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8)Airway

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