Advanced Airway Management Techniques

bag valve mask ventilation.

For example, slow, shallow, gasping or noisy. This includes patients who have a pulse but are not breathing. It is important to avoid over aggressive ventilation as ventilating too fast or with too much pressure can cause damage to the lungs. 

Large volumes of air or high pressures can lead to pneumothorax or irreversible lung damage. You will need a bag valve mask with an appropriately sized mask for the patient, oxygen tubing and an oxygen source. Attach the BVM tubing to the oxygen tank if available and set the flow rate to the highest setting. However, do not delay bag valve mask ventilation. 

Oxygen can be attached later.

One person ventilation technique.

Place the mask over the patient’s mouth and nose. Position your hand in the EC shape. Your thumb and first finger should form a C around the top of the mask, applying even pressure to seal the mask on the face. 

Your last three fingers should reach just under the bony part of the jaw, creating an e shape and pull the jaw upward to open the airway. Think about pulling the face up to the mask while pushing the mask down on the face. If you push down too hard without pulling the face up, you will block the airway, making it difficult to ventilate. 

If you encounter difficulty ventilating, reposition your hands and the mask and try again. If you’re still unable to ventilate after repositioning the mask, consider the possibility of a foreign body obstruction or an air leak. 

Be sure to insert an oral or nasopharyngeal airway device if one is not already in place.

Ventilation process

Hold the bag with one hand and gently squeeze it to provide enough air to make the chest rise to about one third of its volume. 

For an adult, squeeze the bag over one to two seconds to deliver the breath. Do not give the breath too quickly as this can cause lung damage. 

After each breath, allow the chest to fall. before giving the next breath. Watch the chest rise and fall evenly with each breath. If the patient is breathing on their own, deliver breaths only when the patient inhales. 

Do not attempt to deliver a breath as the patient exhales. For adults deliver one breath every six seconds, which is a rate of 10 breaths per minute. Two person technique. Bag valve mask ventilation with two people is easier and more effective than with one because it allows both hands to be used on the mask ensuring a tight seal.  In the two person technique the more experienced operator should handle the mask as maintaining a proper mask seal is the most challenging task. 

Once the first person has achieved a proper seal, the second responder can squeeze the bag. This frees up the first person to use both hands to hold the mask in place and maintain the seal. Squeeze the bag once every six seconds with each squeeze lasting about one second, just enough to see the chest rise. 

This equates to delivering 10, 12 breaths per minute. Count the breaths out loud as you squeeze the bag, and ideally both responders should count together. Look for signs of breathing between bag squeezes. 

Common mistakes with BVM ventilation

include poor mask seal, leading to air leaks; overventilation, which can increase intrathoracic pressure and decrease cardiac output. An adult BVM holds about 1600cc of air, the average adult male needs about 600cc per ventilation, It is very easy to give too much.

Other common mistakes include not allowing for full exhalation; and improper head positioning, which can obstruct the airway. Always ensure proper head tilt, watch for chest rise and fall, and maintain a steady, appropriate rate.  Also know, because of the way the valves on a BVM are set up, controlling the refill of the bag over 2-3 seconds will allow it to take in mostly oxygen and less room air.  

OPAs and NPAs

OPAs are for unconscious patients without a gag reflex, while NPAs can be used in semi-conscious patients. These adjuncts can greatly improve the effectiveness of BVM ventilation by preventing the tongue from obstructing the airway. 

Supraglottic airway devices

advanced airways that sit above the glottis (voice box). They provide a more secure airway than a BVM alone and are often easier to insert than an endotracheal tube. Common types include the Laryngeal Mask Airway (LMA), King LT, and i-gel. These devices can be inserted blindly and provide a good seal for ventilation. 

Supraglottic airways pros and cons

pros:

1. easier to insert than endotracheal tubes

2. don’t require direct visualization of the vocal cords

3. in many systems, can be used by EMT-Basics.

cons:

1. they’re not as secure as endotracheal tubes

2. may not fully protect against aspiration

3. aren’t suitable for all patients, such as those with severe facial trauma or morbid obesity. 

Continuous Positive Airway Pressure

CPAP, is a non-invasive ventilation technique that delivers constant positive pressure throughout the respiratory cycle, which helps open collapsed alveoli, improves gas exchange, and reduces the work of breathing. CPAP is particularly useful in conditions like congestive heart failure, COPD exacerbations, and certain types of pneumonia. It can often prevent the need for more invasive airway management. 

When managing patients in respiratory distress, consider escalating to CPAP when supplemental oxygen via a non-rebreather mask fails to improve the patient’s condition. Before initiating CPAP, ensure the patient meets the necessary criteria for this intervention. The patient must be alert and able to follow commands, as they need to understand and cooperate with mask placement and maintenance. Additionally, the patient must be capable of maintaining adequate respiratory effort, as CPAP supplements but does not replace the patient’s own breathing. 

Hemodynamic stability is essential prior to CPAP application. The patient should maintain a systolic blood pressure of at least 90 mmHg or higher. This requirement exists because CPAP therapy can potentially decrease venous return to the heart, resulting in reduced cardiac output and blood pressure. In patients who are already hypotensive, CPAP could exacerbate their cardiovascular instability. 

With appropriate patient selection and ongoing assessment, CPAP can be a highly effective intervention that may prevent the need for more invasive airway management techniques. Monitor the patient’s respiratory status, oxygen saturation, and blood pressure continuously during CPAP therapy. 

CPAP Settings: Oxygen Flow and Pressure Relationship 

Understanding the relationship between oxygen flow rates and pressure settings is fundamental to effective CPAP therapy. In most EMS CPAP systems, the pressure delivered to the patient, measured in centimeters of water (cmH₂O), is directly related to the oxygen flow rate supplied to the device, measured in liters per minute (LPM). 

When connecting oxygen to the CPAP device, ensure your oxygen source can deliver adequate flow rates. Typically, a CPAP pressure of 5 cmH₂O requires approximately 8-10 LPM of oxygen flow. For each 2.5 cmH₂O increase in pressure, you’ll generally need to increase oxygen flow by about 2-3 LPM. Therefore, a pressure setting of 7.5 cmH₂O would require roughly 10-12 LPM, while 10 cmH₂O would necessitate 12-15 LPM of oxygen flow. 

Start with lower pressure settings (5-7.5 cmH₂O) for most respiratory distress patients, adjusting based on clinical response. For pulmonary edema associated with CHF, higher initial settings of 7.5-10 cmH₂O may be appropriate. Always verify the specific flow-pressure relationship for your particular CPAP device, as this can vary between manufacturers. 

Remember that inadequate oxygen flow will result in insufficient pressure delivery, potentially compromising the therapeutic benefit of CPAP. Conversely, excessive pressure may worsen patient compliance and potentially exacerbate hemodynamic effects. Regular reassessment of both pressure settings and the patient’s response is essential throughout CPAP therapy. 

To apply CPAP

Begin by selecting an appropriately sized mask for your patient’s facial anatomy. The mask should cover the patient’s nose and mouth completely without extending beyond the chin or reaching the eyes. 

Before applying the mask to the patient, ensure the CPAP circuit is properly assembled and connected to oxygen at the appropriate flow rate. Turn on the oxygen flow and verify that the system is generating positive pressure by feeling for airflow at the mask’s valve. 

Next, clearly explain the procedure to the patient in simple terms: “This mask will help you breathe more easily by providing pressure that keeps your airways open. You’ll feel air pushing into your lungs, which may feel unusual at first, but try to relax and breathe normally.” 

Hold the mask with both hands, positioning it over the patient’s face without the straps attached. Place the mask’s base at the bridge of the nose and gently lower it over the mouth to the chin. Maintaining this position with mild pressure, create a proper seal between the mask cushion and the patient’s face. 

This initial manual hold is crucial—observe for leaks around the mask’s perimeter while asking the patient to breathe normally. You should feel pressure building within the mask and minimal air escaping around the edges. Common leak points include the bridge of the nose and the sides of the mouth. If you detect significant leaks, reposition the mask or consider trying a different size. 

Only after establishing a proper seal, should you begin securing the straps. While continuing to hold the mask in position, have a partner apply the head harness or straps, starting with the lower straps near the chin and then securing the upper straps. Alternatively, if working alone, secure one strap at a time while maintaining position with your other hand. 

Adjust the straps to be snug but not overly tight—they should be secure enough to maintain the seal during patient movement but not so tight as to cause discomfort or pressure injuries. A properly fitted mask allows you to slide one finger between the strap and the patient’s skin. 

After securing all straps, perform a final leak check by placing your hand near the mask’s edges to feel for escaping air. Listen for the characteristic whistling sound of air leaks and observe the pressure gauge to ensure stable pressure maintenance. 

Throughout this process, continually reassure and coach the patient. Many patients experience anxiety or claustrophobia with CPAP masks, and your calm guidance can significantly improve compliance. 

While CPAP can be effective for many patients, there are specific clinical scenarios that necessitate transitioning to bag-valve-mask ventilation.

Vigilant monitoring is essential to identify when this transition becomes necessary. 

You should immediately discontinue CPAP therapy and switch to BVM ventilation if the patient experiences a decreased level of consciousness or becomes unable to follow commands. Similarly, if the patient can no longer maintain adequate respiratory effort or if their work of breathing significantly increases despite CPAP therapy, BVM ventilation becomes the appropriate intervention. 

Monitor vital signs closely, as hemodynamic instability—particularly a drop in systolic blood pressure below 90 mmHg—warrants discontinuation of CPAP. Additionally, if the patient’s SpO2 continues to decrease or if they demonstrate clinical signs of worsening hypoxia despite appropriate CPAP settings, this indicates therapy failure and necessitates escalation to BVM ventilation. 

Remember that the transition to BVM should be performed efficiently to minimize any period of inadequate ventilation. Always have BVM equipment readily available whenever CPAP therapy is initiated. 

Endotracheal Intubation. 

While endotracheal intubation is typically performed by advanced providers, EMTs often assist in the procedure. Familiarize yourself with the equipment, laryngoscope, endotracheal tubes of various sizes, styles, bag valve device, and end title CO2 detector. Your role might include preparing equipment, assisting with patient positioning, providing cricoid pressure if requested, and helping to confirm tube placement. Let’s watch an animated video demonstration. The first step in mechanical ventilation is called endotracheal intubation. Once you are asleep, your doctor will use an instrument called a laryngoscope to perform the intubation. A laryngoscope, which consists of a handle, light, and dull blade, helps guide the endotracheal tube to its proper position. The doctor will tilt the patient’s head back slightly and insert the laryngoscope through the mouth and down into the throat, taking special care to avoid contact with the patient’s teeth. Using the blade, the doctor will gently raise the epiglottis, which is a flap of tissue protecting the larynx. He or she will then advance the tip of the endotracheal tube into the trachea. Once the endotracheal tube is in the trachea, the doctor will inflate a small balloon surrounding the tube to make sure it remains snugly in place. The doctor will remove the laryngoscope and tape the tube to the corner of the patient’s mouth to prevent it from being jostled out of position. The doctor will check to see that the tube is properly positioned in the lower part of the trachea by inflating the patient’s lungs with a special bag and listening for breath sounds on both sides of the chest. If the end of the tube is too low, both lungs will not receive the same amount of air. In some cases, an x-ray is taken immediately after intubation to confirm the tube’s placement. Once the endotracheal tube is in the proper position, the doctor will attach it to the mechanical ventilator, a specially designed pump that aids respiration by delivering well-oxygenated air into the lungs and permitting carbon dioxide to escape from the lungs. Levels of oxygen and carbon dioxide will be closely monitored to confirm that the ventilator is working. 

After intubation

confirming proper tube placement is critical. This includes watching for chest rise, listening for breath sounds, and using end-tidal CO2 monitoring. Help secure the tube to prevent dislodgement. Assist with ongoing ventilation, typically 10-12 breaths per minute for adults. Continuously monitor the patient’s oxygenation, ventilation, and overall condition. Be prepared to recognize and report any changes or complications.