The document discusses airway management and ventilation, which are critical steps in assessing patients. It covers anatomy and physiology of the respiratory system, respiratory problems, and assessment techniques. Key points include the importance of establishing a patent airway and adequate breathing. Manual maneuvers like head-tilt chin-lift are described. Basic airway devices like oropharyngeal airways are presented. Methods of ventilation including bag-valve masks are covered. Advanced techniques like endotracheal intubation are discussed in detail, including indications, equipment, techniques, and verification of proper placement. Continuous monitoring of the airway is emphasized.

1. Airway Management
and Ventilation

2. Airway management
and ventilation are the first
and most critical steps in the
initial assessment of every
patient you will encounter.

3. Topics
 Anatomy of the Respiratory System
 Physiology of the Respiratory
System
 Respiratory Problems
 Respiratory System Assessment
 Airway Management

4. Anatomy of the
Respiratory System

5. The respiratory system
provides a passage for
oxygen to enter the body
and for carbon dioxide to exit
the body.

6. Anatomy of the Upper Airway

7. Upper Airway
 Nasal cavity
 Oral cavity
 Pharynx

8. Oral Cavity
 Cheeks
 Hard palate
 Soft palate
 Tongue
 Gums
 Teeth

9. Nasal Cavity
 Maxillary bone  Sinuses
 Frontal bone  Eustachian tubes
 Nasal bone  Nasolacrimal ducts
 Ethmoid bone  Nares
 Sphenoid bone  Mucous membranes
 Septum

10. Pharynx
 Nasopharynx
 Oropharynx
 Laryngopharynx

11. Larynx
 Thyroid cartilage
 Cricoid cartilage
 Glottic opening
 Vocal cords
 Arytenoid cartilage
 Pyriform fossae
 Cricothyroid cartilage

12. Internal Anatomy of the
Upper Airway

13. Lower Airway Anatomy
 Trachea
 Bronchi
 Alveoli
 Lung parenchyma
 Pleura

14. Anatomy of the Lower Airway

15. Anatomy of the Alveoli

16. Anatomy of the Pediatric Airway

17. The Pediatric Airway
 Smaller and more flexible than an
adult.
 Tongue proportionately larger.
 Epiglottis floppy and round.
 Glottic opening higher and more
anterior.
 Vocal cords slant upward, and are
closer to the base of the tongue.
 Narrowest part is the cricoid cartilage.

18. Physiology of the
Respiratory System

19. Total Lung Capacity (TLC)
 Maximum lung capacity
 Average adult male TLC—6 liters

20. Tidal Volume (VT)
 Average volume of gas inhaled
or exhaled in one respiratory cycle.
 Average adult male:
VT = 500 ml (5-7 cc/kg)

21. Dead Space Volume (VD)
 Amount of gases in tidal volume
that remains in the airway.
 Approximately 150 ml in adult male.

22. Alveolar Volume (VA)
 Amount of gas that reaches the
alveoli for gas exchange
VA = (VT - VP)

23. Minute Volume (Vmin)
 Amount of gas moved in and out of
the respiratory tract in one minute.
Vmin = VT x respiratory rate

24. Residual Volume
(RV)
 The amount of air remaining in
the lungs at the end of maximal
expiration.

25. Inspiratory Reserve Volume
(IRV)
 The amount of air that can be
maximally inhaled after normal
inspiration.

26. Expiratory Reserve Volume
(ERV)
 The amount of air that can be
maximally exhaled after a normal
expiration.

27. Functional Residual
Capacity (FRC)
 The volume of gas that remains in
the lungs at the end of normal
expiration.
FRC = ERV + RV

28. Forced Expiratory Volume
(FEV)
 The amount of air that can be
maximally expired after maximum
inspiration.

29. Introduction
 Respiration is the exchange of
gases between a living organism
and its environment.
 Ventilation is the mechanical
process that moves air into and
out of the lungs.

30. The Respiratory Cycle
Pulmonary ventilation depends upon
pressure changes within the
thoracic cavity.

31. Pulmonary Circulation

32. Diffusion of
Gases Across
an Alveolar
Membrane

33. Measuring Oxygen and
Carbon Dioxide Levels
 Partial pressure is the pressure
exerted by each component of a
gas mixture.
 Partial pressure of a gas is its
percentage of the mixture’s total
pressure.

35. Normal Arterial Partial
Pressures
Oxygen (PaO2) =
100 torr (average = 80 –100).
Carbon dioxide (PaCO2) =
40 torr (average = 35 – 45).

36. Diffusion
 Movement of a gas from an area
of higher concentration to an area
of lower concentration.
 Diffusion transfers gases
between the lungs and the blood
and between the blood and
peripheral tissues.

37. Oxygen Concentration
in the Blood
Oxygen saturation =
O2 content/ O2 capacity x 100%

38. Factors Affecting Oxygen
Concentration in the Blood
 Decreased hemoglobin concentration.
 Inadequate alveolar ventilation.
 Decreased diffusion across the
pulmonary membrane when diffusion
distance increases or the pulmonary
membrane changes.
 Ventilation/perfusion mismatch occurs
when a portion of the alveoli collapses.

39. Inadequate minute volume
respirations can compromise
adequate oxygen intake and
carbon dioxide removal.

40. Factors Affecting Carbon
Dioxide Concentrations in
the Blood (1 of 2)
 Hyperventilation lowers CO2 levels
due to increased respiratory rates
or deeper respiration.
 Causes of increased CO2
production include:
Fever, muscle exertion, shivering,
metabolic processes resulting in
the formation of metabolic acids.

41. Factors Affecting Carbon
Dioxide Concentrations in
the Blood (2 of 2)
 Decreased CO2 elimination results
from decreased alveolar
ventilation.
Respiratory depression, airway
obstruction, respiratory muscle
impairment, obstructive diseases.

42. Regulation of
Respiration

43. Respiratory Rate
 Involuntary; however, can be
voluntarily controlled.
 Chemical and physical mechanisms
provide involuntary impulses to
correct any breathing irregularities.

44. Normal Respiratory Rates
Age Rate Per
Minute
Adult 12-20
Children 18-24
Infants 40-60

45. Respiratory Factors
Factor Effect
Fever Increases
Emotion Increases
Pain Increases
Hypoxia Increases
Acidosis Increases
Stimulants Increase
Depressants Decrease
Sleep Decreases

46. Nervous Impulses from the
Respiratory Center
 Main respiratory center is the medulla.
 Neurons within medulla initiate impulses
that produce respiration.
 Apneustic center assumes respiratory
control if the medulla fails to
initiate impulses.
 Pneumotaxic center controls respiration.

47. Stretch Receptors
The Hering-Breuer reflex
prevents over-expansion
of the lungs.

48. Chemoreceptors
 Located in carotid bodies, arch of
the aorta, and medulla.
 Stimulated by decreased PaO2,
increased PaCO2, and decreased
pH.
 Cerebrospinal fluid (CSF) pH is
primary control of respiratory
center.

49. Hypoxic Drive
 Hypoxemia is a profound stimulus
of respiration in a normal
individual.
 Hypoxic drive increases respiratory
stimulation in people with chronic
respiratory disease.

50. Respiratory Problems

51. Airway Obstruction
 The tongue is the most common
cause of airway obstruction.

52. The Tongue as an Airway Obstruction

53. Other Causes of Airway
Obstruction
 Foreign bodies
 Trauma
 Laryngeal spasm and edema
 Aspiration

54. Respiratory System
Assessment

55. Initial Assessment
 Is the airway patent?
 Is breathing adequate?
 Look, listen, and feel.
 If patient is not breathing, open
the airway and assist ventilations
as necessary.

56. Look.

57. Inspection
 Skin color
 Patient’s position
 Dyspnea
 Modified forms of respiration
 Rate
 Pattern
 Mentation

58. Abnormal Respiratory
Patterns (1 of 3)
 Kussmaul’s respirations
Deep, slow or rapid, gasping; common
in diabetic ketoacidosis.
 Cheyne-Stokes respirations
Progressively deeper, faster breathing
alternating gradually with shallow,
slower breathing, indication brain
stem injury.

59. Abnormal Respiratory
Patterns (2 of 3)
 Biot’s respirations:
Irregular pattern of rate and depth with
sudden, periodic episodes of apnea,
indicating increased intracranial
pressure.
 Central neurogenic
hyperventilation:
Deep, rapid respirations, indicating
increased intracranial pressure.

60. Abnormal Respiratory
Patterns (3 of 3)
Agonal respirations:
Shallow, slow, or infrequent breathing,
indicating brain anoxia.

61. Listen.

62. Ausculation
 Listen at the mouth and nose
for adequate air movement.
 Listen with a stethoscope for
normal or abnormal air movement.

63. Position for auscultating
breath sounds.

64. Airway Sounds
Airflow Gas Exchange
Compromise Compromise
Snoring Crackles
Gurgling Rhonchi
Stridor
Wheezing
Quiet

65. Feel.

66. Palpation
 Palpate chest wall for tenderness,
symmetry, abnormal motion,
crepitus, and subcutaneous
emphysema.
 Assess compliance of lungs.

67. Focused History
 Onset
 Symptom development
 Associated symptoms
 Past medical history
 Recent history
 Does anything make symptoms
better or worse?

68. Non-Invasive
Respiratory Monitoring

69. Pulse Oximeter

70. Combined devices check pulse
oximetry, ETCO2 blood pressure,
pulse, respiratory rate, and
temperature.

71. Oxygenation

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73. Oxygen Supply and
Regulators
 To calculate how long an oxygen tank
will last:
tank life in minutes =
(tank pressure in psi x .28)
liters per minute

74. Oxygen Delivery Devices
Device Oxygen
percentage
Nasal cannula 40%
Venturi mask 24, 28, 35, or 40%
Simple face mask 40 – 60%
Nonrebreather mask 80 – 95%

75. Manual Airway
Maneuvers

76. Personal Protective
Equipment

77. Head Tilt/Chin Lift

78. Modified Jaw Thrust
in Trauma

79. Jaw-Thrust Maneuver

80. Jaw-Lift Maneuver

81. Basic Mechanical
Airways

82. Insert oropharyngeal airway
with tip facing palate.

83. Rotate airway 180º into position.

84. Improper placement of
oropharyngeal airway

85. Nasopharyngeal Airway

86. Nasopharyngeal airway,
inserted

87. Ventilation Methods
 Mouth-to-mouth
 Mouth-to-nose
 Bag-valve device
 Demand valve device
 Automatic transport ventilator

88. Bag-valve-mask ventilation

89. Bag-valve-mask with
built-in colorimetric
ETCO2 detector

90. Demand Valve and Mask

91. Portable Mechanical
Ventilator

92. Ventilation of
Pediatric Patients
 Mask seal can be more difficult.
 Bag size depends on age of child.
 Ventilate according to current
standards.
 Obtain chest rise and fall with
each breath.
 Assess adequacy of ventilations by
observing chest rise, listening to lung
sounds, and assessing clinical
improvement.

93. Direct visualization of the
larynx with a laryngoscope
may enable the removal of an
obstructing foreign body.

94. Magill Forceps

95. Foreign body removal with direct
visualization and Magill forceps

96. Suctioning
 Anticipating complications
when managing an airway is
the key for successful
outcomes.
 Be prepared to suction
all airways to remove blood
or other secretions and for
the patient to vomit.

99. Suctioning Techniques
 Wear protective eyewear, gloves,
and face mask.
 Preoxygenate the patient.
 Determine depth of catheter insertion.
 With suction off, insert catheter.
 Turn on suction and suction while
removing catheter (no more than
10 seconds).
 Hyperventilate the patient.

100. Advanced Airway
Management

101. Endotracheal intubation
is clearly the preferred method
of advanced airway management in
prehospital emergency care.

102. Laryngoscope Blades

103. Engaging laryngoscope
blade and handle

104. Activating laryngoscope light source

105. Placement of Macintosh blade
into vallecula

106. Placement of Miller blade
under epiglottis

107. Endotrol ETT

108. ETT, Stylet, and Syringe,
unassembled

109. ETT and Syringe

110. ETT, Stylet, and Syringe,
assembled for intubation

111. Disadvantages of
Endotracheal Intubation
 Requires considerable training and
experience.
 Requires specialized equipment.
 Requires direct visualization of vocal
cords.
 Bypasses upper airway’s functions
of warming, filtering, and humidifying
the inhaled air.

112. Endotracheal Intubation
Indicators
 Respiratory or cardiac arrest.
 Unconsciousness.
 Risk of aspiration.
 Obstruction due to foreign bodies, trauma,
burns, or anaphylaxis.
 Respiratory extremis due to disease.
 Pneumothorax, hemothorax,
hemopneumothorax with respiratory
difficulty.

113. Complications of
Endotracheal Intubation
 Equipment malfunction
 Teeth breakage and soft tissue
lacerations
 Hypoxia
 Esophageal intubation
 Endobronchial intubation
 Tension pneumothorax

114. Advantages of Endotracheal
Intubation
 Isolates trachea and permits
complete control of airway.
 Impedes gastric distention.
 Eliminates need to maintain a mask
seal.
 Offers direct route for suctioning.
 Permits administration of some
medications.

115. Endotracheal Intubation

116. Hyperventilate patient.

117. Prepare equipment.

118. Apply Sellick’s Maneuver
and insert laryngoscope.

119. Sellick’s Maneuver
(Cricoid Pressure)

120. Airway before
applying Sellick’s

121. Airway with Sellick’s applied (note
compression on the esophagus)

122. Visualize larynx and insert
the ETT.

123. Glottis visualized through
laryngoscopy

124. Inflate cuff, ventilate,
and auscultate.

125. Confirm placement with
an ETCO2 detector.

126. Electronic End-Tidal
CO2 Detector

127. Colorimetric End-Tidal
CO2 Detector

128. Esophageal Detector Device

129. An esophageal intubation
detector-bulb style.
A. Attach device to
endotracheal tube
and squeeze
the detector.

130. If bulb refills easily upon release,
it indicates correct placement.

131. If the bulb does not refill, the
tube is improperly placed.

132. Secure tube.

133. Continuously recheck
and reconfirm the placement of
the endotracheal tube.

134. Reconfirm ETT placement.

135. Lighted Stylet for
Endotracheal Intubation

136. Insertion of lighted stylet/ETT

137. Lighted stylet/ETT in position

138. Transillumination of a lighted stylet

139. Digital Intubation
Insert your
middle
and index fingers
into patient’s
mouth

140. Digital Intubation
Walk your fingers
and palpate the
patient’s epiglottis.

141. Blind orotracheal intubation by
digital method

142. Digital Intubation—
insertion of the ETT

143. Endotracheal Intubation
with In-line Stabilization

144. Hyperventilate patient and
apply c-spine stabilization.

145. Apply Sellick’s Maneuver
and intubate.

146. Ventilate patient and
confirm placement.

147. Secure ETT and apply a
cervical collar.

148. Reconfirm placement.

149. Rapid Sequence Intubation
 A patient who needs intubation
may be awake. RSI paralyzes
the patient to facilitate
endotracheal intubation.

152. Endotracheal Intubation
in a Child

154. ETT size (mm) =
(Age in years + 16)
4

155. Hyperventilate the child.

156. Position the head.

157. Insert the laryngoscope.

158. Insert ETT and ventilate
the child.

159. Confirm placement and
secure ETT.

160. Nasotracheal intubation may
be useful in some situations:
 Possible spinal injury
 Clenched teeth
 Fractured jaw, oral injuries, or recent
oral surgery
 Facial or airway swelling
 Obesity
 Arthritis preventing sniffing position

161. Blind Nasotracheal Intubation

162. Other Intubation Devices
 Esophageal CombiTube (ECT)
 Laryngeal mask airway (LMA)
 Pharyngo-tracheal lumen airway (PtL)
 Esophageal gastric tube (EGTA)
 Esophageal obturator airway (EOA)

163. ECT Airway—
tracheal placement

164. ECT Airway—
esophageal placement

165. Laryngeal Mask Airway

166. Pharyngo-Tracheal
lumen airway

167. The only indication
for a surgical airway is
the inability to establish an
airway by any other method.

168. Anatomical Landmarks
for Cricothyrotomy

169. Locate/palpate
cricothyroid membrane.

170. Proper positioning for
cricothyroid puncture

171. Advance the catheter
with the needle.

172. Jet ventilation with
needle cricothyrotomy

173. Open Cricothyrotomy

174. Cannula properly placed
in trachea

175. Locate cricothyroid membrane.

176. Stabilize larynx and make a 1–2 cm skin
incision over cricothyroid membrane.

177. Make a 1 cm horizontal incision
through the cricothyroid membrane.

178. Using a curved hemostat, spread
membrane incision open.

179. Insert an ETT (6.0)
or Shiley (6.0).

180. Inflate the cuff.

181. Confirm placement.

182. Ventilate.

183. Secure tube, reconfirm placement,
evaluate patient.

184. Tracheostomy Cannulae

185. Patients with Stoma Sites
 Patients who have had a laryngectomy
or tracheostomy breathe through a
stoma.
 There are often problems with excess
secretions, and a stoma may
become plugged.

186. Tracheostomy Suction Technique