Airway Management Station

“I will ensure there is a packaged nasal cannula. I will ensure there is a packaged non-rebreather mask. I will ensure there is a full range of OPA’s. I will ensure there is a full range of NPA’s along with unexpired water-soluble lubricant. I will ensure there is an adult and pediatric BVM along with an adult, peds, and infant BVM mask. I will ensure there is a powered suction unit, that it turns on, and when the suction tubing is crimped, the unit will produce 300 mmHg of suction. In addition I will ensure there is a Yankauer, suction tubing, suction catheters, along with a bottle of sterile water. I will ensure there is a V-Vac handle cartridge and suction catheter. Supplies I will make sure to bring: Nasal Cannula, NRM, OPA, NPA, BVM, suction machine, v-vac handle cartridge and cath”

Indications for the use of a nasal cannula include: 1. mild hypoxia 2. nose breathing 3. face-mask intolerance 4. to enrich the FiO2 for a patient who is receiving nebulized treatments via a mask. Contraindications for the use of a nasal cannula include: 1. moderate to severe hypoxia 2. nasal trauma which inhibits nasal inspiration/ expiration. 3.obligate or predominant mouth breathers. 4. basillar skull fracture.*obligate mouth breathing—when someone's airway is restricted or the body has developed a habit that makes them rely entirely on breathing through the mouth. It can alter facial development, narrow the airway, and negatively impact sleep, energy, and posture

“My name is Gloria and I am with EMS, I will be providing you some oxygen now. I will now adjust the flow rate to 2 LPM which will provide the patient with an FiO2 of 28%. I will first ensure flow and then apply the nasal cannula to the patient. I will insert the prongs into the patient’s nostrils, will loop the device around the ears fromt he top down, then will put under the patient’s chin.”

The nasal cannula flows between 1 and 6 liters per minute. At 1 LPM the FiO2 is 24%, at 2 LPM the FiO2 is 28%, at 3 LPM the FiO2 is 32%, at 4 LPM the FiO2 is 36%, at 5 LPM the FiO2 is 40% and at 6 LPM, the FiO2 is 44%. Patients do not receive any extra benefit on a NC with flow rates above 6 LPM and may cause nasal irritation. * Exception: nebulizer with CPAP for preoxygenation and intubation.

Mask Station: “I have taken BSI precautions-I am wearing at a minimum gloves, safety glasses, and a mask. The simple face mask has no reservoir or one-way valves. This device flows between 6-9 LPM with an associated FiO2 of 40-60%. The partial non rebreather mask has one reservoir valve and one mask valve. The full non rebreather mask has one reservoir valve and two mask valves. EMS uses the partial non rebreather mask. This mask uses 10-15 LPM and delivers an oxygen concentration of 80-95% FiO2. As with any mask -FiO2 depends on the patient’s tidal volume and mask seal. Larger tidal volumes reduce FiO2. *note: non-rebreather masks : one way valve, prevents exhaled air from diluting O2 in the reservoir bag and this is useful for CO poisoning, damage from smoke inhalation, and cluster headaches. The flow rate should be adequate to prevent the reservoir from collapsing completely upon inspiration on the partial non-rebreather and non-rebreather mask.

Indications for the use of an NRM include patients who have adequate tidal volume and who are moderately or severly hypoxic. Remember: NRM are useful in CO poisoning, smoke inhalation damage, and cluster headaches.

Partial Non-rebreather masks have one-way valves to prevent exhaled air from diluting the oxygen in the reservoir bag.

Contraindications for the use of the NRM include patients who are moderately or severely hypoxic with an insufficient tidal volume. Caution should be used with patients who are complaining of nausea and vomiting. “My name is Gloria. I will be providing oxygen to you via a face mask. I will ensure that the appropriate size mask is used for this adult (or pediatric) patient. The flow rate will be adjusted to 10 LPM and I will completely prefill the reservoir bag. The bottom of the mask will then be placed under the chin and the top of the mask is placed at the bridge of the nose. The strap will go behind the patient’s head and above the ears and then will be pulled snug. I will crimp the nose-piece and will also ensure that the patient is comfortable with the mask. If the reservoir bag deflates when the patient inhales, I will increase the flow rate to 15 LPM .

Head-Tilt-Chin-Lift Skill: “I have taken BSI precautions-I am wearing at a minimum, gloves, safety glasses and a face mask. Head-Tilt Chin-Lift Maneuvers is used for severely altered or unresponsive patients who cannot maintain their airway. Examples of patients needing the Head-Tilt Chin-L:ift maneuver include: 1. Any unresponsive patient without a mechanism of trauma. 2. Cardiac arrest patients without signs of trauma 3. Apneic patients without signs of trauma. Use the Head-Tilt Chin-Lift Maneuver is temporary and must be replaced or augmented with an upper airway adjunct unless the patient begins adequate spontaneous ventilation. *Head-Tilt Chin Lift is indicated for : unresponsive, cardiac arrest and apneic patients with no signs of trauma or no suspected trauma. The head-tilt chin-lift maneuver is contraindicated in those patients for whom we suspect may have or has a spinal injury. I will place the palm of one hand on the patient’s forehead and will apply firm backward pressure causing the head to tilt backwards into a face foward or sniffing position. Simultaneously place the fingers of my other hand under the mandible near the chin and will lift the jaw anteriorly and then slightly caudally in order to lift the tongue and open the airway effectively. I will then look, listen and feel for 5-10 seconds. I will place my ear next to the patient’s mouth so I can hear and feel if there is any air movement while simultaneously looking for symmetrical rise and fall of the chest.

BVM Skill: “The adult BVM contains approximately 1600 mL’s of volume which is adequate for lung inflation. The BVM is disposable (1 time use). There should be no pop-off valve, or if there is one it should be disabled. This could lead to inadequate tidal volumes. The BVM can be used in all environments. The BVM must have oxygen inlet that allows for 15 LPM. The adult BVM usually provides less tidal volume than mouth-to-mask due to difficulty obtaining a leakproof seal. BVM mask seal is difficult to achieve with only one person. It is sometimes difficult to deliver the required tidal volume (Squeeze the bag adequately). However the BVM delivers a much higher oxygen concentration. Indications for using a BVM include those patient who are apneic or have insufficient tidal volumes. I will (have my silent partner) open the airway with a head tilt-chin lift maneuever. I will select the correct mask size. The apex o fthe mask should be placed on the bridge of the nose and the base of the mask should like between the bottom lip and above the chin. If the mask is one which is round then the center of the mask will be placed over the mouth. I will perform a head-tild chin-life maneuever, if not already done and attach the mask to the BVM (if not also already done). I will establish and maintain a face mask seal using the triple airway maneuever. I will then hold the mask in place using the “EC” clamp method. I will squeeze the bag with the other hand to provide the tidal volume. I will ventilate the patient over 1 second period ensuring that I see adequate rise and fall of the chest. This should require approximately 5-7cc per kilogram tidal volume. I will ventilate the adult patient once every 5 seconds and infants and child once every 3 to 5 seconds. I will have my silent partner deliver 2 breaths using both of his/her hands while I maintain a two-hand seal of the mask. I will have them deliver each ventilation over a 1 second period every 5 seconds (or every three to five seconds for infants/child). If it hasn’t already been done O2 will be supplied to the BVM at 15 LPM. I will extend the resevoir attachment. While bagging, the Sellick Maneuver or cricoid pressure will be provided (if staffing permits) to reduce gastric distention. I will observe for rise and fall of the chest-Does the chest rise and fall with each ventilation?

Modified Jaw Thrust: “I have taken BSI precautions-I am wearing at a minimum, gloves, safety glasses and a face mask. The modified jaw thrust is used when the patient needs manual airway control, when we suspect the patient may have a spinal injury, or when we do not know why the patient requires manual airway control. There are no absolute contraindications for the modified jaw thrust. I will now open the airway on this patient who requires spinal precautions. I will position myself at the top of the patient and place one hand on each side of the patient’s head. If possible, I will anchor my elbows on the surface for stabilization on which the patient is lying. I will grasp the angles of the patient’s mandile with my fingers while my thumbs are on the zygoma or cheek. I will lift with my fingers in an anterior direction and slightly caudally to open the mouth. This will be down without moving the patient’s head or cervical spine. I would be looking for chest movement while simultaneously listening for 5-10 seconds by placing my ear close to their mouth. I will ventilate this patient for 30 seconds.

Oropharyngeal airway Skill: “I have taken BSI precautions-I am wearing, at a minimum, gloves, safety glasses, and a mask. OPA’s assist in maintaining an open airway on unresponsive patients without gag reflex. Patients with a gag reflex may vomit. Examples of patients with or without trauma or any apneic patient being ventilated with a BVM. OPA’s are not used in patients with a partial gag reflex, and close observation should be maintained for when the patient regains their gag reflex such as after the administration of Narcan as one example. I measure the OPA from the center of the mouth to the angle of the jaw or from the corner of the mouth following the angle of the jaw to the earlobe. I will reposition the jaw and attempt another ventilation. If air is escaping from the mask, I will reposition my fingers and the mask. If the chest still does not rise and fall then I will consider using another method of ventilation such as a pocket mask or demand-valve. If necessary, I will consider using an OPA or NPA if not done already. Without the O2 the BVM will deliver 21% oxygen. Without the reservoir attached and with 15 LPM, the BVM will deliver between 40 and 60% O2. With the reservoir extended and 15 LPM supplied, the BVM will deliver 100% assuming a proper face seal. I will establish and maintain a face mask seal using the triple airway maneuver. I will then hold the mask in place using the “EC” clamp method. I will squeeze the bag with the other hand to provide the tidal volume. I will ventilate the patient over 1 second period ensuring that I see adequate rise and fall of the chest. This should require approximately 5-7 cc per kilogram tidal volume. I will ventilate the adult patient once every 5 second and infants and children 3 to 5 seconds. *Triple Airway: 1) head hyperextended 2) anterior displacement of mandible, then 3) inferior displacement of mandible to open mouth . The student is to perform 30 seconds of ventilations. I will open the patient’s airway using either a head-tilt chin-lift or modified jaw thrust method. Since this is a medical patient I will use the head-tilt chin-lift method. If needed I can also assist the insertion by providing a tongue jaw lift. I will insert the OPA upside down and when I feel resistance I will turn the unit 180 degrees, continue insertion so that the flange sits just on the lips. or I can insert the OPA sideways rotating 90 degrees downward when I feel resistance. The flange should rest on the patient’s teeth or lips. I will ensure that I am not pushing the tongue posteriorly. I may consider using a tongue depressor and moving the tongue caudally when inserting an OPA on an infant or child. I would insert the airway after properly sizing it without rotating it. I will Remove the OPA outward in a caudal , one-way direction.

Nasopharyngeal Airway Skill: “I have taken BSI precautions-I am wearing at a minimum, gloves, safety glasses, and a mask. NPA’s are less likely to stimulate vomiting and may be used on patients who are either responsive but need assistance keeping the tongue from obstructing the airway (i.e. snoring respirations) such as an AMS (altered mental status?) case or on a unresponsive patient with a partial gag reflex. Also NPA’s are also indicated for patients with seizures, semi-conscious and trismus. NPA’s are contraindicated in those patients with moderate to severe nasal trauma or severe head injury with blood draining from the nose. Another important consideration is that when inserting the NPA, it should be lubricated with a water-soluble lubricant to facilitate easier insertion and minimize trauma to the nasal passages. I will select an appropriate size NPA. I will measure the NPA form the tip of the nose to the tip of the earlobe. I will select the proper diameter by comparing it against the anterior right nostril/nares or the same width as the diameter of the patient's little finger. I will liberally luricate the distal end of the NPA with a water soluble lubricant. I will insert the NPA using the right nare (usually larger than the left) first with the bevel pointed towards the septum using a “pencil hoding type grip. I will also lift the tip of the nose in a superior direction and will insert the NPA in the direction following the curvature of the floor of the nose in a posterior and not superior direction. I may need to perform either a chin lift or jaw thrust to move the mandible anteriorly so that the tongue is pulled back of the throat when inserting the NPA. The flange or trumpet should, when properly inserted rest against the nasal opening. Mild resistance is commonly encountered when inserting the NPA into the nares. Rotating the tube slightly may help. If I cannot safely overcome this resistance, I would insert the NPA into the left nares. If I must use the left nares, I will insert the NPA upside down so that the bevel faces the septum until resistance is met. Then rotate the NPA 180 degrees into position.

Suction Skill: