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Copyright 2006 © Pearson Education Canada 27:2-1

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


Look


Listen


Feel


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

Child


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

(PtL)


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

open


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


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)

Documents

airway patent

lungsprotects airway

adequate air movement

abnormal air movementright

nosepalpate chest

left basesright

left apicesright

chest wall injuries