Transcript Chapter 15: Airway Management and Ventilation

Chapter 15
Airway Management
and Ventilation
National EMS Education
Standard Competencies
Airway Management, Respiration,
and Artificial Ventilation
Integrates complex knowledge of anatomy,
physiology, and pathophysiology into the
assessment to develop and implement a
treatment plan with the goal of ensuring
a patent airway, adequate mechanical
ventilation, and respiration for patients
of all ages.
National EMS Education
Standard Competencies
Airway Management
• Airway anatomy
• Airway assessment
• Techniques of ensuring a patent airway
National EMS Education
Standard Competencies
Respiration
• Anatomy of the respiratory system
• Physiology and pathophysiology of
respiration
− Pulmonary ventilation
− Oxygenation
− Respiration
• External
• Internal
• Cellular
National EMS Education
Standard Competencies
Respiration (cont’d)
• Assessment and management of adequate
and inadequate respiration
• Supplemental oxygen therapy
National EMS Education
Standard Competencies
Artificial Ventilation
• Assessment and management of adequate
and inadequate ventilation
− Artificial ventilation
− Minute ventilation
− Alveolar ventilation
− Effect of artificial ventilation on cardiac output
Introduction
• Establishing and maintaining a patent
airway and ensuring effective oxygenation
and ventilation are vital to patient care.
− The human body needs a constant supply of
oxygen.
Introduction
• Respiratory system
− Brings in oxygen
− Eliminates carbon dioxide
• Vital organs will not function properly if
process is interrupted.
Introduction
• Failure to manage the airway is a major
cause of preventable death in the
prehospital setting.
− Understand the importance of:
• Early detection of airway problems
• Rapid and effective intervention
• Continual reassessment
Introduction
• Appropriate airway management
− Open, maintain patent airway
− Recognize, treat obstructions
− Assess ventilation, oxygenation status
− Administer oxygen.
− Provide ventilatory assistance.
Anatomy of the Respiratory
System
• Consists of all structures in the body that
make up the airway and help us breathe
− Diaphragm
− Intercostal muscles
− Accessory muscles of breathing
− Nerves from the brain and spinal cord to those
muscles
Anatomy of the Respiratory
System
Anatomy of the Upper Airway
• Upper airway
− Airway structures
above the vocal
chords
• Larynx
− Divides upper and
lower airways
• Pharynx
− Extends from the
nose and mouth to
the esophagus and
trachea
• Nasopharynx
• Oropharynx
• Laryngopharynx
Anatomy of the Upper Airway
Nasopharynx
• Receives air from the nose
• Formed by the union of facial bones
• Lined with a ciliated mucous membrane
− Keeps contaminants out of the respiratory tract
− In illness, additional mucus traps agents
Nasopharynx
• Divided into two
passages by nasal
septum
− May be deviated
• Numerous
openings extend
into the paranasal
sinuses.
Nasopharynx
• Paranasal sinuses
− Prevent contaminants from entering respiratory
tract
• Fractures may cause:
− Cerebrospinal rhinorrhea
− Cerebrospinal otorrhea
Oropharynx
• Forms the posterior of the oral cavity
− Fracture or avulsion of teeth may result in
aspiration
− Tongue
• Attached to mandible and hyoid bone
• Most common cause of airway obstruction
Oropharynx
• Palate
− Separates oropharynx and nasopharynx
− Hard palate and soft palate
• Palatopharyngeal arch: entrance to the
throat (pharynx)
Oropharynx
• Tonsils
− Adenoids
and tonsils
may
become
swollen and
infected.
− May cause
upper
airway
obstruction
Anatomy of the Lower Airway
• Exchanges oxygen
and carbon dioxide
Larynx
• Marks where the upper airway ends and
lower airway begins
• Thyroid cartilage
− Formed by two plates that form the laryngeal
prominence (Adam’s apple)
Larynx
• Cricoid cartilage (cricoid ring)
− First ring of the trachea
• Cricothyroid membrane: ligament between
the thyroid and cricoid cartilage
− Site for emergency surgical and nonsurgical
access to the airway (cricothyrotomy)
Glottis
• Space between the vocal cords
Glottis
• Vallecula
− Pocket between base of tongue and epiglottis
− Important landmark for ET intubation
• Arytenoid cartilages
− Posterior attachment of the vocal cords
− Valuable guides for ET intubation
Glottis
• Piriform fossae
− Airway devices are occasionally inadvertently
inserted into these pockets
• Laryngospasm: spasmodic closure of the
vocal cords
− Seals off the airway
Trachea
• Conduit for air entry into the lungs
− Begins below the cricoid cartilage
− Descends down the midline of the neck and
chest to the fifth or sixth thoracic vertebra
• Esophagus lies posterior to the trachea
Trachea
• Divides into right and left mainstem bronchi
• Trachea and mainstem bronchi lined with:
− Goblet cells
− Cilia
− Beta-2 adrenergic receptors
Lungs
• Consist of smaller bronchi, bronchioles, and
alveoli
Lungs
• Alveoli
− Functional site for the exchange of oxygen and
carbon dioxide
− Increase surface area of the lungs
− Lined with a phospholipid compound
(surfactant)
Lungs
• These landmarks will help you assess and
manage the airway.
Physiology of Breathing
• Respiratory and
cardiovascular
systems work
together.
− Bring oxygen and
nutrients to cells
− Remove waste
Ventilation
• Process of moving air into and out of lungs
− Two phases
• Inhalation (inspiration)
• Exhalation (expiration)
• You must ensure adequate ventilation.
Inhalation
• Active, muscular part of breathing
• Boyle’s law: The pressure of gas is
inversely proportional to its volume.
• Air enters the mouth and nose, moves to
the trachea.
− Diaphragm and intercostal muscles contract.
Inhalation
• Diaphragm
− Specialized skeletal muscle (voluntary and
involuntary)
• Lungs
− Have no muscle tissue
− Depend on movement of the chest and
supporting structures
Inhalation
• The thoracic cage expands during
inhalation and air pressure within the thorax
decreases.
− Negative-pressure ventilation
• Inhalation stops when pressure is
equalized.
Inhalation
• Thoracic cage:
like a bell jar in
which balloons
are suspended
Inhalation
• The role of diffusion
− Involves oxygen transfer from air into capillaries
− Partial pressure: amount of gas in air or
dissolved in a liquid
• Governed by Henry’s law
• Measured in mm Hg or torr
Inhalation
• The role of diffusion (cont’d)
− Deoxygenated arterial blood from the heart has
a partial pressure of oxygen (PaO2) that is lower
than the partial pressure of oxygen in the
alveoli.
• Body attempts to equalize the partial pressure
Lung Volumes
• Breathing becomes deeper as tidal volume
responds to increased demand for oxygen
− Alveolar volume: volume of air that reaches the
alveoli
− Tidal volume: amount of air moved into or out of
the respiratory tract during one breath
• Adult: 5 to 7 mL/kg
• Infants/children: 6 to 8 mL/kg
Lung Volumes
• Dead space volume: portion of tidal volume
that does not reach the alveoli
• Minute volume: amount of air moved
through the respiratory tract in 1 minute
− Including anatomic dead space
Lung Volumes
• Alveolar minute volume: volume of air that
reaches the alveoli each minute
− Affected by variations in tidal volume and/or
respiratory rate
Lung Volumes
• Inspiratory reserve volume: amount of air
inhaled in addition to normal tidal volume
• Functional reserve capacity: amount of air
forced from the lungs in one exhalation
• Expiratory reserve volume: amount of air
exhaled following normal exhalation
Lung Volumes
• Residual volume: air that remains in the
lungs after maximal exhalation
• Vital capacity: amount of air that can be
forcefully exhaled after a full inhalation
− Total lung capacity: vital capacity plus residual
volume
Exhalation
• Passive process
• Stretch receptors signal apneustic center as
chest expands
− Inhibits respiration
− Exhalation occurs
• Feedback loop: Herring-Breuer reflex
Regulation of Ventilation
• The need for oxygen changes constantly.
− Respiratory system responds by altering the
rate and depth of ventilation
• Primarily regulated by pH of CSF
Regulation of Ventilation
• Receptors and feedback loops send
messages about gas concentrations to the
respiratory center.
− Rising oxygen level suspends breathing.
− Rising CO2 level stimulates breathing.
Neural Control of Ventilation
• Originates in medulla oblongata and pons
− Medulla
• Controls rate, depth, and rhythm of breathing in
interaction with the pons
− Apneustic center of the pons
• Secondary control center if the medulla fails
Chemical Control of Ventilation
• Chemoreceptors
− Affect respiratory rate and depth
− Monitor chemical composition of body fluids
− Provide feedback on metabolic processes
Chemical Control of Ventilation
• Chemoreceptors
(cont’d)
− Three sets affect
respiratory
function
• Those in the
carotid bodies
• Those in the
aortic arch
• Central
chemoreceptors
Chemical Control of Ventilation
• Chemoreceptors in the carotid bodies and
the aortic arch
− Measure carbon dioxide in arterial blood
• Central chemoreceptors
− Monitor the pH of the CSF
Chemical Control of Ventilation
• Chemoreceptors in the aortic arch and
carotid bodies are a backup to the primary
control of ventilation.
− Dorsal group: initiates inspiration based on
information from chemoreceptors
− Ventral group: responsible for motor control of
inspiratory and expiratory muscles
Hypoxic Drive
• Patients with COPD have trouble
eliminating carbon dioxide through
exhalation.
− Always have higher blood levels
• Can alter primary respiratory drive
• Body uses backup system
Hypoxic Drive
• Hypoxic drive: secondary control
− Stimulates breathing when arterial oxygen level
falls
− Providing high concentrations of oxygen over
time will increase PaO2.
Control of Ventilation by Other
Factors
• Fever
• Certain medications
• Pain, strong emotions
• Excessive amounts of
narcotic analgesics
and benzodiazepines
• Hypoxia and acidosis
• Metabolic rate
Oxygenation
• Oxygen molecules loaded onto hemoglobin
molecules in the bloodstream
• Required for ventilation but does not
guarantee it
Oxygenation
• Fraction of inspired oxygen (FIO2)
− Percentage of oxygen in inhaled air
− Increases with supplemental oxygen
− Commonly documented as a decimal number
Oxyhemoglobin Dissociation
Curve
• Hemoglobin
− Protein necessary for
life
− Normal values
• Men: 14–16 g/dL
• Women: 12–14 g/dL
• Hematocrit values
− Percentage of red
blood cells in whole
blood
− Normal values
• Men: 45%–52%
• Women: 37%–48%
Oxyhemoglobin Dissociation
Curve
• Oxygen saturation
− SpO2/SaO2 is
proportional to the
amount of oxygen
dissolved in the
plasma (PaO2).
Oxyhemoglobin Dissociation
Curve
• Acidosis and increased carbon dioxide
− Curve shifts to the right
− Hemoglobin gives up oxygen faster
• Alkalosis and decreased carbon dioxide
− Curve shifts to the left
− Hemoglobin holds on to more oxygen
Respiration
• Metabolism: process of cells taking energy
from nutrients
• Respiration: process of exchanging oxygen
and carbon dioxide
− Involves ventilation, diffusion, and transport of
oxygen and carbon dioxide
External Respiration
• Exchange of O2
and CO2 between
alveoli and blood in
pulmonary
capillaries
− Adequate
ventilation is
necessary but
does not guarantee
it.
Internal Respiration
• Exchange of O2 and CO2 between the
systemic circulation and the cells
• Aerobic metabolism: The mitochondria of
the cells convert glucose into energy.
Internal Respiration
• Kreb cycle and oxidative phosphorylation
− Energy is produced in the form of ATP.
• Anaerobic metabolism
− Without adequate oxygen, cells do not
completely convert glucose into energy.
− Cells will eventually die.
Internal Respiration
• When mitochondria use oxygen to convert
glucose to energy, carbon dioxide
accumulates in the cell.
− Without oxygen, anaerobic metabolism leads to
cell death.
Internal Respiration
Pathophysiology of
Respiration
• Disruption of pulmonary ventilation,
oxygenation, and respiration causes
immediate effects.
− Must recognize and correct immediately
Pathophysiology of
Respiration
• Every cell needs a
constant supply of
oxygen to survive.
− Perfusion:
circulation of blood
in adequate
amounts to meet
cells’ needs
Hypoxia
• Tissues and cells do not receive enough
oxygen
• Varying signs and symptoms, including:
− Early signs: restlessness, irritability,
tachycardia, and anxiety
− Late signs: mental status changes, a weak
pulse, and cyanosis
Ventilation-Perfusion Ratio and
Mismatch
• Air and blood flow must be directed to the
same place at the same time.
− Ventilation and perfusion must be matched.
• If not, V/Q mismatch results.
− Blood passes over alveolar membranes without
gas exchange.
− Carbon dioxide is recirculated into bloodstream.
Factors Affecting Ventilation
• Patent airway is critical for the provision of
oxygen to tissues
• Intrinsic and extrinsic factors can cause an
airway obstruction.
Factors Affecting Ventilation
• 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.
Factors Affecting Ventilation
• 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.
Factors Affecting Ventilation
• Hypoventilation
− Carbon dioxide production exceeds elimination.
• Hyperventilation
− Carbon dioxide elimination exceeds production.
External Factors Affecting
Oxygenation and Respiration
• Factors in ambient air
− High altitudes: partial pressure decreases
− Closed environments: oxygen decreases
• Toxic gases displace oxygen in the
environment.
Internal Factors Affecting
Oxygenation and Respiration
• Conditions that reduce surface area for gas
exchange also decrease oxygen supply
− Nonfunctional alveoli inhibit diffusion.
− Fluid in the alveoli inhibits gas exchange.
• Submersion victims
• Patients with pulmonary edema
• Exposure to environmental conditions or
occupational hazards
Internal Factors Affecting
Oxygenation and Respiration
• Hypoglycemia
− Oxygen and glucose levels decrease
• Infection
− Increases metabolic needs
• Hormonal imbalances
− May result in ketoacidosis
Circulatory Compromise
• Inadequate perfusion; oxygen demands will
not be met.
− Obstruction of blood flow is typically related to
trauma.
• Inhibits gas exchange at the tissue level
Circulatory Compromise
• Heart conditions reduce blood flow to
tissues.
• Blood loss and anemia reduce the blood’s
oxygen-carrying ability.
• Shock: oxygen is not delivered efficiently.
− Poor tissue perfusion; anaerobic metabolism
Acid-Base Balance
• Can be disrupted by
− Hypoventilation
− Hyperventilation
− Hypoxia
• May rapidly lead to deterioration, death
Acid-Base Balance
• Respiratory and renal systems help
maintain homeostasis.
− Tendency toward stability in the body
− Requires balance between acids and bases
• Acid in the body can be expelled as carbon
dioxide from the lungs.
Acid-Base Balance
• Acidosis can develop if respiratory function
is inhibited.
• Alkalosis can develop if the respiratory rate
is too high.
− Respiratory acidosis/alkalosis
− Metabolic acidosis/alkalosis
Patient Assessment: Airway
Evaluation
• Quality of care depends on assessment
• Adequate breathing
− Patient is responsive, alert, able to speak
− Rate between 12 and 20 breaths/min
− Adequate depth
− Regular pattern of inhalation and exhalation
− Clear and equal breath sounds
Recognizing Inadequate
Breathing
• Breathing rate of less than 12 breaths/min
or more than 20 breaths/min
• Cyanosis: indicator of low blood oxygen
• Preferential positioning
− Upright sniffing (tripod) position
− Semi-Fowler (semi-sitting) position
Recognizing Inadequate
Breathing
• Potential causes:
−
−
−
−
Severe infection
Trauma
Brainstem insult
Noxious or oxygenpoor environment
− Renal failure
− Upper and/or lower
airway obstruction
− Respiratory muscle
impairment
− Central nervous
system impairment
Recognizing Inadequate
Breathing
• Airway management
steps:
−
−
−
−
Open the airway.
Clear the airway.
Assess breathing.
Provide appropriate
intervention(s).
• Evaluation includes:
− Observe
− Palpate
− Auscultate
Inadequate Breathing
• Note the following:
−
−
−
−
−
−
−
Position
Orthopnea
Chest rise/fall
Skin
Flared nostrils
Pursed lips
Retractions
− Use of accessory
muscles
− Asymmetric chest wall
movement
− Quick breaths, long
exhalation
− Labored breathing
Inadequate Breathing
• Signs:
− Fewer than 12, more
than 20 breaths/min
plus dyspnea
− Irregular rhythm
− Diminished, absent, or
noisy sounds
− Abdominal breathing
− Reduced flow
− Unequal chest
expansion
− Increased effort
− Shallow breathing
− Pale, clammy skin
− Retractions
− Staccato speech
Inadequate Breathing
• Feel for air movement.
• Observe chest for symmetry.
• Note any paradoxical motion.
• Assess for pulsus paradoxus.
− Systolic blood pressure drops more than
10 mm Hg during inhalation.
Inadequate Breathing
• Ask about history of present illness
− Onset, trigger, duration?
− Other symptoms?
− Interventions, previous hospitalization?
− Medications and overall compliance?
− Risk factors?
Protective Airway Reflexes
• Evaluate protective
reflexes.
− Coughing,
sneezing, gagging
• Gag reflex
(eyelash reflex)
− Sighing
− Hiccupping
Assessment of Breath Sounds
• Auscultate breath sounds with stethoscope.
− Should be clear and equal
Assessment of Breath Sounds
Assessment of Breath Sounds
• Duration: length of time for inspiratory and
expiratory phases
− Normal I/E ratio: 1:2
− Expiration is prolonged with lower airway
obstruction.
− Expiration is short with tachypneic patients.
Assessment of Breath Sounds
• Pitch: higher or lower than normal (stridor or
wheezing).
− Intensity of sound depends on:
• Airflow rate
• Constancy of flow throughout inspiration
• Patient position
• Site selected for auscultation
Abnormal Breath Sounds
• Wheezing:
continuous, highpitched
• Stridor: loud, highpitched, heard during
inspiration
• Rhonchi: continuous,
low-pitched
• Pleural friction rub:
surfaces of visceral
and parietal pleura
rub together
• Crackles:
discontinuous
Pulse Oximetry
• Pulse oximeter: measures oxygen
saturation of hemoglobin (Hb)
− Normal: SpO2 of greater than 95%
Pulse Oximetry
• Used for:
− Monitoring oxygenation status during intubation
attempt or suctioning
− Identifying deterioration in a patient with trauma
or cardiac disease
− Identifying high-risk patients
− Assessing vascular status in orthopaedic
trauma
Pulse Oximetry
• Erroneous readings
may result from:
− Bright ambient light
(cover clip)
− Patient motion
− Poor perfusion
− Nail polish
− Venous pulsations
− Abnormal hemoglobin
Pulse Oximetry
• Types of hemoglobin
− Oxyhemoglobin (HbO2)
− Reduced hemoglobin
• CO-oximeter
− Determines HbO2
saturation (percentage
of oxygenated Hb
compared with total
hemoglobin)
Courtesy of Mike Panté.
Peak Expiratory Flow
• Measured to evaluate
bronchoconstriction
− Increasing: patient is
responding to
treatment
− Decreasing: patient’s
condition is
deteriorating
• Perform three times
and take the best rate.
Arterial Blood Gas Analysis
• Blood is analyzed
for pH, PaO2,
HCO3−, base
excess, and SaO2.
− pH, HCO3−: acidbase status
− PaCO2:
effectiveness of
ventilation
− PaO2 and SaO2:
oxygenation
End-tidal Carbon Dioxide
(ETCO2) Assessment
• Detects carbon dioxide in exhaled air
− Adjunct for determining ventilation adequacy
− Confirms advanced airway placement
− ETCO2 detector types:
• Digital
• Waveform
• Digital/waveform
• Colorimetric
End-tidal Carbon Dioxide
(ETCO2) Assessment
• Capnometer
− Numeric reading of
exhaled CO2
• Capnographer
− Graphic
representation of
exhaled CO2
− Three types:
• Waveform
• Digital/waveform
• Colorimetric
Courtesy of PHASEIN Medical Technologies.
End-tidal Carbon Dioxide
(ETCO2) Assessment
• Waveform capnography
− Exhaled carbon dioxide level displayed as a
graphic waveform
− Includes contour, baseline level, rate, and rise
of carbon dioxide level
End-tidal Carbon Dioxide
(ETCO2) Assessment
• Waveform
capnography (cont’d)
− Phase A–B: initial
stage of exhalation
− Phase B–C: expiratory
upslope
− Phase C–D: expiratory
or alveolar plateau
− Phase D–E:
inspiratory down
stroke
End-tidal Carbon Dioxide
(ETCO2) Assessment
• Colorimetric
capnographer
− Reading after 6 to
8 positive-pressure
breaths
− Replace with
quantitative device
as soon as
possible
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
End-tidal Carbon Dioxide
(ETCO2) Assessment
• Capnography can:
− Indicate
effectiveness of
chest
compressions
− Detect return of
spontaneous
circulation
• Use is limited with
cardiac arrest
Airway Management
• Air reaches the
lungs only through
the trachea.
− In a compromised
airway, clearing the
airway and
maintaining
patency are vital.
Positioning the Patient
• Move unresponsive patients found in a
prone position to a supine position.
− Log roll and assess for breathing.
• If the patient is breathing adequately and is
not injured, move to recovery position.
Manual Airway Maneuvers
• If an unresponsive
patient has a pulse
but is not
breathing, you
must open the
airway.
− Maneuver
patient’s head to
propel the tongue
forward and open
the airway.
Head Tilt-Chin Lift Maneuver
• Indications:
− Unresponsive
− No spinal injury
− Unable to protect
airway
• Contraindications:
− Responsive
− Possible spinal injury
• Advantages
− No equipment
− Noninvasive
• Disadvantages
− Hazardous to spinal
injury
− No protection from
aspiration
• Refer to
Skill Drill 15-1.
Jaw-Thrust Maneuver
• Indications
− Unresponsive
− Possible spine injury
− Unable to protect
airway
• Contraindications
− Resistance to opening
the mouth
• Advantages
− Used with spine injury
or cervical collar
− No special equipment
required
Jaw-Thrust Maneuver
• Disadvantages
− Cannot maintain if
patient becomes
responsive or
combative
− Difficult to maintain for
an extended time
− Difficult to use with
bag-mask ventilation
− Thumb must remain in
place
− Requires second
rescuer
− No protection against
aspiration
• Refer to
Skill Drill 15-2.
Tongue-Jaw Lift Maneuver
• Used more commonly to open airway for:
− Suctioning
or
− Inserting an oropharyngeal airway
• Cannot be used to ventilate a patient
− Does not allow for an adequate mask seal
• Refer to Skill Drill 15-3.
Suctioning
• Removes material from the mouth or throat
quickly and efficiently
− Ventilating with secretions in the mouth will
result in upper airway obstruction or aspiration.
• Next priority after opening airway manually
Suctioning Equipment
• Fixed or portable
− Hand-operated
suctioning units
with disposable
canisters
− Mechanical or
vacuum-powered
suction units
Suctioning Equipment
• The following should be readily accessible:
−
−
−
−
Wide-bore, thick-walled, nonkinking tubing
Soft and rigid suction catheters
Nonbreakable, disposable collection bottle
Supply of water for rinsing the catheters
Suctioning Equipment
• Yankauer catheter
− Use with adults
(pharynx), infants,
children
• Whistle-tip catheter
− Can be placed in ET
tube
− Use for nose, back of
mouth, when a rigid
catheter cannot be
used
Suctioning Techniques
• Suctioning removes oxygen.
− Preoxygenate before suctioning.
− Maximum suctioning time
• Adult: 15 seconds
• Child: 10 seconds
• Infant: 5 seconds
Suctioning Techniques
• Do not stimulate back of throat.
• After suctioning, continue ventilation and
oxygenation.
• Soft-tip catheters
− Must lubricate when suctioning the nasopharynx
− Best when passed through an ET tube
− Suction during extraction of catheter
Suctioning Techniques
• Before inserting, measure for proper size.
− Corner of the mouth to the earlobe
• Never insert a catheter past the base of the
tongue.
• Refer to Skill Drill 15-4.
Airway Adjuncts
• May be needed to help maintain patency in
an unresponsive patient after manually
opening and suctioning
− Not a substitute for proper head positioning
Oropharyngeal (Oral) Airway
• Curved, hard plastic device
• Fits over back of the tongue
• Should be inserted in unresponsive patients
who have no gag reflex
Oropharyngeal (Oral) Airway
• Indications
− Unresponsive patients
who have no gag
reflex
• Contraindications
− Responsive patients
− Patients with a gag
reflex
• Advantages
− Noninvasive and
easily placed
− Prevents blockage by
the tongue
• Disadvantages
− No prevention of
aspiration
• Refer to
Skill Drill 15-5
and 15-6.
Nasopharyngeal (Nasal)
Airway
• Soft, rubber tube
• Insert through nose
• Better tolerated
− Do not use with
trauma to the nose
or skull fracture.
• Lubricate the
airway and insert
gently.
Nasopharyngeal (Nasal)
Airway
• Indications
− Unresponsive
− Altered mental status
with an intact gag
reflex
• Contraindications
− Patient intolerance
− Facial fracture or skull
fracture
• Advantages
− Suctioned through
− Patent airway
− Tolerated by
responsive patients
− Can be placed
“blindly”
− No requirement for the
mouth to be open
Nasopharyngeal Airway
• Disadvantages
− Improper technique may result in severe
bleeding.
− Does not protect from aspiration
• Refer to Skill Drill 15-7.
Causes of Airway Obstruction
• Foreign body
• Trauma
• Tongue
• Aspiration
• Laryngeal edema
• Infection or severe
allergic reaction
• Laryngeal spasm
Causes of Airway Obstruction
• Tongue
− With altered LOC, tongue can fall backwards,
closing off the airway
• Partial obstruction: snoring respirations
• Complete obstruction: no respirations
− Simple to correct with manual maneuver
Causes of Airway Obstruction
• Foreign body
− Typical victim: middle-aged or older, dentures,
alcohol
− Signs may include:
• Choking
• Gagging
• Stridor
• Dyspnea
• Aphonia or dysphonia
Laryngeal Spasm and Edema
• Laryngeal spasm
− Spasmodic closure of
vocal cords
− Completely occludes
airway
− Causes include:
• Laryngeal edema
− Glottic opening
narrows or totally
closes
− Causes include:
• Epiglottitis
• Intubation trauma
• Anaphylaxis
• Extubation
• Inhalation injury
Laryngeal Spasm and Edema
• May be relieved by
− Aggressive ventilation
− Forceful upward jaw pull
• May be relieved by muscle relaxants
• May recur; transport patient to hospital for
evaluation
Laryngeal Injury
• Fracture of the larynx increases airway
resistance by decreasing airway size.
• Penetrating and crush injuries to the larynx
can compromise the airway.
Aspiration
• Increases mortality
− Can obstruct the airway
− Destroys bronchiolar tissue
− Introduces pathogens into the lungs
− Decreases patient’s ability to ventilate
• Have suction readily available
Recognition of an Airway
Obstruction
• Mild obstruction
− Patient is responsive, able to exchange air
− Usually has noisy respirations and coughing
− Should be left alone
− Closely monitor the patient’s condition.
− Be prepared to intervene.
Recognition of an Airway
Obstruction
• Severe obstruction
− Inability to breathe, talk, or cough
− May grasp at throat, turn cyanotic, make frantic
movements
− Cough is weak, ineffective, or absent
Courtesy of Rhonda Beck
− Weak inspiratory stridor and cyanosis
Emergency Medical Care for Foreign
Body Airway Obstruction
• Begin treatment immediately if choking is
confirmed by a responsive patient.
− If large pieces of foreign body are found, sweep
them out of the mouth with your finger.
− Insert your finger along the inside of the cheek
and into the throat.
− Try to hook the foreign body to dislodge it.
− Suction as needed.
Emergency Medical Care for Foreign
Body Airway Obstruction
• Abdominal thrust (Heimlich) maneuver
− Creates an artificial cough, expelling the object
− Perform until the object is expelled or the
patient becomes unresponsive.
Emergency Medical Care for Foreign
Body Airway Obstruction
• If patient becomes unresponsive, position
supine, begin chest compressions
− 30 chest compressions
− 15 with two rescuers or infant/child
• Open airway, remove any visible object
• Attempt rescue breath, look for chest rise
Emergency Medical Care for Foreign
Body Airway Obstruction
• If techniques do not work, proceed with
direct laryngoscopy.
− If you see the foreign body, remove it with
Magill forceps.
− Refer to Skill Drill 15-8.
Supplemental Oxygen Therapy
• Administer to any patient with potential
hypoxia
− Enhances compensatory mechanisms during
shock and distressed states
Oxygen Sources
• Oxygen cylinders
− Stores pure
oxygen
− Check label and
test date.
− Various sizes
− Oxygen delivery is
measured in L/min.
Oxygen Sources
• Oxygen cylinders
(cont’d)
− Replace cylinder
when pressure falls
to 200 psi or lower.
− Using the pressure
and flow rate, you
can calculate how
long the supply will
last.
− Cooled to a liquid
− Converts to a gas
when warmed
− Keep upright.
HELiOS® Marathon™ portable oxygen unit. Courtesy of Nellcor Puritan Bennett in affiliation with Tyco Healthcare.
Oxygen Sources
• Liquid oxygen
Safety Reminders
• Keep combustible
materials away.
• Close all valves when
not in use.
• No smoking near
cylinders.
• Secure cylinders.
• Store in a cool,
ventilated area.
• Use only with a
properly fitting
regulator valve.
• Position yourself to
the cylinder’s side.
• Have the cylinder
hydrostat tested every
10 years.
Oxygen Regulators and
Flowmeters
• High-pressure regulators deliver gas under
high pressure.
− Pressure is approximately 2,000 psi.
− Therapy regulator controls flow to patient
• Reduces to 50 psi
Oxygen Regulators and
Flowmeters
• Flowmeters allow oxygen to be adjusted.
− Pressure-compensated flowmeter
− Bourdon-gauge flowmeter
Preparing an Oxygen Cylinder
for Use
• Before administering, you must prepare the
oxygen cylinder and therapy regulator.
• Refer to Skill Drill 15-9.
Nonrebreathing Mask
• Preferred in prehospital
setting
− 90% to 100% oxygen
− Mask and reservoir bag
• Indications
− Spontaneously breathing
patients
• Contraindications
− Apnea and poor
respiratory effort
© Jones & Bartlett Learning. Courtesy of MIEMSS.
Nasal Cannula
• Two small prongs
− 24% to 44% oxygen
• Best for patients who
need long-term
therapy
• Ineffective with:
− Apnea
− Poor respiratory effort
− Severe hypoxia
− Mouth breathing
© Jones & Bartlett Learning. Courtesy of MIEMSS.
Partial Rebreathing Mask
• Lacks one-way
valve
− Residual exhaled
air is rebreathed
• Flow rates of 6 to
10 L/min
© Jones & Bartlett Learning. Courtesy of MIEMSS.
• 35% to 60%
oxygen
Venturi Mask
• Draws room air
into the mask
along with oxygen
• Can deliver 24%,
28%, 35%, or 40%
oxygen
Tracheostomy Masks
• Cover the stoma
and have a strap
that goes around
the neck
− To improvise,
place a face mask
over the stoma.
Oxygen Humidifier
• Bottle of sterile
water moisturizes
oxygen
− Keep upright; only
practical with fixed
unit on ambulance
− Can be source of
infection
Ventilatory Support
• Patient who is not breathing needs artificial
ventilation and 100% supplemental oxygen
− Indications include signs of:
• Altered mental status
• Inadequate minute volume
Normal Ventilation Versus
Positive-Pressure Ventilation
• Normal ventilation
− Diaphragm contracts
− Negative pressure in chest cavity draws in air
• Positive-pressure ventilation
− Generated by a device
− Forces air into the chest cavity from the external
environment
Normal Ventilation Versus
Positive-Pressure Ventilation
Normal Ventilation Versus
Positive-Pressure Ventilation
• With positive-pressure ventilation, more air
is needed to achieve the same effects of
normal breathing.
− Increases overall intrathoracic pressure
− Blood flow is decreased.
Normal Ventilation Versus
Positive-Pressure Ventilation
• Cardiac output is a function of stroke
volume multiplied by the pulse rate.
• Normally, when a person breathes, air
enters the trachea.
− Ventilations that are too forceful can cause
gastric distention.
Assisted Ventilation
• Explain the
procedure.
• After 5 to 10 breaths,
slowly adjust the rate.
• Place the mask over
the patient’s nose
and mouth.
• Adjust the rate and
tidal volume to
maintain adequate
minute volume.
• Squeeze the bag
each time the patient
inhales.
Artificial Ventilation
• Begin artificial ventilation immediately if
patient is not breathing
• Methods include
− Mouth-to-mask technique
− One-, two-, or three-person bag-mask device
technique
− Manually triggered ventilation device
Mouth-to-Mouth Ventilation
• Routinely
performed with a
barrier device
• Alternative: mouthto-nose
• Requires no
special equipment
• Can provide
adequate tidal
volume
Courtesy of AAOS.
Mouth-to-Mask Ventilation
• Places a physical barrier between your
mouth and the patient’s mouth
• Oxygen inlet provides oxygen to
supplement the air from your own lungs
• May be shaped like a triangle or a doughnut
• Refer to Skill Drill 15-10.
Bag-Mask Device
• Can deliver nearly 100% oxygen.
• Can provide adequate tidal volume when
used by an experienced paramedic
− Depends on mask seal integrity
Bag-Mask Device Components
• Disposable, selfinflating bag
• No pop-off valve, or
capability to disable
• Nonrebreathing outlet
valve
• Oxygen reservoir
• One-way, no-jam inlet
valve system
• Transparent face
mask
Bag-Mask Device Components
• Total amount of gas in an adult bag-mask
device is usually 1,200 to 1,600 mL.
• Volume of oxygen to deliver is based on
visible chest rise.
− Deliver each breath over a period of 1 second at
the appropriate rate.
Bag-Mask Device Technique
• Kneel above patient’s
head.
• Place the mask on
the patient’s face.
• Maintain neck in a
hyperextended
position (unless spinal
injury).
• Bring the lower jaw up
to the mask.
− Open the mouth,
suction as needed.
− Insert an oral or nasal
airway.
• Connect the bag to
the mask.
Bag-Mask Device Technique
• Hold the mask in
place while your
partner squeezes
the bag until the
chest visibly rises.
− Squeeze every 5 to
6 seconds for
adults, 3 to 5
seconds for infants
and children.
Courtesy of AAOS
Bag-Mask Device Technique
• If alone, hold your
index finger over the
lower part of the mask
and your thumb over
the upper part.
© Jones & Bartlett Learning. Courtesy of MIEMSS.
• Observe for gastric
distention, changes in
compliance, and
changes in status.
Bag-Mask Device Technique
• Squeeze bag as patient inhales.
− Slowly adjust rate and tidal volume.
− If patient is hyperventilating, first assist at the
rate at which the patient is breathing.
• Then slowly adjust rate and tidal volume.
Bag-Mask Device Technique
• Not adequate if:
− Chest does not rise and fall
− Rate of ventilation is too slow or too fast
− Pulse rate does not improve
Bag-Mask Device Technique
• If the chest does not rise and fall:
− Reposition the head or insert an airway.
− If the stomach seems to be rising and falling,
reposition the head.
− If too much air is escaping, reposition the mask.
• If chest still does not rise and fall, check for
an airway obstruction.
Manually Triggered Ventilation
Devices
• Main use: apneic or hypoventilating patients
• “Demand valve” delivers 100% oxygen
• Makes an airtight seal with patient’s face
• Impossible to assess for lung compliance
Manually Triggered Ventilation
Devices
• Delivers only the volume of oxygen needed
• Expensive, not disposable
• Adapter fits standard ventilation masks
Components of Manually
Triggered Ventilation Devices
• Peak flow rate:
100% oxygen up to
40 L/min
• Inspiratory
pressure safety
release valve
• Alarm if pressure is
exceeded
• Properly positioned
trigger (or lever)
Automatic Transport
Ventilators
• Steps for using:
− Attach to wallmounted oxygen
source.
− Set tidal volume and
ventilatory rate.
− Connect to the
15/22-mm fitting on
the ET tube or airway
device.
− Auscultate breath
sounds and observe
chest rise.
Courtesy of Impact Instrumentation, Inc.
Automatic Transport
Ventilators
• Have bag-mask device available in case
ATV malfunctions
• Most models have adjustments for
respiratory rate and tidal volume.
− Deliver a preset volume at a preset rate.
Automatic Transport
Ventilators
• Generally consumes 5 L/min of oxygen
• Pressure-relief valve can lead to:
− Hypoventilation
− Increased airway resistance
− Airway obstruction
Continuous Positive Airway
Pressure
• Noninvasive means of providing ventilatory
support for patients with respiratory distress
− Increases pressure in the lungs
− Opens collapsed alveoli
− Pushes oxygen across alveolar membrane
− Forces interstitial fluid back into circulation
Continuous Positive Airway
Pressure
• Typically delivered through a face mask
secured with a strapping system.
− Pressure relief valve determines amount of
pressure delivered to the patient
Indications for CPAP
• Guidelines:
− Patient is alert and able to follow commands.
− Obvious signs of respiratory distress from an
underlying disease or after submersion
− Rapid breathing (more than 26 breaths/min) that
affects overall minute volume
− Pulse oximetry of less than 90%
Contraindications to CPAP
• Respiratory arrest
• Hypoventilation
• Signs and symptoms
of a pneumothorax or
chest trauma
• Tracheostomy
• Active GI bleeding or
vomiting
• Inability to follow
verbal commands
• Inability to properly fit
CPAP system mask
and strap
• Inability to tolerate the
mask
Application of CPAP
• Generally composed of:
− Generator
− Mask
− Circuit that contains corrugated tubing
− Bacteria filter
− One-way valve
Application of CPAP
• Patient exhales against a resistance
(positive end-expiratory pressure [PEEP])
− Controlled manually or predetermined
− 5 to 10 cm H2O is general therapeutic range
Application of CPAP
• Continuously monitor available oxygen.
• Some newer units allow you to adjust FIO2
• Refer to Skill Drill 15-11.
Complications of CPAP
• Patients may feel claustrophobic and resist.
• High volume of pressure can cause a
pneumothorax.
• Increased pressure in the chest cavity can
result in hypotension.
• Air may enter the stomach.
Gastric Distension
• Inflation of the stomach with air
− Likely to occur when:
• Excessive pressure is used to inflate the lungs
• Ventilations are performed too fast or too forcefully
• Airway is partially obstructed during ventilation
attempts
Gastric Distension
• Harmful for at least two reasons
− Promotes regurgitation, can lead to aspiration
− Pushes diaphragm up, limits lung expansion
• Signs include
− Increased diameter, distension of the stomach
− Increased resistance to bag-mask ventilations
Gastric Distension
• If signs are noted:
− Reassess and reposition the airway.
− Observe chest for adequate rise and fall.
− Limit ventilation times to 1 second or the time
needed to produce adequate chest rise.
Invasive Gastric
Decompression
• Involves inserting a gastric tube into the
stomach and suctioning the contents
− Should be considered:
• For any patient who will need positive-pressure
ventilation for an extended period
• When gastric distention interferes with ventilations
Invasive Gastric
Decompression
• Nasogastric tube
− Insert through nose
− Decompresses
stomach
• Decreases
pressure
• Limits risk of
regurgitation
Invasive Gastric
Decompression
• Nasogastric tube (cont’d)
− Relatively well tolerated
− Contraindicated with severe facial injuries
• Use OG route instead.
− Refer to Skill Drill 15-12.
Invasive Gastric
Decompression
• Orogastric tube
− Inserted through the mouth
− No risk of nasal bleeding
− Safer in patients with severe facial trauma
− Can use larger tubes
Orogastric Tube
• Orogastric tube (cont’d)
− Less comfortable for responsive patients
• Preferred for patients who are unresponsive without
a gag reflex
− See Skill Drill 15-13.
Laryngectomy
• Surgical removal of the larynx
− Tracheostomy creates a stoma.
− Total laryngectomy: breathe through stoma
• Cannot ventilate by mouth-to-mask technique
− Partial laryngectomy: breathe through stoma
and nose or mouth
Suctioning of a Stoma
• May become occluded with mucous plugs
− Suction with extreme care.
− Limit suctioning to 10 seconds.
• See Skill Drill 15-14.
Ventilation of Stoma Patients
• Head tilt-chin lift and jaw-thrust not required
• If no tracheostomy tube, use:
− Mouth-to-stoma technique
− Bag-mask device
• Use an infant- or child-sized mask to make an
adequate seal.
Ventilation of Stoma Patients
• Two rescuers are needed with a bag-mask
device.
− One to seal the nose and mouth
− The other to squeeze the bag-mask device
• See Skill Drill 15-15 and Skill Drill 15-16.
Tracheostomy Tubes
• Plastic tube placed
within the stoma
− Patients may
receive
supplemental
oxygen via:
• Tubing designed to
fit over the tube
• Placing an oxygen
mask over the tube
Tracheostomy Tubes
• Patients who experience sudden dyspnea
often have thick secretions in the tube
− Suction as you would through a stoma.
− When tube is dislodged, stenosis may occur.
• See Skill Drill 15-17.
Dental Appliances
• Different forms
− Dentures (upper, lower, or both)
− Bridges
− Individual teeth
− Braces (in the younger population)
Dental Appliances
• Determine whether appliance is loose or fits
− If it fits well, leave in place.
− Remove if loose.
• Take care if airway obstruction is caused by
a bridge (can lacerate pharynx or larynx).
• Generally best to remove before intubating
Facial Trauma
• Severe swelling
and bleeding in the
airway may be
present.
− Control with direct
pressure.
− Suction as needed.
© Eddie M. Sperling
Facial Trauma
• Inadequate breathing and severe
oropharyngeal bleeding may be present.
− Suction airway for 15 seconds (less in infants
and children), then ventilate for 2 minutes.
• Alternate until secretions have been cleared.
Facial Trauma
• Suspect cervical spine injury.
− Endotracheal intubation of a trauma patient is
most effectively performed by two paramedics.
• If you are unable to effectively ventilate or
intubate, perform a cricothyrotomy.
Advanced Airway Management
• One of the most common mistakes with
respiratory or cardiac arrest is to use
advanced techniques too early.
− Establish and maintain a patent airway with
basic techniques first.
Advanced Airway Management
• Primary reasons:
− Failure to maintain a patent airway
and/or
− Failure to adequately oxygenate and ventilate
• Involves insertion of advanced airway
devices
Predicting the Difficult Airway
• Anatomic findings:
− Congenital
abnormalities
− Recent surgery
− Trauma
− Infection
− Neoplastic diseases
• LEMON
−
−
−
−
−
Look externally
Evaluate 3-3-2
Mallampati
Obstruction
Neck mobility
LEMON
• Look externally.
− The following can make intubation difficult:
• Short, thick necks
• Morbid obesity
• Dental conditions
LEMON
• Evaluate 3-3-2.
− 3 — mouth width of more than 3 fingers is best
− 3 — mandible length of 3 fingers is best
− 2 — distance from hyoid bone to thyroid notch
of 2 fingers wide is best
LEMON
• Mallampati
− Note oropharyngeal structures visible in an
upright, seated patient.
LEMON
• Obstruction
− Note anything that might interfere with
visualization or ET tube placement.
• Foreign body
• Obesity
• Hematoma
• Masses
LEMON
• Neck mobility
− Sniffing position is ideal
− Neck mobility problems most common with:
• Trauma patients
• Elderly patients
Endotracheal Intubation
• ET tube passes through glottic opening and
is sealed with a cuff inflated against the
tracheal wall
− Orotracheal intubation: through the mouth
− Nasotracheal intubation: through the nose
Endotracheal Intubation
• Advantages
− Secure airway
− Protection against
aspiration
− Alternative to IV or IO
route
• Disadvantages
− Special equipment
− Physiologic functions
bypassed
• Complications
−
−
−
−
−
−
−
Bleeding
Hypoxia
Laryngeal swelling
Laryngospasm
Vocal cord damage
Mucosal necrosis
Barotrauma
Endotracheal Tubes
• Basic structure
includes:
− Proximal end
− Tube
− Cuff and pilot
balloon
− Distal tip
Endotracheal Tubes
• Sizes range
− 2.5 to 9.0 mm in inside diameter
− 12 to 32 cm in length
Endotracheal Tubes
• Pediatric patients
− 2.5 to 4.5 mm tubes used
− Funnel-shaped cricoid ring forms an anatomic
seal with ET tube
• No need for distal cuff in most cases.
Endotracheal Tubes
• Anatomic clues can help determine tube
size
− Internal diameter of the nostril approximates
diameter of glottic opening
− Diameter of the little finger or size of thumbnail
approximates airway size.
• Always have three sizes ready!
Laryngoscopes and Blades
• A laryngoscope is
required to perform
orotracheal
intubation by direct
laryngoscopy.
• Consists of a
handle and
interchangeable
blades
Laryngoscopes and Blades
• Straight (Miller and
Wisconsin) blades
− Tip extends
beneath epiglottis
and lifts it up
• Useful with infants
and small children
• More likely to
damage teeth in
adults
Laryngoscopes and Blades
• Curved
(Macintosh) blades
− Curve conforms to
tongue and
pharynx
− Tip is placed in the
vallecula
• Indirectly lifts
epiglottis to expose
vocal cords
Laryngoscopes and Blades
• Blade sizes range from 0 to 4
− 0, 1, and 2 appropriate for infants and children
− 3 and 4 considered adult sizes
− Pediatric patients: based on age or height
− Adults: based on experience, size of patient
Laryngoscopes and Blades
• Stylet: semirigid wire inserted into ET tube
− Molds and maintains shape of tube
− Should be lubricated for removal
− End should be bent to form a gentle curve
− End should rest at least 1/2″ from end of ET
tube
Laryngoscopes and Blades
• Magill forceps
− Remove airway obstructions under direct
visualization.
− Guide tip of ET tube through glottic opening if
the proper angle cannot be achieved by
manipulating the tube
Orotracheal Intubation by
Direct Laryngoscopy
• ET tube inserted through mouth and into
trachea while visualizing the glottic opening
with a laryngoscope
Orotracheal Intubation by
Direct Laryngoscopy
• Indications
− Airway control needed
due to coma,
respiratory arrest,
and/or cardiac arrest
− Ventilatory support
before impending
respiratory failure
− Prolonged ventilatory
support
−
−
−
−
Absence of gag reflex
Traumatic brain injury
Unresponsiveness
Impending airway
compromise
− Medication
administration
Orotracheal Intubation by
Direct Laryngoscopy
• Contraindications
− Intact gag reflex
− Inability to open mouth because of trauma,
dislocation of the jaw, or a pathologic condition
− Inability to see the glottic opening
− Copious secretions, vomitus, or blood in airway
Standard Precautions
• Intubation can expose you to bodily fluids.
− Take proper precautions.
• Gloves
• Mask that covers your entire face
Preoxygenation
• Critical before intubating
− 2–3 minutes for apneic or hypoventilating
patient
− Prevents hypoxia from occurring
− Monitor SpO2 and achieve as close to 100%
saturation as possible.
Positioning the Patient
• Airway has three
axes: mouth,
pharynx, and
larynx
− At acute angles in
neutral position
− Place patient in
“sniffing” position
to facilitate
visualization of the
airway.
Positioning the Patient
• Sniffing position
− 20° extension of
the atlanto-occipital
joint
− 30° flexion at C6
and C7 with short
neck and/or no
chin
− Elevate head
and/or neck until
ear is at the level
of the sternum
Blade Insertion
• Position yourself at the
patient’s head.
• Grasp laryngoscope.
• If mouth is not open:
− Place thumb below
bottom lip and
push open.
− “Scissor” thumb
and index finger
between molars
− Open with tonguejaw lift
Blade Insertion
• Insert blade into
right side of mouth
• Sweep tongue to
the left while
moving blade into
midline
• Slowly advance the
blade.
© Jones & Bartlett Learning. Courtesy of MIEMSS. Specimens provided by the Maryland State Anatomy Board,
Department of Health and Mental Hygiene at the Anatomical Services Division, University of Maryland School
of Medicine
Blade Insertion
• Exert gentle
traction at a 45°
angle as you lift the
patient’s jaw.
© Jones & Bartlett Learning. Courtesy of MIEMSS. Specimens provided by the Maryland State Anatomy Board,
Department of Health and Mental Hygiene at the Anatomical Services Division, University of Maryland School of
Medicine
− Keep your back
and arm straight as
you pull upward.
Visualization of the Glottic
Opening
• Continue lifting the
laryngoscope as
you look down the
blade.
• Work the tip of the
blade into position.
− The glottic opening
should come into
view.
• The vocal cords lie
within.
Courtesy of James P. Thomas, M.D. www.voicedoctor.net
Visualization of the Glottic
Opening
• Gum elastic bougie
− Flexible device
− Approximately 1 cm in diameter, 60 cm long
− Used in epiglottis-only views to facilitate
intubation
Visualization of the Glottic
Opening
• Gum elastic bougie
(cont’d)
− Insert through the
glottic opening
under direct
laryngoscopy.
− Once placed, it
becomes a guide
for the ET tube.
Tube Insertion
• Pick up preselected ET tube.
− Hold it near connector as you would a pencil.
• Insert tube from the right corner of mouth
through the vocal cords.
− Continue until the proximal end of the cuff is 1
to 2 cm past the vocal cords.
Tube Insertion
• Do not pass the
tube down the
barrel of the
laryngoscope
blade.
− Will obscure your
view of the glottic
opening
Ventilation
• After you have seen the ET tube cuff pass
roughly 1/2″ beyond the vocal cords
− Gently remove the blade.
− Secure tube with right hand
− Remove stylet from tube
Ventilation
• Inflate the distal cuff with 5 to 10 mL of air,
then detach the syringe from the inflation
port.
• Have your assistant attach the bag-mask
device to the ET tube; continue ventilation.
− Ensure that the patient’s chest rises with each
ventilation.
Ventilation
• Listen to both lungs and to the stomach.
− You should hear equal breath sounds and a
quiet epigastrium.
• Ventilation should be dictated by age.
− Adult with a pulse: 10 to 12 breaths/min
− Infant/child with a pulse: 12 to 20 breaths/min
− Patient in cardiac arrest: 8 to 10 breaths/min
Confirmation of Tube
Placement
• Visualize the ET tube passing between the
vocal cords.
• Auscultate.
− Unequal or absent breath sounds suggest:
• Esophageal placement
• Right mainstem bronchus placement
• Pneumothorax
• Bronchial obstruction
Confirmation of Tube
Placement
• Auscultate (cont’d).
− Bilaterally absent breath sounds or gurgling
over the epigastrium: esophagus was intubated
• Immediately remove ET tube.
• Be prepared to suction the airway.
Confirmation of Tube
Placement
• Auscultate (cont’d).
− Breath sounds only on right: tube has been
advanced too far.
• Reposition the tube.
Confirmation of Tube
Placement
• With proper tube position:
− Bag-mask device should be easy to compress.
− You should see corresponding chest expansion.
• Increased resistance may indicate:
− Gastric distention
− Esophageal intubation
− Tension pneumothorax
Confirmation of Tube
Placement
• Continuous waveform capnography plus
clinical assessment
− Most reliable method of confirming placement
− Attach capnography T-piece when bag-mask
device is attached to the ET tube.
Confirmation of Tube
Placement
• Esophageal
detector device
− Syringe model:
plunger is
withdrawn
• Tube in the
trachea: plunger
does not move
• Tube in the
esophagus:
plunger moves
back
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
Confirmation of Tube
Placement
• Esophageal
detector device
(cont’d)
− Bulb model: bulb is
squeezed
• Tube in the
esophagus: bulb
remains collapsed
• Tube in the
trachea: bulb
briskly expands
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
Confirmation of Tube
Placement
• After confirming proper placement, mark ET
tube where it emerges from the mouth
− Shows others whether tube has slipped in or out
Securing the Tube
• Never take your hand off the ET tube before
securing with an appropriate device.
− Support the tube manually while you ventilate to
avoid a sudden jolt from the bag-mask device.
Securing the Tube
• Steps:
− Note the centimeter marking on the ET tube.
− Remove the bag-mask device.
− Position the tube in the center of the mouth.
− Place the securing device over the tube.
− Reattach the bag-mask device, auscultate, and
note the capnography reading and waveform.
Securing the Tube
• Many devices feature a built-in bite block.
− Alternative: Secure tube with tape and insert a
bite block or oral airway.
• Minimize head movement in patient.
• See Skill Drill 15-18.
Nasotracheal Intubation
• Insertion of tube into
trachea through nose
• Indicated:
− Breathing
spontaneously but
requires definitive
airway management
• Contraindicated:
− Apnea
− Head trauma and
midface fractures
− Anatomic
abnormalities;
frequent cocaine use
Nasotracheal Intubation
• 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
• Disadvantage
− Blind technique
• Complications
− Bleeding
Nasotracheal Intubation
Equipment
• Same as for orotracheal intubation
− Minus laryngoscope and stylet
• Some tubes are designed for blind method
• Some devices allow confirmation of
intubation without placing face next to tube
Technique for Nasotracheal
Intubation
• Patient’s spontaneous respirations guide
the tube and confirm proper placement.
− Tube is advanced as patient inhales
Technique for Nasotracheal
Intubation
• Insert tube into
nostril, bevel facing
toward the nasal
septum
− Aim tip straight
back toward ear
− Position just above
the glottic opening
© Jones & Bartlett Learning. Courtesy of MIEMSS.
Technique for Nasotracheal
Intubation
• Manipulate head to control tube tip position
and to maximize air movement.
• Instruct patient to take a deep breath, and
gently advance tube.
− Placement will be evidenced by an increase in
air movement through the tube.
Technique for Nasotracheal
Intubation
• Soft-tissue bulge on either side of the
airway
− Tube is probably in the piriform fossa
• Hold head still, slightly withdraw the tube
• Once maximum airflow is detected, advance tube
• No soft-tissue bulge
− Tube has entered the esophagus.
• Withdraw until you detect airflow; extend head.
Technique for Nasotracheal
Intubation
• Once tube is in place, inflate the distal cuff
− Attach bag-mask device and ventilate.
− Clean up any secretions or excess lubricant.
− Secure the tube with tape.
− Document depth of insertion at the nostril.
− See Skill Drill 15-19.
Digital Intubation
• Directly palpate the glottic structures and
elevate the epiglottis with your finger while
guiding the ET tube into the trachea.
− Option in extreme circumstances
Digital Intubation
• Indications (exceptional circumstances)
− Laryngoscope, or other techniques, have failed
− Patient in confined space
− Patient is obese or has a short neck
− Copious secretions
− Head cannot be moved
− Cannot visualize intubation landmarks
Digital Intubation
• Can be performed in pediatric patients, but
usually impossible due to finger size
• Absolutely contraindicated if patient is:
− Breathing
− Not deeply unresponsive
− Has intact gag reflex
Digital Intubation
• Advantages
− Does not require a
laryngoscope
− Ideal if vocal cords are
obscured by
secretions
− Does not require
sniffing position
• Disadvantages
− Risk of being bitten
− Risk of exposure to
infectious disease
Digital Intubation
• Complications
− Misplacement of the ET tube
− Bite block can cause lip and tooth damage
− Vigorous or improper attempts can cause
airway trauma or swelling.
− Can result in hypoxia
Digital Intubation Equipment
• Same as for orotracheal intubation (minus
laryngoscope), plus fingers
− Stylet
− ETCO2 detector or esophageal detector device
− Appropriate device to secure the tube
Technique for Digital
Intubation
• Prepare equipment as assistant ventilates
− Select tube: one half to a full size smaller than
with direct laryngoscopy
• Tip of the tube is guided into the trachea
Technique for Digital
Intubation
• Two configurations are recommended.
− “Open J” configuration
− “U-handle” configuration
© Jones & Bartlett Learning. Courtesy of MIEMSS.
Technique for Digital
Intubation
• Sniffing position is
not required
• Insert bite block
between molars.
− Insert index and
middle fingers into
right side of the
mouth.
− Press against tongue.
− Pull epiglottis forward.
Technique for Digital
Intubation
• Hold ET tube in right hand; insert it into the
left side of the mouth
• Advance tube toward the glottis
− Once you feel the cuff pass 2″ beyond your
fingertip, stabilize the tube and withdraw fingers
− Remove the stylet and inflate the cuff.
Technique for Digital
Intubation
• Attach bag-mask device and ventilate.
• Confirm placement.
− Auscultate lungs and epigastrium.
− Monitor ETCO2.
− Properly secure the tube in place.
• See Skill Drill 15-20.
Transillumination Techniques
for Intubation
• Bright light source
placed inside the
trachea emits a
bright, wellcircumscribed light
© Jones & Bartlett Learning. Courtesy of MIEMSS.
Transillumination Techniques
for Intubation
• Indicated
− Other techniques have failed.
• Contraindicated
−
−
−
−
Intact gag reflex
Airway obstruction
May be difficult in obese or short neck patients
Pediatric patients: stylet must fit inside tube
Transillumination Techniques
for Intubation
• Advantages
− No laryngoscope
− Visual parameter
− Does not require
visualization of the
glottic opening
− Safe with possible
spinal injuries
• Disadvantages
− Special equipment
− Proficiency with
equipment
− Can be difficult in
brightly lit areas
• Complications
− Misplacement
Transillumination Equipment
• Device with a rigid stylet and a bright light
source at the end
− Light should shine laterally and forward.
− Stylet must be long enough to accommodate a
standard-length ET tube
− Stylet must be secured within the tube
Technique for TransilluminationGuided Intubation
• Preoxygenate for at least 2 to 3 minutes.
• Choose ET tube and check the cuff
• Lubricate and insert the lighted stylet.
− Ensure it is firmly seated into the tube.
Technique for TransilluminationGuided Intubation
• Bend tube into the proper shape
− Head in neutral or slightly extended position
• While holding the stylet, displace the jaw
forwardly.
• Turn on the lighted stylet, and insert it in the
midline of the mouth.
Technique for TransilluminationGuided Intubation
• Continue insertion; draw wrist toward you .
− Tightly circumscribed light slightly below the
thyroid cartilage: tube has entered trachea
− Faintly glowing light and bulging of the soft
tissue: tube is in the vallecular space.
− Dim, diffuse light at the anterior part of the neck:
esophageal placement
Technique for TransilluminationGuided Intubation
• Once light is visible at the midline, hold the
stylet in place and advance the tube.
• When the tube is in the trachea, stabilize it
and withdraw the stylet.
• Inflate the distal cuff, detach the syringe,
and attach the bag-mask device.
Technique for TransilluminationGuided Intubation
• Ventilate the patient while auscultating both
lungs and the epigastrium.
• Secure the tube and continue ventilations.
• See Skill Drill 15-21.
Retrograde Intubation
• Needle: placed percutaneously within the
trachea via the cricothyroid membrane
• Wire: placed through the needle, through
the trachea, into the mouth
− Wire is visualized, secured
− ET tube is placed over wire and guided into
trachea
Retrograde Intubation
• Indications
− Upper airway
obstruction
− Copious secretions in
the airway
− Failure to intubate by
less invasive methods
• Contraindications
− Lack of familiarity with
the procedure
− Laryngeal trauma
− Unrecognizable or
distorted landmarks
− Coagulopathy
− Severe hypoxia
Retrograde Intubation
• Complications
− Hypoxia
− Cardiac dysrhythmia
− Mechanical trauma
− Infection
− Increased intracranial pressure
• See Skill Drill 15-22
Face-to-Face Intubation
• Paramedic’s face is at the same level as
the patient’s face
− Head is stabilized, not in sniffing position.
− Laryngoscope is held in the right hand; ET tube
in left hand.
− Once blade is placed, head may be adjusted by
pulling mandible forward while pressing down.
Failed Intubation
• Definition:
− Failure to maintain oxygen saturation during or
after one or more failed intubation attempts
− Total of three failed intubation attempts
Failed Intubation
• Many rescue airway techniques
− Simple BLS airway maneuvers with oral airway
and/or nasal airway and bag-mask device
− Rescue airway device
Tracheobronchial Suctioning
• Involves passing a suction catheter into the
ET tube to remove pulmonary secretions
− Do not do it if you do not have to!
− If it must be performed:
• Use sterile technique.
• Monitor cardiac rhythm and oxygen saturation.
Tracheobronchial Suctioning
• Preoxygenate for at least 2 to 3 minutes.
• Insert suction catheter until resisted.
− Apply suction as the catheter is extracted
• Reattach bag-mask device, continue
ventilations, and reassess.
• See Skill Drill 15-23.
Field Extubation
• Extubation: process of removing tube from
an intubated patient
− Before performing, contact medical control or
follow local protocols.
Field Extubation
• Risks
− Over-estimating patient’s ability to protect
airway
− Laryngospasm
− Upper airway swelling
• Do not remove tube unless you can
reintubate!
Field Extubation
• Contraindicated with any risk of recurrent
respiratory failure or uncertainty about a
patient’s ability to maintain airway
• If indicated, ensure adequate oxygenation.
Field Extubation
• Explain procedure to patient
• Have patient sit up or lean slightly forward.
• Assemble equipment to suction, ventilate,
and reintubate.
Field Extubation
• Confirm patient can protect airway
• Suction oropharynx
• Deflate distal cuff as patient exhales
• On next exhalation, remove tube
Pediatric Endotracheal
Intubation
• If bag-mask is
not producing
adequate
ventilation,
patient should
be intubated
− Indications are
the same as
those in adults
Laryngoscope and Blades
• Thinner pediatric handles are preferred.
• Straight blades facilitate lifting of epiglottis
• Blade should extend from mouth to ear
Laryngoscope and Blades
• Use length-based resuscitation tape
measure or the following guidelines:
− Premature newborn: size 0 straight blade
− Newborn to 1 year: size 1 straight blade
− 2 years to adolescent: size 2 straight blade
− Adolescent and older: size 3 straight or curved
blade
Endotracheal Tubes
• To estimate the
appropriate size:
− Length-based
resuscitation tape
measure
− Formulas
• [Age (in years) + 16] ÷
4
© Jones & Bartlett Learning. Courtesy of MIEMSS.
• [Age (in years) ÷ 4] + 4
− Anatomic clues
− General guidelines
Courtesy of Marianne Gausche-Hill, MD, FACEP, FAAP
Endotracheal Tubes
• Cuffed ET tubes are generally not used in
the field until the child is 8 to 10 years old.
− Can cause ischemia and damage the tracheal
mucosa
• Have tubes one size smaller and one size
larger than expected
Endotracheal Tubes
• Appropriate depth of insertion is 2 to 3 cm
beyond the vocal cords
− Record depth at corner of mouth
− Uncuffed tubes: stop when black band is at the
vocal cords.
− Cuffed tubes: stop when cuff is just below the
vocal cords.
Pediatric Stylet
• Insert into tube, stop at least 1 cm from end
• Fit tube sizes 3.0 to 6.0 mm
• After inserting into tube, bend tube into a
gentle upward curve
Preoxygenation
• Preoxygenate for at least 2 to 3 minutes.
• Ensure that the child’s head is in the
sniffing position or the neutral position.
• If needed, insert an airway adjunct.
Additional Preparation
• Monitor cardiac rhythm.
• Monitor pulse rate and oxygen saturation.
• Have suction available.
• Atropine sulfate may be administered.
Pediatric Intubation Technique
• With head in sniffing position, apply thumb
pressure on chin to open mouth.
• If an oral airway was inserted, remove it.
• Suction if needed.
• Hold the laryngoscope in “trigger finger”
position.
Pediatric Intubation Technique
• Insert the blade in the right side of the
mouth.
− Sweep tongue to the left, keep under blade.
• Advance the blade; apply traction upward.
− Never use teeth/gums as a fulcrum for the blade
Pediatric Intubation Technique
• Straight blade: When the blade passes the
epiglottis, gently lift the epiglottis.
• Curved blade: place blade tip in vallecula;
lift jaw, tongue, and blade at a 45° angle.
• Identify vocal cords and other landmarks.
Pediatric Intubation Technique
• Hold tube in right hand; insert from the rightside corner of the mouth.
• Guide tube through the vocal cords,
advancing until black band is just beyond
− Record the depth, and remove the blade.
Pediatric Intubation Technique
• Remove stylet; hold tube in place.
• Recheck tube depth.
• Cuffed tube: inflate to form seal
• Attach tube to bag-mask device.
Pediatric Intubation Technique
• Confirm tube placement.
− Bilateral chest rise during ventilation
− Auscultate lungs bilaterally.
− If sounds are decreased on left, tube may be
too deep.
• To correct, withdraw tube until sounds are equal.
− Rerecord tube depth.
Pediatric Intubation Technique
• Auscultate over epigastrium.
− Bubbling sounds indicate esophageal
intubation.
• Additional methods to confirm placement:
− Improvement in skin color, pulse rate, and
oxygen saturation
− Waveform capnography
Pediatric Intubation Technique
• Colorimetric ETCO2 detector or EDD
− Cannot be used in children weighing < 15 kg
− Esophageal bulb or syringe cannot be used in
children weighing < 20 kg
• After placement, secure tube
− Reconfirm placement following any movement.
Pediatric Intubation Technique
• If tube is too large or you cannot identify the
vocal cords and glottic landmarks:
− Abort intubation and ventilate.
− Modify equipment and start from the beginning.
− If intubation cannot be accomplished after two
attempts, discontinue.
Pediatric Intubation Technique
• See Skill Drill 15-24.
• If child’s condition deteriorates, use DOPE
for common causes.
−
−
−
−
Displacement
Obstruction
Pneumothorax
Equipment failure
Complications of Endotracheal
Intubation
• Essentially the same as for adults
−
−
−
−
Unrecognized esophageal intubation
Induction of emesis and aspiration
Hypoxia
Damage to teeth, soft tissues, and intraoral
structures
Pharmacologic Adjuncts to Airway
Management and Ventilation
• Decrease the discomfort of intubation
• Decrease the incidence of complications
• Make aggressive airway management
possible for patients who are unable to
cooperate
Sedation in Emergency
Intubation
• Reduces anxiety, induces amnesia,
decreases gag reflex
• Undersedation:
− Inadequate cooperation
− Complications of gagging
− Incomplete amnesia
Sedation in Emergency
Intubation
• Oversedation:
− Uncontrolled general anesthesia
− Loss of protective airway reflexes
− Respiratory depression
− Complete airway collapse
− Hypotension
Sedation in Emergency
Intubation
• Desired level of
sedation dictates
dose
• Two major classes:
− Analgesics:
decrease
perception of pain
− Sedativehypnotics: induce
sleep, decrease
anxiety
Butyrophenones
• Potent, effective sedatives
− Haloperidol and droperidol relieve anxiety.
• Do not produce apnea
• Little effect on cardiovascular system
• Not recommended to induce anesthesia
Benzodiazepines
• Sedative-hypnotic drugs
• Diazepam and midazolam
− Provide muscle relaxation, mild sedation
− Used as anxiolytic and antiseizure medications
− Provide anterograde amnesia
Benzodiazepines
• Neuromuscular blockers preferred for
muscle relaxation
• Potential side effects:
− Respiratory depression
− Slight hypotension
• Flumazenil: benzodiazepine antagonist
Barbituates
• Sedative-hypnotic
medications
• Thiopental
− Short acting
− Rapid onset
• Methohexital
− Ultra-short acting
− Twice as potent
• Can cause
− Respiratory
depression
− Drop in blood
pressure
• Potentially
irreversible in
hypovolemic
patients
Opioids/Narcotics
• Potent analgesics with sedative properties
• Two most common: fentanyl, alfentanil
• Can cause respiratory and central nervous
system depression
• Naloxone: narcotic antagonist
Nonnarcotic/Nonbarbituate
• Etomidate
− Hypnotic-sedative drug
− Often used in induction of general anesthesia
− Fast-acting, short duration
− Little effect on pulse rate, blood pressure,
intracranial pressure (ICP)
Nonnarcotic/Nonbarbituate
• Etomidate (cont’d)
− No histamine release and bronchoconstriction
− High incidence of myoclonic muscle movement
− Useful induction agent in patients with:
• Coronary artery disease
• Increased ICP
• Borderline hypotension/hypovolemia
Neuromuscular Blockade in
Emergency Intubation
• Cerebral hypoxia can make patients
combative and uncooperative.
− Requires aggressive oxygenation, ventilation
− Neuromuscular blocking agents are safer.
Neuromuscular Blocking
Agents
• Affect every skeletal muscle
• Within about 1 minute, patient is paralyzed
• Must be able to secure the airway
• No effect on LOC.
Pharmacology of Neuromuscular
Blocking Agents
• Skeletal muscles are voluntary.
− Impulse to contract reaches a motor nerve
− Acetylcholine (Ach) is released.
• Diffuses, occupies receptor sites
• Triggers changes in electrical properties of the
muscle fiber (depolarization)
Pharmacology of Neuromuscular
Blocking Agents
• Paralytic
medications
− Relax the muscle
by impeding the
action of Ach
− Two categories:
depolarizing and
nondepolarizing
Depolarizing Neuromuscular
Blocking Agent
• Competitively binds with ACh receptor sites
− Not affected as quickly by acetylcholinesterase
• Succinylcholine chloride is the only agent.
− Fasciculations can be observed during its
administration.
Depolarizing Neuromuscular
Blocking Agent
• Very rapid onset of total paralysis
• Short duration of action
• Use with caution in patients with burns,
crush injuries, and blunt trauma
• Can cause bradycardia
Nondepolarizing Neuromuscular
Blocking Agents
• Bind to ACh receptor sites but do not cause
depolarization of the muscle fiber.
• Prevent fasciculations before a depolarizing
paralytic
Nondepolarizing Neuromuscular
Blocking Agents
• Most commonly used
− Vecuronium bromide (Norcuron)
− Pancuronium bromide (Pavulon)
− Rocuronium bromide (Zemuron)
• Do not give before the airway is secured.
Rapid-Sequence Intubation
(RSI)
• Safe, smooth, rapid sedation and paralysis
followed immediately by intubation
• Generally used for patients who are unable
to cooperate
Preparation of the Patient and
Equipment
• Explain procedure, reassure the patient
• Apply a cardiac monitor and pulse oximeter.
• Check, prepare, assemble equipment
− Have suction available
Preoxygenation
• Adequately preoxygenate all patients.
− If the patient is breathing spontaneously and
has adequate tidal volume:
• Apply high-flow oxygen via nonrebreathing mask.
− If patient is hypoventilating:
• Assist ventilations with a bag-mask device and highflow oxygen.
Premedication
• Stimulation of the glottis with intubation can
cause dysrhythmias and increase ICP.
• If your initial paralytic is succinylcholine,
administer nondepolarizing paralytic.
• Atropine sulfate should be administered to
decrease potential for bradycardia.
Sedation and Paralysis
• As soon as patient is sedated, administer
paralytic agent
− Onset should be complete within 2 minutes.
− Signs of adequate paralysis include:
• Apnea
• Laxity of the mandible
• Loss of the eyelash reflex
Intubation
• Intubate trachea as carefully as possible.
− If you cannot intubate within 30 seconds,
ventilate for 30–60 seconds before trying again.
• If ventilating with a bag-mask device, do so slowly.
Intubation
• Once tube is in the trachea:
− Inflate cuff.
− Remove stylet.
− Verify position of the ET tube.
− Secure the tube.
− Continue ventilations.
Maintenance of Paralysis and
Sedation
• Additional paralytic administration may be
necessary after intubation.
− If you administered succinylcholine, administer
a nondepolarizing agent to maintain paralysis.
− If you administered a long-acting paralytic,
additional dosing is usually not necessary.
Maintenance of Paralysis and
Sedation
• Modification for
unstable patients
− If oxygen
saturation drops,
ventilate slowly.
− If patient is
hemodynamically
unstable, judge
whether sedation is
appropriate.
Multilumen Airways
• Inserted blindly
• Proven to secure airway and allow for better
ventilation.
• Two devices:
− Pharyngotracheal lumen airway
− Combitube
Multilumen Airways
• Combitube
− Long tube
− Can be used for
ventilation
whether it is
inserted into the
esophagus or
trachea
Multilumen Airways
• Indications
− Unresponsive, apneic
patients with no gag
reflex in whom
intubation is not
possible
• Cannot be used in
children younger
than 16 years
• Only use for
patients between 5′
and 7′ tall.
• Contraindications
− Esophageal trauma
− Known pathologic
condition of the
esophagus
− Ingestion of a caustic
substance
− History of alcoholism
Multilumen Airways
• Advantages
− Ventilation in
esophagus or trachea
− Insertion is easier than
ET intubation
− Minimal cervical spine
movement
− No mask seal
− Airway patency
• Disadvantages
− Wrong port results in
no pulmonary
ventilation
− Should be replaced
when possible
− Risk of aspiration
− Intubating the trachea
via direct
laryngoscopy is
challenging.
Complications of Multilumen
Airways
• Unrecognized displacement into esophagus
• Laryngospasm, vomiting, hypoventilation
• Pharyngeal or esophageal trauma
• Ventilation may be difficult if the pharyngeal
balloon pushes the epiglottis over the glottic
opening.
Insertion Techniques
• Combitube
consists of:
− Single tube with
two lumens
− Two balloons
− Two ventilation
attachments
• Before insertion,
prepare
equipment.
Insertion Techniques
• Head should be in a neutral position
− Insert thumb into the mouth and lift the jaw.
• Insert device until incisors are between the
two black lines
• Two valves must be inflated sequentially.
• See Skill Drill 15-25.
Insertion Techniques
• After inflation of balloons, begin to ventilate
− Through the longer (blue) tube first
• Observe for chest rise and auscultate.
− If there are no breath sounds, switch to the
shorter (clear) tube.
• Continuously monitor ventilation.
Laryngeal Mask Airway (LMA)
• Option for
patients who:
− Require more
support than bagmask
− Do not require
ET intubation
• Conduit from
glottic opening to
ventilation device
Laryngeal Mask Airway (LMA)
• Surrounds
larynx opening
with an
inflatable cuff
− Cuff conforms
to airway
contours,
forms airtight
seal
Laryngeal Mask Airway (LMA)
• Indications and contraindications
− Alternative to bag-mask ventilation
− Less effective in obese patients
− Pregnant patients and patients with a hiatal
hernia are at risk for regurgitation.
− Ineffective with patients requiring high
pulmonary pressures
Laryngeal Mask Airway (LMA)
• Advantages
− Better ventilation
− No continual
maintenance of a
mask seal
− No laryngoscopy
− Less risk of trauma
− Protection from
secretions
• Disadvantages
− No protection against
aspiration
− Air may be insufflated
into the stomach
− Not a primary airway
in emergency
situations
Complications of Using LMA
• Involve regurgitation and aspiration
− Weigh against risk of hypoventilation
• Hypoventilation of patients who require high
ventilatory pressures can occur.
• Upper airway swelling has been reported.
Equipment for LMA
• Seven sizes; based on the patient weight
• Consists of tube and inflatable mask cuff
• Two bars at opening prevent occlusion
• Proximal end is fitted with standard adapter
Equipment for LMA
• Cuff has a one-way
valve assembly
• 6.0-mm ET tube
can be passed
through size 3 or 4
LMA
• Fasttrach LMA
guides ET tube into
trachea
King LT Airway
• Latex-free, singleuse, single-lumen
− Positive-pressure
ventilation for
apneic patients
− Maintains airway in
spontaneously
breathing patients
who need
advanced
management
Courtesy of King Systems.
King LT Airway
• Curved tube with
ventilation ports
between two
inflatable cuffs
− Can be inserted
more easily than
the Combitube
King LT Airway
• Two types:
− King LT-D: used
for adults and
children
− King LTS-D: used
for adults
• Five sizes of each
type
King LT Airway
• King LT-D and LTS-D share many features:
− Proximal pharyngeal cuff, distal cuff, ventilation
outlets
− ET tube introducer (gum elastic bougie) can be
inserted through the tube
− Distal end: closed in LT-D; open in LTS-D
King LT Airway
• Indications
− Alternative to bagmask ventilation when
a rescue airway
device is required
− Same considerations
as Combitube
• Contraindications
− Patients with an intact
gag reflex
− Patients with known
esophageal disease
− Patients who have
ingested a caustic
substance
Complications of the King LT
Airway
• Laryngospasm, vomiting, hypoventilation
• Trauma from improper insertion technique
• Pharyngeal balloon may push the epiglottis
over the glottic opening
− May make ventilation difficult
Insertion Technique
• Patient’s height and weight determine size
you should use.
• See Skill Drill 15-27.
Cobra Perilaryngeal Airway
(CobraPLA)
• Shape lets device:
− Slide easily along
the hard palate
− Hold airway’s soft
tissue away from
the laryngeal inlet
• Available in eight
sizes
Courtesy of Candice M. Thompson, NREMT-P
Cobra Perilaryngeal Airway
(CobraPLA)
• Indications
− Usage similar to other
supraglottic airway
devices
− Can be used in
pediatric patients
− Does not protect
against aspiration
• Contraindications
− Risk for aspiration
− Risk for massive
trauma to oral cavity
Contraindications and
Complications
• Complications
− Laryngospasm may
occur with intact gag
reflex
− Cuff inflation may
cause tongue to
disrupt seal.
− Patient cannot be
ventilated if device is
too small.
• Insertion technique
− See Skill Drill 15-28.
Surgical and Nonsurgical
Cricothyrotomy
• Used when
conventional
techniques fail
• Be familiar with:
− Anatomy of the
anterior aspect of
the neck
− Important blood
vessels in area
Open Cricothyrotomy
• Involves:
− Incising the cricothyroid membrane
− Inserting an ET or tracheostomy tube directly
into the subglottic area of the trachea
• Cricothyroid membrane is ideal for surgical
opening into the trachea
Open Cricothyrotomy
• Several types:
− Open (surgical)
cricothyrotomy
− Modified
cricothyrotomy
(Seldinger
technique)
− Device that
functions as an
introducer and an
airway
Courtesy of Cook Medical
Open Cricothyrotomy
• Indications
− Patent airway
cannot be secured
with conventional
means
• Severe foreign
body obstructions
• Swelling of airway
• Maxillofacial
trauma
• Inability to open
mouth
Open Cricothyrotomy
• Contraindications
− Ability to secure a patent airway
− Inability to identify anatomic landmarks
− Crushing injuries to the larynx and tracheal
transection
− Underlying anatomic abnormalities
− Age younger than 8 years
Open Cricothyrotomy
• Advantages
− Can be performed
quickly
− Do not need to
manipulate cervical
spine
• Disadvantages
− Difficult to perform in
children and patients
with short, muscular,
or fat necks
− More difficult than
needle cricothyrotomy
Open Cricothyrotomy
• Complications
− Severe bleeding from laceration of the external
jugular vein.
− Risks of perforating the esophagus and
damaging the laryngeal nerves
− Taking too long will result in hypoxia
− Subcutaneous emphysema from tube
misplacement
Open Cricothyrotomy
Equipment
• If a commercial kit is not available, prepare:
− Scalpel
− ET or tracheostomy tube
− Commercial device (or tape) to secure tube
−
−
−
−
Curved hemostats
Suction apparatus
Sterile gauze pads
Bag-mask device attached to 100% oxygen
Technique for Performing
Open Cricothyrotomy
• Proceed rapidly yet cautiously
• Palpate for V notch of thyroid cartilage
• Slide index finger into depression between
thyroid and cricoid cartilage
− That is the cricothyroid membrane.
Technique for Performing
Open Cricothyrotomy
• Partner prepares equipment
• Maintain aseptic technique.
• Stabilize larynx; make a 1- to 2-cm vertical
incision over the cricothyroid membrane.
Technique for Performing
Open Cricothyrotomy
• Insert a 6.0-mm cuffed ET tube or a 6.0
tracheostomy tube into trachea.
• Inflate the distal cuff.
• Attach the bag-mask device, and ventilate
while your partner auscultates.
Technique for Performing
Open Cricothyrotomy
• Confirm proper tube placement.
• Ensure bleeding has been controlled.
• Secure tube and continue to ventilate.
• See Skill Drill 15-29.
Needle Cricothyrotomy
• 14- to 16-gauge over-the-needle IV catheter
inserted into the trachea
• High-pressure jet ventilator attached to
catheter hub
− Translaryngeal catheter ventilation
Needle Cricothyrotomy
• Indications
− Inability to ventilate by
less invasive means
− Maxillofacial trauma
− Inability to open mouth
− Uncontrolled
oropharyngeal
bleeding
• Contraindications
− Severe airway
obstruction above
catheter insertion
• High-pressure
ventilator leads to
barotrauma and
pneumothorax
− If equipment is not
immediately available
Needle Cricothyrotomy
• Advantages
− Easier than open
cricothyrotomy
− Lower risk of
damaging structures
− Allows for intubation
− No manipulation of
cervical spine
• Disadvantages
− Does not provide
protection from
aspiration
− Technique requires a
specialized, highpressure jet ventilator
Needle Cricothyrotomy
• Complications
− Improper placement can cause severe bleeding.
− Excessive air leakage can cause subcutaneous
emphysema and compression of the trachea.
− Overinflation of lungs: barotrauma
− Underinflation of lungs: hypoventilation
Needle Cricothyrotomy
Equipment
• Large-bore IV catheter (14–16 gauge)
• 10-mL syringe
• 3 mL of sterile water or saline
• Oxygen source (50 psi)
• High-pressure jet ventilator device and
oxygen tubing
Technique for Performing
Needle Cricothyrotomy
• Draw up approximately 3 mL of sterile water
or saline into a 10-mL syringe.
− Attach to IV catheter.
• Place head in neutral position
• Locate the cricothyroid membrane.
• Cleanse area if time permits.
Technique for Performing
Needle Cricothyrotomy
• Stabilize the larynx; insert the needle at a
45° angle toward the feet.
− You should feel a pop as the needle penetrates
the membrane.
• After a pop is felt, insert needle 1 cm
farther; aspirate with the syringe.
Technique for Performing
Needle Cricothyrotomy
• Advance catheter over needle until catheter
hub is flush with skin
− Withdraw the needle; dispose of properly.
• Attach one end of the oxygen tubing to the
catheter; other end to the jet ventilator
Technique for Performing
Needle Cricothyrotomy
• Begin ventilations by opening the release
valve on the jet ventilator
− Turn release valve off with chest rise.
• Secure catheter and continue ventilations.
• See Skill Drill 15-30.
Summary
• The upper airway consists of all structures
above the vocal cords.
• The lower airway consists of all structures
below the vocal cords.
• The diaphragm is the major muscle of
breathing. The intercostal muscles and the
accessory muscles also play a role.
Summary
• The respiratory and cardiovascular systems
deliver oxygen and nutrients to cells and
remove waste products.
• Ventilation, oxygenation, and respiration are
crucial for tissues to receive nutrients.
• Ventilation, the act of moving air into and
out of the lungs, requires the diaphragm
and intercostal muscles. Diffusion allows
oxygen transfer from air into the capillaries.
Summary
• Changes in oxygen demand are regulated
primarily by the pH of CSF. Medullary
respiratory centers control rate, depth, and
rhythm of breathing.
• Negative-pressure ventilation draws air into
the lungs. Positive-pressure ventilation
forces air into the lungs.
• Oxygenation is the process of loading
oxygen molecules onto hemoglobin in the
bloodstream.
Summary
• Respiration is the exchange of oxygen and
carbon dioxide in the alveoli and tissues.
• Primary respiratory drive is based on
increasing arterial CO2 level and pH of CSF.
Hypoxic drive is based on decreasing
arterial oxygen levels.
• Many conditions can inhibit oxygen delivery
to cells. Ventilation/perfusion mismatch can
lead to severe hypoxemia.
Summary
• Other factors that impede oxygen delivery
include airway swelling and obstruction,
some medications, neuromuscular
disorders, respiratory and cardiac diseases,
hypoglycemia, circulatory compromise,
submersion, and trauma.
• Disruptions in the acid-base balance can
lead to rapid deterioration and death.
Summary
• Adequate breathing features a respiratory
rate between 12 and 20 breaths/min,
adequate tidal volume, regular inhalation
and exhalation, symmetric chest rise, and
bilaterally clear and equal breath sounds.
• Inadequate breathing features a rate that is
too slow or too fast, shallow breathing,
irregular inhalation and exhalation,
asymmetric chest movement, adventitious
airway sounds, cyanosis, and altered LOC.
Summary
• Abnormal breathing patterns include agonal
gasps; Cheyne-Stokes, Kussmaul, ataxic,
or apneustic respirations.
• Auscultate breath sounds with a
stethoscope to assess breathing. Breath
sounds should be clear and equal.
• The pulse oximeter measures the
percentage of blood oxygen saturation
(SpO2).
Summary
• Peak expiratory flow assesses
bronchoconstriction and is used to gauge
treatment effectiveness.
• End-tidal CO2 monitors detect carbon
dioxide in exhaled air and help determine
ventilation adequacy in spontaneously
breathing patients or with an advanced
airway.
Summary
• Patients with inadequate breathing require
positive-pressure ventilation; patients with
adequate breathing who are suspected of
being hypoxemic require 100% oxygen via
a nonrebreathing mask.
• Unrecognized inadequate breathing leads
to hypoxia, a dangerous condition in which
cells and tissues do not receive adequate
oxygen.
Summary
• The airway must remain patent at all times.
First position the patient in the recovery
position.
• Properly position the head. Manual airway
maneuvers include the head tilt-chin lift,
jaw-thrust, and tongue-jaw lift.
• Clearing the airway means removing
obstructing material; maintaining the airway
means keeping it open.
Summary
• Oropharyngeal suctioning may be required
after opening an airway.
• Limit oropharyngeal suction to 15 seconds
in an adult, 10 seconds in a child, and 5
seconds in an infant.
• It is critical to differentiate between a partial
and complete airway obstruction.
Summary
• Chest compressions, finger sweeps,
manual removal, and attempts to ventilate is
the recommended sequence with a foreign
body airway obstruction in an unresponsive
adult.
• Basic airway adjuncts include the
oropharyngeal and nasopharyngeal
airways.
Summary
• Administer supplemental oxygen to any
patient with potential hypoxia. Be familiar
with cylinder sizes and duration of flow, and
always use safety precautions.
• The nonrebreathing mask is the preferred
device for oxygenating adequately
breathing patients. Use the nasal cannula if
the patient cannot tolerate the
nonrebreathing mask.
Summary
• The methods of providing artificial
ventilation include the two-person bag-mask
technique, mouth-to-mask with one-way
valve and supplemental oxygen attached,
manually triggered ventilation device, and
the one-person bag-mask technique.
• Continuous positive airway pressure
(CPAP) improves breathing by forcing fluid
from the alveoli or dilating the bronchioles.
Summary
• Remove loose dental appliances before
artificial ventilation.
• Remove dental appliances before
intubation.
• Patients with massive maxillofacial trauma
are at high risk for airway compromise due
to oral bleeding. Assist ventilations, provide
oral suctioning as needed.
Summary
• Ventilating too forcefully or too fast can
cause gastric distention, which can cause
regurgitation and aspiration.
• Invasive gastric decompression involves
inserting a gastric tube into the stomach.
• Patients with a tracheal stoma or
tracheostomy tube may require ventilation,
suctioning, or tube replacement.
Summary
• Patients who are unresponsive or cannot
maintain their own airway are candidates for
endotracheal intubation, the insertion of an
ET tube into the trachea. In orotracheal
intubation, the tube is inserted via the
mouth; in nasotracheal intubation, the tube
is inserted via the nose.
• You must confirm and monitor ET tube
placement in intubation.
Summary
• If an attempted intubation does not result in
acceptable oxygen saturations, perform
BLS maneuvers with an oral airway and/or
nasal airway and a bag-mask device, and
consider using another airway device.
• Tracheobronchial suctioning is indicated if
an intubated patient’s condition
deteriorates because of pulmonary
secretions in the ET tube.
Summary
• Do not extubate unless the patient is
unreasonably intolerant of the tube.
• Pediatric ET intubation involves adult
techniques but smaller equipment.
• Rapid-sequence intubation (RSI) involves
using pharmacologic agents to sedate and
paralyze a patient to facilitate placement of
an ET tube.
Summary
• Drugs used for RSI include sedatives and
neuromuscular blocking agents (paralytics)
to induce complete paralysis.
• Alternative airway devices include the
Combitube, laryngeal mask airway, King LT
airway, and Cobra perilaryngeal airway.
Summary
• Open (surgical) cricothyrotomy involves
incising the cricothyroid membrane,
inserting a tracheostomy tube or ET tube
into the trachea, and ventilating with a bagmask device.
• Needle cricothyrotomy involves inserting a
14- to 16-gauge over-the-needle catheter
through the cricothyroid membrane and
ventilating with a high-pressure jet
ventilation device.
Credits
• Chapter opener: © Mark C. Ide.
• Backgrounds: Orange—© Keith Brofsky/
Photodisc/Getty Images; Purple—Jones & Bartlett
Learning. Courtesy of MIEMSS; Red—© Margo
Harrison/ShutterStock, Inc.; Green—Courtesy of
Rhonda Beck.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for
Emergency Medical Services Systems, or have
been provided by the American Academy of
Orthopaedic Surgeons.