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
When ever I’m blue…..
I remember to breath again.
- Anonymous
Basic Concept:
 Air Goes in and Out
Blood Goes Round and Round
Any thing infringing on this is a
BAD THING!
Respiratory Anatomy
The Upper Airway
 1. Nose
 Warm and humidify air through
turbinates
 2. Mouth and oral cavity
 Advanced airway
 Entra...
The Upper Airway
The Lower Airway
 1. Trachea
 Hollow tube which passes
air to the lower airways
 Supported by cartilage
rings
 2. Cari...
The Lower Airway
The Lower Airway
9
The Lower Airway
10
Key Point
 It takes approximately 150-200 cc
of air movement to reach the
terminal bronchus and the
aveoli…
 This is cal...
The Lower Airway
The Chest Cavity
 Thoracic skin,
muscle, and bones
 Similarities to other
regions
 Also unique features to
allow for ve...
Pulmonary Circulation
The Thoracic “Cage”
Credit: wikipedia.com
The Rib
Credit: wikipedia.com
The Chest Cavity
 The neurovascular bundle lies closely along the
lowest margin of each rib.
 The pleura covers each lun...
Intercostal Muscles and Diaphram
 The Intercostal Muscles
are several groups of
muscles that run
between the ribs
 The d...
Mechanics of Ventilation
 The intercostal muscles (between the ribs) contract
during inhalation.
 The diaphragm contract...
Mechanics of Ventilation
 Patients with a spinal
injury below C5 can
still breathe from the
diaphragm.
 Patients with a ...
The Mechanical Bellows?
The Mechanical Bellows
 The muscles of the ribs
expand the size of the
chest, creating a (relative)
negative pressure.
 ...
The Mechanical Bellows
 The intercostals muscles
relax, allowing the chest
to return to its neutral
position, expelling a...
The Mechanical Bellows
 Example of a
Compromised Bellows
 Positional Asphyxia
Special Thanks to Charlie Miller for this ...
Key Point:
 A comprehensive understanding
of the Anatomy of the airway and
thorax is essential to managing
the airway and...
A K A : H O W W E B R E A T H … . .
Physiology of Respiration
Key Definitions
 Tidal Volume (Vt)
 Typically 500-700 cc
 Minute Volume (Vm)
 Tidal Volume X Respiratory Rate = Minute...
Respiratory Rate
times x
Tidal Volume
(amount of air exchanged
in one breath)
equals =
Minute Ventilation
Minute Ventilati...
Physiology of Respiration
 Diffusion of O2 from the lung to the blood is by the
binding of O2 to the hemoglobin (Hgb)
 T...
Alveolar Ventilation
Minute Ventilation
minus –
Dead Air Space
equals =
Alveolar Ventilation
Dead Air Space: the
trachea, ...
Key components of an intact respiratory system
 An appropriate Drive to Breath
 Airway and respiratory tract
 Mechanica...
Drive to breath
 Controlled by the CNS through information
gathered from receptors in the body.
 Located in the pons reg...
“Hypoxic Drive”
 Develops in some patients with Chronic Lung
Disease
 Pons region of brain becomes sensitized to constan...
Diffusion
An O2 friendly RBC with hgb.
 Hemoglobin is an Iron Based compound essential
to the transport of O2.
 Anemia
 Cyanide P...
An intact circulatory system
 Blood Loss
 Shock
 Pump Problem
 Volume Problem
 Fluid issue
 O2 carrying issue
 Vess...
KEY POINT:
Must have enough of a pulmonary perfusion pressure
to promote diffusion.
Conditions like Hypotension
cause seco...
Physiology of Respiration
 The primary function of the respiratory system is
gaseous exchange.
 Ventilation and Oxygenat...
Physiology of Respiration
 Ventilation is the body’s ability to move gas (usually
atmospheric air) in and out of the ches...
Physiology of Respiration
 Oxygen exchange can be hindered by:
 Condition in the airway
 Disease processes- COPD, asthm...
 All cells need a constant supply of oxygen to survive.
Physiology of Respiration
 Inhalation
 The active part of breathing
 Focused on delivering oxygen to the alveoli
 Tidal volume is the amount of ...
 Exhalation
 Passive process
 Diaphragm and intercostal muscles relax.
 Smaller thorax compresses air out of the lungs...
 Regulation of ventilation
 The body’s need for oxygen is constantly changing.
 Failure to meet the need may result in ...
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
Pneumothorax
 Commonly called a collapsed lung
 Accumulation of air in the pleural space
 Blood passing through the col...
Pneumothorax
Pneumothorax
Open chest wound
Often called an open
pneumothorax or a
sucking chest wound.
Tension Pneumothorax
 Tension pneumothorax
 Results from significant air accumulation in the pleural space
 Increased p...
Tension Pneumothorax
 Blood collects in the
pleural space from
bleeding around the
rib cage or from a lung
or great vessel.
Hemothorax
Pulmonary Edema
 Heart muscle can’t circulate blood properly.
 Left ventricle is compromised resulting in “backflow.”
 ...
Pulmonary Edema
The fluid and
thicker tissue makes
exchange of gasses
less efficient.
Chronic Obstructive Pulmonary Disease
(COPD)
 Slow process of constriction and disruption of
airways and alveoli
 Caused...
Chronic Obstructive Pulmonary Disease
(COPD)
 Emphysema is another type of COPD.
 Loss of elastic material around air sp...
Chronic Obstructive Pulmonary Disease
(COPD)
Chronic Obstructive Pulmonary Disease
(COPD)
 “Wet lungs” vs. “dry lungs”
 “Wet lungs” sounds—pulmonary edema
 “Dry lun...
Asthma, Hay Fever, and Anaphylaxis
 Result of allergic reaction to inhaled, ingested, or
injected substance
 In some cas...
 Asthma is acute spasm of
smaller air passages
(bronchioles).
Asthma
Signs of Mechanical Ventilation Impairment
 Abnormal sounds include wheezing, rales,
rhonchi, and stridor.
Management & Interventions
 Insure adequate airway and ventilation
 Either assisted or on patient’s own
 Use of adjunct...
Assessment
What do we assess?
 Primary Assesment
 Presence or absence?
 Rate
 Quality
 “Doorway Test”
First Impressions
 Air Hungry
 Nasal Flaring
 Tripoding
 Rocking with respirations
 Pursed Lip Breathing
 Barrel or ...
Respiratory Rate
 Decreased by:
 Depressant Drugs
 Sleep
 Increased by:
 Fever
 Fear
 Exertion
Respiratory Quality
 Irregular: Neuro Insult.
 Shallow:
 Respiratory Depressants
 CNS Depressants
 Neuro Insult
 Dee...
Skin Signs
 Cyanosis
 Nail Beds
 Lips
 Ears
 Mottling
 Chest
 Lower Ext
 Abd
Noisy breathing is obstructed breathing
 Snoring: obstruction by tongue
 Gurgling: Funky Junk in upper airway
 Grunting...
Speech Dyspnea
 Inability to speak more than a few syllables in a
sentence between breaths.
Breath Sounds
 Listening by comparison
 Listening anterior
 Listening posterior
 Fremitus
Abnormal breath sounds
 Rales (crackles): fine bubbling sound of fluid in
alveoli (“Rice Krispies”: snap, crackle and pop...
Causes of respiratory abnormalities
 Brain damage: trauma, drugs, stroke
 Spinal cord damage: trauma, polio
 Upper airw...
Signs/symptoms of distress
 Dyspnea
 Restlessness/anxiety
 Tachypnea/Bradypnea
 Cyanosis (core)
 Abnormal sounds
 Re...
More S/S
 Retractions and/or use of accessory muscles
 Abdominal breathing
 Nasal flaring
 Productive cough
 Color?
...
Take another look ….What do you see?
Hows this?
Pursed Lips
Sparrow Chest
Tripoding
Retractions
Abd retractions
Kewl Haircut
O2
Inadequate Breathing: Infants and
Children
Retractions
Nasal Flaring
See-Saw
Breathing
Diaphragmatic Breathing
 A pulse oximeter measures the percentage of
hemoglobin saturation.
 Should be 95% to 100% while breathing room air.
 A...
 Inaccurate pulse oximetry readings may be caused by:
 Hypovolemia
 Anemia
 Severe peripheral vasoconstriction (includ...
Assessment
 Assess for:
 Gag reflex
 Airway obstruction
 Soft tissue obstruction
 Foreign bodies
 Complete or incomp...
Basic Airway Interventions
Basic Airway Interventions
 Manual Airway maneuver
 Head tilt/chin lift
 Jaw thrust
 Airway devices
 OPA
 NPA
 IOM ...
Airway Obstruction
Most common cause: tongue and/or epiglottis
Manual Opening the Airway
Jaw thrust Head tilt–chin lift
The Oropharyngeal Airway
Malposition of
Oropharyngeal Airway
Too short
Nasopharyngeal Airway
Insertion technique
The Bag Valve mask
The Sniffing Position
KEY POINTS
 BVM ventilation is a perishable skill and
surprisingly difficult on mannequins, as well
as many patients. A n...
The E-C Technique
“Double C” or “two Hand Technique
Pirated from www.emsbasics.com
Poor seal, esp. in victims with:
•Obesity
•Facial hair
•The elderly
•Lack of teeth
•Facial Trauma
Current masks are fragil...
Predictors of difficult ventilation…
 In addition to the psycho-motor and provider difficulties of retaining
this vital s...
Nu-Mask
 Nu-Mask is a new alternative to the BVM.
 It is for patients whom a getting a face mask seal is
problematic.
 ...
NuMask IOM® and IOM® w/ OPA in Place
NuMask IOM NuMask IOM with OPA
All Rights Reserved. © 2007-2011 NuMask®, Inc.
An air tight seal in 1/10th the space
of a traditional mask
All Rights Reserved. © 2007-2011 NuMask®, Inc.
KEY POINT
 The IOM uses internal oral tissue to
obtain a superior “wet seal”. Because
hand placement, hand size, and hand...
Key Points about suction…
 300 mm hg for adults
 No more than 120 mm hg for pediatrics
 Intervals
 Prefer < 10 seconds...
Types of Portable Suction
Courtesy of Laerdal Medical Corporation, Armonk, NY
Supra-glottic Airways
AEMT “Supraglottic” airway devices
 Indications
 To promote airway management by providing a patent airway
in the uncons...
KEY POINT
 THE NEW AEMT SCOPE OF PRACTICE DOES
NOT CONTAIN ETT.
 Discussion: Is this a god idea or bad?
 This doesn’t m...
Terms
 Supra-glottic
 Double/Single Lumen
 Peri-glottic
 Esophageal orburtrator airways
Lots of devices over the years
 Esophageal obturation
 Esophageal Gastric Tube Airway (EGTA)
 Esophageal Orbturator Air...
Dual Lumen Supra-Glotic Airways
 Pharyngeal-tracheal Lumen Airway (PTLA)
 AKA: The PTL
 Esophageal-Tracheal Combitube (...
“Peri-Glottic” Airways
 Laryngeo-Mask Airways (LMA)
 Air-Q
 I-Gel
Laryngeo-Mask Airways
I Gel
Single Lumen Airways
 King LTD
 COBRA Peri-Laryngeal Airway (PLA)
Cobra PLA
King Airway
 Size determined
by Pt’s height:
 Yellow: 4-5 ft
 Red: 5-6 ft
 Purple: > 6 ft
Instructions for use
 Choose appropriate size based on patient’s height.
 Test cuffs by inflating to recommended volume ...
Insertion:
 Position the head in a slightly sniffing position,
unless spinal injury is known or suspected. Then
maintain ...
Cuff inflation:
 Inflate cuffs with minimum volume necessary to
seal the airway according to tube size.
 “SEAT THE TUBE”...
ARTIFICIAL
VENTILATION
Management Techniques
 Probably the most important skills in EMS at any
level.
 Basic airway and ventilation techniques are
extremely effectiv...
Basic Airway Adjuncts
 Chin lift
 Jaw thrust
 Positioning/suctioning
 Oropharyngeal airway (OPA)
 Nasopharyngeal airw...
Oxygen Delivery Adjuncts
 Nasal Cannula: 2-6 LPM 24-44%
 Simple mask: 6-10LPM 35-60%
 Non-Rebreather Mask: 10-15LPM 80-...
 When assisting with a bag-mask device:
 Explain the procedure to the patient.
 Place the mask over the nose and mouth....
 Artificial ventilation
 Devices include:
Pocket face masks
Bag-mask device
CPAP/BiPAP
Manually triggered ventilatio...
Assisted and Artificial Ventilation
 Pocket Masks
 Includes IOM/NEW MASK
 Advantages:
 Small, easy to use
 Easy to us...
Assisted and Artificial Ventilation
 Bag Valve Mask
 Advantages
 Self inflating
 Can be used with or without an oxygen...
 Manually triggered ventilation devices
 Advantages:
 Also known as flow-restricted, oxygen-powered ventilation device
...
 Automatic transport
ventilator (ATV)
 Manually triggered device
attached to a control box
 Allows the variables of
ven...
CPAP
 Continuous Positive Airway Pressure
 Advantages
 Is a BLS intervention in many states
 May reduce the need for a...
Automatic transport ventilator (ATV)
 Disadvantages
 requires oxygen. Typical adult ventilation consumes 5 liters
per mi...
 Automatic transport ventilator (ATV)
 Generally consumes 5 L/min of oxygen
 May lead to hypoventilation in patients wi...
 Patients with tracheostomies do not breathe through their mouth and
nose.
 Tracheostomy masks may be available. A face ...
Changes in the body
 There are several changes in the bodies physiology
during positive pressure ventilation:
Air Movemen...
Changes in the body
Blood Movement
 1. Normal ventilation
 a. Blood return from the body happens naturally
 b. Blood is...
Changes in the body
Esophageal Opening Pressure
Positive pressure ventilation
 Air is pushed into the stomach during vent...
Special patient population
 Use caution with artificial ventilation with geriatric
and pediatric patients.
 Geriatric
 ...
Take Home Points….
 All pt’s with SOB get O2. Lots of O2.
 Listen to ALL lungs.
 Beware of the “silent chest”.
 Noisy ...
Questions?
2014 AEMT airway management cole
2014 AEMT airway management cole
2014 AEMT airway management cole
2014 AEMT airway management cole
2014 AEMT airway management cole
2014 AEMT airway management cole
2014 AEMT airway management cole
2014 AEMT airway management cole
2014 AEMT airway management cole
2014 AEMT airway management cole
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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 , physiology, etc. Talks about apniec defusion too.

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2014 AEMT airway management cole

  1. 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. 2. When ever I’m blue….. I remember to breath again. - Anonymous
  3. 3. Basic Concept:  Air Goes in and Out Blood Goes Round and Round Any thing infringing on this is a BAD THING!
  4. 4. Respiratory Anatomy
  5. 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. 6. The Upper Airway
  7. 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. 8. The Lower Airway
  9. 9. The Lower Airway 9
  10. 10. The Lower Airway 10
  11. 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. 12. The Lower Airway
  13. 13. The Chest Cavity  Thoracic skin, muscle, and bones  Similarities to other regions  Also unique features to allow for ventilation
  14. 14. Pulmonary Circulation
  15. 15. The Thoracic “Cage” Credit: wikipedia.com
  16. 16. The Rib Credit: wikipedia.com
  17. 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. 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. 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. 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. 21. The Mechanical Bellows?
  22. 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. 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. 24. The Mechanical Bellows  Example of a Compromised Bellows  Positional Asphyxia Special Thanks to Charlie Miller for this Graphic.
  25. 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. 26. A K A : H O W W E B R E A T H … . . Physiology of Respiration
  27. 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. 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. 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. 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. 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. 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. 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. 34. Diffusion
  35. 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. 36. An intact circulatory system  Blood Loss  Shock  Pump Problem  Volume Problem  Fluid issue  O2 carrying issue  Vessel Problem
  37. 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. 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. 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. 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. 41.  All cells need a constant supply of oxygen to survive. Physiology of Respiration
  42. 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. 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. 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. 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. 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. 47. Pneumothorax
  48. 48. Pneumothorax Open chest wound Often called an open pneumothorax or a sucking chest wound.
  49. 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. 50. Tension Pneumothorax
  51. 51.  Blood collects in the pleural space from bleeding around the rib cage or from a lung or great vessel. Hemothorax
  52. 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. 53. Pulmonary Edema The fluid and thicker tissue makes exchange of gasses less efficient.
  54. 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. 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. 56. Chronic Obstructive Pulmonary Disease (COPD)
  57. 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. 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. 59.  Asthma is acute spasm of smaller air passages (bronchioles). Asthma
  60. 60. Signs of Mechanical Ventilation Impairment  Abnormal sounds include wheezing, rales, rhonchi, and stridor.
  61. 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. 62. Assessment
  63. 63. What do we assess?  Primary Assesment  Presence or absence?  Rate  Quality  “Doorway Test”
  64. 64. First Impressions  Air Hungry  Nasal Flaring  Tripoding  Rocking with respirations  Pursed Lip Breathing  Barrel or Sparrow Chest  Home O2
  65. 65. Respiratory Rate  Decreased by:  Depressant Drugs  Sleep  Increased by:  Fever  Fear  Exertion
  66. 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. 67. Skin Signs  Cyanosis  Nail Beds  Lips  Ears  Mottling  Chest  Lower Ext  Abd
  68. 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. 69. Speech Dyspnea  Inability to speak more than a few syllables in a sentence between breaths.
  70. 70. Breath Sounds  Listening by comparison  Listening anterior  Listening posterior  Fremitus
  71. 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. 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. 73. Signs/symptoms of distress  Dyspnea  Restlessness/anxiety  Tachypnea/Bradypnea  Cyanosis (core)  Abnormal sounds  Retractions  Diminished ability to speak
  74. 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. 75. Take another look ….What do you see?
  76. 76. Hows this? Pursed Lips Sparrow Chest Tripoding Retractions Abd retractions Kewl Haircut O2
  77. 77. Inadequate Breathing: Infants and Children Retractions Nasal Flaring See-Saw Breathing Diaphragmatic Breathing
  78. 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. 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. 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. 81. Basic Airway Interventions
  82. 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. 83. Airway Obstruction Most common cause: tongue and/or epiglottis
  84. 84. Manual Opening the Airway Jaw thrust Head tilt–chin lift
  85. 85. The Oropharyngeal Airway
  86. 86. Malposition of Oropharyngeal Airway Too short
  87. 87. Nasopharyngeal Airway Insertion technique
  88. 88. The Bag Valve mask
  89. 89. The Sniffing Position
  90. 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. 91. The E-C Technique
  92. 92. “Double C” or “two Hand Technique Pirated from www.emsbasics.com
  93. 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. 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. 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. 96. NuMask IOM® and IOM® w/ OPA in Place NuMask IOM NuMask IOM with OPA All Rights Reserved. © 2007-2011 NuMask®, Inc.
  97. 97. An air tight seal in 1/10th the space of a traditional mask All Rights Reserved. © 2007-2011 NuMask®, Inc.
  98. 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. 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. 100. Types of Portable Suction Courtesy of Laerdal Medical Corporation, Armonk, NY
  101. 101. Supra-glottic Airways
  102. 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. 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. 104. Terms  Supra-glottic  Double/Single Lumen  Peri-glottic  Esophageal orburtrator airways
  105. 105. Lots of devices over the years  Esophageal obturation  Esophageal Gastric Tube Airway (EGTA)  Esophageal Orbturator Airway (EOA)
  106. 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. 107. “Peri-Glottic” Airways  Laryngeo-Mask Airways (LMA)  Air-Q  I-Gel
  108. 108. Laryngeo-Mask Airways
  109. 109. I Gel
  110. 110. Single Lumen Airways  King LTD  COBRA Peri-Laryngeal Airway (PLA)
  111. 111. Cobra PLA
  112. 112. King Airway  Size determined by Pt’s height:  Yellow: 4-5 ft  Red: 5-6 ft  Purple: > 6 ft
  113. 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. 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. 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. 116. ARTIFICIAL VENTILATION Management Techniques
  117. 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. 118. Basic Airway Adjuncts  Chin lift  Jaw thrust  Positioning/suctioning  Oropharyngeal airway (OPA)  Nasopharyngeal airway (NPA)  EGTA/Combi-tube/King LT
  119. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 135. Questions?
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