Airway Management Final Set

Rule Number One of Airway Management

Use the least amount of effort necessary

If the Airway is Patent

Leave it alone

If the Airway is Not Patent Consider

→ Reposition

→ Suction

→ Airway adjunct:

• Oropharyngeal Airway (OPA)

• Nasopharyngeal Airway (NPA)

→ Oxygen (O2)

→ Continuous Positive Airway Pressure (CPAP)

→ Bag Valve Mask (BVM)

→ Supraglottic Airway (SGA) (EMT-B only use this when cardiac arrest occurs)

→ ALS

Make-up of the Upper Airway

→ Anything above the larynx:

• Nasopharynx

• Oropharynx

• Epiglottis

• Laryngopharynx / Hypopharynx

Make-up of the Lower Airway

→ Anything below the larynx

• Trachea

• Bronchi

• Lungs

Lobes of Left and Right Lungs

Right Lung (3 lobes)

Left Lung (2 lobes

Why can Pediatric Airways be Challenging

Smaller airway

Larger tongue relative to mouth

Structures are closer together (increasing risk of obstruction)

What is Ventilation (Respiration Process)

Mechanical process where the diaphragm contracts (moves downward) creating negative pressure so air moves into the lungs and relaxes (moves upward) pushing air out of the lungs

Diaphragm DOWN → air IN (inhale)

Diaphragm UP → air OUT (exhale)

What Drives Respiration

Carbon Dioxide (CO2) and PH drive respiration:

↑ CO₂ → ↓ pH (acidosis) → ↑ respiratory drive (hyperventilate)

↓ CO₂ → ↑ pH (alkalosis) → ↓ respiratory drive (hypoventilation)

Cheyne Stokes Pattern

Breaths gradually become deeper, then become shallow, and are then followed by periods of apnea that repeat in this cycle

Cause: Brain injury (inter cranial pressure (ICP)) or neurological dysfunction

Shallow → deeper → deepest → shallower → pause → repeat

Kussmaul Pattern

Breaths are constant, deep, and fast with no pauses. The body is trying to blow off excess CO2

Cause: Metabolic acidosis

Fast + deep → fast + deep → fast + deep (no pause)

Biot’s Pattern

Irregular breathing pattern with clusters of breaths followed by periods of apnea (pause)

Cause: Injury to the medulla oblongata (brain stem)

Breathe → breathe → breathe → pause → breathe → breath → breath → pause (repeat)

Ataxic Pattern

Irregular breathing pattern with unpredictable rate, rhythm, and depth

Cause: Severe injury to the medulla oblongata (brain stem)

Abnormal Respirations Patterns

• Cheyne-Stokes → brain injury

• Kussmaul → metabolic acidosis (DKA)

• Biot’s → Damage to medulla oblongata

• Ataxic → Severe brain injury

What are Peripheral Tissues

Includes:

• Muscles

• Organs

• Brain

• Skin

• All body Cells

Everything beside the lungs

Gas Exchange in Peripheral Tissues

Oxygen is delivered and carbon dioxide is picked up and removed as waste

Oxygen leaves the blood → enters the cell

Carbon dioxide leaves the cell → enters the blood

Gas exchange in lungs

Blood ↔ cells

Gas Exchange in the Lungs

Gas exchange occurs in the alveoli where oxygen moves from the air into the blood stream and carbon dioxide moves from the blood into the air

Lungs: air ↔ blood

Obstructions

Anything that interferes with ventilation or gas exchange

Types:

1.) Mechanical

2.) Disease-related

3.) Peripheral disease

Mechanical Obstructions

Physical problems preventing air from moving and out of the lungs (airflow)

→ Example: Chest wall injury, airway swelling, foreign body obstruction (choking)

Disease-related Obstructions

Lung conditions that impair gas exchange in alveoli

→ Examples: COPD, asthma, bronchitis, or pneumonia

Peripheral Disease Obstructions

Blood-flow issues that prevent oxygen from reaching body tissues

→ Example: Shock or hypoperfusion

Hypoxia (Mild and Severe)

Oxygen is not reaching the cell

→ Mild (patient is compensating)

• Tachypnea

• Dyspnea

• Restlessness / anxiety

• Agitation

• Pale, cool, clammy skin

• Accessory muscle use

*Mental status change is an early red flag

*Mild = restless and working

→ Severe (patient is decompensating)

• Severe dyspnea

• Tachypnea (worsening)

• Cyanosis

• Pale, cool, diaphoretic skin

• LOC

• Cardiac arrest

• Respiratory arrest

*Cyanosis = late and dangerous

*Severe = blue, tired, and crashing

Airway Assessment - Airway

• Look in the airway: physical obstruction (blood, vomit, teeth)

• Listen to the airway: snoring, gurgling, stridor

• Open the airway: Manual maneuvers

Airway Assessment - Breathing

• Rate: ideal is 12 - 20 adult / 10 - 40 child

• Rhythm: regular vs. irregular patterns

• Quality: normal depth, non-labored, clear lung sounds

Conditions of Adequate Breathing

1.) Adequate respiratory rate

2.) Adequate tidal volume (depth)

Tidal Volume

Amount of air moved that is taken with each breath

Decision to Ventilate or Not Ventilate

Bad rate or bad depth = ventilate with BVM

“Under 8 then ventilate”

BVM Ventilation Rates (Adult w advanced airway and w/out)

Adult with no advance airway: 1 breath every 5-6 sec

Adult with ET tube/ i-gel: 1 breath every 6 secs

Complications of BVM

• Drop in cardiac output → drops blood pressure (hypotension)

• Gastric distention → increased risk of aspiration

Normal vs. Positive Airway Ventilations

In normal breathing and natural ventilations the diaphragm creates negative pressure in the thoracic cavity.

Positive airway ventilation involves using an external source (BVM) to create positive pressure that pushes oxygen into the lungs and forces them to expand and contract

Normal (negative pressure) = pull

Positive pressure = push

Head tilt / chin-lift (how and when we use it)

We tilt the head back and lift the chin forward which moves the tongue away from the back of the throat

We use this in patients with NO trauma

DO NOT USE IN TRAUMA PATIENTS

Jaw Thrust (how and when we use it)

Keeping the head and neck neutral (no movement) place your hands on the side of the patients mandible and push the jaw forward to open the airway

We use this in patients with trauma

Recovery Position (how and when we use it)

Lay the patient on their side to maintain a patent airway and let fluids drain

We use this when the patient is unconscious and breathing on their own and voting or secretions are present

Breathing but out = on their side

Assisted Ventilations on a Conscious Patient

Explain the procedure and synchronize bagging with the patient’s inhalations while providing adequate tidal volume

Assisting Ventilations on a Unconscious Patient

For an unconscious or apneic patient, open the airway, apply a mask, and ventilate with a BVM at one breath every 5 seconds with adequate chest rise

Flow Rate of a Non-rebreather

15 liter per minute (LPM)Nasal

Flow Rate of a Nasal Cannula

2 to 6 liters per minute (LPM)

Flow Rate of Bag Valve Mask (BVM)

Up to 25 liters per minute (LPM)

Flow Rate of Continuous Positive Airway Pressure (CPAP)

The flow rate is device-driven

Flow Rate of a Blow-by

15 liter per minute (LPM)

Trick About Remembering Oxygen Tank Sizes

The tank gets bigger as you progress through the alphabet

Oxygen Tank Sizes

• D → Smallest

• E → Standard and Portable (anchor)

• M → Ambulance-sized

• G / H / K → Very large

*All oxygen tanks are full at 2,000 PSI

Rules of Suctioning

• Eye Protection

• Only what we see

• Max 15 seconds

Equipment Needed for Suctioning

• Sterile water

• Suction unit

• Catheter

  • Yankauer (rigid)

  • French (flexible)

Yankauer Catheter (when its used and sizing)

Use: A rigid catheter used to suction the mouth and upper airway

Sizing: Comes in two sizes adult and pedi

French Catheter (when its used and sizing)

Use: used for suctioning in the nose or if a patient has a tracheostomy (can only suction at a length about 2/3rds of your pinky)

Sizing: Sized in French use an approbate size for the patient and their airway

Snoring (indication, common cause, and intervention)

Indicates a partial upper airway obstruction

Common cause: Tongue

Intervention: Reposition and if that does not work OPA (no gag reflex) or NPA (gag reflex)

Snoring = tongue problem → reposition

Gurgling (indication, common cause, and intervention)

Indicates fluid in the airway

Common cause: Blood, vomit, secretions

Interventions: suction and then reassess the airway

Gurgling = fluid → suction

Stridor (indication, common cause, and interventions)

High-pitched and hard sound heard on inhalation indicating narrowing or obstruction of the upper airway

Common causes: Anaphylaxis or infection (croup, epiglottis)

Oropharyngeal Airway (OPA) (Indications, contraindications, and sizing)

Indications: Patient is unconscious with has no gag reflex AND needs help waiting a patent airway

Contraindications: Patient has a gag reflex, patient is conscious

Sizing: from the corner of the mouth to the ear lobe How to

How do You Place an OPA

Size it correctly by measuring from the corner of the mouth to the ear lobe, then insert it upside down into the mouth until the soft palate meets the hard palette, and rotate it 180 degrees

Nasopharyngeal Airway (NPA) (Indications, contraindications, and sizing)

Indications: Patient is consciousness or unconsciousness with a gag reflex

Contraindications: Patient has facial trauma

Sizing: Measure from the tip of the nose to the side of the mouth

How Do You Place a NPA

Size it correctly, lubricate it, and gently insert it into the nostril with the bevel facing the septum, then advance until the flange rests at the nostril

Continuous Positive Airway Pressure (CPAP)

Delivers constant air pressure through a tight fitted mask keeps the alveoli open between breaths allowing oxygen to flow in more easily and preventing collapse

It essentially holds the alveoli open and reduces the work needed to breath adequately

CPAP (Indications and contraindications)

Indications: Patient is an adult who is alert, breathing on their own. They have a systolic BP equal to or greater than 120, a respiratory rate less than 24, and O2 Sat at or above 94%, and is in respiratory distress

CPAP is for alert, self-breathing patients with good BP and failing O2

Contraindications: CRASH

• C - Conscious altered (AMS)

• R - Ruptured lung (suspected pneumothorax)

• A - Airway not protected

• S - Soft tissue facial trauma

• H - Hypotension

If they CRASH, NO CPAP

Advanced Airways - (I-gel / supraglottic airway)

EMT-Bs may place advanced airways ONLY in unconsciousness, pulseless cardiac-arrest patients

If a Patient has Trauma to the Nose and Mouth What Do We Place

An OPA may be used in an unconsciousness patient without a gag reflex even when facial trauma is present. We are not ignoring the trauma but airway patency takes priority