Ch. 16 | Airway & Ventilations

Upper Airway

Type of Airway that contains:

1. Tongue

2. Uvula

3. Pharynx

4. Larynx

Lower Airway

Type of Airway that contains:

1. Thyroid Cartilage

2. Cricothyroid Cartilage

3. Cricoid Cartilage

4. Glottis

5. Epiglottis

6. Trachea

Ventilation

The physical act of moving air in and out of the lungs

Inhalation

The active muscular process of ventilation

Exhalation

A passive process and does not normally require muscular effort during ventilation

Oxygenation

The process of loading oxygen molecules onto hemoglobin molecules in the bloodstream

Respiration

The process of exchanging oxygen and carbon dioxide

External Respiration

A type of respiration that exchanges oxygen and carbon dioxide between the alveoli and the blood in the pulmonary capillaries

Internal Respiration

A type of respiration that exchanges oxygen and carbon dioxide between the systemic circulation and the cells of the body

External Respiration and Perfusion

What are the two processes that must take place in order to prevent tissue death and provide adequate oxygen?

Hypoxia

When tissues and cells do not receive enough oxygen

Cyanosis

A blue or purple skin color

Dyspnea

When a responsive patient has a short of breath feeling

V/Q Mismatch

A failure to match ventilation and perfusion

Hypoventilation

Slow and/or Shallow breathing

Hyperventilation

Rapid and/or Deep breathing

Hypercapnia

Increased carbon dioxide content in arterial blood

Hypocapnia

Decreased carbon dioxide content in arterial blood

Positive Pressure Ventilation

Forcing of air into the lungs

Negative Pressure Ventilations

Drawing of air into the lungs; airflow from the region of higher pressure (outside the body) to a region of lower pressure (the lungs); occurs during normal (unassisted) breathing

Oxyhemoglobin

The bright red, oxygen-bound form of hemoglobin. When oxygen is in the hemoglobin

Intrinsic Factors

• Infection, Allergic Reactions, Unresponsiveness

• The tongue is the most common obstruction in an unresponsive patient

  • Factors may not be directly part of the respiratory system

Extrinsic Factors

• Trauma and foreign body airway obstruction

• Trauma requires immediate intervention

  • Blunt/penetrating trauma and burns can disrupt airflow into the lungs

  • Trauma to the chest wall can lead to inadequate pulmonary ventilation

Minute Volume

The amount of oxygen you breathe in a minute

Hypoglycemia

Oxygen and glucose levels decrease

Respiratory Acidosis

A pathologic condition characterized by a blood pH of less than 7.35; caused by the accumulation of acids in the body from a respiratory cause

Respiratory Alkalosis

A pathologic condition characterized by a blood pH of greater than 7.45; results from the accumulation of bases in the body from a respiratory cause

Assessing for a patent airway

1. Are there any obstructions?

2. Can the pt maintain this on their own?

3. Is pt ventilating?

4. Are they oxygenating?

5. Do we need to give O2 therapy?

6. Do we need to ventilate for the pt?

Adequate Breathing

1. 12-20 breaths/min

2. Adequate Depth/Tidal Volume

3. Regular Breathing Pattern (In & out)

4. Clear and equal breath sounds bilaterally

5. Breathing appears effortless

6. Changes should look subtle

Inadequate Breathing

1. Presents in respiratory distress

2. <12-20 breaths/min

3. Shallow breathing

4. Irregular breathing pattern

5. Altered mentation

6. Cyanotic

Cheynes-Stokes Respirations

Gradually increasing rate and depth of respirations, followed by a gradual decrease of respirations with intermittent periods of apnea, associated with brainstem insult

Kussmaul Respirations

Deep, rapid respirations seen in patients with diabetic ketoacidosis

Biot (ataxic) Respirations

Irregular pattern, rate, and depth of breathing with intermittent periods of apnea, results from increased intracranial pressure

Apneustic Respirations 

Prolonged, gasping inhalation, followed by extremely short, ineffective exhalation, associated with brainstem insult

Agonal Gasps

Slow, shallow, irregular, or occasional gasping breath; result from cerebral anoxia. Agonal gasps may be seen shortly after the heart has stopped but the brain continues to send signals to the muscles of respiration

Ways to assess pt’s breath sounds

1. Auscultate both apexes and bases of both lungs

2. Palpate for bilateral Chest Rise

3. Pulse Ox for pt’s oxygenation

35-45 mmHg

What is the normal ETCO2 levels between?

Recovery Position

Placing the pt in a left lateral recumbent position. Used if the pt has a decreased LOC with no trauma to the spine, hips, or pelvis, self-maintained airway, and adequate breathing

Head tilt chin lift

Opening the airway by tilting the pt’s head back and lifting the chin

Jaw Thrust

Opening the airway by placing your fingers behind the angle of the jaw and lifting the jaw forward. 

1. Indications:

   1. Unresponsive 

   2. Has possible cervical spine injury who is unable to protect their airway

2. Contraindications:

   1. Responsive

Tongue-Jaw LIft

1. Position yourself on pt’s side

2. Place your hand closest to the pt’s head on the forehead

3. With the other hand reach into the pt’s mouth and hook your first knuckle under the gumline

4. While holding the pt’s head and maintaining the hand on the forehead, lift the jaw straight up

1. Only going as far as I can see

2. Suction on the way out

3. 10 seconds max

What are the 3 key steps when suctioning?

Earlobe to corner of mouth

How do you measure an OPA?

Towards the roof of mouth half way and turn 180 towards back of the tongue

How do you insert an OPA?

Earlobe to opening of the nostrils

How do you measure an NPA?

Airway Obstructions

1. Food

2. Small Toys

3. Tongue

4. Laryngeal Edema

5. Laryngeal Spasm

6. Trauma 

What do these have in common?

Laryngeal Spasm

A spasmodic closure of the vocal cords, completely occluding the airway. It is often caused by trauma during an overly aggressive intubation attempt or occurs immediately on extubation, especially when the pt has an altered LOC

Laryngeal Edema

• Epiglottitis 

• Anaphylaxis

• Inhalation Injury/Burns to the Upper Airway

These cause the glottic opening to become extremely narrow or totally closed

Aspiration

The drawing in or out by suction. In the lungs, _____ of food, liquids, blood, or foreign objects can occur when a pt is unable to protect the airway

Laryngeal Injury

When the larynx is penetrated or crushed compromising the airway secondary to swelling and bleeding

12-15 lpm

What is the lpm range for usage of a nonrebreather?

1-5 lpm

What is the lpm range for usage of a nasal cannula?

Pocket Face Mask

A one-way plastic face shield allowing ventilation through the mouth to mask. This is used when a BVM isn’t availble during resuscitation

1. BVM w/ 15 lpm

2. Keep a good seal

3. Ventilate every 5-6 seconds

4. Squeeze till Chest Rise

What are some key details you should remember when using a BVM?

Signs of Adequate Artificial Ventilation

1. Equal Chest rise and fall with ventilation

2. Breath sounds can be heard during auscultation of the chest

3. Ventilations are given at the appropriate rate

   1. 10 bpm for adults

   2. 20-30 bpm for infants and children

   3. Pulse rate returns to a normal range

   4. Oxygen saturation level improves

Signs of Inadequate Artificial Ventilation

1. Minimal or no chest rise and fall

2. Breath sounds cannot be heard during auscultation of the chest

3. Ventilations given too fast or too slow for pt’s age

4. Pulse rate does not return to a normal range

5. Oxygen saturation level does not improve

Automatic Transport Ventilator (ATV)

A portable mechanical ventilator attached to a control box that allows the provider to set the variables of ventilation (Respiratory Rate and Tidal Volume)

Steps to using an ATV

1. Attach ATV to an oxygen source 

2. Set Ventilatory Rate, Tidal Volume, and Peak Inspiratory time on the ATV as appropriate for the pt’s age and condition. If available and clinically indicated, set the ventilation mode and I:E ratio accordingly

3. Connect ATV to the ET tueb or other advanced airway device.

4. Auscultate the pt’s breath sounds and observe for equal chest rise to ensure adequate ventilation

CPAP (Continuous Positive Airway Pressure)

A noninvasive means of providing ventilatory support for pts experiencing respiratory distress.

Indications for CPAP

1. Pt is alert and able to follow commands

2. Obvious signs of moderate to severe respiratory distress from an underlying disease 

3. Respiratory distress after a submersion incident

4. Breathing that is so rapid that it affects the overall minute volume

5. Pulse Ox reading of less than 90%

Contraindications for CPAP

1. Pt is unresponsive and unable to follow commands

2. Respiratory arrest or agonal respirations

3. Pt is unable to speak

4. Pt is unable to maintain the airway

5. Hypoventilation

6. Hypotension

7. Closed head injury

8. Facial trauma 

9. Cardiogenic shock

10. Tracheostomy

11. Active gastrointestinal injury

12. History of recent gastrointestinal surgical procedure

13. Pt is unable to sit up 

14. Inability to properly fit the CPAP system mask and strap

15. Pt cannot tolerate the mask

Gastric Distention

1. Inflation of the pt’s stomach with air, is especially likely to occur if excessive pressure is used to inflate the lungs

Usage for NG or OG Tube

1. Inserted through Nose or Mouth

2. Remove stomach contents (like air or fluids) to relieve pressure or vomiting

3. Feed patients who can’t eat by mouth.

4. Give medication or drain stomach acid.

Steps for NG or OG Tube

1. Explain & prepare: Tell the patient what you’ll do and have them sit up (at least 45°).

2. Measure the tube: From the nose/mouth → ear → xiphoid process (bottom of sternum). Mark that spot.

3. Lubricate: Apply water-based lube to the tube’s tip.

4. Insert: Gently guide the tube through one nostril, straight back (not up), toward the throat.

5. Swallowing helps: Have the patient sip water or swallow as you advance the tube.

6. Check placement:

• Aspirate stomach contents (check pH—should be acidic, around 1–5), or

• X-ray confirmation (most accurate)

LEMON

What is the mnemonic used to guide the assessment of a difficult airway?

Look Externally

The L of LEMON:

• Intubation Difficulty:

  • Short, thick necks

  • Morbid obesity

  • Dental conditions

Evaluate 3-3-2

The E of LEMON:

• 3- Mouth width of >3 fingers is best

• 3- Mandle length of 3 fingers is best

• 2- Distance from hyoid bone to thyroid notch of 2 fingers wide is best

Mallampati

The M of LEMON:

• Note oropharyngeal structures visible in an upright, seated pt

• Cormack-Lehane Classification

Obstruction

The O of LEMON:

• Note anything that might interfere with visualization or ET tube placement

  • Foreign body obstruction

  • Obesity

  • Hematoma

  • Masses

Neck Mobility

The N of LEMON

• Sniffing Position is ideal

• Neck Mobility problems are most common with:

  • Trauma Pts

  • Elderly Pts

Look Externally, Evaluate 3-3-2, Mallampati, Obstruction, Neck Mobility

What does LEMON stand for?

ET Intubation

The process of inserting an endotracheal tube through the glottic opening and sealing the tube with a cuff inflated against the tracheal wall

Factors of ET Intubation

• Advantages:

  • Provision of a secure airway and protection against aspiration

• Disadvantages:

  • Special equipment required:

    • Physiological functions of the upper airway are bypassed

• Complications:

  • Bleeding

  • Hypoxia

  • Laryngeal swelling

  • Laryngospasm

  • Vocal cord damage

  • Mucosal necrosis

  • Barotrauma

7.5-8.0mm

What size range of ET tube for an Adult Male?

7.0-7.5mm

What size range of ET tube for an Adult Female?

2.5-5.0mm

What size range of ET tube for a Pediatric Pt?

3 and 4

What size of Laryngoscope blade should be used for adults?

0,1,2

What size of Laryngoscope blade should be used for Pediatrics?

Orotracheal Intubation

Insertion of an endotracheal tube into the trachea through the mouth 

Indications and Contraindications of Orotracheal Intubation

Indications:

• Airway control needed

• Ventilatory support before impending respiratory failure

• Prolonged ventilatory support required

• Traumatic Brain Injury

• Unresponsiveness

• Impending airway compromise

Contradictions:

• An intact gag reflex

• Inability to open the pt’s mouth because of trauma, dislocation, of the jaw, or a pathologic condition

• Inability to see the glottis opening

• Copious secretions, vomitus, or blood in the airway

Confirming placement of ET Tube

1. Visualize the ET tube passing between the vocal cords

2. Auscultate for clear bilateral lung sounds

Securing placement of ET Tube

1. Note depth of the ET Tube

2. Remove ventilation device from the ET tube

3. Position the ET Tube medial

4. Place the securing device over the ET Tube

5. Reattach Ventilation device

Nasotracheal Intubation

Insertion of an endotracheal tube into the trachea through the nose

Factors of Nasotracheal Intubation

Indication:

• Breathing spontaneously but requires definitive airway management

Contraindications:

• Apnea

• Head trauma and midface fractures

• Anatomic abnormalities; frequent cocaine use

Advantages:

• Can be performed on responsive patients

• No need for laryngoscope

• Mouth does not need to be opened

• Does not require sniffing position

• Patient cannot bite the tube

• Can be secured more easily

Disadvantages:

• Blind Technique 

• Confirming proper tube position requires diligence 

Complications:

• Bleeding

Tracheobronchial Suctioning

A process where you pass a suction catheter into the ET tube to remove pulmonary secretions

Field Extubation

The process of removing the ET tube from an intubated Pt

Steps of Field Extubation

1. Ensure Pt is adequately oxygenated

2. Tell the Pt the procedure

3. Sit Pt up

4. Have all equipment for suction ventilation, and reintubation

5. Suction oropharynx for any secretions

6. Deflate the distal cuff while the Pt exhales

7. On the next exhalation, remove the tube in a steady motion

8. Place a towel infront of Pt’s mouth for vomit

Sedatives used in Airway Management

1. Benzodiazepines: Sedative-Hypnotic

   1. Diazepam/Valium

   2. Midazolam/Versed

2. Dissociative Anesthetics:

   1. Ketamine/Ketalar

3. Opioids: Sedative-Analgesic:

   1. Fentanyl/Sublimaze

   2. Alfentanil/Alfenta

4. Non-Opioids/Nonbarbiturates: Sedative-Hypnotic:

   1. Etomidate/Amidate

Neuromuscular Blocking Agents

1. Succinylcholine (Depolarizing)

2. Vecuronium Bromide (Nondepolarizing)

3. Pancuronium Bromide (Nondepolarizing)

4. Rocuronium Bromide (Nondepolarizing)

Rapid Sequence Intubation (RSI)

A specific set of procedures, performed in rapid succession, to induce sedation and paralysis and intubate a Pt quickly

Steps for RSI

1. Preoxygenation

2. Premedication

3. Sedation and Paralysis

4. Intubation

King LT Airway

A latex-free, single-use, single-lumen airway that is blindly inserted into the esophagus

Factors of King LT Airway

Indications:

• An alternative to BVM and ET Intubation

Contraindications:

• Pt with an intact gag reflex

• Pts with known esophageal disease

• Pts who have ingested a caustic substance

Complications:

• Laryngospasm

• Vomiting

• Possible Hypoventilation

• Improper Insertion causing trauma

• Ventilation can be difficult

Laryngeal Mask Airway (LMA)

A device that surrounds the opening of the larynx with an inflatable silicone cuff positioned in the hypopharynx; an alternative to BVM ventilation

I-gel

A supraglottic airway device that uses a non inflatable, gel-like mask to isolate the larynx and facilitate ventilation

Surgical Cricothyrotomy

An emergency incision of the cricothyroid membrane with a scalpel and insertion of an endotracheal or a tracheostomy tube directly into the subglottic area of the trachea

Needle Cricothyrotomy

1. Insertion of a 14- to 16-gauge over-the-needle intravenous catheter (such as an angiocath) through the cricothyroid membrane and into the trachea