Airway

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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
  • Airway

    1. 1. Airway Management and Ventilation
    2. 2. Airway management and ventilation are the firstand most critical steps in the initial assessment of every patient you will encounter.
    3. 3. Topics Anatomy of the Respiratory System Physiology of the Respiratory System Respiratory Problems Respiratory System Assessment Airway Management
    4. 4. Anatomy of theRespiratory System
    5. 5. The respiratory system provides a passage for oxygen to enter the bodyand for carbon dioxide to exit the body.
    6. 6. Anatomy of the Upper Airway
    7. 7. Upper Airway Nasal cavity Oral cavity Pharynx
    8. 8. Oral Cavity Cheeks Hard palate Soft palate Tongue Gums Teeth
    9. 9. Nasal Cavity Maxillary bone  Sinuses Frontal bone  Eustachian tubes Nasal bone  Nasolacrimal ducts Ethmoid bone  Nares Sphenoid bone  Mucous membranes Septum
    10. 10. Pharynx Nasopharynx Oropharynx Laryngopharynx
    11. 11. Larynx Thyroid cartilage Cricoid cartilage Glottic opening Vocal cords Arytenoid cartilage Pyriform fossae Cricothyroid cartilage
    12. 12. Internal Anatomy of the Upper Airway
    13. 13. Lower Airway Anatomy Trachea Bronchi Alveoli Lung parenchyma Pleura
    14. 14. Anatomy of the Lower Airway
    15. 15. Anatomy of the Alveoli
    16. 16. Anatomy of the Pediatric Airway
    17. 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. 18. Physiology of theRespiratory System
    19. 19. Total Lung Capacity (TLC) Maximum lung capacity Average adult male TLC—6 liters
    20. 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. 21. Dead Space Volume (VD) Amount of gases in tidal volume that remains in the airway. Approximately 150 ml in adult male.
    22. 22. Alveolar Volume (VA) Amount of gas that reaches the alveoli for gas exchange VA = (VT - VP)
    23. 23. Minute Volume (Vmin) Amount of gas moved in and out of the respiratory tract in one minute. Vmin = VT x respiratory rate
    24. 24. Residual Volume (RV) The amount of air remaining in the lungs at the end of maximal expiration.
    25. 25. Inspiratory Reserve Volume (IRV) The amount of air that can be maximally inhaled after normal inspiration.
    26. 26. Expiratory Reserve Volume (ERV) The amount of air that can be maximally exhaled after a normal expiration.
    27. 27. Functional Residual Capacity (FRC) The volume of gas that remains in the lungs at the end of normal expiration. FRC = ERV + RV
    28. 28. Forced Expiratory Volume (FEV) The amount of air that can be maximally expired after maximum inspiration.
    29. 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. 30. The Respiratory CyclePulmonary ventilation depends upon pressure changes within the thoracic cavity.
    31. 31. Pulmonary Circulation
    32. 32. Diffusion ofGases Acrossan AlveolarMembrane
    33. 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. 34. Normal Arterial Partial PressuresOxygen (PaO2) = 100 torr (average = 80 –100).Carbon dioxide (PaCO2) = 40 torr (average = 35 – 45).
    35. 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. 36. Oxygen Concentration in the BloodOxygen saturation = O2 content/ O2 capacity x 100%
    37. 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. 38. Inadequate minute volumerespirations can compromise adequate oxygen intake and carbon dioxide removal.
    39. 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. 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. 41. Regulation of Respiration
    42. 42. Respiratory Rate Involuntary; however, can be voluntarily controlled. Chemical and physical mechanisms provide involuntary impulses to correct any breathing irregularities.
    43. 43. Normal Respiratory Rates Age Rate Per Minute Adult 12-20 Children 18-24 Infants 40-60
    44. 44. Respiratory Factors Factor Effect Fever Increases Emotion Increases Pain Increases Hypoxia Increases Acidosis Increases Stimulants Increase Depressants Decrease Sleep Decreases
    45. 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. 46. Stretch ReceptorsThe Hering-Breuer reflexprevents over-expansion of the lungs.
    47. 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. 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. 49. Respiratory Problems
    50. 50. Airway Obstruction The tongue is the most common cause of airway obstruction.
    51. 51. The Tongue as an Airway Obstruction
    52. 52. Other Causes of Airway Obstruction Foreign bodies Trauma Laryngeal spasm and edema Aspiration
    53. 53. Respiratory System Assessment
    54. 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. 55. Look.
    56. 56. Inspection Skin color Patient’s position Dyspnea Modified forms of respiration Rate Pattern Mentation
    57. 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. 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. 59. Abnormal Respiratory Patterns (3 of 3)Agonal respirations: Shallow, slow, or infrequent breathing, indicating brain anoxia.
    60. 60. Listen.
    61. 61. Ausculation Listen at the mouth and nose for adequate air movement. Listen with a stethoscope for normal or abnormal air movement.
    62. 62. Position for auscultating breath sounds.
    63. 63. Airway SoundsAirflow Gas ExchangeCompromise CompromiseSnoring CracklesGurgling RhonchiStridorWheezingQuiet
    64. 64. Feel.
    65. 65. Palpation Palpate chest wall for tenderness, symmetry, abnormal motion, crepitus, and subcutaneous emphysema. Assess compliance of lungs.
    66. 66. Focused History Onset Symptom development Associated symptoms Past medical history Recent history Does anything make symptoms better or worse?
    67. 67. Non-InvasiveRespiratory Monitoring
    68. 68. Pulse Oximeter
    69. 69. Combined devices check pulseoximetry, ETCO2 blood pressure, pulse, respiratory rate, and temperature.
    70. 70. Oxygenation
    71. 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. 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. 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. 74. Manual Airway Maneuvers
    75. 75. Personal Protective Equipment
    76. 76. Head Tilt/Chin Lift
    77. 77. Modified Jaw Thrust in Trauma
    78. 78. Jaw-Thrust Maneuver
    79. 79. Jaw-Lift Maneuver
    80. 80. Basic Mechanical Airways
    81. 81. Insert oropharyngeal airway with tip facing palate.
    82. 82. Rotate airway 180º into position.
    83. 83. Improper placement of oropharyngeal airway
    84. 84. Nasopharyngeal Airway
    85. 85. Nasopharyngeal airway, inserted
    86. 86. Ventilation Methods Mouth-to-mouth Mouth-to-nose Bag-valve device Demand valve device Automatic transport ventilator
    87. 87. Bag-valve-mask ventilation
    88. 88. Bag-valve-mask withbuilt-in colorimetric ETCO2 detector
    89. 89. Demand Valve and Mask
    90. 90. Portable Mechanical Ventilator
    91. 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. 92. Direct visualization of the larynx with a laryngoscopemay enable the removal of an obstructing foreign body.
    93. 93. Magill Forceps
    94. 94. Foreign body removal with directvisualization and Magill forceps
    95. 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. 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. 97. Advanced Airway Management
    98. 98. Endotracheal intubation is clearly the preferred methodof advanced airway management in prehospital emergency care.
    99. 99. Laryngoscope Blades
    100. 100. Engaging laryngoscope blade and handle
    101. 101. Activating laryngoscope light source
    102. 102. Placement of Macintosh blade into vallecula
    103. 103. Placement of Miller blade under epiglottis
    104. 104. Endotrol ETT
    105. 105. ETT, Stylet, and Syringe, unassembled
    106. 106. ETT and Syringe
    107. 107. ETT, Stylet, and Syringe,assembled for intubation
    108. 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. 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. 110. Complications of Endotracheal Intubation Equipment malfunction Teeth breakage and soft tissue lacerations Hypoxia Esophageal intubation Endobronchial intubation Tension pneumothorax
    111. 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. 112. Endotracheal Intubation
    113. 113. Hyperventilate patient.
    114. 114. Prepare equipment.
    115. 115. Apply Sellick’s Maneuverand insert laryngoscope.
    116. 116. Sellick’s Maneuver(Cricoid Pressure)
    117. 117. Airway beforeapplying Sellick’s
    118. 118. Airway with Sellick’s applied (note compression on the esophagus)
    119. 119. Visualize larynx and insert the ETT.
    120. 120. Glottis visualized through laryngoscopy
    121. 121. Inflate cuff, ventilate, and auscultate.
    122. 122. Confirm placement with an ETCO2 detector.
    123. 123. Electronic End-Tidal CO2 Detector
    124. 124. Colorimetric End-Tidal CO2 Detector
    125. 125. Esophageal Detector Device
    126. 126. An esophageal intubation detector-bulb style.A. Attach device to endotracheal tube and squeeze the detector.
    127. 127. If bulb refills easily upon release, it indicates correct placement.
    128. 128. If the bulb does not refill, the tube is improperly placed.
    129. 129. Secure tube.
    130. 130. Continuously recheckand reconfirm the placement of the endotracheal tube.
    131. 131. Reconfirm ETT placement.
    132. 132. Lighted Stylet forEndotracheal Intubation
    133. 133. Insertion of lighted stylet/ETT
    134. 134. Lighted stylet/ETT in position
    135. 135. Transillumination of a lighted stylet
    136. 136. Digital IntubationInsert yourmiddleand index fingersinto patient’smouth
    137. 137. Digital IntubationWalk your fingersand palpate thepatient’s epiglottis.
    138. 138. Blind orotracheal intubation by digital method
    139. 139. Digital Intubation—insertion of the ETT
    140. 140. Endotracheal Intubationwith In-line Stabilization
    141. 141. Hyperventilate patient andapply c-spine stabilization.
    142. 142. Apply Sellick’s Maneuver and intubate.
    143. 143. Ventilate patient andconfirm placement.
    144. 144. Secure ETT and apply a cervical collar.
    145. 145. Reconfirm placement.
    146. 146. Rapid Sequence Intubation  A patient who needs intubation may be awake. RSI paralyzes the patient to facilitate endotracheal intubation.
    147. 147. Endotracheal Intubation in a Child
    148. 148. ETT size (mm) =(Age in years + 16) 4
    149. 149. Hyperventilate the child.
    150. 150. Position the head.
    151. 151. Insert the laryngoscope.
    152. 152. Insert ETT and ventilate the child.
    153. 153. Confirm placement and secure ETT.
    154. 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. 155. Blind Nasotracheal Intubation
    156. 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. 157. ECT Airway—tracheal placement
    158. 158. ECT Airway—esophageal placement
    159. 159. Laryngeal Mask Airway
    160. 160. Pharyngo-Tracheal lumen airway
    161. 161. The only indication for a surgical airway isthe inability to establish an airway by any other method.
    162. 162. Anatomical Landmarks for Cricothyrotomy
    163. 163. Locate/palpatecricothyroid membrane.
    164. 164. Proper positioning forcricothyroid puncture
    165. 165. Advance the catheter with the needle.
    166. 166. Jet ventilation withneedle cricothyrotomy
    167. 167. Open Cricothyrotomy
    168. 168. Cannula properly placed in trachea
    169. 169. Locate cricothyroid membrane.
    170. 170. Stabilize larynx and make a 1–2 cm skin incision over cricothyroid membrane.
    171. 171. Make a 1 cm horizontal incisionthrough the cricothyroid membrane.
    172. 172. Using a curved hemostat, spread membrane incision open.
    173. 173. Insert an ETT (6.0) or Shiley (6.0).
    174. 174. Inflate the cuff.
    175. 175. Confirm placement.
    176. 176. Ventilate.
    177. 177. Secure tube, reconfirm placement, evaluate patient.
    178. 178. Tracheostomy Cannulae
    179. 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. 180. Tracheostomy Suction Technique

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