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    Airway management.ppt Airway management.ppt Presentation Transcript

    • Chapter 11 Airway Management and Ventilation
    • Patient Airway  Establishing, maintaining, and ensuring effective oxygenation are vital aspects of effective patient care.  Open  No airway, no patient
    • Anatomy of the Upper Airway  All anatomic airway structures above the level of the vocal cords –  Major function   Warm, filter, and humidify air
    • Pharynx  Throat –  Muscular tube that extends from the nose and mouth to the level of the esophagus and trachea –  Composed of the nasopharynx, oropharynx, and laryngopharynx
    • Nasopharynx (1 of 5)  Inhalation –  Air enters the body through the nose. –  Passes into the nasopharynx –  Formed by the union of the facial bones
    • Nasopharynx (2 of 5)  Nasal cavity –  Lined with ciliated mucous membrane –  Mucous membrane  Trauma to the nasal cavity –  Bleeding cannot be controlled by direct pressure. –  Concern for deeper skull and cranial injury
    • Nasopharynx (3 of 5)  Turbinates –  Three bony shelves –  Protrude from the lateral walls of the nasal cavity and extend into the nasal passageway –  Increase the surface area of the nasal mucosa –  Improve the processes of warming, filtering, and humidification of inhaled air
    • Nasopharynx (4 of 5)  Nasal septum –  Divides the nasopharynx into two passages –  One passage is larger than the other. –  Rigid partition composed of bone and cartilage –  Normally in the midline of the nose
    • Nasopharynx (5 of 5)  Sinuses –  Cavities formed by the cranial bones –  Fractures of these bones may cause cerebrospinal fluid to leak from the nose or the ears. –  Significant bleeding from sinus fractures –  Prevent contaminants from entering the respiratory tract
    • Oropharynx (1 of 7)  Forms the posterior portion of the oral cavity –  Bordered superiorly by the hard and soft palates, laterally by the cheeks, and inferiorly by the tongue –  32 adult teeth –  Significant force to dislodge teeth   Easily create an airway obstruction
    • Oropharynx (2 of 7)  Hyoid bone –  Beneath the mandible –  Only human bone that does not articulate with any other bone –  Anchors tongue muscles to jaw to suspend airway –  Anchors to the thyroid cartilage by the thyroid membrane
    • Oropharynx (3 of 7)  Palate –  Forms the roof of the mouth –  Separates the oropharynx and nasopharynx –  Hard palate –  Soft palate
    • Oropharynx (4 of 7)  Adenoids and tonsils –  Located on the posterior nasopharyngeal wall –  Lymphatic tissues that filter bacteria –  Adenoids and tonsils often become swollen and infected –  Severe swelling of the tonsils can cause obstruction of the upper airway.
    • Oropharynx (5 of 7)  Uvula –  Soft-tissue structure –  Resembles a punching bag –  Located in the posterior aspect of the oral cavity, at the base of the tongue
    • Oropharynx (6 of 7)  Epiglottis –  Superior border of the glottic opening –  Leaf-shaped cartilaginous flap –  Prevents food and liquid from entering the larynx during swallowing –  Bacterial infection can cause swelling, creating an airway obstruction.
    • Oropharynx (7 of 7)  Vallecula –  Anatomic space or “pocket” –  Located between the base of the tongue and the epiglottis –  Important landmark for endotracheal intubation
    • Larynx (1 of 8)  Complex structure –  Formed by many independent cartilaginous structures –  Marks where the upper airway ends and the lower airway begins
    • Larynx (2 of 8)  Thyroid cartilage –  Shield-shaped structure –  Formed by two plates that join in a “V” shape anteriorly –  Form the laryngeal prominence known as the Adam’s apple –  Suspended in place by the thyroid ligament –  Directly anterior to the glottic opening
    • Larynx (3 of 8)  Cricoid cartilage –  Lies inferiorly to the thyroid cartilage –  Forms the lowest portion of the larynx –  First ring of the trachea –  Only upper airway structure that forms a complete ring
    • Larynx (4 of 8)  Cricothyroid membrane –  Between the thyroid and cricoid cartilages –  Site for emergency surgical and nonsurgical access to the airway –  Bordered laterally and inferiorly by the highly vascular thyroid gland –  EMS personnel must locate the anatomical landmarks carefully when accessing the airway via this site.
    • Larynx (5 of 8)  Glottis –  Space in between the vocal cords and the narrowest portion of the adult’s airway –  Airway patency is heavily dependent on adequate muscle tone.
    • Larynx (6 of 8)  Arytenoid cartilage –  Pyramid-like cartilaginous structures –  Form the posterior attachment of the vocal cords –  Valuable guides for endotracheal intubation –  As they pivot, the vocal cords open and close, regulating the passage of air through the larynx and controlling the production of sound.
    • Larynx (7 of 8)  Pyriform fossae –  Two pockets of tissue on the lateral borders of the larynx –  Airway devices are occasionally inadvertently inserted into these pockets. –  Tenting of the skin under the jaw
    • Larynx (8 of 8)  Laryngospasm –  Spasmodic closure of the vocal cords, which seals off the airway –  Reflex normally lasts a few seconds –  If persistent it threatens the airway by preventing ventilation.
    • Anatomy of the Lower Airway (1 of 7)  Function –  Exchange oxygen and carbon dioxide  Location –  Externally, it extends from the fourth cervical vertebra to the xiphoid process. –  Internally, it spans the glottis to the pulmonary capillary membrane.
    • Anatomy of the Lower Airway (2 of 7)
    • Anatomy of the Lower Airway (3 of 7)  Trachea –  Conduit for air entry into the lungs –  Tubular structure –  Approximately 10 to 12 cm in length and consists of a series of C-shaped cartilaginous rings –  Begins immediately below the cricoid cartilage –  Descends anteriorly down the midline of the neck and chest to the level of the fifth or sixth thoracic vertebra –  Divides into the right and left mainstem bronchi at the level of the carina
    • Anatomy of the Lower Airway (4 of 7)  Hilum –  All of the blood vessels and the bronchi enter each lung at this spot. –  Lungs consist of the entire mass of tissue that includes the smaller bronchi, bronchioles, and alveoli.
    • Anatomy of the Lower Airway (5 of 7)  Lungs –  Right lung has three lobes. –  Left lung has two lobes. –  Visceral pleura –  Parietal pleura –  Small amount of fluid is found between the pleurae.
    • Anatomy of the Lower Airway (6 of 7)  Bronchus –  Divides into increasingly smaller bronchi –  Bronchioles –  Smaller bronchioles branch into alveolar ducts that end at the alveolar sacs.
    • Anatomy of the Lower Airway (7 of 7)  Alveoli –  Balloon-like clusters of single-layer air sacs –  Functional site for the exchange of oxygen and carbon dioxide –  Surfactant –  Atelectasis
    • Total Lung Capacity  Average adult male –  6 L –  Only a fraction of this capacity is used during normal breathing. –  Most of the gas exchange occurs in the alveoli.
    • Tidal Volume (VT)  Measure of the depth of breathing –  Volume of air that is inhaled or exhaled during a single respiratory cycle –  Inspiratory reserve volume –  Dead space   Anatomic dead space   Physiologic dead space
    • Alveolar Volume  Remaining volume of inhaled air  Reaches the alveoli and participates in gas exchange  Equal to tidal volume minus dead space volume
    • Minute Volume (1 of 2)  Amount of air that moves into and out of the respiratory tract per minute –  Multiply the tidal volume (minus dead space volume) by the respiratory rate –  Will increase if either the tidal volume or the respiratory rate increases –  Will decrease if either the tidal volume or the respiratory rate decreases
    • Minute Volume (2 of 2)
    • Functional Reserve Capacity  Amount of air that can be forced from the lungs in a single exhalation –  Expiratory reserve volume –  Residual volume
    • Fraction of Inspired Oxygen (FIO2)  Percentage of oxygen in inhaled air –  Increases when supplemental oxygen is given to a patient –  Commonly documented as a decimal point
    • Ventilation (1 of 2)  Process of moving air into and out of the lungs –  Two phases   Inspiration: process of moving air into the lungs   Expiration: process of moving air out of the lungs
    • Ventilation (2 of 2)  Cycle –  One inspiration and one expiration   Inspiration: one third of the ventilation cycle   Expiration: two thirds of the ventilation cycle
    • Regulation of Ventilation (1 of 4)  Body’s need for oxygen ’ –  Dynamic –  Constantly changing –  Respiratory system must be able to accommodate those changes by altering the rate and depth of ventilation.   Primarily regulated by the pH of the CSF
    • Regulation of Ventilation (2 of 4)  Neural control of ventilation –  Involuntary control of breathing originates in the brain stem. –  Impulses descend through the spinal cord and can be overridden by voluntary control. –  Phrenic nerve –  Intercostal nerve –  Respiratory rhythmicity center –  Hering-Breur reflex –  Apneustic center –  Pneumotaxic center
    • Regulation of Ventilation (3 of 4)  Chemical control of ventilation –  Chemoreceptors –  Carbon dioxide content monitors –  Central chemoreceptors –  Increase in acidity of the CSF causes increased rate and depth of breathing. –  Primary respiratory drive –  Hypoxic drive
    • Regulation of Ventilation (4 of 4)  Control of ventilation by other factors –  Body temperature –  Medications –  Hypoxia –  Acidosis –  Metabolic rate
    • The Mechanics of Ventilation (1 of 2)  Accomplished –  Pressure changes brought about by contraction and relaxation of the intercostal muscles and diaphragm  Inhalation –  Active process   Initiated by contraction of the respiratory muscles   Net effect is to increase the volume of the chest.   Lungs undergo a comparable increase in volume.   Negative-pressure ventilation
    • The Mechanics of Ventilation (2 of 2)  Exhalation –  Passive process   At the end of inhalation, the respiratory muscles relax.   Natural elasticity of the lungs passively exhales the air.
    • Respiration (1 of 2)  Mechanism to ensure a constant oxygen supply and the removal of excess carbon dioxide –  External respiration (pulmonary respiration) –  Internal respiration (cellular respiration)
    • Respiration (2 of 2)  Diffusion –  Gas exchange in the body –  Process in which a gas moves from an area of higher concentration to an area of lower concentration –  Dissolved oxygen crosses the pulmonary capillary membrane and binds to the hemoglobin molecule of the red blood cell. –  Approximately 97% of the body’s total oxygen is bound to hemoglobin. –  Pulse oximetry measures the percentage of hemoglobin that is saturated with oxygen.
    • Decreased Oxygen Concentrations (1 of 4)   Numerous conditions –  Lower partial pressure of atmospheric oxygen –  Severe bleeding –  Anemia: deficiency in red blood cells –  Carbon monoxide poisoning
    • Decreased Oxygen Concentrations (2 of 4)   Conditions that reduce the surface air for gas exchange –  Flail chest –  Diaphragmatic injury –  Simple or tension pneumothorax –  Open pneumothorax –  Hemothorax –  Hemopneumothorax
    • Decreased Oxygen Concentrations (3 of 4)   Decreased mechanical effort –  Severe chest pain secondary to trauma or a medical condition –  Traumatic asphyxia –  Hypoventilation
    • Decreased Oxygen Concentrations (4 of 4)   Medical conditions –  Pneumonia, pulmonary edema, and chronic obstructive pulmonary disease –  Nonfunctional alveoli –  Intrapulmonary shunting –  Diminished lung capacity due to disease or injury
    • Abnormal Carbon Dioxide Concentrations (1 of 3)  Balance –  Amount of CO2 produced remains relatively constant. –  As metabolic rate goes up more carbon dioxide is produced. –  Type of metabolism affects the levels as well.
    • Abnormal Carbon Dioxide Concentrations (2 of 3)  Hypoventilation –  Carbon dioxide production exceeds the body’s ability to eliminate it by ventilation.  Hyperventilation –  Occurs when carbon dioxide elimination exceeds production
    • Abnormal Carbon Dioxide Concentrations (3 of 3)  Minute volume –  Decrease in minute volume causes a decrease in carbon dioxide elimination. –  Hypercarbia –  Hypocarbia
    • Measurement of Gases  Dalton’s law of partial pressure ’ –  Total pressure of a gas is the sum of the partial pressure of the components of that gas, or the pressure exerted by a specific atmospheric gas.
    •   You are dispatched to a private home for an unconscious patient.  When you arrive on scene you find the fire department performing CPR.  You note the patient’s abdomen to be grossly distended.
    • Airway Evaluation (1 of 2)  If you can see or hear a patient breathing –  Usually a problem –  Breathing at rest should appear effortless. –  Respiratory rate between 12 and 20 breaths/min
    • Airway Evaluation (2 of 2)  Patients will try to compensate. –  Preferential positioning –  Upright tripod position (elbows out) –  Semi-Fowler’s (semi-sitting) position –  Avoid a supine position.
    • Recognition of Airway Problems (1 of 4)  Conscious, alert, and able to speak –  No immediate airway or breathing problems –  You must still closely monitor a patient’s airway and breathing status and be prepared to intervene.  Adult patient with abnormal respiratory rate –  Evaluate for other signs of inadequate ventilation.
    • Recognition of Airway Problems (2 of 4)  Causes of inadequate ventilation –  Severe infection –  Trauma –  Brain stem insult –  Noxious or oxygen-poor atmosphere –  Renal failure  Causes of respiratory distress –  Upper and/or lower airway obstructions –  Impairment of the respiratory muscles –  Impairment of the nervous system
    • Recognition of Airway Problems (3 of 4)  Dyspnea –  Any difficulty in respiratory rate, regularity, or effort –  Hypoxemia –  Hypoxia –  Anoxia
    • Recognition of Airway Problems (4 of 4)  Nonpatent airway or absent/inadequate breathing –  Proper airway management involves   Opening the airway   Clearing the airway   Assessing, intervening, and reassessing breathing
    • Evaluation of the Airway (1 of 4)  Visual techniques –  How is the patient positioned? –  Is rise and fall of the chest adequate? –  Is the patient gasping for air? –  What is the skin color? –  Is there flaring of the nostrils?
    • Evaluation of the Airway (2 of 4)  Visual techniques (continued) –  Is the patient breathing through pursed lips? –  Do you note any retractions? –  Is the patient using accessory muscles to breathe? –  Is the patient’s chest wall moving symmetrically?
    • Evaluation of the Airway (3 of 4)  Listen –  Air movement at the patient’s nose and mouth –  Auscultate breath sounds with a stethoscope.
    • Evaluation of the Airway (4 of 4)  Feel –  Note any resistance or change in ventilatory compliance   Increased compliance   Decreased compliance –  Pulsus paradoxus –  Change in pulse quality, or even the disappearance of a pulse during inhalation may also be detected.
    • History of the Patient’s ’ Present Illness (1 of 2)  Was the onset of the problem sudden or gradual over time?  Is there any known cause or “trigger” of the event? ”  What is the duration?  Does anything alleviate or exacerbate the problem?  Are there any other associated symptoms, such as a productive cough, chest pain or pressure, or fever?
    • History of the Patient’s ’ Present Illness (2 of 2)  Were any interventions attempted prior to EMS arrival?  Has the patient been evaluated by a physician or admitted to the hospital for this condition in the past?  Is the patient currently taking any medications?  Does the patient have any risk factors that could cause or exacerbate his or her condition, such as alcohol or illicit drug use, cigarette smoking, or a poor diet?
    • Evaluate for Modified Forms of Respiration (1 of 3)  Protective reflexes of the airway –  Coughing –  Sneezing –  Gagging –  Gag reflex –  Aspiration
    • Evaluate for Modified Forms of Respiration (2 of 3)  Protective reflexes (continued) –  Eyelash reflex –  Sighing –  Hiccupping
    • Evaluate for Modified Forms of Respiration (3 of 3)
    • Diagnostic Testing (1 of 3)  Pulse oximeter –  Measures the percentage of hemoglobin in the arterial blood that is saturated –  Designed to assess pulsating blood vessels –  Normally oxygenated should be between 95% and 99% –  Monitor the oxygenation of a patient during an intubation attempt or during suctioning.
    • Diagnostic Testing (2 of 3)
    • Diagnostic Testing (3 of 3)  Circumstances that might produce erroneous readings –  Bright ambient light –  Patient motion –  Poor perfusion –  Nail polish –  Venous pulsations –  Abnormal hemoglobin
    • Skill Drill 11-1: Performing Pulse OximetryStep 1 Step 2
    • Peak Expiratory Flow  Peak rate of a forceful exhalation –  Increasing suggests that the patient is responding to treatment. –  Decreasing is an early indication that the patient’s condition is deteriorating.
    • Skill Drill 11-2: Peak Expiratory Flow MeasurementStep 1 Step 2 Step 3
    • Airway Management (1 of 2)  Positioning the patient –  Supine position   In a perfect world all patients would present in this position.   Quickly open the airway, assess breathing, and intervene without moving them.   Log roll the individual as a unit
    • Airway Management (2 of 2)–  Recovery position   Left lateral recumbent position   Should be used in all nontrauma patients with a decreased LOC who are able to maintain their own airway spontaneously and are breathing adequately
    • Manual Airway Maneuvers  Most common cause of airway obstruction –  Tongue –  Manually maneuver the patient’s head to propel the tongue forward.
    • Head Tilt–Chin Lift Maneuver  Tilting the patient’s head back and lifting the chin ’ –  Preferred technique for opening the airway of a patient who has not sustained trauma –  Indications –  Contraindications –  Advantages –  Disadvantages
    • Skill Drill 11-3:Head Tilt–Chin Lift Maneuver Step 1 Step 2 Step 3 Step 4
    • Jaw-Thrust Maneuver  If you suspect a cervical spine injury –  Open the airway by placing your fingers behind the angle of the jaw and lifting the jaw forward. –  Indications –  Contraindications –  Advantages –  Disadvantages
    • Skill Drill 11-4: Jaw-Thrust Maneuver Step 1 Step 2 Step 3
    • Jaw-Thrust Maneuver With Head Tilt   Similar to the head tilt–chin lift maneuver –  Indications –  Contraindications –  Advantages –  Disadvantages
    • Skill Drill 11-5: Jaw-Thrust Maneuver With Head TiltStep 1 Step 2 Step 3
    • Tongue-Jaw Lift Maneuver  Used more commonly to open a patient’s airway ’ for the purpose of suctioning or inserting an oropharyngeal airway  Cannot be used to ventilate a patient
    • Skill Drill 11-6: Tongue-Jaw Lift Maneuver Step 1 Step 2 Step 3
    • Causes of Airway Obstruction (1 of 5)  Secondary to an infectious process or a severe allergic reaction  Tongue –  Snoring respirations in partial obstruction –  Complete obstruction, no respiration –  Simple to correct
    • Causes of Airway Obstruction (2 of 5)  Foreign body –  Typical victim is middle-aged or older and wears dentures. –  Patients with conditions that decrease their airway reflexes are at an increased risk. –  Mild or severe airway obstruction
    • Causes of Airway Obstruction (3 of 5)  Laryngeal spasm and edema –  Results in spasmodic closure of the vocal cords –  Often caused by trauma during an overly aggressive intubation attempt or immediately upon extubation
    • Causes of Airway Obstruction (4 of 5)  Fractured larynx –  Patency depends on good muscle tone to keep the trachea open –  Increases airway resistance by decreasing airway size secondary to decreased muscle tone, laryngeal edema, and ventilatory effort –  Advanced airway may be required.
    • Causes of Airway Obstruction (5 of 5)  Aspiration –  Blood or other fluid significantly increases mortality. –  Destroys delicate bronchiolar tissue, introduces pathogens into the lungs, and decreases the patient’s ability to ventilate –  Suction should be readily available.
    • Recognition of an Airway Obstruction (1 of 3)  Foreign body lodged in the upper airway –  Can cause a mild or severe airway obstruction –  Rapid but careful assessment
    • Recognition of an Airway Obstruction (2 of 3)  Mild airway obstruction –  Conscious and able to exchange air –  May show varying degrees of respiratory distress –  Usually have noisy respirations and may be coughing –  Should be left alone; a forceful cough is the most effective means of dislodging the obstruction.
    • Recognition of an Airway Obstruction (3 of 3)   Severe airway obstruction –  Typically experiences a sudden inability to breathe, talk, or cough –  Grasps at his or her throat –  Weak, ineffective, or absent coughPhotographed by Kimberly Potvin.
    • Care for Foreign Body Airway Obstruction (1 of 4)  Patient with a suspected airway obstruction –  If conscious, ask “Are you choking?” If the patient nods “yes,” begin treatment. –  If the obstruction is not promptly cleared the amount of oxygen in the blood will decrease dramatically.
    • Care for Foreign Body Airway Obstruction (2 of 4)  Unresponsive patient –  Manage as if he or she has a compromised airway. –  Open and maintain the airway with the appropriate manual maneuver. –  Assess for breathing. –  Provide artificial ventilation if necessary.
    • Care for Foreign Body Airway Obstruction (3 of 4)  After opening the airway –  If you are unable to ventilate or if you feel resistance when ventilating, reopen the airway and again attempt to ventilate the patient. –  Lung compliance
    • Care for Foreign Body Airway Obstruction (4 of 4)  Large pieces of vomitus, mucus, loose dentures, or blood clots –  If found in the airway, sweep them forward and out of the mouth with your gloved index finger. –  Blind finger sweeps of the mouth –  Take care not to force the foreign body deeper into the airway. –  Do not blindly insert any object into the patient’s mouth. –  Suction to clear the airway of secretions.
    • Skill Drill 11-7:Managing Severe Airway Obstruction in a Conscious Adult or ChildStep 1 Step 2
    • Skill Drill 11-8: Managing Severe Airway Obstruction in an Unconscious Adult or ChildStep 1 Step 2 Step 3 Step 4
    • Skill Drill 11-9:Managing Severe Airway Obstruction in a Conscious Infant Step 1 Step 2
    • Skill Drill 11-10: Managing Severe Airway Obstruction in an Unconscious InfantStep 1 Step 2 Step 3 Step 4
    • Heimlich Maneuver  Abdominal thrusts –  Most effective method of dislodging and forcing an object out of the airway –  Aims to create an artificial cough by forcing residual air out of the victim’s lungs –  If the patient is in the advanced stages of pregnancy or is morbidly obese, perform chest thrusts instead.
    • Direct Laryngoscopy (1 of 2)  Visualization of the airway with a laryngoscope for the removal of the foreign body in unresponsive patients –  If you are unable to relieve a severe airway obstruction in an unconscious patient –  Insert the blade into the patient’s mouth.
    • Direct Laryngoscopy (2 of 2)–  If you see the foreign body, carefully remove it from the upper airway.–  Magill forceps
    • Skill Drill 11-11: Removal of an Upper Airway Obstruction With Magill ForcepsStep 1 Step 2 Step 3 Step 4
    • Suctioning  Patient’s mouth filled ’ –  Vomitus, blood, or secretions –  Suction apparatus enables you to remove the liquid quickly and efficiently. –  Ventilating a patient with secretions in his or her mouth will force material into the lungs, resulting in an upper airway obstruction or aspiration. –  If you hear gurgling, the patient needs suctioning!
    • Suctioning Equipment (1 of 7)  Ambulances should carry: –  Fixed suction unit –  Portable suction unit –  Regardless of location  Hand-operated suctioning units –  Disposable containers –  Reliable, effective, and relatively inexpensive
    • Suctioning Equipment (2 of 7)  Mechanical or vacuum-powered suction units –  Should be capable of generating a vacuum of 300 mm Hg within 4 seconds of clamping off the tubing –  Amount of suction should be adjustable for use in children and intubated patients. –  Check the vacuum at the beginning of every shift.
    • Suctioning Equipment (3 of 7)
    • Suctioning Equipment (4 of 7)
    • Suctioning Equipment (5 of 7)  Other supplies –  Wide-bore, thick-walled, nonkinking tubing –  Soft and rigid suction catheters –  A nonbreakable, disposable collection bottle –  A supply of water for rinsing the catheters
    • Suctioning Equipment (6 of 7)  Suction catheter –  Hollow, cylindrical device –  Used to remove fluids and secretions from the patient’s airway –  Yankauer catheter (tonsil-tip catheter)   Rigid catheter
    • Suctioning Equipment (7 of 7)  Suction catheter (continued) –  Whistle-tip catheters   Soft catheters
    • Suctioning Techniques (1 of 3)  Mortality increases significantly if a patient aspirates. –  Suctioning the upper airway is critical to avoid this fatal event. –  Removes not only liquids from the airway, but also oxygen –  Any patient who is to be suctioned should be adequately preoxygenated first.
    • Suctioning Techniques (2 of 3)  Using soft-tip catheters –  Must be lubricated when suctioning the nasopharynx –  Used through an ET tube –  Catheter is inserted and suction is applied during extraction of the catheter to clear the airway.
    • Suctioning Techniques (3 of 3)  Before inserting any suction catheter –  Make sure you measure for the proper size. –  Never insert a catheter past the base of the tongue.
    • Skill Drill 11-12: Suctioning a Patient’s Airway ’Step 1 Step 2 Step 3 Step 4
    • (continued)   Your partner takes over the airway from the fire department.   You immediately apply the ECG monitor and see the patient is in asystole.   You partner is asking for a suction unit to remove vomitus from the airway. –  What is your next immediate treatment?
    • Airway Adjuncts  First step –  Open the airway, initially by manual methods.   If the patient has an altered LOC, an artificial airway may then be needed to help maintain an open air passage.   An artificial airway is not a substitute for proper head positioning.
    • Oropharyngeal Airway (1 of 3)  Oral –  Curved, hard plastic device –  Fits over the back of the tongue –  Designed to hold the tongue away from the posterior pharyngeal wall
    • Oropharyngeal Airway (2 of 3)  Considerations –  Indications –  Contraindications –  Advantages –  Disadvantages –  Complications
    • Oropharyngeal Airway (3 of 3)  Improperly sized or inserted incorrectly –  Could actually push the tongue back into the pharynx, creating an airway obstruction –  Rough insertion can injure the hard palate, resulting in oral bleeding and creating a risk of vomiting or aspiration. –  Prior to inserting, suction the oropharynx as needed to ensure that the mouth is clear of blood or other fluids.
    • Skill Drill 11-13:Inserting an Oral AirwayStep 1 Step 2 Step 3
    • Skill Drill 11-14: Inserting an Oral Airway With a 90-degree RotationStep 1 Step 2 Step 3
    • Nasopharyngeal Airway (1 of 2)  Nasal –  –  Inserted through the nose into the posterior pharynx behind the tongue –  Allows passage of air from the nose to the lower airway –  Much better tolerated than an oral airway in patients who have an intact gag reflex yet an altered LOC
    • Nasopharyngeal Airway (2 of 2)  Considerations –  Indications –  Contraindications –  Advantages –  Disadvantages –  Complications
    • Skill Drill 11-15: Inserting a Nasal AirwayStep 1 Step 2 Step 3 Step 4
    • Measuring the Nasal Airway  Tip of the nostril to the angle of the jaw rather than the earlobe –  If it is too long it may obstruct the patient’s airway. –  If the patient becomes intolerant of the nasal airway, gently remove it from the nasal passage.
    • Supplemental Oxygen Therapy  Should be administered to any patient with potential hypoxia, regardless of his or her clinical appearance –  In some conditions, a part of the patient’s body does not receive enough oxygen, even though the oxygen supply to the body as a whole is entirely adequate. –  Increasing the available oxygen supply also enhances the body’s compensatory mechanisms during shock and other distressed states.
    • Oxygen Sources (1 of 2)  Pure (100%) oxygen –  Stored in seamless steel or aluminum cylinders –  Labeled “medical oxygen” –  Month and year stamps
    • Oxygen Sources (2 of 2)  Delivery –  Measured in terms of liters per minute (L/min) –  Replace an oxygen cylinder with a full one when the pressure falls to 200 psi or below.
    • Liquid Oxygen   Cooled to an aqueous state –  Converts to a gaseous state when warmed –  Special requirements for large volume storage and cylinder transferHELiOS® Marathon™ portable oxygen unit. Courtesy of Nellcor Puritan Bennett in affiliation with Tyco Healtcare.
    • Oxygen Regulators and Flowmeters (1 of 5)   High-pressure regulators –  Attached to the cylinder stem –  Used to transfer cylinder gas from tank to tank –  Pressure of gas in a full oxygen cylinder is approximately 2,000 psi. –  Too much pressure to deliver directly into a patient’s airway
    • Oxygen Regulators and Flowmeters (2 of 5)   Therapy regulator –  Controls gas flow from an oxygen cylinder to the patient –  Attaches to the stem of the oxygen cylinder and reduces the high pressure of gas to a safe range
    • Oxygen Regulators and Flowmeters (3 of 5)   Flowmeters –  Usually permanently attached to the therapy regulator –  Allow the oxygen delivered to the patient to be adjusted within a range of 1 to 25 L/min
    • Oxygen Regulators and Flowmeters (4 of 5)   Pressure-compensated flowmeter –  Incorporates a float ball within a tapered calibrated tube –  Gas flow is controlled by a needle valve located downstream from the float ball.
    • Oxygen Regulators and Flowmeters (5 of 5)   Bourdon-gauge flowmeter –  Not affected by gravity and can be placed in any position –  Calibrated to record the flow rate –  Major disadvantage is that it does not compensate for backpressure.
    • Skill Drill 11-16:Placing an Oxygen Cylinder Into ServiceStep 1 Step 2 Step 3 Step 4
    • Safety Considerations (1 of 3)  Cylinder containing compressed gas under high pressure –  Under the right conditions, it has the potential to become a rocket. –  Oxygen presents the additional hazard of fire.
    • Safety Considerations (2 of 3)  Handling oxygen cylinders –  Keep combustible materials, such as oil or grease, away from contact with the cylinder itself, the regulators, fittings, valves, or tubing. –  Do not permit smoking in any area where oxygen cylinders are in use or on standby. –  Store oxygen cylinders in a cool, well-ventilated area. –  Use an oxygen cylinder only with a safe, properly fitting regulator valve. –  Close all valves when the cylinder is not in use, even if the tank is empty.
    • Safety Considerations (3 of 3)  Handling oxygen cylinders (continued) –  Secure cylinders so that they will not topple over. In transit, keep them in a proper carrier or rack, or strap them onto the stretcher with the patient. –  When working with an oxygen cylinder, always position yourself to its side. Never place any part of your body over the cylinder valve. –  Have the cylinder hydrostat tested every 10 years, to make sure it can still sustain the high pressures required. The original test date is stamped onto the cylinder together with its serial number.
    • Supplemental Oxygen-Delivery Devices (1 of 11)  Nonrebreathing mask –  Preferred device   Good mask-to-face seal   Flow rate of 15 L/min   Capable of delivering between 90% and 100% inspired oxygen
    • Supplemental Oxygen-Delivery Devices (2 of 11)–  Combination mask and reservoir bag system   Oxygen fills a reservoir bag that is attached to the mask by a one-way valve.   Permits the patient to inhale from the reservoir bag but not to exhale back into it   Exhaled gas escapes through one-way flapper valves located on the side of the mask.
    • Supplemental Oxygen-Delivery Devices (3 of 11)–  Prior to administering oxygen   Ensure that the reservoir bag is completely filled.   Oxygen flow rate is adjusted from 12 to 15 L/min to prevent collapse of the bag during inhalation.   Use a pediatric nonrebreathing mask for infants and small children.
    • Supplemental Oxygen-Delivery Devices (4 of 11)–  Considerations   Indications   Contraindications   Patient’s respirations must be of adequate depth to open the one-way valve and draw air from the reservoir bag into the lungs.   Patient with reduced tidal volume will benefit very little.
    • Supplemental Oxygen-Delivery Devices (5 of 11)  Nasal cannula –  Delivers oxygen via two small prongs that fit into the patient’s nostrils   Oxygen flow rate of 1 to 6 L/min   Oxygen concentration of 24% to 44%   Higher flow rates irritate the nasal mucosa.
    • Supplemental Oxygen-Delivery Devices (6 of 11)  Nasal cannula (continued) –  Oxygen humidifier should be used when delivering oxygen via nasal cannula for a prolonged period of time. –  Low to moderate oxygen enrichment –  Generally well tolerated, especially in patients who are claustrophobic and intolerant of an oxygen mask over their face
    • Supplemental Oxygen-Delivery Devices (7 of 11)  Simple face mask –  Full mask enclosure with open side ports   Room air is drawn through the ports.   Exhaled air is vented through holes.   Delivers between 40% and 60% oxygen at 10 L/min   Rarely used in the field
    • Supplemental Oxygen-Delivery Devices (8 of 11)  Partial rebreathing mask –  Similar to nonrebreathing mask   Room air is not drawn in with inspiration.   Residual expired air is mixed and rebreathed.   Higher concentrations are attainable at flow rates of 6 to 10 L/min (35% to 60%).   Rarely used in the field
    • Supplemental Oxygen-Delivery Devices (9 of 11)  Venturi mask –  Draws room air along with oxygen flow   Allows for the administration of highly specific oxygen concentrations   Delivers 24%, 28%, 35%, or 40% oxygen   Long-range transport of patients
    • Supplemental Oxygen-Delivery Devices (10 of 11)  Small-volume nebulizer –  Nebulizer   Used primarily to deliver aerosolized medications   Oxygen enters an aerosol chamber that contains 3 to 5 mL of fluid.
    • Supplemental Oxygen-Delivery Devices (11 of 11)  Oxygen humidifier –  Oxygen stored in cylinders   Zero humidity   Rapidly dries the patient’s mucous membranes   Small bottle of water moisturizes oxygen before it reaches the patient.   Practical only for the fixed oxygen unit
    • Assisted and Artificial Ventilation  Patient who is not breathing –  Needs artificial ventilation with 100% oxygen –  Same is true of patients who are breathing inadequately –  Inadequate negative-pressure ventilation is treated with some form of positive-pressure ventilation.
    • Mouth-to-Mouthand Mouth-to-Nose Ventilation (1 of 3)  Mouth-to-mouth –  Most basic form of ventilation  Mouth-to-nose –  Simply involves ventilating through the nose. –  Apnea and when other ventilation devices are not available
    • Mouth-to-Mouthand Mouth-to-Nose Ventilation (2 of 3)  Disadvantages –  Psychological barriers secondary to sanitary and communicable disease issues –  Potential for exposure to blood and other body fluids through direct contact –  Other methods are safer for the rescuer.
    • Mouth-to-Mouthand Mouth-to-Nose Ventilation (3 of 3)  Potential complications –  Hyperventilation of the patient’s lungs –  Hyperventilation of the rescuer –  Gastric distention, increasing the risk of vomiting and aspiration –  Always carry a pocket mask or face shield.
    • Mouth-to-Mask Ventilation (1 of 2)  Eliminates direct contact –  Use of a one-way valve over the mask’s mouthpiece virtually eliminates any possibility of contact with the patient’s secretions and diverts the patient’s exhaled air away from the rescuer’s mouth. –  Easier to maintain an effective seal and deliver excellent tidal volume
    • Mouth-to-Mask Ventilation (2 of 2)  Complications –  Hyperinflation of the patient’s lungs –  Hyperventilation of the rescuer –  Gastric distention
    • Skill Drill 11-17:Mouth-to-Mask Ventilation Step 1 Step 2 Step 3
    • One-Person Bag-Mask Ventilation (1 of 2)   Bag-mask device –  Most common device used to ventilate patients in the field –  Oxygen flow rate of 15 L/min and a reservoir attached –  Indicated for apneic patients and for patients who are breathing inadequately –  Allows the rescuer to ventilate the patient for extended periods of time without fatigue
    • One-Person Bag-Mask Ventilation (2 of 2)   Major challenge –  Maintaining an effective mask-to-face seal –  Single person must keep the airway properly positioned, maintain a mask seal, and squeeze the bag. –  Complications
    • Skill Drill 11-18:One-Person Bag-Mask Ventilation Step 1 Step 2 Step 3
    • Two-Person Bag-Mask Ventilation (1 of 2)   Much more efficient –  One can maintain an adequate mask-to-face seal, while the other squeezes the bag. –  Facilitates the delivery of excellent tidal volume and high oxygen concentrations –  Indications –  Contraindications
    • Two-Person Bag-Mask Ventilation (2 of 2)   Disadvantage –  Requires additional personnel –  Complications include hyperinflation of the patient’s lungs and gastric distention.
    • Skill Drill 11-19:Two-Person Bag-Mask VentilationStep 1 Step 2
    • Three-Person Bag-Mask Ventilation (1 of 2)   Indications –  Apneic patients –  Patients who are breathing inadequately –  Patients who cannot be ventilated by one or two rescuers –  Patients with a possible spinal injury –  Contraindicated in patients who are intolerant of the device.
    • Three-Person Bag-Mask Ventilation (2 of 2)   Disadvantages –  Technique requires additional personnel. –  Area around the patient’s head can become very crowded.   Complications –  Hyperinflation of the patient’s lungs –  Gastric distention
    • Skill Drill 11-20:Three-Person Bag-Mask Ventilation Step 1 Step 2 Step 3
    • Flow-Restricted, Oxygen-Powered Ventilation Device (1 of 4)  Third potential source for artificial ventilation –  Manually triggered ventilator or demand valve –  Used to ventilate apneic patients or to administer supplemental oxygen to spontaneously breathing patients
    • Flow-Restricted, Oxygen-Powered Ventilation Device (2 of 4)–  Demand valve triggered by the negative pressure generated during inhalation–  Valve automatically delivers 100% oxygen and stops the flow of gas at the end of inhalation.–  Patients find it most comfortable if they hold the mask to their face themselves.
    • Flow-Restricted, Oxygen-Powered Ventilation Device (3 of 4)  Apneic patients –  Pushbutton on top of the FROPVD can control the flow of oxygen. –  When depressed, 100% oxygen flows at a rate of 40 L/min.  Requires an oxygen source –  Operator cannot feel whether the patient is being adequately ventilated with this device.
    • Flow-Restricted, Oxygen-Powered Ventilation Device (4 of 4)  Use –  Has been used for several years –  Recent findings suggest that it should not be used routinely because of the high incidence of gastric distention and damage to intrathoracic structures caused by barotraumas. –  Should not be used when ventilating infants or children or for patients with possible cervical spine or chest injury –  Cricoid pressure must be maintained to ventilate nonintubated patients.
    • Skill Drill 11-21: Flow-Restricted, Oxygen-Powered Ventilation for Apneic Patients (1 of 2)Step 1 Step 2 Step 3
    • Skill Drill 11-21:Flow-Restricted, Oxygen-PoweredVentilation for Apneic Patients (2 of 2) Step 4 Step 5
    • Skill Drill 11-22: Flow-Restricted, Oxygen-Powered Ventilation Device for Conscious, Spontaneously Breathing PatientsStep 1 Step 2 Step 3
    • Automatic Transport Ventilators (1 of 5)   Solves the problems of other ventilators –  Maintaining a mask seal –  Variations in the rate and duration of ventilationCourtesy of Impact Instrumentation, Inc.
    • Automatic Transport Ventilators (2 of 5)  Control box –  Allows the variables of ventilation (tidal volume and respiratory rate) to be set –  Minute volume controlled with considerable accuracy –  Indicated when patients need extended periods of ventilation
    • Automatic Transport Ventilators (3 of 5)  Small and compact –  Some no larger than portable tape players –  Mechanical simplicity, durability, and portability –  Frees up your hands to tend to other tasks
    • Automatic Transport Ventilators (4 of 5)  Settings –  Respiratory rate is set at the midpoint for the patient’s age. –  Tidal volume is usually set in a range of 6 to 7 mL/kg. –  Deliver a preset volume at a preset ventilatory rate
    • Automatic Transport Ventilators (5 of 5)
    • Cricoid Pressure (1 of 4)  Sellick maneuver  Gastric distention –  Can be partially prevented or alleviated –  Can also help prevent passive regurgitation with aspiration
    • Cricoid Pressure (2 of 4)  Posterior pressure to the cricoid cartilage –  Esophagus is partially occluded. –  Provides more air delivery into the lungs and less air delivery into the stomach –  Indicated only in unconscious patients who cannot protect their own airway and are at imminent risk for vomiting
    • Cricoid Pressure (3 of 4)  Disadvantages –  Extreme or a large quantity of emesis if pressure is removed –  Should be maintained until the patient is intubated –  Requires two providers –  If a cervical spine injury is present, may cause further injury.
    • Cricoid Pressure (4 of 4)  Potential complications –  Trauma to the larynx if excessive force is used –  Esophageal rupture from unrelieved high gastric pressures –  Obstruction of the trachea when used in small children
    • Skill Drill 11-23:Cricoid Pressure (Sellick Maneuver) Step 1 Step 2 Step 3
    • (continued)   Your partner finishes suctioning, ventilates the patient, and attempts intubation.   You partner verbalizes that he is unable to “see anything.” –  What do you want to consider next?
    • Gastric Distention (1 of 2)  Inflation of the stomach with air –  Any form of artificial ventilation that blows air into the patient’s mouth –  Likely to occur when   Excessive pressure is used to inflate the lungs   Ventilations are performed too fast   Airway is partially obstructed during ventilation attempts
    • Gastric Distention (2 of 2)  Signs –  Increase in the diameter of the stomach –  Increasingly distended abdomen –  Increased resistance to bag-mask ventilations
    • Invasive Gastric Decompression  Gastric tube –  Inserted into the stomach; removes the contents with suction   Decreases the pressure on the diaphragm   Virtually eliminates the risk of regurgitation and aspiration   Orogastric tube or nasogastric tube   Should be considered for any patient who will need positive-pressure ventilation for an extended period of time
    • Nasogastric Tube  Inserted through the nose –  Also used to perform gastric lavage –  Relatively well tolerated –  Most patients who are awake will gag and may vomit. –  Poor technique can cause trauma.
    • Skill Drill 11-24: Nasogastric Tube Insertion in a Conscious Patient (1 of 3)Step 1 Step 2 Step 3
    • Skill Drill 11-24: Nasogastric Tube Insertion in a Conscious Patient (2 of 3)Step 4 Step 5 Step 6
    • Skill Drill 11-24: Nasogastric Tube Insertion in a Conscious Patient (3 of 3)Step 7 Step 8 Step 9
    • Orogastric Tube  Inserted through the mouth instead of the nose –  No risk of nasal bleeding –  Safer in patients with severe facial trauma –  Less comfortable for conscious patients
    • Skill Drill 11-25:Orogastric Tube Insertion (1 of 2) Step 1 Step 2Step 3 Step 4
    • Skill Drill 11-25: Orogastric Tube Insertion (2 of 2)Step 5 Step 6 Step 7
    • Endotracheal Intubation (1 of 6)  Defined –  Passing an endotracheal (ET) tube through the glottic opening and sealing the tube with a cuff inflated against the endotracheal wall –  Orotracheal –  Nasotracheal –  Most definitive means of achieving complete control of the airway
    • Endotracheal Intubation (2 of 6)  Considerations –  Indications –  Contraindications –  Advantages –  Disadvantages –  Complications
    • Endotracheal Intubation (3 of 6)  Structure –  Proximal end, the tube, the cuff and pilot balloon, and the distal tip –  Inflation port with a pilot balloon –  Distal cuff –  Pilot balloon
    • Endotracheal Intubation (4 of 6)  Structure (continued) –  Centimeter markings provide a measurement of its depth. –  Murphy’s eye –  Range in size from 2.5 to 9.0 mm inside diameter, and length from 12 to 32 cm
    • Endotracheal Intubation (5 of 6)  Laryngoscope –  Required to perform orotracheal intubation by direct laryngoscopy –  Laryngoscope –  Handle contains the power source
    • Endotracheal Intubation (6 of 6)  Laryngoscope (continued) –  Straight (Miller) blade –  Curved blade –  Blade sizes range from 0 to 4. –  Stylet –  Magill forceps
    • Orotracheal Intubation by Direct Laryngoscopy (1 of 16)  Considerations –  Indications –  Contraindications –  Advantages –  Disadvantages –  Complications
    • Orotracheal Intubationby Direct Laryngoscopy (2 of 16)
    • Orotracheal Intubation by Direct Laryngoscopy (3 of 16)  Body substance isolation –  Intubation may expose you to blood or other fluids. –  Mask that covers your entire face  Preoxygenation –  Critical step prior to intubation –  Monitor the patient’s saturated oxygen levels.
    • Orotracheal Intubation by Direct Laryngoscopy (4 of 16)  Positioning the patient –  Three axes: mouth, pharynx, and larynx –  “Sniffing” position
    • Orotracheal Intubationby Direct Laryngoscopy (5 of 16)
    • Orotracheal Intubation by Direct Laryngoscopy (6 of 16)  Blade insertion –  Position yourself at the top of the patient’s head. –  Hold the laryngoscope as low down on the handle as possible. –  Insert the blade into the right side of the patient’s mouth.
    • Orotracheal Intubation by Direct Laryngoscopy (7 of 16)  Blade insertion (continued) –  Use the flange of the blade to sweep the tongue gently to the left side of the mouth while moving the blade into the midline. –  Slowly advance the blade. –  Exert gentle traction at a 45° angle to the floor as you lift the patient’s jaw.
    • Orotracheal Intubationby Direct Laryngoscopy (8 of 16)
    • Orotracheal Intubation by Direct Laryngoscopy (9 of 16)  Visualization of the glottic opening –  Continue lifting the laryngoscope as you look down the blade. –  With the curved blade, walk the blade down the tongue. –  With the straight blade, insert the blade straight back until the tip touches the posterior pharyngeal wall.
    • Orotracheal Intubation by Direct Laryngoscopy (10 of 16)  Visualization (continued) –  Vocal cords are white fibrous bands that lie vertically within the glottic opening. –  If you are having difficulty seeing the opening, take your right hand and locate the lower third of the thyroid cartilage. –  Gum bougie
    • Orotracheal Intubation by Direct Laryngoscopy (11 of 16)  Tube insertion –  Insert the tube from the right corner of the patient’s mouth through the vocal cords. –  Continue to insert the tube until the proximal end of the cuff is 1 to 2 cm past the vocal cords. –  Blade is not a guide for the tube.
    • Orotracheal Intubation by Direct Laryngoscopy (12 of 16)  Ventilation –  Remove the blade, hold the tube securely, and remove the stylet from the tube. –  Inflate the distal cuff with 5 to 10 mL of air and then detach the syringe from the inflation port. –  Have your assistant attach the bag-mask device to the ET tube and continue ventilation. –  Monitor the patient’s chest to ensure that it rises with each ventilation.
    • Orotracheal Intubation by Direct Laryngoscopy (13 of 16)  Confirmation of tube placement –  Misplaced tube that goes undetected is a fatal error. –  Auscultation –  Bilaterally absent breath sounds or gurgling over the epigastrium indicate you have intubated the esophagus.
    • Orotracheal Intubation by Direct Laryngoscopy (14 of 16)  Repositioning the tube –  Loosen or remove the tube-securing device. –  Deflate the distal cuff. –  Place your stethoscope over the left side of the chest. –  While ventilation continues, slowly retract the tube while simultaneously listening for breath sounds over the left side of the chest.
    • Orotracheal Intubation by Direct Laryngoscopy (15 of 16)  Repositioning the tube (continued) –  Stop as soon as bilaterally equal breath sounds are heard. –  Note the depth of the tube at the patient’s teeth. –  Reinflate the distal cuff. –  Secure the tube. –  Resume ventilations.
    • Orotracheal Intubation by Direct Laryngoscopy (16 of 16)   End-tidal carbon dioxide detectors –  Detect the presence of carbon dioxide in exhaled air –  Reliable method for confirming proper tube placement –  Capnographer –  CapnometerCourtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
    • Skill Drill 11-26:Using Colorimetric Capnography for Carbon Dioxide Detection Step 1 Step 2 Step 3 Step 4
    • Esophageal Detector Device (EDD)   Bulb or syringe with a 15/22-mm adapter –  Syringe model –  Bulb modelCourtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
    • Securing the Tube  Last step –  Inadvertent extubation caused by the patient or someone else is relatively common. –  Reintubaton will almost certainly be more difficult. –  Never take your hand off the ET tube before it has been secured with tape or a commercial device.
    • Skill Drill 11-27: Securing an Endotracheal Tube With Tape (1 of 2)Step 1 Step 2 Step 3
    • Skill Drill 11-27: Securing an Endotracheal Tube With Tape (2 of 2)Step 4 Step 5
    • Skill Drill 11-28: Securing an Endotracheal Tube With a Commercial Device (1 of 2)Step 1 Step 2 Step 3
    • Skill Drill 11-28:Securing an Endotracheal TubeWith a Commercial Device (2 of 2)Step 4 Step 5
    • Bite Block  If the patient bites the tube or experiences a seizure, the ET tube may become occluded. –  Insert a bite block or oral airway in between the patient’s molars. –  Minimize head movement in the intubated patient.
    • Skill Drill 11-29: Intubation of the TracheaUsing Direct Laryngoscopy (1 of 4) Step 1 Step 2 Step 3 Step 4
    • Skill Drill 11-29: Intubation of the TracheaUsing Direct Laryngoscopy (2 of 4) Step 5 Step 6 Step 7 Step 8
    • Skill Drill 11-29: Intubation of the Trachea Using Direct Laryngoscopy (3 of 4)Step 9 Step 10 Step 11
    • Skill Drill 11-29: Intubation of the Trachea Using Direct Laryngoscopy (4 of 4)Step 12 Step 13 Step 14
    • Nasotracheal Intubation (1 of 6)  “Blind” ” –  Performed without direct visualization of the vocal cords –  Excellent technique for establishing control over the airway in situations where it is either difficult or hazardous to perform laryngoscopy –  Must be performed on patients with spontaneous breathing
    • Nasotracheal Intubation (2 of 6)  Considerations –  Indications and contraindications –  Advantages and disadvantages –  Complications
    • Nasotracheal Intubation (3 of 6)  Equipment –  Same equipment for orotracheal intubation— minus the laryngoscope and stylet –  Standard ET tubes –  Endotrol tube
    • Nasotracheal Intubation (4 of 6)
    • Nasotracheal Intubation (5 of 6)  Techniques for nasotracheal intubation –  Use the patient’s spontaneous respirations to guide the ET tube. –  Tube is advanced as the patient inhales. –  Angle of insertion is critical; aim the tip of the tube straight back toward the ear.
    • Nasotracheal Intubation (6 of 6)  Techniques for nasotracheal intubation (continued) –  Position the tube just above the glottic opening. –  Patient will draw the tube into the trachea when he or she inhales deeply. –  Placement of the tube in the trachea will be evidenced by an increase in air movement through the tube.
    • Skill Drill 11-30:Blind Nasotracheal Intubation (1 of 3) Step 1 Step 2 Step 3 Step 4
    • Skill Drill 11-30:Blind Nasotracheal Intubation (2 of 3) Step 5 Step 6 Step 7 Step 8
    • Skill Drill 11-30:Blind Nasotracheal Intubation (3 of 3) Step 9 Step 10 Step 11 Step 12
    • Digital Intubation (1 of 4)  Intubation without a laryngoscope –  Blind or tactile intubation –  Involves directly palpating the glottic structures and elevating the epiglottis with your middle finger –  Option in extreme circumstances
    • Digital Intubation (2 of 4)  Considerations –  Indications and contraindications –  Advantages and disadvantages –  Complications  Equipment –  Less equipment is needed. –  Same equipment except the laryngoscope
    • Digital Intubation (3 of 4)  Techniques for digital intubation –  Rarely performed because of the variety of alternative airway devices available –  “Open J” configuration –  “U-handle” configuration
    • Digital Intubation (4 of 4)  Techniques (continued) –  Positioned at the left side facing toward the head –  Insert a bite block.
    • Skill Drill 11-31: Digital Intubation (1 of 4) Step 1 Step 2 Step 3 Step 4
    • Skill Drill 11-31: Digital Intubation (2 of 4) Step 5 Step 6 Step 7 Step 8
    • Skill Drill 11-31: Digital Intubation (3 of 4) Step 9 Step 10 Step 11
    • Skill Drill 11-31: Digital Intubation (4 of 4) Step 12 Step 13 Step 14
    • Transillumination Techniques for Intubation (1 of 4)  Rarely considered a first-line technique to definitively secure the airway –  May prove valuable in some situations –  Number of devices can be used for this technique. –  “Lighted stylet”
    • Transillumination Techniques for Intubation (2 of 4)  Considerations –  Indications and contraindications –  Advantages and disadvantages –  Complications  Equipment –  Device with a rigid stylet and a bright light source at the end –  Must be long enough to accommodate a standard- length ET tube
    • Transillumination Techniques for Intubation (3 of 4)  Technique for transillumination-guided intubation –  Patient must be preoxygenated. –  Lubricate and insert the lighted stylet so that the light is positioned immediately at the tip of the tube. –  Prepare the tube by bending it into the proper shape. –  Stylet will act as the pivot point when you direct it into the trachea.
    • Transillumination Techniques for Intubation (4 of 4)  Techniques (continued) –  Place the patient’s head in a neutral or slightly extended position. –  Light should become visible at the midline of the neck. –  A tightly circumscribed light slightly below the thyroid cartilage indicates that the tip of the tube has entered the trachea.
    • Skill Drill 11-32:Transillumination Intubation (1 of 4) Step 1 Step 2 Step 3 Step 4
    • Skill Drill 11-32:Transillumination Intubation (2 of 4) Step 5 Step 6 Step 7
    • Skill Drill 11-32:Transillumination Intubation (3 of 4) Step 8 Step 9 Step 10
    • Skill Drill 11-32:Transillumination Intubation (4 of 4) Step 11 Step 12 Step 13
    • Tracheobronchial Suctioning  Suction catheter into the ET tube –  Remove pulmonary secretions. –  First rule—Don’t do it if you don’t have to! –  Strict attention to sterile technique –  Can cause cardiac dysrhythmias –  Avoid unless secretions are so massive that they interfere with ventilation. –  Preoxygenation is essential.
    • Skill Drill 11-33: PerformingTracheobronchial Suctioning (1 of 2) Step 1 Step 2 Step 3 Step 4
    • Skill Drill 11-33: PerformingTracheobronchial Suctioning (2 of 2) Step 5 Step 6 Step 7
    • Field Extubation (1 of 3)  Process of removing the tube from an intubated patient –  Rarely extubated in the prehospital setting –  Generally only if the patient is unreasonably intolerant of the ET tube –  Better to sedate the patient than remove the ET tube.
    • Field Extubation (2 of 3)  Risk –  Overestimation of the patient’s ability to protect his or her own airway –  High risk of laryngospasm when performed on conscious patients –  Most patients experience some degree of upper airway swelling because of the trauma of having the tube in the trachea. –  If you are not absolutely sure that you can reintubate the patient, do not remove the tube!
    • Field Extubation (3 of 3)  If indicated –  Hyperoxygenate the patient. –  Discuss the procedure with the patient. –  Have the patient sit up or lean slightly forward. –  Assemble and have available all equipment to suction, ventilate, and reintubate, if necessary. –  Suction the oropharynx. –  Deflate the distal cuff. –  Remove the tube in one steady motion.
    • Skill Drill 11-34:Performing Extubation (1 of 2)Step 1 Step 2Step 3 Step 4
    • Skill Drill 11-34:Performing Extubation (2 of 2)Step 5 Step 6 Step 7
    • Pediatric Endotracheal Intubation (1 of 9)  If bag-mask ventilations are not producing adequate ventilation –  Cardiopulmonary arrest –  Respiratory failure/arrest –  Traumatic brain injury –  Unresponsiveness –  Inability to maintain a patent airway
    • Pediatric Endotracheal Intubation (2 of 9)
    • Pediatric Endotracheal Intubation (3 of 9)   Laryngoscope and blades –  Most paramedics prefer the thinner pediatric handles. –  Straight blades facilitate lifting of the floppy epiglottis. –  Blade should extend from the child’s mouth to the tragus of the ear.
    • Pediatric Endotracheal Intubation (4 of 9)  Laryngoscope and blades (continued) –  Premature newborn: size 0 straight blade –  Full-term newborn to 1 year of age: size 1 straight blade –  2 years of age to adolescent: size 2 straight blade –  Adolescent or older: size 3 straight or curved blade
    • Pediatric Endotracheal Intubation (5 of 9)   Endotracheal tubes –  Selected by using a length-based resuscitation tape measure –  For children older than 1 year of age: Age in years ÷ 4 + 4 or Age in years + 16 ÷ 4 –  Anatomic cluesCourtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
    • Pediatric Endotracheal Intubation (6 of 9)
    • Pediatric Endotracheal Intubation (7 of 9)   Pediatric stylet –  Matter of personal preference when intubating the pediatric patient –  Bend the tube into a gentle upward curve.   Preoxygenation –  Adequate with a bag-mask device and 100% for at least 30 seconds prior to attempting intubation
    • Pediatric Endotracheal Intubation (8 of 9)   Additional preparation –  Stimulation of the parasympathetic nervous system can occur during intubation in children. –  Pulse oximeter should be used throughout the intubation attempt. –  Suction should be readily available to clear oral secretions. –  Atropine sulfate
    • Pediatric Endotracheal Intubation (9 of 9)   Intubation technique –  Place the child’s head in a sniffing position. –  Open his or her mouth by applying thumb pressure on the chin. –  Record the depth of the tube as measured at the right-side corner of the child’s mouth. –  Confirm proper ET tube placement. –  Breath sounds travel easily in a child.
    • Skill Drill 11-35: Performing PediatricEndotracheal Intubation (1 of 3) Step 1 Step 2 Step 3 Step 4
    • Skill Drill 11-35: Performing PediatricEndotracheal Intubation (2 of 3) Step 5 Step 6 Step 7 Step 8
    • Skill Drill 11-35: Performing Pediatric Endotracheal Intubation (3 of 3)Step 9 Step 10 Step 11
    • If Condition Deteriorates (1 of 2)  Take immediate action to identify and correct the underlying problem.  DOPE mnemonic –  Displacement –  Obstruction –  Pneumothorax –  Equipment failure
    • If Condition Deteriorates (2 of 2)
    • Complications of Endotracheal Intubation   Unrecognized esophageal intubation   Induction of emesis and possible aspiration   Hypoxia resulting from prolonged intubation attempts   Damage to teeth, soft tissues, and intraoral structures
    • (continued)   Your partner asks you to “take a look.”   When you insert the blade, you agree with your partner that you are unable to see anything.   You insert a secondary airway device and ventilate the patient through it. –  What do you want to consider next?
    • Multilumen Airways (1 of 7)  Combitube and pharyngeotracheal lumen airway (PtL) –  Provide better airway management and ventilation compared to esophageal airways –  Long tube blindly inserted into the airway –  Ventilation is possible regardless of whether the tube is placed into the esophagus or the trachea.
    • Multilumen Airways (2 of 7)
    • Multilumen Airways (3 of 7)  Considerations –  Indications and contraindications –  Advantages and disadvantages –  Complications
    • Multilumen Airways (4 of 7)  Equipment –  PtL   Two tubes and two cuffs
    • Multilumen Airways (5 of 7)  Equipment (continued) –  Combitube   Single tube with two lumens, two balloons, and two ventilation ports
    • Multilumen Airways (6 of 7)  Procedures before and during insertion –  Check and prepare all your equipment. –  Check both cuffs. –  Preoxygenate with 100% oxygen. –  Place head in a neutral position. –  Forwardly displace the jaw. –  Insert the device. –  Inflate the cuffs.
    • Multilumen Airways (7 of 7)  Procedures after insertion –  After you inflate the balloons, begin to ventilate the patient. –  With the PtL, first ventilate the short tube. –  With the Combitube, ventilate through the longer tube. –  Confirm adequate chest rise and the presence of breath sounds.
    • Skill Drill 11-36: Insertion of the PtL (1 of 2)Step 1 Step 2Step 3 Step 4
    • Skill Drill 11-36: Insertion of the PtL (2 of 2)Step 5 Step 6Step 7 Step 8
    • Skill Drill 11-37:Insertion of the Combitube (1 of 3) Step 1 Step 2 Step 3 Step 4
    • Skill Drill 11-37:Insertion of the Combitube (2 of 3) Step 5 Step 6 Step 7
    • Skill Drill 11-37:Insertion of the Combitube (3 of 3) Step 8 Step 9 Step 10
    • The Laryngeal Mask Airway (1 of 9)  Originally developed for use in the operating room –  Alternative to bag-mask ventilation –  Commonly used during short surgical procedures –  Not designed for emergency use –  Not a replacement for endotracheal intubation
    • The Laryngeal Mask Airway (2 of 9)  Designed –  Provides a conduit from the glottic opening to the ventilation device –  Surrounds the opening of the larynx with an inflatable silicone cuff –  Inflatable cuff conforms to the contours of the airway and forms a relatively airtight seal.
    • The Laryngeal Mask Airway (3 of 9)  Considerations –  Indications and contraindications –  Advantages and disadvantages –  Complications
    • The Laryngeal Mask Airway (4 of 9)  Equipment –  5 sizes   Selection of size based on patient’s weight
    • The Laryngeal Mask Airway (5 of 9)  Equipment (continued) –  Device   Consists of an inflatable cuff attached to an obliquely cut tube   Two vertical bars at the opening of the tube prevent occlusion.   Proximal end of the tube is fitted with a standard 15/22-mm adapter.
    • The Laryngeal Mask Airway (6 of 9)  Procedures before and during insertion –  Check and prepare all equipment. –  Preoxygenate the patient.
    • The Laryngeal Mask Airway (7 of 9)  Procedures before and during insertion (continued) –  Place the patient’s head in a sniffing position. –  Insert your finger between the cuff and the tube. –  Insert the LMA along the roof of the mouth. –  Inflate the cuff.
    • The Laryngeal Mask Airway (8 of 9)  Procedures after insertion –  Following inflation of the cuff, attach bag-valve device and begin to ventilate the patient. –  Confirm chest rise and the presence of breath sounds. –  Continuously and closely monitor for regurgitation in the tube.
    • The Laryngeal Mask Airway (9 of 9)  Procedures after insertion (continued) –  Fast-trach LMA is designed to guide an ET tube into the trachea and may prove a viable alternative to direct laryngoscopy.
    • Skill Drill 11-38: LMA Insertion (1 of 2) Step 1 Step 2 Step 3 Step 4
    • Skill Drill 11-38: LMA Insertion (2 of 2) Step 5 Step 6 Step 7
    • Pharmacologic Adjuncts (1 of 3)  Sedation in emergency intubation –  Used in airway management to reduce the patient’s anxiety, induce amnesia, and decrease the gag reflex –  Useful for anxious, combative, or agitated patients  Complications –  Undersedation –  Oversedation
    • Pharmacologic Adjuncts (2 of 3)  Classes –  Analgesics –  Sedative-hypnotics –  Butrophenones –  Benzodiazepines –  Barbituates –  Opioids/narcotics –  Etomidate –  Ketamine
    • Pharmacologic Adjuncts (3 of 3)
    • Neuromuscular Blockade in Emergency Intubation (1 of 5)  Cerebral hypoxia –  Can make an ordinarily docile person combative, aggressive, belligerent, and uncooperative –  Difficult and dangerous situation
    • Neuromuscular Blockade in Emergency Intubation (2 of 5)  Cerebral hypoxia (continued) –  Common practice, in the past, to physically restrain the patient to obtain a definitive airway –  Safer, more effective approach is to “chemically paralyze” the patient with neuromuscular blocking agents.
    • Neuromuscular Blockade in Emergency Intubation (3 of 5)  Neuromuscular blocking agents –  Much more effective to administer a drug specifically designed to induce paralysis –  Affect every skeletal muscle in the body –  Convert a breathing patient into an apneic patient with no airway –  No effect on level of consciousness
    • Neuromuscular Blockade in Emergency Intubation (4 of 5)  Pharmacology of neuromuscular blocking agents –  Acetylcholine –  Depolarizing –  Nondepolarizing
    • Neuromuscular Blockadein Emergency Intubation (5 of 5)
    • Rapid-Sequence Intubation (1 of 3)  Culmination and integration of all your skills –  Preparation of the patient and equipment –  Preoxygenation –  Premedication –  Sedation and paralysis –  Posterior cricoid pressure –  Intubation –  Maintenance of paralysis and sedation
    • Rapid-Sequence Intubation (2 of 3)
    • Rapid-Sequence Intubation (3 of 3)
    • Surgical and Nonsurgical Airways (1 of 2)   In most cases –  Paramedic is able to secure a patent airway with relative ease using either basic or advanced methods. –  In some situations, the patient’s condition or other factors preclude the use of conventional airway techniques.
    • Surgical and Nonsurgical Airways (2 of 2) –  Two methods   Open cricothyrotomy   Translaryngeal catheter ventilation –  Blood vessels in this area   Superior cricothyroid vessels   External jugular vein
    • Open Cricothyrotomy (1 of 6)  Incising the cricothyroid membrane –  Scalpel –  Inserting an endotracheal or tracheostomy tube directly into the subglottic area of the trachea
    • Open Cricothyrotomy (2 of 6)  Considerations –  Indications and contraindications –  Advantages and disadvantages –  Complications
    • Open Cricothyrotomy (3 of 6)  Equipment –  Commercially manufactured cricothyrotomy kits
    • Open Cricothyrotomy (4 of 6)  Equipment (continued) –  Scalpel –  ET tube or tracheostomy tube –  Commercial device (or tape) for securing the tube –  Curved hemostats –  Suction apparatus –  Sterile gauze pads for minor bleeding control –  Bag-mask device attached to 100% oxygen
    • Open Cricothyrotomy (5 of 6)  Technique for performing open cricothyrotomy –  Identify the cricothyroid membrane by palpating for the V notch. –  Stabilize the larynx. –  Depression between the thyroid and cricoid cartilage –  Prepare equipment and ensure that the cardiac monitor and pulse oximeter are attached to the patient.
    • Open Cricothyrotomy (6 of 6)  Technique (continued) –  Maintain aseptic technique as you cleanse the area with iodine. –  Make a 1- to 2-cm vertical incision over the cricothyroid membrane. –  Insert the curved hemostats into the opening and spread it apart. –  Gently insert the ET tube or tracheostomy tube. –  Confirm the correct tube placement.
    • Skill Drill 11-39:Performing an Open Cricothyrotomy (1 of 3) Step 1 Step 2 Step 3 Step 4
    • Skill Drill 11-39:Performing an Open Cricothyrotomy (2 of 3) Step 5 Step 6 Step 7 Step 8
    • Skill Drill 11-39:Performing an Open Cricothyrotomy (3 of 3) Step 9 Step 10 Step 11 Step 12
    • Needle Cricothyrotomy (1 of 5)  14- to 16-gauge over-the-needle IV catheter –  Inserted through the cricothyroid membrane and into the trachea –  Adequate oxygenation and ventilation are then achieved by attaching a high-pressure jet ventilator to the hub of the catheter. –  Temporary measure until a more definitive airway can be obtained
    • Needle Cricothyrotomy (2 of 5)  Considerations –  Indications and contraindications –  Advantages and disadvantages –  Complications
    • Needle Cricothyrotomy (3 of 5)  Equipment –  Large-bore IV catheter (14 to 16 gauge) –  10-mL syringe –  3 mL of sterile water or saline –  Oxygen source (50 psi) –  High-pressure jet ventilator device and oxygen tubing
    • Needle Cricothyrotomy (4 of 5)  Technique for performing needle cricothyrotomy –  Place the patient’s head in a neutral position. –  Locate the cricothyroid membrane. –  Carefully insert the needle into the midline of the cricothyroid membrane at a 45-degree angle toward the feet.
    • Needle Cricothyrotomy (5 of 5)  Technique (continued) –  After the pop is felt, insert the needle approximately 1 cm farther and then aspirate the syringe. –  Secure the catheter. –  Continue ventilations.
    • Skill Drill 11-40:Performing Needle Cricothyrotomy andTranslaryngeal Catheter Ventilation (1 of 3) Step 1 Step 2 Step 3 Step 4
    • Skill Drill 11-40:Performing Needle Cricothyrotomy andTranslaryngeal Catheter Ventilation (2 of 3) Step 5 Step 6 Step 7 Step 8
    • Skill Drill 11-40:Performing Needle Cricothyrotomy andTranslaryngeal Catheter Ventilation (3 of 3) Step 9 Step 10 Step 11 Step 12
    • Special Patient Considerations (1 of 3)  Laryngectomy, tracheostomy, stoma, and tracheostomy tubes –  Laryngectomy   Surgical procedure in which the larynx is removed   Tracheostomy   Stoma
    • Special Patient Considerations (2 of 3) –  Laryngectomy (continued)   Total laryngectomy   “Neck breather”   Partial laryngectomy   “Partial neck breathers”
    • Special Patient Considerations (3 of 3)  Suctioning of a stoma –  Failure to recognize and identify these patients could result in hypoxia. –  Common for a patient’s stoma to become occluded with mucous plugs –  Less efficient cough –  Performed with extreme care –  Limit suctioning to 10 seconds.
    • Skill Drill 11-41:Suctioning of a Stoma (1 of 2)Step 1 Step 2 Step 3
    • Skill Drill 11-41:Suctioning of a Stoma (2 of 2)Step 4 Step 5 Step 6
    • Ventilation of Stoma Patients  Neither the head tilt–chin lift nor the jaw-thrust maneuver is required for ventilating a patient with a stoma.  Stoma and no tracheostomy tube, mouth-to-stoma technique  Use an infant- or child-size mask to make an adequate seal over the stoma.  Two rescuers needed
    • Skill Drill 11-42: Mouth-to-Stoma Ventilation Using a Resuscitation Mask (1 of 2)Step 1 Step 2 Step 3
    • Skill Drill 11-42: Mouth-to-Stoma VentilationUsing a Resuscitation Mask (2 of 2) Step 4 Step 5
    • Skill Drill 11-43:Bag-Mask-Device-to-Stoma Ventilation Step 1 Step 2 Step 3 Step 4
    • Tracheostomy Tubes  Plastic tube placed within the tracheostomy site –  Requires a 15/22-mm adapter to be compatible with ventilatory devices –  Often have thick secretions in the tube –  Stenosis
    • Skill Drill 11-44: Replacing a Dislodged Tracheostomy Tube (1 of 2)Step 1 Step 2 Step 3
    • Skill Drill 11-44: Replacing a Dislodged Tracheostomy Tube (2 of 2)Step 4 Step 5 Step 6
    • Dental Appliances (1 of 2)  Many different forms –  Dentures (upper, lower, or both) –  Bridges –  Individual teeth –  Braces –  If the appliance fits well, leave it in place. –  If it is loose, it could easily become an airway obstruction and should be removed.
    • Dental Appliances (2 of 2)  Airway obstruction caused by a dental appliance –  Perform the usual steps in clearing an obstruction. –  Bridge
    • Facial Trauma (1 of 2)  Especially challenging –  Face is highly vascular. –  Severe tissue swelling and bleeding into the airway –  Control bleeding with direct pressure and suction the airway as needed. –  Suction the patient’s airway for 15 seconds and then provide ventilation for 2 minutes.
    • Facial Trauma (2 of 2)  Increase your index of suspicion. –  Cervical spine injury –  Use the jaw-thrust maneuver and keep the patient’s head in a neutral in-line position. –  Stay alert for changes in ventilation compliance or sounds that may indicate laryngeal edema.
    • Summary   You believe that you have successfully inserted a secondary airway device.   You also attempt to insert an NG tube to help relieve some of the gastric distention caused by the inadequate ventilations.
    • Summary  Anatomy of the airway  Ventilation and respiration  Airway management  Advanced airway management  Pharmacology  Surgical and nonsurgical airways