This is the introduction to airway management for Advanced EMTs though some medics might find it useful too. Focuses mainly on supraglottic and periglottic airway devices as well as basic anatomy , physiology, etc. Talks about apniec defusion too.
5. The Upper Airway
1. Nose
Warm and humidify air through
turbinates
2. Mouth and oral cavity
Advanced airway
Entrance to the digestive system
Also involved in the production of
speech
Tongue
3. Jaw
Facial bones
Maxilla
mandible
4. Pharynx
Nasopharynx
Oropharynx
Hypopharynx
Laryngopharyx
5. Larynx
Epiglottis – muscular structure
which protects the airway of
conscious patients during
swallowing
Vocal cords – thin muscles which
are the center for speech and
protect the lower airways
Thyroid cartilage
Cricoid ring
6. Jugular notch
7. The Lower Airway
1. Trachea
Hollow tube which passes
air to the lower airways
Supported by cartilage
rings
2. Carina
The bifurcation of the
trachea into the two main
stem bronchi
3. Bronchi
Hollow tubes which
further divide into lower
airways of the lungs
Supported by cartilage
Alveoli
4. Lungs
a. Bronchioles
i. thin hollow tubes leading to the
alveoli
ii. remain open through smooth
muscle tone
Bronchial smooth muscle
Beta2 adrenergic receptors
b. Alveoli
i. the end of the airway
ii. millions of thin walled sacs
iii. each alveolus surrounded by
capillary blood vessels
iv. site where oxygen and carbon
dioxide (waste) are exchanged
c. Pulmonary capillary beds
i. blood vessels that begin as capillary
surrounding each alveolus
ii. with adequate blood volume and
blood pressure, the vessels return
oxygenated blood to the heart
13. Key Point
It takes approximately 150-200 cc
of air movement to reach the
terminal bronchus and the
aveoli…
This is called “Dead Air Space”
Tidal volumes less than 200 cc typically
do not oxygenate/ventilate at the
aveolar level.
20. The Chest Cavity
The neurovascular bundle lies closely along the
lowest margin of each rib.
The pleura covers each lung and the thoracic cavity
The visceral pleura covers the lungs and the parietal pleura
covers the thoracic cavity.
There is also a negative pressure between the two that keeps
them stuck together yet not actually attached.
Surfactant allows the lungs to move freely against the inner
chest wall during respiration.
21. Intercostal Muscles and Diaphram
The Intercostal Muscles
are several groups of
muscles that run
between the ribs
The diaphragm is a
muscle that separates
the thoracic cavity from
the abdominal cavity.
Together they help the
“Mechanical Bellows”
22. Mechanics of Ventilation
The intercostal muscles (between the ribs) contract
during inhalation.
The diaphragm contracts at the same time.
The intercostal muscles and the diaphragm relax
during exhalation.
The body should not have to work to breathe when
in a resting state.
23. Mechanics of Ventilation
Patients with a spinal
injury below C5 can
still breathe from the
diaphragm.
Patients with a spinal
injury above C3 may
lose the ability to
breathe altogether.
25. The Mechanical Bellows
The muscles of the ribs
expand the size of the
chest, creating a (relative)
negative pressure.
Air (with O2) moves in to
fill the void.
Commonly thought of as
Oxygenation.
Actual oxygenation takes
place at the cellular level.
Special Thanks to Charlie Miller for this Graphic.
26. The Mechanical Bellows
The intercostals muscles
relax, allowing the chest
to return to its neutral
position, expelling air out
of the lungs (and CO2
with it.)
Commonly thought of as
Ventilation.
Actual ventilation takes
place at the cellular level.
Special Thanks to Charlie Miller for this Graphic.
27. The Mechanical Bellows
Example of a
Compromised Bellows
Positional Asphyxia
Special Thanks to Charlie Miller for this Graphic.
28. Key Point:
A comprehensive understanding
of the Anatomy of the airway and
thorax is essential to managing
the airway and respiratory
functions of your patient.
29. A K A : H O W W E B R E A T H … . .
Physiology of Respiration
30. Key Definitions
Tidal Volume (Vt)
Typically 500-700 cc
Minute Volume (Vm)
Tidal Volume X Respiratory Rate = Minute Volume
Functional Reserve Capacity (FRC)
Typically 2,400 cc in a 70 kg Human
Inspired Oxygen (FiO2)
Fraction of Inspired Oxygen
Expressed as a decimal, i.e. 80% is 0.8 FiO2. 100% is 1.0
FiO2
Work of Breathing (WOB)
31. Respiratory Rate
times x
Tidal Volume
(amount of air exchanged
in one breath)
equals =
Minute Ventilation
Minute Ventilation
RR x TV = minute volume
32. Physiology of Respiration
Diffusion of O2 from the lung to the blood is by the
binding of O2 to the hemoglobin (Hgb)
This is dependant on a pressure gradient.
This is a Passive transport system.
It is also dependant on available surface area and distance
it must travel to cross the threshold.
Capillaries and Alveoli are where the real
Oxygenation and ventilation take place.
33. Alveolar Ventilation
Minute Ventilation
minus –
Dead Air Space
equals =
Alveolar Ventilation
Dead Air Space: the
trachea, bronchi, and
bronchioles.
There is NO gas exchange in
these areas.
34. Key components of an intact respiratory system
An appropriate Drive to Breath
Airway and respiratory tract
Mechanical Bellows
A diffusion friendly place for gas exchange to
happen.
An O2 friendly RBC with hgb.
An intact circulatory system to carry the gasses
and waste through out the body.
Must have enough of a pressure to promote diffusion.
An intact capillary bed
Its like a truck shipping company.
35. Drive to breath
Controlled by the CNS through information
gathered from receptors in the body.
Located in the pons region of the brainstem
Detects increases in CO2 or decreases in pH and
informs the brain to increase the respiratory rate.
Increased respiratory rate reduces CO2 and will
increase pH.
Other things can effect our drive to breath
36. “Hypoxic Drive”
Develops in some patients with Chronic Lung
Disease
Pons region of brain becomes sensitized to constant
increased CO2 state
Regulation is now based on O2 level in blood
Increased oxygen level states may tell the brain to
stop breathing
38. An O2 friendly RBC with hgb.
Hemoglobin is an Iron Based compound essential
to the transport of O2.
Anemia
Cyanide Poisoning
CO Poisoning
39. An intact circulatory system
Blood Loss
Shock
Pump Problem
Volume Problem
Fluid issue
O2 carrying issue
Vessel Problem
40. KEY POINT:
Must have enough of a pulmonary perfusion pressure
to promote diffusion.
Conditions like Hypotension
cause secondary hypoxia by
promoting low perfusion.
41. Physiology of Respiration
The primary function of the respiratory system is
gaseous exchange.
Ventilation and Oxygenation.
Air is composed of a mixture of gases.
Breathing is largely controlled by the Autonomic
Nervous system, in response to changes sensed
in all parts of the body. The biggest part of this is
the “Hypoxic Drive”.
42. Physiology of Respiration
Ventilation is the body’s ability to move gas (usually
atmospheric air) in and out of the chest and lung
tissue.
Respiration is the exchange of gases in the alveoli of
the lung tissue.
43. Physiology of Respiration
Oxygen exchange can be hindered by:
Condition in the airway
Disease processes- COPD, asthma, pneumonia, pulmonary edema
Traumatic conditions
Abnormalities in pulmonary vessels
Altitude
Closed environment
Toxins or poisonous environment
Drowning
Occupational exposure
44. All cells need a constant supply of oxygen to survive.
Physiology of Respiration
45. Inhalation
The active part of breathing
Focused on delivering oxygen to the alveoli
Tidal volume is the amount of air that moves into or out of
the lungs during a single breath.
Minute ventilation (minute volume) is the amount of air
moved through the lungs in 1 minute minus the dead space.
Ventilation
46. Exhalation
Passive process
Diaphragm and intercostal muscles relax.
Smaller thorax compresses air out of the lungs.
Vital capacity is the amount of air that can be forcibly
expelled from the lungs after breathing deeply.
Residual volume refers to the air that remains after maximal
expiration.
Ventilation
47. Regulation of ventilation
The body’s need for oxygen is constantly changing.
Failure to meet the need may result in hypoxia.
For most people, the drive to breathe is based on pH
changes in blood and cerebrospinal fluid.
Ventilation
48. Q U I C K R E V I E W
A L S O R E V I E W E D I N M E D I C A L E M E R G E N C I E S
Respiratory Compromise
49. Pneumothorax
Commonly called a collapsed lung
Accumulation of air in the pleural space
Blood passing through the collapsed portion of the lung is not
oxygenated.
You may hear diminished, absent, or abnormal breath
sounds.
52. Tension Pneumothorax
Tension pneumothorax
Results from significant air accumulation in the pleural space
Increased pressure in the chest causes:
Complete collapse of the affected lung
Mediastinum to be pushed into the opposite pleural
cavity
54. Blood collects in the
pleural space from
bleeding around the
rib cage or from a lung
or great vessel.
Hemothorax
55. Pulmonary Edema
Heart muscle can’t circulate blood properly.
Left ventricle is compromised resulting in “backflow.”
Fluid builds up within alveoli and in lung tissue.
Usually result of congestive heart failure
Pulmonary trauma
Chemical exposures
57. Chronic Obstructive Pulmonary Disease
(COPD)
Slow process of constriction and disruption of
airways and alveoli
Caused by chronic bronchial obstruction
Tobacco smoke can create chronic bronchitis.
58. Chronic Obstructive Pulmonary Disease
(COPD)
Emphysema is another type of COPD.
Loss of elastic material around air spaces
Causes include inflamed airways and smoking.
Most patients with COPD have elements of both
chronic bronchitis and emphysema.
60. Chronic Obstructive Pulmonary Disease
(COPD)
“Wet lungs” vs. “dry lungs”
“Wet lungs” sounds—pulmonary edema
“Dry lungs” sounds—COPD
Can be easily confused with congestive heart failure
61. Asthma, Hay Fever, and Anaphylaxis
Result of allergic reaction to inhaled, ingested, or
injected substance
In some cases an allergen cannot be identified.
Asthma is acute spasm of smaller air passages
(bronchioles).
62. Asthma is acute spasm of
smaller air passages
(bronchioles).
Asthma
63. Signs of Mechanical Ventilation Impairment
Abnormal sounds include wheezing, rales,
rhonchi, and stridor.
64. Management & Interventions
Insure adequate airway and ventilation
Either assisted or on patient’s own
Use of adjuncts
Pulse oximetry
Provide supplemental oxygen
NRB, NC, Nebulizer with Albuterol
Reference ACP SWO Appendix A
Provide positive pressure ventilations if indicated
BVM
Demand valve
Automatic transport ventilator (ATV)
76. Abnormal breath sounds
Rales (crackles): fine bubbling sound of fluid in
alveoli (“Rice Krispies”: snap, crackle and pop)
Alveoli popping open.
Rhonchi: fluid in larger airways, obstructing object
in the bronchus
Wheezes: high pitched whistling, air through
narrowed airways
SILENCE IS BAD NEWS
83. A pulse oximeter measures the percentage of
hemoglobin saturation.
Should be 95% to 100% while breathing room air.
AHA recommendations are to maintain a saturation of
greater than 94%.
A saturation of 75% is extremely low. Approximately the
level of oxygen that should be returning from the tissues.
Assessment
84. Inaccurate pulse oximetry readings may be caused by:
Hypovolemia
Anemia
Severe peripheral vasoconstriction (including cold)
Nail polish (turn sensory sideways)
Dirty fingers
Carbon monoxide poisoning
Assessment
85. Assessment
Assess for:
Gag reflex
Airway obstruction
Soft tissue obstruction
Foreign bodies
Complete or incomplete
Upper vs. lower
Work of breathing
Laryngospasm
Laryngeal edema
Penetrating injuries.
98. KEY POINTS
BVM ventilation is a perishable skill and
surprisingly difficult on mannequins, as well
as many patients. A number of studies have
demonstrated the difficulties performing
BVM ventilation on real patients in field
situations.
The “weak link” in using the BVM is the “Face
Mask Seal”.
103. Predictors of difficult ventilation…
In addition to the psycho-motor and provider difficulties of retaining
this vital skill, research has shown us that the patient themselves
present many predictable difficulties to successful BVM ventilation.
Some of the major ones are:
a body mass index of 30 kg/square meter or more
Presence of a beard
Mallampati score of three or four
Age of 57 or older
Severely limited jaw protrusion
Snoring.
Maxillo-Facial Trauma
Short thyromental distance
The edentulous, and obese patients.
Of these 9 co-morbid factors, 5 of which are directly dependant on face
mask seal, and therefore these five which would be mitigated if not
eliminated with the use of the IOM.
Kheterpal S, Han R, Tremper KK, et al. Incidence and predictors of
difficult and impossible mask ventilation. Anesthesiology. 2006 Nov;
105(5):885-91.
104. Nu-Mask
Nu-Mask is a new alternative to the BVM.
It is for patients whom a getting a face mask seal is
problematic.
It is the only device for difficult aiways that can be
used by both BLS and ALS providers.
ACP/ACEMSS is deploying these to all BLS and ALS
units in the system.
107. KEY POINT
The IOM uses internal oral tissue to
obtain a superior “wet seal”. Because
hand placement, hand size, and hand
position are not as crucial, the IOM is
easier to use.
108. Key Points about suction…
300 mm hg for adults
No more than 120 mm hg for pediatrics
Intervals
Prefer < 10 seconds (2010 ECC Guidelines for CPR)
Devices
Soft tip
Yankour/Big Stick
In Line
109. Types of Portable Suction
Courtesy of Laerdal Medical Corporation, Armonk, NY
111. AEMT “Supraglottic” airway devices
Indications
To promote airway management by providing a patent airway
in the unconscious, and/or apneic patient.
Contraindications
Responsive patients with an intact gag reflex.
Patients with known esophageal disease, i.e. esophageal
varices.
Patients known or suspected to have ingested caustic
substances.
112. KEY POINT
THE NEW AEMT SCOPE OF PRACTICE DOES
NOT CONTAIN ETT.
Discussion: Is this a god idea or bad?
This doesn’t mean that the AEMT shouldn’t have a
working understanding of the ETT so as to be a
better clinical provider and member of the overall
health care team.
122. King Airway
Size determined
by Pt’s height:
Yellow: 4-5 ft
Red: 5-6 ft
Purple: > 6 ft
123. Instructions for use
Choose appropriate size based on patient’s height.
Test cuffs by inflating to recommended volume of
air and deflate cuffs completely before attempting
to insert. 60-90ml air based on device size.
Generously lubricate tube using a water based
lube.
Pre-oxygenate patient with 100% O2
Have suction available.
124. Insertion:
Position the head in a slightly sniffing position,
unless spinal injury is known or suspected. Then
maintain cervical alignment and keep the head in a
neutral position.
Insert King rotated 45-90 degrees laterally and
insert into mouth
As you gently advance the tube rotate tube to
midline.
Advance tube until base of connector aligns with
teeth or gums.
125. Cuff inflation:
Inflate cuffs with minimum volume necessary to
seal the airway according to tube size.
“SEAT THE TUBE”
GENTLY tug on the tube to appropriately place it…
Attach to resuscitator bag and ventilate using 100%
O2 source.
Assure chest rise and fall. Auscultate breath
sounds.
Secure tube, using a commercially approved
device, noting depth of tube placement.
Monitor end tidal CO2 if available.
127. Probably the most important skills in EMS at any
level.
Basic airway and ventilation techniques are
extremely effective.
Airway management is the one advanced skill that
can have the greatest impact on patient mortality
and morbidity.
It is imperative that you become experts at basic
and advance airway management.
Assisted and Artificial Ventilation
130. When assisting with a bag-mask device:
Explain the procedure to the patient.
Place the mask over the nose and mouth.
Squeeze the bag each time the patient breathes.
Maintain an adequate minute volume.
Assisted and Artificial Ventilation
131. Artificial ventilation
Devices include:
Pocket face masks
Bag-mask device
CPAP/BiPAP
Manually triggered ventilation device
Automatic transport ventilator
Assisted and Artificial Ventilation
132. Assisted and Artificial Ventilation
Pocket Masks
Includes IOM/NEW MASK
Advantages:
Small, easy to use
Easy to use two handed technique
Oxygen optional
Disadvantages
Down near the patients face---YUCK
High FiO difficult
133. Assisted and Artificial Ventilation
Bag Valve Mask
Advantages
Self inflating
Can be used with or without an oxygen source
Can be used with the IOM/NuMask
Disadvantages
Difficult to obtain a mask seal at times (dentures removed,
facial hair, etc. )
Best results if used with more than one rescuer
134. Manually triggered ventilation devices
Advantages:
Also known as flow-restricted, oxygen-powered ventilation device
Allows single rescuer to use both hands to maintain mask-to-face seal while
providing positive-pressure ventilation
Should not be used routinely
Disadvantages
Difficult to maintain adequate
ventilation without assistance
Requires oxygen. Typical adult ventilation
consumes 5 liters per minute O2 versus
15-25 liters per minute for a bag-valve-mask
Typically used on adult patients only
Requires special unit and additional
training for use in pediatric patients
The rescuer is unable to easily assess lung
compliance
High ventilator pressures may damage lung tissue
Assisted and Artificial Ventilation
135. Automatic transport
ventilator (ATV)
Manually triggered device
attached to a control box
Allows the variables of
ventilation to be set
Lacks the control of a hospital
ventilator
Frees the EMT to perform other
tasks
Assisted and Artificial Ventilation
Courtesy of Impact Instrumentation, Inc.
136. CPAP
Continuous Positive Airway Pressure
Advantages
Is a BLS intervention in many states
May reduce the need for advanced airway management
Reduces in hospital stays
Better outcomes overall…
Disadvantages
Requires an EXCELLENT face-mask seal
Will not provide ventilation, only assist the patients own ventilatory
effort
May lower the blood pressure
May promote gastric distention
Can not be used if airway reflexes are compromised.
137. Automatic transport ventilator (ATV)
Disadvantages
requires oxygen. Typical adult ventilation consumes 5 liters
per minute 02 versus 15-25 liters per minute for a bag-valve-
mask
may require an external power source
must have bag-valve-mask device available
may interfere with timing of chest compressions during CPR
must monitor to assure full exhalation
barotrauma
138. Automatic transport ventilator (ATV)
Generally consumes 5 L/min of oxygen
May lead to hypoventilation in patients with:
Poor lung compliance
Increased airway resistance
Airway obstruction
Assess patient for full chest recoil.
Assisted and Artificial Ventilation
139. Patients with tracheostomies do not breathe through their mouth and
nose.
Tracheostomy masks may be available. A face mask may also be used.
If the trach has a 15mm
adaptor, a standard BVM
will fit onto the adaptor. If
not you will need to us a pediatric
mask for a seal.
Tracheostomy
140. Changes in the body
There are several changes in the bodies physiology
during positive pressure ventilation:
Air Movement
Normal ventilation has a negative intrathoracic pressure
leading air to get “sucked” into the lungs.
With positive pressure you are “pushing” the air into the cavity
141. Changes in the body
Blood Movement
1. Normal ventilation
a. Blood return from the body happens naturally
b. Blood is pulled back to the heart during normal breathing
2. Positive pressure ventilation
a. Venous return is decreased during lung inflation
Use caution to not overinflate
b. Amount of blood pumped out of the heart is reduced
142. Changes in the body
Esophageal Opening Pressure
Positive pressure ventilation
Air is pushed into the stomach during ventilation
Gastric distention may lead to vomiting
Sellick’s maneuver (cricoid pressure)
Use during positive pressure ventilation
Reduces amount of air in stomach
Procedure
identify cricoid cartilage
apply firm backward pressure to cricoid cartilage with thumb and index finger
Do not use if
patient is vomiting or starts to vomit
patient is responsive
breathing tube has been placed by advanced level providers
143. Special patient population
Use caution with artificial ventilation with geriatric
and pediatric patients.
Geriatric
Geriatric disease process break down lung tissue and elasticity
of their lungs, use caution with positive pressure ventilation.
Pediatric
Pediatric airways are significantly smaller (the size of THEIR
pinky finger) and require less volume.
Large, floppy tongues
Padding under shoulders
Do not hyperextend pt neck, it will “kink” the trachea
Gastric distention
144. Take Home Points….
All pt’s with SOB get O2. Lots of O2.
Listen to ALL lungs.
Beware of the “silent chest”.
Noisy Breathing is abnormal breathing
Visible Breathing is abnormal breathing.
Positional breathing is abnormal breathing.
Abnormal Breathing gets O2.