Advanced Airway Management 1


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  • Feel free to share this with anybody, so long as credit is given….Thanks
  • I am an avid cat lover and have 4 cats of my own. Even still, I laugh at this clip!
  • General function of the respiratory system Remove carbon dioxide from the blood Transfer oxygen into the blood
  • Structures: Nose, Nasopharynx, mouth, oropharynx, hypopharynx, larynx, epiglottis Functions: Passage way for air, warms, humidifies, filters, protection – gag reflex & cough, speech
  • Trachea, main stem bronchi, secondary bronchi, bronchiolus Function: Air passage, gas exchange, warm and humidify
  • Advanced Airway Management 1

    1. 1. EMT Basic Advanced Airway Management Pharyngeal Esophageal Airway Device (PEAD) A.K.A. Combitube © PowerPoint developed by Jennifer Stanislaw, EMT-P, EMS Training Officer West Valley Fire District, Willamina, OR
    2. 2. The Cat Fan (No Pun Intended)
    3. 3. Agenda <ul><li>Review Objectives </li></ul><ul><li>Lesson 1 </li></ul><ul><ul><li>Respiratory Anatomy & Physiology </li></ul></ul><ul><li>Lesson 2 </li></ul><ul><ul><li>Respiratory Volume and Management </li></ul></ul><ul><li>Lesson 3 </li></ul><ul><ul><li>Assessing Respiratory Problems </li></ul></ul>
    4. 4. Agenda cont’d <ul><li>Lesson 4 </li></ul><ul><ul><li>Respiratory/Cardiac Arrest </li></ul></ul><ul><ul><li>Basic Airway Management </li></ul></ul><ul><li>Lesson 5 </li></ul><ul><ul><li>Suctioning </li></ul></ul><ul><li>Lesson 6 </li></ul><ul><ul><li>Dual-Lumen Airway Devices </li></ul></ul>
    5. 5. Agenda cont’d <ul><li>Demonstration </li></ul><ul><li>Practical Stations </li></ul><ul><ul><li>Basic Airway Management </li></ul></ul><ul><ul><ul><li>Manual Maneuvers and Simple Adjuncts </li></ul></ul></ul><ul><ul><ul><li>Supplemental Oxygen </li></ul></ul></ul><ul><ul><ul><li>Ventilation </li></ul></ul></ul><ul><ul><ul><li>Suctioning </li></ul></ul></ul><ul><ul><li>Combitube Insertion </li></ul></ul>
    6. 6. Practical <ul><li>Testing must be done with the Physician Advisor (or another Physician of his / her choosing) </li></ul>
    7. 7. Objectives <ul><li>Describe the anatomy and function of the upper and lower airways </li></ul><ul><li>Describe respiratory volumes and capacities in relationship to the need for assisted ventilations </li></ul><ul><li>Identify the specific observations and physical findings commonly found in patients presenting in respiratory and/or cardiac arrest. </li></ul><ul><li>Identify the basic principles of airway management </li></ul>
    8. 8. Objectives (cont’d) <ul><li>Describe the indications for suctioning. </li></ul><ul><li>Identify rigid and flexible suction catheters and the indications for use. </li></ul><ul><li>Identify indications and contraindications for use of the PEAD’s. </li></ul><ul><li>Identify the advantages and disadvantages of using PEAD’s. </li></ul>
    9. 9. Objectives (cont’d) <ul><li>Identify those situations in which PEAD’s may be removed. </li></ul><ul><li>Demonstrated placement of PEAD’s. </li></ul><ul><li>Demonstrate methods of assuring and maintaining correct placement of PEAD’s. </li></ul><ul><li>Demonstrate re-ventilation for missed placement of PEAD’s. </li></ul>
    10. 10. Objectives (cont’d) <ul><li>Demonstrate on a manikin the proper technique for the use and maintenance of the following airway adjuncts: </li></ul><ul><ul><li>Nasal cannula </li></ul></ul><ul><ul><li>Non-rebreather mask </li></ul></ul><ul><ul><li>Bag-Valve-Mask </li></ul></ul><ul><li>Demonstrate sterile suctioning techniques on a manikin with a PEAD in place. </li></ul>
    11. 11. Lesson 1 Respiratory Anatomy & Physiology
    12. 12. Respiratory Anatomy & Physiology
    13. 13. Function of the Respiratory System <ul><li>Removes carbon dioxide from the blood </li></ul><ul><li>Transfers oxygen to the blood </li></ul>
    14. 14. The Upper Airway <ul><li>Epiglottis </li></ul><ul><li>Mandible </li></ul><ul><li>Frontal Sinus </li></ul><ul><li>Soft Palate </li></ul><ul><li>Trachea </li></ul><ul><li>Glottis </li></ul><ul><li>Esophagus </li></ul><ul><li>Vocal Cords </li></ul>A B C D E F G H
    15. 15. The Upper Airway <ul><li>Other Structures </li></ul><ul><ul><li>Nasopharynx </li></ul></ul><ul><ul><li>Oropharynx </li></ul></ul><ul><ul><li>Hypopharynx </li></ul></ul><ul><ul><li>Larynx </li></ul></ul><ul><li>Functions </li></ul>
    16. 16. Functions of the Upper Airway <ul><li>Passageway for air </li></ul><ul><li>Warm </li></ul><ul><li>Filter </li></ul><ul><li>Humidify </li></ul><ul><li>Protection </li></ul><ul><ul><li>Gag Reflex </li></ul></ul><ul><ul><li>Cough </li></ul></ul><ul><li>Speech </li></ul>
    17. 17. The Lower Airway <ul><li>Primary Bronchi </li></ul><ul><li>Hyoid Bone </li></ul><ul><li>Right Lung </li></ul><ul><li>Secondary Bronchi </li></ul><ul><li>Tracheal Ligament </li></ul><ul><li>Trachea </li></ul><ul><li>Larynx </li></ul><ul><li>Esophagus </li></ul><ul><li>Left Lung </li></ul><ul><li>Trachea </li></ul>A B C D E F G H I J
    18. 18. Alveoli <ul><li>Gas Exchange </li></ul>
    19. 19. Lungs <ul><li>Structure </li></ul><ul><li>Lobes </li></ul><ul><li>Pleura </li></ul>
    20. 20. Physiology of Respiration <ul><li>Define Respiration </li></ul><ul><ul><li>The exchange of gases between a living organism and the environment </li></ul></ul><ul><li>Define Ventilation </li></ul><ul><ul><li>Mechanical Process that moves air in and out of the lungs </li></ul></ul>
    21. 21. Muscles of Breathing <ul><li>Intercostal Muscles </li></ul><ul><li>Diaphragm </li></ul>
    22. 22. Regulation of Respiration <ul><li>Where is the Respiratory Center Controlled? </li></ul><ul><li>Brainstem </li></ul><ul><ul><li>Medulla </li></ul></ul><ul><ul><li>Apeustic Center (pons) </li></ul></ul><ul><ul><li>Pneumotaxic center (pons) </li></ul></ul><ul><li>Stretch receptors </li></ul><ul><ul><li>Hering-Breuer reflex </li></ul></ul><ul><li>Chemoreceptors </li></ul><ul><ul><li>CSF </li></ul></ul><ul><ul><li>Blood </li></ul></ul>
    23. 23. Voluntary or Involuntary <ul><li>Both </li></ul><ul><ul><li>Humans can override body’s urge to breathe </li></ul></ul><ul><ul><li>But only for so long </li></ul></ul>
    24. 24. Respiratory Cycle <ul><li>Inspiration </li></ul><ul><ul><li>Active phase </li></ul></ul><ul><ul><li>Lasts 1-2 seconds </li></ul></ul><ul><li>Expiration </li></ul><ul><ul><li>Passive phase </li></ul></ul><ul><ul><li>Lasts 5 seconds </li></ul></ul>
    25. 25. Lesson 2 Respiratory Volume and Management
    26. 26. Drinking Straw Exercise <ul><li>Breathe through straws for 1 minute </li></ul>
    27. 27. Carbon Dioxide & The Respiratory System <ul><li>High CO2 </li></ul><ul><ul><li>Increases respiratory rate </li></ul></ul><ul><li>Low CO2 </li></ul><ul><ul><li>Decreases respiratory rate </li></ul></ul><ul><li>Hypoxic Drive </li></ul><ul><ul><li>Chronic COPD patients </li></ul></ul>
    28. 28. Normal Respiratory Rates <ul><li>Adult </li></ul><ul><li>Children </li></ul><ul><li>Infants </li></ul><ul><li>Newborns </li></ul><ul><li>12 – 20 / min </li></ul><ul><li>18 – 24 / min </li></ul><ul><li>22 – 36 / min </li></ul><ul><li>40 – 60 / min </li></ul>
    29. 29. Factors Affecting Respiratory Rate <ul><li>Fever </li></ul><ul><li>Depressant Drugs </li></ul><ul><li>Anxiety </li></ul><ul><li>Insufficient Oxygen </li></ul><ul><li>Stimulant Drugs </li></ul><ul><li>Sleep </li></ul>
    30. 30. Respiratory Volumes <ul><li>Lung Capacity </li></ul><ul><li>Tidal Volume </li></ul><ul><li>Dead Space </li></ul><ul><li>Alveolar Air </li></ul><ul><li>6000 mL of air </li></ul><ul><li>500 mL at rest </li></ul><ul><li>150 mL </li></ul><ul><li>350 mL </li></ul>
    31. 31. Minute Volume <ul><li>Total air moved per minute </li></ul><ul><li>Rate X Volume = Minute volume </li></ul><ul><li>Important Assessment Item </li></ul>
    32. 32. Factors Affecting Minute Volume <ul><li>Head, neck, chest injury </li></ul><ul><li>Shock </li></ul><ul><li>Diabetes </li></ul><ul><li>CO2 / O2 rapid changes </li></ul>
    33. 33. Maintaining the A in ABC <ul><li>Patient positioning </li></ul><ul><li>Suctioning </li></ul><ul><li>Supplemental Oxygen </li></ul><ul><li>Mechanical Assistance </li></ul>
    34. 34. Pulse Oximetry <ul><li>Measures amount of oxygen in the blood. </li></ul><ul><li>Gives percent of hemoglobin saturated </li></ul><ul><ul><li>Tool only, do not rely on totally </li></ul></ul><ul><ul><li>Why? </li></ul></ul><ul><li>Normal Values </li></ul><ul><ul><li>95% - 100% Normal </li></ul></ul><ul><ul><li>90% - 95% - Mild – Normal for COPD </li></ul></ul><ul><ul><li>< 90 % Moderate – High Flow Oxygen </li></ul></ul>
    35. 35. End-Tidal CO2 Detection <ul><li>Measured </li></ul><ul><ul><li>Colorimetric and Digital </li></ul></ul><ul><li>Tool to aid in determining correct placement </li></ul>
    36. 36. Lesson 3 Assessing Respiratory Problems
    37. 37. Patient Assessment
    38. 38. General Patient Assessment <ul><li>Primary Survey </li></ul><ul><ul><li>LOC </li></ul></ul><ul><ul><li>ABC’s </li></ul></ul><ul><ul><li>Speech Pattern </li></ul></ul><ul><ul><li>Obvious Respiratory Noise </li></ul></ul><ul><ul><li>Patient Position </li></ul></ul>
    39. 39. General Assessment (cont’d)
    40. 40. Secondary Assessment <ul><li>SAMPLE history </li></ul><ul><li>Chief Complaint </li></ul><ul><li>Pertinent Negatives </li></ul><ul><li>Chest Pain (pleuritic vs cardiac) </li></ul><ul><li>Cough History </li></ul><ul><li>Edema </li></ul><ul><li>Vitals </li></ul>
    41. 41. Respiratory Assessment <ul><li>Confusion, Agitation, Orientation </li></ul><ul><li>Cyanosis (late sign) </li></ul><ul><li>Diaphoresis </li></ul><ul><li>Retractions </li></ul><ul><li>Accessory Muscle Use </li></ul><ul><li>Jugular Venous Distention </li></ul><ul><li>Nasal Flaring / Pursed Lip Breathing </li></ul>
    42. 42. Palpation <ul><li>Skin </li></ul><ul><ul><li>Turgor </li></ul></ul><ul><ul><li>Color </li></ul></ul><ul><ul><li>Temperature </li></ul></ul><ul><ul><li>Diaphoresis </li></ul></ul><ul><li>Pulse </li></ul><ul><ul><li>Rate </li></ul></ul><ul><ul><li>Rhythm </li></ul></ul><ul><ul><li>Quality </li></ul></ul><ul><li>Chest Wall Pain </li></ul><ul><li>Tracheal Deviation </li></ul>
    43. 43. Assessing Lung Sounds <ul><li>Methods </li></ul><ul><li>Hand Out </li></ul>
    44. 44. Lung Sounds <ul><li>Normal </li></ul><ul><li>Wheezes </li></ul><ul><li>Rales (Crackles) </li></ul><ul><li>Stridor </li></ul><ul><li>Rhonchi </li></ul><ul><li>Pleural Rub </li></ul><ul><li>Listen on every patient </li></ul><ul><li>End of Expiration </li></ul><ul><li>End of Inspiration </li></ul><ul><li>During both phases </li></ul><ul><li>Expiration </li></ul><ul><li>End of Inspiration </li></ul>
    45. 45. Respiratory Diseases <ul><li>COPD </li></ul><ul><li>Asthma </li></ul><ul><li>Pneumonia </li></ul><ul><li>Pulmonary Edema </li></ul><ul><li>Pulmonary Embolus </li></ul><ul><li>Trauma </li></ul>
    46. 46. COPD
    47. 47. Chronic Obstructive Pulmonary Disease <ul><li>Pink Puffers and Blue Bloaters </li></ul><ul><li>Frequently on Home oxygen </li></ul><ul><li>Assessment </li></ul><ul><ul><li>Typical Lung Sounds </li></ul></ul><ul><li>Common Medications </li></ul><ul><li>May or May not be Hypoxic Drive </li></ul>
    48. 48. Asthma
    49. 49. Asthma <ul><li>Bronchiole Constriction & Mucous Production </li></ul><ul><li>Lung Sounds </li></ul><ul><ul><li>Wheezes </li></ul></ul><ul><ul><li>Diminished </li></ul></ul><ul><ul><li>None </li></ul></ul><ul><li>Usually Diagnosed </li></ul>
    50. 50. Pneumonia
    51. 51. Pneumonia <ul><li>Fever </li></ul><ul><li>Productive Cough </li></ul><ul><ul><li>Colored Sputum </li></ul></ul><ul><li>General Illness </li></ul><ul><li>Elderly & Pediatric most at risk </li></ul><ul><li>Lung Sounds </li></ul><ul><ul><li>Rhonchi, Rales, Wheezes </li></ul></ul>
    52. 52. Pulmonary Edema
    53. 53. Pulmonary Edema <ul><li>Congestive Heart Failure </li></ul><ul><ul><li>Acute – Flash Pulmonary Edema </li></ul></ul><ul><ul><li>Chronic – Heart Failure </li></ul></ul><ul><ul><ul><li>Medications </li></ul></ul></ul><ul><ul><ul><li>Orthopnea, PND </li></ul></ul></ul><ul><li>Lung Sounds </li></ul><ul><li>Keep them upright with legs dangling </li></ul>
    54. 54. Pulmonary Embolus
    55. 55. Pulmonary Embolus <ul><li>Lung Sounds </li></ul><ul><li>History </li></ul><ul><ul><li>Surgery </li></ul></ul><ul><ul><li>Bed Confined </li></ul></ul><ul><ul><li>Long trip </li></ul></ul><ul><li>Rapid Transport & High Flow Oxygen </li></ul>
    56. 56. Trauma
    57. 57. Trauma <ul><li>Maintain spinal control </li></ul><ul><li>Airway Management </li></ul><ul><li>High Flow Oxygen </li></ul><ul><li>Rapid Transport </li></ul><ul><li>Seal Chest Wounds </li></ul><ul><li>Stabilize Impaled Objects </li></ul>
    58. 58. Lesson 4 Respiratory/Cardiac Arrest Basic Airway Management
    59. 59. Respiratory & Cardiac Arrest
    60. 60. Assessing the Patient <ul><li>First Steps of CPR </li></ul><ul><li>Annie, Annie You Okay? </li></ul><ul><li>Other Signs and Symptoms </li></ul><ul><ul><li>Unconsciousness </li></ul></ul><ul><ul><li>Cardiac Seizure </li></ul></ul><ul><ul><li>Agonal respirations or apnea </li></ul></ul><ul><ul><li>Cyanosis, Ashen, Mottled </li></ul></ul><ul><ul><li>No signs of spontaneous respiration or circulation </li></ul></ul><ul><ul><li>No Pulse </li></ul></ul>
    61. 61. Combitube
    62. 62. When to Use the Combitube <ul><li>CPR </li></ul><ul><ul><li>Remember to do CPR! </li></ul></ul><ul><ul><li>Attach AED! </li></ul></ul><ul><li>Respiratory Arrest </li></ul><ul><ul><li>Agonal Respirations without intact gag reflex </li></ul></ul><ul><ul><li>Respiratory Arrest leads to Cardiac Arrest </li></ul></ul>
    63. 63. Airway Management – The Basics <ul><li>Manual Maneuvers </li></ul><ul><li>Chin Lift </li></ul><ul><li>Jaw Lift </li></ul><ul><li>Jaw Thrust </li></ul><ul><li>Head Tilt – Chin Lift </li></ul><ul><li>Modified Jaw thrust </li></ul>
    64. 64. Airway Management – The Basics <ul><li>Mechanical Airways </li></ul><ul><li>NPA’s </li></ul><ul><li>OPA’s </li></ul><ul><li>Description </li></ul><ul><li>Advantages </li></ul><ul><li>Disadvantages </li></ul><ul><li>Indications </li></ul><ul><li>Contraindications </li></ul><ul><li>Methods of Insertion </li></ul>
    65. 65. Airway Management – The Basics <ul><li>Ventilation </li></ul><ul><li>Mouth to Mask </li></ul><ul><li>BVM </li></ul><ul><li>Description </li></ul><ul><li>Advantages </li></ul><ul><li>Disadvantages </li></ul><ul><li>Indications </li></ul><ul><li>Contraindications </li></ul><ul><li>Methods of Use </li></ul>
    66. 66. Evaluation of Effectiveness <ul><li>How do I know I am ventilating? </li></ul><ul><ul><li>Chest movement </li></ul></ul><ul><ul><li>Lung Sounds </li></ul></ul><ul><ul><li>Epigastric sounds/Abdominal distention </li></ul></ul><ul><ul><li>Patient Response </li></ul></ul>
    67. 67. Lesson 5 Suctioning
    68. 68. Reviewing Suctioning <ul><li>BSI – Scene Safety </li></ul><ul><li>Equipment </li></ul><ul><ul><li>Suction device </li></ul></ul><ul><ul><li>Rigid or Soft Tip </li></ul></ul><ul><li>Insert with Suction Off </li></ul><ul><li>Withdraw while Suctioning </li></ul><ul><li>No more than 15 seconds before ventilating! </li></ul>
    69. 69. Oh, That Sucks! <ul><li>Vomitus </li></ul><ul><ul><li>Food </li></ul></ul><ul><ul><li>Protein dissolving enzymes </li></ul></ul><ul><ul><li>Hydrochloric Acid </li></ul></ul><ul><li>Aspiration damage </li></ul><ul><ul><li>Alveolar Damage </li></ul></ul><ul><ul><li>Increased fluid </li></ul></ul><ul><ul><li>Obstruction </li></ul></ul><ul><ul><li>Aspiration Pneumonia </li></ul></ul>
    70. 70. Oh, Go Spit on It <ul><li>Saliva </li></ul><ul><ul><li>Digestive enzymes </li></ul></ul><ul><ul><li>Bacteria </li></ul></ul><ul><li>Aspiration Damage </li></ul><ul><ul><li>Fills alveoli </li></ul></ul><ul><ul><li>Pneumonia </li></ul></ul>
    71. 71. Food <ul><li>Clogs airways </li></ul><ul><li>Interferes with ventilation </li></ul><ul><li>Pneumonia </li></ul>
    72. 72. Blood <ul><li>Contents </li></ul><ul><ul><li>Protein </li></ul></ul><ul><ul><li>Fibrin </li></ul></ul><ul><ul><li>Water </li></ul></ul><ul><ul><li>Electrolytes </li></ul></ul><ul><li>Aspiration Damage </li></ul><ul><ul><li>Clog small airways </li></ul></ul><ul><ul><li>Creates chemical reaction </li></ul></ul>
    73. 73. Suction Catheters <ul><li>Rigid </li></ul><ul><li>Advantages </li></ul><ul><li>Disadvantages </li></ul><ul><li>Indications </li></ul><ul><li>Contraindications </li></ul><ul><li>Methods of Use </li></ul><ul><li>Flexible </li></ul><ul><li>Advantages </li></ul><ul><li>Disadvantages </li></ul><ul><li>Indications </li></ul><ul><li>Contraindications </li></ul><ul><li>Methods of Use </li></ul>
    74. 74. Lesson 6 Dual-Lumen Airway Devices
    75. 75. Combitube ©
    76. 76. Description <ul><li>Other Similar Devices </li></ul><ul><ul><li>Pharyngeal tracheal lumen airway (PTLA) </li></ul></ul><ul><ul><li>EGTA </li></ul></ul><ul><ul><li>EOA </li></ul></ul><ul><li>What we use </li></ul><ul><ul><li>Combitube © </li></ul></ul>
    77. 77. Indications for Combitube © <ul><li>Respiratory Arrest </li></ul><ul><li>Cardiac Arrest </li></ul><ul><li>Unconscious, without a gag reflex </li></ul>
    78. 78. Contraindications for Combitube © <ul><li>Gag Reflex </li></ul><ul><li>Conscious </li></ul><ul><li>Breathing Adequately </li></ul><ul><li>Caustic Ingestion </li></ul><ul><li>Known esophageal disease or varices </li></ul><ul><li>Under 16 y/o </li></ul><ul><li>Under 5 feet or over 6 feet 8inches </li></ul>
    79. 79. Advantages for Combitube © <ul><li>Rapid Insertion </li></ul><ul><li>Limits regurgitation, aspiration & distention </li></ul><ul><li>Blind insertion </li></ul><ul><li>High oxygen delivery </li></ul><ul><li>Less training required </li></ul><ul><li>Inserted in neutral position </li></ul>
    80. 80. Disadvantages for Combitube © <ul><li>Patient must be unresponsive without gag reflex </li></ul><ul><li>Some are difficult to obtain adequate seal </li></ul><ul><li>Some do not totally protect against aspiration </li></ul><ul><li>Most responsive patients will vomit when removed </li></ul><ul><li>May damage esophagus </li></ul>
    81. 81. Demonstration
    82. 82. When Can I Remove the Combitube? <ul><li>Patient returns to full consciousness </li></ul><ul><li>Patient able to maintain own airway </li></ul><ul><li>Orders from OLMC </li></ul>
    83. 83. Procedure for Removing <ul><li>SUCTION READY! </li></ul><ul><li>Deflate Tube #2 </li></ul><ul><li>Deflate Tube #1 </li></ul><ul><li>Tell patient to exhale </li></ul><ul><li>Pull out quickly and in-line </li></ul><ul><li>SUCTION </li></ul>
    84. 84. Demonstration
    85. 85. Skills Labs <ul><li>Basic Airway Management </li></ul><ul><ul><li>Manual Maneuvers and Simple Adjuncts </li></ul></ul><ul><ul><li>Supplemental Oxygen </li></ul></ul><ul><ul><li>Ventilation </li></ul></ul><ul><ul><li>Suctioning </li></ul></ul><ul><li>Advanced Airway Management </li></ul><ul><ul><li>Combitube </li></ul></ul>
    86. 86. Questions?