bled_ppt_ch27_part02 (1)

Chapter 27, Part 2Airway

Management and Ventilation

Airway management and ventilation are the first

and most critical steps in the initial assessment of every patient you will encounter.

Lecture Outline

Respiratory Problems

Respiratory System Assessment

Airway Management

Airway Obstruction Immediate threat to life and true

emergency Interference with air movement through

the upper airway Tongue is the most common cause Other causes:

Foreign bodies Trauma Laryngeal spasm and edema Aspiration

The Tongue as an airway obstruction

Partial Airway Obstruction

Adequate air exchange Effective cough

Poor air exchange Ineffective cough Stridor (high-pitched noise while inhaling) Cyanosis Gagging, choking Dysphonia (difficulty speaking)

Inadequate Ventilation Compromise oxygen intake and

carbon dioxide removal Hypoxia Hypercarbia

Caused by reduction of rate or tidal volume

Respiratory System

Assessment

Is the airway patent? Is breathing adequate? Look, listen, and feel. If patient is not breathing

Open the airway Assist ventilations as necessary

Primary Assessment

Listen

Bag-valve-mask ventilation

Onset Symptom development Associated symptoms Past medical history Recent history Does anything make symptoms

better or worse?

Focused History

Skin color Patient’s position Dyspnea Modified forms of respiration Rate Pattern Mentation

Inspection

Modified Forms of Respiration Coughing

Forceful exhalation of large volume of air from lungs

Protects airway from irritants Sneezing

Forceful exhalation from nose Caused by nasal irritation

Hiccoughing Spasmodic contraction of diaphragm Occasionally associated with inferior myocardial

infarction

Modified Forms of Respiration

Sighing Slow deep involuntary inspiration and

expiration Re-expands the alveoli

Grunting Forceful expiration against partially

closed glottis Usually an indication of respiratory

distress

Abnormal Respiratory Patterns

Kussmaul’s respirations Cheyne-Stokes respirations Biot’s respirations Central neurogenic hyperventilationCentral neurogenic hyperventilation Agonal respirationsAgonal respirations

Auscultation Listen at the mouth and nose

for adequate air movement. Listen with a stethoscope for

normal or abnormal air movement Right and left apices Right and left bases Right and left back or midaxillary

Posterior surface is preferable Heart sounds do not interfere

Position for auscultating breath sounds

Airflow Compromise Snoring

Partial airway obstruction by the tongue Gurgling

Accumulation of fluid in airway Stridor

Associated with laryngeal edema or constriction Wheezing

Associated with bronchiolar constriction Quiet

Ominous finding indicating a serious problem

Compromise of Gas Exchange

Crackles Fine bubbling noises heard on inspiration Associated with fluid in smaller

bronchioles

Rhonchi Coarse rattling noise heard on inspiration Associated with inflammation, mucous or

fluid in the bronchioles

Palpation Air movement through mouth and nose Palpate chest for rise and fall Palpate chest wall

Tenderness Symmetry Abnormal motion Crepitus Subcutaneous emphysema

Assess for compliance

Compliance

Refer to stiffness or flexibility of lungs

Good Airflow meets minimal resistance

Poor Ventilation is harder to achieve Occurs in diseased lungs, chest wall

injuries or tension pneumotharx

Compliance and Ventilation

Airway open Head properly positioned Tension pneumothorax ET tube in right mainstem ET tube displaced into esophagus Ventilation equipment functioning

properly

Non-Invasive Respiratory Monitoring

Pulse oximetry Capnography Esophageal detector device Peak expiratory flow testing

Pulse Oximetry

Widely used in prehospital setting Measure hemoglobin saturation in

peripheral tissues Correlates with PaO2

Accurate and continually reflect changes in oxygenation

Pulse Oximeter

Sources of Error

False readings infrequent Carbon monoxide poisoning High intensity lighting Absence of pulse in extremity

Hypovolemia Hypothermia

Severely anaemic patients

Capnography Measure exhaled carbon dioxide

concentrations Reflects adequacy of ventilation Colorimetric or waveform monitoring Most commonly for placement

confirmation for intubation Absence of ETCO2 strongly suggests esophageal

placement

Colorimetric End-Tidal CO2 Detector

Electronic End-Tidal CO2 Detector

Combined devices check SpO2, ETCO2 BP, pulse,

respiratory rate, and temp.

Esophageal Detector Device

Simple tool for ET tube placement confirmation

Bulb or syringe style Trachea is a rigid tube, esophagus

is collapsible If air is easily withdrawn, confirms

placement in trachea

Squeeze device then attach it to the ET tube

If the bulb refills easily on release, it indicates correct

placement

If the bulb does not refill, the tube is improperly

placed

Manual Airway Maneuvers

Personal Protective Equipment

Head Tilt/Chin Lift

Modified Jaw Thrust in Trauma

Jaw-Thrust Maneuver

Jaw-Lift Maneuver

Sellick’s Maneuver (Cricoid Pressure)

Airway before applying Sellick’s

Airway with Sellick’s applied (note compression on the

esophagus)

Basic Mechanical Airways

Nasopharyngeal airway, inserted

Nasopharyngeal Airway

Insert oropharyngeal airway with tip facing palate

Rotate airway 180º into position

Improper placement of oropharyngeal airway

Advanced Airway Management

Endotracheal intubation is clearly the preferred

method of advanced airway

management in prehospital emergency care.

Engaging laryngoscope blade and handle

Activating laryngoscope light source

Laryngoscope Blades

Placement of Macintosh blade into vallecula

Placement of Miller blade under epiglottis

Endotrol ETT

ETT, stylet, and syringe, unassembled

ETT and Syringe

ETT, Stylet, and Syringe, assembled for intubation

Magill Forceps

Indications 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.

Advantages 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.

Disadvantages 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.

Complications

Equipment malfunction Teeth breakage and soft tissue

lacerations Hypoxia Esophageal intubation Endobronchial intubation Tension pneumothorax

Endotracheal Intubation

Hyperoxygenate the patient

Prepare the equipment

Apply Sellick’s manoeuver (if required) and insert

laryngoscope

Visualize the larynx and insert the ETT

Glottis visualized through laryngoscopy

Inflate the cuff, ventilate and auscultate

Confirm placement with an ETCO2 detector or an EDD

Secure the tube

Reconfirm ETT placement

Tube Placement Confirmation

Visualization Ausculation End tidal CO2

Esophageal detector device (EDD) Condensation inside the ETT Absence of vomitus in the tube Absence of vocal sounds

Continuously recheck and reconfirm the placement

of the endotracheal tube.

Lighted Stylet for Endotracheal

Intubation

Insertion of lighted stylet/ETT

Lighted stylet/ETT in position

Transillumination of a lighted stylet

Blind orotracheal intubation by digital method

Digital Intubation Used when proper positioning is

difficult Trapped spinal injury patient Facial injuries

Increased risk to paramedic Patient may clamp down on teeth

Contraindicated Conscious patients Unconscious patients with a gag reflex

Insert your middle finger into the patient’s mouth

Walk your fingers and palpate the patient’s

epiglottis

Insert the ETT

Endotracheal Intubation with In-line

Stabilization

Hyperoxygenate patient and apply C-spine stabilization

Apply Sellick’s Maneuver and intubate

Ventilate patient and confirm placement

Secure ETT and apply a cervical collar

Reconfirm placement

Rapid Sequence Intubation

Patient requires intubation but condition makes success unlikely Altered mental status with hypoxia Conscious patient

RSI sedates and temporarily paralyzes patient to facilitate intubation

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.

The Pediatric Airway

Pediatric Tube Size

ETT size (mm) = (age in years + 16) / 4

ETT size (mm) = (age in years / 4) + 4

Endotracheal Intubation in a

Hyperoxygenate the child

Position the head

Insert the laryngoscope

Insert the ETT and ventilate the child

Confirm placement and secure the ETT

Nasotracheal Intubation Blind procedure without direct

visualization of the cords Generally oral intubation preferred Consider in case of

Conscious patients Trismus Facial and airway swelling

Advantages

The head and neck can remain in neutral position.

Better tolerated by awake patient Less stimulation of gag reflex

It can be secured more easily The patient cannot bite the ETT

Disadvantages More difficult and time-consuming Potentially more traumatic for patients May kink or clog more easily Poses a greater risk of infection Improper placement is more likely Requires that the patient be breathing

Blind Nasotracheal Intubation

ETC Airway— tracheal placement

ETC Airway-esophageal placement

Other Intubation Devices

Esophageal CombiTube (ECT) Laryngeal mask airway (LMA) Pharyngo-tracheal lumen airway

Advantages of ECT Provides alternate airway control

When conventional intubation techniques are unsuccessful or unavailable.

Insertion is rapid and easy Does not require visualization of the larynx No special equipment.

Pharyngeal balloon anchors the airway behind the hard palate

Patient may be ventilated regardless of tube placement

Advantages of ECT Significantly diminishes gastric

distention and regurgitation Can be used on trauma patients

Neck can remain in neutral position during insertion and use.

If tube is placed in esophagus, gastric contents can be suctioned for decompression through the distal port

Disadvantages of ETC Maintaining adequate mask seal is

difficult Suctioning tracheal secretions is

impossible when the airway is in the esophagus.

Cannot be used in conscious patients or in those with a gag reflex

Cuffs can cause esophageal, tracheal, and hypopharyngeal ischemia

Disadvantages of ETC Does not isolate and completely

protect the trachea Cannot be used in patients with

esophageal disease or caustic ingestions

Cannot be used with pediatric patients

Laryngeal Mask Airway

Pharyngo-Tracheal lumen airway

Advantages of PtL Airway

Can function in either the tracheal or esophageal position.

No face mask to seal. Does not require direct visualization. Can be used in trauma patient

Neck can remain in neutral position during insertion and use.

Helps protect the trachea from upper airway bleeding and secretions

Disadvantages of PtL Airway Does not isolate and completely protect

the trachea The oropharyngeal balloon can migrate

out of the mouth anteriorly Intubation around the PtL is extremely

difficult Cannot be used in

Conscious patients or those with a gag reflex. Pediatric patients.

Can only be passed orally.

Foreign body removal with direct visualization and Magill

forceps

Surgical

Airways

Anatomical Landmarksfor Cricothyrotomy

Locate/palpate cricothyroid membrane

Proper positioning for cricothyroid puncture

Advance the catheter with the needle

Cannula properly placed in trachea

Jet ventilation with needle cricothyrotomy

Open Cricothyrotomy

Locate cricothyroid membrane

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

membrane

Make a 1 cm horizontal incision through the cricothyroid

membrane

Using a curved hemostat, spread membrane incision

Insert an ETT (6.0) or Shiley (6.0)

Inflate the cuff

Confirm placement

Ventilate

Secure tube, reconfirm placement,

evaluate patient

Patients with Stoma Sites Laryngectomy or tracheostomy

Patients breathe through a stoma

Problems with a stoma Excess secretions Stoma may become plugged

Suctioning Prevents a simple vomiting episode from

becoming a life-threat

Tracheostomy Cannulae

Suctioning Technique BSI

Preoxygenate the patient. Determine depth of catheter

insertion. With suction off, insert catheter. Turn on suction

Suction while removing catheter (no more than 10 seconds)

Hyperoxygenate the patient

Gastric Decompression Gastric distension

Common problem with ventilating a nonintubated patient

Occurs when the procedure’s high pressures trap air in the stomach

Gastric decompression Placement of a tube in the stomach to relieve

pressure Uses either orogastric or nasogastric approach

Gastric Tube Placement Prepare patient

Head in neutral position Preoxygenate

Determine length of tube insertion Measure from epigastrum to the angle of the jaw,

then to the tip of the nares. If patient is awake, suppress the gag

reflex Topical anasthetic applied into the posterior

oropharynx IV lidocaine

Gastric Tube Placement Lubricate the distal tip of the gastric tube

and gently insert Into the nares and along the nasal floor Into the oral cavity at midline

Advance tube gently If patient is awake, encourage swallowing to facilitate

tube’s passage Advance to predetermined mark on tube

Confirm placement Apply suction and note gastric contents that

pass through the tube Secure the tube in place

Oxygenation

Supplemental oxygen Diminish hypoxia’s secondary effects

Oxygen should never be withheld Toxicity is rarely a concern

Tank Duration

Tank life in minutes =

gauge pressure – safe residual pressure x tank constant

oxygen delivered in litres per minute

Oxygen Delivery Devices Nasal cannula

Venturi mask Simple face mask Partial face mask Nonrebreather mask Small-volume nebulizer Oxygen humidifier

Ventilation Methods

Mouth-to-mouth Mouth-to-nose Mouth-to-mask Bag-valve device Demand valve device Automatic transport ventilator

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

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

Observe chest rise Listening to lung sounds Assessing clinical improvement

Portable Mechanical Ventilator

CARvent ALS Resuscitator

Summary

Respiratory System Assessment

Airway Management

bled_ppt_ch27_part02 (1)

airway patent

lungsprotects airway

adequate air movement

abnormal air movementright

nosepalpate chest

left basesright

left apicesright

chest wall injuries

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