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Emergency Education Training Center

EETC - Airway Management

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Emergency Care CHAPTER Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe THIRTEENTH EDITION Airway Management 9
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Topics • Airway Physiology • Airway Pathophysiology • Opening the Airway • Airway Adjuncts • Suctioning • Keeping an Airway Open: Definitive Care • Special Considerations
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Physiology
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Physiology • Upper airway  Begins at mouth and nose • Air is warmed and humidified in nasal turbinates.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Physiology • Pharynx • Oropharynx, nasopharynx, and laryngopharynx • Ends at glottic opening
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Physiology The upper airway.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Physiology • Lower airway  Begins below the larynx  Composed of: • Trachea • Bronchi • Bronchial passages • Alveoli
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Physiology The lower airway. (A) The bronchial tree.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Physiology • Alveoli  Tiny sacs in grapelike bunches at the end of the airway  Surrounded by pulmonary capillaries  Oxygen and carbon dioxide diffuse through pulmonary capillary membranes.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Physiology The lower airway. (B) The alveolar sacs (clusters of individual alveoli).
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Pathophysiology
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Pathophysiology • Variety of obstructions interfere with air flow  Foreign bodies • Food, small toys  Liquids • Blood, vomit • Obstruction may also result from poor muscle tone caused by altered mental status. continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Pathophysiology • Obstructions can be acute or chronic. • Providers must initially evaluate airway and monitor patency over time. continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Pathophysiology • Airway obstructions  Acute • Foreign bodies • Vomit • Blood  Occurring over time • Edema from burns, trauma, or infection • Decreasing mental status continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Pathophysiology • Airway obstructions  Bronchoconstriction • Disorder of lower airway • Smooth muscle constricts internal diameter of airway.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Patient Assessment • Addressed in primary assessment • Two questions must be answered.  Is airway open?  Will airway stay open?
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Is the Airway Open? • In most patients, can be determined by simply saying hello • "Sniffing position" seen when swelling obstructs airflow through upper airway continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Is the Airway Open? • Findings indicating breathing problems  Inability to speak  Unusual raspy quality to voice  Stridor-The high-pitched sound caused by an upper airway obstruction  Snoring  Gurgling
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Will the Airway Stay Open? • Airway assessment is not just a moment in time. • Must give constant consideration
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Signs of an Inadequate Airway • No signs of breathing or air movement • Evidence of foreign bodies in airway • No air felt or heard • Inability or difficulty speaking • Unusual hoarse or raspy voice • Absent, minimal, or uneven chest movement continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Signs of an Inadequate Airway • Abdominal breathing • Diminished or absent breath sounds • Abnormal noises such as wheezing, crowing, stridor, snoring, gurgling, or gasping during breathing • In children and infants, nasal flaring • In children, retractions above the clavicles
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Opening the Airway
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Patient Care • The airway  When primary assessment indicates inadequate airway, a life-threatening condition exists.  Take prompt action to open and the maintain airway
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Opening the Airway • If airway is not open, use position to open it. • Indications of head, neck, spinal injury  Mechanism of injury known to cause such injuries  Any injury at or above the level of the shoulders  Family or bystanders give information leading you to suspect it. continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Opening the Airway • Head-tilt, chin-lift maneuver and jaw-thrust maneuver move airway structures into position allowing air movement.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Head-Tilt, Chin-Lift Maneuver Head-tilt, chin-lift maneuver, side view. Right image shows EMT’s fingertips under the bony area at the center of the patient’s lower jaw.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Head-Tilt, Chin-Lift Maneuver 1. Place one hand on patient's forehead and fingertips of other hand at the center of patient's lower jaw. 2. Tilt head. 3. Lift chin. 4. Do not allow mouth to close.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Jaw-Thrust Maneuver Jaw-thrust maneuver, side view. Inset shows EMT’s finger position at angle of the jaw just below the ears.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Jaw-Thrust Maneuver 1. Keep patient's head, neck, and spine aligned, moving patient as a unit into the supine position. 2. Kneel at the top of patient's head. 3. Place one hand on each side of patient's lower jaw, at angles of jaw below ears. 4. Stabilize patient's head with your forearms. continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Performing Jaw- Thrust Maneuver 5. Using index fingers, push angles of patient's lower jaw forward. 6. You may need to retract patient's lower lip with your thumb to keep the mouth open. 7. Do not tilt or rotate patient's head.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Management • After airway has been opened, position must be maintained to keep airway open. • Airway must be cleared of secretions and other obstructions.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Adjuncts
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Adjuncts • Airway position and maneuvers are short-term solutions. • Airway adjunct provides longer term air channel. • Two most common airway adjuncts  Oropharyngeal airway (OPA)  Nasopharyngeal airway (NPA)
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Rules for Using Airway Adjuncts • Use OPA only on patients not exhibiting gag reflex. • Open patient's airway manually before using adjunct device. • When inserting airway, take care not to push patient's tongue into pharynx. continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Rules for Using Airway Adjuncts • Have suction ready prior to inserting any airway. • Do not continue inserting airway if patient gags. • Maintain head position after adjunct insertion and monitor airway. continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Rules for Using Airway Adjuncts • Continue to be ready to provide suction if fluid or blood obstructs the airway. • If patient regains consciousness or develops a gag reflect, remove the airway immediately. • Use infection control practices while maintaining airway.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Oropharyngeal Airway • Device used to move tongue forward as it curves back to pharynx • Sizes  Infant to large adult
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Oropharyngeal Airway Oropharyngeal airways.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Sizing Oropharyngeal Airways Ensure the oropharyngeal airway is the correct size by checking to make sure it either extends from the center of the mouth to the angle of the jaw or…
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Sizing Oropharyngeal Airways Measure from the corner of the patient's mouth to the tip of the earlobe.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Oropharyngeal Airway • Inserting OPA 1. Place patient on his back, and use appropriate method to open the airway 2. Open mouth with crossed-finger technique 3. Position airway with tip pointing toward roof of mouth
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Inserting OPA Use the crossed-fingers technique to open the patient's mouth.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Oropharyngeal Airway • Inserting OPA 4. Insert device along roof of mouth 5. Gently rotate airway 180 degrees so tip is pointing down into patient's pharynx 6. Position patient 7. Check that flange of airway is against patient's lips 8. Monitor patient closely continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Inserting OPA Insert the airway with the tip pointing to the roof of the patient's mouth.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Oropharyngeal Airway • Inserting OPA  Use tongue depressor or rigid suction tip and insert OPA directly
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Nasopharyngeal Airway • Soft, flexible tube inserted through nostril and into hypopharynx • Moves tongue and soft tissue forward to provide a channel for air continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Nasopharyngeal Airway • Can be used in patients with intact gag reflex or clenched jaw • Contraindicated if clear (cerebrospinal) fluid coming from nose or ears continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Nasopharyngeal Airway • Come in various sizes • Must be measured • Typical adult sizes  34, 32, 30, and 28 French
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Inserting NPA • Inserting NPA 1. Measure for correct size 2. Lubricate outside of tube with water- based lubricant before insertion
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Inserting NPA Measure the nasopharyngeal airway from the patient's nostril to the tip of the earlobe or to the angle of the jaw.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Inserting NPA Apply a water-based lubricant before insertion.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Inserting NPA • Inserting NPA 3. Push tip of nose upward; keep head in neutral position 4. Insert into nostril; advance until flange rests firmly against nostril
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Inserting NPA Gently push the tip of the nose upward, and insert the airway with the beveled side toward the base of the nostril or toward the septum (wall that separates the nostrils). Insert the airway, advancing it until the flange rests against the nostril.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe LAB
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suctioning
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suctioning • Obvious liquids (blood, secretions, vomitus) must be removed from airway to prevent aspiration into lungs. • Use vacuum device to remove liquids from airway.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Mounted suction systems  Installed near head of stretcher  Furnish air intake of at least 30 liters per minute  Generate vacuum of no less than 300 mmHg when collecting tube clamped continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Portable suction units  Same requirements as mounted  Oxygen- or air-powered or powered by batteries/electricity  Manual continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Tubing, tips, and catheters  Tubing  Suction tips  Suction catheters  Collection container  Container of clean or sterile water
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Systems A mounted suction unit installed in the ambulance’s patient compartment.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Tubing, tips, and catheters  Rigid pharyngeal suction tip • Also called Yankauer tip • Larger bore than flexible catheters
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Rigid Pharyngeal Tip Place the convex side of the rigid tip against the roof of the mouth. Insert just to the base of the tongue.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Tubing, tips, and catheters  Rigid pharyngeal suction tip • Suction only as far as you can see. • Do not lose sight of distal end. • Careful insertion helps prevent gag reflex or vagal stimulation. continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Tubing, tips, and catheters  Flexible suction catheters • Designed to be used when a rigid tip cannot be used • Can be passed through a tube such as the nasopharyngeal or endotracheal tube • Can be used for suctioning the nasopharynx continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Tubing, tips, and catheters  Flexible suction catheters • Come in various sizes identified by a number "French" • Larger the number, larger the catheter continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Tubing, tips, and catheters  Flexible suction catheters • Not typically large enough to suction vomitus or thick secretions • May kink • In event of copious, thick secretions consider removing tip or catheter and using large bore, rigid suction tubing. continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Tubing, tips, and catheters  Flexible suction catheters • Measured in similar way as OPA • Length of catheter that should be inserted into patient's mouth equals distance between corner of patient's mouth and earlobe.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Measuring Flexible Suction Catheter If you are using a flexible catheter, measure it from the patient's earlobe to the corner of the mouth or from the center of the mouth to the angle of the jaw.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Techniques of Suctioning • Use appropriate infection control practices while suctioning  Includes protective eyewear, mask, disposable gloves
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suctioning Techniques Position yourself at the patient's head and turn the patient's head or entire body to the side.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Techniques of Suctioning • Suction no longer than ten seconds at a time.  Prolonged suctioning can cause hypoxia and bradycardia.  If patient vomits for longer than ten seconds, continue suction. • Patient may be suctioned more than 10 seconds if the patient has continuous vomiting continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Techniques of Suctioning • Place tip or catheter where you want to begin suctioning and suction on the way out.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suctioning—Oral Pharyngeal Video Click on the screenshot to view a video on the subject of suctioning. Back to Directory
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Keeping an Airway Open: Definitive Care
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Keeping an Airway Open: Definitive Care • Keeping the airway open may exceed capabilities of a basic EMT. • Medications and/or surgical procedures may be necessary to resolve airway obstruction. continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Keeping an Airway Open: Definitive Care • Rapidly evaluate and treat airway problems. • Quickly recognize when more definitive care is necessary.  May be Advanced Life Support intercept  May be closest hospital
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Think About It • If you were not able to manage an airway at the basic level, what advanced resources might be available to you?
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Special Considerations
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Special Considerations • Facial injuries  Frequently result in severe swelling or bleeding that may block or partially block airway  Bleeding may require frequent suctioning or more definitive airway. continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Special Considerations • Obstructions  Many suction units are not adequate for removing solid objects.  Objects may have to be removed with manual techniques • Abdominal thrusts • Chest thrusts • Finger sweeps continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Special Considerations • Dental appliances  Leave in place during airway procedures when possible.  Partial dentures may become dislodged during an emergency.  Be prepared to remove if airway endangered.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Pediatric Note • Variety of anatomical differences to consider when managing the airway • Anatomic considerations  Smaller mouth and nose  Larger tongue  Narrow, flexible trachea
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Pediatric Anatomical Considerations Comparison of child and adult respiratory passages.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Pediatric Note • Management considerations  Open airway gently  Do not hyperextend neck  Consider adjuncts when other measures fail  Use rigid tip with adjunct, but do not touch back of airway
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Vocabulary • Gurgling. • Stridor. • Rhonchi. • Rales • Hypercarbia. • Hyperventilation. • Hypoxia • tidal volume. • Inhalation. • Respiration. • Ventilation. • External respiration. • Dehydration. • Internal respiration. • Oxygenation. • Pocket face mask • Bag-valve mask • 15/22 fitting mask • Self-refilling shell • Non-jam valve
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Chapter Review
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Chapter Review • The airway is the passageway by which air enters the body during respiration, or breathing. • A patient cannot survive without an open airway. • Airway adjuncts—the oropharyngeal and nasopharyngeal airways—can help keep the airway open. continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Chapter Review • It may be necessary to suction the airway or to use manual techniques to remove fluids and solids from the airway before, during, or after artificial ventilation.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Remember • Always use proper personal protective equipment when managing an airway. • Airway assessment must be an ongoing process. Airway status can change over time. • Airway management should start simply and become more complicated only if necessary.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Questions to Consider • Name the main structures of the airway. • Explain why care for the airway is the first priority of emergency care. • Describe the signs of an inadequate airway. continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Questions to Consider • Explain when the head-tilt, chin-lift maneuver should be used and when the jaw-thrust maneuver should be used to open the airway—and why. • Explain how airway adjuncts and suctioning help in airway management.
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Critical Thinking • On arrival at the emergency scene, you find an adult female patient with gurgling sounds in the throat and inadequate breathing slowing to almost nothing. How do you proceed to protect the airway? continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Critical Thinking • When evaluating a small child you hear stridor. What does this sound tell you? What are your immediate concerns regarding this sound? continued on next slide
Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Critical Thinking • When assessing an unconscious patient, you note snoring respirations. Should you be concerned with this and if so, what steps can you take to correct this situation?

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Ch09 airway

  • 1. Emergency Care CHAPTER Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe THIRTEENTH EDITION Airway Management 9
  • 2. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Topics • Airway Physiology • Airway Pathophysiology • Opening the Airway • Airway Adjuncts • Suctioning • Keeping an Airway Open: Definitive Care • Special Considerations
  • 3. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Physiology
  • 4. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Physiology • Upper airway  Begins at mouth and nose • Air is warmed and humidified in nasal turbinates.
  • 5. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Physiology • Pharynx • Oropharynx, nasopharynx, and laryngopharynx • Ends at glottic opening
  • 6. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Physiology The upper airway.
  • 7. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Physiology • Lower airway  Begins below the larynx  Composed of: • Trachea • Bronchi • Bronchial passages • Alveoli
  • 8. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Physiology The lower airway. (A) The bronchial tree.
  • 9. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Physiology • Alveoli  Tiny sacs in grapelike bunches at the end of the airway  Surrounded by pulmonary capillaries  Oxygen and carbon dioxide diffuse through pulmonary capillary membranes.
  • 10. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Physiology The lower airway. (B) The alveolar sacs (clusters of individual alveoli).
  • 11. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Pathophysiology
  • 12. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Pathophysiology • Variety of obstructions interfere with air flow  Foreign bodies • Food, small toys  Liquids • Blood, vomit • Obstruction may also result from poor muscle tone caused by altered mental status. continued on next slide
  • 13. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Pathophysiology • Obstructions can be acute or chronic. • Providers must initially evaluate airway and monitor patency over time. continued on next slide
  • 14. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Pathophysiology • Airway obstructions  Acute • Foreign bodies • Vomit • Blood  Occurring over time • Edema from burns, trauma, or infection • Decreasing mental status continued on next slide
  • 15. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Pathophysiology • Airway obstructions  Bronchoconstriction • Disorder of lower airway • Smooth muscle constricts internal diameter of airway.
  • 16. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Patient Assessment • Addressed in primary assessment • Two questions must be answered.  Is airway open?  Will airway stay open?
  • 17. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Is the Airway Open? • In most patients, can be determined by simply saying hello • "Sniffing position" seen when swelling obstructs airflow through upper airway continued on next slide
  • 18. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Is the Airway Open? • Findings indicating breathing problems  Inability to speak  Unusual raspy quality to voice  Stridor-The high-pitched sound caused by an upper airway obstruction  Snoring  Gurgling
  • 19. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Will the Airway Stay Open? • Airway assessment is not just a moment in time. • Must give constant consideration
  • 20. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Signs of an Inadequate Airway • No signs of breathing or air movement • Evidence of foreign bodies in airway • No air felt or heard • Inability or difficulty speaking • Unusual hoarse or raspy voice • Absent, minimal, or uneven chest movement continued on next slide
  • 21. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Signs of an Inadequate Airway • Abdominal breathing • Diminished or absent breath sounds • Abnormal noises such as wheezing, crowing, stridor, snoring, gurgling, or gasping during breathing • In children and infants, nasal flaring • In children, retractions above the clavicles
  • 22. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Opening the Airway
  • 23. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Patient Care • The airway  When primary assessment indicates inadequate airway, a life-threatening condition exists.  Take prompt action to open and the maintain airway
  • 24. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Opening the Airway • If airway is not open, use position to open it. • Indications of head, neck, spinal injury  Mechanism of injury known to cause such injuries  Any injury at or above the level of the shoulders  Family or bystanders give information leading you to suspect it. continued on next slide
  • 25. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Opening the Airway • Head-tilt, chin-lift maneuver and jaw-thrust maneuver move airway structures into position allowing air movement.
  • 26. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Head-Tilt, Chin-Lift Maneuver Head-tilt, chin-lift maneuver, side view. Right image shows EMT’s fingertips under the bony area at the center of the patient’s lower jaw.
  • 27. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Head-Tilt, Chin-Lift Maneuver 1. Place one hand on patient's forehead and fingertips of other hand at the center of patient's lower jaw. 2. Tilt head. 3. Lift chin. 4. Do not allow mouth to close.
  • 28. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Jaw-Thrust Maneuver Jaw-thrust maneuver, side view. Inset shows EMT’s finger position at angle of the jaw just below the ears.
  • 29. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Jaw-Thrust Maneuver 1. Keep patient's head, neck, and spine aligned, moving patient as a unit into the supine position. 2. Kneel at the top of patient's head. 3. Place one hand on each side of patient's lower jaw, at angles of jaw below ears. 4. Stabilize patient's head with your forearms. continued on next slide
  • 30. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Performing Jaw- Thrust Maneuver 5. Using index fingers, push angles of patient's lower jaw forward. 6. You may need to retract patient's lower lip with your thumb to keep the mouth open. 7. Do not tilt or rotate patient's head.
  • 31. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Management • After airway has been opened, position must be maintained to keep airway open. • Airway must be cleared of secretions and other obstructions.
  • 32. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Adjuncts
  • 33. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Airway Adjuncts • Airway position and maneuvers are short-term solutions. • Airway adjunct provides longer term air channel. • Two most common airway adjuncts  Oropharyngeal airway (OPA)  Nasopharyngeal airway (NPA)
  • 34. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Rules for Using Airway Adjuncts • Use OPA only on patients not exhibiting gag reflex. • Open patient's airway manually before using adjunct device. • When inserting airway, take care not to push patient's tongue into pharynx. continued on next slide
  • 35. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Rules for Using Airway Adjuncts • Have suction ready prior to inserting any airway. • Do not continue inserting airway if patient gags. • Maintain head position after adjunct insertion and monitor airway. continued on next slide
  • 36. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Rules for Using Airway Adjuncts • Continue to be ready to provide suction if fluid or blood obstructs the airway. • If patient regains consciousness or develops a gag reflect, remove the airway immediately. • Use infection control practices while maintaining airway.
  • 37. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Oropharyngeal Airway • Device used to move tongue forward as it curves back to pharynx • Sizes  Infant to large adult
  • 38. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Oropharyngeal Airway Oropharyngeal airways.
  • 39. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Sizing Oropharyngeal Airways Ensure the oropharyngeal airway is the correct size by checking to make sure it either extends from the center of the mouth to the angle of the jaw or…
  • 40. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Sizing Oropharyngeal Airways Measure from the corner of the patient's mouth to the tip of the earlobe.
  • 41. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Oropharyngeal Airway • Inserting OPA 1. Place patient on his back, and use appropriate method to open the airway 2. Open mouth with crossed-finger technique 3. Position airway with tip pointing toward roof of mouth
  • 42. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Inserting OPA Use the crossed-fingers technique to open the patient's mouth.
  • 43. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Oropharyngeal Airway • Inserting OPA 4. Insert device along roof of mouth 5. Gently rotate airway 180 degrees so tip is pointing down into patient's pharynx 6. Position patient 7. Check that flange of airway is against patient's lips 8. Monitor patient closely continued on next slide
  • 44. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Inserting OPA Insert the airway with the tip pointing to the roof of the patient's mouth.
  • 45. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Oropharyngeal Airway • Inserting OPA  Use tongue depressor or rigid suction tip and insert OPA directly
  • 46. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Nasopharyngeal Airway • Soft, flexible tube inserted through nostril and into hypopharynx • Moves tongue and soft tissue forward to provide a channel for air continued on next slide
  • 47. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Nasopharyngeal Airway • Can be used in patients with intact gag reflex or clenched jaw • Contraindicated if clear (cerebrospinal) fluid coming from nose or ears continued on next slide
  • 48. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Nasopharyngeal Airway • Come in various sizes • Must be measured • Typical adult sizes  34, 32, 30, and 28 French
  • 49. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Inserting NPA • Inserting NPA 1. Measure for correct size 2. Lubricate outside of tube with water- based lubricant before insertion
  • 50. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Inserting NPA Measure the nasopharyngeal airway from the patient's nostril to the tip of the earlobe or to the angle of the jaw.
  • 51. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Inserting NPA Apply a water-based lubricant before insertion.
  • 52. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Inserting NPA • Inserting NPA 3. Push tip of nose upward; keep head in neutral position 4. Insert into nostril; advance until flange rests firmly against nostril
  • 53. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Inserting NPA Gently push the tip of the nose upward, and insert the airway with the beveled side toward the base of the nostril or toward the septum (wall that separates the nostrils). Insert the airway, advancing it until the flange rests against the nostril.
  • 54. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe LAB
  • 55. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suctioning
  • 56. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suctioning • Obvious liquids (blood, secretions, vomitus) must be removed from airway to prevent aspiration into lungs. • Use vacuum device to remove liquids from airway.
  • 57. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Mounted suction systems  Installed near head of stretcher  Furnish air intake of at least 30 liters per minute  Generate vacuum of no less than 300 mmHg when collecting tube clamped continued on next slide
  • 58. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Portable suction units  Same requirements as mounted  Oxygen- or air-powered or powered by batteries/electricity  Manual continued on next slide
  • 59. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Tubing, tips, and catheters  Tubing  Suction tips  Suction catheters  Collection container  Container of clean or sterile water
  • 60. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Systems A mounted suction unit installed in the ambulance’s patient compartment.
  • 61. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Tubing, tips, and catheters  Rigid pharyngeal suction tip • Also called Yankauer tip • Larger bore than flexible catheters
  • 62. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Rigid Pharyngeal Tip Place the convex side of the rigid tip against the roof of the mouth. Insert just to the base of the tongue.
  • 63. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Tubing, tips, and catheters  Rigid pharyngeal suction tip • Suction only as far as you can see. • Do not lose sight of distal end. • Careful insertion helps prevent gag reflex or vagal stimulation. continued on next slide
  • 64. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Tubing, tips, and catheters  Flexible suction catheters • Designed to be used when a rigid tip cannot be used • Can be passed through a tube such as the nasopharyngeal or endotracheal tube • Can be used for suctioning the nasopharynx continued on next slide
  • 65. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Tubing, tips, and catheters  Flexible suction catheters • Come in various sizes identified by a number "French" • Larger the number, larger the catheter continued on next slide
  • 66. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Tubing, tips, and catheters  Flexible suction catheters • Not typically large enough to suction vomitus or thick secretions • May kink • In event of copious, thick secretions consider removing tip or catheter and using large bore, rigid suction tubing. continued on next slide
  • 67. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suction Devices • Tubing, tips, and catheters  Flexible suction catheters • Measured in similar way as OPA • Length of catheter that should be inserted into patient's mouth equals distance between corner of patient's mouth and earlobe.
  • 68. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Measuring Flexible Suction Catheter If you are using a flexible catheter, measure it from the patient's earlobe to the corner of the mouth or from the center of the mouth to the angle of the jaw.
  • 69. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Techniques of Suctioning • Use appropriate infection control practices while suctioning  Includes protective eyewear, mask, disposable gloves
  • 70. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suctioning Techniques Position yourself at the patient's head and turn the patient's head or entire body to the side.
  • 71. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Techniques of Suctioning • Suction no longer than ten seconds at a time.  Prolonged suctioning can cause hypoxia and bradycardia.  If patient vomits for longer than ten seconds, continue suction. • Patient may be suctioned more than 10 seconds if the patient has continuous vomiting continued on next slide
  • 72. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Techniques of Suctioning • Place tip or catheter where you want to begin suctioning and suction on the way out.
  • 73. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Suctioning—Oral Pharyngeal Video Click on the screenshot to view a video on the subject of suctioning. Back to Directory
  • 74. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Keeping an Airway Open: Definitive Care
  • 75. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Keeping an Airway Open: Definitive Care • Keeping the airway open may exceed capabilities of a basic EMT. • Medications and/or surgical procedures may be necessary to resolve airway obstruction. continued on next slide
  • 76. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Keeping an Airway Open: Definitive Care • Rapidly evaluate and treat airway problems. • Quickly recognize when more definitive care is necessary.  May be Advanced Life Support intercept  May be closest hospital
  • 77. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Think About It • If you were not able to manage an airway at the basic level, what advanced resources might be available to you?
  • 78. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Special Considerations
  • 79. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Special Considerations • Facial injuries  Frequently result in severe swelling or bleeding that may block or partially block airway  Bleeding may require frequent suctioning or more definitive airway. continued on next slide
  • 80. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Special Considerations • Obstructions  Many suction units are not adequate for removing solid objects.  Objects may have to be removed with manual techniques • Abdominal thrusts • Chest thrusts • Finger sweeps continued on next slide
  • 81. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Special Considerations • Dental appliances  Leave in place during airway procedures when possible.  Partial dentures may become dislodged during an emergency.  Be prepared to remove if airway endangered.
  • 82. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Pediatric Note • Variety of anatomical differences to consider when managing the airway • Anatomic considerations  Smaller mouth and nose  Larger tongue  Narrow, flexible trachea
  • 83. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Pediatric Anatomical Considerations Comparison of child and adult respiratory passages.
  • 84. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Pediatric Note • Management considerations  Open airway gently  Do not hyperextend neck  Consider adjuncts when other measures fail  Use rigid tip with adjunct, but do not touch back of airway
  • 85. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Vocabulary • Gurgling. • Stridor. • Rhonchi. • Rales • Hypercarbia. • Hyperventilation. • Hypoxia • tidal volume. • Inhalation. • Respiration. • Ventilation. • External respiration. • Dehydration. • Internal respiration. • Oxygenation. • Pocket face mask • Bag-valve mask • 15/22 fitting mask • Self-refilling shell • Non-jam valve
  • 86. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Chapter Review
  • 87. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Chapter Review • The airway is the passageway by which air enters the body during respiration, or breathing. • A patient cannot survive without an open airway. • Airway adjuncts—the oropharyngeal and nasopharyngeal airways—can help keep the airway open. continued on next slide
  • 88. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Chapter Review • It may be necessary to suction the airway or to use manual techniques to remove fluids and solids from the airway before, during, or after artificial ventilation.
  • 89. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Remember • Always use proper personal protective equipment when managing an airway. • Airway assessment must be an ongoing process. Airway status can change over time. • Airway management should start simply and become more complicated only if necessary.
  • 90. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Questions to Consider • Name the main structures of the airway. • Explain why care for the airway is the first priority of emergency care. • Describe the signs of an inadequate airway. continued on next slide
  • 91. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Questions to Consider • Explain when the head-tilt, chin-lift maneuver should be used and when the jaw-thrust maneuver should be used to open the airway—and why. • Explain how airway adjuncts and suctioning help in airway management.
  • 92. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Critical Thinking • On arrival at the emergency scene, you find an adult female patient with gurgling sounds in the throat and inadequate breathing slowing to almost nothing. How do you proceed to protect the airway? continued on next slide
  • 93. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Critical Thinking • When evaluating a small child you hear stridor. What does this sound tell you? What are your immediate concerns regarding this sound? continued on next slide
  • 94. Copyright © 2016, 2012, 2009 by Pearson Education, Inc. All Rights Reserved Emergency Care, 13e Daniel Limmer | Michael F. O'Keefe Critical Thinking • When assessing an unconscious patient, you note snoring respirations. Should you be concerned with this and if so, what steps can you take to correct this situation?

Editor's Notes

  1. Planning Your Time: Plan 120 minutes for this chapter. Airway Physiology (20 minutes) Airway Pathophysiology (20 minutes) Opening the Airway (20 minutes) Airway Adjuncts (15 minutes) Suctioning (15 minutes) Keeping an Airway Open: Definitive Care (15 minutes) Special Considerations (15 minutes) Core concepts: Physiology of the airway Pathophysiology of the airway How to recognize an adequate or an inadequate airway How to open an airway How to use airway adjuncts Principles and techniques of suctioning Note: The total teaching time recommended is only a guideline.
  2. Teaching Time: 20 minutes Teaching Tips: This lesson lends itself well to multimedia presentations. Anatomical models and web graphics will enhance your presentation on physiology and pathophysiology. Build upon previous lessons from Chapter 6. Use take-home lessons/online assignments to enhance understanding of anatomy and to help prioritize classroom time.
  3. Covers Objective: 9.2 Point to Emphasize: The airway begins at the mouth and nose and terminates at the alveoli. Knowledge Application: Assign a take-home/online assignment. Have students label a blank illustration of airway structures.
  4. Covers Objective: 9.3 Knowledge Application: Discuss the flow of air. Anticipate your discussion of pathophysiology by asking the class to discuss how airflow might be interrupted. Ask for specific examples.
  5. Covers objective: 9.2 Point to Emphasize: The upper airway and lower airway are divided at the glottic opening. Discussion Topic: Describe how the airway is protected. Specifically discuss the role of cartilage.
  6. Covers Objective: 9.3 Knowledge Application: Using an anatomical model, have students or groups of students point out specific airway structures.
  7. Covers Objective: 9.2 Discussion Topic: Describe the path that air takes as it moves from the mouth and nose to the alveoli. Critical Thinking: Review your knowledge of airway anatomy. Which structures are most vulnerable to outside trauma, and why?
  8. Covers Objective: 9.2
  9. Teaching Time: 20 minutes Teaching Tips: This lesson lends itself well to multimedia presentations. Very good web-based pathophysiology graphics exist. Consider using these types of examples to underscore your lecture. Use real-world examples and "war stories" to illustrate pathophysiology.
  10. Covers Objective: 9.4 Point to Emphasize: Airway obstructions can be caused by foreign bodies, loss of muscle tone, or swelling in the airway. Discussion Topic: Describe the causes of airway obstruction. Discuss specific examples.
  11. Covers Objective: 9.4 Discussion Topic: Define the term patent airway.
  12. Covers Objective: 9.4
  13. Covers Objective: 9.4 Discussion Topic: Explain how bronchoconstriction causes airway obstruction. Knowledge Application: Use anatomical models and manikins. Assign specific airway scenarios and have students discuss the findings of their assessment. Critical Thinking: What types of infectious diseases might present a threat to the airway? Give specific examples.
  14. Covers Objective: 9.5 Teaching Tip: Airway assessment is a key point. Spend time on this topic to assure comprehension before moving on to airway skills. Point to Emphasize: Assessment of the airway must consider both immediate and long-term patency. Talking Points: Airway assessment is a high priority for, without the ability to move air, the patient will die. In most cases, airway is the first area checked during the primary assessment.
  15. Covers Objective: 9.6
  16. Covers Objective: 9.7
  17. Covers Objective: 9.8 Discussion Topic: Describe the signs of an inadequate airway.
  18. Covers Objectives: 9.7 and 9.8 Discussion Topic: Describe the signs of an inadequate airway. Knowledge Application: Use programmed patients. Have the patients present signs of both adequate and inadequate airways. Have groups of students practice assessment and decision making
  19. Teaching Time: 20 minutes Teaching Tips: Attempt to keep this lesson grounded in reality. Use programmed patients and not just manikins to teach key techniques. Link psychomotor skills to assessment. Demonstrate that the use of skills is guided by assessment and critical decision making. Assure proper supervision in practical skill stations. Imprint correct techniques early.
  20. Covers Objective: 9.8 Point to Emphasize: In many patients, the ability to speak implies an open airway. Discussion Topic: Describe how evaluating airway patency might be different for a conscious person from what it would be for an unconscious person.
  21. Covers Objective: 9.9 Point to Emphasize: EMTs must evaluate the potential for spinal injury in order to choose the most appropriate method for opening an airway.
  22. Covers Objective: 9.9 Point to Emphasize: EMTs must evaluate the potential for spinal injury in order to choose the most appropriate method for opening an airway.
  23. Covers Objective: 9.9 Point to Emphasize: The head-tilt, chin-lift maneuver is used to open the airway of a patient who does not have a spinal injury.
  24. Covers Objective: 9.9 Talking Points: Do not apply pressure to the soft tissue of the lower jaw and do not allow the mouth to close. Discussion Topic: Describe the technique for opening an airway using a head-tilt, chin-lift technique.
  25. Covers Objective: 9.9 Point to Emphasize: The jaw-thrust maneuver is used to open the airway of a patient who has a potential spinal cord injury.
  26. Covers Objective: 9.9 Talking Points: You may need to retract the patient's lower lip with your thumb to keep the mouth open. Discussion Topics: Explain when it might be appropriate to employ a jaw-thrust maneuver instead of a head-tilt, chin-lift maneuver. Describe the technique for opening an airway using a jaw-thrust technique. Class Activity: Have students identify hand position for a jaw-thrust maneuver on the student seated next to them. Do not actually move the jaw, but have instructors confirm correct finger position. Critical Thinking: Consider a patient with a broken lower jaw. Given that he likely has a traumatic mechanism of injury, discuss how you might open his airway.
  27. Covers Objective: 9.9
  28. Covers Objective: 9.11 Knowledge Application: Have students describe various patient scenarios requiring airway management. In each case, have students decide on an appropriate method for opening the airway. Discuss.
  29. Teaching Time: 15 minutes Teaching Tips: This lesson is more than just practical skills. Teach the value of airway adjunct use. Assure proper supervision in practical skill stations. Imprint correct techniques early. Utilize the whole-part-whole technique of demonstrating practical skills. First, demonstrate the skill in its entirety. Next, break down the skill, discussing each step. Finally, demonstrate the skill in its entirety again.
  30. Covers Objective: 9.10 Point to Emphasize: Airway adjuncts may be used to assist initially in the opening of an airway and then used continually to help keep an airway open. Discussion Topic: Discuss when it might be appropriate to use an airway adjunct.
  31. Covers Objective: 9.10 Point to Emphasize: In adults, rotate the oral airway while inserting the airway adjunct so as to move the tongue out of the path of the adjunct.
  32. Covers Objective: 9.10
  33. Covers Objective: 9.10 Knowledge Application: Present a variety of airway scenarios. Ask students if they would utilize an adjunct and, if so, what type they would use. Discuss their choices.
  34. Covers Objective: 9.10
  35. Covers Objective: 9.10
  36. Covers Objective: 9.10 Point to Emphasize: Sizing of airway adjuncts is important. The principles are important, but so is the value of sizing adjuncts. Discussion Topic: Describe the technique for sizing an oropharyngeal airway. Knowledge Application: Ask students why sizing an airway adjunct is important. Discuss their answers.
  37. Covers Objective: 9.10 Point to Emphasize: Sizing of airway adjuncts is important. The principles are important, but so is the value of sizing adjuncts. Discussion Topic: Describe the technique for sizing an oropharyngeal airway. Knowledge Application: Ask students why sizing an airway adjunct is important. Discuss their answers.
  38. Covers Objective: 9.10
  39. Covers Objective: 9.10
  40. Covers Objective: 9.10
  41. Covers Objective: 9.10
  42. Covers Objective: 9.10
  43. Covers Objective: 9.10
  44. Covers Objective: 9.10
  45. Covers Objective: 9.10 Critical Thinking: What are the limitations of airway adjuncts? Describe a scenario in which the adjuncts might not protect the airway enough.
  46. Covers Objective: 9.10
  47. Covers Objective: 9.10 Critical Thinking: What are the limitations of airway adjuncts? Describe a scenario in which the adjuncts might not protect the airway enough.
  48. Covers Objective: 9.10
  49. Covers Objective: 9.10 Discussion Topic: Describe the procedure for inserting a nasopharyngeal airway. Class Activity: Using an airway manikin, demonstrate the proper sizing and insertion technique for both an oropharyngeal and a nasopharyngeal airway.
  50. Covers Objective: 9.10 Discussion Topic: Describe the procedure for inserting a nasopharyngeal airway. Class Activity: Using an airway manikin, demonstrate the proper sizing and insertion technique for both an oropharyngeal and a nasopharyngeal airway.
  51. Teaching Time: 15 minutes Teaching Tips: Link the decision to suction to assessment findings. Attempt to create reality-based decisions. Assure proper supervision in practical skill stations. Imprint correct techniques early.
  52. Covers Objective: 9.11 Point to Emphasize: Suctioning is the use of a vacuum device to remove foreign substances from the airway.
  53. Covers Objective: 9.13 Point to Emphasize: Both portable and mounted suction devices exist. Various types of tips and catheters enable suctioning under different circumstances. Discussion Topic: Compare and contrast the capabilities and limitations of portable suction devices compared to wall-mounted units. Knowledge Application: Tour an ambulance or a hospital. Identify the various types of suction devices.
  54. Covers Objective: 9.13 Point to Emphasize: Both portable and mounted suction devices exist. Various types of tips and catheters enable suctioning under different circumstances. Discussion Topic: Compare and contrast the capabilities and limitations of portable suction devices compared to wall-mounted units. Knowledge Application: Tour an ambulance or a hospital. Identify the various types of suction devices.
  55. Covers Objective: 9.13
  56. Covers Objective: 9.13 Point to Emphasize: Both portable and mounted suction devices exist. Various types of tips and catheters enable suctioning under different circumstances. Discussion Topic: Compare and contrast the capabilities and limitations of portable suction devices compared to wall-mounted units. Knowledge Application: Tour an ambulance or a hospital. Identify the various types of suction devices.
  57. Covers Objective: 9.13
  58. Covers Objective: 9.13
  59. Covers Objective: 9.12
  60. Covers Objective: 9.13
  61. Covers Objective: 9.13
  62. Covers Objective: 9.12
  63. Covers Objective: 9.13 Discussion Topic: Discuss the rules for suctioning. What are the key elements?
  64. Covers Objective: 9.13
  65. Covers Objective: 9.13
  66. Covers Objective: 9.13
  67. Covers Objective: 9.13 Point to Emphasize: Always use appropriate infection control practices while suctioning, and try to limit suctioning to no longer than ten seconds at a time. Critical Thinking: Your patient has a severe bleed in his throat. After ten seconds of suctioning, his airway is still filled with blood. What should you do?
  68. Covers Objective: 9.13 Discussion Topic: Describe the proper procedure for suctioning the airway. Class Activity: Using an airway manikin and appropriate, functioning suction equipment, demonstrate the proper technique for suctioning the airway.
  69. Video Clip Suctioning—Oral Pharyngeal Why is it necessary to test the equipment prior to using it? How far should the catheter be inserted? When should an EMT apply suction to the catheter? What should an EMT do after suctioning is complete? Discuss the necessity of maintaining a clear airway.
  70. Teaching Time: 15 minutes Teaching Tips: This section teaches humility. Encourage providers to recognize when they need help. Use a scenario-based approach. Keep this decision making process steeped in reality.
  71. Covers Objective: 9.7 Point to Emphasize: An EMT must understand his limitations, constantly evaluate for the need of further intervention, and know the availability of advanced resources. Discussion Topic: Describe airway-related circumstances in which advanced intervention is necessary.
  72. Covers Objective: 9.7 Discussion Topic: Considering the situations for which definitive care is needed, discuss the types of local resources that would be available to provide advanced intervention. Knowledge Application: To put it all together, divide the class into small groups. Assign each group a scenario that includes assessing, opening, and clearing an airway. Ask each group to evaluate the need for advanced intervention. Discuss. Critical Thinking: The closest paramedic intercept is 18 minutes away. The closest hospital is 18 minutes away. Which would be the more appropriate source of advanced care, and why?
  73. Talking Points: Many airways will need more advanced intervention. Advanced care could come in the form of an ALS intercept or could be obtained by transporting to the nearest hospital.
  74. Teaching Time: 15 minutes Teaching Tips: Multimedia graphics of facial injuries may enhance comprehension of special ventilatory circumstances. Have pediatric anatomy models on hand to describe differences. Demonstrate pediatric-specific airway equipment.
  75. Covers Objective: 9.14 Point to Emphasize: Facial injuries may impair breathing and alter the procedure for opening the airway. Discussion Topic: Explain how a facial injury or airway obstruction might alter the traditional methods of airway management. Knowledge Application: Provide examples of facial injuries (and/or show graphics) and discuss methods to properly assess and manage the airway. Specifically highlight how such injuries might alter normal procedures.
  76. Covers Objective: 9.14 Point to Emphasize: Airway obstructions require immediate procedures to clear the airway.
  77. Covers Objective: 9.14 Point to Emphasize: Dental appliances should be left in place, but they potentially can threaten airway management. If they interfere with the airway, they should be removed.
  78. Covers Objective: 9.14 Point to Emphasize: Pediatric patients often are anatomically different from adults; thus, they may require specialized equipment and different airway management techniques. Discussion Topic: Describe examples of pediatric airway anatomy (or pediatric anatomy in general) that might require pediatric-specific management techniques.
  79. Covers Objective: 9.14
  80. Covers Objective: 9.14 Knowledge Application: Divide the class into small groups. Assign each group a "special consideration" such as a facial injury, a pediatric patient, dentures, and the like. Have the group discuss the potential challenges, improvise a solution, and present its findings to the class. Critical Thinking: You are caring for a child who needs an airway adjunct and suctioning. You have only adult-sized equipment. Discuss the steps that you would take to care for this child's airway. How might you adapt?
  81. Talking Points: The airway begins at the nose and mouth, continues through the oropharynx, nasopharynx, and hypopharynx, and then enters the lower airway via the glottic opening and travels through the lungs through the right and left bronchi and bronchiole tubes. The airway terminates at the alveoli. The airway is the first priority of care because without oxygen, death is assured. Signs of an inadequate airway include inability to speak, stridor, no air movement, and gurgling.
  82. Talking Points: The head-tilt, chin-lift causes the neck and c-spine to move. The jaw-thrust minimizes neck movement. Adjuncts help create a channel for air into the lungs. They help direct air to the proper place. Suctioning clears liquids out of the path of air and prevents aspiration of those liquids into the lungs.
  83. Talking Points: Gurgling indicates suctioning. Other necessary treatments include position, insertion of an airway adjunct, and positive pressure ventilation.
  84. Talking Points: Stridor indicates a partially obstructed airway. Immediate concerns include the fact that this airway is threatened and could become completely obstructed.
  85. Talking Points: Snoring indicates at a minimum, airway impedance, and at its worst, poor muscle control of the airway. Typically better positioning and/or insertion of an airway adjunct will resolve this problem.