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8)Airway
8)Airway
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8)Airway

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  • 1. Airway It ALL starts here…
  • 2. Respiratory System <ul><li>Function </li></ul><ul><ul><li>Gas exchange with outside environment </li></ul></ul><ul><ul><li>Filtration/Humidification/Warming/Conduction of air </li></ul></ul><ul><li>Structures </li></ul><ul><ul><li>Nose </li></ul></ul><ul><ul><li>Mouth </li></ul></ul><ul><ul><li>Naso/Oro/Laryngopharynx </li></ul></ul><ul><ul><li>Larynx </li></ul></ul><ul><ul><li>Bronchi </li></ul></ul><ul><ul><ul><li>Bronchioles </li></ul></ul></ul><ul><ul><li>Lungs </li></ul></ul><ul><ul><li>Diaphragm </li></ul></ul><ul><ul><ul><li>Associated muscles </li></ul></ul></ul><ul><ul><li>Alveoli </li></ul></ul>
  • 3. Upper Airway Nose/Mouth <ul><li>Function </li></ul><ul><ul><li>Filters </li></ul></ul><ul><ul><li>Warms </li></ul></ul><ul><ul><li>Moistens </li></ul></ul>
  • 4. Upper Airway Pharynx <ul><li>Location </li></ul><ul><ul><li>Posterior to mouth </li></ul></ul><ul><ul><li>Superior to esophagus, larynx, trachea </li></ul></ul><ul><li>Function </li></ul><ul><ul><li>Conducts air to bronchi </li></ul></ul><ul><li>3 Divisions </li></ul><ul><ul><ul><li>Nasopharynx </li></ul></ul></ul><ul><ul><ul><li>Oropharynx </li></ul></ul></ul><ul><ul><ul><li>Laryngopharynx </li></ul></ul></ul>
  • 5. Upper Airway Epiglottis <ul><li>Location </li></ul><ul><ul><li>Sits posterior to larynx </li></ul></ul><ul><ul><li>Attached to tongue </li></ul></ul><ul><li>Structure </li></ul><ul><ul><li>Leaf shaped cartilage </li></ul></ul><ul><li>Function </li></ul><ul><ul><li>Prevents food/liquid from entering larynx during swallowing </li></ul></ul><ul><ul><li>Guards opening to vocal cords (glottis) </li></ul></ul>
  • 6. Upper Airway Larynx <ul><li>AKA: “Voice box” </li></ul><ul><li>Location </li></ul><ul><ul><li>Inferior to epiglottis </li></ul></ul><ul><ul><li>Superior to trachea </li></ul></ul><ul><li>Structure </li></ul><ul><ul><li>Cartilaginous rings </li></ul></ul><ul><ul><ul><li>Thyroid Cartilage = “Adam’s Apple” </li></ul></ul></ul><ul><ul><ul><ul><li>Bulk of anterior wall </li></ul></ul></ul></ul><ul><ul><ul><li>Cricoid Cartilage </li></ul></ul></ul><ul><ul><ul><ul><li>Firm rings forming lower aspect/base </li></ul></ul></ul></ul><ul><li>Function </li></ul><ul><ul><li>Stops foreign objects that pass epiglottis </li></ul></ul><ul><ul><ul><li>Laryngospasm </li></ul></ul></ul><ul><ul><li>Voice production </li></ul></ul>
  • 7. Lower Airway Trachea <ul><li>AKA: “Windpipe” </li></ul><ul><li>Location </li></ul><ul><ul><li>Inferior to Larynx </li></ul></ul><ul><ul><li>Anterior to Esophagus </li></ul></ul><ul><ul><li>Bifurcates into primary bronchi </li></ul></ul><ul><li>Structure </li></ul><ul><ul><li>Cartilaginous rings anterior and lateral </li></ul></ul><ul><ul><ul><li>Approx 15-20 </li></ul></ul></ul><ul><ul><li>Smooth muscle tissue posterior </li></ul></ul><ul><ul><ul><li>Trachealis muscle </li></ul></ul></ul><ul><ul><li>Why???? </li></ul></ul>
  • 8. Lower Airway Bronchi <ul><li>Location </li></ul><ul><ul><li>Bifurcation of trachea </li></ul></ul><ul><ul><ul><li>2 nd Intercostal space </li></ul></ul></ul><ul><ul><ul><ul><li>Angle of Louis </li></ul></ul></ul></ul><ul><ul><li>Right and Left main stem </li></ul></ul><ul><li>Structure </li></ul><ul><ul><li>Smooth muscle </li></ul></ul><ul><ul><li>Irregular hyaline cartilage rings </li></ul></ul><ul><li>Function </li></ul><ul><ul><li>Conducts air to lungs </li></ul></ul>
  • 9. Lower Airway Bronchioles <ul><li>Location </li></ul><ul><ul><li>Distal bifurcations of the bronchi </li></ul></ul><ul><ul><li>Terminate at alveoli </li></ul></ul><ul><li>Function </li></ul><ul><ul><li>Conduct air to alveoli </li></ul></ul><ul><li>Structure </li></ul><ul><ul><li>1 st airways with NO cartilage </li></ul></ul><ul><ul><li>ALL muscle </li></ul></ul><ul><ul><ul><li>Bronchoconstriction </li></ul></ul></ul><ul><ul><ul><li>Bronchospasm </li></ul></ul></ul><ul><ul><li>&lt; 1 mm wide =Tiny </li></ul></ul>
  • 10. Lower Airway Alveoli <ul><li>Location </li></ul><ul><ul><li>Terminal sacs of bronchial tree </li></ul></ul><ul><ul><li>Distal to bronchioles </li></ul></ul><ul><ul><li>Particular to mammalian lungs </li></ul></ul><ul><ul><li>150 million/lung </li></ul></ul><ul><li>Structure </li></ul><ul><ul><li>1 cell thick </li></ul></ul><ul><ul><li>Surface are= 75m 2 (Tennis court) </li></ul></ul><ul><ul><li>Increased SA= Increased 0 2 absorption </li></ul></ul><ul><ul><li>0.2-0.3 mm diameter </li></ul></ul><ul><ul><li>Covered in capillaries (70%) </li></ul></ul><ul><ul><li>Bathed in surfactant </li></ul></ul><ul><li>Function </li></ul><ul><ul><li>Diffusion of gas with capillaries </li></ul></ul>
  • 11. &nbsp;
  • 12. Lower Airway Lungs <ul><li>Location </li></ul><ul><ul><li>Bilateral of midline </li></ul></ul><ul><li>Structure </li></ul><ul><ul><li>Divided into lobes </li></ul></ul><ul><ul><ul><li>Left= 2 </li></ul></ul></ul><ul><ul><ul><li>Right= 3 </li></ul></ul></ul><ul><li>Function </li></ul><ul><ul><li>Houses structure for gas exchange </li></ul></ul><ul><ul><li>Alteration of pH </li></ul></ul>
  • 13. Lower Airway Mucociliary Escalator <ul><li>Location </li></ul><ul><ul><li>Along epithelium of primary bronchi </li></ul></ul><ul><ul><li>Beat in rhythm </li></ul></ul><ul><li>Structure </li></ul><ul><ul><li>Cilia projections </li></ul></ul><ul><ul><li>“ Hair like” </li></ul></ul><ul><li>Function </li></ul><ul><ul><li>Move debris up out of lungs </li></ul></ul><ul><ul><ul><li>Cough or swallow </li></ul></ul></ul><ul><ul><ul><ul><li>Smokers… </li></ul></ul></ul></ul><ul><ul><li>Prevent mucous accumulation </li></ul></ul>
  • 14. &nbsp;
  • 15. Respiratory Physiology How we breathe… <ul><li>Ventilation </li></ul><ul><ul><li>Mechanical movement of air into/out of the body </li></ul></ul><ul><li>Inhalation ( Active ) </li></ul><ul><ul><li>Muscles Used </li></ul></ul><ul><ul><ul><li>Diaphragm &amp; External Intercostals </li></ul></ul></ul><ul><ul><li>Physiology </li></ul></ul><ul><ul><ul><li>Diaphragm contracts downward </li></ul></ul></ul><ul><ul><ul><li>External intercostals pull ribs up and out </li></ul></ul></ul><ul><ul><ul><li>Increases dimension of chest cavity </li></ul></ul></ul><ul><ul><ul><li>Increased diameter of chest drops intra thoracic pressure </li></ul></ul></ul><ul><ul><ul><li>Air rushes in until pressure is equalized </li></ul></ul></ul>
  • 16. Respiratory Physiology How we breathe… <ul><li>Ventilation </li></ul><ul><ul><li>Mechanical movement of air into/out of the body </li></ul></ul><ul><li>Exhalation ( Passive ) </li></ul><ul><ul><li>Physiology </li></ul></ul><ul><ul><ul><li>Diaphragm relaxes as well as intercostals </li></ul></ul></ul><ul><ul><ul><li>Chest cavity dimension decreases </li></ul></ul></ul><ul><ul><ul><li>Decrease in dimension increases intrathoracic pressure </li></ul></ul></ul><ul><ul><ul><li>Air rushes out </li></ul></ul></ul><ul><ul><ul><li>Lungs recoil </li></ul></ul></ul>
  • 17. &nbsp;
  • 18. Respiratory Physiology Gas Exchange <ul><li>Respiration </li></ul><ul><ul><li>Process by which the body utilizes oxygen </li></ul></ul><ul><ul><li>Diffusion </li></ul></ul><ul><ul><ul><ul><li>Net movement of molecules from an area of high concentration to an area of low concentration </li></ul></ul></ul></ul>
  • 19. &nbsp;
  • 20. Respiratory Physiology Gas Exchange <ul><li>Respiration </li></ul><ul><ul><li>Process by which the body utilizes oxygen </li></ul></ul><ul><li>Alveolar/Capillary Exchange </li></ul><ul><ul><li>Physiology </li></ul></ul><ul><ul><ul><li>O 2 rich air enters alveoli </li></ul></ul></ul><ul><ul><ul><li>O 2 poor blood in capillaries pass alveoli </li></ul></ul></ul><ul><ul><ul><li>O 2 diffuses down its concentration gradient into the capillaries </li></ul></ul></ul><ul><ul><ul><li>CO 2 diffuses down its concentration gradient into the alveoli </li></ul></ul></ul><ul><ul><ul><li>CO 2 is exhaled and O 2 transported to tissues </li></ul></ul></ul>
  • 21. Respiratory Physiology Gas Exchange <ul><li>Respiration </li></ul><ul><ul><li>Process by which the body utilizes oxygen </li></ul></ul><ul><li>Capillary/Cellular Exchange </li></ul><ul><ul><li>Physiology </li></ul></ul><ul><ul><ul><li>O 2 rich blood passes cells </li></ul></ul></ul><ul><ul><ul><li>O 2 diffuses across its concentration gradient into the cells </li></ul></ul></ul><ul><ul><ul><li>CO 2 diffuses across its concentration gradient into the capillary </li></ul></ul></ul><ul><ul><ul><li>CO 2 is transported to the alveoli </li></ul></ul></ul>
  • 22. Respiratory Evaluation <ul><li>Areas of assessment </li></ul><ul><ul><li>Rate. Rhythm. Depth. Quality. </li></ul></ul><ul><li>Rate </li></ul><ul><ul><li>Adult = 12-20 per minute </li></ul></ul><ul><ul><li>Child = 15-30 per minute </li></ul></ul><ul><ul><li>Infant = 30-60 per minute </li></ul></ul><ul><li>Rhythm </li></ul><ul><ul><li>Regular or irregular </li></ul></ul><ul><li>Depth </li></ul><ul><ul><li>Tidal volume adequate or inadequate </li></ul></ul><ul><ul><ul><li>Amount of air breathed in/out in one ventilation </li></ul></ul></ul><ul><ul><ul><li>Approx 500 mL </li></ul></ul></ul>
  • 23. Respiratory Evaluation cont’d. <ul><li>Quality </li></ul><ul><ul><li>Breath sounds </li></ul></ul><ul><ul><ul><li>Present or diminished or absent </li></ul></ul></ul><ul><ul><li>Chest expansion </li></ul></ul><ul><ul><ul><li>Unequal or symmetrical </li></ul></ul></ul><ul><ul><li>Increased effort </li></ul></ul><ul><ul><ul><li>Accessory muscles </li></ul></ul></ul><ul><ul><ul><li>“ Seesaw” breathing </li></ul></ul></ul><ul><ul><ul><ul><li>Infants </li></ul></ul></ul></ul><ul><ul><ul><li>Nasal flaring </li></ul></ul></ul><ul><ul><ul><li>Retractions </li></ul></ul></ul><ul><ul><ul><ul><li>Above clavicles, between ribs </li></ul></ul></ul></ul><ul><ul><ul><li>Cyanosis </li></ul></ul></ul><ul><ul><ul><li>Shortness of breath </li></ul></ul></ul><ul><ul><ul><li>Altered mental status </li></ul></ul></ul>
  • 24. Accessory Muscle Use Nasal Flaring Retractions
  • 25. Respiratory Evaluation cont’d. <ul><li>Cyanosis </li></ul><ul><ul><li>Blue/pale coloring of skin </li></ul></ul><ul><ul><ul><li>Nail beds </li></ul></ul></ul><ul><ul><ul><li>Lips </li></ul></ul></ul><ul><ul><ul><li>Eyelids </li></ul></ul></ul><ul><ul><li>Why is this seen in these areas first??? </li></ul></ul><ul><ul><li>Indicates poor perfusion </li></ul></ul>
  • 26. Pulse Oximetry <ul><li>“ 5 th Vital Sign” </li></ul><ul><li>Normal SpO2 </li></ul><ul><ul><li>95-100% </li></ul></ul><ul><li>Sp02 Ranges </li></ul><ul><ul><li>91-94% = Mild Hypoxia – Supplemental O2 </li></ul></ul><ul><ul><li>86-91% = Moderate Hypoxia – Supplemental O2 </li></ul></ul><ul><ul><li>85%-&lt; = Severe Hypoxia – IMMEDIATE intervention </li></ul></ul><ul><li>False Readings </li></ul><ul><ul><li>CO poisoning, high intensity lighting, hemoglobin abnormalities, no pulse in extremity, hypovolemia, severe anemia </li></ul></ul>
  • 27. Pediatric Considerations <ul><li>Mouth/Nose </li></ul><ul><ul><li>Smaller and easily obstructed </li></ul></ul><ul><li>Pharynx </li></ul><ul><ul><li>Tongue is BIG </li></ul></ul><ul><li>Trachea </li></ul><ul><ul><li>Narrower </li></ul></ul><ul><ul><li>Softer and more flexible </li></ul></ul><ul><li>Cricoid Cartilage </li></ul><ul><ul><li>Less developed/Less rigid = easily kinked </li></ul></ul><ul><li>Diaphragm </li></ul><ul><ul><li>Chest is soft </li></ul></ul><ul><ul><li>Depend on diaphragm to do most of the work of breathing </li></ul></ul><ul><ul><ul><li>Seesaw Breathing…. </li></ul></ul></ul>
  • 28. Accessory Muscle Use Nasal Flaring Retractions
  • 29. Respiratory Distress <ul><li>“ The pt is able to compensate for the underlying problem and get enough O 2 to maintain mental responsiveness and muscle tone to move air .” </li></ul><ul><li>Resp. distress can progress to resp. failure </li></ul><ul><ul><li>Exhaustion </li></ul></ul>
  • 30. Respiratory Distress Assessment <ul><li>Respiratory Distress </li></ul><ul><ul><li>Work of breathing is increased </li></ul></ul><ul><ul><li>Maintains LOC </li></ul></ul><ul><li>Signs/Symptoms </li></ul><ul><ul><li>Increased resp rate </li></ul></ul><ul><ul><li>Accessory muscle use </li></ul></ul><ul><ul><li>Nasal flaring </li></ul></ul><ul><ul><li>Tripod position </li></ul></ul><ul><ul><li>Diff speaking in complete sentences </li></ul></ul><ul><ul><li>Agitated/Restless </li></ul></ul><ul><li>Treatments </li></ul><ul><ul><li>Maintain clear airway </li></ul></ul><ul><ul><li>Supplemental O 2 </li></ul></ul><ul><ul><li>Bronchodilatory drugs </li></ul></ul>
  • 31. Respiratory Failure <ul><li>“ The pt is not able to maintain mental status, display muscle tone, or move adequate amounts of air to the lungs” </li></ul><ul><li>Resp. failure can progress to resp. arrest </li></ul>
  • 32. Respiratory Failure Assessment <ul><li>Respiratory Failure </li></ul><ul><ul><li>Inadequate ventilate to support life </li></ul></ul><ul><ul><li>LOC diminishes </li></ul></ul><ul><li>Mechanisms </li></ul><ul><ul><li>Impaired brain function </li></ul></ul><ul><ul><li>Muscle fatigue after respiratory distress </li></ul></ul><ul><ul><li>Chest wall injury </li></ul></ul><ul><ul><li>Airway obstruction </li></ul></ul><ul><li>Sings/Symptoms </li></ul><ul><ul><li>Low O 2 sat. </li></ul></ul><ul><ul><li>Sleepiness/weakness </li></ul></ul><ul><ul><li>Cyanosis </li></ul></ul><ul><ul><li>Low respiratory rate </li></ul></ul><ul><ul><li>Little/no chest movement </li></ul></ul><ul><ul><li>AMS </li></ul></ul>
  • 33. Respiratory Failure Treatment <ul><li>Treatment </li></ul><ul><ul><li>Positive pressure ventilation </li></ul></ul><ul><ul><li>Err on side of ventilation if in doubt </li></ul></ul><ul><ul><ul><li>If pt accepts then it’s a sign they need it </li></ul></ul></ul><ul><ul><ul><li>If a pt fights it it’s a sign they are trying to ventilate </li></ul></ul></ul>
  • 34. Respiratory Arrest <ul><li>Respiratory Arrest </li></ul><ul><ul><li>Complete cessation of breathing </li></ul></ul><ul><li>Can progress to cardiac arrest </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Secure patent airway </li></ul></ul><ul><ul><li>Positive pressure ventilation </li></ul></ul>
  • 35. Airway Management It ALL starts with “A”… <ul><li>Goals of airway management </li></ul><ul><ul><li>Est./maintain patent airway </li></ul></ul><ul><ul><li>Ensure adequate ventilation </li></ul></ul><ul><ul><li>Ensure adequate oxygenation </li></ul></ul><ul><li>Methods of Securing Airways </li></ul><ul><ul><li>Manual </li></ul></ul><ul><ul><li>Suctioning </li></ul></ul><ul><ul><li>Mechanical </li></ul></ul>
  • 36. Opening the airway Manual techniques <ul><li>Tongue </li></ul><ul><ul><li>Attached to lower jaw </li></ul></ul><ul><ul><li>Obstructs airway in unconscious pt </li></ul></ul><ul><ul><li>Simple manual techniques can fix this </li></ul></ul><ul><li>2 Techniques </li></ul><ul><ul><li>Head tilt chin lift </li></ul></ul><ul><ul><li>Jaw Thrust </li></ul></ul>
  • 37. Opening the airway Head Tilt Chin Lift <ul><li>When to do it… </li></ul><ul><ul><li>Patients not traumatically injured </li></ul></ul><ul><li>How to do it… </li></ul><ul><ul><li>Place index and middle finger of 1 hand under the bony part of pts lower jaw </li></ul></ul><ul><ul><li>Place other hand on pts forehead </li></ul></ul><ul><ul><li>Lift the jaw with one hand while tilting the head back with the other </li></ul></ul>
  • 38. &nbsp;
  • 39. Opening the airway Jaw Thrust <ul><li>When to do it… </li></ul><ul><ul><li>Traumatically injured pts </li></ul></ul><ul><ul><li>Opens airway without neck extension </li></ul></ul><ul><li>How to do it… </li></ul><ul><ul><li>Place hands on either side of pt head </li></ul></ul><ul><ul><li>Place index and middle fingers beneath the angle of the jaw just below ears </li></ul></ul><ul><ul><li>Place thumbs on either side of mouth at pt chin </li></ul></ul><ul><ul><li>Lift jaw up while opening mouth by pushing with your thumbs </li></ul></ul>
  • 40. &nbsp;
  • 41. Securing the airway Suctioning <ul><li>Purpose </li></ul><ul><ul><li>Remove blood, food, and other liquids from the airway </li></ul></ul><ul><ul><li>Inadequate for solid material </li></ul></ul><ul><ul><li>Clear airway when ventilating if gurgling is heard </li></ul></ul>
  • 42. Suctioning Units <ul><li>Types of units </li></ul><ul><ul><li>Mounted </li></ul></ul><ul><ul><li>Portable </li></ul></ul><ul><ul><ul><li>Electrical </li></ul></ul></ul><ul><ul><ul><li>Hand operated </li></ul></ul></ul>
  • 43. Suction Catheters <ul><li>Hard/Rigid </li></ul><ul><ul><li>Yankauer/“Tonsil sucker/Tonsil tip </li></ul></ul><ul><ul><li>Suction of unresponsive pt </li></ul></ul><ul><ul><li>Do NOT touch back of pediatric airway </li></ul></ul><ul><ul><li>Insert only as far as you can see </li></ul></ul><ul><ul><ul><li>Base of tongue </li></ul></ul></ul><ul><li>Soft </li></ul><ul><ul><li>Suction of nasopharynx </li></ul></ul><ul><ul><li>Situations when a rigid catheter cannot be used </li></ul></ul><ul><ul><li>Insert only to base of tongue </li></ul></ul><ul><ul><li>Measure from corner of mouth to earlobe </li></ul></ul>
  • 44. Suctioning <ul><li>How to… </li></ul><ul><ul><li>Turn unit on </li></ul></ul><ul><ul><ul><li>Check for 300 mmHg vacuum </li></ul></ul></ul><ul><ul><li>Attach catheter </li></ul></ul><ul><ul><li>Insert into oro/nasopharynx without suction on </li></ul></ul><ul><ul><li>Apply suction </li></ul></ul><ul><ul><li>Move catheter from side to side </li></ul></ul><ul><ul><li>Suction for NO more than 15 seconds </li></ul></ul><ul><ul><ul><li>Lesser time for infants </li></ul></ul></ul><ul><ul><ul><li>If there is a lot of secretions log roll pt and clear </li></ul></ul></ul><ul><ul><ul><li>15 sec. suction-ventilate 2 min- 15 sec. suction </li></ul></ul></ul>
  • 45. Airway Adjuncts <ul><li>Functions </li></ul><ul><ul><li>Keeps tongue off posterior oropharynx </li></ul></ul><ul><li>Types </li></ul><ul><ul><li>Oropharyngeal Airway (OPA/Oral) </li></ul></ul><ul><ul><li>Nasopharyngeal Airway (NPA/Nasal) </li></ul></ul>
  • 46. Orophayngeal Airway <ul><li>Form: </li></ul><ul><ul><li>Curved plastic device extending from lips to base of tongue </li></ul></ul><ul><li>When to use it: </li></ul><ul><ul><li>Unconscious pt without a gag reflex </li></ul></ul><ul><li>How to use it: </li></ul><ul><ul><li>Measure from corner of pt mouth to angle of jaw </li></ul></ul><ul><ul><li>Open pt mouth </li></ul></ul><ul><ul><li>Insert OPA upside down (curve pointing to roof of mouth) </li></ul></ul><ul><ul><li>Insert until slight resistance then invert 180 O </li></ul></ul><ul><ul><li>Rest flanges on teeth </li></ul></ul><ul><ul><li>ALTERNATELY: </li></ul></ul><ul><ul><ul><li>Use tongue blade and insert curved side down </li></ul></ul></ul><ul><ul><ul><ul><li>Pediatric pts </li></ul></ul></ul></ul>
  • 47. &nbsp;
  • 48. Nasophayngeal Airway <ul><li>Form: </li></ul><ul><ul><li>Flexible plastic tube beveled on one side that extends from nostril to base of tongue </li></ul></ul><ul><li>When to use it: </li></ul><ul><ul><li>Pt with gag reflex </li></ul></ul><ul><ul><li>Unable to advance OPA </li></ul></ul><ul><li>When not to use it: </li></ul><ul><ul><li>Pt with facial trauma </li></ul></ul><ul><li>How to use it: </li></ul><ul><ul><li>Measure from tip of pt nose to angle of jaw </li></ul></ul><ul><ul><li>LUBE it… </li></ul></ul><ul><ul><li>Insert it posteriorly with bevel pointing toward septum </li></ul></ul><ul><ul><li>If it doesn’t work in one nostril try the next </li></ul></ul>
  • 49. &nbsp;
  • 50. Ventilating the Airway <ul><li>Methods of ventilation </li></ul><ul><ul><li>Mouth-to-Mask </li></ul></ul><ul><ul><li>Two-person Bag-Valve-Mask </li></ul></ul><ul><ul><li>Flow restricted, oxygen powered ventilation device </li></ul></ul><ul><ul><li>One-person Bag-Valve-Mask </li></ul></ul>
  • 51. Mouth-to-Mouth <ul><li>How to… </li></ul><ul><ul><li>Open Airway </li></ul></ul><ul><ul><li>Seal your mouth over the pt </li></ul></ul><ul><ul><li>Pinch pt nostrils closed </li></ul></ul><ul><ul><li>Give 2 breaths each over 2 seconds </li></ul></ul><ul><ul><li>Assess for chest rise </li></ul></ul><ul><ul><li>Reposition head and reattempt if none </li></ul></ul><ul><li>How often: </li></ul><ul><ul><li>1 breath every 5 seconds= Adult </li></ul></ul><ul><ul><li>1 breath every 3 seconds= Child </li></ul></ul>
  • 52. Mouth-to-Mask <ul><li>Position yourself directly above pt </li></ul><ul><li>Apply mask to pt </li></ul><ul><ul><li>Use bridge of nose as guide </li></ul></ul><ul><li>Secure mask to pt face using “E-C” technique </li></ul><ul><li>Provide rescue breaths over 2 seconds </li></ul><ul><ul><li>Breath-release-release” </li></ul></ul><ul><li>Continue at rates previously listed </li></ul>
  • 53. Ventilating the Airway “E-C” Technique <ul><li>Place thumbs on superior aspect of mask (Half C) </li></ul><ul><ul><li>Bridge of Nose </li></ul></ul><ul><li>Place index fingers on inferior aspect of mask (Half C) </li></ul><ul><ul><li>Chin </li></ul></ul><ul><li>Place remaining fingers on the bony ridge of the lower jaw and form and “E” </li></ul><ul><li>Bring jaw upwards to mask with “E” and push down to seal with “C” </li></ul><ul><li>Ventilate the pt. </li></ul>
  • 54. &nbsp;
  • 55. Ventilating the Airway Bag-Vale-Mask Self Inflating Bag One Way Valve Face Mask O 2 Reservoir O 2 Tubing
  • 56. Bag-Vale-Mask <ul><li>Issues: </li></ul><ul><ul><li>1600 milliliter volume </li></ul></ul><ul><ul><li>Less volume than mouth-to-mask </li></ul></ul><ul><ul><li>Airtight seal is difficult with 1 EMT </li></ul></ul><ul><ul><li>Position above pt head for ease </li></ul></ul><ul><ul><li>Use airway adjunct with BVM </li></ul></ul><ul><li>Anatomy of the BVM </li></ul><ul><ul><li>Self-refilling bag washable/disposable </li></ul></ul><ul><ul><li>Non jam valve with O 2 inlet for 15 lpm </li></ul></ul><ul><ul><li>Absent or disabled pop-off valve </li></ul></ul><ul><ul><li>Standardized 15/22mm fittings </li></ul></ul><ul><ul><li>O 2 inlet and reservoir for high concentration O 2 </li></ul></ul><ul><ul><li>True non rebreather valve </li></ul></ul><ul><ul><li>Function in extreme conditions </li></ul></ul><ul><ul><li>Infant, child, adult sizes </li></ul></ul>
  • 57. Bag-Vale-Mask <ul><li>How to use it… (Non traumatic) </li></ul><ul><ul><li>Open airway and select mask size </li></ul></ul><ul><ul><li>Place thumbs at apex of mask </li></ul></ul><ul><ul><li>Lower mask over pt face using bridge of nose as a guide </li></ul></ul><ul><ul><li>Connect BVM if not already </li></ul></ul><ul><ul><li>Complete E-C Technique </li></ul></ul><ul><ul><li>Have assistant squeeze bag with 2 hands until chest rise is observed </li></ul></ul><ul><ul><li>Ventilate pt </li></ul></ul><ul><ul><ul><li>1 ventilation every 5 seconds = Adult </li></ul></ul></ul><ul><ul><ul><li>1 ventilation every 3 seconds = Child </li></ul></ul></ul><ul><ul><ul><li>“ Squeeze – Release – Release” </li></ul></ul></ul>
  • 58. &nbsp;
  • 59. Bag-Vale-Mask <ul><li>How to use it… (Non traumatic) </li></ul><ul><ul><li>If alone </li></ul></ul><ul><ul><ul><li>Proceed as before only moving thumbs from apex of mask to around the ventilator port </li></ul></ul></ul><ul><ul><ul><li>Continue with E-C technique as usual </li></ul></ul></ul>
  • 60. &nbsp;
  • 61. Bag-Vale-Mask <ul><li>How to use it… (Traumatic) </li></ul><ul><ul><li>Proceed as before only immobilizing the head with </li></ul></ul><ul><ul><ul><li>Knees </li></ul></ul></ul><ul><ul><ul><li>Manual stabilization by partner </li></ul></ul></ul><ul><ul><li>Don’t tilt head back to seal to mask </li></ul></ul><ul><ul><li>Pull jaw forward with E-C technique </li></ul></ul>
  • 62. Ventilating the Airway Special Cases <ul><li>Bag-to-Stoma or Tracheostomy tube </li></ul><ul><ul><li>Use child/infant bag </li></ul></ul><ul><ul><li>Place directly over stoma </li></ul></ul><ul><ul><li>Extension of head is not needed </li></ul></ul><ul><ul><li>Squeeze bag until chest rise is observed </li></ul></ul><ul><ul><li>Continue as normal </li></ul></ul><ul><ul><li>If you cant ventilate: </li></ul></ul><ul><ul><ul><li>Suction stoma </li></ul></ul></ul><ul><ul><ul><li>Move to upper airway </li></ul></ul></ul><ul><ul><ul><ul><li>Seal off stoma </li></ul></ul></ul></ul><ul><ul><li>If pt has tracheostomy: </li></ul></ul><ul><ul><ul><li>Connect BVM directly to trach tube and ventilate through it </li></ul></ul></ul><ul><ul><ul><li>Suction may be needed to clear obstructions </li></ul></ul></ul>
  • 63. &nbsp;
  • 64. Flow Restricted, Oxygen Powered Ventilation Device <ul><li>Flow rate of up to 100% @ 40 lpm </li></ul><ul><li>Inspiratory pressure relief valve </li></ul><ul><li>Opens at 60 cm of water </li></ul><ul><li>Vents remaining air off </li></ul><ul><li>Audible alarm that sounds when the valves pressure is exceeded </li></ul><ul><li>Trigger that allows both EMT’s hands to be on the mask </li></ul>
  • 65. Flow Restricted, Oxygen Powered Ventilation Device <ul><li>How to use it (non traumatic) </li></ul><ul><ul><li>Open airway and insert adjunct </li></ul></ul><ul><ul><li>Place mask on pt face by E-C technique </li></ul></ul><ul><ul><li>Connect device to mask if not already </li></ul></ul><ul><ul><li>Trigger the device until the chest rises </li></ul></ul><ul><li>How to use is (trauma) </li></ul><ul><ul><li>Immobilize head </li></ul></ul><ul><ul><ul><li>Knees </li></ul></ul></ul><ul><ul><ul><li>Partner </li></ul></ul></ul><ul><ul><li>Open airway and insert adjunct </li></ul></ul><ul><ul><li>Place mask on pt face by E-C Technique </li></ul></ul><ul><ul><li>Proceed as normal without tilting pt head to mask </li></ul></ul>
  • 66. Adequate Ventilation <ul><li>Adequate Ventilation </li></ul><ul><ul><li>Chest rise/fall </li></ul></ul><ul><ul><li>Lung sounds </li></ul></ul><ul><ul><li>“ Pinking up” of patient </li></ul></ul><ul><ul><li>Sufficient rate </li></ul></ul><ul><ul><ul><li>Adult - 12 bpm </li></ul></ul></ul><ul><ul><ul><li>Child – 20 bpm </li></ul></ul></ul><ul><li>If no chest rise is observed: </li></ul><ul><ul><li>Reposition head </li></ul></ul><ul><ul><li>Assess for a leak and correct </li></ul></ul><ul><ul><li>Assess for obstruction and treat </li></ul></ul><ul><ul><li>Use another method to ventilate pt </li></ul></ul><ul><li>Complication </li></ul><ul><ul><li>Gastric distention </li></ul></ul>
  • 67. Oxygen… Tanks <ul><li>Atmospheric O 2 concentration </li></ul><ul><ul><li>21% </li></ul></ul><ul><li>O 2 cylinders </li></ul><ul><ul><li>Color coded Green </li></ul></ul><ul><ul><li>Various sizes </li></ul></ul><ul><ul><ul><li>D = 350 Liters </li></ul></ul></ul><ul><ul><ul><li>E = 625 Liters </li></ul></ul></ul><ul><ul><ul><li>M =3,000 Liters </li></ul></ul></ul><ul><ul><ul><li>G = 5,300 Liters </li></ul></ul></ul><ul><ul><ul><li>H = 6,900 Liters </li></ul></ul></ul>D cylinder M cylinder E Cylinder
  • 68. Oxygen Regulators <ul><li>Function: </li></ul><ul><ul><li>Reduce high pressure of gas inside cylinder to a level that is safe for the pt. </li></ul></ul><ul><ul><li>Has pressure gage (psi) </li></ul></ul><ul><ul><ul><li>Full tank = 2000 psi </li></ul></ul></ul>
  • 69. Setting up Oxygen <ul><li>How to set your O 2 up </li></ul><ul><ul><li>Remove protective seal </li></ul></ul><ul><ul><li>Find plastic “O” ring and place on the cylinder opening/regulator opening </li></ul></ul><ul><ul><li>Quickly open then shut main valve </li></ul></ul><ul><ul><ul><li>Blows dust out </li></ul></ul></ul><ul><ul><li>Attach regulator to tank </li></ul></ul><ul><ul><ul><li>Line up pins from the regulator to the holes in the tank </li></ul></ul></ul><ul><ul><li>Open main valve and check pressure (2000psi) </li></ul></ul><ul><ul><li>Attach O 2 device and turn regulator to desired setting </li></ul></ul><ul><ul><li>When complete </li></ul></ul><ul><ul><ul><li>Remove device from pt </li></ul></ul></ul><ul><ul><ul><li>Turn off main valve </li></ul></ul></ul><ul><ul><ul><li>Bleed pressure out of the regulator </li></ul></ul></ul>
  • 70. Oxygen Delivery Devices <ul><li>Nasal Cannula </li></ul><ul><ul><li>22-24% Oxygen </li></ul></ul><ul><ul><li>1-6 Lpm </li></ul></ul><ul><li>Simple Face Mask </li></ul><ul><ul><li>40-60% Oxygen </li></ul></ul><ul><ul><li>8-12 Lpm </li></ul></ul><ul><ul><li>Admin no less than 6 Lpm </li></ul></ul><ul><li>Non Rebreather </li></ul><ul><ul><li>80-100% Oxygen, 15 Lpm </li></ul></ul><ul><ul><li>No less than 8 Lpm </li></ul></ul><ul><li>Venturi Mask </li></ul><ul><ul><li>Used for COPD </li></ul></ul><ul><ul><li>Controlled precise amount of oxygen </li></ul></ul><ul><ul><li>24, 28, 35, 40% Oxygen </li></ul></ul>
  • 71. Nonrebreathers <ul><li>How to use them… </li></ul><ul><ul><li>Attach NRB to O2 tank </li></ul></ul><ul><ul><li>Pre-fill the reservoir </li></ul></ul><ul><ul><li>Set to desired flow rate </li></ul></ul><ul><ul><ul><li>Reservoir bag shouldn’t go flat when pt inhales </li></ul></ul></ul><ul><ul><ul><ul><li>i.e. 15 liters per minute </li></ul></ul></ul></ul><ul><ul><li>Extend elastic band and place mask on pt face </li></ul></ul><ul><ul><li>Cinch metal band to pt nose </li></ul></ul><ul><ul><li>Cinch elastic band to pt face </li></ul></ul>
  • 72. Oxygen… Nasal Cannula <ul><li>How to use it… </li></ul><ul><ul><li>Attach to tank </li></ul></ul><ul><ul><li>Set on desired flow rate </li></ul></ul><ul><ul><ul><li>i.e. 6 liters per minute </li></ul></ul></ul><ul><ul><li>Place prongs in pt nose </li></ul></ul><ul><ul><ul><li>Curve down </li></ul></ul></ul><ul><ul><li>Loop tubing around pt ear and under chin </li></ul></ul><ul><ul><li>Cinch tubing below chin </li></ul></ul>
  • 73. Cylinder Calculations <ul><li>Can you make it??? </li></ul><ul><ul><li>Time(min)= (Tank Pressure[psi]-200psi)xConstant </li></ul></ul><ul><ul><ul><li>Flow Rate (L/min) </li></ul></ul></ul><ul><li>Constants </li></ul><ul><ul><li>D cylinder= 0.16 E cylinder= 0.28 </li></ul></ul><ul><ul><li>M cylinder= 1.56 H cylinder= 3.4 </li></ul></ul><ul><li>Example </li></ul><ul><ul><li>You are transporting a patient who is receiving 15L/min of oxygen by NRB. The transport time is 20 min. On your E cylinder, the psi is 1200. Do you have enough oxygen for your patient, of should you prepare to change you settings? </li></ul></ul><ul><ul><li>Time =(1200psi-200psi)X0.28 </li></ul></ul><ul><ul><li>15L/min </li></ul></ul><ul><ul><li>=18 2/3 min = NOT ENOUGH </li></ul></ul>
  • 74. Special Considerations <ul><li>Laryngectomies (stomas) </li></ul><ul><ul><li>If obstructed =suction </li></ul></ul><ul><ul><li>If ventilating and air escapes = Close mouth/nose </li></ul></ul><ul><li>Facial Injuries </li></ul><ul><ul><li>Rich blood supply to face </li></ul></ul><ul><ul><li>Severe bleeding/swelling </li></ul></ul><ul><ul><li>Challenge to manage </li></ul></ul><ul><ul><ul><li>Suctioning </li></ul></ul></ul><ul><li>Obstructions </li></ul><ul><ul><li>Foreign Body Airway Obstruction Protocols </li></ul></ul><ul><li>Dental Appliances </li></ul><ul><ul><li>Leave in place unless they get in the way </li></ul></ul>
  • 75. Special Considerations <ul><li>Pediatrics </li></ul><ul><ul><li>Do not hyperextend </li></ul></ul><ul><ul><ul><li>Neutral/”sniffing” position = Infant </li></ul></ul></ul><ul><ul><ul><li>Slightly past neutral position = Child </li></ul></ul></ul><ul><ul><li>Use only enough pressure to achieve chest rise </li></ul></ul><ul><ul><li>Gastric distention is common </li></ul></ul><ul><ul><li>Consider adjuncts if other attempts fail </li></ul></ul><ul><ul><li>NEVER manipulate the back of a pediatric airway </li></ul></ul>
  • 76. Special Considerations <ul><ul><li>Breathing Control </li></ul></ul><ul><ul><ul><li>Voluntary/Involuntary </li></ul></ul></ul><ul><ul><ul><li>Sensors in brain/brainstem </li></ul></ul></ul><ul><ul><ul><ul><li>O 2 , CO 2 , acid levels </li></ul></ul></ul></ul><ul><ul><ul><li>Normal control to breath is high CO 2 </li></ul></ul></ul><ul><ul><li>When CO 2 increases the brainstem signals to: </li></ul></ul><ul><ul><ul><li>Increase resp rate </li></ul></ul></ul><ul><ul><ul><li>Increase depth </li></ul></ul></ul><ul><ul><li>What if CO 2 chronically builds up??? </li></ul></ul><ul><ul><ul><li>COPD… </li></ul></ul></ul>
  • 77. Special Considerations COPD <ul><li>Chronic Obstructive Pulmonary Disease </li></ul><ul><li>Includes: </li></ul><ul><ul><li>Chronic Bronchitis </li></ul></ul><ul><ul><li>Emphysema </li></ul></ul><ul><ul><li>Asthma </li></ul></ul><ul><li>Causes: </li></ul><ul><ul><ul><li>Loss of elasticity of alveoli </li></ul></ul></ul><ul><ul><ul><li>Collapse of bronchioles </li></ul></ul></ul><ul><ul><ul><li>Decreased inspiratory volume </li></ul></ul></ul><ul><ul><ul><li>“ Trappe” air </li></ul></ul></ul><ul><ul><ul><li>Poor tissue perfusion </li></ul></ul></ul><ul><li>Problem: </li></ul><ul><ul><li>Chronic high CO 2 </li></ul></ul><ul><ul><li>Sensors become desensitized to CO 2 and switches to O 2 </li></ul></ul><ul><ul><li>Resp drive now based on O 2 NOT CO 2 </li></ul></ul><ul><ul><li>Does anyone see the problem???? </li></ul></ul>
  • 78. It all starts with aggressive airway management….

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