ATS - airway management

Emergency Medical Technician
7 - Airway Management & Artificial Ventilation
© 2014

© 2014
• Management of the
airway is an extremely
critical step in the care
of any patient
• Without an open and
clear airway, a patient
will become hypoxic,
this leads to:
– A loss of consciousness
– Coma
– Death
3

© 2014
• When providing
emergency care you
must:
– Determine whether the
patient’s airway is
open
– Clear any obstruction
you find
– Make sure that the
airway is adequate
– Provide supplemental
oxygen or ventilatory
support if indicated
4

© 2014
1. Assuring a Patent Airway
2. Clearing the Airway
3. Portable Oxygen Cylinders
4. Supplemental Oxygen Therapy

© 2014
• To assure a patent
airway, there are two
manual maneuvers you
can use:
– Head-tilt, chin-lift
technique
– Jaw-thrust maneuver
• These maneuvers help to
correct the position of
the tongue:
– The tongue is the most
common cause of airway
obstruction in
unconscious patients
7

© 2014
• Airway management is
optimal for both
maneuvers when the
patient is:
– Supine
– Lying flat on the back
8

© 2014
• The “head-tilt, chin-lift
maneuver” provides
maximum opening of
the airway
• It should be used for
patients with no
suspected injury to the
spine
9

© 2014
• Put one hand on the
patient’s forehead
• Put the fingertips of
your other hand under
the bony part of the
patient’s chin
• Apply gentle pressure
to the forehead to tilt
the head back
10

© 2014
• Using your fingertips, lift
the chin until the lower
teeth nearly touch the
upper teeth:
• Avoid compressing the
soft tissue under the jaw
• It may be necessary to
prevent the mouth from
closing by using your
thumb to pull back the
patient’s lower lip:
• Keep your thumb from
entering the patient’s
mouth
11

© 2014
• The jaw-thrust
maneuver should be
used for:
– Patients who are
unconscious
– Who have suspected
cervical spine injury
12

© 2014
• To perform the
maneuver, kneel at the
top of the head
• Put one hand on each
side of the jaw, just
below the ears
• Press your thumbs
against the cheek bones
as you use your fingers
to push the jaw
forward:
– Take care not to tilt or
rotate the patient’s head
13

© 2014
• Once you have the
patient’s airway
positioned, assess for
obstructions
• Use a thumb to pull
back the patient’s lip if
necessary to keep the
mouth open
14

© 2014
• A variation of the
standard jaw thrust:
– Used with a pocket
face mask
• Select an appropriate
size mask with a one-
way valve and assemble
the two together
• While kneeling at the
top of the patient’s
head, place the mask
over the patient’s nose
and mouth
15

© 2014
• Place the thumbs across
both sides of the mask
while using the index
and middle fingers of
both hands to pull
forward at the angles of
the jaw
• Pull the jaw forward
into the mask without
tilting the head back:
– Now you are able to
provide mouth-to-mask
ventilations
16

© 2014
• Oropharyngeal airway
(OPA) is an airway
adjunct
• Helps assure a patent
airway
• When inserted into
the mouth:
• Restricts the
movement of the
tongue
• Holds the airway
open
17

© 2014
• Use the
oropharyngeal airway
only on unresponsive
patients who do not
have a gag reflex
18

© 2014
• Before using an OPA
you must select the
right size
• Hold the device next to
the patient’s face:
It should extend from the
corner of the mouth to the
ear lobe
Or:
From the center of the
mouth to the angle of the
jaw
19

© 2014
• Open the mouth
• Cross your thumb and
forefinger and place them
on the upper and lower
teeth to one side of the
mouth and spread them
apart
• Position the OPA so the tip
is pointing to the roof of
the mouth
• Slide it back along the roof
of the mouth, taking care
not to push the tongue
back into the throat
20

© 2014
• Continue pushing until you
meet resistance at the soft
palate, or about halfway in
• Carefully watch what
you’re doing
• Gently Rotate OPA 180
Degrees:
– Tip points toward base of
tongue
21

© 2014
• Flange of device is
next to patients lips
• The device is now
ready for use in
ventilation
22

© 2014
• The insertion technique
is different for children
than that of adults
• Choose the correct size:
– Measuring it from the
corner of the mouth to
the earlobe
• Use a tongue depressor
to hold the tongue
down against the base
of the mouth
23

© 2014
• Insert the OPA the
same position it will
remain after insertion:
• The tip pointing toward
the tongue and throat
24

© 2014
• If during insertion the
patient exhibits a gag
reflex, immediately
remove it to prevent
vomiting:
• Instead maintain an
open airway manually
25

© 2014
• Maintain the head-tilt,
chin lift or the jaw-thrust
maneuver whenever you
use an airway adjunct
• Monitor the airway
throughout care
• If the patient regains
consciousness during
your care or exhibits a
gag reflex during
insertion:
• Immediately remove the
device
• Be prepared to suction
26

© 2014
• The nasopharyngeal
airway (NPA) is
inserted through the
nose
• It is a flexible tube that
“gives” if the patient
were to swallow
27

© 2014
• Used on patients with a
reduced level of
responsiveness:
– Who still might have an
intact gag reflex
– May regain
consciousness during
interventions
28

© 2014
• Use the NPA only on
patients who have not
suffered a head trauma:
– No signs and
symptoms of skull
fracture or facial
injuries
29

© 2014
• Select diameter:
– Approximately matches
nostril
• To measure the length:
– Hold it next to the
patient’s face
– It should extend from
the tip of the nose to
the tip of the ear lobe
• OR:
– Tip of the nose to the
angle of the jaw
30

© 2014
• Apply a sterile, water-
soluble lubricant to the
outside of NPA
• Gently push the tip of
the nose upward
• Insert the device in the
larger, more open
nostril:
– Until flange rests
against the nostril
31

© 2014
• As a general rule,
nasopharyngeal airways
should be avoided in
young children and
infants due to the
smaller size of the nose
32

© 2014
• At times, it will be necessary to clear
an obstruction from a patient’s airway
• Common airway obstructions include:
– The tongue
– Food
– Vomit
– Blood
– Teeth
– Foreign bodies

© 2014
• Use the finger-sweep
method to remove
foreign objects that are
blocking the airway
• Perform this maneuver
ONLY on:
– Unresponsive patients
– Only when you can see
an object in the
patient’s mouth
35

© 2014
• To perform the finger
sweep:
– Open the mouth using
the crossed-finger
technique
– Slide the index finger
of your other hand into
the patient’s mouth
– Remove the object in a
smooth, scooping
motion
– Repeat the maneuver if
necessary
36

© 2014
• Be extremely careful not to force any
object back down the patient’s throat
• If the patient responds with a gag
reflex, stop:
– Can cause vomiting
 Inhalation risk

© 2014
• Suctioning can be used
to clear obstructions
caused by liquids such
as blood or mucus from
the upper airway
• Risk of fluid splatter is
high:
– Infection control
practices should
always be used
38

© 2014
• Select the proper
catheter size
• Measure it prior to
insertion
• It should match the
length of the distance
from the corner of the
mouth to the earlobe
39

© 2014
• To provide suctioning:
– Turn on the unit to
make sure it is working
– Open the patient’s
mouth
– Place the catheter tip
at the location where
suctioning is needed,
– Take care not to trigger
a gag reflex by placing
it too far back
40

© 2014
– Place your finger over
the proximal opening
at the near end of the
tube:
 This starts suctioning
operations at the tip
– Move the tip from side
to side to prevent the
catheter from pulling
at soft tissue
– Withdraw the catheter
from the mouth as you
suction
41

© 2014
• Try to limit suctioning
to 15 seconds or less:
 Prolonged suctioning
requires cessation of
ventilations
 If the patient vomits
continue to suction
• If no injury to the spine
is suspected:
– Turn the patient’s head
or log roll into the
recovery position:
 Helps to facilitate the
drainage of fluids
42

© 2014
• Supplemental oxygen
can be a helpful therapy
for many patients
• Local protocols advise
which patient benefit
most from supplemental
oxygen
• Sometime the use of
supplemental oxygen is
contraindicated
44

© 2014
• Portable oxygen
cylinders used for
medical purposes come
in a variety of sizes
• You will most likely
encounter the D and E
size cylinders in the
field setting
45

© 2014
• Standard D cylinder:
– Capable of holding
about 425 liters of
oxygen
– When filled to 2000 psi
• Standard E cylinder:
– Capable of holding
about 680 liters of
oxygen
– When filled to 2000 psi
46

© 2014
• Tank has a pressure
regulator that reduces
the pressure to a
working pressure
between 30–70 psi
• Regulator is attached to
a yoke assembly that
secures it to the
cylinder with built-in
pins
47

© 2014
• Flowmeter
– Attached to the
regulator
• Allows control of the
amount of liters per
minute that flow from
the oxygen tank
• Oxygen flows out of the
tank, through the
pressure regulator and
through a tube that
leads to a delivery
device
48

© 2014
• For a breathing patient,
use either a:
– Facemask
– Nasal cannula
49

© 2014
• If the patient is not
breathing:
– Oxygen must be forced
into the lungs, usually
with a bag mask device
50

© 2014
• Oxygen is stored under
pressure of about
2000 psi
51

© 2014
• Pressurized tanks:
– Extremely dangerous
– Require careful
handling to prevent
damage
– If a valve breaks off,
the cylinder can
become a high-
powered missile
52

© 2014
• Oxygen in the tank is
able to:
– Contribute to ignition
– Accelerate combustion
of surrounding materials
• 100% oxygen gas can
saturate cloth and hair,
causing them to ignite
easily
• Exercise a great deal of
caution when performing
work in the vicinity of
any oxygen product
53

© 2014
• Oxygen equipment
should only be used
away from smoking and
open flames
• Make sure there is no
tape or tape residue on
the cylinder:
– Oxygen can react with
the adhesive and cause
combustion
54

© 2014
• Make sure you do not
have grease on:
– Your hands
– Any device that will be
attached to the
cylinder
• Make sure the “O” ring
is in good condition to
prevent leaks
55

© 2014
• Make sure the pressure
gauge reads above the
safe residual level of
200 psi
• If the tank is empty or
below the safe residual
level, you must use a
new cylinder
56

© 2014
• Always make sure your
oxygen cylinders are
full and ready for use at
the beginning of each
shift
• When using the
cylinder, open the valve
one full turn
57

© 2014
• To prevent damage and
leaking, always place an
oxygen tank on its side
unless someone is
holding it
• Always store an oxygen
cylinder:
– In a cool, ventilated
area
– Away from high heat
and out of the sun
58

© 2014
• Supplemental oxygen
therapy may be helpful
for patients exhibiting
inadequate ventilation
• Always follow your local
protocols governing the
administration of
oxygen
60

© 2014
• Select the cylinder and
check that the label
reads “Oxygen USP”
61

© 2014
• Remove the wrapper or
cap that protects the
cylinder outlet
• On some models you
may find an “O” ring,
which will be used as a
gasket on the pressure
regulator’s oxygen port
62

© 2014
• To release dust and
debris from the
oxygen valve:
• Crack the main
valve for 1 second
by twisting the
knob a short
distance
counterclockwise
• Then close it
63

© 2014
• Make sure there is an
“O” ring on the
pressure regulator’s
oxygen port
• If you do not see one ,
insert the “O” ring from
the cap
64

© 2014
• Slide the pressure
regulator into place
over the valve assembly
on the cylinder
• Align the safety pins
that will secure the
pressure regulator in
place on the cylinder
65

© 2014
• Open the main valve
again to determine
whether there is a leak:
– Hissing sound indicates
a leak
– Silence indicates that
there is no leak
• If there is a leak:
– Tighten the T-screw
again
– Check again for
leakage
67

© 2014
• Attach an oxygen-
delivery tube to the
oxygen outlet on the
pressure regulator
• Turn the pressure
regulator to the desired
flow setting
• Device is now ready to
deliver oxygen to the
patient
68

© 2014
• Use an oxygen-delivery
device to administer
supplemental oxygen to
a patient:
– Nasal cannula
– Nonrebreather mask
– Pocket mask with an
oxygen inlet
– Bag mask device
69

© 2014
• Some patients will
require high-flow
oxygen:
– Use a nonrebreather
mask (NRB)
• Attach the oxygen hose
to the tank and turn the
regulator to a flow rate
of 10–15 lpm
70

© 2014
• Inflate the reservoir
bag:
– Press a finger on the
one-way valve inside
the mask:
 Forces oxygen into the
bag
• Bag must not deflate
more than 1/3 when
the patient takes his
deepest breath
71

© 2014
• Place the mask over the
patient’s nose and
mouth:
– Ensure a good seal
between the mask and
the face
– Patient’s exhaled
breath will vent
through the port holes
on the mask
72

© 2014
• Nasal cannula:
– Delivers oxygen
directly into the
nostrils
– Use if patient:
 Is unable to tolerate
the NRB mask
 Only needs low-flow
oxygen
73

© 2014
• Attach the oxygen hose
to the tank
• Turn the regulator to a
low-flow level below 6
lpm
• Slip the oxygen-delivery
tubes into the nostrils
• Loop the tube over each
of the patient’s ears
• Secure the tube by
raising the clasp under
the chin
74

© 2014
• Provide positive-
pressure ventilation to
force air into the lungs
if the patient is:
– Not breathing
– Apneic
• Do this with a:
– Pocket mask
– Bag mask device
75

© 2014
• Pocket mask:
– Common device used
for delivering air and
oxygen to a patient in
respiratory distress or
failure
– Covers the nose and
mouth
76

© 2014
• Pocket mask chimney:
– One-way valve
– High-efficiency
particulate air filter
– Reduces exposure to
infectious diseases
when administering
mouth-to-mask
ventilations
77

© 2014
• Attach the oxygen line
to the inlet
• Turn the regulator to a
flow rate of 15 lpm
• Kneel beside or at the
top of the patient’s
head
79

© 2014
• Place the mask over the
patient’s nose and
mouth while keeping
the airway open
• Make sure it seals to the
facial contours for
maximum effectiveness
80

© 2014
• Hold the mask firmly in
place by using your
thumbs and index
fingers to make a “C”
shape around the cone
• Apply even pressure
81

© 2014
• Take a normal breath
• Deliver air by mouth
through the chimney for
1 second
• Look for the patient’s
chest to rise
• Exhaled air will escape
through the vents in the
mask valve
82

© 2014
• Continue to deliver rescue breaths for
as long as necessary
• Delivering one breath every:
– 5–6 seconds for an adult
– 3–5 seconds for an infant or child

© 2014
• If you have a bag mask
device, use that instead
of the pocket mask
• Bag mask device:
– Delivers room air to
the patient
– Can be supplemented
with oxygen from a
cylinder
84

© 2014
• One rescuer should:
– Kneel at the top of the
patient’s head
– Ensure an open airway
• If using supplemental
oxygen, another rescuer
should:
– Attach the oxygen to
the inlet
– Turn the regulator to a
flow rate of 15 lpm
85

© 2014
• Place the mask on the
patient’s face
• Hold it firmly in place
with both hands
• Use your thumbs to
hold the mask over the
bridge of the nose and
your index fingers to
hold it to the chin
• Your remaining fingers
should grip the chin and
jaw
86

© 2014
• Other rescuer squeezes
the bag with both hands
over 1 second, just
enough to see the chest
rise
• Then releases it to
allow the patient to
exhale
• Exhaled air will release
through vents in the
mask, allowing the
mask to remain in place
87

© 2014
• Whenever delivering oxygen to any
patient:
– Always follow your local protocols
– Monitor the patient carefully for any
changes while you wait for further
assistance

© 2014
• Your ability to quickly assess and
maintain a patient’s airway is
critical
• Knowing how to insert airway
adjuncts, how to set up different
oxygen delivery devices and how to
provide supplemental oxygen are
essential EMS skills

ATS - airway management

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