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2014 AEMT airway management cole


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This is the introduction to airway management for Advanced EMTs though some medics might find it useful too. Focuses mainly on supraglottic and periglottic airway devices as well as basic anatomy , …

This is the introduction to airway management for Advanced EMTs though some medics might find it useful too. Focuses mainly on supraglottic and periglottic airway devices as well as basic anatomy , physiology, etc. Talks about apniec defusion too.

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  • 1. 2 0 1 4 A E M T C O U R S E P R E S E N T E D B Y : R O B E R T S . C O L E P A R A M E D I C , O C D Airway Management
  • 2. When ever I’m blue….. I remember to breath again. - Anonymous
  • 3. Basic Concept:  Air Goes in and Out Blood Goes Round and Round Any thing infringing on this is a BAD THING!
  • 4. Respiratory Anatomy
  • 5. The Upper Airway  1. Nose  Warm and humidify air through turbinates  2. Mouth and oral cavity  Advanced airway  Entrance to the digestive system  Also involved in the production of speech  Tongue  3. Jaw  Facial bones  Maxilla  mandible  4. Pharynx  Nasopharynx  Oropharynx  Hypopharynx  Laryngopharyx  5. Larynx  Epiglottis – muscular structure which protects the airway of conscious patients during swallowing  Vocal cords – thin muscles which are the center for speech and protect the lower airways  Thyroid cartilage  Cricoid ring  6. Jugular notch
  • 6. The Upper Airway
  • 7. The Lower Airway  1. Trachea  Hollow tube which passes air to the lower airways  Supported by cartilage rings  2. Carina  The bifurcation of the trachea into the two main stem bronchi  3. Bronchi  Hollow tubes which further divide into lower airways of the lungs  Supported by cartilage  Alveoli  4. Lungs  a. Bronchioles  i. thin hollow tubes leading to the alveoli  ii. remain open through smooth muscle tone  Bronchial smooth muscle  Beta2 adrenergic receptors  b. Alveoli  i. the end of the airway  ii. millions of thin walled sacs  iii. each alveolus surrounded by capillary blood vessels  iv. site where oxygen and carbon dioxide (waste) are exchanged  c. Pulmonary capillary beds  i. blood vessels that begin as capillary surrounding each alveolus  ii. with adequate blood volume and blood pressure, the vessels return oxygenated blood to the heart
  • 8. The Lower Airway
  • 9. The Lower Airway 9
  • 10. The Lower Airway 10
  • 11. Key Point  It takes approximately 150-200 cc of air movement to reach the terminal bronchus and the aveoli…  This is called “Dead Air Space”  Tidal volumes less than 200 cc typically do not oxygenate/ventilate at the aveolar level.
  • 12. The Lower Airway
  • 13. The Chest Cavity  Thoracic skin, muscle, and bones  Similarities to other regions  Also unique features to allow for ventilation
  • 14. Pulmonary Circulation
  • 15. The Thoracic “Cage” Credit:
  • 16. The Rib Credit:
  • 17. The Chest Cavity  The neurovascular bundle lies closely along the lowest margin of each rib.  The pleura covers each lung and the thoracic cavity  The visceral pleura covers the lungs and the parietal pleura covers the thoracic cavity.  There is also a negative pressure between the two that keeps them stuck together yet not actually attached.  Surfactant allows the lungs to move freely against the inner chest wall during respiration.
  • 18. Intercostal Muscles and Diaphram  The Intercostal Muscles are several groups of muscles that run between the ribs  The diaphragm is a muscle that separates the thoracic cavity from the abdominal cavity.  Together they help the “Mechanical Bellows”
  • 19. Mechanics of Ventilation  The intercostal muscles (between the ribs) contract during inhalation.  The diaphragm contracts at the same time.  The intercostal muscles and the diaphragm relax during exhalation.  The body should not have to work to breathe when in a resting state.
  • 20. Mechanics of Ventilation  Patients with a spinal injury below C5 can still breathe from the diaphragm.  Patients with a spinal injury above C3 may lose the ability to breathe altogether.
  • 21. The Mechanical Bellows?
  • 22. The Mechanical Bellows  The muscles of the ribs expand the size of the chest, creating a (relative) negative pressure.  Air (with O2) moves in to fill the void.  Commonly thought of as Oxygenation.  Actual oxygenation takes place at the cellular level. Special Thanks to Charlie Miller for this Graphic.
  • 23. The Mechanical Bellows  The intercostals muscles relax, allowing the chest to return to its neutral position, expelling air out of the lungs (and CO2 with it.)  Commonly thought of as Ventilation.  Actual ventilation takes place at the cellular level. Special Thanks to Charlie Miller for this Graphic.
  • 24. The Mechanical Bellows  Example of a Compromised Bellows  Positional Asphyxia Special Thanks to Charlie Miller for this Graphic.
  • 25. Key Point:  A comprehensive understanding of the Anatomy of the airway and thorax is essential to managing the airway and respiratory functions of your patient.
  • 26. A K A : H O W W E B R E A T H … . . Physiology of Respiration
  • 27. Key Definitions  Tidal Volume (Vt)  Typically 500-700 cc  Minute Volume (Vm)  Tidal Volume X Respiratory Rate = Minute Volume  Functional Reserve Capacity (FRC)  Typically 2,400 cc in a 70 kg Human  Inspired Oxygen (FiO2)  Fraction of Inspired Oxygen  Expressed as a decimal, i.e. 80% is 0.8 FiO2. 100% is 1.0 FiO2  Work of Breathing (WOB)
  • 28. Respiratory Rate times x Tidal Volume (amount of air exchanged in one breath) equals = Minute Ventilation Minute Ventilation RR x TV = minute volume
  • 29. Physiology of Respiration  Diffusion of O2 from the lung to the blood is by the binding of O2 to the hemoglobin (Hgb)  This is dependant on a pressure gradient.  This is a Passive transport system.  It is also dependant on available surface area and distance it must travel to cross the threshold.  Capillaries and Alveoli are where the real Oxygenation and ventilation take place.
  • 30. Alveolar Ventilation Minute Ventilation minus – Dead Air Space equals = Alveolar Ventilation Dead Air Space: the trachea, bronchi, and bronchioles. There is NO gas exchange in these areas.
  • 31. Key components of an intact respiratory system  An appropriate Drive to Breath  Airway and respiratory tract  Mechanical Bellows  A diffusion friendly place for gas exchange to happen.  An O2 friendly RBC with hgb.  An intact circulatory system to carry the gasses and waste through out the body.  Must have enough of a pressure to promote diffusion.  An intact capillary bed  Its like a truck shipping company.
  • 32. Drive to breath  Controlled by the CNS through information gathered from receptors in the body.  Located in the pons region of the brainstem  Detects increases in CO2 or decreases in pH and informs the brain to increase the respiratory rate.  Increased respiratory rate reduces CO2 and will increase pH.  Other things can effect our drive to breath
  • 33. “Hypoxic Drive”  Develops in some patients with Chronic Lung Disease  Pons region of brain becomes sensitized to constant increased CO2 state  Regulation is now based on O2 level in blood  Increased oxygen level states may tell the brain to stop breathing
  • 34. Diffusion
  • 35. An O2 friendly RBC with hgb.  Hemoglobin is an Iron Based compound essential to the transport of O2.  Anemia  Cyanide Poisoning  CO Poisoning
  • 36. An intact circulatory system  Blood Loss  Shock  Pump Problem  Volume Problem  Fluid issue  O2 carrying issue  Vessel Problem
  • 37. KEY POINT: Must have enough of a pulmonary perfusion pressure to promote diffusion. Conditions like Hypotension cause secondary hypoxia by promoting low perfusion.
  • 38. Physiology of Respiration  The primary function of the respiratory system is gaseous exchange.  Ventilation and Oxygenation.  Air is composed of a mixture of gases.  Breathing is largely controlled by the Autonomic Nervous system, in response to changes sensed in all parts of the body. The biggest part of this is the “Hypoxic Drive”.
  • 39. Physiology of Respiration  Ventilation is the body’s ability to move gas (usually atmospheric air) in and out of the chest and lung tissue.  Respiration is the exchange of gases in the alveoli of the lung tissue.
  • 40. Physiology of Respiration  Oxygen exchange can be hindered by:  Condition in the airway  Disease processes- COPD, asthma, pneumonia, pulmonary edema  Traumatic conditions  Abnormalities in pulmonary vessels  Altitude  Closed environment  Toxins or poisonous environment  Drowning  Occupational exposure
  • 41.  All cells need a constant supply of oxygen to survive. Physiology of Respiration
  • 42.  Inhalation  The active part of breathing  Focused on delivering oxygen to the alveoli  Tidal volume is the amount of air that moves into or out of the lungs during a single breath.  Minute ventilation (minute volume) is the amount of air moved through the lungs in 1 minute minus the dead space. Ventilation
  • 43.  Exhalation  Passive process  Diaphragm and intercostal muscles relax.  Smaller thorax compresses air out of the lungs.  Vital capacity is the amount of air that can be forcibly expelled from the lungs after breathing deeply.  Residual volume refers to the air that remains after maximal expiration. Ventilation
  • 44.  Regulation of ventilation  The body’s need for oxygen is constantly changing.  Failure to meet the need may result in hypoxia.  For most people, the drive to breathe is based on pH changes in blood and cerebrospinal fluid. Ventilation
  • 45. Q U I C K R E V I E W A L S O R E V I E W E D I N M E D I C A L E M E R G E N C I E S Respiratory Compromise
  • 46. Pneumothorax  Commonly called a collapsed lung  Accumulation of air in the pleural space  Blood passing through the collapsed portion of the lung is not oxygenated.  You may hear diminished, absent, or abnormal breath sounds.
  • 47. Pneumothorax
  • 48. Pneumothorax Open chest wound Often called an open pneumothorax or a sucking chest wound.
  • 49. Tension Pneumothorax  Tension pneumothorax  Results from significant air accumulation in the pleural space  Increased pressure in the chest causes: Complete collapse of the affected lung Mediastinum to be pushed into the opposite pleural cavity
  • 50. Tension Pneumothorax
  • 51.  Blood collects in the pleural space from bleeding around the rib cage or from a lung or great vessel. Hemothorax
  • 52. Pulmonary Edema  Heart muscle can’t circulate blood properly.  Left ventricle is compromised resulting in “backflow.”  Fluid builds up within alveoli and in lung tissue.  Usually result of congestive heart failure  Pulmonary trauma  Chemical exposures
  • 53. Pulmonary Edema The fluid and thicker tissue makes exchange of gasses less efficient.
  • 54. Chronic Obstructive Pulmonary Disease (COPD)  Slow process of constriction and disruption of airways and alveoli  Caused by chronic bronchial obstruction  Tobacco smoke can create chronic bronchitis.
  • 55. Chronic Obstructive Pulmonary Disease (COPD)  Emphysema is another type of COPD.  Loss of elastic material around air spaces  Causes include inflamed airways and smoking.  Most patients with COPD have elements of both chronic bronchitis and emphysema.
  • 56. Chronic Obstructive Pulmonary Disease (COPD)
  • 57. Chronic Obstructive Pulmonary Disease (COPD)  “Wet lungs” vs. “dry lungs”  “Wet lungs” sounds—pulmonary edema  “Dry lungs” sounds—COPD  Can be easily confused with congestive heart failure
  • 58. Asthma, Hay Fever, and Anaphylaxis  Result of allergic reaction to inhaled, ingested, or injected substance  In some cases an allergen cannot be identified.  Asthma is acute spasm of smaller air passages (bronchioles).
  • 59.  Asthma is acute spasm of smaller air passages (bronchioles). Asthma
  • 60. Signs of Mechanical Ventilation Impairment  Abnormal sounds include wheezing, rales, rhonchi, and stridor.
  • 61. Management & Interventions  Insure adequate airway and ventilation  Either assisted or on patient’s own  Use of adjuncts  Pulse oximetry  Provide supplemental oxygen  NRB, NC, Nebulizer with Albuterol  Reference ACP SWO Appendix A  Provide positive pressure ventilations if indicated  BVM  Demand valve  Automatic transport ventilator (ATV)
  • 62. Assessment
  • 63. What do we assess?  Primary Assesment  Presence or absence?  Rate  Quality  “Doorway Test”
  • 64. First Impressions  Air Hungry  Nasal Flaring  Tripoding  Rocking with respirations  Pursed Lip Breathing  Barrel or Sparrow Chest  Home O2
  • 65. Respiratory Rate  Decreased by:  Depressant Drugs  Sleep  Increased by:  Fever  Fear  Exertion
  • 66. Respiratory Quality  Irregular: Neuro Insult.  Shallow:  Respiratory Depressants  CNS Depressants  Neuro Insult  Deep:  Hyperglycemia with Acidosis (DKA): “Kussmal Respirations  Electrolyte Imbalances  Neuro Insult
  • 67. Skin Signs  Cyanosis  Nail Beds  Lips  Ears  Mottling  Chest  Lower Ext  Abd
  • 68. Noisy breathing is obstructed breathing  Snoring: obstruction by tongue  Gurgling: Funky Junk in upper airway  Grunting: Physiologic PEEP  Stridor: harsh, high pitched sound on inhalation:  Laryngeal edema  Epiglotitis  FBAO
  • 69. Speech Dyspnea  Inability to speak more than a few syllables in a sentence between breaths.
  • 70. Breath Sounds  Listening by comparison  Listening anterior  Listening posterior  Fremitus
  • 71. Abnormal breath sounds  Rales (crackles): fine bubbling sound of fluid in alveoli (“Rice Krispies”: snap, crackle and pop) Alveoli popping open.  Rhonchi: fluid in larger airways, obstructing object in the bronchus  Wheezes: high pitched whistling, air through narrowed airways  SILENCE IS BAD NEWS
  • 72. Causes of respiratory abnormalities  Brain damage: trauma, drugs, stroke  Spinal cord damage: trauma, polio  Upper airways: tongue, swelling, foreign body, trauma  Lower airways: asthma, chronic bronchitis  Alveoli: atelectasis, obstruction  Impaired pulmonary circulation: embolism
  • 73. Signs/symptoms of distress  Dyspnea  Restlessness/anxiety  Tachypnea/Bradypnea  Cyanosis (core)  Abnormal sounds  Retractions  Diminished ability to speak
  • 74. More S/S  Retractions and/or use of accessory muscles  Abdominal breathing  Nasal flaring  Productive cough  Color?  Irregular breathing  Tripod position  Pursed-lip breathing
  • 75. Take another look ….What do you see?
  • 76. Hows this? Pursed Lips Sparrow Chest Tripoding Retractions Abd retractions Kewl Haircut O2
  • 77. Inadequate Breathing: Infants and Children Retractions Nasal Flaring See-Saw Breathing Diaphragmatic Breathing
  • 78.  A pulse oximeter measures the percentage of hemoglobin saturation.  Should be 95% to 100% while breathing room air.  AHA recommendations are to maintain a saturation of greater than 94%.  A saturation of 75% is extremely low. Approximately the level of oxygen that should be returning from the tissues. Assessment
  • 79.  Inaccurate pulse oximetry readings may be caused by:  Hypovolemia  Anemia  Severe peripheral vasoconstriction (including cold)  Nail polish (turn sensory sideways)  Dirty fingers  Carbon monoxide poisoning Assessment
  • 80. Assessment  Assess for:  Gag reflex  Airway obstruction  Soft tissue obstruction  Foreign bodies  Complete or incomplete  Upper vs. lower  Work of breathing  Laryngospasm  Laryngeal edema  Penetrating injuries.
  • 81. Basic Airway Interventions
  • 82. Basic Airway Interventions  Manual Airway maneuver  Head tilt/chin lift  Jaw thrust  Airway devices  OPA  NPA  IOM (NuMask)  BVM  Relief of foreign body airway obstruction  (per AHA guidelines)  Upper airway suctioning  Lower airway suctioning  After placement of advanced airway
  • 83. Airway Obstruction Most common cause: tongue and/or epiglottis
  • 84. Manual Opening the Airway Jaw thrust Head tilt–chin lift
  • 85. The Oropharyngeal Airway
  • 86. Malposition of Oropharyngeal Airway Too short
  • 87. Nasopharyngeal Airway Insertion technique
  • 88. The Bag Valve mask
  • 89. The Sniffing Position
  • 90. KEY POINTS  BVM ventilation is a perishable skill and surprisingly difficult on mannequins, as well as many patients. A number of studies have demonstrated the difficulties performing BVM ventilation on real patients in field situations.  The “weak link” in using the BVM is the “Face Mask Seal”.
  • 91. The E-C Technique
  • 92. “Double C” or “two Hand Technique Pirated from
  • 93. Poor seal, esp. in victims with: •Obesity •Facial hair •The elderly •Lack of teeth •Facial Trauma Current masks are fragile and cumbersome Easy to learn, difficult to retain Often needs 2 providers for adequate seal on difficult patients Why traditional facemasks can be problematic All Rights Reserved. © 2007-2011 NuMask®, Inc.
  • 94. Predictors of difficult ventilation…  In addition to the psycho-motor and provider difficulties of retaining this vital skill, research has shown us that the patient themselves present many predictable difficulties to successful BVM ventilation. Some of the major ones are:  a body mass index of 30 kg/square meter or more  Presence of a beard  Mallampati score of three or four  Age of 57 or older  Severely limited jaw protrusion  Snoring.  Maxillo-Facial Trauma  Short thyromental distance  The edentulous, and obese patients.  Of these 9 co-morbid factors, 5 of which are directly dependant on face mask seal, and therefore these five which would be mitigated if not eliminated with the use of the IOM. Kheterpal S, Han R, Tremper KK, et al. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology. 2006 Nov; 105(5):885-91.
  • 95. Nu-Mask  Nu-Mask is a new alternative to the BVM.  It is for patients whom a getting a face mask seal is problematic.  It is the only device for difficult aiways that can be used by both BLS and ALS providers.  ACP/ACEMSS is deploying these to all BLS and ALS units in the system.
  • 96. NuMask IOM® and IOM® w/ OPA in Place NuMask IOM NuMask IOM with OPA All Rights Reserved. © 2007-2011 NuMask®, Inc.
  • 97. An air tight seal in 1/10th the space of a traditional mask All Rights Reserved. © 2007-2011 NuMask®, Inc.
  • 98. KEY POINT  The IOM uses internal oral tissue to obtain a superior “wet seal”. Because hand placement, hand size, and hand position are not as crucial, the IOM is easier to use.
  • 99. Key Points about suction…  300 mm hg for adults  No more than 120 mm hg for pediatrics  Intervals  Prefer < 10 seconds (2010 ECC Guidelines for CPR)  Devices  Soft tip  Yankour/Big Stick  In Line
  • 100. Types of Portable Suction Courtesy of Laerdal Medical Corporation, Armonk, NY
  • 101. Supra-glottic Airways
  • 102. AEMT “Supraglottic” airway devices  Indications  To promote airway management by providing a patent airway in the unconscious, and/or apneic patient.  Contraindications  Responsive patients with an intact gag reflex.  Patients with known esophageal disease, i.e. esophageal varices.  Patients known or suspected to have ingested caustic substances.
  • 103. KEY POINT  THE NEW AEMT SCOPE OF PRACTICE DOES NOT CONTAIN ETT.  Discussion: Is this a god idea or bad?  This doesn’t mean that the AEMT shouldn’t have a working understanding of the ETT so as to be a better clinical provider and member of the overall health care team. 
  • 104. Terms  Supra-glottic  Double/Single Lumen  Peri-glottic  Esophageal orburtrator airways
  • 105. Lots of devices over the years  Esophageal obturation  Esophageal Gastric Tube Airway (EGTA)  Esophageal Orbturator Airway (EOA)
  • 106. Dual Lumen Supra-Glotic Airways  Pharyngeal-tracheal Lumen Airway (PTLA)  AKA: The PTL  Esophageal-Tracheal Combitube (ETC)  AKA: The Combi-tube  AKA: Rush Easy Tube
  • 107. “Peri-Glottic” Airways  Laryngeo-Mask Airways (LMA)  Air-Q  I-Gel
  • 108. Laryngeo-Mask Airways
  • 109. I Gel
  • 110. Single Lumen Airways  King LTD  COBRA Peri-Laryngeal Airway (PLA)
  • 111. Cobra PLA
  • 112. King Airway  Size determined by Pt’s height:  Yellow: 4-5 ft  Red: 5-6 ft  Purple: > 6 ft
  • 113. Instructions for use  Choose appropriate size based on patient’s height.  Test cuffs by inflating to recommended volume of air and deflate cuffs completely before attempting to insert. 60-90ml air based on device size.  Generously lubricate tube using a water based lube.  Pre-oxygenate patient with 100% O2  Have suction available.
  • 114. Insertion:  Position the head in a slightly sniffing position, unless spinal injury is known or suspected. Then maintain cervical alignment and keep the head in a neutral position.  Insert King rotated 45-90 degrees laterally and insert into mouth  As you gently advance the tube rotate tube to midline.  Advance tube until base of connector aligns with teeth or gums.
  • 115. Cuff inflation:  Inflate cuffs with minimum volume necessary to seal the airway according to tube size.  “SEAT THE TUBE”  GENTLY tug on the tube to appropriately place it…  Attach to resuscitator bag and ventilate using 100% O2 source.  Assure chest rise and fall. Auscultate breath sounds.  Secure tube, using a commercially approved device, noting depth of tube placement.  Monitor end tidal CO2 if available.
  • 116. ARTIFICIAL VENTILATION Management Techniques
  • 117.  Probably the most important skills in EMS at any level.  Basic airway and ventilation techniques are extremely effective.  Airway management is the one advanced skill that can have the greatest impact on patient mortality and morbidity.  It is imperative that you become experts at basic and advance airway management. Assisted and Artificial Ventilation
  • 118. Basic Airway Adjuncts  Chin lift  Jaw thrust  Positioning/suctioning  Oropharyngeal airway (OPA)  Nasopharyngeal airway (NPA)  EGTA/Combi-tube/King LT
  • 119. Oxygen Delivery Adjuncts  Nasal Cannula: 2-6 LPM 24-44%  Simple mask: 6-10LPM 35-60%  Non-Rebreather Mask: 10-15LPM 80-95%  Bag-valve-mask 15LPM 95-100%
  • 120.  When assisting with a bag-mask device:  Explain the procedure to the patient.  Place the mask over the nose and mouth.  Squeeze the bag each time the patient breathes.  Maintain an adequate minute volume. Assisted and Artificial Ventilation
  • 121.  Artificial ventilation  Devices include: Pocket face masks Bag-mask device CPAP/BiPAP Manually triggered ventilation device Automatic transport ventilator Assisted and Artificial Ventilation
  • 122. Assisted and Artificial Ventilation  Pocket Masks  Includes IOM/NEW MASK  Advantages:  Small, easy to use  Easy to use two handed technique  Oxygen optional  Disadvantages  Down near the patients face---YUCK  High FiO difficult
  • 123. Assisted and Artificial Ventilation  Bag Valve Mask  Advantages  Self inflating  Can be used with or without an oxygen source  Can be used with the IOM/NuMask  Disadvantages  Difficult to obtain a mask seal at times (dentures removed, facial hair, etc. )  Best results if used with more than one rescuer
  • 124.  Manually triggered ventilation devices  Advantages:  Also known as flow-restricted, oxygen-powered ventilation device  Allows single rescuer to use both hands to maintain mask-to-face seal while providing positive-pressure ventilation  Should not be used routinely  Disadvantages  Difficult to maintain adequate ventilation without assistance  Requires oxygen. Typical adult ventilation consumes 5 liters per minute O2 versus 15-25 liters per minute for a bag-valve-mask  Typically used on adult patients only  Requires special unit and additional training for use in pediatric patients  The rescuer is unable to easily assess lung compliance  High ventilator pressures may damage lung tissue Assisted and Artificial Ventilation
  • 125.  Automatic transport ventilator (ATV)  Manually triggered device attached to a control box  Allows the variables of ventilation to be set  Lacks the control of a hospital ventilator  Frees the EMT to perform other tasks Assisted and Artificial Ventilation Courtesy of Impact Instrumentation, Inc.
  • 126. CPAP  Continuous Positive Airway Pressure  Advantages  Is a BLS intervention in many states  May reduce the need for advanced airway management  Reduces in hospital stays  Better outcomes overall…  Disadvantages  Requires an EXCELLENT face-mask seal  Will not provide ventilation, only assist the patients own ventilatory effort  May lower the blood pressure  May promote gastric distention  Can not be used if airway reflexes are compromised.
  • 127. Automatic transport ventilator (ATV)  Disadvantages  requires oxygen. Typical adult ventilation consumes 5 liters per minute 02 versus 15-25 liters per minute for a bag-valve- mask  may require an external power source  must have bag-valve-mask device available  may interfere with timing of chest compressions during CPR  must monitor to assure full exhalation  barotrauma
  • 128.  Automatic transport ventilator (ATV)  Generally consumes 5 L/min of oxygen  May lead to hypoventilation in patients with:  Poor lung compliance  Increased airway resistance  Airway obstruction  Assess patient for full chest recoil. Assisted and Artificial Ventilation
  • 129.  Patients with tracheostomies do not breathe through their mouth and nose.  Tracheostomy masks may be available. A face mask may also be used.  If the trach has a 15mm adaptor, a standard BVM will fit onto the adaptor. If not you will need to us a pediatric mask for a seal. Tracheostomy
  • 130. Changes in the body  There are several changes in the bodies physiology during positive pressure ventilation: Air Movement  Normal ventilation has a negative intrathoracic pressure leading air to get “sucked” into the lungs.  With positive pressure you are “pushing” the air into the cavity
  • 131. Changes in the body Blood Movement  1. Normal ventilation  a. Blood return from the body happens naturally  b. Blood is pulled back to the heart during normal breathing  2. Positive pressure ventilation  a. Venous return is decreased during lung inflation  Use caution to not overinflate  b. Amount of blood pumped out of the heart is reduced
  • 132. Changes in the body Esophageal Opening Pressure Positive pressure ventilation  Air is pushed into the stomach during ventilation  Gastric distention may lead to vomiting  Sellick’s maneuver (cricoid pressure)  Use during positive pressure ventilation  Reduces amount of air in stomach  Procedure  identify cricoid cartilage  apply firm backward pressure to cricoid cartilage with thumb and index finger  Do not use if  patient is vomiting or starts to vomit  patient is responsive  breathing tube has been placed by advanced level providers
  • 133. Special patient population  Use caution with artificial ventilation with geriatric and pediatric patients.  Geriatric  Geriatric disease process break down lung tissue and elasticity of their lungs, use caution with positive pressure ventilation.  Pediatric  Pediatric airways are significantly smaller (the size of THEIR pinky finger) and require less volume.  Large, floppy tongues  Padding under shoulders  Do not hyperextend pt neck, it will “kink” the trachea  Gastric distention
  • 134. Take Home Points….  All pt’s with SOB get O2. Lots of O2.  Listen to ALL lungs.  Beware of the “silent chest”.  Noisy Breathing is abnormal breathing  Visible Breathing is abnormal breathing.  Positional breathing is abnormal breathing.  Abnormal Breathing gets O2.
  • 135. Questions?