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Airway Management Part 1. Prof. M.H. MUMTAZ. Topics for Discussion. Airway Maintenance Objectives Airway Anatomy & Physiology Review Causes of Respiratory Difficulty & Distress Assessing Respiratory Function Methods of Airway Management Methods of Ventilatory Management

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airway management part 1

Airway ManagementPart 1

Prof. M.H. MUMTAZ

topics for discussion
Topics for Discussion

Airway Maintenance Objectives

Airway Anatomy & Physiology Review

Causes of Respiratory Difficulty & Distress

Assessing Respiratory Function

Methods of Airway Management

Methods of Ventilatory Management

Common Out-of-Hospital Equipment Utilized

Advanced Methods of Airway Management and Ventilation

Risks to the Paramedic

objectives of airway management ventilation
Objectives of Airway Management & Ventilation

Primary Objective:

Ensure optimal ventilation

Deliver oxygen to blood

Eliminate carbon dioxide (C02) from body

Definitions

What is airway management?

How does it differ from spontaneous, manual or assisted ventilations?

objectives of airway management ventilation1
Objectives of Airway Management & Ventilation

Why is this so important?

Brain death occurs rapidly; other tissue follows

EMS providers can reduce additional injury/disease by good airway, ventilation techniques

EMS providers often neglect BLS airway, ventilation skills

airway anatomy review
Airway Anatomy Review

Upper Airway Anatomy

Lower Airway Anatomy

Lung Capacities/Volumes

Pediatric Airway Differences

upper airway anatomy
Upper Airway Anatomy

Functions: warm, filter, humidify air

Nasal cavity and nasopharynx

Formed by union of facial bones

Nasal floor towards ear not eye

Lined with mucous membranes, cilia

Tissues are delicate, vascular

Adenoids

Lymph tissue - filters bacteria

Commonly infected

upper airway anatomy1
Upper Airway Anatomy

Oral cavity and oropharynx

Teeth

Tongue

Attached at mandible, hyoid bone

Most common airway obstruction cause

Palate

Roof of mouth

Separates oropharynx and nasopharynx

Anterior= hard palate; Posterior= soft palate

upper airway anatomy2
Upper Airway Anatomy

Oral cavity and oropharynx

Tonsils

Lymph tissue - filters bacteria

Commonly infected

Epiglottis

Leaf-like structure

Closes during swallowing

Prevents aspiration

Vallecula

“Pocket” formed by base of tongue, epiglottis

upper airway anatomy4
Upper Airway Anatomy

Sinuses

cavities formed by cranial bones

act as tributaries for fluid to, from eustachian tubes, tear ducts

trap bacteria, commonly infected

upper airway anatomy5
Upper Airway Anatomy

Larynx

Attached to hyoid bone

Horseshoe shaped bone

Supports trachea

Thyroid cartilage

Largest laryngeal cartilage

Shield-shaped

Cartilage anteriorly, smooth muscle posteriorly

“Adam’s Apple”

Glottic opening directly behind

upper airway anatomy6
Upper Airway Anatomy

Larynx

Glottic opening

Adult airway’s narrowest point

Dependent on muscle tone

Contains vocal bands

Arytenoid cartilage

Posterior attachment of vocal bands

upper airway anatomy7
Upper Airway Anatomy

Larynx

Cricoid ring

First tracheal ring

Completely cartilaginous

Compression (Sellick maneuver) occludes esophagus

Cricothyroid membrane

Membrane between cricoid, thyroid cartilages

Site for surgical, needle airway placement

upper airway anatomy8
Upper Airway Anatomy

Larynx and Trachea

Associated Structures

Thyroid gland

below cricoid cartilage

lies across trachea, up both sides

Carotid arteries

branch across, lie closely alongside trachea

Jugular veins

branch across and lie close to trachea

upper airway anatomy10
Upper Airway Anatomy

Pediatric vs Adult Upper Airway

Larger tongue in comparison to size of mouth

Floppy epiglottis

Delicate teeth, gums

More superior larynx

Funnel shaped larynx due to undeveloped cricoid cartilage

Narrowest point at cricoid ring before ~8 years old

upper airway anatomy11
Upper Airway Anatomy

From: CPEM, TRIPP, 1998

lower airway anatomy
Lower Airway Anatomy

Function

Exchange O2 , CO2 with blood

Location

From glottic opening to alveolar-capillary membrane

lower airway anatomy1
Lower Airway Anatomy

Trachea

Bifurcates (divides) at carina

Right, left mainstem bronchi

Right mainstem bronchus shorter, straighter

Lined with mucous cells, beta-2 receptors

lower airway anatomy2
Lower Airway Anatomy

Bronchi

Branch into secondary, tertiary bronchi that branch into bronchioles

Bronchioles

No cartilage in walls

Small smooth muscle tubes

Branch into alveolar ducts that end at alveolar sacs

lower airway anatomy3
Lower Airway Anatomy

Alveoli

“Balloon-like” clusters

Site of gas exchange

Lined with surfactant

Decreases surface tension  eases expansion

 surfactant  atelectasis (focal collapse of alveoli0

lower airway anatomy4
Lower Airway Anatomy

Lungs

Right lung = 3 lobes; Left lung = 2 lobes

Parenchymal tissue

Pleura

Visceral

Parietal

Pleural space

lower airway anatomy6
Lower Airway Anatomy

Occlusion of bronchioles

Smooth muscle contraction (bronchospasm

Mucus plugs

Inflammatory edema

Foreign bodies

lung volumes capacities
Lung Volumes/Capacities

Typical adult male total lung capacity = 6 liters

Tidal Volume (VT)

Gas volume inhaled or exhaled during single ventilatory cycle

Usually 5-7 cc/kg (typically 500 cc)

lung volumes capacities1
Lung Volumes/Capacities

Dead Space Air (VD)

Air unavailable for gas exchange

lung volumes capacities2
Lung Volumes/Capacities

Dead Space Air (VD)

Anatomic dead space (~150cc)

Trachea

Bronchi

Physiologic dead space

Shunting

Pathological dead space

Formed by factors like disease or obstruction

Examples: COPD

lung volumes capacities3
Lung Volumes/Capacities

Alveolar Air (alveolar volume) [VA]

Air reaching alveoli for gas exchange

Usually 350 cc

lung volumes capacities4
Lung Volumes/Capacities

Minute Volume [Vmin](minute ventilation)

Amount of gas moved in, out of respiratory tract per minute

Tidal volume X RR

Alveolar Minute Volume

Amount of gas moved in, out of alveoli per minute

(tidal volume - dead space volume) X RR

lung volumes capacities5
Lung Volumes/Capacities

Functional Reserve Capacity (FRC)

After optimal inspiration, amount of air that can be forced from lungs in single exhalation

lung volumes capacities6
Lung Volumes/Capacities

Inspiratory Reserve Volume (IRV)

Amount of gas that can be inspired in addition to tidal volume

Expiratory Reserve Volume (ERV)

Amount of gas that can be expired after passive (relaxed) expiration

ventilation
Ventilation

Movement of air in, out of lungs

Control via:

Respiratory center in medulla

Apneustic, pneumotaxic centers in pons

ventilation1
Ventilation

Inspiration

Stimulus from respiratory center of brain (medulla)

Transmitted via phrenic nerve to diaphragm, spinal cord/intercostal nerves to intercostal muscles

Diaphragm contracts, flattens

Intercostal muscles contract; ribs move up and out

Air spaces in lungs stretch, increase in size

 intrapulmonic pressure (pressure gradient)

Air flows into airways, alveoli inflate until pressure equalizes

ventilation2
Ventilation

Expiration

Stretch receptors in lungs signal respiratory center via vagus nerve to inhibit inspiration (Hering-Breuer reflex)

Natural elasticity of lungs pulls diaphragm, chest wall to resting position

Pulmonary air spaces decrease in size

Intrapulmonary pressure rises

Air flows out until pressure equalizes

ventilation5
Ventilation

Respiratory Drive

Chemoreceptors in medulla

Stimulated  PaCO2 or  pH

PaCO2 is normal neuroregulatory control of ventilations

Hypoxic Drive

Chemoreceptors in aortic arch, carotid bodies

Stimulated by  PaO2

Back-up regulatory control

ventilation6
Ventilation

Other stimulants or depressants

Body temp: fever; hypothermia

Drugs/meds: increase or decrease

Pain: increases, but occasionally decreases

Emotion: increases

Acidosis: increases

Sleep: decreases

gas measurements
Gas Measurements

Total Pressure

Combined pressure of all atmospheric gases

760 mm Hg (torr) at sea level

Partial Pressure

Pressure exerted by each gas in a mixture

gas measurements1
Gas Measurements

Partial Pressures

Atmospheric

Nitrogen 597.0 torr (78.62%); Oxygen 159.0 torr (20.84%); Carbon Dioxide 0.3 torr (0.04%); Water 3.7 torr (0.5%)

Alveolar

Nitrogen 569.0 torr (74.9%); Oxygen 104.0 torr (13.7%); CO2 40.0 torr (5.2%); Water 47.0 torr (6.2%)

respiration
Respiration

Ventilation vs. Respiration

Exchange of gases between living organism, environment

External Respiration

Exchange between lungs, blood cells

Internal Respiration

Exchange between blood cells, tissues

respiration1
Respiration

How are O2, CO2 transported?

Diffusion

Movement of gases along a concentration gradient

Gases dissolve in water, pass through alveolar membrane from areas of higher concentration to areas of lower concentration

FiO2

% oxygen in inspired air expressed as a decimal

FiO2 of room air = 0.21

respiration2
Respiration

Blood Oxygen Content

dissolved O2 crosses capillary membrane, binds to Hgb of RBC

Transport = O2 bound to hemoglobin (97%) or dissolved in plasma

O2 Saturation

% of hemoglobin saturated with oxygen (usually carries >96% of total)

O2 content divided by O2 carrying capacity

respiration3
Respiration

Oxygen saturation affected by:

Low Hgb (anemia, hemorrhage)

Inadequate oxygen availability at alveoli

Poor diffusion across pulmonary membrane (pneumonia, pulmonary edema, COPD)

Ventilation/Perfusion (V/Q) mismatch

Blood moves past collapsed alveoli (shunting)

Alveoli intact but blood flow impaired

respiration4
Respiration

Blood Carbon Dioxide Content

Byproduct of work (cellular respiration)

Transported as bicarbonate (HCO3- ion)

 20-30% bound to hemoglobin

Pressure gradient causes CO2 diffusion into alveoli from blood

Increased level = hypercarbia

inspired air p o2 160 p co2 0 3
Inspired Air: PO2 160 & PCO2 0.3

Alveoli PO2 100 & PCO2 40

PO2 40 & PCO2 46 - Pulmonary circulation - PO2 100 & PCO2 40

Heart

Oxygenated

Deoxygenated

PO2 40 & PCO2 46 - Systemic circulation - PO2 100 & PCO2 40

Tissue cell PO2 <40 & PCO2 >46

diagnostic testing
Diagnostic Testing

Pulse Oximetry

Peak Expiratory Flow Testing

Pulmonary Function Testing

End-Tidal CO2 Monitoring

Laboratory Testing of Blood

Arterial

Venous

causes of hypoxemia
Causes of Hypoxemia

Lower partial pressure of atmospheric O2

Inadequate hemoglobin level in blood

Hemoglobin bound by other gas (CO)

 pulmonary alveolar membrane distance

Reduced surface area for gas exchange

Decreased mechanical effort

causes of airway ventilatory compromise
Causes of Airway/Ventilatory Compromise

Airway Obstruction

Tongue

Foreign body obstruction

Anaphylaxis/angioedema

Upper airway burn

Maxillofacial/laryngeal/trachebronchial trauma

Epiglottitis

Croup

obstruction
Obstruction

Tongue

Most common cause

Snoring respirations

Corrected by positioning

foreign body
Foreign Body

Partial or Full

Symptoms include

Choking

Gagging

Stridor

Dyspnea

Aphonia

Dysphonia

laryngeal spasm
Laryngeal Spasm

Spasmatic closure of vocal cords

Frequently caused by

Overly aggressive technique during intubation

Immediately upon extubation

laryngeal edema
Laryngeal Edema

Causes

Angioedema

Anaphylaxis

Upper airway burns

Epiglottitis

Croup

Trauma

aspiration
Aspiration

Significantly increases mortality

Obstructs Airway

Destroys bronchial tissue

Introduces pathogens

Decreases ability to ventilate

Frequently occult

obstructive airway disease
Obstructive Airway Disease

Obstructive airway disease

Asthma

Emphysema

Chronic Bronchitis

gas exchange surface
Gas Exchange Surface

Pulmonary edema

Left-sided heart failure

Toxic inhalation

Near drowning

Pneumonia

Pulmonary embolism

Blood clots

Amniotic fluid

Fat embolism

causes of airway ventilatory compromise1
Causes of Airway/Ventilatory Compromise

Thoracic Bellows

Chest trauma

Fib fractures

Flail chest

Pneumothorax

Hemothorax

Sucking chest wound

Diaphragmatic hernia

causes of airway ventilatory compromise2
Causes of Airway/Ventilatory Compromise

Thoracic Bellows

Pleural effusion

Spinal cord trauma

Morbid obesity (Pickwickian Syndrome)

Neurological/neuromuscular disease

Poliomyelitis

Myasthenia gravis

Muscular dystrophy

Gullian-Barre syndrome

causes of airway ventilatory compromise3
Causes of Airway/Ventilatory Compromise

Control System

Head trauma

Cerebrovascular accident

Depressant drug toxicity

Narcotics

Sedative-Hypnotics

Ethanol

assessment of airway ventilatory compromise
Assessment of Airway/Ventilatory Compromise

Respiratory Distress/Dyspnea = Possible Life Threat

Assess/Manage Simultaneously

Priorities

Airway

Breathing

Circulation

Disability

assessment of airway ventilatory compromise1
Assessment of Airway/Ventilatory Compromise

Airway

Listen to patient talk/breathe

Noisy breathing = Obstructed breathing

But, all obstructed breathing is not noisy

Adventitious sounds

Snoring = Tongue

Stridor = “Tight” Upper Airway

assessment of airway ventilatory compromise2
Assessment of Airway/Ventilatory Compromise

Breathing

Look

Symmetry of Chest Expansion

Signs of Increased Effort

Skin Color

Listen

Mouth and Nose

Lung Fields

Feel

Mouth and Nose

Symmetry of Expansion

assessment of airway ventilatory compromise3
Assessment of Airway/Ventilatory Compromise

Breathing

Tachypnea

Bradypnea

Signs of distress

Nasal flaring

Tracheal tugging

Retractions

Accessory muscle use

Tripod positioning

Cyanosis

assessment of airway ventilatory compromise4
Assessment of Airway/Ventilatory Compromise

Circulation

Don’t let respiratory failure distract you!!!

Tachycardia = Early hypoxia in adults

Bradycardia = Early hypoxia in infants, children; Late hypoxia in adults

assessment of airway ventilatory compromise5
Assessment of Airway/Ventilatory Compromise

Disability

Restlessness, anxiety, combativeness = hypoxia until proven otherwise

Drowsiness, lethargy = hypercarbia until proven otherwise

When the fighting stops, a patient isn’t always getting better

assessment of airway ventilatory compromise6
Assessment of Airway/Ventilatory Compromise

Focused Exam

Respiratory Patterns

Cheyne-Stokes = diffuse cerebral cortex injury

Kussmaul = acidosis

Biot’s (cluster) = increased ICP; pons, upper medulla injury

Central Neurogenic Hyperventilation = increased ICP; mid-brain injury

Agonal = brain anoxia

assessment of airway ventilatory compromise7
Assessment of Airway/Ventilatory Compromise

Focused Exam

Neck

Trachea mid-line?

Jugular vein distension?

Subcutaneous emphysema?

Accessory muscle use?/hypertrophy?

assessment of airway ventilatory compromise8
Assessment of Airway/Ventilatory Compromise

Focused Exam

Chest

Barrel chest?

Deformity, discoloration, asymmetry?

Flail segment, paradoxical movement?

Adventitious breath sounds?

Third heart sound?

Subcutaneous emphysema?

Fremitus?

Dullness, hyperresonance to percussion?

assessment of airway ventilatory compromise9
Assessment of Airway/Ventilatory Compromise

Focused Exam

Extremities

Edema?

Nail bed color?

Clubbing?

assessment of airway ventilatory compromise10
Assessment of Airway/Ventilatory Compromise

Mechanical Ventilation

Increased resistance

Changing compliance

assessment of airway ventilatory compromise11
Assessment of Airway/Ventilatory Compromise

Pulsus Paradoxus

Systolic BP drops > 10 mm Hg w/inspiration

May detect change in pulse quality

COPD, asthma, pericardial tamponade

assessment of airway ventilatory compromise12
Assessment of Airway/Ventilatory Compromise

History

Onset gradual or sudden?

What makes it worse, better?

How long?

Cough? Productive? Of what?

Pain? What kind?

Fever?

assessment of airway ventilatory compromise13
Assessment of Airway/Ventilatory Compromise

Past History

Hypertension, AMI, diabetes

Chronic cough, smoking, recurrent “colds”

Allergies, acute/seasonal SOB

Lower extremity trauma, recent surgery, immobilization

Interventions

Past admission? Ever admitted to ICU?

Medications? Frequency of prn medication use?

Ever intubated before?

bls airway ventilation methods
BLS Airway/Ventilation Methods

Supplemental Oxygen

Increased FiO2 increases available oxygen

Objective = Maximize hemoglobin saturation

oxygen equipment
Oxygen Equipment

Oxygen source

Compressed gas

Tank size

D 400L

E 660L

M 3450 L

Liquid oxygen

oxygen equipment1
Oxygen Equipment

Regulators

High Pressure

Cylinder to cylinder

Low Pressure

Cylinder to patient

Humidifier

delivery devices
Delivery Devices

Nasal cannula

Simple face mask

Partial rebreather mask

Non-rebreather mask

Venturi mask

Small volume nebulizer

nasal cannula
Nasal Cannula

Optimal delivery 40% at 6 LPM

Indication

Low FiO2

Long term therapy

Contraindications

Apnea

Mouth breathing

Need for High FiO2

venturi mask
Venturi Mask

Specific O2 Concentrations

24%

28%

35%

40%

simple face mask
Simple Face Mask

Range 40-60% at 10 LPM

Volumes greater that 10 LPM does not increase O2 delivery

Indications

Moderate FiO2

Contraindications

Apnea

Need for High FiO2

non rebreather mask
Non-Rebreather Mask

Range 80-95% at 15 LPM

Indications

Delivery of high FiO2

Contraindications

Apnea

Poor respiratory effort

partial rebreather
Partial Rebreather

Range 40 – 60%

Indications

Moderate FiO2

Contraindications

Apnea

Need for High FiO2

bls airway ventilation methods1
BLS Airway/Ventilation Methods

Airway Maneuvers

Head-tilt/Chin-lift

Jaw thrust

Sellick’s maneuver

Other Types

Tracheostomy with tube

Tracheostomy with stoma

Airway Devices

Oropharyngeal airway

Nasopharyngeal airway

bls airway ventilation methods2
BLS Airway/Ventilation Methods

Mouth-to-Mouth

Mouth-to-Nose

Mouth-to-Mask

One-person BVM

Two-person BVM

Three-person BVM

Flow-restricted, gas powered ventilator

Transport ventilator

bls airway ventilation methods3
BLS Airway/Ventilation Methods

Mouth to Mouth

Mouth to Nose

Mouth to Mask

bls airway ventilation methods4
BLS Airway/Ventilation Methods

One-Person BVM

Difficult to master

Mask seal often inadequate

May result in inadequate tidal volume

Gastric distention risk

Ventilate only until see chest rise

bls airway ventilation methods5
BLS Airway/Ventilation Methods

Two-person BVM

Most efficient method

Useful in C-spine injury

improved mask seal, tidal volume

Three-person BVM

Less utilized

Used when difficulty with mask seal

Crowded

bls airway ventilation methods6
BLS Airway/Ventilation Methods

Flow-restricted, gas-powered ventilator

Cardiac sphincter opens at 30 cm H2O

High volume/high concentration

Not recommended for children, poor pulmonary compliance, or poor tidal volume

Oxygen delivered on inspiratory effort

May cause barotrauma

bls airway ventilation methods7
BLS Airway/Ventilation Methods

Automatic transport ventilators

Not like “real” ventilator

Usually only controls volume, rate

Useful during prolonged ventilation times

Not useful in obstructed airway, increased airway resistance

Frees personnel

Cannot respond to changes in airway resistance, lung compliance

bls airway ventilation methods8
BLS Airway/Ventilation Methods

Pediatric considerations

Mask seal force may obstruct airway

Best if used with jaw thrust

BVM sizes: neonate, infant=450 ml +

Children > 8 y.o. require adult BVM

Just enough volume to see chest rise

Squeeze - Release - Release

bls airway ventilation methods9
BLS Airway/Ventilation Methods

Stoma patients

Expose stoma

Pocket mask

BVM

Seal around stoma site

Seal mouth, nose if air leak is evident

bls airway ventilation methods10
BLS Airway/Ventilation Methods

Airway obstruction techniques

Positioning

Finger sweep with caution

Suctioning

Oral airway/nasal airway (tongue)

Heimlich maneuver

Chest thrusts

Chest thrust/back blows for infants

Direct laryngoscopy

bls airway ventilation methods11
BLS Airway/Ventilation Methods

Suctioning

Manual or powered devices

Suction catheters

Rigid

Soft

bls airway ventilation methods12
BLS Airway/Ventilation Methods

Gastric Distention

Common when ventilating without intubation

Complications

Pressure on diaphragm

Resistance to BVM ventilation

Vomiting, aspiration

Increase BVM ventilation time