Objectives Name the major components of the upper and lower airways Describe the functions of the upper and lower airways Describe the process of ventilation Describe the process of respiration Identify the S.A.L.T.™ device Demonstrate use of the S.A.L.T.™ device Explain the SMO for the S.A.L.T.™ device
Upper Airway Anterior Nares - These are the holes in the nose on the front of the face through which air is entrained for the purpose of ventilation. Vestibule – This space is the area just inside the nose that serves as a collection area as air enters the respiratory system through the nose. The Vibrissae (nose hair) are located here and this is where large particulate matter is trapped in the first step of filtering and purifying the air we breathe. Mucosal lining – The lining of the entire respiratory tract all the way down to the smallest of the bronchioles is made of mucosal epithelium which is rich with goblet cells that produce mucus. Also noteworthy is that these cells have cilia. This important structure is very vascular as well. It serves multiple functions including warming, adding moisture, further filtering the air. The rich blood supply warms the air. The mucus it produces serves to moisten the air and to trap the smaller particulate matter to further purify the air. The cilia move the mucus. Septum – This structure forms the middle ridge line of the nose dividing it into left and right halves. The majority of the septum is made of cartilage which is attached to the septal bone of the nose.
Upper Airway Nasal turbinates / Conchae – There are three sets of turbinates (a.k.a., Conchae). The inferior are the largest and have the most surface area in which to warm and moisten the air. Then there are the middle and the superior turbinates. The mucosal lining becomes thinner and less vascular as it goes up and in the superior turbinates it is more yellow than red. It is here that the olfactory nerve endings extend through the Ethmoid bone and air is gathered for the sense of smell. The Conchae are located on the lateral walls of the interior of the nose. Posterior nares – The posterior nares are the openings of the posterior nose into the Nasopharynx. Nasopharynx – The superior portion of the throat that is directly behind the nose and extends down to the opening of the oral cavity at the posterior soft palate. Oropharynx – The portion of the throat directly behind the oral cavity from the soft palate down to the superior rim of the hyoid bone. Pharynx - Is about 12.5 cm long extending from the base of the skull to the esophagus encompassing the Nasopharynx and the oropharynx.
Upper Airway Larynx – (a.k.a., voice box) serves as the entry point into the trachea and extends from the base of the tongue to the top of the trachea using the third – the sixth vertebrae as a reference in adult men. It is typically higher in women and children. Epiglottis – Is a cartilaginous structure that is the superior portion of the larynx. It serves as a flap to cover the glottis during swallowing since the oropharynx is a passage way for both food and air. Vocal folds – There are two sets of vocal folds. The false vocal folds, so called because they do not make actual vocalization, are the two white appearing lines of the vocal cords that vibrate as air passes through them to make sound. Rima glottidis – The space between the two true vocal folds (cords). Glottis - The entirety of the false and true vocal folds and the rima glottidis.
Flow of Air in the Upper Airway Flow of Air Anterior nares Vestibule Vibrissae Nasal turbinates(conchae) Inferior Middle Superior Posterior nares Nasopharynx Oropharynx Epiglottis Glottis Vocal folds Rima glottidis
Upper and Lower Airways
Lower Airway Anatomy Trachea Mucous membrane C-shaped cartilaginous rings Carina Left main bronchus Right main bronchus Bronchial Tree Bronchioles Alveolar ducts Alveolar sacs Alveoli ̴300,000,000 Capillaries
Lower Airway Trachea – Sometimes referred to as the “wind pipe”, the trachea the first structure of the lower airway. It is, as noted earlier, lined with the same type of mucus membrane as the rest of the airways. It extends from the inferior edge of the larynx to the carina. C-Shaped cartilaginous rings – As the name suggests, these structures are „C‟ shaped with the opening in the posterior and they are made of cartilage. The serve to provide shape, support and protection to the trachea. Without these rings, the trachea could collapse shutting off the vital supply of air. They are not complete rings so as to allow expansion and contraction of the trachea as its smooth muscles respond to the ever-changing conditions of the human body. Carina – This is the inferior wall of the trachea that sits at the bifurcation of the trachea into two main bronchi. Right main bronchus – This is the right branch of the trachea and is often larger and has a less acute angle to the trachea. Its size and position make it the more common path of endotracheal tubes that are placed too deep. It serves as the primary branch for all other branches of the bronchial tree in the right lung.
Lower Airway Left main bronchus – The primary branch of the bronchial tree that supplies the left lung. Its angle to the trachea is typically more acute and it is often smaller in diameter than its right counterpart. Bronchial Tree – This term is used to describe the branching of the bronchi down to the innumerable bronchioles that serve to transmit air into the alveoli. As the branches get smaller, the cartilaginous rings become more irregularly shaped and complete so as to support the small airways and prevent collapse. Bronchioles – These are the smallest airways of the lower airway anatomy. They terminate into the alveolar ducts which are the connection to the alveoli. At this level, the rings of cartilage have disappeared. Alveolar ducts – These are the small, acartilaginous airways that transmit air into the alveolar sacs.
Lower Airway Alveolar sacs – The terminal of gas exchange is the alveolar sac. These are often said to look like a bunch of grapes. These tiny (microscopic) sacs are enveloped in capillaries that are in contact with their surface. The „grape-like‟ structure provides a large surface area for efficient gas exchange. Alveoli – This is the term applied to the „bunches of grapes‟ and it has been estimated that there are around 300,000,000 alveoli in the human lungs. Capillaries – The capillaries are the smallest of blood vessels and are typically only one cell thick. This allows for efficient exchange of gases, glucose, and waste products between individual cells and the blood.
Ventilation vs. Respiration Ventilation is the Respiration is said to mechanical be the “processes movement of air that result in the into and out of the absorption, transport, and utilization or body. exchange of respiratory gases between an organism and its environment.”₁We can produce artificial ventilation but we cannot produce artificial respiration!
Respiration Respiration begins at the anterior nares and ends at the anterior nares and it includes everything that happens in between. Ventilation moves the oxygen rich air in and displaces the carbon dioxide rich air out. It is in the alveoli that gas exchange takes place and the airways are the transmission pathways for the gases. As mentioned before, the walls of the capillaries are in contact with the walls of the alveoli and this contact is the point at which CO2 trades places with O2 making it possible for the body to remain homeostatic. Keeping in mind that all of this occurs at the cellular level, remember that our job is keeping as many cells alive as we can for as long as we can.
“the lungs serve the alveoli” justas “the circulatory system servesthe capillaries.” ₁
Alveolar Function Gas exchange easily takes place in the alveoli Alveoli are thin- walled Each alveolus is in contact with the capillaries that surround it Capillary walls at this level are only 1 cell thick
Supraglottic AirwayLaryngopharangeal Tube “The S.A.L.T.™ is a unique single patient use oropharyngeal airway which can be utilized to facilitate blind, endotracheal intubation. The S.A.L.T.™ can also be utilized to reduce accidental endotracheal tube extubation.”
S.A.L.T.™ Supraglottic Airway Laryngopharangeal Tube –“ The S.A.L.T.™ is a unique single patient use oropharyngeal airway which can be utilized to facilitate blind, endotracheal intubation. The S.A.L.T.™ can also be utilized to reduce accidental endotracheal tube extubation.”(Though this is not grammatically correct, it is a direct quotation and so was not changed.) This device will be used as an adjunct to open the airway and to facilitate endotracheal intubation in the difficult airway patients. We, here at National EMS, will use it after two (2) attempts at intubation via direct laryngoscopy or when patient access is compromised making direct laryngoscopy unreasonable. This device can be inserted using the tongue blade method the same way standard OPA‟s are inserted or by direct laryngoscopy. Remember that good BLS is a prerequisite to any ALS procedure. Always begin with simple airway maneuvers such as the head-tilt/chin-lift or jaw-thrust then bag-valve-mask ventilation if required. Once the decision has been made to move on to advanced airway management, we will start with endotracheal intubation via direct laryngoscopy. This is a skill we need to maintain and practice is the only way to do that. If intubation by direct laryngoscopy is not successful after the second attempt, insertion of the S.A.L.T.™ should be done as follows:
S.A.L.T.™Indications1. The S.A.L.T.™ is designed and intended for airway management in emergency or difficult airway cases.2. Absence of a gag reflex.Contraindications1. Responsive patients with an intact gag reflex.2. Patients with known esophageal disease.3. Patients who have ingested caustic substances.
Suggested Instructions for Use1. Confirm anatomical compatibility by measuring the S.A.L.T.™ from the level of the patients lips to the superior edge of the larynx.2. Open-patients airway utilizing appropriate manual maneuvers.3. Ventilate/oxygenate patient via bag-valve mask or pocket face mask and observe for adequate chest rise/expansion and ventilatory compliance. If patients airway is obstructed, remove obstruction prior to insertion of the S.A.L.T.™ If the patient exhibits no signs of foreign body airway obstruction and has no gag reflex, prepare for insertion of the SALT4. Lubricate the distal end of the S.A.L.T.™ with a water soluble lubricant.5. Grasp the distal end of the S.A.L.T.™ by placing the thumb against one lateral wall and the index finger against the opposite lateral wall.
Suggested Instructions for Use6. Align the patients airway in a neutral position.7. Insert tongue depressor into patients posterior oropharynx and push anteriorly, retracting the tongue. This action will aid in displacing the epiglottis superiorly allowing the S.A.L.T.™ to be advanced beneath the epiglottis.8. Insert the S.A.L.T.™ into the patients oropharynx, grasp the proximal end of the S.A.L.T.™ and advance following the anatomical contour of the airway until: a) resistance is encountered (indicating the SAL.T. has abutted against the corniculate cartilage and/or b) the depth indicator ring rests against the lips or gumline.9. Remove tongue depressor after the S.A.L.T.™ has been inserted to the proper depth.10. Ventilate/oxygenate the patient via bag-valve mask or pocket face mask and observe for adequate chest rise/expansion and ventilatory compliance.
Alternate Instructions for Use 1. Utilizing a laryngoscope, advance a laryngoscope blade (straight #3, curved #3, or curved #4) into the patients posterior pharynx and gently lift upward. This action will displace the epiglottis superiorly allowing the S.A.L.T.™ to be advanced beneath the epiglottis. Note: Visualization of the epiglottis is not required. 2. Insert the S.A.L.T.™ into the patients oropharynx, grasp the proximal end of the S.A.L.T.™ and advance the airway until: a) resistance is encountered (indicating the S.A.L.T. has abutted against the corniculate cartilage and/or b) the depth indicator ring rests against the lips or gumline. 3. Remove laryngoscope blade after the S.A.L.T.™ has been inserted to the proper depth. 4. Ventilate/oxygenate the patient via bag-valve mask or pocket face mask and observe for adequate chest rise/expansion and ventilatory compliance.Note: If rescuer encounters poor ventilatory compliance; slightly withdrawS.A.L.T.™, re-advance S.A.L.T., and reassess ventilatory status.
Insertion of Endotracheal Tube 1. Ensure patient is being adequately ventilated/oxygenated. 2. Lubricate distal end of endotracheal tube with a water soluble lubricant. 3. Insert the endotracheal tube and advance to proper depth. Note: If resistance is encountered during endotracheal tube insertion: a) withdraw endotrachealtube and slightly withdraw S.A.L.T.™. Readvance S.A.L.T.™ and reattempt endotracheal tube insertion or b) withdraw endotracheal tube, apply cricoid pressure and reattempt endotracheal tube insertionNote: If esophageal placement is either detected or suspected, the endotracheal tube should be immediately removed and thepatient should be ventilated via bag-valve mask and supplemental oxygen prior to repeated endotracheal intubation attempts oralternative airway management.
Insertion of Endotracheal Tube 4. Ventilate patient via bag-valve resuscitator/supplemental oxygen and confirm endotracheal tube placement by: a) observing chest for adequate chest rise/expansion. b) auscultating over epigastric region for absence of gurgling sounds. c) auscultating over lung fields (left and right anterior chest/left and right lateral chest) for presence of bilateral breath sounds. d) observing moisture in the endotracheal tube. e) utilizing an end-tidal C02 detector and observing color change indicative of adequate concentration of C02. f) utilizing an esophageal intubation detector. g) utilizing capnometry/capnography and observing readings/waveforms indicative of adequate concentration of C02.Note: If esophageal placement is either detected or suspected, the endotracheal tube should be immediately removed and thepatient should be ventilated via bag-valve mask and supplemental oxygen prior to repeated endotracheal intubation attempts oralternative airway management.
Instructions for ET TubeSecuring/Clamping Device1. Place ET Tube securing clamp around ET Tube at the superior edge of the SAL.T. Note tube depth.2. Secure clamp firmly around ET Tube. DO NOT CRUSH or COLLAPSE ET TUBE.3. Place strap under/behind patients head/neck.4. Pull strap tight and connect to securing post on opposite side of ET Tube Clamp securing post.5. Verify ET Tube placement after securing of tube.
Instructions for Removal of S.A.L.T. with ET Tube in Place 1. Ensure the patient is well oxygenated. 2. Remove tape or tube securing device. 3. Disconnect the 15 mm adapter from the endotracheal tube. 4. Gently retract the S.A.L.T.™, allowing it to slide over the endotracheal tube. 5. As soon as practical, grip the endotracheal tube while removing the S.A.L.T.™ from the oropharynx to ensure minimal movement of the endotracheal tube. 6. Confirm endotracheal tube placement in accordance with local protocol. 7. Secure endotracheal tube in accordance with local protocol.Note: Because the S.A.L.T.™ serves to protect against accidental endotracheal tube extubation, it isrecommended that the S.A.L.T.™ not be removed during the prehospital phase of care, unless absolutelynecessary.³
Standing Medical Order* A. Open Airway 1. Manual maneuvers 2. Clear obstructions using the appropriate techniques/suction 3. If necessary, insert appropriate airway device to maintain the airway (i.e. oropharyngeal, nasopharyngeal, endotrach eal tube, S.A.L.T. ™, Combi-tube/King Airway, cricothyrotomy)*The following SMO is provided as an example only. Check with your Medical Director for the current Airway Management SMOat your service.
Standing Medical Order 4. Intubate any unconscious patient without a gag reflex a. monitor patient‟s pulse oximetry and cardiac rhythm at all times to prevent unrecognized hypoxia b. hyper oxygenate prior to intubation attempt c. if not able to place tube within 30 sec., withdraw, hyper oxygenate, and re-attempt d. verify placement using Ambu tube check device, observing appropriate chest rise, end tidal CO2 monitoring, and auscultation of breath sounds e. orotracheal or nasotracheal intubation as indicated f. secure tube with ET tube holder (pediatric – use tape) g. in the cardiac arrest situation, initial airway management should be completed with manual maneuvers, & simple adjuncts.
Standing Medical Order 5. After two unsuccessful attempts at intubation by direct laryngoscopy, hyper oxygenate the patient, place S.A.L.T. ™ adjunct, hyper oxygenate, then intubate through the S.A.L.T. ™. The S.A.L.T. ™ is only indicated in patients for whom 6.5mm through 9.0mm ETT is appropriate. 6. Nasotracheal intubation and nasal airways should be avoided in the patient with facial trauma, or suspected basal skull fracture. 7. Extreme caution should be exercised in any patient experiencing significant head injury, or with signs of rising intracranial pressure.
Standing Medical Order 8. With suspected head injuries, administer Lidocaine 1.5 mg/kg prior to ETT intubation to help prevent rise in ICP. 9. For any patient with a GCS < 8, complete endotracheal intubation 10. Only if necessary, in the unusually difficult intubation, and when the patient can not otherwise be oxygenated by basic life support measures, consider giving Versed (or valium) 5 mg IVP + Morphine Sulfate 2 mg IVP to facilitate intubation per Medication Facilitated Intubation Standing Order.
Standing Medical Order 11. A Combi-tube/King Airway should be used if attempts at intubation with the S.A.L.T. ™ are unsuccessful. For EMT-I‟s, the Combi-tube/King Airway is the advanced airway for utilization. The Combi-tube/King Airway is contraindicated in the following: a. patients under 5 feet in height or over 6‟4” in height b. patients who are less than 16 years of age c. patients who weigh less than 90 lbs d. patients who have known esophageal disease e. patients who have ingested caustic substances
Objectives Review Name the major components of the upper and lower airways Describe the functions of the upper and lower airways Describe the process of ventilation Describe the process of respiration Identify the S.A.L.T.™ device Demonstrate use of the S.A.L.T.™ device Explain the SMO for the S.A.L.T.™ device
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