temple college ems program1 management of airway and breathing emergency medical technician - basic

Temple College EMS Program 1

Management of Airway and Breathing

Emergency Medical Technician - Basic


Airway Functions

• Passage that allows air to move from atmosphere to alveoli

• Must remain patent (open) at all times

• Anything that blocks airway will cause decrease in oxygen available to body

• Size of obstruction affects available air exchange


Opening the Airway

• Techniques– Head-tilt/Chin-lift– Jaw Thrust– Suctioning– Nasopharyngeal airway– Oropharyngeal airway


Head-Tilt/Chin-Lift

• Used when no neck injury is suspected

• Temporary procedure

• Must be replaced with an airway adjunct unless patient begins adequate spontaneous ventilation


Head-Tilt/Chin-Lift

• Technique– Place one hand on patient’s forehead– Apply firm, backward pressure with palm

causing head to tilt backward– Place fingers of other hand under bony part of

patient’s lower jaw near chin– Lift jaw upward to bring chin forward


Head-Tilt/Chin-Lift

• Patients needing head-tilt/chin-lift– Unresponsive patient without history of trauma– Cardiac arrest patients without signs of trauma– Apneic patients without signs of trauma


Jaw Thrust

• Used when spinal injury suspected

• Temporary procedure

• Must be replaced with airway adjunct unless patient begins adequate spontaneous ventilation


Jaw Thrust

• Technique– Place one hand on either side of patient’s head,

resting elbows on surface on which victim is lying

– Grasp angles of patient’s lower jaw, lift with both hands

– If patient’s lips close, retract lower lips with thumbs


Jaw Thrust

• Patients needing jaw thrust– Unresponsive trauma patient– Unresponsive patient with undetermined

mechanism of injury


Suctioning

• Purpose– Remove blood, vomit, other liquids, food

particles from airway– May not be adequate for removing large, solid

objects (teeth, foreign bodies, food)– Should be performed immediately when

gurgling is heard with spontaneous or artificial ventilation


Suctioning

• Suction devices– Mounted in ambulance– Portable

• Electrical

• Hand operated

– Should generate 300mm Hg vacuum– Ensure batteries in units remain properly

charged


Suctioning

• Rigid Suction Catheter– Used to suction mouth, oropharynx of

unresponsive patient– Inserted only as far as you can see– Take caution not to touch back of airway,

particularly in infants and children (can cause heart rate to drop)


Suctioning

• Soft Suction Catheter– Useful for suctioning nasopharynx or

tracheostomy tubes– Should be inserted only as far as base of tongue

or end of tracheostomy tube


Suctioning

• Techniques– Turn on unit– Attach catheter– Insert catheter into oral cavity without suction– Insert only to base of tongue– Apply suction, move catheter from side to side– Suction no longer than 15 seconds in adults, 10 seconds

in children, 5 seconds in infants– Rinse catheter with saline or water to prevent

obstruction


Nasal Airways

• Used on responsive patients who need help keeping tongue out of airway

• Insertion is uncomfortable for responsive patients


Nasal Airways

• Technique– Measure from tip of nose to earlobe

– Ensure airway will fit through nostril

– Lubricate with water-soluble lubricant

– Insert with bevel toward base of nostril or septum

– If resistance is met, try other nostril

– Do not use in patients with mid-face trauma or possible basilar skull fractures


Nasal Airways

• Patients needing nasal airway– Unresponsive patients who are snoring– Unresponsive patients with gag reflex


Oral Airways

• Used on unresponsive patients without gag reflex

• Helps hold tongue away from back of throat


Oral Airways

• Technique– Measure from corner of mouth to earlobe or angle of

jaw

– Open patient’s mouth

– In adults insert with tip facing roof of patient’s mouth, advance until resistance encountered, turn 180o until flange comes to rest on patient’s teeth

– In infants and children use tongue depressor to lift tongue, insert oral airway right side up


Oral Airways

• Patients needing oral airway– Unresponsive, apneic patients with or without

trauma– Any apneic patient being ventilated with a

BVM


Airway Limitations

• Nasal/oral airways are not definitive devices• Manual maneuvers must be used with nasal/oral

airways to ensure airway stays open• Patients may require frequent suctioning to

remove blood, vomit, other secretions from airway• Definitive devices such as endotracheal tubes are

required to completely protect the airway


Adequate Breathing

• Normal Rate– Adult: 12 to 20/minute– Child: 15 to 30/minute– Infant: 25 to 50/minute

• Regular Rhythm• Adequate Quality

– Movement of air at mouth, nose– Chest expansion adequate, symmetrical (equal)– Breath sounds present, equal– Minimum effort of breathing– Adequate tidal volume (depth)


Inadequate Breathing

• Abnormal Rate– Adult: <12 to >20/minute– Child: <15 to >30/minute– Infant: <25 to >50/minute

• Irregular Rhythm• Inadequate Quality

– Absent or reduced at mouth, nose– Chest expansion inadequate or asymmetrical (unequal)– Breath sounds diminished, unequal, noisy, absent– Increased effort of breathing, use of accessory muscles– Indequate (shallow) tidal volume


Inadequate Breathing

• Skin changes– Pale, cool, clammy: Early sign

– Cyanosis: Late, unreliable sign

• Retractions of soft tissues above clavicles, between ribs, below rib cage

• Flaring of nostrils• “Seesaw” breathing in infants


Ventilation Techniques(In order of preference)

1. Mouth-to-mask with supplemental oxygen2. Two-person bag-valve mask with oxygen

reservoir and supplemental oxygen3. Flow restricted, oxygen-powered

ventilation device (manually-triggered ventilator)

4. One-person bag-valve mask with oxygen reservoir and supplemental oxygen


Ventilation Techniques

• Mouth-to-Mouth– Open airway– Pinch nose closed or seal nose with cheek– Take deep breath– Seal lips around patient’s mouth to create

airtight seal– Blow into patient’s mouth slowly over 2

seconds until patient’s chest rises



• Mouth-to-Mask– Connect mask to oxygen at 15 liters per minute

– Kneel directly above patient’s head

– Apply mask to patient’s face

– Place thumbs along sides of mask, index fingers of both hands under patient’s mandible

– Lift jaw into mask, tilt head if neck injury not suspected

– Blow into one-way valve slowly over 2 seconds until patient’s chest rises



• Bag-valve mask– Self-inflating bag– One-way valve– Face mask– Oxygen reservoir

Must be connected to oxygen to perform most effectively



• BVM Issues– Provides less volume than mouth-to-mask– Single rescuer may have difficulty maintaining

air-tight seal– Two rescuers using device are more effective– Position yourself at top of patient’s head for

best performance– Oral or nasal airway should be inserted



• BVM Technique (Two Rescuer)– Open airway, insert oral or nasal airway– Position thumbs over top half of mask, index and

middle fingers over bottom half– Place apex of mask over bridge of nose, lower mask

over mouth/upper chin– Use ring and little fingers to bring jaw up to mask– Have assistant squeeze bag with two hands until chest

rises– Ventilate every 5 seconds for adults, every 3 seconds

for infants and children



• BVM Technique (One Rescuer)– Open airway, insert oral or nasal airway– Form a “C” around ventilation port with thumb,

index finger– Use middle, ring, little fingers under jaw to

maintain chin lift, complete seal– Squeeze bag with other hand until chest rises– Ventilate every 5 seconds for adults, every 3

seconds for infants and children



• BVM Technique (Suspected Trauma)– Open airway, insert oral or nasal airway– Have assistant hold patient’s head or use your knees to prevent

movement– Position thumbs over top half of mask, index and middle fingers

over bottom half– Place apex of mask over bridge of nose, lower mask over

mouth/upper chin– Use ring and little fingers to bring jaw up to mask without tilting

head or neck– Have assistant squeeze bag with two hands until chest rises– Ventilate every 5 seconds for adults, every 3 seconds for infants

and children continue to hold jaw up without moving head or neck



• If chest does not rise, reevaluate– If abdomen rises, reposition head or jaw– If air escapes under mask, reposition fingers

and mask– Check for obstruction– If chest still does not rise and fall use another

method of ventilation



• Flow Restricted, Oxygen-Powered Ventilation Devices (Manually-Triggered Ventilator)– Peak flow of 100% oxygen at maximum of 40 lpm

– Pressure relief valve that opens at 60 cm H2O

– Audible alarm that sounds when relief valve pressure is exceeded

– Trigger so both hands remain on mask to maintain seal

Do NOT use on children or infants!!!



• Manually-Triggered Ventilator – Open airway, insert oral or nasal airway

– Position thumbs over top half of mask, index/middle fingers over bottom half

– Place apex of mask over bridge of nose, lower mask over mouth and chin

– Use ring/little fingers to bring jaw up to mask

– Trigger device until chest rises

– Repeat every 5 seconds



• Manually-Triggered Ventilator (Suspected Trauma) – Open airway, insert oral or nasal airway– Have assistant hold head manually or use knees to prevent

movement– Position thumbs over top half of mask, index/middle fingers over

bottom half– Place apex of mask over bridge of nose, lower mask over mouth

and chin– Use ring/little fingers to bring jaw up to mask without tilting head

and neck– Trigger device until chest rises– Repeat every 5 seconds


Assisting Patients Who Are Breathing

• Who needs assistance?– A patient who is not breathing– A patient who has reduced respiratory rate and

tidal volume– A patient whose breathing rate is increased, but

whose tidal volume is inadequate



• Patients with rapid, shallow breathing– Explain procedure to patient– Place mask over patient’s mouth and nose– Initially assist ventilations at rate at which

patient is breathing. Squeeze bag as patient inhales

– Slowly adjust rate and tidal volume until adequate ventilations are achieved



• Patients with slow, shallow breathing– Place bag over patient’s mouth and nose– Squeeze bag each time patient inhales– Adjust rate and tidal volume until adequate

ventilations are achieved


Special Considerations

• Stoma or tracheostomy tube– Attach BVM to tube, or use infant/child mask

to make seal over stoma– Seal mouth/nose if air is escaping when

ventilating at stoma– If unable to ventilate

• Suction stoma or tracheostomy tube

• Seal stoma, attempt to ventilate through mouth/nose



• Infants and children– Place infant’s head in neutral position– Extend child’s head slightly past neutral– Avoid excessive hyperextension– Avoid excessive ventilation, just make chest

rise– Gastric distension is more common in children– Do not use BVMs with pop-off valves



• Dentures– Leave in place unless obviously loose– Remove if loose– Be prepared to remove if displacement occurs


Oxygen

• Oxygen cylinder sizes– D cylinder 350 liters– E cylinder 625 liters– M cylinder 3,000 liters– G cylinder 5,300 liters– H cylinder 6,900 liters

• Contents under pressure• Should be positioned to prevent falling, blows to

valve-gauge assembly


Oxygen

• Operating procedures– Remove protective seal– Quickly open, then shut valve– Attach regulator-flow meter to tank– Select proper size of oxygen mask for patient – Attach oxygen mask to flowmeter– Open flow meter to desired setting– Apply device to patient– When complete, remove device from patient, turn off

device, remove all pressure from regulator


Oxygen

• Non-rebreather mask– Preferred method of giving oxygen to

prehospital patients– Up to 90% oxygen can be delivered– Non-rebreather bag must be full before mask is

placed on patient– Flow rate should be adjused so when patient

inhales, bag does not collapse (~15 lpm)


Oxygen

• Nasal cannula– Rarely best method for giving adequate oxygen

in emergency care settings– Should be used only if patient will not tolerate

non-rebreather mask in spite of coaching


Oxygen

• Concerns about giving too much oxygen to patients with COPD, infants, and children are NOT valid during short-term emergency administration

• Patients with COPD, infants, and children who require oxygen should be given high concentration oxygen.

temple college ems program1 management of airway and breathing emergency medical technician - basic

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