3. Objectives
Name the major components of the upper
and lower airways
Describe the functions of the upper and
lower airways
Describe the process of ventilation
Describe the process of respiration
Identify the S.A.L.T.™ device
Demonstrate use of the S.A.L.T.™ device
Explain the SMO for the S.A.L.T.™ device
8. Upper Airway
Anterior Nares - These are the holes in the nose on the front of the
face through which air is entrained for the purpose of ventilation.
Vestibule – This space is the area just inside the nose that serves as a
collection area as air enters the respiratory system through the nose.
The Vibrissae (nose hair) are located here and this is where large
particulate matter is trapped in the first step of filtering and purifying
the air we breathe.
Mucosal lining – The lining of the entire respiratory tract all the way
down to the smallest of the bronchioles is made of mucosal
epithelium which is rich with goblet cells that produce mucus. Also
noteworthy is that these cells have cilia. This important structure is very
vascular as well. It serves multiple functions including
warming, adding moisture, further filtering the air. The rich blood
supply warms the air. The mucus it produces serves to moisten the air
and to trap the smaller particulate matter to further purify the air. The
cilia move the mucus.
Septum – This structure forms the middle ridge line of the nose dividing
it into left and right halves. The majority of the septum is made of
cartilage which is attached to the septal bone of the nose.
9. Upper Airway
Nasal turbinates / Conchae – There are three sets of turbinates
(a.k.a., Conchae). The inferior are the largest and have the most
surface area in which to warm and moisten the air. Then there are
the middle and the superior turbinates. The mucosal lining becomes
thinner and less vascular as it goes up and in the superior turbinates it
is more yellow than red. It is here that the olfactory nerve endings
extend through the Ethmoid bone and air is gathered for the sense of
smell. The Conchae are located on the lateral walls of the interior of
the nose.
Posterior nares – The posterior nares are the openings of the posterior
nose into the Nasopharynx.
Nasopharynx – The superior portion of the throat that is directly behind
the nose and extends down to the opening of the oral cavity at the
posterior soft palate.
Oropharynx – The portion of the throat directly behind the oral cavity
from the soft palate down to the superior rim of the hyoid bone.
Pharynx - Is about 12.5 cm long extending from the base of the skull to
the esophagus encompassing the Nasopharynx and the oropharynx.
10. Upper Airway
Larynx – (a.k.a., voice box) serves as the entry point into the
trachea and extends from the base of the tongue to the top
of the trachea using the third – the sixth vertebrae as a
reference in adult men. It is typically higher in women and
children.
Epiglottis – Is a cartilaginous structure that is the superior
portion of the larynx. It serves as a flap to cover the glottis
during swallowing since the oropharynx is a passage way for
both food and air.
Vocal folds – There are two sets of vocal folds. The false vocal
folds, so called because they do not make actual
vocalization, are the two white appearing lines of the vocal
cords that vibrate as air passes through them to make sound.
Rima glottidis – The space between the two true vocal folds
(cords).
Glottis - The entirety of the false and true vocal folds and the
rima glottidis.
11. Flow of Air in the Upper Airway
Flow of Air
Anterior nares
Vestibule
Vibrissae
Nasal turbinates(conchae)
Inferior
Middle
Superior
Posterior nares
Nasopharynx
Oropharynx
Epiglottis
Glottis
Vocal folds
Rima glottidis
13. Lower Airway Anatomy
Trachea
Mucous membrane
C-shaped cartilaginous
rings
Carina
Left main bronchus
Right main bronchus
Bronchial Tree
Bronchioles
Alveolar ducts
Alveolar sacs
Alveoli
̴300,000,000
Capillaries
14. Lower Airway
Trachea – Sometimes referred to as the “wind pipe”, the trachea the
first structure of the lower airway. It is, as noted earlier, lined with the
same type of mucus membrane as the rest of the airways. It extends
from the inferior edge of the larynx to the carina.
C-Shaped cartilaginous rings – As the name suggests, these structures
are „C‟ shaped with the opening in the posterior and they are made
of cartilage. The serve to provide shape, support and protection to
the trachea. Without these rings, the trachea could collapse shutting
off the vital supply of air. They are not complete rings so as to allow
expansion and contraction of the trachea as its smooth muscles
respond to the ever-changing conditions of the human body.
Carina – This is the inferior wall of the trachea that sits at the
bifurcation of the trachea into two main bronchi.
Right main bronchus – This is the right branch of the trachea and is
often larger and has a less acute angle to the trachea. Its size and
position make it the more common path of endotracheal tubes that
are placed too deep. It serves as the primary branch for all other
branches of the bronchial tree in the right lung.
15. Lower Airway
Left main bronchus – The primary branch of the bronchial tree
that supplies the left lung. Its angle to the trachea is typically
more acute and it is often smaller in diameter than its right
counterpart.
Bronchial Tree – This term is used to describe the branching of
the bronchi down to the innumerable bronchioles that serve
to transmit air into the alveoli. As the branches get
smaller, the cartilaginous rings become more irregularly
shaped and complete so as to support the small airways and
prevent collapse.
Bronchioles – These are the smallest airways of the lower
airway anatomy. They terminate into the alveolar ducts
which are the connection to the alveoli. At this level, the rings
of cartilage have disappeared.
Alveolar ducts – These are the small, acartilaginous airways
that transmit air into the alveolar sacs.
16. Lower Airway
Alveolar sacs – The terminal of gas exchange is the
alveolar sac. These are often said to look like a
bunch of grapes. These tiny (microscopic) sacs are
enveloped in capillaries that are in contact with
their surface. The „grape-like‟ structure provides a
large surface area for efficient gas exchange.
Alveoli – This is the term applied to the „bunches of
grapes‟ and it has been estimated that there are
around 300,000,000 alveoli in the human lungs.
Capillaries – The capillaries are the smallest of blood
vessels and are typically only one cell thick. This
allows for efficient exchange of gases, glucose, and
waste products between individual cells and the
blood.
17. Ventilation vs. Respiration
Ventilation is the Respiration is said to
mechanical be the “processes
movement of air that result in the
into and out of the absorption, transport,
and utilization or
body.
exchange of
respiratory gases
between an
organism and its
environment.”₁
We can produce artificial ventilation but we cannot produce artificial respiration!
18. Respiration
Respiration begins at the anterior nares and ends at
the anterior nares and it includes everything that
happens in between.
Ventilation moves the oxygen rich air in and displaces
the carbon dioxide rich air out.
It is in the alveoli that gas exchange takes place and
the airways are the transmission pathways for the
gases.
As mentioned before, the walls of the capillaries are in
contact with the walls of the alveoli and this contact is
the point at which CO2 trades places with O2 making it
possible for the body to remain homeostatic.
Keeping in mind that all of this occurs at the cellular
level, remember that our job is keeping as many cells
alive as we can for as long as we can.
19. “the lungs serve the alveoli” just
as “the circulatory system serves
the capillaries.”
₁
20. Alveolar Function
Gas exchange easily
takes place in the
alveoli
Alveoli are thin-
walled
Each alveolus is in
contact with the
capillaries that
surround it
Capillary walls at this
level are only 1 cell
thick
21.
22. Supraglottic Airway
Laryngopharangeal Tube
“The S.A.L.T.™ is a
unique single patient
use oropharyngeal
airway which can be
utilized to facilitate
blind, endotracheal
intubation. The
S.A.L.T.™ can also be
utilized to reduce
accidental
endotracheal tube
extubation.”
23. S.A.L.T.™
Supraglottic Airway Laryngopharangeal Tube –“ The S.A.L.T.™ is a unique single
patient use oropharyngeal airway which can be utilized to facilitate
blind, endotracheal intubation. The S.A.L.T.™ can also be utilized to reduce
accidental endotracheal tube extubation.”(Though this is not grammatically
correct, it is a direct quotation and so was not changed.)
This device will be used as an adjunct to open the airway and to facilitate
endotracheal intubation in the difficult airway patients.
We, here at National EMS, will use it after two (2) attempts at intubation via direct
laryngoscopy or when patient access is compromised making direct
laryngoscopy unreasonable.
This device can be inserted using the tongue blade method the same way
standard OPA‟s are inserted or by direct laryngoscopy.
Remember that good BLS is a prerequisite to any ALS procedure. Always begin
with simple airway maneuvers such as the head-tilt/chin-lift or jaw-thrust then
bag-valve-mask ventilation if required.
Once the decision has been made to move on to advanced airway
management, we will start with endotracheal intubation via direct laryngoscopy.
This is a skill we need to maintain and practice is the only way to do that.
If intubation by direct laryngoscopy is not successful after the second
attempt, insertion of the S.A.L.T.™ should be done as follows:
24. S.A.L.T.™
Indications
1. The S.A.L.T.™ is designed and intended for
airway management in emergency or difficult
airway cases.
2. Absence of a gag reflex.
Contraindications
1. Responsive patients with an intact gag reflex.
2. Patients with known esophageal disease.
3. Patients who have ingested caustic
substances.
25. Suggested Instructions for Use
1. Confirm anatomical compatibility by measuring the
S.A.L.T.™ from the level of the patient's lips to the superior
edge of the larynx.
2. Open-patient's airway utilizing appropriate manual
maneuvers.
3. Ventilate/oxygenate patient via bag-valve mask or pocket
face mask and observe for adequate chest rise/expansion
and ventilatory compliance. If patient's airway is
obstructed, remove obstruction prior to insertion of the
S.A.L.T.™ If the patient exhibits no signs of foreign body
airway obstruction and has no gag reflex, prepare for
insertion of the SALT
4. Lubricate the distal end of the S.A.L.T.™ with a water soluble
lubricant.
5. Grasp the distal end of the S.A.L.T.™ by placing the thumb
against one lateral wall and the index finger against the
opposite lateral wall.
26. Suggested Instructions for Use
6. Align the patient's airway in a neutral position.
7. Insert tongue depressor into patient's posterior oropharynx
and push anteriorly, retracting the tongue. This action will
aid in displacing the epiglottis superiorly allowing the
S.A.L.T.™ to be advanced beneath the epiglottis.
8. Insert the S.A.L.T.™ into the patient's oropharynx, grasp the
proximal end of the S.A.L.T.™ and advance following the
anatomical contour of the airway until:
a) resistance is encountered (indicating the SAL.T. has abutted
against the corniculate cartilage and/or
b) the depth indicator ring rests against the lips or gumline.
9. Remove tongue depressor after the S.A.L.T.™ has been
inserted to the proper depth.
10. Ventilate/oxygenate the patient via bag-valve mask or
pocket face mask and observe for adequate chest
rise/expansion and ventilatory compliance.
27. Alternate Instructions for Use
1. Utilizing a laryngoscope, advance a laryngoscope blade
(straight #3, curved #3, or curved #4) into the patient's
posterior pharynx and gently lift upward. This action will
displace the epiglottis superiorly allowing the S.A.L.T.™ to be
advanced beneath the epiglottis. Note: Visualization of the
epiglottis is not required.
2. Insert the S.A.L.T.™ into the patient's oropharynx, grasp the
proximal end of the S.A.L.T.™ and advance the airway until:
a) resistance is encountered (indicating the S.A.L.T. has abutted
against the corniculate cartilage and/or
b) the depth indicator ring rests against the lips or gumline.
3. Remove laryngoscope blade after the S.A.L.T.™ has been
inserted to the proper depth.
4. Ventilate/oxygenate the patient via bag-valve mask or
pocket face mask and observe for adequate chest
rise/expansion and ventilatory compliance.
Note: If rescuer encounters poor ventilatory compliance; slightly withdraw
S.A.L.T.™, re-advance S.A.L.T., and reassess ventilatory status.
28. Insertion of Endotracheal Tube
1. Ensure patient is being adequately
ventilated/oxygenated.
2. Lubricate distal end of endotracheal tube with a
water soluble lubricant.
3. Insert the endotracheal tube and advance to proper
depth.
Note: If resistance is encountered during endotracheal
tube insertion:
a) withdraw endotrachealtube and slightly withdraw
S.A.L.T.™. Readvance S.A.L.T.™ and reattempt
endotracheal tube insertion or
b) withdraw endotracheal tube, apply cricoid pressure and
reattempt endotracheal tube insertion
Note: If esophageal placement is either detected or suspected, the endotracheal tube should be immediately removed and the
patient should be ventilated via bag-valve mask and supplemental oxygen prior to repeated endotracheal intubation attempts or
alternative airway management.
29. Insertion of Endotracheal Tube
4. Ventilate patient via bag-valve
resuscitator/supplemental oxygen and confirm
endotracheal tube placement by:
a) observing chest for adequate chest rise/expansion.
b) auscultating over epigastric region for absence of
gurgling sounds.
c) auscultating over lung fields (left and right anterior
chest/left and right lateral chest) for presence of bilateral
breath sounds.
d) observing moisture in the endotracheal tube.
e) utilizing an end-tidal C02 detector and observing color
change indicative of adequate concentration of C02.
f) utilizing an esophageal intubation detector.
g) utilizing capnometry/capnography and observing
readings/waveforms indicative of adequate
concentration of C02.
Note: If esophageal placement is either detected or suspected, the endotracheal tube should be immediately removed and the
patient should be ventilated via bag-valve mask and supplemental oxygen prior to repeated endotracheal intubation attempts or
alternative airway management.
30. Instructions for ET Tube
Securing/Clamping Device
1. Place ET Tube securing clamp around ET Tube
at the superior edge of the SAL.T. Note tube
depth.
2. Secure clamp firmly around ET Tube. DO NOT
CRUSH or COLLAPSE ET TUBE.
3. Place strap under/behind patients
head/neck.
4. Pull strap tight and connect to securing post
on opposite side of ET Tube Clamp securing
post.
5. Verify ET Tube placement after securing of
tube.
31. Instructions for Removal of
S.A.L.T. with ET Tube in Place
1. Ensure the patient is well oxygenated.
2. Remove tape or tube securing device.
3. Disconnect the 15 mm adapter from the
endotracheal tube.
4. Gently retract the S.A.L.T.™, allowing it to slide over
the endotracheal tube.
5. As soon as practical, grip the endotracheal tube
while removing the S.A.L.T.™ from the oropharynx
to ensure minimal movement of the endotracheal
tube.
6. Confirm endotracheal tube placement in
accordance with local protocol.
7. Secure endotracheal tube in accordance with
local protocol.
Note: Because the S.A.L.T.™ serves to protect against accidental endotracheal tube extubation, it is
recommended that the S.A.L.T.™ not be removed during the prehospital phase of care, unless absolutely
necessary.³
32. Standing Medical Order*
A. Open Airway
1. Manual maneuvers
2. Clear obstructions using the appropriate
techniques/suction
3. If necessary, insert appropriate airway
device to maintain the airway (i.e.
oropharyngeal, nasopharyngeal, endotrach
eal tube, S.A.L.T. ™, Combi-tube/King
Airway, cricothyrotomy)
*The following SMO is provided as an example only. Check with your Medical Director for the current Airway Management SMO
at your service.
33. Standing Medical Order
4. Intubate any unconscious patient without a gag
reflex
a. monitor patient‟s pulse oximetry and cardiac rhythm
at all times to prevent unrecognized hypoxia
b. hyper oxygenate prior to intubation attempt
c. if not able to place tube within 30
sec., withdraw, hyper oxygenate, and re-attempt
d. verify placement using Ambu tube check
device, observing appropriate chest rise, end tidal
CO2 monitoring, and auscultation of breath sounds
e. orotracheal or nasotracheal intubation as indicated
f. secure tube with ET tube holder (pediatric – use tape)
g. in the cardiac arrest situation, initial airway
management should be completed with manual
maneuvers, & simple adjuncts.
34. Standing Medical Order
5. After two unsuccessful attempts at intubation by
direct laryngoscopy, hyper oxygenate the
patient, place S.A.L.T. ™ adjunct, hyper
oxygenate, then intubate through the S.A.L.T. ™.
The S.A.L.T. ™ is only indicated in patients for
whom 6.5mm through 9.0mm ETT is appropriate.
6. Nasotracheal intubation and nasal airways
should be avoided in the patient with facial
trauma, or suspected basal skull fracture.
7. Extreme caution should be exercised in any
patient experiencing significant head injury, or
with signs of rising intracranial pressure.
35. Standing Medical Order
8. With suspected head injuries, administer
Lidocaine 1.5 mg/kg prior to ETT intubation to
help prevent rise in ICP.
9. For any patient with a GCS < 8, complete
endotracheal intubation
10. Only if necessary, in the unusually difficult
intubation, and when the patient can not
otherwise be oxygenated by basic life
support measures, consider giving Versed
(or valium) 5 mg IVP + Morphine Sulfate 2 mg
IVP to facilitate intubation per Medication
Facilitated Intubation Standing Order.
36. Standing Medical Order
11. A Combi-tube/King Airway should be used if
attempts at intubation with the S.A.L.T. ™ are
unsuccessful. For EMT-I‟s, the Combi-tube/King
Airway is the advanced airway for utilization. The
Combi-tube/King Airway is contraindicated in
the following:
a. patients under 5 feet in height or over 6‟4” in
height
b. patients who are less than 16 years of age
c. patients who weigh less than 90 lbs
d. patients who have known esophageal disease
e. patients who have ingested caustic substances
37. Objectives Review
Name the major components of the upper
and lower airways
Describe the functions of the upper and
lower airways
Describe the process of ventilation
Describe the process of respiration
Identify the S.A.L.T.™ device
Demonstrate use of the S.A.L.T.™ device
Explain the SMO for the S.A.L.T.™ device
