Lesson 3 – Advanced Airway Management Techniques

Indications for Bag-Valve Mask (BVM) Ventilation

Used for patients not breathing or breathing inadequately, such as those with slow, shallow, gasping, or noisy respirations. Also indicated for unconscious patients with abnormal breathing, even if they have a pulse.

Risks of Overaggressive Ventilation

Ventilating too fast or with too much pressure can cause lung damage, pneumothorax, or irreversible lung injury.

BVM Equipment Requirements

Bag valve mask with an appropriately sized mask, oxygen tubing, and an oxygen source. Attach tubing to oxygen tank and set flow rate to the highest setting. Do not delay BVM use if oxygen is not yet attached.

One-Person BVM Technique

Use EC hand position: thumb and first finger form a C to seal the mask; remaining fingers lift the jaw in an E shape. Pull face up while sealing mask down to avoid airway blockage.

Ventilation Process with BVM

Squeeze the bag over 1–2 seconds to make the chest rise ~1/3 of normal. Avoid fast breaths. Let chest fall between breaths. Deliver 1 breath every 6 seconds (10 bpm) in adults.

Two-Person BVM Technique

One rescuer uses both hands to seal the mask, the other squeezes the bag once every 6 seconds (10–12 bpm). Count breaths out loud and observe chest rise.

Common BVM Mistakes

Poor mask seal, overventilation, failure to allow exhalation, and improper head positioning. BVMs hold ~1600cc but only ~600cc needed per breath.

OPA and NPA Indications

OPAs: for unconscious patients without gag reflex. NPAs: for semi-conscious patients. Both prevent tongue obstruction and improve BVM effectiveness.

Supraglottic Airway Devices

Advanced airways above the glottis, easier than endotracheal tubes. Includes LMA, King LT, and i-gel. Inserted blindly, provide good ventilation seal.

Advantages and Limitations of Supraglottic Airways

Advantages: easy insertion, no vocal cord visualization, usable by EMT-B. Limitations: less secure, limited aspiration protection, not for facial trauma or morbid obesity.

Continuous Positive Airway Pressure (CPAP)

Non-invasive therapy with constant positive pressure. Opens alveoli, improves gas exchange, lowers breathing work. Used for CHF, COPD, pneumonia.

CPAP Use Criteria

Patient must be alert, cooperative, breathing adequately, and have systolic BP ≥ 90 mmHg. Hemodynamic stability required due to potential BP drop.

CPAP Oxygen Flow and Pressure

5 cmH₂O ≈ 8–10 LPM. Increase 2.5 cmH₂O → add 2–3 LPM. E.g., 10 cmH₂O ≈ 12–15 LPM. Start with 5–7.5 cmH₂O and adjust. Check device specs for exact flow-pressure relation.

CPAP Mask Application

Choose proper mask size. Connect and turn on O₂. Explain to patient. Manually hold mask for initial seal, then secure straps. Check for leaks and adjust straps for snug fit.

Transition from CPAP to BVM

Switch to BVM if decreased consciousness, poor respiratory effort, BP < 90 mmHg, or worsening hypoxia. Have BVM ready when starting CPAP.

Endotracheal Intubation Process

Performed by advanced providers. EMTs assist. Laryngoscope lifts epiglottis; ET tube placed in trachea; balloon inflated; tube secured and ventilator attached.

Confirming ET Tube Placement

Check chest rise, auscultate breath sounds, use end-tidal CO₂ monitor. Monitor ventilations (10–12 bpm), oxygenation, and patient condition. Watch for dislodgement or complications.

Case Study – COPD Exacerbation

60M, severe respiratory distress, SpO₂ 85%. Consider BVM and CPAP. Assess consciousness, respiratory effort, and BP. Choose CPAP if criteria met, else BVM if worsening.

Lesson Summary

Covered BVM, OPAs/NPAs, supraglottic airways, CPAP, and ET intubation. EMTs must master BVM and adjuncts; understand advanced devices to assist AL