EMR ch9

Copyright ©2012 by Pearson Education, Inc.
All rights reserved.
Emergency Care, Twelfth Edition
Daniel J. Limmer • O’Keefe • Grant • Murray • Bergeron • Dickinson
Emergency Medical Responder: First on Scene, Ninth Edition
Le Baudour • Bergeron • Wesley
CHAPTERCHAPTER
Airway Management and VentilationAirway Management and Ventilation
99

BREATHINGBREATHING

BreathingBreathing
• Respiration: act of breathing; exchange
of oxygen and carbon dioxide takes
place in lungs.
• Body uses oxygen to produce energy.
• Respiratory compromise: patient not
breathing adequately.
• Hypoxia: insufficient level of oxygen in
blood and tissues.

BreathingBreathing
• Respiratory arrest: absence of
breathing.
• Causes of respiratory compromise:
– Asthma
– Bronchitis
– Heart attack
– Severe allergic reactions
– Exposure to toxic substances
– Inhalation of super-heated air

BreathingBreathing
• Respiratory system plays role in normal
acid-base balance.
• Without proper pH, brain functions
cease.
• Apnea: absence of breaths.

BreathingBreathing
• Respiratory arrest: absence of
breathing.
• Cardiac arrest: absence of heartbeat.
• Clinical death: both heartbeat and
respirations stop.
• Biological death: too many brain cells
die (irreversible death).

BreathingBreathing
• How we breathe: It's Automatic!
– Lungs elastic and expandable.
– Diaphragm primary breathing muscle.
– Simple law: as volume increases, pressure
decreases.
– Inhalation (breath taken in).
– Exhalation (breathing out).

The respiratory cycle.

Think About ItThink About It
• What is the role of the brain and central
nervous system in the process of
breathing?
• What are some of the complications
that can result when treating an ill or
injured patient who has an underlying
respiratory condition such as asthma?

RESPIRATORY SYSTEM ANATOMYRESPIRATORY SYSTEM ANATOMY

Respiratory System AnatomyRespiratory System Anatomy
• Major Structures
– Nose; mouth
– Throat; epiglottis
– Trachea
– Larynx
– Bronchial tree
– Lungs
– Alveoli

The respiratory system.

• Respiratory Cycle
– Air flows through mouth and nose, into
throat, past epiglottis, into trachea.
– Air flows into left/right main stem bronchi,
through smaller bronchioles to alveoli.
– Oxygen/carbon dioxide exchange takes
place.
(continued)

• Respiratory Cycle
– Oxygen travels through walls of alveoli,
into blood, delivers it to cells.
– Carbon dioxide travels from blood through
alveoli walls, where eliminated when
exhaled.

• An Open and Clear Airway
– Airway: nose, mouth, throat, trachea.
– Patent: open and clear airway.
– Causes of obstruction
 Patient's own tongue
 Foreign object
 Swelling of tissues

SIGNS OF NORMAL BREATHINGSIGNS OF NORMAL BREATHING

Signs of Normal BreathingSigns of Normal Breathing
• Look for adequate tidal volume.
• Listen for air entering and leaving nose
and mouth.
• If unresponsive, feel for air moving into
and out of nose and mouth.
• Observe skin color.
• Observe level of responsiveness.

SIGNS OF ABNORMAL BREATHINGSIGNS OF ABNORMAL BREATHING

Signs of Abnormal BreathingSigns of Abnormal Breathing
• Signs and Symptoms
– Increased work of breathing.
– Absent or shallow rise and fall of chest.
– Little or no air heard or felt at nose or
mouth.
– Noisy breathing or gasping sounds.
(continued)

– Breathing that is irregular, too rapid, or too
slow.
– Breathing that is too deep or labored.
– Use of accessory muscles in chest,
abdomen, and around neck.
– Nostrils that flare when breathing.
(continued)

– Skin that is pale or cyanotic.
– Sitting or leaning forward in tripod position.
– Agonal respirations: slow, sporadic gasps
of air from unresponsive patient.

• What causes cyanosis?
• Why is cyanosis considered a “late”
sign?
• You respond to find an unresponsive
23-year-old male with a history of
narcotic abuse. He is making snoring-
like breathing sounds with periods of
apnea. What are these respirations
called?

RESCUE BREATHINGRESCUE BREATHING

Rescue BreathingRescue Breathing
• Indicated when patient (responsive or
unresponsive) is unable to breathe in
and out adequately to sustain life.
• When you perform rescue breathing,
you are breathing for patient.

• What is meant by “positive pressure
ventilation”?
• Why is it important to perform rescue
breathing for someone in need even if
you don't have supplemental oxygen?

OPENING THE AIRWAYOPENING THE AIRWAY

Opening the AirwayOpening the Airway
• Ensure nose, mouth, back of throat are
clear of obstructions.
• Repositioning head may open airway.
• Head-tilt/chin-lift maneuver: used to
open airway of patient with no
suspected neck or spine injury.

• Head-tilt/chin-lift
– Position your hands.
– Tilt patient's head back as far as it will
comfortably go.
– Lifts tongue away from back of throat;
allows air to flow as patient breathes.

Use the head-tilt/chin-lift maneuver to open the airway if there are
no spine injuries. (A) First, position your hands.
A

Use the head-tilt/chin-lift maneuver to open the airway if there are
no spine injuries. (B) Then, tilt the patient's head back as far as it
will comfortably go.
B

• Jaw-thrust maneuver: used to open
airway of patient with neck/spine
injury.
– Position yourself at head.
– Reach forward; place index and middle
fingers of each hand on either side of jaw.
– Lift jaw forward; do not tilt or rotate head.

Use the jaw-thrust maneuver if there are possible neck or spine
injuries. (A) Side view.
A

Use the jaw-thrust maneuver if there are possible neck or spine
injuries. (B) front view of the Emergency Medical Responder's hand
position.
B

• You respond to a call for a 37-year-old
male who has fallen from a ladder. He
is unresponsive and does not appear to
be breathing. You attempt to open his
airway using which method? Why?

BARRIER DEVICESBARRIER DEVICES

Barrier DevicesBarrier Devices
• Pocket face mask: helps provide
ventilations; chimney with one-way
valve and HEPA filter.
• Face shield: durable plastic sheet with
built-in filter.
• Take all steps to ensure protection from
infectious diseases.

Figure 8.6 Pocket face mask with one-way valve and HEPA filter.

MOUTH-TO-MASK VENTILATIONMOUTH-TO-MASK VENTILATION

Mouth-to-Mask VentilationMouth-to-Mask Ventilation
• Recommended for single rescuer.
• Kneel beside patient; confirm
unresponsiveness; open airway.
• Firmly hold mask in place while keeping
airway open.
• Breathe slowly into one-way valve.
• If patient does not begin breathing
adequately, begin CPR.

Deliver ventilations using the lateral position.

Deliver ventilations using the cephalic position.

MOUTH-TO-SHIELDMOUTH-TO-SHIELD
VENTILATIONVENTILATION

Mouth-to-Shield VentilationMouth-to-Shield Ventilation
• Kneel beside patient; confirm
unresponsiveness; open airway.
• Place barrier over mouth. Keep airway
open as you pinch nose closed.
• Open your mouth wide; take normal
breath; place your mouth over face
shield opening.
• Make tight seal; press lips against it.

• Exhale slowly into patient's mouth until
you see chest rise.
• Break contact with face shield to allow
patient to exhale; take another breath
and ventilate patient again; give two
initial breaths.
• If patient does not begin breathing
adequately on own, begin CPR.

• Common problems
– Failure to form tight seal.
– Failure to pinch nose closed.
– Failure to tilt head back to open airway.
– Failure to open patient's mouth wide
enough to receive ventilations.
(continued)

• Common problems
– Failure to deliver enough air.
– Providing breaths too quickly.
– Failure to clear airway obstructions.

Mouth-to-Nose VentilationMouth-to-Nose Ventilation
• Use your hand to seal mouth shut; do
not pinch nose.
• Seal mouth around patient's nose.
• Deliver ventilations through nose.
• Break contact with nose and open
mouth slightly to allow patient to
exhale.
• Keep your hand on patient's forehead
to keep airway open.

• What diseases can be transmitted
through bodily fluids?
• Why is it important for rescuers to
learn mouth-to-mouth and mouth-to-
nose techniques?

SPECIAL PATIENTSSPECIAL PATIENTS

Special PatientsSpecial Patients
• Infants and Children
– Mouth, nose much smaller; easily
obstructed.
– Tongue takes up more space.
– Trachea (windpipe) smaller.
– Chest muscles not as developed.
– Chest cavity and lung volumes smaller.

• Ventilations for Infant
– Take appropriate BSI precautions.
– Kneel or stand beside patient; confirm
unresponsiveness.
– Open airway.
– Use barrier device.
– Assist ventilations with gentle but adequate
breaths.

• Terminally Ill Patients
– For guidelines on how to care for hospice
or DNR patients, check jurisdiction for
training programs; follow local protocols.

• Stomas
– Opening made from outside neck to
trachea; creates airway for breathing.
– Use mouth-to-mask-to-stoma technique.
– Keep patient's head in neutral or normal
position; do not tilt head.
(continued)

• Stomas
– Ensure stoma is free of obstructions.
– Use same procedures as you would for
mouth-to-barrier resuscitation, except:
 Do not pinch patient's nose closed.
 Place mask or face shield on neck over
stoma.

A typical neck stoma.
(© Shout Pictures/Custom Medical Stock Photo)

• Crash Victims
– Airway, breathing always first priorities.
– Reach victim as quickly as possible.
– Look, listen, feel for breathing before
moving.
– Spine/neck injury, patient not breathing,
stabilize head and open airway.

• Why is it important to recognize and
treat airway issues rapidly in infants
and children?
• Why is it especially important to take
appropriate BSI precautions with the
stoma patient?
• What are your first patient care
priorities for a motor-vehicle collision
victim?

AIR IN THE STOMACH ANDAIR IN THE STOMACH AND
VOMITINGVOMITING

Air in the Stomach and VomitingAir in the Stomach and Vomiting
• Air in stomach caused by overinflating
lungs or breathing too quickly.
• Gastric distention: abdomen distends.
– Can cause extra pressure in stomach;
patient can vomit.
– Vomit can obstruct airway and damage
lungs.
• Do not push on stomach to release air.

• What can the rescuer do to reduce the
chance of gastric distention?
• What is the danger of an unconscious
patient vomiting?

AIRWAY OBSTRUCTIONAIRWAY OBSTRUCTION

Airway ObstructionAirway Obstruction
• Causes of Upper Airway Obstruction
– Obstruction by tongue (anatomical
obstruction).
– Foreign objects (mechanical obstruction).
– Tissue damage.
– Allergic reactions.
– Infections.

• Signs of Partial Airway Obstruction
– Noisy breathing (snoring, gurgling,
crowing, wheezing, stridor).
– Encourage responsive patient to cough.
– Do not interfere with patient's efforts to
clear airway.
– Begin care as if complete airway
obstruction.

• Signs of Complete Airway Obstruction
– Responsive patient will be unable to speak,
breathe, or cough.
– Patient often will grasp neck and open
mouth, which is universal sign of choking.
– Will not have typical chest movements or
signs of good air exchange.

Universal sign of choking.

• Clearing a Foreign Body Airway
Obstruction (Responsive Adult or Child)
– Abdominal thrusts most effective method
for clearing airway.
– Determine there is complete obstruction or
partial obstruction.
– Position yourself behind patient, and with
index finger and, locate navel.

• Clearing a Foreign Body Obstruction
(Responsive Adult or Child)
– Make fist; place against abdomen thumb
side in just above navel.
– Grasp fist with first hand; give up to five
abdominal thrusts in rapid succession.

Stand behind the patient. Place one leg between the patient's legs to
obtain a stable stance.

Reach around with one hand to locate the patient's navel.

With the other hand, make a fist and place it just above the patient's
navel.

Grasp your fist with the first hand and pull in and up with swift, firm
thrusts.

(Unresponsive Adult or Child)
– Move swiftly to clear airway.
– Act quickly to determine if you are able to
provide ventilations.
– Begin CPR.
(continued)

– Patient lying face up, tap and shout to
assess responsiveness.
– If unresponsive, activate 911.
– Begin CPR with chest compressions.
(continued)

– After each set of 30 compressions, open
airway; check for foreign object and
remove if visible.
– Attempt two rescue breaths.
– If breaths do not go in, continue CPR with
chest compressions.

• Clearing a Foreign Body (Responsive
Infant)
– Pick up infant and support between
forearms of both arms.
– Rapidly deliver five back blows between
shoulder blades.
– Turn infant over onto back.
(continued)

• Clearing a Foreign Body (Responsive
Infant)
– Locate compression site and deliver five
chest thrusts with tips of fingers.
– Continue sequence of back slaps and chest
thrusts until object is expelled or infant
loses responsiveness.
– Begin CPR if infant unresponsive.

Place the infant over your arm with the head lower than the body
and provide 5 back blows.

Chest thrusts on an infant.

• Clearing a Foreign Body (Unresponsive
Infant)
– With infant supine, tap and shout to assess
responsiveness.
– If infant is unresponsive, activate 911.
(continued)

• Clearing a Foreign Body (Unresponsive
Infant)
– Begin CPR with chest compressions.
– After each set of 30 compressions, open
airway; check for foreign object.
– Remove if visible.
– Attempt two rescue breaths. If breaths do
not go in, continue CPR.

Place the infant supine on a firm surface.

Assess breathing for no more than 10 seconds.

Attempt to ventilate the infant.

If unable to ventilate, start CPR beginning with chest compressions.

• Obese and Pregnant Patients
– Determine if there is complete or partial
obstruction.
– Behind patient; place thumb side of one fist
on center of breastbone.
– Grasp fist with other hand; give up to five
chest thrusts in rapid succession.
(continued)

• Obese and Pregnant Patients
– If airway remains obstructed, repeat
thrusts until airway is cleared or until
patient loses responsiveness.
– If patient becomes unresponsive before
you are able to clear airway obstruction,
call 911; begin CPR.

• Finger Sweeps
– Use finger to sweep patient's mouth in
attempt to remove foreign object.
– Only perform if you see object in patient's
mouth.
– May stimulate gag reflex, cause vomiting.
– Only attempt finger sweeps on
unresponsive patients.

• Why is it important to call for Advanced
Life Support paramedics in the case of
a foreign body airway obstruction?
• What is the purpose of initiating CPR
for the airway obstruction patient who
has suddenly becomes unresponsive?

AIDS TO AIRWAY MANAGEMENTAIDS TO AIRWAY MANAGEMENT

Aids to Airway ManagementAids to Airway Management
• Oropharyngeal airway (OPA): device,
made of plastic, inserted to help keep
tongue off back of throat.
– Only used in unresponsive patients who do
not have a gag reflex.
– Numerous sizes to fit infants, children,
adults.
– See Scan 8.3: Inserting an Oropharyngeal
Airway.

Properly measure the airway prior to insertion.

Insert the airway with the tip pointing to the roof of the patient's
mouth. When halfway in, rotate 180 degrees.

The flange should rest on the outside of the lips and never any
further than the teeth.

Alternative insertion method: 90 degrees into position. Insert the
airway sideways and rotate 90 degrees.

Alternative insertion method: Insertion of an oropharyngeal airway
into a child, using a tongue depressor.

Various sizes of oropharyngeal airways (OPAs).

• Nasopharyngeal Airways: soft, flexible
tubes inserted into nose to create clear
and open path for air.
– Preferred choice when patient is not
unresponsive or has gag reflex.
– Easy to insert; numerous sizes to fit
infants, children, adults.
(continued)

Various types of nasopharyngeal airways (NPAs).

• Nasopharyngeal Airway:
– If indication of head or facial injury, do not
insert NPA.

Measure the NPA from the tip of the nose to the earlobe, or to the
angle of the jaw.

Apply a water-based lubricant before insertion.

Gently insert the airway, advancing it until the flange rests against
the nostril.

Nasopharyngeal airway, properly inserted.

BAG-MASK VENTILATIONBAG-MASK VENTILATION

Bag-Mask VentilationBag-Mask Ventilation
• Device for ventilating nonbreathing
patient; delivers oxygen.
• Sizes for infants, children, adults.
• Infection control barrier between you
and patient.
• Parts
– Self-refilling bag, valves that control one-
way flow of air, face mask.

Disposable bag-mask devices.

• Two-Rescuer Bag-Mask Ventilation
– One rescuer uses two hands to maintain
good mask seal; second rescuer squeezes
bag.

Proper technique for using the bag-mask device with two rescuers.

Proper hand position for bag-mask ventilation with two rescuers.

• One-Rescuer Bag-Mask Ventilation
– For single rescuer, bag-mask device can be
difficult to maintain mask-to-face seal with
one hand.

Proper technique for using the bag-mask device with one rescuer.

An alternative is to press the bag against your leg.

SUCTION SYSTEMSSUCTION SYSTEMS

Suction SystemsSuction Systems
• Assist keeping patient's airway clear.
• Manually-powered, oxygen- or air-
powered, electrically-powered units.

An oxygen-powered portable suction unit.

Manually operated suction device (V-VAC).

Battery-powered portable suction unit.

Mounted suction unit installed in an ambulance patient compartment.

• Thick-walled, nonkinking, wide-bore
tubing
• Nonbreakable collection container
(bottle)
• Sterile, disposable, semirigid but
flexible or rigid suction tips

• Use appropriate BSI precautions.
• Keep suctioning time to a minimum.
• If copious fluid in patient's airway, roll
onto side and then suction.
• Measure suction catheter before
inserting into patient's mouth.

• Activate suction unit only after
completely inserted; withdraw catheter.
• Twist and turn tip of catheter removing
it from mouth, nose, stoma.
• Concentrate on back corners of mouth.

Prepare suction unit.

Insert the device as far as you can see, and initiate suction.

• You respond to a college dorm for an
unresponsive 18-year-old female that,
according to roommates, has been
“drinking all day.” You open the airway
and begin to place an OPA, but she has
an active gag reflex. What do you do?
• While ventilating, the patient begins to
vomit, how long will you suction?

SUMMARYSUMMARY

SummarySummary
• Respiratory compromise caused by
asthma, bronchitis, drowning, choking.
• Clinical death occurs the moment that
both breathing and heartbeats stop.
• Biological (irreversible) death occurs
approximately four to six minutes
following clinical death.

SummarySummary
• Patent airway is clear and open.
• Air contains approximately 21%
oxygen.
• Signs of inadequate breathing:
– Increased work of breathing.
– Shallow, rapid, noisy, or gasping breathing.

SummarySummary
• Provide rescue breaths using
appropriate barrier device; use firm
seal with mask.
• Causes of Airway Obstruction:
– Patient's own tongue
– Blood
– Saliva
– Foreign objects

SummarySummary
• Provide immediate care for removal of
obstruction.
• Preferred method for opening airway of
unresponsive patient who is uninjured
is head-tilt/chin-lift maneuver.
• Preferred method for unresponsive
patient with suspected neck or spine
injury is jaw-thrust maneuver.

SummarySummary
• If you are unable to open airway using
jaw-thrust, attempt head-tilt/chin-lift
maneuver.
• Unresponsive patients with no gag
reflex should receive an OPA.
• For patients with gag reflex (somewhat
responsive), NPA best choice.

SummarySummary
• When patient is not breathing
adequately or not at all, provide
positive pressure ventilations or rescue
breaths.
• Best sign that you are providing good
rescue breaths is good chest rise and
fall with each breath.

SummarySummary
• To minimize flow of air into stomach
during rescue breaths, provide slow,
even breaths, do not overinflate chest.
• If patient's airway becomes obstructed
with fluid (saliva, blood, vomit), it will
be necessary to suction mouth and/or
nose to remove fluid and clear airway.

REVIEW QUESTIONSREVIEW QUESTIONS

1. What is the oxygen concentration of
room air?
2. What are common causes of
respiratory compromise?
3. What is the difference between clinical
and biological death?
4. What are the signs of a patent
airway?
5. What are the signs and symptoms of
adequate and inadequate breathing?
6. What are common causes of airway
obstruction? (continued)

7. What is the difference between
anatomical and mechanical airway
obstruction?
8. What are the signs and symptoms of a
partial and a complete airway
obstruction?
9. How would you care for a patient with
a partial and complete airway
obstruction (adult, child, infant)?
10.How do you best manage a patient's
airway when there is a suspected
spine injury?
(continued)

11.What are the indications and
contraindication for the insertion of an
a. oropharyngeal airway?
b. nasopharyngeal airway?
11.What are the benefits, indications,
and contraindications of positive
pressure ventilation?
12.What are the signs of adequate versus
inadequate ventilations?
13.How do you determine if oral or nasal
suctioning is indicated?
(continued)

15.What is the difference between
manual, electric- and oxygen-powered
suction devices?
16. In what ways do you differently
manage the airway of pediatric, adult,
and geriatric patients?
17. What is the rationale for using a
barrier device when ventilating a
patient?

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