Call Girls in Dwarka Mor Delhi Contact Us 9654467111
Backup airways
1. Backup AirwaysBackup Airways
New HampshireNew Hampshire
Division of Fire Standards & Training andDivision of Fire Standards & Training and
Emergency Medical ServicesEmergency Medical Services
3. Purpose
It is vital that the prehospital crew be
confident and comfortable with the rescue
airways approved for their level of
licensure.
During this module you will review and
practice the back up airways for your level
of licensure.
6. The Basics
Position
OPA
BVM
Suction
Most difficult airways will still be
manageable using basic airway
maneuvers!
7. The Need for Oxygen
0 – 1 minute: cardiac irritability
0 – 4 minutes: brain damage not likely
4 – 6 minutes: brain damage possible
6 – 10 minutes: brain damage very likely
> 10 minutes: irreversible brain damage
8. Oxygen and Carbon Dioxide Exchange
Oxygen-rich air is inhaled
to alveoli
O2 exchanged at
alveolocapillary level
Perfusion to capillary beds
O2/CO2 exchange at
cellular level
Perfusion from capillary
beds
CO2 exhanged at
alveolocapillary level
CO2 exhaled
16. Basic Airway Adjuncts
Oropharyngeals
Keeps tongue from blocking oropharynx
Eases suctioning
Used with BVM
Patients without gag reflex
Nasopharyngeals
Maintains patency of oropharynx
Patients with gag reflex
Should not be used with head trauma
17. Oxygen
Nonrebreathing mask
– Provides up to 90% oxygen
– Used at 10 to 15 L/min
Nasal cannula
– Provides 24% to 44% oxygen
– Used at 1 to 6 L/min
18. Oxygen
Nasal cannula
24-40% at 1-6 liters
Non-rebreather mask
Up to 90% at 15 liters
BVM
21% atmosphere
Up to 100% at 15 liters with reservoir
20. Ventilation Rates
Adults: 8 - 10 breaths per minute
Approximately one breath every 6 – 8 seconds
Pediatric: 12 – 20 breaths per minute
Approximately one breath every 3 – 6 seconds
21. Bag Valve Mask
Delivers > 90% oxygen
Requires practice and proficiency
Use with airway adjuncts and/or advanced
airways
O2 Reservoir
Bag
Valve
Mask
22. BVM-Problems encountered
Inattentiveness
Poor mask seal = poor ventilatory ability
Varying ventilatory rates
Varying expiration rates
Varying tidal volumes
Often excessive airway pressure
Often hyper-ventilation
Mastering the BVM overcomes these obstacles!
23. BVM – One person
Insert an oral/nasal airway
Seal mask by placing the apex over the bridge of
the nose and lower portion of the mask over the
mouth and upper chin.
Make a “C” with your index finger and thumb
around the mask.
Maintain the airway with your middle, ring and
little finger, creating a “E”, under the jaw to
maintain the chin lift.
Squeeze the bag with your other hand slowly at a
rate of one breath every 6–8 seconds.
Monitoring SpO2
24. BVM – Two Person
Insert oral/nasal airway
First provider hold the bag portion of the BVM
with both hands.
Second provider seals the mask with apex over
the bridge of the nose and base at the upper
chin.
Using two hands the second provider places
his/her thumbs over the top half of the mask;
index and middle finger over bottom half; ring
and little finger under jaw.
Second provider also maintains chin-lift
First provider squeezes bag every 6–8 seconds
Monitoring SpO2.
27. Asthma and COPD
These patients complicate the
traditional RSI approach due to the
difficulty encountered when mask
ventilating
Alveolar hyperinflation secondary to
underlying pathophysiology must be
considered and adequate passive
ventilation time must be ensured
Tidal volumes should be reduced,
initially, to reduce likelihood of
barotrauma and air trapping
28. Gastric Distention
Air fills the stomach from too forceful or
too frequent ventilations
Airway may be blocked and ventilations
are re-routed to stomach
Decreases lung capacity
May cause patient to vomit
30. Recognizing an Obstruction
Partial or complete?
Can patient speak? Cough?
If unconscious, deliver artificial ventilation
Does air go in? Does the chest rise?
32. Suctioning
Turn on unit and ensure proper suctioning
pressure (300 mmHg)
Select proper tip and measure
Insert with suction off
Suction on the way out
Suction for no more than 15 seconds
34. CPAP Indications
Any patient in respiratory distress associated
with CHF with any of the below obvious signs
and symptoms or a history of CHF:
Bibasilar or diffuse rales
Respiratory rate greater than 25
Pulse oximetry below 92%
Retractions or accessory muscle use
Abnormal capnography (rate, waveform, CO2 levels)
35. RSI Indication
Immediate severe airway compromise in
the context of trauma, drug overdose,
status epilepticus, etc. where respiratory
arrest in imminent.
36. Always have a back-up plan.
Plans “A”, “B”, and “C”
Know the answers before you begin
37. Plan “A”: (ALTERNATIVES)
Different:
Size of blade
Type of blade
Miller
Macintosh
Specialty
Position (patient & provider)
Hockey stick bend in ETT or Directional tip ETT
Remove the stylette as you pass through the cords
“BURP” (aka “ELM”)
Gum Elastic Bougie
2-person technique
“cowboy” or “skyhook”
Have someone else try
38. Viewmax Scope
Easy of use
Can be used like a Mac or Miller
Should improve your view by one grade
39. “BURP” – a.k.a. “External
Laryngeal Manipulation”
Backward, Upward,
Rightward Pressure:
manipulation of the
trachea
90% of the time the
best view will be
obtained by pressing
over the thyroid
cartilage
Differs from the Sellick ManeuverDiffers from the Sellick Maneuver
40. Plan “B”: (BVM and BACK UP
Airways)
Can you ventilate with a BVM?
(Consider two NPA’s and an OPA, +
Cricoid pressure w/ gentle ventilation)
KING–LT-D
Combitube
LMA
64. Insertion Technique
• Tongue-Jaw Lift
• Anatomical
Insertion
• Black rings will lie
between teeth or
alveolar ridges
• Bending the tip
prior to use may
ease insertion
69. LMA
The LMA was invented by Dr. Archie Brain at
the London Hospital in Whitechapel in 1981
The LMA consists of two parts:
The mask
The tube
The LMA has proven to be a very effective
management tool for the airway
70. Introduction continued
The LMA design:
Provides an “oval seal around
the laryngeal inlet” once the
LMA is inserted and the cuff
inflated.
Once inserted, it lies at the
crossroads of the digestive
and respiratory tracts.
71. Indications
Situations involving a difficult mask (BVM) fit.
May be used as a back-up device where endotracheal
intubation is not successful.
May be used as a “second-last-ditch” airway where a
surgical airway is the only remaining option.
72. Contraindications
Greater than 14 to 16 weeks pregnant
Patients with multiple or massive injury
Massive thoracic injury
Massive maxillofacial trauma
Patients at risk of aspiration
NOTE: Not all contraindications are absolute
73. Complications
Throat soreness
Dryness of the throat and/or mucosa
Complications due to improper placement vary
based on the nature of the placement
74. Equipment for LMA Insertion
Body Substance Isolation equipment
Appropriate size LMA
Syringe with appropriate volume for LMA cuff
inflation
Water soluble lubricant
Ventilation equipment
Stethoscope
Tape or other device(s) to secure LMA
75. Preparation
Step 1: Size selection
Step 2: Examination of the LMA
Step 3: Check deflation and inflation
of the cuff
Step 4: Lubrication of the LMA
Step 5: Position the Airway
76. Step 1: Size Selection
Verify that the size of the LMA is correct for the
patient
Recommended Size guidelines:
Size 1: under 5 kg
Size 1.5: 5 to 10 kg
Size 2: 10 to 20 kg
Size 2.5: 20 to 30 kg
Size 3: 30 kg to small adult
Size 4: adult
Size 5: Large adult/poor seal with size 4
77. Step 2: Examine the LMA
Visually inspect the LMA cuff for tears or other
abnormalities
Inspect the tube to ensure that it is free of
blockage or loose particles
Deflate the cuff to ensure that it will maintain a
vacuum
Inflate the cuff to ensure that it does not leak
78. Step 3: Deflation & Inflation
Slowly deflate the cuff to form a smooth flat
wedge shape which will pass easily around
the back of the tongue and behind the
epiglottis.
During inflation the maximum air in cuff
should not exceed:
Size 1: 4 ml
Size 1.5: 7 ml
Size 2: 10 ml
Size 2.5: 14 ml
Size 3: 20 ml
Size 4: 30 ml
Size 5: 40 ml
79. Step 4: Lubrication
Use a water soluble lubricant to lubricate the LMA
Only lubricate the LMA just prior to insertion
Lubricate the back of the mask thoroughly
Important Notice:
Avoid excessive amounts of lubricant
on the anterior surface of the cuff or
in the bowl of the mask.
Inhalation of the lubricant following placement may
result in coughing or obstruction.
80. Step 5: Positioning of the Airway
Extend the head and flex the
neck
Avoid LMA fold over:
Assistant pulls the lower
jaw downwards.
Visualize the posterior oral
airway.
Ensure that the LMA is not
folding over in the oral
cavity as it is inserted.
82. LMA Insertion Step 1
Grasp the LMA by the
tube, holding it like a pen
as near as possible to the
mask end
Place the tip of the LMA
against the inner surface
of the patient’s upper
teeth
83. LMA Insertion Step 2
Under direct vision:
Press the mask tip upwards
against the hard palate to
flatten it out.
Using the index finger, keep
pressing upwards as you
advance the mask into the
pharynx to ensure the tip
remains flattened and avoids
the tongue.
84. LMA Insertion Step 3
Keep the neck flexed
and head extended:
Press the mask into
the posterior
pharyngeal wall
using the index
finger.
85. LMA Insertion Step 4
Continue pushing with your
index finger.
Guide the mask downward
into position.
86. LMA Insertion Step 5
Grasp the tube firmly with the
other hand
Then withdraw your index
finger from the pharynx.
Press gently downward with
your other hand to ensure the
mask is fully inserted.
87. LMA Insertion Step 6
Inflate the mask with the
recommended volume of air.
Do not over-inflate the LMA.
Do not touch the LMA tube while it
is being inflated unless the position
is obviously unstable.
Normally the mask should be
allowed to rise up slightly out of the
hypopharynx as it is inflated to find
its correct position.
88. Verify Placement of the LMA
Connect the LMA to a Bag-Valve Mask device or
low pressure ventilator
Ventilate the patient while confirming equal
breath sounds over both lungs in all fields and the
absence of ventilatory sounds over the
epigastrium
89. Securing the LMA
Insert a bite-block or roll of gauze to prevent
occlusion of the tube should the patient bite
down.
Now the LMA can be secured utilizing the same
techniques as those employed in the securing of
an endotracheal tube.
92. Problems with LMA Insertion
Failure to press the
deflated mask up against
the hard palate or
inadequate lubrication or
deflation can cause the
mask tip to fold back on
itself.
93. Problems with LMA Insertion
Once the mask tip has
started to fold over, this
may progress, pushing the
epiglottis into its down-
folded position causing
mechanical obstruction
94. Problems with LMA Insertion
If the mask tip is deflated
forward it can push down the
epiglottis causing obstruction
If the mask is inadequately
deflated it may either
push down the epiglottis
penetrate the glottis
100. Move your fingers about one inch down the
neck until you find another bulge.
This is the cricoid cartilage. The indentation between
the two is the cricothyroid membrane, where the
incision will be made.
108. Procedure
Using a dilator,
hemostat, or gloved
finger to maintain
surgical opening,
insert the cuffed tube
into the trachea.
Cric tube from the kit
of a 6.0 ETT is usually
sufficient.
109. Procedure
Using a dilator,
hemostat, or gloved
finger to maintain
surgical opening,
insert the cuffed tube
into the trachea.
Cric tube from the kit
of a 6.0 ETT is usually
sufficient.
110. Procedure
Inflate the cuff with 5-
10cc of air and
ventilate the patient
while manually
stabilizing the tube.
111. Procedure
All of the standard assessment techniques
for ensuring tube placement should be
performed (auscultation, chest rise and
fall, end-tidal CO2 detector, etc..
Secure the tube.
114. RSI Procedure: The Seven P’s
1. Preparation
2. Preoxygenate the patient
3. Premedicate the patient
4. Paralyze the patient
5. Pass the tube
6. Proof of placement
7. Post intubation care
Editor's Notes
The ASA calls a Failed/Difficult Laryngoscopy an:
Any airway that takes more than 3 attempts
Any airway that takes more than 10 minutes to secure an airway
No wonder they say they have a 90 % success rate
If we had those standards our Pt’s would be dead.
http://www.nurseminerva.co.uk/images/resp.jpg
Practice sizing and inserting the Orophyarngeal and Nasopharyngeal airways.
2005 AHA Guidelines for the patient with advanced airway adjuncts. This does not include rates for hyperventilating or hyperoxygenating the patient.
Parts of the BVM
Oxygen tubing (not shown in photo, refer to actual device): attached to oxygen source to ensure oxygen rich air is delivered to the patient
O2 Reservoir – area where oxygen accumulates ensuring each ventilation will contain up to 100 % oxygen
Bag: squeezed to push the oxygen through an opening into a one-way valve
Valve: allows oxygen rich air to enter the mask from the bag. Re-routes exhaled air through vents, so as to not contaminate oxygen rich air from the bag
Mask: Sealed over the patients mouth and nose to deliver oxygen rich air to the oral and nasal cavities.
John G. Sheed, M.D, FACEP, Volusia County EMS Medical Director. Advanced Airway Management, a comprehensive review for the Volusia Countyr Paramedic
Type of blade
Miller: anterior airway, big teeth,
immobilized pt, floppy epiglottis
Macintosh: better tongue control
Specialty: Grand View; View Max, etc.
90% of the time the best view will be obtained by pressing over the thyroid cartilage – because, anatomically, the vocal cords are connected here.
“BURP”-backwards, upwards, right, pressure
May help with difficult intubation
