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  • Brain death occurs within 6 to 10 minutes Practice good basic interventions, proper mask seal and positioning. Reassess
  • The upper airway warms, filters and humidifies incoming air.
  • Right mainstem is straight Right side 3 lobes
  • Alveoli are the site of gas exchange and are lined with surfactant which decreases surface tension and facilitates ease of expansion. Atelectasis – alveoli colapse
  • Also, ribs are soft so children depend more heavily on diaphram to breath. In addition, neonates are obligate nasal breathers.
  • Anatomic dead space – trachea, Bronchi Physiologic – formed by disease such as COPD and atelectasis


  • 1. Airway Management and Ventilation
  • 2. Airway management and ventilation are the firstand most critical steps in the initial assessment of every patient you will encounter.
  • 3. Topics Anatomy of the Respiratory System Physiology of the Respiratory System Respiratory Problems Respiratory System Assessment Airway Management
  • 4. Anatomy of theRespiratory System
  • 5. The respiratory system provides a passage for oxygen to enter the bodyand for carbon dioxide to exit the body.
  • 6. Anatomy of the Upper Airway
  • 7. Upper Airway Nasal cavity Oral cavity Pharynx
  • 8. Oral Cavity Cheeks Hard palate Soft palate Tongue Gums Teeth
  • 9. Nasal Cavity Maxillary bone  Sinuses Frontal bone  Eustachian tubes Nasal bone  Nasolacrimal ducts Ethmoid bone  Nares Sphenoid bone  Mucous membranes Septum
  • 10. Pharynx Nasopharynx Oropharynx Laryngopharynx
  • 11. Larynx Thyroid cartilage Cricoid cartilage Glottic opening Vocal cords Arytenoid cartilage Pyriform fossae Cricothyroid cartilage
  • 12. Internal Anatomy of the Upper Airway
  • 13. Lower Airway Anatomy Trachea Bronchi Alveoli Lung parenchyma Pleura
  • 14. Anatomy of the Lower Airway
  • 15. Anatomy of the Alveoli
  • 16. Anatomy of the Pediatric Airway
  • 17. The Pediatric Airway Smaller and more flexible than an adult. Tongue proportionately larger. Epiglottis floppy and round. Glottic opening higher and more anterior. Vocal cords slant upward, and are closer to the base of the tongue. Narrowest part is the cricoid cartilage.
  • 18. Physiology of theRespiratory System
  • 19. Total Lung Capacity (TLC) Maximum lung capacity Average adult male TLC—6 liters
  • 20. Tidal Volume (VT) Average volume of gas inhaled or exhaled in one respiratory cycle. Average adult male: VT = 500 ml (5-7 cc/kg)
  • 21. Dead Space Volume (VD) Amount of gases in tidal volume that remains in the airway. Approximately 150 ml in adult male.
  • 22. Alveolar Volume (VA) Amount of gas that reaches the alveoli for gas exchange VA = (VT - VP)
  • 23. Minute Volume (Vmin) Amount of gas moved in and out of the respiratory tract in one minute. Vmin = VT x respiratory rate
  • 24. Residual Volume (RV) The amount of air remaining in the lungs at the end of maximal expiration.
  • 25. Inspiratory Reserve Volume (IRV) The amount of air that can be maximally inhaled after normal inspiration.
  • 26. Expiratory Reserve Volume (ERV) The amount of air that can be maximally exhaled after a normal expiration.
  • 27. Functional Residual Capacity (FRC) The volume of gas that remains in the lungs at the end of normal expiration. FRC = ERV + RV
  • 28. Forced Expiratory Volume (FEV) The amount of air that can be maximally expired after maximum inspiration.
  • 29. Introduction Respiration is the exchange of gases between a living organism and its environment. Ventilation is the mechanical process that moves air into and out of the lungs.
  • 30. The Respiratory CyclePulmonary ventilation depends upon pressure changes within the thoracic cavity.
  • 31. Pulmonary Circulation
  • 32. Diffusion ofGases Acrossan AlveolarMembrane
  • 33. Measuring Oxygen and Carbon Dioxide Levels Partial pressure is the pressure exerted by each component of a gas mixture. Partial pressure of a gas is its percentage of the mixture’s total pressure.
  • 34. Normal Arterial Partial PressuresOxygen (PaO2) = 100 torr (average = 80 –100).Carbon dioxide (PaCO2) = 40 torr (average = 35 – 45).
  • 35. Diffusion Movement of a gas from an area of higher concentration to an area of lower concentration. Diffusion transfers gases between the lungs and the blood and between the blood and peripheral tissues.
  • 36. Oxygen Concentration in the BloodOxygen saturation = O2 content/ O2 capacity x 100%
  • 37. Factors Affecting OxygenConcentration in the Blood Decreased hemoglobin concentration. Inadequate alveolar ventilation. Decreased diffusion across the pulmonary membrane when diffusion distance increases or the pulmonary membrane changes. Ventilation/perfusion mismatch occurs when a portion of the alveoli collapses.
  • 38. Inadequate minute volumerespirations can compromise adequate oxygen intake and carbon dioxide removal.
  • 39. Factors Affecting Carbon Dioxide Concentrations in the Blood (1 of 2) Hyperventilation lowers CO2 levels due to increased respiratory rates or deeper respiration. Causes of increased CO2 production include: Fever, muscle exertion, shivering, metabolic processes resulting in the formation of metabolic acids.
  • 40. Factors Affecting Carbon Dioxide Concentrations in the Blood (2 of 2) Decreased CO2 elimination results from decreased alveolar ventilation. Respiratory depression, airway obstruction, respiratory muscle impairment, obstructive diseases.
  • 41. Regulation of Respiration
  • 42. Respiratory Rate Involuntary; however, can be voluntarily controlled. Chemical and physical mechanisms provide involuntary impulses to correct any breathing irregularities.
  • 43. Normal Respiratory Rates Age Rate Per Minute Adult 12-20 Children 18-24 Infants 40-60
  • 44. Respiratory Factors Factor Effect Fever Increases Emotion Increases Pain Increases Hypoxia Increases Acidosis Increases Stimulants Increase Depressants Decrease Sleep Decreases
  • 45. Nervous Impulses from the Respiratory Center Main respiratory center is the medulla. Neurons within medulla initiate impulses that produce respiration. Apneustic center assumes respiratory control if the medulla fails to initiate impulses. Pneumotaxic center controls respiration.
  • 46. Stretch ReceptorsThe Hering-Breuer reflexprevents over-expansion of the lungs.
  • 47. Chemoreceptors Located in carotid bodies, arch of the aorta, and medulla. Stimulated by decreased PaO2, increased PaCO2, and decreased pH. Cerebrospinal fluid (CSF) pH is primary control of respiratory center.
  • 48. Hypoxic Drive Hypoxemia is a profound stimulus of respiration in a normal individual. Hypoxic drive increases respiratory stimulation in people with chronic respiratory disease.
  • 49. Respiratory Problems
  • 50. Airway Obstruction The tongue is the most common cause of airway obstruction.
  • 51. The Tongue as an Airway Obstruction
  • 52. Other Causes of Airway Obstruction Foreign bodies Trauma Laryngeal spasm and edema Aspiration
  • 53. Respiratory System Assessment
  • 54. Initial Assessment Is the airway patent? Is breathing adequate? Look, listen, and feel. If patient is not breathing, open the airway and assist ventilations as necessary.
  • 55. Look.
  • 56. Inspection Skin color Patient’s position Dyspnea Modified forms of respiration Rate Pattern Mentation
  • 57. Abnormal Respiratory Patterns (1 of 3) Kussmaul’s respirations Deep, slow or rapid, gasping; common in diabetic ketoacidosis. Cheyne-Stokes respirations Progressively deeper, faster breathing alternating gradually with shallow, slower breathing, indication brain stem injury.
  • 58. Abnormal Respiratory Patterns (2 of 3) Biot’s respirations: Irregular pattern of rate and depth with sudden, periodic episodes of apnea, indicating increased intracranial pressure. Central neurogenic hyperventilation: Deep, rapid respirations, indicating increased intracranial pressure.
  • 59. Abnormal Respiratory Patterns (3 of 3)Agonal respirations: Shallow, slow, or infrequent breathing, indicating brain anoxia.
  • 60. Listen.
  • 61. Ausculation Listen at the mouth and nose for adequate air movement. Listen with a stethoscope for normal or abnormal air movement.
  • 62. Position for auscultating breath sounds.
  • 63. Airway SoundsAirflow Gas ExchangeCompromise CompromiseSnoring CracklesGurgling RhonchiStridorWheezingQuiet
  • 64. Feel.
  • 65. Palpation Palpate chest wall for tenderness, symmetry, abnormal motion, crepitus, and subcutaneous emphysema. Assess compliance of lungs.
  • 66. Focused History Onset Symptom development Associated symptoms Past medical history Recent history Does anything make symptoms better or worse?
  • 67. Non-InvasiveRespiratory Monitoring
  • 68. Pulse Oximeter
  • 69. Combined devices check pulseoximetry, ETCO2 blood pressure, pulse, respiratory rate, and temperature.
  • 70. Oxygenation
  • 71. ee iNvr wthhold y e fromox g n np n ay ati et for w ihom t i s i n i c te . dad
  • 72. Oxygen Supply and Regulators To calculate how long an oxygen tank will last: tank life in minutes = (tank pressure in psi x .28) liters per minute
  • 73. Oxygen Delivery Devices Device Oxygen percentage Nasal cannula 40% Venturi mask 24, 28, 35, or 40% Simple face mask 40 – 60% Nonrebreather mask 80 – 95%
  • 74. Manual Airway Maneuvers
  • 75. Personal Protective Equipment
  • 76. Head Tilt/Chin Lift
  • 77. Modified Jaw Thrust in Trauma
  • 78. Jaw-Thrust Maneuver
  • 79. Jaw-Lift Maneuver
  • 80. Basic Mechanical Airways
  • 81. Insert oropharyngeal airway with tip facing palate.
  • 82. Rotate airway 180º into position.
  • 83. Improper placement of oropharyngeal airway
  • 84. Nasopharyngeal Airway
  • 85. Nasopharyngeal airway, inserted
  • 86. Ventilation Methods Mouth-to-mouth Mouth-to-nose Bag-valve device Demand valve device Automatic transport ventilator
  • 87. Bag-valve-mask ventilation
  • 88. Bag-valve-mask withbuilt-in colorimetric ETCO2 detector
  • 89. Demand Valve and Mask
  • 90. Portable Mechanical Ventilator
  • 91. Ventilation of Pediatric Patients Mask seal can be more difficult. Bag size depends on age of child. Ventilate according to current standards. Obtain chest rise and fall with each breath. Assess adequacy of ventilations by observing chest rise, listening to lung sounds, and assessing clinical improvement.
  • 92. Direct visualization of the larynx with a laryngoscopemay enable the removal of an obstructing foreign body.
  • 93. Magill Forceps
  • 94. Foreign body removal with directvisualization and Magill forceps
  • 95. Suctioning Anticipating complications when managing an airway is the key for successful outcomes.  Be prepared to suction all airways to remove blood or other secretions and for the patient to vomit.
  • 96. Suctioning Techniques Wear protective eyewear, gloves, and face mask. Preoxygenate the patient. Determine depth of catheter insertion. With suction off, insert catheter. Turn on suction and suction while removing catheter (no more than 10 seconds). Hyperventilate the patient.
  • 97. Advanced Airway Management
  • 98. Endotracheal intubation is clearly the preferred methodof advanced airway management in prehospital emergency care.
  • 99. Laryngoscope Blades
  • 100. Engaging laryngoscope blade and handle
  • 101. Activating laryngoscope light source
  • 102. Placement of Macintosh blade into vallecula
  • 103. Placement of Miller blade under epiglottis
  • 104. Endotrol ETT
  • 105. ETT, Stylet, and Syringe, unassembled
  • 106. ETT and Syringe
  • 107. ETT, Stylet, and Syringe,assembled for intubation
  • 108. Disadvantages of Endotracheal Intubation Requires considerable training and experience. Requires specialized equipment. Requires direct visualization of vocal cords. Bypasses upper airway’s functions of warming, filtering, and humidifying the inhaled air.
  • 109. Endotracheal Intubation Indicators Respiratory or cardiac arrest. Unconsciousness. Risk of aspiration. Obstruction due to foreign bodies, trauma, burns, or anaphylaxis. Respiratory extremis due to disease. Pneumothorax, hemothorax, hemopneumothorax with respiratory difficulty.
  • 110. Complications of Endotracheal Intubation Equipment malfunction Teeth breakage and soft tissue lacerations Hypoxia Esophageal intubation Endobronchial intubation Tension pneumothorax
  • 111. Advantages of Endotracheal Intubation Isolates trachea and permits complete control of airway. Impedes gastric distention. Eliminates need to maintain a mask seal. Offers direct route for suctioning. Permits administration of some medications.
  • 112. Endotracheal Intubation
  • 113. Hyperventilate patient.
  • 114. Prepare equipment.
  • 115. Apply Sellick’s Maneuverand insert laryngoscope.
  • 116. Sellick’s Maneuver(Cricoid Pressure)
  • 117. Airway beforeapplying Sellick’s
  • 118. Airway with Sellick’s applied (note compression on the esophagus)
  • 119. Visualize larynx and insert the ETT.
  • 120. Glottis visualized through laryngoscopy
  • 121. Inflate cuff, ventilate, and auscultate.
  • 122. Confirm placement with an ETCO2 detector.
  • 123. Electronic End-Tidal CO2 Detector
  • 124. Colorimetric End-Tidal CO2 Detector
  • 125. Esophageal Detector Device
  • 126. An esophageal intubation detector-bulb style.A. Attach device to endotracheal tube and squeeze the detector.
  • 127. If bulb refills easily upon release, it indicates correct placement.
  • 128. If the bulb does not refill, the tube is improperly placed.
  • 129. Secure tube.
  • 130. Continuously recheckand reconfirm the placement of the endotracheal tube.
  • 131. Reconfirm ETT placement.
  • 132. Lighted Stylet forEndotracheal Intubation
  • 133. Insertion of lighted stylet/ETT
  • 134. Lighted stylet/ETT in position
  • 135. Transillumination of a lighted stylet
  • 136. Digital IntubationInsert yourmiddleand index fingersinto patient’smouth
  • 137. Digital IntubationWalk your fingersand palpate thepatient’s epiglottis.
  • 138. Blind orotracheal intubation by digital method
  • 139. Digital Intubation—insertion of the ETT
  • 140. Endotracheal Intubationwith In-line Stabilization
  • 141. Hyperventilate patient andapply c-spine stabilization.
  • 142. Apply Sellick’s Maneuver and intubate.
  • 143. Ventilate patient andconfirm placement.
  • 144. Secure ETT and apply a cervical collar.
  • 145. Reconfirm placement.
  • 146. Rapid Sequence Intubation  A patient who needs intubation may be awake. RSI paralyzes the patient to facilitate endotracheal intubation.
  • 147. Endotracheal Intubation in a Child
  • 148. ETT size (mm) =(Age in years + 16) 4
  • 149. Hyperventilate the child.
  • 150. Position the head.
  • 151. Insert the laryngoscope.
  • 152. Insert ETT and ventilate the child.
  • 153. Confirm placement and secure ETT.
  • 154. Nasotracheal intubation maybe useful in some situations: Possible spinal injury Clenched teeth Fractured jaw, oral injuries, or recent oral surgery Facial or airway swelling Obesity Arthritis preventing sniffing position
  • 155. Blind Nasotracheal Intubation
  • 156. Other Intubation Devices Esophageal CombiTube (ECT) Laryngeal mask airway (LMA) Pharyngo-tracheal lumen airway (PtL) Esophageal gastric tube (EGTA) Esophageal obturator airway (EOA)
  • 157. ECT Airway—tracheal placement
  • 158. ECT Airway—esophageal placement
  • 159. Laryngeal Mask Airway
  • 160. Pharyngo-Tracheal lumen airway
  • 161. The only indication for a surgical airway isthe inability to establish an airway by any other method.
  • 162. Anatomical Landmarks for Cricothyrotomy
  • 163. Locate/palpatecricothyroid membrane.
  • 164. Proper positioning forcricothyroid puncture
  • 165. Advance the catheter with the needle.
  • 166. Jet ventilation withneedle cricothyrotomy
  • 167. Open Cricothyrotomy
  • 168. Cannula properly placed in trachea
  • 169. Locate cricothyroid membrane.
  • 170. Stabilize larynx and make a 1–2 cm skin incision over cricothyroid membrane.
  • 171. Make a 1 cm horizontal incisionthrough the cricothyroid membrane.
  • 172. Using a curved hemostat, spread membrane incision open.
  • 173. Insert an ETT (6.0) or Shiley (6.0).
  • 174. Inflate the cuff.
  • 175. Confirm placement.
  • 176. Ventilate.
  • 177. Secure tube, reconfirm placement, evaluate patient.
  • 178. Tracheostomy Cannulae
  • 179. Patients with Stoma Sites Patients who have had a laryngectomy or tracheostomy breathe through a stoma. There are often problems with excess secretions, and a stoma may become plugged.
  • 180. Tracheostomy Suction Technique