary • Patients with inadequate breathing require positive-pressure ventilation; patients with adequate breathing who are suspected of being hypoxemic require 100% oxygen via a nonrebreathing mask. • Unrecognized inadequate breathing leads to hypoxia, a dangerous condition in which cells and tissues do not receive adequate oxygen. Summary • The airway must remain patent at all times. First position the patient in the recovery position. • Properly position the head. Manual airway maneuvers include the head tilt-chin lift, jaw-thrust, and tongue-jaw lift. • Clearing the airway means removing obstructing material; maintaining the airway means keeping it open. Summary • Oropharyngeal suctioning may be required after opening an airway. • Limit oropharyngeal suction to 15 seconds in an adult, 10 seconds in a child, and 5 seconds in an infant. • It is critical to differentiate between a partial and complete airway obstruction. Summary • Chest compressions, finger sweeps, manual removal, and attempts to ventilate is the recommended sequence with a foreign body airway obstruction in an unresponsive adult. • Basic airway adjuncts include the oropharyngeal and nasopharyngeal airways. Summary • Administer supplemental oxygen to any patient with potential hypoxia. Be familiar with cylinder sizes and duration of flow, and always use safety precautions. • The nonrebreathing mask is the preferred device for oxygenating adequately breathing patients. Use the nasal cannula if the patient cannot tolerate the nonrebreathing mask. Summary • The methods of providing artificial ventilation include the two-person bag-mask technique, mouth-to-mask with one-way valve and supplemental oxygen attached, manually triggered ventilation device, and the one-person bag-mask technique. • Continuous positive airway pressure (CPAP) improves breathing by forcing fluid from the alveoli or dilating the bronchioles. Summary • Remove loose dental appliances before artificial ventilation. • Remove dental appliances before intubation. • Patients with massive maxillofacial trauma are at high risk for airway compromise due to oral bleeding. Assist ventilations, provide oral suctioning as needed. Summary • Ventilating too forcefully or too fast can cause gastric distention, which can cause regurgitation and aspiration. • Invasive gastric decompression involves inserting a gastric tube into the stomach. • Patients with a tracheal stoma or tracheostomy tube may require ventilation, suctioning, or tube replacement. Summary • Patients who are unresponsive or cannot maintain their own airway are candidates for endotracheal intubation, the insertion of an ET tube into the trachea. In orotracheal intubation, the tube is inserted via the mouth; in nasotracheal intubation, the tube is inserted via the nose. • You must confirm and monitor ET tube placement in intubation. Summary • If an attempted intubation does not result in acceptable oxygen saturations, perform BLS maneuvers with an oral airway and/or nasal airway and a bag-mask device, and consider using another airway device. • Tracheobronchial suctioning is indicated if an intubated patient’s condition deteriorates because of pulmonary secretions in the ET tube. Summary • Do not extubate unless the patient is unreasonably intolerant of the tube. • Pediatric ET intubation involves adult techniques but smaller equipment. • Rapid-sequence intubation (RSI) involves using pharmacologic agents to sedate and paralyze a patient to facilitate placement of an ET tube. Summary • Drugs used for RSI include sedatives and neuromuscular blocking agents (paralytics) to induce complete paralysis. • Alternative airway devices include the Combitube, laryngeal mask airway, King LT airway, and Cobra perilaryngeal airway. Summary • Open (surgical) cricothyrotomy involves incising the cricothyroid membrane, inserting a tracheostomy tube or ET tube into the trachea, and ventilating with a bagmask device. • Needle cricothyrotomy involves inserting a 14- to 16-gauge over-the-needle catheter through the cricothyroid membrane and ventilating with a high-pressure jet ventilation device. Credits • Chapter opener: © Mark C. Ide. • Backgrounds: Orange—© Keith Brofsky/ Photodisc/Getty Images; Purple—Jones & Bartlett Learning. Courtesy of MIEMSS; Red—© Margo Harrison/ShutterStock, Inc.; Green—Courtesy of Rhonda Beck. • Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.