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BASIC AIRWAY MANAGEMENT. Basic Airway Objectives. Upon completion the student will be able to: Describe the anatomy of the airway and the physiology of respiration. Explain the primary objective of airway maintenance Identify commonly neglected prehospital skills related to the airway

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basic airway objectives
Basic Airway Objectives

Upon completion the student will be able to:

  • Describe the anatomy of the airway and the physiology of respiration.
  • Explain the primary objective of airway maintenance
  • Identify commonly neglected prehospital skills related to the airway
  • Describe assessment of the airway and the respiratory system
  • Describe the modified forms of respiration and list the factors that affect respiratory rate and depth
  • Discuss the methods for measuring oxygen and carbon dioxide in the blood and their prehospital use.
basic airway objectives3
Basic AirwayObjectives
  • Define and explain the implications of partial airway obstruction with good and poor air exchange and complete airway obstruction
  • Describe the common causes of upper airway obstruction, including:
  • The tongue
  • Foreign body aspiration
  • Laryngeal spasm
  • Laryngeal edema
  • Trauma
basic airway objectives4
Basic AirwayObjectives
  • Describe complete airway obstruction maneuvers, including:
  • Heimlich maneuver
  • Removal with magill forceps
  • Describe causes of respiratory distress, including:
  • Upper and lower airway obstruction
  • Inadequate ventilation
  • Impairment of respiratory muscles
  • Explain the risk of infection to EMS providers associated with airway management and ventilation
basic airway objectives5
Basic AirwayObjectives
  • Describe manual airway maneuvers including:
  • Head0tilt/chin-lift maneuver
  • Jaw-thrust maneuver
  • Modified jay-thrust maneuver
  • Discuss the indications, contraindications, advantages, disadvantages, complications, special considerations, equipment, and techniques of the following:
  • Upper airway and tracheobronchial suctioning
  • Nasogastric and orogastric tube insertion
basic airway objectives6
Basic AirwayObjectives
  • Oropharyngeal and nasopharyngeal airway
  • Ventilating a patient by mouth-to-mouth, mouth-to-nose, mouth-to-mask, one/two/three person bag-valve mask, flow-restricted oxygen-powered ventilation device, automatic transport ventilator
  • Compare the ventilation techniques used for an adult patient to those used for pediatric patients, and describe special considerations in airway management and ventilation for the pediatric patient
basic airway objectives7
Basic AirwayObjectives
  • Identify types of oxygen cylinders and pressure regulators, and explain safety considerations of oxygen storage and delivery, including steps for delivering oxygen, from a cylinder and regulator
  • Describe the indications, contraindications, advantages, disadvantages, complication, liter flow range, and concentration of delivered oxygen for the following supplemental oxygen delivery devices:
  • Nasal cannula
  • Simple face mask
basic airway objectives8
Basic AirwayObjectives
  • Partial rebreather mask
  • Nonrebreather mask
  • Venturi mask
  • Describe the use, advantages, and disadvantages of an oxygen humidifier
administration
ADMINISTRATION

Oxygen is the most important drug that we

can give a patient. Without it, the body’s cells

die and thus the patient dies also.

  • Room air contains approximately 30% oxygen
administration10
ADMINISTRATION
  • Usually stored in seamless, steel cylinders - color GREEN
  • Sizes and Capacity:

* “D” 350 L

* “E” 600 L

* “M” 3,000 L

  • Pressure: 2,000-2,200 psi
administration11
ADMINISTRATION

Pin Index Safety System (PISS)

  • Prevents interchanging different gases and regulators

Delivery

1. Demand Valve

* Activated manually or by negative

pressure

administration13
ADMINISTRATION

2. Flow Meter (Two Types)

  • Pressure Compensated

* Small ball in a calibrated tube; affected

by gravity, measures actual delivered

flow; found in Units mounted on wall.

  • Bourdon Gauge

* Not affected by gravity; records a higher

reading when an obstruction blocks

tubing; used on portable O2 tanks

administration14
ADMINISTRATION
  • Nasal Cannula: 2-6 lpm; 25-50%
  • Basic Mask: 6-10 lpm; 35-60%
  • Partial Rebreather: 10 & higher lpm; 60%
  • Non Rebreather: 10 & higher lpm; 60-95%
  • Demand Valve: 100 lpm; 100%
  • BVM: 0 lpm 21%

15 w/o reservoir 50%

15 w/reservoir up to 95%

manual techniques
MANUAL TECHNIQUES
  • Head Tilt/Chin Lift

Opens most common cause of obstruction, the

tongue

manual techniques25
MANUAL TECHNIQUES
  • Modify for suspected spinal injury:

1. Tongue/jaw lift

2. Modified jaw thrust

body position
BODY POSITION
  • Left or right lateral positioning of a patient aids airway maintenance by allowing fluids/vomitus to drain out
  • Only to be used when spinal injury is NOT suspected
  • If spinal injury is suspected, the patient must be secured solidly to a rigid board so that the body can be turned to the side as a total unit.
oropharyngeal airway op airway
OROPHARYNGEAL AIRWAY (OP AIRWAY)
  • Semicircular, disposable and made of hard plastic. Guedel and Berman are the frequent types.
  • Guedel is tubular and has a hollow center.
  • Berman is solid and has channeled sides.
  • Displaces the tongue away from the posterior pharyngeal wall.
op airway
OP AIRWAY

Even when in place, it is necessary to

maintain manual positioning of the airway by

a head-tilt, chin-lift or jaw-thrust maneuver.

INDICATIONS

  • Adjunct for airway control, determines presence of gag reflex.
  • Unconscious/unresponsive
op airway32
OP AIRWAY

INDICATIONS

  • Remove the airway if patient regains a gag reflex
  • May be inserted as a bite block after successful intubation
op airway33
OP AIRWAY

SIZING

  • Hold the airway next to the side of the patient's face and measuring the length of the airway from the corner of the mouth to the tip of the earlobe,
  • Center of the mouth to the angle of the mandible.
insertion
INSERTION
  • Choose the appropriate size
  • Open the airway
  • Insert the airway:

1. Using a tongue blade. Preferred method in

children.

2. Insert upside down and rotate into place.

Not to be used in children.

complications
COMPLICATIONS
  • With intact gag reflex could cause vomiting.
  • Laryngospasm
  • Inappropriate size:

1. To Long: may push the epiglottis closed

over the glottic opening, causing complete

airway obstruction

2. To Short: May be easily displaced, distal opening may become obstructed by tongue

complications36
COMPLICATIONS
  • May occur from insertion. Improperly placed may push the tongue back into the pharynx and cause obstruction.
  • Aggressive insertion may cause trauma to the upper airway and bleeding.
  • The lumen of the tube is not large enough to allow for suctioning. Suctioning must be performed around the tube.
nasopharyngeal airway np airway
NASOPHARYNGEAL AIRWAYNP AIRWAY

A curved hollow tube constructed of soft

plastic or rubber with a bevel at the distal end

and a flange or flare at the proximal end.

This airway is less likely to stimulate gagging

and vomiting because the the pliable tube

moves and flexes as the patient swallows.

np airway
NP AIRWAY

It may be used in a patient who is breathing

but needs assistance in maintaining a patent

airway.

15cm in length.

The distal tip sits at the posterior pharynx

while the proximal flare is seated on the

external nare.

np airway42
NP AIRWAY
  • Still requires manual airway maneuvers be maintained during its use.
np airway44
NP AIRWAY
  • Indications:

1. When OP is not able to be inserted

2. Airway of choice in spontaneously breathing, but less responsive patient needing airway control.

  • Sizing

1. Proximal end of the tube at the tip of the nose and the distal end at the earlobe

np airway46
NP AIRWAY
  • Technique of Insertion

* Needs to be lubricated.

* Proper size

* Advance with bevel toward the septum

* If patient is breathing you should feel

airflow when placed properly.

* If you meet resistance, remove and use

other nare.

np airway48
NP AIRWAY
  • Complications

* Improper size and too long could end up

in the esophagus

* Too short could be occluded by the

tongue

* Laryngospasm

* Trauma

esophageal obturator airway eoa
ESOPHAGEAL OBTURATOR AIRWAY (EOA)
  • Was widely used, but due to complications and ET training its use has dropped.
  • Recommended in situations when airway control was necessary and not able to intubate.
  • Comprised of a mask and a cuffed esophageal tube with a sealed distal end.
  • 16 air holes allow for ventilation.
slide50
EOA
  • Inflation port to inflate the cuff with a syringe and a pilot balloon to indicate the cuff volume.
  • Placed in the esophagus, to seal and not allow air entry into the esophagus
  • During ventilation, the air is forced through the mask and out of the openings in the proximal end. Air is facilitated in to the glottic opening and hence the trachea.
eoa complications
Esophageal rupture

Laryngospasm

Stimulation of vomiting

Aspiration of gastric contents during insertion

Soft tissue damage from cuff pressure

Inadequate mask seal

Unrecognized tracheal intubation

Do not leave in place for longer than 2 hours

Have suction available when removing

Remove when patient resumes breathing

EOA/COMPLICATIONS
eoa contraindications
Patient is alert, responsive, or has gag reflex

Less than 16 years of age

Ingested caustic substance

Less than 5 feet tall, greater than 7 feet tall

Significant airway bleed

EOA/CONTRAINDICATIONS
eoa advantages
Insertion does not require visualization and no equipment is necessary

Prevents air from entering the stomach

Prevents vomitus from traveling up the esophagus

ET may still be inserted with EOA in place

Head and neck of a C-Spine Injury may be maintained in a neutral in-line position during its insertion

EOA/ADVANTAGES
eoa disadvantages
Tight mask seal must still be maintained

May cause trauma to the esophagus or airway

Can be easily misplaced in the trachea

Cannot be left in place for prolonged periods of time

Does not isolate the trachea and prevent aspiration of contents from the upper airway

Tracheobronchial suctioning cannot be performed.

EOA/DISADVANTAGES
eoa insertion
Head neutral or flexed forward.

Insert the tube (with mask attached) blindly into the mouth and throat

Pass the tube gently until the mask seats on the patients face

Cuff Inflation

* Do not inflate the cuff until proper placements is confirmed

* Auscultate 4 lung fields and the epigastric region

EOA/INSERTION
eoa insertion57
Cuff Inflation

* If accidentally placed in the trachea and the cuff is inflated before checking for proper placement, serious damage to the trachea can result (30-35 cc’s of air)

REMOVAL

* Patient regains gag reflex, position patient on side

* Stand by with “crash” suction

* Remove the mask

* Deflate the cuff

EOA/INSERTION
eoa removal
EOA/REMOVAL
  • Remove the tube at peak inhalation
  • Get ready to SUCTION
esophageal gastric tube airway egta
ESOPHAGEAL GASTRIC TUBE AIRWAY (EGTA)
  • More recent design of the older version of the EOA.
  • Allows for the placement of a nasogastric tube through the lumen of the obturator for decompression of the stomach
  • Ventilation occurs directly into the oropharynx, rather than through the holes of the obturator
egta essentials
EGTA/ESSENTIALS
  • It is used only in patients who are unresponsive and without protective reflexes
  • It should NOT be used in patients with upper airway or facial trauma where bleeding into the oropharynx is a problem
  • It must NOT be used in any patient with injury to the esophagus, or in children who are below the age of 16
egta essentials62
EGTA/ESSENTIALS
  • Adequate mask seal must be ensured
  • Great attention must be paid to proper placement.
  • One of the great disadvantages of this airway is the fact that correct placement can be determined only by auscultation and observation of chest movement, both may be quite unreliable in the field setting
  • Insertion must be gentle and without force
egta insertion
EGTA/INSERTION
  • Ventilate and suctioning performed prior to insertion of the airway
  • After lubrication, the airway, with mask attached, is slid into the oropharynx while the tongue and jaw are pulled forward
  • The airway is advanced along the tongue and into the esophagus
egta insertion64
EGTA/INSERTION
  • Following gentle insertion so that the mask now rests easily on the face, the mask is sealed firmly on the face as the jaw is pulled forward to ensure an airway
  • Prior to inflating the cuff, ventilation is attempted as well as auscultation
  • If there is any doubt about placement of the airway remove it and reinsert
pharyngotracheal lumen airway ptl
PHARYNGOTRACHEAL LUMEN AIRWAY (PTL)
  • PTL consists of a smaller-diameter long tube inside of a short large-diameter tube.
  • The tube goes either into the trachea or the esophagus, while the shorter tube opens into the lower pharynx
  • Each tube has a cuff, the longer tube seals the esophagus or trachea, the shorter tube seals the oropharynx so that there is no air leak when ventilating
slide67
PTL
  • Insertion is blind, you must determine placement.
  • If longer tube is in trachea you ventilate through it
  • If longer tube is in the esophagus you ventilate through the shorter tube
ptl essentials
PTL/ESSENTIALS
  • Use only in patients who are unresponsive and without gag reflexes
  • Do NOT use in patient with injury to the esophagus or in children under the age of 15
  • Pay careful attention to placement
  • Insertion must be gentle and without force
  • In the patient regains consciousness, you must remove the PTL (vomiting)
ptl insertion
PTL/INSERTION
  • Ventilate and suction before insertion
  • Prepare the airway
  • Lubricate, and slide the airway into the oropharynx
  • Immediately inflate both cuffs
  • Determine placement
  • Secure
esophageal tracheal combitube
ESOPHAGEAL TRACHEAL COMBITUBE
  • Similar to the PTL in that it has a double lumen.
  • The two lumens are separated by a partition rather than one being inside of the other.
  • One tube is sealed at the distal end, and there are perforations in the area of the tube that would be in the pharynx.
combitube
COMBITUBE
  • When the long tube is in the esophagus, the patient is ventilated through this short tube
  • The long tube is open at the distal end, and it has a cuff that is blown up to seal the esophagus or the trachea
  • If the long tube goes into the esophagus, the cuff is inflated and the patient is ventilated through the short tube.
combitube74
COMBITUBE
  • If the long tube goes into the trachea, the cuff is inflated and the patient is ventilated through the long tube.
  • The Combitube is somewhat quicker and easier to insert than the PTL
combitube essentials
COMBITUBE/ESSENTIALS
  • Use only in patients who are unresponsive and without protective gag reflex
  • Do not use in any patient with injury to the esophagus and children below 15
  • Pay attention to placement
  • Insert gently and without force
  • Remove once patient regains consciousness
combitube technique
COMBITUBE/TECHNIQUE
  • Insert the tube blindly, watching for the two black rings on the tube for measuring the depth of insertion. These rings should be positioned between the teeth and the lips
  • Use the large syringe to inflate the pharyngeal cuff with 100 cc of air
  • Use the small syringe to fill the distal cuff with 10-15 cc of air
combitube insertion
COMBITUBE/INSERTION
  • The long tube will usually go into the esophagus. Ventilate through the esophageal connector. Longer of the tubes and marked “1”.
  • Check placement, if not placed properly:
  • Ventilate through the shorter tracheal connector which is marked “2”
laryngeal mask airway lma
LARYNGEAL MASK AIRWAY (LMA)
  • Developed as an alternative to the face mask for achieving and maintaining control of the airway during routine anesthetic procedures in the operating room.
  • Found to be useful in the emergency situation when intubation is not possible and you can’t ventilate with a BVM
  • May prevent doing a surgical procedure to open the airway
slide80
LMA
  • Not designed to seal the esophagus and was not originally meant for emergency use.
  • It is not equal to the ET and should only be used when efforts to intubate the trachea have been unsuccessful and ventilation is compromised.
lma warnings
LMA/WARNINGS
  • Use only in patients who are unresponsive and without protective reflexes.
  • Do not use in any patient with injury to the esophagus
  • Lubricate only the posterior surface of the LMA to avoid blockage of the aperture or aspiration of the lubricant
  • Patients should be adequately monitored
lma warnings82
LMA/WARNINGS
  • Never force the device to avoid trauma to the airway
  • Never overinflate the cuff. May cause malposition, loss of seal, or trauma.
  • If airway problems persist, it should be removed and reinserted.
  • Does not prevent aspiration if the patient vomits
lma warnings83
LMA/WARNINGS
  • If the patient regains consciousness, you must remove it.
lma insertion
LMA/INSERTION
  • Ventilate with mouth-to-mask or BVM, and suction
  • Remove the valve tab and check the integrity of the LMA cuff by inflating with maximum volume
  • Cuff should be tightly deflated using the enclosed syringe so that it forms a flat oval disk with the rim facing away from the aperture.
lma insertion85
LMA/INSERTION
  • Lubricate the posterior surface
  • Preoxygenate the patient
  • If no danger of spinal injury, position the patient with the neck flexed and the head extended, otherwise neutral position.
  • Hold the LMA like a pen and insert.
  • Use the index finger to guide the LMA, pressing upwards and backwards toward the ears
lma insertion86
LMA/INSERTION
  • Without holdings the tube, inflate the cuff with just enough air to obtain a seal. The tube will “bob” when properly placed.
  • Connect the LMA to the BVM and check position.
suctioning
SUCTIONING
  • Often a neglected skill.
  • Very important skill that must accompany airway maintenance
  • Can be used to open an airway or to maintain an airway
  • All suctioning should be considered “sterile”
suctioning general rules
Hyperventilate the patient, or apply oxygen in a high-concentration to those who are spontaneously breathing and monitor ECG

Use only sterile devices

Be gentle

Lubricate all suction catheters and tips

Maximum of 10 seconds of suction time

Suction on withdrawal of catheter, rotating slowly (ET)

SUCTIONINGGENERAL RULES
suctioning93
SUCTIONING

NASO, OROPHARYNX

  • Use either the soft, flexible catheter or the “tonsil tip” catheter
  • The tonsil tip is preferred for oropharyngeal suctioning
  • Another consideration is the V-Vac Suction Device
  • Flexible catheter preferred for naso
suctioning94
SUCTIONING

ET TUBE

  • “Sterility” is especially important since you have by-passed the body’s natural protective elements
  • Use only soft flexible catheters
  • Be GENTLE
  • Observe the monitor for arrhythmias
suctioning98
SUCTIONING

CRASH SUCTIONING

  • For those times when the patient suddenly vomits, it can be very catastrophic for the patient
  • Involves increasing the bore of the suction device
  • Remember: Since “CRASH” suctioning removes large amounts of fluids, it also removes large amount of air