Alexander ch16 lecture

Copyright © 2017, 2012 Pearson Education, Inc. All Rights Reserved.
Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 16
Airway
Management,
Ventilation, and
Oxygenation

• Applies knowledge of upper airway anatomy
and physiology to patient assessment and
management in order to ensure a patent airway,
adequate mechanical ventilation, and respiration
for patients of all ages.
Advanced EMT
Education Standard

1. Define the key terms introduced in this chapter.
2. Relate the anatomy and physiology of the respiratory
system to oxygenation, perfusion, and removal of
carbon dioxide.
3. Give examples of complaints and conditions that are
associated with risk of hypoxia and hypoventilation.
4. Relate findings from the assessment of the airway
and ventilation to the patient’s need for interventions
in airway, ventilation, and respiration.
5. Recognize signs and symptoms of mild, moderate,
and severe hypoxia.
Objectives (1 of 4)

6. Distinguish between adequate and inadequate breathing.
7. Use patient monitoring technology to guide decisions
regarding management of airway, ventilation, and
respiration.
8. Demonstrate the proper technique of auscultating
breath sounds.
9. Describe the pathophysiological mechanisms
associated with specific abnormal breathing sounds.
10.Identify the different presentations and needs of
pediatric and geriatric patients with regard to airway,
ventilation, and respiration.
Objectives (2 of 4)

11.Take immediate action to correct impaired airway,
ventilation, and respiration.
12.Utilize manual positioning and suction (portable and
fixed devices) to keep the airway clear in intubated and
nonintubated patients.
13.Given a variety of scenarios, select and insert
appropriate basic and advanced airway devices.
14.Employ appropriate safety precautions when handling,
transporting, and administering oxygen.
15.Administer supplemental oxygen via devices suited to the
individual patient’s needs.
Objectives (3 of 4)

16.Describe the concept of positive end-expiratory
pressure (PEEP).
17.Ventilate or assist the ventilations of patients using
the ventilation equipment best suited to the individual
patient’s needs.
18.Modify techniques of managing airway and ventilation,
and administering supplemental oxygen for patients
with conditions that make standard approaches difficult
or ineffective.
19.Discuss the physiologic differences, including potential
complications, of artificial ventilation compared to
normal ventilation.
Objectives (4 of 4)

• Function of respiratory system
– Obtain oxygen needed for cell metabolism; eliminate
carbon dioxide produced by cell metabolism
• Ventilation
– Mechanical process of moving air in and out of
the lungs
– Requires a patent airway
Introduction (1 of 4)

• Respiration
– Gas exchange across the alveoli into the capillaries.
– Each gas diffuses for an area of higher concentration to
lower concentration.

• Problem with any aspect of ventilation or
respiration can quickly result in death.
– Compensatory ability is limited
– Must be corrected
• AEMTs skilled in variety of techniques from
simple and noninvasive to more complex.

• Airway and ventilatory management requires
providers to use clinical judgment and critical
thinking.
• Consider
– Patient’s condition
– Amount and type of help available
– Factors that may complicate situation
– Short-term intervention versus long-term solution

Figure 16-1
Ventilation is required for external and internal respiration.

Think About It
• How would you describe your general impression
of the patient?
• What evidence supports your description?
• What does the evidence indicate should be Brian
and Tiffany’s first action?

• What additional information do you need about
this patient?
• How will Brian and Tiffany integrate the need to
collect further information with the need to treat
and transport the patient?
Think About It

Anatomy and Physiology Review (1 of
10)
• External respiration
– Oxygen and carbon dioxide exchanged across
respiratory membrane (alveolar and pulmonary
capillary walls)
• Internal respiration
– Exchange of oxygen and carbon dioxide between
blood and cells

10)
• Physiology of air movement
– Ventilation
 controlled by levels of carbon dioxide (CO2) and oxygen (O2)
in blood and cerebrospinal fluid (CSF).
– Chemoreceptors
 signal inspiratory center in medulla oblongata of brainstem
when carbon dioxide levels increase or oxygen levels
decrease.

10)
• Physiology of air movement (continued)
– Inspiratory center stimulates contraction of diaphragm
and intercostal muscles
 Increases volume of thoracic cavity and lungs
 Air flows from higher atmospheric pressure to lower
intrapulmonary pressure

10)
• Physiology of air movement (continued)
– Stretch receptors in lungs send signals that terminate
inspiration, and in response diaphragm and intercostal
muscles relax (Hering-Breuer reflex).
 Volume of chest and lungs decreases.
 Pressure within lungs increases.
 Air flows from higher (intrapulmonary) pressure to lower
(atmospheric) pressure.

Figure 16-3
Anatomy of the upper airway.

10)
• Upper airway
– Structures above glottis.
– Mouth and nose.
– Pharynx at nasopharynx.
– Hypopharynx (laryngopharynx).
– Oral cavity, oropharynx, hypopharynx provide
passageway for digestive and respiratory systems.

10)
• Upper airway (continued)
– Epiglottis
– Gag reflex
– Cough reflex

10)
• Upper airway (continued)
– Degree of muscle tone required to keep tongue from
relaxing and falling into pharynx.
– Basic airway adjuncts
 Oropharyngeal and nasopharyngeal
• What is the most common cause of airway
obstruction?

Figure 16-5
Anatomy of the lower airway.

10)
• Lower airway
– Begins at glottic opening into trachea.
– Trachea bifurcates.
 right and left bronchus at the carina.
– Bronchi divide and become bronchioles.
– Alveoli.

10)
• Gas exchange
– External expiration
– Internal respiration
– Ventilation-perfusion (VQ) mismatch

10)
• Ventilation
– Alveolar ventilation
– Tidal volume
– Minute volume
– Dead space air
• When tidal volume decreases, volume of dead
space remains constant at expense of alveolar
ventilation.

Pathophysiology of the Airway,
Ventilation, and Oxygenation (1 of 3)
• Upper airway problems
– Decreased level of responsiveness.
– Foreign body airway obstruction.
– Active bleeding, blood clots, direct injury to airway
structures.

Table 16-1
Abnormal Respiratory Sounds
Sound Description Significance
Snoring Harsh, vibrating, rattling sound that may be
soft or loud
Partial obstruction of the upper airway by the
tongue
Gurgling Liquid, bubbling sound Fluid in the upper airway
Stridor Harsh inspiratory sound Partial upper airway obstruction; may indicate
laryngeal edema, foreign body airway
obstruction, or epiglottitis
Coughing Spasmodic forceful air expulsion that may
sound “dry” or “wet”
Irritation of the respiratory mucosa from infection
or Irritants
Wheezing Whistling, musical sound of the lower airways,
often heard on expiration but can be heard on
inspiration
Narrowing of the bronchioles from edema or
Bronchoconstriction
Crackles (rales) Fine bubbling, crackling sounds heard in the
lower airways
Fluid in the alveoli and lower airways
Rhonchi Coarse, liquid lower airway sound Secretions in the bronchi

• Lower airway problems
– Bronchoconstriction
 From inflammation and bronchospasm
– Fluid or pus in alveoli and bronchioles
 Such as pulmonary edema or pneumonia

• Ventilation problems
– Trauma or problem that interferes with ability to move
chest wall or diaphragm.
 Paralysis of respiratory muscles
 Trauma
 Drug overdose
 Respiratory disease

• Every patient’s airway should be evaluated in
scene size-up and primary assessment.
• Evaluate, identify, and correct life threats to
airway, ventilation, or oxygenation.
• Obtain additional information in the secondary
assessment and history.
Assessment of the Airway,

• Scene size-up (patients evaluated for airway,
ventilation, and oxygenation)
– General impression
– Responsive or unresponsive
– Indications of injury or distress

• Scene size-up (continued)
– Severe respiratory distress
 Increased effort to breathe, use of accessory muscles,
abnormal breath sounds, tripod position, and cyanosis
– Responsive patient
 Determine chief complaint
 Quality of patient’s speech

• Primary assessment
– Apparently unresponsive patient
 Cyanotic or mottled
 No respiratory effort or agonal breathing
 Check carotid pulse
 Cardiac arrest; begin chest compressions
 Sleeping, intoxicated, suffering from medical or traumatic
problems
– May respond to loud voice or painful stimulus

Figure 16-8
A modified jaw-thrust maneuver. (© Daniel Limmer)

• Primary assessment (continued)
 Assess airway; evaluate breathing and circulation
 Cervical-spine injury not suspected, use head-tilt/chin-lift
maneuver
 Suspected cervical-spine injury, use modified jaw-thrust
maneuver
 Trauma chin lift

Scan 16-1 (1 of 6)
Assessing and Managing the Airway—Unresponsive Patient
1. Move the patient to the floor.

Scan 16-1 (2 of 6)
2. Open the airway.

Scan 16-1 (3 of 6)
3. Suction if necessary.

Scan 16-1 (4 of 6)
4. Insert an oral airway if the patient is responsive without a gag reflex.

Scan 16-1 (5 of 6)
5. Ventilate the patient if not breathing or breathing inadequately.

Scan 16-1 (6 of 6)
6. Administer oxygen if the patient is breathing adequately but has indications of hypoxia.

 If airway contains fluid (blood or vomit), suction airway
to clear it.
 Airway adjunct (oropharyngeal/nasopharyngeal) inserted
at this point, if patient deeply unresponsive.
 To assess breathing
– Look, listen, feel
 Breathing inadequate or absent, use bag-valve-mask device
or artificial ventilation.
 Ventilations obstructed and repositioning airway does not
help, suspect foreign body obstruction.

– Responsive patient
 Look and listen to assess airway and breathing.
 Significant sign of hypoxia is decreasing level of
responsiveness.
 Look for indications of respiratory distress.

Table 16-2
Findings That Indicate Inadequate Breathing
 Increased work of breathing/use of accessory muscles
 Noisy breathing (stridor, snoring, gurgling, wheezing, crackles [rales])
 Decreased or absent air movement or breath sounds
 Apnea/respiratory arrest
 Ventilatory rate < 8 or > 30 per minute in an adult
 An SpO2 of less than 95 percent
 Irregular breathing
 Cyanosis

– Clinical decision making
 Goal of primary assessment
– Identify and intervene in situations that pose immediate
threat to life
 Best approach to managing patient’s airway
– Moving from simple to complex
 Complaint of dyspnea or impaired ventilation and oxygenation
must receive supplemental oxygen.
 Determine possibility of respiratory distress or respiratory
failure.
 Decreasing level of responsiveness is threat to patency of
airway.

Figure 16-10
Clinical decision making in airway and ventilation management.

• Secondary assessment and reassessment
– Specific respiratory rate and patterns.
– Normal adult respiratory rate
 12 to 20 per minute
– Auscultate breath sounds
– Pulse oximetry
 assesses oxygen saturation of hemoglobin in peripheral
tissues.
 maintain SpO2 of 95% or higher by administering oxygen.

Table 16-3
Normal and Abnormal Respiratory Patterns
Condition Description Causes
Eupnea Normal breathing rate and pattern
Tachypnea Increased respiratory rate Fever, anxiety, exercise, shock
Bradypnea Decreased respiratory rate Sleep, drugs, metabolic disorder, head
injury, stroke
Apnea Absence of breathing Deceased patient, head injury, stroke
Hyperpnea Normal rate but deep respirations Emotional stress, diabetic ketoacidosis
Cheyne-Stokes
respirations
Gradual increases and decreases in
respirations with periods of apnea
Increasing intracranial pressure,
brainstem injury
Biot’s
respirations
Rapid, deep respirations (gasps)
with short pauses between sets
Spinal meningitis, many CNS causes,
head injury
Kussmaul’s
respirations
Tachypnea and hyperpnea Renal failure, metabolic acidosis,
diabetic Ketoacidosis
Apneustic
respirations
Prolonged inspiratory phase with
shortened expiratory phase
Lesion in brainstem
Source: Bledsoe, B. E., R. S. Porter, R. A. Cherry. Intermediate Emergency Care: Principles and Practice, 1st
Edition, © 2004. Reprinted with permission of Pearson Education, Inc., Upper Saddle River, NJ.

Figure 16-12
A pulse oximeter. (© Edward T. Dickinson, MD)

Figure 16-13
An electronic capnography device.

(continued)
– Capnometry
 Measurement of carbon dioxide in exhaled air
 Normal capnometry value 35 to 45 mmHg
– Capnography
 Provides a waveform of the changes in carbon dioxide

(continued)
– Peak expiratory flow rate (PEFR)
 Measurement of maximal flow rate of air during expiration
– Compare ongoing findings to baseline values obtained
in primary and secondary assessments.

• Case study
– What is the best approach to correcting the patient’s
hypoxia?
– What are the pros and cons of different options
available for treating the patient?
– How should you prioritize the various actions needed?
Think About It

Figure 16-16
Left lateral recumbent (recovery) position.

Airway Management (1 of 16)
• Positioning and manual maneuvers
– Sitting or lateral recumbent position
 Prevents aspiration
– Head-tilt/chin-lift maneuver
 Lines up internal structures of airway; prevents obstruction
of glottic opening
– Modified jaw-thrust maneuver
 Opens airway in patients with suspected spine injury

• Removing foreign bodies/fluids from airway
– Blood
– Vomit
– Secretions
– Broken teeth
– Food
– Other objects

• Removing foreign bodies/fluids from
airway (continued)
– Noisy breathing
 Partial airway obstruction
– Harsh, crowing sound of stridor
 Upper airway obstruction
– Localized wheezing in one lung
 Partial airway obstruction in bronchus
– Bubbling or gurgling noises
 Fluid in airway

airway (continued)
– Position patient on his side.
– Use gloved hand to sweep matter out of airway.
– Suctioning may help after large debris and copious
amounts of fluid removed manually.

airway (continued)
– Foreign body airway obstruction (FBAO).
– Partial obstruction allows some air to pass.
– Complete obstruction prevents air movement
altogether.
– Patient with mild FBAO may be coughing, but will have
air movement.
– Poor air exchange
– Cyanosis
– Inability to speak or breathe

airway (continued)
– Do not interfere with coughing and breathing efforts of
patient with mild FBAO.
– Conscious patient with severe FBAO, use repeated
abdominal thrusts to clear obstruction.
– If patient becomes unresponsive, lower to ground and
begin CPR.

airway (continued)
– Allow pediatric patient to clear his own airway by
coughing.
– Conscious child with severe FBAO, perform
subdiaphragmatic abdominal thrusts in same manner
that you would use for an adult.
– If child becomes unresponsive, perform 30 chest
compressions, then open airway using head-tilt/chin-lift
or modified jaw-thrust maneuver.

Figure 16-22 (1 of 2)
(A) Foreign body airway obstruction relief in an infant: chest thrusts.

Figure 16-22 (2 of 2)
(B) Foreign body airway obstruction relief in an infant: back blows.

airway (continued)
– Conscious infant, use combination of back blows and
chest thrusts.
– Do not use abdominal thrusts on infant.
– Infant unconscious, use same procedure as for
unconscious child with severe FBAO.

airway (continued)
– Suction
 Vacuum to remove liquids from airway.
– Rigid suction catheters (Yankauer)
 Used to suction oropharynx.
– Soft catheters (French)
 Used for suctioning trachea.
– Do not delay suctioning, if patient is in immediate
jeopardy of aspirating fluids into airway.

airway (continued)
– Suction risks
 Causing or worsening hypoxia
 Trauma to oropharynx
 Stimulating gag reflex
 Inducing bradycardia through stimulation of hypopharynx
– Use gloves and eye protection as minimum PPE.

Scan 16-4 (1 of 5)
Oral Suctioning
1. Move the patient to the lateral recumbent position.

Scan 16-4 (2 of 5)
Oral Suctioning
2. Make sure the suction unit is properly assembled.

Scan 16-4 (3 of 5)
Oral Suctioning
3. Measure the catheter from the corner of the patient’s mouth to the earlobe.

Scan 16-4 (4 of 5)
Oral Suctioning
4. Open the patient’s mouth and insert the catheter.

Scan 16-4 (5 of 5)
Oral Suctioning
5. Apply suction as you withdraw the catheter.

• Suctioning the lower airway
– Patients who have endotracheal tube or tracheostomy
tube occasionally require suction to clear trachea of
secretions.
– Use a soft suction catheter.

Scan 16-5 (1 of 8)
Tracheal Suctioning of an Intubated Patient
1. If possible, preoxygenate the patient prior to suctioning. If copious secretions are
preventing ventilation and oxygenation, suction them immediately.

Scan 16-5 (2 of 8)
2. Assemble and check the suction equipment. Maintain sterility of the flexible suction
catheter by keeping it covered with the packaging.

Scan 16-5 (3 of 8)
3. While maintaining the sterility of the suction catheter, measure the suction catheter from
the earlobe, around the top of the ear, and down the neck to the sternal notch.

Scan 16-5 (4 of 8)
4. Use a sterile glove to handle the suction catheter.

Scan 16-5 (5 of 8)
5. Insert the suction catheter into the endotracheal tube to the measured depth without
applying suction.

Scan 16-5 (6 of 8)
6. Cover the side port and apply suction as you slowly withdraw the catheter using a
twisting motion. Monitor SpO2 and cardiac rhythm while suctioning.

Scan 16-5 (7 of 8)
7. Limit suctioning to 10 seconds. Ventilate the patient before suctioning again. If suctioning
is to be repeated, suction sterile water through the catheter to clear it.

Scan 16-5 (8 of 8)
8. Dispose of the used suction catheter by wrapping it around your gloved hand.
Turn the glove inside out as you remove it. Dispose of the glove and catheter in a
biohazardous waste bag.

Figure 16-25
Oropharyngeal airways come in a variety of sizes, from neonatal to large adult.
(© Edward T. Dickinson, MD)

• Airway adjuncts
– Oropharyngeal (oral) airway
 Curved device used to displace soft tissue of tongue to
provide channel for air to flow through oropharynx.
 Proper oropharyngeal airway size essential to effectiveness.

Scan 16-6 (1 of 6)
Inserting an Oropharyngeal Airway
1. 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 …

Scan 16-6 (2 of 6)
2. … or it measures from the corner of the patient’s mouth to the tip of the earlobe.

Scan 16-6 (3 of 6)
3. Use the crossed-fingers technique to open the patient’s mouth.

Scan 16-6 (4 of 6)
4. Insert the airway with the tip pointing to the roof of the patient’s mouth.

Scan 16-6 (5 of 6)
5. Rotate the airway 180 degrees into position. When it is positioned properly, the flange
should rest against the patient’s mouth.

Scan 16-6 (6 of 6)
6. After proper insertion of the oropharyngeal airway, the patient is ready for ventilation.

Figure 16-26
Nasopharyngeal airways.

• Airway adjuncts (continued)
– Nasopharyngeal (nasal) airways used in patients when
access to oropharynx is impossible.
– Sizing essential; always lubricate.
– Avoid inserting in patients with severe head or midface
trauma, or basilar skull fracture.

Scan 16-7 (1 of 4)
Inserting a Nasopharyngeal Airway
1. Measure the nasopharyngeal airway.

Scan 16-7 (2 of 4)
2. Lubricate it with water-soluble lubricant.

Scan 16-7 (3 of 4)
3. Insert the airway with the bevel toward the septum or base of the tonsil.

Scan 16-7 (4 of 4)
4. Advance the airway until the flange is seated against the patient’s nostril.

Figure 16-27
An esophageal tracheal Combitube.

• Combitube and supraglottic airway devices
– Nonvisualized airways or blind insertion devices
– Relatively easy to use
– Can be inserted quickly
– Some protection from aspiration
– Follow local protocol

• Combitube and supraglottic airway
devices (continued)
– Esophageal tracheal combitube
 Obstructs esophagus and pharynx so that air enters trachea.
 Unlikely event it enters trachea, combitube can still function.

Figure 16-28
King LTD airway. (© Edward T. Dickinson, MD)

• Combitube and supraglottic airway
devices (continued)
– Supraglottic device inserted into hypopharynx
– Creates seal around glottic opening; pressure applied
to force air into trachea
– Laryngeal Mask Airways (LMA), King LTD, and Cobra
devices

Table 16-4
Indications and Contraindications for Advanced
EMT Airway Devices
Combitube Laryngeal
Mask Airway
King LTD
Indications Contraindications Indications Contraindications Indications Contraindications
Patient is
unresponsive
without a gag
reflex and
requires a
more secure
airway and
route of
ventilation
than can be
provided by
more basic
means.
Patient under 5 feet
tall (a small adult
size exists and can
be used in patients
between 4½ to 5
feet tall).
Patient under
16 years old.
Presence of
esophageal disease
or trauma.
Laryngectomy with
stoma.
Patient is
unresponsive
without a gag
reflex and
requires a more
secure airway
and route of
ventilation than
can be provided
by more basic
means.
No contraindications
for use as a rescue
airway in patients
who are completely
unresponsive and do
not have a gag
reflex
Laryngectomy with
stoma.
Patient is
unresponsive
without a gag
reflex and requires
a more secure
airway and route
of ventilation than
can be provided
by more basic
means.
Patient under
4 feet tall.
Laryngectomy with
stoma.

Figure 16-29
Continuous positive airway pressure (CPAP) device.

Ventilation (1 of 8)
• Once airway secured, assess need for artificial
ventilation.
• CPAP assists patient approaching respiratory
failure; may improve oxygenation enough to avoid
intubation.

• Respiratory distress
– Supplemental O2 guided by pulse ox
• Severe respiratory distress, failure, or arrest
– Supplement spontaneous respiratory effort, or provide
artificial ventilation

• Positive pressure ventilation
– Normal breathing
 Inspiration generated by negative intrathoracic pressure.
– Artificial ventilation devices move air into lungs under
increased pressure (positive pressure ventilation).

• Positive pressure ventilation (continued)
– CPAP
– Bag-valve-mask devices with supplemental oxygen
– Manually triggered ventilation devices
– Automatic transport ventilators
• Apnea and respiratory failure quickly result in
death.

Figure 16-30
(A) Bag-valve-mask device with oxygen bag reservoir. Tubing-type reservoirs are also
available. (B) Adult, child, and infant bag-valve-mask devices.

Figure 16-33
Two-provider bag-valve-mask ventilation technique.

• Bag-valve-mask ventilations
– Self-inflating bag attached to mask creates seal
around patient’s mouth and nose and has reservoir
for collecting oxygen.
– Adult, pediatric, infant, neonatal sizes.
– Requires that patient’s airway is open.
– Mask covers face from bridge of nose to depression
between lower lip and tip of chin with sufficient
coverage of mouth.
– Ventilate at appropriate depth and appropriate rate.

Table 16-5
Indications of Effective and Ineffective Positive
Pressure Ventilation
Adequate Ventilation Inadequate Ventilation
Good seal of mask to the face, mask covers the
mouth and nose.
Air leaks around the face mask during ventilation.
Tidal volume is appropriate to patient; each
ventilation delivered over about 1½ seconds until
patient’s chest just begins to rise.
There is excessive chest rise, no chest rise, or abdominal
distention.
Ventilation rate is appropriate to patient’s age:
10–12 per minute for adults, 12–20 per minute
for pediatric patients, > 20 per minute for infants.
Ventilation rate is too fast or too slow for the patient’s age.
Air flows into the lungs with slight resistance. There is no resistance to airflow (check connections and
seals) or significant/increasing resistance to airflow (check for
airway position and gastric distention; check breath sounds).
Patient’s condition stabilizes or improves. Patient’s condition fails to improve or deteriorates (check
mental status, skin color, breath sounds, vital signs, and
SpO2 and CO2 levels).

Figure 16-36
A flow-restricted oxygen-powered ventilation device (FROPVD).

• Manually triggered ventilation devices
– Deliver positive pressure without provider needing to
squeeze a bag.
– Operator sets rate and volume of ventilations.
– Uses power of compressed oxygen to deliver
ventilations.

• Automatic transport ventilators
– Patient requiring bag-valve-mask ventilation.
– Delivered by device in hands-free operation.
– Operator sets rate and volume of ventilations.

• Continuous positive airway pressure (CPAP)
– Positive pressure to improve air flow in spontaneously
breathing patients.
– Useful in acute pulmonary edema.
– Positive end-expiratory pressure (PEEP).
– Not mechanical ventilation; not a ventilator.
– Used to improve ventilations already taking place; only
in patients responsive and able to follow commands.

Think About It
• Mask seal is essential to effective bag-valve-mask
treatment.
• Choose the appropriately sized mask.
• Obtain a mask seal and maintain proper airway
position.
– Single provider—“E-C” grip
– Two providers—one maintains mask and modified jaw
thrust; other ventilates.

Oxygenation (1 of 10)
• All patients with complaints of dyspnea or who are
in respiratory distress, failure, or arrest should
receive supplemental oxygen.
• Beneficial to patients with SpO2 less than 95%.

Scan 16-8 (1 of 12)
Administering Oxygen
1. Select the desired cylinder. Check for label “Oxygen U.S.P.”

Scan 16-8 (2 of 12)
2. Place the cylinder in an upright position and then stand to one side.

Scan 16-8 (3 of 12)
3. Remove the plastic wrapper or cap protecting the cylinder outlet. Keep the plastic
washer (some setups).

Scan 16-8 (4 of 12)
4. “Crack” the main valve for one second.

Scan 16-8 (5 of 12)
5. Select the correct pressure regulator and flow meter. A pin yoke for portable tanks
is shown.

Scan 16-8 (6 of 12)
6. Tighten the T-screw for the pin yoke.

Scan 16-8 (7 of 12)
7. Align the pins.

Scan 16-8 (8 of 12)
8. Explain to the patient the need for oxygen.

Scan 16-8 (9 of 12)
9. Attach the tubing and delivery device.

Scan 16-8 (10 of 12)
10. Open the main valve.

Scan 16-8 (11 of 12)
11. Adjust the flow meter.

Scan 16-8 (12 of 12)
12. Place an oxygen delivery device on the patient.

• Oxygen is a medication.
– Administer according to indications by acceptable
routes in approved dosages.
• Side effects and mechanisms of action:
– As vasoactive drug, can decrease perfusion to
ischemic tissues.
– Hyperoxia increases morbidity and mortality in
resuscitation from cardiac arrest.

• Oxygen administration can dry and irritate
mucous membranes.
• Never withhold oxygen from patient who needs it.
– Use caution with COPD patients since they breathe
primarily on the hypoxic drive but do not withhold
oxygen from a patient that needs it.

Table 16-6
Indications for Administration of Oxygen
 Cardiac or respiratory arrest
 Respiratory distress or respiratory failure
 Any patient requiring assisted ventilations
 Inadequate tidal volume
 Respiratory rate < 8 or > 30
 SpO2 less than 95 percent
 Patient has an altered mental status/decreased level of responsiveness
 Patient complains of difficulty breathing/shortness of breath
 Patient complains of chest pain
 Other medical conditions that can cause hypoxia, such as seizures, stroke, overdose,
toxic inhalation, and wheezing
 Signs and symptoms of shock or severe internal or external bleeding
 Major or multiple trauma

• Oxygen equipment
– Supplied in small portable tanks (cylinders)
– Pressurized oxygen passes through regulators;
pressure regulator adjusts 2,000 psi pressure
– Flow meter connected to regulator to allow for
adjustment of oxygen flow to patient.
– Oxygen cylinder green or silver with green band;
labeled that it contains oxygen; accepts only oxygen
regulator.

• Oxygen safety
– Oxygen enhances combustion when exposed to fire.
– Oxygen is a pressurized gas.
– Petroleum products can react with oxygen.
• What are some of the safety precautions you
should take with oxygen and fire exposure?

Figure 16-38 (1 of 2)
(A) A nonrebreather mask.

Figure 16-38 (2 of 2)
(B) Cutaway view of a nonrebreather mask.

• Oxygen delivery devices (nonrebreather mask)
– Delivery of high-flow oxygen, high concentrations
of oxygen.
– Reservoir bag and flaps act as one-way valves to direct
both oxygen flow and patient’s exhaled air.
– Near 100% oxygen on 15 LPM.

Table 16-7
Comparison of Oxygen Delivery Devices
Device Flow Rate (in L/min) Oxygen Concentration
Delivered
Nasal cannula 1–6 (rates over 4 L/min are irritating to nasal
mucosa; usual prehospital flow rate is 2 to 4 L/min)
24–44 percent
Simple face mask 6–10 35–60 percent
Venturi mask 4–8 25–60 percent
Partial rebreather mask 5–10 40–60 percent
Nonrebreather mask 10–12 (flow rate must be adequate to keep
reservoir bag inflated)
95 percent
Bag-valve-mask device 12–15 >95 percent

• Oxygen delivery devices (nonrebreather mask)
(continued)
– Adequate ventilations, but need high-flow oxygen, high
concentration of oxygen.
– Patient may feel suffocated by having something
placed over mouth and nose.

Figure 16-39 (1 of 2)
(A) A nasal cannula.

Figure 16-39 (2 of 2)
(B) Cutaway view of a nasal cannula.

• Oxygen delivery devices (nasal cannula)
– Oxygen tubing that resembles lasso; two short prongs
that are placed in nares to deliver oxygen.
– Low-flow device
 Provides 24–44% oxygen at a rate of 4–6L/min
– Patient must be able to breathe through nose.

Figure 16-40
A Venturi mask.

• Oxygen delivery devices (Venturi masks)
– Designed to mix specific amounts of ambient air
and oxygen to achieve specific, relatively low
concentrations of oxygen.
– Either have an adjustable port or interchangeable
fittings to deliver different oxygen concentration.

• Oxygen delivery devices (Venturi mask)
(continued)
– Simple face mask
 Does not have one-way valves or reservoir bag; delivers
lower concentrations of oxygen (6–10L/min)
– Tracheostomy mask
 Supplemental oxygen to patients who have tracheostomy
tube or stoma and who do not require positive ventilation
(8–10L/min)

Chapter Summary (1 of 4)
• Without adequate airway, ventilations, or
oxygenation, body cannot perform normal
cellular metabolism.
• Without adequate internal and external
respiration, hypoxia quickly ensues.
• Ensure patient has open airway, adequate
ventilation, and adequate oxygenation.
• Immediate problems with airway and breathing
addressed in primary assessment.

• Variety of manual airway maneuvers and basic
airway adjuncts, FBAO maneuvers, suction,
oxygen, bag-valve-mask devices to restore and
maintain airway, ventilation, oxygenation.
• May use Combitube, supraglottic airway,
FROPVD, CPAP, ATV to assist in airway
management and ventilation.

• Finding correctable underlying cause for impaired
airway and breathing preferable to continued
airway management.
• Alert patient can protect airway better than you
can protect it with mechanical devices.

• Ensure you are applying techniques correctly to
minimize complications.
• Goal of airway management, positive pressure
ventilation, oxygen administration is to prevent
hypoxia.
• Always use the findings of patient assessment
and clinical judgment to treat patient.

Alexander ch16 lecture

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