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Airway management part 1

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Airway management part 1

  1. 1. Airway Management Part 1 EMS Professions Temple College
  2. 2. Topics for Discussion <ul><li>Airway Maintenance Objectives </li></ul><ul><li>Airway Anatomy & Physiology Review </li></ul><ul><li>Causes of Respiratory Difficulty & Distress </li></ul><ul><li>Assessing Respiratory Function </li></ul><ul><li>Methods of Airway Management </li></ul><ul><li>Methods of Ventilatory Management </li></ul><ul><li>Common Out-of-Hospital Equipment Utilized </li></ul><ul><li>Advanced Methods of Airway Management and Ventilation </li></ul><ul><li>Risks to the Paramedic </li></ul>
  3. 3. Objectives of Airway Management & Ventilation <ul><li>Primary Objective: </li></ul><ul><ul><li>Ensure optimal ventilation </li></ul></ul><ul><ul><ul><li>Deliver oxygen to blood </li></ul></ul></ul><ul><ul><ul><li>Eliminate carbon dioxide (C0 2 ) from body </li></ul></ul></ul><ul><li>Definitions </li></ul><ul><ul><li>What is airway management ? </li></ul></ul><ul><ul><li>How does it differ from spontaneous, manual or assisted ventilations ? </li></ul></ul>
  4. 4. Objectives of Airway Management & Ventilation <ul><li>Why is this so important? </li></ul><ul><ul><li>Brain death occurs rapidly; other tissue follows </li></ul></ul><ul><ul><li>EMS providers can reduce additional injury/disease by good airway, ventilation techniques </li></ul></ul><ul><ul><li>EMS providers often neglect BLS airway, ventilation skills </li></ul></ul>
  5. 5. Airway Anatomy Review <ul><li>Upper Airway Anatomy </li></ul><ul><li>Lower Airway Anatomy </li></ul><ul><li>Lung Capacities/Volumes </li></ul><ul><li>Pediatric Airway Differences </li></ul>
  6. 6. Anatomy of the Upper Airway
  7. 7. Upper Airway Anatomy <ul><li>Functions: warm, filter, humidify air </li></ul><ul><li>Nasal cavity and nasopharynx </li></ul><ul><ul><li>Formed by union of facial bones </li></ul></ul><ul><ul><li>Nasal floor towards ear not eye </li></ul></ul><ul><ul><li>Lined with mucous membranes, cilia </li></ul></ul><ul><ul><li>Tissues are delicate, vascular </li></ul></ul><ul><ul><li>Adenoids </li></ul></ul><ul><ul><ul><li>Lymph tissue - filters bacteria </li></ul></ul></ul><ul><ul><ul><li>Commonly infected </li></ul></ul></ul>
  8. 8. Upper Airway Anatomy <ul><li>Oral cavity and oropharynx </li></ul><ul><ul><li>Teeth </li></ul></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><ul><li>Attached at mandible, hyoid bone </li></ul></ul></ul><ul><ul><ul><li>Most common airway obstruction cause </li></ul></ul></ul><ul><ul><li>Palate </li></ul></ul><ul><ul><ul><li>Roof of mouth </li></ul></ul></ul><ul><ul><ul><li>Separates oropharynx and nasopharynx </li></ul></ul></ul><ul><ul><ul><li>Anterior= hard palate; Posterior= soft palate </li></ul></ul></ul>
  9. 9. Upper Airway Anatomy <ul><li>Oral cavity and oropharynx </li></ul><ul><ul><li>Tonsils </li></ul></ul><ul><ul><ul><li>Lymph tissue - filters bacteria </li></ul></ul></ul><ul><ul><ul><li>Commonly infected </li></ul></ul></ul><ul><ul><li>Epiglottis </li></ul></ul><ul><ul><ul><li>Leaf-like structure </li></ul></ul></ul><ul><ul><ul><li>Closes during swallowing </li></ul></ul></ul><ul><ul><ul><li>Prevents aspiration </li></ul></ul></ul><ul><ul><li>Vallecula </li></ul></ul><ul><ul><ul><li>“ Pocket” formed by base of tongue, epiglottis </li></ul></ul></ul>
  10. 10. Upper Airway Anatomy
  11. 11. Upper Airway Anatomy <ul><li>Sinuses </li></ul><ul><ul><li>cavities formed by cranial bones </li></ul></ul><ul><ul><li>act as tributaries for fluid to, from eustachian tubes, tear ducts </li></ul></ul><ul><ul><li>trap bacteria, commonly infected </li></ul></ul>
  12. 12. Upper Airway Anatomy <ul><li>Larynx </li></ul><ul><ul><li>Attached to hyoid bone </li></ul></ul><ul><ul><ul><li>Horseshoe shaped bone </li></ul></ul></ul><ul><ul><ul><li>Supports trachea </li></ul></ul></ul><ul><ul><li>Thyroid cartilage </li></ul></ul><ul><ul><ul><li>Largest laryngeal cartilage </li></ul></ul></ul><ul><ul><ul><li>Shield-shaped </li></ul></ul></ul><ul><ul><ul><li>Cartilage anteriorly, smooth muscle posteriorly </li></ul></ul></ul><ul><ul><ul><li>“ Adam’s Apple” </li></ul></ul></ul><ul><ul><ul><li>Glottic opening directly behind </li></ul></ul></ul>
  13. 13. Upper Airway Anatomy <ul><li>Larynx </li></ul><ul><ul><li>Glottic opening </li></ul></ul><ul><ul><ul><li>Adult airway’s narrowest point </li></ul></ul></ul><ul><ul><ul><li>Dependent on muscle tone </li></ul></ul></ul><ul><ul><ul><li>Contains vocal bands </li></ul></ul></ul><ul><ul><li>Arytenoid cartilage </li></ul></ul><ul><ul><ul><li>Posterior attachment of vocal bands </li></ul></ul></ul>
  14. 14. Upper Airway Anatomy <ul><li>Larynx </li></ul><ul><ul><li>Cricoid ring </li></ul></ul><ul><ul><ul><li>First tracheal ring </li></ul></ul></ul><ul><ul><ul><li>Completely cartilaginous </li></ul></ul></ul><ul><ul><ul><li>Compression (Sellick maneuver) occludes esophagus </li></ul></ul></ul><ul><ul><li>Cricothyroid membrane </li></ul></ul><ul><ul><ul><li>Membrane between cricoid, thyroid cartilages </li></ul></ul></ul><ul><ul><ul><li>Site for surgical, needle airway placement </li></ul></ul></ul>
  15. 15. Upper Airway Anatomy <ul><li>Larynx and Trachea </li></ul><ul><ul><li>Associated Structures </li></ul></ul><ul><ul><ul><li>Thyroid gland </li></ul></ul></ul><ul><ul><ul><ul><li>below cricoid cartilage </li></ul></ul></ul></ul><ul><ul><ul><ul><li>lies across trachea, up both sides </li></ul></ul></ul></ul><ul><ul><ul><li>Carotid arteries </li></ul></ul></ul><ul><ul><ul><ul><li>branch across, lie closely alongside trachea </li></ul></ul></ul></ul><ul><ul><ul><li>Jugular veins </li></ul></ul></ul><ul><ul><ul><ul><li>branch across and lie close to trachea </li></ul></ul></ul></ul>
  16. 16. Upper Airway Anatomy
  17. 17. Upper Airway Anatomy <ul><li>Pediatric vs Adult Upper Airway </li></ul><ul><ul><li>Larger tongue in comparison to size of mouth </li></ul></ul><ul><ul><li>Floppy epiglottis </li></ul></ul><ul><ul><li>Delicate teeth, gums </li></ul></ul><ul><ul><li>More superior larynx </li></ul></ul><ul><ul><li>Funnel shaped larynx due to undeveloped cricoid cartilage </li></ul></ul><ul><ul><li>Narrowest point at cricoid ring before ~8 years old </li></ul></ul>
  18. 18. Upper Airway Anatomy From: CPEM, TRIPP, 1998
  19. 19. Upper Airway Anatomy
  20. 20. Glottic Opening
  21. 21. Lower Airway Anatomy <ul><li>Function </li></ul><ul><ul><li>Exchange O 2 , CO 2 with blood </li></ul></ul><ul><li>Location </li></ul><ul><ul><li>From glottic opening to alveolar-capillary membrane </li></ul></ul>
  22. 22. Lower Airway Anatomy <ul><li>Trachea </li></ul><ul><ul><li>Bifurcates (divides) at carina </li></ul></ul><ul><ul><li>Right, left mainstem bronchi </li></ul></ul><ul><ul><li>Right mainstem bronchus shorter, straighter </li></ul></ul><ul><ul><li>Lined with mucous cells, beta-2 receptors </li></ul></ul>
  23. 23. Lower Airway Anatomy <ul><li>Bronchi </li></ul><ul><ul><li>Branch into secondary, tertiary bronchi that branch into bronchioles </li></ul></ul><ul><li>Bronchioles </li></ul><ul><ul><li>No cartilage in walls </li></ul></ul><ul><ul><li>Small smooth muscle tubes </li></ul></ul><ul><ul><li>Branch into alveolar ducts that end at alveolar sacs </li></ul></ul>
  24. 24. Lower Airway Anatomy <ul><li>Alveoli </li></ul><ul><ul><li>“ Balloon-like” clusters </li></ul></ul><ul><ul><li>Site of gas exchange </li></ul></ul><ul><ul><li>Lined with surfactant </li></ul></ul><ul><ul><ul><li>Decreases surface tension  eases expansion </li></ul></ul></ul><ul><ul><ul><li> surfactant  atelectasis (focal collapse of alveoli0 </li></ul></ul></ul>
  25. 25. Lower Airway Anatomy <ul><li>Lungs </li></ul><ul><ul><li>Right lung = 3 lobes; Left lung = 2 lobes </li></ul></ul><ul><ul><li>Parenchymal tissue </li></ul></ul><ul><ul><li>Pleura </li></ul></ul><ul><ul><ul><li>Visceral </li></ul></ul></ul><ul><ul><ul><li>Parietal </li></ul></ul></ul><ul><ul><ul><li>Pleural space </li></ul></ul></ul>
  26. 26. Lower Airway Anatomy
  27. 27. Lower Airway Anatomy <ul><li>Occlusion of bronchioles </li></ul><ul><ul><li>Smooth muscle contraction (bronchospasm </li></ul></ul><ul><ul><li>Mucus plugs </li></ul></ul><ul><ul><li>Inflammatory edema </li></ul></ul><ul><ul><li>Foreign bodies </li></ul></ul>
  28. 28. Lung Volumes/Capacities <ul><li>Typical adult male total lung capacity = 6 liters </li></ul><ul><li>Tidal Volume (V T ) </li></ul><ul><ul><li>Gas volume inhaled or exhaled during single ventilatory cycle </li></ul></ul><ul><ul><li>Usually 5-7 cc/kg (typically 500 cc) </li></ul></ul>
  29. 29. Lung Volumes/Capacities <ul><li>Dead Space Air (V D ) </li></ul><ul><ul><li>Air unavailable for gas exchange </li></ul></ul>
  30. 30. Lung Volumes/Capacities <ul><li>Dead Space Air (V D ) </li></ul><ul><ul><li>Anatomic dead space (~150cc) </li></ul></ul><ul><ul><ul><li>Trachea </li></ul></ul></ul><ul><ul><ul><li>Bronchi </li></ul></ul></ul><ul><ul><li>Physiologic dead space </li></ul></ul><ul><ul><ul><li>Shunting </li></ul></ul></ul><ul><ul><li>Pathological dead space </li></ul></ul><ul><ul><ul><li>Formed by factors like disease or obstruction </li></ul></ul></ul><ul><ul><ul><li>Examples: COPD </li></ul></ul></ul>
  31. 31. Lung Volumes/Capacities <ul><li>Alveolar Air (alveolar volume) [V A ] </li></ul><ul><ul><li>Air reaching alveoli for gas exchange </li></ul></ul><ul><ul><li>Usually 350 cc </li></ul></ul>
  32. 32. Lung Volumes/Capacities <ul><li>Minute Volume [V min ](minute ventilation) </li></ul><ul><ul><li>Amount of gas moved in, out of respiratory tract per minute </li></ul></ul><ul><ul><li>Tidal volume X RR </li></ul></ul><ul><li>Alveolar Minute Volume </li></ul><ul><ul><li>Amount of gas moved in, out of alveoli per minute </li></ul></ul><ul><ul><li>(tidal volume - dead space volume) X RR </li></ul></ul>
  33. 33. Lung Volumes/Capacities <ul><li>Functional Reserve Capacity (FRC) </li></ul><ul><ul><li>After optimal inspiration, amount of air that can be forced from lungs in single exhalation </li></ul></ul>
  34. 34. Lung Volumes/Capacities <ul><li>Inspiratory Reserve Volume (IRV) </li></ul><ul><ul><li>Amount of gas that can be inspired in addition to tidal volume </li></ul></ul><ul><li>Expiratory Reserve Volume (ERV) </li></ul><ul><ul><li>Amount of gas that can be expired after passive (relaxed) expiration </li></ul></ul>
  35. 35. Lung Volumes/Capacities
  36. 36. Ventilation <ul><li>Movement of air in, out of lungs </li></ul><ul><li>Control via: </li></ul><ul><ul><li>Respiratory center in medulla </li></ul></ul><ul><ul><li>Apneustic, pneumotaxic centers in pons </li></ul></ul>
  37. 37. Ventilation <ul><li>Inspiration </li></ul><ul><ul><li>Stimulus from respiratory center of brain (medulla) </li></ul></ul><ul><ul><li>Transmitted via phrenic nerve to diaphragm, spinal cord/intercostal nerves to intercostal muscles </li></ul></ul><ul><ul><li>Diaphragm contracts, flattens </li></ul></ul><ul><ul><li>Intercostal muscles contract; ribs move up and out </li></ul></ul><ul><ul><li>Air spaces in lungs stretch, increase in size </li></ul></ul><ul><ul><li> intrapulmonic pressure (pressure gradient) </li></ul></ul><ul><ul><li>Air flows into airways, alveoli inflate until pressure equalizes </li></ul></ul>
  38. 38. Ventilation <ul><li>Expiration </li></ul><ul><ul><li>Stretch receptors in lungs signal respiratory center via vagus nerve to inhibit inspiration (Hering-Breuer reflex) </li></ul></ul><ul><ul><li>Natural elasticity of lungs pulls diaphragm, chest wall to resting position </li></ul></ul><ul><ul><li>Pulmonary air spaces decrease in size </li></ul></ul><ul><ul><li>Intrapulmonary pressure rises </li></ul></ul><ul><ul><li>Air flows out until pressure equalizes </li></ul></ul>
  39. 39. Ventilation
  40. 40. Ventilation
  41. 41. Ventilation <ul><li>Respiratory Drive </li></ul><ul><ul><li>Chemoreceptors in medulla </li></ul></ul><ul><ul><li>Stimulated  PaCO 2 or  pH </li></ul></ul><ul><ul><li>PaCO 2 is normal neuroregulatory control of ventilations </li></ul></ul><ul><li>Hypoxic Drive </li></ul><ul><ul><li>Chemoreceptors in aortic arch, carotid bodies </li></ul></ul><ul><ul><li>Stimulated by  PaO 2 </li></ul></ul><ul><ul><li>Back-up regulatory control </li></ul></ul>
  42. 42. Ventilation <ul><li>Other stimulants or depressants </li></ul><ul><ul><li>Body temp: fever  ; hypothermia  </li></ul></ul><ul><ul><li>Drugs/meds: increase or decrease </li></ul></ul><ul><ul><li>Pain: increases, but occasionally decreases </li></ul></ul><ul><ul><li>Emotion: increases </li></ul></ul><ul><ul><li>Acidosis: increases </li></ul></ul><ul><ul><li>Sleep: decreases </li></ul></ul>
  43. 43. Gas Measurements <ul><li>Total Pressure </li></ul><ul><ul><li>Combined pressure of all atmospheric gases </li></ul></ul><ul><ul><li>760 mm Hg (torr) at sea level </li></ul></ul><ul><li>Partial Pressure </li></ul><ul><ul><li>Pressure exerted by each gas in a mixture </li></ul></ul>
  44. 44. Gas Measurements <ul><li>Partial Pressures </li></ul><ul><ul><li>Atmospheric </li></ul></ul><ul><ul><ul><li>Nitrogen 597.0 torr (78.62%); Oxygen 159.0 torr (20.84%); Carbon Dioxide 0.3 torr (0.04%); Water 3.7 torr (0.5%) </li></ul></ul></ul><ul><ul><li>Alveolar </li></ul></ul><ul><ul><ul><li>Nitrogen 569.0 torr (74.9%); Oxygen 104.0 torr (13.7%); CO2 40.0 torr (5.2%); Water 47.0 torr (6.2%) </li></ul></ul></ul>
  45. 45. Respiration <ul><li>Ventilation vs. Respiration </li></ul><ul><li>Exchange of gases between living organism, environment </li></ul><ul><li>External Respiration </li></ul><ul><ul><li>Exchange between lungs, blood cells </li></ul></ul><ul><li>Internal Respiration </li></ul><ul><ul><li>Exchange between blood cells, tissues </li></ul></ul>
  46. 46. Respiration <ul><li>How are O 2 , CO 2 transported? </li></ul><ul><ul><li>Diffusion </li></ul></ul><ul><ul><ul><li>Movement of gases along a concentration gradient </li></ul></ul></ul><ul><ul><ul><li>Gases dissolve in water, pass through alveolar membrane from areas of higher concentration to areas of lower concentration </li></ul></ul></ul><ul><ul><li>FiO 2 </li></ul></ul><ul><ul><ul><li>% oxygen in inspired air expressed as a decimal </li></ul></ul></ul><ul><ul><ul><li>FiO 2 of room air = 0.21 </li></ul></ul></ul>
  47. 47. Respiration <ul><li>Blood Oxygen Content </li></ul><ul><ul><li>dissolved O 2 crosses capillary membrane, binds to Hgb of RBC </li></ul></ul><ul><ul><li>Transport = O 2 bound to hemoglobin (  97%) or dissolved in plasma </li></ul></ul><ul><ul><li>O 2 Saturation </li></ul></ul><ul><ul><ul><li>% of hemoglobin saturated with oxygen (usually carries >96% of total) </li></ul></ul></ul><ul><ul><ul><li>O 2 content divided by O 2 carrying capacity </li></ul></ul></ul>
  48. 48. Respiration <ul><li>Oxygen saturation affected by: </li></ul><ul><ul><li>Low Hgb (anemia, hemorrhage) </li></ul></ul><ul><ul><li>Inadequate oxygen availability at alveoli </li></ul></ul><ul><ul><li>Poor diffusion across pulmonary membrane (pneumonia, pulmonary edema, COPD) </li></ul></ul><ul><ul><li>Ventilation/Perfusion (V/Q) mismatch </li></ul></ul><ul><ul><ul><li>Blood moves past collapsed alveoli (shunting) </li></ul></ul></ul><ul><ul><ul><li>Alveoli intact but blood flow impaired </li></ul></ul></ul>
  49. 49. Respiration <ul><li>Blood Carbon Dioxide Content </li></ul><ul><ul><li>Byproduct of work (cellular respiration) </li></ul></ul><ul><ul><li>Transported as bicarbonate (HCO 3 - ion) </li></ul></ul><ul><ul><li> 20-30% bound to hemoglobin </li></ul></ul><ul><ul><li>Pressure gradient causes CO 2 diffusion into alveoli from blood </li></ul></ul><ul><ul><li>Increased level = hypercarbia </li></ul></ul>
  50. 50. Respiration
  51. 51. Inspired Air: P O2 160 & P CO2 0.3 Alveoli P O2 100 & P CO2 40 P O2 40 & P CO2 46 - Pulmonary circulation - P O2 100 & P CO2 40 Heart P O2 40 & P CO2 46 - Systemic circulation - P O2 100 & P CO2 40 Tissue cell P O2 <40 & P CO2 >46 Oxygenated Deoxygenated
  52. 52. Diagnostic Testing <ul><li>Pulse Oximetry </li></ul><ul><li>Peak Expiratory Flow Testing </li></ul><ul><li>Pulmonary Function Testing </li></ul><ul><li>End-Tidal CO 2 Monitoring </li></ul><ul><li>Laboratory Testing of Blood </li></ul><ul><ul><li>Arterial </li></ul></ul><ul><ul><li>Venous </li></ul></ul>
  53. 53. Causes of Hypoxemia <ul><li>Lower partial pressure of atmospheric O 2 </li></ul><ul><li>Inadequate hemoglobin level in blood </li></ul><ul><li>Hemoglobin bound by other gas (CO) </li></ul><ul><li> pulmonary alveolar membrane distance </li></ul><ul><li>Reduced surface area for gas exchange </li></ul><ul><li>Decreased mechanical effort </li></ul>
  54. 54. Causes of Airway/Ventilatory Compromise <ul><li>Airway Obstruction </li></ul><ul><ul><li>Tongue </li></ul></ul><ul><ul><li>Foreign body obstruction </li></ul></ul><ul><ul><li>Anaphylaxis/angioedema </li></ul></ul><ul><ul><li>Upper airway burn </li></ul></ul><ul><ul><li>Maxillofacial/laryngeal/trachebronchial trauma </li></ul></ul><ul><ul><li>Epiglottitis </li></ul></ul><ul><ul><li>Croup </li></ul></ul>
  55. 55. Obstruction <ul><li>Tongue </li></ul><ul><ul><li>Most common cause </li></ul></ul><ul><ul><li>Snoring respirations </li></ul></ul><ul><ul><li>Corrected by positioning </li></ul></ul>
  56. 56. Foreign Body <ul><li>Partial or Full </li></ul><ul><li>Symptoms include </li></ul><ul><ul><li>Choking </li></ul></ul><ul><ul><li>Gagging </li></ul></ul><ul><ul><li>Stridor </li></ul></ul><ul><ul><li>Dyspnea </li></ul></ul><ul><ul><li>Aphonia </li></ul></ul><ul><ul><li>Dysphonia </li></ul></ul>
  57. 57. Laryngeal Spasm <ul><li>Spasmatic closure of vocal cords </li></ul><ul><li>Frequently caused by </li></ul><ul><ul><li>Overly aggressive technique during intubation </li></ul></ul><ul><ul><li>Immediately upon extubation </li></ul></ul>
  58. 58. Laryngeal Edema <ul><li>Causes </li></ul><ul><ul><li>Angioedema </li></ul></ul><ul><ul><li>Anaphylaxis </li></ul></ul><ul><ul><li>Upper airway burns </li></ul></ul><ul><ul><li>Epiglottitis </li></ul></ul><ul><ul><li>Croup </li></ul></ul><ul><ul><li>Trauma </li></ul></ul>
  59. 59. Aspiration <ul><li>Significantly increases mortality </li></ul><ul><ul><li>Obstructs Airway </li></ul></ul><ul><ul><li>Destroys bronchial tissue </li></ul></ul><ul><ul><li>Introduces pathogens </li></ul></ul><ul><ul><li>Decreases ability to ventilate </li></ul></ul><ul><ul><li>Frequently occult </li></ul></ul>
  60. 60. Obstructive Airway Disease <ul><li>Obstructive airway disease </li></ul><ul><ul><li>Asthma </li></ul></ul><ul><ul><li>Emphysema </li></ul></ul><ul><ul><li>Chronic Bronchitis </li></ul></ul>
  61. 61. Gas Exchange Surface <ul><li>Pulmonary edema </li></ul><ul><ul><li>Left-sided heart failure </li></ul></ul><ul><ul><li>Toxic inhalation </li></ul></ul><ul><ul><li>Near drowning </li></ul></ul><ul><li>Pneumonia </li></ul><ul><li>Pulmonary embolism </li></ul><ul><ul><li>Blood clots </li></ul></ul><ul><ul><li>Amniotic fluid </li></ul></ul><ul><ul><li>Fat embolism </li></ul></ul>
  62. 62. Causes of Airway/Ventilatory Compromise <ul><li>Thoracic Bellows </li></ul><ul><ul><li>Chest trauma </li></ul></ul><ul><ul><ul><li>Fib fractures </li></ul></ul></ul><ul><ul><ul><li>Flail chest </li></ul></ul></ul><ul><ul><ul><li>Pneumothorax </li></ul></ul></ul><ul><ul><ul><li>Hemothorax </li></ul></ul></ul><ul><ul><ul><li>Sucking chest wound </li></ul></ul></ul><ul><ul><ul><li>Diaphragmatic hernia </li></ul></ul></ul>
  63. 63. Causes of Airway/Ventilatory Compromise <ul><li>Thoracic Bellows </li></ul><ul><ul><li>Pleural effusion </li></ul></ul><ul><ul><li>Spinal cord trauma </li></ul></ul><ul><ul><li>Morbid obesity (Pickwickian Syndrome) </li></ul></ul><ul><ul><li>Neurological/neuromuscular disease </li></ul></ul><ul><ul><ul><li>Poliomyelitis </li></ul></ul></ul><ul><ul><ul><li>Myasthenia gravis </li></ul></ul></ul><ul><ul><ul><li>Muscular dystrophy </li></ul></ul></ul><ul><ul><ul><li>Gullian-Barre syndrome </li></ul></ul></ul>
  64. 64. Causes of Airway/Ventilatory Compromise <ul><li>Control System </li></ul><ul><ul><li>Head trauma </li></ul></ul><ul><ul><li>Cerebrovascular accident </li></ul></ul><ul><ul><li>Depressant drug toxicity </li></ul></ul><ul><ul><ul><li>Narcotics </li></ul></ul></ul><ul><ul><ul><li>Sedative-Hypnotics </li></ul></ul></ul><ul><ul><ul><li>Ethanol </li></ul></ul></ul>
  65. 65. Assessment of Airway/Ventilatory Compromise <ul><li>Respiratory Distress/Dyspnea = Possible Life Threat </li></ul><ul><li>Assess/Manage Simultaneously </li></ul><ul><li>Priorities </li></ul><ul><ul><li>Airway </li></ul></ul><ul><ul><li>Breathing </li></ul></ul><ul><ul><li>Circulation </li></ul></ul><ul><ul><li>Disability </li></ul></ul>
  66. 66. Assessment of Airway/Ventilatory Compromise <ul><li>Airway </li></ul><ul><ul><li>Listen to patient talk/breathe </li></ul></ul><ul><ul><li>Noisy breathing = Obstructed breathing </li></ul></ul><ul><ul><li>But, all obstructed breathing is not noisy </li></ul></ul><ul><ul><li>Adventitious sounds </li></ul></ul><ul><ul><ul><li>Snoring = Tongue </li></ul></ul></ul><ul><ul><ul><li>Stridor = “Tight” Upper Airway </li></ul></ul></ul>
  67. 67. Assessment of Airway/Ventilatory Compromise <ul><li>Breathing </li></ul><ul><ul><li>Look </li></ul></ul><ul><ul><ul><li>Symmetry of Chest Expansion </li></ul></ul></ul><ul><ul><ul><li>Signs of Increased Effort </li></ul></ul></ul><ul><ul><ul><li>Skin Color </li></ul></ul></ul><ul><ul><li>Listen </li></ul></ul><ul><ul><ul><li>Mouth and Nose </li></ul></ul></ul><ul><ul><ul><li>Lung Fields </li></ul></ul></ul><ul><ul><li>Feel </li></ul></ul><ul><ul><ul><li>Mouth and Nose </li></ul></ul></ul><ul><ul><ul><li>Symmetry of Expansion </li></ul></ul></ul>
  68. 68. Assessment of Airway/Ventilatory Compromise <ul><li>Breathing </li></ul><ul><ul><li>Tachypnea </li></ul></ul><ul><ul><li>Bradypnea </li></ul></ul><ul><ul><li>Signs of distress </li></ul></ul><ul><ul><ul><li>Nasal flaring </li></ul></ul></ul><ul><ul><ul><li>Tracheal tugging </li></ul></ul></ul><ul><ul><ul><li>Retractions </li></ul></ul></ul><ul><ul><ul><li>Accessory muscle use </li></ul></ul></ul><ul><ul><ul><li>Tripod positioning </li></ul></ul></ul><ul><ul><li>Cyanosis </li></ul></ul>
  69. 69. Assessment of Airway/Ventilatory Compromise <ul><li>Circulation </li></ul><ul><ul><li>Don’t let respiratory failure distract you!!! </li></ul></ul><ul><ul><li>Tachycardia = Early hypoxia in adults </li></ul></ul><ul><ul><li>Bradycardia = Early hypoxia in infants, children; Late hypoxia in adults </li></ul></ul>
  70. 70. Assessment of Airway/Ventilatory Compromise <ul><li>Disability </li></ul><ul><ul><li>Restlessness, anxiety, combativeness = hypoxia until proven otherwise </li></ul></ul><ul><ul><li>Drowsiness, lethargy = hypercarbia until proven otherwise </li></ul></ul><ul><ul><li>When the fighting stops, a patient isn’t always getting better </li></ul></ul>
  71. 71. Assessment of Airway/Ventilatory Compromise <ul><li>Focused Exam </li></ul><ul><ul><li>Respiratory Patterns </li></ul></ul><ul><ul><ul><li>Cheyne-Stokes = diffuse cerebral cortex injury </li></ul></ul></ul><ul><ul><ul><li>Kussmaul = acidosis </li></ul></ul></ul><ul><ul><ul><li>Biot’s (cluster) = increased ICP; pons, upper medulla injury </li></ul></ul></ul><ul><ul><ul><li>Central Neurogenic Hyperventilation = increased ICP; mid-brain injury </li></ul></ul></ul><ul><ul><ul><li>Agonal = brain anoxia </li></ul></ul></ul>
  72. 72. Assessment of Airway/Ventilatory Compromise <ul><li>Focused Exam </li></ul><ul><ul><li>Neck </li></ul></ul><ul><ul><ul><li>Trachea mid-line? </li></ul></ul></ul><ul><ul><ul><li>Jugular vein distension? </li></ul></ul></ul><ul><ul><ul><li>Subcutaneous emphysema? </li></ul></ul></ul><ul><ul><ul><li>Accessory muscle use?/hypertrophy? </li></ul></ul></ul>
  73. 73. Assessment of Airway/Ventilatory Compromise <ul><li>Focused Exam </li></ul><ul><ul><li>Chest </li></ul></ul><ul><ul><ul><li>Barrel chest? </li></ul></ul></ul><ul><ul><ul><li>Deformity, discoloration, asymmetry? </li></ul></ul></ul><ul><ul><ul><li>Flail segment, paradoxical movement? </li></ul></ul></ul><ul><ul><ul><li>Adventitious breath sounds? </li></ul></ul></ul><ul><ul><ul><li>Third heart sound? </li></ul></ul></ul><ul><ul><ul><li>Subcutaneous emphysema? </li></ul></ul></ul><ul><ul><ul><li>Fremitus? </li></ul></ul></ul><ul><ul><ul><li>Dullness, hyperresonance to percussion? </li></ul></ul></ul>
  74. 74. Assessment of Airway/Ventilatory Compromise <ul><li>Focused Exam </li></ul><ul><ul><li>Extremities </li></ul></ul><ul><ul><ul><li>Edema? </li></ul></ul></ul><ul><ul><ul><li>Nail bed color? </li></ul></ul></ul><ul><ul><ul><li>Clubbing? </li></ul></ul></ul>
  75. 75. Assessment of Airway/Ventilatory Compromise <ul><li>Mechanical Ventilation </li></ul><ul><ul><li>Increased resistance </li></ul></ul><ul><ul><li>Changing compliance </li></ul></ul>
  76. 76. Assessment of Airway/Ventilatory Compromise <ul><li>Pulsus Paradoxus </li></ul><ul><ul><li>Systolic BP drops > 10 mm Hg w/inspiration </li></ul></ul><ul><ul><li>May detect change in pulse quality </li></ul></ul><ul><ul><li>COPD, asthma, pericardial tamponade </li></ul></ul>
  77. 77. Assessment of Airway/Ventilatory Compromise <ul><li>History </li></ul><ul><ul><li>Onset gradual or sudden? </li></ul></ul><ul><ul><li>What makes it worse, better? </li></ul></ul><ul><ul><li>How long? </li></ul></ul><ul><ul><li>Cough? Productive? Of what? </li></ul></ul><ul><ul><li>Pain? What kind? </li></ul></ul><ul><ul><li>Fever? </li></ul></ul>
  78. 78. Assessment of Airway/Ventilatory Compromise <ul><li>Past History </li></ul><ul><ul><li>Hypertension, AMI, diabetes </li></ul></ul><ul><ul><li>Chronic cough, smoking, recurrent “colds” </li></ul></ul><ul><ul><li>Allergies, acute/seasonal SOB </li></ul></ul><ul><ul><li>Lower extremity trauma, recent surgery, immobilization </li></ul></ul><ul><li>Interventions </li></ul><ul><ul><li>Past admission? Ever admitted to ICU? </li></ul></ul><ul><ul><li>Medications? Frequency of prn medication use? </li></ul></ul><ul><ul><li>Ever intubated before? </li></ul></ul>
  79. 79. BLS Airway/Ventilation Methods <ul><li>Supplemental Oxygen </li></ul><ul><ul><li>Increased FiO 2 increases available oxygen </li></ul></ul><ul><ul><li>Objective = Maximize hemoglobin saturation </li></ul></ul>
  80. 80. Oxygen Equipment <ul><li>Oxygen source </li></ul><ul><ul><li>Compressed gas </li></ul></ul><ul><ul><ul><li>Tank size </li></ul></ul></ul><ul><ul><ul><ul><li>D 400L </li></ul></ul></ul></ul><ul><ul><ul><ul><li>E 660L </li></ul></ul></ul></ul><ul><ul><ul><ul><li>M 3450 L </li></ul></ul></ul></ul><ul><ul><li>Liquid oxygen </li></ul></ul>
  81. 81. Oxygen Equipment <ul><li>Regulators </li></ul><ul><ul><li>High Pressure </li></ul></ul><ul><ul><ul><li>Cylinder to cylinder </li></ul></ul></ul><ul><ul><li>Low Pressure </li></ul></ul><ul><ul><ul><li>Cylinder to patient </li></ul></ul></ul><ul><li>Humidifier </li></ul>
  82. 82. Delivery Devices <ul><li>Nasal cannula </li></ul><ul><li>Simple face mask </li></ul><ul><li>Partial rebreather mask </li></ul><ul><li>Non-rebreather mask </li></ul><ul><li>Venturi mask </li></ul><ul><li>Small volume nebulizer </li></ul>
  83. 83. Nasal Cannula <ul><li>Optimal delivery 40% at 6 LPM </li></ul><ul><li>Indication </li></ul><ul><ul><li>Low FiO 2 </li></ul></ul><ul><ul><li>Long term therapy </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Apnea </li></ul></ul><ul><ul><li>Mouth breathing </li></ul></ul><ul><ul><li>Need for High FiO 2 </li></ul></ul>
  84. 84. Venturi Mask <ul><li>Specific O 2 Concentrations </li></ul><ul><ul><li>24% </li></ul></ul><ul><ul><li>28% </li></ul></ul><ul><ul><li>35% </li></ul></ul><ul><ul><li>40% </li></ul></ul>
  85. 85. Simple Face Mask <ul><li>Range 40-60% at 10 LPM </li></ul><ul><li>Volumes greater that 10 LPM does not increase O2 delivery </li></ul><ul><li>Indications </li></ul><ul><ul><li>Moderate FiO 2 </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Apnea </li></ul></ul><ul><ul><li>Need for High FiO 2 </li></ul></ul>
  86. 86. Non-Rebreather Mask <ul><li>Range 80-95% at 15 LPM </li></ul><ul><li>Indications </li></ul><ul><ul><li>Delivery of high FiO2 </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Apnea </li></ul></ul><ul><ul><li>Poor respiratory effort </li></ul></ul>
  87. 87. Partial Rebreather <ul><li>Range 40 – 60% </li></ul><ul><li>Indications </li></ul><ul><ul><li>Moderate FiO 2 </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Apnea </li></ul></ul><ul><ul><li>Need for High FiO 2 </li></ul></ul>
  88. 88. BLS Airway/Ventilation Methods <ul><li>Airway Maneuvers </li></ul><ul><ul><li>Head-tilt/Chin-lift </li></ul></ul><ul><ul><li>Jaw thrust </li></ul></ul><ul><ul><li>Sellick’s maneuver </li></ul></ul><ul><li>Other Types </li></ul><ul><ul><li>Tracheostomy with tube </li></ul></ul><ul><ul><li>Tracheostomy with stoma </li></ul></ul><ul><li>Airway Devices </li></ul><ul><ul><li>Oropharyngeal airway </li></ul></ul><ul><ul><li>Nasopharyngeal airway </li></ul></ul>
  89. 89. BLS Airway/Ventilation Methods <ul><li>Mouth-to-Mouth </li></ul><ul><li>Mouth-to-Nose </li></ul><ul><li>Mouth-to-Mask </li></ul><ul><li>One-person BVM </li></ul><ul><li>Two-person BVM </li></ul><ul><li>Three-person BVM </li></ul><ul><li>Flow-restricted, gas powered ventilator </li></ul><ul><li>Transport ventilator </li></ul>
  90. 90. BLS Airway/Ventilation Methods <ul><li>Mouth to Mouth </li></ul><ul><li>Mouth to Nose </li></ul><ul><li>Mouth to Mask </li></ul>
  91. 91. BLS Airway/Ventilation Methods <ul><li>One-Person BVM </li></ul><ul><ul><li>Difficult to master </li></ul></ul><ul><ul><li>Mask seal often inadequate </li></ul></ul><ul><ul><li>May result in inadequate tidal volume </li></ul></ul><ul><ul><li>Gastric distention risk </li></ul></ul><ul><ul><li>Ventilate only until see chest rise </li></ul></ul>
  92. 92. BLS Airway/Ventilation Methods <ul><li>Two-person BVM </li></ul><ul><ul><li>Most efficient method </li></ul></ul><ul><ul><li>Useful in C-spine injury </li></ul></ul><ul><ul><li>improved mask seal, tidal volume </li></ul></ul><ul><li>Three-person BVM </li></ul><ul><ul><li>Less utilized </li></ul></ul><ul><ul><li>Used when difficulty with mask seal </li></ul></ul><ul><ul><li>Crowded </li></ul></ul>
  93. 93. BLS Airway/Ventilation Methods <ul><li>Flow-restricted, gas-powered ventilator </li></ul><ul><ul><li>Cardiac sphincter opens at 30 cm H 2 O </li></ul></ul><ul><ul><li>High volume/high concentration </li></ul></ul><ul><ul><li>Not recommended for children, poor pulmonary compliance, or poor tidal volume </li></ul></ul><ul><ul><li>Oxygen delivered on inspiratory effort </li></ul></ul><ul><ul><li>May cause barotrauma </li></ul></ul>
  94. 94. BLS Airway/Ventilation Methods <ul><li>Automatic transport ventilators </li></ul><ul><ul><li>Not like “real” ventilator </li></ul></ul><ul><ul><li>Usually only controls volume, rate </li></ul></ul><ul><ul><li>Useful during prolonged ventilation times </li></ul></ul><ul><ul><li>Not useful in obstructed airway, increased airway resistance </li></ul></ul><ul><ul><li>Frees personnel </li></ul></ul><ul><ul><li>Cannot respond to changes in airway resistance, lung compliance </li></ul></ul>
  95. 95. BLS Airway/Ventilation Methods <ul><li>Pediatric considerations </li></ul><ul><ul><li>Mask seal force may obstruct airway </li></ul></ul><ul><ul><li>Best if used with jaw thrust </li></ul></ul><ul><ul><li>BVM sizes: neonate, infant=450 ml + </li></ul></ul><ul><ul><li>Children > 8 y.o. require adult BVM </li></ul></ul><ul><ul><li>Just enough volume to see chest rise </li></ul></ul><ul><ul><li>Squeeze - Release - Release </li></ul></ul>
  96. 96. BLS Airway/Ventilation Methods <ul><li>Stoma patients </li></ul><ul><ul><li>Expose stoma </li></ul></ul><ul><ul><li>Pocket mask </li></ul></ul><ul><ul><li>BVM </li></ul></ul><ul><ul><ul><li>Seal around stoma site </li></ul></ul></ul><ul><ul><ul><li>Seal mouth, nose if air leak is evident </li></ul></ul></ul>
  97. 97. BLS Airway/Ventilation Methods <ul><li>Airway obstruction techniques </li></ul><ul><ul><li>Positioning </li></ul></ul><ul><ul><li>Finger sweep with caution </li></ul></ul><ul><ul><li>Suctioning </li></ul></ul><ul><ul><li>Oral airway/nasal airway (tongue) </li></ul></ul><ul><ul><li>Heimlich maneuver </li></ul></ul><ul><ul><li>Chest thrusts </li></ul></ul><ul><ul><li>Chest thrust/back blows for infants </li></ul></ul><ul><ul><li>Direct laryngoscopy </li></ul></ul>
  98. 98. BLS Airway/Ventilation Methods <ul><li>Suctioning </li></ul><ul><ul><li>Manual or powered devices </li></ul></ul><ul><ul><li>Suction catheters </li></ul></ul><ul><ul><ul><li>Rigid </li></ul></ul></ul><ul><ul><ul><li>Soft </li></ul></ul></ul>
  99. 99. BLS Airway/Ventilation Methods <ul><li>Gastric Distention </li></ul><ul><ul><li>Common when ventilating without intubation </li></ul></ul><ul><ul><li>Complications </li></ul></ul><ul><ul><ul><li>Pressure on diaphragm </li></ul></ul></ul><ul><ul><ul><li>Resistance to BVM ventilation </li></ul></ul></ul><ul><ul><ul><li>Vomiting, aspiration </li></ul></ul></ul><ul><ul><li>Increase BVM ventilation time </li></ul></ul>

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